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.

Statistics

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:

• 12 percent of the veterans who had the registry health exam had no health complaint (among the first 52,000 computerized records).
  
• 26 percent of the same group rated their health as poor or very poor, while 73 percent reported their health as all right to very good (the remaining 1 percent did not have an opinion).
  

VA Health Programs for Gulf Veterans

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.

Medical Research

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.

VA Disability Compensation

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.