Gulf War Illnesses:

Improved Monitoring of Clinical Progress and Reexamination of Research Emphasis Are Needed

NSIAD-97-163: Published: Jun 23, 1997. Publicly Released: Jun 23, 1997.

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Pursuant to a legislative requirement, GAO analyzed the effectiveness of the government's clinical care and medical research programs relating to illnesses that members of the armed forces might have contracted as a result of their service in the Persian Gulf War, focusing on the: (1) Department of Defense's (DOD) and the Department of Veterans Affairs' (VA) efforts to assess the quality of treatment and diagnostic services provided to Gulf War veterans and their provisions for follow-up of initial examinations; (2) government's research strategy to study the veterans' illnesses and the methodological problems posed in its studies; and (3) consistency of key official conclusions with available data on the causes of veterans' illnesses.

GAO noted that: (1) neither DOD nor VA has systematically attempted to determine whether ill Gulf War veterans are any better or worse today than when they were first examined; (2) while ongoing epidemiological research will provide descriptive data on veterans' illnesses, formidable methodological problems are likely to prevent researchers from providing answers regarding the causes of veterans' illnesses; (3) over 100,000 of the approximately 700,000 Gulf War veterans have participated in DOD and VA health examination programs established after the war; (4) based on the examinations and reports provided by DOD and VA, nearly 90 percent of the examined veterans are symptomatic, reporting a wide array of health complaints and disabling conditions; (5) while some measures of quality are in place for military or VA health care, neither agency can now determine the appropriateness or effectiveness of the treatment received by ill Gulf War veterans; (6) federal research on Gulf War veterans' illnesses has not been pursued proactively; (7) without accurate exposure information, the investment of millions of dollars in further epidemiological research on the risk factors for veterans' illnesses may result in little return; (8) the Presidential Advisory Committee on Gulf War Veterans' Illnesses concluded that stress is likely to be an important contributing factor to the broad range of illnesses being reported by Gulf War veterans; (9) however, the link between stress and these veterans' physical symptoms is not well established in the evidence the Committee cited, and the reported prevalence of post-traumatic stress disorder among Gulf War veterans may be overestimated; (10) based on a small number of diagnosed cases, VA and DOD concluded that the likelihood of leishmania tropica (a parasite) as an important risk factor has diminished and the Committee found it unlikely to be "responsible for long term health effects in Gulf War veterans," but the extent of asymptomatic leishmania infection is unknown; (11) the Committee concluded that it was unlikely that the health effects reported by Gulf War veterans are the results of exposure to organophosphate or mustard chemical warfare agents, even though there is substantial evidence that organophosphate compounds might be associated with delayed or long-term health effects; and (12) unresolved questions concern the extent to which veterans may have been exposed to: (a) chemical agents as a result of fallout from the destruction of suspected chemical weapons storage sites; and (b) the biological agent aflatoxin, the health effects of which may not be known for months, or even years, after exposure.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: DOD noted in comments on the report that it had requested a draft feasibility proposal to evaluate the current health status of Comprehensive Clinical Evaluation Program participants. However, it asserted that its utilization management practices provided adequate oversight for the care provided. An Institute of Medicine study commissioned by VA and issued on September 14, 1999, identified a methodology for longitudinal assessment of changes in war veterans' health status. In comments on ongoing GAO work, DOD cited the need for such a methodological study in order to devise a means of assessing veterans' progress. On July 17, 2000, a VA official stated that longitudinal components had been added to federally sponsored research projects in Iowa, Louisiana, New Jersey, and Boston to develop information on the ongoing welfare of Gulf War veterans.

    Recommendation: Because of the numbers of Gulf War veterans who continue to experience illnesses that may be related to their service during the Gulf War, the Secretary of Defense, in conjunction with the Secretary of Veterans Affairs, should develop and implement a plan to monitor the clinical progress of Gulf War veterans in order to help promote appropriate and effective treatment and provide direction to the research agenda.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: VA has contracted with the National Academy of Sciences to conduct a review of methodologies for monitoring the health of Gulf War veterans. The report from this review was issued on September 14, 1999. On July 17, 2000, a VA official stated that longitudinal components had been added to federally sponsored research projects in Iowa, Louisiana, New Jersey, and Boston to provide information on changes in the welfare of Gulf War veterans.

    Recommendation: Because of the numbers of Gulf War veterans who continue to experience illnesses that may be related to their service during the Gulf War, the Secretary of Defense, in conjunction with the Secretary of Veterans Affairs, should develop and implement a plan to monitor the clinical progress of Gulf War veterans in order to help promote appropriate and effective treatment and provide direction to the research agenda.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: DOD has contributed funds to a VA-administered randomized clinical trials for treatments of conditions that afflict Gulf War veterans. Patient recruitment for these trials began in 1999 and they are ongoing. DOD continues to pursue a variety of large, epidemiological studies in which data are analyzed without respect to veterans' specific exposures. Research continues to be impeded by poor information regarding the nature and intensity of veterans' exposures. In October 2000, DOD reassessed exposure to sarin from demolition conducted at Khamisiyah, Iraq and reclassified the exposure status of 60,000 veterans, half from not exposed to exposed and half in the reverse direction.

    Recommendation: Because of the numbers of Gulf War veterans who continue to experience illnesses that may be related to their service during the Gulf War, the Secretary of Defense, in conjunction with the Secretary of Veterans Affairs, should give greater priority to research on treatment for ill veterans and on low-level exposures to chemicals and their interactive effects and less priority to further epidemiological studies.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: Persian Gulf Veterans Coordinating Board officials from VA have stated that they see no need for additional, large epidemiological studies. In 1999, with combined VA and DOD financing, VA initiated patient recruitment for large randomized clinical trials of treatments for conditions that afflict Gulf War veterans.

    Recommendation: Because of the numbers of Gulf War veterans who continue to experience illnesses that may be related to their service during the Gulf War, the Secretary of Defense, in conjunction with the Secretary of Veterans Affairs, should give greater priority to research on treatment for ill veterans and on low-level exposures to chemicals and their interactive effects and less priority to further epidemiological studies.

    Agency Affected: Department of Veterans Affairs

  5. Status: Closed - Not Implemented

    Comments: No action is intended.

    Recommendation: The Secretaries of Defense and Veterans Affairs should refine the current approaches of the clinical and research programs for diagnosing posttraumatic stress disorder consistent with suggestions recently made by the Institute of Medicine, which noted the need for improved documentation of screening procedures and patient histories (including occupational and environmental exposures) and the importance of ruling out alternative causes of impairment.

    Agency Affected: Department of Defense

  6. Status: Closed - Not Implemented

    Comments: No action is intended.

    Recommendation: The Secretaries of Defense and Veterans Affairs should refine the current approaches of the clinical and research programs for diagnosing posttraumatic stress disorder consistent with suggestions recently made by the Institute of Medicine, which noted the need for improved documentation of screening procedures and patient histories (including occupational and environmental exposures) and the importance of ruling out alternative causes of impairment.

    Agency Affected: Department of Veterans Affairs

 

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