THE HONORABLE JONATHAN B. PERLIN, MD, PHD
DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
ON PRE- AND POST-DEPLOYMENT HEALTH ISSUES
July 9, 2003
Mr. Chairman, I am pleased to be here to testify before the Subcommittee on VA's role in the care of veterans of Operation Iraqi Freedom. With me today is Dr. Craig Hyams, VA's Chief Consultant for Occupational and Environmental Health.
Because over 200,000 U.S. troops have been engaged in Operation Iraqi Freedom, I am grateful for the opportunity to emphasize that VA is prepared to provide high quality health care and disability assistance to Iraqi Freedom veterans. Since the Gulf War in 1991, VA has developed and implemented improved policies and programs to care for our nation's newest war veterans. As we have all witnessed over the last couple of months, this conflict is not over and our men and women in uniform remain in harms way and deserve our best efforts.
Health Care following Combat
It is critical to provide high-quality health care after every war. Congress understands this and under 38 U.S.C. § 1710(e)(1)(D), added by Public Law 105-368, VA was authorized to provide health care for a two-year period to veterans who serve on active duty in a theater of combat operations during a period of war after the Gulf War, or in combat against a hostile force during a period of hostilities after November 1, 1998. Consequently, combat veterans, like those now serving in Iraq, have a two-year period of access to free VA health care, unless there is sufficient medical evidence to conclude that the illness is not attributable to that service.
To date, 22 combat veterans have been transferred to VA from DoD for specialized, long-term health care and rehabilitation. These patients have had spinal cord injuries, gunshot and grenade wounds, and other combat trauma. There have been relatively few veterans of Operation Iraqi Freedom who have otherwise presented for care at a VA medical center because most combat troops are still serving in Iraq or remain on active duty. The Iraqi war veterans presenting to our clinics have had a varied range of health problems. No illnesses due to chemical or biological agents have been reported.
Assessment of Health Care Needs
In addition to providing high-quality health care for veterans, VA now has the capability to collect and analyze comprehensive health information with its computerized outpatient and inpatient medical records. The capability to assess the health status of veterans has been greatly improved since the Gulf War. Standard health care databases help VA evaluate specific health questions. Importantly, VA clinicians are able to review veterans' prior treatment in VA when the veterans obtain care from the Department. This capability will support broad, long-term, and comprehensive assessment of health status because many veterans return frequently for VA health care and are often seen in different clinics, and may be evaluated in different parts of the country for specialized health care needs.
VA is working with DoD to obtain a roster of recent combat veterans to facilitate analysis of computerized health records. Furthermore, veterans of Operation Iraqi Freedom are eligible for evaluation in the Gulf War clinical registry. Every Iraqi Freedom veteran is being offered an opportunity to participate in this registry, which provides a thorough clinical evaluation and documentation of symptoms and potential exposures.
Supplementary Clinical Programs
VA is developing a new clinical reminder that will pop-up on the computer screens of VA health care providers when they encounter a new patient who may be a veteran of the war in Iraq or Afghanistan. This clinical reminder will ensure that health care providers evaluate veterans for deployment-related medical and psychological risks. It will also provide Internet links with relevant clinical practice guidelines and exposure health risk information.
In addition, the VA Depleted Uranium Follow-Up Program at the Baltimore VAMC is coordinating screening of the urine of veterans who may have been exposed to depleted uranium during Operation Iraqi Freedom. The service is being provided to both VA patients and to the Defense Department for active duty troops. The results of this testing are provided directly to the veteran and their VA or DoD physician.
Ensuring High Quality Post-Deployment Health Care
Specialized health care during the post-deployment period can help prevent long-term health problems. Therefore, VA and DoD developed evidence-based clinical guidance for treating veterans following deployment. Clinical Practice Guidelines (CPG's), which are based on the best scientifically supported practices, give health care providers the structure, clinical tools, and educational resources they need to diagnose and manage patients with deployment-related health concerns. VA and DoD have developed two post-deployment CPG's: a general purpose Post-Deployment CPG and a CPG for unexplained fatigue and pain. Our goal is to make sure that all VA health care providers are well-informed about specific deployments and related health hazards. Information on these Clinical Practice Guidelines is available online at www.va.gov/environagents.
Assessment of Difficult-to-Diagnose Illnesses
The majority of veterans returning from combat and peacekeeping missions are able to make the transition to civilian life with few problems. Most who come to VA for health care receive conventional diagnoses and treatments. Some veterans have greater problems on their return to civilian life, and a small percentage of them develop difficult-to-diagnose symptoms. Sustained clinical care and research is needed to understand post-deployment health problems. Consequently, VA has established two "War-Related Illness and Injury Study Centers" ( WRIISC's), in East Orange, NJ, and Washington, DC, to provide specialized health care for veterans from all combat and peace-keeping missions who suffer difficult-to-diagnose but disabling illnesses.
VA's two WRIISC's focus on determining the causes and most effective treatments for chronic symptoms, which are a problem following all wars. Health care at the centers is available to veterans of all eras -- including recent war veterans -- through referral by primary VA health care providers. The two centers also provide research into better treatments and diagnoses, develop educational materials, and develop specialized health care programs to meet veterans' unique needs. More information on the WRIISC's can be found at the VA website, www.va.gov/environagents.
Veterans Health Initiative
VA has built upon the lessons learned from our experiences with Gulf War and Vietnam veterans' programs to implement innovations and improved approaches to health care for all veterans. The Veterans Health Initiative ( VHI) is a comprehensive program designed to improve recognition and treatment of deployment health effects, to better document veterans' military and exposure histories, and to establish a database for further study.
The education component of the VHI prepares VA healthcare providers to better serve their patients. VA has completed modules on spinal cord injury, cold injury; traumatic amputation; Agent Orange; the Gulf War; Post-Traumatic Stress Disorder; ex- POW health effects; blindness/visual impairment and hearing loss; and, radiation. We are currently developing modules on infectious disease health risks in Southwest Asia; sexual trauma; traumatic brain injury; health effects from weapons of mass destruction; and, occupational lung diseases. These important tools are integrated with other VA educational efforts to enable VA practitioners to more quickly and accurately arrive at a diagnosis and to provide more effective treatment.
Veterans and their families, elected representatives, the media, and the nation all need timely and reliable information about wartime health risks. Consequently, VA has developed two brochures that addresses the main health concerns for military service in Afghanistan and Iraq. These brochures answer health-related questions that veterans, their families, and health care providers may have about these hazardous deployments. They also describe relevant medical care programs at VA. These two brochures can be accessed at:
Another challenge for outreach is to address the specific concerns of veterans and their families over the potential long-term health impact of environmental exposures during deployment. These concerns are addressed through newsletters and fact-sheets to veterans covering health and compensation issues, including environmental health risks; regular briefings of veterans service organizations; national meetings on health and research issues; media interviews; and, other educational material and websites with information, like www.va.gov/environagents.
Very importantly, VA recently published -- in collaboration with DoD -- a new brochure called "A Summary of VA Benefits for National Guard and Reservists Personnel." This brochure does an excellent job of summarizing the benefits available to this special population of veterans upon their return to civilian life. Too often Reservists and National Guard personnel have not received timely information about the benefits they have earned. A million copies of this brochure are being printed and distributed. This brochure is also available on line at: http://www.va.gov/environagents/docs/SVABENEFITS.pdf.
Recruit Assessment Program (RAP)
VA is committed to the development of a life-long health record for all military personnel and veterans. Therefore, VA is supportive of DoD's efforts to develop and implement the Recruit Assessment Program ( RAP) that will collect comprehensive baseline health data from U.S. military recruits.
VA Vet Center Program
VA's Vet Centers, originally conceived to provide a wide variety of readjustment services to Vietnam veterans, have been invaluable in providing similar services to veterans from more recent combat and peacekeeping missions. More than 115,000 veterans of the Gulf War have made use of their services. The VA Vet Centers are now ready to help veterans of the current hostilities in Iraq.
To assist in disability evaluations, VA has actively worked with DoD to implement a standardized separation physical examination that thoroughly documents a veteran's health status at the time of separation from military service and that also meets the requirements of the physical examination needed by VA in connection with a veteran's claim for compensation benefits.
Additionally, VA has worked to provide fair compensation for Gulf War veterans with difficult-to-diagnose illnesses. Under 38 U.S.C. § 1117 (as amended by Public Law 107-103), VA has authority to compensate Gulf War veterans for chronic disabilities resulting from an undiagnosed illness or certain medically unexplained chronic multi-symptom illnesses. Service members who serve in the Southwest Asia Theater of Operations during the current conflict with Iraq will also be eligible for compensation for disabilities resulting from undiagnosed illnesses under this authority.
VA places a high priority on the development of improved methods of diagnosis, treatment, and prevention of illnesses related to deployments. In October 2002, VA's Office of Research and Development released a Program Announcement on Deployment Health Research to expand VA's research portfolio on long-term health effects of hazardous deployments, such as the Gulf War, Bosnia/Kosovo, Afghanistan, and the current war in Iraq. Up to 20 million dollars will be spent on research to evaluate deployment health hazards. The results of this research program should provide useful guidance in improving the medical care of veterans who return from combat, and in improving preventive medicine efforts during future deployments.
Deployment Health Work Group
One of the important lessons learned since the Gulf War was the need for continuous and formal intergovernmental coordination among VA, DoD, and Department of Health and Human Services ( HHS). As a result, the Deployment Health Work Group of the VA- DoD Health Executive Council was established in 2002 to ensure interagency coordination for all veteran and military deployment health issues. Governmental coordination will play a critical role in addressing health problems among veterans in future conflicts and peacekeeping missions. This work group has met repeatedly during the recent conflict in Iraq to coordinate government efforts, such as the development of a roster of deployed troops.
Transmission of Health Data between DoD and VA
VA and DoD are closely collaborating to develop the capability to share medical information electronically. Recently, the VA/ DoD Joint Executive Council and Health Executive Council approved the adoption of the Joint VA/ DoD Electronic Health Records Plan. This plan provides for the exchange of health data and development of a common health information infrastructure supported by common data communications, security and software standards. This will allow interoperability of DoD and VA high performance health information systems. Since June 2002, VA providers have had online access to health information from DoD's Composite Health Care System for discharged and retired service members. Currently, such information is available for more than 1.5 million separated service members. Key initiatives in the Electronic Health Records Plan are the Federal Health Information Exchange ( FHIE) and HeatlhePeople (Federal), which allows VA clinicians to view DoD health information for separated service members.
VA applauds the efforts of DoD to prevent health problems among deployed troops and to provide immediate care for combat casualties. DoD has made substantial progress in lowering morbidity and mortality rates on the battlefield. Nevertheless, we have to focus greater attention on the long-term health problems of veterans that occur after every war. The trauma of warfare has lasting effects. The physical and psychological wounds of war heal slowly, and toxic exposures on the battlefield may have enduring health consequences long after the actual war has ended.
The key to addressing the long-term needs of veterans is improved medical record-keeping and environmental surveillance. VA therefore is actively engaged with DoD in obtaining as much deployment health and exposure information as possible, including data on troop locations and data collected as part of pre- and post-deployment health screening.
A veteran separating from military service and seeking assistance today from VA will receive improved health care and disability assistance. VA has successfully developed new programs and adapted many existing programs for the benefit of combat veterans. VA also has significant experience with the special provisions in law authorizing disability compensation for war veterans with unexplained symptoms. In collaboration with other federal agencies, VA has initiated new programs for developing and coordinating federal research on veterans' health questions. The Department of Veterans Affairs is committed to helping ensure the health of service members both during deployment and after they leave military service.
Mr. Chairman, this concludes my statement. Dr. Hyams and I will be happy to respond to any questions that you or other members of the subcommittee might have.