VA Testimony of Joseph Thompson before Congress on October 26, 1999

United States Department of Veterans Affairs

STATEMENT OF
JOSEPH THOMPSON
UNDER SECRETARY FOR BENEFITS
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON BENEFITS

October 26, 1999

Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to testify today on Gulf War veterans' issues. I am pleased to be here with you to provide a status report on the adjudication of Gulf War veterans’ claims and to discuss the efforts the Department has made to improve Gulf War programs.

I last testified before this Subcommittee on Gulf War issues in February 1998. Since that time, I believe that the Department has made progress in the processing of Gulf War claims, in the identification of initiatives which will aid in the processing of all claims, including those for Gulf War, and in collaboration between the health and benefits components of the VA with regard to Gulf War issues.

You have asked that our testimony include information on the adjudication of Gulf War veterans' claims, including an update on the second review of Gulf War claims; the most common illnesses claimed, and any trends or patterns that have emerged in these claims; initiatives that will aid in claims processing; and the interaction and coordination efforts between the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) which would assist in the adjudication of Gulf War veterans' claims. The rest of my testimony will address these specific issues.

Claims Processing

As you know, in September 1994, we established four Area Processing Offices to handle Gulf War claims because we wanted to establish a process under which a small number of regional offices could develop expertise in complex adjudicative issues and devote resources to providing veterans timely and accurate claims processing. The complexities and numbers of these cases, however, created workload problems for the four offices that continued to worsen. In the best interests of veterans and the offices, we decided to redistribute the Gulf War cases to all regional offices. This was accomplished in June 1997, and initially required training for all regional offices in the complexities involved in these cases. A Rapid Response Team composed of individuals highly proficient in Gulf War issues and rating procedures was established to provide immediate answers to general or claims specific questions and technical support in evaluating Gulf War issues and rating procedures. Since that time, all regional offices have become more proficient in responding to these claims. Although our current systems do not allow us to identify the specific length of time it takes to process a Gulf War veteran’s claim, I can tell you that to date, we have processed some 704,040 claims of Gulf War conflict, theater, and era-veterans with 103,220 claims pending.,

You have asked me to identify the number of claims favorably adjudicated for undiagnosed illness, the most common illnesses claimed by Gulf War veterans, and any

trends or patterns VA believes have emerged in these claims. Of the total number of undiagnosed illness claims adjudicated, 3,077 of them, or 27 percent, have been granted, while 8,330 have been denied. Most denials resulted from a finding of no disability, a diagnosis that was not service-connected, or a diagnosis that was service-connected. These 11,407 claims represent less than 6 percent of the 202,272 decisions which have been made on claims filed by Gulf War Theater and Conflict veterans. The undiagnosed conditions for the 3,077 claims granted, fall into 32 categories, the most prevalent being musculoskeletal diseases, miscellaneous neurological conditions, systemic diseases, lower digestive system, skin, joints, skull and ribs, trachea and bronchi, and psychoneurotic.

It should be noted that the Gulf War cohort has the highest percentage of living veterans in receipt of disability compensation (16.1 percent) of any period of recent service including World War II (8.6 percent), Korea (5 percent), Peacetime periods (9.5 percent), and Vietnam (9.6 percent). Additionally, the number of disabilities per veteran is also highest among Gulf War veterans (3.2), with World War II being (1.79), Korea (2.01), Peacetime periods (2.52), and Vietnam (2.76).

With respect to the prevalence of service-connected conditions among Gulf War veterans, the number one service-connected condition claimed is impairment of the knee, followed by skeletal system disability, lumbosacral strain, arthritis due to trauma, scars, hearing loss, hypertension, intervertebral disc syndrome, tinnitus, and osteoarthritis.

Trends/Patterns

We have noted a few trends emerging from our review of Gulf War claims. Of the top twenty service-connected conditions for Gulf War veterans, none were for psychological conditions, such as PTSD or anxiety disorder. Psychological conditions are among the most prevalent service-connected conditions for periods of service during war other than the Gulf War Era; for the World War II and the Korean War veterans the psychological condition was general anxiety disorder, for the Vietnam Era veterans it was PTSD. Other than undiagnosed illnesses and the absence of psychological conditions, the service-connected conditions of Gulf War veterans are very similar to service-connected conditions for veterans of other periods of service.

Training Efforts on Gulf War Issues

We have made considerable efforts to provide detailed training to employees and to ensure quality, particularly regarding the processing of Gulf War claims. Quality review of Gulf War processing at the field stations is accomplished by a special quality improvement review of a sample of Gulf War claims each month, with the results reported to our headquarters for further review and analysis. In early 1998, VBA began a new accuracy study designed to give us a current profile of Gulf War claims and a current assessment of the accuracy of claims adjudication. That study was conducted using the systematic technical accuracy review (STAR), which is a structured and comprehensive review and analysis of all processing elements associated with a claim. It included a representative sampling of approximately 4 percent of the cases completed for Gulf War claims. Sixty percent of these cases involved undiagnosed conditions. Results of this study showed that the special training, communication, and continuing reviews have had a positive impact on the quality of claims processing, resulting in better performance in the complex Gulf War area. The Compensation and Pension Service and representatives from VHA have conducted or sponsored four nationwide satellite broadcasts on Gulf War issues, including one specifically focused on disability examinations for Gulf War veterans. Hearing Officers at our regional offices were previously trained in Gulf War issues and are thus subject matter experts who can assist claims examiners as well. VHA and VBA representatives jointly developed guidelines to assist examiners who conduct Gulf War veterans’ examinations. These guidelines have been incorporated into the AMIE (Automated Medical Information Exchange) System, which is a primary communication medium between VBA and VHA. A joint letter from the Under Secretaries for Health and for Benefits in early 1998 explained that examinations of Gulf War veterans must follow those guidelines or they would be returned as insufficient for rating purposes. Finally, our Training and Performance Support System (TPSS), which is geared to new rating personnel, includes instructions on handling Gulf War veterans’ claims.

Second Review Status

I am pleased to inform you that the second review of over 10,000 Gulf War claims has been completed. The review resulted in the following findings:

a grant of a newly considered undiagnosed condition – 256 claims (2.6 percent)
a grant of a previously denied undiagnosed condition – 929 claims (9.3 percent)
a grant of a newly considered diagnosed condition – 735 claims (7.4 percent)
a grant of a previously denied diagnosed condition – 512 claims (5.1 percent)
a prior service-connected grant for any other condition not changed after readjudication – 4,734 claims (47 percent)
a new claim denied, service-connection not granted for any other condition – 647 claims (6.5 percent), and
a confirmation that service-connection was not granted for all other cases reviewed.

Outreach to Gulf War Veterans

I would like to mention the specific efforts we have made to reach out to Gulf War veterans. VA has established a Gulf War Health Examination Registry, and nearly 77,000 have registered with VA voicing their health concerns. Most of these have been diagnosed with a variety of conditions, while about 20 percent of those examined have undiagnosed symptoms. In early 1995, VA established the Gulf War Information Center/Helpline (1-800-PGW-VETS), which has received over 300,000 calls. This service is available 24 hours a day, 7 days a week and allows callers to obtain information about medical care, the Gulf War Registry, medical research involving exposure to environmental hazards, and disability compensation benefits for undiagnosed illnesses resulting from service in the Gulf. VA also published an information pamphlet, "Gulf War Veterans’ Illnesses: Questions and Answers" that is available in all VA regional offices and centers, and all VHA medical facilities. Periodically, VA publishes a report to veterans on Gulf War issues. The latest was released in September 1999, and included reports on what VA is doing in the Environmental Hazards Research Centers, other epidemiology studies, new VA research efforts, information on the NAS’ Institute of Medicine activities, and highlights of research findings. Approximately twice a year, VA publishes a newsletter, the "Gulf War Review" and sends it to every person on the Gulf War Registry. In addition to the latest news and information for veterans who served in the Gulf, the newsletter includes information on where veterans can go for help, either for treatment or seeking disability compensation. VA has also established an Internet site (http://www.va.gov/gulf.htm) dedicated to Gulf War veterans’ issues, which is linked to other helpful sites and information. VBA has developed a slide show presentation on Gulf War veterans’ issues, which is distributed to all military coordinators around the world to use in briefings for TAP and DTAP, and is also available on VA’s internet web site.

I will now turn to the issues related to research on Gulf War illnesses, including undiagnosed illnesses, and the interaction between the medical and benefits components of VA.

Coordination of Federal Research into Gulf War Veterans' Illnesses

Coordination of research on Gulf War veterans' health is the primary responsibility of the Research Working Group of the Persian Gulf Veterans Coordinating Board (PGVCB). The mission of the Research Working Group is to provide programmatic review of and recommendations to funding agencies concerning research proposals that have been competitively reviewed for scientific excellence and programmatic relevance. VA and the other member Departments of the PGVCB, the Departments of Defense (DoD) and Health and Human Services (HHS), have spent $134M over the last 6 years on 145 federal research projects directly related to Gulf War veterans’ health issues. As the lead agency in this effort, VA submitted its 5^th annual report on the results, status, and research priorities of this program to the Veterans’ Affairs Committees of the Senate and House of Representatives, in June 1999.

VA Research

The Department of Veterans Affairs is helping to meet the commitment to research by sponsoring a coordinated and varied national research agenda that focuses upon the health needs of Gulf War veterans. On the basis of an assessment of the health problems experienced by Gulf War veterans, VA's current research program includes studies that are classified as follows:

1. Basic Biomedical Research -- studies of the underlying mechanisms of diseases and illnesses using animal and other models;

2. Patient-Focused Research – the application of interventions such as controlled trials of medical therapies, or the use of clinical investigative methods such as case-control studies to examine disease risk factors; and

3. Epidemiology Research -- the use of population based studies (focusing on outcomes such as mortality, symptoms, hospitalizations) and other information collection techniques such as postal surveys, telephone interviews, and records reviews.

The number of research projects in various research focus areas has changed over the last six years, as our understanding of Gulf War veterans’ illnesses has changed and improved. Following is a description of some initiatives currently in progress that we hope will provide valuable information.

To characterize more completely the health status of the Gulf War veteran population, VA funded the National Health Survey of Gulf War Era Veterans and Their Families. Health questionnaires were mailed to a random sample of 15,000 Gulf War veterans and 15,000 era veteran controls. The study compares rates of various symptoms and medical conditions, including problems in reproductive health, and attempts to relate them to various self-reported environmental exposures. Currently, VA is in the midst of the final phase (the Phase III component), which includes a physical examination of the veterans, their spouses, and their children. When completed, the study will examine 2,000 veterans and approximately 3,000 spouses and children.

In 1999, VA initiated two Multi-Center Treatment Trials for Gulf War veterans. From several studies we know that thousands of Gulf War veterans suffer from a wide variety of symptoms including fatigue, muscle and joint pain, and difficulty with memory and thinking. In many cases, the cause of these difficulties cannot be identified nor a single underlying disease can be identified. In response, VA is undertaking a $20M project with DoD on two large-scale treatment trials of innovative methods for treating undiagnosed illnesses in Gulf War veterans.

Exercise/Behavioral Therapy trial. This focuses on exercise and behavioral therapy techniques that have proven effective in managing symptoms of some chronic illnesses. Application of these techniques will not necessarily cure Gulf War veterans’ illnesses, but we hope that they may help to reduce suffering and allow veterans to enjoy an increased level of functioning in their lives.
Antibiotic Treatment trial. This addresses the suggestion that infection with Mycoplasma is at the root of some Gulf War veterans’ illnesses. Although there is no established link between Gulf War veterans' illnesses and infection with Mycoplasma, some veterans are taking the antibiotic doxycycline for up to a year in the hope of improving their health. This trial should help establish the value of an approach using antibiotic therapy because this drug is being used for a condition for which it is not currently approved by FDA. We have obtained FDA approval to use it under an Investigational New Drug application.

On July 30, 1999, an ad hoc Advisory Committee, which included representatives from the VA Cooperative Studies and Epidemiologic Research and Information Center Programs, VA Environmental Hazards Research Centers and Environmental Epidemiology Service, the ALS Association, and neurology experts from VA and academic institutions, met to review available data on the number of known cases of amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) cases among Gulf War veterans, the possible rate of occurrence of ALS, and the age distribution of cases. The Advisory Committee concluded that while there is no clear indication of an excess rate of ALS in Gulf War veterans, the available data may underestimate the actual rate, and the age distribution of cases may be younger than the age distribution of ALS cases in the general U.S. population. The Committee, therefore, recommended that VA proceed with the planning of a large epidemiologic study of ALS among Gulf War veterans. The planning for this study is underway. The central focus of the study will be a nation-wide effort to identify all cases of ALS or other motor-neuron diseases occurring among Gulf War veterans, determine their health status, and describe their exposures to potential etiologic and risk factors from in-home interviews and clinical examinations in neurologic diseases. VA expects to initiate the study early in the year 2000.

To foster input from stakeholders into our research agenda, VA is establishing the Research Advisory Committee on Gulf War Veterans Illnesses, as required by §104 of Public Law 105-368. This Committee will provide advice on proposed research studies, plans, and strategies relating to the health consequences of military service in Southwest Asia and during the Gulf War. It will make recommendations to VA's Under Secretary for Health and the Secretary of Veterans Affairs. Nominations for membership on the Committee have been made to the Secretary. Included among those nominated are both government and non-government scientists from the Institute of Medicine, VA and DOD, and representatives from a variety of veterans service organizations. The first meeting of the committee will be within 45 days following appointment of the Committee members.

Contribution of Research to Clinical Practice

While research is a basic tool to further our understanding of Gulf War veterans’ illnesses, it is equally important to translate the results of research into effective clinical treatment of those illnesses. The following three initiatives are important examples of how VA’s research, clinical, and benefits programs collaborate to improve the quality of health care provided to Gulf War veterans.

Since 1995, VA has sponsored an annual conference of federally funded research on Gulf War health. This conference brings together stakeholders, researchers, clinicians, veterans, veterans’ groups, and government representatives to exchange and discuss research results and current best practices for the treatment of Gulf War illnesses.

Since 1992, VHA headquarters has conducted quarterly conference calls with Gulf War health registry physicians and coordinators at VA medical centers. These conference calls are designed to provide VA field staff with the latest information on research and health care for Gulf War veterans.

A March 1998 directive from the Under Secretary for Health required all VA physicians to complete VA’s Continuing Medical Education Program, "A Guide to Gulf War Veterans’ Health." This educational program covers all of our current knowledge about Gulf War veterans’ health issues, including research findings and unexplained illnesses.

Literature Review by the National Academy of Sciences-Institute of Medicine (NAS-IOM)

Aware of the concerns of Gulf War veterans about long-term health consequences of military service in the Gulf, the Under Secretary for Health requested that the National Academy of Sciences (NAS) conduct a review of the available scientific and medical information regarding the association between exposures during the Gulf War and adverse health effects experienced by some Gulf War veterans. The National Academy of Sciences’ proposal for this task was accepted and the contract was signed on June 24, 1998.

The project will be carried out by the NAS’ Institute of Medicine’s (IOM) Board on Health Promotion and Disease Prevention. An NAS Committee will provide a comprehensive review, evaluation, and summary of available scientific/medical information regarding the association between exposure during the Gulf War and adverse health effects experienced by Gulf War veterans. This review will include an assessment of biologic plausibility that exposures, or synergistic effects of combinations of exposures, are associated with illnesses experienced by Gulf War veterans. The NAS will make recommendations for additional scientific studies to resolve areas of continued scientific uncertainty related to health consequences.

This IOM study is an important development for VA Gulf War veterans' programs. The first milestone will be a complete review in August 2000 of the following:

Pyridostigmine bromide (PB)
Vaccines (Anthrax, Botulinum toxin, Squalene adjuvant)
Uranium
Depleted Uranium
Sarin, and
Cyclosarin

Following its completion, the Secretary of Veterans Affairs will determine which, if any, health effects should be considered for presumption of service-connection. The model for this activity is the ongoing Agent Orange studies conducted by IOM that provide the basis for presumptive service-connection for Vietnam veterans. It is a model that has proven to be effective in forming a solid basis for compensation for Vietnam veterans.

Use and Exchange of VBA Data

VBA and VHA routinely engage in numerous forms of data exchanges to support benefits and health care delivery. From on line access to the data available in the Gulf War Veterans Information System (GWVIS) to the Automated Information Medical Exchange (AMIE) program, to the basic exchange of "hard copy" claims folders and medical records, we continue to share, and search for new ways of expanding information sharing, to improve services.

Although claims data is by and large not a satisfactory source information for clinical research purposes VHA has used VBA data in medical surveillance of Gulf War veterans’ illnesses. For example:

When VHA began its review of ALS diagnoses in Gulf War veterans a search was made of VBA benefits data and VHA Registry, outpatient and inpatient databases. This became the key initial step in VHA’s ongoing research on ALS in the Gulf War veteran population.

VHA and VBA databases have been used in combination to ascertain the number of Gulf War veterans with cancer diagnoses.

Death data from VBA’s Beneficiary Identification and Records Locator Subsystem (BIRLS) is used by VHA’s Environmental Epidemiology Service to identify deceased veterans whose death certificates are subsequently reviewed for the purposes of the VA’s Mortality Follow-up Study of Gulf War Veterans. This study will compare the overall mortality rates and causes of mortality of the nearly 700,000 Gulf War veterans who served during the period of hostilities with those of a control group of non-deployed veterans.

Most recently, VBA generated an extract from the GWVIS identifying veterans filing claims for undiagnosed illnesses. The first part of a three phase exchange project and specific to claims granted, the data is being used to identify veterans receiving treatment at VA health care facilities and physicians demonstrating particular competency treating Gulf War illnesses. Additional data, identifying veterans whose claims were denied and veterans whose claims for undiagnosed illness were subsequently diagnosed, is under development as second and third phases of the effort.

While we have a lot of work left to do, we feel that we have made significant progress in the treatment of Gulf War veterans and in the adjudication of their claims. Mr. Chairman, as I have said before, we owe veterans and their families the best service we can provide in the most sensitive, caring way possible to ensure that they receive benefits in a manner befitting their service to our Nation.

This concludes my prepared statement. My colleagues and I will be pleased to answer any questions Subcommittee members might have.

Appendix

Gulf War Common Definitions

Gulf Conflict

Active duty military service in the Southwest Asia theater of operations beginning on or after August 2, 1990 through July 31, 1991.

Gulf Theater

A period of active duty military service beginning after July 31, 1991 and continuing to the present, occurring in the Southwest Asia theater of operations as defined by 38 CFR 3.317. It includes Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above all of these locations.

Gulf Era

Active duty military service beginning on or after August 2, 1990 and continuing to the present, that did not at any time occur within the Southwest Asian theater of operations. This includes all individuals activated from "Reserve" or "National Guard" status and subsequently separated from active duty.