United States General Accounting Office

GAO Testimony

Before the Subcommittee on Human Resources,

Committee on Government Reform and Oversight, House

of Representatives

For Release on Delivery

Expected at

10:00 a.m., EST

Tuesday,

February 24, 1998

GULF WAR ILLNESSES

Federal Research Strategy

Needs Reexamination

Statement of Donna Heivilin, Director of Planning and

Reporting, National Security and International Affairs

Division

GAO/T-NSIAD-98-104

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss our evaluation of the federal

strategy to research Gulf War illnesses. We reported our findings on this

strategy in June 1997 as part of our response to a congressional mandate

regarding the government’s clinical care and medical research programs

relating to illnesses suffered by Gulf War veterans.1

 I will first summarize

our findings and provide some background information on the

government’s research program before giving you the details on our

findings.

Results in Brief In short, we found that

(1) the government was not proactive in researching Gulf War illnesses;

(2) the government’s early research emphasized stress as a cause for Gulf

War veterans’ illnesses and gave other hypotheses, such as multiple

chemical sensitivity, little attention;

(3) in contrast, the private sector pursued research on the health effects of

low-level exposures to certain chemical warfare agents or industrial

chemical compounds;

(4) government research used an epidemiological approach, but little

research on treatment was funded; and

(5) most of the ongoing epidemiological research focusing on the

prevalence or causes of Gulf War-related illnesses will not provide

conclusive answers, particularly in identifying risk factors or potential

causes due to formidable methodological and data problems.

Background U.S. troops were reportedly exposed before, during, and after the Gulf War

to a variety of potentially hazardous substances. These substances include

decontaminating and protective compounds used without proper

safeguards (particularly decontaminating solution 2, or DS2, and chemical

agent resistant coating); diesel fuel used as a sand suppressant in and

around encampments, fuel oil used to burn human waste; fuel in shower

water; and leaded vehicle exhaust used to dry sleeping bags. Other

1

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

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

Page 1 GAO/T-NSIAD-98-104 Gulf War Illnesses
potential hazards included infectious diseases (most prominently

leishmaniasis, a parasitic infection); pyridostigmine bromide and vaccines

(to protect against chemical and biological weapons); depleted uranium

(contained in certain ammunition and in residues from the use of this

ammunition); pesticides and insect repellents, chemical and biological

warfare agents; and compounds and particulate matter contained in the

extensive smoke from the oil-well fires at the end of the war. Over 100,000

of the approximately 700,000 Gulf War veterans have participated in health

examination programs that the Department of Defense (DOD) and the

Department of Veterans Affairs (VA) established between 1992 and 1994. Of

those veterans examined by DOD and VA, nearly 90 percent have reported a

wide array of health complaints and disabling conditions, including

fatigue, muscle and joint pain, gastrointestinal complaints, headaches,

depression, neurologic and neurocognitive impairments, memory loss,

shortness of breath, and sleep disturbances. Some of the veterans fear that

they are suffering from chronic disabling conditions because of exposure

during the war to substances with known or suspected health effects.

The federal government, primarily through DOD and VA, has sponsored a

variety of research on Gulf War veterans’ illnesses. DOD’s research is one

component of a broader agenda coordinated under the aegis of the Persian

Gulf Veterans’ Coordinating Board (PGVCB), which comprises the

Secretaries of the Department of Health and Human Services, VA, and DOD.

The details of this agenda are described in the PGVCB publication entitled 

A Working Plan for Research on Persian Gulf Veterans’ Illnesses.

2

 This

agenda was developed in response to an Institute of Medicine conclusion

that the DOD and VA should determine specific research questions that need

to be answered and design epidemiologic research to these questions.

Accordingly, most of the research sponsored under this agenda is

characterized by PGVCB as epidemiological.

The objectives of epidemiologic research are to determine the extent of

diseases and illness in the population or subpopulations, the causes of

disease and its modes of transmission, the natural history of disease, and

the basis for developing preventive strategies or interventions.3

 To

conduct such research, investigators must follow a few basic generally

accepted principles.

2

A Working Plan for Research on Persian Gulf Veterans’ Illnesses (First Revision), Department of

Veterans Affairs, November 1996.

3

A. M. Lilienfeld and D. E. Lilienfeld, Foundations of Epidemiology (New York: Oxford University

Press, 1980).

Page 2 GAO/T-NSIAD-98-104 Gulf War Illnesses
First, they must specify diagnostic criteria to (1) reliably determine who

has the disease or condition being studied and who does not and (2) select

appropriate controls (people who do not have the disease or condition).

Second, the investigators must have valid and reliable methods of

collecting data on the past exposure(s) of those in the study and possible

factors that may have caused the symptoms. The need for accurate,

dose-specific exposure information is particularly critical when low-level

or intermittent exposure to drugs, chemicals, or air pollutants is possible.

It is important not only to assess the presence or absence of exposure but

also to characterize the intensity and duration of exposure. To the extent

that the actual exposure of individuals is misclassified, it is difficult to

detect any effects of the exposure. Another means of linking

environmental factors to disease is to determine whether or not evidence

shows that as the exposure increases, the risk of disease also increases.

However, this dose-response pattern can be detected only if the degree of

exposure among different groups can be determined.

Finally, in addition to specific case definition and dose-specific exposure

information with known accuracy, it is important that a sufficient number

of persons be studied to have a reasonable likelihood of detecting any

relationship between exposures and disease. To the extent that this

relationship is subtle or obscured in particular investigations by “loose”

case definition (that is, a case definition that is too broad and

encompasses different types of illnesses) or problems in measuring

exposure, larger samples would be required. For example, the Institute of

Medicine noted that “very large groups must be studied in order to identify

the small risks associated with low levels of exposure, whereas a relatively

small study may be able to detect the effect of heavy or sustained

exposure to a toxic substance. In this way, a study’s precision or statistical

power is also linked to the extent of the exposure and the accuracy of its

measurement. Inaccurate assessment of exposure can obscure the

existence of such a trend and thus make it less likely that a true risk will

be identified.”4

 Similarly, if an exposure had an effect only on a particular

birth defect for example, this effect might be missed by studying all birth

defects as a group.

4

Veterans and Agent Orange: Update 1996 (Washington, D.C.: Institute of Medicine, 1996), pp. 99-100.

Page 3 GAO/T-NSIAD-98-104 Gulf War Illnesses
Government Was Not

Proactive in

Researching Causes

of Gulf War Veterans’

Illnesses

Although Gulf War veterans’ health problems began surfacing in the early

1990s, the vast majority of research was not initiated until 1994 or later.

And much of that research responded to legislative requirements or

external reviewers’ recommendations. As noted by external reviewers,

since federal research goals and objectives were not identified until 1995,

after most research activities had been initiated, the research reflects a

rationalization of ongoing activity rather than a research management

strategy.

The government’s 3-year delay complicated the researchers’ tasks and

limited the amount of completed research available. Of the 91 studies

receiving federal funding, over 70 had not been completed at the time of

our review. The results of some studies will not be available until after

2000.

By the time research was accelerated and broadened, opportunities had

been missed to collect critical data that researchers cannot accurately

reconstruct. Even efforts to measure the chemical content of the oil-fire

smoke, begun only 2 months after the fires began burning, were initiated

after most troops had left the affected areas and the climatological

dynamics were different. Consequently, researchers had to use statistical

models of the behavior of smoke plumes in order to infer the ground-level

exposures experienced by the large numbers of troops who had departed

by the time they began collecting data. Even if such models could

accurately explain the behavior of the smoke plumes, they had not been

validated as measures of individual exposure, and their accuracy for this

purpose could not be presumed. Similar and even more serious problems

were caused in the measurement of other exposures by the failure to

collect data promptly and maintain adequate records.5

The delay in starting research has also hindered accurate reporting of

exposures by Gulf War veterans. At the time of our review, 6 years after

the war ended, questionnaires were being distributed requesting

information from veterans on their exposures to certain agents during the

war.

5

See Defense Health Care: Medical Surveillance Has Improved Since the Gulf War, but Results in

Bosnia Are Mixed (GAO/NSIAD-97-136, May 13, 1997) and Institute of Medicine, Health Consequences

of Service During the Persian Gulf War: Recommendations for Research and Information Systems, p. 5

(Washington, D.C.: National Academy Press), 1996.

Page 4 GAO/T-NSIAD-98-104 Gulf War Illnesses
Initial Government

Research Emphasized

Stress; Other

Hypotheses Were Not

Pursued Until Later

Early federal research appeared to emphasize risks associated with

psychological factors such as stress. To support this emphasis, DOD

pointed out that the psychological state of mind can influence physical

well-being. DOD also pointed to a recent argument that from the American

Civil War onward (and perhaps even earlier), a small number of veterans

have reacted to the stress of war by suffering symptoms similar to those

reported by some Gulf War veterans.6

Of the 19 studies initiated before 1994, roughly half focused on exposures

to stress or the potential for posttraumatic stress disorder (PTSD) among

returning troops.7

 As late as December 1996, the Presidential Advisory

Committee noted that “stress is the risk factor funded for the greatest

fraction of total - 32 studies (30 percent).”8

While research on exposures to stress received early emphasis, other

hypotheses have received scant support. In its Final Report, the Institute

of Medicine discusses the evidence for a number of disease hypotheses,

including multiple chemical sensitivity, fibromyalgia, and

organophosphate-induced delayed neuropathy. However, the federal

research program has supported only one study of the relationship

between symptoms reported by veterans and fibromyalgia. In addition,

prior to October 1996, only one of the studies initiated in response to Gulf

War veterans’ illnesses focused on the health effects of potential

exposures to chemical warfare agents.9

 While multiple studies of the role

of stress in the veterans’ illnesses have been supported with federal

research dollars, other hypotheses have been pursued largely outside the

federal research program.

Although veterans raised concerns about potential chemical exposures

soon after the war, the federal research plan was not modified to include

an investigation of these concerns until 1996, when DOD acknowledged

potential exposures to chemical agents at Khamisiyah, Iraq. The failure to

6

K.C. Hyams et al., “War Syndromes and Their Evaluation: From Civil War to the Persian Gulf War,”

Annals of Internal Medicine, vol. 125 (1996), pp. 398-405.

7

An additional 3 of the 19 studies did not provide information about veterans’ illnesses but were

instead building databases or methods to be used in later studies. Notably, according to PGVCB, none

of these three studies had been completed as of June 1997.

8

Presidential Advisory Committee on Gulf War Veterans’ Illnesses, Final Report, p. 34 (Washington

D.C.:GPO), December 1996.

9

This study of the impacts of sulfur mustard agent is a collaborative effort between the Portland VA

Medical Center and the Oregon Health Sciences University. The principal investigator for the study

pointed out that the possibility of chemical warfare exposure seemed plausible even in 1994 when he

sought initial funding for this research.

Page 5 GAO/T-NSIAD-98-104 Gulf War Illnesses
fund such research cannot be traced to an absence of investigator-initiated

submissions. According to DOD officials, three recently funded proposals

on low-level chemical exposure had previously been rejected.10

Private Sector

Pursued Variety of

Hypotheses

A substantial body of research suggests that low-level exposures to

chemical warfare agents or chemically related compounds, such as certain

pesticides, are associated with delayed or long-term health effects. For

example, abundant evidence from animal experiments, studies of

accidental human exposures, and epidemiologic studies of humans shows

that low-level exposures to certain organophosphorus compounds,

including sarin nerve agents to which our troops may have been exposed,

can cause delayed, chronic neurotoxic effects. This syndrome is

characterized by clinical signs and symptoms manifested 4 to 21 days after

exposure to organophosphate compounds. The symptoms of delayed

neurotoxicity can take at least two forms: (1) a single large dose may

cause nerve damage with paralysis and later spastic movement and

(2) repetitive low doses may damage the brain, causing impaired

concentration and memory, depression, fatigue, and irritability. These

delayed symptoms may be permanent.

As early as the 1950s, studies demonstrated that repeated oral and

subcutaneous exposures to neurotoxic organophosphates produced

delayed neurotoxic effects in rats and mice. In addition, German personnel

who were exposed to nerve agents during World War II displayed signs

and symptoms of neurological problems even 5 to 10 years after their last

exposure. Long-term abnormal neurological and psychiatric symptoms as

well as disturbed brain wave patterns have also been seen in workers

exposed to sarin in sarin manufacturing plants.11 The same abnormal brain

wave disturbances were produced experimentally in primates by exposing

them to low doses of sarin.12

10The three previously unfunded proposals address central nervous system targets for

organophosphates, development of a DNA-based method for assessing exposures to mustard agent,

and work on the pharmacokinetics of the nerve agent VX.

11F. H. Duffy et al., “Long-Term Effects of an Organophosphate Upon the Human

Electroencephalogram,” Toxicology and Applied Pharmacology, vol. 47 (1979), pp. 161-176, and F.R.

Sidell,”Soman and Sarin: Clinical Manifestations and Treatment of Accidental Poisoning by

Organophosphates,” Clinical Toxicology, vol. 7 (1979), pp. 1-17.

12J. L. Burchfield et al., “Persistent Effect of Sarin and Diodrin Upon the Primate

Electroencephalogram,” Toxicology and Applied Pharmacology, vol. 35 (1976), pp. 365-379.

Page 6 GAO/T-NSIAD-98-104 Gulf War Illnesses
Delayed, chronic neurotoxic effects were also seen in animal experiments

after the administration of organophosphates.13 These effects include

difficulty in walking and paralysis. In recent experiments, animals given a

low dosage of the nerve agent sarin for 10 days showed no signs of

immediate illness but developed delayed chronic neurotoxicity after 

2 weeks.14

It has been suggested that the ill-defined symptoms experienced by Gulf

War veterans may be due in part to organophosphate-induced delayed

neuropathy.15 This hypothesis was tested in a privately supported

epidemiological study of Gulf War veterans.16 In addition to clarifying the

patterns among veterans’ symptoms by use of statistical factor analysis,

this study concluded that vague symptoms of the ill veterans are

associated with objective brain and nerve damage compatible with the

known chronic effects of exposures to low levels of organophosphates.17 It

further linked the veterans’ illnesses to exposure to combinations of

chemicals, including nerve agents, pesticides in flea collars; DEET and

highly concentrated insect repellents; and pyridostigmine bromide tablets.

Finally, research that we reviewed also indicates that agents like

pyridostigmine bromide, which some Gulf War veterans took to protect

themselves against the immediate, life-threatening effects of nerve agents,

may alter the metabolism of organophosphates in ways that activate their

13M. B. Abou-Donia, “Organophosphorus Ester-induced Delayed Neurotoxicity,” Annual Review of

Pharmacology Toxicology, vol. 21 (1981), pp. 511-548, and M. K. Johnson, “The Target for Initiation of

Delayed Neurotoxicity by Organophosphorus Esters: Biochemical Studies and Neurotoxicological

Applications,” Review of Biochemistry and Toxicology, vol. 4 (1982), pp. 141-212.

14K. Husain et al., “Assessing Delayed Neurotoxicity in Rodents after Nerve Gas Exposure,” Defense

Science Journal, vol. 44 (1994), pp. 161-164; K. Husain et al., “Delayed Neurotoxic Effects of Sarin in

Mice After Repeated Inhalation Exposure,” Journal of Applied Toxicology, vol. 13 (1993), pp. 143-145;

and K. Husain et al., “A Comparative Study of Delayed Neurotoxicity in Hens Following Repeated

Administration of Organophosphorus Compounds,” Indian Journal of Physiology and Pharmacology,

vol. 39 (1995), pp. 47-50.

15R. W. Haley et al., “Preliminary Findings of Studies on the Gulf War Syndrome,” Presentations to the

Intergovernmental Coordinating Board for the Gulf War Illnesses and the Staff of the Presidential

Advisory Committee on Gulf War Veterans’ Illnesses,” September 16, 1995, and R. W. Haley,

“Organophosphate-Induced Delayed Neurotoxicity,” Internal Medicine Grand Rounds, University of

Texas Southwestern Medical Center, Dallas, Texas, October 10, 1996.

16This research, conducted at the University of Texas Southwestern Medical Center, has been

supported in part by funding from the Perot Foundation.

17R. W. Haley et al., “Is There a Gulf War Syndrome? Searching for Syndromes by Factor Analysis of

Symptoms,” Journal of American Medical Association, vol. 277 (1997), pp. 215-222; R. W. Haley et al.,

“Evaluation of Neurologic Function in Gulf War Veterans: A Blinded Case-Control Study,” Journal of

American Medical Association, vol. 277 (1997), pp. 223-230; and R. W. Haley et al., “Self-reported

Exposure to Neurotoxic Chemical Combinations in the Gulf War: A Cross-sectional Epidemiologic

Study,” Journal of American Medical Association, vol. 277 (1997), pp. 231-237.

Page 7 GAO/T-NSIAD-98-104 Gulf War Illnesses
delayed, chronic effects on the brain.18 Moreover, exposure to

combinations of organophosphates and related chemicals like

pyridostigmine or DEET has been shown in animal studies to be far more

likely to cause morbidity and mortality than any of the chemicals acting

alone.19

Despite the fact that in 1994, Congress directed DOD and VA to research

treatments for ailing Gulf War veterans, such research has largely not

taken place. While 61 of the 91 federally sponsored studies (67 percent)

were classified as epidemiological by the PGVCB, only three of the studies

had focused primarily on identification and improvement of treatments for

these illnesses.

Formidable

Methodological

Problems Have

Hampered Research

Our review indicated that most of the epidemiological studies have been

hampered by data problems and methodological limitations and

consequently may not provide conclusive answers in response to their

stated objectives, particularly in identifying risk factors or potential

causes.

Measurement of

Exposures Is Problematic

The research program to answer basic questions about the illnesses that

afflict Gulf War veterans has at least three major problems in linking

exposures to observed illness or symptoms. First, it is extremely difficult

to gather information about unplanned exposures (for example, oil-fire

smoke and insects) that may have occurred in the Gulf. And DOD has

acknowledged that records of planned or intentional exposures (for

example, the use of vaccines and pyridostigmine bromide to protect

against chemical/biological warfare agents) were inadequate. Second, the

veterans were typically exposed to a wide array of agents with commonly

accepted health effects, making it difficult to isolate and characterize the

effects of individual factors or to study their combined effects. Third, the

passage of time following these exposures has made it increasingly

18C. N. Pope and S. Padilla, “Potentiation of Organophosphorus Delayed Neurotoxicity,” Journal of

Toxicology and Environmental Health, vol. 31 (1990), pp. 261-273.

19M. B. Abou-Donia et al., “Increased Neurotoxicity Following Concurrent Exposure to Pyridostigmine

Bromide, DEET, and Chlorpyrifos,” Fundamental of Applied Toxicology, vol. 34 (1996), pp. 201-222

and M. B. Abou-Donia et al., “Neurotoxicity Resulting From Coexposure to Pyridostigmine Bromide,

Deet, and Permethrin,” Journal of Toxicology and Environmental Health, vol. 48 (1996), pp. 35-56.

Page 8 GAO/T-NSIAD-98-104 Gulf War Illnesses
difficult to have confidence in any information gathered through

retrospective questioning of veterans.20

In part, the latter difficulty was created by the delayed release of

information about detection of chemical warfare agents during the war as

well as the delayed collection of exposure data. Five years passed before

DOD acknowledged that American soldiers may have been exposed to

chemical warfare agents shortly after the war ended in 1991 (at the

Khamisiyah site). Moreover, although chemical detections by Czech forces

are regarded as valid by DOD, the origin of the detected chemical agents

has not been identified by either DOD or the Central Intelligence Agency

(CIA). In the face of denials by DOD officials, several researchers told us

that they had considered it pointless to pursue hypotheses that the

symptoms may have been associated with exposures to chemical

weapons.

When we asked investigators responsible for federally funded

epidemiological research how they were collecting data on the various

elements to which Gulf veterans may have been exposed, they indicated

that they had no means other than self-reports for measuring most of these

elements. This reliance on self-reports was not much less for elements

such as vaccines, for which the opportunity for record keeping clearly

existed.21

Two problems are associated with reliance on self-reports for exposure

assessments. First, recalled information may be inaccurate or biased after

such a long time period; that is, some veterans may not remember that

they were exposed to particular factors, while others may not have been

exposed but nonetheless inaccurately report that they were. Information

also may be biased if, for example, veterans who became sick following

the war recalled their exposures earlier, more often, or differently from

veterans who had not become sick. Second, there is often no

20Large numbers of veterans questioned during their participation in the VA’s health registry

examination program reported they did not know whether they were exposed to certain agents. “Don’t

know” responses were greatest for nerve gas (64.9 percent), mustard gas (60.2 percent), depleted

uranium (52.5 percent), chemical-agent resistant coating (47.8 percent), microwaves (32.8 percent),

paints or solvents (24.9 percent), and pyridostigmine (21.1 percent). To the extent that a response of

some kind reflects greater certainty, veterans were more confident in their reports regarding smoke

from tent heaters, passive smoking, diesel or other petrochemical fumes, skin exposure to fuel,

pesticides in cream or spray form, and burning trash or feces, each of which resulted in fewer than

11 percent of respondents reporting “don’t know.” While such confidence does not necessarily mean

that the reports are accurate, the lack of confidence in responding to questions about some exposures

raises questions about studies relying on self-reports to assess these exposures.

21Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed Results in Bosnia

(GAO/NSIAD-97-136).

Page 9 GAO/T-NSIAD-98-104 Gulf War Illnesses
straightforward way to test the validity of self-reported exposure

information, making it impossible to separate bias from actual differences

in exposure frequency.

Several investigators were also relying on a model developed by the U.S.

Army Environmental Hygiene Agency for assessing exposures to

components of oil-fire smoke through the combination of unit location

data with information from models of the distribution of oil-fire smoke.

However, this model requires the use of unit location as a proxy for

exposure, and the validity of this approach is unknown. The Presidential

Advisory Committee has noted, “DOD’s Persian Gulf Registry of Unit

Locations lacks the precision and detail necessary to be an effective tool

for the investigation of exposure incidents.”

Case Definition Is

Complicated by Presence

of Nonspecific Symptoms

Another major hurdle to the development of a successful research agenda

has been the difficulty in classifying symptoms into one or more distinct

illnesses. Some veterans complain of gastrointestinal pain, others report

musculoskeletal pain or weakness, and still others report emotional or

neurological symptoms. As explained previously, development of one or

more specific case definition is essential to conducting certain types of

epidemiological studies.

The VA collected some data on symptoms beginning in 1992 with the

initiation of its registry. However, these efforts to collect information

about symptoms and exposures from registry participants were limited

and nonspecific. This constrained VA’s potential use of the information for

improving understanding of the patterns of veterans’ complaints. These

data limitations were unfortunate, as detailed information about

symptoms and exposures might have yielded earlier, more reliable

analyses of the nature and causes of veterans’ complaints and could have

also assisted in developing working case definitions.

We also found that both the federally supported projects and the federal

registry programs have generally failed to study the conjunction of

multiple symptoms in individual veterans. Articles and briefing documents

that we obtained from DOD and VA reported findings that addressed only

the incidence of single symptoms and diagnoses. There were two

exceptions. First, for an Air National Guard unit in Pennsylvania, the

Center for Disease Control and Prevention developed an operational case

definition, which was quite similar to the case definition of chronic fatigue

Page 10 GAO/T-NSIAD-98-104 Gulf War Illnesses
syndrome. Second, the studies conducted by Haley et al. also focused on

identifying symptom clusters.

For those ongoing, epidemiological studies that were built on case-control

designs, we asked about how a case was defined. The specificity of this

definition is important because a vague case definition can lead to

considering multiple kinds of illnesses together. When this is done, it is not

surprising to find no commonality of experience among the cases.

Moreover, the use of specific case definition is particularly critical to

achieving meaningful results within this type of research design. At the

same time, for the case definition to be relevant, it must fit the symptoms

described by an important portion of the group being studied.

Sample Size Most of the investigators we interviewed took steps to estimate the size of

the sample they would require to have a reasonable expectation of

detecting the effects of exposures to hazardous substances. However,

many other variables were involved in such calculations, for example, the

prevalence of exposures, some of which were unknown at the time the

studies were planned. Thus, they had to make estimates within somewhat

broad parameters.

Although steps were clearly taken to plan for an adequate sample size,

some investigators reported difficulty in locating subjects due to factors

beyond their control, such as the rate of referrals from VA examination

centers or the rate of identification of subjects that fit highly specific case

definitions. Moreover, other studies, such as those on specific birth

defects, required extremely large samples.

Conclusions The ongoing epidemiological research cannot provide precise, accurate,

and conclusive answers regarding the causes of veterans’ illnesses

because of researchers’ methodological problems as well as the following:

• Researchers have found it extremely difficult to gather information about

many key exposures. For example, medical records of the use of

pyridostigmine bromide tablets and vaccinations to protect against

chemical/biological warfare exposures were inadequate.

• Gulf War veterans were typically exposed to a wide array of agents,

making it difficult to isolate and characterize the effects of individual

agents or to study their combined effects.

Page 11 GAO/T-NSIAD-98-104 Gulf War Illnesses
• Most of the epidemiological studies on Gulf War veterans’ illnesses have

relied only on self-reports for measuring most of the agents to which

veterans might have been exposed.

• The information gathered from Gulf War veterans years after the war may

be inaccurate or biased. There is often no straightforward way to test the

validity of self-reported exposure information, making it impossible to

separate bias in recalled information from actual differences in the

frequency of exposures. As a result, findings from these studies may be

spurious or equivocal.

• Classifying Gulf War veterans’ symptoms and identifying their illnesses

have been difficult. From the outset, the symptoms reported have been

varied and difficult to classify into one or more distinct groups. Moreover,

several different diagnoses might provide plausible explanations for some

of the specific health complaints. It has thus been difficult to develop one

or more working case definitions to describe veterans undiagnosed

complaints.

Recommendations Because of the numbers of veterans who have experienced illnesses that

might be related to their service during the Gulf War, we recommended in

our report that the Secretary of Defense, with the Secretary of Veterans

Affairs, give greater priority to research on effective treatment for ill

veterans and on low-level exposures to chemicals and other agents as well

as their interactive effects and less priority to further epidemiological

studies.

Mr. Chairman, that concludes my prepared remarks. I will be happy to

answer any questions you may have.

(713019) Page 12 GAO/T-NSIAD-98-104 Gulf War Illnesses
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