Operation Desert Storm: Health Concerns of Selected Indiana Persian Gulf War Veterans
Published: 1995-05-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Pursuant to a congressional request, GAO provided information on certain Persian Gulf War veterans' chronic health problems, focusing on: (1) the veterans' current military and health status; (2) the health care services they received after the war; and (3) their opinions on post-war care.
section_title: What GAO Found
paragraphs: GAO found that: (1) the veterans surveyed were still concerned about their health and were dissatisfied with the Department of Veterans Affairs' (VA) and the Department of Defense's (DOD) services; (2) most of these veterans were still on active duty and believe their health problems are linked to their service in the Persian Gulf; (3) less than half of the separated veterans reported that health problems related to their Persian Gulf service contributed to their discharges; (4) most of the veterans reported that their health problems limited their physical and social activities; (5) almost one-third of the respondents reported that family members also experienced health problems that were related to their Gulf service; (6) although over half of these veterans had used VA or DOD health care services, many veterans received care from sources other than VA or DOD; and (7) VA and DOD have taken a variety of actions to address Persian Gulf veterans' concerns by expanding special health examinations and their outreach efforts.

section_title: Letter
paragraphs: 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. The 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.
subsections: section_title: Background
paragraphs: 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 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.
section_title: Military Status
paragraphs: 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 appropriate benefits, because of those illnesses; without the new presumption, such members could only receive benefits if a specific diagnosis could be made.
section_title: Current Health Status
paragraphs: 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.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 believed his child had developed cancer as a result of the respondent’s service in the Persian Gulf.
section_title: Medical Care Provided to Persian Gulf War Veterans
paragraphs: 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 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.
subsections: section_title: Follow-Up to Walter Reed Study
paragraphs: 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. 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 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.
section_title: Special Examinations for Persian Gulf Veterans
paragraphs: 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. 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 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.
section_title: Other Care Received From VA, DOD, and Other Sources
paragraphs: 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.
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.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.
section_title: VA and DOD Outreach Efforts
paragraphs: 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.
subsections: section_title: VA Outreach
paragraphs: 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. Also, in 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.
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 month of operation. They believed that this indicated the outreach mechanism was having a substantial impact.
section_title: DOD Outreach
paragraphs: 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. 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.
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.
section_title: Satisfaction With Care Received
paragraphs: 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.
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 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.
section_title: Agency Comments
paragraphs: 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 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.
section_title: Survey Scope and Methodology
subsections: section_title: Survey Population
paragraphs: 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.
section_title: Data Collection
paragraphs: 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 their current military status, whether they had received the special examinations offered by VA and DOD, 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.
section_title: Nonresponse Analysis
paragraphs: 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 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.
section_title: Summary of Questionnaire Responses
section_title: Comments From the Secretary of Veterans Affairs
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subsections: section_title: Address Correction Requested