KENNETH W. KIZER, M.D., M.P.H.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
U. S. HOUSE OF REPRESENTATIVES
GULF WAR VETERANS PROGRAMS
February 5, 1998
Mr. Chairman and members of the Committee, thank you for this opportunity to discuss VA’s response to the health problems of Gulf War veterans and to comment on recent reports that assess our efforts.
Before discussing our current healthcare and research efforts, I will provide background information about VHA's overall response to Gulf War veterans' healthcare needs.
On August 2, 1990, Saddam Hussein invaded Kuwait, and American military personnel were deployed to Southwest Asia soon thereafter. Ultimately, nearly 700,000 U.S. troops were deployed to the Persian Gulf in Operations Desert Shield and Desert Storm. It was clear to the military leaders planning this action that military personnel engaged in these actions would be exposed to a variety of risks, including the possible exposure to chemical and biological warfare agents. A number of preventive measures were taken to provide potential protection for military personnel against these agents, including the administration of a licensed vaccine, an experimental drug, and an experimental vaccine.
After months of tense military build-up in a foreign desert environment, coalition military forces fought a successful air war, followed by a four-day ground war. For some Gulf War military personnel, however, the trauma and pain of war did not end with the cease-fire. Veterans returned home, and began to come to VA for help with a variety of symptoms and illnesses. They reported a long list of environmental exposures that occurred during their service in the Gulf War. We listened to the veterans' concerns and utilized the increasing knowledge gained to design and implement special healthcare programs to serve their needs. These special Gulf War programs are a supplement to the full-range of healthcare services VA provides for the nation's veterans of other conflicts.
VA's Persian Gulf Registry Health Examination Program was the first component of VA's comprehensive Gulf War response. VA developed the Registry in 1991, and implemented it in 1992. The Gulf War Registry was established primarily to assist Gulf War veterans to gain entry into the continuum of VA health care services by providing them with a free, complete physical examination with basic laboratory studies; and to act as a health screening database. As such, VA staff are instructed to encourage all Gulf War veterans, symptomatic or not, to get a Registry examination. The Registry's database, which in addition to allowing VA to communicate with Gulf War veterans via periodic newsletters, provides a mechanism to catalogue prominent symptoms and report exposures and diagnoses. This record of symptoms, diagnoses and exposures makes the Registry valuable for health surveillance purposes; however, the voluntary, self-selected nature of the database means that the experiences, illnesses and health profile of those in the Registry cannot be generalized to represent those of all Gulf War veterans. The Registry was neither designed nor intended to be a research tool. It was also not envisioned to be a "stand-alone" healthcare program, nor a mechanism to monitor the health outcomes of Gulf War veterans through longitudinal follow-up. Another significant limitation is that it records the results of a single evaluation of veterans examined over a variable time period since their Gulf War service.
Since the Registry examination program was initiated, VHA's Gulf War programs have grown to encompass a comprehensive approach to health services, addressing relevant medical care, research, outreach and educational issues. In 1993, at the request of VA, Congress passed legislation later enacted as Public Law 103-210, giving Gulf War veterans special eligibility (priority care) for VA healthcare. This law gave VA the authority it requested to treat Gulf War veterans who have health problems which may have resulted from exposure to a toxic substance or environmental hazard during Gulf War service. We are also pleased that Congress passed legislation subsequently enacted as P.L. 105-114, which expands Gulf War veteran’s eligibility for health care for any condition that might be associated with the veteran’s service in the Gulf War. VA now provides Gulf War Registry health examinations and hospital and outpatient follow-up care at its medical facilities nationwide, specialized evaluations at four regional Referral Centers, and readjustment and sexual trauma counseling at Vet Centers and VA Medical facilities nationwide to Gulf War veterans. To date, almost 65,000 Gulf War veterans have completed Registry examinations; more than 2.5 million ambulatory care visits have been provided to 221,225 veterans; more than 22,000 veterans have been hospitalized at VA medical facilities; over 470 veterans have received specialized Referral Center evaluations; and more than 83,000 Gulf War veterans have been counseled at VA's Vet Centers.
Gulf War veterans participating in the Registry examination program have commonly reported that they suffer from a diverse array of symptoms, including fatigue, skin rash, headache, muscle and joint pain, memory problems, shortness of breath, sleep disturbances, gastrointestinal symptoms, and chest pain. Veterans experiencing these multi-system symptoms have been treated seriously, and veteran patients have received medical evaluations, as appropriate. Of note, 12 percent of the VA Registry examination participants have had no specific health complaints but have wished to participate in the examination because they were concerned that their future health might be affected as a consequence of their service in the Gulf War. Overall, while 26 percent of the Registry participants rated their health as poor, 73 percent receiving this examination reported their health as all right to good.
An examination of all the diagnoses of Registry participants indicates that they do not cluster in one organ system or disease category. Instead, the diagnoses span a wide range of illnesses and diagnostic categories. A large majority of symptomatic Gulf War veterans evaluated in the VA Registry suffer from symptoms or illnesses that have been successfully diagnosed. Depending on the particular nomenclature used, between 10 and 25 percent of veterans from the Registry who have been examined have unexplained illnesses. While some symptoms of Gulf War veterans are difficult to diagnose and remain unexplained, there is consensus among government and non-government physicians and scientists alike that current evidence does not support the conclusion that these illnesses represent a single, unique illness that can explain every Gulf War veteran's symptoms. As such, the unexplained illnesses of Gulf War veterans do not meet the clinical definition of a medical syndrome, per se.
As previously stated, the majority of Gulf War veterans have a wide spectrum of diagnosed medical conditions, spanning the range of known medical conditions. We agree with the consensus of the scientific community, including prior findings of the Institute of Medicine, that Gulf War veterans’ illnesses appear to be a heterogeneous group of disorders, exhibiting widely varying manifestations and not amenable to a single unifying case definition. The overall frequency of unexplained symptoms among Gulf War veterans appears to be about the same as in a general medical practice (i.e., a non-VA or non-military general medical practice). However, medical scientists have not completed their study of these unexplained conditions and much is uncertain about their character, natural history and potential causes. VA is working hard to better understand these important health problems and develop effective treatments for the symptomatic veterans receiving care at VA facilities.
We recognize that the wide variety of medical conditions diagnosed in Gulf War veterans and the lack of a unique set of characteristics representing a single illness or "Gulf War Syndrome" per se has created significant challenges for VA clinicians. We believe that Gulf War veterans who seek care from VA are suffering from genuine illnesses and, as indicated already, we are providing a substantial amount of healthcare and treatment for these veterans.
HEALTH STATUS OF GULF WAR VETERANS
At present, we do not have a valid mechanism to determine the health outcomes of all Gulf War veterans from VA, DOD, or other existing health care databases. However, we are committed to developing a better understanding of the natural history of Gulf War veterans’ illnesses and in overcoming the barriers that have precluded this ability to date.
In the meantime, as a surrogate, we have looked at our existing systems to get a snapshot of Gulf War veterans health status over time. First, we looked at the self-reported health status of 18,938 Gulf War veterans on their original Registry exam and on a later survey response. The characteristics of those Gulf War veterans who responded to the survey were somewhat different from the overall VA Registry participants. Relatively more Reserve and National Guard unit members (44.2% vs. 39.2%), whites (66.8% vs. 64.3%) and older veterans (32.5 vs 30.4, mean age as of 1991) responded to the 1996 survey. At the time they participated in the Registry examination, the self-reported health status of those Gulf War veterans who responded to the survey was similar to that of the overall Registry examination participants. Among the 18,938 Gulf War veterans who participated in the Registry and subsequently responded to the 1996 follow-up survey, self-reported health status was unchanged for 8443 (45%), better for 3589(19%) veterans and worse for 6906 (36%) veterans. As the time interval increased between the Registry exam and the follow-up survey response dates, a greater proportion of veterans reported worsening health status. This data is limited by a poor response rate (less than 50%) and by inability to assess the contribution of other confounding factors. However, we feel that the results merit further assessment. In this regard, we intend to look at self-reported health status longitudinally on our annual customer satisfaction survey. This additional report should be available in April 1998.
CASE MANAGEMENT AND DEMONSTRATION PROJECTS
In response to Public Law 105-114, VA will initiate clinical demonstration projects for case management and multidisciplinary clinical care for Gulf War veterans.
Last year, I implemented a new case management initiative aimed at improving services to veterans with complex medical problems. In their Special Report, the Presidential Advisory Committee on Gulf War Veterans Illnesses supported our efforts to implement case management. Significant progress has already been made. Case management as a routine clinical strategy for Gulf War Veterans has already been implemented at nearly 20 VA medical centers. In addition, performance measures for the Network Directors have been established to ensure that the appropriate resources are devoted to these efforts at all facilities.
The demonstration projects are an important component of this effort. The projects will use objective outcome measures to assess whether health care for Gulf War veterans is improved by multidisciplinary clinics or case management approaches. Awards for the demonstration projects will be made before the end of this fiscal year. These projects will be funded as two-year studies. We look forward to reviewing their conclusions.
COMPENSATION AND PENSION EXAMINATIONS
VHA is committed to providing quality compensation and pension examinations for all veterans. I have recently appointed a Director of Forensic Medicine to spearhead these efforts within VHA. Of particular concern is assuring improvement in examinations of Gulf War veterans with undiagnosed illnesses. We recognize that there have been problems in this area and have worked cooperatively with VBA to develop clearer guidelines to the physicians performing these examinations. These guidelines will be supplemented by a focused training program for regional office and medical center staff who are involved in working Gulf War veterans’ compensation cases. A copy of these enhanced guidelines has been provided to the Committee.
In response to congressional concerns about Gulf War information management issues, the Department has taken the following steps: First, the Acting Secretary has designated the Assistant Secretary for Policy and Planning to serve as the Department's focal point and responsible official for coordination and release of all departmental data pertaining to Gulf War veterans issues. Secondly, the Assistant Secretary has been charged with assessing and evaluating all current data sources relative to Gulf War veterans and to determine any associated data gaps or vulnerabilities. As a result, an electronic match of disparate data sets maintained by Veterans Benefits Administration (VBA), Veterans Health Administration (VHA) and the Department of Defense (DoD) will be accomplished and a Gulf War Management Information System will be established as part of the Department's Corporate Information Repository. It is hoped that these efforts will provide a mechanism for more consistently recording and reporting accurate information regarding the VA healthcare and benefits statistics regarding Gulf War veterans.
In order to maintain the quality of health care provided to Gulf War veterans and keep our healthcare providers informed about the latest developments related to Gulf War veterans’ health, VHA has utilized a wide array of communication methods, including periodic nationwide conference calls, mailings, satellite video-teleconferences and annual on-site continuing medical education (CME) conferences. In 1995 and 1996, we broadcast teleconferences on undiagnosed illnesses and on the evaluation and management of chronic fatigue syndrome. A 1996 CME conference was comprised of workshops focused on evaluation and management of common symptoms and medical conditions identified in Gulf War veterans. The most recent national training program, Gulf War CME Conference, was held on June 3-4, 1997, in Long Beach, California.
VA's past internal educational efforts have been primarily aimed at developing a cadre of well-informed Registry physicians and staff, who in turn provide a source of education and consultation to other healthcare providers at their facilities. However, with the universal implementation of primary care and the growing recognition that the health problems of Gulf War veterans span all medical subspecialties, we are expanding our educational programs to encompass other medical personnel. Our goal is that all VA healthcare providers will have a working understanding of Gulf War exposures and health issues and will be able to discuss with their Gulf War patients how these issues could impact on their current or future health status. The Presidential Advisory Committee also concluded that we needed to expand our educational efforts to all direct care providers. As a first step to meet this challenge, the Veterans Health Administration is publishing a self-study Gulf War CME program in March of 1998 that will then be distributed to every VA physician. We will make this educational tool available to non-VA physicians, at cost, as well.
STATUS OF GULF WAR RESEARCH
In order to get the best assessment of the health status of Gulf War veterans, a carefully designed and well-executed research program is necessary. VA, as lead agent for federally sponsored Gulf War research, has laid the foundation for such a program. Under the auspices of the Persian Gulf Veterans Coordinating Board Research Working Group, VA has developed a structured research portfolio to address the currently recognized, highest priority medical and scientific issues. Over 120 federally sponsored research projects are pending, underway or have been completed. VA’s own research programs related to illnesses of Gulf War veterans include more than 40 research projects amounting to a cumulative expenditure of research dollars projected from FY 1994 through FY 1998 of approximately $27 million. Federally funded researchers have, to date, published approximately 60 papers in the peer reviewed literature, including nearly 40 from VA investigators alone. The research portfolio of VA encompasses a variety of research approaches, including epidemiology, basic research, clinical research, and applied research, applied to a vast array of potential exposures and health outcomes. Issues studied by VA researchers include epidemiology surveys, mortality studies, studies of the health effects of exposure to petroleum products, including the oil well fires, pesticides, the parasitic infection Leishmaniasis, and chemical warfare agents. In addition, VA research is embarking on some important steps toward the assessment of effective treatments for Gulf War veterans’ illnesses.
The Research Working Group is preparing its Annual Report to Congress for federally sponsored research on Gulf War veterans’ illnesses. This report will provide significant detail about the research efforts of VA and the other participating federal departments. There has been significant progress on a number of key VA research studies. The Office of Research and Development has awarded funding for Phase III of the National Health Survey of Persian Gulf Veterans and preliminary site selection has begun. It is expected that physical examinations will begin in the near future. As you may recall, the National Survey is designed to determine the prevalence of symptoms and illnesses among a random sampling of Persian Gulf veterans across the nation. The Survey is being conducted in three phases. Phase I was a population-based mail survey of the health of 30,000 randomly selected veterans from the Persian Gulf era (15,000 Persian Gulf veterans and 15,000 non-Persian Gulf veterans, males and females). The data collection phase is complete and analysis of the data continues. Phase II consisted of a telephone interview of 2,000 non-respondents from Phase I (1,000 from each group) to determine if there are any response differences between respondents and non-respondents. Additionally, 1,000 veterans from each group will be selected for a telephone interview to validate their responses from the mail survey. Phase II is nearing completion. In Phase III the 2,000 veterans who responded to the postal survey and underwent a telephone interview will be invited, along with their family members, to participate in a comprehensive physical examination protocol. These examinations will be conducted at 18 VA medical centers nationwide and involve specialized examinations including neurological, rheumatological, psychological, and pulmonary evaluations. Completion of data collection is anticipated around mid-1999. When the National Survey is complete we will have a much clearer picture of the prevalence of symptoms and illnesses among Gulf War veterans.
The VA Office of Research and Development has initiated the planning stages for a multi-site randomized clinical trial to assess the effectiveness of treatments for Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM) in Gulf War veterans. These conditions appear to significantly overlap with the types of symptoms and illnesses reported by many Gulf War veterans. Such a study is possible because these conditions have clearly defined case definitions along with proposed treatments that have undergone preliminary evaluation. This study will be carried out in collaboration with the Department of Defense and conducted at multiple VA and DoD health care facilities. VA and DoD are investing up to $5 million each to conduct this trial. Because of its experience and research on the characteristics of these diseases, we plan to consult with NIH in the development of these research protocols. In addition, the VA Office of Research and Development has issued a Program Announcement, or general invitation to VA clinicians/scientists, to propose additional multi-site trials to evaluate the effectiveness of different treatment strategies. The planned treatment trial, along with any trials proposed in response to the Program Announcement, will undergo rigorous scientific peer review by VA’s federally chartered Cooperative Studies Evaluation Committee.
VA has been concerned about the adequacy of research on the neurobiological effects of stressors. The Office of Research and Development has taken some new steps to address this issue.
VA and DoD have issued a request for intramural proposals valued at $5 million for research on the neurobiology of stress and stress-related disorders. Proposals will undergo scientific review by a joint VA/DoD appointed panel of experts, and programmatic review by the Research Working Group. Proposals will undergo peer review this spring, with the award and funding of projects expected by July 1, 1998.
In June 1997, VA funded a multi-center cooperative study examining the effectiveness of a computerized battery of neuropsychological tests that could improve the accuracy of the diagnosis of PTSD by enabling the clinician to rule out organic central nervous system dysfunction.
In July 1996 VA funded a new multi-center treatment trial investigating the efficacy of trauma-based group therapy in the treatment of PTSD. In addition VA issued a Program Announcement in August 1997 requesting proposals for additional multi-center trials of PTSD treatment. Methodologies being sought include new, non-pharmacologic approaches to treatment, and focus on targeted subpopulations such as women and Persian Gulf veterans.
PAC SPECIAL REPORT
The PAC Special Report recommends that "All research on Gulf War veterans’ illnesses that is funded by the government should be subjected to external competition and independent peer review." The Report acknowledges the necessity for some rare exceptions, but the message is clear. VA agrees with the PAC on this matter. The policy of VA’s Office of Research and Development is to fund only competitively peer-reviewed projects. It applies this same concept in its coordination of its research portfolio for Gulf War veterans’ illnesses. The Research Working Group, chaired by VA, has always promoted competitive peer review as a means for all member agencies to obtain the best research. Indeed the Research Working Group has played a major role in the selection process of peer reviewed, competitively funded research for all of the member Departments or agencies. However, it must be emphasized that the Research Working Group only makes funding recommendations to member Departments. It does not direct them to fund particular projects.
The PAC also recommended that "The White House and VA should work with Congress to establish a permanent, statutory program for Gulf War veterans’ illnesses. The Committee envisions legislation that directs VA to contract with an organization with the appropriate scientific expertise--e.g., the National Academy of Sciences (NAS)-- for a periodic review, for benefits and future research purposes, of the available scientific evidence regarding associations between illnesses and Gulf War service. The object of such an analysis would be to determine statistical association between service in the Gulf War and morbidity and mortality, while also considering whether a plausible biological mechanism exists, whether research results are capable of replication and of clinical significance, and whether the data withstand peer review." VA agrees with this PAC recommendation. Gulf War veterans who are suffering with health problems deserve to know what happened to them in the Gulf War and whether evidence exists that their illnesses could be related to service. VA believes that this review by the NAS would ensure that the best scientific minds would be brought to bear on the complex array of Gulf War veterans health problems and that a consistent, continuous and equitable effort is sustained. Earlier this week I approved the NAS contract proposal and we have provided a copy of the contract to the committee. I would welcome any input that the Committee members have regarding this effort.
Besides recommendations from the PAC, the Institute of Medicine, and other panels of experts, there have been other reports on the government’s research programs for Gulf War veterans’ illnesses. The General Accounting Office (GAO) has issued reports and is currently engaged in ongoing reviews of issues centering on Gulf War veterans’ illnesses including research. In June 1997, the GAO issued their report, Gulf War Illnesses: Improved Monitoring of Clinical Progress and Reexamination of Research Emphasis are Needed. VA provided a detailed response to the GAO report, which is contained in the report’s appendix.
The House Appropriations Committee Report 105-175 states, "GAO recently found that DoD and VA did not have a systematic approach to monitoring the health of Gulf War veterans after their initial examination and consequently could not provide information on the effectiveness of the treatment they had received or whether they were better or worse than when first examined." The report goes on to say that "DoD and VA should develop and implement a plan to provide: (1) data on the effectiveness of treatments received by these veterans, and (2) longitudinal information on the health of veterans who reported illnesses after the war." The review, according to the report, should be "focused on resolving those conditions that have proven intractable or resistant to current therapies."
We agree that the goal of identifying improved therapies for veterans is an important one. In the traditional view of treatment outcomes research such ill-defined, symptom-based illnesses are not amenable to outcomes research because one or all of the following requirements for a treatment trial are lacking: a clearly defined definition of the disease, a measurable health outcome result, and a single treatment aimed at a biologically plausible etiology. Treatment trials are the foundation of evidence-based medicine, which is changing the way clinicians carry out their mission by informing them of the best, most effective approaches to treatment and care.
The issues raised by the GAO and House reports are not simple. Gulf War veterans have experienced a wide variety of diagnosed and undiagnosed medical conditions, which span the entire range of medical experience. The methodology for evaluating health outcomes and treatment efficacy in such a complex situation has not been developed by the health research community. The task of designing a protocol for acquiring and analyzing longitudinal information to provide an accurate assessment of hundreds of health outcomes and the effectiveness of thousands of treatments in Gulf War veterans poses a significant challenge. VA and DoD have asked the National Academy of Sciences Institute of Medicine to conduct a workshop and provide us with advice and recommendations on valid scientific methods to collect this information. Based on this advice, we will design a program to carry out this activity.
Additionally, a report entitled, Gulf War Veterans’ Illnesses: VA, DoD Continue to Resist Strong Evidence Linking Toxic Causes to Chronic Health Effects, was released last fall by the House Committee on Government Reform and Oversight. This report resulted from a series of hearings conducted by the Subcommittee.
The Committee’s report included several findings and recommendations. Some of these findings and recommendations warrant a response on the part of VA. There are strong negative assertions made in the report about the management of the government’s research on Gulf War veterans’ illnesses. These are even reflected in title of the report. The title implies the existence of two facts: (1) there is strong scientific evidence linking toxic causes to chronic health effects; and (2) VA and DoD have resisted this strong evidence in setting their research agendas. These assertions do not comport with the facts. VA has not resisted the possibility that exposures to toxic agents in the Gulf War are responsible for veterans’ illnesses. VA and the Research Working Group are committed to continuing the pursuit of the health effects of toxic exposures. The combined efforts of all agencies have resulted in approximately $20 million alone on research directly related to the potential health consequences of exposure to toxic substances. These exposures include oil well fires, chemical warfare nerve agents, pesticides, and pyridostigmine bromide. This figure does not include all of the epidemiological health studies on Gulf War veterans that acquire self-report exposure data in an attempt to identify potential links between toxic exposure and outcome. One of VA’s initial major investments in research on Gulf War veterans’ illnesses was the three environmental hazards research centers located at Boston VAMC, East Orange VAMC, and Portland VAMC. This evidence clearly counters the notion that we have resisted exploring potential linkages.
Evidence linking toxic exposures to chronic health effects in Gulf War veterans is incomplete at this time. However, VA, and the Research Working Group which it chairs, has continued to pursue all leads with respect to potential causes of Gulf War veterans’ illnesses. However, at this time, research reports claiming a causal relationship between toxic exposures and health outcomes in Gulf War veterans are incomplete. We face two problems in this area of causation: (1) quantitative exposure data, which are necessary ingredients for establishment of causation, have been difficult to obtain beyond self-reported exposures; (2) it is still too early in the research cycle to make definitive research-based claims about causation.
In the Committee’s report itself, there are three research-related findings, and five research-related recommendations. The findings contained in the report restate the previous assertion that the federal research strategy has disregarded evidence of causal links between toxic exposures and health outcomes. As stated before, this is simply untrue.
The report findings also suggest that "institutional and methodological constraints make it unlikely that the current research structure will find the causes and effective treatments for Gulf War veterans’ illnesses". We acknowledge the possibility that we may never definitively know the precise cause, or causes, of Gulf War veterans’ illnesses. However, as discussed before, the limitations to finding a cause are not due to constraints imposed on research by the government, but are due, in part, for example, to the inherent methodological problems imbedded in the difficult job of acquiring accurate, quantitative exposure data that can be linked to health outcomes. Despite this, we continue to strive to ascertain the cause or causes through innovative methods of exposure ascertainment.
The notion put forward in the report that current research will not identify effective treatments is also inaccurate. Much of the current research is directed at establishing working case definitions for Gulf War illnesses. This is a prerequisite for conducting treatment trials. As stated earlier, the VA Office of Research and Development is proceeding with planning for multi-site treatment trials that will initially rely on standard case definitions for CFS and FM. When, and if, better case criteria can be established, VA will be prepared to use those in future trials.
The report recommends that Congress create or designate an agency independent from VA and DoD to coordinate research and allocate research funds. Panels of scientists and experts such as, the IOM, have commended the Research Working Group on its research directions and processes for selecting research. The direction of research should be based on accurate, expert, and independent assessments of existing data. We strongly disagree with this report recommendation because it is inconsistent with other expert opinion and has no basis.
The report recommends that research focus on evaluation and treatment of disorders such as Chronic Fatigue Syndrome and Fibromyalgia. As noted earlier, VA has undertaken efforts to develop effective treatment strategies for these disorders. Included in the report’s recommendation, however, are disorders identified as "Gulf War Syndrome" and "Multiple Chemical Sensitivity". As we have often stated before, there is no collection of signs and symptoms manifested by Gulf War veterans that can be uniquely ascribed to a single novel disease pathology that could be given a name as specific as "Gulf War Syndrome". We know Gulf War veterans are suffering, and we believe that their illnesses are associated in some way with their service in the Gulf War.
Multiple Chemical Sensitivity is another condition that does not have an accepted case definition. We in the medical and environmental health community have long acknowledged that health consequences can arise from exposures to chemicals alone or in combinations. These health consequences are generally well described medically and include such conditions as peripheral neuropathy, pulmonary fibrosis, occupational asthma, cancer, and many others. The condition that goes by the name "Multiple Chemical Sensitivity", however, has eluded accurate case definition, which is a prerequisite to the development of treatment trials. However, VA supports peer reviewed research on Multiple Chemical Sensitivity that is scientifically credible. In the current government research portfolio on Gulf War veterans’ illnesses there are seven projects examining different aspects of Multiple Chemical Sensitivity. Thus VA, as well as other federal Departments and agencies, support research on Multiple Chemical Sensitivity that meet criteria of scientific merit.
Another recommendation of the Committee’s report suggests that VA and DoD medical systems augment their research and clinical capabilities with regard to women’s health issues and the health effects of combat service in women. We agree with this recommendation and will continue to encourage more research on women’s health issues. The VA Office of Research and Development has already identified women’s health as a priority research area within its program of Designated Research Areas. VA researchers are currently carrying out nine research projects, valued at $1.3 million, specifically targeted at the health consequences of the military experience of women. VA and other federal agencies are sponsoring this research. The Health Services Research Service in the VA Office of Research and Development has also issued a Program Announcement inviting submissions of proposals to study the impact of gender differences in health.
Finally, the report recommends that VA join with other federal agencies to create an interdisciplinary research and clinical program on the prevention, intervention and treatment of environmental neuropathies. We agree with the report that prevention, intervention, and treatment of environmentally induced neuropathies is important. We also encourage the merging of research expertise from different federal agencies to tackle vexing health problems. VA has done this in a number of health areas already. Consequently, we will build on prior efforts to work with other federal agencies in exploring the feasibility of creating such an interdisciplinary program. In addition, VA will issue a request for applications (RFA) within VA for research proposals on the prevention, intervention, and treatment of environmental neuropathies.
IMPROVING CARE AND RESEARCH
VA has been a leader in the development of veterans’ healthcare programs, improvement of understanding concerning Gulf War health issues and dissemination of knowledge on Gulf War-related health issues. As we have previously testified, we believe that our programs have been well designed; we also know that they are neither uniformly delivered nor perfect. We also recognize that some veterans have not received the kind of reception or care at VA medical facilities that we strive for. To both the Committee and those veterans here today, I want you to know that the Veterans Health Administration is working diligently to improve their satisfaction with our services. One of the new initiatives aimed at improving services to veterans with complex medical problems is implementation of case management.
VHA has also conducted Gulf War focus groups and developed a new customer satisfaction survey, which includes a large sample of Gulf War veterans. This national survey was sent to veterans in the fall of 1997. It will provide us the specific opinions of Gulf War veterans. The survey will produce adequate statistical power from which to draw valid conclusions about these data. These programs will allow us to collect data for quality improvement of VA programs and support our goal of providing the highest quality care to veterans. The analysis of the survey results will be available in March 1998. A final report will be forwarded to the Committees at that time.
I have just described VA's extensive treatment and research efforts on behalf of Gulf War veterans. You should know that we continue to take steps to improve the program when weaknesses have been identified. We believe the approaches being pioneered for these veterans will benefit others in the future.
Research related to the illnesses of Gulf War veterans is highly complex, and this is equally true of outcomes research. VA is committed to meeting these challenges and providing quality healthcare and the most effective treatments to Gulf War veterans. We will continue to solicit the advice of scientific experts, oversight groups and this Committee to improve our programs for veterans. VA healthcare providers are dedicated to providing compassionate care and answering important medical questions. President Clinton has made it clear that no effort should be spared in this regard.
Mr. Chairman, that concludes my prepared statement. We welcome your specific suggestions for how VA care can be improved and how VA can be more responsive to those whom it serves. I will now be happy to respond to any questions the Committee may have.