HOUSE COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
JULY 27, 2010
STATEMENT OF JOHN R. GINGRICH
CHIEF OF STAFF,
U.S. DEPARTMENT OF VETERANS AFFAIRS
July 27, 2010
Chairman Mitchell, Ranking Member Roe, and Members of the Subcommittee, thank you for holding today’s hearing. I am John Gingrich, Chief of Staff for the Department of Veterans Affairs (VA), and Chairman of the Gulf War Veterans’ Illnesses Task Force (GWVI-TF, or “Task Force”). Joining me today are Dr. Victoria Cassano, Director, Radiation and Physical Exposures Service, and Acting Director, Environmental Agents Service, Office of Public Health and Environmental Hazards, Veterans Health Administration (VHA); Dr. Joel Kupersmith, Chief Research and Development Officer, Office of Research and Development, VHA; and Bradley Mayes, Director, Compensation & Pension Service, Veterans Benefits Administration (VBA). Dr. Cassano, Dr. Kupersmith, and Mr. Mayes also serve as members of the Task Force.
I am pleased to come before you today to provide an overview of the Task Force mission, accomplishments, and recommendations contained in its report. The Task Force represents a bold step forward in how VA considers and addresses the challenges facing not just Veterans of a specific era, but the challenges facing all Veterans.
Our ability to address the challenges facing 1990-1991 Gulf War Veterans is not applicable just to that cohort of Veterans, it is representative of VA’s commitment to all our Veterans. We welcome the opportunity to work with the Congress, Veterans’ Service Organizations (VSOs), and all stakeholders in applying the lessons we have learned in caring for Gulf War Veterans across the spectrum of care and benefits for all Veterans.
Task Force Mission, Efforts, and Approach
The Task Force was formed in August 2009 to provide a unified and cohesive organizational instrument to address the concerns and needs of Gulf War Veterans, especially those who suffer from unexplained chronic multisymptom, or undiagnosed illnesses. From the outset, VA recognized that this was a complex issue with many people deeply invested in its resolution. We recognized the frustrations that many Veterans and their families experience on a daily basis as they look for answers, and seek benefits and health care.
In order to meet these challenges, the Task Force was designed as a matrix organization within VA that meets regularly to investigate allegations and perceptions, analyze facts and data, coordinate and review findings and proposals, and collaboratively develop recommendations. The Task Force includes staff from the Office of the Secretary (OSVA), VHA, VBA, Office of Public and Intergovernmental Affairs (OPIA), Office of Policy and Planning (OPP), and the Office of Congressional and Legislative Affairs (OCLA). The staff from these offices represented a broad spectrum of subject matter expertise and stakeholder perspectives necessary to ensure success. Members were charged with defining the key areas of review, consulting key experts and relevant stakeholders, and capturing the issues, data, programmatic and performance information necessary to inform their recommendations.
From the outset, I expected Task Force members to be candid and thorough during the review process. In order to meet the Task Force goals, and develop results-oriented proposals, members were asked to be aggressive and innovative. They met those expectations. Although the report the Task Force produced is but the first of many steps in a dynamic and still unfolding plan to address the needs of Gulf War Veterans, I am confident that we are moving in the right direction.
The Task Force was charged with conducting a comprehensive review of all VA programs and services that serve the Gulf War cohort of Veterans. The Task Force was further charged to identify gaps in services as well as opportunities to better serve this Veteran cohort, and then develop results-oriented recommendations to decisively advance VA’s efforts to address their needs. The Task Force considered a successful mission outcome as a coherent, comprehensive and facts-based action plan, which considers and integrates appropriate viewpoints from stakeholders and subject matter experts.
The Task Force focused its efforts on Veterans of the conflict in Operation Desert Shield or Operation Desert Storm, components of the 1990-1991 Gulf War period. However, as part of the Task Force charge to develop innovative and forward-looking solutions, it identified lessons learned from past practices and policy that can be applied to today’s programs and services supporting the Operation Enduring Freedom/Operation Iraqi Freedom cohort.
The Gulf War is legally defined as beginning on August 2, 1990, and extending through a date to be prescribed by Presidential proclamation or law. The term "Gulf War Veterans" could refer to all Veterans of conflicts in Southwest Asia during this period, including Veterans of Operation Iraqi Freedom, and subsequent conflicts in this theater. We considered these possibilities when developing our recommendations, in the hopes that this report would serve as a foundation for treating the unique wounds of war of the present conflicts. We were also mindful that this cohort of Veterans includes significant percentages of women and minority Veterans; and so we worked diligently to ensure that we addressed their needs.
The Task Force report reflects an unprecedented VA approach to problem solving. The approach uses an interdisciplinary team of subject matter experts from across multiple horizontal domains of VA, to include direct senior leader participation. The GWVI-TF worked over several months to develop a comprehensive plan of action consistent with the challenge inherent in Secretary Shinseki’s pledge to all Veterans in his comments before the National Society of the Sons of the American Revolution on 9 January 2010: “At VA, we advocate for Veterans – it is our overarching philosophy and, in time, it will become our culture.”
Task Force Objectives
The report’s action plans form an initial roadmap to transform the care and services we deliver to the Gulf War cohort. Execution of these plans will deliver the critical tools for frontline staff to address issues raised by VA and Gulf War Veterans, Veteran Service Organizations, Congress, and other external stakeholders.
Due to significant limitations in VA’s Gulf War Veterans Information System (GWVIS) and the reports generated from the various data sources used by GWVIS, it is extremely difficult to accurately portray the experiences of the 1990-1991 Gulf War cohort and their respective disability claims or health care issues. That said, this shortfall did not prevent the GWVI-TF from identifying gaps in services as well as opportunities to better serve this Veteran cohort.
The Task Force developed action plans to deliver new and improved tools for VA personnel based on seven core themes:
Partnerships: Partner with the Department of Defense (DoD) to improve communication and subsequently the care and services VA delivers to Veterans;
Benefits: Reassess and revise benefit policies as needed and empower and train VA compensation personnel to better secure the benefits Veteran clients have earned;
Clinician Education and Training: Empower clinical staff to better serve Veteran needs through a new model of interdisciplinary health education and training;
Ongoing Scientific Reviews: Ensure long-term population-based surveillance efforts for improved care for Veterans;
Medical Surveillance: Transition from reactive to proactive medical surveillance to identify and better manage possible adverse health outcomes of Veterans’ potential hazardous exposures;
Research and Development: Strengthen the foundation today for tomorrow’s more comprehensive short and long-term program for research and development; and
Outreach: Enhance outreach to reconnect Veterans to VA care, services, information and databases.
These action plans are not meant to be the definitive panacea for caring for Gulf War Veterans. While a starting point, this Veteran-centric care will require continued efforts and vigilance on the part of all stakeholders. Implementing the recommendations in this report will provide VA staff with the means to continue to advocate and care for all Gulf War Veterans.
Task Force Recommendations
The Task Force report is organized around the seven themes, previously mentioned. These themes drive action plans for the way ahead.
Partnerships: Veteran care is profoundly influenced by how well DoD and VA share information and resources in the areas of deployment health surveillance, assessment, follow-up care, health risk communication, and research and development. VA is dependent on DoD to identify environmental hazards and Servicemembers who were possibly exposed to those hazards.
VA and DoD already collaborate through the Deployment Health Working Group (DHWG). The report proposes to leverage the DHWG as the principal mechanism for VA to receive data on environmental exposures of Servicemembers, but this proposal has not been coordinated yet with the DHWG. Additionally, the report proposes using the DHWG to provide regular progress reports on data sharing efforts to the VA/DoD Health Executive Council. As of July 1, 2010, a draft Data Transfer Agreement is being reviewed by DoD and VA.
Benefits: The Task Force received input from Veterans and Veterans' stakeholders concerning the benefits and services targeted to Gulf War Veterans. Specifically, there was concern that some Veterans were continuing to suffer from symptom clusters that could not be attributed to known diseases or disabilities through conventional medical diagnostic testing and that these Veterans were "falling through the cracks" within the current disability compensation scheme.
As a result, the Task Force reviewed the current legislative and regulatory provisions unique to the Gulf War cohort of Veterans. Rule-making is also underway to establish the presumption of service connection for nine infectious diseases identified in the National Academy of Sciences' report titled "Gulf War and Health Volume 5: Infectious Diseases" issued on October 16, 2006.
To further assist Gulf War Veterans, VBA Compensation and Pension (C&P) Service published two training letters designed to inform and instruct regional office personnel on proper development and adjudication of disability claims based on Southwest Asia service. Training Letter 10-01, titled Adjudicating Claims Based on Service in the Gulf War and Southwest Asia, was released on February 4, 2010. This training letter provides background information on the Gulf War of 1990-1991, and explains the initial 1994 and subsequent 2001 legislation found in Title 38 United States Code, Section 1117, which was a response to the ill-defined disability patterns experienced by returning Gulf War Veterans. It explains the terms “undiagnosed illness” and “medically unexplained chronic multisymptom illness” used in the legislation, and notes that VA plans to amend its regulations to clarify that the three currently listed medically unexplained, chronic, multisymptom illnesses, chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, are only examples of chronic unexplained multisymptom illnesses and not an exhaustive list of conditions subject to the presumption of service connection. It also provides step-by-step procedures for procuring supporting evidence and for rating a disability claim based on Southwest Asia service under section 3.317 of title 38 of the Code of Federal Regulations. The training letter includes a separate memorandum to be sent with the VA medical examination request so that examiners are informed of the issues related to qualifying chronic disabilities and are better able to evaluate a Gulf War Veteran’s disability pattern.
Additional assistance was provided in Training Letter 10-03, titled Environmental Hazards in Iraq, Afghanistan, and Other Military Installations, which was coordinated with the Veterans Health Administration and DoD. This training letter provides regional office personnel with information on environmental hazards associated with Gulf War and Southwest Asia service. It discusses airborne toxic substances resulting from the widespread use of burn pit fires to incinerate a variety of waste materials in Iraq and Afghanistan, as well as hexavalent chromium contamination at the Qarmat Ali water treatment plant in Basrah, Iraq, from April through September 2003. The training letter was sent to VBA’s regional offices on April 26, 2010.
In addition to Southwest Asia environmental hazards, the training letter provided details of the contaminated drinking water situation at Camp Lejeune, North Carolina, from the 1950s to the 1980s. The purpose of this information is to alert regional office personnel to the potential for disability claims based on exposure to any of these environmental hazards. The training letter outlines development and rating procedures for such claims and provides “fact sheets” for VA medical examiners that explain each hazard. We will continue to coordinate with DoD to ensure that VA claims processing personnel remain informed about future environmental hazard exposures as additional information becomes available.
Clinician Education and Training: VHA has historically used a series of clinician training programs, titled Veterans Health Initiative (VHI), to prepare clinician staff to treat Veterans. However, the current programs are unwieldy, information is out-of-date, the format is not user-friendly, and the process for updating these training programs lacks agility.
In order to address this training deficit, an interdisciplinary team of VA subject matter experts met on December 8 and 9, 2009, to rewrite and reorganize the Gulf War Veterans’ Illnesses training program. This was the first time that such a wide array of policy makers, subject matter experts, and clinicians in the field were brought together to review every facet of a training program. A conference call on December 28, 2009, was held to continue editing the content. A two-day offsite meeting on February 1 and 2, 2010, finalized the content. The training program is now ready for review by the peer review board. The target date for on-line availability is October 31, 2010.
And while primary care providers currently do an excellent job of providing patients with work-ups based on symptoms, they do not always have the necessary tools to provide thorough exposure assessments. An initial seminar was developed in August 2009 in conjunction with Mount Sinai Medical Center and the New Jersey War Related Illness and Injury Study Center (WRIISC) to overcome this deficiency.
Lessons learned from prior conflicts, including the 1990-1991 Gulf War, were coupled with the lessons learned at the August 2009 seminar to build more comprehensive training for VA staff. This past month, VHA conducted two exportable workshops in exposure evaluation and assessment to update VA clinicians on the unique exposure concerns of returning OEF/OIF Veterans, and to provide educational and clinical tools for evaluation of exposure risk and the health outcomes relevant to these risks. Additional seminars are being planned for fiscal year (FY) 2011. In addition, later this year, a segment of this workshop seminar will be offered as a satellite broadcast available to all VA providers.
Recent training provided to VBA field stations included guidance for VA medical professionals who conduct compensation and pension examinations for conditions associated with Gulf War-related exposures. VA’s War Related Illness and Injury Study Center (WRIISC) program is fully operational with facilities located in Washington, DC, East Orange, NJ and Palo Alto, CA. The WRIISCs, staffed by teams of multidisciplinary clinicians uniquely qualified to evaluate Veterans with deployment –related health concerns, provide a clinical “second opinion” resource to Veterans via a referral process based on geographic location.
Ongoing Scientific Reviews: VA recognizes the need to leverage additional resources available to us and our partners to provide the kind of attention to Gulf War Veterans that they deserve.
We will continue to support the long-term Institute of Medicine (IOM) scientific reviews of health outcomes related to Veterans’ service in Gulf War combat theaters. VA is collaborating with the Centers for Disease Control and Prevention (CDC) to incorporate de-identified Veteran-specific data collection and analyses into three major longitudinal health-related national surveys: National Health and Nutrition Examination Survey (NHANES); National Health Interview Survey (NHIS); and National Immunization Survey (NIS). VA staff has had several discussions with investigators on the NHANES and NHIS. Staffs from both surveys have expressed willingness to include Veteran-specific questions and to plan for oversampling of the Veteran population to ensure an adequate number of Veterans to allow for comparisons to the adult U.S. population.
As of July 1, 2010, VA has submitted to NHANES and NHIS staff specific questions that, when answered, will identify Veteran study subjects beginning in 2011 in both these National surveys. This effort will enable contrasts to be made between current disability and health status of Veterans and non-Veterans. Additionally, these questions will enable VA to assess the health of Veterans during multiple periods and eras of service.
To prepare for and address future needs, in June 2009, we announced the National Health Study for a New Generation of U.S. Veterans to study the health status of 60,000 Veterans who have separated from active duty, Guard, or Reserves, half of whom served in either Iraq or Afghanistan and half who did not. Women Veterans are being oversampled to permit appropriate comparisons.
Medical Surveillance: DoD has discussed with VA events or situations when Servicemembers may have been exposed to hazardous substances during the current conflicts in Iraq and Afghanistan. These possible exposure events include exposure to hexavalent chromium, burn pit smoke, and other contaminants.
Unfortunately, medical surveillance has not been extensive for 1990 – 1991 GW Veterans, despite the efforts of DOD’s Comprehensive Clinical Evaluation Program, which was not focused on exposure related disease. One of the lessons learned from the first Gulf War is that VA must get information regarding potentially exposed troops as soon as available from DOD, in order to provide ongoing medical surveillance of Veterans who may be at risk of adverse health outcomes. A program is being developed for those Veterans who may have been exposed to sodium dichromate while performing duties at Qarmat Ali, Iraq. This model will be used to develop medical surveillance programs for the other exposure events. The event at Qarmat Ali is the most well-defined event in that there is a relatively small number of potentially exposed Veterans, there is only one offending chemical, and the exposure has ceased.
Among Gulf War Veterans, there are known instances where Servicemembers were hit by coalition fire and are believed to still have depleted uranium (DU) fragments present in their bodies. The need to monitor the effects of long-term DU exposure still exists. The Depleted Uranium follow-up program was started in 1993 at the Baltimore VA Medical Center (VAMC). This program periodically re-evaluates Servicemembers who have known embedded DU fragments. In 2008 the Toxic Embedded Fragment Study Center was established to clinically evaluate all Servicemembers with any type of embedded fragment. These programs have been supported by the Division of Biophysical Toxicology at the Armed Forces Institute of Pathology (AFIP). The Joint Pathology Center (JPC), authorized in NDAA 2008, will serve as the new Pathology Reference Center for the federal government providing pathology consultation, education, research, and oversight of the vast Tissue Repository housed at AFIP, which will close in 2011. VA will continue to support the work of the JPC to maintain these vital programs for Veterans with Toxic Embedded Fragments of all kinds.
Research and Development: There has been significant Federal support for research on Gulf War Veterans’ Illnesses that has answered many epidemiological questions and studied a number of potential biological indicators of illness in Gulf War Veterans. Effective treatments and objective diagnostic tests, however, have not yet been identified. We know that this is of particular frustration to Veterans and their families.
The most recent IOM Report, Gulf War and Health: Volume 8, concluded that while PTSD was causally linked to traumatic war experiences associated with GW deployment, the excess of unexplained medical symptoms reported by GW Veterans cannot be reliably ascribed to any known psychiatric disorder. Although the precise cause for these symptoms remains unknown, the fact that some GW Veterans are ill and suffer adverse effects on their daily lives remains unquestioned.
VA agrees with the recommendation of the VA Research Advisory Committee on Gulf War Veterans’ Illnesses in its 2008 report that a renewed Federal research commitment is needed to identify effective treatments for Gulf War illnesses and address other priority Gulf War health issues. VA remains committed to conducting research to identify new treatments for ill GW Veterans. Clinical trials have examined new therapies for sleep disturbances and gastrointestinal problems, and tested the feasibility of performing cognitive behavioral therapy via telephone. Additionally, VA researchers are conducting clinical trials funded through the Congressionally Directed Medical Research Program managed by DoD in hopes of finding new treatments for GW Veterans.
VA’s Office of Research and Development (ORD) issued three new Requests for Applications (RFAs) on November 10, 2009, which incorporated more than 80 percent of the research recommendations the Research Advisory Committee on Gulf War Veterans’ Illnesses made in their 2008 report. Three of the 13 applications received, focused on testing or developing new treatments for ill Gulf War Veterans, have been selected for funding. These RFAs will be re-issued twice a year to regularly request submission of new proposals and revisions of previously reviewed, but not funded, applications.
The results of VA’s short term plans to move forward are encouraging that the goal of identifying effective treatments will be met. Previous VA-funded clinical trials have examined new therapies for sleep disturbances, cognition, pain, fatigue and gastrointestinal problems, and tested the feasibility of performing cognitive behavioral therapy via telephone. Another major focus of VA’s current research portfolio is to identify biomarkers, or biological indicators, that can distinguish ill Gulf War Veterans from their healthier counterparts.
In addition, ORD’s long-term plans include the design of a new study of a National cohort of Gulf War Veterans under the auspices of VA’s Cooperative Studies Program, which has extensive experience in developing multi-site VA clinical trials and clinical studies. The design of this new study will include a Genome Wide Association Study (GWAS) and other elements, based on evaluation of the existing body of scientific/clinical knowledge about the illnesses affecting Gulf War Veterans.
Let me also take this opportunity to say clearly that our decision to not exercise the two option years of the contract with the University of Texas Southwestern Medical Center (UTSW) was because of our commitment to ensuring that Gulf War Veterans receive only the best care. Our decision was based on persistent noncompliance with contract terms and conditions, and numerous performance deficiencies documented by the Contracting Officer, the Contracting Officer’s Technical Representative, and the Office of the Inspector General. Unobligated funds from FY 2009, the third UTSW contract period, have been retained for use in FY 2010 and FY 2011 for modifications and close-out costs of previously approved contract task orders and for data transfer costs at the conclusion of the contract. VA will maintain funding levels for Gulf War research as close as possible to the $15 million per year recommended in the Senate Committee on Appropriations’ report language which accompanied the FY 2010 Military Construction and Veterans Affairs and Related Agencies Appropriation Bill.
Even with the unanticipated decision to stop accepting new task orders during the latter portion of FY 2009 and to not exercise the third option year (FY 2010) of the contract, VA exceeded the $15 million target for FY 2009 and is currently projecting $9.7 million for FY 2010. It is anticipated that additional VA research projects focused on the illnesses affecting Gulf War Veterans will be identified for funding in FY 2010 and beyond as a result of the short- and long-term plans described above. Although we are aware that some of our stakeholders viewed our decision regarding the UTSW contract as a disservice to Gulf War Veterans, let me say it again: We are committed to the best possible care for this cohort of Veterans.
Outreach: There is a general lack of engagement on, and knowledge of, the efforts VA is taking to address the issue of Gulf War Veterans’ Illnesses. Additionally, VA has not been consistent in conducting targeted outreach, nor in building awareness about Gulf War Illnesses and research among the general public and professional communities. VA needs a more robust outreach plan which will ensure that there is a more inclusive approach when communicating to the Gulf War Veteran community. In addition, VA should communicate Department-wide to its employees about the changes to the rating schedule and presumptions related to Gulf War Veterans, and will execute an outreach program to interested scientists and clinicians in conducting Gulf War illness research.
As part of the renewed effort to acknowledge and engage Gulf War Veterans, the GWVI-TF has formulated a proactive outreach strategy that combines consolidated strategic communication initiatives with educational resources to ensure that Gulf War Veterans are informed of the benefits and services available to them. We will also be reaching out to you, our partners in Congress, to help us provide this information to your Gulf War Veteran constituents.
Partnering With Our Stakeholders
VA reviewed and evaluated all the public comments related to the draft findings for subsequent inclusion into the final written report to the Secretary. This was an unprecedented step for VA to take for any task force report, but we believe this course of action was both necessary and beneficial to the process.
The Task Force completed the draft written report on March 29, 2010. On April 1, 2010 VA released the written report for public comment. This was the first initiative in which VA provided two ways for Veterans to submit feedback on policy proposals. The public was notified per a Federal Register notice and a simultaneous outreach campaign support by VSOs. The public could make comment two ways: via the Your Gulf War Voice Website, or a formal written submission directly to VA. The public comment period closed on May 3, 2010.
The public response was one of the largest in VA’s history to a proposed rule, regulation, or policy with over 150 suggestions submitted, 300 additional comments, and more than 2,100 votes were cast by 189 unique public respondents. Despite this outreach effort and the robust public response to the draft written report, VA did not reach as many Veterans as it wanted to reach. Based on the public comments to the draft written report, many Veterans believed the opportunity to comment on this report should have been be posted in all VA facilities at the point of service (i.e. waiting areas and vet centers). VA will publish subsequent findings and recommendations of the Task Force in a public forum for comment and review, and we will consider ways to post future Gulf War information in VA facilities.
In developing this report, VA made every effort to be transparent and aggressively advocate for Veterans. We strived to hold ourselves accountable for our shortcomings, and build on our successes. VA’s team views this report as a foundation upon which we can collectively build iterative future improvements in the care and services VA delivers by leveraging the lessons learned by this Task Force across the full spectrum of all Veteran communities and their families.
We are keenly aware that not every stakeholder will agree with everything in the report. We recognize that there is mistrust among some of our stakeholders, and there are many misperceptions. Regardless, VA encourages all stakeholders to avoid letting individual differences prevent further collaboration or progress for Gulf War Veterans. We welcome your recommendations and criticisms in the hopes of forming a constructive dialogue that results in better services for our Veterans. VA looks forward to partnering with all stakeholders in implementing the Task Force recommendations and devising new strategies with the members of the Task Force as they continue to refine the way ahead – always with the goal of serving our Gulf War Veterans.
Mr. Chairman, this concludes my testimony. I will be happy to respond to any questions from you and the other Members of this Subcommittee.