Gulf War Veterans’ Illnesses 

Task Force Report

March 2012
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Table of Contents

Contents

Executive Summary ........................................................................................................ 5

Introduction ..................................................................................................................... 9

Overarching Concept .................................................................................................... 10

Clinical Care: Leveraging Veteran Centric Specialty Services in Primary Care ............ 12

Background: .............................................................................................................. 12

Current Efforts: .......................................................................................................... 12

Public Comment Feedback:....................................................................................... 13

Plan: .......................................................................................................................... 13

Metrics and Accountability: ........................................................................................ 14

Clinical Education and Training: Putting Clinical Knowledge into Practice.................... 16

Background: .............................................................................................................. 16

Current Efforts: .......................................................................................................... 16

Public Comment Feedback:....................................................................................... 16

Plan: .......................................................................................................................... 17

Metrics and Accountability: ........................................................................................ 18

Veteran Benefits: Delivering Compensation and Pension and Fiduciary Services........ 19

Background: .............................................................................................................. 19

Current Efforts: .......................................................................................................... 21

Public Comment Feedback:....................................................................................... 21

Plan: .......................................................................................................................... 22

Metrics and Accountability: ........................................................................................ 22

Veteran Outreach: Improving Communications to Gulf War Veterans .......................... 23

Background: .............................................................................................................. 23

Current Efforts: .......................................................................................................... 23

Public Comment Feedback:....................................................................................... 24

Plan: .......................................................................................................................... 24

Metrics and Accountability: ........................................................................................ 27

Partnerships: Improved Data Sharing with the Department of Defense (DoD)............. 28
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Background: .............................................................................................................. 28

Current Efforts: .......................................................................................................... 28

Plan: .......................................................................................................................... 29

Metrics and Accountability: ........................................................................................ 30

Ongoing Scientific Reviews and Population Based Surveillance: Taking Advantage of 

Untapped Sources of Data Related to Veterans’ Health ............................................... 31

Background: .............................................................................................................. 31

Current Efforts: .......................................................................................................... 31

Plan: .......................................................................................................................... 35

Metrics and Accountability: ........................................................................................ 36

Research and Development: Encouraging Targeted Efforts ......................................... 37

Background: .............................................................................................................. 37

Current Efforts: .......................................................................................................... 37

Public Comment Feedback:....................................................................................... 38

Plan: .......................................................................................................................... 40

Metrics and Accountability: ........................................................................................ 41

APPENDIX A – Veterans Affairs GWVI Research ........................................................ 43

APPENDIX B – Draft Gulf War Veterans Illnesses Provider Pocket Guide................... 44

APPENDIX C – Research Advisory Committee for Gulf War Veterans’ Illnesses ......... 46

APPENDIX D – Gulf War Steering Committee Members .............................................. 48

APPENDIX E – Gulf War Veterans’ Illnesses Task Force Members............................. 49

APPENDIX F – GWVI Web sites and Links .................................................................. 51
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Executive Summary

The Gulf War Veterans Illnesses Task Force (GWVI-TF) was formed to ensure that the 

Department of Veterans Affairs (VA) maintained a focus on the unique issues of 

Veterans of the 1990-1991 Gulf War. The Persian Gulf War is legally defined in title 38 

U.S.C. § 101(33) as beginning on August 2, 1990, and ending on the date thereafter 

prescribed by Presidential proclamation or by law. While the term "Gulf War Veterans" 

could refer to all Veterans of conflicts during this period, including Veterans of Operation 

Iraqi Freedom, and subsequent conflicts, the GWVI-TF target population is Veterans 

who were deployed on the Operation Desert Shield and/or Operation Desert Storm 

components of the 1990 - 1991 Gulf War, hereafter referred to as the Gulf War.

In August 2009, the Secretary of VA directed a comprehensive review of the 

Department’s programs to support this population of Veterans, develop an overarching 

action plan to advance their services, and ultimately improve their satisfaction with the 

quality of services and support VA provides. One year later, the GWVI-TF prepared its 

first annual report. The report broadly reviewed programs and efforts and identified

seven areas where VA service improvement was necessary. The report also developed 

an initial roadmap to transform the care and services delivered to Gulf War Veterans.

Over the past year, the GWVI-TF has refined this initial roadmap and taken concrete 

steps to improve care and services to Gulf War Veterans. The work has proceeded 

around a premise that the efforts must become a part of the culture and ongoing 

operations of VA and not simply the purview of a special Task Force. To accomplish 

this outcome, the GWVI-TF adopted a slightly revised framework for organizing and 

synchronizing its efforts. That framework serves as the overarching template for this 

report. The framework is composed of the following lines of effort:

Clinical Care: Leveraging Veteran-Centric Specialty Services in Primary Care

Clinical Education and Training: Putting Clinical Knowledge Into Practice

Veteran Benefits: Delivering Compensation and Pension and Fiduciary Services

Veteran Outreach: Getting Out the Word and Listening to the Feedback

Partnerships: Improved Data Sharing with the Department of Defense

Ongoing Scientific Review and Surveillance: Taking Advantage of Untapped 

 Sources of Data Related to Veterans’ Health

Research and Development: Encouraging Targeted Efforts

Clinical Care: Leveraging Veteran-Centric Specialty Services in Primary Care 

One of the most substantial additions to the framework is the Clinical Care line of effort. 

Clinical health care for Gulf War Veterans is one of the most critical services VA can 

provide. This line of action is directly supported by Clinical Education and Training to 

ensure VA providers are well prepared to care for this population. Clinical Care also 

benefits from research and development and Ongoing Scientific Review and 

Surveillance which inform and direct the best in evidence-based healthcare. The 

GWVI-TF has developed a prototype for a networked Gulf War Clinic which will be 
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implemented at the Salt Lake City Veterans Affairs Medical Center (VAMC) in 2012. 

The clinic will link subject matter experts and clinical specialists with primary care 

providers to optimize the care delivered to these patients. Teaching aids, referral 

networks, and other collaborative processes will be exercised in this effort.

Clinical Education and Training: Putting Clinical Knowledge into Practice

The GWVI-TF Clinical Education and Training effort focused on improving VA’s ability to 

put critical clinical knowledge and expertise at the point of care. Where the Clinical 

Care work was aimed at synchronizing specialty and primary health care, this effort was 

in direct support, providing necessary clinical education, training, and subject matter 

expertise. The Veterans Health Administration (VHA) Office of Public Health created a 

series of training modules now universally available online for patients and clinicians. 

Additionally, VA hosted a series of exposure seminars to enhance clinician knowledge 

about the health impacts of various environmental exposures. In the coming year, 

again in direct support of Clinical Care, this effort will publish an environmental health 

pocket card for primary care providers and collaborate in the formal 

development/improvement of a three tiered network of care presented in the prototype 

clinic for Gulf War health care.

Veteran Benefits: Delivering Compensation and Pension and Fiduciary Services

As research and environmental study evolves or new legislative and regulatory 

provisions are written regarding illnesses for Gulf War Veterans, the VA Compensation 

Service of the Veterans Benefits Administration (VBA) performs necessary rule-making 

and develops field training to support the changes. To further assist Gulf War Veterans, 

Compensation Service developed two training letters designed to inform and instruct 

regional office personnel on development and adjudication of disability claims based on 

Southwest Asia service. VA also completed a regulation to add functional 

gastrointestinal disorders to the list of disabilities that are presumed to have resulted 

from service in the Gulf War. The final rule was published and became effective on 

August 15, 2011. VBA continues to work with the VA/Department of Defense (DoD)

Deployment Health Working Group to identify environmental exposures whether related 

to the Gulf War or elsewhere. Finally, VBA worked with the VHA on an effort to develop 

and execute a separation health assessment with DoD, an effort that is intended to help 

Veterans establish service connection for exposure-related illnesses and injuries years 

after service.

Veteran Outreach: Getting Out the Word and Listening to the Feedback

VA is dedicated to improving the lives of Veterans of all eras and their eligible family 

members and survivors by providing them with the benefits and services they have 

earned. Research shows there is a lack of awareness when it comes to specific 

services, and Gulf War Veterans continue to require and rightfully expect timely and 

accurate information about VA’s efforts to support them. VA has worked to develop a 

proactive and systematic effort for providing this important information and assistance 
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on VA’s services and benefits. As a clearinghouse of Gulf War Veterans Illnesses 

(GWVI) information, VA maintained the Gulf War Veterans' Illnesses Web site 

(http://www.publichealth.va.gov/exposures/gulfwar/) as a source of information for 

Veterans, healthcare providers, and other stakeholders. VA conducted a number of 

GWVI specific outreach events and published news releases for key events during the 

past year. Moving forward, VA’s outreach efforts for GWVI will increasingly leverage 

evolving technology and social media and work to significantly improve transparency 

regarding VA’s work for this important Veteran population.

Partnerships: Improved Data Sharing with the Department of Defense (DoD)

DoD and VA provide health care and benefits to the same population at different times 

in their lives. Environmental exposures occur during active duty whereas the potential 

clinical consequences can manifest later when the former Service member is a Veteran. 

For this reason it is critical that VA and DoD share clinical and exposure data. The 

GWVI-TF continued to build robust relationships with DoD, through such forums as the 

Deployment Health Working Group, to ensure timely and thorough access to data 

related to military service. The experiences of the Gulf War Veterans continue to 

influence the development of ongoing data sharing efforts with DoD which should aid 

both Gulf War Veterans as well as generations of Veterans who follow.

Ongoing Scientific Review and Surveillance: Taking Advantage of Untapped Sources of 

Data Related to Veterans’ Health

Ongoing scientific review is critical to understanding the environment that impacts 

health. There are Veterans’ health-related data available from sources other than 

studies conducted by VA. Having access to and understanding these data sources is

important in comprehending the complex array of adverse health effects associated with 

deployment. VA has developed and maintained active participation in ongoing 

longitudinal reviews and surveillance projects including the Centers for Disease Control 

and Prevention/National Center for Health Statistics’ National Health and Nutrition 

Examination Survey, the DoD Millennium Cohort Study, and the VA National Study for a 

New Generation of U.S. Veterans. These programs help VA identify Gulf War Veteran 

health trends through focused comparisons with broader populations. VA has also 

engaged in more focused surveillance and epidemiologic research regarding the Gulf 

War through the additional study of Neurological Disease, a 30,000 Veteran study of 

1990-1991 Gulf War Veterans, and ongoing Depleted Uranium and Toxic Embedded 

Fragment Surveillance Center and Registry work. Much of this work is longitudinal in 

nature (some continuing out into 2022), but results and findings from some are 

expected to be published in peer reviewed publications in the coming year.

Research and Development: Encouraging Targeted Efforts

Through the Office of Research & Development (ORD), VA funds research that will 

further the goal of improving the health and lives of Veterans who have GWVI, the 

complex of chronic symptoms that affect Veterans of the 1990-1991 Gulf War. To 
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improve specific management of the GWVI portfolio of research, ORD actively pursued 

staffing additions to support these efforts. ORD continued to support and advertise 

requests for proposals for GWVI research and collaborate with VA, DoD, and other 

research activities through professional collaboration events and forums. Additionally, 

with support from the Gulf War Research Steering Committee and input from the 

Research Advisory Council for Gulf War Veterans’ Illnesses, a GWVI Research 

Strategic Plan was drafted. This plan, combined with the targeted staffing changes, is 

expected to provide focus and accountability to this research portfolio. 

The GWVI-TF posted a draft of this report for public comment in October-November 

2011. The public comments were collected through direct responses to the Federal 

Register announcement as well as through a social media website created specifically 

to elicit responses on the report. During the thirty day comment period, there were 

twenty-five direct comments submitted through the Federal Register process. The 

social media website received over 450 comments from over 500 registered users. 

Many of the comments submitted in both venues were not directly responsive to the 

report, but all have been reviewed and either included in this report or as guidance for 

the task force to consider as it moves forward. Comments specifically included in this 

report are annotated accordingly. Many of the remaining comments and suggestions 

will guide the manner in which the GWVI-TF communicates with Gulf War Veterans. 

Finally, there were a number of individual requests for assistance, some of which were 

referred to appropriate offices for action and others that were not specific enough or 

were anonymously submitted and will serve only as background for consideration on 

areas for the task force to study in the future.

The focus of the GWVI-TF is to integrate new knowledge into services that will directly 

benefit Veterans of the 1990-1991 Gulf War. Taken together, the activities in the seven 

lines of effort described above demonstrate the work done by VA to support these 

Veterans and provide a road map to institutionalizing these efforts moving forward. 
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Introduction

Over twenty years have passed since the start of the deployment and combat 

operations known as Operations Desert Shield and Desert Storm. Since then, many 

Veterans of that conflict have endured adverse health consequences from the war. The 

Persian Gulf War is legally defined in 38 U.S.C. § 101(33) as beginning on August 2, 

1990, and ending on the date thereafter prescribed by Presidential proclamation or by 

law. While the term "Gulf War Veterans" could refer to all Veterans of conflicts during 

this still open time period, including Veterans of Operation Iraqi Freedom, and 

subsequent conflicts, the GWVI-TF target population is Veterans who were deployed on 

the Operation Desert Shield and/or Operation Desert Storm components of the 1990 -

1991 Gulf War, hereafter referred to as the Gulf War.

A recently published VA report provides a series of statistical insights into this 

population of Veterans.1 Of the 529,034 Service members who served in Operation 

Desert Shield (of whom approximately 6.8 percent were women), 152,126 Veterans 

filed disability compensation claims and were subsequently service-connected for at 

least one condition. Of these service-connected Veterans, 79,415 also received VA 

healthcare. Of the 581,683 Service members who served in Operation Desert Storm (of 

whom 7.1 percent were women), 165,596 Veterans filed disability compensation claims 

and were subsequently service-connected for at least one condition. Of these serviceconnected Veterans, 87,612 also received VA healthcare. 

Combined, these Veterans have made over 2 million outpatient visits for health care 

and had over 20,000 inpatient admissions in the VA healthcare system. In support of 

care and services to the Veterans of the first Gulf War, VA participated in Federal 

research efforts on Gulf War illnesses totaling more than $13.8 million in fiscal year (FY) 

2010 and just over $159 million in total Federal commitment since 1994 (see 

Appendix A, Veterans Affairs GWVI Research, for a more detailed listing). 

Yet throughout these years many Veterans have felt disenfranchised in these efforts, 

and underserved by VA. Stakeholders have been critical of VA’s culture and processes 

as well. The excess of unexplained medical symptoms reported by deployed 1990 –

1991 Gulf War Veterans continues to elude connection to any specific medical condition 

or conditions. VA’s stakeholders have also criticized the Department’s emphasis in its 

research and clinician training materials and in public statements regarding the causes 

and treatment of Gulf War illnesses. The GWVI-TF was set up to respond to these 

criticisms. 

The mission of the GWVI-TF is three-fold: 

 

1 Gulf War Veterans Report: Pre 9/11, August 2, 1990 to September 10, 2001, Department of Veterans 

Affairs, Washington, D.C. February 2011. Note: This report groups service to cover Veterans into clearly 

described but overlapping cohorts spanning the time from August 6, 1990 to January 31, 1992. 

(http://www.va.gov/vetdata/docs/SpecialReports/GW_Pre911_report.pdf) 
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• To identify gaps in services as well as opportunities to better serve 1990 – 1991 

Gulf War Veterans, inclusive of women Veterans who served; 

• To develop results-oriented recommendations that decisively advance VA’s 

efforts to address their needs; and 

• To apply lessons learned from past practices and policies that can improve 

today’s programs and services supporting Operation Enduring Freedom/Operation Iraqi 

Freedom Veterans.

Overarching Concept

The GWVI-TF published its first annual report in September 2010. This report was 

organized around seven overarching themes which were identified though Veteran and 

other stakeholder feedback. These themes were: Partnerships; Benefits; Clinician 

Education and Training; Ongoing Scientific Reviews and Population Based

Surveillance; Enhanced Medical Surveillance of Potential Hazardous Exposure;

Research and Development; and Veteran Outreach. Perceptions, findings, and 

recommendations related to these seven themes were developed into the basis of the 

report. The recommendations, along with a report on the current status for each area,

served as an action plan for the past year.

Moving forward from that foundation, the GWVI-TF has continued to refine the focus of 

efforts to support the Gulf War Veteran population. In this report there are still seven 

major themes, although this year Ongoing Scientific Reviews and Population Based 

Surveillance and Enhanced Medical Surveillance of Potential Hazardous Exposure have 

been merged and Clinical Care has been added. The seven overarching themes in this 

report are now:

• Clinical Care: Leveraging Veteran-Centric Specialty Services in Primary Care

• Clinical Education and Training: Putting Clinical Knowledge Into Practice

• Veteran Benefits: Delivering Compensation and Pension and Fiduciary Services

• Veteran Outreach: Getting Out the Word and Listening to the Feedback

• Partnerships: Improved Data Sharing with the Department of Defense (DoD)

• Ongoing Scientific Review and Surveillance: Proactive Literature and 

 Environmental Scanning

• Research and Development: Encouraging Targeted Efforts

This year, emphasis was placed on establishing measurable performance objectives 

within the scope of GWVI-TF. The focus was on development of results-oriented 
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recommendations to decisively advance VA’s ability to address the needs of the Gulf 

War Veteran through proactive and meaningful initiatives. Most importantly, task force 

members were asked to ensure that efforts to serve these Veterans were integrated into 

institutional practice and lasting VA culture. To foster this transition from special project 

to ongoing practice, this report includes measurable objectives, a clearly identified intent 

for each recommended activity, and recommends a leadership reporting process to 

maintain accountability for completion.

Despite its focus on the cohort of Veterans from the 1991 Gulf War, this task force has 

been the impetus for major introspection by VA and review of its practices towards all 

Veterans. This is most obvious in the VHA reorganization from which emerged the VHA 

Office of Disability and Medical Assessment. For the first time at VA, the medical 

evaluation of Veterans for their disability benefits is considered a Veteran healthcare 

service line rather than a business arrangement with VBA. This is a major paradigm 

shift and has created a collaborative partnership between VHA and VBA heretofore not 

realized. The outcomes of this partnership are further elucidated in the Compensation 

and Pension Fiduciary Services section below.

This Report reflects the work completed since the last report was issued in September

2010. More importantly it serves to lay out how VA will actively and aggressively pursue 

improvements in the care and services that it provides for Veterans from the 1990-1991 

Gulf War era. VA has and will continue to make strides to ensure services for this 

cohort of Veterans are at once integrated into the ongoing strategic and operational 

efforts of the Department, and also uniquely managed to support the specific needs of 

these Veterans.
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Clinical Care: Leveraging Veteran Centric Specialty Services in 

Primary Care

Background: 

Facilities across the VHA are currently working on bold, innovative programs to 

synchronize primary care and specialty care services. The core of this process is the 

Patient Aligned Care Team (PACT). The institution of the VHA’s PACT, designed to 

increase access, coordination, communication, and continuity of care for patients, is 

VA’s commitment to a patient-centric program to integrate primary care and specialty 

care. The goal is to provide our Veteran patients with cutting edge care that will 

redefine the way VHA delivers seamless service to patients.

VHA continues to refine and implement the Specialty Care Access Network (SCAN) 

concept which leverages specialty medical capabilities, often more available at larger 

medical centers, to provide higher level clinical expertise and enhanced access to high 

quality post-deployment clinical care for Veterans system wide. The SCAN provides 

specialty medical consultation and care at the right time and place, synchronized with 

the PACT goals described above.

Building on lessons learned from post-deployment care concerns of Veterans returning 

from conflicts in the past, including Gulf War Veterans, VA has made major steps 

forward over the past decade to formalize its approaches to post-combat care. The 

Post-Deployment Integrated Care Initiative (PDICI) in primary care has resulted in the 

creation of points of service in the form of integrated care clinics for Veterans returning 

from OEF/OIF conflicts. These programs are now being aligned with the PACT model 

to create platforms for clinically relevant post-deployment assessment and care that will 

serve not only Veterans of the current conflicts, but also Veterans from prior conflicts 

who have deployment related health concerns (including Gulf War). These services will 

also be in place for Veterans returning from conflicts in the future. Other improvements 

in post-deployment care include: enhanced training of clinicians in post-deployment 

health issues (including those of Gulf War Veterans) through updates of the Veteran 

Health Initiative (VHI), and the creation of the Talent Management System (TMS) 

training on military culture, post-deployment care, deployment related environmental 

exposures and benefits available to deployed Veterans. 

Creating stronger collaborations between the Office of Public Health, specialized postdeployment clinics operated under the umbrella of the War Related Injury and Illness 

Study Center (WRIISC), and the Office of Disability and Medical Assessment, has 

served to formalize the notion of “post-deployment care” and strengthen our system of 

integrated services for Veterans with deployment related health concerns. 

Current Efforts:
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Currently there are multiple areas of clinical expertise that need to be shared with the 

primary care field. Gulf War Veterans have been exposed to numerous potential toxins 

that are not often encountered in primary care practice. These include pyridostigmine, 

depleted uranium, and petrochemical by-products, among numerous others. Exposure 

to these potential toxins and resultant clinical implications are described in the 2008 

Institute of Medicine comprehensive Gulf War exposure report. 

Proactive efforts are also being taken to address the common health care challenges 

facing VHA and the DOD. VA is initiating an innovative program that will combine Gulf 

War specific specialty medical treatment models with primary care to produce a 

seamless, patient-centric model that will improve patient and provider education, safety, 

and satisfaction.

VHA has initiated the PACT program across VA. Additionally, there is a well developed 

network of specialty care providers in many VA health care facilities, supported by the 

highest levels of specialty medical care at larger teaching medical centers. Each 

Veterans Integrated Service Network (VISN) also has an Occupational Health M.D. that 

can serve as a point of contact to individual medical centers. Finally, VA has developed 

WRIISCs, located in Washington, DC; East Orange, NJ; and Palo Alto, CA. The 

WRIISCs provide teams of multidisciplinary clinicians uniquely qualified to evaluate 

Veterans with deployment-related health concerns and provide a clinical “second 

opinion” resource to Veterans via a referral process based on geographic location. If a 

Veteran is eligible to be treated at one of the WRIISC facilities, the primary care 

physician may contact that WRIISC program directly about a referral through either a 

telephone or telemedicine consultation.

Public Comment Feedback:

Gulf War Veterans clearly expressed frustration in their ability to get relief from the 

symptoms of their illnesses. The quality of clinical care is a key concern of the VHA and 

is reflected in the performance measures that VHA leaders use to assess the care of 

Veterans at all levels of the healthcare system. In particular, Veterans expressed 

concerns over the continuity of care they receive and how this impacts their ability to 

make progress in the care they require. Further, there were a number of comments 

regarding the inability of the Veterans’ providers to adequately integrate their GWVI 

specific issues into a plan for their healthcare. This report describes some key and 

focused efforts to develop systems for ensuring that clinical providers are armed with 

current knowledge regarding GWVI related topics. The pilot program described below 

is designed to systematically integrate improved provider knowledge with further subject 

matter expertise with a primary goal of improving providers’ ability to effectively deliver 

care while also improving the Veterans’ satisfaction with their care.

Plan:

While a network of specialized health care services and expertise is available as 

described above, VA needs to create more formal linkages and organize these 

resources to create a more effective capability to access these valuable resources at 
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the local level. To accomplish this goal in support of Gulf War Veterans, VHA is 

launching a prototype program at the Salt Lake City VAMC (SLCVAMC). This prototype 

will refine a network-based system of care for Gulf War patients which will leverage the 

PACT concept now taking root across VHA, and proactively integrate the necessary 

specialty care experts with the primary care team. The specialty care project will focus 

on treating the unique health care requirements of the Gulf War population. This 

program will further leverage information technology including the VA and DoD

electronic health records and the existing VA tele-health infrastructure. Clinical 

Education and Training efforts detailed below will further empower this program and 

provide a structure for engagement of specialty providers with both patients and primary 

care teams. Some specific details of the prototype effort include:

• The Gulf War specific specialty care pilot was initiated at SLCVAMC and 

select Community Based Outpatient Clinics (CBOCs) on October 1, 2011. 

Educational preparation and tele-health planning is underway leading up to 

that start date.

• A tiered program for accessing Gulf War subject matter experts (SME). The 

Gulf War clinical champion will act as the point of contact for the primary care 

physicians and will staff the prototype clinical module. 

• SLCVAMC Environmental and Occupational medicine experts were identified.

These SMEs will begin an educational outreach program consisting of 

conferences at the VAMC and real time teleconferences to the six outlying 

CBOCs. These conferences are currently taking place at the SLCVAMC.

• This educational system will utilize the current Talent-Based Management 

module designed by the WRIISCs. 

• An educational pamphlet titled, "Questions and Answers; A Pocket Guide for 

Gulf War Illnesses,” was be distributed to primary care providers, nurse 

managers, and staff. This guide includes point of contact information for the 

SME's as well as general information on Gulf War exposures.

Metrics and Accountability:

A data pull from the centralized patient records warehouse will identify patients with 

service in Gulf War and the following data will be collected:

• Baseline customer satisfaction: "How confident are you that your provider 

can answer questions directly related to your Gulf War Illnesses service?"

• Baseline trainee satisfaction (medical residents and students): "How 

confident are you that you can answer, or have access in real time, to 

questions related to your patient’s Gulf War service?"
15

• Baseline provider satisfaction (frontline primary care providers): "How 

confident are you that you can answer, or have access in real time, to 

questions related to your patient’s Gulf War service?"

• This data pull will be repeated at three-month and six-month intervals for the 

next two years.

• The SMEs at SLVAMC will record the number of telephone consults and 

tele-health consults they receive each week. They will also record the nature 

of each interaction and the time spent on each interaction using a 

standardized “patient point of care” worksheet. These worksheets will also 

be collected at the 3 month and 6 month intervals.

• The data and structure of the project will be reviewed at 6 months (February

2012) and 12 months (July 2012). A formal project review and summary will 

be presented to VHA leadership and stakeholders including the GWVI-TF at 

each time point for analysis and direction. 
16

Clinical Education and Training: Putting Clinical Knowledge into 

Practice

Background: 

The unique exposures experienced by Gulf War Veterans during their military service 

require that specialized knowledge concerning environmental hazards is widely 

available throughout VA and specifically within the clinical environment. However, the 

health effects of many environmental hazards are not taught to the majority of health 

care providers during their clinical training. Specific expertise concerning the health 

effects of environmental hazards is usually limited to clinicians trained in occupational 

medicine. The challenge for VA is to ensure that specialized knowledge about 

deployment related environmental hazards is available to all clinicians who provide 

health care to Veterans. Deployment related clinical education and training are 

essential enablers of optimal clinical care for Gulf War Veterans.

Current Efforts: 

The following actions have been taken to address this issue:

• The Veteran Health Initiative (VHI) on the Gulf War, extensively revised and 

updated since January 2011, is available on the internal VA Talent Management 

System (TMS). This new VHI, “Caring for Gulf War Veterans,” is also available 

to Veterans and the public in a PDF format at 

http://www.publichealth.va.gov/docs/vhi/caring-for-gulf-war-veterans-vhi.pdf and 

on the VHA Gulf War Veterans’ Illnesses Web site at 

http://www.publichealth.va.gov/exposures/gulfwar/.

• VHA conducted a total of five exposure seminars training over 500 VA health 

care providers. Feedback from these seminars was extremely positive and an 

additional half-day workshop on conducting an exposure history was added. 

• A WRIISC sponsored conference was held in August 2011. The conference 

presented material regarding environmental exposure screening as well as 

numerous topics related to the current cohort of Gulf War Veterans from Iraq and 

Afghanistan.

• A listing of the Environmental Health Clinicians and Coordinators has been 

developed and is posted for online access at:

http://www.publichealth.va.gov/exposures/coordinators.asp

Public Comment Feedback:

As noted briefly in the section above, many concerns were submitted relating to primary 

care provider awareness of Gulf War Veterans’ Illnesses, potential exposures and VA’s 

established care and compensation processes. These unique exposures experienced 
17

by Gulf War Veterans during their military service require that specialized knowledge 

concerning environmental hazards is widely available throughout VA and specifically 

within the clinical environment. However, the health effects of many environmental 

hazards are not taught to the majority of health care providers during their clinical 

training. Specific expertise concerning the health effects of environmental hazards is 

usually limited to clinicians trained in occupational medicine. 

The challenge for VA is to ensure that specialized knowledge about deployment related 

environmental hazards is available to all clinicians who provide health care to Veterans. 

In response to these identified concerns, the VHA Office of Public Health is 

collaborating with the “Patient Aligned Care Team” initiative to improve access to 

educational products to integrate into Veteran healthcare. This effort is described 

below. 

Veterans expressed concern that obtaining access to the War Related Illness and Injury 

Study Center (WRIISC) services was cumbersome and slow. The present WRIISC 

referral system depends on primary provider knowledge about the program and is a 

paper based system requiring clinicians to fill in multiple forms and then faxing these 

forms to a central referral office. A far more streamlined approach is nearing completion 

and is described below.

Plan: 

The initiative to redesign primary care within VHA via PACT mandates improved health 

care provider education regarding the health effects of environmental hazards. VHA is 

designing a three-tiered approach to the delivery of environmental hazards information

and expertise. Primary care providers will be provided with a pocket card of essential 

information during orientation. This card will contain information on local SMEs, key 

Web sites, and major deployment-related environmental hazards. A draft of this pocket

card is provided at Appendix B. Each PACT will be aligned with an Environmental 

Health SME who will serve as the second tier in the VA Environmental Health delivery 

system. The Office of Public Health will coordinate improved access to environmental 

consultants for primary care clinicians. The Environmental Health clinician will facilitate 

referrals to the WRIISCs which serve as the tertiary level of Environmental Health care. 

Environmental hazards education will be tailored to each of these three levels of care.

At present, familiarization with the WRIISC is part of the Provider Education initiative. 

Public Health’s Post Deployment Strategic Healthcare Group has worked for the past 

year to develop an electronic referral system that will be similar to the standard interfacility consult process clinicians use to refer Veterans for other specialty consults. This 

system is presently being tested at the Palo Alto WRIISC and should be available at the 

other two WRIISC sites by the end of December 2012. Providers then will be able to 

enter consults to the WRIISC through VA’s Computerized Patient Record System. 

Letters explaining the procedure will be sent to VAMC Chiefs of Staff within each of the 

WRIISC regions. This will expedite Veterans’ access to the WRIISC.
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Metrics and Accountability:

• Final development of pocket cards for distribution to existing and new primary 

care providers by June 1, 2012.

• Each PACT will have an associated Environmental Health SME by June 1, 2012.

• Environmental Health clinicians will have an established structure by June 1, 

2012 and new responsibilities will be established by Dec 31, 2012.

• Continued specialized training of Environmental Health clinicians through 

seminars, Webinars, and other media. 
19

Veteran Benefits: Delivering Compensation and Pension and 

Fiduciary Services

Background:

VBA’s Compensation Service provides service-connected disability and death benefits 

to Veterans with honorable service during the Gulf War for disabilities incurred in or 

aggravated by such service. VBA’s Pension and Fiduciary Service provides disability 

and death benefits to Veterans and surviving dependents of Veterans who served in the 

Gulf War who are totally disabled, age 65 or older, or who died from a disability not 

related to the Veteran’s service. These benefits are needs based. 

In FY 2010, the GWVI-TF reviewed the legislative and regulatory provisions unique to 

the Gulf War cohort of Veterans. Rule-making was undertaken to add additional 

diseases to the list of those subject to the presumption of service connection based on 

evidence provided by the National Academy of Sciences on chronic diseases 

associated with service in Southwest Asia. 

To further assist Gulf War Veterans, VBA Compensation Service developed two training 

letters designed to inform and instruct regional office personnel on development and 

adjudication of disability claims based on Southwest Asia service. Training Letter 

10-01, titled Adjudicating Claims Based on Service in the Gulf War and Southwest Asia, 

was released on February 4, 2010. This training letter provides background information 

on the Gulf War of 1990-1991, and explains the initial 1994 and subsequent 2001 

legislation found in title 38, U.S.C., § 1117, which was a response to the ill-defined 

disability patterns experienced by returning Gulf War Veterans. It explains the terms 

“undiagnosed illness” and “medically unexplained chronic multisymptom illness” used in 

the legislation, and stresses that service connection may be granted for other diagnosed 

chronic, multisymptom illness in addition to chronic fatigue syndrome, fibromyalgia, and 

irritable bowel syndrome, which are identified as examples in the legislation. It also 

provides step-by-step procedures for procuring supporting evidence and for rating a 

disability claim based on Southwest Asia service under § 3.317 of title 38 Code of 

Federal Regulations. The training letter includes a separate memorandum to be sent 

with the VA medical examination request so that examiners are informed of the issues 

related to qualifying chronic disabilities and better able to evaluate a Gulf War Veteran’s 

disability pattern. 

The Gulf War Training Letter was due in part to what VA has learned from this cohort of 

Veterans. Essentially, that disability patterns are complex and the law governing Gulf 

War disability rating policy is equally complex. Training Letter 10-01 provided valuable 

refresher training to field personnel while implementing uniformity across VA with 

respect to Gulf War examinations and Gulf War claims adjudication policy. 

Additional assistance was provided in Training Letter 10-03, Environmental Hazards in 

Iraq, Afghanistan, and Other Military Installations, which was coordinated with DoD. 

This training letter provides regional office personnel with information on environmental 

hazards associated with Gulf War and Southwest Asia service. It discusses airborne 
20

toxic substances resulting from the widespread use of burn pit fires to incinerate a 

variety of waste materials in Iraq and Afghanistan, as well as hexavalent chromium 

contamination at the Qarmat Ali water treatment plant in Basrah, Iraq, from April through 

September 2003. The training letter was sent to VBA’s regional offices on April 26, 

2010.

The purpose of this information is to alert regional office personnel to the potential for 

disability claims based on exposure to any of these environmental hazards. The 

training letter outlines development and rating procedures for such claims and provides 

fact sheets for VA medical examiners that explain each hazard. VA coordinated with 

DoD to assure that these fact sheets accurately described the environmental hazards. 

A review of VA’s nationwide accuracy data for Gulf War claims reveals a 4.2 percent 

improvement in quality since the release of the training letters. The improvement is also 

attributed to the establishment of a dedicated mailbox for individuals who work Gulf War 

and other environmental hazard claims. Claims representatives from the 57 regional 

offices frequently send in questions and concerns regarding claims-specific issues. 

This allows policy makers to provide feedback and refine existing Gulf War adjudication 

policies.

In addition to efforts within the VBA, on March 25, 2011, the VHA established the Office 

of Disability and Medical Assessment (DMA) as part of the VHA re-organization. DMA is 

tasked with oversight of all disability evaluation services including those conducted 

within VHA, through National contracts, and in the Integrated Disability Evaluation 

Program (IDES) which is a joint VA/DoD program to provide a single disability 

evaluation and rating for Servicemembers separating because of unfitting conditions.

One of the early efforts of the VHA DMA office has been to support VBA’s development 

and deployment of the Disability Benefits Questionnaires (DBQs). DBQs are designed 

to help medical providers clearly and easily document the ratable criteria necessary for 

VBA to rate a claim. This results in more accurate and timely claims processing. The 

DBQs specific to Gulf War were released by end of FY 2011.

DMA held two major training conferences in 2011. The first conference, held in June 

2011, focused on the IDES process and was attended by over 500 individuals. The 

second conference, held in November 2011, was a joint VHA/VBA initiative focused on 

the clinical decision making necessary to complete the DBQs as well practical 

instruction in completing the forms. This conference was attended by over 600 

individuals including VBA raters, Disability Evaluators from numerous specialties, 

Primary Care Providers, Medical Subject Matter experts, DoD colleagues and 

contractors completing Disability evaluations for VHA.

This conference was divided into tracks for general disability evaluators involved in 

traditional C&P examinations and IDES as well as for psychologists, audiologists,

primary care physicians who are now completing DBQs for their patients. One 

complete day was devoted to topics related to both the 1990-1991 Gulf War and current 
21

service in SW Asia. Topics included: Undiagnosed and Unexplained Illnesses, New 

Presumptions for Infectious Diseases and Functional Gastro-intestinal Disorders; 

Evaluating Environmental Exposures; Respiratory Problems in Returning SWA 

Veterans; and Completing the DBQs related to service in SWA throughout the entire 

Gulf War period (1990 to present). 

Current Efforts:

On November 17, 2010, VA published a proposed regulation to add functional 

gastrointestinal disorders to the list of disabilities that are presumed to have resulted 

from service in the Gulf War. The final rule was published July 15, 2011, and became 

final on August 15, 2011. 

Additionally, VHA is working with DoD to develop a separation health assessment 

program that will indicate, at time of discharge, the Servicemember’s health status as 

well as occupational and environmental exposure information, where it is available. 

This will support/assist Veterans trying to prove exposure or conditions related to an 

event on active military service, when the events or exposures may not have clinically 

significant health consequences for many years after the event. The experience of Gulf 

War Veterans has added to the drive to achieve this valuable joint process.

Public Comment Feedback:

Numerous comments received during the public comment period were related to 

concerns over processing delays, errors in specific rating decisions, and the improper 

application of existing regulations related to disability ratings. 

Additionally, there were a number of comments regarding the process for determining 

which conditions were considered qualifying disabilities for those who served during the 

Gulf War. Numerous scientific studies have been conducted to investigate possible 

causes and associations between Gulf War Veterans and these illnesses. The 

National Academy of Sciences’ Institute of Medicine (IOM) has also conducted a series 

of reviews of scientific literature documenting research in these areas to identify and 

explain disability patterns associated with Gulf War service in terms of the potential 

health hazards experienced in the Southwest Asian environment. In response to these 

reviews and various laws that have been passed, VA has created a regulation in 38 

CFR §3.317 that reflects the results of the scientific studies and statutory requirements. 

VA recognizes the disabilities and disability patterns which have been validated by 

scientific research in the regulation as qualifying disabilities for Gulf War Veterans for 

purposes of payment of disability compensation. 

Last, there were a number of comments regarding VA decisions on both “Undiagnosed 

Illnesses” and “Medically Unexplained Chronic Multi-Symptom Illnesses”. The GWVITF recognizes that the application of the rules regarding these issues is difficult to 

understand and implement. 38 C.F.R. §3.317 provides a list of specific presumptive 

disabilities that will be service connected in a Veteran with a qualifying period of service 

in the Southwest Asia theater of operations. The conditions must become manifest to a 
22

degree of 10 percent or more within 1 year from the date of separation from the 

qualifying period of service. In addition to the specific presumptive conditions noted in 

§3.317, there are two distinct categories that are also considered qualifying conditions 

for purposes of administering disability compensation. 

The first category is “undiagnosed illnesses,” which may manifest with symptoms such 

as fatigue, signs or symptoms involving skin, headache, etc. Although this category, by 

definition, cannot be associated with a diagnosis, it is nonetheless subject to service 

connection. However, if a medical doctor links one of the listed symptoms to a disease, 

then service connection may not be warranted, (e.g., doctor links the Veteran’s claimed 

“fatigue” to hypothyroidism). 

The second category is: “medically unexplained chronic multisymptom illnesses.” This 

category refers to diagnosed illnesses that are without conclusive pathophysiology or 

etiology and are characterized by a cluster of signs and symptoms featuring fatigue, 

pain, disability out of proportion to physical findings, and inconsistent laboratory 

findings. Illnesses that are partially understood in terms of etiology are not considered 

“medically unexplained.” Examples of unexplained chronic multisymptom illnesses are 

provided in § 3.317. They include, but are not limited to: (1) chronic fatigue syndrome; 

(2) fibromyalgia; and (3) functional gastrointestinal disorder. Service connection is 

appropriate for any of these when diagnosed. 

The issue of whether a Veteran’s particular disability pattern is linked to a conclusive or 

partially understood etiology, or represents one of the disability patterns listed above, 

must be determined on a case-by case basis and will require a medical opinion.

Plan:

VBA continues to work with the VA/DoD Deployment Health Working Group to identify 

environmental exposures, whether related to the Gulf War or elsewhere. 

Metrics and Accountability:

Continue to monitor research and studies on potential exposures to environmental 

hazards in the Gulf War.
23

Veteran Outreach: Improving Communications to Gulf War Veterans

Background: 

VA is dedicated to improving the lives of Veterans of all eras and their eligible family 

members and survivors by providing them with the benefits and services they have 

earned. VA staff throughout the country is committed to fulfilling President Lincoln’s 

promise: “To care for him who shall have borne the battle, and for his widow, and his 

orphan.” Intrinsic in this promise is the need for the Department to actively engage its 

Nation’s heroes and to educate them, their families, and their survivors about the 

benefits and services they may be eligible to receive. Research shows there is a lack of 

awareness when it comes to specific services. To overcome this, increasing outreach 

must be a proactive and systematic effort providing important information and 

assistance on VA’s services and benefits.

Current Efforts: 

The Gulf War Review newsletter and Web site continue to be important communication 

channels to individual Veterans, VA facilities and Veteran Service Organizations

(VSOs). The newsletter and Web site have been improved in the following areas:

• Editorial process and review have been streamlined.

• Continued to review and update VA sponsored Web sites related to the Gulf War

to ensure information is up to date, accessible, and easy to use. 

• Published and promoted new brochure on health registry programs, including the 

Gulf War Registry. Brochure was promoted and distributed to VAMCs, Vet 

Centers, VA Regional Offices, VSOs and Veterans, and VA program offices.

In addition, VA promoted monthly VHA Gulf War updates and reminders via 

announcements on the VHA Website and distributed them to subscribers and used 

Facebook postings and tweets to augment these announcements.

As discussed in the Clinical Education and Training section, VHA Office of Public Health 

posted a new VHI study guide, Caring for Gulf War Veterans, on the VHA Gulf War 

Veterans Illnesses Website. Gulf War Veterans and their families may wish to read the 

guide in order to better understand or discuss their health concerns with their health 

care providers.

Key Dates Gulf War Outreach Highlights:

• Blog post by Brandon Friedman on VAntage Point that marked the transition from 

Operation Desert Shield to Operation Desert Storm, the event that inspired his 

own military service a year later http://www.blogs.va.gov/VAntage/?p=1197
24

• Note: Several dozen comments on blog and approximately 200 more on 

Facebook

• February 23, 2011- Ground War Anniversary

• Blog post by Chief of Staff, Department of Veterans Affairs (COSVA) John 

Gingrich: Personal story and VA’s progress in supporting Gulf War Veterans, and 

request era photos from Gulf War Veterans

• Photo of COSVA from Gulf War – with one or two soldiers

• Blog sent to VA Employees via email to submit their own experiences with era 

photo. (Hey VA!)

News Releases: 

• A new integrated report on Gulf War Veterans that includes numbers and 

statistics from VHA and VBA regarding Gulf War Veterans titled Gulf War Era 

Veterans Report: Pre-9/11 at http://www.va.gov/vetdata/

• GWVI Research Advisory Committee Meeting, COSVA was a keynote speaker.

• Photos collected and displayed/circulated on VA’s Flickr account.

• COSVA responded to pertinent blog postings

Public Comment Feedback:

The use of social media to gather public comment was a deliberate component of the 

GWVI-TF outreach effort. The task force recognizes a need to seek and receive 

feedback from those interested in the work of the task force. The most common 

comments received with regard to the VA outreach efforts regarding GWVI were 

regarding the lack of mechanisms for input from the public and the efficacy of the task 

force in communicating what it was focused on (between annual reports). Moreover, 

the feedback received during the public comment period has served to advise the task 

force that the effectiveness of the work it performs is in many ways affected by how well 

the work is communicated both to outside stakeholders as well as those within the VA. 

In the words of one commenter, “The local caregivers can provide a wealth of date that 

is verifiable and well documented. The feedback from said "in-reach" can save time and 

millions of taxpayer dollars as it helps to refine the nature of the health issues and 

solutions”.2

Plan: 

 Comments also expressed concern on information available related to Gulf

War exposures. Some Veterans expressed a desire for information that is not currently 

on VA’s Gulf War Veterans’ Illnesses Web site. 

In 2012, we will conduct a deliberate and dedicated GWVI communications plan. The 

following describes the elements of this plan:

 

2 Comment received on the VA sponsored UserVoiceTM web portal to collect public comments regarding 

the draft of this report (http://vagulfwartaskforce.uservoice.com/). 
25

Themes:

The GWVI-TF is fostering continuous partnerships that are agile and responsive to the 

health care concerns and needs of Gulf War Veterans, and improving their level of 

satisfaction with VA services and benefits. Providing regular communication on how VA 

is working to improve research, health care, and benefits for GW Veterans is key to 

changing perceptions of the Task Force’s effectiveness and the Department’s 

responsiveness.

Messages:

At VA, we are advocates for all Veterans – it is our overarching philosophy and we are 

working to make it our culture at every level of the organization. 

VA is rapidly improving access to benefits and services for Gulf War Veterans, and 

Veterans of all eras. We are making it easier for Veterans and their families to receive 

the right benefits, meeting their expectations for quality, timeliness, and responsiveness. 

Increasing outreach activities will not only educate Veterans and their families about 

VA’s excellent healthcare, benefits and services, but empower Veterans to make more 

informed decisions and change their perceptions about the VA . 

Outreach Strategy:

Engage stakeholders by sponsoring focus groups to solicit feedback from Gulf War

Review readers to add to internal feedback already received. This project will be 

initiated in 2012.

Explore timetable for regular updates: The GWVI-TF should provide quarterly updates 

through established channels to improve outreach to GW Veterans as well as regular 

updates for broader audiences. These include:

o Quarterly fact sheets

o Regular GWVI Web site updates

o Briefings to Congressional staff and members

o Gulf War Veteran Illnesses Task Force Report 

o National press releases

o Video clip/slide show/key messages ticker

Engage emerging Veterans organizations and the VSOs that are the most critical of VA 

efforts and provide them timely updates while releasing this related information on the

Web. 

Increase the use of social media. By using social media, VA can amplify bi-directional 

communication with critical or questioning VSOs and gain direct feedback from a 
26

significant number of Veterans instantaneously. Current social media efforts include VA 

and VHA Web sites, VA and VHA Facebook and Twitter, and VA Flickr and YouTube. 

Modify communications distribution methods: Previous GWVI-TF communications 

delivery methods included the shipping of printed materials (reports, posters, brochures) 

to individual Veterans, VA facilities, and VSOs. Although print materials are still much 

appreciated by some Veterans, facilities, and VSOs, to enhance effectiveness and 

efficiency while reducing costs, the use of more Web-based download options for 

materials will be continued. Additionally the development of messages for local 

newsletters and social media, short videos and public service announcements will be 

utilized for major updates to make use of facility Targetvision and closed-circuit 

television video feeds. Short video materials, no longer than 3 minutes, will be 

considered as MP4, MOV or AVI files for quick upload and download from appropriate 

Web portals. 

Periodic newsletters are distributed to Gulf War Veterans and Veterans in the Gulf War 

Registry have information mailed directly to them. Others can also request information 

to be emailed to them by signing up on the Web site. 

The Gulf War Veterans’ Illnesses Web site has a large amount of information which has 

grown significantly over time and is available at: http://www.publichealth.va.gov. VHA, 

Office of Public Health is in the process of updating its Web site to make it more usable 

for Veterans. A link will be added to allow the Veteran to sign up for e-mail updates as 

they are published. In addition, we plan to add specifics on exposure information 

identified as a concern by Veterans. This will include information on potential exposure 

to ammonia perchlorate (rocket fuel) and anthrax vaccination.

Stakeholders: Communication concerning Gulf War issues and news should be 

planned for multiple audiences:

• Gulf War Veterans and their families,

• Media,

• VSOs,

• Members of Congress and their staff,

• VA employees (VHA, VBA, NCA),

• VA Program Offices,

• Non-governmental organizations, and

• DoD

Vehicles: A variety of vehicles will be used to reach these audiences:

• Press Releases,

• Email,

• Direct mail,

• Facility (Targetvision or CCTV),

• Web sites,
27

• Blog(s),

• Facebook, and

• Twitter

Metrics and Accountability: 

Outreach efforts will be reported at monthly GWVI-TF meetings to discuss efforts, 

impacts, and support required from Task Force members to facilitate content for 

outreach. 
28

Partnerships: Improved Data Sharing with the Department of Defense 

(DoD)

Background: 

DoD and VA provide health care and benefits to the same population at different times 

in their lives. Environmental exposures occur during active duty whereas the potential 

clinical consequences often manifest later when the former Servicemember is a 

Veteran. For this reason it is critical that VA and DoD share clinical and exposure data. 

Confidentiality provisions, such as the Privacy Act and the Privacy Rule implementing 

the Health Insurance Portability and Accountability Act (HIPAA) of 1996, generally 

prohibit disclosures of personal information without the individual’s authorization and 

can make data sharing between Federal agencies challenging. Improved data sharing 

is an important component in providing optimum clinical care to Gulf War Veterans.

Current Efforts: 

Deployment Health Working Group (DHWG): Increased VA/DoD collaboration and 

information sharing strengthens and identifies potential gaps in Gulf War related 

research. The DHWG identifies and develops recommendations for coordinated 

response plans to potential environmental hazards. The following actions have been 

taken to improve VA/DoD information sharing and research collaboration: 

• A robust VA/DoD Data Transfer Agreement (DTA) is essential to facilitate

research and medical surveillance on Veterans exposed to potential 

environmental hazards during deployment. The DHWG has drafted a DTA which 

is presently being finalized.

• During the past 3 months the DHWG has monitored new studies related to burn 

pit exposure and has been briefed by members of a DoD sponsored pulmonary 

research group on the latest research on burn-pits, particulate matter, and other 

potential pulmonary exposures.

• The DHWG has continued to update senior VA and DoD leaders on the current 

state of deployment related research and other initiatives. On November 8, the 

DHWG briefed the VA/DoD Health Executive Committee (HEC) on Burn Pit 

Smoke Exposure Concerns. This briefing summarized the most recent report by 

DoD entitled “Epidemiological Studies of Health Outcomes among Troops 

Deployed to Burn Pit Sites,” published in May 2010. The briefing also covered 

the current status of the VA sponsored IOM report “Long-term Health 

Consequences of Exposure to Burn Pits in Iraq and Afghanistan,” and 

summarized the current and planned research by DoD and VA investigators.

• On December 6, 2010, the DHWG sponsored a one day seminar for over 50 

DoD and VA personnel involved in environmental exposure research and policy. 

This meeting improved VA/DoD coordination and facilitated information sharing 

on environmental exposure issues.
29

• On November 5, 2010, the DHWG received an update on Depleted Uranium 

(DU) research and the Embedded Metal Fragment Registry. This update 

confirmed that a robust DU research and Embedded Metal Fragments Registry 

are in place and serving the needs of Veterans.

Congressionally Directed Medical Research Programs (CDMRP): In a December 

2010 meeting, ORD staff engaged with DoD staff to collaborate more closely to reduce 

duplication. Following that meeting, VA participated in several additional CMRDP 

meetings and discussed collaborative efforts regarding funding and programs.

Rural Health Initiative Clinical Training Program:, a module of four training subjects 

(Post-Deployment Care, Environmental Exposures in Veterans, C&P/Benefits, and 

Military Culture) provides additional information on the exposure concerns and health 

concerns of Gulf War Veterans. These modules are available in VA Talent Management 

System (TMS) for VA clinicians and staff to access.

VA/DoD Electronic Health Record (EHR) Integration: Secretary Shinseki and 

Secretary Gates met in a series of sessions beginning in March 2011 and committed 

the DoD and VA to an integrated Electronic Health Record (iEHR). Unlike past efforts 

at integration, this next-generation iEHR will be based on a common data and software 

platform. VA and DoD have created a joint governance structure to manage this 

integration. This effort is expected to significantly improve the ability to transition 

service-connected health information to VA, and will support assessment of 

environmental exposures and longitudinal studies for deployment-related health 

concerns.

Plan:

In 2012, VA will continue to build successful partnerships that will improve research and 

clinical care for Gulf War Veterans. Key components of this plan will be a finalized DTA,

continued monitoring of environmental exposures, fostering of VA/DoD collaboration on 

deployment-related research and surveillance, and continued work on the VA/DoD

iEHR.
30

Metrics and Accountability: 

• Leverage DHWG reporting to high level DoD/VA Joint Executive Committee 

(JEC) as requested. 

• Completed VA drafting of VA/DOD Data Transfer Agreement in December 2011 

(currently in DOD staffing process).

• Continue monitoring research and issues related to potential environmental 

toxins encountered by Gulf War Veterans.

• Conduct a DoD/VA research seminar focusing on studies that follow the impact 

of deployment to the health of Veterans over time.

• Monitor monthly “In-Progress Reviews” on the iEHR program.
31

Ongoing Scientific Reviews and Population Based Surveillance: 

Taking Advantage of Untapped Sources of Data Related to Veterans’ 

Health

Background:

Ongoing scientific review is critical to understanding the environment that impacts 

health. Veterans’ health-related data and information are reported from sources other 

than studies conducted by VA. Having access to and understanding reports is 

important to comprehending the complex array of adverse health effects associated with 

deployment. Additionally, it is important to expand and continue VA funded long-term 

studies of Veterans’ health as it relates to deployment and associated environmental 

exposures. Data from all these activities helps inform policy makers of the adverse 

health effects associated with deployment, provides information relative to treatment, 

and identifies future potential preventive strategies.

In some well defined environmental exposures, medical surveillance can prevent or 

allow the early detection of disease. Exposure to chromium at Qarmat Ali, radiation, 

and depleted uranium, and toxic fragments are examples of well defined exposures with 

known potential clinical sequelae. These programs are well established but are 

dependent on clinical providers being aware that they are available for Veterans. 

Throughout VA there will be continued emphasis on educating medical providers on 

these programs, and ensuring that evolving knowledge and understanding of these 

complex issues can be quickly leveraged for care of Veterans. The key enablers for 

getting this information from these programs to providers are clinical education and 

publication of findings in the peer-reviewed medical literature.

Current Efforts: 

Collaboration with Centers for Disease Control and Prevention (CDC)/National 

Center for Health Statistics (NCHS): Increased collaboration with the CDC/NCHS 

provides an opportunity to collect and examine data related to Veterans’ health from a 

national sample of the U.S. population. The data collected by the CDC/NCHS may 

expand our understanding of the range of illnesses associated with deployment to the 

Gulf and other theaters of operation. The following actions have been taken to expand 

health-related data collection on Veterans:

• VA has worked with the CDC/NCHS to ensure Veteran-specific identifying 

questions and analyses are included in two major longitudinal health-related 

national surveys: the National Health and Nutrition Examination Survey 

(NHANES); and the National Health Interview Survey (NHIS).

• The NHANES and NHIS in 2011 added detailed questions regarding Veteran 

status to ascertain better enumeration of participants who have served in the 

military. The precise wording of the questions has been agreed upon by both 

NHANES and NHIS. 
32

The NHANES program began in the early 1960s and has been conducted as a series of 

surveys focusing on different population groups or health topics. In 1999, the survey 

became a continuous program that has a changing focus on a variety of health and 

nutrition measurements to meet emerging needs. The survey examines a nationally 

representative sample of about 5,000 persons each year. 

The NHIS is the principal source of information on the health of the civilian noninstitutionalized population of the U.S. and is one of the major data collection programs 

of the NCHS which is part of the Centers for Disease Control and Prevention (CDC). 

The National Health Survey Act of 1956 provided for a continuing survey and special 

studies to secure accurate and current statistical information on the amount, distribution, 

and effects of illness and disability in the U.S. and the services rendered for or because 

of such conditions. The survey referred to in the Act, now called the National Health 

Interview Survey, was initiated in July 1957. Since 1960, the survey has been 

conducted by NCHS, which was formed when the National Health Survey and the 

National Vital Statistics Division were combined.

Collaboration with the DoD Millennium Cohort Study (MCS): The MCS is 

examining the health-related effects of deployment on military personnel and Veterans. 

As with the CDC/NCHS studies, the data collected by the MCS may expand our 

understanding of the range of illnesses associated with deployment. To expand 

collection of health-related data on Veterans from this study, representatives from VHA 

Offices including OPH and ORD, have met with MCS investigators. OPH has worked 

with MCS investigators to design and conduct a study of respiratory symptoms among 

study participants who have separated from active duty. This collaboration is 

proceeding well and a peer-reviewed journal article should be available during the 

second quarter of FY 2012.

Conduct a National Health Study for a New Generation of U.S. Veterans: The 

Epidemiology Program (EP) within the OPH is conducting a study on the health status 

of 60,000 Veterans who have separated from active duty, National Guard, or Reserves, 

half of whom served in either Iraq or Afghanistan and half who did not. This includes an 

oversampling of women Veterans to permit an appropriate examination of health effects 

associated with deployment in this group. The following actions have been taken:

• Data collection is complete and results are projected to be available early 2012.

Initial studies are focused on respiratory illness and Traumatic Brain injury (TBI). 

• Planning for a clinical follow-up study with a physical examination component is 

underway. 

• Regulatory requirements are being satisfied; staffing and procurement efforts are 

ongoing. 

• The clinical follow-up study implementation is expected in the 2nd quarter FY12. 
33

Explore the feasibility of examining Military Working Dog (MWD) health records to 

identify diseases common to deployed military personnel and deployed MWDs: 

The following actions have been taken:

• VHA negotiated with MWD Center at Lackland AFB and with the Armed Forces 

Institute of Pathology to create a research database. 

• There has been one presentation at an epidemiology research meeting. VHA 

staff met with staff from the MWD Center during the first week in January 2011.

• A project was formally proposed to review MWD health records. That proposal 

was approved. Initial MWD health records were obtained in July 2011. These 

health records represent the clinical history of MWDs deployed to the Gulf and 

other regions. These dogs were exposed to the same environmental hazards as 

military personnel and therefore, may serve as sentinels for adverse health 

effects in humans. 

Study of Post War Mortality from Neurological Disease in Gulf War Veterans: 

The original study of Post War Mortality from Neurological Disease in Gulf War

Veterans is complete. VA is funding $125,000 for additional study, with results 

expected in 2013. The study is currently contacting next of kin of decedents to obtain 

permission for medical record retrieval and collecting medical records for analysis.

Follow-up study of an established permanent panel of 30,000 deployed and nondeployed Veterans from the 1990 – 1991 Gulf War period:

Baseline and follow-up data have been previously collected (1995 and 2005). This 

study will examine health trends over time and the current status of the health of 1990 –

1991 Gulf War Veterans. A study proposal has been prepared and approved by the DC 

VAMC IRB. An Office of Management and Budget (OMB) justification package has 

been submitted through the VHA OMB liaison and the 60-day Federal Register Notice 

“Comment Request” was published. The cost of this surveillance initiative is estimated 

to be approximately $2.0 million. The contract has been awarded and study procedures 

are under development. Completion of data collection is planned for 2013, and results 

should be available for publication in late 2013 or 2014.
34

Depleted Uranium (DU) Surveillance:

The purpose of the DU Surveillance program is to determine DU-related health effects 

in exposed soldiers and to study the medical and surgical management of fragments.

3,192 urine samples have been screened for DU with four Veterans found to have a 

positive screen. The 79 Veterans with documented DU exposure have been followed 

every 2 years since 1993. Veterans travel to the Baltimore VAMC and have had a 

complete medical examination with extensive laboratory studies to include urine, semen 

and blood uranium, chromosomal analysis, and neurocognitive testing.

Results: Subtle effects on bone metabolism and kidney filtration have been detected but 

no clinical diseases have yet been attributed to DU. This well established program is 

now evaluating new Veterans from current conflicts. It is vitally important that clinical 

providers are aware of this program and understand how to refer Veterans, or Veterans 

know to request referrals if they are aware of exposure to DU.

Toxic Embedded Fragment Surveillance Center (TEFSC) and Registry:

As many as 40,000 Veterans may have retained fragments secondary to being exposed 

to explosions. The TEFSC was established to create a registry of wounded Veterans 

with retained fragments; determine fragment composition, provide biomonitoring 

services (via mail), assist in medical and surgical management guidelines for Veterans 

with fragments, and provide consultation to local providers concerning care and 

management of patients. As with the DU program described above, the key to this 

successful program is wide dissemination of knowledge of this resource among clinical 

providers and Veterans.

Qarmat Ali Medical Surveillance Program:

Although this surveillance program focuses on environmental exposure during 

Operation Iraqi Freedom (OIF), it is noted here because it is a first effort to 

systematically monitor the health of a group of deployed personnel post-exposure 

through a well-defined medical surveillance program. In July 2010 VA started 

contacting affected Veterans by phone and offered enrollment in the Qarmat Ali medical 

surveillance program. This initial phone contact was followed by a letter signed by both 

Secretary Shinseki and Secretary Gates. Currently, 794 out of a possible 830 Veterans 

have been contacted either by letter or phone. Inevitably some addresses are out of 

date and VA and DoD are continuing to find addresses and contact all remaining 

Qarmat Ali Veterans. To date, 135 Veterans have obtained medical surveillance 

exams. Medical exams will be repeated every five years to monitor the health of each 

Veteran exposed to chromium.
35

Plan:

Centers for Disease Control and Prevention/National Center for Health Statistics:

The studies associated with the CDC/NCHS collaboration are intended to continue for 

as long as the CDC/NCHS maintain their efforts in this area. 

Veteran-specific findings from NHIS and NHANES should be available in the fourth 

quarter of 2012. This is a function of resources and the need to accumulate sufficient 

numbers of subjects who are Veterans in order to accomplish meaningful statistical 

analyses.

Millennium Cohort Study (MCS) was initiated in 2001 and is scheduled to continue 

until 2022. VA plans to continue to examine Veteran-specific data related to health 

outcomes through the end of the study.

The National Health Study for a New Generation of U.S. Veterans was funded 

through its first iteration. VA is planning to repeat the study, contingent on resources, at 

three year intervals.

Military Working Dog Studies are at present a feasibility study designed to determine 

the value of examining MWD health records for adverse health effects and the utility of 

using MWDs as a sentinel population for human health. Whether or not this effort 

continues will be dependent on the value of the data collected for this purpose and the 

availability of resources.

The Study of Post-War Mortality from Neurological Disease in Gulf War Veterans

is a follow-up study. The study is the second iteration of this effort. We plan to continue 

this study at approximately five year intervals as findings suggest and resources are 

available.

Depleted Uranium Surveillance is a long-term surveillance effort. These Veterans will 

be followed for years to monitor their health and newly identified Veterans will be 

brought into the program as they are identified. Information gleaned from the program 

will identify long-term sequelae if they occur, help to identify treatment if appropriate, 

and inform prevention strategies where applicable.

The TEFSC will continue to determine fragment composition, provide biomonitoring

services (via mail), assist in medical and surgical management guidelines for Veterans 

with fragments, and provide consultation to local providers concerning care and 

management of patients. New Veterans will be enrolled in the Registry as required.

The Qarmat Ali Medical Surveillance program will monitor the health of the Veterans 

for decades. Additionally, the program itself, established as a new way to monitor the 

health of Veterans potentially exposed to an environmental toxicant during deployment, 

will be evaluated as a possible way to address future exposure related concerns.
36

Metrics and Accountability:

These studies are longitudinal and long-term by design. Where reasonable for each 

study, date of availability of results serves as the essential metric. It is worth noting that 

these dates are estimates as the study process is dependent on contracting, availability 

of resources, and other factors that are often beyond the control of the study 

proponents. 

Results of studies will be presented in peer-reviewed publications and data will be 

presented in appropriate scientific and other forums, informing Veterans and the public 

of study results, ensuring that study findings are considered in discussions of 

presumption of service connection as appropriate, and informing Congress of new 

information related to the health of Veterans post-deployment.

The goal is greater than 98 percent contact rate for all Qarmat Ali Veterans and 100

percent contact rate to remind Veterans of every five year exams. For all surveillance 

programs, VA will initiate the appropriate treatment and prevention strategies and inform

research strategies as indicated by the information being collected.
37

Research and Development: Encouraging Targeted Efforts

Background:

ORD funds research that will further the goal of improving the health and lives of 

Veterans who have GWVI, which refers to the complex of chronic symptoms that affects

Veterans of the 1990-1991 Gulf War at an excess rate. The illnesses are characterized 

by persistent symptoms such as chronic headache, chronic widespread pain, cognitive 

difficulties, unexplained debilitating fatigue, gastrointestinal problems, respiratory 

symptoms, subtle neuropsychological symptoms, and other abnormalities that are not 

explained by familiar medical or psychiatric diagnoses. Particular areas of interest 

include studies that can improve diagnostic testing for GWVI and/or understanding of its 

pathobiology. These include research on objective indicators of biological processes or 

abnormalities in GWVI. ORD also funds controlled clinical trials and epidemiological 

investigations of the effectiveness of new pharmacological or non-pharmacological 

treatments for GWVI. In addition, ORD is committed to funding research that improves

VA’s understanding and ability to treat illnesses, such as Amyotrophic Lateral Sclerosis 

(ALS) and Multiple Sclerosis (MS), which may occur at higher prevalence in Gulf War

Veterans.

Current Efforts:

Maintain and Promote a Robust Gulf War Research Portfolio:

ORD has improved its focus on Gulf War related research. Staffing for the Gulf War

research portfolio has been addressed this year to provide more dedicated personnel. 

Dr. Robert Jaeger has been named as the Director of Deployment Health Research. 

Additionally, Dr. Victor Kalasinsky was hired to serve as the Program Manager position 

for the GWVI/Military Environmental Exposures (MEE) research portfolio, a new 

addition to the ORD staff. 

The VA Gulf War Program Manager presents the VA Gulf War research portfolio as part 

of the annual vision setting meeting for the Gulf War Illnesses Research Program 

(GWIRP) within the Congressionally Directed Medical Research Program (CDMRP), 

managed by DoD. The scope of the VA Gulf War research portfolio (types of projects 

funded as well as specifics about individual funded projects) and all upcoming Requests 

for Applications (RFAs) are discussed at this meeting. This allows VA and CDMRP to 

maintain coordination between their respective Gulf War research programs.

The VA Gulf War research portfolio (and the GWIRP research portfolio) are presented 

and discussed at one or more of the three annual meetings of the VA Research 

Advisory Committee on Gulf War Veterans’ Illnesses (RACGWVI). This allows the 

RACGWVI to maintain its understanding of the activities within each agency’s Gulf War

research program so that appropriate recommendations may be formulated. The listing 

of the membership of the RACGWVI is available in Appendix C.
38

Representatives from the GWIRP are invited to present at VA Gulf War Steering 

Committee meetings so that the Committee is aware of the scope and potential overlap 

between the VA and DoD programs. This will allow the Steering Committee to 

recommend changes to the Gulf War Research Strategic Plan as needed. A listing of 

the membership of the Gulf War Steering Committee is available in Appendix D.

New Strategic Plan for Gulf War Research:

The Gulf War Steering Committee met on April 20, 2011, to develop a new Strategic 

Plan for VA Gulf War Research. A Draft Strategic Plan was prepared and has been 

reviewed by the Steering Committee Chair and his initial comments/suggestions were 

incorporated. The intent of the Gulf War Research Strategic Plan is to complement the 

existing VA Research and Development Strategic Plan, which is the strategic plan for all 

research in ORD. 

The draft Gulf War Research Strategic Plan was distributed to members of both the Gulf 

War Steering Committee and RACGWVI in advance of the June 27-28, 2011 meeting of 

the RACGWVI. Copies of the draft Strategic Plan were also made available to the 

public audience at the meeting and are available at the link below:

http://www.va.gov/RACGWVI/docs/Minutes_and_Agendas/Presentations_June2011_AppendixB_DRAFTGulfW

arStrategicPlanJune21forRACGWVI.doc.

The Steering Committee Chair presented the draft Strategic Plan and led the discussion

at the June 27-28, 2011 meeting of the RACGWVI. The Steering Committee Chair will 

continue to lead the effort to complete the Strategic Plan; the process will involve 

members of both the Steering Committee and the RACGWVI.

Public Comment Feedback:

There were comments questioning the value of the VA research that has been 

accomplished, the availability of research results, modifications in the ways that VA 

research projects are designed, and whether or not more research needs to be done. 

Many of the comments questioned the effectiveness of the two decades of VA 

supported research in general while others addressed specific research topics such as 

Anthrax Vaccine and Pyridostigmine Bromide Tablets. While VA research has led to 

effective treatments and supported decisions to add conditions to the regulations 

regarding Gulf War disabilities, efforts continue to refine and expand understanding in 

this arena. 

The vast body of VA research findings related to Gulf War Veterans’ illnesses is either 

published in the open scientific literature (accessible through the National Library of 

Medicine, http://www.ncbi.nlm.nih.gov/pubmed), in government reports (available 

through the individual agencies or the Government Printing Office), in annual reports to 

Congress 

(http://www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf%20W

ar%20Reports), or on the VA website (http://www.research.va.gov/resources/pubs/). 
39

The annual report to Congress includes lists of abstracts and the amounts of funding 

provided by DoD, HHS, and VA. VA makes a concerted effort to make research results 

available and to coordinate with DoD to ensure that high-quality research is being 

conducted. The research funded by VA includes basic mechanistic research into a 

disease process, clinical trials for promising new treatments, and everything in between. 

In addition, the Institute of Medicine (IOM) of the National Academies publishes reports 

which are reviews of medical and scientific research results 

(http://www.iom.edu/Reports/). 

Veterans who display symptoms associated with the recognized terminology of Gulf 

War Veterans’ are often tested in VA Medical Centers as suggested in the online 

comments. However, it is typically not effective to do extensive tests on Veterans who 

do not have any symptoms. Similarly, there were suggestions that VA simply label the 

medical problems of Gulf War Veterans as a single new disease. These calls have 

been raised since Gulf War Veterans were first recognized to be suffering following their 

service. The fact that there are so many symptoms and so many people with different 

sets of symptoms make it difficult to understand how there can be a single condition 

affecting everyone. This is the reason that VA has referred to Gulf War Veterans’ 

“illnesses” rather than “illness” or “syndrome.” Grouping patients together without a 

solid medical rationale is difficult to justify.

There were many possible environmental/military exposures (more than thirty are listed 

in the on-line comments to the GWVI Task Force Report) in Southwest Asia. As 

mentioned above, many comments expressed concerns over specific exposures to 

Anthrax vaccine and Pyridostigmine Bromide (PB).

There has been considerable research into the anthrax vaccine. Any adverse reactions 

to a vaccine must be reported to the FDA where they are evaluated and a determination 

is made as to whether some action should be taken. With the anthrax vaccine, there 

was FDA action concerning the potency of the vaccine and its ability to provide 

adequate protection from anthrax. There were not concerns about toxicity, and the 

anthrax vaccine was FDA approved. The toxicity issue with the anthrax vaccine relates 

to specific production lots of vaccine which reportedly contained squalene as part of the 

adjuvant. The original results which indicated that squalene may have caused adverse 

reactions could not be replicated in other laboratories, so the question of squalene 

toxicity has become less of an issue with respect to Gulf War Veterans’ illnesses.

Pyridostigmine bromide (PB) was given FDA approval for use by the military during 

combat situations as a protectant against nerve agents. It was approved for used in 

patients with a condition called “myasthenia gravis” since the 1950s, and it is currently 

(within the last 10 years) also used to treat orthostatic hypotension.

Even though the anthrax vaccine and PB are FDA approved, this does not guarantee 

that some individuals would not have adverse reactions to them. To test this possibility 

with PB, there are research projects currently underway designed to study the effects of 

PB in combination with other materials that Gulf War Veterans were exposed to. VA is 
40

not currently funding any studies of the anthrax vaccine because there does not appear 

to be a reason to do so. However, if a researcher proposes a study of the anthrax 

vaccine, PB, or any other material and is able to show that the planned study has 

scientific merit, ORD will consider providing the necessary research funds.

VA recognizes that more research into the medical problems facing Gulf War Veterans 

is necessary. Future research directions are influenced by past research results. The 

strategic planning efforts described below demonstrate the VA’s continuing commitment 

to finding answers for Gulf War Veterans.

Plan:

Gulf War Research Portfolio:

Investigator Initiated Gulf War Research

ORD has re-issued the three previous RFAs, (solicitations for submission of research 

proposals), and issued two new RFAs to specifically solicit pilot project applications. 

Both the Gulf War Steering Committee and RACGWVI have concurred on issuing/reissuing these RFAs.

The lists of topics of interest for these RFAs incorporate over 80 percent of the research 

recommendations contained in the 2008 report from the RACGWVI and direct 

RACGWVI input to ORD. These lists are also fully aligned with the major elements of 

the draft Strategic Plan for Gulf War Research that the Chair of the Gulf War Steering 

Committee presented to the RACGWVI.

Service-Directed Gulf War Research

Two major service-directed Gulf War research projects are in development as elements

of new research infrastructure ORD is creating to further the ability of investigators to do 

Gulf War research. A limiting factor on the ability to do clinical trials and other 

investigative studies on this population of Veterans has been the availability of research 

subjects in sufficient quantity.

Gulf War Era Cohort and Blood Biorepository (CSP585)

VA is developing a pilot project to enroll Gulf War-era Veterans from across the U.S.

into a new longitudinal cohort, regardless of where they receive their health care (i.e., 

users and non-users of the VA Health Care System).

This new study will include questionnaires on health care utilization and symptoms. GW 

Veterans who agree to participate will also agree to be contacted about participating in 

other GW studies. The cohort will be a resource for other investigators to utilize; no 

research will be done at this time on the blood samples of Veterans enrolled in the 

cohort.
41

A Genome Wide Association Study (GWAS), which was originally planned to be 

included in this study, was removed during the final design of the project. The GWAS 

will be developed later as a separate project after the cohort is recruited.

Gulf War Biorepository Trust (CSP 501B)

Although the RACGWVI recommended that this project not be funded, ORD is moving 

forward with development of the Gulf War Biorepository Trust, a tissue repository and 

DNA bank for full autopsy collection of tissues from Gulf War Veterans from across the 

U.S.

This is an extension of the Gulf War brain and DNA bank for Veterans with ALS, which 

is now in full operation. The lessons learned in establishing this tightly focused tissue 

bank and collecting material from Veterans with ALS from across the U.S. was critical in 

designing the more generalized tissue bank.

The investigators are preparing to submit the protocols to their local IRB for approval. 

They are working with ORD to develop the outreach plan and “message” to announce 

the roll-out of this new program to collect autopsy material from Gulf War Veterans from 

across the country. 

Metrics and Accountability:

The VA Gulf War Program Manager presents the VA Gulf War research portfolio as part 

of the annual vision setting meeting for the GWIRP within the CDMRP, managed by 

DoD. The scope of the VA Gulf War research portfolio (types of projects funded as well 

as specifics about individual funded projects) and all upcoming RFAs are discussed at 

this meeting. This allows VA and CDMRP to maintain coordination between their 

respective Gulf War research programs.

The VA Gulf War research portfolio, and the GWIRP research portfolio, are presented 

and discussed at one or more of the three annual meetings of the VA RACGWVI. This 

allows the RACGWVI to maintain its understanding of the activities within each 

Department’s Gulf War research program so that appropriate recommendations may be 

formulated.

Representatives from the GWIRP are invited to present at VA Gulf War Steering 

Committee meetings so that the Committee is aware of the scope and potential overlap 

between the VA and DoD programs. This will allow the Steering Committee to 

recommend changes to the Gulf War Research Strategic Plan as needed.

VA is the lead agency for preparing the Annual Report to Congress on Federally 

Sponsored Research on Gulf War Veterans’ Illnesses that is required by § 707 of Public 

Law 102-585, as amended by § 104 of Public Law 105-368 and § 502 of Public Law 

111-163. The report focuses on the results, status, and priorities of research activities 

related to the health consequences of military service in the Gulf War (Operations 
42

Desert Shield and Desert Storm; August 2, 1990 – July 31, 1991). The 2010 Annual 

Report to Congress was released in late October, 2011. The 2009 Annual Report to 

Congress was published in August 2010 and can be found at: 

http://www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf%20Wa

r%20Reports.
43

APPENDIX A – Veterans Affairs GWVI Research

Fiscal Year VA* UTSW Contract** DoD* HHS* FY Total

1994 $ 1,157,879 $ - $ 6,492,882 $ - $ 7,650,761

1995 $ 2,334,083 $ - $ 10,973,000 $ 2,514,762 $ 15,821,845

1996 $ 3,853,095 $ - $ 11,905,214 $ 1,616,755 $ 17,375,064

1997 $ 2,834,790 $ - $ 28,880,536 $ - $ 31,715,326

1998 $ 4,722,820 $ - $ 13,213,232 $ 1,634,347 $ 19,570,399

1999 $ 9,006,155 $ - $ 22,674,338 $ 1,640,378 $ 33,320,871

2000 $ 12,020,519 $ - $ 23,847,679 $ 1,567,439 $ 37,435,637

2001 $ 8,576,675 $ - $ 31,587,006 $ 998,870 $ 41,162,551

2002 $ 4,512,676 $ - $ 18,827,819 $ 799,814 $ 24,140,309

2003 $ 5,746,467 $ - $ 16,419,497 $ 964,105 $ 23,130,069

2004 $ 7,644,560 $ - $ 11,096,063 $ 466,126 $ 19,206,749

2005 $ 9,484,679 $ - $ 10,091,848 $ 466,481 $ 20,043,008

2006 $ 13,013,552 $ - $ 10,128,261 $ 455,587 $ 23,597,400

2007 $ 6,977,767 $ 15,000,000 $ 3,417,570 $ 441,974 $ 25,837,311

2008 $ 7,059,242 $ 15,000,000 $ 11,672,967 $ 433,467 $ 34,165,676

2009 $ 9,628,318 $ 6,972,481 $ 10,380,423 $ - $ 26,981,222

2010 $ 11,567,997 $ 2,288,755 $ 3,145,000 $ - $ 17,001,752

Total

1994 - 2010 $ 120,141,274 $ 39,261,236 $ 244,753,335 $ 14,000,105 $ 418,155,950

** Funds obligated for reimbursement to UTSW at completion of contracted work on individual task orders

* Funds expended to support Gulf War research projects

The VA expenditure for FY10 includes 40% of MRI imaging equipment upgrade at San Francisco for Gulf War research and 

use of unobligated FY2009 UTSW Contract funds for close-out costs of approved task orders and data transfer costs. VA 

expenditures for FY 2011 are currently being collected and validated and were not available for this report.
44

APPENDIX B – Draft Gulf War Veterans Illnesses Provider Pocket 

Guide
45
46

APPENDIX C – Research Advisory Committee for Gulf War Veterans’

Illnesses

CHAIRPERSON

James H. Binns

2398 East Camelback Road, Suite 280

Phoenix, AZ 85016

SCIENTIFIC DIRECTOR

Roberta F. White, Ph.D.

Chair, Department of Environmental 

 Health

Professor, Environmental Health

Boston University School of Public Health

715 Albany St., T2E

Boston, MA 02118

MEMBERS

Carrolee Barlow, M.D., Ph.D.

Chief Scientific Officer, BrainCells, Inc.

3565 General Atomics Court, Suite 200

San Diego, CA 92121

Floyd E. Bloom, M.D.

Professor Emeritus

Molecular & Integrative Neuroscience 

 Department

The Scripps Research Institute

10550 North Torrey Pines Rd., SP-102

La Jolla, CA 92037

Dedra S. Buchwald, M.D.

Professor, Department of Medicine 

Director, University of Washington Twin 

 Registry

Director, Center for Clinical and 

 Epidemiological Research

University of Washington

1730 Minor Avenue, Suite 1760

Seattle, WA 98101

Beatrice A. Golomb, M.D., Ph.D. 

Associate Professor of Internal Medicine

University of California, San Diego

9500 Gilman Drive 0995

La Jolla, CA 92093-0995

Marguerite L. Knox, MN, ANP-ACNP

SCARING, Medical Detachment

1325 South Carolina National Guard Road

Eastover, SC 29044

William J. Meggs, M.D., Ph.D.

Chief, Division of Toxicology

Dept. of Emergency Medicine, 3ED311

The Brody School of Medicine

East Carolina University School of 

Medicine.

Greenville, NC 27858-4354

James P. O'Callaghan, Ph.D.

Head, Molecular Neurotoxicology

CDC Distinguished Consultant

Toxicology & Molecular Biology Branch 

(MS-3014)

Health Effects Laboratory Division

Centers for Disease Control and 

Prevention - NIOSH

1095 Willowdale Road

Morgantown, WV 26505-2888

Lea Steele, Ph.D.

Institute of Biomedical Studies

Baylor University

One Bear Place, Box 97224

Waco, TX 76798
47

Joel C. Graves, DMin

Lacey, WA 

Anthony Hardie 

Madison, WI 

LTC Adam A. Such

Chandler, AZ 

CONSULTANT TO THE COMMITTEE 

Jack Melling, Ph.D.

Consultant, U.S. Government Accountability Office

1 Folly Close

Salisbury

Wiltshire SP2 8BU

Great Britain
48

APPENDIX D – Gulf War Steering Committee Members

CHAIRPERSON

L. Maximilian Buja, M.D.

Executive Director

Houston Academy of Medicine - Texas Medical Center Library

1133 John Freeman Blvd.

Houston, Texas 77030-2809

MEMBERS

David Christiani, M.D., MPH

Harvard School of Public Health and 

Harvard School of Medicine

665 Huntington Avenue

Building I Room 1407

Boston, Massachusetts 02115

Tilo Grosser, M.D.

Institute for Translational Medicine and 

Therapeutics

University of Pennsylvania

809 Biomedical Research Building II/III

421 Curie Blvd

Philadelphia, PA 19104

Anthony Hardie

Madison, WI 

Loren Koller

Corvallis, Oregon 

James O’Callaghan, Ph.D.

CDC-NIOSH

1095 Willowdale Road

Morgantown, WV 26505

Roberta White, Ph.D.

Professor and Chair, Department of 

Environmental Health Associate Dean for 

Research 

Boston University School of Public Health

715 Albany St.-Talbot 4W

Boston, MA 02118

Richard Wenzel, M.D., MSc

Professor and Chair, Department of 

Internal Medicine

VCU Medical Center

1001 E. Board St. Old City Hall

BOX 980663

Richmond, VA 23284

Robert Kelch, M.D.

South Haven, MI 
49

APPENDIX E – Gulf War Veterans’ Illnesses Task Force Members

CHAIRPERSON

John Gingrich

Chief of Staff

Department of Veterans Affairs

MEMBERS

Mr. Thomas Murphy

Director, Compensation Service

Veterans Benefits Administration

Mr. Kerry Baker 

Chief of Legislative Staff, Compensation 

 Service

Veterans Benefits Administration

Mr. Brad Flohr

Assistant Director for Policy, 

 Compensation Service

Veterans Benefits Administration

Ms. Susan Schiffner

Health Science Specialist

Veterans Health Administration

Dr. Joel Kupersmith

Chief, Office of Research & Development

Veterans Health Administration

Dr. William Goldberg

Scientific Program Manager

VHA, Office of Research & Development

Dr. Robert Jaeger

Director, Deployment Health Research

VHA, Office of Research & Development

Dr. Victor Kalasinsky 

Program Manager, Gulf War Veterans’ 

 Illnesses

VHA, Office of Research & Development

Dr. Robert Jesse

Principal Deputy Undersecretary for 

Health

Veterans Health Administration

Dr. George Arana

Asst. Deputy Undersecretary for Health for 

Clinical Operations

Veterans Health Administration

Dr. Gavin West

Chief, Primary Care

Salt Lake City VAMC

Dr. Stephen Hunt

Persian Gulf Registry Physician

Puget Sound Healthcare System 

Mr. Carroll Montalva

VA Office of Policy and Planning

Dr. Michael Peterson 

Chief Consultant, 

Post Deployment Health,

VHA, Office of Public Health

Dr. Terry Walters

Deputy Chief Consultant,

Post Deployment Health,

VHA, Office of Public Health
50

Dr. Victoria Cassano

VHA, Disability & Medical Assessment

Ms. Connie Raab

Director, Public Health Communications

VHA, Office of Public Health

Ms. Jan Northstar

Interim Director, National Veterans 

 Outreach Center

VA Office of Public and Intergovernmental 

 Affairs

ADMINISTRATIVE SECRETARY

COL John Kent

Special Assistant to the Secretary

Office of the Secretary of Veterans Affairs

COL Jeffrey Peters

Special Assistant to the Secretary

Office of the Secretary of Veterans Affairs

CONSULTANTS TO THE COMMITTEE 

Mr. John Spinelli

Senior Advisor

Office of the Secretary of Veterans Affairs

Mr. Kevin Secor

VSO Liaison

Office of the Secretary of Veterans Affairs

Mr. Carter Moore

VA Office of Congressional and 

 Legislative Affairs
51

APPENDIX F – GWVI Web sites and Links

Gulf War Veterans' Illnesses Web site

Veterans Health Administration

Department of Veterans Affairs

(http://www.publichealth.va.gov/exposures/gulfwar/)

Caring for Gulf War Veterans

This study guide provides an overview of Gulf War experience, the Department of 

Veterans Affairs and the Department of Defense health programs available for Gulf War 

Veterans, and the common symptoms and diagnoses of these Veterans. Emphasis is 

placed on providing the most recent information from clinical and scientific studies of 

Gulf War Veterans’ illnesses.

http://www.publichealth.va.gov/docs/vhi/caring-for-gulf-war-veterans-vhi.pdf

Environmental Health Clinicians and Coordinators

Veterans Health Administration

Department of Veterans Affairs

http://www.publichealth.va.gov/exposures/coordinators.asp

War Related Illness and Injury Study Center (WRIISC)

The War Related Illness and Injury Study Center (WRIISC) is a National VA PostDeployment Health Resource, focused on the post deployment health concerns of 

Veterans and their unique health care needs. The WRIISCs develop and provide postdeployment health expertise to Veterans and their health care providers through clinical 

programs, research, education, and risk communication.

http://www.warrelatedillness.va.gov/WARRELATEDILLNESS/index.asp

Gulf War Veterans Report: Pre 9/11

The purpose of this report is to provide comprehensive statistics on the utilization of VA 

benefits and healthcare services by Gulf War Era Veterans from the Pre-9/11 Period 

(August 2, 1990 to September 10, 2001).

(http://www.va.gov/vetdata/docs/SpecialReports/GW_Pre911_report.pdf)

Research Advisory Committee on Gulf War Veterans' Illnesses 

The mission of the Committee is to make recommendations to the Secretary of 

Veterans Affairs on government research relating to the health consequences of military 

service in the Southwest Asia Theater of operations during the Persian Gulf War.

http://www.va.gov/rac-gwvi/

Gulf War Veterans Illnesses Research and Development Strategic Plan

http://www.va.gov/RACGWVI/docs/Minutes_and_Agendas/Presentations_June2011_AppendixB_DRAFTGulfW

arStrategicPlanJune21forRACGWVI.doc
52

Federally Sponsored Research on Gulf War Veterans' Illnesses

2009 Annual Report to Congress 

http://www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf%20Wa

r%20Reports.

(Note: The 2010 Annual Report to Congress has been submitted for VA concurrence 

and will be submitted to DoD for interagency concurrence for publication in 2011.)