United States General Accounting Office

GAO Testimony

Before the Committee on Veterans Affairs, House of

Representatives

For Release on Delivery

Expected at

1:00 p.m., EDT

Thursday,

February 5, 1998

GULF WAR ILLNESSES

Research, Clinical

Monitoring, and Medical

Surveillance

Statement of Donna Heivilin, Director of Planning and

Reporting, National Security and International Affairs

Division

GAO/T-NSIAD-98-88

Mr. Chairman and Members of the Committee:

I am pleased to be here today to discuss two recent GAO reports that

responded to congressional mandates1

 regarding health care issues of

military personnel deployed for military operations overseas. In the first,

we reported on the government’s clinical care and medical research

programs relating to illnesses suffered by Gulf War veterans.2

 For the

second, we assessed the medical surveillance3

 of military personnel in

Bosnia.4

 Based on these two reports, I will discuss four issues:

• the adequacy of the mechanisms used by the Department of Defense (DOD)

and Veterans Affairs (VA) to monitor the quality, appropriateness, and

effectiveness of Gulf War veterans’ care and to follow up on their clinical

progress over time;

• the government’s research strategy for studying Gulf War veterans’

illnesses and the methodological problems posed in its studies;

• the consistency of key official conclusions with available data on the

causes of Gulf War veterans’ illnesses; and

• the extent to which DOD’s efforts for Operation Joint Endeavor in Bosnia

were successful in overcoming the medical surveillance problems

encountered during the Gulf War.

We are currently working on several related studies requested by other

congressional committees. For example, we are looking at the incidence

of tumors among Gulf War veterans; the possible presence of antibodies

for synthetic squalene5

 in blood samples of Gulf War veterans; the

processes, methods, and criteria used by the Persian Gulf Veteran’s

Coordinating Board (PGVCB),6 DOD, and VA to approve or disapprove

research protocols; and the extent to which ongoing research can provide

information on what caused Gulf War veterans’ illnesses. We will be happy

to share the results of this work with you once it is completed.

1

National Defense Authorization Act for Fiscal Year 1997 (P.L. 104-201, sec. 744, Sept. 23, 1996).

2

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

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

3

Medical surveillance involves the regular or repeated collection, analysis, and dissemination of

uniform health information.

4

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

(GAO/NSIAD-97-136, May 13, 1997).

5

Squalene is an acyclic hydrocarbon that is widely distributed in nature but is unhealthful to humans in

synthetic form.

6

The PGVCB, which comprises the Secretaries of Defense, Veterans Affairs, and Health and Human

Services, was charged with coordinating the federal response to Gulf War veterans’ illnesses.

Page 1 GAO/T-NSIAD-98-88 Gulf War Illnesses
Results in Brief I will first summarize our findings on the four issues and then provide

detailed information on them. In our report on Gulf War veterans’

illnesses, we noted that while DOD and VA had provided care to eligible Gulf

War veterans, they had no system for following up on their health to

determine the effectiveness of their care after initial treatment. Also,

because of methodological problems and incomplete medical records on

the veterans, research has not come close to providing conclusive answers

on the causes of the illnesses. Given the data needed versus what is

available, which is primarily anecdotal, it will be very difficult, if not

impossible, to determine the causes of the illnesses. Finally, the support

for some official conclusions regarding stress, leishmaniasis (a parasitic

infection), and exposure to chemical agents was weak or subject to other

interpretations.

Regarding our report on the medical surveillance of servicemembers

deployed in Bosnia, while we found that DOD had improved its capability to

monitor and assess the effects of deployments on servicemembers’ health

since the Gulf War, certain problems remained: the database containing

deployment information was inaccurate, not all troops received

postdeployment medical assessments, and many of the medical records

we reviewed were incomplete.

After I have provided details on the findings of our reports, I will discuss

our reports’ recommendations, the relevant agencies’ comments on them,

and our evaluation of those comments.

Background Before providing you details on the results of our work, let me briefly

provide some background information. During service associated with the

Gulf War, many of the approximately 700,000 veterans might have been

exposed to a variety of potentially hazardous substances. These

substances include compounds used to decontaminate equipment and

protect it against chemical agents, pesticides, vaccines, and drugs to

protect against chemical warfare agents (for example, pyridostigmine

bromide). Following the postwar demolition of Iraqi ammunition facilities,

some veterans might also have been exposed to the nerve agent sarin.

Over 100,000 of the approximately 700,000 Gulf War veterans have

participated in DOD and VA health examination programs 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

Page 2 GAO/T-NSIAD-98-88 Gulf War Illnesses
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.

In 1992, VA established a program through which Gulf War veterans could

receive medical examinations and diagnostic services. Participants

received a regular physical examination with basic laboratory tests. In

1994, VA established a standardized examination to obtain information

about exposures and symptoms related to diseases endemic to the Gulf

region and to order specific tests to detect the “biochemical fingerprints”

of certain diseases. If a diagnosis was not apparent, veterans could receive

up to 22 additional tests and additional specialty consultations. In

addition, if the illness defied diagnosis, the veterans could be referred to

one of four VA Persian Gulf referral centers.

In 1994, DOD initiated its Comprehensive Clinical Evaluation Program,

through which it used a clinical protocol and provided diagnostic services

similar to those of the VA program.

In examining the causes of Gulf War veterans’ illnesses, the Presidential

Advisory Committee on Gulf War Veterans’ Illnesses and the Institute of

Medicine confirmed the need for effective medical surveillance

capabilities. They found that research efforts to determine the causes of

the veterans’ illnesses were hampered by incomplete data on (1) the

names and locations of deployed personnel, (2) the exposure of personnel

to environmental health hazards, (3) changes in the health status of

personnel while deployed, and (4) immunizations and other health

services for personnel while deployed.

Subsequently, in May 1997, we reviewed the actions DOD had taken since

the Gulf War to improve its medical surveillance capabilities. Specifically,

we determined what medical surveillance procedures DOD had used in

Operation Joint Endeavor, which was conducted in the countries of

Bosnia-Herzegovina, Croatia, and Hungary, and whether DOD had corrected

the problems that surfaced during the Gulf War.

Page 3 GAO/T-NSIAD-98-88 Gulf War Illnesses
DOD and VA Had No

Systematic Approach

to Monitoring Gulf

War Veterans’ Health

After Initial

Examination

DOD and VA officials claimed that regardless of the cause of Gulf War

veterans’ illnesses, the veterans had received appropriate and effective

symptomatic treatment. Both agencies tried to measure or ensure the

quality of veterans’ initial examinations by training health care specialists

and maintaining standards for physicians’ qualifications. However, these

mechanisms did not ensure a given level of effectiveness for the care

provided or help to identify the most effective treatments.7

Beyond the initial examination, neither DOD nor VA had mechanisms for

monitoring the quality, appropriateness, or effectiveness of these veterans’

care or clinical progress, and they had no plans to establish such

mechanisms. VA officials told us that they regarded monitoring the clinical

progress of registry participants as a separate research project, and

officials from DOD’s Clinical Care and Evaluation Program made similar

comments.

We noted that such monitoring was important because (1) undiagnosed

conditions were not uncommon among ill veterans, (2) treatment for

veterans with undiagnosed conditions was based on their symptoms,

(3) veterans with undiagnosed conditions or multiple diagnoses might see

multiple providers, (4) follow-up could provide a better understanding of

the clinical progression of the illnesses over time, and (5) the success or

failure of physicians’ treatments of Gulf War veterans could be identified.

Without follow-up of their treatment, DOD and VA cannot say whether these

ill veterans are any better or worse today than when they were first

examined.

Most of the Federally

Funded Research Was

Ongoing, and Some

Hypotheses Were Not

Initially Pursued

Federal research on Gulf War veterans’ illnesses and factors that might

have caused their problems was not pursued proactively. Although these

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

responded to legislative requirements or external reviewers’

recommendations. This 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.

7

See VA Health Care: Observations on Medical Care Provided to Persian Gulf Veterans

(GAO/T-HEHS-97-158, June 19, 1997).

Page 4 GAO/T-NSIAD-98-88 Gulf War Illnesses
While research on exposure to stress was emphasized in earlier studies,

research on low-level chemical exposure was not pursued until legislated

in 1996. The failure to fund such research could not be traced to an

absence of proposals. According to DOD officials, three recently funded

proposals on low-level chemical exposure had previously been denied

funds because, at the time, DOD did not believe that U.S. troops had been

exposed to chemical warfare agents.

We found that additional hypotheses were pursued in the private sector. A

substantial body of this research suggests that low-level exposure to

chemical warfare agents or chemically related compounds, such as certain

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

example, animal experiments, studies of accidental human exposures, and

epidemiological studies of humans offer evidence that low-level exposures

to certain organophosphorus compounds,8

 including sarin nerve agents to

which some of our troops may have been exposed, can cause delayed,

chronic neurotoxic effects.

It was suggested that the ill-defined symptoms experienced by Gulf War

veterans might be due in part to organophosphate-induced delayed

neurotoxicity. This hypothesis was tested in a privately supported

epidemiological study of Gulf War veterans.9

 The study clarified the

patterns among veterans’ symptoms through the use of statistical factor

analyses and demonstrated that vague symptoms of the ill veterans were

associated with brain and nerve damage compatible with the known

chronic effects of exposures to low levels of organophosphates. It further

linked the veterans’ illnesses to exposure to combinations of chemicals,

including nerve agents, insect repellents, and pyridostigmine bromide

tablets.

Toxicological research indicates that pyridostigmine bromide, which 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 delayed, chronic effects on

the brain. Moreover, exposure to combinations of organophosphates and

related chemicals like pyridostigmine bromide has been shown in animal

8

Organophosphates are used in many pesticides and chemical warfare agents, and sarin has been used

as a chemical warfare agent since World War II, most recently during the Iran-Iraq war and by

terrorists in Japan.

9

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

supported in part by funding from the Perot Foundation.

Page 5 GAO/T-NSIAD-98-88 Gulf War Illnesses
studies to be far more likely to cause morbidity and mortality than any of

the chemicals acting alone.

Aside from the hypotheses being emphasized in the research being done,

we found that the bulk of ongoing federal research on Gulf War veterans’

illnesses was focused on the epidemiological study of the prevalence and

cause of the illnesses. It is important to note that to conduct such studies,

investigators must adhere to basic, generally accepted principles.

First, investigators 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, they must have valid and reliable methods

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

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.

The epidemiological federal research we examined had two

methodological problems: the lack of a case definition (that is, a reliable

way to identify individuals with a specific disease) and the absence of

accurate exposure data. Without valid and reliable data on exposures and

the multiplicity of agents to which the veterans were exposed, researchers

will likely continue to find it difficult to detect relatively subtle effects and

to eliminate alternative explanations for Gulf War veterans’ illnesses.

Prevalence data can be useful, but it requires careful interpretation in the

absence of better information on the factors to which veterans were

exposed. While multiple federally funded studies on the role of stress in

the veterans’ illnesses have been done, basic toxicological questions

regarding the substances to which they were exposed remain unanswered.

The ongoing epidemiological research cannot provide precise, accurate,

and conclusive answers regarding the causes of veterans’ illnesses

because of these methodological problems as well as the following:

• Researchers have found it extremely difficult to gather information about

exposures to such things as oil-well fire smoke and insects carrying

infection.

Page 6 GAO/T-NSIAD-98-88 Gulf War Illnesses
• 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.

• 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 the symptoms and identifying veterans’ illnesses have been

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

difficult to classify into one or more distinct illnesses. Moreover, several

different diagnoses might provide plausible explanations for some of the

specific health complaints. It has thus been difficult to develop a case

definition.

Support for Key

Government

Conclusions Was

Weak or Subject to

Alternative

Interpretations

Six years after the war, little was conclusively known about the causes of

Gulf War veterans’ illnesses. In the absence of official conclusions from

DOD and VA, we examined conclusions drawn in December 1996 by the

Presidential Advisory Committee on Gulf War Veterans’ Illnesses. In

January 1997, DOD endorsed the Committee’s conclusions about the

likelihood that exposure to 10 commonly cited chemical agents

contributed to the explained and unexplained illnesses of these veterans.

We found the evidence to support three of these conclusions to be either

weak or subject to alternative interpretations.

First, the Committee concluded that stress was likely a contributing factor

to Gulf War veterans’ illnesses. While stress can induce physical illness,

the link between stress and these veterans’ physical symptoms has not

been firmly established. For example, a large-scale, federally funded study

concluded that stress and exposure to combat or its aftermath bear little

relationship to the veterans’ distress. The Committee also stated that

“epidemiological studies to assess the effects of stress invariably have

found higher rates of posttraumatic stress disorder (PTSD) in Gulf War

Page 7 GAO/T-NSIAD-98-88 Gulf War Illnesses
veterans than among individuals in nondeployed units or in the general

U.S. population of the same age.”

Our review indicated that the prevalence of PTSD among Gulf War veterans

might be overestimated due to problems in the methods used to identify it.

Specifically, the studies on PTSD to which the Committee referred did not

exclude other conditions, such as neurological disorders that produce

symptoms similar to PTSD and can also elevate scores on key measures of

PTSD. Also, the use of broad and heterogenous groups of diagnoses (e.g.,

“psychological conditions”—ranging from tension headache to major

depression) in data from DOD’s clinical program might contribute to an

overestimation of the extent of serious psychological illnesses among Gulf

War veterans.

Second, the Committee concluded that “it is unlikely that infectious

diseases endemic to the Gulf region are responsible for long-term health

effects in Gulf War veterans, except in a small known number of

individuals.” Similarly, the PGVCB concluded that because of the small

number of reported cases “the likelihood of leishmania tropica as an

important risk factor for widely reported illness has diminished.” While

this is the case for observed symptomatic infection with the parasite, the

prevalence of asymptomatic infection is unknown. Such infection could

reemerge in cases in which the patient’s immune system becomes

deficient. As the Committee noted, the infection could remain dormant up

to 20 years. Because of this long latency, the infected population is hidden,

and because even classic forms of leishmaniasis are difficult to recognize,

we noted that leishmania should be retained as a potential risk factor for

individuals who suffer from immune deficiency.

Third, the Committee concluded that it is unlikely that the health effects

reported by many Gulf War veterans were the result of (1) biological or

chemical warfare agents, (2) depleted uranium, (3) oil-well fire smoke,

(4) pesticides, (5) petroleum products, and (6) pyridostigmine bromide or

vaccines. However, our review of the Committee’s conclusions indicated

the following:

• While the government found no evidence that biological weapons were

deployed during the Gulf War, the United States lacked the capability to

promptly detect biological agents, and the effects of one agent, aflatoxin,

would not be observed for many years.

• Evidence from various sources indicated that chemical agents were

present at Khamisiyah, Iraq, and elsewhere on the battlefield. The

Page 8 GAO/T-NSIAD-98-88 Gulf War Illnesses
magnitude of exposures to chemical agents has not been fully resolved. As

we reported in June 1997, 16 of 21 sites categorized by Gulf War planners

as nuclear, biological, and chemical (NBC) facilities were destroyed.

However, the United Nations Special Commission found after the war that

not all the possible NBC targets had been identified by U.S. planners. The

Commission investigated a large number of the facilities suspected by the

U.S. authorities as being NBC related. Regarding those the Commission had

not inspected, we determined that each was attacked by coalition aircraft

during the Gulf War.10

• Exposure to certain pesticides can induce a delayed neurological

condition without causing immediate symptoms.

• Available research indicates that exposure to pyridostigmine bromide can

alter the metabolism of organophosphates in ways that enhance chronic

effects on the brain.

Success in Improving

Medical Surveillance

Was Mixed for

Servicemembers

Deployed to Bosnia

In 1994, DOD began developing a directive and implementing instruction to

address the problems experienced in the medical surveillance of Gulf War

veterans. Although DOD had not issued this guidance when Operation Joint

Endeavor began, it did develop a comprehensive medical surveillance plan

in January 1996 for the Bosnia deployment. The plan included establishing

a system to identify which servicemembers deployed to the theater,

assessing environmental health threats, monitoring diseases and nonbattle

injuries, and conducting postdeployment medical assessments.

In examining medical surveillance in Bosnia in late 1996 and early 1997,

we found many remaining problems, despite DOD’s attempts to implement

its plan. These problems are as follows:

• First, DOD had not developed a system for accurately tracking the

movement of individual servicemembers in units within the theater. Such a

system is important for accurately identifying exposures of

servicemembers to health hazards where they are located.

• Second, predeployment blood samples were not available for many

servicemembers who deployed to Bosnia, and of the blood samples that

were available in the repository for servicemembers who deployed, many

were quite old.

• Third, many Army personnel did not receive required postdeployment

medical assessments. Moreover, when the assessments were done, they

were done much later than required.

10Operation Desert Storm: Evaluation of the Air Campaign (GAO/NSIAD-97-134, June 12, 1997), p. 2.

Page 9 GAO/T-NSIAD-98-88 Gulf War Illnesses
• Fourth, the centralized database for monitoring the extent to which

required medical assessments were done was incomplete for the 618

servicemembers whose medical records we reviewed. More specifically, it

omitted 12 percent of the in-theater medical assessments and 52 percent of

the home unit medical assessments.

• Finally, many of the medical records that we reviewed were incomplete

regarding in-theater postdeployment medical assessments done,

servicemembers’ visits to battalion aid stations for medical treatment

during deployment, and documentation of personnel being vaccinated

against tick-borne encephalitis (a health threat in the theater).

Methodology To address our first objective—the extent of DOD’s clinical follow-up and

monitoring of treatment and diagnostic services—we reviewed literature

and agency documents and conducted structured interviews with DOD and

VA officials. We asked questions designed to identify and contrast their

methods for monitoring the quality and outcomes of their treatment and

diagnostic programs and the health of the registered veterans.

To examine PGVCB’s research strategy, we conducted a systematic review

of pertinent literature and agency documents and reports. We also

interviewed representatives from PGVCB’s Research Working Group and

officials from VA, DOD, and the Central Intelligence Agency. We surveyed

primary investigators of ongoing epidemiological studies.

Because different methodological standards apply to various types of

research and because the overwhelming majority of federally sponsored

research is categorized as epidemiological, we limited our survey to those

responsible for ongoing epidemiological studies. With the help of an

expert epidemiological consultant, we devised a questionnaire to assess

critical elements of these studies (including the quality of exposure

measurement, specificity of case definition, and steps to ensure adequate

sample size) and to identify specific problems that the primary

investigators might have encountered in implementing their studies. We

interviewed primary investigators for 31 (72 percent) of the 43 ongoing

epidemiological studies identified by PGVCB in the November 1996 plan. We

also reviewed and categorized descriptions of all 91 projects identified by

April 1997, based on their apparent focus and primary objective. Finally, to

review the progress of major ongoing research efforts, we visited the

Walter Reed Army Institute of Research, the Naval Health Research

Center, and two of VA’s Environmental Hazards Research Centers.

Page 10 GAO/T-NSIAD-98-88 Gulf War Illnesses
To address the third objective, we reviewed major conclusions of the

PGVCB and the Presidential Advisory Committee on Gulf War Veterans’

Illnesses to determine the strength of evidence supporting them. The

purpose of this review was not to critique the efforts of PGVCB or the

Presidential Advisory Committee but rather to describe the amount of

knowledge about Gulf War illnesses that had been generated by research 

6 years after the war. We reviewed these conclusions because they were

the strongest statements that we had found on these matters by any

official body. The Presidential Advisory Committee’s report was

significant because the panel included a number of recognized experts

who were assisted by a large staff of scientists and attorneys. In addition,

the Committee conducted an extensive review of the research. Thus, we

believed that evaluating these conclusions would provide important

evidence about how fruitful the federal research had been. We addressed

this objective by reviewing extant scientific literature and by consulting

experts in the fields of epidemiology, toxicology, and medicine.

Because of the scientific and multidisciplinary nature of this issue, we

ensured that staff conducting the work had appropriate backgrounds in

the field of epidemiology, psychology, environmental health, toxicology,

engineering, weapons design, and program evaluation and methodology. In

addition, we used in-house expertise in chemical and biological warfare

and military health care systems. Also, medical experts reviewed our

work. Moreover, we held extensive discussions with experts in academia

in each of the substantive fields relevant to this issue. Finally, we talked to

a number of the authors of the studies that we cited in our report to ensure

that we correctly interpreted their findings and had independent experts

review our draft report.

Finally, regarding our fourth objective, we interviewed key agency

officials, examined relevant information from the DOD Deployment

Surveillance Team’s database, and reviewed the medical records of active

duty servicemembers in selected Army units in Germany who were

deployed to Operation Joint Endeavor.

Our work was completed between October 1996 and April 1997 in

accordance with generally accepted government auditing standards.

Appendix I contains a bibliography of research material referred to in our

testimony.

Page 11 GAO/T-NSIAD-98-88 Gulf War Illnesses
Recommendations to

the Secretaries of

Defense and Veterans

Affairs

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, (1) set up a plan for monitoring the clinical progress of Gulf War

veterans to help promote effective treatment and better direct the research

agenda and (2) give greater priority to research on effective treatment for

ill veterans and on low-level exposures to chemicals and their interactive

effects and less priority to further epidemiological studies.

We also recommended that the Secretaries of Defense and Veterans

Affairs refine the current approaches of the clinical and research programs

for diagnosing posttraumatic stress disorder consistent with suggestions

recently made by the Institute of Medicine. The Institute noted the need

for improved documentation of screening procedures and patient histories

(including occupational and environmental exposures) and the importance

of ruling out alternative causes of impairment.

While DOD agreed with the thrust of our recommendations, VA believed

they “reflected a lack of understanding of clinical research, epidemiology,

and toxicology.” The Presidential Advisory Committee disagreed with our

findings, particularly that the support for some of its conclusions was

weak. Despite these disagreements with our report, none of the comments

we received provided evidence to challenge our principal findings and

conclusions.

In response to our recommendation regarding the treatment of Gulf War

veterans, in December 1997, DOD and VA asked the Institute of Medicine to

establish a committee to assess the appropriate methodology for

monitoring the health outcomes and treatment efficacy for Gulf War

veterans. On February 2, 1998, PGVCB informed us that it had initiated a

joint program with DOD to conduct multicenter treatment trials for

fibromyalgia and chronic fatigue syndrome in Gulf War veterans. It is

anticipated that such a protocol will begin in late 1998 or early 1999.

In response to our recommendation on research programs, as of

January 1998, according to the research working group of PGVCB, 23 studies

had been added to the research portfolio, including research on the

toxicology of low-level exposures to neurotoxins such as pyridostigmine

bromide, insecticides, and chemical warfare nerve agents, with an

emphasis on interactions among them.

Page 12 GAO/T-NSIAD-98-88 Gulf War Illnesses
In our report on the deployment and medical records for servicemembers

deployed to Bosnia, we recommended that the Secretary of Defense direct

the Assistant Secretary of Defense for Health Affairs, along with the

military services, the Joint Chiefs of Staff, and the Unified Commands, as

appropriate, to

• expeditiously complete and implement a DOD-wide policy on medical

surveillance for all major deployments of U.S. forces, using lessons

learned during Operation Joint Endeavor and the Gulf War;

• develop procedures to ensure that medical surveillance policies are

implemented, to include emphasizing (a) the need for unit commanders to

ensure that all servicemembers receive required medical assessments in a

timely manner and (b) the need for medical personnel to maintain

complete and accurate medical records; and

• develop procedures for providing accurate and complete medical

assessment information to the centralized database.

In response to our recommendation, DOD established a new policy and

implementing guidance in August 1997 and has emphasized to field

commanders the importance of the system. The guidance mandated

medical surveillance of servicemembers before, during, and after military

deployments and specified procedures for conducting such surveillance.

It is important to note that GAO has not evaluated DOD’s, VA’s, and the

PGVCB’s proposed plans regarding the treatment and research for Gulf War

veterans’ illnesses. Also, while we have reviewed DOD’s new medical

surveillance guidance, we have not evaluated the implementation of it.

Nonetheless, we believe that if the guidance is properly implemented,

DOD’s medical surveillance system would be greatly enhanced.

A number of other actions—particularly legislative actions—have taken

place to help ailing Gulf War veterans. In a law sponsored by this

Committee (P.L. 105-114, sec. 209, Nov. 21, 1997), the Secretary of

Veterans Affairs is required to set up a program, by July 1, 1998, to test

new approaches to treating those veterans suffering from undiagnosed

illnesses and disabilities. Also, recent defense authorization legislation

(P.L. 105-85, Nov. 18, 1997), requires DOD and VA to (1) prepare a plan, by

March 1, 1998, for providing appropriate health care to Gulf War veterans

and (2) establish a program of clinical trials at multiple sites to assess the

effectiveness of protocols for treating the veterans.

Page 13 GAO/T-NSIAD-98-88 Gulf War Illnesses
In addition to the legislation, on October 31, 1997, the Presidential

Advisory Committee issued a special report in which it noted that (1) VA

should move quickly to incorporate Gulf War veterans into its case

management system and (2) DOD should place a higher priority on medical

surveillance to ensure that the health data problems that occurred during

the Gulf War do not recur in future military operations.

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

answer any questions you or members of the Committee may have.

Page 14 GAO/T-NSIAD-98-88 Gulf War Illnesses
Page 15 GAO/T-NSIAD-98-88 Gulf War Illnesses
Bibliography

M. B. Abou-Donia et al., “Increased Neurotoxicity Following Concurrent

Exposure to Pyridostigmine Bromide, DEET, and Chlorpyrifos,”

Fundamentals of Applied Toxicology, vol. 34 (1996), pp. 201-222.

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.

R. W. Haley et al., “Preliminary Findings of Studies on the Gulf War

Syndrome,” Presentations to the Intergovernmental Coordinating Board

for the Gulf War Illness and the Staff of the Presidential Advisory

Committee on Gulf War Veterans’ Illnesses,” September 16, 1995.

R. W. Haley, “Organophosphate-Induced Delayed Neurotoxicity,” Internal

Medicine Grand Rounds, University of Texas Southwestern Medical

Center, Dallas, Texas, October 10, 1996.

R. 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.

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.

G. A. Jamal et al., “The Gulf War Syndrome: Is There Evidence of

Dysfunction in the Nervous System?” Journal of Neurology, Neurosurgery

and Psychiatry, vol. 60 (1996), pp. 449-451.

Presidential Advisory Committee on Gulf War Veterans’ Illnesses, Final

Report (Washington, D.C.: GPO, 1996).

Presidential Advisory Committee on Gulf War Veterans’ Illnesses, Special

Report (Washington, D.C.: GPO, 1997).

C. N. Pope and S. Padilla, “Potentiation of Organophosphorus Delayed

Neurotoxicity,” Journal of Toxicology and Environmental Health, vol. 31

(1990), pp. 261-273.

Page 16 GAO/T-NSIAD-98-88 Gulf War Illnesses
Bibliography

R. H. Stretch et al., “Physical Health Symptomatology of Gulf War-era

Service Personnel From the States of Pennsylvania and Hawaii, Military

Medicine, vol. 160 (1995), pp. 131-136.

(713017) Page 17 GAO/T-NSIAD-98-88 Gulf War Illnesses
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. VISA and MasterCard credit cards are accepted, also.

Orders for 100 or more copies to be mailed to a single address

are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 37050

Washington, DC 20013

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (202) 512-6000 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

For information on how to access GAO reports on the INTERNET,

send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Rate

Postage & Fees Paid

GAO

Permit No. G100