United States General Accounting Office

GAO Report to Congressional Requesters

May 1995 OPERATION DESERT

STORM

Health Concerns of

Selected Indiana

Persian Gulf War

Veterans

GAO/HEHS-95-102

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-258098 

May 16, 1995

The Honorable Dan Burton

The Honorable Steve Buyer

The Honorable Lee H. Hamilton

The Honorable John Hostettler

The Honorable Andrew Jacobs, Jr.

The Honorable John T. Myers

The Honorable Mark E. Souder

House of Representatives

Many veterans of the Persian Gulf War have expressed concern that their

service in Southwest Asia in some way caused chronic health problems.

The severity of these problems reported varies; some veterans report

relatively mild symptoms, while others report debilitating illnesses. The

cause or causes of these problems is unknown, but many causes have

been suggested, including exposure to chemical or other toxic agents,

parasitic infestations, medications given as a precaution against possible

exposure to nerve agents, and stress. Persian Gulf veterans’ health

concerns have received considerable attention by Congress, federal

agencies and the media. Both the Department of Veterans Affairs (VA) and

the Department of Defense (DOD) have undertaken research efforts to

determine the extent and causes of these illnesses and have established

programs to provide health examinations to identify and respond to these

veterans’ health concerns.

You asked that we obtain information related to health concerns for

certain Gulf War veterans from the 123rd Army Reserve Command

(ARCOM), headquartered in Indianapolis, Indiana. Members of the ARCOM,

according to command officials, were among the first to raise Persian

Gulf-related health concerns. Early in 1992, the Surgeon General of the

Army directed a team from the Walter Reed Army Institute of Research to

examine the 125 ARCOM members who, by that time, had made their health

concerns known to the ARCOM.

In response to your request, we obtained information on the current

military and health status of these 125 Persian Gulf War veterans, the

health care they have received, and their opinions of that health care. Most

of this information was obtained through a survey of the 125 ARCOM

veterans we conducted in November 1994. Of the 125, 89 responded.1 The

1

After mailing out the survey, we learned that 2 of the 125 reservists had passed away. Of the remaining

123, 72 percent (89) responded to our survey.

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information reported from the survey cannot be generalized beyond these

respondents to any other Persian Gulf veterans. Information on health

status and quality of care was not verified through means such as physical

examinations and is based solely on the perceptions of the respondents.

We also interviewed officials from the Departments of Defense and

Veterans Affairs; the Walter Reed Army Institute of Research; the VA

medical center in Indianapolis, Indiana; and the ARCOM. We also reviewed

pertinent policy documents. We did our work between July 1994 and

March 1995 in accordance with generally accepted government auditing

standards.

Appendix I describes the methodology for our survey. Appendix II is a

copy of the survey showing responses for each question.

Results in Brief Despite DOD and VA efforts to address the concerns of these and other

Persian Gulf veterans, those we surveyed still expressed concerns about

their health and dissatisfaction with services from DOD and VA. Most

respondents were still in the reserves and almost all reported that they had

health problems they believed were caused by their service in the Persian

Gulf. Most also reported that these problems limited their physical and

social activities to some extent. Because all of the individuals we surveyed

had already expressed some concern about their health, the fact that they

reported having health problems after returning from the Persian Gulf is

not surprising.

Over half of the respondents had taken advantage of medical services,

either the special examinations or other health care, available to them

through VA or DOD. Many, however, were dissatisfied with the medical care

they received or were unaware of services available. DOD and VA have

undertaken a variety of efforts to address the concerns raised by Persian

Gulf veterans, including expanding the health examinations available to

them. Also, in response to recent legislation, both agencies are expanding

outreach efforts to better ensure that veterans are aware of services

available. Whether these efforts will satisfy these veterans’ concerns

remains to be seen.

Background Between November 1990 and March 1991, 1,200 members of the ARCOM

were sent to the Persian Gulf; most returned between March and August

1991. The ARCOM’s mission was combat service support, and members were

not involved in frontline combat. In January 1992, officials of the ARCOM

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first became aware of members’ medical complaints and symptoms. In

February 1992, one ARCOM member, concerned about these health

complaints, distributed an unofficial questionnaire asking members if they

had health concerns. In March 1992, the ARCOM surgeon examined some of

the members who were complaining of health problems.

By early spring 1992, the ARCOM was aware of 125 members who had health

concerns. Those concerns included fatigue, joint pain, skin rashes, and

loss of memory. In response to the Surgeon General’s directive, the Walter

Reed team visited the ARCOM headquarters on April 11 and 12, 1992, to

examine the soldiers. The ARCOM attempted to schedule appointments for

all 125 soldiers; 79 reported for the examination. According to ARCOM

officials, the remaining 46 were not examined for a variety of reasons,

including scheduling conflicts—the appointments were made on fairly

short notice.

Military Status Sixty-one of the 89 respondents to our survey reported that they were still

in the military on active duty or in a Selected Reserve or National Guard

unit; 47 were still in the ARCOM. Of the 28 who indicated that they were no

longer on active duty or in units, 20 reported that they had Persian

Gulf-related health problems at the time they left their units. Of those, 12

said that these health problems contributed to some extent to their

separation from the military; 1 of these reported being denied reenlistment

because of weight, and 1 reported being discharged before being eligible

for reenlistment.

Although the military can discharge a reservist for medical reasons, an

ARCOM official said he was unaware of any members discharged

involuntarily because of health problems that may have been caused by

service in the Persian Gulf. Additionally, in June 1994, the Under Secretary

of Defense for Personnel and Readiness asked the Secretaries of the Army,

Navy, and Air Force to direct that no service member with symptoms

“associated with Persian Gulf illness” be discharged unless he or she

requests it in writing or he or she can be medically retired or separated. In

October 1994, the National Defense Authorization Act for 1995 (P.L.

103-337, Oct. 5, 1994) provided a presumption that a Persian Gulf veteran

who is ill became ill as a result of service in the Persian Gulf, unless

medical evidence establishes another cause, and specifies that such a

presumption can be used in disability determinations. DOD officials

explained that passage of this act allowed service members with illnesses

that could not be diagnosed to be medically retired or separated, with

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appropriate benefits, because of those illnesses; without the new

presumption, such members could only receive benefits if a specific

diagnosis could be made.

Current Health Status Most respondents continued to have health problems and reported having

those problems within the 6 months prior to completing our survey. The

problems indicated by most respondents are similar to the symptoms

reported to the Walter Reed research team. At least two-thirds of the

respondents reported chronic fatigue, achy joints, short-term memory loss,

headaches, difficulty concentrating, nervousness or irritability, inability to

sleep through the night, and depression.

Most respondents reported that these health problems limited their

activities to some extent. They most frequently cited limitations in

vigorous activities; climbing several flights of stairs; or in bending,

kneeling, or stooping. They least often cited limitations in less vigorous

types of activities, like walking a block or bathing and dressing. Nineteen

reported that they were limited to a great extent in performing one or

more types of activity. However, most reported that they had worked

within the 6 months prior to completing the survey. Fifty-three reported

that during that time period they missed no days of work for health

reasons, but 9 said they were unable to work at all during that period.

Most, but not all, respondents attributed their health problems to Persian

Gulf service. Eighty-one reported that they were currently experiencing

health problems associated with that service; 76 reported that, overall,

their health was worse than shortly before they went to the Persian Gulf.2

Sixty-nine respondents said that health problems, which they believed

were caused to some extent by their Persian Gulf service, limited their

physical (56) or social activities (57). Most of those 69 reported that they

had worked within the 6 months prior to completing the survey.

Thirty-four reported that during that time period they had missed no days

of work for health reasons, but four said they were unable to work at all.

Additionally, 23 respondents reported that family members or individuals

they lived with were experiencing health problems the veteran believed

were related to the veteran’s Persian Gulf service. The veterans reported

that these individuals had a wide range of problems including fatigue, achy

joints, irritability, and depression. One respondent indicated that he

2

Forty-one described their health as fair or poor; only 14 described their health as very good or better.

Overall, the veterans who are no longer on active duty or in Reserve or Guard units reported health

problems that are similar to those who are still in the service.

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believed his child had developed cancer as a result of the respondent’s

service in the Persian Gulf.

Medical Care

Provided to Persian

Gulf War Veterans

We obtained information about several kinds of medical care that was

available to these Persian Gulf War veterans:

• stress management training recommended by the Walter Reed team for

ARCOM members,

• special examinations offered by VA and DOD for Persian Gulf veterans to

help identify their concerns and ensure appropriate treatment, and

• other medical care they may have received in VA and DOD facilities as well

as care outside these two medical systems.

Because some veterans told us they were unaware of one or more of these

services, we also discussed with VA and DOD officials efforts to inform

Persian Gulf veterans of the services available to them.

Follow-Up to Walter Reed

Study

The Walter Reed study team recommended that the ARCOM continue to

provide stress management evaluation and intervention, which the ARCOM

had initiated earlier, to members who had been deployed.3 In response to

our survey, 33 reported receiving stress management counseling from the

ARCOM. In total, 45 respondents said that they had received stress

management counseling from DOD, VA, or other sources.

ARCOM records indicated that medical personnel from the ARCOM’s 55th

Medical (Psychiatric) Detachment, assisted by psychiatrists, offered stress

management training to three ARCOM units in Lafayette and Scottsburg,

Indiana. These units included approximately 360 of the 1,200 who

deployed. An ARCOM official told us that the ARCOM had limited resources

and offered stress management to these units because they were the first

in which concerns were raised.

ARCOM records indicated that on May 16, 1992, personnel from the medical

detachment met with the 417th Quartermaster Company in Scottsburg,

Indiana. Seventy-five members of the company, which deployed 126

reservists, and 8 family members participated in the session. Also, on

June 13 and 14, 1992, medical detachment personnel met with the 209th

3

The Walter Reed team made specific recommendations for follow-up care for a few people, either

further tests for parasitic infestation or psychological evaluation for Post-Traumatic Stress Disorder.

ARCOM officials said that they made the necessary referrals for the needed care but that they do not

know whether the veterans actually sought and obtained the care.

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Service and Support Company in Lafayette, Indiana. About 110 members

of that unit, which deployed 171 reservists, and 7 family members attended

this session. In both cases the format of the meetings included (1) large

group discussions with both unit and family members, (2) small group

discussions, and (3) individual counseling upon request. Officials also

sought help from other sources outside the ARCOM, such as chaplains.

Officials could not provide information on participation at a third session

they said was held with the 300th Supply and Support Battalion.

Special Examinations for

Persian Gulf Veterans

Many of the veterans who responded to our survey received the special

examinations offered by VA and DOD for Persian Gulf veterans. However,

some were not aware of these services.

The Persian Gulf War Veterans’ Health Status Act (P.L. 102-585, Nov. 4,

1992) directed VA to establish a Persian Gulf War Veterans’ Health

Registry, and authorized special health examinations for veterans of the

Persian Gulf War. Any veteran who served during the Persian Gulf War is

eligible for this examination. VA had begun providing examinations in

September 1992, before enactment of the legislation, and by January 1995,

about 40,000 had been given. Initial examinations are given at VA medical

centers or clinics by physicians specifically charged with conducting these

examinations. If after the initial examination the veteran still has an

unexplained illness, the veteran may be referred to specialists for

additional examinations and, ultimately, to one of three VA Persian Gulf

referral centers. Forty-six respondents reported receiving the VA

examination; two more had appointments to receive it.

DOD began giving examinations, called Comprehensive Clinical Evaluation

Program (CCEP) examinations, to Persian Gulf veterans in June 1994. The

examination protocol has three phases; the second and third phases are

given if additional care or diagnostics are needed.4

 By the end of 1994 DOD

reported that 1,000 examinations had been completed and another 8,000

were at various stages. DOD instructions issued in June 1994 indicated that

active duty members, certain retirees, and reservists who are on active

duty seeking an examination should go to a military medical facility. Other

reserve members and retirees have the option of seeking an examination

4

In June 1994 VA recommended to medical facilities that if a diagnosis is not made after the registry

examination and other routine medical evaluations, the CCEP protocol is to be followed. This

encourages more thorough examination at the local medical facility, reducing the need for the veteran

to travel to one of the referral centers. The information letter with this recommendation noted that the

CCEP protocol had been developed for use in VA’s referral centers and had been adapted for use by

both VA and DOD.

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at military facilities or VA medical centers. All other Persian Gulf veterans

are to seek an examination at VA medical centers. Fourteen respondents

reported receiving the CCEP examination; 1 had an appointment to receive

it.

Overall, more than half of the respondents (49) had received the VA or DOD

examination; 11 reported receiving both. Of the 47 respondents still in the

ARCOM, 38 had received the VA or the DOD examination. Respondents gave a

variety of reasons for not receiving the examinations. Relatively few (6 for

VA and 4 for DOD) said that they could not get an appointment at a

convenient time or that the facility was too far away. Most frequently

respondents said that they were unaware of the examinations. Of all

respondents, 20 were unaware of the VA examination; most (67) were

unaware of the DOD examination.

Other Care Received From

VA, DOD, and Other

Sources

Sixty-two respondents reported that they had received medical

care—other than the VA or DOD special examinations—for health problems

they believe were caused by their Persian Gulf service. Some received care

from more than one source, but more veterans received care from outside

VA and DOD than from VA or DOD facilities.

Public Law 103-210 (Dec. 20, 1993) authorized VA to provide health care

services on a priority basis to Persian Gulf veterans if VA (1) determines

that they may have been exposed to toxins or environmental hazards while

serving in the Persian Gulf and (2) does not determine that the veterans’

health problems were caused by factors other than that possible exposure.

Before this legislation, these veterans were not eligible for care in VA

hospitals without reimbursement unless VA had determined that their

health problems were service connected or they met other eligibility

requirements such as income criteria. Those on active duty are eligible for

care for all health problems in DOD facilities; and those still in the reserves

are eligible for health care at DOD facilities only for health-related problems

that occurred, or were aggravated, while on active duty. Those no longer

in the military are eligible for care from VA but not from DOD.

Of the 62 who reported receiving care for health problems they believed to

be related to Persian Gulf service, 47 got care in the civilian sector (20 got

care only from the civilian sector), and 42 got care from VA (33) or DOD

(24). Whatever the source, most veterans received care as an outpatient.

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Most reported getting less than half of the care they believe they need for

their Persian Gulf-related health problems. Sixty-three veterans reported

that they need care for these health problems, but fewer than half of these

(29) were under a physician’s care at the time of our survey.

Thirty-six reported that they were not receiving care from VA but would

like to; 44 reported that they were not receiving care from DOD but would

like to. The reason most often cited for not receiving care was that they

were not aware they were eligible for it—14 did not know they were

eligible for VA care; 29 did not know they were eligible for DOD care.5

Relatively few (7 for VA and 6 for DOD) reported that they had not received

care because the facilities were too far away or they could not get an

appointment at a convenient time.

VA and DOD Outreach

Efforts

Both VA and DOD have undertaken outreach efforts to publicize the

examinations and other services available to Persian Gulf veterans. Some

efforts began before our survey, and others are planned or began after our

survey was conducted in response to recent legislation and concerns we

raised during our study.

VA Outreach VA headquarters outreach has been done primarily through veterans

service organizations; a computer bulletin board; public service

announcements; and published literature, chiefly the Persian Gulf Review.

VA officials told us that this newsletter is sent to all veterans who have

received the VA exam, to veterans service organizations, and to veterans

who ask to be on the mailing list; it is also being placed in waiting rooms in

VA medical centers. However, officials said that local efforts are more

important in informing veterans of the examinations and care available.

Officials at the Indianapolis VA medical center told us that the center’s

Persian Gulf Coordinator had visited every National Guard and Reserve

unit in Indiana to describe medical care available to Persian Gulf veterans

and pass out literature. He also arranged for public service

announcements, was interviewed on local radio and television, and

conducted a variety of other local outreach activities.6

 Also, in

5

While all Persian Gulf veterans are eligible for care in VA facilities for problems possibly related to

exposure to toxins or environmental hazards during Persian Gulf service (and not found to have other

causes), not all are eligible for DOD care. Most of those who said they did not know they were eligible

for DOD care, in fact, may not be. For example, most reservists not on active duty and those no longer

associated with the military are not eligible for DOD care beyond the CCEP examination.

6

After we discussed the results of our survey with the Persian Gulf Coordinator at the Indianapolis VA

medical center, he agreed to contact those respondents who told us they were unaware of services, to

explain their eligibility for the special medical examinations and other medical care available from VA

and DOD.

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January 1993 the ARCOM Command Executive Officer sent a memorandum

to ARCOM unit heads requiring them to notify unit members that the VA

examination was available.

The Veterans’ Benefits Improvements Act (P.L. 103-446, Nov. 2,

1994) requires that VA implement a program to inform veterans and their

families of the medical care and other benefits that may be provided by VA

and DOD arising from service in the Persian Gulf War, as well as the results

of research related to Persian Gulf illnesses. This program is to

communicate information through a toll-free telephone number and a

semiannual newsletter to all those on the Persian Gulf War Health

Registry. The registry was authorized in November 1992 by the Persian

Gulf War Veterans Health Status Act, which specified five groups who

were to be included: Persian Gulf veterans who (1) had requested the VA

examination, (2) had applied for medical service in VA medical facilities,

(3) had filed a claim for compensation for a disability that might be related

to Persian Gulf service, (4) had died and are survived by a claimant for VA

dependency and indemnity compensation, or (5) had received the DOD

special examination and asked to be included in the VA registry.7

VA is continuing publication of the Persian Gulf Review. However, at the

time of our study, VA did not have in one place a registry with the names of

all the required veterans in the five groups—although officials indicated

they had access to the names in all five groups. The newsletter was being

sent to veterans who had received the VA special examination, but not to

members of the other groups the law required to be included in the

registry. After we discussed these issues with VA officials, they indicated

that they were taking steps to consolidate the registry list and to mail the

newsletter and other information to an expanded number of veterans. This

could have substantial impact. For example, while only about 40,000

veterans had received the VA special examination, and therefore were

receiving information from VA, VA indicated that another 110,000 Persian

Gulf veterans had received inpatient or outpatient care from VA. VA officials

told us that they expected to have a complete registry and to mail required

information to all on the registry by the end of May 1995.

VA also instituted the toll-free telephone information service, required by

the Veterans’ Benefits Improvement Act, in February 1995. Officials

reported that about 29,000 veterans had called the number in the first

7

The act also required VA, from time to time, to provide veterans on the registry with information

concerning significant developments in research on the health consequences of military service in the

Persian Gulf.

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month of operation. They believed that this indicated the outreach

mechanism was having a substantial impact.

DOD Outreach DOD has also taken steps to publicize services available to Persian Gulf

veterans. For example, in May 1994 DOD sent a memorandum to Persian

Gulf veterans notifying them that they were eligible for an examination

and how to arrange for one. DOD sent the memorandum by mail to retirees

and those who had left the military. DOD officials stated that they went to

considerable lengths to find up-to-date mailing addresses for these people,

including purchasing addresses from a private credit reporting firm. DOD

also sent the memorandum to the services for distribution through

command channels to active duty and reserve members. However, during

our review, DOD officials determined that the services had sent the

memorandum to active duty units but not to reserve units, instead relying

on public communication channels to inform reservists. Officials of the

ARCOM told us that they had not received information about the CCEP from

Reserve headquarters. DOD officials indicated that it is often difficult for

them to reach members of reserve units because the units are so dispersed

nationally.

Additionally, in June 1994 DOD initiated a toll-free number for Persian Gulf

veterans. Callers to this hotline receive information about the special

examinations and other medical care available from VA and DOD and are

referred to medical facilities to receive the VA or DOD examination, if they

so desire. However, in April 1995 an ARCOM official told us he was unaware

of either the DOD or VA hot line.

In October 1994 the National Defense Authorization Act for 1995 required

that DOD establish an outreach program for those in the military who

served in the Persian Gulf. Among other things, DOD is to inform them of

(1) illnesses that might be associated with Persian Gulf service,

(2) counseling and medical care available to them from DOD and VA, and

(3) procedures for being put on the VA registry or another registry, the

Persian Gulf War Health Surveillance System, managed by DOD.

8 DOD

officials emphasized that, in addition to the memorandums and the

telephone hot line discussed, they are continuing extensive contacts with

media and with veteran and military organizations. They noted that the

toll-free number was receiving about 400 calls per week, indicating, they

believed, that outreach efforts are effective.

8

This act also required DOD to provide information on all individuals who were registered in DOD’s

registry to VA for inclusion in the VA registry. DOD provided this information to VA in April 1995.

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In commenting on a draft of this report, DOD officials outlined other

outreach activities they are planning. These include the following:

• DOD plans to publish research findings in both scientific and medical

journals and general media. Specific publication methods have not yet

been decided. Agency officials do not expect research findings to be

available until early 1996.

• Another toll-free telephone number will be established to answer

questions and provide information to veterans about their individual

circumstances, such as unit locations and possible exposures.

• DOD plans to develop information to send directly to reserve units to

inform reservists about available health services, such as the CCEP and hot

line.

Satisfaction With Care

Received

Of those who received care through VA and DOD, most were dissatisfied

with it. Many of the veterans were dissatisfied with the special

examinations they were given. Of the 46 who had received the VA

examination, 28 were dissatisfied with it. Likewise, 7 of the 14 who had

received the DOD examination were dissatisfied with it. Most respondents

were also dissatisfied with the other care they received from VA and DOD

medical facilities. Of the 33 who had received other care from VA, 22 were

dissatisfied; 13 of 24 were dissatisfied with the other care from DOD. In

contrast, more veterans were satisfied than dissatisfied with care received

outside VA and DOD. Of the 47 who had received care outside DOD and VA, 7

reported being dissatisfied.

The following table compares veterans’ satisfaction with selected aspects

of care in VA and DOD, and outside VA and DOD.

Table 1: Veterans’ Satisfaction With

Selected Aspects of Care Number who rated care fair or poor

Aspect of care

VA

(n=33)

DOD

(n=24)

Other

(n=47)

Ability to diagnose problem 26 21 21

Outcome of care received; how much it helped 26 20 22

Attention providers gave to what respondent said 23 16 6

VA officials told us that dissatisfaction with care does not necessarily mean

that the care was of poor quality. They noted, for example, that if these

individuals believed they were sick and were not improved or cured, they

might be dissatisfied, even if the medical provider had done all that was

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B-258098 

possible to diagnose and treat the problem. They also noted that

satisfaction with physicians’ ability to diagnose problems should not be

viewed as an indication of the accuracy of the diagnosis. These officials

suggested that the initial assessment by the Walter Reed team—that many

of the health problems were caused by stress—was not accepted by many

of the veterans examined, and that this initial assessment may also have

colored veterans’ overall satisfaction with both DOD and VA health care.

Additionally, many of these veterans might have received care in 1992 or

1993, before DOD began the CCEP examination and before VA expanded the

protocol for the examination provided at local medical facilities.

Summary Most of the respondents, all of whom had expressed concerns about their

health in 1992, reported that they continued to have health problems they

believed were related to service in the Persian Gulf. Over half had taken

advantage of medical services, either the special examinations or other

health care, available to them through DOD and VA. However, despite VA and

DOD efforts to provide health examinations and care to these veterans and

to inform them of these services, many respondents were either unaware

of services or dissatisfied with them. Whether changes made in outreach

and services will alleviate the concerns these veterans reported to us is

unknown.

Agency Comments In a letter dated April 17, 1995, commenting on a draft of this report, the

Secretary of Veterans Affairs expressed concern that readers would

misinterpret the report findings. (See app. III.) He was concerned that

readers would generalize the findings about this small group of Persian

Gulf veterans to all Persian Gulf veterans and that the readers would

consider these veterans’ perceptions of care as conclusive evidence about

care received. As stated in the report, we agree that the responses of the

89 veterans cannot be generalized to any larger population and that the

information on health status and health care received was based on

veterans’ memories and perceptions.

DOD officials, including the Deputy Assistant Secretary of Defense for

Clinical Services, provided comments on the draft in an April 18, 1995,

meeting. The officials said that they generally concurred with the

information in the report, but expressed concern similar to that expressed

by the Secretary of Veterans Affairs about the possibility that readers

would generalize our findings beyond the 89 respondents. The officials

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also outlined additional outreach efforts that were being planned; we

incorporated that information into the report.

We are sending copies of this report to interested congressional

committees, the Secretaries of Defense and Veterans Affairs, and other

interested parties.

This work was done under the supervision of Ruth Ann Heck, Assistant

Director. Other major contributors were William Stanco, Edward Murphy,

and Clarita Mrena. Please call me on (202) 512-7101 or Ms. Heck on

(202) 512-7007 if you have any questions.

David P. Baine

Director, Federal Health Care

 Delivery Issues

Page 13 GAO/HEHS-95-102 Persian Gulf War Veterans
Contents

Letter 1

Appendix I 

Survey Scope and

Methodology

16

Survey Population 16

Data Collection 16

Nonresponse Analysis 17

Appendix II 

Summary of

Questionnaire

Responses

18

Appendix III 

Comments From the

Secretary of Veterans

Affairs

42

Table Table 1: Veterans’ Satisfaction With Selected Aspects of Care 11

Abbreviations

ARCOM 123rd Army Reserve Command

CCEP Comprehensive Clinical Evaluation Program

DOD Department of Defense

VA Department of Veterans Affairs

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Page 15 GAO/HEHS-95-102 Persian Gulf War Veterans
Appendix I 

Survey Scope and Methodology

Survey Population Much of the information contained in this report is based on a survey we

conducted with 125 of the 1,200 reservists from the 123rd Army Reserve

Command (ARCOM) who were deployed to the Persian Gulf during

Operation Desert Storm. These 125 reservists were scheduled to be

evaluated in 1992 by the Walter Reed Army Institute of Research in

response to concerns about their health that they expressed just after

returning from the Persian Gulf.

Data Collection To collect the data, we designed a mail questionnaire that included

questions regarding the reservists’ current military status; health status;

participation in special VA and DOD examinations; other health care

received from VA, DOD, and other providers; opinions about the quality of

the care received; and satisfaction with that care. To determine reservists’

current health status, we included a list of possible health problems. This

list was adapted from items on a medical questionnaire developed by the

Epidemiology Consultant Service within the Walter Reed Army Institute of

Research and administered to those reservists from the ARCOM who were

evaluated by the Institute in April 1992. The contents of the questionnaire

were discussed with VA and DOD officials. The questionnaire itself was

pretested with several members of the ARCOM. On the basis of these

discussions and the pretests, the questionnaire was revised accordingly.

To develop the mailing list for the veterans in our survey, we used

databases maintained by the ARCOM, DOD’s Office of Reserve Affairs, the VA

medical center in Indianapolis, and VA’s central information system. The

questionnaire was first mailed to the reservists on October 28, 1994. Those

who did not respond to the initial mailing were sent a second

questionnaire. Subsequent to mailing out the questionnaire, we learned

that 2 of the 125 reservists had passed away—one prior to the start of our

survey, the other shortly after our first mailing. Eighty-nine of the

remaining 123 reservists (72 percent) completed and returned our

questionnaire. The information obtained through this survey pertains to

only these 89 respondents and cannot be generalized to any other

population.

Data from surveys such as ours rely on respondents’ memories. Because of

the extensive resources that would be involved, we did not conduct

examinations or review medical files to verify the health status these

veterans reported. As a limited check on the accuracy of the responses

provided, we compared information available in VA and DOD automated

records to respondents’ answers about

Page 16 GAO/HEHS-95-102 Persian Gulf War Veterans
Appendix I 

Survey Scope and Methodology

• their current military status,

• whether they had received the special examinations offered by VA and DOD,

and

• whether they had received inpatient or outpatient care in VA facilities.

It was not feasible to compare responses regarding care received from DOD

health facilities to DOD data because DOD medical records for the reservists

are not centrally located. Taking into account that VA and DOD records did

not always cover the same time periods addressed in our questionnaire,

those survey responses we could compare with existing data are generally

consistent with VA and DOD records.

Nonresponse Analysis We also used automated information from these VA and DOD records to

compare those who responded to our survey with those who did not.

Nonrespondents and respondents were similar in many ways. About the

same proportion of each group

• were still in the military at the time of our survey,

• were examined by the Walter Reed Army Institute of Research team in

1992, and

• had received outpatient care from VA since returning from the Persian

Gulf.

In other ways, however, respondents and nonrespondents were different.

Over one-third of the respondents received VA’s special Persian Gulf

examination, as opposed to about one-fifth of the nonrespondents. Also, a

few of the respondents were admitted to a VA medical facility from fiscal

years 1991 to 1993, but none of the nonrespondents was admitted during

that time.

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Appendix II 

Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Summary of Questionnaire Responses

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Appendix II 

Summary of Questionnaire Responses

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Summary of Questionnaire Responses

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Summary of Questionnaire Responses

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Summary of Questionnaire Responses

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Page 41 GAO/HEHS-95-102 Persian Gulf War Veterans
Appendix III 

Comments From the Secretary of Veterans

Affairs

Now on pp. 1-2.

Now on p. 16.

Page 42 GAO/HEHS-95-102 Persian Gulf War Veterans
Appendix III 

Comments From the Secretary of Veterans

Affairs

(406090) Page 43 GAO/HEHS-95-102 Persian Gulf War Veterans
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