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79–944 2013

GULF WAR: WHAT KIND OF CARE ARE VETERANS 

RECEIVING 20 YEARS LATER? 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, MARCH 13, 2013 

Serial No. 113–9 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MARK E. AMODEI, Nevada 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

HELEN W. TOLAR, Staff Director and Chief Counsel 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

DAN BENISHEK, Michigan 

JACKIE WALORSKI, Indiana 

ANN KIRKPATRICK, Arizona, Ranking 

Minority Member 

MARK TAKANO, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

March 13, 2013 

Page 

Gulf War: What Kind of Care Are Veterans Receiving 20 Years Later? ............ 1 

OPENING STATEMENTS 

Hon. Mike Coffman, Chairman, Subcommittee on Oversight and Investigations ....................................................................................................................... 1 

Prepared Statement of Hon. Coffman ............................................................. 25 

Hon. Ann Kirkpatrick, Ranking Minority Member, Subcommittee on Oversight and Investigations ...................................................................................... 2 

Prepared Statement of Hon. Kirkpatrick ....................................................... 25 

WITNESSES 

Dr. Lea Steele, Research Professor of Biomedical Studies & Director, Veterans 

Health Research Program, Baylor University ................................................... 3 

Prepared Statement of Dr. Steele ................................................................... 26 

Dr. Steven S. Coughlin, Adjunct Professor of Epidemiology, Emory University 6 

Prepared Statement of Dr. Coughlin .............................................................. 29 

Dr. Bernard M. Rosof, Chairman, Board of Directors, Huntington Hospital, 

Chair, Committee on Gulf War and Health: Treatment for Chronic Multisymptom Illness, Institute of Medicine of the National Academies ................. 9 

Prepared Statement of Dr. Rosof .................................................................... 31 

Executive Summary of Dr. Rosof .................................................................... 34 

Anthony Hardie, Gulf War Veteran ....................................................................... 11 

Prepared Statement of Mr. Hardie ................................................................. 35 

Dr. Victoria Davey, Chief Officer, Office of Public Health and Environmental 

Hazards, Veterans Health Administration, U.S. Department of Veterans 

Affairs .................................................................................................................... 18 

Prepared Statement of Dr. Davey ................................................................... 44 

Accompanied by: 

Dr. Maureen McCarthy, Deputy Chief, Patient Care Services Office, 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Dr. Stephen Hunt, Director, Post-Deployment Integrated Care Initiative, U.S. Department of Veterans Affairs 

Dr. Gavin West, Acting Chief Medical Officer, Salt Lake City VAMC, 

Special Assistant, Office of the Assistant Deputy Under Secretary 

for Health for Clinical Operations, U.S. Department of Veterans 

Affairs 

Mr. Tom Murphy, Director of Compensation Service, Veterans Benefits 

Administration, U.S. Department of Veterans Affairs 

STATEMENT FOR THE RECORD 

Melissa A. Forsythe, Ph.D., RN, Program Manager For Gulf War Illness 

Research Program, United States Army Medical Research And Materiel 

Command .............................................................................................................. 47 

David K. Winnett, Jr., Gulf War Veteran .............................................................. 49 

Chris Thomas, Gulf War Veteran .......................................................................... 51 

Kirt Love, Gulf War Veteran .................................................................................. 53 

Dr. Beatrice Golomb, Professor of Medicine, Division of General Internal 

Medicine, University of California, San Diego School of Medicine .................. 55 

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iv 

QUESTIONS FOR THE RECORD 

Letter From: Hon. Michael H. Michaud, Minority Ranking Member, Committee on Veterans’ Affairs, To: The Hon. Eric K. Shinseki, Secretary, 

U.S. Department of Veterans Affairs ................................................................. 57 

Questions From: Committee on Veterans’ Affairs, To: U.S. Department of 

Veterans Affairs ................................................................................................... 57 

Questions and Responses From: U.S. Department of Veterans Affairs, To: 

Committee on Veterans’ Affairs .......................................................................... 58 

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GULF WAR: WHAT KIND OF CARE ARE 

VETERANS RECEIVING 20 YEARS LATER? 

Wednesday, March 13, 2013 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

Washington, D.C. 

The Subcommittee met, pursuant to notice, at 3:45 p.m., in Room 

334, Cannon House Office Building, Hon. Mike Coffman [Chairman 

of the Subcommittee] presiding. 

Present: Representatives Coffman and Kirkpatrick. 

OPENING STATEMENT OF CHAIRMAN COFFMAN 

Mr. COFFMAN. Good afternoon. I would like to welcome everyone 

to today’s hearing titled ‘‘Gulf War: What Kind of Care Are Veterans Receiving 20 Years Later?’’ 

Yes, it has been over 20 years since the Gulf War. I remember 

it very well, having been there myself as a Marine Corps officer. 

Now, as Chairman of this Subcommittee, I am asking the same 

questions many fellow Gulf War veterans have; namely, how is this 

unique set of veterans being treated by the VA? 

While it may be pretty easy to determine whether a veteran 

served in the Gulf War, it has been difficult for some time to accurately identify what constitutes Gulf War Illness; however, a lot of 

people, both in the veteran community and the medical community, 

agree that it exists. In fact, VA’s current Chief of Staff John Gingrich once made the following comment about Gulf War Illness: 

Quote, ‘‘While commanding an artillery battalion during Gulf War 

I, one of my soldiers suddenly became quite ill. Despite the best efforts of our medical team, they could not diagnose what made him 

so sick. Out of 800 soldiers under my command, no one else was 

that sick. Now here we are almost 20 years later, and this veteran 

is still suffering and has been since the war. I have watched him 

when he could barely stand up, couldn’t cross the room on his own. 

His legs were so weak. He has been in and out of hospitals many 

times, seen by some of the best doctors, and yet there is no explanation for his debilitating illness. And this veteran is not alone,’’ 

unquote. 

Chronic Multisymptom Illness, or CMI, is by its own definition 

not just one item that a VA physician can look for. However, there 

are certain things a VA physician can and should look for in determining whether a veteran likely has CMI that can be attributed to 

service in the first Gulf War. This should be a straightforward 

process; however, I am concerned that it is not happening in practice. 

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This hearing today is not about whether Gulf War Illness exists; 

this hearing is about how it is identified, diagnosed and treated, 

and how the tools put in place to aid these efforts have been used. 

For example, is the Gulf War Registry working as intended and 

being used properly? If not, what is VA doing to fix the problem, 

and what can this Committee do to help VA in that effort? 

Are the findings of the Research Advisory Committee being put 

to use in identifying, diagnosing and treating those veterans suffering from Gulf War Illness? If not, where is the disconnect? How 

can this Committee help VA better assist these veterans? 

We have learned a lot in the last 20 years. Science and research 

has identified unique medical issues for the veterans of the Gulf 

War and established baselines from which we can gain a better understanding of those unique issues. Gulf War Illness has significant 

physical effects on the lives and well-being of those veterans, and 

we need to make sure that VA can and does make every effort to 

accurately identify, diagnose and treat them in a timely fashion. To 

be sure, it should not take another 20 years for us all to get this 

right. 

I look forward to hearing from today’s witnesses on what is working in treating Gulf War Illness, where problems remain, and how 

the entire process can be improved. 

With that, I yield to Ranking Member Kirkpatrick for a statement. 

[THE PREPARED STATEMENT OF CHAIRMAN COFFMAN APPEARS IN

THE APPENDIX]

OPENING STATEMENT OF HON. ANN KIRKPATRICK 

Mrs. KIRKPATRICK. Thank you, Mr. Chairman. 

Because we know that the deployment experience of our veterans 

is especially important in the world of research and the care and 

treatment of injuries and illnesses, I want to thank you for holding 

this hearing on Gulf War veterans and the progress or not of recognizing and treating these veterans for ill-defined and undiagnosed 

conditions. 

It is estimated that up to 35 percent of veterans who have served 

in the Gulf War suffer from symptoms that are not readily identifiable or well understood. In the Institute of Medicine’s report released just this past January, and on which this hearing is based, 

these conditions are called Chronic Multisymptom Illness, or CMI. 

Veterans from the 1991 Gulf War have struggled for more than 

two decades to dispel the all-too-often accusation that ‘‘it is all in 

your head.’’ Veterans of the Iraq and Afghanistan wars have recently presented to the Veterans Health Administration with similar symptoms and have joined their fellow veterans in the fight for 

effective treatments and legitimate recognition of CMI by providers. 

Keeping the struggle of this generation of veterans in the forefront of this Subcommittee is not just important, but crucial for us 

as a Nation to finally look at service in combat not so narrowly as 

just that span of time served in combat, but to look at the whole 

experience of a servicemember from the perspective of 

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predeployment, deployment and postdeployment as the sum total of 

things that have happened to a servicemember. 

Hopefully this hearing will provide us a better perspective and 

a more holistic approach in understanding their unique needs and 

the full toll that serving takes on everyone. In this way we are better able to contribute to their healing and readjustment. 

I think it is incumbent upon us to learn as much as we can about 

what our Nation is asking from our servicemembers and families 

when they volunteer and raise their right hand. We must recognize 

and be prepared to address the consequences of that service and 

bring to bear our best efforts to ensure that they are thoroughly 

prepared to serve, and, when they return home, we commit to making them whole again. 

Thank you, Mr. Chairman. I yield back. 

[THE PREPARED STATEMENT OF HON. ANN KIRKPATRICK APPEARS

IN THE APPENDIX]

Mr. COFFMAN. Thank you, Ranking Member Kirkpatrick. 

I ask that all Members waive their opening remarks as per this 

Committee’s custom and invite the first panel to the witness table. 

On this panel we will hear from Dr. Lea Steele, Research Professor of Biomedical Studies and Director of the Veterans Health 

Research Program at Baylor University; Dr. Steven S. Coughlin, 

Adjunct Professor of Epidemiology at Emory University; Dr. Bernard M. Rosof, Chairman of the Board of Directors at Huntington 

Hospital and Chair of the Committee on Gulf War and Health: 

Treatment for Chronic Multisymptom Illness of the National Academies; and, finally, from Mr. Anthony Hardie, a Gulf War veteran 

himself. 

All of your complete written statements will be made part of the 

hearing record. 

Dr. Steele, you are now recognized for 5 minutes. 

STATEMENTS OF LEA STEELE, RESEARCH PROFESSOR OF 

BIOMEDICAL STUDIES, AND DIRECTOR, VETERANS HEALTH 

RESEARCH PROGRAM, BAYLOR UNIVERSITY; STEVEN S. 

COUGHLIN, ADJUNCT PROFESSOR OF EPIDEMIOLOGY, 

EMORY UNIVERSITY; BERNARD M. ROSOF, CHAIRMAN, 

BOARD OF DIRECTORS, HUNTINGTON HOSPITAL, AND 

CHAIR, COMMITTEE ON GULF WAR AND HEALTH: TREATMENT FOR CHRONIC MULTISYMPTOM ILLNESS, INSTITUTE 

OF MEDICINE OF THE NATIONAL ACADEMIES; AND ANTHONY HARDIE, GULF WAR VETERAN 

STATEMENT OF LEA STEELE 

Dr. STEELE. Good afternoon. I am Lea Steele, Research Professor 

of Biomedical Studies at Baylor, where I direct a multidisciplinary 

research program on the health of Gulf War veterans with scientists from across the country. I have also served on several Federal committees that plan and advise government agencies on Gulf 

War research, including the Research Advisory Committee on Gulf 

War Veterans Illnesses, which we commonly call the RAC. 

I have been asked to testify on the work of Federal agencies in 

addressing Gulf War Illness. By this we mean the serious, often 

disabling symptom complex resulting from military service in the 

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1991 Gulf War. I want to be clear, Gulf War Illness refers to a 

characteristic profile of symptoms, persistent cognitive and neurological problems, widespread pain, respiratory and other concurrent 

symptoms that are not explained by established medical or psychiatric diagnoses. 

In recent years the government has made progress understanding Gulf War Illness, but there remain serious problems on 

a number of fronts at VA, including the need for adequate health 

care for Gulf War veterans. 

Twenty-two years after the war, we know Gulf War Illness is not 

a stress-induced or psychiatric disorder. Rates of PTSD, for example, were much lower in the 1991 Gulf War veterans than in veterans from other wars, and studies consistently show that Gulf 

War Illness is not due to war trauma or serving in combat. Rather, 

studies identify links with a number of hazardous exposures during 

the war, and there is no disagreement among scientists working in 

this area that Gulf War Illness is a real and serious problem affecting 25 to 33 percent of the nearly 700,000 veterans who served in 

that war. Further, few veterans have recovered in the 22 years 

since the war, unfortunately. 

This is an incredibly important time for Gulf War Illness research. Scientific advances have provided important insights into 

this problem, its causes and the biological processes that drive veterans’ symptoms. At the same time, results are beginning to come 

in from treatment studies that show benefits for veterans with Gulf 

War Illness, with more treatment research in the pipeline and 

more results expected in the near term. After so many years of 

waiting, there is finally some hope for Gulf War veterans, hope 

that they will have answers that are long overdue, and hope that 

treatments can be found that meaningfully improve their health 

and their lives. 

Those of us most involved in this research believe, based on recent progress, that these successes are within sight. But I regret 

to say that in some sectors within VA, there appears to have been 

backward movement with actions that seem intended to ignore the 

science and minimize this condition as a problem. 

Fundamentally we have a situation where two Federal agencies 

sponsor very different scientific programs, both ostensibly to address Gulf War health issues. DoD’s Gulf War Research Program 

is managed by the Office of Congressionally Directed Medical Research Programs, or CDMRP. This office has made great strides in 

a short time with about $34 million in funding over 5 years between 2006 and 2011. This program began in 2006 by defining a 

mission, establishing priorities and enlisting the input and guidance of experts in the field and veteran stakeholders. This missionoriented approach has yielded impressive progress, and the proof is 

in the results. 

The highest priority research for Gulf War Illness are studies to 

identify effective treatments. Of the 50 projects approved for 

CDMRP funding between 2006 and 2011, 18 are treatment related, 

11 clinical studies to assist treatments for ill veterans, and additional research on treatments in animal models of Gulf War Illness, 

a very impressive record. 

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In contrast to DoD’s mission-oriented approach, VA has not managed an effective program that achieves targeted priorities for Gulf 

War veterans. Research programs at VA often run counter to the 

advice of scientific experts. The proof, again, is in the results. VA 

has reported spending over $120 million for Gulf War research over 

the 10 years between 2002 and 2011. This includes a total of just 

five human and animal projects related to treatment for Gulf War 

Illness, two focused on stress reduction. 

So, what happened? The devil is often in the details, of course, 

but there are two overarching themes. First, VA has been slow to 

clearly and accurately acknowledge the Gulf War Illness problem. 

VA continues to provide mixed signals and vague or inaccurate representations concerning the reality and the nature of Gulf War Illness. This generic representation of the Gulf War Illness problem 

as a constellation of disparate symptoms that overlap considerably 

with psychiatric disorders provided the basis for the recent IOM report on treatments, which others on the panel will be talking 

about. Unfortunately, the misrepresentation of Gulf War Illness by 

VA was amplified in this report, but we will hear more about that 

later. 

There are many examples, large and small, of VA minimizing the 

Gulf War Illness problem. It is unbelievable, for example, that VA’s 

current national study of Gulf War veterans conducted in 2013 

does not even assess Gulf War Illness symptoms. This is the largest study of 1991 Gulf War veterans in the U.S. and targets 30,000 

veterans. It includes scores of questions in many areas like psychological stress, substance abuse and alternative medicine, but not 

the basic symptoms needed to define Gulf War Illness by any case 

definition. This is a wasteful and inexcusable missed opportunity 

at best and something akin to scientific malpractice at worst. 

Further, VA has never established an effective research program 

to address priority Gulf War health issues. There are two main reasons that I can talk about here, although many countless examples 

might be provided. 

First, VA’s program has been scientifically ineffective. Despite 

strong urging from scientific experts, VA did not begin the process 

of developing a strategic plan for Gulf War research until 20 years 

after the war. A comprehensive process was finally undertaken in 

2011 to develop such a plan with nongovernment experts and 

stakeholders from multiple institutions and offices, nine groups of 

at least six members each working over many months to craft and 

review the plan. 

The draft plan was largely approved by two expert committees 

early in 2012, but in the next several months the plan was extensively changed by VA internal editors, who removed references to 

Gulf War Illness and substantially altered the program developed 

to define and treat this problem. The Federal Research Advisory 

Committee on which I serve had long urged VA to develop a plan 

of this type, but last June, the RAC withdrew its support of the 

plan and reported to the Secretary that, under current circumstances, the Committee had no confidence in VA’s ability to develop an effective Gulf War research program. 

Just one final point briefly. The other major issue related to VA’s 

Gulf War research program relates to research funding. The RAC 

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was charged by Congress to review all Federal research programs 

that address Gulf War health issues. Our Committee staff review 

of Gulf War research expenditures each year invariably finds that 

a large portion of VA-identified Gulf War studies would not be considered Gulf War research by any other government or nongovernment program. 

This is not a trivial problem. In many years, 60 percent or more 

of the millions of dollars identified for Gulf War research is actually used for other types of research, with no link in any important 

respect to 1991 Gulf War veterans. There are far too many examples to identify here, but they include high-dollar research items 

like the $10 million used to fund a postmortem brain tissue bank, 

identified as the Gulf War Bio-Repository Trust. In reality, this 

program is a brain bank for veterans with ALS, or Lou Gehrig’s 

disease. Despite its name and the $10 million in Gulf War funding 

used for this program, it neither targets nor studies veterans in 

any important way. As of 2010, only 1 of the 60 contributors to this 

brain bank was a Gulf War veteran. 

So, as always, the proof is in the results. Together VA’s poor representation of the Gulf War Illness problem and failure to apply 

current scientific knowledge to develop a focused state-of-the-art research program have led to relatively little in the way of tangible 

benefits for ill veterans. From my perspective as a scientist who 

has worked in this area for many years, it is time to get this right, 

and certainly the many thousands of veterans who have suffered 

with Gulf War Illness for more than 20 years would say it is long 

past time. 

Thank you. 

[THE PREPARED STATEMENT OF DR. LEA STEELE APPEARS IN THE

APPENDIX]

Mr. COFFMAN. Thank you, Dr. Steele. 

Dr. Coughlin. 

STATEMENT OF STEVEN S. COUGHLIN 

Mr. COUGHLIN. Chairman Coffman and Members of the Subcommittee, distinguished guests, thank you for the privilege of testifying today. I am Steve Coughlin. I have worked as an epidemiologist for over 25 years, including positions as a Senior Cancer Epidemiologist at the Centers for Disease Control and Prevention, and as Associate Professor of Epidemiology and Director of 

the Program in Public Health Ethics at Tulane University. I 

chaired the writing group that prepared the ethics guidelines for 

the American College of Epidemiology, and have authored or edited 

several key texts on public health ethics and ethics in epidemiology. 

For the past 4-1/2 years, I was a Senior Epidemiologist in the Office of Public Health at the Department of Veterans Affairs. In December 2012, I resigned my position in the U.S. Civil Service because of serious ethical concerns that I am here to testify about 

today. 

The Office of Public Health conducts large studies of the health 

of American veterans; however, if the studies produce results that 

do not support the Office of Public Health’s unwritten policy, they 

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don’t release them. This applies to data regarding adverse health 

consequences of environmental exposures, such as burn pits in Iraq 

and Afghanistan, and toxic exposures in the Gulf War. 

On the rare occasions when embarrassing study results are released, data are manipulated to make them unintelligible. The 

2009-2010 National Health Study of a New Generation of U.S. Veterans targeted 60,000 OAF and OEF veterans and cost $10 million, 

not including the salaries of those who worked on it and were employed by the VA. Twenty to thirty percent of these veterans were 

also Gulf War-era veterans, and the study produced data regarding 

their exposures to pesticides, oil well fires, and pyridostigmine bromide pills. It also included meticulously coded data as to what 

medications they were taking. 

The Office of Public Health has not released these data or even 

disclosed the fact that this important information on Gulf War veterans exists. Anything that supports the position that Gulf War Illness is a neurological condition is unlikely to ever be published. 

I coauthored a journal article for publication on important research findings from the New Generation study having to do with 

the relationship between exposures to burn pits and other inhalational hazards and asthma and bronchitis in OEF/OIF veterans. 

My immediate supervisor, Dr. Aaron Schneiderman, told me not to 

look at data regarding hospitalizations and doctors’ visits. The tabulated findings obscure rather than highlight important associations. When I advised him I did not want to continue as a coinvestigator under these circumstances, he threatened me. 

Speaking as a senior epidemiologist with almost 30 years of research experience, there is no reason to work night and day for 

years on a complex data collection effort which costs U.S. taxpayers 

millions of dollars if you are not comfortable putting your name on 

publications stemming from this study or if no scientific publications are released. 

Another example of important data that have never been released are the results of the Gulf War Family Registry which was 

mandated by Congress. These were physical examinations provided 

at no charge to Gulf War veterans’ family members. I have been 

advised that these results have been permanently lost. 

The Office of Public Health has also manipulated information regarding veterans’ health through the questions included in their 

surveys. During the preparation of a major survey of Gulf War-era 

veterans of which I was principal investigator, the Follow-up Study 

of a National Cohort of Gulf War and Gulf War-era veterans, the 

Research Advisory Committee on Gulf War Illness made extensive 

recommendations regarding changes to the survey. I considered 

many of those changes as very constructive, and some were adopted. 

The VA Chief of Staff, Mr. John Gingrich, directed my supervisors to send the Gulf War study scientific protocol and draft questionnaire out for additional objective scientific peer review. The 

OPH Chief Science Officer, Dr. Michael Peterson, contacted a longtime friend of his, who is dean of a U.S. school of public health. 

The dean identified a faculty member at his school, although the 

individual has no background in Gulf War health research. 

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My direct supervisor Dr. Schneiderman spoke with the peer reviewer and told him that the Research Advisory Committee comments were politically motivated; i.e., not objective in nature. The 

reviewer responded that he would certainly try to help out. Not 

surprisingly, the reviewer’s comments were highly favorable. The 

Chief of Staff Mr. Gingrich was never informed that the outside reviewer worked for a friend of Dr. Peterson. 

My supervisors also made false statements in writing to the 

Chief of Staff. For example, they falsely stated that putting the 

study on hold long enough to further revise the questionnaire 

would cost the government $1 million, delay the study for a year 

or longer, and potentially result in contract default. None of that 

was true. 

The contract for the study was specifically worded in a way that 

the contractor was only paid for each deliverable as they completed 

that piece of the work product. As a result, the Chief of Staff ordered the survey to proceed without the changes. 

The Office of Public Health also handles the VA dealings with 

the Institute of Medicine, which is part of the National Academies 

of Science. Congress and VA leadership rely on the IOM for authoritative objective information on medical science. I have personally 

served on IOM committees and workshops having to do with public 

health ethics. 

Last year the Department of Veterans Affairs contracted with 

IOM for a congressionally mandated study of treatments for Chronic Multisymptom Illness in Gulf War veterans. Many Gulf War veterans were distressed that five speakers selected to brief the IOM 

committee presented the view that the illness may be psychiatric, 

although science has long discredited that position. My understanding is that Dr. Peterson identified the speakers the IOM 

should invite. 

I wish to close with a subject of particular importance to me. Almost 2,000 research participants from the National Health Study 

of a New Generation of U.S. Veterans self-reported that they had 

thoughts in the previous 2 weeks that they would be better off 

dead; however, only a small percentage of those veterans, roughly 

5 percent, ever received a callback from a study clinician. Some of 

those veterans are now homeless or deceased. 

I was unsuccessful in getting senior Office of Public Health officials to address this problem in the New Generation study. I was 

successful in incorporating these callbacks in the Gulf War survey, 

and they have saved lives, but only after my supervisors threatened to remove me from the study and attempted disciplinary action against me when I appealed their refusal to provide for callbacks to a higher authority. 

I urge this Committee to direct the VA to immediately identify 

procedures to ensure that veterans who participate in VA largescale epidemiologic studies receive appropriate follow-up care so 

that this tragedy is not repeated. I also urge you to initiate legislation to cure the epidemic of serious ethical problems in the Office 

of Public Health, I described to you today. 

In view of the pervasive pattern where some of these officials 

failed to tell the truth even to VA leadership, VA cannot be expected to reform itself. These problems impact the balance of risks 

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and benefits of federally funded human-subjects research costing 

tens of millions of dollars and which fail to serve the interests of 

the veterans they are intended to benefit. 

The VA mental health professionals who made callbacks for the 

2012 Gulf War follow-up survey, who are over at the VA medical 

center here in D.C., saved lives and ameliorated human suffering. 

They helped vulnerable research participants get access to health 

care benefits to which they are entitled to by acts of Congress. 

When you are suffering from a neurologic condition such as Gulf 

War Illness or traumatic brain injury, or a psychiatric condition 

such as major depression or post-traumatic stress disorder, it can 

be extremely difficult to navigate the bureaucratic procedures for 

getting access to health care benefits. That is why it is essential 

to have clinical psychologists, licensed clinical social workers, and 

other mental health professionals as coinvestigators on these largescale national surveys. 

The quality of measures to assist research participants who are 

experiencing pronounced psychological distress varies widely across 

epidemiological studies conducted by the Department of Veterans 

Affairs, studies that are targeting hundreds of thousands of U.S. 

servicemen and women and U.S. veterans. In some studies, such as 

the National Health Study for a New Generation of U.S. Veterans, 

only a small percentage or none of the research participants who 

self-report suicide ideation receive a callback from a study clinician. This practice is unethical and should be strongly discouraged. 

[THE PREPARED STATEMENT OF DR. STEVEN S. COUGHLIN APPEARS

IN THE APPENDIX]

Mr. COFFMAN. I am going to have to try and remind the witnesses to try and keep it to 5 minutes—you are at 10 minutes right 

now—because we are going to have to return to vote in a little 

while, so we want to get through as much as we possibly can. 

Dr. Rosof. 

STATEMENT OF BERNARD M. ROSOF 

Dr. ROSOF. Good afternoon, Mr. Chairman, Ranking Member 

Kirkpatrick, and Members of the Subcommittee. My name is Bernie Rosof. I am Chairman of the Board of Directors of Huntington 

Hospital, part of the North Shore LIJ Health System in Huntington, New York. I am a specialist in internal medicine and gastroenterology, and professor of medicine at the Hofstra North 

Shore-LIJ School of Medicine. I also served as chair of the Institute 

of Medicine’s Committee on Gulf War and Health: Treatment for 

Chronic Multisymptom Illness. 

The Institute of Medicine, or the IOM, as you know, is the health 

arm of the National Academy of Sciences, an independent nonprofit 

organization that provides unbiased and authoritative advice to decision-makers and to the public. The IOM was asked by the Department of Veterans Affairs to comprehensively review, evaluate 

and summarize the scientific and medical literature regarding 

treatments for Chronic Multisymptom Illness, or, as you have 

heard, CMI, among Gulf War veterans. 

The IOM assembled an expert committee of which I was chair to 

address this task. We met in person five times over a 9-month peVACREP180 with DISTILLER

10 

riod to gather evidence, deliberate on our conclusions and recommendations, and write our report. That report underwent a rigorous, independent, external review before being released in January of this year. More detailed information on the committee’s recommendations is included with my longer written statement. 

CMI is a very serious condition that imposes an enormous burden of suffering on our Nation’s veterans. It is a very complex condition. Veterans who have CMI often have a combination of physical symptoms and cognitive symptoms, along with comorbid syndromes, such as chronic-fatigue syndrome, fibromyalgia and irritable-bowel syndrome. Other clinical entities such as depression 

and anxiety may occur as well. 

There is no consensus among physicians, researchers and others 

as to the cause of CMI. The range of unexplained symptoms experienced by people who have CMI could result from multiple factors, 

but the etiology remains unknown. 

We didn’t attempt to identify the causes of CMI. As laid out in 

the charge, we evaluated treatments for CMI and made recommendations for improving health care for veterans who have 

this condition. We conducted an extensive systematic assessment 

and review of the evidence on treatment for CMI. We also assessed 

treatments for a number of related and comorbid conditions to determine whether any of those treatments may be beneficial for 

CMI. 

Based on our assessment, we cannot recommend any specific 

therapy as a treatment for veterans who have CMI. We concluded 

that a one-size-fits-all approach is not effective for managing these 

veterans. We recommend that the VA implement a systemwide, integrated, multimodal, long-term management approach. 

In our report we make a number of additional recommendations 

aimed at identifying veterans who have CMI, bringing them into 

the VA health care system, and improving the quality of their care. 

The VA should commit the necessary resources to ensure that veterans complete a comprehensive health examination immediately 

upon separation from active duty. To improve coordination of care, 

the results should become part of a veteran’s health record and 

should be made available to every clinician caring for the veteran, 

whether in or outside the VA health care system. Additionally, the 

VA should include in its electronic health record a pop-up screen 

to prompt clinicians to ask questions to ascertain whether a patient 

has symptoms consistent with CMI. 

Once a veteran has been identified as having CMI and has entered the VA health care system, the next step is to provide comprehensive care for the veteran not only for CMI, but also any comorbid conditions. Existing VA programs, such as post-deployment 

patient-aligned care teams, or PACTs, could be adapted to best 

serve veterans who have CMI. The VA should commit the resources 

needed to ensure that PACTs have the time and the skills required 

to meet the needs of veterans who have CMI as specified in the 

veterans’ integrated personal-care plans; that the adequacy of time 

for clinical encounters is measured routinely; and that clinical caseloads are adjusted in response to the data. 

A major determinant of the VA’s ability to manage veterans who 

have CMI is the training of clinicians and teams of professionals 

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in providing care for these patients. The VA should designate CMI 

champions to serve as an internal resource at each VA medical center. These individuals should be integrated into the care system to 

ensure clear communication and coordination among clinicians. 

The VA also should develop peer networks to introduce new information, norms and skills related to managing veterans who have 

CMI. 

Finally, many studies on treatments for CMI reviewed by the 

committee have methodological flaws. Therefore, future studies 

funded and conducted by the VA to assess treatments for CMI 

should adhere to well-accepted methodologic and reporting guidelines for clinical trials. We can’t emphasize that too much. 

We identified several interventions that may hold promise for 

treatment of CMI. Although this is not an exhaustive list, the VA 

should consider funding and conducting studies of interventions, 

such as biofeedback, acupuncture, aerobic exercise and multimodal 

therapies. 

Numerous opportunities exist for the VA to improve and expand 

its health care services of veterans who have CMI. Our veterans 

deserve the very best health care. 

Thank you very much for the opportunity to testify. I certainly 

would be happy to answer any questions. 

[THE PREPARED STATEMENT OF DR. BERNARD M. ROSOF APPEARS

IN THE APPENDIX]

Mr. COFFMAN. Thank you, Dr. Rosof. 

Mr. Hardie for 5 minutes, please. 

STATEMENT OF ANTHONY HARDIE 

Mr. HARDIE. Thank you for today’s hearing, and thank you to the 

Gulf War veterans who are here or watching from home or from 

the hospital in the case of at least one. I myself am a veteran of 

the 1991 Gulf War as well as Somalia and four other deployments. 

I developed health issues that began in the gulf that have plagued 

me ever since. My experiences are far from unique, and we now 

know roughly one in three of us Gulf War veterans are similarly 

afflicted. 

In 2010, a landmark IOM report confirmed what we Gulf War 

veterans already knew. Gulf War Illness is likely the result of environmental agents plus other factors. It is not psychiatric, and it is 

likely that treatments and preventions can be found. Though such 

a renewed national effort has not yet fully happened, special 

thanks to Congressmen Miller, Michaud, and Roe and others for 

helping fund the Gulf War Illness CDMRP, the only Federal research program in the last two decades aimed at improving the 

health and lives of us ill Gulf War veterans. I’ll provide more detail 

in my written statement. 

VA’s past Gulf War research failures have previously been well 

documented, much of it focused on stress, psychological and other 

irrelevant issues, little of it aimed at developing Gulf War Illness 

treatments. As we just heard Dr. Coughlin, such failures have not 

been by accident. VA staff misdeeds continued with the recent IOM 

Treatments Committee, and last year, as we also have already 

heard, VA staff effectively killed the first-of-its-kind strategic plan 

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finally aimed at improving the health and lives of veterans suffering from Gulf War Illness. VA staff unilaterally whitewashed the 

plan. Participants, including myself, felt betrayed in having wasted 

a year and a half. 

The Research Advisory Committee on which I serve unanimously 

rejected VA’s whitewash, declared no confidence in VA’s handling 

of Gulf War Illness research, and described even more issues: secret VA cuts to the Gulf War Illness research budget; VA staff misrepresentations to VA leadership and Congress; blatant violation of 

statutory mandates; prioritizing research not on treatments, but 

on, quote, ‘‘whether Gulf War veterans’ illnesses are linked to Gulf 

War service.’’ And the RAC has not been allowed to hold a public 

meeting since then. There are more issues with details in my written submission. 

VA staff have initiated a process to create a new case definition 

for Gulf War Illness via a literature review, unprecedented, from 

what I am told, and in opposition to the strategic plan mentioned 

earlier. VA staff refused to provide the RAC with more information. 

VA’s medical surveillance of serious Gulf War health outcomes 

remains broken. VA refuses to implement a 2008 law mandating 

an MS prevalence study. VA is still not doing obvious infectious 

disease workups, as exhibited by a recent Iraq War veteran who 

after a 4-year battle was finally diagnosed and treated with Q 

fever. 

VA’s Gulf War Task Force ignores—includes only VA staff. It operates in secret, and it asks for, but ignores, veterans’ input. VA 

has failed to publish its quarterly Gulf War and OIF/OEF newsletters and claims data reports since 2010. The VA continues to exclude Gulf War veterans whose service was in Turkey or Israel. VA 

continues to exclude from Gulf War veterans’ benefits Afghanistan 

war veterans, yet includes Iraq War veterans. 

VA still hasn’t fixed rating problems for fibromyalgia and chronic 

fatigue, with up to 100 percent ratings for one, but only 40 percent 

ratings for both. Yes, you heard that right. And these conditions 

are presumptive for Gulf War and Iraq veterans, but not Afghanistan veterans. DoD and VA continue to find no evidence for other 

serious military health issues like burn pits, vaccination injuries 

and more. 

VA staff routinely ignore Congress, the law and expert advisers, 

wasting more precious years squandering experts’ time and energy, 

and further alienating not just the most engaged advisers, but also 

the very Gulf War veterans they are supposed to be helping. 

Most importantly of all, VA still has no proven effective treatments for Gulf War Illness patients who walk through VA’s doors, 

where they frequently are still thought to be psychosomatic. VA 

has only Band-Aids for symptoms and to help cope. Today we are 

hearing why. 

I encourage this body to take—to help right these ongoing 

wrongs, including comprehensive legislation to help force solutions, 

reallocation of funding from these nonperforming entities, further 

investigation of their misdeeds, and criminal sanctions for such behavior. 

We Gulf War veterans have been fighting with VA and DoD for 

what is right for most of the last 22 long years. We have had countVACREP180 with DISTILLER

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less congressional hearings like this one on Gulf War veterans’ 

issues with more empty VA promises. We have seen laws pass only 

to see VA staff circumvent them or ignore them with impunity. I 

hope today’s hearing will be different. 

Thank you, Mr. Chairman, Madam Ranking Member, Members 

of the Committee, and I am happy to answer any questions you 

may have. 

[THE PREPARED STATEMENT OF ANTHONY HARDIE APPEARS IN THE

APPENDIX]

Mr. COFFMAN. Thank you, Mr. Hardie, and thank you so much 

for your service to our country. 

Doctor—and if you all could do your best to keep your questions 

down to a minimum in terms of time so we can get to the second 

panel, and our Ranking Member has questions as well as I do. 

Dr. Coughlin, your written testimony stated that, quote, ‘‘on the 

rare occasions when embarrassing study results are released, data 

are manipulated to make them unintelligible,’’ unquote. Please explain and cite an example. 

Dr. COUGHLIN. Several examples can be cited. The best example 

that comes to mind is we set out to analyze data from the National 

Health Study for a New Generation of U.S. Veterans looking at 

self-reported exposure to burn pits, oil well fire smoke, other inhalational hazards, in relation to physician-diagnosed asthma and 

bronchitis. 

The initial exposure analyses, which were produced by the writing group and the statistician, showed that a sizable percentage of 

the deployed veterans had been exposed to burn pit smoke, and 

burn pit fumes were associated with asthma and bronchitis. Then 

in a later iteration of the tabulated results, those results were set 

aside or discarded, and the focus was instead on deployment, deployment status in relation to asthma and bronchitis. 

Well, those 30,000 deployed vets and 30,000 nondeployed vets included veterans who served on ships in the Indian Ocean, or in the 

Philippines, or in Germany in hospitals. In other words, people 

were deployed OEF/OIF and served in the War on Terror, but were 

never in Iraq or Afghanistan on the ground and had no potential 

exposure to burn pits. So the way that the refined results were tabulated, it obscured rather than highlighted the associations of interest. And I could elaborate if you would like. 

Mr. COFFMAN. Okay. Mr. Hardie, can you explain in your opinion 

why the Research Advisory Committee in their latest Institute of 

Medicine report is flawed? 

Mr. HARDIE. Yes. Thank you for that question. 

First I want to recognize that I believe that the researchers, distinguished researchers like the gentleman sitting next to me, who 

served on that committee were well intentioned. However, VA staff 

issued a scope of work and committee charge that radically diverged from the law, that effectively prevented—and also effectively prevented what the committee could consider. I believe that 

these helped to prevent—prevented the IOM committee from meeting the expectations of the law. 

VA staff directed the panel to do a literature review rather than, 

as the law directed, focusing on physicians experienced in treating 

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Gulf War Illness. VA staff knew little such literature exists, because VA’s two decades of failures to develop treatments have 

helped to ensure that fact. 

Additionally, most of the presenters to the panel focused on psychosomatic issues, stress as cause and things like relaxation therapies as treatments. Our Gulf War veterans who called in to listen 

to that meeting were naturally outraged. VA staff were among the 

presenters to the committee, including at least one sitting here 

today. VA staff muddied the waters by directing IOM to include not 

just 91 Gulf War veterans as the law directs, but many others. 

And finally, all of this involvement by VA staff is a far cry from 

previous claims that these panels operate independent of biasing 

influence from the contracting agency. 

Mr. COFFMAN. Thank you, Mr. Hardie. 

Dr. Rosof, the law required that VA’s agreement with the Institute of Medicine was to, quote, ‘‘convene a group of medical professionals who are experienced in treating individuals who served,’’ 

unquote, ‘‘in the Southwest Asia theater of operations of the Persian Gulf War during 1990 or 1991, and who have been diagnosed 

with Chronic Multisymptom Illness or another health condition related to such service,’’ unquote. 

Of the members of your committee, how many have experience 

in medically treating Gulf War veterans? 

Dr. ROSOF. Well, I can’t answer as to the number of members of 

my committee who had experience, but all of the members of the 

committee had experience in dealing with Chronic Multisymptom 

Illness, some directly with veterans who served in those theaters 

of war. 

In addition, there are members of the committee, including myself, that have been on other IOM committees that have dealt with 

the issues of Gulf War Chronic Multisymptom Illness or illnesses 

of that sort. So there was considerable expertise sitting around the 

table in addition to methodical expertise to evaluate the literature 

on best treatments. 

Mr. COFFMAN. Thank you. 

Ranking Member Kirkpatrick. 

Mrs. KIRKPATRICK. Mr. Hardie, can you enlighten the Committee 

on the role of the Research Advisory Committee on Gulf War Illness in the preparation of a major survey of Gulf War-era veterans 

that Dr. Coughlin was talking about in his testimony? Were the 

recommendations that the Research Advisory Committee made regarding the changes to the survey ignored, and what has happened 

to the survey? 

Mr. HARDIE. Thank you very much for that question, Madam 

Ranking Member. 

The Research Advisory Committee made a number of recommendations early on when the committee first became aware 

that the survey existed. Many of those Office of Public Health staff, 

including Dr. Aaron Schneiderman that was mentioned earlier, refused to provide the Research Advisory Committee with answers to 

whether or not that the requested changes had been made. If any 

changes had been made, they refused even to tell our chairman 

where his office was so the chairman could come and have a private meeting with him. 

VACREP180 with DISTILLER

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I was frankly shocked, and candidly I expressed at that meeting 

that I hadn’t seen such a display of arrogance and insolence, and 

that I thought that he should be fired. I was absolutely shocked. 

So my understanding when we finally saw the survey that went 

out, the expert—I am simply a Gulf War veteran on the panel that 

has had a lot of experience with these things, but I look to many 

of the scientists that I find to be brilliant, and experts in their field 

had put together a comprehensive survey list and focusing on the 

important issues to veterans like Gulf War—frankly, Gulf War Illness issues, and it did not appear that those issues were being included in the survey. And when we finally saw the survey, it was 

extremely troubling that much of it was focused on psychological 

and psychiatric issues. Frankly, it was extremely upsetting for Gulf 

War veterans. 

Mrs. KIRKPATRICK. Do you know where the survey is now? 

Mr. HARDIE. I think that others may be better suited to answer 

that question. 

Mrs. KIRKPATRICK. Okay. Dr. Coughlin. 

Mr. COUGHLIN. The Research Advisory Committee on Gulf War 

Illness provided scientific critiques as part of the formal Office of 

Management and Budget’s regulatory process. We published an announcement in the Federal Register as required by OMB about this 

national data collection, and the public can indeed provide written 

comments, which VA is obligated to respond to. 

The false statements and other ethical problems that I mention 

in my testimony, those problems may well have compromised the 

integrity of the OMB regulatory process. So I just wanted to reinforce Mr. Hardie’s comments. 

Mrs. KIRKPATRICK. Thank you. 

This question is for the entire panel. What do you believe are the 

top three challenges the VA faces in addressing the inadequacy of 

the Gulf War veterans research programs and the lack of effective 

treatment? So what are the three reasons, challenges, that they are 

unable to address this? 

Dr. Steele? 

Ms. STEELE. Yes, thank you. I briefly outlined that in my testimony, and I can just summarize them very quickly. 

The top reasons have to do with lack of expertise in this area 

among the people who are designing and executing the program. So 

it is almost as if they are designing a program that is well suited 

to the mid-1990s, soon after the Gulf War, when we didn’t know 

anything about Gulf War Illness. 

But a lot has changed since then. We have learned a lot, and certainly there is a lot of scientific promise now and scientific information now that could be built on to develop an effective research program to address Gulf War Illness, as the Department of Defense 

has done in recent years. 

So is partially the lack of expertise. It almost appears to be the 

lack of will, just in looking how Gulf War Illness is typically portrayed on VA Web sites and VA literature, how the studies appear 

to be designed to actually ignore Gulf War Illness for the most 

part, or minimize it as an important problem. So some of it probably has to do with political will, and some of it has to do with expertise. 

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But I would also say that just the use of funding is totally inappropriate. So much of the funding is used for studies that have 

nothing to do with Gulf War veterans or Gulf War Illness. 

So, you know, it is sort of a three-pronged problem; lack of expertise, lack of intention to address the problem and misallocation of 

funds. 

Mrs. KIRKPATRICK. Thank you, Doctor. 

And, Mr. Chairman, I have almost used up my time, so I will 

yield back. 

Mr. COFFMAN. Thank you, Ranking Member Kirkpatrick. 

Dr. Rosof, on the monitors in this room, there are slides from five 

presentations from different speakers who appeared before your 

committee on February 29th of last year. As you can see, these 

speakers appear to be giving the committee the message that this 

illness is psychiatric, stress, PTSD and so forth. 

Who selected these speakers to present to the committee? 

Dr. ROSOF. Let me correct some of the statements that were 

made initially. The selection of the speakers to the committee was 

done by our committee. It was not done, as indicated previously, by 

Dr. Peterson or any other individual. It was selected by our committee. 

The committee wanted to better understand the treatment modalities that would affect positively the veterans and their health. 

We reviewed, identified— 

Mr. COFFMAN. Excuse me 1 second. Did VA or DoD have any 

input into the choice of these speakers? 

Dr. ROSOF. The committee made the decision on what speakers 

to choose, clear understanding on the part of the committee. We reviewed in addition 6,541 unique references, enabling us to make 

some decisions about the treatment of veterans. So our conclusions 

were not based solely on the people who you saw; in addition, there 

were others. And if you read—if our report is read clearly, you can 

see our conclusions were not that this was a psychological or psychosomatic disorder. 

We clearly make the statement we do not know the etiology. No 

one treatment will be able to affect positively the treatment for patients with CMI, Chronic Multisymptom Illness. It requires a group 

of physicians, a team-based approach, who understand the patients, who enable the patient to have a decision in the care he or 

she receives, and at the same time better understand the satisfaction of the veterans in their care. We strongly believe that this is 

an illness that has and requires a multimodal therapeutic intervention. 

Mr. COFFMAN. All right. Dr. Coughlin, on October 23rd this Subcommittee asked VA how many veterans have self-identified as suicidal and later committed suicide in the Follow-up Study of a National Cohort of Gulf War and Gulf-era veterans. On February 

19th, VA responded stating, quote, ‘‘VA has no evidence to date 

that any veteran in this study has committed suicide,’’ unquote. 

Are these the same results you saw in your study? 

Mr. COUGHLIN. Yes. Fortunately, we did not lose any of the research participants. As I mentioned in my testimony, my efforts to 

identify mental health professionals to get involved with the study 

as coinvestigators, to place these callbacks to vulnerable research 

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participants were initially blocked by my supervisors, and that is 

why I contacted the IRB chair in writing and also the VA Office 

of Inspector General. 

After a delay of 2 or 3 months, we were able to start the callback 

process, and a team of mental health professionals at the Washington, D.C., VA Medical Center did a fantastic job of reaching out 

to the veterans. 

We had vets who had been told by their local VA clinic or hospital that they were not eligible for free health care, but when they 

called the toll-free number and reached somebody in VBA and the 

VA central office, they were told the opposite. So the social workers 

were able to sort this out and get them into health care. 

These were vulnerable veterans, men and women, who had major 

depression or other medical and psychiatric conditions, and they 

needed assistance to get into health care to save their lives. 

Mr. COFFMAN. Thank you. 

Ranking Member Kirkpatrick, any other questions before we go 

to the next panel? 

Mrs. KIRKPATRICK. Any other questions I’ll submit in writing in 

the interest of time. 

[THE INFORMATION APPEARS IN THE APPENDIX]

Mr. COFFMAN. Very well. Thank you very much for your testimony. 

I now invite the second panel to the witness table. On this panel 

we will hear from Dr. Victoria Davey, Chief Officer of VHA’s Office 

of Public Health and Environment Hazards. Dr. Davey is accompanied by Dr. Maureen McCarthy, Deputy Chief of VHA’s Patient 

Care Services Office; Dr. Stephen Hunt, Director of VA’s Post-Deployment Integrated Care Initiative; Dr. Gavin West, Acting Chief 

Medical Officer of the Salt Lake City VAMC and Special Assistant 

in the Office of the Assistant Deputy Under Secretary for Health 

for Clinical Operations; and Mr. Tom Murphy, Director of VBA’s 

Compensation Service. 

Dr. Davey, your complete written statement will be made part of 

the hearing record. You are now recognized for 5 minutes. 

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STATEMENT OF VICTORIA DAVEY, CHIEF OFFICER, OFFICE OF 

PUBLIC HEALTH AND ENVIRONMENTAL HAZARDS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS, ACCOMPANIED BY MAUREEN MCCARTHY, DEPUTY CHIEF, PATIENT CARE SERVICES OFFICE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; STEPHEN HUNT, DIRECTOR, POST-DEPLOYMENT INTEGRATED CARE INITIATIVE, U.S. DEPARTMENT OF VETERANS AFFAIRS; GAVIN WEST, ACTING CHIEF 

MEDICAL OFFICER, SALT LAKE CITY VAMC, SPECIAL ASSISTANT, OFFICE OF THE ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND TOM MURPHY, DIRECTOR OF COMPENSATION SERVICE, VETERANS BENEFITS 

ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF VICTORIA DAVEY 

Ms. DAVEY. Mr. Chairman, Madam Ranking Member and Members of the Subcommittee, thank you for the opportunity to submit 

my written testimony for the record. 

I am accompanied today by Dr. Stephen Hunt, who flew overnight to be here today because he didn’t want to cancel his clinic 

appointments yesterday; Dr. Maureen McCarthy; and Dr. Gavin 

West; as well as Mr. Tom Murphy. The three physicians I just referenced have extensive experience treating Gulf War veterans. 

Mr. Chairman, this is our message: VA has learned a great deal 

about identifying, diagnosing and treating Gulf War veterans over 

the past 22 years. We will continue to improve our abilities to provide world-class health care for Gulf War veterans, better educate 

our health care providers, and possibly most of all, in reference to 

the speakers that preceded me, expand the evidence base for the 

treatments we provide for these veterans, indeed for all veterans. 

Let me provide you with a summary of where we are. We agree 

with Dr. Steele. As you know, a debilitating cluster of medically 

unexplained symptoms affects many Gulf War veterans. We refer 

to the illness that these veterans have as Chronic Multisymptom 

Illness, or CMI. Our present thinking is that a complex combination of environmental exposures and individual genetic characteristics may be behind this illness. 

Veterans with CMI, like all veterans enrolled for VA care, receive 

personalized, proactive, patient-driven care. In addition, VA offers 

a number of programs and services uniquely designed to meet the 

needs of Gulf War veterans with CMI. 

VA links our patient-aligned care teams, or PACT teams, working with Gulf War veterans with specialty-care capability that focuses on treating the unique health requirements of these veterans. 

The program includes teaching aids, referral networks and other 

types of collaboration. Frontline clinicians have been educated 

through our monthly community of practice conference calls, informational messages, pocket cards and Web sites. 

Another program specifically for Gulf War veterans is our registry program, which offers a health examination at any of our 

health care facilities to any veteran with Gulf War service. To date, 

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about 130,000 Gulf War veterans have undergone a registry exam. 

The comprehensive health exam includes an exposure and medical 

history, laboratory tests and a physical exam. VA health professionals discuss the results face to face with veterans. This provides 

us an opportunity to partner with the veteran to develop an individualized care plan. An individual is very important to this discussion. 

Since 2001, the War-Related Illness and Injury Study Centers of 

the VA Office of Public Health, known as the WRIISC, have supported specialized care for Gulf War veterans and conducted cutting-edge research, clinical education and a veteran referral program. VA’s three WRIISCs have teams of clinicians ready to evaluate Gulf War veterans with deployment-related concerns. Based on 

a comprehensive evaluation, the WRIISC team develops an individual, holistic treatment plan for veterans with CMI or other illdefined conditions through our referral process based on geographic 

location. 

VA’s Office of Public Health holds quarterly conference calls with 

environmental health coordinators and clinicians throughout VA. 

The calls provide coordinators and clinicians with ongoing training, 

and allows them to share patient questions, challenges, administrative issues and solutions that have come up at their facilities. 

VA recently engaged the Institute of Medicine, as you heard, to 

convene a committee to comprehensively review, evaluate and summarize the available scientific and medical literature regarding the 

best treatments for CMI among Gulf War veterans. The report, as 

you heard, was released on January 23rd. 

IOM made recommendations to VA in five categories, including 

how to treat CMI, how to improve systems of care and management of care, how to provide information about care, improve the 

collection and quality of data on care outcomes and satisfaction 

with care, and how to conduct future research. VA is already taking actions, and these include a program to provide every 

servicemember with a health care assessment upon separation 

from service; improvements in systems of care and management of 

CMI in Gulf War veterans, including the use of clinical reminders 

and streamlined consults for specialty care; and the innovative 

PACT program I described earlier that integrates and coordinates 

personalized care for Gulf War veterans. 

We are improving communication among VA health providers 

and between them and the patients they care for. We are modifying 

our patient satisfaction measurement tools and training our staff 

to better recognize CMI. We are also developing a champions program and Webinars on this subject and taking steps to strengthen 

our research protocols. 

Mr. Chairman, we appreciate the opportunity to discuss with you 

this important issue. We are proud to continue evaluation and 

treatment for the 700,000 deserving men and women who served 

in Operations Desert Shield and Desert Storm. 

My colleagues and I are prepared to answer your questions. 

Thank you. 

[THE PREPARED STATEMENT OF DR. VICTORIA DAVEY APPEARS IN

THE APPENDIX]

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Mr. COFFMAN. Thank you, Dr. Davey. 

Is Gulf War Illness a psychological condition? 

Ms. DAVEY. Gulf War Illness is not a psychologic condition. Gulf 

War Illness is a group of chronic multisymptom—multiple symptoms. We do not believe that it is psychological. 

Mr. COFFMAN. Dr. Hunt, I understand you made a presentation 

to the IOM Treatment Committee on the topic, quote, ‘‘VA Approaches to the Management of Chronic Multisymptom Illness in 

Gulf War I Veterans,’’ unquote. 

The slide you presented to the committee shows that some VA 

doctors think Gulf War Illness is, quote, ‘‘mostly a physical disorder,’’ unquote, and some think it is, quote, ‘‘mostly a mental disorder,’’ unquote. However, this information is from an 11-year-old 

paper. 

The current VA treatment guidelines revised in 2011 state, 

quote, that ‘‘chronic multisymptom illness is real and cannot be reliably ascribed to any known psychiatric disorder,’’ unquote. 

I understand that you served on the committee that wrote the 

new guidelines, Dr. Hunt, but you didn’t present the new guidelines to the committee. 

In speaking on VA Approaches to the Management of Chronic 

Multisymptom Illness in Gulf War I Veterans, why did you tell the 

committee the 11-year-old information that it might be physical or 

it might be mental, but didn’t tell the committee VA’s current 

guideline that clearly states it is not mental? 

Dr. HUNT. Actually, thank you, Mr. Chairman, and thanks for 

the opportunity to be here. And I want to also acknowledge the 

service of all of our veterans here, and particularly our Gulf War 

veterans. 

This slide was used to illustrate when Gulf War veterans first 

started coming back. The psychologist and I who ended up starting 

the first Gulf War veterans clinic at VA Puget Sound were noticing 

that people were coming in with a lot of symptoms, a lot of physical 

symptoms of different sorts that we would do lots of tests for, and 

we couldn’t find a disease to link up to the symptom. And so we 

knew we were facing something that ultimately now we are calling 

Chronic Multisymptom Illness. At that time we were describing it 

as medically unexplained symptoms. 

We knew that we needed a new model of care, and the way that 

we sort of established that was by doing a survey of providers at 

that time when people were early on in the process of coming back. 

And so we asked the medical providers, do you think this Gulf 

War Illness is more of a physical condition or more of a mental 

health condition? The medical—and we asked mental health providers, do you think it is more of a physical condition or mental 

health condition? These are providers at VA Puget Sound, VA Portland and Walter Reed. These are good clinicians, smart clinicians 

that know what they are doing. 

What this showed to me, and the point that I was trying to make 

was, our paradigm wasn’t working, because our medical provider 

said, gosh, I am doing these tests, and they are all negative, so I 

can’t find a disease here, so maybe we should have them checked 

out by behavioral health. 

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Behavioral health people would look at them and say, gosh, there 

is all these symptoms, you know, but they don’t really meet criteria 

for any mental health diagnosis. I—they have some condition. I 

think we should send them back to their medical provider for more 

tests. 

This is the dilemma of Chronic Multisymptom Illness, and this 

is why we really appreciate the work that IOM has done in framing 

this thing for us in a bigger way, because our old paradigm, is it 

physical or is it mental, does not work. 

We needed a paradigm where we said, look, you have been off 

to war, your health has been changed in a number of ways, we appreciate your service, we are glad you are here, and the way that 

we are going to address this is by having a medical provider, a 

mental health provider, social worker kind of put your care together in a way that— 

Mr. COFFMAN. Dr. Hunt, did you think it is a mental condition 

or a physical condition? 

Dr. HUNT. I think it is a health condition, and I don’t think in 

mental health, physical health— 

Mr. COFFMAN. Is it mental, or is it physical? 

Dr. HUNT. It is a physical condition, and it has—our minds and 

bodies can’t be split up in that way. I certainly would not say it 

is a mental condition or a psychological condition for sure. It is a 

health condition that we need to be very circumspect in our way 

of evaluating and treating. 

Mr. COFFMAN. Dr. Davey, the law required the VA’s agreement 

with the Institute of Medicine was to, quote, ‘‘convene a group of 

medical professionals who are experienced in treating individuals 

who served,’’ unquote, ‘‘in the southeast Asia theater of operations 

of the Persian or Gulf War during 1990 and 1991,’’ unquote. But 

in looking at the statement of work, VA tasked IOM to, quote, ‘‘review, evaluate, and summarize the available scientific and medical 

literature regarding the best treatments for Chronic Multisymptom 

Illness among Gulf War veterans,’’ unquote. 

Why did VA change the methodology of the congressionally mandated study? 

Ms. DAVEY. In our statement of work, we asked the IOM to convene a group of medical professions, that is absolutely right, and 

to do the work around the kernel of the existing research. 

Inherent in that, certainly intended, was that those medical professionals would bring their clinical research expertise to the table. 

And, as we know, experience and clinical experience in particular 

is one form of knowledge that we know, as is knowledge from research studies. We expected that those professionals would have 

discussions based on their experience as well as the research. 

Mr. COFFMAN. And why wasn’t—why weren’t the findings of this 

research published for peer review purposes? 

Ms. DAVEY. You may be referring to Dr. Coughlin’s comments 

about some of our research in the Office of Public Health, the large 

epidemiologic studies. When you do a study such as a survey with 

scores of questions, you collect much data, and you prioritize in an 

analysis plan which analyses are going to take place first. Those 

analyses do take place in order, and we do carry them out. 

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Mr. COFFMAN. Why does it appear that there has been a misappropriation of funds appropriated for the purpose of research for 

Gulf War Illness that seems to be diverted for other purposes? 

Ms. DAVEY. Mr. Chairman, that is a question for my research colleagues, and I would like to take that one for the record. We were 

not prepared here to talk about research funding. 

[THE ATTACHMENT APPEARS IN THE APPENDIX]

Mr. COFFMAN. Very well. Ranking Member Kirkpatrick. 

Mrs. KIRKPATRICK. Dr. Davey, in your testimony you state that 

the VA is now in the process of developing additional innovative 

training resources, such as mobile devices and Internet applications. After 22 years this seems a bit late to just now be developing 

applications for the environmental exposure symptoms and conditions. So when did this process begin, and when do you think you 

will be able to roll it out to veterans so that it might be helpful? 

Ms. DAVEY. Well, to speak to your larger question, the care and 

treatment that we have learned, and we are experts in the care of 

veterans, have taken place over the course of 22 years because that 

is what time it takes. We have to understand what we are dealing 

with, and it has taken that amount of time. 

With regard to the specific innovative tools, obviously since the 

technology has been available, but let me refer to Dr. West, who 

is developing one of the Internet applications or the mobile app— 

Mrs. KIRKPATRICK. Please, Dr. West. 

Ms. DAVEY.—comment more. 

Dr. WEST. Well, thank you so much. I am actually a primary care 

physician and a general internist by trade, and I am proud to say 

that every day I take care of Gulf War veterans and all veterans, 

and it is really my privilege. 

To answer that question directly, we have already developed a lot 

of these tools. In fact, in your packet you have one of them, the 

pocket card—I don’t know if you guys have looked at it—which has 

essentially a lot of what Dr. Steele was talking about, a lot of the 

exposure concerns, a lot of the public health Web sites, Webinars, 

and training modules that have been developed through Office of 

Public Health and through VHA, you know, as a whole. 

As far as getting that onto a mobile app, that is in the process. 

Otherwise we have talked a little bit about the IOM pop-ups and 

clinical reminders for physicians, which is another computer-based 

application. We have already developed a type of pop-up called a 

clinical reminder that helps physicians, A, understand where their 

veterans are coming from, their service; second, actually goes 

through the chronic multisystem illness and lays that out in a way 

that they can kind of follow a simple screen, answer questions, and 

better adequately answer the veterans’ questions. 

I mean, that is a key. I mean, these tools are really important 

to train providers, to get them out on the frontlines. Again, I see 

patients every day in clinic. 

Mrs. KIRKPATRICK. And let me just interrupt quickly. I understand that, but my concern is how do we communicate to veterans 

so that they may get the resources they need? And the mobile apps, 

I know, are in the process, but do you have a timeline for when 

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you are going to roll that out, when that is actually going to be 

available to veterans so they can learn about it? 

Dr. WEST. I don’t have an exact timeline for the veterans communication app, so I would have to take that back for the record. 

[THE ATTACHMENT APPEARS IN THE APPENDIX]

Mrs. KIRKPATRICK. Okay. Could you get back to me on that. I 

think it is— 

Dr. WEST. Absolutely. 

Mrs. KIRKPATRICK.—essential. 

One of the things that I realize, it seems like the VA is always 

a little behind on this, and it has been 22 years, and so, I really 

would like to have some benchmarks, some timetables so that we 

can report to our veterans that we are moving forward with this. 

And, Mr. Chairman, in the interest of time, I am going to yield 

back. I know we are going to have votes here in just a second. 

Mr. COFFMAN. Mr. Murphy, in a recent request for information, 

VA responded to this Committee that they could not provide the 

total number of Gulf War-era veterans who were in receipt of service-connected disability benefits for CMI, because VBA does not 

have a diagnostic code to identify only CMI-related claims, and it 

could not be separated from other undiagnosed illnesses. 

Other than CMI, what other undiagnosed illnesses does VA 

award service-connected benefits for? 

Mr. MURPHY. Mr. Chairman, I don’t have the answer to that 

question, but I can tell you that they are covered under a group 

of undiagnosed illnesses, which makes it very difficult without literally sitting down and going through file page by page, veteran by 

veteran to come in. 

Mr. COFFMAN. I think the question is, is what other undiagnosed 

illnesses are there that benefits are awarded for other than CMI? 

Mr. MURPHY. That is one I have to take for the record. I don’t 

have an answer for that. 

Mr. COFFMAN. You don’t know? 

Mr. MURPHY. No, sir, I do not. 

Mr. COFFMAN. Okay. I want that information. 

Mr. MURPHY. Yes, sir. 

[THE ATTACHMENT APPEARS IN THE APPENDIX]

Mr. COFFMAN. If you are awarded service—if you are awarding 

service-connection for other undiagnosed illnesses, then why does 

38 CFR 3.317, referring to the statute or regulation, the only regulation which explicitly mentions undiagnosed illness in CMI, and it, 

in fact, is labeled, quote, ‘‘compensation for disability due to 

undiagnosed illness and medically unexplained Chronic Multisymptom Illness,’’ unquote, specifically state that it applies to Persian 

Gulf veterans, defining both that phrase and the phrase, quote, 

‘‘Southwest Asia theater of operations,’’ unquote, within the regulation? 

Mr. MURPHY. I don’t understand the question, Mr. Chairman. 

Mr. COFFMAN. Why don’t we take that one for the record? 

Mr. MURPHY. Okay. 

[THE ATTACHMENT APPEARS IN THE APPENDIX]

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Mr. COFFMAN. Why doesn’t VA have a specific diagnostic code to 

evaluate CMI? Is this something that is being looked into as part 

of the current rating schedule revision that is taking place? 

Mr. MURPHY. Yes, absolutely. Under the rewrite project, this is 

absolutely being considered as a change, because the entire volume, 

in its entirety, is under rewrite. 

Dr. HUNT. Mr. Chairman, there has kind of been a shift because 

the IOM report really has characterized this thing using the term 

and a kind of the nomenclature ‘‘Chronic Multisymptom Illness.’’ 

Up until this point we have been using different nomenclature, 

‘‘medically unexplained or undiagnosed illnesses.’’ It is the same 

symptoms, and it is almost any physical symptom a person can 

have that a person can get service-connected for, a Gulf War veteran. 

It is just that now we are calling it Chronic Multisymptom Illness, and there is some debate about how do we create a case definition for exactly what that means. Originally we said fatigue, idiopathic pain, and cognitive disturbances. Those are the three main 

ones. But then we started seeing bowel symptoms, we started seeing other neurological symptoms. So then we said really any symptoms a person has, and now we are—it is a new kind of characterization of it. It is not a new term, but now we are saying, look, we 

are going to—this is Chronic Multisymptom Illness; this is the way 

we get our arms around it and really start treating it more effectively. 

Mr. COFFMAN. Ranking Member Kirkpatrick, any final questions 

or comments? 

Mrs. KIRKPATRICK. No. 

Mr. COFFMAN. Thank you all. I want to thank you all for testifying, both panels for testifying today. I want to say as a Gulf War 

veteran, I find the conduct of the Veterans Administration embarrassing on this issue in terms of their treatment of veterans. 

I have to ask you, is anybody a Gulf War veteran that is on this 

panel right now? 

You know, I think if there were—if there was one or if there 

were Gulf War veterans in senior positions in the Veterans Administration, I don’t think we would be here today. 

[Whereupon, at 5:01 p.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Hon. Mike Coffman, Chairman 

Good afternoon. I’d like to welcome everyone to today’s hearing titled ‘‘Gulf War: 

What Kind of Care are Veterans Receiving 20 Years Later?’’ 

Yes, it has been over 20 years since the Gulf War. I remember it very well, having 

been there myself as a Marine. Now, as Chairman of this subcommittee, I am asking the same questions many fellow Gulf War veterans have- namely, how is this 

unique set of veterans being treated by VA? 

While it may be pretty easy to determine whether a veteran served in the Gulf 

War, it has been difficult for some time to accurately identify what constitutes ‘‘Gulf 

War Illness.’’ However, a lot of people, both in the veteran community and the medical community, agree that it exists. In fact, VA’s current Chief of Staff, John Gingrich, once made the following comment about Gulf War Illness: 

‘‘While commanding an artillery battalion during Gulf War I, one of my soldiers 

suddenly became quite ill. Despite the best efforts of our medical team, they could 

not diagnose what made him so sick. Out of 800 solider is [sic] under my command, 

no one else was that sick. Now here we are, almost 20 years later and this Veteran 

is still suffering– and has been since the war. I have watched him when he could 

barely stand up, couldn’t cross the room on his own, his legs were so weak. He has 

been in and out of hospitals many times, seen by some of the best doctors and yet 

there is still no explanation for his debilitating illness . . . and this Veteran is not 

alone.‘‘ 

Chronic, multisymptom illness, or ‘‘CMI’’, is by its own definition not just one item 

that a VA physician can look for. However, there are certain things a VA physician 

can and should look for, and determining whether a veteran likely has CMI that 

can be attributed to service in the first Gulf War should be a straightforward process. However, I’m concerned that is not what is happening in practice. 

This hearing today is not about whether Gulf War Illness exists; this hearing is 

about how it is identified, diagnosed, and treated, and how the tools put in place 

to aid these efforts have been used. For example, is the Gulf War Registry working 

as intended and being used properly? If not, what is VA doing to fix the problem, 

and what can this Committee do to help VA in that effort? 

Are the findings of the Research Advisory Committee being put to use in identifying, diagnosing, and treating those veterans suffering from Gulf War Illness? If 

not, where is the disconnect? How can this Committee help VA better assist these 

veterans? 

We have learned a lot in the last twenty years. Science and research has identified unique medical issues for the veterans of the Gulf War, and established baselines from which we can gain a better understanding of those unique issues. Gulf 

War Illness has significant physical effects on the lives and well-beings of those veterans, and we need to make sure that VA can and does make every effort to accurately identify, diagnose, and treat them in a timely fashion. To be sure, it should 

not take another 20 years for us all to get this right. 

I look forward to hearing from today’s witnesses on what is working in treating 

Gulf War Illness, where problems remain, and how the entire process can be improved. 

With that, I yield to Ranking Member Kirkpatrick for a statement. 

f 

Prepared Statement of Hon. Ann Kirkpatrick 

Thank you Mr. Chairman. 

Because we know that the deployment experience of our veterans is especially important in the world of research, and the care and treatment of injuries and illnesses, I want to thank you for holding this hearing on Gulf War veterans and the 

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progress or not, of recognizing and treating these veterans, for ill defined and 

undiagnosed conditions. 

It is estimated that up to 35 percent of veterans who have served in the Gulf War 

suffer from symptoms that are not readily identifiable or well understood. 

In the Institute of Medicine’s report released just this past January and on which 

this hearing is based, these conditions are called Chronic Multisymptom Illness or 

CMI. 

Veterans from the 1991 Gulf War have struggled for more than two decades to 

dispel the all too often accusation that ‘‘it is all in your head’’. 

Veterans of the Iraq and Afghanistan wars have recently presented to the Veterans Health Administration with similar symptoms and have joined their fellow 

veterans in the fight for effective treatments and legitimate recognition of CMI by 

providers. 

Keeping the struggle of this generation of veterans in the forefront of this Subcommittee is not just important, but crucial for us, as a Nation, to finally look at 

service in combat not so narrowly as just that span of time served in combat, but 

to look at the whole experience of the servicemember from the perspective of pre 

deployment, deployment and post deployment as the sum total of the things that 

have happened to a servicemember. 

Hopefully this hearing will provide us a better perspective and a more holistic approach in understanding their unique needs and the full toll that serving takes on 

everyone. In this way, we are better able to contribute to their healing and readjustment. 

I think it is incumbent upon as to learn as much as we can about what our Nation 

is asking of our servicemembers and families when they volunteer to raise their 

right hand. 

We must recognize and be prepared to address the consequences of that service 

and bring to bear our best efforts to ensure that they are thoroughly prepared to 

serve and when they return home we commit to making them whole again. 

f 

Prepared Statement of Lea Steele, Ph.D. 

Thank you for inviting my testimony today. My name is Dr. Lea Steele. I’m an 

epidemiologist and have been involved in research on the health of 1991 Gulf War 

veterans since 1998, when I directed a Gulf War research program sponsored by the 

State of Kansas. Since that time, I’ve also served on a number of federal committees 

charged with planning, reviewing, and advising government agencies on Gulf War 

research. This includes appointment to the Congressionally-mandated Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC), and the privilege of serving as the Committee’s Scientific Director from 2003 – 2008. I am currently Research Professor of Biomedical Studies at Baylor University, where I direct a multifaceted research program on the health of Gulf War veterans, in collaboration with 

scientists across the United States. 

I’ve been asked today to provide information on the effectiveness of federal agencies in addressing health issues that affect veterans of the 1990–1991 Gulf War. The 

most prominent and widespread health problem from that war, as you know, is the 

condition commonly known as Gulf War illness. There are also other health issues 

of concern, but due to time constraints, my comments today will focus on this signature health problem. We use the term Gulf War illness to refer to the serious, often 

disabling symptom complex associated with military service in the 1990–1991 Gulf 

War. I want to be clear: by Gulf War illness, we mean a characteristic profile of 

symptoms—persistent memory, cognitive, and other neurological problems, widespread pain, disabling fatigue, digestive abnormalities, respiratory difficulties—concurrent symptoms that are not explained by established medical or psychiatric diagnoses. 

Now, 22 years after the war, this pattern of chronic symptoms has been well documented in 1991 veterans from across the U.S. and other Coalition countries. We also 

know, from consistent research findings, that Gulf War illness is not a stress-induced or psychiatric disorder. Rates of stress and trauma-induced disorders like 

PTSD were much lower in Gulf War veterans than in other wars, and studies consistently find no association between war trauma or serving in combat, and rates 

of Gulf War illness. But studies do identify links between Gulf War illness and a 

number of hazardous exposures encountered by military personnel in theater. I 

should point out that today, March 13, 2013, is 22 years, almost to the day, since 

U.S. ground troops were exposed to low levels of chemical nerve agents following 

demolitions at a massive Iraqi munitions depot near Khamisiyah, Iraq, in the weeks 

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after the February 28 cease fire. The Pentagon estimates that about 100,000 U.S. 

troops located downwind were potentially exposed to low levels of nerve agents— 

sarin and cyclosarin gas—as a result. 

Nerve agents are just one of a number of Gulf War-related toxicants identified as 

potential causes or contributors to the Gulf War illness problem. Regardless of its 

cause, however, there is no disagreement among scientists who have studied this 

issue that Gulf War illness is a real and serious problem for the many thousands 

of affected veterans. How many? Studies indicate between one fourth and one third 

of the nearly 700,000 veterans who served in the 1991 Gulf War developed Gulf War 

illness. Studies also show that few veterans have recovered, or even substantially 

improved, in the 22 years since the war. 

In recent years, the federal government has made important progress in improving our understanding of Gulf War illness. However, there remain serious problems 

on a number of fronts at VA—including providing adequate healthcare for Gulf War 

veterans, and sponsoring the type of research needed to tangibly improve veterans’ 

health. 

I regret to say that, in some sectors within VA, there appears to have been backward movement, with actions that seem intended to ignore the science and minimize the fact that there is a serious medical condition resulting from military service in the 1991 Gulf War. This is a throwback to early speculation from the 1990s 

that there was no problem, or that veterans just had random, disconnected symptoms—symptoms that invariably develop after any military deployment and are 

likely stress-induced. Such opinions were more common in the 1990s, when there 

was limited research in this area. But they are inexplicable today, in 2013, in the 

face of consistent scientific evidence to the contrary. Such portrayals are especially 

troubling when they come from sectors within the federal agency tasked with serving veterans, and when they negatively affect government policies, healthcare, and 

research. 

This is an incredibly important time for Gulf War illness research. Scientific advances in the last decade have provided important insights into Gulf War illness— 

how many people are affected, which factors are most implicated as contributing to 

this problem, and the biological processes that drive veterans’ symptoms. Multiple 

research groups have now identified a range of neurological differences in veterans 

with Gulf War illness—differences in brain structures, brain function, and autonomic regulation. Studies have also identified specific immune, endocrine, and 

hematological differences in veterans with Gulf War illness. At the same time, results are beginning to come in from treatment studies that show significant benefits 

for veterans with Gulf War illness, with more treatment research in the pipeline, 

and more results expected in the near term. After so many years of waiting, there 

is finally some hope for Gulf War veterans—hope that they will have answers that 

are long overdue and hope that treatments will be found that can meaningfully improve their health and their lives. Those of us most involved in this research believe, based on recent progress, that these successes are possible, and within sight. 

What is not acceptable, at this stage, is federal research that is poorly informed, 

based on notions developed in the early years after the Gulf War, rather than on 

the scientific evidence now available. Fundamentally, we have a situation wherein 

two federal agencies sponsor very different scientific research programs, both ostensibly to address health issues affecting Gulf War veterans. One program, the Department of Defense’s Gulf War Illness Research Program (GWIRP) is managed by 

DOD’s Office of Congressionally Directed Medical Research Programs (CDMRP), and 

has made great strides in a short time period, with about $34 million in funding 

provided over just 5 years between FY2006 and FY2011 (the most recent year for 

which full information is available). When this program was developed in 2006, it 

began by defining a mission, by establishing priorities, and by enlisting the input 

and guidance of experts in the field and veteran stakeholders. This mission-oriented 

approach has yielded impressive progress, and the proof is in the results. The highest priority research for Gulf War illness are studies to identify effective treatments. 

Of the 50 separate projects approved for CDMRP funding between 2006 and 2011, 

18 are treatment-related projects—11 clinical studies to assess treatments for Gulf 

War illness, and additional studies to evaluate treatments in animal models of Gulf 

War illness. 

In contrast to DOD’s mission-oriented approach, the Department of Veterans Affairs has not historically established a research vision or scientific plan, or managed 

a coordinated program to achieve targeted priorities for Gulf War veterans. Although long advised by a Congressionally-mandated independent panel of experts 

in Gulf War research (the RAC committee on which I serve), research programs and 

studies at VA often run counter to the advice of scientific experts. The proof, again, 

is in the results. VA has reported spending over $120 million for ‘‘Gulf War reVACREP180 with DISTILLER

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search’’ over the 10 years from 2002–2011. This includes a total of just 5 human 

and animal projects related to treatment for Gulf War illness—two focused on stress 

reduction. Overall, the many millions of research dollars identified by VA as supporting ‘‘Gulf War’’ research yielded a very limited pay-off for ill Gulf War veterans. 

What happened? Although the devil is often in the details, there are two overarching themes. 

VA has been slow to clearly and accurately acknowledge the Gulf War illness problem. VA continues to provide mixed signals and vague or inaccurate representations concerning the reality and nature of Gulf War Illness. This condition, 

initially called Gulf War Syndrome by the media, is now most commonly identified 

as ‘‘Gulf War illness’’—by scientists, by the Department of Defense, and by veterans. 

The one exception is VA, where this illness is referred to in different ways in different places, often in vague terms, and suggesting that veterans have no specific 

or identifiable symptom complex resulting from the 1991 Gulf War. 

This ‘‘generic’’ representation of the Gulf War illness problem, as a constellation 

of disparate symptoms that overlap considerably with psychiatric disorders, and are 

commonly found in all populations, provided the basis for the recent Institute of 

Medicine (IOM) report on treatments, commissioned by VA in response to a Congressional directive. As detailed elsewhere, VA’s charge to IOM differed from that 

directed by Congress. The resulting report usefully points out shortcomings in the 

health care provided to ill veterans. But the report also repeats and amplifies VA’s 

mischaracterization of the 1991 Gulf War illness problem. Regrettably, VA’s charge 

did not direct the IOM panel to consider the biological mechanisms of Gulf War illness that could be amenable to treatment. Nor did the IOM identify methods that 

experienced physicians have found to be beneficial for treating this condition. The 

report, then, not only failed to address the charge directed by Congress, it missed 

the opportunity to provide new and informed insights about treatments that might 

be brought to bear for veterans with Gulf War illness. 

There are widespread examples, large and small, of VA ‘‘minimizing’’ the Gulf 

War illness problem. It is unthinkable, for example, that VA’s current national 

study of Gulf War veterans, conducted in 2013, does not assess Gulf War illness 

symptoms. This is the largest study of 1991 Gulf War veterans conducted in the 

U.S., targeting 30,000 veterans. It includes scores of questions in such areas as psychological stress, substance abuse, and alternative medicine. But it does not include 

the basic symptom data needed to define Gulf War illness, by any case definition. 

This is a wasteful and inexcusable missed opportunity at best, and something akin 

to scientific malpractice at worst. 

VA’s failure to establish an effective and strategic scientific research program to address priority Gulf War illness research questions. This has been 

an ongoing and serious problem detailed by the RAC in major reports and annual 

evaluations. Among many possible examples, I will emphasize here two overarching 

problems: the lack of focus, expertise, and planning in VA’s Gulf War research program, and the lack of accountability in how funding is allocated for this research. 

Scientific ineffectiveness of VA’s Gulf War research program. Despite strong urging 

from scientific experts, VA did not begin the process of developing a strategic plan 

for Gulf War research until 20 years after the war. A comprehensive process was 

finally undertaken in 2011 to develop such a plan, with nongovernment scientific 

experts and stakeholders from multiple institutions and offices within VA—nine 

groups of at least 6 members each—working over many months to craft and review 

the plan. The draft comprehensive plan was largely approved, by two expert committees, early in 2012. In the next several months, however, the plan was extensively changed by VA internal editors, who removed references to Gulf War illness 

and substantially altered the program developed to effectively define, study, and 

treat this problem. The federal Research Advisory Committee (RAC) on which I 

serve had long urged VA to develop a plan of this type, and some of its members 

assisted in developing the draft plan. But the Committee was extremely concerned 

about the extensive changes made internally by VA, which they believed to take the 

science and the teeth out of the plan. Last June, the RAC withdrew its support of 

the plan, and reported to the Secretary that, under current circumstances, the Committee had no confidence in VA’s ability to develop an effective Gulf War research 

program. 

Misallocated and misrepresented Gulf War research funding. The Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC) was charged by Congress to 

review and advise on all federal research programs that address Gulf War health 

issues. Our committee staff’s review of Gulf War research expenditures each year 

invariably finds that a large proportion of VA-identified ‘‘Gulf War’’ research studies 

would not be considered ‘‘Gulf War’’ research by any other government or nongovernment program. Many of the studies identified as Gulf War research at VA 

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have limited relevance, or no relevance at all, to the health of 1991 Gulf War veterans. This is not a trivial problem. In many years, 60 percent or more of the millions of dollars identified for ‘‘Gulf War’’ research is actually used for other types 

of research with no link, in any important respect, to Gulf War service. There are 

far too many examples to identify here. But they include notable high-dollar research items, like the $10 million dollars used to fund a post mortem brain tissue 

bank identified as the ‘‘Gulf War Biorepository Trust.’’ In reality, this program is 

a brain bank for veterans with ALS, or Lou Gehrig’s disease. Most VA ALS patients 

are older veterans who served in earlier eras. As of 2010, only 1 of the 60 brains 

in this brain bank came from a Gulf War veteran, despite the use of $10 million 

in Gulf War funding for this program that, despite its name, neither targets nor 

studies Gulf War veterans in any important way. In contrast to the millions in ‘‘Gulf 

War’’ funding used for non-Gulf War projects, VA has sponsored relatively few studies in high priority Gulf War research areas—for example, studies to advance improved diagnosis and treatments for Gulf War illness. 

The proof, as always, is in the results. Together, VA’s poor representation of the 

Gulf War illness problem, and failure to apply current scientific knowledge to develop a focused, state-of-the-art research program, have led to relatively little in the 

way of tangible benefits for ill Gulf War veterans. From my perspective as a scientist who has worked in this area for many years, it is time to get this right. And 

certainly the many thousands of veterans who have suffered with Gulf War illness 

for more than 20 years would say it is long past time. 

f 

Prepared Statement of Steven S. Coughlin, Ph.D. 

Chairman Miller, and Members of the Subcommittee, thank you for the privilege 

of testifying today. I am Dr. Steven Coughlin, and I have worked as an epidemiologist for over twenty-five years, including positions as a senior cancer epidemiologist 

at the CDC and as Associate Professor of Epidemiology and Director of the Program 

in Public Health Ethics at Tulane University. I chaired the writing group that prepared the ethics guidelines for the American College of Epidemiology. 

For the past 4 1/2 years, I was a senior epidemiologist in the Office of Public 

Health at the Department of Veterans Affairs. In December 2012, I resigned my position in the US Civil Service because of serious ethical concerns that I am here to 

testify about today. 

The Office of Public Health conducts large studies of the health of American veterans. However, if the studies produce results that do not support OPH’s unwritten 

policy, they do not release them. This applies to data regarding adverse health consequences of environmental exposures, such as burn pits in Iraq and Afghanistan, 

and toxic exposures in the Gulf War. On the rare occasions when embarrasing study 

results are released, data are manipulated to make them unintelligible. 

The 2009–2010 National Health Study of a New Generation of US Veterans targeted 60,000 OIF and OEF veterans and cost $10 million plus the salaries of those 

of us who worked on it. Twenty to thirty percent of these veterans were also Gulf 

War veterans, and the study produced data regarding their exposures to pesticides, 

oil well fires, and pyridostigmine bromide pills. It also included meticulously coded 

data as to what medications they take. The Office of Public Health has not released 

these data, or even the fact that this important information on Gulf War veterans 

exists. Anything that supports the position that Gulf War illness is a neurological 

condition is unlikely to ever be published. 

I coauthored a paper for publication on important research findings from the New 

Generation study on the relationship between exposures to burn pits and other inhalational hazards and asthma and bronchitis in OIF/OEF veterans. My supervisor, 

Dr. Aaron Schneiderman, told me not to look at data regarding hospitalizations and 

doctors’ visits. The tabulated findings obscure rather than highlight important associations. When I advised him I did not want to continue as a co-investigator under 

these circumstances, he threatened me. Speaking as a senior epidemiologist with almost 30 years of research experience, there is no reason to work night and day for 

years on a complex data collection effort (which cost US taxpayers millions of dollars) if you are not comfortable putting your name on publications stemming from 

the study or if no scientific publications are released. 

Another example of important data that has never been released are the results 

of the Gulf War family registry mandated by Congress. These were physical examinations provided at no charge to Gulf War veterans’ family members. I have been 

advised that these results have been permanently lost. 

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The Office of Public Health has also manipulated information regarding veterans’ 

health through the questions included in their surveys. During the preparation of 

a major survey of Gulf War era veterans of which I was principal investigator, the 

Follow-up Study of a National Cohort of Gulf War and Gulf War Era Veterans, the 

Research Advisory Committee on Gulf War Illness made extensive recommendations 

regarding changes to the survey. I considered these changes as constructive, and 

some were adopted. 

The VA Chief of Staff (COS) directed my supervisors to send the Gulf War study 

scientific protocol and draft questionnaire out for additional, objective scientific peer 

review. The OPH Chief Science Officer, Dr. Michael Peterson, contacted a long-time 

friend of his who is Dean of a school of public health, who identified a faculty member at his school, although the individual had no background in Gulf War health 

research. My direct supervisor, Dr. Schneiderman, spoke with the peer reviewer and 

told him that the RAC’s comments were politically motivated, i.e. not objective in 

nature. The reviewer responded that he would ‘‘certainly try to help out.’’ Not surprisingly, the reviewer’s comments were very favorable. The Chief of Staff was never 

informed that the outside reviewer worked for a friend of Dr. Peterson. 

My supervisors also made false statements in writing to the Chief of Staff. For 

example, they falsely stated that putting the study on hold long enough to revise 

the questionnaire would cost the Government $1,000,000, delay the study for a year 

or longer, and potentially result in contract default. None of this was true. But as 

a result, the Chief of Staff ordered the survey to proceed without the changes. 

The Office of Public Health also handles VA’s dealings with the Institute of Medicine, which is part of the National Academies of Science. Congress and VA leadership rely on the Institute of Medicine for authoritative, objective information on 

medical science. 

Last year, VA contracted with the IOM for a Congressionally-mandated study of 

treatments for chronic multisymptom illness in Gulf War veterans. Many Gulf War 

veterans were distressed that five speakers selected to brief the IOM committee presented the view that the illness may be psychiatric, although science long ago discredited that position. My understanding is that Dr. Peterson, an OPH Chief 

Science Officer, identified the speakers the IOM should invite. 

I wish to close with a subject of particular importance to me. Almost 2,000 research participants from the New Generation survey self-reported that they had 

thoughts in the previous two weeks that they would be better off dead. However, 

only a small percentage of those veterans ever received a call back from a mental 

health clinician. Some of those veterans are now homeless or deceased. I was unsuccessful in getting senior Office of Public Health officials to address this problem in 

the New Generation study. 

I was successful in incorporating these call-backs in the Gulf War survey, and 

they have saved lives, but only after my supervisors threatened to remove me from 

the study and attempted disciplinary action against me when I appealed their refusal to provide for call backs to higher authority. 

I urge this Committee to direct VA to immediately identify procedures to ensure 

that veterans who participate in VA large-scale epidemiologic studies received appropriate follow-up care so that this tragedy is not repeated. 

I also urge you to initiate legislation to cure the epidemic of serious ethical problems in the Office of Public Health I have described to you today. In view of the 

pervasive pattern where these officials fail to tell the truth, even to VA leadership, 

VA cannot be expected to reform itself. These problems impact the balance of risks 

and benefits of federally funded human subjects research costing tens of millions of 

dollars and which fail to serve the interests of the veterans they are intended to 

benefit. 

* * * 

Included below is additional written testimony regarding efforts to ensure that 

call-back services were available to Gulf War veterans expressing suicidal thoughts, 

and mechanisms to provide for the sharing of survey data to qualified researchers. 

In the Spring of 2012, in the course of planning the follow study of Gulf War Veterans, I had discussions with my supervisors at VA and with the Chair of the Institutional Review Board (IRB) at the VA Medical Center in Washington, DC about 

the need to identify mental health professionals who could call-back research participants who were experiencing suicidal ideation and assist them with getting into 

VA health care. After my efforts to ensure that Veterans enrolled in the study were 

appropriately cared for were blocked by my supervisors, I contacted the IRB Chair 

and the VA Office of Inspector General. I was then openly threatened and retaliated 

against by my supervisors, who made false and misleading statements in writing 

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1 IOM. 2013. Gulf War and Health: Treatment of Chronic Multisymptom Illness. Washington, 

DC: The National Academies Press. 

about my efforts to put the call-back procedures in place. I received a written admonition and was also told I might be replaced as Principal Investigator of the study. 

Over the course of a few months, I successfully appealed the admonition by telling 

the truth, with the assistance of a VHA Deputy Under-Secretary. 

In August of 2012, I was finally allowed to engage VAMC mental health professionals as co investigators on the study. Between August 2, 2012, and January 1, 

2013, a team of licensed clinical social workers and psychologists completed 1,331 

calls to Veterans. As of January 31st VHA clinical personnel have been able to directly contact 984 of those Veterans. Of these, 48 Veterans were referred to the Veterans Crisis Line for immediate assistance. The majority of calls provided the Veteran with either the Veterans Crisis Line toll free number, information about local 

resources including Vet Centers (local VA mental health centers) or community 

based outpatient clinics, and information on how to enroll for VA health care. Veterans were also encouraged to talk with their primary care physician about depression if they were not already engaged in mental health treatment. The VA mental 

health professionals who made the call-backs saved lives and ameliorated human 

suffering, partly by helping vulnerable research participants get access to health 

care benefits to which they are entitled to. When you are suffering from a neurologic 

condition such as Gulf War Illness, or a psychiatric condition such as major depression, it can be quite difficult to navigate the procedures for gaining access to health 

care benefits. 

As a further practical suggestion, the Office of Public Health should put data from 

their surveys into VINCI (the VA Office of Research and Development’s national 

data sharing resource). There are a lot of qualified VA researchers around the country who would love to have access to New Gen Study data (e.g., the extensive coded 

data on prescription medications and doctors visits in the past year) that have never 

been published. VINCI provides requires IRB review and approval and strict confidentiality safeguards. OPH has lost some key data sets that were stored at the 

Austin automation center mainframe computer in Texas. A notable example is the 

national registry developed several years for family members of Gulf War Veterans. 

That registry database, which was mandated by Congress, is apparently lost forever. 

The use of the VINCI data repository and data sharing resource developed by the 

VA Office of Research and Development (ORD) would protect against future catastrophic loss of data. 

f 

Prepared Statement of Bernard Rosof, M.D. 

Mr. Chairman, Ranking Member Kirkpatrick, and Members of the Subcommittee, 

I am Bernard Rosof, Chairman of the Board of Directors at Huntington Hospital in 

Huntington, New York. I also served as Chair of the Institute of Medicine’s Committee on Gulf War and Health: Treatment for Chronic Multisymptom Illness. The 

Institute of Medicine, or IOM, is the health arm of the National Academy of 

Sciences, an independent, nonprofit organization that provides unbiased and authoritative advice to decision makers and the public. Thank you for the opportunity to 

submit testimony for the record based on the IOM’s report Gulf War and Health: 

Treatment for Chronic Multisymptom Illness. 1

Background 

Chronic multisymptom illness (CMI) is a serious condition that imposes an enormous burden of suffering on our nation’s veterans. Veterans who have CMI often 

have physical symptoms (such as fatigue, joint and muscle pain, and gastrointestinal symptoms) and cognitive symptoms (such as memory difficulties) and may 

have shared symptoms with known syndromes (such as chronic-fatigue syndrome 

[CFS], fibromyalgia, and irritable-bowel syndrome [IBS]) and other clinical entities 

(such as depression and anxiety). In its report, the IOM committee defined CMI as 

the presence of a spectrum of chronic symptoms experienced for 6 months or longer 

in at least two of six categories—fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic—that may overlap with but are not fully 

captured by known syndromes (such as CFS, fibromyalgia, and IBS) or other diagnoses. 

Despite considerable efforts by researchers in the United States and elsewhere, 

there is no consensus among physicians, researchers, and others as to the cause of 

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CMI. The constellation of unexplained symptoms experienced by people who have 

CMI could result from multiple factors, but the etiology remains unknown. 

The Charge to the Committee 

The IOM study was mandated by Congress in the Veterans Benefits Act of 2010 

(Public Law 111–275, October 13, 2010). That law directs the secretary of veterans 

affairs ‘‘to enter into an agreement with the Institute of Medicine of the National 

Academies to carry out a comprehensive review of the best treatments for CMI in 

Persian Gulf War veterans and an evaluation of how such treatment approaches 

could best be disseminated throughout the Department of Veterans Affairs [VA] to 

improve the care and benefits provided to veterans.’’ 

In August 2011, VA asked that IOM conduct a study to address that charge, and 

IOM appointed the Committee on Gulf War and Health: Treatment for Chronic 

Multisymptom Illness. The complete charge to the committee follows. 

The IOM will convene a committee to comprehensively review, evaluate, and summarize the available scientific and medical literature regarding the best treatments 

for CMI among Gulf War veterans. In its evaluation, the committee will look broadly for relevant information. Information sources to pursue could include, but are not 

limited to: 

• Published peer-reviewed literature concerning the treatment of multisymptom 

illness among the 1991 Gulf War veteran population; 

• Published peer-reviewed literature concerning treatment of multisymptom illness among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn active duty service members and veterans; 

• Published peer-reviewed literature concerning treatment of multisymptom illness among similar populations such as allied military personnel; and 

• Published peer-reviewed literature concerning treatment of populations with a 

similar constellation of symptoms. 

In addition to summarizing the available scientific and medical literature regarding the best treatments for CMI among Gulf War veterans, the IOM will: 

• Recommend how best to disseminate this information throughout the VA to improve the care and benefits provided to veterans. 

• Recommend additional scientific studies and research initiatives to resolve 

areas of continuing scientific uncertainty. 

• Recommend such legislative or administrative action as the IOM deems appropriate in light of the results of its review. 

The IOM Committee’s Conclusions and Recommendations 

The committee’s conclusions and recommendations are in five major categories: 

• Treatments for CMI. 

• The VA health-care system as it is related to improving systems of care and 

the management of care for veterans who have CMI. 

• Dissemination of information through the VA health-care system about caring 

for veterans who have CMI. 

• Improving the collection and quality of data on outcomes and satisfaction of 

care for veterans who have CMI and are treated in VA health-care facilities. 

• Research on diagnosing and treating CMI and on program evaluation. 

Treatments for CMI 

The committee conducted a de novo systematic assessment of the evidence on 

treatments for symptoms associated with CMI. The committee also identified evidence-based guidelines and systematic reviews on treatments for related and comorbid conditions (fibromyalgia, chronic pain, CFS, somatic symptom disorders, 

sleep disorders, IBS, functional dyspepsia, depression, anxiety, posttraumatic stress 

disorder, traumatic brain injury, substance-use and addictive disorders, and selfharm) to determine whether any treatments found to be effective for one of these 

conditions may be beneficial for CMI. On the basis of the extensive evidence reviewed, the committee cannot recommend any specific therapy as a set treatment 

for veterans who have CMI. The committee concluded that a ‘‘one size fits all’’ approach is not effective for managing veterans who have CMI and that individualized 

health-care management plans are necessary. Specifically, the committee recommends that VA implement a system-wide, integrated, multimodal, long-term 

management approach to manage veterans who have CMI. 

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The VA health-care system as it is related to improving systems of care and 

the management of care for veterans who have CMI 

To identify veterans who have CMI and bring them into the VA health-care system, VA should commit the necessary resources to ensure that veterans complete 

a comprehensive health examination immediately upon separation from active duty. 

The results should become part of a veteran’s health record and should be made 

available to every clinician caring for the veteran, whether in or outside the VA 

health-care system. Coordination of care, focused on transition in care, is essential 

for all veterans to ensure quality, patient safety, and the best health outcomes. Additionally, VA should include in its electronic health record a ‘‘pop-up’’ screen to 

prompt clinicians to ask questions about whether a patient has symptoms consistent 

with the committee’s definition of CMI. 

Once a veteran has been identified as having CMI and has entered the VA healthcare system, the next step is to provide comprehensive care for the veteran, not only 

for CMI but also for any comorbid conditions. Existing VA programs, such as 

postdeployment patient-aligned care teams (PACTs), could be adapted to best serve 

veterans who have CMI. VA should develop PACTs specifically for veterans who 

have CMI (that is, CMI–PACTs) or CMI clinic days in existing PACTs at larger facilities, such as VA medical centers. A needs assessment should be conducted to determine what expertise is necessary to include in a CMI–PACT. Furthermore, VA 

should commit the resources needed to ensure that PACTs have the time and skills 

required to meet the needs of veterans who have CMI as specified in the veterans’ 

integrated personal-care plans, that the adequacy of time for clinical encounters is 

measured routinely, and that clinical case loads are adjusted in response to the data 

generated by measurements. VA should use PACTs that have been demonstrated 

to be centers of excellence as examples so that other PACTs can build on their experiences. VA should develop a process for evaluating awareness among teams of professionals and veterans of its programs for managing veterans who have CMI, including PACTs, specialty care access networks (SCANs), and war-related illness and 

injury study centers (WRIISCs); for providing education where necessary; and for 

measuring outcomes to determine whether the programs have been successfully implemented and are improving care. Finally, VA should take steps to improve coordination of care among PACTs, SCANs, and WRIISCs so that veterans can transition 

smoothly across these programs. 

Dissemination of information through the VA health-care system about caring for veterans who have CMI 

A major determinant of VA’s ability to manage veterans who have CMI is the 

training of clinicians and teams of professionals in providing care for these patients. 

To disseminate information about CMI to clinicians, VA should provide resources for 

and designate ‘‘CMI champions’’ at each VA medical center. The champions should 

be integrated into the care system (for example, PACTs) to ensure clear communication and coordination among clinicians. VA also should develop learning, or peer, 

networks to introduce new information, norms, and skills related to managing veterans who have CMI. Because many veterans receive care outside the VA healthcare system, clinicians in private practice should be offered the opportunity to be 

included in the learning networks and VA should have a specific focus on community outreach. Another dissemination opportunity is for VA to provide required education and training for its clinicians in communicating effectively with and coordinating the care of veterans who have unexplained conditions, such as CMI. 

Improving the collection and quality of data on outcomes and satisfaction 

of care for veterans who have CMI and are treated in VA health-care 

facilities 

To improve outcomes and ultimately to improve the quality of care that the VA 

health-care system delivers, VA should provide the resources needed to expand its 

data collection efforts to include a national system for the robust capture, aggregation, and analysis of data on the structures, processes, and outcomes of care delivery 

and on the satisfaction with care among patients who have CMI so that gaps in clinical care can be evaluated, strategies for improvement can be planned, long-term 

outcomes of treatment can be assessed, and this information can be disseminated 

to VA health-care facilities. 

Research on diagnosing and treating CMI and on program evaluation 

Many studies on treatments for CMI reviewed by the committee have methodological flaws. Therefore, future studies funded and conducted by the VA to assess 

treatments for CMI should adhere to the methodologic and reporting guidelines for 

clinical trials, including appropriate elements (problem–patient–population, interVACREP180 with DISTILLER

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1 IOM. 2013. Gulf War and Health: Treatment of Chronic Multisymptom Illness. Washington, 

DC: The National Academies Press. 

vention, comparison, and outcome of interest) to frame the research question, extended follow up, active comparators (such as standard of care therapies), and consistent, standardized, validated instruments for measuring outcomes. VA should 

fund and conduct studies of interventions that evidence suggests may hold promise 

for treatment of CMI. 

The committee did not find comprehensive evaluations of VA programs, such as 

the PACTs, SCAN–ECHO programs, and WRIISCs. Program evaluation—including 

assessments of structures, processes, and outcomes—is essential if VA is to continually improve its services and research. Therefore, the VA should apply principles 

of quality and performance improvement to internally evaluate VA programs and 

research related to treatments for CMI and overall management of veterans who 

have CMI. This task can be accomplished using such methods as comparative-effectiveness research, translational research, implementation-science methods, and 

health-systems research. 

Summary 

As detailed above, numerous opportunities exist for VA to improve and expand its 

health-care services for veterans who have CMI. The IOM committee encourages VA 

to apply the principles set forth in its report, including at a minimum adequate resources to ensure early entry into the VA health-care system and adherence to the 

principles of patient-centered and compassionate care, shared decision-making, and 

regular clinical follow up as necessary. Our veterans deserve the very best health 

care. 

Thank you, again. I would be happy to answer any questions the Subcommittee 

might have. 

Executive Summary 

Gulf War and Health: Treatment for Chronic Multisymptom Illness 

On January 23, 2013, the Institute of Medicine (IOM) released its report, Gulf 

War and Health: Treatment for Chronic Multisymptom Illness. 1 IOM is the health 

arm of the National Academy of Sciences, an independent, nonprofit organization 

that provides unbiased and authoritative advice to decision makers and the public. 

Chronic multisymptom illness (CMI) is a serious condition that imposes an enormous burden of suffering on our nation’s veterans. Veterans who have CMI often 

have physical symptoms (such as fatigue, joint and muscle pain, and gastrointestinal symptoms) and cognitive symptoms (such as memory difficulties) and may 

have shared symptoms with known syndromes (such as chronic-fatigue syndrome, 

fibromyalgia, and irritable-bowel syndrome) and other clinical entities (such as depression and anxiety). Despite considerable efforts by researchers in the United 

States and elsewhere, there is no consensus among physicians, researchers, and others as to the cause of CMI. 

The Department of Veterans Affairs (VA) asked that IOM conduct a study to 

evaluate treatments for CMI among Gulf War veterans to determine how to best 

manage care for veterans who have this condition. IOM assembled an expert committee to address this task. 

The committee conducted an extensive systematic assessment of the evidence on 

treatments for CMI. It also assessed treatments for a number of related and comorbid conditions to determine whether any of them may be beneficial for CMI. On 

the basis of its assessment, the committee cannot recommend any specific therapy 

as a set treatment for veterans who have CMI. The committee concluded that a ‘‘one 

size fits all’’ approach is not effective for managing these veterans and that individualized health-care management plans are necessary. Specifically, the committee 

recommends that VA implement a system-wide, integrated, multimodal, long-term 

management approach to manage veterans who have CMI. 

In its report, the committee makes 13 additional recommendations aimed at identifying veterans who have CMI, bringing them into the VA health-care system, and 

improving the quality of their care. VA should provide comprehensive care for the 

entire constellation of symptoms experienced by the veteran—including CMI as well 

as other health conditions. A health-care team-based approach is essential to provide this type of comprehensive care. Existing VA programs, such as postdeployment 

patient-aligned care teams, could be adapted to best serve veterans who have CMI. 

Numerous opportunities exist for VA to improve and expand its health-care services for veterans who have CMI. Our veterans deserve the very best health care. 

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35 

Prepared Statement of Anthony Hardie 

Thank you, Chairman Coffman, Ranking Member Kirkpatrick and Members of 

the Veterans’ Affairs Subcommittee on Oversight and Investigations for today’s 

hearing. 

Special thanks also to full committee Chairman Miller, Ranking Member 

Michaud, and Dr. Roe, whose leadership is helping fund the Gulf War Illness Congressionally Directed Medical Research Program – the only federal program in the 

22 years since the 1991 Gulf War effectively working to improve the health and 

lives of ill Gulf War veterans. 

Thank you also to the Gulf War veterans who traveled to attend this hearing, and 

to all the affected veterans watching from home. 

BACKGROUND 

As several Members already know, I’m a veteran of more than seven years active 

duty Army Special Operations service that included the 1991 Gulf War, Somalia, 

and four additional, non-combat overseas deployments. As I’ve provided in previous 

testimony, I developed health issues that commenced in the Gulf and have plagued 

me ever since, including a chronic cough that has never subsided, and other chronic 

health issues including chronic sinusitis, fatigue, irritable bowel, widespread pain, 

neurological, and other health issues. 

As I have testified previously, many of us Gulf War veterans’ chronic health 

issues began while still in the Gulf, in the prime of our young adulthood and at the 

peak of our health and physical fitness. Twenty-two years later, for many of us, our 

health issues have only worsened since first onset. In 2009, my own health worsened to the point where I was no longer able to continue working. 

I wish that it was only me who was affected, but my experience is far from 

unique. A 2010 Institute of Medicine report summarized a large body of existing research and showed that Gulf War chronic multi-symptom issues continue to afflict 

roughly one in three of us Gulf War veterans. 

Like nearly all other service-injured veterans I’ve encountered, the quest remains 

the same: effective treatments, and justice. As such, I’m honored to serve on the 

Congressionally chartered Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC), and the integration panel of the treatment-focused Gulf War Illness 

Congressionally Directed Medical Research Program (CDMRP) that sets the direction of the program and makes final recommendations on which research proposals 

to fund. I’ve also been honored to serve on the VA’s Gulf War Research Steering 

Committee. 

WHAT’S NOT WORKING 

In 2009, I noted in testimony that Gulf War veterans looked to the new VA leadership, ‘‘with hopeful anticipation and continue to wish for their encouragement in 

achieving so many long-overdue and deeply needed goals on our behalf.’’ Despite an 

initially strong restart, disappointingly, Gulf War veterans again seem to have been 

lost in the shuffle. 

In 2009, I also testified that VA’s own Gulf War research advisory ‘‘committees 

were not only not consulted; they still haven’t even been informed of . . . decisions 

made without their input on issues directly within their purview.’’ These problems 

are now much worse. VA staff routinely ignore Congress, the law, expert advisors, 

basic democratic principles, and common decency. 

The real proof for Gulf War veterans is one of outcomes: VA still has no proven 

effective treatments for Gulf War Illness patients at VA medical centers, where they 

are often still thought to be psychosomatic. No VA newsletters to keep Gulf War 

veterans informed. No implementation of expert advisors’ strategic plans and recommendations. No consistent, reliable medical surveillance of Gulf War veterans, including data on the prevalence of MS, cancers, or other serious health outcomes 

among Gulf War veterans. 

VA’s research focus over the last two decades has been largely related to stress, 

psychological issues, other diseases that affect veterans of all eras, and what has 

in the end amounted to trying to disprove there’s anything wrong with the estimated one-third of Gulf War veterans suffering from Gulf War Illness. Instead of 

being aimed squarely at treatments and improving ill veterans’ health and lives, 

many of these misguided efforts have continued through to the present. In VA’s 

most recent annual national research review publication, VA’s Gulf War research 

focus is characterized as, ‘‘investigating whether service in the Gulf War is linked 

to illnesses Gulf War veterans have experienced’’. [emphasis added] 

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These failures are no accident. 

IOM Treatments Committee. A landmark 2010 report by the Institute of Medicine (IOM) confirmed successive research findings that the chronic multi-symptom 

illness we call Gulf War Illness is a unique diagnosis, that it is physical (not psychiatric) in nature, that it likely involves the interplay between environmental 

agents and individual genetics, that it affects more than 250,000 veterans of the 

1991 Gulf War and other U.S. forces, and that treatments can likely be found. This 

IOM report confirmed similar 2008 RAC findings. IOM urged ‘‘a renewed research 

effort with substantial commitment to well-organized efforts,’’ to diagnose and treat 

GWI. Congress quickly followed with additional mandates to launch research, followed by a new VA contract with IOM related to treatments. 

At its first meeting, presenters before a new IOM ‘‘treatments’’ panel diverged 

radically from both the Congressional authorizing language and established science. 

The panel was charged by VA to conduct a literature review rather than to consult 

with knowledgeable medical practitioners experienced in treating ill Gulf war veterans. And nearly all of the first presenters focused on ‘‘stress-as-cause’’, psychological, and psychosomatic issues – all debunked years ago. 

For example, one of the stress-as-cause presenters to the IOM ‘‘treatments’’ committee said, ‘‘Stress has been indicated as a factor in Gulf War Illness,’’i citing three 

studies as reference. I immediately recognized one of cited studies, as its principal 

investigator had presented her findings to the RAC on which I serve, noting that 

what she found in ill Gulf War veterans was distinct from and not PTSD. The researcher’s actual conclusions were: ‘‘Despite the overlap of chronic unexplained 

health symptoms and PTSD in GWV, these symptom constellations appear to be biologically distinct.’’ii This blatant mischaracterization of the research conclusions was 

not unique. And similar to other presenters that day, this presenter focused the second half of his talk on ‘‘stress management via relaxation-response (RR) therapies’’ 

– a mere band-aid for suffering veterans. The ill Gulf War veterans who called in 

to listen to the panel’s two public meetings were of course outraged. 

Furthermore, the statutory mandate was for IOM to, ‘‘convene a group of medical 

professionals,’’ ‘‘experienced in treating,’’ 1990–91 Gulf War veterans. Instead, VA 

created a charge to the committee that it was to conduct a highly restricted literature review of published studies – which missed the entire statutory intent of 

eliciting potentially effective treatment modalities from experienced practitioners already caring for ill Gulf War veterans. 

Additionally, the panel was led to lump together all sorts of chronic multisymptom 

issues, (‘‘pick any two of six’’) including in the general population, defined so broadly 

as to include nearly any human health condition. 

In July 2009, a former IOM Gulf War and Health committee chair testified as to 

the unbiased and independent nature of such IOM committees: ‘‘The reports are developed through an established study process designed to ensure committees and 

the reports they produce are free from actual or potential conflicts of interests, are 

balanced for any biases, and are independent of oversight from the sponsoring agency.’’iii However, in the case of this IOM treatments committee, the sponsoring agency – VA – not only issued the contract, but also presented its charge to the committee, shifted and limited the scope of what the committee could consider from the 

statutory authorizing language, and included multiple presenters to the committee 

– a far different reality from the unbiased 2009 expert witness testimony portrait. 

A written request by three of us veterans to the IOM President for a copy of the 

VA–IOM contract and the presenter selection criteria was minimized and never fulfilled. A request to the VA Secretary’s office for the contract and appendant documents was similarly never fulfilled; the same goes for a FOIA request to VA. However, what is clear is the statutory language directing the formation of the committee, the VA’s charge to the committee that it of course followed, and the dramatic 

divergence between the two. 

Thus, the process was fatally flawed through the actions of VA and likely other 

staff. The result was the well-intentioned, veteran-focused panel members almost 

entirely failed to meet the committee’s statutory mandate requiring a focus on consultation with medical practitioners experienced in treating ill Gulf War veterans, 

which could have gleaned important, beneficial insights. Furthermore, the final report included nearly 50 pages of recommended psychological treatment for a condition that is not psychiatric in nature. Finally, the report missed the main point emphasized by the 2010 IOM panel: effective treatments for GWI do not yet exist, but 

likely can be found, and a renewed national effort is recommended to develop treatments and preventions. 

Strategic Plan. After being publicly criticized for not having a strategic plan to 

solve Gulf War Illness treatment, VA staff tasked its new, non-public Gulf War 

Steering Committee (on which I was appointed to serve as the sole Gulf War vetVACREP180 with DISTILLER

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eran representative) to begin work to create such a plan. The Steering Committee, 

the RAC, and the VA’s National Research Advisory Council (NRAC), and a myriad 

of drafting subcommittees that included VA and non-VA researchers and Gulf War 

veterans spent a year and a half in a model process finally developing a strategic 

plan. 

The plan was a comprehensive, outcome-oriented, consensus-based. It was developed with the expertise of a substantial number of scientists and affected Gulf War 

veterans serving on a myriad of engaged, all-volunteer drafting subcommittees. It 

was aimed squarely at improving the health and lives of veterans suffering from 

Gulf War Illness. It met the approval of the Steering Committee, RAC, and NRAC. 

However, after the report had been completed, VA staff quietly and unilaterally 

gutted and whitewashed the plan. Despite having been active participants in every 

step of the process, VA staff even went so far as to remove ‘‘Gulf War Illness’’ from 

the title. The end result was that it was no longer a plan to execute the IOM’s call 

for a ‘‘renewed research effort . . . to better identify and treat multisymptom illness 

in Gulf War veterans.’’ Instead, it had become a renewed license for VA staff to do 

pursue whatever research whims might next tickle their fancy, which to date has 

largely included research irrelevant or even inimical to Gulf War veterans’ treatment needs – in other words, more of the same. One leading NRAC participant described feeling, ‘‘betrayed’’, and having ‘‘wasted’’ a year-and-a-half – sentiments I 

echoed then and today. 

When the RAC met to discuss the whitewashed report, the Gulf War veteran 

members of the RAC were so angry at the wasted efforts of more than a year, the 

other Gulf War veteran on the panel stormed out in protest, and I discussed resignation with the committee chair. Our panel responded by a unanimous decision 

to reject and return the plan to VA as unacceptable, and to declare ‘‘No Confidence’’ 

in VA’s handling of Gulf War Illness research. 

It continues to get worse. VA staff have initiated sole-source contracting with IOM 

for a ‘‘literature review’’ to develop a new Gulf War Illness case definition. In addition to this process being in complete contravention to the thorough, careful process 

to develop a new case definition laid out in the draft Strategic Plan, I’m also told 

that this process is unprecedented and likely to harm Gulf War veterans. And, VA 

staff not only didn’t inform the RAC of this initiative (the legal announcement was 

discovered online by another Gulf War veteran) but have refused to provide any details to the RAC. Why is VA allowed to continue unchecked? 

Multiple VA Failures. The ensuing June 19, 2012 RAC report found that, ‘‘those 

responsible for VA [Gulf War] research fail to mount even a minimally effective program, while promoting the scientifically discredited view that 1991 Gulf War veterans have no special health problem as a result of their service.’’ 

The RAC report goes on to detail serious new grievances against VA, which in 

addition to gutting the proposed Gulf War Illness Research Strategic Plan, include 

secret cuts to the Gulf War Illness research budget, misrepresentation to VA leadership and Congress, blatant misdirection from statutory mandates, law violations, 

and citing as its research priority efforts to determine ‘‘whether’’ Gulf War veterans’ 

illnesses are in fact linked to their Gulf War service rather than treatments to improve their health and lives. 

No Meetings. VA staff have for one reason or another not allowed the RAC to 

hold a public meeting since that June 19th meeting. Public meetings scheduled for 

November/December and February in Washington, DC had to be cancelled. 

In more recent times, the VA Secretary’s office has remained largely and disappointingly silent and disengaged. Unlike his predecessors, and despite the Congressional language charging the RAC to advise the Secretary, Secretary Shinseki 

has never once personally come to a RAC meeting. 

OPH Survey. Among the issues identified in the June 19th RAC report is regarding a follow-up survey by the VA’s Office of Public Health (OPH) of a national cohort 

of Gulf War and Gulf War Era Veterans (earlier studies were conducted in 1995 and 

2005; the health surveys are done to understand possible health effects of service 

and guide health care delivery). 

This survey was heavily critiqued by the RAC on which I serve for failing to include expert recommendations related to Gulf War Illness, the overarching concern 

of the largest number of Gulf War veterans. Not only did the responsible VA staff 

stonewall our panel during a public meeting, entrenched VA bureaucrats ultimately 

convinced VA leadership to ignore the RAC’s sound recommendations. 

MS Law. Another of the issues identified in the RAC report is that VA continues 

to violate the law that requires VA to contract with IOM for a large-scale study to 

determine how prevalent Multiple Sclerosis is among veterans of the 1990–91 Gulf 

War and the Iraq and Afghanistan Wars. 

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The 2008 law directs VA to contract with IOM to conduct the prevalence study 

with a specific deadline. That deadline has long past, but VA continues to violate 

the law. It is my understanding that VA–OPH is the entity responsible for VA contracts with IOM. 

It’s more than a little ironic that while VA continues to ignore this law mandating 

MS prevalence research, an August 7, 2012 VA press release touted MS research 

as among VA accomplishments for Gulf War veterans. 

GWVI Task Force. VA’s Gulf War Task Force initially seemed to get off to a 

good start. However, VA leadership chose to not follow recommendations to involve 

affected stakeholders on the Task Force. As a closed group composed solely of internal VA staff, it has been prone to ‘‘groupthink’’, to repeating the same old problems, 

and to being entirely closed to and seemingly unresponsive to the Gulf War veteran 

public it was intended to serve. It operates in secret. Its meetings are not open to 

veterans or the public, the minutes of its monthly meetings are not made public, 

it has no website, and it has publicized only two reports in its multi-year existence. 

This secrecy is a far cry from the openness and transparency promised by our President and expected by affected veterans. 

To its credit, the Task Force has fostered substantial written input from Gulf War 

veterans on its draft reports. However, most of that input has not appeared to impact the Task Force’s final reports. 

The Task Force reports have also included a number of initiatives. As one example, VA outlined a new clinical care initiative in its 2011 GWVI Task Force Report. 

Since information about it is neither public nor has been shared with the federal 

panel charged by Congress with overseeing Gulf War health research, we can only 

guess at how the clinical care model project might be going. In any case, it’s hard 

to imagine how helpful a mere model of healthcare delivery will be to ill veterans 

when VA has not yet developed even a single proven effective GWI treatment. 

Discontinuation of ‘‘Gulf War Review’’. In my 2007 testimony, I noted that 

VA’s ‘‘Gulf War Review’’ newsletter – VA’s quarterly direct-mail publication to Gulf 

War veterans – had apparently been discontinued. VA OPH staff testified at that 

hearing that a new issue would be forthcoming soon. Instead, no issues were published that year at all. 

Now, the Gulf War and OIF/OEF newsletters have not been published since 2010. 

Ironically, the last Gulf War issue included a feature article: ‘‘Secretary Shinseki 

Marks 20th Anniversary of Gulf War with Renewed Pledge to Improve Care and 

Services to Gulf War Veterans.’’ Congress should pass legislation mandating the 

continuation in perpetuity of this and related quarterly veteran-oriented publications, which should include ongoing, clear, spin-free updates on every federally funded research study and benefits change relevant to the target population. 

Consequences of ‘‘Psychiatrization’’ of Physical Illness. Many of us heard 

recently of an American Legion Iraq War veteran whose longstanding symptoms 

were found to be caused by Q–Fever. After appropriate treatment, he was essentially cured. 

It is unconscionable that DoD and VA do not perform comprehensive infectious 

disease and immunological testing in veterans returning from overseas areas where 

such diseases are endemic. IOM’s 2012 ‘‘treatments’’ report noted that Iraq and Afghanistan War veterans are symptomatic of the committee’s loosely defined, ‘‘chronic multisymptom illness’’. 

Congress should pass legislation requiring such testing identify, treat, or definitively rule out a clear list of at least nine debilitating, chronic infectious diseases 

endemic to southwest Asia deployments. 

Claims. After a complete overhaul, VA has now apparently ceased publishing its 

data report on Gulf War veterans. The report was formerly published quarterly; VA 

has failed to published any further reports since February 2011. These reports are 

important for identifying approval rates of VA claims, among other issues. 

In 2010, VA issued a new FAST letter clarifying ‘‘medically unexplained chronic 

multisymptom illness’’ claims. However, any aggregate effect of this effort remains 

unclear due to VA’s discontinued publication of its quarterly Gulf War/Era/OIF/OEF 

data report. Congress should pass legislation to fix this problem. 

I believe VA’s new efforts to create Disability Benefits Questionnaires (DBQ’s) are 

steps in the right direction. However, the fact that there is not one for ‘‘medically 

unexplained chronic multisymptom illness’’ claims diminishes the weight of the related 2010 FAST letter. Nothing will help change the VA culture of deferring, delaying, and denying these claims than creating a clear DBQ in black and white and 

ensuring its full implementation in the claims approval process. Congress should 

hold VA accountable until VA fixes this problem. 

VA has made no apparent effort to correct flaws in the rating schedule for 

Fibromyalgia and Chronic Fatigue Syndrome (CFS/ME), as I noted in my 2009 testiVACREP180 with DISTILLER

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mony, which continue to authorize 100 percent ratings for veterans with CFS alone 

but unjustly limit ratings to 40 percent for veterans with both CFS and 

fibromyalgia. Congress should pass legislation to fix this longstanding problem that 

VA continues to ignore but which affects many Gulf War veterans. 

However, VA continues to publish an annual report on Gulf War research, in accordance with Section 707 of Public Law 102–585, as amended by section 104 of 

Public Law 105–368 and section 502 of Public Law 111–163, which require that an 

annual report be submitted to the Senate and House Veterans’ Affairs Committees 

on the results, status, and priorities of research activities related to the health consequences of military service in the Gulf War (GW) in Operations Desert Shield and 

Desert Storm; August 2, 1990 – July 31, 1991. 

Congress should pass similar legislation requiring VA to submit to Congress quarterly reports regarding 1991 Gulf War, OIF, OEF, and Gulf War Era veterans, providing aggregate data of claims filed, pending, approved, and denied, health care enrollment, and other benefits usage, similar to the former Gulf War Veterans Information System (GWVIS) and Gulf War Era Veterans Reports. 

VA Still Excludes Some Gulf War Veterans. VA continues to unjustly exclude 

some Gulf War veterans from Gulf War-specific benefits, including those whose Gulf 

War service was in Turkey or Israel. And, Gulf War chronic multisymptom illness 

presumptives extend to Iraq War, but not Afghanistan War (OEF) veterans. Congress should pass legislation to fix these problems. 

Cabal. To date, VA has no proven effective treatments, not because such treatments are impossible to find, but because a small cabal of federal bureaucrats and 

contractors work at every step to delay, defer, and deny, and even so far as to obfuscate and refuse to implement laws, policies, and expert recommendations. 

These issues are not just limited to affecting veterans of the 1991 Gulf War. DoD’s 

‘‘Force Health Protection’’ and VA’s Office of Public Health (OPH) continue to find 

‘‘no evidence’’ of the very real health issues affecting countless thousands of additional veterans caused by their exposure to burn pits, chemical solvents in drinking 

water, contaminated and questionable anthrax and other vaccinations, inhaled or 

ingested Depleted Uranium (DU) particulates. These misguided people also continue 

to minimize and spin the all to real health effects of blast waves, concussions and 

other brain injuries, combat psychological traumas, and more. 

These are not abstract forces or nameless, faceless bureaucrats. They are people 

like Kelley Ann Brix from the Defense Department’s misleadingly named ‘‘Force 

Health Protection’’ office and psychiatrist Charles Engel, people who have seemed 

at every step of the way for most of the last two decades to have fought against 

the legitimate health interests of Gulf War veterans. 

If these bureaucrats and contractors somehow believe they’re helping, one need 

only evaluate the outcomes. Look only to what VA has to offer ill veterans coming 

to VA for help: band aids for symptoms and psychological counseling to at best help 

cope with enduring physical ailments. 

Much of the propaganda that has come out of ‘‘Force Health Protection’’ does not 

foster servicemembers’ health, it denies that health hazards are hazardous, that war 

has health consequences, that the health conditions afflicting troops are even real. 

They construct studies that look in the wrong direction, then finding nothing as 

would reasonably be expected they use these flawed findings to justify stopping 

looking. 

It is possible this cabal, which for all intents and purposes appears to be working 

against veterans’ legitimate health interests, is taking its direction from the 1998 

Presidential Review Directive 5, which was developed as a result of emerging Gulf 

War health issues and included extensive recommendations on ‘‘strategic health 

communications’’. Perhaps some have construed these extensive recommendations 

as a directive to coordinate national public relations efforts to minimize deployment 

health issues. But ‘‘spin’’ is no substitute for epidemiology to identify deployment 

injury and illness with the end goals of treatment and prevention. Congress should 

carefully review, repeal, and replace PRD–5 and regulations and programs subsequent to PRD–5. 

For example, the RAND study on Gulf War vaccinations has been suppressed for 

more than a decade. Taxpayers paid for that study, and Congress should order it 

released. 

As Administrations come and go, these heretofore unaccountable staff and contractors must be held accountable. When VA appointees are misled and misdirected 

and VA appointees fail to fix longstanding problems, then perhaps only Congress 

can create the statutory conditions to ensure desired outcomes. 

Divergence from the letter and spirit of the law should be criminalized, with violators sentenced to prison. 

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And until these changes can be made, these wayward entities, including FHP and 

VA–OPH should be substantially defunded, their employees permanently laid off, 

their contractors cut loose, and their funding redirected to entities like the CDMRP 

and DARPA that continue to prove they can achieve outcome-oriented results. 

In short, despite all the best promises and intentions, actions speak louder than 

words: VA has again broken Gulf War veterans’ trust. 

WHAT IS WORKING 

However, there are two bright spots for the treatment of ill Gulf War veterans. 

The GWI CDMRP. As an ill and affected Gulf War veteran, I am strongly supportive of the work being done by the Gulf War Illness Congressionally Directed 

Medical Research Program (CDMRP). It is very much unlike other VA and DoD efforts, which have been consistently criticized over the last two decades. 

People suffering from the health condition under review, called ‘‘consumers,’’ are 

fully integrated into the entire CDMRP research proposal review process – a key 

feature of all of the CDMRP’s. Consumer reviewers are placed on par with the scientist reviewers as equally respected, personally affected advisors, helping to enhance the program’s focus, ensure appropriate impact of funded proposals, and impart the sense of urgency felt by fellow afflicted patients. 

Since the program began with Fiscal Year 2006 funding, I’ve had the honor of 

serving as a consumer reviewer for the Gulf War Illness CDMRP. I’ve found the program efficient, agile, carefully focused by the Congressional authorizing language, 

and fully engaged in finding and successfully funding the best, most responsive research proposals aimed at improving the health and lives of veterans afflicted by 

Gulf War Illness. And I’ve found the staff and contractors to be consistently capable 

and competent, responsive to the review panel, and integral to the success of the 

programs. 

It is my understanding from other consumer reviewers that the same holds true 

for other CDMRP research programs. 

And, as a consumer reviewer since the program began, I’ve also had the privilege 

of reviewing virtually all of the hundreds of pre- and full proposals in the history 

of the program, which has imparted a unique perspective. 

As previously described, the collective efforts of this small cabal of DoD and VA 

(and perhaps also IOM) staff have produced a dearth of tangible results, no proven 

treatments, and have served only to disenfranchise, anger, and unite ill Gulf War 

veterans. However, in stark contrast to the national disgrace of that failed cabal, 

there are literally hundreds of highly capable scientists and medical practitioners 

who are ready, willing, able, and actively working to help solve Gulf War Illness. 

Many are at top research institutions. They spend countless hours compiling detailed research proposals, often as long as a hundred or more pages, carefully articulating how and why they believe they can help ill Gulf War veterans. For those who 

are ultimately funded, they appear to be truly making a difference. 

One of the earliest successes of the GWI CDMRP is the discovery that a particular 

anti-oxidant can help reduce some Gulf War Illness symptoms. Another, studying 

the sarin nerve agent to which hundreds of thousands of Gulf War troops were exposed, may have important implications for future military or civilian populations 

in a homeland security situation since the research findings suggest low-dose, nonsymptomatic exposure to sarin may result in long-lasting cardiac and neurological 

dysfunction. Another is that chronic inflammation may underlie many Gulf War Illness symptoms, and if so, effective treatments may already exist. Still another is 

taking an animal model of Gulf War Illness chemical exposures, which has effectively reproduced GWI symptoms, and testing an already available drug to treat 

pain and memory deficits common in GWI. 

It is also clear that many researchers are making great strides towards unraveling and treating Gulf War Illness without the need to know the specific substance(s) 

of causation. Unraveling the specifics of what is happening now in the brains and 

bodies of ill Gulf War veterans appears to be at least as relevant to the identification and development of effective treatments. 

The 2010 IOM committee wrote that effective treatments for Gulf War Illness can 

likely be found and suggested a path forward, ‘‘to speed the development of effective 

treatments, cures, and, it is hoped, preventions.’’ To date, only the Gulf War Illness 

CDMRP has been fully engaged in this effort, though still inadequately funded. 

Most importantly, these CDMRP efforts are producing real results. 

Meanwhile, VA staff have wasted more precious years, squandered myriad experts’ time, energy, and hard work, and further alienated not just their most engaged advisors but also the very Gulf War veterans they are supposed to be helping. 

And though VA research staff have told us they are now funding treatment studies, 

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the RAC on which I serve has not been provided specific information on these new 

efforts. 

VA’s WRIISC’s. In addition to the GWI CDMRP, I hear almost exclusively praise 

from ill Gulf War and other veterans who have participated in the VA’s three regional War Related Illness and Injury Study Centers (WRIISC’s). The centers take 

veterans on referral from local VA healthcare providers and ensure a comprehensive 

workup to identify any diagnosable health conditions. I also hear from some veterans that they’ve been able to use WRIISC evaluations to support their VA claims, 

an important piece of justice while proven effective treatments remain to be found. 

And, WRIISC clinicians are thereby regularly exposed to a constant inflow of patients whose collective experiences could help solve Gulf War Illness, another potential benefit. 

However, as word regarding these important clinical resources has spread among 

veterans, there are now apparently long waits to participate. I’ve been told by some 

veterans the waiting list is now many months long, perhaps even as long as a year. 

Congress can help ailing veterans by allocating additional authorization and funding 

to these two areas that are indeed helping. 

NEXT STEPS 

We Gulf War veterans have been fighting the federal bureaucracy for much of the 

last 22 long years. We’ve seen laws passed only to seem them circumvented or not 

implemented with impunity. The independent expert panel created by Congress in 

1998 was supposed to end gridlock at VA. The release of the RAC’s 2008 report, and 

the IOM’s 2010 study showed not only that GWI is real—what Gulf War veterans 

had been saying all along—but that effective treatments could be found, bringing 

much hope to many distraught service-disabled veterans. However, it is now clear 

that VA staff have continued are presumably will continue to betray Gulf War veterans for the reasons described above. 

We have had countless Congressional hearings on Gulf War veterans’ health and 

benefits. Time after time, researchers, advocates, veterans, and family members 

have told Congressional committees about the ongoing, serious problems they’re experiencing and recommendations to fix them. Time after time, the Congressional 

committee members ask VA pointed questions about the VA’s many missteps, and 

VA staff make more on-the-spot promises, which almost always turn out to be 

empty. Then a year or two later, and it’s yet another round of the same. 

I hope today’s hearing will be different. I hope that Committee members, and perhaps finally even VA’s present leadership, will see that that Gulf War veterans have 

been right all along – again: that VA and DoD staff, including in VA’s Office of Public Health and DoD’s Force Health Protection and possibly with cooperation from 

one or more IOM staff, have been circumventing and flouting the law, Congress, and 

the needs of veterans; that on occasion after occasion they have been obfuscating, 

manipulating, and even lying. The end result is that while we’re closer today to 

finding effective treatments for the one-third of Gulf War veterans who, like me, remain ill and disabled more than two decades later, any progress is in spite of and 

not because of this cabal’s efforts. 

Today’s hearing will not uncover every serious misdeed and transgression coming 

out of the longtime staff and contractors at VA or in DoD’s Force Health Protection. 

In the strongest possible terms, I encourage the Members of this body to take further steps necessary to right these ongoing wrongs, including reallocation of funding 

from these non-performing entities, legislation to provide criminal sanctions for such 

behavior, and comprehensive legislation to right these many wrongs. 

And despite all the best promises and intentions, actions speak louder than words: 

VA continues unabated in its long tradition of violating Gulf War veterans’ trust. 

RECOMMENDED LEGISLATION 

VA staff must be forced by law to seek out, foster, and find the best Gulf War 

Illness treatment research aimed at improving the health and lives of those whose 

health has been impacted by their wartime exposures. To that and related ends, 

Congress should develop and pass legislation that includes: 

1) A provision making it a crime punishable by federal imprisonment for a government employee or contractor to attempt to manipulate an IOM report ordered by 

a government agency, or for an IOM employee or member to conspire with a government employee or contractor for the purpose of manipulating a report. 

2) A provision directing VA to immediately contract with the IOM for a study to 

determine the prevalence of multiple sclerosis in Gulf War and later veterans, as 

directed by P.L. 110–389, Section 804, and to provide criminal penalties for failure 

to comply. 

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3) A provision directing VA to immediately terminate the IOM case definition contract and contract instead with the DoD Congressionally Directed Medical Research 

Programs (CDMRP) Gulf War Illness program to develop a case definition that is 

linked to Gulf War service and excludes mental conditions, and that follows customary case definition practices (including assembling a committee of experts in the 

illness, who can consult original data sources). 

4) Provisions to defund mis-performing VA–OPH and DOD FHP functions. 

5) A provision requiring VA to make the data obtained from its surveys available 

to qualified researchers subject to reasonable restrictions, similar to other agencies. 

6) A provision requiring an addendum to the national Follow-Up Survey of Gulf 

War and Gulf War Era Veterans be sent immediately to the full survey cohort that 

asks the RAC’s recommended symptom inventory. 

7) A provision requiring VA medical staff be trained in the new 2011 standards, 

which show Gulf War Illness is not psychiatric. 

8) A provision mandating future VA Gulf War research be focused on developing 

effective treatments to improve the health and lives of ill Gulf War veterans. 

9) A provision amending the statute requiring the reports (Section 707 of Public 

Law 102–585, as amended by section 104 of Public Law 105–368 and section 502 

of Public Law 111–163), to provide that these annual VA research summary reports 

to Congress should include only those human studies in which 1990–1991 GW veterans represent at least a majority of the cases (vs. controls), and only those animal 

studies addressing exposures pertinent to the 1990–1991 Gulf War. 

10) A provision requiring VA to contract with the DoD CDMRP Gulf War Illness 

research program, to conduct the review of best treatments for chronic multisymptom illness in Persian Gulf War veterans specified in Sec. 805(a) of PL 111–275, 

which VA staff manipulated into an inconsequential literature review. 

11) Provisions providing adequate funding for Gulf War Illness research to identify effective treatments, including: 

a) Provisions in the FY14 and subsequent DoD authorization and appropriations bills that allocate at least $25 million in annual DoD funding to the CDMRP Gulf 

War Illness research program; 

b) Provisions in the FY14 and subsequent VA authorization and appropriations bills, requiring that VA spend at least $25 million annually on GWI research AND 

directing VA to contract with DoD CDMRP to conduct at least $20 million of VAfunded research as part of the CDMRP Gulf War Illness research program, as the 

CDMRP determines in its sole discretion. 

c) Adequately funding research to identify treatments for Gulf War Illness is imperative now to make up for the twenty-two years lost while the federal government 

has obstructed this research. 

12) Provisions in the FY14 and subsequent VA authorization and appropriations 

bills directing to expand the number, scope, reach, and funding for VA’s War Related Illness and Injury Study Centers (WRIISC’s). 

13) A provision directing VA to implement the February 1, 2012 published RAC 

recommendations for the New Gulf War-Era Data Report. 

14) A provision directing VA to implement the consensus Gulf War Illness Research Strategic Plan recommended by the RAC and NRAC, prior to unilateral VA 

staff revisions. 

15) A provision mandating the continuation in perpetuity of the ‘‘Gulf War Review’’ and related quarterly veteran-oriented publications for veterans of other eras, 

which should include ongoing, clear updates free of ‘‘strategic health risk communication’’ minimization, on each newly concluding federally funded research study, 

and each benefits change relevant to the target population. 

16) Provisions to correct injustices in the ratings for fibromyalgia and chronic fatigue. 

17) Provisions strengthening the authority of the present Research Advisory Committee on Gulf War Veterans’ Illnesses. 

18) Provisions that repeal and replace portions of Presidential Review Directive5/National Science and Technology Council (PRD–5/NSTC), and subsequent programs and governing regulations, including: 

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a) Provisions related to the use of investigational drugs and products on military 

service members. 

b) Provisions related to health risk communication. 

c) Provisions related to interagency applied research program on health risk communication for military members, veterans, and their families. 

d) Provisions related to electronic communications with state and community public health departments to disseminate health risk information to veterans and their 

families through local public health infrastructure. 

e) Provisions related to training local public health officials on the use of essential 

information technologies to disseminate and receive health risk information from 

veterans and their families. 

f) Repeal and replace the Military and Veterans Health Coordinating Board 

(MVHCB). 

19) A provision requiring the consistent federal government use of a term for 

‘‘Gulf War Illness’’. 

B. Finally, as a group of 14 Gulf War veteran advocates has previously recommended, Congress should immediately develop and ensure the enactment of legislation to: 

1) Reauthorize the expired provisions of the Gulf War Acts of 1998 [Persian Gulf 

War Veterans Act of 1998 (Title XVI, PL 105–277); Title I of the Veterans Programs 

Enhancement Act of 1998 (PL 105–368)] 

2) Provisions that explicitly and directly grant exposure-based service-connection 

presumptions to known, suspected, or plausible Gulf War exposures including: 

a. Sarin (GB) 

b. Cyclosarin (GF) 

c. Sulfur Mustard (HD) 

d. Tabun (GA) 

e. Lewisite (L) 

f. Soman (GD) 

g. VX nerve agent 

h. Particulates (PM2.5: sub-2.5 micrometer in size, which are respirable and too 

small to be removed by the lungs’ natural exfoliating processes) 

i. Pyridostigmine Bromide (PB) nerve agent protective pills (NAPP) 

j. Anthrax vaccine 

k. Multiple vaccinations 

l. Depleted Uranium (DU) 

m. Chemical pesticides 

3) A provision that grants exposure-based service-connection presumptions for exposures in (2) above for all U.S. servicemembers who served anywhere in the Southwest Asia theater of operations (38 CFR 3.317) or were awarded the Southwest Asia 

Service Medal (32 CFR 578.27) for service between January 16, 1991 and the end 

of 1991. {Note: last oil well fire put out ‘‘by November’’ 1991}. 

4) Require VA to contract with the Institute of Medicine of the National Academy 

of Sciences to identify a comprehensive listing of health conditions and symptoms, 

including chronic and delayed onset, which are associated in humans or animals 

with exposure to acute, subacute, and low levels for each of the named exposures 

in (2) above and explicitly and directly require VA to include each of these conditions as presumptives for Gulf War veterans as described in (3) above. The review 

should be explicitly required to include data from a comprehensive review of the 

medical literature, and to also include: 

a. 1993 IOM report on WWII veteran Mustard/Lewisite experimentation survivors; 

b. Medical literature assessing long-term health effects of the cohort of Iranian 

mustard-exposed veterans of the 1980–88 Iran-Iraq War; 

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c. Classified and unclassified published and unpublished research by the federal 

government, federal contractors, and federally funded entities into acute and longterm health effects of even low levels of the above named exposures; 

d. Animal studies. 

5) Ensure the perpetuity, without expiration, of adding new presumptive conditions as described in (4) above as they become identified by medical research. 

6) Expand the definition of the Southwest Asia theater of operations, for purposes 

of all VA benefits including healthcare, to include service qualifying for the award 

of the Southwest Asia Service Medal. 

7) Establish permanent eligibility by law for Priority Group 6 VA healthcare for 

veterans who have been awarded the Southwest Asia Service Medal. 

8) Require DOD to monitor, develop and retain accurate and detailed records regarding future troop hazardous exposures. 

i p. 14, Dusek, Jeffery, PowerPoint presentation: ‘‘Chronic Stress and Its Role 

in Emotional, Somatic, and Cognitive Symptoms’’; Presented at Meeting 2: Institute 

of Medicine Committee on Gulf War and Health: Treatment of Chronic Multisymptom Illness, Feb. 29, 2012. 

ii Golier, JA et al, ‘‘Twenty-four hour plasma cortisol and adrenocorticotropic 

hormone in Gulf War veterans: relationships to posttraumatic stress disorder and 

health symptoms. Biol Psychiatry 2007 Nov 15; 62(10):117t-8. Epub 2007 Jul 5. 

iii Walters, Terry, Office of Public Health, U.S. Department of Veterans Affairs: 

‘‘Institute of Medicine Committee on Gulf War and Health: Treatments for MultiSymptom Illness,’’ a PowerPoint presentation before the Institute of Medicine, Committee on Gulf War and Health: Treatment of Chronic Multisymptom Illness, Dec. 

12, 2011, pp. 37–40. Retrieved from the Internet 3/10/13: http://www.iom.edu/Activities/Veterans/GulfWarMultisymptom/2011–DEC–12.aspx 

f 

Prepared Statement of Victoria J. Davey, Ph.D., MPH, RN 

Good morning, Mr. Chairman, Madam Ranking Member, and Members of the 

Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA) efforts to identify, diagnose, and treat Gulf War-era Veterans. 

I am accompanied today by Dr. Maureen McCarthy, Deputy Chief Patient Care 

Services Office, Dr. Stephen Hunt, Persian Gulf Registry Physician, and Dr. Gavin 

West, Physician, Salt Lake City VA medical center (VAMC). 

VA focuses on all eras of Veterans and recognizes unique aspects of service associated with each era. In 2009, Secretary Shinseki established a Gulf War Veterans 

Illnesses Task Force (Task Force), headed by VA’s Chief of Staff (COS), a Gulf War 

Veteran. The Task Force’s mission is to ensure that VA maintains a focus on the 

unique needs of Gulf War Veterans. It was chartered to conduct a comprehensive 

review of VA’s programs to support this population of Veterans; develop an overarching action plan to advance service to them; and ultimately to improve their satisfaction with the quality of services and support VA provides. The Task Force has 

prepared three annual reports detailing concrete steps VA has taken, and continues 

to take, to improve care and services to Gulf War Veterans. The Secretary and COS 

believe that ultimately, the Task Force’s efforts must become a part of the culture 

and ongoing operations of VA?and not simply the purview of a special Task Force. 

At this time, Mr. Chairman, I would like to focus on the efforts the Veterans 

Health Administration has made in response to both the guidance of the Task Force 

and the needs of Gulf War Veterans, to improve their health and well-being. 

VA is proud to offer continuing treatment as well as evaluation of the nearly 

700,000 men and women who served in Operations Desert Shield and Desert Storm. 

My purpose today is to communicate the personalized and compassionate care that 

VA strives to deliver to fulfill the unique needs of the men and women who served 

in these Operations. 

Many Gulf War Veterans are affected by a debilitating cluster of medically unexplained chronic symptoms that can include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems. 

These symptoms can wax and wane, and may have lasted since deployment in 

some Veterans. Unfortunately, we yet do not know the cause, but a complex combination of environmental hazards, exposures, and individual genetic characteristics 

may be behind these symptoms. We refer to the illness that these Veterans describe 

as chronic multisymptom illness or ‘CMI’. 

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Terminology like ‘CMI’ helps us define the populations of concern, plan treatments, and drive research. However, VA’s fundamental approach to health care has 

evolved over the first decade of the 21st century. We believe the person, not the disease or the terminology, is the center of importance in the health care relationship. 

We want to meet the patient where he or she is in life, and develop with the patient 

a health plan of care that returns the patient to his or her highest possible level 

of health and enjoyment of life. As with every other Veteran, VA seeks to provide 

Veterans with CMI personalized, proactive, patient-driven care. As part of our services to Gulf War Veterans, VA offers a number of programs and services that are 

uniquely designed to meet their needs. 

VA facilities throughout the Nation are working on bold, innovative programs that 

combine primary care and specialty care services. One such program links primary 

care services with specialty medical treatment models specific to Gulf War Veterans, 

in order to produce a seamless, patient-centric model that will improve patient care, 

safety, and satisfaction, as well as provider knowledge. This program is creating a 

system of care, which leverages VA’s Patient-Aligned Care Team (PACT) concept. 

Through PACT, providers and staff members from multiple disciplines, outlooks, 

and experiences work together to provide the best possible care. Patients and family 

members are considered part of their own PACT. 

VA has linked PACT teams working with Gulf War Veterans with a specialty care 

capability that focuses on treating the unique health care requirements of Gulf War 

Veterans. The program includes teaching aids, referral networks, and other types 

of collaboration. Front-line clinicians have been educated through monthly community of practices conference calls, informational meetings, pocket cards, and Web 

sites. The meetings are led by clinicians trained in issues specifically related to the 

integration of primary and specialty care. 

Facilities involved in the program have seen improvement in their recent customer service scores; an improvement that has been corroborated in VA-led focus 

groups. VA is currently preparing a social media campaign to improve feedback on 

the program from Veterans, to keep Veterans involved in the progress of the program, and to allow Gulf War Veterans served by the program to communicate more 

easily. 

VA providers being trained in clinical issues related to the Gulf War include family medicine and internal medicine doctors in training, nurse practitioner students, 

and those intending to become physician assistants. Many practitioners at participating VA hospitals and Community-Based Outpatient Clinics (CBOC) have noted 

a substantial increase in their knowledge about Gulf War Veterans issues, and have 

found it significantly easier to find information they require about the subject. Veterans have also noted that clinicians involved in the program are now more knowledgeable about their issues. 

Another program specifically for Gulf War Veterans is our registry program, 

begun by VA in August 1992. The program offers a health examination at any of 

our health care facilities to any Veteran with Gulf War service. To date, about 

130,000 Gulf War Veterans have undergone a registry exam, allowing their health 

concerns to be evaluated by VA physicians, and enabling them to be referred for additional care when needed. The comprehensive health exam includes an exposure 

and medical history, laboratory tests, and a physical exam. VA health professionals 

discuss the results face-to-face with Veterans and in a follow-up letter. 

Since 2001, the War Related Illness and Injury Study Centers (WRIISC) have 

supported specialized care for Gulf War Veterans, and conducted cutting-edge research, clinician education, and a Veteran referral program. VA’s three WRIISC locations have teams of clinicians ready to evaluate Gulf War Veterans with deployment-related concerns. Based on a comprehensive evaluation, the WRIISC team develops an individual, holistic treatment plan for Veterans with CMI or other ill-defined conditions, through a referral process based on geographic location. 

Primary care physicians throughout VHA contact the WRIISC to refer Veterans 

to one of the three regional centers, using the consult process in VA’s computerized 

patient record system. VA recently developed this streamlined specific interfacility 

consult for the Veteran’s integrated team to use to seek help from the WRIISC for 

consultation and development of a coordinated treatment plan. 

The WRIISC is not the only way in which the special needs of Gulf War Veterans 

are met throughout VA’s health care system. VA conducts special educational programs for health care providers, Veterans, and their families. These include in-person training sessions, webinars, Web sites, and publications for both patients and 

providers on topics including assessments of environmental exposure and difficultto-diagnose conditions. 

VHA’s Office of Public Health (OPH) holds quarterly conference calls with Environmental Health coordinators and clinicians located at every VA hospital. These 

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coordinators and clinicians are subject matter experts for Veterans and VA staff, offering advice on environmental exposure experience during military service. The 

conference calls provide coordinators and clinicians with ongoing training, allowing 

them to share patient care questions, challenges, administrative issues, and solutions that have come up at their facilities and provide an opportunity to discuss the 

latest information on environmental health. 

Recently, OPH developed an Environmental Exposure pocket card that includes 

questions for practitioners to ask Veterans about their health concerns, including 

those related to Gulf War deployments. It also provides contacts Veterans can use 

to obtain information about additional VA resources and benefits to which they may 

be entitled. The card is available at http://www.publichealth.va.gov/docs/exposures/environmental-exposure-pocket-card.pdf. 

VA now is in the process of developing additional innovative training resources, 

such as a mobile device and internet application that will provide real-time information on environmental exposures, associated symptoms and conditions, and potential 

treatments beneficial for clinicians in treating these Veterans. 

Mr. Chairman, in accordance with Public Law 105–277, VA contracts with the National Academy of Sciences to independently examine and evaluate the medical and 

scientific literature regarding illnesses and deployment in support of the Gulf War. 

Since 2000, the Academy’s Institute of Medicine (IOM) has provided its scientific 

conclusions on the strength of the evidence for associations between such exposures 

and illness. VA uses IOM’s reports to help inform policy decisions regarding whether 

certain diseases or illnesses, called presumptive diseases, are related to qualifying 

military service. 

VA recently engaged IOM to convene a committee to comprehensively review, 

evaluate, and summarize the available scientific and medical literature regarding 

the best treatments for CMI among Gulf War Veterans. 

On January 23, 2013, IOM released a study containing recommendations to VA 

on how to recognize and treat Gulf War Veterans with CMI. IOM based 

its recommendations on a review of 47 existing studies. IOM provided a working 

definition of CMI, as ‘‘the presence of a spectrum of chronic symptoms’’ in at least 

two of six categories, including fatigue; mood and cognition (such as memory difficulties); musculoskeletal; gastrointestinal, respiratory, and neurologic issues. IOM 

indicated that the symptoms of conditions that are already defined, such as chronic 

fatigue syndrome; fibromyalgia; functional gastrointestinal disorders; In addition, 

co-morbid conditions, such as depression and anxiety, may overlap those of CMI. 

IOM made recommendations to VA in five categories, including how to: treat CMI; 

improve systems of care and management of care for Veterans with CMI; provide 

information throughout VHA about care for Veterans with CMI; improve the collection and quality of data on care outcomes and satisfaction with care for Veterans 

who have CMI; and how to conduct future research on diagnosing and treating CMI 

and on evaluating programs to treat the illness. 

VA welcomes this opportunity to address these recommendations in an effort to 

improve how we meet the clinical needs and expectations of Gulf War Veterans. VA 

shares IOM’s concern that Veterans experiencing CMI be managed compassionately 

and that they experience personalized, proactive, patient-driven care specific to their 

needs. Actions that we already are taking include a pilot program to provide every 

Veteran with a full health assessment when he or she separates from service. This 

is a combined VA–DoD separation health assessment. The Secretaries of Defense 

and Veterans Affairs acknowledged their commitment to full implementation of a 

universal, standardized separation health assessment for all transitioning 

Servicemembers (SMs) was supported through the resources of both DoD and VA 

in December 2012. Currently, VA and DoD representatives are drafting the memorandum of agreement (MOA) which will be ready for coordination by end of March 

2013. The MOA will formally establish roles, responsibilities, standard exam criteria, and monitoring requirements. DoD and VA staff have been meeting weekly 

to discuss implementation options along with the drafting of the MOA. A pilot is 

taking place at the Washington, DC VAMC to test the processes related to performing the standardized health assessment elements as part of a VA disability 

exam in support of a claim for benefits.; 

Moreover, other actions include VA’s addition of a clinical reminder to its computerized patient record system to prompt clinicians to ask all Gulf War separating 

Servicemembers whether they may have symptoms consistent with CMI; and the 

special PACT program for Gulf War Veterans described previously in this testimony. 

We are improving communication among VA health care providers and with patients; improving patient satisfaction measurement tools, and training our staff to 

better recognize CMI. We are also developing a champions program and additional 

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webinars, and taking steps to strengthen research protocols submitted for funding 

in complementary and alternative medicine. 

IOM notes in its report that the impacts of CMI are wide-ranging, and extend far 

beyond the health of individual Veterans. CMI has personal, occupational, and social consequences that impact not only Veterans and their families but also their 

employers and the communities in which they live. VA understands this. We remain 

committed to providing evidence-based, compassionate care for these Veterans, and 

for all of the Veterans it is our privilege to serve. VA intends to continue our ongoing efforts to improve our abilities to provide health care for Gulf War Veterans; 

to better educate our health care providers; and to expand the evidence basis for 

the treatments we provide for Gulf War Veterans, and all Veterans. 

Mr. Chairman, this concludes my testimony. We appreciate the opportunity to appear before you today to discuss this important issue. My colleagues and I are prepared to answer your questions. 

f 

Statement For The Record 

Statement by Melissa A. Forsythe, PhD, RN, Program Manager for Gulf War 

Illness Research Program, United States Army Medical Research and Materiel Command 

Chairman Coffman, Ranking Member Kirkpatrick, distinguished Members of the 

Subcommittee; I thank you for the opportunity to provide this testimony on behalf 

of the Department of Defense (DoD) Gulf War Illness Research Program. This program studies the multi-symptom cluster known as Gulf War Illness (GWI) that afflicts as many as 250,000 of the 750,000 service members and Veterans who served 

in the Persian Gulf War theatre of operations during 1990 and 1991. 

Overview of DoD GWI Research Funding 

DoD-funded GWI research began in 1994 with the establishment of a Gulf War 

Veterans’ Illnesses Research Program (GWVIRP) to study the health effects on the 

service members deployed in the 1990–1991 Persian Gulf War. From Fiscal Year 

(FY) 1994 to FY 2005, the GWVIRP was managed by the US Army Medical Research and Materiel Command (USAMRMC) Military Operational Medicine Research Program (MOMRP). Research pertaining to GWI also has been funded intermittently through the Congressionally Directed Medical Research Programs’ 

(CDMRP) Peer Reviewed Medical Research Program (PRMRP) that supports selected military health-related research topics each fiscal year. 

The MOMRP shared management responsibility for the GWVIRP with the 

CDMRP in FY 06 with separate $5 million (M) appropriations. Although the 

GWVIRP, renamed the Gulf War Illness Research Program (GWIRP), did not receive funding in FY 2007, a $10M appropriation renewed the program in FY 2008 

to be managed fully by the CDMRP. Since that time, the GWIRP has been maintained with $8M appropriations in FY 2009, FY 2010, and FY 2011. The FY 2012 

GWIRP appropriation was $10M. The program’s mission is to ‘‘Improve the health 

and lives of Veterans who have Gulf War Illness.’’ Thus, the program supports innovative, competitive peer-reviewed research for treatments that address the complexity of symptoms comprising GWI, identify objective markers (biomarkers) for the 

disease, and understand the pathobiology underlying GWI. 

CDMRP GWIRP Processes 

As with all CDMRP-managed programs, the GWIRP program management cycle 

includes a two-tier review process for application evaluation recommended by the 

National Academy of Sciences’ Institute of Medicine. The first tier of evaluation is 

an external scientific peer review of applications against established criteria for determining scientific merit. This review is conducted by scientific and clinician experts in Gulf War Illness with input from consumers - veterans suffering from GWI. 

The second tier is a programmatic review conducted by an Integration Panel (IP) 

composed of program-specific researchers, clinicians, and consumers who evaluate 

applications on innovation, potential impact, programmatic priorities, and mechanism specific criteria. The IP is composed of prominent members of the GWI research community, including Gulf War consumers. The IP coordinates with the Office of Research and Development within the Department of Veterans Affairs (VA) 

to ensure there is no overlap of funding and that portfolios are complementary. 

The IP recommends applications for funding that best fulfill the program’s vision 

and mission while also demonstrating innovative science. The recommendations of 

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1 Hannan KL. Berg DE. Baumzweiger W. Harrison HH. Berg LH. Ramirez R. Nichols D. Activation of the coagulation system in Gulf War Illness: a potential pathophysiologic link with 

chronic fatigue syndrome, a laboratory approach to diagnosis. Blood Coagulation and 

Fibrinolysis. 11(7): 673–678, 2000. 

IP members enable the GWIRP to find and fund cutting-edge research and set important program priorities to benefit ill Gulf War Veterans. The Commanding General of USAMRMC issues final approval for funding prior to award negotiations and 

execution. 

The Role of Veterans as Consumers 

A unique aspect of the CDMRP is the active participation of consumer advocates 

throughout the program. Consumers for the GWIRP are Gulf War Veterans who are 

experiencing symptoms and illnesses related to their military service in the 1990– 

1991 Persian Gulf War theater. Consumer advocates are a vital part of all CDMRP 

programs in that they express the collective views of survivors, patients, family 

members, and those affected by the disease. They sit side by side with research professionals on both peer and programmatic review panels, they vote as equal members of these panels, and their voices play a pivotal role in maintaining an appropriate focus within the program. 

CDMRP GWIRP Portfolio 

The GWIRP has focused on the development of treatments to address the myriad 

of symptoms that plague ill Gulf War Veterans. To that end, the GWIRP has offered 

Clinical Trial Awards (CTAs), Innovative Treatment Evaluation Awards (ITEAs), 

and Investigator-Initiated Research Awards (IIRAs) that support pilot studies and 

larger, more definitive clinical trials to investigate potential treatments for GWI. To date, the GWIRP has funded 3 CTAs ($3.6M), 5 ITEAs ($3.1M), and 39 IIRAs 

($29M). Of these, 13 awards are focused on developing treatments, 15 are pursuing 

biomarkers, 8 are examining symptoms, and 6 are investigating exposures, while 

others are conducting basic research related to Gulf War Illness. Examples of these 

funded awards include the following: 

a. IIRAs: (1) Beatrice Golomb, M.D., Ph.D., University of California, San Diego 

recently completed a 3‡-year study (FY 2006 IIRA) examining the benefits of daily 

coenzyme Q10 (Q10) in ill Gulf War Veterans. Q10 is naturally produced in the 

human body where it is involved in cellular energy production as a key antioxidant. 

But, levels of Q10 can be inadequate to meet needs when there is increased 

‘‘oxidative stress’’ or impaired energy production. Dr. Golomb hypothesized that 

mitochondrial dysfunction, linked to cellular energy production, may contribute to 

symptoms of GWI and sought to assess whether Q10 conferred benefit to overall 

health and symptoms in GWI. 

Initial analysis of the study results found that the 100 mg dose led to better selfrated health scores than the 300 mg treatment. More importantly, fatigue with exertion, which 54% (25) of subjects reported at baseline, demonstrated significant improvement with Q10 at 100 mg compared to placebo treatment. The benefit to fatigue with exertion is important because increased exercise tolerance is a bridge to 

many health benefits (e.g., mood, function, and cognitive performance) as well as 

quality of life benefits crucial to ill Gulf War Veterans. 

These findings provide important preliminary information that could inform a 

larger trial of Q10 better powered to show benefit to global health in ill Gulf War 

Veterans. 

(2) Dr. Ronald Bach at the VA Medical Center in Minneapolis (VAMC Minneapolis) is using a FY 2008 GWIRP IIRA to further develop findings from VA-funded studies that indicated that ill Gulf War Veterans may be in a hyper-coaguable 

state of unknown etiology 1. Earlier work showed strong correlations between the 

plasma concentrations of inflammation-related proteins and symptoms of GWI. 

Thus, he hypothesized that chronic inflammation is part of GWI pathophysiology. 

Analyses determined that C-reactive protein (CRP) levels, a marker of systemic 

inflammation, were significantly higher in Gulf War Veterans with three symptoms 

(as defined in health surveys) versus asymptomatic veterans. Dr. Bach subsequently 

observed statistically significant linear correlations between CRP and a group of 18 

plasma proteins. This set of pro-inflammatory potential GWI biomarkers has been 

labeled ‘‘The Gulf War Proteome’’, though more in-depth analysis is pending. 

b. ITEAs: (1) Dr. Ashok Tuteja of the Western Institute for Biomedical Research, 

is using a FY 2009 ITEA to study irritable bowel syndrome (IBS) resulting from 

gastroenteritis commonly found in ill Gulf War Veterans. Dr. Tuteja is examining 

the potential of pro-biotic treatment (live bacteria that re-establish normal gut flora) 

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to improve GWI-associated IBS, fatigue, joint pain, and headaches in a clinical trial 

of 80 Gulf War Veterans. This study is on-going. 

(2) Dr. David Rabago of the University of Wisconsin, Madison, is using a FY 2010 

ITEA to examine the effectiveness of routine nasal care plus saline or xylitol nasal 

irrigation compared to routine care alone as therapy for chronic rhino sinusitis and 

fatigue in 75 ill Gulf War Veterans. Study outcomes will gauge responses to surveys 

and assess the cost-effectiveness of the treatment. Dr. Rabago will also examine proinflammatory cytokine markers and cell types in the mucosal profile to elucidate 

biomarkers of the condition. This study is on-going. 

The Way Forward 

Since its inception at CDMRP in FY 2006, the GWIRP has served as a springboard for GWI Research, identifying and developing a community of researchers and 

clinicians dedicated to pursuing robust research. The quality of applications submitted to the GWIRP has increased from overall scientific merit scores averaging 

3.0 (on a scale of 1.0 to 5.0, with 1.0 representing a ‘perfect’ application) in FY 2006, 

to scores of 1.9 on average in FY 12. While quality has improved significantly, the 

quantity of awards made has not, given the available appropriations. In FY 2012, 

the GWIRP funded 13% of applications. 

In FY 2010, the GWIRP took a bold step by offering a Consortium Development 

Award (CDA). This award provided $200,000 over one year for researchers to create 

a Coordinating Center and to establish the necessary collaborations at potential research sites to develop a multi-institutional GWI research effort. 

The CDA supported experts from differing fields of GWI, and helped to bring their 

consolidated efforts to bear toward moving research forward, finding new treatments, developing biomarkers, and improving our understanding of GWI. Three 

CDAs were awarded, all of which scored very high on scientific merit, and also addressed a different focus of GWI. 

In FY 2012, these three CDA awardees competed for a full Consortium Award. 

Two of the three were selected for initial funding ($2.5M each), with the additional 

funds (again, $2.5M each) to be awarded as an option from FY 2014 funds, depending on the availability of funds and the progress of each consortium toward accomplishing its specific goals. While both of these awards are under negotiations, they 

are poised to propel the field of GWI research beyond what could be accomplished 

by individual researchers’ efforts. 

In addition to the Consortium Award, in FY 2012 the GWIRP again offered the 

Investigator-Initiated Research Award, Clinical Trial Award, and the Innovative 

Treatment Evaluation Award established in FY 2009. These awards will add to the 

growing portfolio of GWIRP-funded, high-impact research designed to help our ill 

Gulf War Veterans. 

f 

From David K. Winnett, Jr. 

Dear Chairman Miller and Distinguished Members of the Committee, 

Today, almost twenty-two years after the 1991 Persian Gulf War (PGW) more 

than 250,000 Veterans of that war continue to suffer from very debilitating medical 

symptoms directly related to their wartime service. 

As a four-time ‘‘Consumer Reviewer’’ panelist on the ‘‘Congressionally Directed 

Medical Research Programs’’ (CDMRP) for Gulf War Illness Research, the consensus 

among the scientific and medical communities now points to the strong likelihood 

that PGW Veterans sustained neurological damage to the part of the brain that regulates the autonomic nervous system. This seems a quite viable explanation given 

the myriad of symptoms that have destroyed the quality of life for so many PGW 

Veterans and their families. Unfortunately, researchers who for years have valiantly 

searched for effective treatments for the numerous symptoms associated with Gulf 

War Illness have been greatly handicapped by not knowing precisely what caused 

these illnesses. 

Today there are many thousands of documents that remain classified concerning 

events that occurred before, during, and after the PGW. Former Senator Donald 

Riegle’s 1994 report on Gulf War Illness made public a number of disturbing revelations concerning weapons technologies that were authorized for sale by the United 

States government to the Iraqis during the late 1980’s. The Senator’s report inferred 

that some of those same weapons technologies, chemical and biological weapons 

among them, may have been the cause of Gulf War Illness. His report also recommended a Justice Department investigation into these questionable weapons 

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sales to Iraq; an investigation that the Justice Department has never deemed important enough to pursue. 

Not surprisingly, compelling evidence to explain Gulf War Illness now points to 

confirmed widespread battlefield exposures to chemical warfare agents, including 

Sarin Gas that were inadvertently released into the atmosphere by pre-ground war 

American/Allied aerial bombing of Iraqi ammo storage areas within the theater of 

operations, and/or administration of medicines (i.e., Pyridostigmine Bromide pills) 

that were prescribed to all ground forces, despite the fact that at the time they were 

not yet FDA approved, and/or tainted vaccinations - i.e., excessive Squalene utilized 

in the adjuvant (booster) of mandatory vaccines administered to our troops without 

their informed consent. 

Also suspect as a possible cause of Gulf War Illness, now referred to as ‘‘Chronic 

Multisymptom Illness’’ was widespread ingestion of micro-particulates of post-impact 

Depleted Uranium (DU), a heavy weapons technology first used on a large scale during the 1991 PGW. Despite the fact that DU has been proven by DOD and others 

to cause extremely long-term environmental damage as well as posing considerable 

health risks to anyone exposed to it, DU is still in use in America’s arsenal today. 

Perhaps that might explain why many of today’s Warriors are coming home with 

symptoms eerily similar to Gulf War Illness? 

There is little dispute now that Gulf War Illnesses are real, but for reasons that 

continue to confound the Veteran community, the majority of Persian Gulf War Veterans who have submitted claims for Veterans disability compensation related to 

their wartime service have had their claims denied. This prevents the chronically 

ill Veteran from receiving financial compensation that would help to offset their loss 

of earning capacity and denies them the priority medical care status that the VA 

extends to Veterans with service-connected disabilities. 

The disenfranchisement of the over 250,000 men and women who carried out one 

of the most effective military operations in our country’s history is a tragedy of the 

highest order. These are American heroes whose life-altering chronic medical problems have been largely ignored by their fellow countrymen for over twenty years, 

a human tragedy far beyond anything that I am aware of in our country’s history 

where American War Veterans are concerned. 

Despite numerous setbacks that our Persian Gulf War Veteran community has experienced over the last two decades, I remain extremely confident that sooner or 

later, the truth will be known. The question I have for the Chairman, and for the 

Honorable Members of your Committee is - which side of history will you be on? 

Will you choose the side that the vast majority of our Colonels, Generals, and the 

Politicians who presided over the Persian Gulf War have chosen? Like them, will 

you remain loyally silent to your last breath – will you sleep soundly at night under 

the morally misguided perception that ‘‘matters of national security’’ or the release 

of ‘‘sensitive information’’ trumps the health and welfare of America’s sick Gulf War 

Veterans? Like them will you be deafened to the cries for help that continue to echo 

from the battlefield – pleas for help from the same brave and selfless Warriors who 

did the dirty work that made so many of our Generals overnight celebrities? Like 

them, will you continue to turn your back on this magnificent group of American 

heroes who carried out one of the most resounding wartime victories in our country’s history? Or, will you be on the side of moral justice - the side that advocates 

for complete truth and transparency, no matter its cost, when it comes to once and 

for all declassifying and disclosing the precise reason(s) why so many Persian Gulf 

War Veterans fell ill after the war, no matter whose military or political legacies 

may suffer, and no matter the potential for embarrassment and/or civil liability that 

certain defense contractors may face? 

I am very close to completing a book that describes what I believe to be the largest disenfranchisement of American military personnel in the history of this country. The working title of the book is ‘‘To Fight for Right and Freedom’’ (A Marine 

Corps ‘‘Mustang’s’’ battle with Gulf War Illness, and the War Machine that created 

it). The book, now over 400 pages in length does not paint a kind picture of those 

within our government and defense establishment whom I believe to be complicit 

in this unconscionable act of betrayal against our troops. I’ve paid an enormous personal price as a direct result of my public outspokenness over this often controversial issue, the details of which are explicitly outlined in my book. But there is no 

penalty that anyone can possibly levy on me that will succeed in deterring me from 

continuing to exercise the moral leadership that I was so blessed to assimilate as 

a United States Marine. This mission will be accomplished, and I plan to be around 

when that day comes. I very much hope to see you all there. 

And so, in closing I would respectfully ask only two things from each of you when 

it comes to making decisions about how best to deal with the issue of Gulf War Illnesses - and they are, BE HONEST and DO THE HONORABLE THING. Do what 

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you were elected to do - represent the interests of the American citizens; the citizen 

Warriors who put their lives on the line twenty-two years ago, serving you, so that 

you could one day have the privilege of serving them. So please, serve them. They 

may not have paid for your political campaigns, but they have paid dearly for your 

freedoms. It is up to each of you to decide which holds the most value. 

It’s been twenty-two years. That’s quite long enough. Too many have died, too 

many have suffered with constant pain, profound fatigue, and other debilitating 

symptoms too numerous to list. More importantly, far too many continue to have 

their disability claims denied by the Department of Veterans Affairs, despite voluminous regulations that your honorable body created; laws that were supposed to give 

the benefit of the doubt (‘‘Presumption of service connection) to the symptomatic Persian Gulf War Veteran. With great respect, please trust me; by in large the very 

laws (the Direct Orders!) that you issued to the VA to take care of these Veterans 

are being summarily ignored at the vast majority of VA Regional Offices across this 

country. That is beyond unconscionable. 

History is watching. 

Very Respectfully, 

David K. Winnett, Jr. 

Captain, United States Marine Corps (Retired) 

100% Disabled Persian Gulf War Veteran 

f 

Chris Thomas, Summary of My Case History with the Veteran’s 

Administration 

• In 1991 and 1993, I served with the 3rd Armored Cavalry Regiment in the Persian Gulf region. Between May and December of 1993 he was gassed and 

shelled in combat with my regiment. Military records support this point and 

have been undisputed in claims made to the VARO. 

• I was discharged from active duty service in 1996. I began service in the reserves from 1996 to 2000. I suffered chronic kidney problems (stones, other) 

during the years leading up to my discharge from the reserves. 

• October 13, 2008 I suffered an episode of anaphylaxis resulting severe respiratory distress. I had to be rushed by ambulance to the Skyline Medical Center where I was intubated. This experience is consistent with my claim that 

symptoms of Parasympathetic Autonomic Dysfunction (PAD) began in 2008. 

• I was diagnosed on December 4, 2008 by Dr. Zia, a private practice neurologist 

in Bowling Green, with Parasympathetic Autonomic Dysfunction (ANS/ALS & 

neuro condition) by my neurologist and began losing feeling in my feet and legs. 

DRO Chuck Tate dismissed this diagnosis because he thinks Zia practices in a 

rural market and doesn’t have the skills of physicians in a university setting. 

Zia is a Boston University and Harvard Medical School graduate. Dr. Zia performs over 300 tilt table tests annually to determine Parasympathetic Autonomic Dysfunction. Dr. Smith (VA neurologist) also rejected Zia’s diagnosis. 

• November, 2008 I was hospitalized for migraine and tremor. 

• December, 2008 I was hospitalized for chest pain. 

• April, 2009 I required surgical removal of grossly enlarged axillary lymph 

nodes. 

• May, 2009 Dr. Diana Cavanaugh, Allergist with Graves-Gilbert Clinic writes a 

letter opining that the anaphylactic episodes, joint pain, migraines, tremor, 

lymphadenopathy and chest pain symptoms must have some underlying cause 

which can link all of these symptoms together. 

• June 6, 2009 I took the Gulf War Registry exam which was not a complete 

physical. Examiner didn’t review my registry paperwork. My claim was denied. 

• August 15, 2009 I was diagnosed by (Dr. Dewey Dunn) VAMC Nashville as having (a) mild restrictive lung disease; (b) migrane headache disorder; (c) multiple 

arthralgias of unknown etiology and (d) irritable bowel syndrome. Yet the DRO 

said I did not have lung disease and IBS in his denial of my claims for assistance. 

• March 3, 2010 was the first scheduled appointment with Dr. DeMuth as the primary care physician. 

• April 21, 2010 While an inpatient at VAMC, Dr. Hatfield (VA Gastroenterologist) indicated to me that Irritable Bowel Syndrome (IBS) is secondary 

to PAD. 

• May, 2010 After losing nutrition and fluid and experiencing vomiting for several 

over two weeks, I was admitted as an inpatient at VAMC. I went through 

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multisystem failure and was on the verge of coding and was transferred to Jewish Hospital from May 14–18, 2011. Medical staff at Jewish said my bowels 

were dying. Dr. Hatfield explained to me that Gulf War Syndrome degrades 

your bowels/stomach because they are part of your auto immune system. He 

said serin attacks every phase of your auto immune system. • June 3, 2010 Dr. Ron Stattenberg, VA Radiologist conducted a MRI of my brain 

and reported evidence of chronic small vessel ischemic change. Small vessel 

ischemic change is consistent with stroke, hypertension, migraines or other 

medical conditions. I have a history of these symptoms. • July 6th, 2010 Dr. Ramirez, Infections Disease physician with VAMC Louisville 

diagnosed me with radiation poisoning. Dr. Smith, Neurologist stopped the proposed medications to treat the radiation poisoning so Ginko Balboa or fish oil 

was proposed as an over the counter medication. This treatment was discontinued shortly due to adverse gastrointestinal side effects. Smith’s nurse told 

me ‘Nothing is wrong with you.’ Again Dr. Smith rejects another physician’s diagnosis as he did with when he rejected Dr. Zia’s diagnosis of Parasympathetic 

Autonomic Dysfunction. • June through late 2010, I was treated at Southern Kentucky Rehab Hospital 

where I was treated for physical therapy, speech therapy and occupational therapy. My inability to perform basic exercises is well documented by qualified 

therapists. My musculoskeletal functions progressively worsened and pain increased over those months. Rehab care was discontinued the hospital for fear 

that lack of progress would threaten the reimbursement of costs for such care. • Early 2011, My condition worsened. I frequently experienced swelling and inability to urinate. Weakness in the left side of his body worsened and I experienced tremors frequently. No cohesive plan of care was established so I reached 

out to Congressman Guthrie to do something to get the VAMC to take me seriously and develop a cohesive plan of care to make me better. • In late Spring 2011, Mark Lord from Guthrie’s staff secured a meeting with 

Louisville VAMC leadership including Director Pfeffer, Chief of Staff Marylee 

Rothschild, VAMC legal counsel and risk management staff. Rothschild debated 

my claims about a lack of diligent care and the risk management person 

pressed that I was not compliant with efforts to seek PTSD treatment. Mr. Lord 

made the point that his anxiety will be dramatically reduced if his medical 

needs will be treated diligently. Director Pfeffer brought up the prospect of 

sending Ito the War Related Injury and Illness Center because he said they are 

the specialists for these types of cases. • August 2011, I went to the WRIISC in Washington, DC. It was a major disappointment. What was described as a specialty center to treat war related injuries of an obscure nature like GWI turned out to be a research facility with 

very little treatment capacity. The bottom line was I came home with a diagnosis of low testosterone and a big bag of vitamins. I also came home very sick 

and hurting from the MRI’s which heated up the shrapnel in my body. 

• Six weeks passed and no one from WRIISC and the VAMC nor primary care 

were talking with each other. So I got Congressman Guthrie’s staff to press 

them to take action. Congressman Guthrie got wrote a letter on my behalf complaining about the poor continuity of care associated with my case. 

• In November of 2011, my health is worsening under the care of the VA. Dr. Ramirez and Dr. Peyrani, Infectious Disease physicians in the VA described me 

as having progressive neurological symptoms and multiorgan dysfunction affecting the heart, brain, kidneys, bone marrow, peripheral nerves and the immune 

system. 

• As my condition worsened under the VA, the care providers did not demonstrate 

appropriate diligence in carrying out a treatment plan for me. My first appointment to discuss the recommendations from the WRIISC did not going to happen 

until February of 2012 which would have been six months from my discharge 

from the WRIISC. Fortunately, with Congressman Guthrie’s help it was moved 

up to November. 

• The continuity of care with my case was very poor given the acuity of my symptoms. My primary care physician, Dr. DeMuth, was not communicating well 

with specialists involved in my care. Other than one consultation with WRIISC 

physician, Dr. Li, DeMuth did not have consultations with the specialists involved in my care. He relied only on case notes. Given my involved and worsening condition, more diligence should reasonably be expected. 

• DeMuth did not communicate adequately with me. DeMuth told me that he 

would complete the referral for me to see a cardiologist and an urologist for the 

severe symptoms that I was experiencing. Instead of completing the referral he 

put in for tests to take place weeks later that would qualify me to see the speVACREP180 with DISTILLER

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cialists. DeMuth also prescribed tests that would expose me to high levels of 

radiation that could be potentially harmful to a patient with probable radiation 

poisoning, yet did not consult with me and did not take my phone calls about 

the matter days before the procedure was to be done. In late 2011, DeMuth 

began sending vitamins and drugs to me without consultation about the purpose of them. DeMuth even went so far as to demand that I sign a contract with 

him limiting the number of medical concerns that I can talk to him about at 

two concerns per visit. The contract also limited the amount of his time that 

I could have in a patient visit. • Through late 2011, VAMC leadership was not advocating any material change 

in the way I was treated. Upon my desperate request for help Congressman 

Guthrie’s, sent a letter to Director Pfeffer and Chief of Staff Rothschild outlining these concerns. The response from Chief Rothschild was that the care I 

was receiving was completely within their standard of care and that this office 

‘‘should let doctors be doctors.’’ Her only recommendation was to designate a 

nurse on DeMuth’s staff as a case manager and encourage DeMuth to spend 

30 minute visits with me rather than the customary 15 minutes typically provided. This seems ironic that she advocated letting the doctors be doctors yet 

nine months ago their plan was to get me into the care of the WRIISC because 

the appropriate expertise was not sufficient in this VA region to care for me 

adequately. 

• There is apparently no defined protocol to treat veterans with symptoms of radiation poisoning or biological/chemical combat exposures. 

• Meanwhile, I pleaded desperately for the opportunity to see a specialist for the 

symptoms that I was experiencing. I have grown increasingly angry at the VA 

system for not treating my combat injuries and for treating me as though my 

symptoms are fiction. I acknowledged that I am 100% PTSD disabled and I am 

willing to get treatment. But I want my physical symptoms to be taken credibly 

so I can get care that is consistent with private health care providers outside 

the VA system. 

• In late 2011, I felt that I didn’t not have long to live. As a former critical care 

nurse at the Vanderbilt Hospital, I know that untreated atrial fibrillation of the 

heart, the chronic kidney dysfunction and weakened immune system can easily 

lead to death rapidly. This and numerous other symptoms combined to degrade 

my quality of life. 

• In early 2012, we seemed to have exhausted all options at the Louisville VAMC 

level with no good reason to expect improvement in my care. So Congressman 

Guthrie’s staff escalated my complaint to VISN 9 Director Dandridge conceded 

to move my care outside the VA to private physicians. 

• Currently, I am making some progress now but my physicians have almost no 

experience treating the patients with exposures to bio/chem agents or radiation 

poisoning. Reimbursements from the VA are chronically slow pay which makes 

them want to drop me as a patient. Likewise, there have been frequent battles 

with the VA pharmacy to get the meds filled the way the doctors want them 

filled. 

f 

From Kirk P. Love 

Dear OI subcommittee 

My name is Kirt P. Love. I served in the 1990 Persian Gulf War as a generator 

mechanic with 141 Single Battalion attached to VII Corp. Our unit deployed from 

Germany in November 1990 and left in April 1991. 

I got deathly ill in 1993 and the system failed me. Filed for VA benefits in 1994 

that turned into a nightmare battle heading to my 2002 meeting with Sec Principi’s 

staff after my BVA hearing. Have been 60% rated since 2002. It should not have 

taken a meeting with the VA Secretaries staff after 8 years of fighting with VA to 

make it happen. 

Since 1997 I’ve run a survey and website advocating Gulf War veterans. By 1999 

I attended regular meetings with the Pentagon with 33 other advocacy groups over 

our concerns. By 2002 the Pentagon shut down outreach with the GWI community 

and put the whole show in VA’s hands. The Research Advisory Committee was 

formed about that time but only specialized in research. 

By 2005 healthcare and benefits issues were moot as only the RAC had any Congressional mandate or interest. The Gulf War Registry as well as any other GW Programs had floundered badly. The only venue for us to replace the defunct Gulf War 

Referral centers was the War Related Illness and Injury Study Centers. There howVACREP180 with DISTILLER

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ever were one time visits provided you could get a referral from your primary care 

physician. My own health struggled as I kept defying the system such as getting 

multiple referrals to the WRIISC that did not allow it. No matter what I did from 

the days of the Gulf War Illness referral centers, to the WRIISC, and so on – I could 

not get answers or long term help. 

Conditions that were acute in the 90’s have progressed to chronic in the present 

while VA’s answer to me is ‘‘we don’t know’’ or worse. 

By 2008 I managed to get a VA Gulf War Illness Advisory Committee through 

the system with Rep. Chet Edwards help. But, VA sabotaged the committee with 

ringers since it wasn’t a chartered Congressional committee and the chairman 

pushed hard to wrap it up early even if the final report was thin. In the end the 

committee did not do the job it should have and I disputed the final report as putting Dr. Stephen Hunt in charge of the show. The visit in Seattle had shown me 

he was running a psyche clinic railroading vets through that did not want to return. 

They called it the PDICI and over time shifted the focus to a different term to the 

PACT but same focus. Mental health rather than physical evidence. 

VA snowballed our committee and did not want to provide any hard line information during our tenure. The only statistical reporting system at that time was the 

GWVIS which had become more and more erratic. I discovered a variance in the 

data in which they had been showing a 10% drop in the overall numbers of those 

filing for benefits. This lead to a subcommittee to look into the numerical error, and 

lead to the change to the GWVIS into the pre911 report. However, VA decided to 

do one report and then mothball it since it wasn’t under any mandate. 

Our committee was made promises by VA of such things as the Gulf War Review 

being published 2 to 3 times a year. They published only one in July 2010 following 

our disbanding and produced none since then. 

They followed our committee up with the Gulf War Illness Task Force. Complete 

with annual reports and a public comments website. The first year they completely 

left out the public comments and the second year they edited them for content rather than included verbatim. Only to find later the committee was deaf to input, and 

operated in secret with no public meetings or even basics like blog or website to 

show there meetings. In effect this private internal committee became the end all 

be all that did not have to interact with the public or actually acknowledge outside 

interest in our own plight. 

VA tried to parade its newest incarnation the Gulf War Veterans’ Illnesses Biorepository in January as if it was a positive thing. Except, I was there in 2006 when 

we pushed for the Gulf War Brain Bank as a tissue repository to replace the defunct 

AFIP that did not cooperate with researchers as it should have. The brain bank languished from lack of support. It changed hands, became the ALS repository in Tucson AZ. Then changed hands again under Dr. Neil Kowall, M.D who later confirmed 

in 2010 before the RAC they had not collected one sample. In 2012 he confided with 

the RAC the GWVIB only has 2 years of funding. They gave no reference in 2012 

of collected samples. So far to date all they have is the brain of Wade George. 

I can go into much greater detail with 17 years of email and correspondence with 

a large plethora of folks all around all this. But, long story short at each stage that 

I try to get my own answers I find more and more bureaucracy that thwarts my 

attempts to find answers to my question of what went wrong 22 years ago in the 

Gulf War. From the reclassification of 6 million records from the war to the continued efforts of VA to push GW vets into psychiatry rather than cutting edge research. Now we have the most resent insult wherein the IOM’s volume 9 report on 

Multisymptom Illness takes a total departure from the content of its former Volume 

8 report which had been more realistic. Why? The results might have been coached 

by VA for a less happy agenda? 

A current realistic attempt would be the effort to have 100 GW veterans genomes 

sequenced and look at the total genome for answer asto any defective gaps that 

might answer current medical mythos on cause. The ’’Gulf War Genome Project’’ 

would finally put to bed the debate over physical cause if it finds anomalies that 

surface in regularity outside the general population. 

But, having done this type of work for 17 years now I’ve learned its better to be 

brief with Congressional committees or risk being ignored. In short, if we financed 

a genomic study we can put all this to rest and head towards ‘‘diagnoses/treatment’’ 

with real possible results. All else is treacle as the genome is the final answer in 

medical research circles. A tangible goal with a real future. Granted long term. 

Asto the rest, VA has for 22 years mishandled Gulf War Medical Research and 

any possible treatment trials of value. It cannot govern itself and should be stripped 

of any authoritative position concerning Gulf War vets. They should no longer receive funding for GW IOM projects as neither the IOM nor VA can be objective of 

such. There should be PERMANENT over sight in place with VA over any future 

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Gulf War Illness concerns as veterans have suffered long enough at there hands. 

The GWVITF should be disbanded since it only serves VA internally as a tool of 

elderly agendas that do not fit current medical theology. In short, you can’t leave 

the child in charge of the cookie jar. 

Sincerely 

Kirt P. Love 

Director, DSBR 

Former member VA ACGWV 

f 

From Beatrice A. Golomb, MD, Ph.D. 

I. It is a mistake to group together GWI with other chronic multisymptom 

conditions. 

Multiple chronic symptoms can be seen in numerous conditions, from 

hypothyroidism to vitamin D deficiency to mitochondriopathy. For each of these, the 

constellation of symptoms might be viewed as not ‘‘distinct.’’ The same symptoms 

commonly reported at elevated rates in each such condition are also present at lower 

levels in people without these conditions (and also at elevated levels, in people with 

the others of these conditions), and no specific symptom is either required or 

pathognomonic. 

In these cases, the conditions are potentially distinguishable because ultimately 

the mechanism involved was ascertained and tests became available. (Moreover, it 

is the case that some of these ‘‘chronic’’ conditions can cease to be chronic when the 

cause is identified and leads to a definitive treatment.) However, this has not always been the case, and indeed, it has not been the case for all that long historically. 

The constellation of symptoms in GWI may be seen in many other conditions – 

such as the conditions cited, hypothyroidism to vitamin D deficiency to 

mitochondriopathy. For each of these (as for GWI), the constellation of symptoms 

might also be viewed as not ‘‘distinct.’’ The same symptoms commonly reported at 

elevated rates in each such condition are also present at lower levels in people without these conditions (and also at elevated levels, in people with the others of these 

conditions), and no specific symptom is either required or pathognomonic. In these 

cases, the conditions are potentially distinguishable because ultimately the mechanism involved was ascertained and tests are available; however, this has not always 

been the case, and indeed, it has not been the case for all that long historically. 

There are specific environmentally induced versions of these conditions: radioactivity induced hypothyroidism; bariatric surgery induced vitamin D deficiency; medication-induced mitochondriopathy. If tests were not yet available, there would have 

remained strong utility in grouping persons with these elevated multisymptom 

health problems in the context of their common exposure setting, in order to facilitate research to enable these distinct conditions and their foundations to be ultimately elucidated and understood. 

It is true that some treatments may provide some benefit, taking the edge of the 

impact of chronic multiple symptoms (and for that matter, many diagnosed conditions), irrespective of the mechanism that produced the chronic symptoms – coping 

mechanisms, gentle exercise, addressing the anxiety that may arise from health 

problems. But grouping GWI together with other chronic multisymptom conditions 

has potential to do a terrible disservice to those affected. It may retard or extinguish 

prospects for identifying mechanisms and providing treatments that are so urgently 

needed by these veterans. Many who served in the Persian Gulf are affected by disabling symptoms, and these problems arose as a consequence of service to their nation. It is possible that their conditions need not remain chronic, if the mechanism 

is identified and addressed. That should be the goal in GWI. 

II. It is a mistake to group these with war-related multisymptom conditions 

While unquestionably, health conditions have arisen in association with many 

prior conflicts, it should be recognized that a range of factors, differing in profile, 

will have contributed in different conflicts: malnutrition, dehydration and electrolyte 

imbalance (from diarrheal illness), trenchfoot, malaria, brucellosis, parasitic illness, 

etc have all affected health of military personnel in different deployments. Many of 

these (and many other conditions) can produce fatigue and CNS symptoms, and 

some can engender a broader set of symptoms, commonly in the short term, providing a reminder that common symptoms can arise in different conflicts from difVACREP180 with DISTILLER

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ferent causes with different optimal treatments. More relevant than the existence 

of symptoms that are features of many conditions, and that have therefore not surprisingly occurred also with prior wartime conditions, is that GWI embodies characteristics that distinguish it from other post-war conflicts. In any case, the existence 

of features common to many health conditions does not imply the health conditions 

are the same or are optimally managed in the same fashion. 

Conditions that are prominent in veterans of recent conflicts are PTSD, TBI, and 

GWV: These can be conceptualized as resulting from psychic stress, mechanical 

brain injury, and environmental/chemical injury respectively. While some symptoms 

(and even some downstream pathways) may be in common, separate means for protection from these conditions, and separate study to understand mechanisms are in 

order – and separate or minimally, stratified treatment trials. Treatment with thyroid hormone – though a definitive treatment for hypothyroidism - may not show 

up as conferring significantly beneficial, if persons with hypothyroidism are combined with persons with numerous other causes of multisymtom illness, diluting the 

effect. Equally troubling, a treatment may be effective due to benefit in a subgroup, 

and demonstration of effectiveness, if the groups are conceptualized as one entity, 

may lead a treatment effective in one group to be inflicted on another group in 

which it is ineffective or harmful. 

For these reasons, it remains desirable to retain conditions with distinct proximal 

causes, nonidentical mechanisms, and possibly very distinct optimal treatments as 

distinct, even if some mitigating treatments test as being helpful for several or all 

of them. 

It may ultimately prove to be the case that common causes and mechanisms are 

involved in some instances of chronic multisymptom health problems in veterans of 

subsequent deployments, in nondeployed veterans, and in civilians. But it is preserving the group with a common corpus of exposures that provides the greatest 

chances of ultimately identifying the foundations of this condition, and helping not 

only Gulf War veterans, but others who have developed similar problems from related exposures. 

III. GWV are disadvantaged in screening and referrals 

Presently, veterans with GWI seen at the VA are the forgotten stepsisters among 

veterans with chronic problems. While there are mechanisms in place for screening 

and referral for TBI and PTSD, no such approaches are in place for GWI. Many VA 

physicians, nurses, and scientists are not even aware that GWI differs from PTSD, 

because no formal training occurs about GWI for those who join the VA. Physicians 

who have been at the VA for a long time received mandated training about GWI 

that implied they were not ill or it was basically all in their heads. (This was not 

a conclusion that could be drawn from evidence even at the time; and copious subsequent evidence has refuted this position.) 

Physicians that have been at the VA for a shorter time have had no formal required training on GWI, so have no reason to be aware of a difference from PTSD. 

This is compounded by the fact that the VA has chosen to define and label as Gulf 

War veterans not only those deployed in 1990–1, but all deployed to the region from 

1990 onward. This also precludes meaningful use of VA databases to track health 

problems and outcomes separately in Gulf War veterans. 

GWV with chronic multisymptom problems are often not treated with compassion 

they deserve. Physicians unfamiliar with their issues, and with limited time, may 

have little patience for their multiple problems, not understanding that these arose 

from military exposures. One Gulf War veteran in a high paying job requiring excellent skills who developed new onset weakness with no known cause, read the RAC 

report and became familiar with evidence on Gulf War illness. He reasonably was 

concerned that his Gulf War experience might relate to his problems. He presumed 

that VA physicians would be knowledgable and went to the local VA. He was seen 

by a neurologist there who told him categorically that he did not believe in Gulf War 

illness. (The patient shared with me that he cried.) The neurologist told him he only 

believed in real diagnoses, and so labeled him with a different diagnosis, despite acknowledging that the test results were not consistent with that diagnosis. In frustration, that veteran actually chose to fly to another city to get primary care from 

a physician who had some knowledge about GWI. 

IV. Outside referrals 

In principle there are referral approaches for veterans with Gulf War illness that 

can allow them to undergo more comprehensive evaluation and management at a 

war related illness center. In practice, there are no meaningful (controlled or randomized) data to say if these centers provide benefit (though, at least patients may 

feel their problems are receiving attention). Additionally, many VA physicians are 

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not aware that there is an option to refer to these centers, and this option may in 

practice be limited both by restricted capacity of these centers (there are just a few, 

not geographically distributed) and the requirement that the local VA cover any 

costs to fly the patient to the center, which the VA may decline due to fiscal considerations (providing selective access to those who are geographically close). 

f 

Questions For The Record 

Letter From: Hon. Michael H. Michaud, Minority Ranking Member, Committee on Veterans’ Affairs, To: The Hon. Eric K. Shinseki, Secretary, 

U.S. Department of Veterans Affairs 

March 20, 2013 

The Honorable Eric K. Shinseki 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Mr. Secretary: 

In reference to our Full Committee hearing entitled, Gulf War: What Kind of Care 

are Veterans Receiving 20 Years Later? that took place on March 13, 2013, I would 

appreciate it if you would answer the enclosed hearing questions by the close of 

business on May 1, 2013. 

In preparing your answers to these questions, please provide your answers consecutively and single-spaced and include the full text of the question you are addressing in bold font. To facilitate the printing of the hearing record, please e-mail 

your response in a Word Document, to Carol Murray at 

Carol.Murray@mail.house.gov by the close of business on May 1, 2013. If you have 

any questions please contact her at 202–225–9756. 

Sincerely, 

MICHAEL H. MICHAUD 

Ranking Member 

CW:cm 

f 

Questions From: Committee on Veterans’ Affairs, To: U.S. Department of 

Veterans Affairs 

Submitted by Ranking Member Kirkpatrick 

1. The War Related Illness and Injury Study Centers, or WRIISCs seem to be popular among the Gulf War veterans and receive high marks. We have heard from 

the first panel that there is a waiting list to get in to the centers. 

a. Is there a waiting list and if there is how long is it? 

b. What process does VA have in place to get data from the WRIISCs and other 

programs to measure outcomes to determine whether the programs have been successfully implemented and is improving care? 

c. Should we expand access to the WRIISCs? 

2. Please tell the Committee about the National Health Study of a New Generation of US Veterans. 

a. How many veterans were involved? 

b. How much did VA spend on the study? 

c. Have the results been released? If they have, what did they tell us? If they have 

not, when will they be released? 

d. How is VA going to use the findings of the study? 

3. According to your testimony VA seeks to provide veterans with CMI, personalized, proactive, patient-driven care. 

a. What challenges has VA faced in implementing this care? 

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b. Are the Patient-Aligned Care Teams staffed and if not when do you think they 

will be? 

c. How long has VA been linking PACT teams working with Gulf War veterans 

with a specialty care capability? 

4. Please elaborate on the social media campaign VA is engaging in to improve 

feedback on the program to veterans? 

a. How is VA ensuring that Gulf War veterans served by the program can communicate more easily? 

5. I understand that about 130,000 Gulf War veterans have undergone a registry 

exam. However, the IOM has reported that VA does a poor job of gathering data. 

a. How is VA gathering and aggregating data, so that it is useful, in the bigger 

picture to the treatment and care of Gulf War veterans? 

6. We all know how important research is. In April 2012 the Committee received 

the Annual Report to Congress on Federally Sponsored Research on Gulf War Veterans’ Illnesses for 2011 mandated by Congress. According to the report this is the 

eighteenth report on Federal research and research activities. There are many 

projects listed in the report. The report is 112 pages long. The report talks about 

VA creating a Gulf War Research Strategic Plan to map the direction of research 

for the next five years. 

a. Where is VA in reaching that goal? Do you have a timeline? 

b. Have stakeholders, like the first panel, been brought in to help VA with the 

strategic plan? If not, why not? 

7. The IOM had 14 recommendations, yet, reading your testimony VA seems to 

have all the bases covered and everything is fine. I think the first panel may disagree. Please elaborate on the Office of Public Health and the quarterly conference 

calls with Environmental health coordinators and clinicians located at every VA 

hospital. 

a. How long have the quarterly calls been going on? 

b. Are there minutes kept of the calls that are shared with interested parties and 

stakeholders? If not, why not? 

c. What kind of policy and procedures actually are products of these calls that 

benefit veterans? 

8. In testimony you state that VA is now in the process of developing additional 

innovative training resources such as a mobile device and internet applications. 

After 22 years, this seems a bit late to just now be developing applications for the 

environmental exposures, symptoms and conditions. 

a. When did the process begin? When do you think it will be rolled out to veterans 

who may find it helpful? 

9. I find it hard to believe and disappointing that VA is testifying that they are 

just now adding a clinical reminder to the computerized patient record system to 

prompt clinicians to ask all Gulf War separating servicemembers whether they may 

have symptoms consistent with CMI. I am sure you would agree this is long overdue 

and is a disservice to the men and women who have served in the Gulf. 

a. How are you improving communication among VA health care providers and 

with patients concerning CMI? 

b. What do you mean when you say you are improving training to staff to better 

recognize CMI? 

c. How are you measuring whether this training is effective or not? 

f 

Questions and Responses From: U.S. Department of Veterans Affairs, To: 

Committee on Veterans’ Affairs 

Submitted by Ranking Member Kirkpatrick 

1. The War Related Illness and Injury Study Centers, or WRIISCs seem 

to be popular among the Gulf War veterans and receive high marks. We 

have heard from the first panel that there is a waiting list to get in to the 

centers. 

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a. Is there a waiting list and if there is how long is it? 

Response: Each War Related Illness and Injury Study Center (WRIISC) site offers a suite of clinical services based on the complexity of the medical needs of the 

individual Veteran. These range from a comprehensive, in-person multi-day evaluation to more focused evaluations. Multi-day evaluations may take up to five days 

and involve as many as ten clinicians. Each site manages referrals made through 

the electronic medical record independently. The amount of time between the consult request and the determination of eligibility and appropriateness varies on a 

case-by-case basis due to Veteran and referring provider responsiveness to requests 

for essential information and completion of preliminary tests at the referring site. 

The WRIISCs proactively communicate with both referred Veterans and their providers to ensure questions are resolved as quickly as possible. Each WRIISC may 

have approximately six Veterans who are awaiting an appointment as the details 

of their referral are refined and timing of the appointment is agreed upon with the 

Veteran. Once eligibility and appropriateness for comprehensive WRIISC examinations are determined, the average wait is four months to obtain a comprehensive 

inpatient evaluation. Urgent cases are evaluated sooner. Waiting times are less for 

Veterans seen on an outpatient basis. While there is currently a waiting list for appointments, the length of these waits is decreasing due to filling staff vacancies at 

the WRIISCs, streamlining the intake process, and working more closely with referring providers to ensure the completeness and appropriateness of each consult. We 

anticipate that these wait times will continue to decrease through these efforts and 

through additional ongoing efforts to provide referring clinicians with the information they need to handle more of these cases such as a train the trainer pilot for 

post deployment health champions. 

b. What process does VA have in place to get data from the WRIISCs and 

other programs to measure outcomes to determine whether the programs 

have been successfully implemented and is improving care? 

Response: Each WRIISC site engages in ongoing quality improvement processes, 

including evaluation of clinical services and patient and provider feedback. WRIISCs 

systematically collect patient satisfaction data at the completion of the in-person 

comprehensive evaluation and elicit referring provider feedback. Results of these 

surveys consistently indicate overall patient satisfaction with their visit at over 95 

percent. In addition, WRIISCs conduct follow-up calls with Veterans after their inperson evaluation to assess implementation of the recommendations and to problem 

solve barriers to that implementation. The WRIISCs are currently developing a strategic plan that will incorporate objective measures of outcomes. OPH is establishing 

a formal and regular review process of the WRIISC activities to provide oversight 

and guidance of WRIISC performance. 

WRIISC personnel regularly use their clinical experience and research findings to 

educate VA, DoD, and other providers as well as the Veteran community. The 

WRIISCs regularly host conferences, webinars, and other opportunities for continuing education. WRIISC Veteran and provider educational activities promote 

greater appreciation of the impact of deployment on health and greater knowledge 

on how best to address and manage deployment health concerns (e.g., CA WRIISC 

sponsored a conference in July 2012 entitled ‘‘Gulf War Illnesses: What Providers 

Need to Know’’). 

Finally, WRIISCs have a track record of publishing research based on the clinical 

experience in peer-reviewed journals (e.g., the Journal of Occupational and Environmental Medicine’s special issue on Health Hazards of deployment to Iraq and Afghanistan published in 2012). These publications provide information about WRIISC 

evaluations and Veterans seen, and provide evidence that the data collected and the 

results obtained regarding symptoms and exposure concerns stand up to the scrutiny of review by other medical and scientific experts. 

c. Should we expand access to the WRIISCs? 

Response: The best way to expand access to high quality of care modeled by the 

WRIISCs is to take what the WRIISCs have learned from providing clinical care to 

Veterans with the most serious and debilitating deployment health concerns, especially First Gulf War Veterans, and disseminating it to other VA providers through 

clinical consultation and educational activities. The WRIISCs already partner with 

colleagues from VHA (including Patient Aligned Care Teams (PACT), Veteran Service Organizations (VSO), Veterans Benefit Administration, (VBA), academia, and 

DoD) to expand the reach of educational and clinical care activities nationally. Strategic expansion that leverages these existing collaborations is an appropriate apVACREP180 with DISTILLER

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proach towards expanding Veterans access to high quality post-deployment health 

care. 

The three parts of the WRIISC mission: clinical care, research, and education, 

interact to allow the advancement of the knowledge and expertise necessary to improve the lives of Veterans. For example, Veterans are invited to participate in research protocols, and, in return, Veterans benefit from the application of innovative 

approaches to diagnosis and treatment (e.g., all three sites have programs and research activities promoting and evaluating Complementary and Alternative Medicine (CAM) practices to aid in the management of chronic symptoms). Similarly, the 

WRIISC clinical experience is leveraged to create educational products and training 

events to disseminate knowledge and best practices to providers in the field. This 

experience and knowledge is translated into educational products for Veterans and 

their families. 

2. Please tell the Committee about the National Health Study of a New 

Generation of US Veterans. 

a. How many veterans were involved? 

Response: The VA Post-Deployment Health Epidemiology Program (EP) conducted the ‘‘National Health Study for a New Generation of U.S. Veterans.’’ Thirty 

thousand Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans and thirty thousand Veterans who served elsewhere during the same time period were invited to participate. Surveys were sent to 60,000 Veterans. In total, 

20,563 Veterans provided complete surveys (11,337 OEF/OIF Veterans and 9,226 

Veterans who served elsewhere during the same period). The participants for the 

health survey were selected from Veterans who served in each of these cohorts from 

the onset of the conflict in October 2001 through June 2008, and the survey was 

conducted from August 2009 to January 2011. The survey used postal, Web-based, 

and telephone administered surveys to collect self-reported health information from 

deployed and non-deployed Veterans concerning their chronic medical conditions, 

history of traumatic brain injury (TBI), Post-traumatic Stress Disorder (PTSD) and 

other psychological conditions, general health perceptions, reproductive health, pregnancy outcomes, functional status, health care utilization, and behavioral risk factors. Results from the study will be prepared for publication in the peer-reviewed 

scientific literature. The response to 2.c. below provides additional detail about topics that will be examined over the next 12 months. Five papers from the Study have 

been submitted to peer reviewed journals; data for an additional three papers are 

being analyzed; and an additional six studies are being planned. 

b. How much did VA spend on the study? 

Response: VA contracted the logistical support and implementation of the survey 

to a Service Disabled Veteran Owned Small Business. The value of the contract was 

just under $5 million. 

c. Have the results been released? If they have, what did they tell us? If 

they have not, when will they be released? 

Response: The study is still ongoing. There are a number of planned studies as 

well as an initial pilot to test incentives to improve overall response rate. 

Articles on the following topics are in preparation for submission to peer-reviewed 

journals or have been submitted: 

Goals for the next five months: 

• The National Health Study for a New Generation of United States Veterans: 

Methods for a Large-Scale Study on the Health of Recent Veterans – in preparation 

• Adjustments for Temporal Misclassification of Exposure Status in Surveys of 

Health Outcomes - submitted 

• Prevalence of Respiratory Diseases among Veterans of OEF and OIF: Results 

from the National Health Study for a New Generation of U.S. Veterans – submitted 

Goals greater than 5 months: 

• History of infertility among men and women Veterans: underlying causes, medical evaluation, and outcomes – in preparation 

• Population Prevalence Estimates of Screening Positive for TBI and PTSD: Results from the ‘‘National Health Study for a New Generation of U.S. Veterans’’ 

– in preparation 

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• Prevalence of functional health measures, illness, and military exposures – in 

preparation • Respiratory disease and associated risk factors – in preparation • The relationship of TBI/PTSD to self report of suicidal ideation – in preparation • Use of Complementary and Alternative Medicine (CAM) modalities – in preparation • Self reported birth defects among OEF/OIF era Veterans – in preparation • Health risk behaviors: Smoking and alcohol rates – in preparation • HIV risk taking behaviors among OIF/OIF Veterans – in preparation • Self reported risky driving behaviors and health behavior correlates – in preparation 

The initial pilot (noted above) included a test on the use of incentives to encourage 

greater response rate because previous VA studies have suffered from low response 

rates, raising concerns about the generalizability of the findings. This test was recommended by the Office of Management and Budget to assess the effect of small 

monetary incentives in improving response and decreasing non-response bias. The 

results showed that a small pre-paid monetary incentive significantly increased participation rates. This was important to test as no data were available regarding the 

acceptability and success of using incentives in research with Veterans, and these 

results have been published in the journal, Survey Practice (2011). 

One study assessed the prevalence estimates of TBI and PTSD. The results were 

presented in a poster presentation at the 2012 National Meeting of the International Society for Traumatic Stress Studies, November 2, 2012, in Los Angeles, 

CA. 

Main findings: 

Population prevalence estimates (screening): 

• possible TBI among deployed =15.7% vs. possible TBI among non-deployed = 

8.9%. • possible PTSD among deployed =15.7% vs. possible PTSD among non-deployed 

= 10.9%. • possible TBI & PTSD among deployed =7.7% vs. possible TBI & PTSD among 

non-deployed = 3.1%. 

These figures are based on self-reports of illness based on clinical visits. The positive TBI screening would suggest a referral to second level TBI evaluation. 

d. How is VA going to use the findings of the study? 

Response: Results from the study will be used to inform VA leadership, Congress, Veterans, healthcare providers, the public and other stakeholders about the 

health and illness experience of the OEF/OIF Veteran population. The information 

will be used by VA leadership in the development of policy and provision of care. 

3. According to your testimony VA seeks to provide veterans with CMI, 

personalized, proactive, patient-driven care. 

a. What challenges has VA faced in implementing this care? 

Response: Effectively assessing and managing Chronic Multi-Symptom Illness 

(CMI) is a challenge in any medical setting. The process of ruling out the broad 

range of diagnosable diseases or specific conditions that might be causing any particular symptom or cluster of symptoms is the first step in the assessment and management of CMI. Health care in the Veterans Health Administration (VHA) is widely acknowledged to meet the highest standards in terms of disease diagnosis and 

management. If a specific diagnosis cannot be established to account for a symptom 

or cluster of symptoms, then a symptom-based syndrome such as CMI must be considered. Avoiding redundancy in repeated testing, assessments and empirical interventions, while being ever vigilant for emerging diagnosable conditions that may be 

contributing to the symptoms, requires a critical balance that is best served by 

team-based care with continuity over time. The PACT model is specifically designed 

to provide the type of patient centered, team based, continuous, health oriented care 

recommended by the Institute of Medicine (IOM) report and by the best practices 

described in the literature for assessing and managing CMI. The challenges in implementing personalized, proactive, patient driven care for Gulf War (GW) Veterans 

with CMI are in many ways the same challenges involved in the transformation to 

the PACT model: integrating services at all levels within the VHA; creating highfunctioning interdisciplinary teams within our medical centers and clinics; educating 

and training teams consistent with the new paradigm of care generally as well as 

with respect to unique needs of specific cohorts of Veterans such as GW Veterans 

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with CMI; and monitoring care to ensure progress and fidelity to the standards and 

practices established for PACT. 

b. Are the Patient-Aligned Care Teams staffed and if not when do you 

think they will be? 

Response: National standards for staffing PACT have been developed. Nationally 

staffing of PACTs meets the recommended levels. There is local variation however, 

and not all teams currently have all the support staff that is recommended. Overall 

staffing continues to improve, and we are working with those sites that are lagging 

to determine the barriers they are facing and how they can be alleviated. Many aspects of PACT can be fully implemented regardless of staffing and all sites that provide Primary Care in VHA are expected to use the PACT model of care. 

c. How long has VA been linking PACT teams working with Gulf War veterans with a specialty care capability? 

Response: Many of the principles and practices recommended by IOM as well as 

by the clinical medical literature for optimally addressing the concerns of individuals with CMI were in motion prior to the implementation of PACT. The WRIISCs, 

the Gulf War Registry program, and the Gulf War Veterans Health Initiative (VHI) 

were oriented toward assessing the unique concerns of GW Veterans with 

undiagnosed symptoms. The VBA Program establishing presumptive service connection for undiagnosed conditions allowed for additional benefits and services for GW 

Veterans with CMI. The importance of comprehensive assessments of these, and of 

all, Veterans was served by the implementation of the Primary Care-Mental Health 

Integration Program throughout VA beginning in 2007, and the Post-Deployment 

Integrated Care Initiative (PDICI) in 2008. The latter built upon the work of the 

OEF/OIF/Operation New Dawn (OND) Program and supported the development of 

the type of integrated post-deployment care specifically mentioned in the IOM Report as the recommended approach to caring for individuals with CMI. These efforts 

served to strengthen the subsequent implementation of PACT, as these approaches 

are all derived from a common set of clinical principles: Veteran-centered, team-delivered, evidence-based, and health-oriented care. The alignment of PDICI teams 

with PACT resulted in Post-Deployment PACTs in many Centers, as well as an 

overall increased emphasis on enhancing the quality of ‘‘deployment health care’’ in 

all VHA facilities. This is being accomplished by broad based education of VHA staff 

on issues such as Military Culture, Deployment Health concerns (including CMI in 

GW Veterans), Military Service-related environmental exposures, and Compensation 

and Pension/Benefits-related to specific cohorts of Veterans (such as GW Veterans 

with CMI). The evolution of this heightened awareness of deployment related health 

concerns has components that relate to GWI Veterans specifically. These enhancements of post-deployment care and the emphasis on ‘‘PACT based post-deployment 

care’’ will serve not only our GW Veterans with CMI, but all Veterans with deployment related health issues, as it is important to remember that while CMI is much 

more common in GW Veterans than in other combat Veteran cohorts, it is a phenomenon we see in combat Veterans after all wars. 

4. Please elaborate on the social media campaign VA is engaging in to improve feedback on the program to veterans? 

a. How is VA ensuring that Gulf War veterans served by the program can 

communicate more easily? 

Response: A multifaceted combination of traditional and new methods enhance 

communication with VA and Gulf War Veterans. Over the last 22 years, VA produced 41 editions of its Gulf War Newsletter. 

A new ‘‘Gulf War Update’’ format is being developed for wide mailing and web 

posting. Examples of other communications include the following: 

• Three versions of a Gulf War ‘‘VA Cares’’ poster to alert GW Veterans to health 

care, benefits, and the registry program 

• A registry brochure in a print and online format 

• A comprehensive web page at http://www.publichealth.va.gov/exposures, with 

substantial Gulf War-related health information at http:// 

www.publichealth.va.gov/exposures/gulfwar/index.asp. This site has been improved by Veteran feedback. 

• Active updating of the web pages with findings and reports, along with email 

subscriptions for web page updates as content changes are made 

• Announcements via email and social media (Facebook and Twitter) on content 

updates that include both news (such as the posting of a report) and reminders 

about VA care (such as the availability of the Gulf War Registry program or 

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of certain resumptions). VA monitors social media for comments and questions 

when Gulf War topics are posted 

• Solicitation of comments via the online tool UserVoice on the annual VA’s Gulf 

War Veterans’ Illnesses Task Force Report. VA reviews these comments for follow up and incorporates samples into the final report 

• Interactive briefings at regular meetings VHA holds with Veterans Service 

Groups 

• Response to media interviews and queries 

• A variety of clinical education materials and tools that are made publicly available to Gulf War Veterans, including those that will be usable on smartphones 

and tablets 

As more Gulf War Veteran care is provided by patient-centered care teams, there 

will be an emphasis on personalized and proactive care, with attention to rapport 

between the Veteran and an identified, interdisciplinary team of professionals. Care 

continuity will include of routine outgoing communications and outreach to the Veteran, including medication reconciliation and test notification, post-discharge telephone follow-up, and care management and telehealth around specific symptoms or 

clinical conditions. In addition, communication will improve via self-help resources 

on MyHealtheVet and other online platforms, secure messaging directly to each Veteran’s PACT team, and telephone service capabilities with a variety of clinical resources. PACT based post-deployment care continues to enhance communication 

with Gulf War Veterans in a number of ways. First, the emphasis on personalized 

and proactive care in PACT is critical for Veterans with CMI, and establishes rapport between the Veteran and an identified, interdisciplinary team of professionals. 

The identification of a specific team of individuals serving each Veteran within 

PACT cannot be overestimated in promoting a smooth process of communication and 

any necessary dialogue to ensure understanding of the information by both patient 

and providers. Second, the overall goal of excellent continuity in care for Veterans 

is further advanced by a variety of routine outgoing communications and outreach 

to the Veteran, including medication reconciliation and test notification, post-discharge telephone follow-up, and care management and telehealth around specific 

symptoms or clinical conditions. Finally, VHA has established and is continuously 

improving multiple modalities of communication to better serve the Veteran, including self-help resources on MyHealtheVet and other online platforms, secure messaging directly to each Veteran’s PACT team, and telephone service capabilities 

with a variety of clinical resources. 

5. I understand that about 130,000 Gulf War veterans have undergone a 

registry exam. However, the IOM has reported that VA does a poor job of 

gathering data. 

a. How is VA gathering and aggregating data, so that it is useful, in the 

bigger picture to the treatment and care of Gulf War veterans? 

Response: The Gulf War Registry Examination is an important part of VA’s commitment to the health care of Gulf War Veterans with environmental health concerns. VA uses the registry program, in effect since 1992, and data from other programs to obtain a comprehensive view of Veterans’ health. The registry examinations capture self-reported symptoms and exposures and are used by VA researchers. In addition, to ensure VA obtains a full representative estimate of health effects 

in those who served in the Gulf War, VA continues to support and conduct wellplanned research studies, such as the Office of Public Health Gulf War Veteran surveys. 

VA realizes the importance of improving our health care system through monitoring performance of new and existing efforts that address the health care needs 

of Gulf War Veterans. VA agrees with IOM’s recommendations 8 through 11 on ‘‘Improving Data Quality and Collection’’ in its ‘‘Treatment for Chronic Multisymptom 

Illness’’ report, and is developing plans to use all health care encounters, not just 

registry data, in our process metrics. As most primary care providers do not have 

extensive knowledge of the long-term health effects of environmental toxins, VA is 

improving coordination between PACT and the registry program Environmental 

Health Clinicians to ensure Veterans have these concerns appropriately addressed 

in their overall care plan. 

6. We all know how important research is. In April 2012 the Committee 

received the Annual Report to Congress on Federally Sponsored Research 

on Gulf War Veterans’ Illnesses for 2011 mandated by Congress. According 

to the report this is the eighteenth report on Federal research and research activities. There are many projects listed in the report. The report 

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is 112 pages long. The report talks about VA creating a Gulf War Research 

Strategic Plan to map the direction of research for the next five years. 

a. Where is VA in reaching that goal? Do you have a timeline? 

Response: The ‘‘Gulf War Research Strategic Plan – 2013–2017’’ was approved 

in February 2013. It will be available on the VA Office of Research and Development Web site very soon. 

b. Have stakeholders, like the first panel, been brought in to help VA 

with the strategic plan? If not, why not? 

Response: The draft Gulf War Research Strategic Plan was discussed in January 

2012 at a meeting of the Research Advisory Committee on Gulf War Veterans’ Illnesses (RACGWVI). The RACGWVI and the National Research Advisory Council 

(NRAC), who are stakeholders in the Gulf War research program, provided recommendations which were incorporated into the draft Strategic Plan. As discussed 

at the January 2012 meeting, some sections were re-worded during VA review and 

concurrence to be consistent with VA policy and statutory requirements. 

7. The IOM had 14 recommendations, yet, reading your testimony VA 

seems to have all the bases covered and everything is fine. I think the first 

panel may disagree. Please elaborate on the Office of Public Health and the 

quarterly conference calls with Environmental health coordinators and clinicians located at every VA hospital. 

a. How long have the quarterly calls been going on? 

Response: They began about 1980 with discussions about environmental exposure issues that predated the Gulf War. 

b. Are there minutes kept of the calls that are shared with interested parties and stakeholders? If not, why not? 

Response: Minutes are kept for each quarterly Environmental Health Quarterly 

Conference Call. Written transcripts of the quarterly calls are kept on a SharePoint 

site that is available for all Environmental Health providers. This allows information sharing, collaboration, reference material for those providers. Each call typically covers a wide variety of topics that span across multiple eras of Veterans with 

many different communication needs. VA analyzes these needs by topic and develops focused external outreach products based on these needs. 

c. What kind of policy and procedures actually are products of these calls 

that benefit veterans? 

Response: Each environmental health registry program, such as the Gulf War 

Registry, is documented in a VHA handbook to provide guidance for field staff. The 

quarterly calls provide an opportunity for dissemination of new policies and procedures to the field and to receive questions and comments from the field. Comments 

and suggestions from field staff are considered during handbook revisions and development of education products supported by the Office of Public Health. Through 

these processes, field staff has access to up-to-date and relevant information to care 

for Veterans with environmental health concerns. As an example, the recommendations in the 2013 IOM report were discussed in detail during the March 2013 call. 

One hundred and twenty-five call-in lines were required to support a large audience 

of field staff. Briefly, the agenda included a welcome to new staff and discussion of 

the IOM January 2013 report, Camp Lejeune health care law and ATSDR studies, 

Agent Orange reports, the Shipboard Hazard and Defense (SHAD) IOM study (currently in data collection phase), planning for the Open Burn Pit Registry, and planning for a train-the-trainer initiative. 

8. In testimony you state that VA is now in the process of developing additional innovative training resources such as a mobile device and internet 

applications. After 22 years, this seems a bit late to just now be developing 

applications for the environmental exposures, symptoms and conditions. 

a. When did the process begin? When do you think it will be rolled out 

to veterans who may find it helpful? 

Response: VA continues to maximize all available modes of training to ensure 

staff is prepared to assist Veterans with GW health concerns. Over the last 22 

years, VA Office of Public Health products have included face-to-face workshops and 

seminars, Veterans Health Initiative (VHI) study guides, and VHA training letters. 

VA produced 41 editions of its Gulf War Newsletter, three versions of a Gulf War 

‘‘VA CARES’’ poster, including a 20th anniversary edition, VHI topics include a 

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‘‘Guide to Infectious Diseases of Southwest Asia’’ and ‘‘Guide to Gulf War Veterans’ 

Health.’’ Information on depleted uranium includes a fact sheet and pocket card. In 

recent years, as technology has evolved, we have focused our efforts on more Webbased products, such as our comprehensive Webpage, http:// 

www.publichealth.va.gov/exposures, to allow for ease of access to pertinent information as it becomes available. Currently, we are developing a Web and mobile application that providers can use to access exposure-related information during patient 

visits. Our concept is to offer the application on multiple platforms, including 

smartphones, tablets, and desktop computers, and although providers are our target 

audience, it will be made publicly available for download so that the information is 

available to anyone who might find it useful, such as Veterans, family members of 

Veterans, and VSOs. We started this effort in January 2012 and expect that the application will be available for providers in the field in calendar year 2014. 

9. I find it hard to believe and disappointing that VA is testifying that 

they are just now adding a clinical reminder to the computerized patient 

record system to prompt clinicians to ask all Gulf War separating service 

members whether they may have symptoms consistent with CMI. I am sure 

you would agree this is long overdue and is a disservice to the men and 

women who have served in the Gulf. 

a. How are you improving communication among VA health care providers and with patients concerning CMI? 

Response: VA understands the critical importance of communication between patients and their care teams to achieve positive health outcomes. VA developed and 

provided specialized training on military culture and the events related to the Gulf 

War to provide VHA staff a common awareness of what Veterans have experienced 

to foster a shared understanding. VHA has also provided seminars for field staff 

through its WRIISC on chronic multisymptom illness, health risk communication, 

and other deployment health related issues. In the last two years, the WRIISCs 

have offered more than six nationally broadcasted webinars or satellite broadcasts 

per year. 

b. What do you mean when you say you are improving training to staff 

to better recognize CMI? 

Response: In some cases, a Veteran may be seen multiple times before the entire 

constellation of symptoms develops to qualify as a multisymptom illness. While a 

clinical reminder provides an additional tool to prompt a screening evaluation, it is 

not clear how often this screening should occur to ensure this illness is recognized. 

Therefore, regardless of a clinical reminder, staff must be able to recognize Veterans 

who develop chronic multisymptom illness each time a Veteran presents for care. 

Recognizing CMI in the clinical environment is challenging because the clinical 

presentation of CMI varies considerably between patients. Many CMI symptoms are 

non-specific and could be secondary to other common medical conditions. A lack of 

a consensus definition of CMI and validated screening tools further adds to the diagnostic difficulties in diagnosing CMI. Clinically this means that providers must determine if a Veteran has CMI on a case-by-case basis. VA’s Post-Deployment Integrated Care Initiative and WRIISCs continue to educate providers on these complex 

issues through webinars, consultations, and seminars. A WRIISC webinar originally 

broadcast in March 2012 remains available through the VA Talent Management 

System. In addition, a pocket card with resource links was distributed to over 

23,000 VA staff. 

c. How are you measuring whether this training is effective or not? 

Response: Process and outcome measures are used to determine training effectiveness. As with all continuing medical education, participants are required to complete program evaluations to receive credit for their attendance. This evaluates if 

the training was perceived by each provider to be effective and the potential impact 

on the participant’s practice. VA is working to incorporate more direct measures of 

effectiveness such as a pre and post test evaluation system. Measures of patient satisfaction for VA’s Salt Lake City Gulf War Clinic Pilot program were collected and 

these data are currently being evaluated. Family medicine doctors in training, nurse 

practitioner students, physicians’ assistant students, and internal medicine doctors 

in training have all noted significant improvement in comfort with knowledge-base 

and ease in providing referrals to GW Veterans. These results are part of an ongoing study which uses focus groups and patient surveys. Through focus groups and 

surveys, staff in outlying clinics have also noted an increase in knowledge and ease 

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prove training for primary care providers include two planned conferences designed 

to provide education for local trainers. The planned Environmental Health train-thetrainer course will include measures of pre-intervention knowledge and post-intervention knowledge. 

Æ 

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