August 1997
VA PROGRAMS FOR GULF WAR VETERANS
The Department of Veterans Affairs (VA) offers Gulf War veterans physical examinations and special eligibility for follow-on care, and it operates a toll-free hotline at 800-749-8387 to inform these veterans of the program and their benefits. VA also is compensating veterans under unprecedented regulations addressing undiagnosed conditions. Special research centers and other investigations are searching for answers to aid seriously ill patients whose underlying disease is unexplained. Most Gulf veterans are diagnosed and treated; but for some, such symptoms as joint pain or fatigue have been chronic. Some respond to treatment of symptoms even though their doctors have not yet identified an underlying illness or pathogenic agent.
UNEXPLAINED ILLNESS: The prevalence of unexplained illnesses among Gulf War veterans is uncertain. Answers about illness prevalence are expected through epidemiologic research involving representative samples of the Gulf veteran population. Data reviewed from about 6,000 of the most recent exams in the special Gulf War Registry health examination program showed physicians had determined that the veteran had unexplained illness in about 12 percent of the cases.
GULF WAR "SYNDROME" UNDEFINED: Several panels of government physicians and private-sector scientific experts have been unable to discern any new illness or unique symptom complex such as that popularly called "Gulf War Syndrome." "No single disease or syndrome is apparent, but rather multiple illnesses with overlapping symptoms and causes," wrote an outside panel led by professors from Harvard and Johns Hopkins University that convened for an April 1994 National Institutes of Health (NIH) workshop. VA has neither confirmed nor ruled out the possibility of a singular Gulf syndrome. Some studies are developing "case definitions" to classify participants for purposes of research hypotheses, but the ultimate clinical value of these classifications remains uncertain.
RESEARCH AND RISK FACTORS:
With variation in exposures and veterans' concerns ranging from depleted
uranium in armaments to possible contamination from Iraqi chemical/biological
agents, VA has initiated wide-ranging research projects evaluating illnesses
as well as risk factors in the Gulf environment, spending more than $3.6
million annually. The activation of four research centers has enabled VA
to broaden its activity from largely descriptive evaluations to greater
emphasis on hypothesis-driven research.
More than 996,000 servicemembers served in the Gulf from August 1990 through the end of 1995, nearly 697,000 of them serving in the first year. About 608,700 have become potentially eligible for VA care as veterans, having separated from the military or having become deactivated reservists or Guard members. Approximately 67,989 veterans have responded to VA's outreach encouraging any Gulf veteran to get a free physical exam under VA's Gulf War Program. Not all are ill:
SPECIAL HEALTH EXAMINATION: A free, complete physical
examination with basic lab studies is offered to every Gulf War veteran,
whether or not the veteran is ill. A centralized registry of participants,
begun in August 1992, is maintained to enable VA to update veterans on research
findings or new compensation policies through periodic newsletters. This
clinical database also provides information about possible health trends
and may suggest areas to be explored in future scientific research. The
67,989 Gulf War veterans who have taken advantage of the physical examination
program become part of a larger Gulf War Registry. As defined by P.L.102-585,
this includes about 242,000 Gulf veterans (generally including those counted
in the special examination program) who have been seen for routine VA hospital
or clinic care, or who have filed compensation claims -- or whose survivor
registers a claim.
GULF VETERAN INFORMATION CENTER: VA offers a toll-free information line
at 800-PGW-VETS (800-749-8387) where operators are trained to help veterans
with general questions about medical care and other benefits. It also provides
recorded messages that enable callers to obtain information 24 hours a day.
SPECIAL ACCESS TO FOLLOW-ON CARE: VA has designated a physician at every
VA medical center to coordinate the special examination program and to receive
updated educational materials and information as experience is gained nationally.
Where an illness possibly related to exposure to an environmental hazard
or toxic substance is detected during the examination, followup care is
provided on a higher-eligibility basis than most non-service-connected care.
As with the health examination registry, VA requested and received special
statutory authority to bypass eligibility rules governing access to the
VA health system.
GULF VETERAN REFERRAL CENTERS: If the veteran's illness defies diagnosis,
the veteran may be referred to one of four Gulf War Referral Centers. Created
in 1992, the first centers were located at VA medical centers in Washington,
D.C.; Houston; and Los Angeles, with an additional center designated at
Birmingham, Ala., in June 1995. These centers provide assessment by specialists
in such areas as pulmonary and infectious disease, immunology, neuropsychology,
and additional expertise as indicated in such areas as toxicology or multiple
chemical sensitivity. There have been approximately 411 veterans assessed
at the centers; most ultimately are being diagnosed with known/definable
conditions.
STANDARDIZED EXAM PROTOCOLS: VA has expanded its special examination protocol
as more experience has been gained with the health of Gulf veterans. The
protocol elicits information about symptoms and exposures, calls the clinician's
attention to diseases endemic to the Gulf region, and directs baseline laboratory
studies including chest X-ray (if one has not been done recently), blood
count, urinalysis, and a set of blood chemistry and enzyme analyses that
detect the "biochemical fingerprints" of certain diseases. In
addition to this core laboratory work for every veteran undergoing the Gulf
War program exam, physicians order additional tests and specialty consults
as they would normally in following a diagnostic trail -- as symptoms dictate.
If a diagnosis is not apparent, facilities follow the "comprehensive
clinical evaluation protocol" originally developed for VA's referral
centers and now used in VA and military medical centers nationwide. The
protocol suggests 22 additional baseline tests and additional specialty
consultations, outlining dozens of further diagnostic procedures to be considered,
depending on symptoms.
Risk Factors of Concern to Veterans
Veterans have reported a wide range of
factors observed in the Gulf environment or speculative risks about which
they have voiced concerns. Some are the subject of research investigations
and none have been ruled out. There appears to be no unifying exposure that
would account for all unexplained illnesses. Individual veterans' exposures
and experiences range from ships to desert encampments, and differences
in military occupational specialty frequently dictate the kinds of elements
to which servicemembers are exposed. Veteran concerns include exposure to
the rubble and dust from exploded shells made from depleted uranium (or
handling of the shells); the possibility of exposure to the nerve agent
sarin or some yet-unconfirmed Iraqi chemical-biological agent; and use of
a nerve agent pre-treatment drug, pyridostigmine bromide. Many other risk
factors also have been raised. In 1991, VA initially began to develop tracking
mechanisms that matured into the Gulf War Registry as a direct consequence
of early concerns about the environmental influence of oil well fires and
their smoke and particulate.
Interagency Coordination and White
House Response
The federal response to the health consequences
of Gulf War service is being led by the Persian Gulf Veterans Coordinating
Board composed of the Departments of VA, Defense and Health and Human Services.
Working groups are collaborating in the areas of research, clinical issues
and disability compensation. The Board and its subgroups are a valuable
vehicle for communication between top managers and scientists, including
a staff office for the Board that follows up on critical issues and promotes
continuity in agency activities. President Clinton designated VA as the
Coordinating Board's lead agency.
In March 1995, President Clinton announced formation of the Presidential
Advisory Committee on Gulf War Veterans' Illnesses to review and make recommendations
on: Coordinating Board activities; research, medical examination and treatment
programs; federal outreach; and other issues ranging from risk factors to
chemical exposure reports. It has been meeting since August 1995 and published
reports Feb. 15, 1996, and Dec. 31, 1996.
Environmental Hazards Research Centers: Through a vigorous scientific competition, VA developed
major focal points for Gulf veteran health studies at three medical centers:
Boston; East Orange, N.J.; and Portland, Ore. With 14 protocols among them,
the centers are conducting a variety of interdisciplinary projects, including
some aimed at developing a case definition for an unexplained illness and
clarification of risk factors. Some protocols involve areas of emerging
scientific understanding, such as chronic fatigue syndrome or multiple chemical
sensitivity, while others are evaluating or comparing factors in immunity,
psychiatry, pulmonary response, neuroendocrinology and other body systems,
some at the molecular level. A fourth research center, the Center for the
Study of Environmental Hazards to Reproductive Health, funded in late 1996,
is a joint venture of the Louisville VA Medical Center and the University
of Louisville's Kentucky Institute for the Environment and Sustainable Development.
One project will be addressing reproductive outcomes in Gulf War veterans.
Health Survey and Mortality Study. VA's Environmental
Epidemiology Service is managing a study surveying 15,000 randomly selected
Gulf veterans and an equal size control group of veterans of the same time
period (but who were not deployed) to compare symptoms in veterans and their
family members, examining risk factors and providing physical examinations
for a representative sample to help validate the self-reported health data.
That office also is engaged in a continuing mortality study, analyzing death
certificates to determine any patterns of difference in causes of deaths
between deceased Gulf veterans and matched controls. In their initial report
covering the first two years after the war, as has been observed after other
wars, veterans of the Gulf War have experienced a higher incidence of death
due to accidents. When this contributing factor is excluded, Gulf War veterans
have not experienced a higher mortality rate due to disease-related causes.
Both the Gulf War and non-deployed control group veterans had a lower death
rate than Americans their age in general. A report was published Nov. 14,
1996, in the New England Journal of Medicine.
Exposure-Oriented Studies: Some current VA investigations
are examining hypotheses of specific potential risks and comparing study
subjects with controls who did not serve in the Gulf to determine differences
in health patterns. A Baltimore project is following the health status of
individuals who retained tiny embedded fragments of depleted uranium.A Birmingham,
Ala., pilot program offers an extensive battery of neurological tests aimed
at detecting dysfunction that would be expected after exposure to certain
chemical weapons.
Other Federal and Collaborative Studies: In its fourth annual
report to Congress in April 1997, VA, on behalf of the Persian Gulf Veterans
Coordinating Board participating agencies, detailed Gulf War veteran research
initiatives, reviews and clinical investigations, many involving VA. For
example, VA investigators are collaborating with the Naval Medical Research
Center in San Diego in general epidemiological studies that have compared
Gulf veterans and control-group veterans (who served elsewhere) to detect
differences in symptoms, hospitalizations, and birth outcomes in large cohorts
of active duty servicemembers. A detailed research working plan is available
online at http://www.va.gov/gulf.htm via Internet. There are now more than
90 federally supported research projects.
Outside Reviews: In addition to the work of the Presidential
Advisory Committee on Gulf War Veterans' Illnesses, VA and the Department
of Defense (DOD) contracted with the National Academy of Sciences (NAS)
to review existing scientific and other information on the health consequences
of Gulf operations. Another nongovernment expert panel brought together
at an NIH technology assessment workshop in April 1994 examined data and
heard from both veterans and scientists, concluding that no single or multiple
etiology or biological explanation for the reported symptoms could be identified
and indicating it is impossible at this time to establish a single case
definition for the health problems of Gulf veterans.
Since early 1995, VA has been providing compensation
payments to chronically disabled Gulf War veterans with undiagnosed illnesses.
This benefit was expanded under an April 29, 1997, regulation that essentially
eliminated the date of initial manifestation of latent symptoms as a consideration
in adjudication through the end of the year 2001. A disability is considered
chronic if it has existed for at least six months.
Outside of the new regulation, VA has long based monthly compensation for
veterans on finding evidence a condition arose during or was aggravated
by service. VA has approved more than 67,989 compensation claims of Gulf
veterans for service injuries or illnesses of all kinds, with nearly 30,000
disabled at a compensable level who are receiving monthly benefits. The
67,989 approved claims include 2,091 claims in which the veteran alleged
the cause was an environmental hazard, and within that group, 1,117 claims
were approved under the new undiagnosed illnesses regulation.
Last updated 8/19/97. TLJ Mirrored from the Official Va.gov Site.