Following Iraq’s invasion of Kuwait in August 1990, the United States and other allied nations sent troops to the Persian Gulf region in Operation Desert Shield. In the winter of 1991, the allied forces attacked Iraq in an air campaign and subsequent invasion by ground forces (Operation Desert Storm). Despite the harsh environment, illness, injury, and death rates among approximately 700,000 U.S. military personnel were significantly lower than in previous major conflicts. Yet, shortly after the war, some veterans began reporting health problems that they believed might be due to their participation in the war. VA, DOD, HHS, and other federal agencies initiated research and investigations into these health concerns and the consequences of possible hazardous exposures. In 1993, the President designated VA as the lead coordinator of research activities on the health consequences of service in the Gulf War. Subsequently, in 1998, the Congress expanded VA’s coordination to include all Gulf War health-related activities. These activities include ensuring that the findings of all federal Gulf War illnesses research are made available to the public and that federal agencies coordinate outreach to Gulf War veterans in order to provide information on potential health risks from service in the Gulf War and corresponding services or benefits. The Secretary of VA is required to submit an annual report on the results, status, and priorities of federal research activities related to the health consequences of military service in the Gulf War to the Senate and House Veterans’ Affairs Committees. VA has provided these reports to congressional committees since 1995. In May 2004, VA issued its annual report for 2002. VA has carried out its coordinating role through the auspices of interagency committees, which have changed over time in concert with federal research priorities and needs. The mission of these interagency committees has evolved to include coordination for research on all hazardous deployments, including but not limited to the Gulf War. (See fig. 1.) Federal research efforts for Gulf War illnesses have been guided by questions established by the interagency Research Working Group (RWG), which was initially established under the Persian Gulf Veterans Coordinating Board (PGVCB) to coordinate federal research efforts. From 1995 through 1996, RWG identified 19 major research questions related to illnesses in Gulf War veterans. In 1996, the group added 2 more questions regarding cancer risk and mortality rates to create a set of 21 key research questions that serves as an overarching strategy in guiding federal research for Gulf War illnesses. (See app. II for the list of key questions.) The 21 research questions cover the extent of various health problems, exposures among the veteran population, and the difference in health problems between Gulf War veterans and control populations. In 1998, RWG expanded federal Gulf War illnesses research priorities to include treatment, longitudinal follow-up of illnesses, disease prevention, and improved hazard assessment; however, RWG did not add any new research questions. With regard to veterans’ health status, the research questions cover the prevalence among veterans and control populations of symptoms, symptom complexes, illnesses, altered immune function or host defense, birth defects, reproductive problems, sexual dysfunction, cancer, pulmonary symptoms, neuropsychological or neurological deficits, psychological symptoms or diagnoses, and mortality. With regard to exposure, the research questions cover Leishmania tropica (a type of parasite), petroleum, petroleum combustion products, specific occupational/environmental hazards (such as vaccines and chemical agents, pyridostigmine bromide (given to troops as a defense against nerve psychophysiological stressors (such as exposure to extremes of human suffering). Separately from these research efforts, DOD is responsible for investigating and reporting incidents of possible chemical and biological agent exposures and other potential occupational and environmental hazards. Within DOD, the entities responsible for overseeing Gulf War exposure investigations have also evolved over time. (See fig. 2.) In 2002, VA established RAC to provide advice to the Secretary of VA on proposed research relating to the health consequences of military service in the Gulf War. RAC, which is composed of members of the general public, including non-VA researchers and veterans’ advocates, was tasked with assisting VA in its research planning by exploring the entire body of Gulf War illnesses research, identifying gaps in the research, and proposing potential areas of future research. VA provides an annual budget of about $400,000 for RAC, which provides salaries for two full- time employees and one part-time employee and supports committee operating costs. RAC’s employees include a scientific director and support staff who review published scientific literature and federal research updates and collect information from scientists conducting relevant research. RAC’s staff provide research summaries for discussion and analysis to the advisory committee through monthly written reports and at regularly scheduled meetings. RAC holds public meetings several times a year at which scientists present published and unpublished findings from Gulf War illnesses research. In 2002, RAC published a report with recommendations to the Secretary of VA. It expects to publish another report soon. More than 80 percent of the 240 federally funded Gulf War illnesses research projects have been completed. In recent years, funding for this research has decreased, federal research priorities have expanded to incorporate the long-term health effects of all hazardous deployments, and interagency coordination of Gulf War illnesses research has waned. In addition, with respect to the federal research strategy, VA has not reassessed the research findings to determine whether the 21 key research questions have been answered or to identify the future direction of federal research in this area. In a separate but related effort, as of April 2003, all of DOD’s Gulf War investigations were complete. Since 1991, 240 federally funded research projects have been initiated by VA, DOD, and HHS to address the health concerns of individuals who served in the Gulf War. As of September 2003, 194 of the 240 federal Gulf War illnesses research projects (81 percent) had been completed; another 46 projects (19 percent) were ongoing. (See fig. 3.) From 1994 through 2003, VA, DOD, and HHS collectively spent a total of $247 million on Gulf War illnesses research. DOD has provided the most funding for Gulf War illnesses research, funding about 74 percent of all federal Gulf War illnesses research within this time frame. Figure 4 shows the comparative percentage of funding by these agencies for each fiscal year since 1994. After fiscal year 2000, overall funding for Gulf War illnesses research decreased. (See fig. 5.) Fiscal year 2003 research funding was about $20 million less than funding provided in fiscal year 2000. This overall decrease in federal funding was paralleled by a shift in federal research priorities, which expanded to include all hazardous deployments and shifted away from a specific focus on Gulf War illnesses. VA officials said that although Gulf War illnesses research continues, the agency is expanding the scope of its research to include the potential long-term health effects in troops who served in hazardous deployments other than the Gulf War. In October 2002, VA announced plans to commit up to $20 million for research into Gulf War illnesses and the health effects of other military deployments. Also in October 2002, VA issued a program announcement for research on the long-term health effects in veterans who served in the Gulf War or in other hazardous deployments, such as Afghanistan and Bosnia/Kosovo. As of April 2004, one new Gulf War illnesses research project was funded for $450,000 under this program announcement. Although DOD has historically provided the majority of funding for Gulf War illnesses research, DOD officials stated that their agency currently has no plans to fund new Gulf War illnesses research projects. Correspondingly, DOD has not funded any new Gulf War illnesses research in fiscal year 2004, except as reflected in modest supplements to complete existing projects and a new award pending for research using funding from a specific appropriation. DOD also did not include Gulf War illnesses research funding in its budget proposals for fiscal years 2005 and 2006. DOD officials stated that because the agency is primarily focused on the needs of the active duty soldier, its interest in funding Gulf War illnesses research was highest when a large number of Gulf War veterans remained on active duty after the war—some of whom might develop unexplained symptoms and syndromes that could affect their active duty status. Since 2000, DOD’s focus has shifted from research solely on Gulf War illnesses to research on medical issues of active duty troops in current or future military deployments. For example, in 2000 VA and DOD collaborated to develop the Millennium Cohort study, which is a prospective study evaluating the health of both deployed and nondeployed military personnel throughout their military careers and after leaving military service. The study began in October 2000 and was awarded $5.25 million through fiscal year 2002, with another $3 million in funding estimated for fiscal year 2003. VA’s coordination of federal Gulf War illnesses research has gradually lapsed. Starting in 1993, VA carried out its responsibility for coordinating all Gulf War health-related activities, including research, through interagency committees, which evolved over time to reflect changing needs and priorities. (See fig. 1.) In 2000, interagency coordination of Gulf War illnesses research was subsumed under the broader effort of coordination for research on all hazardous deployments. Consequently, Gulf War illnesses research was no longer a primary focus. The most recent interagency research subcommittee, which is under the Deployment Health Working Group (DHWG), has not met since August 2003, and as of April 2004, no additional meetings had been planned. Additionally, VA has not reassessed the extent to which the collective findings of completed Gulf War illnesses research projects have addressed the 21 key research questions developed by the RWG. (See app. II.) The only assessment of progress in answering these research questions was published in 2001, when findings from only about half of all funded Gulf War illnesses research were available. Moreover, the summary did not identify whether there were gaps in existing Gulf War illnesses research or promising areas for future research. No reassessment of these research questions has been undertaken to determine whether they remain valid, even though about 80 percent of federally funded Gulf War illnesses research projects now have been completed. In 2000, we reported that without such an assessment, many underlying questions about causes, course of development, and treatments for Gulf War illnesses may remain unanswered. As of April 2003, DOD had completed all of its Gulf War health-related investigations, which are separate from Gulf War illnesses research. DOD began conducting investigations on Gulf War operations and their implications for service members’ and veterans’ health in 1996. Generally, DOD instituted an investigation after it received a report of a possible exposure to a chemical or biological agent or some other environmental, chemical, or biological hazard. From 1996 to 2003, DOD conducted 50 investigations at a cost of about $68 million. DOD published the 50 investigations in the form of 20 case narratives, 10 information papers, 5 closeout reports, and 5 environmental exposure reports. Additionally, the RAND Corporation was contracted by the Office of Special Assistant for Gulf War Illnesses (OSAGWI) to publish 10 reports reviewing the medical and scientific literature on the known health effects of substances to which Gulf War veterans may have been exposed. Some investigations focused on examining possible exposures to chemical warfare agents or the presence of chemical weapons at specific sites. Other investigations studied the possible linkage between environmental hazards (such as contaminated water, equipment used during the Gulf War, oil well fires, and particulate matter) and illnesses or health effects. OSAGWI published four annual reports summarizing the results of investigations. Generally, these reports concluded that there were limited exposures by troops to some hazards and limited or no short- or long-term adverse effects expected from these exposures. The last annual report was published in December 2000. As of April 2004, federal agencies had funded seven research projects related to cancer incidence among Gulf War veterans, four of which have been completed. Published results from the completed and ongoing studies generally show that rates of cancer among Gulf War veterans were similar to or lower than the rates among nondeployed veterans or the general population. However, results of these studies may not be reliable due to limitations in research related to cancer incidence in Gulf War veterans. Future research efforts may also be hindered by inadequate federal data on the health characteristics of Gulf War veterans. Of the 240 federally funded research projects on Gulf War illnesses, VA officials stated that only 7 were related to cancer incidence in Gulf War veterans—accounting for about 3 percent of the entire research portfolio. Four of the seven research projects have been completed; the other three are ongoing. Only two of the seven research projects specifically studied cancer incidence. The remaining five research projects did not focus on cancer incidence, but instead included cancer as a component of a broader analysis of mortality, hospitalization, or general health status of Gulf War veterans. (See table 1 for more details on these studies.) Overall, the four published research projects found that deployed Gulf War veterans did not have demonstrable differences in cancer-related ailments compared with nondeployed veterans or the general population. In addition, one of the published studies found that rates of hospitalization among Gulf War veterans were similar or lower than among nondeployed veterans, and another found that cancer-related mortality rates among Gulf War veterans were similar or lower than in the general population. Research efforts are continuing for one of the two funded research projects specifically related to cancer incidence in Gulf War veterans. Researchers conducted a pilot project, scheduled to end in September 2004, which matched the cancer registries of six states and the District of Columbia with a database of all Gulf War veterans. In order to build on these efforts, the researchers plan to expand the pilot study to include additional states with cancer registries to obtain a more refined estimate of cancer incidence in Gulf War veterans. While this approach appears promising, the study’s principal investigator said further efforts beyond September 2004 would be limited to working with state cancer registries that do not charge a fee or do not require on-site use of a registry. A number of inherent limitations in research related to cancer incidence in Gulf War veterans could adversely affect the reliability of the findings from such research. (See table 1.) For example, since some cancers can take 15 years or more to develop and subsequently be detected, it may be too early to determine cancer incidence in Gulf War veterans, as studies 4 and 5 in table 1 were designed to do. Hospitalization studies of Gulf War veterans are applicable only to those veterans who seek care in specific hospitals included in the studies; veterans who use other health care systems are not included. Mortality studies of Gulf War veterans are limited because only veterans who have died of cancer are captured; other veterans who have not died, but have been diagnosed with cancer, are not included. Additionally, some general health studies of Gulf War veterans may use self-reported data only, which may not be accurate unless validated by objective physical or laboratory findings. Other research projects, which have samples that are not representative of all Gulf War veterans, such as studies 1 and 5 in table 1, may not reliably assess the possibility of elevated levels of cancer incidence or related ailments in Gulf War veterans when compared to the general population or nondeployed veterans. Research related to cancer incidence in Gulf War veterans may also be hampered by incomplete federal data on the health characteristics of Gulf War veterans. In 1998, we reported that VA and DOD did not have data systems providing complete information on the health characteristics of Gulf War veterans that could be used to accurately estimate cancer incidence. For example, data from medical records and files on disability claims, treatment, and pensions do not include all Gulf War veterans. These data do not account for veterans who are separated from the services and receive non-VA health care or disability benefits. Furthermore, linking VA and DOD data systems still would not overcome these shortcomings. VA officials have also stated that existing data systems, such as medical record or pension systems, are not adequate for determining cancer incidence and that epidemiological research projects are needed. RAC’s efforts to provide advice and make recommendations on Gulf War illnesses research may have been impeded by VA’s limited sharing of information on research initiatives and program planning as well as VA’s limited collaboration with the committee. However, VA and RAC are exploring ways to improve information sharing, including VA’s hiring of a senior scientist who would both guide the agency’s Gulf War illnesses research and serve as the agency’s liaison to provide routine updates to RAC. VA and RAC are also proposing changes to improve collaboration, including possible commitments from VA to seek input from RAC when developing research program announcements. At the time of our review, most of these proposed changes were in the planning stages. According to RAC officials, VA senior administrators’ poor information sharing and limited collaboration with the committee about Gulf War illnesses research initiatives and program planning may have hindered RAC’s ability to achieve its mission of providing research advice to the Secretary of VA. RAC is required by its charter to provide advice and make recommendations to the Secretary of VA on proposed research studies, research plans, and research strategies relating to the health consequences of service during the Gulf War. (See app. III for RAC’s charter.) RAC’s chairman and scientific director said that the recommendations and reports that the advisory committee provides to the Secretary of VA are based on its review of research projects and published and unpublished research findings related to Gulf War illnesses. Although RAC and VA established official channels of communication, VA did not always provide RAC with important information related to Gulf War illnesses research initiatives and program planning. In 2002, VA designated a liaison to work with RAC’s liaison in order to facilitate the transfer of information to the advisory committee about the agency’s Gulf War illnesses research strategies and studies. However, RAC officials stated that most communication occurred at their request; that is, the VA liaison and other VA staff were generally responsive to requests, but did not establish mechanisms to ensure that essential information about research program announcements or initiatives was automatically provided to the advisory committee. RAC officials cited the following instances in which VA did not fully collaborate with the advisory committee or provide information that RAC considered important: According to RAC’s scientific director, bimonthly teleconferences between the advisory committee’s and VA’s liaisons did not result in full disclosure of relevant ongoing research activities. For example, despite several months of discussions in which RAC’s liaison requested information about proposed research program announcements for Gulf War illnesses research, VA’s liaison did not inform RAC that VA’s Office of Research and Development was preparing a research program announcement until it was published in October 2002. Consequently, RAC officials said that they did not have an opportunity to carry out the committee’s responsibility of providing advice and making recommendations on research strategies and plans. RAC officials stated that VA did not notify advisory committee members that the Longitudinal Health Study of Gulf War Era Veterans—a study designed to address possible long-term health consequences of service in the Gulf War—had been developed and that the study’s survey was about to be sent to study participants. RAC officials expressed concern that VA did not inform the advisory committee about the survey even after the plans for it were made available for public comment. Although the survey had been finalized, the study’s principal investigator provided additional time to allow RAC to recommend additional survey question topics and incorporated RAC’s suggested changes into the survey. In May 2004, VA published its annual report that described the results, status, and priorities of federally funded Gulf War illnesses research as of 2002. However, RAC officials said they had not seen a draft of this report and had not been asked to review or comment on the document before it was published, even though the advisory committee has a responsibility to advise the Secretary of VA on the state and direction of Gulf War illnesses research. According to RAC officials, there were also instances in which information relevant to Gulf War illnesses research provided by VA’s liaison or other VA officials was unclear or incomplete. Miscommunication about the purpose of the October 2002 research program announcement and the details of a corresponding VA plan to increase funding up to $20 million for research related to hazardous military deployments, which would include the Gulf War, led RAC members to believe that VA had committed a large portion of this $20 million to Gulf War illnesses research for fiscal year 2004. Moreover, RAC officials did not receive routine reports on Gulf War illnesses research proposals that had been either received or funded by VA under the October 2002 research program announcement. RAC officials said that until VA administrators were asked to brief the advisory committee in February 2004, advisory committee members were unaware that only one new Gulf War illnesses research project had received funding for fiscal year 2004 under this program announcement and that no other proposals were under review. Information sharing about these types of issues is common practice among advisory committees of the National Institutes of Health (NIH), which has more federal advisory committees than any other executive branch agency. A senior official within NIH’s Office of Federal Advisory Committee Policy said that it is standard practice for NIH advisory committees to participate closely in the development of research program announcements. For example, some advisory committees’ members review preliminary drafts of announcements, and some discuss program announcements during regular committee meetings. Furthermore, this official stated that many NIH institutes require advisory committee approval before issuing research program announcements. In addition, NIH’s advisory committee members are routinely asked to make recommendations on both research concepts and priorities for research projects, and are kept up-to-date about the course of ongoing research projects. This official also stated that NIH advisory committee members often review draft reports summarizing research findings or research progress prior to their publication. Additionally, RAC officials stated that VA’s staffing choices for the liaison position and more recent VA staff turnover have hindered the development of working relationships and information flow. RAC officials stated that the initial VA liaison—a senior official in one of VA’s four research services—was not very knowledgeable about current Gulf War illnesses research developments. In early 2003, VA’s Chief Research and Development Officer (CRADO), whom RAC officials said was knowledgeable about Gulf War illnesses issues, began to serve as the VA liaison to RAC. (See fig. 6 for organizational chart.) However, this individual left VA in December 2003, and according to RAC officials, further communication with the advisory committee was delegated to lower-level VA staff. After the advisory committee’s February 2004 meeting, the acting CRADO (appointed in December 2003) and the deputy CRADO began to communicate regularly with the advisory committee. However, the acting CRADO has additional management responsibilities that can limit the amount of time available to coordinate with RAC. Specifically, in early April 2004, this official was named to temporarily head VA’s health care system—the Veterans Health Administration. For this reason, the deputy CRADO more often has acted as a point of contact for the committee. In recognition of RAC’s concerns, VA is proposing several actions to improve information sharing, including VA’s hiring of a senior scientist to guide its Gulf War illnesses research and improving formal channels of communication. In addition, VA and RAC are exploring methods to improve collaboration. These would include possible commitments from VA to seek input from RAC when developing research program announcements and to include RAC members in a portion of the selection process for funding Gulf War illnesses research projects. As of April 2004, most of the proposed changes were in the planning stages. Since the February 2004 RAC meeting, VA and RAC officials said they have had multiple meetings and phone conversations and have corresponded via e-mail in an attempt to improve communication and collaboration. VA officials said they have already instituted efforts to hire a senior scientist to guide the agency’s Gulf War illnesses research efforts. The official assigned to this position will be the RAC liaison and coordinator of VA’s research on Gulf War illnesses and health issues related to other hazardous deployments. According to VA officials, this official will be required to formally contact RAC officials weekly, with informal communications on an as needed basis. In addition, this official will be responsible for providing periodic information on the latest publications or projects related to Gulf War illnesses research. To facilitate collaboration with RAC, VA has proposed involving RAC members in developing VA program announcements designed to solicit research proposals, both specifically for Gulf War illnesses and related areas of interest, such as general research into unexplained illnesses. RAC officials stated that throughout March and April 2004, VA and RAC officials had been jointly developing a new research program announcement for Gulf War illnesses. In addition, VA has proposed that RAC will be able to recommend scientists for inclusion in the scientific merit review panels. VA also plans to involve RAC in reviews of project relevancy to Gulf War illnesses research goals and priorities after the research projects undergo scientific merit review. This could facilitate RAC’s ability to provide recommendations to the CRADO on the projects that it has judged to be relevant to the Gulf War illnesses research plan. While more than 80 percent of federally funded Gulf War illnesses research projects have been completed, little effort has been made to assess progress in answering the 21 key research questions or to identify the direction of future research in this area. Additionally, in light of decreasing federal funds and expanding federal research priorities, research specific to Gulf War illnesses is waning. Without a comprehensive reassessment of Gulf War illnesses research, underlying questions about the unexplained illnesses suffered by Gulf War veterans may remain unanswered. Since RAC’s establishment in January 2002, its efforts to provide the Secretary of VA with advice and recommendations may have been hampered by incomplete disclosure of VA’s Gulf War illnesses research activities. By limiting information sharing with RAC, VA has not fully realized the assistance that the scientists and veterans’ advocates who serve on RAC could provide in developing effective policies and guidance for Gulf War illnesses research. VA and RAC are exploring new approaches to improve information sharing and collaboration. If these approaches are implemented, RAC’s ability to play a pivotal role in helping VA reassess the direction of Gulf War illnesses research may be enhanced. However, most of these changes had not been formalized at the time of our review. With respect to the federal Gulf War illnesses research efforts, we recommend that the Secretary of Veterans Affairs take the following action: conduct a reassessment of the Gulf War illnesses research strategy to determine whether the 21 key research questions have been answered, whether they remain relevant, and whether there are promising areas for future research. To facilitate RAC’s ability to provide advice on Gulf War illnesses research, we recommend that the Secretary of Veterans Affairs take the following additional two actions: ensure that a liaison who is knowledgeable about Gulf War illnesses research is appointed to routinely share information with RAC and ensure that VA’s research offices collaborate with RAC on Gulf War illnesses research program development activities. We provided a draft of this report for comment to VA and DOD. In commenting on this draft, VA agreed with the report’s conclusions and concurred with the report’s recommendations. VA said that it has begun a preliminary assessment of the federal Gulf War illnesses research strategy, including an evaluation of the 21 key research questions, to ensure the research strategy’s continued validity and to identify promising areas for future research. The agency also noted that it has undertaken various steps, such as coordinating its most recent request for Gulf War research applications with RAC, in order to better collaborate with the advisory committee. VA’s written comments are in appendix IV. DOD informed us that it had no substantive comments on the draft report. Both VA and DOD provided technical comments, which we incorporated where appropriate. We are sending copies of this report to the Secretary of VA, the Secretary of Defense, and the Secretary of HHS. We will also provide copies to others upon request. In addition, the report will be available at no charge on GAO’s Web site at http://www.gao.gov. If you or your staff have any questions about this report, please call me at (202) 512-7119 or Bonnie Anderson at (404) 679-1900. Karen Doran, John Oh, Danielle Organek, and Roseanne Price also made key contributions to this report. To describe the status of research and investigations on Gulf War illnesses, we reviewed reports to congressional committees outlining annually awarded and completed research projects and research funding. We summarized data from the Department of Veterans Affairs’ (VA) annual reports to congressional committees, including numbers of funded research projects and total funding by federal agency, in order to determine the status of completed research. We interviewed VA’s then- Assistant Chief Research and Development Officer (CRADO) and the Department of Defense’s (DOD) Deputy Director of the Deployment Health Support Directorate (DHSD) regarding the agencies’ current and future Gulf War illnesses research and investigation plans. We also interviewed CRADO and DHSD staff and senior managers with DOD’s medical research offices, including Defense Research and Engineering and the Army’s Medical Research and Materiel Command. We reviewed other relevant documents, including interagency coordinating council meeting minutes, federal laws, presidential directives, and VA- and DOD-published documents on Gulf War illnesses research and DOD investigations. To describe efforts made by VA and DOD to monitor cancer incidence among Gulf War veterans, we interviewed VA’s then-Assistant CRADO, a VA senior research manager, and VA researchers, along with DOD’s Deputy Director of DHSD. We reviewed annual reports to congressional committees describing federally funded Gulf War illnesses research, published articles from peer-reviewed journals reporting research findings, and other agency documents describing research projects. To evaluate the VA’s Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC) efforts to provide advice on Gulf War illnesses research, we interviewed RAC’s Chairman and Scientific Director, attended the most recent RAC meeting in February 2004, and reviewed RAC reports and recommendations to the Secretary of VA. We also interviewed officials with the National Institutes of Health’s (NIH) Office of Federal Advisory Committee Policy and officials within an NIH advisory committee to identify common practices related to information sharing and collaboration between NIH and its advisory committees. To determine VA’s efforts to improve information sharing and collaboration with RAC, we interviewed VA’s deputy CRADO and CRADO staff. From 1995 through 1996, the Research Working Group (RWG) of the interagency Persian Gulf Veterans’ Coordinating Board identified 19 major research questions related to illnesses in Gulf War veterans. RWG later added 2 more questions to create a set of 21 key research questions to serve as a guide for federal research on Gulf War illnesses. (See table 3.)

Summary: More than a decade after the 1991 Persian Gulf War, there is continued interest in the federal response to the health concerns of Gulf War veterans. Gulf War veterans' reports of unexplained illnesses and possible exposures to various health hazards have prompted numerous federal research projects on Gulf War illnesses. This research has been funded primarily by the Department of Veterans Affairs (VA), the Department of Defense (DOD), and the Department of Health and Human Services. GAO is reporting on (1) the status of research and investigations on Gulf War illnesses, (2) the efforts that have been made by VA and DOD to monitor cancer incidence among Gulf War veterans, and (3) VA's communication and collaboration with the Research Advisory Committee on Gulf War Veterans' Illnesses (RAC). Most federally funded Gulf War illnesses research projects and investigations are complete, but VA--the agency with lead responsibility for coordination of Gulf War illnesses issues--has not yet analyzed the latest research findings to identify whether there are gaps in current research or to identify promising areas for future research. As of September 2003, about 80 percent of the 240 federally funded medical research projects for Gulf War illnesses had been completed. In recent years, VA and DOD funding for this research has decreased, federal research priorities have changed, and interagency coordination of Gulf War illnesses research has waned. In addition, VA has not reassessed the extent to which the collective findings of completed Gulf War illnesses research projects have addressed key research questions. The only assessment of progress in answering these research questions was published in 2001, when findings from only about half of all federally funded Gulf War illnesses research were available. Moreover, it did not identify whether there were gaps in existing Gulf War illnesses research or promising areas for future research. This lack of comprehensive analysis leaves VA at greater risk of failing to answer unresolved questions about causes, course of development, and treatments for Gulf War illnesses. In a separate effort, DOD has conducted 50 investigations since 1996 on potential hazardous exposures during the Gulf War. Generally, these investigations concluded that there were limited exposures by troops to some hazards and, at most, limited short- or long-term adverse effects expected from these exposures. As of April 2003, all investigations were complete. Federal agencies have funded seven research projects related to cancer incidence among Gulf War veterans. However, several limitations exist that affect research related to cancer incidence. For example, some cancers may take many years to develop and be detected. In addition, some research projects studying cancer incidence have not studied enough Gulf War veterans to reliably assess cancer incidence. Research may also be impeded by incomplete federal data on the health characteristics of Gulf War veterans. RAC's efforts to provide advice and make recommendations on Gulf War illnesses research to the Secretary of VA may have been hampered by VA senior administrators' incomplete or unclear information sharing and limited collaboration on research initiatives and program planning. VA and RAC are exploring ways to improve collaboration, including VA's hiring of a senior scientist who would both guide VA's Gulf War illnesses research and serve as the agency's liaison for routine updates to the advisory committee. However, most of these changes had not been finalized at the time of our review.