105th Congress, 1st Session House Report 105-388

By COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

Document Dated: Nov-07-1997

1997 Union Calendar No. 228 105th Congress, 1st Session House Report 105-388

GULF WAR VETERANS' ILLNESSES: VA, DOD CONTINUE TO RESIST STRONG EVIDENCE LINKING TOXIC CAUSES TO CHRONIC HEALTH EFFECTS

SECOND REPORT

by the

COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

together with

ADDITIONAL VIEWS

November 7, 1997. Committed to the Committee of the Whole House on the State of the Union and ordered to be printed

Union Calendar No. 228

105th Congress

Report

HOUSE OF REPRESENTATIVES

1st Session

105-388

GULF WAR VETERANS' ILLNESSES: VA, DOD CONTINUE TO RESIST STRONG EVIDENCE LINKING TOXIC CAUSES TO CHRONIC HEALTH EFFECTS

November 7, 1997.-Committed to the Committee of the Whole House on the State of the Union and ordered to be printed

Mr. Burton, from the Committee on Government Reform and Oversight, submitted the following

SECOND REPORT

On October 31, 1997, the Committee on Government Reform and Oversight approved and adopted a report entitled ``Gulf War Veterans' Illnesses: VA, DOD Continue to Resist Strong Evidence Linking Toxic Causes to Chronic Health Effects.'' The chairman was directed to transmit a copy to the Speaker of the House.

I. SUMMARY

Responding to requests by veterans, the subcommittee in March 1996 initiated a far-reaching oversight investigation into the status of efforts to understand the clusters of symptoms and debilitating maladies known collectively as ``Gulf War Syndrome.'' We sought to ensure sick Gulf War veterans were being diagnosed accurately, treated effectively and compensated fairly for service-connected disabilities, despite official denials and scientific uncertainty regarding the exact causes of their ailments. We also sought to determine whether the Gulf War research agenda was properly focused on the most likely, not just the most convenient, hypotheses to explain Gulf War veterans' illnesses.

After 19 months of investigation and hearings, the subcommittee finds the status of efforts on Gulf War issues by the Department of Veterans Affairs [VA], the Department of Defense [DOD], the Central Intelligence Agency [CIA] and the Food and Drug Administration [FDA] to be irreparably flawed. We find those efforts hobbled by institutional inertia that mistakes motion for progress. We find those efforts plagued by arrogant incuriosity and a pervasive myopia that sees a lack of evidence as proof. As a result, we find current approaches to research, diagnosis and treatment unlikely to yield answers to veterans' life-or-death questions in the foreseeable, or even far distant, future.

We do not come to these conclusions lightly. Nor do we discount all that has been done to care for, cure and compensate Gulf War veterans. But lives have been lost, and many more lives are at stake.

Six years and hundreds of millions of dollars have been spent in the effort to determine the causes of the illnesses besetting Gulf War veterans. Yet, when asked what progress has been made healing sick Gulf War veterans, VA and DOD can't say where they've been and concede they may never get where they're supposed to be going. The CIA continues to resist broader declassification of Gulf War records. The FDA meekly chastises the Defense Department for the failure to observe agreed-upon rules for the humane use of experimental drugs.

Sadly, when it comes to diagnosis, treatment and research for Gulf War veterans, we find the Federal Government too often has a tin ear, a cold heart and a closed mind.

Our hearings convinced us the journey from cause to cure for Gulf War veterans runs through the pools, clouds and plumes of toxins in which they lived and fought. It is a journey VA and DOD might never have taken but for persistent pressure from this subcommittee, and other House and Senate panels, that forced the Pentagon to acknowledge a ``watershed event'' - the probable exposure of United States troops to chemical weapons fallout at Khamisiyah, Iraq.

With that first admission, the three pillars of Government denial - no credible detections, no exposures, no health effects - began to crumble. As the number of U.S. troops presumed exposed grew from 400 to almost 100,000, as the credibility of other chemical detections was sustained, and as private research probed the parallels between Gulf War illnesses and the known symptoms of chemical poisoning, some significant role for toxins in causing, triggering or amplifying neurological damage and chronic symptoms could no longer be denied.

Before Khamisiyah, voluminous and compelling, albeit circumstantial, evidence regarding neurotoxic exposures had been ignored, denied or discredited, while far less abundant evidence and far less plausible psychological theories of causation were pursued with vigor. As a result, diagnostic protocols were insensitive to exposure effects, treatments were limited and vital research was delayed.

Only recently were VA and DOD health registry questionnaires modified to consistently capture the best and only remaining evidence of toxic exposures: veterans' recollections. Only recently was research funded to measure the health effects of sustained, low-dose exposure to the combinations of chemicals, pharmaceuticals and environmental toxins to which Gulf War veterans were exposed.

Those denials and delays are symptomatic of a system content to presume the Gulf War produced no delayed casualties, and determined to shift the burden of proof onto sick veterans to overcome that presumption. That task has been made difficult, if not impossible, because most of the medical records needed to prove toxic causation are missing or destroyed. Nevertheless, VA and DOD insist upon reaping the benefit of any doubts created by the absence of those records.

The subcommittee believes the current presumptions about neurotoxic causes and effects should be reversed and the benefit of any doubt should inure to the sick veteran.

Finally, we reluctantly conclude that responsibility for Gulf War illnesses, especially the research agenda, must be placed in a more responsive agency, independent of the DOD and the VA.

Fortunately for Gulf War veterans, excellent research into Gulf War illnesses has taken place outside Government sponsorship. This research has advanced a case definition for some illnesses, an important step toward improved diagnosis and treatment. Some experimental treatments have brought relief to afflicted veterans and their families. The subcommittee believes this work must be included within the scope of that agency made responsible for Federal efforts to solve the puzzle of Gulf War illnesses.

We note with approval efforts at the National Institute of Environmental Health Sciences [NIEHS] and other public health agencies to study exposure effects and genetic susceptibility to environmental toxins. Funding for this research would be an important first step in the effort to have an independent agency, with significant expertise in environmental hazards, involved in the solution to Gulf War veterans' health problems.

There is no ``silver bullet'' to explain or cure so-called Gulf War Syndrome, which is not a discrete syndrome at all, but a variable cluster of symptoms and disease states with different triggers and susceptibilities. The battle to cure Gulf War illnesses must be fought at the cellular, molecular and genetic levels if we hope to heal the delayed wounds of that war and protect future warriors. Absent precise exposure data which can never be recaptured, the best evidence linking toxic causes to chronic effects lies within the bodies and minds of Gulf War veterans. That evidence has been too long ignored.

A. FINDINGS IN BRIEF

Diagnosis

1. VA and DOD did not listen to sick Gulf War veterans as to possible causes of their illnesses.

2. The presence of a variety of toxic agents in the Gulf War theater strongly suggests exposures have a role in causing, triggering or amplifying subsequent service-connected illnesses.

3. Gulf War troops were not trained to protect themselves from the effects of exposure to depleted uranium dust and particles.

4. Pyridostigmine bromide [PB] can have serious side effects and interactions when taken in combination with other drugs, vaccines, chemical exposures, heat and/or physical exercise.

5. VA and DOD health registry diagnostic protocols relied on the unfounded conclusion there were no chemical, biological or other toxic exposures to U.S. troops in the Gulf War theater.

6. VA and DOD health registry diagnosis protocols continue to be based on the unwarranted conclusion that, unless there is an immediate and acute reaction, exposures to chemical weapons and other toxins do not cause delayed or chronic symptoms.

7. Prematurely ruling out toxic exposures as causative, VA and DOD doctors relied on diagnoses of somatoform disorder and Post Traumatic Stress Disorder [PTSD] to explain Gulf War veterans' illnesses.

8. There is no credible evidence that stress or PTSD causes the illnesses reported by many Gulf War veterans.

9. Accurate diagnosis of veterans' illnesses remains difficult due to inadequate or missing personal medical records, missing toxic detection logs, and unreleased classified documents.

10. Accurate diagnosis of veterans illnesses was also hampered by the VA's lack of medical expertise in toxicology and environmental medicine.

11. Exposures to low levels of chemical warfare agents and other toxins can cause delayed, chronic health effects.

Treatment

12. Neither the VA nor the DOD has systematically attempted to determine whether sick Gulf War veterans are any better or worse today than when they first reported symptoms.

13. Treatment of sick Gulf War veterans by VA and DOD to date has largely focused on stress and PTSD.

Compensation

14. Compensation ratings for sick veterans are minimized due to inadequate personal medical records, missing toxic detection logs, and unreleased classified documents which could help veterans establish service-connection of post-war disabilities.

15. Compensation ratings are also minimized by over-reliance on somatoform disorder and PTSD as the basis of disability claims.

Research

16. Federal research strategy has been blind to promising hy-potheses due to reliance on unfounded DOD conclusions regarding chemical exposures.

17. Institutional and methodological constraints make it unlikely the current research structure will find the causes and effective treatments for Gulf War veterans' illnesses in the short term.

18. The FDA was passive in granting and failing to enforce the conditions of a waiver to permit use of PB by DOD.

B. RECOMMENDATIONS IN BRIEF

Diagnosis

1. Congress should enact a Gulf War toxic exposure act establishing the presumption, as a matter of law, that veterans were exposed to hazardous materials known to have been present in the war theater.

2. The VA should contract with an independent scientific body composed of non-Government scientific experts representing, at a minimum, the disciplines of toxicology, immunology, microbiology, molecular biology, genetics, biochemistry, chemistry, epidemiology, medicine and public health for the purpose of identifying those diseases and illnesses associated in peer-reviewed literature with singular, sustained, or combined exposures to the hazardous materials to which Gulf War veterans are presumed to have been exposed.

3. The VA Gulf War Registry and the DOD Comprehensive Clinical Evaluation Program should be re-evaluated by an independent scientific body which shall make specific recommendations to change both programs from crude research tools into effective clinical diagnosis and outcomes monitoring efforts.

4. The VA should refer all Phase II Registry examinations to Gulf War Referral Centers.

5. The VA should add toxicological and environmental medicine expertise to the staff resources dedicated to Gulf War illnesses.

6. DOD and VA should make every effort to find, and where necessary re-create through veterans' testimony, individual Gulf War medical records to reflect vaccines administered, PB use, and exposure to DU, pesticides and other hazardous materials.

7. The President should order an intensified effort to declassify Gulf War documents in any way related to Gulf War veterans' illnesses and should personally certify to the appropriate committees of Congress when he deems declassification of such documents to be against the national interest.

8. DOD failure to adhere to recordkeeping requirements or clinical protocols under an informed consent waiver should result in the presumption of service-connection for any subsequent illness(es) suffered by service personnel to whom the drug or protocol was administered.

Treatment

9. VA and DOD should systematically and effectively monitor the clinical progress of Gulf War veterans to determine the most effective treatments.

10. VA and DOD clinicians should be encouraged to pursue, and be trained in, new treatment approaches to suspected neurotoxic exposure effects.

11. The diagnoses for somatoform disorders and Post Traumatic Stress Disorder [PTSD] should be refined to insure that physiological causes are not overlooked.

Compensation

12. Denials of Gulf War veterans' compensation claims attributable in any way to missing medical records should be reviewed and veterans given the benefit of any doubt regarding the presumptive role of toxic exposures in causing post-war illnesses and disability.

13. For purposes of compensation determinations, disabilities associated with presumed exposures should be deemed service-connected without any limitation as to time.

Research

14. Congress should create or designate an agency independent from the Departments of Defense and Veterans Affairs as the lead Federal agency responsible for coordination of all research into Gulf War veterans' illnesses and allocation of all research funds.

15. The lead Federal agency on Gulf War veterans' illnesses should focus research on the evaluation and treatment of the common spectrum of neuroimmunological disorders known as Gulf War Syndrome, multiple chemical sensitivity, chronic fatigue syndrome and fibromyalgia.

16. DOD and VA medical systems should augment research and clinical capabilities with regard to women's health issues and the health effects of combat service on women's health.

17. VA, in collaboration with NIH, CDC, FDA and other public health agencies should establish an interdisciplinary research and clinical program on the identification, prevention and treatment of environmentally induced neuropathies.

18. FDA should grant a waiver of informed consent requirements for the use of experimental or investigational drugs by DOD only upon receipt of a Presidential finding of efficacy and need.

II. BACKGROUND

Since the Gulf War ended in 1991, there has been a growing number of reports of chronic illnesses among the nearly 700,000 United States troops who served in Saudi Arabia, Kuwait, and Iraq. Although the illnesses are most common among reservists and National Guardsmen who served in the Gulf, full-time active-duty soldiers have also complained about various maladies.⁽¹⁾

Health complaints by Gulf veterans from Canada, Great Britain, Kuwait, Australia, Czech Republic, Hungary, New Zealand and Norway have also begun to surface. There has also been an increased incidence of similar illnesses in the civilian populations of Kuwait, Iraq, and Saudi Arabia, according to a report to the Human Resources Subcommittee by chemical/biological weapons expert Dr. Jonathan Tucker, director of the chemical and biological nonproliferation project, Monterey (CA) Institute for International Studies.⁽²⁾

Listed in the Persian Gulf health registries of the Departments of Defense [DOD] and Veterans Affairs [VA] are about 113,000 Gulf War veterans [DOD's Comprehensive Clinical Evaluation Program with 44,900 names as of August 1997, and VA's Gulf Health Registry with 67,989 names as of May 1997].⁽³⁾ Most participants in the registries have been diagnosed, approximately 20 percent remained undiagnosed, and roughly 10 percent of those listed had no detectable symptoms.⁽⁴⁾ Many veterans have reported flu-like symptoms, chronic fatigue, rashes, joint and muscular pain, headaches, memory loss, reproductive problems, depression, loss of concentration, gastroin-testinal problems, and other maladies.⁽⁵⁾

According to American Legion: ``One of the key questions that arises from evaluating [VA Health] Registry data is: What is happening to those veterans that complain of the most common symptoms? What is the outcome of their visit to the VA? Are they getting better, or are they slipping through the cracks? Our hypothesis is that these veterans who complain of the symptoms are not receiving the proper follow-up and treatment they deserve.''⁽⁶⁾

Many Gulf War veterans are concerned that their medical problems are chronic and disabling, and are the result of exposures to one or more chemical, biological or nuclear agents present in the theater of operations. Health problems of Gulf veterans may stem not only from chemical and biological warfare agents but from other sources such as: pesticides and insect repellants; leaded diesel fuel; depleted uranium; oil well fires; infectious agents; and the anti-nerve agent drug, pyridostigmine bromide.⁽⁷⁾

In 11 hearings⁽⁸⁾ since March 1996, the Human Resources Subcommittee has examined issues dealing with veterans' symptoms and complaints about the handling of their health problems by the VA, especially about inappropriate medical treatment or denial of treatment, missing or inadequate personal medical records, compensation issues, and lack of valid and timely Government research conclusions about the causes of their illnesses. The subcommittee also sought to ensure that any research programs conducted by the Departments of Defense [DOD], Health and Human Services [HHS], and the Environmental Protection Agency [EPA] were well-focused and coordinated.

The subcommittee has examined studies of effects of low level chemical exposures on humans and animals, and probable exposures of large numbers of troops to chemical warfare agents and other toxins during and after the war. Typical complaints of Gulf veterans are similar to known effects on humans who have been exposed to organophosphates, such as pesticides and other chemical agents.⁽⁹⁾ Organophosphates are chemically related to Sarin and other warfare agents present in the Gulf War theater.

Not listening to veterans' health complaints, many military and VA doctors - often unable or unwilling to diagnose veterans' illnesses as the after-effects of possible neurotoxic exposures - have insisted veterans suffered instead from stress, or post-traumatic-stress-disorder [PTSD].⁽¹⁰⁾ Many private physicians and researchers believe DOD and VA doctors have relied too heavily on psychological theories of causation while discounting the possibility of neurotoxic exposures.⁽¹¹⁾

The Human Resources Subcommittee has listened carefully to hundreds of Gulf War veterans who have written and called the subcommittee since hearings began in March 1996. The subcommittee has also listened to the testimony of 23 Gulf veterans who testified in the 11 hearings held.

A. LISTENING TO GULF WAR VETERANS

Among Gulf veterans testifying before the subcommittee were Steven Wood, Barry Kapplan, Chris Kornkven, Julia Dyckman, and Brian Martin, all of whom reported health complaints typical of the range of maladies often called the ``Gulf War Syndrome.''

Army S/Sgt. Steven Wood testified that during the first week of March 1991, he drove through ammunition storage sites destroyed by U.S. forces. Near a bombed out bunker, he inspected artillery rounds on the ground which he identified in an Army manual as chemical weapons. ``Later that day,'' Sgt. Wood stated, ``I started to get very sick with symptoms I suffer still today. I sought medical assistance that day ... [and] ... never once received any comprehensive, much less compassionate, treatment from the Army. I was told it was `all in my head.'''

Transferred back to Germany following the war, his symptoms continued. In 1994, Sgt. Wood, unable to get treatment from Army doctors and unable to perform his duties, contacted a German physician. ``This German doctor did more tests in 2 hours than the Army did in 5 years. When my wife and I left the [German] doctor's office, we were told that I `had been poisoned.' These findings were immediately dismissed [by Army doctors] as being worthless since they did not come from a military doctor. Then it was stated to me by this military doctor that they did not like Gulf War veterans [complaining] with health problems.''⁽¹²⁾

Major Barry Kapplan, a career Army pilot who had passed 15 flight physicals in the 11 years prior to deployment to the Gulf War, ``began to feel increasingly ill'' in April 1991 but dismissed the symptoms as related to the harsh desert environment. On May 8, he reported ``violent nausea, vomiting, diarrhea attack.'' On May 28, now back in Germany, he was admitted to a military hospital with ``cardiac arrhythmias ... severely bleeding gums, cough with sputum production, shortness of breath, severe fatigue, diarrhea, hair loss, skin rashes/lesions, and abdominal discomfort.'' Military doctors diagnosed Major Kapplan with ``just post traumatic stress.'' With severe brain, nerve, heart and gastrointestinal problems but still being diagnosed with ``somatoform disorder,'' he was given a discharge by the Army ``due to unemployability'' in October 1995.⁽¹³⁾

Major Kapplan's wife Nancy, a registered nurse, testified about ``the medical issues facing our family'' since her husband's return from the Gulf. Her four children have suffered from continual chronic infections and one child has ``... esophagitis, gastritis and gastroesophageal reflux disease ... with little relief of her symptoms.'' Mrs. Kapplan reported that she has similar chronic symptoms since her husband came home from the war.⁽¹⁴⁾

S/Sgt. Chris Kornkven, an Army Reservist, reported, ``While still in the Gulf I began experiencing symptoms that continue to this day. I had difficulty remembering significant events that happened days earlier ... my knees and shoulders [were] especially painful ... and fatigue stayed with me constantly.'' After the war, his symptoms worsened and included intestinal problems and headaches. He sought treatment in 1992 from VA doctors who - without any physical exam, testing or treatment - referred him to the mental health clinic where he was diagnosed ``PTSD.''⁽¹⁵⁾

``I reported blinding headaches with only offers of aspirin. I reported memory loss ... dismissed as stress. I reported skin problems ..`it's not cancer yet ... come back as needed.' I reported breathing problems ... no diagnosis. I reported intestinal problems ... and rectal bleeding ... dismissed [and] no follow-up. I reported joint pain ... diagnosed as fibromyalgia ... no treatment other than Motrin. I reported chest pains ... and racing heart beats ... [and] was told it was due to an abnormal heart valve ... [which] was hereditary,'' a point which S/Sgt. Kornkven says ``nicely avoids VA's rating guidelines.''⁽¹⁶⁾

During the war, thousands of troops, including S/Sgt. Kornkven, climbed on Iraqi vehicles destroyed by depleted uranium [DU] rounds which leave a residue of dangerous radioactive dust particles when inhaled or ingested. He was tested by the VA and told he ``had a higher DU count than those [troops] carrying around [DU] fragments in their bodies ... [but] it was nothing for me to worry about.''⁽¹⁷⁾

``My wife had a miscarriage in which the fetus had to be surgically removed. She has as much trouble with fatigue as I do. She was diagnosed by a private physician as having fibromyalgia. My son, who is 2 years old, has not slept a complete night since being born. He appears to have intestinal problems, his stools are very acidic, he is VERY light sensitive, and has the exact same rashes on his legs as I do.''⁽¹⁸⁾

As far as the VA's emphasis on stress as a cause of Gulf veterans' illnesses is concerned, S/Sgt. Kornkven stated that while stress may play some part in his malady, he believes that ``... veterans are subjected to much more stress by trying to navigate the bureaucracy of the VA, and with worrying how to cope with medical conditions that are ignored. All the while being unable to work, and wondering how to feed or house a family.''⁽¹⁹⁾

Gulf War and Vietnam War veteran Reserve Navy Captain Julia Dyckman is a registered nurse who was in charge of the emergency room and the out-patient clinic of Combat Zone Fleet Hospital 15 near Al Jubayl, Saudi Arabia, an area often under SCUD missile attacks. Her unit took care of 8,211 out-patients, 697 in-patients, and 90 combat admissions. In her hearing statement, she identified the following medical conditions reported by troops in-theater and treated by her hospital personnel: respiratory problems; unexplained fevers; vomiting; diarrhea; various rashes; numerous reactions to immunizations; unexplained stomach and abdominal pains; and cardiac problems.⁽²⁰⁾

On returning to the United States, Captain Dyckman was assigned to interview returning Gulf veterans. She stated: ``Many personnel voiced concerns over long term health effects, current health conditions, and numerous pay and family situations. The Readiness Commander did not like the results of my interviews ... interfered with my medical care ... [and] ... records of interviews I conducted were discarded. For most Gulf reservists, the only avenue available for medical care was civilian or possibly the VA. Some veterans were too ill to hold down a job and therefore had no medical insurance to cover civilian care.''⁽²¹⁾

``During this time my health continued to deteriorate. I was released from active duty even though my medical problems were not resolved. I sought care at the VA [for the following]: hearing loss; bronchitis; chronic cough; hypertension; rashes; foot and joint pain; stomach ulcer; diarrhea; headaches; abdominal pain. I was diagnosed with gout (although the gout test was negative); offered Tylenol; and told, `Nothing is wrong with you, get it through your head!'''⁽²²⁾

``For over 2-1/2 years I was shuffled from one VA clinic to another, each investigating a different body system. No coordinated treatment or diagnostic effort was ever experienced. It has been a problem with records [needed] for disability claims ... [which were] ... lost in the VA system. Disability and claims procedures are complicated and time consuming. In order to obtain VA treatment for Gulf illness, you have to first have a service connected illness or injury which is difficult to prove even when you were treated in-theater. Also, the VA only considers military and VA medical records for service connection, excluding expert civilian records. Additionally, they only use selected parts of records that agree with the VA and disregard any positive findings.''⁽²³⁾

``You might ask what it is like to be a Persian Gulf war veteran after 6 years. Each day starts with uncertainty. When you eat you are constantly sick and have intermittent diarrhea. Mobility is difficult due to swollen joints and muscle aches. Severe headaches are intermittent. Sometimes you forget what you are doing and what you were going to do. Pain and fatigue are constant companions. You are forced to deal with constant denials from the Pentagon that `nothing happened' during the war. These statements confuse medical providers who then doubt your credibility. What is needed is recognition, though not coded by the CDC, that Gulf war illness is a combination of unique symptoms and outcomes. This is why specific protocols need to be run before the VA says that this illness `doesn't exist' or is `all in your head.'''⁽²⁴⁾

Sgt. Brian Martin was a former member of the 37th Airborne Engineer Battalion, a unit which detonated and destroyed the Iraqi ammunition depot at Khamisiyah containing 100 bunkers and 43 warehouses. He videotaped the event and made it available to the subcommittee and television networks in the summer of 1996. Sgt. Martin testified: ``On March 4th, 1991, we entered the depot area, placing explosives in and around 33 bunkers. We set time charges for detonation, then moved south 3 miles to what we considered a `safe zone.' At no time whatsoever did we fear ... chemical exposure. We were told ... there were no chemicals in the area. Our commanders knew nothing about chemicals in the bunkers. Seven minutes later the destruction of Khamisiyah began.''

``Witnessing these awesome explosions was a remarkable sight. The explosions blew straight into the air, then would spread at the top ... [it was] ... the closest thing to a nuclear mushroom we would ever see. Our excitement quickly turned to fear when `cook offs' or fallout from the explosions began showering down on us. Several missiles landed underneath our trucks, spinning and taking off until blowing up. Men were running everywhere for cover. Giant clouds ... were covering us. The 82d Airborne [12 miles away] asked us to stop the detonation because of `cook-offs' penetrating their area. Our battalion moved into convoy formation and proceeded to vacate the area. Twenty miles later we found an area with no signs of `cook-offs.'''

``For the next 3 days it rained harder than any of us had seen in the 6 months we were there. Our commanders joked about us `putting something into the air to change the weather.' For the next 5 days it was unsafe for us to return to Khamisiyah to finish destroying the remaining 67 bunkers. The skies were dark, gray and cloudy for those 5 days.''

``Since Khamisiyah, I suffer from ... blood in vomit and stools, blurred vision, shaking and trembling ... muscles weakening ... chest pounding like my heart was going to explode. My symptoms were simply written off [by Army doctors] as a `stomach viral infection of an unknown origin.' My medical conditions were ignored. In December 1991, I put in for an `early out' from the military. I did not receive an exit exam nor did I know I was supposed to.''

``I suffer from excruciatingly painful headaches, memory loss, and severe diarrhea ... mood swings ... I violently vomit if I smell perfumes, vapors or chemicals. I get lost and forget where I am sometimes. I am an ex-paratrooper who needs a cane and wheelchair to get around. My joints ... swell, burn and hurt.''

``Today ... I have some clearly defined diagnoses from the VA of multiple chemical sensitivity, inflammatory bowel disease with scarring of the colon and stomach due to chemical exposure, temporal lobe brain damage also with scarring due to chemical exposure, Reiter's Syndrome, chronic fatigue syndrome, and tinnitus. I have abnormally high platelets around my blood cells, and recently I began testing for Lupus and Alzheimer's Disease. I am worn out all the time, yet I am an insomniac. For all of this, except [for] the chemical injuries ... the VA rated me in 1994 at 100 percent compensation ... then in 1996 added Permanent and Total [disability, following DOD's announcement about Khamisiyah].''⁽²⁵⁾

Other Gulf veterans testified before the subcommittee about life-threatening illnesses such as cancers, heart and lung problems, and Amyotrophic Lateral Sclerosis [ALS].

Colonel Gilbert Roman, U.S. Army Reserve, volunteered for active duty in the Gulf War and was named Deputy Commander of the 311th Evacuation Hospital, Army Medical Service Corps. He stated [in spite of profuse nasal bleeding from pre-cancerous polyps during testimony]: ``I arrived in Theater on January 6, 1991 ... [and] ... during official visits to strategic military cities there were frequent SCUD attacks during which I heard chemical alarms sound. When I asked if these alarms meant chemicals had been detected, I was told that the chemical alarms had malfunctioned. I [soon] became ill and was treated for nausea, headaches, vomiting, diarrhea and high temperature. Rashes I had over my body I thought were normal and expected since I spent most days in the sand, wind and sun with all the attendant fleas, flies and desert parasites. Headaches I attributed to fatigue and lack of sleep.''⁽²⁶⁾

``The symptoms ... continued after I returned home and got progressively worse. In 1993, I registered at [a] veterans' hospital after receiving an invitation from the VA to come in for an examination if I was a Gulf veteran. They recorded all of the ailments I indicated ... [but] ... no treatment was offered. The VA hospital billed me for my supposed `free examination' and they ended up attaching my next year's meager tax return.''⁽²⁷⁾

``To date, although I have now had three official examinations since 1993, I still continue to receive requests for more and more information from the VA claims office. Materials sent are never acknowledged as received, phone numbers given are not to any VA recognized exchange, and the name given for contact is not a true VA employee. Frustration ... [I've been] in the VA `system' 4 years with no real contact from a person; just requests for more information.''⁽²⁸⁾

``In 1996, I was hospitalized three times and treated by my private physician for a respiratory ailment. I could not walk more than 25 steps without having to stop, out of breath and fatigued. This ailment, which was life threatening, would not allow me to lie on my back to sleep as I would begin to drown ... as my lungs filled with fluid. I was forced to sit up for sleep and was constantly fatigued due to lack of sleep and no energy.''⁽²⁹⁾

``My [private] cardiologist, Dr. Peter Steele, diagnosed me as having `cardiomyopathy with congestive heart failure.' Dr. Steele stated [in a letter]: `What is clear is that he served in the Middle East and that he has a cardiomyopathy. I would submit that this may well be part of the Gulf War Syndrome.'''⁽³⁰⁾

Major Michael Donnelly, USAF retired, who flew 44 combat missions during the Gulf War, often flying through plumes from bombed Iraqi munitions manufacturing and storage facilities, stated: ``Upon return from the Gulf, I was reassigned to Florida ... [where] ... I first started to experience strange health problems. I didn't feel as strong as I once had or as coordinated ... [and] ... always fighting a cold or the flu. By the summer of 1995 ... [and] ... stationed in Texas ... I was exposed to malathion fogging, an organophosphate pesticide used for mosquito control, while jogging in the evenings. I started to have serious health problems.''

``Schetoma, or blind spots, in front of my eyes and my heart would beat irratically. Palpitations, night sweats, sleeplessness, trouble concentrating and remembering, and trouble taking a deep breath. Extremely tired much of the time. By December, I had trouble walking and experienced weakness in my right leg. In January 1996, I explained my symptoms, and mentioned I had been in the Gulf War, to a flight surgeon who immediately talked about the effects of stress. I was referred to a neurologist.''

``During the first visit with the neurologist, I heard the line that I would hear throughout the whole Air Force medical system: `There's no conclusive evidence that there's any link between service in the Gulf and any illness.'''⁽³¹⁾

Major Donnelly, in his 20's during the war, was diagnosed in January 1996 with ALS or ``Lou Gehrig's Disease.'' ALS, a rare fatal disease which generally affects people between the ages of 40 to 70, is ``a progressive wasting of muscles that have lost their nerve supply.''⁽³²⁾

DOD's Special Assistant for Gulf War Illnesses Dr. Bernard Rostker, an economist, has admitted that nine cases of ALS among Gulf veterans have been confirmed, and stated under oath that ``for the population that served in the Gulf, we would expect to see roughly between 7 and 11 cases of ALS. And we're looking at nine cases of ALS.''⁽³³⁾

However, [in response to Dr. Rostker's claim] the director of the Cecil B. Day Laboratory for Neuromuscular Research at Massachusetts General Hospital and an ALS expert, Robert H. Brown, Jr., M.D. and Ph.D., stated in a letter to the Human Resources Subcommittee:

``The incidence of new cases of ALS is about 1/100,000 individuals in our [overall] population. Thus, it is true to say that a group of 700,000 individuals might, in the aggregate, be expected to show 7 or so new cases of ALS over a year's time. However, these statements about aggregate populations must be interpreted carefully. In particular, they assume an age-spread that reflects an entire population [emphasis added]. If one looks at the age of onset of ALS, the mean onset age is 55 years. The number of cases showing onset below the age of 40 [emphasis added] is probably no more than 20-25 percent or so of the total. Thus, one might expect 0.20-0.25 cases/100,000 individuals [or an estimated 1.4-1.7 cases of ALS in the 18-40 age range]. As I understand it, there are now 9 or 11 cases of ALS in the Gulf War veterans population. This seems excessive to me [emphasis added].''⁽³⁴⁾

According to a study by Dr. Will Longstreth, professor of neurology at the University of Washington School of Medicine, people exposed to organophosphate compounds, such as pesticides and other chemicals, may be at twice the risk of developing ALS.⁽³⁵⁾

Another Gulf veteran with ALS is Marine Major Randy Hebert, also a subcommittee witness, who testified that he may have been contaminated from a reported exploding chemical mine near his vehicle when the Kuwait invasion began February 24, 1991. Major Hebert stated: ``I recall my right hand feeling cool and tingling''<sup>(36)</sup> as he struggled into his protective clothing and gear. After removing his mask when told it was a false alarm, he received another radio message: ``Your lane is dirty, chemical mine has gone off, go to MOPP 4 [full protective equipment].'' Major Hebert testified, ``I now feel that [removing his mask] was a mistake.'' Shortly after, Major Hebert said, ``he felt funny'' and had trouble breathing.⁽³⁷⁾

Returning home in May 1991, Major Hebert reported symptoms of memory loss, mood swings, vomiting, diarrhea, depression, and severe daily headaches. By the fall of 1994, he experienced uncontrollable coughing, throat muscle constriction, and atrophy in the right arm and hand. In October 1995, after more than 4 years of undiagnosed symptoms, he was finally diagnosed with ALS. ``I believe the medical problems I have discussed are due to low level chemical exposure over an extended period,''⁽³⁸⁾ Major Hebert concluded.

Nick Roberts, a subcommittee witness, was a Seabee with Naval Mobile Construction Battalion 24 stationed near the Port of Al Jubayl, Saudi Arabia -an area reportedly hit by SCUDs. He stated: ``On January 20, 1991, I was awakened by a loud explosion. Running to the bunker, I heard a second explosion and noticed a large fireball. I put my gas mask on. We sat there for approximately 20 minutes and then the all-clear was given. We went outside. I estimate that half of the unit returned to their tents and the other half remained outside talking.''

``I was one of the men outside talking. Within just a few minutes, my arms, neck and face were stinging, my lips felt numb and I had a strange taste in my mouth, like a copper penny ... a metallic taste. Some say a mist came over the camp ... [it seemed] more of a fog. Chemical alarms began sounding. Alarms going off everywhere. Marines camped nearby began to yell, `Go back to your bunkers. We have been gassed.' We were ordered to MOPP level 4. Radio transmissions were coming in, `Confirmed gas attack. Repeat, confirmed gas attack.'''

``We were given the all-clear once again. Afterwards, many of us went to the water tank and washed ourselves down to stop the stinging. My first symptoms were redness of the skin and welts on my chest that afternoon.''

Petty Officer Roberts reported that ``in the days and weeks that followed my symptoms began to grow in number: rashes and small blisters, fever, night sweats, and flu-like symptoms, just to mention a few. After a month, my lymph glands were swollen and my joints hurt. Once home ... we were turned over to the VA ... the Navy said they were not set up to take care of our medical needs. I never got any medication from the VA, nor was I ever diagnosed by the VA.''

Petty Officer Roberts reported that after 1-1/2 years of no help from the Navy or VA, ``I sought private medical help. Within 6 weeks of testing and a biopsy of my lymph gland, I was diagnosed with non-Hodgkin's lymphoma, a cancer, in stage three. I started on chemotherapy 2 days later.''

``The cause of my symptoms is very obvious. I stand by my charge - as I have from the very beginning - of chemical [warfare] exposure, not to mention the overall exposure from fallout due to intensive [United States] bombing of [Iraqi] chemical and biological plants, radiation fallout from thousands of depleted uranium rounds used by the United States, exposure to vaccines and nerve gas pills, and months of breathing smoke from more than 300 oil well fires. I don't see how you can call it anything else. Gulf veterans are suffering [from] chemical poisoning.''⁽³⁹⁾

Petty Officer Roberts concluded: ``By the end of 1993, [there were] 399 men out of 758 [in Battalion 24] who had been put out of the service because they were medically unfit.''⁽⁴⁰⁾

B. CHEMICAL DETECTIONS AND EXPOSURES

According to Gulf veterans who testified before the Human Resources Subcommittee, thousands of chemical alarms sounded and numerous chemical detections by trained U.S. chemical specialists with state-of-the-art equipment were made only to be ignored by American commanders. Czech chemical warfare experts recorded numerous detections, including detections along the Saudi border where hundreds of thousands of United States troops were massed for the invasion.

DOD has admitted that ``the Czech detections were valid.''⁽⁴¹⁾

In May 1994, DOD Secretary William Perry and Joint Chiefs Chairman John Shalikashvili signed a memorandum to Gulf veterans declaring: ``There have been reports in the press of the possibility that some of you were exposed to chemical or biological weapons agents. There is no information, classified or unclassified, that indicates that chemical or biological weapons were used in the Persian Gulf.''⁽⁴²⁾

In October 1994, however, the Senate Banking Committee released a staff report which compiled official documents and eyewitness testimony suggesting that U.S. troops had been exposed to chemical warfare agents during the Gulf War.⁽⁴³⁾

In March 1995, another event cast some doubt on DOD's insistence that there were no chemical or biological warfare agent exposures. In a television interview, John Deutch, then Deputy Secretary of DOD repeatedly qualified his statements regarding chemical weapons exposures in the Gulf War:

Mr. Deutch. Our most thorough and careful efforts to determine whether chemical agents were used in the Gulf lead us to conclude that there was no widespread use of chemicals against U.S. troops.

Bradley. Was there any use? Forget widespread.

Mr. Deutch. I - I do not believe ...

Bradley. ... was there any use?

Mr. Deutch. I do not believe there was any offensive use of chemical agents by Iraqi military troops. There was not ...

Bradley. Was there any - any accidental use. Were our troops exposed in any way?

Mr. Deutch. I do not believe that our troops were exposed in any widespread way to chemical ...

Bradley. In any narrow way? In any way?

Mr. Deutch. The Defense Science Board did an independent study of this matter and found, in their judgment, that there was not confirmation of chemical weapon widespread use in the Gulf.⁽⁴⁴⁾ (emphasis added)

The Pentagon, after 5 years of denial that United States troops were exposed to chemical weapons, finally admitted in June 1996 that 300 to 400 soldiers were ``presumed exposed'' to chemical warfare agents from fallout following detonation of Iraqi munitions bunkers at Khamisiyah. The number of ``presumed exposed'' continued to rise rapidly and by July 1997 the Pentagon had raised the number of exposed to 98,900.⁽⁴⁵⁾

In a January 1996 report to the Human Resources Subcommittee, Dr. Jonathan Tucker stated, ``Considerable data [exists] suggestive of such exposures during the Gulf War. During 1993-94, the staff of the U.S. Senate Banking Committee issued three reports compiling extensive circumstantial evidence for both direct and indirect exposures to U.S. troops to CBW [Chemical/Biological Warfare] agents during the war. In addition, a workshop sponsored by the National Institutes of Health [NIH] in April 1994 found that despite the lack of hard evidence, the possibility of CBW exposures should not be ruled out prematurely. The NIH report concluded, `Until it can be unequivocally established that chemical and/or biological weapons were not used and that troops were not exposed to plumes of destroyed stockpiles, the possibility remains that some symptoms are chronic manifestations of such exposure.'''⁽⁴⁶⁾

Dr. Tucker pointed out that in the last few years considerable information in the public domain - including press accounts, interviews, declassified Government documents under the Freedom of Information Act or posted on GulfLink⁽⁴⁷⁾ - presents a variety of evidence indicating Coalition troops were exposed to low levels of chemical warfare agents. He stated that while these exposures had no influence on the war's outcome, ``they appear to have resulted in delayed health problems in many of the exposed troops.'' In addition to ``affected United States troops, Gulf War illness has been reported among Australian, British, Canadian, Czech, Hungarian, Kuwaiti, New Zealander, and Norwegian veterans.''

Chemical detections during the war were also reported by French and Czech forces, Dr. Tucker stated. Among detections by the French were nerve and mustard vapors near King Khalid Military City during the air bombing campaign. Among the Czech detections were some along the Saudi border where hundreds of thousands of United States ground troops were massed for the invasion of Iraq.

According to a General Accounting Office [GAO] report, ``It is important to note that detections of the nerve agent Sarin occurred on January 19, 1991, and of mustard gas on January 24, 1991, by Coalition partners from Czechoslovakia in areas near Hafir al Batin. DOD has verified the reliability of the Czech equipment but has never identified the source [emphasis added] of these detections, although both DOD and CIA have deemed the detections credible. One cannot rule out the possibility that these detections were the result of fallout from Coalition bombing.''⁽⁴⁸⁾

A recent NY Times report, following an interview in Prague with Defense officials and Gulf War veterans, stated: ``Czech detection teams patrolling the northern Saudi Arabian desert in January 1991 were convinced that nerve gas detected in the early days of the war had been released from Iraqi chemical plants bombed by the United States.''

``Yet despite the reputation of Czech soldiers and their chemical equipment for reliability, combat logs compiled by officers working for Gen. Norman Schwarzkopf show that American commanders ignored Czech warnings that low levels of nerve and mustard gas had been detected in the vicinity of American troops,'' The Times reported. ``Czech soldiers recalled that even as they hurriedly pulled on their gas masks and rubberized chemical warfare suits after detecting chemical agents in the northern Saudi desert, the Americans who were stationed only several hundred feet away remained unprotected.''⁽⁴⁹⁾

According to the Tucker Report, ``Although DOD officials insist that all chemical agent detections by United States forces in the Gulf were false, they have reluctantly admitted that detections by Czech chemical defense detachments operating under contract to the Saudi government appear to have been authentic.''⁽⁵⁰⁾

``In addition to chemical alarms not associated with any obvious military activity, which were presumably triggered by chemical fallout from the bombing campaign,'' Dr. Tucker stated, ``many sick Gulf War veterans describe incidents in which they believe they were directly exposed to a chemical attack. Although most of these accounts are based exclusively on eyewitness testimony, in some cases the veterans' accounts have been corroborated by the available documentary record. A number of direct chemical exposures reported by veterans were associated with attacks by Iraqi SCUD or Frog ballistic missiles.''⁽⁵¹⁾

One such exposure cited by Dr. Tucker included the statement: ``Testifying in March 1994 before a subcommittee of the House Armed Services Committee, Sgt. George Vaughn ... described a SCUD attack ... in which he claimed he was exposed to some toxic chemical. During an alert, Vaughn experienced a problem with sealing his gas mask and the lens fogged up ... but in the heat of the moment ... [he] took the mask off his head. He immediately experienced a bitter almond taste and began choking. Within a day or two, Vaughn and three other members of his unit began to experience nausea, diarrhea, and severe fatigue. The gastrointestinal symptoms persisted after the four men returned from the Gulf. All four also developed fatty skin tumors called angiolipomas, which were surgically removed but have grown back repeatedly. Vaughn testified that the tumors have caused numbness in his arms and limited his motor skills.''⁽⁵²⁾

Among numerous detection devices and equipment used in the war by U.S. forces were M8A1 detector/alarms and the FOX detection vehicles. The Tucker report states that each of the nearly 14,000 M8A1 alarms deployed in the war went off an average of two or three times a day.⁽⁵³⁾

``The alarms went off so frequently, day and night, that some commanders ordered their troops to disregard or even disable them because no obvious symptoms of nerve-agent poisoning had been observed. DOD officials contend that every one of the tens of thousands of chemical agent alerts during the Gulf War was a false alarm,''⁽⁵⁴⁾ Dr. Tucker reported.

The most sophisticated CW agent detection system deployed in the Gulf was the German-made FOX Nuclear/Biological/Chemical [NBC] Reconnaissance Vehicle, an air-tight detector vehicle designed to detect chemical contamination on the ground so that advancing troops can avoid those areas. It carries a crew of four.

Two detection experts in the Gulf War, Army Major Michael Johnson and Marine Gy/Sgt. George Grass, appeared before the Human Resources and Intergovernmental Relations Subcommittee on December 10, 1996. Though still on active duty, they agreed to testify despite concerns about their military careers.

Major Johnson was commander of a FOX troop of detection vehicles. In testimony before the Human Resources Subcommittee, he stated: ``On 7 August 1991, the 54th Chemical Troop received the task of confirming the presence of a suspect liquid chemical agent at the Sabahiyah High School for Girls [Kuwait]. I led the mission ... [with] two FOX vehicles. The mass spectrometer showed the presence of H-Agent (Mustard, a highly volatile blister agent) in the soil. Simultaneously, a dismounted collection team, in full chemical over garments, moved to the container (estimated to be 800-1,000 liter capacity) with chemical agent monitors [CAM] and chemical detection equipment. The dismounted collection team employed detection paper and the CAM ... the detection paper [registered] H-Agent detection; the CAM registered H-Agent.''⁽⁵⁵⁾

Major Johnson indicated that additional tests by both FOX vehicles registered the same results - H-Mustard agent. He also reported that while withdrawing liquid from the container, a British soldier and member of team, had liquid drops make contact with his wrist. He was in extreme pain immediately and going into shock. He was decontaminated and taken to the hospital. The tapes and samples were turned over to personnel wearing camouflage with no rank or patches. It is unknown what happened to the tapes and samples [or the British soldier], according to Major Johnson.⁽⁵⁶⁾

``I would like to emphasize that these are the facts and not speculation of what actions we took,'' stated Major Johnson. ``I know that my unit ... did in fact detect and confirm the presence of toxic chemical warfare agents in Kuwait.''⁽⁵⁷⁾

Gy/Sgt. Grass, a FOX vehicle commander, also reported confirmed detections to the Human Resources Subcommittee. One detection reported was near an ammunition storage area outside Kuwait City. He testified: ``The alarm sounded on the mass spectrometer with a full and distinct spectrum across the monitor and a lethal vapor concentration of S-Mustard. We drove the FOX closer to the dug-in ammo bunkers and fully visible were the skull and crossbones on yellow tape with red lettering, and scull and crossbones on boxes [of ammo] and on signs. As we continued driving through the same ammo storage area the alarm sounded again ... HT-Mustard in lethal dose came across the monitor ... again with skull and cross bones. Another alarm sounded showing positive readings of Benzine Bromide.''⁽⁵⁸⁾

Gy/Sgt. Grass stated: ``I gave my superior officers all the mass spectrometer tickets from the Al Jaber Airfield [detections in the oil fields] and the ammo storage area ... I never saw the tickets I had given them again. When the EOD [ordnance disposal team] arrived, I escorted them to where the chemical weapons were detected [in the ammo storage area] ... they donned full protective equipment ... [and later] ... verbally acknowledged the presence of chemicals weapons in the storage area.''⁽⁵⁹⁾

``Since returning from the Gulf War, I have spoken to almost every FOX vehicle commander from both the 1st and 2d Marine Divisions,'' Gy/Sgt. Grass concluded, ``and every one of them has verbally acknowledged the positive identification of chemical agents in their area of operations.''⁽⁶⁰⁾

A DOD report on the Gy/Sgt. Grass' detection stated: ``Based on the information available thus far in this investigation, the presence of a chemical warfare agent in this area ... is judged to be `Unlikely.' Although two members of the FOX crew believe that their mass spectrometer detected something, the MM-1 did not sound an alarm. Senior NBC officers said that there was no report of chemical warfare agents at this time. Finally, there is no physical evidence - no spectrum, no sample, et cetera.''⁽⁶¹⁾

When a subcommittee Member asked Major Johnson and Gy/Sgt. Grass if they were suffering any physical effects from their Gulf War service, both men answered yes. Major Johnson said he began to have problems after he returned home ... ``changes in my blood pressure, headaches, burning eyes, joint pain, a mysterious growth in my left knee, chest pains, and gastrointestinal bleeding.''⁽⁶²⁾

Gy/Sgt. Grass said, ``I have rashes on my ankle and other parts of my body. My wife has been diagnosed with multiple sclerosis, and there are just numerous cases of illnesses that people have from something that went on over there, whether that was the exposure of chemical weapons or the biological weapons or both.''⁽⁶³⁾

Dr. Tucker, in testimony before the Human Resources Subcommittee, stated: ``Low level exposures to chemical weapons appear to have resulted from three sources: Chemical fallout from the aerial bombardment of Iraqi field munitions depots containing chemical weapons; explosive demolition of munitions bunkers by United States combat engineers; and sporadic and uncoordinated Iraqi use of chemical weapons in the ground campaign. The Pentagon would have us believe that the Khamisiyah incident is the whole story, I will argue that it is just the tip of the iceberg.''⁽⁶⁴⁾

Dr. Tucker, in his statement, identified over 55 specific chemical weapons detection or exposure incidents, and their locations, from January 13 to March 26, 1991.⁽⁶⁵⁾ In addition, he cites a U.S. Marine Corps survey of 1,600 chemical-defense specialists from Marine units who served in the Gulf War. A declassified Marine report stated that 221 respondents (about 13 percent) reported some contact with or detection of Iraqi chemical weapons during the ground war.⁽⁶⁶⁾

In addition, the possibility is raised by Dr. Tucker that the Iraqi saboteurs who ignited the Kuwaiti oil well fires may have deliberately contaminated some of them with chemical warfare agents. He cites a captured top-secret Iraqi military record which gives detailed instructions for sabotaging 31 oil wells with explosives. The record includes an attached letter from the commander of the 29th Infantry Battalion which states in part: ``Please send an assigned person from your personnel to the Chemical Rank Command of Battalion 14 to receive the chemical preparations (Tucker emphasis) distributed to your units according to the directions of the command above.'' Part of the document also makes reference to the use of individual chemical protective gear and decontamination stations for equipment and vehicles.⁽⁶⁷⁾

``This document raises the possibility that Iraqi troops deliberately contaminated the oil well fires with chemical warfare agents, generating clouds of poison-laced smoke with the intent of debilitating Coalition forces downwind,''⁽⁶⁸⁾ Dr. Tucker stated.

In that connection, FOX vehicle operator Gy/Sgt. Grass also testified about detections at Kuwait's Al Jaber Airfield during the oil well fires: ``As the mass spectrometer was monitoring for chemical agent vapor contamination with the usual readings from the oil fires, the alarm went off and the monitor showed a lethal vapor concentration of the chemical agent S-Mustard.'' Gy/Sgt. Grass noted that when he reported the detection to the Division NBC officer, he was told the reading was false and had been produced by oil well vapors. ``We explained to him [NBC officer] that we already know what the oil fire vapors looked like on the monitor and the readings were clearly distinct with the words S-Mustard printed across the screen and on the tape printed out as evidence of the contamination the Marines were exposed to. Division still insisted we had false readings and abruptly signed off the radio.''⁽⁶⁹⁾

Dr. Tucker's hypothesis about Iraqi disbursement of toxic agents in the updraft and high downwinds of the oil well fires is supported by the experience of ex-CIA agent Dr. David Morehouse. While in the Gulf theater, Dr. Morehouse and other CIA agents found multiple empty canisters or metal cylinders about 20 inches long and 4 inches in diameter placed upright in the sand [and] ``leaned like the Tower of Pisa,'' downwind of numerous well-head fires. In his book ``Psychic Warrior,'' he writes: ``It's obvious that the Iraqis placed the canisters next to the fires to mask the plume from the canisters. So I think they released a slow-acting toxin to poison the Coalition forces, and they covered it up with oil well fires. Every soldier downwind of those fires must've inhaled the bug of whatever it was. The heroes had been poisoned.''⁽⁷⁰⁾

Dr. Tucker's subcommittee statement concluded: ``Evidence in the public domain from a variety of sources indicates a far larger number of credible chemical weapons detection and exposure incidents than DOD or CIA have thus acknowledged. Eyewitness accounts, declassified intelligence records, and operational logs all suggest that Iraq deployed chemical weapons into the Kuwait Theater of Operations [KTO] prior to the Gulf War and may have employed them in a sporadic and uncoordinated manner against the Coalition forces during the ground war. U.S. troops also appear to have been exposed to low level chemical warfare agents from the air bombardment and ground detonations of chemical facilities.''⁽⁷¹⁾

Dr. Tucker, a former senior policy analyst to the Presidential Advisory Committee on Gulf War Veterans' Illnesses [hereinafter ``PAC''], was dismissed summarily from the PAC in December 1995, allegedly for his research on chemical exposures to U.S. troops and gathering the views of people inside and outside the Government who also believed that Gulf veterans were suffering from toxic exposures. His dismissal with only 1 hour's notice was in spite of high performance review ratings.⁽⁷²⁾

C. TOXIC EXPOSURES IN GULF WAR THEATER

U.S. troops who served in the Gulf War were exposed to multiple toxins, any one of which - alone or a combination of toxins producing a synergistic interaction - may well be responsible for the illnesses reported by thousands of veterans.

According to a GAO report, ``U.S. troops might have been exposed to a variety of potentially hazardous substances. These substances include compounds used to decontaminate equipment and protect it against chemical agents, fuel used as a sand suppressant in and around encampments, fuel oil used to burn human waste, fuel in shower water, leaded vehicle exhaust used to dry sleeping bags, depleted uranium, parasites, pesticides, drugs to protect against chemical warfare agents (such as pyridostigmine bromide), and smoke from oil-well fires. DOD acknowledged in June 1996 that some veterans may have been exposed to the nerve agent Sarin following post-war demolition of Iraqi ammunition facilities.''⁽⁷³⁾

Chemical Weapons

After 5 years of denial that United States troops were exposed to any chemical weapons, DOD disclosed on June 21, 1996 that some 400 soldiers were ``presumed exposed'' to Iraqi nerve agents. This event occurred when the 37th Army Combat Engineers detonated enemy munitions bunkers at Khamisiyah, Iraq in March 1991, sending plumes of nerve gas wafting into the atmosphere and dispersing over unprotected soldiers.⁽⁷⁴⁾

The number of exposed troops began to rise in following months as the DOD and CIA reconsidered modeling results pertaining to wind direction and other factors. In September 1996, DOD raised the number to 5,000 exposed; in October, to nearly 21,000 exposed.⁽⁷⁵⁾

On July 24, 1997, results of a new computer modeling study were revealed by the DOD and CIA suggesting that 98,900 United States troops must be ``presumed exposed'' to chemical weapons from the Khamisiyah bunker detonations. Original CIA computer modeling estimates released in June 1996 stated the plumes carried northerly for perhaps 25 miles. New modeling estimates stated the plumes carried southerly for perhaps 300 miles from the blast site, producing fallout over some 100,000 troops positioned in southern Iraq, Kuwait, and northern Saudi Arabia.⁽⁷⁶⁾

In April 1997, the CIA released 41 declassified documents, 1 of which stated the CIA had warnings starting in 1984 that thousands of chemical weapons were stored in Khamisiyah bunkers.⁽⁷⁷⁾ According to news accounts, the CIA claims they notified the Pentagon before the war of the presence of these weapons at Khamisiyah. The DOD had denied it until February 25, 1997, when the Pentagon disclosed that the CIA had in fact warned the Army but it never reached commanders of the 37th Army Engineers Battalion that detonated the Khamisiyah depot.⁽⁷⁸⁾

The United Nations Special Commission on Iraq [UNSCOM] testified on July 29, 1997 at the Presidential Advisory Committee [PAC] meeting in Buffalo, NY that the aerial bombardment during the war of the Ukhaydir, Iraq chemical weapons storage depot, and possibly the Mymona depot, sent toxins into the air that may have produced fallout over United States troops stationed in Saudi Arabia.⁽⁷⁹⁾ The CIA, also in testimony at the PAC meeting, stated: ``CIA and DOD now assess that there may have been a release of chemical agent from the Ukhaydir Ammunition Depot as a result of aerial bombing ...'' The CIA is continuing exposure modeling of this event.⁽⁸⁰⁾

[hereinafter ``UNSCOM''], ``Investigation of Deployment of Chemical Weapons,'' July 1997.

In August 1997, it was reported that a 1990 study by the Lawrence Livermore National Laboratory informed the U.S. Air Force - 3 months before the Gulf War began - that bombing of Iraqi chemical weapons manufacturing facilities would release deadly nerve agents over U.S. troops who were massing several hundred miles to the south. This report predicted a dispersion of chemical warfare agents over an area 10 times greater than subsequent DOD and CIA studies would show.⁽⁸¹⁾

According to testimony before the Human Resources Subcommittee by Gulf War expert James Tuite, director of the Gulf War Research Foundation, the Livermore Laboratory study proved to be prophetic. He stated: ``Up to now, the missing element ... has been the mystery of how the [chemical] agents were transported from the research, production and storage sites in Iraq to [Coalition] troops.'' This has been an especially difficult issue given that it has been the long-held assertion of DOD, DIA, and the CIA that the winds were blowing in the wrong direction [northerly] during the detection events.

``The report I submit today [I believe] solves the mystery of the [chemical] detections that occurred after the initial wave of Coalition bombings of these chemical warfare agent storage facilities during the first 2 days of the air war. Using available visible and infrared meteorological satellite imagery from NOAA [National Oceanic and Atmospheric Administration], which was available to military planners [but not used] during the war - a war before which they expressed deep concern over the fallout effects from these bombings - I have been able to determine that a thermal plume rose into the atmosphere over the largest Iraqi chemical warfare agent research, production, and storage facility at Muthanna after Coalition aircraft and missile bombardment.''

``Seventeen metric tons of Sarin were reportedly destroyed during these attacks, which began on January 17, 1991. These thermal and visual plumes extended [southerly] directly toward the areas where those same chemical warfare agents were detected and confirmed by Czechoslovak chemical specialists. Hundreds of thousands of U.S. servicemen and women were in the area where these detections occurred, assembling for the upcoming ground invasion of Iraq and the liberation of Kuwait.''⁽⁸²⁾

Biological Weapons

According to Dr. Jonathan Tucker's 1996 report to the subcommittee, Iraq had initially denied possession of biological weapons following the war. Over the next 5 years, however, persistent detective work by UNSCOM personnel gradually forced Iraqi authorities to admit the existence of an offensive biological warfare program, an extensive and sophisticated effort led by Ph.D. scientists trained in the West.

Dr. Tucker stated: ``As the centerpiece of this effort, Iraq mass-produced and weaponized three [biological] agents on a large scale: the bacterial agent that causes the disease anthrax, which is nearly always fatal within 4 days; botulinum toxin, an exceedingly potent bacterial toxin; and aflatoxin, a fungal toxin that is a liver carcinogen but can also serve as an incapacitating agent. In addition ... Iraq experimented with a range of other lethal and incapacitating agents.''⁽⁸³⁾

Dr. Tucker reported that Iraq conducted field trials of biological agents in bombs, rockets and aerosol generators from 1988 until Iraq invaded Kuwait in August 1990. At this point, their research and development [R&D] program shifted to a ``crash'' effort on large-scale production and weaponization.

``Even if Iraq was deterred from a large-scale or overt use of chemical and biological weapons [as a result of United States warnings of massive retaliation], it may still have engaged in covert or insidious (i.e., low-level) operations. Certainly, Iraq would have nothing to gain by admitting that it had employed chemical or biological weapons during the Gulf War, and much to lose politically and economically, since such as admission would make it even less likely that the UN sanctions would be lifted. Thus, Iraq's denials [of chemical and biological weapons use] should not be taken at face-value, especially in view of the evidence for Iraqi chemical weapons use.''

Dr. Tucker cites Iraqi military manuals on the use of chemical and biological weapons. An Iraqi Air Force Academy manual on nerve agents notes that these poisons ``have a cumulative effect; if small doses are used repeatedly on a target, the damage can be very severe.''<sup>(84)</sup> An Iraqi Chemical Corps manual states: ``It is possible to select anti-personnel biological agents in order to cause lethal or incapacitating casualties in the battle area or in the enemy's rear areas ... [and] incapacitating agents are used to inflict casualties which require a large amount of medical supplies and treating facilities, and many people to treat them. Thus it is possible to hinder the opposing military operations.''⁽⁸⁵⁾

A report by the U.S. Navy's Biological Defense Research Program, which performed BW detection and analysis for U.S. forces during the Gulf War, concluded: ``No agents (including anthrax and botulinum toxin) detected during Desert Shield/Storm despite fielding of state-of- the-art detection methods.''⁽⁸⁶⁾

A recent GAO report stated: ``DOD has consistently denied that Gulf War veterans were intentionally or unintentionally exposed to biological warfare agents, and prior to June 1996, it denied any exposure to chemical warfare agents. If servicemembers were exposed, exposure would have occurred in one of three ways: 1) through intentional Iraqi use of chemical or biological warfare agents; 2) through theaterwide contamination resulting from air war bombings of Iraq, or 3) through site-specific events. DOD has taken the position that chemical and biological agent exposures can be confirmed only through evidence of mass [and immediate] incidents of morbidity and mortality. Since there were no such instances, DOD asserted that Gulf War veterans were not exposed.''⁽⁸⁷⁾

The GAO report observed: ``According to the CIA ... the Iraqis had weaponized several biological agents at the time of the Gulf War, including anthrax, botulism, and aflatoxin (a potent liver carcinogen). ... [Aflatoxin's] effects may not be observed until decades after low-level exposure ...''⁽⁸⁸⁾

Infectious Diseases

According to the PAC December 1996 report, ``Infectious diseases endemic to the Gulf region include shigellosis, malaria, sandfly fever, and cutaneous leishmaniasis. Along with these infectious diseases, DOD medical personnel also monitored troops for dengue, Sindbis, West Nile fever, Rift Valley fever, and Congo-Crimean hemorrhagic fever. The documented low rates of infection among U.S. troops suggest exposures were minimal and/or preventive measures were ineffective.''<sup>(89)</sup> [hereinafter ``PAC Report''], pp. 98-99.

Microbiologist and immunologist Dr. Howard Urnovitz, chairman of the Calptye Biomedical Corp., testified before the Human Resources Subcommittee on the Gulf War Syndrome. He stated: ``One of my research efforts is focused on how chemical and infectious agents interact to initiate and maintain a chronic disorder. The symptoms [of Gulf War Syndrome] are similar to those of over a dozen unexplained epidemics over the last 60 years ... including headache, muscle pain, slight paralysis, damage to the brain, spinal cord or peripheral nerves, mental disorders ...''

``Recent studies have found that prolonged and aggressive antibiotic therapy appears to abate many of the symptoms associated with Gulf War Syndrome. Usually the therapy takes longer than ordinary treatments (i.e., 6 to 9 weeks instead of less than 3 weeks) and in many cases the symptoms return when the therapy is discontinued. It is not clear whether this response is directly due to the control of some antibiotic-sensitive microorganisms or a direct action on an inflammatory or neurologic process or some placebo effect.''

``It is known that the Gulf War was one of the most toxic battlefields in the history of modern warfare. Syndromes associated with organophosphate-induced delayed neuropathy [OPIDN] could explain many of the observed and unexplained illnesses. However, it may not be mutually exclusive to have tissue damage resulting from toxic exposures, which leads to inflammatory responses in critical tissues with ensuing opportunistic bacteriological, viral, and fungal infections. The continued presence of these pathogens may greatly impair a possible healing process. All of these risk factors need to be considered in trying to understand the underlying pathology of Gulf War Syndrome.''⁽⁹⁰⁾

Dr. Garth Nicolson, chief scientific officer and research professor at the Institute for Molecular Medicine, states that some illnesses can be explained by exposure of veterans to various biological agents, called chronic pathogenic infections, in combination with chemicals and then transported home to family members. Dr. Nicolson, who has studied 650 Gulf veterans and their immediate family members, discounts stress as a major factor in causing Gulf veterans' illnesses.

In testimony before the Human Resources Subcommittee, Dr. Nicolson stated: ``Gulf War illness [GWI] is not caused by stress, it is caused by multiple exposures to chemical, environmental, radiological and/or biological agents that cause chronic multisystem signs and symptoms that for the most part can be diagnosed as existing diseases. We have been particularly interested in veterans with GWI whose family members are now also sick with similar signs and symptoms, suggesting that many GWI patients suffer from biological, not chemical or radiological, origins for their illnesses. Illnesses caused by chemical or radiological exposures should not be transmitted to family members. GWI in immediate family members is officially denied by DOD and VA.''⁽⁹¹⁾

``After examining GWI patients'' blood for the presence of chronic biological agents, the most common infection found was an unusual microorganism, Mycoplasma fermentans (incognitus strain), a slow-growing mycoplasma located deep inside blood leukocytes (white blood cells) of slightly under one-half of GWI patients studied. When they are in the blood, similar to other bacteria, they can cause a dangerous system-wide or systemic infection. In addition, cell-penetrating mycoplasmas, such as Mycoplasma fermentans, may produce unusual autoimmune-like signs and symptoms ...''⁽⁹²⁾

``In GWI patients that tested positive for mycoplasmal infections in their blood, we have found that this type of infection can be successfully treated with multiple courses of specific antibiotics, such as doxycycline. Multiple treatment cycles are required, and patients relapse often after the first few cycles, but subsequent relapses are milder and patients eventually recover.''⁽⁹³⁾

``Chemical exposures can cause toxicological effects and produce many but not all of the signs and symptoms of GWI. In addition, chemical exposures can result in immunosuppression and leave an individual susceptible to infections.''⁽⁹⁴⁾

Leishmaniasis is also an infectious disease and is caused by a microscopic parasite that invades certain types of white blood cells. The disease is transmitted by sandflies, and a number of different leishmania species are known to infect humans. Disease that involve low levels of parasite infection can be particularly difficult to diagnose. It is rarely seen in the United States; however, more than 30 cases have been diagnosed among Gulf veterans. Accurate diagnosis of leishmaniasis, which can have a long latency period, is important because effective treatment involves the use of potentially toxic drugs in clinical trials but not yet approved by the Food and Drug Administration [FDA].⁽⁹⁵⁾

Depleted Uranium

Depleted uranium [DU] is a highly, toxic, radioactive by-product of the uranium enrichment process.⁽⁹⁶⁾ DU is used in munitions as armor-piercing rounds fired at enemy tanks, and as protective armor on U.S. tanks. When a DU penetrator impacts a hard target, most of the round burns up, scattering uranium dust and shrapnel in and around the target. In the Gulf War, DU is credited with destroying over 1,400 Iraqi tanks, as well as other equipment and weapons storage facilities.⁽⁹⁷⁾

``Exposure to DU armor and/or penetrators is dangerous, but DU poses the greatest risk to those who: breathe smoke or dust from a burning vehicle hit by DU rounds; climb on or enter a vehicle hit by DU rounds; or were in a friendly fire incident involving DU rounds.''⁽⁹⁸⁾

One of the more severe DU exposure events occurred in July 1991 in Doha, Kuwait when a major U.S. Army ammunition depot and motor pool exploded and burned for 2 days. DU armor on vehicles and 9,000 pounds of DU rounds were oxidized to powder exposing 3,500 soldiers in the vicinity to radiation and DU aerosol particles that were widely distributed by high winds. Soldiers involved in the cleanup several days after the fire were not warned of DU contamination and, therefore, wore no protective gear.⁽⁹⁹⁾

[Abstract 5, ``How U.S. Troops Were Exposed to DU'']

According to the booklet ``DU: The Stone Unturned,'' published by Swords to Plowshares: ``Even after the [Doha] fire, soldiers were never told about the presence of DU contamination. Soldiers swept the compound with brooms, picked up debris with their bare hands, and were never issued respiratory masks or other protective clothing.''⁽¹⁰⁰⁾

``Like most soldiers,'' the DU publication continues, ``S/Sgt. Chris Kornkven was unaware of the use of DU munitions during the war. Due to his exposure to DU dust on destroyed Iraqi vehicles, he has since tested positive for internalized depleted uranium.'' [S/Sgt. Kornkven testified before the Human Resources Subcommittee on January 21, 1997.]⁽¹⁰¹⁾

Radiation exposure expert Dr. Asaf Durakovic, a medical unit commander in the Gulf War and most recently the chief of nuclear medicine at the VA Medical Center in Wilmington, DE was a witness at the Human Resources Subcommittee hearing on June 26, 1997. Dr. Durakovic reported that his expertise was never used because he and his staff were never informed of the intended use of DU before the war or during the war.⁽¹⁰²⁾

In late 1991, following the war, 24 ill soldiers from the 144th Transportation & Supply Company in New Jersey were referred to Dr. Durakovic at the VA Medical Center in Wilmington for diagnosis and treatment. These soldiers had worked on battle damaged tanks and vehicles in the Gulf from January to March 1991 without protective equipment or clothing. In March, a Battle Damage Assessment Team arrived in full radioprotective clothing, inspected the vehicles, declared them ``hot'' and off-limits.⁽¹⁰³⁾

Preliminary testing showed 14 of 24 veterans ``contained decay products of radioactive uranium.'' According the Dr. Durakovic, urine samples sent to the Army Radiochemistry Lab in Aberdeen, MD, disappeared. Dr. Durakovic recommended additional, more comprehensive testing - including tests to determine if the 24 veterans had also inhaled DU particles - but further tests and treatments were denied by the VA. Of the 14 veterans, 2 have since died, and the remaining members of the 144th Company have scattered around the country making medical follow-up unlikely.⁽¹⁰⁴⁾

``None of my recommendations was ever followed. Every conceivable road block was put in my line of management of those patients. I was ridiculed. There were obstacles throughout my attempt to properly analyze the problems of those patients. My plan failed because of total lack of interest on the part of the VA to do anything for those unfortunate patients. I [even] received phone calls from DOD suggesting that this work is not going to yield meaningful information and should be discontinued.''⁽¹⁰⁵⁾

Dr. Durakovic was later terminated by the Wilmington VA hospital, he alleges for his outspoken views of the VA concerning the diagnosis and treatment of sick Gulf War veterans.

Physicist and DU expert Leonard Dietz, who testified before the Human Resources Subcommittee, writes and speaks frequently on the dangers of depleted uranium. In a recent abstract he stated, ``A large number of unprotected Gulf War veterans could easily have acquired dangerous quantities of DU in their bodies. We refer to scientific measurements that have been made of the atmospheric wind-borne transport of uranium aerosols up to 25 miles from their sources. Micrometer particles of DU can spread over a large region and poison many people both radiologically and chemically.''⁽¹⁰⁶⁾

[Abstract 20, ``DU Spread & Contamination of GW Veterans.'']

``A comprehensive epidemiological study should be made of all Gulf War veterans and their families,'' Dietz said, ``searching for evidence of residual DU in their bodies and for causes of genetic defects in their children. The health issues associated with DU munitions should be investigated and evaluated by independent medical and scientific experts separated completely from the DOD, VA, National Laboratories, U.S. military services and their contractors.''⁽¹⁰⁷⁾

Dr. Michio Kaku, nuclear physics professor at City University of New York, stated, ``Ultimately, the Gulf War Syndrome will be traced to a variety of factors, simply because the Pentagon released so much firepower on the Iraqis during that war that large quantities of materials were sent into the atmosphere, including DU and chemicals stored in warehouses. Ultimately, when the final chapter is written, DU will have a large portion of the blame.''⁽¹⁰⁸⁾

[Abstract 17, ``DU: Huge Quantities of Dangerous Waste.'']

``The Pentagon should release all its classified information concerning the Gulf War Syndrome and depleted uranium,'' Dr. Kaku said. ``It is a national embarrassment that the Pentagon, even at this late date, is still withholding vital information about precisely what happened during the Gulf War.''⁽¹⁰⁹⁾

A 1993 report by the GAO concluded, ``Although the Army's stated policy is to minimize personnel's exposure to radiation, it has not effectively educated its personnel in the hazards of DU contamination and in proper safety measures appropriate to the degrees of hazard. What little information is available is not widely disseminated and training on DU is basically limited ...''⁽¹¹⁰⁾

The DOD did not properly train Gulf troops to the dangers of DU before and during the war, according to Dr. Bernard Rostker, DOD's Special Assistant for Gulf War Illness. He made this statement in a July 1997 meeting on depleted uranium with Human Resources Subcommittee staff. Dr. Rostker advised the Human Resources staff that steps were being taken to educate troops, who may fight future wars, on the toxic effects of DU exposure.

Oil Well Fires and Petroleum Contamination

Iraqi troops, in a deliberate act of sabotage and revenge, ignited hundreds of Kuwaiti oil wells during the Gulf War. According to a Defense Science Board Report, ``On February 23, 1991, Iraqi forces began to destroy and set fire more than 700 oil wells throughout Kuwait.''<sup>(111)</sup> The date is challenged by the University of Arizona's Environmental Research Laboratory, concluding that, ``Solar radiation data indicate that the first oil well fires were most likely set on or around January 17, 1991''⁽¹¹²⁾ [an important date because it suggests an additional month of troop contamination]. The last of the 749 oil well fires, including storage tanks and refineries, were extinguished 10 months later, in November 1991.⁽¹¹³⁾

Oil well fires and petroleum related exposures are another possible cause of the Gulf War Syndrome. In testimony submitted to the Presidential Advisory Committee [PAC], chemical engineer and expert on health effects of petroleum exposure, Craig Stead stated: ``Petroleum was a major Gulf War environmental exposure. American troops were exposed to petroleum from oil well fires, oil contaminated drinking and shower water, oil soaked clothing, and use of petroleum for dust suppression, pesticide application, and fuel. Petroleum inhalation, ingestion and skin absorption causes illness. The symptoms of petroleum illness are consistent with symptoms reported by Gulf War veterans.''

``Clinical techniques exist to diagnose petroleum illness,'' Mr. Stead said. ``These techniques include broncho alveolar lavage [BAL], computed tomography, and magnetic resonance imaging. Known treatments for petroleum include the use of anti-inflammatory steroids, expectoration of oil in the lungs, and diet. Left untreated, petroleum illness is a progressive disease which can lead to emphysema and cancer as endpoints.''⁽¹¹⁴⁾

Sick Gulf War veterans testified about their experiences before the Presidential Advisory Committee and a National Institutes of Health Gulf War workshop. Testimony included:

``When they blew the oil well fires, it was unlike anything I ever seen in my life. It was like being in a locked closet in the dark. We are in the middle of 500 oil well fires. And the only thing that they [U.S. military] gave us was a white T-shirt and [said] `Put it over your face.' When they brought in the civilian contractors to put out these oil well fires, they had self-contained breathing apparatus. They had chemical suits. They had everything. Members of my team did [get ill].''⁽¹¹⁵⁾

``[I] was in the center of the oil fires in Kuwait City with no capability of distinguishing the sun from the moon for the first 6 weeks after the liberation of Kuwait. [My] body was so oil and soot covered that a black watch band was camouflaged on [my] wrist. The scarf [I] wore around [my] face did not filter out the air borne debris. [My] spit looked like oil and when [I] sneezed [my] mucus looked like axle grease.''⁽¹¹⁶⁾

``We were by the oil well fires for 2 weeks and we camped right next to them.''⁽¹¹⁷⁾

``I developed severe nasal problems from the oil smoke. I got breathing problems.''⁽¹¹⁸⁾

``I lived six city blocks from the fires for almost 2 weeks. I flew in the stuff every day.''⁽¹¹⁹⁾

``For 7 months, my husband's ship chartered through burning oil derricks in the water. They were on the oil spill. They ingested oil-infested water. They cooked with it. They showered in it. He has chemical sensitivity. He has asthma. He got it in the service.''⁽¹²⁰⁾

``We suffered chemical ingestion when our drinking, cooking, washing, and bathing water became heavily contaminated with some sort of chemical that burned our mouth, throat, esophagus, and stomach. When we took our showers, we smelled of petrochemicals as well as the freshly washed clothes we put on. The food tasted of kerosene. We were in a 100 percent contaminated environment. I became very sick with digestive problems that same day that the contamination came aboard ship in our drinking water. The Navy ships' distilling plants ... cannot filter out chemicals.''⁽¹²¹⁾

Gulf War veteran Debbie Judd, an Air Force nurse, testified before the PAC on a survey completed in 1995 by the Operation Desert Storm Association on 10,051 sick Gulf veterans. She reported the following results: ``Specific to the oil in the environment there, those breathing or enveloped in oil fire smoke was 96 percent; within clear visual area of the oil fires was 90 percent; worked in, lived in, or made travel through the burning oil fields was 72 percent; washed in water with an oily sheen was 68 percent. Those having oily taste to their food was 66 percent, and those with oily taste to the drinking water was 65 percent.''⁽¹²²⁾

A study, ``Kuwait Oil Fire Health Risk Assessment,'' by the U.S. Army's Environmental Health Agency concluded: ``Results of this [report] indicate the potential for significant long-term adverse health effects for the exposed troop or civilian employee populations is minimal ...''⁽¹²³⁾ [Executive Summary].

Craig Stead provided a statement to the Human Resources Subcommittee in which he said the Army study was flawed: ``In 1994, the Army issued the final Kuwait Oil Fire Health Risk Assessment. The Assessment used Gulf air pollution data gathered in May through November 1991. Air pollution from the oil field fires during this time was much less than during the Gulf War for the following reasons: The months of May through November [when the study was done] have the Shamal winds blowing from the northwest causing the smoke plume from the oil field fires to disperse widely and ascend to great heights. During the Gulf War (February and March) low wind speeds and air inversions were common. Under these conditions the smoke plume was on the ground, creating high localized levels of air pollution to which the troops were exposed.''⁽¹²⁴⁾

An Institute of Medicine [IOM] document confirms Mr. Stead's statement: ``The Army Health Risk Assessment could not launch a successful air-sampling effort until the beginning of May, after the more stagnant air conditions of the winter months had passed. Those who undertook the sampling efforts did so with this knowledge.''<sup>(125)</sup> Principal author of the Army report, Dr. Jack Heller, also confirmed the Stead statement: ``What we measured at the time we were there starting in May when the Shamal winds were strongly blowing and there was a lot of thermal lofting of the pollution. We didn't have those ground level impacts [present during the war]. In fact the whole time I was there I had [only] one ground level impact.''⁽¹²⁶⁾

Mr. Stead stated: ``Dr. Heller did not factor into the Assessment study the high levels of wartime air pollution to which the troops were actually exposed. The Assessment is seriously flawed ... [and] ... is a primary document relied upon by DOD, PAC, VA and IOM in concluding the oil field fires presented no health hazard to the troops.''⁽¹²⁷⁾ Mr. Stead also said the study was additionally flawed because it neglected to include troop exposures to contaminated rain during the fires, oil contamination in water for drinking, cooking and showering.⁽¹²⁸⁾

Also, a January 1991 study by the U.S. Army Intelligence Agency, issued on the eve of the invasion, forewarns of the threat of the oil well fires and tends to refute the U.S. Army Environmental Health Agency's Risk Assessment. The Army Intelligence report stated: ``Owing to Iraq's defensive `scorched earth' plan for Kuwait, the overall Kuwaiti oil infrastructure presents a serious hazard to advancing ally ground forces. There is overwhelming evidence that once ordered, the Iraqi forces will initiate demolition of oil wells, oil-gathering centers, oil-storage depots, pumping stations, large tank farms, refineries, and oil/product loading terminals. Demolition of these facilities and complexes will result in massive fires - `Burning Kuwait.'''

``The danger of oil fires, toxic gas, and smoke in the Kuwaiti Theater of Operations [KTO] is very serious [emphasis added]. These dangers ... are as follows: 1) Associated toxic and highly flammable gas from spilled raw sour crude oil from nonburning oil wells; 2) Intense heat of oil-well fires, possible natural-gas wells, and fire trenches; 3) Dense smoke and superheated gases from these fires. By far the greatest danger is from dissociated hydrogen sulfide gas and highly volatile light ends [gases] released from wellhead blowouts. In the KTO, the prevailing winds generally blow from the north-northwest southward toward Saudi Arabia [emphasis added]. Smoke and gases from Kuwaiti fires and blowouts most likely will be blown in the face of northerly advancing [United States] forces along the southern front of the KTO.''⁽¹²⁹⁾

Experimental Drugs and Vaccines

In December 1990, a month before the war, the Food and Drug Administration [FDA] agreed to issue a waiver to the DOD allowing the military to issue experimental drugs and vaccines to U.S. personnel in the Gulf without first obtaining informed consent. A factor possibly contributing to the illnesses of Gulf veterans was the ingestion of anti-nerve gas pills, pyridostigmine bromide tablets [PB tabs]. Troops were required to take the experimental drug to counter the effects of potential exposure to chemical warfare agents.

PB expert Dr. Thomas Tiedt, a neuroscientist and former pharmaceutical industry researcher, testified before the Human Resources Subcommittee that ``evidence shows that Gulf War Syndrome was easily predicted. The symptoms largely match those of cholinergic syndrome, which results from inhibition of the life-critical and development-critical enzyme acetylcholinesterase [AchE]. Pyridostigmine bromide, Sarin, and organophosphate pesticides are examples of AchE inhibitors ... [which] cause stunning nerve and muscle degeneration moments after a single dose, which worsens with multiple doses.''⁽¹³⁰⁾

``My team's research at the University of Maryland during the mid-1970's about physiological and microscopic AchE toxicity was comprehensive,'' Dr. Tiedt stated. ``Our work was followed by an explosion of research by DOD during the 1980's, the most relevant of which was produced by my co-authors and colleagues at Maryland and the [Army's] chemical-warfare R&D center in Aberdeen [MD]. DOD [research] established by the early 1980's that: 1) PB would be harmful in healthy individuals; 2) PB was worthless, even counterproductive, as a protectant against chemical warfare; and 3) PB was more toxic than sub-lethal doses of chemical warfare agents. I understand PB was taken by about 500,000 soldiers ... [and] it has been reported that 50-60 percent of soldiers taking PB have acute side effects.''⁽¹³¹⁾

Dr. Tiedt concluded: ``More attention is needed on the long record by the military to conduct involuntary, meritless, and hazardous experiments on soldiers. The Nuremberg Code [signed following World War II] states, `No experiments should be conducted where there is an a priori reason to believe that death or disabling injury will occur.' The use of PB was an experiment. It was the first time we used PB for such a purpose. There were no data supporting its use or the way it was used. Sadly, no records remain or were kept.''⁽¹³²⁾

Researcher and pharmacologist Mohamed Abou-Donia of Duke University has conducted research on animals using pyridostigmine bromide and other chemicals. Dr. Abou-Donia fed groups of hens with the anti-nerve agent PB, the insecticide permethrin, and the insect repellant DEET - all routinely used by the military in the Gulf War theater. Each chemical was administered alone and in various combinations.

According to Dr. Abou-Donia: ``This study shows that relatively high doses of PB, DEET, and permethrin appear to cause minimal health risk when used individually. It demonstrates, however, the increased neurotoxicity associated with coexposure to the same doses of test compounds. Although this study was not intended to simulate actual exposure conditions that may have existed during the Persian Gulf War, nor was it designed as a dose-response study, from it one can hypothesize why co-exposure to test compounds may have contributed to Gulf War veterans' illnesses. The variety of symptoms reported by veterans make it unlikely that a single etiologic cause is responsible for producing the Gulf War illnesses.''⁽¹³³⁾

Dr. Satu Somani, PB expert and professor of pharmacology and toxicology at Southern Illinois University's School of Medicine, also testified before the Human Resources Subcommittee on the health effects of pyridostigmine bromide. Dr. Somani stated:

``Years after Desert Storm, many veterans continue to suffer from medical problems such as fatigue, headache, joint pain, gastrointestinal disorders, and other ailments. This testimony is based on the premise that Gulf veterans were taking pyridostigmine as a precautionary measure against potential exposure to nerve agents (e.g., Sarin) and they were exposed to insecticides and other harmful chemicals. They were also under physical stress that modified the effects of such exposure. The toxic, harmful or poisonous nature of nerve agents is exacerbated by the fact, even if an individual were provided pre- or post-treatment, there is still a strong potential for such effects to continue because of delayed neurotoxicity [Somani emphasis]. Further, while acute toxicity can be treated with atropine, oxime and diazepam, no treatment is available for delayed neurotoxicity.''⁽¹³⁴⁾

``Delayed neurotoxicity, first reported in the 1950's, can occur 5 or 10 years after exposure to nerve agents. Studies have shown that organophosphate-induced delayed neurotoxicity [OPIDN] is due to inhibition of neurotoxic esterase enzyme in the nervous system, and histopathological axonal degeneration. This also produces muscular weakness and ataxia (difficulty in movement).''⁽¹³⁵⁾

Dr. Somani concluded: ``Based on recent experimental evidence and the similarities of symptoms of delayed neurotoxicity reported by workers in the organophosphate industry and also by Desert Storm veterans, the author concludes that GWS may be due to low-level exposure to Sarin [a chemical warfare agent] exposure, intake of pyridostigmine [bromide], and exposure to pesticides and other chemicals. The adverse effects of such exposures were amplified by physical stress conditions.''⁽¹³⁶⁾

Vaccines were also given to Gulf War troops. Anthrax was tested and approved by the FDA for limited use, and was administered to about 150,000 troops in the Gulf region. Botulinum toxoid vaccine was approved by the FDA for use with a waiver of informed consent, and about 8,000 troops were given this vaccine. It is also not known if side effects could occur with these vaccines when combined with PB or other chemicals.⁽¹³⁷⁾

The PAC report was critical of the FDA and DOD handling of experimental drugs and vaccines. It stated: ``The Committee also found that DOD and FDA deliberated carefully before enabling, through rulemaking, DOD to require troops to take pyridostigmine bromide [PB] and botulinum toxoid [BT] vaccine as pretreatments for possible CBW agents without FDA approval of the products for that purpose. We were concerned that FDA had failed, in the 5 years since the Gulf War, to devise better long-term methods governing military use of drugs and vaccines for CBW defense. We also found DOD's inability to produce records of who received PB or BT indicative of much need for wholesale improvement in the government's performance on medical recordkeeping during military engagements.''⁽¹³⁸⁾

Pesticides and Multiple Chemical Sensitivity [MCS]

Multiple chemical sensitivity is a disease that is being debated throughout the medical field. While a number of leading medical organizations have published papers that question the existence of multiple chemical sensitivity its diagnosis and its possible treatments,⁽¹³⁹⁾ a growing number of physicians and scientists have accepted the basic premise that exposure to a wide range of chemicals existing in the modern world can produce synergistic effects and cause a variety of health problems.

MCS expert Dr. Claudia Miller of the University of Texas Southwest Medical Center at San Antonio has focused her research, and co-authored several books over the past 9 years on patients who report developing chronic illnesses and chemical intolerances. These illnesses follow low level exposure to various chemicals, including pesticides, solvents, and combustion products. In subcommittee testimony, she stated: ``In 1995, we published a study of 37 patients who had been exposed to pesticides ... who subsequently reported developing multi-system symptoms and new-onset chemical, food and drug intolerances. Eighty percent of these individuals ... were no longer able to work or could only work part-time because of their health problems.''⁽¹⁴⁰⁾

Dr. Miller testified that common symptoms reported by these patients at the time they were exposed were often flu-like illnesses, fatigue, concentration difficulties, headaches, shortness of breath, musculoskeletal pain, and gastrointestinal symptoms. The patients also reported, according to Dr. Miller, ``new and unusual intolerances for common chemicals such as fragrances, traffic exhaust, gasoline, and household cleaning products. In addition, many found they could no longer tolerate alcoholic beverages, various foods, caffeine, and medications.''⁽¹⁴¹⁾

Beginning in 1992, Dr. Miller was asked by the Houston VA Medical Center to consult on the first group of sick Gulf War veterans. Dr. Miller evaluated 75 veterans and testified that ``These veterans' symptoms and their frequent reports of new-onset intolerances to chemicals, foods, and medications reminded me of the civilians we studied with histories of exposure to organophosphate or carbamate pesticides or to mixtures of solvents at low levels. Comparison of eight symptom scales derived by factor analysis revealed similar ordering of symptoms in the Gulf veterans and the pesticide-exposed civilians.''⁽¹⁴²⁾

Pesticides and insect repellants were heavily used before, during and after the Gulf War, according to Albert Donnay, executive director of the MCS Referral & Resources in Baltimore. Information he received from the DOD indicates that 21 different pesticides were used but no records were kept of amounts used, what they were used for, or who applied them.

In a memorandum to the Human Resources Subcommittee, Mr. Donnay stated: ``Officials in DOD responsible for pesticide use have told me that they kept no records of pesticide use during the Persian Gulf deployment. We urge DOD to focus on the chronic effects of pesticide exposures, not just the two pesticides currently being studied (DEET and Permethrin), but all 21 pesticides that the DOD admits sending to and using in the Persian Gulf during Operation Desert Shield and Desert Storm.'' Mr. Donnay wrote that ``... data from the EPA, DowElanco and others linking MCS to organophosphate pesticides [showed that] ... of the top 10 pesticides associated with MCS reports from 1984-1990 by the EPA-funded National Pesticide Telecommunications Network, 7 are on the DOD list of those used in the Persian Gulf. Even if the veterans' exposures to nerve agent fallout were not enough to induce illness, the DOD failed to consider how these may have interacted synergistically [emphasis added] with the veterans' extensive exposure to chemically similar pesticides. None of the CCEP [DOD's Gulf health registry] reports published to date discuss MCS data. We are concerned that MCS [data] was abandoned without any analysis ... and data are now being withheld from qualified researchers.''⁽¹⁴³⁾

The PAC report states, ``The Committee concludes it is unlikely that health effects and symptoms reported today by Gulf War veterans are the result of exposure to pesticides during the Gulf War. Lindane is an animal liver carcinogen, but it is too early to see an elevated liver cancer rate in Gulf War veterans.'' The PAC report draws no conclusion about MCS, but comments that ``There is no consensus case definition for MCS, although two recent government-sponsored conferences have attempted to develop one.''⁽¹⁴⁴⁾

D. ACUTE V. CHRONIC EFFECTS OF LOW LEVEL CHEMICAL EXPOSURES

In testimony before the subcommittee, Dr. Stephen Joseph, formerly DOD's Assistant Secretary for Health Affairs, stated, ``Current accepted medical knowledge is that chronic symptoms or physical manifestations do not later develop among persons exposed to low levels of chemical nerve agents who did not first exhibit acute symptoms of toxicity.''⁽¹⁴⁵⁾ This unequivocal statement became the basic medical policy of DOD and VA in terms of diagnosis, treatment, compensation and research of the illnesses affecting thousands of Gulf War veterans.

Dr. Claudia Miller, an expert on low level chemical exposures, stated before the subcommittee that Dr. Joseph's statement was not necessarily true. ``I think it is premature for anyone to say that low levels of organophosphates cannot cause chronic health problems,'' Dr. Miller said. ``There is a lot of literature now suggesting that is quite a possibility and there are ways to approach that question scientifically.''⁽¹⁴⁶⁾

``Sarin was not the only organophosphate-type exposure soldiers may have encountered in the Gulf: pesticides in this chemical class and pyridostigmine bromide, a related carbamate drug, were also widely used,'' Dr. Miller stated. ``There are now several studies, in addition to our own, linking chronic, multi-system symptoms to [low level] organophosphate/carbamate exposure.''⁽¹⁴⁷⁾

Dr. Stephanie Padilla, Environmental Protection Agency [EPA] neurotoxicology expert, agrees. In subcommittee testimony, Dr. Padilla said, ``Exposure to organophosphates may produce residual adverse effects ...'' and cause ``... organophosphate-induced-delayed-neuropathy [OPIDN]. Recent studies ... indicate there may be long-term health effects associated with exposure ...'' and ``... one [study] concluded that `results clearly indicate that there are chronic neurological sequelae to acute organophosphate poisoning ... .'''⁽¹⁴⁸⁾

In response to Dr. Joseph's statement that chronic symptoms from low level chemical exposure do not later develop unless acute symptoms first appeared, Dr. Padilla testified that pyridostigmine bromide, the anti-nerve gas tablets which the troops were required to take, would dampen or ``mask the acute effects'' of chemical exposure.⁽¹⁴⁹⁾

The subcommittee also learned that a 1974 study of low level chemical exposures, conducted by Dr. Karlheinz Lohs, then director of the Institute of Chemical Toxicology of the East German Academy of Sciences, concluded that ``mustard CW agents are capable of producing a wide range of mutagenic, carcinogenic, hepatotoxic [causing liver damage] and neurotoxic effects. It is important to note that even in the case of exposure to very slight amounts which do not necessarily bring on acute symptoms, toxic reactions may set in. How far this may lead to nerve-cell, hematopoietic or parenchymatous lesions depends largely on the state of health of the individual (for example, previous injury to any particular organ), duration of exposure or intervals between exposures and, last but not least, on individual `detoxification capacity' (enzymatic polymorphism, genetic disposition, and so on.)''⁽¹⁵⁰⁾

Dr. Joseph was not familiar with the Lohs study.⁽¹⁵¹⁾

Also in the 1970's, Dr. Frank Duffy, associate professor of neurology at Harvard University Medical School, and his research associates conducted a study for the U.S. Army's Rocky Mountain Arsenal [RMA], a facility where nerve gas containing munitions were stored and decommissioned. The Army post surgeon, Dr. Maurice Gaon, noted an unusual number of civilian employees with a symptom complex including fatigue, sleep difficulties, memory loss, trouble concentrating, irritability, loss of libido, among others. These symptoms were primarily noticed in employees much later following reported exposures to the nerve agent Sarin, an organo-phosphate. The Army called on Dr. Duffy and his associates to plan and implement a study of these exposures.⁽¹⁵²⁾

This situation provided Dr. Duffy with an opportunity to study the effects of accidental low level Sarin exposures on humans after 1 year, comparing their symptoms with symptoms of rhesus monkeys after 1 year by injecting the primates with low doses of Sarin.

The results, according to Dr. Duffy, indicated that ``low levels of exposure to the nerve agent Sarin can produce long-lasting effects. It was perfectly clear that not only were people, after [low level Sarin] exposure showing long-term effects, but it was widely accepted in the pesticide industry that exposure to related compounds like malathion and parrathion or the chlorinated hydrocarbon insecticides led to long-term consequence.''⁽¹⁵³⁾

Dr. Duffy stated: ``It has been suggested that since Army personnel did not appear to suffer acute symptoms which could be clearly recognized as resulting from acute Sarin exposure, that this explanation for Gulf War Syndrome must be irrelevant. This is not necessarily a valid assumption. First, the low level exposure to the monkey group demonstrated no symptoms ... and second, most of the exposed Army personnel at RMA suffered relatively minor symptomatology.''⁽¹⁵⁴⁾

According to the NY Times, Dr. Frank Duffy and his research colleagues Dr. James Burchfiel of the University of Rochester and Dr. Peter Bartels of the University of Arizona, ``said in interviews that the Pentagon seemed intent on ignoring or dismissing their evidence. Their research, which studied the effects of low doses of Sarin on humans and primates, showed the exposure resulted in long-term or chronic, perhaps permanent, changes in brain waves, which could be connected with ... symptoms common among Gulf veterans.''⁽¹⁵⁵⁾

In a 1987 letter to Robert Hall of the Hawaii Institute for Biosocial Research, Dr. Duffy also noted the possible confusion between organophosphate-delayed-neuropathy and stress: ``I applaud your effort in raising the level of consciousness about the serious potential for long-term effects due to exposures to these [organophosphate] compounds. It has been our experience that the side effects of minimal but continual exposures to the compounds mimic the symptoms associated with a stressful life [emphasis added]. Accordingly, most individuals are unable to determine whether their irritability is related to a stressful life or to a recent organophosphate exposure. This is a serious issue.''⁽¹⁵⁶⁾

Results of U.S. Air Force [USAF] studies on the health effects of sublethal, low dose exposure to nerve agents, published in 1992, bear on the question of acute v. chronic symptoms. The study was ordered because some AF personnel (e.g., bomb loaders and medical personnel) worked in potentially contaminated environments. USAF's Armstrong Laboratory conducted the studies of nerve agent behavioral toxicity in laboratory rhesus monkeys, and concluded that: ``Behavioral deficits [in primates] can be reliably detected in the absence of any overt [acute] signs of toxicity. This is especially important when assessing the effects of low-level exposures to extremely toxic compounds such as OP [organophosphate] nerve agents.'' The Air Force studies suggest that ``... repeated low-dose exposure to soman [a nerve agent] caused progressive and lasting inhibition of ChE [cholinesterase enzyme] ...''⁽¹⁵⁷⁾

Also disputing Dr. Joseph's statement was Dr. Seymour Antelman, University of Pittsburgh professor of psychiatry, who in a letter to the editor of the New York Times, stated: ``[Dr. Joseph's] view ... is almost certainly wrong. My research, published in leading scientific journals and the subject of a June 21, 1988, Science Times article, has shown that the effects of chemicals can develop and grow over time, and need not be present at the time of exposure. Such `time dependent sensitization' is more likely after exposure to a low level stimulus.''⁽¹⁵⁸⁾

In May 1996, 7 weeks prior to DOD's first admission of chemical exposures, Major General Ronald Blanck, commander of the Walter Reed Army Medical Center and the Army's chief physician, said, ``Clearly there is some evidence of low level exposure.''⁽¹⁵⁹⁾

Two VA physicians - Dr. Victor Gordan of the Manchester (NH) VA Medical Center and Dr. Charles Jackson of the Tuskegee (AL) VA Medical Center - began to suggest soon after the war that the sick Gulf veterans they had examined were exposed to chemicals. However, their views did not receive much attention from VA headquarters, DOD, or the news media.

In Human Resources Subcommittee testimony, Dr. Gordan, who has treated 544 Gulf veterans since 1991, stated, ``What is strikingly consistent in these veterans' stories are: 1) a drastic change in their health status from very good to perfect, as it was before deployment to the Gulf War, to poor to fair after their return from the war; 2) the large variety and number of symptoms suggesting dysfunction of more than one organ system in their bodies; and 3) the very consistent history of being exposed to chemicals in the Gulf, including the strong belief [by veterans] of being exposed to chemical warfare. These consistent stories point very strongly toward the environmental hazards as the cause or causes of these unexplained illnesses. Unless the science addresses these environmental hazards, we will never be able to adequately explain and hopefully solve these medical problems.''⁽¹⁶⁰⁾

Dr. Gordan concluded, ``Chemicals ... are the greatest masquerader in the modern medicine ... because they penetrate into all sorts of systems and organs, and those organs get dysfunctional, and those dysfunctions bypass symptoms, and symptoms can mimic so-called quantifiable disease, including arthritis, even PTSD.'' [emphasis added]⁽¹⁶¹⁾

In the same hearing, Dr. Jackson, an environmental physician covering Agent Orange and Gulf War illnesses, said, in reference to the chairman's earlier question to the VA, ``Well, one of the questions that you asked to Dr. Mather was whether or not one person in the VA had made the clinical opinion that there was a veteran exposed to chemical and/or biological agents, and, yes, there was. We did this back 3 years ago.''⁽¹⁶²⁾

Attributing the illnesses he was seeing to the product of multiple chemical exposures, Dr. Jackson said, ``Symptoms of the veterans are not inconsistent with those of the farm and veterinary workers with chronic low dose exposure to organophosphorus insecticides.''⁽¹⁶³⁾

Dr. Jackson added, ``Recent DOD and CIA revelations concerning the destruction of tons of mustard and Sarin in Iraq have supported the probability of exposure to the ... agents.''<sup>(164)</sup> ``We have gone on record as saying that we believe this is a significant factor. ... It was not a popular opinion, nor was it the official opinion of the VA.''⁽¹⁶⁵⁾

Dr. Frances Murphy, the VA's Director of Environmental Agents Service, offered the Department's official opinion, which supports Dr. Joseph, in testimony before the Human Resources Subcommittee: ``Studies of low level chemical warfare agent exposure were not given high priority ... because military and intelligence sources had stated that U.S. troops had not been exposed to chemical agents. Current body of research proves that low level exposures cannot cause health effects [emphasis added].''⁽¹⁶⁶⁾

The results of a study conducted by Dr. David Schwartz and his University of Iowa Medical School research colleagues were recently published in the Journal of the American Medical Association [JAMA].⁽¹⁶⁷⁾ The Schwartz study, supported by the Centers for Disease Control and Prevention, found that Persian Gulf veterans are reporting more medical and psychiatric conditions than their military peers who were not deployed to the Gulf War. Gulf veterans reported an 11 percent higher prevalence of symptoms of cognitive dysfunction or problem thinking, but only a 1 percent increase in PTSD.⁽¹⁶⁸⁾

Dr. Robert Haley and his research colleagues at the University of Texas Southwestern Medical Center also completed a study in early 1997 of Gulf veterans, the results of which were published in three articles in JAMA. According to the study, ``Some Gulf War veterans may have delayed, chronic neurotoxic syndromes from wartime exposure to combinations of chemicals'' and that ``clusters of symptoms of many Gulf War veterans reflect a spectrum of neurologic injury involving the central, peripheral, and autonomic nervous systems.''⁽¹⁶⁹⁾

People have asked why most Gulf War veterans have not reported illnesses while only some veterans were affected. Dr. Kenneth Olden, director of the National Institute of Environmental Health Sciences, was recently quoted in the press: ``We've known for a long time that when several hundred people are exposed to the same environmental toxicants, some people get sick and others don't. There are a number of enzyme systems that detoxify chemicals. If you have too little - that's a problem.''⁽¹⁷⁰⁾

The results of a second study by Dr. Haley on Gulf veterans was published in August 1997 by the National Academy of Neuropsychology.⁽¹⁷¹⁾ The new study compared the brain-related and psychological functions of ill and well Gulf veterans, and found no evidence of psychological problems, including PTSD or other stress-related illnesses. Some Gulf veterans, the study says, suffer from a form of brain damage found in toxic poisoning victims.

A New York Times article reported, ``Stephen C. Joseph, the Pentagon doctor overseeing the investigation of the Gulf War Syndrome, is under attack on the political battlefield. Senator John D. Rockefeller 4th (D-WV) has called him arrogant and demanded his resignation. ``Dr. Joseph is at the heart of a culture that has never looked at this problem seriously enough,'' said one senior White House official involved in this issue. The uproar involves ... questions over how the Pentagon responded to veterans' health complaints and its refusal to acknowledge that the veterans might have reason to worry about exposure to chemical or biological agents, anti-nerve gas pills, or other environmental factors in the Persian Gulf.''⁽¹⁷²⁾

As a result of increased congressional and news media attention on issues surrounding the Gulf War veterans' illnesses, then DOD Deputy Secretary John White assumed the role of DOD spokesman on Gulf issues in October 1996.

Dr. Joseph resigned in March 1997.

One of the most frequently asked questions by the veterans, public and press is why the DOD for 5 years continued to deny that troops were exposed to chemical warfare agents or that low level exposures caused illness. The U.S. News & World Report in an article ``Gulf War Mysteries'' stated:⁽¹⁷³⁾

``If exposure to chemicals is ever tied to widespread illnesses among veterans, the government may face other dilemmas. A link could open the door to thousands of disability claims, plus legislation mandating greatly expanded health coverage for veterans. The repercussions could reach to future battlefields as well. An official determination that chemicals have seriously harmed U.S. soldiers would be an admission of vulnerability, likely to encourage Iraq and other potential foes such as North Korea to use chemical weapons if they ever face off against the United States in the future. The next time the alarms start going off, the all-clear may not be so quick to follow.''

E. EXPOSURES AND VA MEDICAL PROTOCOLS FOR GULF VETERANS

In view of DOD's admission on June 21, 1996, after 5 years of denial, that Gulf War troops were presumed exposed to chemical warfare agents at the Khamisiyah bunker detonations, and in view of the missing or inadequate medical records of veterans and chemical detection logs, Human Resources Subcommittee Chairman Shays wrote to then VA Secretary Jesse Brown calling for an immediate re-evaluation of the diagnostic and treatment protocols, and compensation practices, for Gulf War veterans.

The chairman's letter follows:

October 3, 1996

The Honorable Jesse Brown

Secretary

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

Dear Mr. Secretary:

The Subcommittee is deeply concerned that Department of Veterans Affairs (VA) diagnosis, treatment, research and compensation policies with regard to Persian Gulf War veterans continue to rely on discredited conclusions by the Department of Defense (DOD) concerning exposure of U.S. troops to chemical weapons and other toxins.

At our September 19, 1996 hearing on Gulf War Veterans' Illnesses, Dr. Frances Murphy, Director of the VA Environmental Health Service, conceded in testimony that the VA research agenda through 1995 placed a low priority on low-level chemical warfare agent exposure "because military and intelligence sources had stated that U.S. troops had not been exposed to chemical agents." We fear more than VA research has been distorted by reliance on premature, erroneous and misleading conclusions by DOD about the presence and effects of chemical weapons in the Gulf War theater.

As part of our continuing oversight of VA activities to address the serious illnesses suffered by Gulf War veterans, the Subcommittee requests your prompt response to the following inquiries:

1. Why did the VA diagnostic screening protocol for Gulf War veterans fail to identify even one veteran exposed to chemical weapons agent(s) or other toxins?

The DOD now estimates more than 15,000 troops were in the path of the toxic plume generated by the detonation of Iraqi chemical weapons in the pit area at Khamisiyah. We can only expect that number to increase. From an initial estimate of 400, Pentagon estimates of U.S. troops probably exposed to toxic nerve or blister agents have steadily increased, first to 1,100, then 5,000, now 15,000. A recent news report indicates the number could be as high as 130,000.

VA adherence to the DOD "no exposures" doctrine, often in the face of compelling clinical evidence to the contrary, could be viewed as Department-wide medical malpractice. Many of those exposed have been examined by the Gulf War Health Registry program. Others have sought treatment at VA facilities. How is it that VA doctors appear to have misdiagnosed all of them?

2. Please identify each specific element of the VA diagnostic screening protocol for Gulf War veterans designed to capture evidence of chemical exposure.

Recently, both Dr. Kenneth Kizer, Under Secretary for Health Affairs, and Dr. Murphy testified the "VA has always remained open to the possibility that [Persian Gulf War] PGW veterans were potentially exposed to a wide variety of hazardous agents while serving in the Southwest Asia theater of operations, including chemical warfare agents." Yet veterans consistently tell the Subcommittee that VA officials ignore or discount their recollections of battlefield exposures.

As a result, the variable range of veterans' illnesses, characterized by rashes, headaches, muscle and joint pain, gastrointestinal dysfunction and impaired cognition, are diagnosed as Post Traumatic Stress Disorder (PTSD), somatoform disorder or other psychological conditions. Could these same symptoms be associated with exposure to low levels of toxic agents?

Has the VA ignored logical, even obvious, theories of toxicological causation for Gulf War veterans illnesses for five years simply because DOD had already concluded, erroneously, that U.S. troops had not been exposed?

3. What immediate changes will VA make to diagnosis, treatment and compensation policies in light of recent disclosures by DOD regarding exposure of U.S. troops to chemical agents?

In testimony before a joint hearing of the Senate Select Intelligence and the Senate Veterans Affairs Committees, Dr. Kizer said, "The diagnosis of conditions related to nerve toxins, whether they be chemical warfare agents, pesticides or hazardous industrial chemicals, is based on two things: first, known or presumed [emphasis added] exposure to the chemical agent, and second, symptoms or physical signs consistent with the known biological effects of the chemical. Absent definite exposure data and/or typical symptoms and signs, it is essentially impossible to make a definitive diagnosis of chemical-related neurotoxicity."

Do you believe you now have "definitive exposure data?" Prior to the recent revelations, the VA neither acknowledged nor presumed exposures in diagnosis, treatment or compensation of Gulf War veterans. Now that exposures may, indeed must, be presumed, will VA policies change? In what way?

4. On what data does the VA rely to conclude that low-level chemical exposures cause no chronic health effects in the absence of acute symptoms at the time of exposure?

Both DOD and VA continue to insist that low-level exposures cause no long-term, chronic health effects unless acute symptoms appeared at the time of exposure. However, given the status of research in this area, that conclusion seems premature. Dr. Kizer told the joint Senate hearing "the research in this area is sparse and in VA's judgment it should not be construed to mean that clinically important adverse health effects cannot or definitely do not occur in the setting of low-level neurotoxin exposures." Shouldn't sick veterans be given the benefit of any doubts in this regard?

While VA research in this area is underway, what role will VA health screening and health care play in gathering data to support, rather than disprove, the hypothesis that low-level exposures can cause chronic health effects, even in the absence of evidence of acute symptoms at the time of exposure? The Subcommittee has been troubled by the VA's selective, even disingenuous, use of Gulf War Health Registry information to support epidemiological hypotheses favorable to the "no exposure" conclusion, while the VA aggressively disputes any contrary implications drawn from Registry data due to the self-selected nature of the cohort.

5. Why does the VA assume there were no acute symptoms of chemical exposure?

What does the VA consider an "acute" symptom? What evidence does VA require to support a veteran's claim that acute symptoms were the direct result of an exposure? Does the VA believe only incapacitating symptoms are acute?

Sick veterans consistently reported flu-like symptoms, rashes, headaches and other maladies during their service in the Gulf. Others simply went about their duties as best they could, and did not report the ill-effects variably attributed to pills, vaccines, pesticides, engine fumes, rocket fuel, oil fires, indigenous infectious agents ... and chemical warfare agents.

Even when illnesses were reported, DOD medical records are not complete. Some were "lost" or destroyed. Unit chemical detection logs are also missing. DOD troop locator data is unreliable. Given this lack of consistent or reliable DOD information on chemical exposures and their effects, as opposed to consistent and persistent reports of illnesses by veterans, why does the VA choose to listen to DOD rather than the veterans? How can the VA conclude that Gulf War exposures caused no immediate health effects?

At our most recent hearing, medical witnesses discussed the possibility that pyridostigmine bromide (PB) could mute or mask the onset of acute symptoms resulting from chemical exposure. Could this account for any lack of acute symptoms noted by DOD?

Finally, I am personally skeptical of the Pentagon's call for another review of its handling of this matter by the Institute of Medicine (IOM) and the National Academy of Sciences (NAS). Those are both prestigious institutions, but the IOM has already made detailed recommendations about the quality and quantity of government research into Gulf War illnesses. Another review of the current investigation could involve the IOM in a critique of their own earlier work. If only to avoid the perception that DOD is seeking a friendly forum for its a priori conclusions, shouldn't another review of these issues be truly independent of all that went before?

Moreover, many of the disease conditions of which Gulf War veterans often complain - chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity - are poorly understood and only recently characterized by standardized diagnostic criteria. Shouldn't an independent review of the issues surrounding Gulf War veterans' illnesses be broad enough to include researchers and practitioners involved in the study and treatment of these disease states?

Sincerely,

Christopher Shays

Chairman

Secretary Brown's response follows:

THE SECRETARY OF VETERANS AFFAIRS

WASHINGTON

NOV 19, 1996

The Honorable Christopher Shays

Chairman, Subcommittee on Human Resources

and Intergovernmental Relations

Committee on Government Reform and Oversight

U.S. House of Representatives

Washington, DC 20515-6143

Dear Mr. Chairman:

Enclosed are the Department's responses to post-hearing questions you posed in connection with the September 19, 1996, hearing on issues related to Persian Gulf veterans.

We regret the delay in getting these questions answered and appreciate the opportunity to submit this information for the record.

Sincerely yours,

Jesse Brown

Enclosure

JB/rlh

cc: Hon. William F. Clinger, Jr. Hon. Edolphus Towns

Hon. Bob Stump

Hon. G.V. (Sonny) Montgomery

POST-HEARING QUESTIONS

CONCERNING THE SEPTEMBER 19, 1996

HEARING ON ISSUES RELATED TO

PERSIAN GULF WAR VETERANS

FOR THE DEPARTMENT OF VETERANS AFFAIRS

FROM THE HONORABLE CHRISTOPHER SHAYS

CHAIRMAN, SUBCOMMITTEE ON HUMAN RESOURCES

AND INTERGOVERNMENTAL RELATIONS

HOUSE COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

Question 1: Why did the VA diagnostic screening protocol for Gulf War veterans fail to identify even one veteran exposed to chemical weapons agent(s) or other toxins?

The DoD now estimates more than 15,000 troops were in the path of the toxic plume generated by the detonation of Iraqi chemical weapons in the pit area at Khamisiyah. We can only expect that number to increase. From an initial estimate of 400, Pentagon estimates of U.S. troops probably exposed to toxic nerve or blister agents have steadily increased, first to 1,100, then 5,000, now 15,000. A recent news report indicates the number could be as high as 130,000.

VA adherence to the DoD "no exposures" doctrine, often in the face of compelling clinical evidence to the contrary, could be viewed as Department-wide medical malpractice. Many of those exposed have been examined by the Gulf War Health Registry program. Others have sought treatment at VA facilities. How is it that VA doctors appear to have misdiagnosed all of them?

Answer: The question assumes that there is some diagnostic test to detect temporally remote neurotoxic exposure. Unfortunately, there is no such test. The challenge we face with neurotoxic chemical warfare agents is that there is no pathognomonic set of signs or symptoms, diagnostic test or biomarker for chronic toxicity. Likewise, there is no specific treatment for any chronic effects from these exposures once they occur in an individual. Causal inference in most cases is not scientifically possible, unless exposure has been quantified by specific measurement and accurately documented. There are many similar examples where medical science cannot link a specific outcome to a specific toxic exposure in an individual patient Conversely, similar clinical effects can be the end result of a variety of different toxic or nontoxic causes.

Inability to assign a definitive cause for an individual veteran's diagnosis hardly equates to misdiagnosis. VA's Registry physicians are aware of the environmental exposures and toxins relevant to Persian Gulf War service and have been instructed to ask questions in the veteran's medical history concerning this wide range of exposures. These exposures include, but are not limited to: chemical warfare agents; smoke from oil well fires, tent heaters, and burning trash; CARC paint; fuels and solvents; pyridostigmine bromide; vaccinations; and depleted uranium. Many veterans report exposure to one or more of these agents during their Gulf service. In some cases, a diagnosed medical condition has been causally linked to one of the reported exposures, e.g., CARC paint and asthma. However, in many cases medical science is simply unable to determine the cause for individual symptoms or diagnoses. This does not mean such individuals were "misdiagnosed."

We strongly disagree that VA has either adhered to a "no exposures" belief or ignored compelling clinical evidence. Our policy makers, researchers, and clinicians have been open to all possibilities, and we are deeply disappointed that you would intimate that the Department committed medical malpractice. VA has diligently pursued scientifically supportable medical diagnoses in Persian Gulf War veterans. Our care is consistent with medical community standards. There is simply no factual support for your statement that there was "compelling clinical evidence" for chemical warfare agent exposure.

Question 2: Please identify each specific element of the VA diagnostic screening protocol for Gulf War veterans designed to capture evidence of chemical exposure.

Recently, both Dr. Kenneth W. Kizer, Under Secretary for Health and Dr. Frances M. Murphy testified the "VA has always remained open to the possibility that [Persian Gulf War] PGW veterans were potentially exposed to a wide variety of hazardous agents while serving in the Southwest Asia theater of operations, including chemical warfare agents." Yet veterans consistently tell the Subcommittee that VA officials ignore or discount their recollections of battlefield exposures.

As a result, the variable range of veterans' illnesses, characterized by rashes, headaches, muscle and joint pain, gastrointestinal dysfunction and impaired cognition, are diagnosed as Post Traumatic Stress Disorder (PTSD), somatoform disorder or other psychological conditions. Could these same symptoms be associated with exposure to low levels of toxic agents?

Has VA ignored logical, even obvious, theories of toxicological causation for Gulf War veterans illnesses for five years simply because DoD had already concluded, erroneously, that U.S. troops had not been exposed?

Answer: The Registry examination requires a careful medical history including an exposure history. The exposure history asks the veteran to report whether he or she believes that they were exposed to a nerve agent or mustard gas. A complete physical examination is required, which includes mental status and neurologic examinations. The Phase II protocol, a set of clinical guidelines for Persian Gulf veterans with difficult-to-diagnose medical conditions, contains symptom-specific diagnostic guidelines for numbness, muscle complaints, and memory loss which could potentially result from a toxic exposure to chemical warfare nerve agents. A copy of the manual and code sheet are attached (Attachment 1), and the relevant sections are tagged and highlighted. As outlined in our testimony, the issue of chemical warfare agents is given specific attention and focus in the protocol.

Many of the signs, symptoms, and medical diagnoses of individual Persian Gulf veterans who have undergone VA registry examinations are not conventionally considered to be causally linked to chemical warfare agent exposures. You have stated "Both DoD and VA continue to insist that low-level exposures cause no long-term, chronic health effects unless acute symptoms appeared at the time of exposure." In VA's view, the published literature, while limited, does not demonstrate the development of readily identifiable, long-term adverse health effects due to nerve agent exposures in human subjects who have not shown signs of acute toxicity or poisoning. There are no scientifically endorsed, published studies showing clinically important adverse health effects after low dose exposures. Several prestigious medical advisory groups, including The National Academy of Science's Institute of Medicine and the Armed Forces Epidemiology Board, have also concluded that the available published scientific literature does not contain clear evidence that long-term, chronic adverse health effects result from exposures that do not produce acute clinical signs and symptoms. However, as we stated in our testimony before a joint hearing of the Senate Veterans' Affairs Committee and the Senate Select Intelligence Committee, "[I]n VA's judgment this should not be construed to mean that clinically important adverse health effects cannot or definitely do not occur in the setting of low-level neurotoxin exposures, especially if combined with other components or environmental stressors." Because there are so few studies on this question, we believe that additional research is needed to determine whether exposure to low-levels (non-poisoning, subtoxic) of chemical warfare nerve agents cause long-term health effects, including chronic or delayed onset of a characteristic set of symptoms, signs or medical conditions.

VA is fully committed to pursuing answers to this question. VA will work with DoD on a call for proposals to fund research in this area. VA is also sponsoring an international symposium on low-level chemical warfare and nerve agent exposure to stimulate scientific thinking and benefit from the scientific experts published and unpublished knowledge of the topic.

Question 3: What immediate changes will VA make to diagnosis, treatment and compensation policies in light of recent disclosures by DoD regarding exposure of U. S. troops to chemical agents?

In testimony before a joint hearing of the Senate Select Intelligence and the Senate Veterans' Affairs Committees, Dr. Kizer said, "The diagnosis of conditions related to nerve toxins, whether they be chemical warfare agents, pesticides or hazardous industrial chemicals, is based on two things: first, known or presumed [emphasis added] exposure to the chemical agent, and second, symptoms or physical signs consistent with the known biological effects of the chemical. Absent definite exposure data and/or typical symptoms and signs, it is essentially impossible to make a definitive diagnosis of chemical-related neurotoxicity."

Do you believe you now have "definitive exposure data?" Prior to the recent revelations, the VA neither acknowledged nor presumed exposures in diagnosis, treatment or compensation of Gulf War veterans. Now that exposures may, indeed must, be presumed, will VA policies change? In what way?

Answer: In light of the recent DoD announcements concerning the destruction of the Khamisiyah Ammunition Storage Area in March 1991, we believe there is evidence of release of nerve agents to the atmosphere and exposure of U.S. troops in the vicinity to unknown levels of these agents. No verifiable determination of the amount of nerve agents released or measurements of sarin or cyclosarin concentrations in the air at the time of release is available to us. Therefore, despite use of modeling techniques, the identification of troops exposed and level of the exposure will never be exact or absolute.

VHA has also requested that our advisory groups review the protocols in light of this new information. We have begun a thorough review of the evidence utilizing internal, interagency, and external advisory groups.

We have reviewed our clinical protocols and compensation policies. Based on currently available scientific information and evidence and the fact that we have always accepted the possibility of exposures, no changes in diagnosis, treatment or compensation policies will be undertaken, until the review is completed. As discussed in Response 2, current clinical protocols were designed to identify the sequelae of neurotoxic exposures. In the absence of a definitive diagnostic test and lack of specific treatment clinical care for Persian Gulf veterans will not immediately change. Treatment, appropriate to symptoms and/or diagnosis, will continue to be provided. We have initiated several continuing medical education activities to ensure that VA health care providers have the latest information regarding chemical warfare agent exposure of Persian Gulf veterans. These activities reinforce appropriate use of the Phase I and II protocols.

While we will continue to assess our compensation policies on an ongoing basis, no immediate changes appear to be indicated. Current VBA policies already allow compensation for conditions which began during or were exacerbated by military service, including exposure to chemical warfare agents resulting in medically recognized disabling sequelae. In addition, VA can compensate Persian Gulf veterans for chronic disabilities resulting from undiagnosed conditions which develop within two years of military service in the Persian Gulf.

Question 4: On what data does VA rely to conclude that low-level chemical exposures cause no chronic health effects in the absence of chronic symptoms at the time of exposure?

Both DoD and VA continue to insist that low-level exposures cause no long-term, chronic health effects unless acute symptoms appeared at the time of exposure. However, given the status of research in this area, that conclusion seems premature. Dr. Kizer told the joint Senate hearing "the research in this area is sparse and in VA's judgment it should not be construed to mean that clinically important adverse health effects cannot or definitely do not occur in the setting of low-level neurotoxin exposures." Shouldn't sick veterans be given the benefit of any doubts in this regard?

While VA research in this area is underway, what role will VA health screening and health care play in gathering data to support, rather than disprove, the hypothesis that low-level exposures can cause chronic health effects, even in the absence of evidence of acute symptoms at the time of exposure? The Subcommittee has been troubled by the VA's selective, even disingenuous, use of Gulf War Health Registry information to support epidemiological hypotheses favorable to the "no exposure" conclusion, while the VA aggressively disputes any contrary implications drawn from Registry data due to the self-selected nature of the cohort.

Answer: VA's assessment, based on current published scientific literature, is that low-level asymptomatic exposures to chemical warfare nerve agents have not been shown to cause delayed or long-term health effects. However, VA also recognizes that the existing scientific data is incomplete and contains gaps which need to be addressed by further scientific investigations. We have based these conclusions regarding the potential health effects of exposure on our review of the available medical literature on the subject. Several bibliographies of relevant literature are attached (Attachment 2). In addition, VA has given due consideration to the expert opinions of external scientific advisory committees. The Armed Forces Epidemiology Board and the National Academy of Science's Institute of Medicine Committee on the Health Consequences of Persian Gulf War Service have recently released reports which support this conclusion (Attachment 3).

Despite the lack of scientific evidence that long-term adverse health outcomes result from subtoxic exposures to organophosphate nerve agents, VA has provided Registry examinations and ambulatory and inpatient medical care under special medical care eligibility. In 1993, legislation that we supported gave special eligibility for VA health care to any Persian Gulf veteran whose health concerns or problems cannot be attributed to a cause other than an environmental or toxic exposure which occurred during their Gulf War service. Thus, our health care policies resolve benefit of the doubt in favor of the Persian Gulf veteran.

We strongly disagree with your statement that VA has been "disingenuous" in its use of the Persian Gulf Registry data. We would also like to emphasize that the clinical information contained in the Persian Gulf Registry and patient treatment file (PTF) databases has not been used as a method to support a conclusion of "no exposure" on any Persian Gulf health issue. VA has repeatedly stated that all exposures are still under active consideration.

The VA Persian Gulf Registry Health Examination program was established in 1992 as a health surveillance program and a mechanism for Persian Gulf veterans to gain entry to the VA health care system. The Persian Gulf Health Registry and the VA patient treatment file databases are not epidemiologic tools and, therefore, cannot be used to determine that low-level chemical warfare nerve agent exposures cause chronic health effects in the absence of acute symptoms at the time of exposure, as you suggest in your letter. However, these clinical databases can be utilized as a health surveillance and hypothesis-generating tool for future research studies. To date, VA has not found evidence from the Registry to support a hypothesis that neurotoxic exposures are responsible for the illnesses of the majority of Persian Gulf veterans. If there were a neurotoxic exposure that could cause serious neurologic disease in a high proportion of Persian Gulf veterans, it would probably have been identified in the 60,000 Registry exams completed to date. However, if the illness was mild or affected a very small number of veterans, it may not be recognized in the larger clinical case series. This negative data did not change VA's resolve to continue to look for evidence to support the hypothesis that Persian Gulf veterans' illnesses could be caused by low-level chemical warfare exposure but did cause that particular hypothesis to be given a lower priority by both the internal and external scientific reviewers prior to DoD's June 1996 announcement. In contrast, if a high frequency of certain peripheral or central nervous system conditions had been identified which suggested the possibility that neurotoxic exposures occurred, research is this area would have been aggressively pursued at an earlier date. These conclusions were supported by numerous internal and external scientists who have reviewed the information contained in this database.

Our use of the Registry and other clinical databases has been appropriate and scientifically accurate. In the past, VA has resisted inappropriate use or interpretation of this clinical data. VA will continue to utilize these databases in a scientifically sound manner.

Question 5: Why does VA assume there were no acute symptoms of chemical warfare exposure?

What does VA consider an "acute" symptom? What evidence does VA require to support a veteran's claim that acute symptoms were the direct result of an exposure? Does VA believe only incapacitating symptoms are acute?

Sick veterans consistently reported flu-like symptoms, rashes, headaches and other maladies during their service in the Gulf. Others simply went about their duties as best they could, and did not report the ill-effects variably attributed to pills, vaccines, pesticides, engine fumes, rocket fuel, oil fires, indigenous infectious agents... and chemical warfare agents.

Even when illnesses were reported, DOD medical records are not complete. Some were "lost" or destroyed. Unit chemical detection logs are also missing. DoD troop locator data is unreliable. Given this lack of consistent or reliable DoD information on chemical exposures and their effects, as opposed to consistent and persistent reports of illnesses by veterans, why does VA choose to listen to DoD rather than the veterans? How can VA conclude that Gulf War exposures caused no immediate health effects?

At our most recent hearing, medical witnesses discussed the possibility that pyridostigmine bromide (PB) could mute or mask the onset of acute symptoms resulting from chemical exposure. Could this account for any lack of acute symptoms noted by DoD?

Finally, I am personally skeptical of the Pentagon's call for another review of its handling

of this matter by the Institute of Medicine (IOM) and the National Academy of Sciences (NAS). Those are both prestigious institutions, but the IOM has already made detailed recommendations about the quality and quantity of government research into Gulf War illnesses. Another review of the current investigation could involve the IOM in a critique of their own earlier work. If only to avoid the perception that DoD is seeking a friendly forum for its a priori conclusions, shouldn't another review of these issues be truly independent of all that went before?

Moreover, many of the disease conditions of which Gulf War veterans often complain chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity- are poorly understood and only recently characterized by standardized diagnostic criteria. Shouldn't an independent review of the issues surrounding Gulf War veteran's illnesses be broad enough to include researchers and practitioners involved in the study and treatment of these disease states?

Answer: In medical terminology, acute symptoms are not synonymous with incapacitating symptoms. Acute in this context is defined as occurring "immediately" or "in a short period of time" after exposure to the chemical warfare nerve agents.

Exposures to high concentrations of organophosphate nerve agents, such as sarin or cyclosarin, cause loss of muscle control, generalized twitching, paralysis, unconsciousness, convulsions, and coma or even death. The most common cause of death is acute respiratory failure due to diaphragmatic paresis/paralysis. Exposure to moderate or even small amounts of these agents may result in sudden onset of impaired vision, drooling, coryza, severe flu-like symptoms, chest discomfort, and hyperhidrosis. These symptoms would have occurred either immediately or a short time after exposure. Since both pyridostigmine bromide (PB) and organophosphate nerve agents increase the amount of synaptic acetylcholine of cholinergic nerves, even if PB pretreatment had been used, one would not expect PB to blunt these acute symptoms. Troops located in the same geographic area would be expected to experience and report this characteristic constellation of symptoms simultaneously. Such outcomes were very evident after the unexpected terrorist attacks in Matsumoto and Tokyo, Japan, in 1994 and 1995, respectively. The release of sarin during these incidents resulted in large numbers of emergency room visits and hospital admissions. Neither DoD nor veterans responding to their telephone survey have reported that this occurred at Khamisiyah. Furthermore, DoD reports that no such characteristic set of signs or symptoms were reported or identified by specially-trained military physicians in the vicinity of Khamisiyah. A characteristic pattern of toxicity was not identified on DoD's review of the medical information for units in the vicinity of Khamisiyah. Veterans likewise have not reported to VA that they noted sudden onset of this symptom complex in their units near Khamisiyah in Southern Iraq during early March 1991.

In order to confirm DoD's conclusions regarding the health of troops in the vicinity of Khamisiyah in early March 1991, VA has asked to review the data upon which their conclusions were based. The data would include data from medical logs, surveys, and questionnaires. We would also welcome the review and opinions of other external scientific advisory committees on these matters.

Finally, you asked whether VA supported an independent review of these issues. VA feels that the reviews of the National Academy of Sciences Institute of Medicine, the VA Persian Gulf Expert Scientific Advisory Committees and the Presidential Advisory Committee will provide such independent, objective reviews. You also ask whether these reviews shouldn't be broad enough to include researchers and practitioners from the multiple chemical sensitivity, chronic fatigue syndrome and fibromyalgia community. I can assure you that these groups have been represented on the previous and current external, independent advisory committees, and we would welcome continuing input from credible experts in these areas. We look forward to the recommendations of these advisory groups on this important issue.

If the VA claims it has ``always accepted the possibility of exposures,'' it should be noted that: 1) the VA did not add specific questions on chemical warfare exposures to its VA Gulf Health Registry until late 1995, 4 years after veterans began reporting illnesses; and 2) there is no VA or DOD research on the health effects of low level exposure to neurotoxic agents yet available.

In a subcommittee hearing on December 11, 1996, Chairman Christopher Shays questioned Dr. Susan Mather, VA's Chief Public Health and Environmental Hazards Officer, and Dr. Frances Murphy, VA's Director of Environmental Agents Service, about when the VA first ``accepted the possibility of chemical exposures.'' Their testimony follows:

Mr. Shays. Do they [VA doctors] listen to that [sick] veteran or do they listen to DOD who says we have had no credible verification of chemicals being used? Who do they listen to?

Dr. Mather. The veterans.

Mr. Shays. If you were listening to veterans, why are we still now only beginning to think that maybe exposure to chemicals might in fact be credible?

Dr. Mather. Our perspective and our emphasis has been on the illness that the veterans had, and we were looking at the illnesses that the veterans had and working back from that.

Mr. Shays. To help you in this analysis ... to truly understand the illnesses that are affecting your patients, you would want to know what kind of an environment they were in and what physical confrontation they had with that environment.

Dr. Mather. Exactly. That's the reason we revised the questions we asked the veteran.

Mr. Shays. When did you make that revision?

Dr. Mather. Unfortunately, the revision did not get finished until this past year. It took a long time to get it approved and I apologize for that.

Dr. Murphy. We began educating our physicians early on about all the exposures that were known. We addressed the whole range of exposures and asked them to question veterans about those exposures.

Mr. Shays. But the fact is, we have under oath documentation that soldiers weren't asked vital questions dealing with chemical exposures until after Khamisiyah [events were announced]. When did you really start to change your approach? When, if fact, did the form get changed?

Dr. Murphy. The form was published in September 1995.⁽¹⁷⁴⁾

In the following Gulf War hearing on January 21, 1997, the same subject was raised again by Chairman Shays with the witness Dr. Kenneth Kizer, VA's Under Secretary for Health:

Mr. Shays. Dr. Kizer, what mistakes has the VA made in the last 6 years with regard to the Gulf War issue?

Dr. Kizer. I don't know I would characterize them as mistakes ... the research agenda ... was delayed because of information that was provided.

Mr. Shays. Provided where?

Dr. Kizer. By the Department of Defense.

Mr. Shays. So in essence, the only thing you would describe as a mistake, and you wouldn't even describe it as a mistake, is that you relied on information from the DOD that our troops weren't exposed to chemicals ... ?

Dr. Kizer. The issue of chemical warfare agents ... and the investigation into that arena, was delayed, and that investigative focus was given a lower priority because of the information that had been provided by DOD.

Mr. Shays. So the bottom line is, because the DOD denied ... any exposure ... VA made a determination that therefore our troops were not exposed to ... chemicals?

Dr. Kizer. No, I don't think that characterizes what I said, Mr. Chairman.

Mr. Shays. OK. Say it over again in a different way.

Dr. Kizer. The VA has been consistently ... open to and have been concerned about the exposure of troops to chemical warfare agents. As far as specific research protocols that were funded, the potential exposure was given lower priority than others.

Mr. Shays. Because?

Dr. Kizer. Because of the information that was provided by DOD ...

Mr. Shays. So you didn't ever begin to ask our troops until 1995 if they felt they were exposed to chemicals?

Dr. Kizer. I don't believe that is correct, sir, because our physicians were asking the question before that.

Mr. Shays. So I will ask the question again. Is it a fact that the Registry did not require these questions [to be asked by VA physicians] until 1995?

Dr. Kizer. Again, physicians performing the Registry examinations before that time [1995] asked those questions. Did everybody ask it? I can't say they did, no ...⁽¹⁷⁵⁾

In the December 11, 1997 hearing, Chairman Shays questioned VA's Dr. Mather and Dr. Murphy about research on low level chemical exposures. Their testimony follows:

Mr. Shays. The VA has expressed to us that there has not been a focus on low level exposure because the DOD, whose information you rely on, has said there has been no use of chemicals in the Gulf and no exposure.

Dr. Mather. That is very true in the research arena. I think research into low level exposure has a low priority.

Dr. Murphy. It was not viewed as high priority to take asymptomatic exposures to chemical warfare nerve agents and look for health effects, because there was no evidence either from what we were being told from DOD ... [or] that [exposure] was a likely possibility. What we did not address was low level exposures and the potential long-term health effects. Current body of research proves that low level exposures cannot cause health effects [emphasis added].⁽¹⁷⁶⁾

Veterans and medical witnesses at Human Resources Subcommittee hearings maintain that the VA medical protocol does not sufficiently address exposure history. In fact, the VA Health Registry questionnaire relies on the ability of the veteran to recognize toxic exposures by asking such questions as: ``Did you witness Chemical Alarms?''⁽¹⁷⁷⁾

In addition, VA physicians who examine Gulf veterans for the first time are not trained to take toxic exposure histories.⁽¹⁷⁸⁾ This is critical in that many veterans may have been exposed in theater but would not have realized it. VA physicians trained to ask the right questions can identify potential exposures of which the veteran may not have been aware.

The issue of trained VA physicians to detect the health effects of chemical exposures was also raised in Human Resources Subcommittee hearings:

Mr. Shays. I get the sense that you don't really have the background in chemical exposures. Is that correct?

Dr. Mather. I'm not a toxicologist. I'm a chest physician.

Dr. Murphy. I'm a neurologist, sir.

Mr. Shays. How many doctors work for the VA?

Dr. Murphy. Over 1,800.

Mr. Shays. How many toxicologists?

Dr. Mather. I don't know.

Dr. Murphy. Physicians are rarely toxicologists. That's a Ph.D. level kind of specialty. Dr. Kizer, for instance, is a medical toxicologist physician. I would have to go back and look specifically.

Mr. Shays. It would be an estimate. One percent? Ten percent? A half percent?

Dr. Murphy. I cannot estimate.

Dr. Mather. I honestly don't know.

Mr. Shays. Can you name me 10 toxicologists that you know are working for the VA?

Dr. Mather. No.

Dr. Murphy. I can't come up with 10 off the top of my head.

Mr. Shays. Can you name me five?

Dr. Murphy. Dr. Peter Spencer is a neurotoxicoligist.

Mr. Shays. That's one. Can you name another?

Dr. Murphy. No, sir.

Mr. Shays. You can only name one expert in a field that deals with chemical exposure? What other specialities would there be besides the toxicologists?

Dr. Murphy. Most of the subspecialities we have in investigating toxic exposures, include neurologists, pulmon-ologists, and occupational health physicians.

Mr. Shays. So it might not be their primary focus, but they might have some knowledge of chemical exposure and its effect?

Dr. Murphy. Yes.

Mr. Shays. It is telling though that you cannot name more than one person in the entire [VA] department [who is a toxicologist.].

Dr. Murphy. We can provide that for the record.

Mr. Shays. I would definitely like it for the record.⁽¹⁷⁹⁾

On February 11, 1997, the VA provided the following information:

DEPARTMENT OF VETERANS AFFAIRS (VA)

VETERANS HEALTH ADMINISTRATION (VHA)

Responses to Information Request from Chairman Christopher Shays

1. The results of a survey of each VA medical center to gather specific information on specialized professional and research credentials of VIA medical personnel.

We were aware of your earlier requests for information related to the number of toxicologists and other specialists on VA medical staff and were in the process of assembling it. Based on our employment records, we have found four toxicologists on the research rolls. However, the toxicologists do not treat patients. Persian Gulf veterans are treated by licensed medical doctors who are internists or primary care providers supplemented by specialists. As of Dec. 31, 1996, the following number of specialists were on our rolls (note that occupational medicine is not a physician specialty category):

_____________________Full Part_____Time Time

Neurologists.....................181..................299

Pulmonologists.................175..................134

Oncologists.......................46....................54

Infectious Disease.............94...................109

Rheumatologists...............33....................92

Gastroenterologists...........122.................178

Dermatologists.................31...................160

Toxicologists (non-physician)......4..........0

The lack of a specific case diagnostic criteria for Gulf illnesses also reflects a flawed approach to these illnesses on the part of the VA. Illnesses in Gulf veterans have been reported since 1991. A critical factor in identifying uncharacterized illnesses is the development of a case definition of the illness. Gulf War illnesses include a range of symptoms previously mentioned - rashes, headaches, muscle and joint pains, neurological and cognitive abnormalities, and more.

Dr. William C. Reeves of the Centers for Disease Control and Prevention [CDC], presented results of his epidemiological investigation into the Gulf War Syndrome to the PAC in both January and September 1996. CDC was able to develop a working case definition of Gulf illnesses. CDC defines a case as ``at least one chronic (present for 6 months or longer) symptom from two or more of the following categories: fatigue; mood and cognition related symptoms (feeling depressed, difficulty remembering or concentrating, feeling moody, feeling anxious, trouble finding words or lack of interest in sex); and musculoskeletal related symptoms (joint pain, joint stiffness or muscle pain).''⁽¹⁸⁰⁾

Using this definition, Dr. Reeves showed that Gulf-related illnesses are more frequent in Gulf War veterans than non-deployed troops. If CDC could conduct an epidemiological investigation, it would seem logical that the VA could also have conducted a similar epidemiological study and achieved the same results. Furthermore, CDC did not start its investigation until late 1994, whereas VA began receiving complaints from Gulf veterans as early as 1991 and could have initiated a study.

VA medical policy may have been biased against findings of chemical exposure by relying on DOD assertions and unproven theories of toxic causation. VA continues today to maintain that chronic symptoms in Gulf veterans cannot be attributed to toxic exposures unless acute symptoms first appear at the time of exposure.

There is no credible, scientific evidence to substantiate the VA and DOD position that chronic symptoms cannot later develop from low level chemical exposures unless acute symptoms are observed when the exposure occurred.

The question of whether delayed or chronic effects result from exposure to low level chemical agents without first having acute or immediate symptoms is critical to Gulf veterans. The answer determines whether or not Gulf veterans will be diagnosed and treated properly, as well as compensated appropriately for injuries suffered in the war zone. Many sick veterans did not report acute symptoms during the war but later developed chronic symptoms, thereby being denied appropriate compensation for their illnesses.

On the other hand, many veterans report that they may have had flu-like symptoms, rashes, or other reactions during the war which they ignored as part of serving in a harsh, desert environment or as a reaction to vaccines or drugs. The ``low level'' symptoms could be considered acute, but mild, reactions to low level chemical agents. The taking of anti-nerve gas pills [PB] may also have masked acute symptoms, as Dr. Padilla testified.

F. IMPACT ON VETERANS OF MISSING RECORDS

Personal medical records of veterans, including sick call records, are inadequate or missing. Documents which could help verify possible exposures and military unit locations remain in DOD files.⁽¹⁸¹⁾ Most of the military nuclear-biological-chemical [NBC] logs, which are records of toxic warfare agent detections, are missing or destroyed. Readouts from chemical detection equipment have vanished. Many CIA intelligence logs concerning Iraqi chemical/biological weapons [CBW] storage depots and manufacturing facilities, and documents concerning enemy capabilities and intentions to use CBW against U.S. troops, have remained unreleased since the war.

All this critical information comprises the complete medical history of each Gulf War veteran. In the absence of full documentation needed to prove a service-connection, sick veterans have a difficult - if not impossible - task of receiving proper medical treatment and fair compensation.

Since no Government low level exposure research is available, proof of toxic exposure as a cause of medical disability is nearly impossible to obtain. Furthermore, the burden of proof that the disability or illness is service-connected falls on the veteran exclusively under current VA regulations. Since the scientific research on the medical effects of exposure to low level chemical and biological has not been conducted, a veteran cannot prove a service-connected disability related to chemical or biological toxic exposure.

``Current VBA policies allow compensation for conditions which began during or were exacerbated by military service, including exposure to chemical warfare agents resulting in medically recognized sequelae.''⁽¹⁸²⁾

If basic scientific research has not been conducted to identify medically recognized sequelae produced by toxic exposures, compensation for service connected disability cannot be proven by the veteran and the VA will not compensate the veteran without this proof.

Congress enacted legislation in 1994 allowing the VA to pay compensation benefits to veterans for disabilities related to the Gulf War caused by ``undiagnosed'' illnesses.⁽¹⁸³⁾ In the past, the VA had always required that compensation be based on clearly diagnosed diseases.

According to Congressional Research Service [CRS], ``Under regulations issued in February 1995 (38 CFR 3.317), a veteran can be compensated only for undiagnosed illnesses that manifest themselves during Gulf War service or arise within 2 years of departing from the Gulf. Veterans must provide objective evidence of chronic illness and be at least 10 percent disabled. However, as of January 1997, the VA had denied 9,688 (93.5 percent) of the 10,357 undiagnosed illness claims that had been reviewed. Approximately 55 percent of the denied claims were rejected because the illness did not manifest itself until after the 2-year presumptive period. President Clinton [last March] extended the presumptive period by 8 years, until December 31, 2001. The VA plans to re-evaluate the claims that were denied on the basis of a 2-year presumptive period to determine if they now qualify for compensation under the extended period."⁽¹⁸⁴⁾

G. STRESS-RELATED DIAGNOSES OF VETERANS' ILLNESSES

VA has consistently diagnosed veterans presenting these symptoms as stress-related, or PTSD, or other psychological conditions, as opposed to conducting the appropriate epidemiological investigations to differentiate psychological conditions from psycho-neuro-immunological conditions such as fibromyalgia, chronic fatigue syndrome and central nervous system disorders which may have resulted from toxic exposures.

Of the 21 sick Gulf veterans - all with symptoms of undiagnosed origin - who appeared before the Human Resources Subcommittee as witnesses, 13 were diagnosed by VA and/or DOD doctors as ``Stress'' or ``PTSD,'' 3 cases as ``Nothing wrong; all in the head,'' 3 cases as ``Undiagnosed,'' and only 2 cases of ``Chemical exposure.''

One sick veteran who testified, Air Policeman James Green of the Air Force, with orders to ship out to the Gulf War from Germany, had taken the vaccines and PB tabs and become sick. His orders were canceled at the last moment. ``I signed up for the VA Health Registry in 1994. They sent me to the VA hospital for an exam. The [VA] doctor asked me what was wrong and to describe the symptoms. I was ... referred to the mental health clinic for stress-related problems. Seems awful funny to me that my illness is stress and I was not even in the theater.''⁽¹⁸⁵⁾

Dr. Matthew Friedman, a professor of psychiatry at Dartmouth Medical School and executive director of the National Center of Post Traumatic Stress Disorder, disputes emphasis on stress as the principal cause of the illnesses. The NY Times quoted Dr. Friedman: ``They [the PAC, DOD and VA] have very nicely laid out why this is such an attractive hypothesis [stress], but the data are not there to support it.'' The Times article stated that Dr. Friedman's research on sick Gulf veterans ``showed that only about 10 percent ... were suffering from PTSD ... an extreme form of stress caused by exposure to battle or other forms of trauma.''⁽¹⁸⁶⁾

Dr. Katherine Murray Leisure, an infectious disease specialist formerly at the VA Medical Center in Lebanon, PA, who treated more than 700 sick Gulf veterans, said in the same Times article it was clear to her that battlefield stress had little to do with the veterans' ailments. She said, ``Out of the hundreds of people I've seen, there's been fewer than a half dozen who had PTSD. It's negligible.''⁽¹⁸⁷⁾

Neurologist and psychiatrist Dr. William Baumzweiger, a former fellow at the VA Outpatient Clinic in Los Angeles who has examined more than 100 sick Gulf veterans, stated in prepared testimony before the subcommittee, ``I do not believe that the majority of symptomatic Gulf War participants experienced any stress which would be sufficient to precipitate PTSD. I concluded they had suffered from environmental intoxication ... and that the disorders are neurological illnesses that involve the central nervous system and the immune system.''⁽¹⁸⁸⁾

According to Dr. Leisure and Dr. Baumzweiger, both doctors were recently released by the VA, allegedly for their outspoken views on the cause and treatment of Gulf veterans' illnesses.⁽¹⁸⁹⁾

Dr. Eula Bingham, a toxicologist and environmental health professor who is chairman of the VA's Gulf War Expert Scientific Committee, in an earlier interview with the New York Times said, ``It's pretty clear that the veterans who were in the gulf have a whole series of symptoms that other veterans don't.'' She added, ``Certainly we know that there was widespread exposure to chemicals during the war. We really don't have good data on what health effects are caused by long-term, low-level exposure to those agents.'' Dr. Bingham was further quoted saying, ``I'm very troubled when any committee says, `Well, it's stress.' Have they analyzed it? Why are they saying it? I think it's a very poor word to use at this time.''⁽¹⁹⁰⁾ Dr. Bingham is also the former Administrator of OSHA.

In the same Times article, Dr. Claudia Miller, a physician and environmental research professor who is also a member of the VA's Gulf War Expert Scientific Committee, said that ``stress may be a contributor to these health problems but we should be looking at potential chemical causes, particularly given the kind of chemical environment that our soldiers faced in the Gulf.''⁽¹⁹¹⁾

A 1993-1994 study of veterans from Pennsylvania and Hawaii, sponsored by the Walter Reed Army Institute of Research, stated: ``The major conclusion concerning physical health of these veterans is that for those who deployed to the Gulf War and recently reported physical symptoms, neither stress nor exposure to combat or its aftermath bear much relationship to their distress; only the fact of deployment differentiates them from their less-burdensome counterparts.''⁽¹⁹²⁾

Dr. Daniel Clauw, Assistant Professor of Medicine at Georgetown University Medical Center, in testimony before the Human Resources Subcommittee, stated: ``The problem with considering these [Gulf War] illnesses as psychiatric conditions: In clinical practice, telling an individual with this type of illness that it is `all in their head,' or that there is no `organic' basis for their symptoms, will always lead to frustration and a sense of abandonment by the individual. It is not difficult to see why many of the veterans with these illnesses, as well as their families and advocates, have become so frustrated with this vicious cycle of no diagnoses, no effective treatment, and psychiatric attribution of symptoms.''⁽¹⁹³⁾

``Take these veterans seriously. The physical and emotional toll of this type of illness is great, and these individuals developed these problems while serving our country. View with skepticism anyone who might assert that because there are no abnormalities on these individuals' blood tests, x rays, or other diagnostic studies, that there is nothing wrong, or that the individual is suffering from a psychiatric condition. It is arrogant of us as scientists to feel that because we cannot precisely define a problem, it doesn't exist.''⁽¹⁹⁴⁾

H. TREATMENT AND RESEARCH

The GAO Report on ``Gulf War Illnesses'' responded to the mandate of the Fiscal Year 1997 Defense Authorization Act. GAO examined three issues and made findings and recommendations based on results of the study. The GAO conducted a 6-month study on the Government's clinical care and medical research programs relating to illnesses that members of the armed forces might have contracted as a result of their service in the Persian Gulf War.⁽¹⁹⁵⁾

Issue 1: The efforts of DOD and VA to assess the quality of treatment and diagnostic services provided to Gulf War veterans and their provisions for follow-up of initial examinations.

Finding: Neither DOD nor VA has systematically attempted to determine whether ill Gulf War veterans are any better or worse today than when they were first examined.

Issue 2: The Government's research strategy to study the Gulf War veterans' illnesses and the methodological problems posed in its studies.

Finding: The majority of the research has focused on the epidemiological study of the prevalence and cause of the illnesses rather than diagnosis, treatment, and prevention of them.

Issue 3: The consistency of key official conclusions with available data on the causes of the veterans' illnesses.

Finding: Support for some official conclusions regarding stress, leishmaniasis (a parasitic infection), and exposure to chemical agents was weak or subject to alternative interpretations.

Dr. Donna Heivilin, Director of Planning and Reporting for GAO's National Security and International Affairs Division, appeared before the Human Resources Subcommittee on June 24, 1997, to review results of the GAO study. Concerning the quality of medical treatment and diagnostic services, Dr. Heivilin stated: ``Over 100,000 of the approximately 700,000 Gulf War veterans have participated in DOD and VA health examination programs [DOD's Comprehensive Clinical Evaluation Program or CCEP, and VA's Persian Gulf Health Registry]. Of those veterans examined, nearly 90 percent have reported a wide array of health complaints and disabling conditions. Officials of both DOD and VA have claimed that regardless of the cause of veterans' illnesses, veterans are receiving appropriate and effective symptomatic treatment. Both agencies have tried to measure or ensure the quality of veterans' initial examinations through such mechanisms as training and standards for physician qualification. However, these mechanisms do not ensure a given level of effectiveness for the care provided or permit identification of the most effective treatments.''

``We found that neither DOD nor VA has mechanisms for monitoring the quality, appropriateness, or effectiveness of these veterans care or clinical progress after their initial examination and has no plans to establish such mechanisms. VA officials involved in administering the Health Registry program told us they regarded monitoring the clinical progress of registry participants as a separate research project, and DOD's [CCEP] program made similar comments.''

Dr. Heivilin said that such monitoring is important because: 1) undiagnosed conditions are not uncommon among ill veterans; 2) treatment for veterans with undiagnosed conditions is based on their symptoms; and 3) veterans with undiagnosed conditions or multiple diagnoses may see multiple providers.

``Without follow-up of their treatment, DOD and VA cannot say whether these ill veterans are any better or worse today than when they were first examined.''⁽¹⁹⁶⁾

Concerning the Government's research strategy, Dr. Heivilin stated: ``Federal research on Gulf War veterans' illnesses and factors that might have caused their problems has not been pursued proactively. Although these veterans' health problems began surfacing in the early 1990's, the vast majority of research was not initiated until 1994 or later. This 3-year delay has complicated the task facing researchers and has limited the amount of completed research currently available. Although at least 91 studies have received Federal funding, over 70 or four-fifths of the studies are not yet complete, and the results of some studies will not be available until after the year 2000.''⁽¹⁹⁷⁾

``We found that some hypotheses [about causes of the illnesses] received early emphasis, while some hypotheses were not initially pursued. While research of exposure to stress received early emphasis, research on low level chemical exposure was not pursued until legislated in 1996. The failure to fund such research cannot be traced to an absence of investigator-initiated submissions. According to DOD officials, three recently funded proposals on low level chemical exposure had previously been denied funds. We found that additional hypotheses were pursued in the private sector. A substantial body of research suggests that low level exposure to chemical warfare agents or chemically related compounds, such as certain pesticides, is associated with delayed or long-term health effects.''⁽¹⁹⁸⁾

Dr. Heivilin said there is evidence from animal experiments, studies of accidental human exposures, and epidemiological studies of humans that low level exposures to certain organophosphorus compounds, including Sarin nerve agents to which some of our troops may have been exposed, can cause delayed, chronic neurotoxic effects. The ill-defined symptoms may be associated with objective brain and nerve damage, and due in part to organo-phosphate-induced delayed neurotoxicity [OPIDN], according to Dr. Heivilin.⁽¹⁹⁹⁾

Studies ``further linked the veterans' illnesses to exposure to combinations of chemicals [emphasis added],'' Dr. Heivilin stated, ``including nerve agents, pesticides, insect repellants, and pyridostigmine bromide tablets. Exposure to combinations of organophosphates and related chemicals ... has been shown in animal studies to be far more likely to cause morbidity and mortality than any of the chemicals acting alone.''⁽²⁰⁰⁾

The GAO study found the ongoing epidemiological Federal research suffered from two methodological problems: a lack of case definition, and absence of accurate exposure data. Without valid and reliable data on exposures and the multiplicity of [chemical] agents to which the veterans were exposed, researchers will likely continue to find it difficult to detect relatively subtle effects and to eliminate alternative explanations for Gulf War veterans' illnesses. The study found that while multiple federally funded studies of the role of stress in the illnesses have been done, basic toxicological questions regarding the substance to which they were exposed remain unanswered.⁽²⁰¹⁾

Dr. Heivilin stated: ``We found that Federal researchers have faced several methodological challenges and encountered significant problems in linking exposures or potential causes to observed illnesses or symptoms. For example:

Researchers have found it extremely difficult to gather information about exposures to such things as oil well fire smoke and insects carrying infection.

DOD has acknowledged that records of the use of pyridostigmine bromide and vaccinations to protect against chemical/biological warfare exposures were inadequate.

Gulf veterans were typically exposed to a wide array of agents, making it difficult to isolate and characterize the effects of individual agents or to study their combined effects.

Most epidemiological studies on Gulf illnesses have relied only on self-reports for measuring most of the agents to which veterans may have been exposed.

Information gathered from Gulf veterans gathered years after the war may be inaccurate or biased. There is often no straightforward way to test the validity of self-reported exposure information. As a result, findings from these studies may be spurious or equivocal.

Classifying the symptoms and identifying illnesses of Gulf veterans have been difficult. From the outset, symptoms reported by veterans have been varied and difficult to classify into one or more distinct illnesses. It has thus been difficult to develop a case definition (that is, a reliable way to identify individuals with a specific disease), which is a criterion for doing effective epidemiological research.

``In summary,'' Dr. Heivilin stated, ``the ongoing [Federal] epidemiological research will not be able to provide precise, accurate, and conclusive answers regarding the causes of veterans' illnesses because of these formidable methodological problems.''⁽²⁰²⁾

I. OTHER EXECUTIVE AGENCY ACTIONS ON GULF VETERANS' ILLNESSES

DOD and CIA Gulf War Illnesses Investigation Teams

In November 1996, Deputy Secretary John White appointed Bernard Rostker, Ph.D. economist and Assistant Secretary of Navy Manpower, to the position of Special Assistant for Gulf War Illnesses. Under Dr. Rostker, DOD expanded its Gulf illness investigative team from 10 to more than 100 people. It was up to an estimated 150 people as of October 1997. To date, the DOD team has focused its investigation mainly on troop chemical exposures from fallout resulting from the Iraqi bunker detonations at Khamisiyah, and on case narratives to disprove specific chemical detection incidents reported by military specialists such as Human Resources Subcommittee witnesses Major Johnson and Gy/Sgt. Grass.

On March 3, 1997, Deputy Secretary John White directed the DOD Inspector General to take over the investigation of what happened to the missing nuclear, biological, chemical [NBC] logs maintained at U.S. Central Command during the Gulf War. As mentioned, in March 1997 Dr. Stephen Joseph resigned. In April 1997, Secretary Cohen named former Senator Warren Rudman as his special advisor on Gulf War illnesses. In July 1997, Deputy Secretary White resigned. DOD's former Deputy Assistant Secretary for Health Affairs, Dr. Sue Bailey, is expected to be nominated by the President to replace Dr. Joseph.

In March 1997, CIA Director George Tenet formed a Task Force on Gulf War Illnesses headed by Robert Walpole. The team's assignment is to declassify and make public as many CIA documents as possible concerning the controversy about events at Khamisiyah. To date, 41 documents have been released,⁽²⁰³⁾ 1 of which indicates the CIA had received warnings in the 1980's that chemical weapons were stored in Khamisiyah munitions bunkers.

According to the Congressional Research Service [CRS], ``On April 9 [1997], amid growing tension and charges of a cover-up, the CIA released a report showing that the agency had solid intelligence in 1986 that thousands of chemical weapons had been stored at Khamisiyah. However, the CIA failed to include the depot on a list of suspected CW sites provided to the Pentagon before the war. The CIA warned the Army of the possible presence of chemical weapons at Khamisiyah just days before the depot was blown up, but the information was not relayed to the engineers who carried out the detonations.''⁽²⁰⁴⁾

Presidential Advisory Committee on Gulf War Veterans' Illnesses

President Clinton established the Presidential Advisory Committee on Gulf War Veterans' Illnesses [PAC] in May 1995 to examine the health concerns related to Gulf War service. The Committee, a 12-member panel made up of veterans, scientists, health care professionals, and policy experts, held 18 meetings between August 1995 and November 1996 to hear witness testimony and take public comment. A Final Report of findings and recommendations was issued December 31, 1996. However, the President extended the panel's investigation until September 30, 1997. The PAC held additional meetings this year, with plans to present its updated Special Report to the President by late October 1997.

While the PAC's December 1996 report found that ``many veterans have illnesses likely to be connected to their service in the Gulf,'' it did not support a causal link between the illnesses and exposures to environmental risk factors.<sup>(205)</sup> In the face of overwhelming evidence that Gulf War veterans were exposed to multiple toxic agents, the PAC instead placed emphasis on stress as a cause of these health problems. The PAC report stated: ``Stress is likely to be an important contributing factor to the broad range of illnesses currently being reported by Gulf War veterans.''⁽²⁰⁶⁾

The PAC also discounted most environmental risk factors as causes of veterans illnesses. The December report stated: ``Current scientific evidence does not support a causal link between the symptoms and illnesses reported by Gulf War veterans and exposures while in the Gulf region to the following environmental risk factors assessed by the Committee: pesticides, chemical warfare agents, biological warfare agents, vaccines, pyridostigmine bromide, infectious agents, depleted uranium, oil well fires and smoke, and petroleum products.''⁽²⁰⁷⁾

The PAC report did identify DOD and VA ``problems related to missing medical records, the absence of baseline health data, inaccurate records of troop locations, and incomplete data on the health effects of what should have been viewed as reasonably anticipated risks.''⁽²⁰⁸⁾

As numbers of troops presumed exposed to chemical weapons continued to rise following the events at Khamisiyah, DOD's handling of the investigation into the Gulf veterans' illnesses came under criticism from PAC members and staff. In September 1996, the PAC's chief investigator, James Turner, stated in a committee hearing that since the Gulf War, DOD's position has remained essentially unchanged ``and inflexible ... in the face of growing evidence that there were possible low level exposures.'' Turner said DOD's position ``can be summarized in three no's ... there was no use, no exposures, and no presence of chemical warfare agents in-theater.''

Turner stated, ``The slow, reluctant on-again, off-again release of information to the public by the ... [DOD's] senior level oversight panel, has also served to undermine credibility and confidence in the DOD's efforts. To fulfill the government's obligation to tell the truth about chemical warfare agent exposures to veterans and the American public, DOD's investigations must be timely, thorough, independent, credible and public. On each of these counts ... DOD's efforts have fallen short of the mark.''

Turner's statement found the evidence of chemical agent release at Khamisiyah overwhelming, other site-specific exposures must be presumed, and DOD has conducted a superficial investigation of possible chemical and biological exposures ``which is unlikely to provide credible answers to veterans' questions.''⁽²⁰⁹⁾

In the PAC's final public hearing September 5, 1997, monitored by Human Resources Subcommittee staff and covered by national news media, the PAC did not amend its conclusions about the importance of stress as a cause of Gulf War illnesses, nor its rejection of most environmental risk factors as possible causes. Some panel members suggested that the updated Final Report include a statement acknowledging the possibility of low level chemical warfare exposures, but no vote on the proposal was taken.

Members did agree in the final meeting, however, to recommend that the Pentagon's investigation of Gulf War illnesses be transferred to another agency in view of DOD's loss of credibility in the handling of chemical weapons exposures.

``The Pentagon is failing in a multimillion dollar effort to salvage its credibility among ailing Persian Gulf War veterans for its investigations into the possible sources of their illnesses, according to the draft of a final report by a White House advisory committee,'' the Washington Post reported.

``The report,'' according to the Post, ``scheduled to be presented to President Clinton next month, concludes, `Public mistrust about the government's handling of Gulf War illnesses not only has endured, but has expanded' in the 10 months since the Defense Department, at the panel's urging, agreed to intensify its research efforts. It blames the office of the Pentagon's special assistant for Gulf War illnesses [Dr. Bernard Rostker] for failing to examine reported incidents thoroughly and suggests the DOD may be institutionally incapable of acknowledging that chemical exposures could have occurred.''⁽²¹⁰⁾

In a the New York Times article, Defense Secretary William Cohen took issue with the PAC's recommendation. ``I think that the Pentagon is fully capable of conducting an investigation. So I would disagree with that recommendation.''⁽²¹¹⁾

Others also disagree with the PAC. In a letter to PAC Chairman Dr. Joyce Lashof, Congressman Bernard Sanders (I-VT), a subcommittee member, called for a reassessment of the PAC's conclusions relating to stress and environmental factors in its Final Report to the President in view of the growing numbers of troops that were exposed to chemical weapons and other toxic agents. The letter, signed by more than 80 Members of Congress including Subcommittee Chairman Christopher Shays, stated:

``We are writing to ask you to reassess your conclusion that current scientific evidence does not support a causal link between the symptoms and illnesses reported by Gulf War veterans and their exposure to a variety of chemicals during their service in the Persian Gulf War. In fact, it is our belief that more and more scientific evidence suggests that a major cause of Persian Gulf illness is the synergistic effect of a wide variety of chemicals to which our soldiers were exposed. Our hope is that by reassessing your conclusion, you will recommend increasing research into and treatment for the health effects of chemical exposures experienced in the Persian Gulf.''⁽²¹²⁾

In response, Dr. Lashof informed Congressman Sanders that ``... peer-reviewed literature published since the Final Report does not, to date, indicate a causal link between the commonly cited risk factors and the broad range of illnesses currently being reported by Gulf War veterans.''⁽²¹³⁾

Concerning the PAC's official conclusions about the causes of Gulf veterans' illnesses, GAO's Dr. Heivilin in her June 24, 1997 statement to the Human Resources Subcommittee hearing said: ``Six years after the war, little is known about the causes of Gulf War veterans' illnesses. In the absence of official conclusions from DOD and VA, we examined conclusions drawn in December 1996 by the Presidential Advisory Committee on Gulf War Veterans' Illnesses [PAC].''

``First, the Committee [PAC] concluded that `stress is likely to be an important contributing factor to the broad range of illnesses currently being reported by Gulf veterans.' While stress can induce physical illness, the link between stress and these veterans' physical symptoms has not been firmly established. For example, a large-s