HEARING ON WARRELATED ILLNFSSFS AND ON

THE VA'S SEXUAL TRAUMA COUNSEliNG

PROGRAM

HEARING
BEFORE THE

SUBCOMMITTEE ON HEALTH
OF THE

COMMITTEE ON VETERANS' AFFAIRS

HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
SECOND SESSION

APRIL 23, 1998

Printed for the use of the Committee on Veterans' Affairs

Serial No. 105-35

U.S. GOVERNMENT PRINTING OFFICE

50-714CC WASHINGTON : 1998

For sale by the U.S. Government Printing Office

Superintendent of Documents. Congressional Sales Office. Washington, DC 20402
ISBN 0 - 16-057507-9
 COMMITTEE ON VETERANS' AFFAIRS
BOB STUMP, Arizona, Chairman
CHRISTOPHER H. SMITH, New Jersey LANE EVANS, Illinois
MICHAEL BILIRAKIS, Florida JOSEPH P. KENNEDY II, Massachusetts
FLOYD SPENCE, South Carolina BOB FILNER, California
TERRY EVERETT, Alabama LUIS V. GUTIERREZ, Illinois
STEVE BUYER, Indiana JAMES E. CLYBURN, South Carolina
JACK QUINN, New York CORRINE BROWN, Florida
SPENCER BACHUS, Alabama MICHAEL F. DOYLE, Pennsylvania
CLIFF STEARNS, Florida FRANK MASCARA, Pennsylvania
DAN SCHAEFER, Colorado COLLIN C. PETERSON, Minnesota
JERRY MORAN, Kansas JULIA CARSON, Indiana
JOHN COOKSEY, Louisiana SILVESTRE REYES, Texas
ASA HUTCHINSON, Arkansas VIC SNYDER, Arkansas
J.D. HAYWORTH, Arizona CIRO D. RODRIGUEZ, Texas
HELEN CHENOWETH, Idaho
RAY LAHOOD, ILLINOIS
BILL REDMOND, New Mexico
CARL D. COMMENATOR, Chief Counsel and Staff Director

SUBCOMMITTEE ON HEALTH
CLIFF STEARNS, Florida, Chairman
CHRISTOPHER H. SMITH, New Jersey LUIS V. GUTIERREZ, Illinois
MICHAEL BILIRAKIS, Florida JOSEPH P. KENNEDY II, Massachusetts
SPENCER BACHUS, Alabama CORRINE BROWN, Florida
JERRY MORAN, Kansas MICHAEL F. DOYLE, Pennsylvania
JOHN COOKSEY, Louisiana COLLIN C. PETERSON, Minnesota
ASA HUTCHINSON, Arkansas JULIA CARSON, Indiana
HELEN CHENOWETH, Idaho

(II)
 CONTENTS
OPENING STATEMENTS
Page
Chairman Stearns .......... ............................................... .. ............. ....... .................... 1
Hon. Luis V. Gutierrez .............................................................................. .............. 2
Hon. Lane Evans, ranking democratic member, Full Committee on Veterans'
Affairs .................................................................................................................... 4
Prepared statement of Congressman Evans .................... .... .......................... 49
Hon. Joseph P. Kennedy II ........................................ ................................ .. ........... 5
Hon. Helen Chenoweth ................. ...... ....... ......... .......... ........... ........ ..... ........... 50
WITNESSES
A'Zera, Veronica, National Legislative Director, AMVETS ................................ . 40
Prepared statement of Ms. A'Zera ................................................................ .. 105
Backhus, Stephen, Director of Veterans' Affairs and Military Health Care
Issues, Health, Education and Human Services Division, General Account-
ing Office; accompanied by Shelia Drake, Assistant Director of Veterans'
Affairs and Military Health Care Issues, Health, Education and Human
Services Division, General Accounting Office ...................... .............. .............. .. 38
Prepared statement of Mr. Backhus .............................................................. . 78
Christopherson, Gary, Acting Assistant Secretary of Defense for Health Af-
fairs; Principal Deputy Assistant Secretary for Health Affairs, Department
of Defense ....... ........................ ................................................... .......................... . 23
Prepared statement of Mr. Christopherson and Dr. Mazzuchi .... .... ............ . 89
Garthwaite, Thomas L., M.D., Deputy Under Secretary for Health, Depart-
ment of Veterans Affairs; accompanied by Frances Murphy, M.D., Director,
Environmental Agents Service, Department of Veterans Affairs; Joan
Furey, Director, Center for Women Veterans, Department of Veterans Af-
fairs; Andrea Van Hom, CNP, Women Veterans' CoordinatorlPrimary Care
Nurse Practitioner, VA Maryland Health Care System .................................. . 21
Prepared statement of Dr. Garthwaite .. .................. ...... ............................ .... . 78
Hyams, Captain Craig, M.D., U.S. Navy, Infectious Diseases Department,
Naval Medical Research Institute .................................................................... .. 7
Prepared statement of Captain Hyams ........................................................ .. 51
M:=~~dc~~D:p~~~~t ~feg~Pe'n~:s.~~.~~~~..~.~~~.~~~..~~~ ..~~~.i.~~.. ~~..~.~~ 24
Prepared statement of Mr. Christopherson and Dr. Mazzuchi .................... . 89
Miller, Richard, M.D., Director, Medical Follow-up Agency, Institute of Medi-
cine, National Academy of Sciences .......................................... ........................ .. 9
Prepared statement of Dr. Miller ...................... ............................................ .. 57
Puglisi, Matthew, Assistant Director for Gulf War Veterans, National Veter-
ans' Affairs and Rehabilitation Commission, The American Legion, accom-
Ma:Jk~n~~..~~~.~.~~.l...~~~~~~~:...~:~: ~ .. ~~~.~~~.i.~:. . ~~ . ?~~.~~~~~~~ ..~~~~.~ . ~~ 11
Prepared statement of Mr. Puglisi .................. .............................. ................ .. 65
MATERIAL SUBMITTED FOR THE RECORD
Statements:
Kelli R. Willard West, Director of Government Relations, Vietnam Veter-
ans of America .................................... ................... ........................................ 108
Patrick G. Eddington, Executive Veterans for Integrity in Government .... 118

(III)
 IV
Page
Written committee questions and their responses:
Congressman Evans to Captain Hyams, U.S. Navy .... ..... ....... ...................... 121
Congressman Evans to Department of Veterans Affairs ................... ........ 129, 135
Congressman Evans to National Academy of Sciences ................................. 138
Congressman Evans to Department of Defense ........ ..................................... 140
Congressman Evans to General Accounting Office ..... .. ............. ... ....... ......... 147
Congressman Evans to The American Legion ........ ..... .... ........ ..... .. ....... .. ...... 150
HEARING ON WAR-RELATED ILLNESSES AND
ON THE VA'S SEXUAL TRAUMA COUNSEL-
ING PROGRAM

THURSDAY, APRIL 23,1998

HOUSE OF REPRESENTATIVES,
SUBCOMMITTEE ON HEALTH,
COMMITTEE ON VETERANS' AFFAIRS,
Washington, DC.
The subcommittee met, pursuant to notice, at 9:38 a.m., in room
334, Cannon House Office Building, Hon. Cliff Stearns (chairman
of the subcommittee) presiding.
Present: Representatives Stearns, Smith, Bilirakis, Cooksey,
Hutchinson, Gutierrez, Kennedy, Peterson, and Evans (ex officio).
OPENING STATEMENT OF CHAIRMAN STEARNS
Mr. STEARNS (presiding). The committee will come to order.
Our subcommittee meets this morning to continue our review of
issues raised by the U.S. troops' participation in the Persian Gulf
War and to examine VA's sexual trauma counseling program.
In the Veterans' Health Care Act of 1992, Congress enacted the
first of several measures to address the health problems of Persian
Gulf War veterans. In that law, Congress also established a specific
authority for VA to provide counseling to women veterans to over-
come sexual trauma in service. The specific statutory authorities
under which VA provides trauma counseling and treatment for Per-
sian Gulf War veterans will expire on December 31. This hearing
can help guide us as we consider the need for further legislation.
Certainly the Veterans' Affairs Committee and this subcommit-
tee have a long record of oversight on the health status of Persian
Gulf veterans. AB we've learned, scientists have not identified any
single Gulf War illness or any single cause for the illness seen in
these veterans. There remains large, unanswered questions about
the nature and prevalence of their illnesses.
This hearing, however, provides us an opportunity to provide the
Persian Gulf veterans' experience in the broader context of the
military combat experience generally. A recent study on a group of
World War II veterans, for example, found that overseas combat
was a significant predictor of a physical decline or death in the 15
years after the war. Another important study concluded that unex-
plained war-related illnesses with symptoms similar to those re-
ported in Persian Gulf veterans have been documented after wars
from the Civil War on.
(1)
 2
These and other studies led me to develop legislation which I be-
lieve can help us apply lessons painfully learned from our Persian
Gulf experience, our hearings record on Gulf war illnesses, and the
medical literature highlighting the importance of early treatment
in overcoming health problems thought to be linked to wartime
service.
Conversely, the failure to address war-related health problems
early and effectively can lead to chronic illness. At the same time,
it has become very clear that medicine lacks a full understanding
of how some of these war-related diseases develop and how to best
treat them.
In my view, the Department of Veterans Affairs, working closely
with the Defense Department, can and should be a leader in foster-
ing research on war-related illnesses, in developing improved treat-
ment techniques, and in disseminating its findings.
The legislation I've developed would call for VA to establish a na-
tional center for war-related illnesses to carry out needed research,
treatment, and training.
The bill would also create a broad new authority for VA to pro-
vide needed care for veterans of future combat missions and would
extend and expand VA's special authority to treat Persian Gulf
veterans.
I particularly appreciate the enthusiastic support expressed for
the bill by our largest national veterans' organIzation, the Amer-
ican Legion, and by others. I welcome the opportunity to obtain tes-
timony on this legislation as well as to hear testimony on VA's sex-
ual trauma counseling program.
Before calling on my first panel of witnesses, let me tum to my
good friend and ranking member of the subcommittee, Mr. Gutier-
rez, for an opening statement.
OPENING STATEMENT OF HON. LUIS V. GUTIERREZ
Mr. GUTIERREZ. Thank you, Chairman Stearns, and allow me
commend you on your work as chairman of the subcommittee. Your
commitment to ensuring that this subcommittee addresses the
most important issues affecting the health care provided to our Na-
tion's veterans should be duly noted by all those who follow these
matters.
Today, in reviewing the research and treatment of war-related
illnesses and Department of Veterans Affairs sexual trauma coun-
seling program, this committee is once again demonstrating its
dedication to improving veterans' medical care.
Mr. Chairman, our country has been compelled to restore peace
to the world and protect the interest of our people many times dur-
ing the past half century. We are living in a time of relative peace
today, but we cannot be sure that threats to our freedom and na-
tional security will not arise again. Thus, we must be prepared as
a nation for this unfortunate possibility. When I say prepared, I do
not just mean with new weapons and technology. I also mean we
must be prepared to deal with the possibility that thousands of
brave men and women who serve in future conflicts may come
home from war sicker than when they left. These veterans may
also suffer from complex illnesses that we cannot readily diagnose.
We must be prepared for this event, so that we do not repeat the
 3
failures of the past. We must be prepared, so that we do not treat
future veterans as we have those who have served in Vietnam and
the Persian Gulf. We must be able to provide answers and sound
treatments for future veterans, and we must develop these proce-
dures now for those who served in Operation Desert Storm and
Southeast Asia.
I am pleased that this subcommittee will look at ways to address
this issue today. Anticipating our future obligations and improving
our current programs that help the veterans of America heal from
war-related illnesses are wise steps for us to take.
I'm also encouraged that this morning we will address another
issue of the utmost importance to the future of veterans' health
care. In July of last year, I introduced the Veterans' Sexual Trau-
ma Treatment Act. I did so because I believe that Congress must
improve the current law governing the provision of sexual trauma
counseling at the VA. In conversations with women veterans and
VA medical practitioners, I've also learned about significant gaps
in the law that have prevented some veterans from receiving this
needed care for sexual trauma. Sixty-seven Members of Congress,
including thirteen members of the House of Veterans' Affairs Com-
mittee, co-sponsored my legislation to eliminate these discrepancies
and improve health care for our veterans.
I want to briefly summarize the important highlights of this bill.
Current law does not govern, Mr. Chairman, for veterans who have
served less than 24 months in the military. Yet we know, from Ab-
erdeen and other high-profile incidents of sexual violence in the
military, that often the victims of these crimes suffer these inci-
dents in the early months of their service. Often, these crimes go
unreported. Because of the drama caused by these actions and the
stress of working with offenders, these women are often discharged
prior to the 24-month period. Upon discharge, our laws do not en-
able those veterans to receive the care they need and deserve to
overcome the varied physiological and psychological effects of sex-
ual trauma. This is wrong. The VA is wrong and is taking steps
to address the problem. The VA General Counsel has stated that
the 2-year service requirement no longer applies to the VA sexual
trauma program. I strongly commend this interpretation of the
law.
By caring for veterans who have no choice but to leave the mili-
tary because they have served 2 years because of sexual harass-
ment or abuse should not be a matter of interpretation. It should
be a matter of law. My bill will achieve this goal.
In addition, Reservists and National Guard personnel who have
been the victims of these terrible crimes while on duty should also
be eligible to receive sexual trauma counseling. My bill would qual-
ify them to do so.
Ensuring that all veterans in need receive sexual trauma coun-
seling and treatment also demands that we make the VA program
required. Currently, the VA has the authority to provide this care
for veterans, but the law does not .mandate that the VA do so.
Under its current leadership, the VA has done a commendable job
in establishing a sexual trauma program throughout our Nation.
However, cases have been documented where VA officials have de-
nied trauma counseling to veterans who need and qualify for these
 4
services. In addition, many VA medical facilities in regions of our
Nation are not adequately served by this program.
Revising the law to mandate the continuation of VA's sexual
trauma program to take care of veterans who were the victims of
abuse and harassment during their military service a priority is a
goal this committee, this Congress, and the VA should work to
achieve. I strongly believe that our Government has a responsibil-
ity, that it should be required to ensure treatment for women of
sexual abuse and harassment. These women made the highest com-
mitment to our freedom. They pledged to serve and protect our peo-
ple and, sadly, their own safety and honor were compromised. We
must do more to protect women in the military from future inci-
dents, just as important as to acknowledge our responsibility to aid
veterans already suffering the consequences of sexual trauma. Fail-
ure to accept this challenge is an affront to all veterans who have
defended America.
Mr. Chairman, thank you again for your interest in this matter.
I look forward to working with you to re-authorize and make the
improvement necessary.
I also want to applaud the work of the VA employees and women
veterans such as Joan Furey and Andrea Van Horn. You are abso-
lutely critical to providing all our veterans with the quality care
they deserve and require. I also want to thank the veterans' com-
munity and service organizations who have contributed so much to
our knowledge and understanding of these issues. I truly appre-
ciate their assistance.
Thank you once again, Mr. Chairman.
Mr. STEARNS. Thank you. Mr. Evans, the ranking member of the
full committee.
OPENING STATEMENT OF HON. LANE EVANS, RANKING DEMO-
CRATIC MEMBER, FULL COMMITTEE ON VETERANS' AF
FAIRS
Mr. EVANS. Thank you, Mr. Chairman. I will try to keep my re-
marks very brief since we have a full agenda. I do want to com-
pliment you for the work you're doing in this area. I think it's bi-
partisan concern that we've seen on this committee, and I'm very
pleased to see that the draft legislation we'll be discussing today
offers another approach to addressing the problems that veterans
of the Persian Gulf continue to experience 7 years after their serv-
ice to our country. But I would add, it's just one of the approaches
that has been offered to the House Committee of Veterans' Affairs
for review.
While I'm eager to hear the experts from the scientific and Gov-
ernment agencies discuss this proposal, I am equally anxious for
other bills, including my own comprehensive Persian Gulf bill and
Mr. Kennedy's legislation, to have a fair hearing on those pieces of
legislation. I hope that the chairman of the full committee will
work with me to ensure that our committee consider more of these
measures before it chooses which course is most appropriate for
action.
And I ask that my entire statement be added into the record at
this time.
Mr. STEARNS. So ordered.
 5
[The prepared statement of Congressman Evans appears on p.
49.]
Mr. STEARNS. Mr. Peterson? Mr. Kennedy?
OPENING STATEMENT OF HON. JOSEPH P. KENNEDY II
Mr. KENNEDY. Thank you very much, Mr. Chairman. First of all,
Mr. Chairman, I want to thank you. I know that it's the tradition
around here for everybody to compliment the ranking member on-
excuse me-the chairman of the committee on whatever is happen-
ing, no matter how ridiculous. But in this particular case, I think
you really do deserve some credit for the leadership that you have
shown on this committee, Mr. Stearns. Your willingness to really
take the lid off the top on many of the issues that have surrounded
the Persian Gulf illness, in particular, is something that I think ev-
erybody on both sides of the aisle should commend you for. It's
been a privilege to be on this subcommittee with you because of
that independent spirit. So I just want to thank you very much for
that.
Mr. STEARNS. Thank you, I appreciate that.
Mr. KENNEDY. Mr. Chairman, as you know, there have been very
serious issues over our Nation's veterans and, in particular, in the
last 7 years those Persian Gulf veterans who have suffered from a
series of mysterious symptoms that have led to a variety of unex-
plained illnesses. Lane Evans and I held a hearing in Boston in
1992 to gather testimony from sick veterans, and at that hearing
we learned of a myriad of illnesses from which Persian Gulf veter-
ans suffer. At that time, we were unsure of the sources of those ill-
nesses, and today we are still faced with many of these same unan-
swered questions. Mr. Chairman, I want to thank you for holding
this hearing in order to discuss veterans' access to health care
problems that are caused by combat service.
As you know, both Mr. Evans and I have introduced Persian Gulf
bills. It is my hope that the committee leadership will work with
us and other members of the committee to craft a bipartisan bill
to find effective treatment for our veterans' undiagnosed illnesses.
I am an original co-sponsor of Mr. Evans' bill, the Persian Gulf Vet-
erans' Act in 1998, and I appreciate his hard work to secure the
highest possible compensation levels for Persian Gulf War
veterans.
My bill, H.R. 3661, the Persian Gulf Veterans' Health and Medi-
cal Research Act of 1998, researches the Persian Gulf research
within the VA and DOD. It also establishes a database to monitor
the Persian Gulf veterans' health. It requires attending physicians
to be trained in new treatment protocols and directs the GAO to
evaluate the research and database once a year and report to this
committee whether the research and medical treatment are moving
in the right direction. I want to thank the members of the commit-
tee who support the bill, and I look forward to the support of Rank-
ing Member Evans and other members of the committee. It's my
hope that we can negotiate a bipartisan bill which finally solves the
Persian Gulf veterans' illnesses, so that they can get well and live
normal lives again.
I'd like to say a few words about the need for greater Persian
Gulf treatment. Over the years, the VA and DOD have provided
 6
great services to our Nation's veterans and military personnel. But
when it comes to Persian Gulf syndrome, VA and DOD simply have
not had a coordinated effort to provide coherent research plans
since the Persian Gulf War ended. VA and DOD have spend mil-
lions of dollars over the course of the past 7 years predominately
looking into the cause, but they have initiated very little research
into finding effective treatment for low-level exposure to chemicals.
I know the VA chose to do this research this way because for
years the Pentagon continued to deny any link between the veter-
ans' health problems and exposure to chemicals while serving in
the Gulf. But in April of 1996, the CIA released a report showing
solid evidence that thousands of chemical weapons were stored in
Khamisiyah, and that while U.S. troops were demolishing the
bunker they may have been exposed to these deadly agents.
We need a fresh start. In June of 1997, in the GAO report enti-
tled, "Gulf War Illness," it was pointed out that research had been
primarily focused on the cause of Persian Gulf illnesses and that
the VA has done very little in finding effective treatments for expo-
sure to chemicals. That's why my bill directs the Persian Gulf re-
search will still be done within the VA and DOD. However, the re-
search agenda will be established and managed by the National In-
stitutes of Health.
NIH is the natural organization to manage the research. They
have a far superior research infrastructure already in place. They
have a scientific approach to the peer review process, and they can
reach out to toxicologists from around the country who understand
the health effects of chemical and biological agents entering the
body.
And again, Mr. Chairman, I hope that we can craft a bipartisan
agreement on Persian Gulf veterans' health care bill. And I want
to thank you for refocusing today's hearing on extending the VA
authority to treat any illnesses that can be attributable to a veter-
an's service during combat.
On a second topic-and I'm also a co-sponsor of Mr. Gutierrez'
bill to make VA sexual trauma counseling program permanent and
mandatory-I'm pleased that the AMVETS, the American Legion
and VFW and Vietnam Veterans, all support his bill and I hope
that it will be enacted during this legislative session.
Again, Mr. Chairman, I want to thank you. I just, again very
briefly, want to recognize the fact that under this legislation it is
true that there would be other committees that would be looking
at this legislation, but I do believe that it is important that we rec-
ognize that we ought to be looking out after the health needs of our
veterans first. And if, in fact, the GAO has been so critical of both
the VA and the Pentagon's ability to conduct this research not only
in terms of what the relationship is between chemical and biologi-
cal agents and these illnesses, but how to actually treat them, it
seems to me we ought to go to the best agency in the Government
to get the veterans the health care that they need and deserve.
Thank you very much, Mr. Chairman, for your consideration.
Mr. STEARNS. Thank you, Joe, and I thank Mr. Evans for his
work, too. Dr. Cooksey, opening statement?
Dr. COOKSEY. No, Mr. Chairman.
 7

[The prepared statement of Congresswoman Chenoweth appears

on p. 50.]
Mr. STEARNS. Without further ado then, we'll have the first panel
come forward. The first panel will testify to the need for study and
treatment of war-related illnesses. We have Captain Hyams, Dr.
Richard Miller, Mr. Puglisi, accompanied by Dr. Hodgson. We want
to welcome all you folks this morning, and I think we'll start with
Captain Hyams for your opening statement.
STATEMENTS OF CAPTAIN CRAIG HYAMS, M.D., U.S. NAVY, IN-
FECTIOUS DISEASES DEPARTMENT, NAVAL MEDICAL RE-
SEARCH INSTITUTE; RICHARD MILLER, M.D., DIRECTOR,
MEDICAL FOLLOW-UP AGENCY, INSTITUTE OF MEDICINE,
NATIONAL ACADEMY OF SCIENCES; MATl'HEW PUGLISI, AS-
SISTANT DIRECTOR FOR GULF WAR VETERANS, NATIONAL
VETERANS' AFFAIRS AND REHABU,ITATION COMMISSION,
THE AMERICAN LEGION, ACCOMPANIED BY MICHAEL HODG-
SON, M.D., UNIVERSITY OF CONNECTICUT SCHOOL OF
MEDICINE
STATEMENT OF CAPTAIN CRAIG HYAMS
Captain HYAMS. Good morning, Mr. Chairman. My name is Ken-
neth Craig Hyams. I am a Captain in the Medical Corps of the U.S.
Navy. Currently, I'm the head of the Infectious Diseases Threat As-
sessment Division of the Naval Medical Research Institute in Be-
thesda, MD. I am a physician, board-certified in internal medicine
and infectious diseases, and I have a degree in public health from
Johns Hopkins University. I am also an author on over 130 sci-
entific publications. The following testimony represents my sci-
entific and personal opinion and does not necessarily reflect the of-
ficial views of the administration, the Department of Defense, or
the U.S. Navy.
My involvement in the Persian Gulf War health care began in
August 1990, when I deployed to the Persian Gulf to help set up
a diagnostic laboratory. With the support of numerous military sci-
entists and preventive health officers, and the U.S. Naval Medical
Research Unit No.3 in Cairo, Egypt, the Navy Forward Laboratory
was established in Al-Jubayl, Saudi Arabia. The Navy Forward
Laboratory served as the theater-wide infectious diseases reference
laboratory during Operations Desert Shield and Desert Storm. Our
job was to evaluate clinical specimens and environmental samples
for infectious disease threats. We were able to identify the most im-
portant infectious disease problems during the war, which led to
lmproved clinical care and preventive health efforts among coali-
tion forces.
The diagnostic and surveillance activities of the Navy Forward
Laboratory have also helped prioritize and direct medical research
programs since the war. The U.S. Army, Navy, and Air Force main-
tain an extensive medical research program which conducts epide-
miological studies to determine the major health threats for our
troops, develops improved preventive health measures, develops
new diagnostic tests, and develops new drugs and vaccines.
The military's medical research program has played a major role
in the Government's effort to understand the health problems of
 8
Gulf war veterans. The first large-scale epidemiological studies of
hospitalizations and birth defects among Gulf war veteran popu-
lations were conducted at the Naval Health Research Center, in
San Diego, California, and a new form of parasitic infection,
viscerotropic leishmaniasis, was identified in 12 Gulf war veterans
at the Walter Reed Army Institute of Research in Washington, DC.
In December 1993, I was detailed to the Tri-agency Persian Gulf
Veterans' Coordinating Board and spent over 2 years at the De-
partment of Veterans Affairs assisting in the evaluation of veter-
ans' unexplained symptoms. One of the earliest questions we had
to address was whether similar illnesses had occurred after pre-
vious wars. In a collaborative study between DOD and VA-the
principal investigator for VA was Dr. Robert Roswell-we con-
ducted an extensive search for scientific publications dealing with
prior war-related illnesses. Initially, we expected to find psycho-
logical problems like post-traumatic stress disorder to be common
after wars. What we discovered was a much more complicated pic-
ture of veterans' health problems.
In addition to well-know stress-related conditions, we found that
similar unexplained symptoms have been associated with armed
conflicts since at least the U.S. Civil War. War veterans have re-
peatedly suffered from fatigue, shortness of breath, headaches,
sleep disturbances, and impaired memory and concentration. These
symptoms have been categorized as distinct syndromes, which have
been variously called DaCosta's syndrome, soldier's heart, neur-
asthenia, effort syndrome, and most recently Gulf War syndrome.
Our research also revealed one other unifying factor. War syn-
dromes have been repeatedly defined, explained, and studied in a
similar manner since the U.S. Civil War. These postulated syn-
dromes have been identified by diverse physical symptoms which
do not fit easily into well-characterized diagnostic categories. In ad-
dition, war syndromes have remained unexplained, even after dec-
ades of medical follow-up of veterans who were finitely ill, because
unique physical abnormalities were not identified.
Lastly, there have been extensive governmental efforts in the
United States, Great Britain, and Canada to understand war syn-
dromes and provide clinical care and assistance to veterans. De-
spite these concerted efforts, the existence and causes of distinct
war-related diseases have not been conclusively determined, which
has resulted in over a century of unresolved public and scientific
controversy.
When all available clinical and research data is carefully
weighed, it is clear that war veterans have suffered from a broad
variety of medical and psychological illness which were due to com-
plex and frequently unknown factors. There are two rrincipal rea-
sons for the continued uncertainly about the causes 0 these health
problems. For one, epidemiological studies cannot be conducted in
the midst of a chaotic and unpredictable battlefield where the over-
riding objective has to be the defeat of the enemy. Consequently,
it has not been possible to collect the extensive risk factor data
needed to conclusively answer all post-war health questions. Also,
it is not possible in a research laboratory to recreate the exact com-
bination of events, exposures, and experiences during a war to
prove whether a potential health risk is the cause of illness.
 9
The other principal reason why it has not been possible to ex-
plain war syndromes is that we are dealing with fundamental, un-
answered health questions shared by every adult population.
Symptoms such as chronic fatigue and pain are frequent causes of
suffering and disability in all civilian populations, yet the underly-
ing causes and most effective treatments for these symptoms re-
main largely unknown.
The findings of our study of war syndromes clearly demonstrate
that more research is needed to understand the causes of chronic
physical symptoms. Basic scientific research is essential, as is in-
creased surveillance of military personnel and veterans before, dur-
ing, and after hazardous deployments. Just as clearly, our research
demonstrates that some veterans may require specialized health
care after life-threatening deployments. Because it may not be pos-
sible to verify an association between ill health and wartime expo-
sures, even with well-designed research studies, requiring individ-
ual veterans to prove causation following future conflicts may be
unrealistic. Although active duty military personnel automatically
receive health care within the military health system and Gulf War
veterans are covered by legislation, future Reservists, National
Guard personnel, and troops who leave active duty soon after haz-
ardous deployments will have to establish financial need or service
connection before the VA can legally provide medical care. Given
the unanswered scientific questions involving post-war health prob-
lems, the requirement for service connection can be very hard to
meet, resulting in a frustrating process for ill veterans, their fami-
lies, and health care providers.
Mr. Chairman, I'll be happy to answer any questions you or the
other committee members may ask.
lTheprepared statement of Captain Hyams appears on p. 51.]
Mr. STEARNS. Thank you.
Dr. Miller, do you have an opening statement?
STATEMENT OF RICHARD MILLER
Dr. MILLER. Yes, sir, I do.
Mr. STEARNS. Okay. Feel free to start.
Dr. MILLER. Mr. Chairman, members of the subcommittee, I'm
Richard Miller, Director of the Medical Follow-Up Agency at the
National Academy of Sciences. I speak as the head of the small or-
ganization that has been carrying out research on veterans' health
issues for more than 50 years, since our founding by Dr. Michael
DeBakey in 1946.
It is appropriate to point out that I am the principal investigator
of a study jointly funded by the VA and DOD into the health per-
ceptions and health care seeking behaviors of Persian Gulf War
veterans enrolled in the VA Persian Gulf Health Registry and the
DOD Comprehensive Clinical Evaluation Program. Further, we in-
tend to submit one or more proposals to the VA and DOD in the
near future to conduct other studies of war-related illness. I am,
therefore, a knowledgeable, but involved witness.
I will also testify as a veteran of 29 years of active duty in the
U.S. Army who now receives a portion of his medical care at a VA
medical center and as a physician who has cared for both military
and civilian patients. However, I do not feel qualified to comment
 10
on the portion of the bill dealing with health care of veterans ex-
cept to make a personal observation that at least some war-related
illnesses appear to be associated with psychological stress, and that
a significant stressor for veterans is uncertainly about the avail-
ability of medical care. There could, therefore, be a paradoxical re-
duction in the need for medical care produced by the assurances to
veterans that care is available. An additional personal speculation
is that the provision of care to recent war veterans may well obvi-
ate the need for the complex and expensive registries and evalua-
tion programs such as the Persian Gulf Health Registry.
All remaining comments will deal with the proposed National
Center for the Study of War-Related Illnesses, which I believe is
an excellent and long overdue effort to elucidate the causes of a
major portion of veteran illnesses.
Wars pose unique combinations of psychological and environ-
mental exposures. A center organized around the phenomenon of
war-related illness, rather than a single discipline or disease, can
bring together the appropriate mix of expertise and foster appro-
priate collaborations. Cooperative efforts between psychologists,
psychiatrists, toxicologists, environmental medicine physicians, and
other specialties may bring new insights and perhaps help combat
the stigma of psychological illness in the minds of some by treating
war-related stress as just another unavoidable risk associated with
going to war. I particularly like Dr. Hyams' term ''war syndromes"
since it connotes an occupational hazard for our Nation's warriors
and not the perception by some veterans that Government doctors
are saying their illness is not real.
I hope that the new center will, as the draft bill states, fund
studies of the causes of war-related illness. Epidemiologic studies
of risk factors for developing war-related illness with the goal of
preventing them, or at least ameliorating their effects, are
essential.
The recently published work of Dr. Hyams and his colleagues in-
dicates that the problem of war-related illness is much more com-
plex than originally believed and has been with us after most
major military deployments. Sometimes, as after the Persian Gulf
War, medically-unexplained illnesses constitute the majority of the
resulting medical problems of veterans. The lack of an easy answer
to the causes of these illnesses suggests the need to look at the
problem in new ways.
The work of a national center for the study of war-related ill-
nesses may also have major implications for civilian health care. It
is clear that medically-unexplained illnesses are by no means lim-
ited to veteran populations. Any physician who practices primary
care or family medicine is well aware of the burden of unexplained
illness for patients, for clinic staff, and for those who pay the ever-
increasing costs of medical care.
Thank you, Mr. Chairman, and I will be happy to answer ques-
tions.
[The prepared statement of Dr. Miller appears on p. 57.]
Mr. STEARNS. Thank you. Mr. Puglisi.
 11
STATEMENT OF MATTHEW PUGLISI
Mr. PuGLISI. Thank you, Mr. Chairman. Good morning, and good
morning to the other members of the committee.
Thank you for providing the American Legion the opportunity to
participate in today's hearing regarding research on, and treatment
of, war-related illnesses and your draft legislation to provide au-
thority to furnish priority health care to treat illnesses which may
be attributable to future wartime service.
With my today is Dr. Hodgson, assistant professor of medicine at
the University of Connecticut. The American Legion consults with
Dr. Hodgson on Gulf war illnesses, and he assisted in the writing
of portions of this testimony.
Mr. Chairman, this is your third hearing in this Congress re-
garding Gulf War veterans' illnesses. Your leadership and energy
have provided the public and Congress with the facts regarding the
health effects of the Gulf War and a lucid analysis of the Federal
Government's reaction to veterans' health complaints. The draft
bill before the committee applies the knowledge gained through
this subcommittee's exhaustive investigation of Gulf War veterans'
illnesses and investigations of illnesses found after past wars. If
passed, it would represent a historic step in addressing the health
problems of today's veterans and tomorrow's as well. It would also
be a bright display of how Congress can learn lessons from the Na-
tion's e~erience in preceding wars. This could signal another step
forward m the Nation's revolving commitment of caring for its war
veterans, and it has the enthusiastic support of the Nation's largest
veterans' service organization.
Since late 1991, thousands of veterans returning from combat
service in the Persian Gulf have reported a broad range of symp-
toms, syndromes, and diseases. The possible causes of these
illnesses have been summarized in a series of committee reports.
Now, 7 years later, many veterans still feel ill and seek answers
that will help them feel better. Increasingly, the questions is where
they, and future redeployed veterans, should receive health care.
Returning veterans have reported similar symptoms after previous
wars; symptoms that were chronic, disabling, and medically
unexplained.
In spite of the appearance of medically-unexplained symptom
syndromes after all our wars, since at least 1860, the Federal Gov-
ernment has not responded with programs that would anticipate
these illnesses and provide access to health care for these veterans.
That would change with the passage of this draft bill.
AB you mentioned earlier, Mr. Chairman, World War II, Viet-
nam, and service in the Gulf all predicted poor health in those who
deployed to those theaters and poor health at a significantly great-
er rate that those who didn't deploy to those theaters.
Today we are confronted with thousands of ill Gulf War veterans.
The population of Gulf War veterans is significantly more ill than
those non-deployed Gulf War veterans. They appear to use the
health care system more frequently for a broad range of problems,
from asthma to ill-defined conditions. Some of these represent iden-
tifiable diseases commonly treated in primary care settings. Some
veterans are commonly seen but not treated well by primary care
physicians who have little training in veterans' health.
 12
The American Legion has long held the view that the most press-
ing issue facing sick Gulf War veterans was the development of ef-
fective use of medical treatments for their illnesses. There have
been obstacles in the way, the most apparent being the failure to
recognize that medically-unexplained symptom syndromes may be
a natural consequence of participation in a war. Another was that
Gulf War veterans were only gradually given access to health care,
when the medical literature is clear that the sooner interventions
occur the more likely a sick patient will get better.
The bill overcomes these obstacles. First, it provides health care
for Gulf War veterans through the year 2001 and future war veter-
ans. Secondly, it will eventually enable VA to effectively treat these
illnesses through medical knowledge developed at a national center
on war-related illnesses.
The bill not only is a key part of VA's current efforts to deter-
mine which medical approaches effectively treat these illnesses, but
it will help create a VA system ready to "hit the deck running"
after our next war. The bill provides VA with the opportunity to
address the next Gulf War syndrome competently.
At the height of the Second World War, veterans of the First
World War sat in Legion and Posts across the United States and
talked about the hardships they faced upon their return from
France in 1919. These discussions turned into ideas and soon into
action. Congress passed the Serviceman's Readjustment Act, the GI
Bill of Rights, before the war had ended. Discharged veterans
didn't return home unemployed while the Federal Government
slowly decided what could be done for them. Instead, the GI Bill
enabled these veterans to attend college and buy homes, and it
generated the greatest era of prosperity in the Nation's history.
This bill, although much more modest in scale than the GI Bill,
parallels its vision. It applies the lessons learned from our recent
and distant past. It implements policies before they are needed by
veterans. This will enable sick war veterans to return from future
wars and be given every chance to recover their health and lead
productive lives.
Mr. Chairman, this concludes my testimony. I'll be happy to an-
swer any questions.
[The prepared statement of Mr. Puglisi appears on p. 65.]
Mr. STEARNS. Thank you. Dr. Hodgson.
Dr. HODGSON. Mr. Chairman, thanks for the invitation. I'm just
here to help Mr. Puglisi answer questions you would have.
Mr. STEARNS. Okay. Okay, let me just start. Captain Hyams, I
heard your testimony. And let me just say I had a young man, Mi-
chael Adcock, in my congressional district die when he came back.
He was a star athlete in high school. He went over in the best of
health. He came back, and he had three or four different illnesses.
He finally died of a brain tumor-an excruciating death. He was
22 years old. If I went to the mother of Michael Adcock and said
that there has been historically Gulf War-type syndromes since
Civil War, that probably wouldn't alleviate her pain, and I under-
stand that.
But let me just ask as a general question: Don't you think,
though, that something that happened in the Gulf War, it's distinct
and different than what happened in other wars? Or do you think
 13
what happened in the Gulf War is very similar to what's happened
in all wars since the Civil War?
Captain HYAMS. I think all the wars are very different. They're
conducted in different locations; the sort of weapons that are in-
volved, and the sort of experiences of soldiers are very, very dif-
ferent. And, yes, the wars themselves are quite different, but some
of the post-war health questions are similar. I think you have to
draw a distinction between the actual experience and the health-
related questions we ask after the war.
Mr. STEARNS. Mr. Puglisi, in terms of health care and research
issues, do you feel that our legislation-I think the words you
might have used are "a modest step forward"-will provide or cre-
ate more priority on these problems and get some more concentra-
tion of interest and discovery?
Mr. PuGLISI. Yes, Mr. Chairman, I think it would. After the Gulf
War, VA was very well-prepared for things it thought would hap-
pen after the Gulf War. It was looking for respiratory illness in vet-
erans from the smoke from the oil well fires. It was looking for
post-traumatic stress disorder from those who had experienced
traumatic events, and it found bulk.
But as growing numbers of Gulf War veterans reported illnesses
and diseases that didn't fit either one of those categories, they had
a more difficult time in getting in the system. VA didn't have a uni-
form approach to those veterans. If, after every war, we have vets
who have unexplained symptoms regardless of what the cause is-
and the American Legion isn't suggesting that it's stress or stress
alone. Stress seems to be an ingredient, according to a number of
scientific panels that have met, but there are other possible causes
that are being investigated as well.
So we are not getting into the cause of the debate so much as
just acknowledging that, if this has always happened, and it may
always happen, VA needs to be ready and able to treat people who
have these kinds of illnesses after future wars.
Mr. STEARNS. Dr. Hodgson, are you familiar with the legislation
that we have in place here?
Dr. HODGSON. Yes.
Mr. STEARNS. I think then what I would ask you is, tell me a lit-
tle bit what you see as the role of the Center for the Study of War-
Related Illnesses. How should it be structured, staffed, operated?
Maybe give some insight into, if you were the administrator, if you
were effectively implementing this, how would you go about to
structure this?
Dr. HODGSON. Some of the points that Dr. Miller made are cru-
cial. Those include the pulling professionals together with a broad
range of expertise, not just in epidemiology and toxicology, but also
in evaluating the outcomes of certain intervention strategies. One
of the weaknesses of the research portfolio as it's evolved is that
it took a while to get an overall agenda focused on some specifi-
cally-measurable benefit to, not just the scientific community, but
also to the affected individuals. The way Dr. Miller presented the
center, I'm looking at the effectiveness of whatever is being done
is essential.
The question of how to structure that, whether in specific dis-
ciplines that involve toxicology, epidemiology, clinical medicine, or
 14
organizing it around teams that are more specifically around spe-
cific research projects, is really something that will probably
change as different conflicts arise. For example, in some of the
work that is going on right now, the VA has, in fact, begun plan-
ning on a randomized controlled intervention trail for fatigue-like
symptoms. If the VA had not, the war disease center would have
to do that. But I'm not sure at this point if one could actually say
A, B, or C is the preferable structure without knowing all the
things the different agencies are internally shifting.
Mr. STEARNS. When we started this investigation, we heard dif-
ferent concerns from different agencies. And we talked to the De-
partment of Defense, and then the Department of Defense told us,
. and then different things came out. Is it appropriate to keep the
investigation, control of it, with the Department of Defense? Should
they play in the operation for a center for war-related illnesses?
What steps should we take to ensure that appropriate coordinated
concerns are implemented? Because I think a lot of us, when we
looked at this problem, just didn't know even where to go, what
agency to start with, and who to believe, and so to try and bring
this into focus so that we have one agency, one individual's group
that's on top of it. I think the question is open to the panel, as far
as the appropriateness of the Department of Defense to be involved
here.
Mr. PUGLISI. Mr. Chainnan, I'm assuming that you're asking
about the Department of Defense in investigating chemical expo-
sures and chemical weapons and-the Department of Defense has
really become the whip~ing boy on this issue, and to its own credit
really, and no one else s. By denying that chemical weapons were
even in the Kuwait theater of operations for a number of years, set
back the research agenda by that period of time and left a real bad
taste in the mouth of all Gulf War vets.
Since then, they've expanded their investigation from 12 folks to
over 125, and the Presidential Advisory Committee has overseen
their efforts, as has the General Accounting Office, congressional
committees, and now an oversight panel that the White House is
putting together. So, there's plenty of oversight of DOD, and so far
over the last year and a half, they've shown a good-faith effort in
trying to get the bottom of what's been going on in the Gulf-or
what occurred in the Gulf. The important thing, however, is in re-
searching war-related illnesses; the Department of Defense must
play a role; otherwise, there isn't going to be a good handoff of
these future war veterans from DOD to VA. So, I would encourage
that the legislation, as it does, continue to ensure that DOD is in-
volved in this process down the road.
Mr. STEARNS. Well, certainly the DOD-they have the records;
they have the data and all the infonnation on exposures and every-
thing. So, hopefully, you know, that would make them as a pre-
requisite. Yes?
Mr. PuGLISI. Actually, if I could just touch on that last comment,
actually, one of the biggest problems with the Gulf War was that
the Department of Defense didn't have the records, didn't have the
exposure data, and didn't maintain good medical records and shot
records for troops. I know that they've addressed that, or attempted
to, in Bosnia, and GAO said that they did a better job in Bosnia
 15
but fell a little short. But the key isn't after the war; it's before and
during.
Dr. HODGSON. One of my hats is occupational medicine. There is
an interesting model that's evolved in the U.S. since the 1950's in
the controversial area of occupational disease. So called tri-partied
studies were pioneered by the National Institute of Health in the
1950's to address some of the conflicts that arise in the use of the
scientific method to get data used both by industry and labor. So,
for example, the National Cancer Institute, for the first time in
1959, set up the co-government workers mortality study and put a
steering committee in place that had equal representation from the
Steel Workers, the National Cancer Institute, and the steel indus-
tries. And only by having this tri-partied steering committee did,
in fact, that work become as useful as it is. That model has been
used in occupational studies not just in the U.S. now, but also in
Canada. And most academic scientists will push very hard for hav-
ing a tri-partied committee to help guide and, shall we say, take
some of the heat off of their findings when the work is actually
published. Making sure that there is representation of the affected
individuals on that committee also ensures that the work is done
with an eye towards the affected subjects.
Mr. STEARNS. That's an interesting observation. Before I con-
clude, I think every member here wishes we could ultimately find
the answer to the Gulf War syndrome.
And lots of stories have come on the AP wire. I have one that
came in April 21. A doctor in Belfast believes he's found the key
to unraveling the mystery of the Gulf War syndrome, and with a
pioneering treatment, that could mean the end of suffering. The
claim by Environmental Practitioner Dr. Magee comes just a month
after he teamed up with a leading pharmaceutical company to find
out why so many former soldiers were acutely ill. He found that
former soldiers based in Northern Ireland when suffering from Gulf
War syndrome had been poisoned by a toxic mix of eight
chlorinated and organophorus pesticides. He made the discovery
after having fat samples from former soldier Steve Fords examined
by a London laboratory and hit upon the idea of having fat tested
because poisons in the blood break down within a few hours. And,
evidently, that same technique was used to come up with the iden-
tification of Agent Orange.
I put that in the record because, as you know, there's many peo-
ple that claim that they have found the solution to the Gulf War
illness. But I think, on the other hand, we cannot discount when
people come forward with new ideas.
And Captain Hyams, I'm going to obviously give you a copy of
this, but do you care to comment at all on perhaps what I've just
read to you? I know you haven't had prior presentation on this
idea.
Captain HYAMS. No, without reviewing the data, it'd be very
hard for me to say something about it. But we have a peer review
process where we evaluate and research fmdings. When that data
is published and other scientists have a chance to evaluate it and
try to duplicate the findings, then we'll know exactly what it means
in relationship to the Gulf War veterans. These findings have to be
re-created scientifically before you can really act on them.
 16
Mr. STEARNS. Well, I think if you could for me, then, is review
it, and we'll give you a copy of the article, and I'd like to have your
written reply into the authenticity of it or perhaps what you think
if there's any--
Captain HYAMS. Yes, sir.
Mr. STEARNS (continuing). Credibility to it, because I understand
that fat sample analysis from the toxins found in soldiers sprayed
with Agent Orange were finally identified, and this is the process.
And so, you know, I think many of us in Congress say, "Why
wasn't this done a long time ago." And, so that's something
that--
Captain HYAMS. Let me add just one other thing. I think there's
no substitute for first-hand experience. We had a lot medical per-
sonnel in the Gulf. A lot of scientists and researchers had a chance
to observe the conditions over there firsthand. These first-hand ex-
periences by people who really were there and understood what
happened, are essential to any evaluation of post-war health prob-
lems. In that regard, I think DOD is essential.
[The information follows:]
DEPARTMENT OF THE NAVY
INFORMATION PAPER
VETERANS' AFFAIRS
SUEJECT:HEALTHISSUES
Representative Cliff Stearns (R-FL) requested CAPT Hyams to evaluate an April
21, 1998, news article from PA News: "Gulf war syndrome-Doc hopes for break-
through." An. environmental practitioner, Dr. Finbarr Magee, is reported to have di-
agnosed the cause of Gulf war syndrome (a toxic mix of eight chlorinated and
"organophorus" pesticides) in one veteran by testing his fat tissue and to have found
a treatment for this condition after teaming up with a leading pharmaceutical
company.
CAPT Hyams response: I had difficulty evaluating this news item because I was
unable to locate: 1) the report in the scientific literature; 2) previous scientific pa-
pers by a Dr. Finbarr Magee; and, 3) specific findings from our British colleagues
who are working on Gulf war health questions. Eventually, I was able to contact
Dr. F. Magee in Northern Ireland.
Dr. F. Magee related that he tested just one Gulf war veteran and considers his
findings very preliminary. He is planning to test more veterans. At this stage, I can-
not determine the relevancy of reported findings. More Gulf war veterans will have
to be evaluated to ascertain whether the test results in this one veteran is a wide-
spread or an isolated finding. Also, a control group will have to be tested in a blind-
ed fashion to evaluate the accuracy of the test in measuring chemical agents in fat
and to evaluate local or job-related exposures, rather than exposure in the Persian
Gulf seven years ago. If I learn more about this report from Northern Ireland, I will
relay the information to the Subcommittee on Health, Committee on Veterans'
Affairs.
Mr. STEARNS. Do we work with the British? We work with the
British Government and the British military and we've been cor-
responding with them, haven't we?
Captain HYAMS. Yes, sir.
Mr. STEARNS. In terms of their research?
Captain HYAMS. We have a liaison officer here that we work with
almost on a daily or weekly basis.
Mr. STEARNS. Okay. Well, I've finished my questions.
Mr. Gutierrez.
 17
Mr. GUTIERREZ. Thank you, Mr. Chairman. Thank you to the
members of the panel.
I think probably the only question I have is, how do you see this
center-given that I arrived here in 1993 and the problem didn't
seem to be one of much of diagnosis, but just that both from the
Veterans' Administration and from the Department of Defense kind
of-they used words like, there is a certain level of malingering
going on here and people who have excuses and are looking for
pensions. There were those kinds of responses brought up-much
as we hear in the general community about people who try to ac-
cess any kind of Government program, you know. So how do we
deal with-I mean, how does the center deal with that if we have
a center and they come up with great information and we have a-
how do you advocate for veterans? Or does it advocate for veterans?
That's the only question I have for anybody on the panel.
Mr. PuGLISI. Well, Congressman, as a Gulf War veteran who
served with Gulf War vets who are sick, I took great exception to
those things you pointed out when folks would suggest-usually
very subtly that-"Wow, gee, an awful lot of compensation is prob-
ably at stake for this person." And that was sort of the explanation
as to why these unexplained symptoms were being reported. It's
clear that that's not the case. And scientific studies have shown
that this population is more ill than you would expect and more ill
than their peers who didn't go to the Gulf.
So, I believe that anyway, and the science has now validated my
beliefs that this center would, for the first time, acknowledge that
folks who go to war and come back and were not always going to
understand or explain exactly why they're ill. And instead of mak-
ing them prove that their illness is tied to the war, we just pre-
sume that it is. And instead of making them prove service connec-
tion in order to get care, we're going to give them care, and the cen-
ter is going to try to figure out, hopefully before the next war, what
medical treatments work.
Because when you ask Gulf War veterans, as all of you have Gulf
War veterans in your districts, and you talk to them, and they tell
you, "I just want to get better. I just want to get whole," I mean,
these are young people who have their whole lives ahead of them.
And getting $150 a month from VA for the rest of their lives isn't
going to pay the bills and take care of things. So, they want to get
better. They're not looking for compensation, and this center is part
of a very comprehensive effort to find medical treatments to make
them better.
Mr. GUTIERREZ. Anyone else care to comment? Yes, Doctor?
Dr. HODGSON. It turns out that the idea of compensation neuro-
sis is vastly overrated in the medical literature over the last 20
years. There's been a major re-thinking of that.
First of all, we don't think it happens as often. Second, from a
social perspective, no matter where you look at which disability
system, whether it's workers' compensation or social security, it
turns out that most people who rely on disability payments would
far rather work. In this society, work is still used as a measure of
success and respectability. And for most people, being dependent on
the pension is not desirable.
 18
That has, in fact, given rise to a very different model of manag-
ing disability in the medical context. Rehabilitation medicine, or
psychiatry, focuses aggressively on identifying obstacles to getting
people to where they want to be. And so a war-related center could,
m fact, do that in a far more aggressive way than physicians who
are often out of tune to, you know, problems that would be hard
to recognize for a primary care doctor.
Mr. GUTIERREZ. I think we should obviously look forward to
working on this legislation and seeing how we can do it because I
think the questions have been answered. I mean we need to figure
out that veterans don't have to come back and basically, you know,
confront us to-from those who said they were going to help them
when they came back. I think those are very vital, important
issues. I think we've seen that over-if we've learned nothing
else-over the last 5 years, that's what we've learned.
Thank you, Mr. Chairman, very much.
Mr. STEARNS. I thank my colleague. Mr. Evans.
Mr. EVANS. Thank you, Mr. Chairman.
Captain Hyams, your statement concludes that, for a variety of
reasons, it may be impossible to determine associations between ill
health and wartime exposures, and requiring individual veterans to
prove causation following future conflicts may be unrealistic.
Would you apply the same type of rationale to Persian War veter-
ans? And on what basis should VA award compensation if the asso-
ciations between exposure and health outcomes can not be found?
Captain HYAMS. It's very difficult to prove causation after a war-
time event. Wars are focused on a lot of different issues, conducting
large-scale epidemiologic studies where comprehensive data is col-
lected is not one of them. Also in the strictest scientific sense, it's
not possible to prove causation after a wartime event. You have to
be able to get in front of the event and do what we call clinical
trials or experimental studies to prove causation. Causation is a
difficult term to apply to a single event that comes and goes. And
you can't go back in time and recreate all the circumstances that
occurred in that event, so causation is always very difficult to de-
termine after a wartime events.
As far as compensation, I really have no background or knowl-
edge about that.
Mr. EVANS. Let me ask for the veterans of the American Legion
official position on the highest priorities of the Persian Gulf veter-
ans in this Congress.
Mr. PuGLISI. Well, Mr. Evans, Gulf War veterans want to see
Congress absorb the lessons from the Gulf War and past wars and
ensure that they're going to be taken care of for the rest of their
lives, should we not find medical treatments that can make them
better now or anytime soon. They want some hope that they'll be
taken care of. Mr. Stearns' bill is going to do that, and you, your-
self, have introduced a bill that combats the problem of Gulf War
illnesses and attacks different problems associated with Gulf War
illnesses, but also is very long ranging in its vision and would take
care of veterans as far as presumption and compensation as well.
So, the American Legion sees your bill and Mr. Stearns' bill as
being very important and complementary-not mutually exclu-
sive-because they each tackle different aspects of the problem.
 19
Mr. EVANS. Have you had a chance to look at the Kennedy legis-
lation?
Mr. PuGLISI. Yes, sir, I have.
Mr. EVANS. Does the Legion support it or--
Mr. PuGLISI. Well, the Legion, as you know, supports your bill
very strongly. It meets the mandate of the members as far as an
approach to the research and an approach to presumption and com-
pensation. And we're just looking forward to Mr. Kennedy and
yourself working out something to where one bill is put forward,
and perhaps that approach and Mr. Steams' approach can be
joined together, and the ultimate outcome from this Congress
would be something that tackles all the problems that are outlined
in all the bills or attacked in each bill.
Mr. EVANS. All right. Thank you. Thank you, Mr. Chairman.
Mr. STEARNS. Dr. Cooksey.
Dr. COOKSEY. Thank you, Mr. Chairman. Mr. Puglusi-Puglisi-
is that close?
Mr. PuGLISI. Yes.
Dr. COOKSEY. And Dr. Hodgson, I understand that there is in
this legislation proposal to really shift a lot of the research from
the VA and DOD over to NIH to do the analysis-analysis of veter-
ans' records, their treatment, their medical management. Do you
think this is a good use of resources, assuming the resources are
finite?
Mr. PuGLISI. Well, Congressman, actually you're referring to Mr.
Kennedy's bill which has provisions that would shift the authority
for the research, in our interpretation of it, to the NIH. And the
American Legion, however, supports Mr. Evans' bill which would
establish a contract between the Institute of Medicine and VA for
the Institute of Medicine to review the published literature at cer-
tain periods-2-year periods-and publish a report determining
what illnesses and diseases have been associated with the Gulf
War vast population, much as what we see with the Agent Orange
Act of 1991. So it's a similar approach. And the American Legion
supports Mr. Evans' bill.
Dr. COOKSEY. So basically, you're saying that you support Mr.
Evans' concept instead of Mr. Kennedy's concept?
Mr. PuGLISI. Well--
Dr. COOKSEY (continuing). Reflected in their concepts in their
legislation?
Mr. PUGLISI. Yes, Congressman, and what we're looking-it's be-
cause there is a lot of overlap between the two bills, and we're con-
fident that at some point in the near future they'll be probably one
cohesive approach to that part of the problem as far as research.
Dr. COOKSEY. Dr. Hodgson, what do you think about the records,
the medical records of the military-I've assumed you've looked at
some of them-as far as quality of information, volume of informa-
tion, accessibility?
Dr. HODGSON. The whole-- .
Dr. COOKSEY. DOD records, not Veterans' Administration
records, but DOD records primarily and then maybe the Veterans'
Administration records secondarily.
Dr. HODGSON. I actually have not seen DOD records at all.
Dr. COOKSEY. You're an internist by training?
 20
Dr. HODGSON. That's correct.
Dr. COOKSEY. Okay. I'm a physician, also, that's the way I used
to make an honest living before I got this new day job. (Laughter.)
But one of my criticisms of our colleagues in medicine is that we
do not have electronic medical records to date. I do in my medical
office and have had for 10 years, but too many physicians are still
doing pen and paper, which is the way this Congress was run until
3 or 4 years ago, too. But in this information age, all physicians
should be using electronic medical records. And I happen to know
that the Department of Defense is ahead of probably a lot of people
in the private sector, a lot of physicians in the private sector, in
moving into this electronic medical record age that we're well into.
If we had that, then I think that this study that is proposed by this
legislation would be easy to accomplish. You could do immediate
transfers of great volumes of information and then-but what is
your reaction to that? Do you share my criticism of our colleagues?
Dr. HODGSON. I'm privileged to have very thoughtful colleagues
who actually in the hallway before this meeting actually pointed
out the DOD and VA were moving towards a far more aggressive
structured and thoughtful approach to medical record management
for the next conflict that arises. The question that was on the table
in the hall beforehand was whether the presence of a uniform ac-
cessible medical record would solve problems as they have been
arising. Whether, for example, the early recognition of war-related
psychological syndrome or other problems would be possible simply
on the basis of a record-keeping system without heightened aware-
ness or active seeking of such problems. And I think that's more
philosophical than a, you know, technical question.
Dr. COOKSEY. Dr. Hyams, I'm intrigued by your paper. I've read
your paper last year. It is an interesting paper. What is your reac-
tion to this move toward more electronic reactions?
Captain HYAMS. Well--
Dr. COOKSEY. Electronic medical records?
Captain HYAMS. It'd definitely help, Congressman. It would allow
us to answer lots of questions. It may not answer all the questions,
but it would certainly help in this process. Within DOD, I'm work-
ing on a part of the electronic medical record process by obtaining
baseline health information from all of our military personnel. It
will help, but it will not answer all questions. We have basic unan-
swered questions both in the military and in the civilian population
on just what causes chronic fatigue or chronic pain or some of these
other chronic symptoms. Until we understand those causes, it's
going to be difficult to answer all of these post-war health
questions.
Dr. COOKSEY. Sure, well, I feel very strongly that we need to
move in that direction. You know, I was in the military when I was
in my twenties and I still have my medical records because, when
I went off active duty, I acquired them. And back then, you know,
when you're in your twenties, you feel like you're immortal. You
have good health. You have dark hair and a lot of it. (Laughter.)
And a flat belly. (Laughter.)
And, you know, I feel like that's true. A lot of the veterans that
were over there, they were young and healthy, and probably did
not have extensive records. And yet I, as a physician and as a
 21
Member of Congress, I've had occasion to review some medical
records of veterans that come into my office with problems. And in-
cidentally, veterans and social security problems are about three-
fourths of the work that's done in my district offices. But anyway,
in reviewing these records, they really become quite lengthy. But
they become lengthy after most of these people are off active duty,
unless they had some devastating injury in combat. And it needs
to be moved in that direction.
No other comments, Mr. Chairman. Thank you.
Mr. STEARNS. Mr. Hutchinson.
Mr. HUTCHINSON. Mr. Chairman, I, as lawyer, get a little nerv-
ous following Dr. Cooksey on medical testimony. And I just want
to express my thanks to the witnesses for their testimony today
and for your leadership and your work on this legislation.
And I want to yield back my time. .
Mr. STEARNS. I thank my colleague.
I would thank the panel very much. We appreciate their time
and efforts. And now we'll have the second panel, dealing with sex-
ual trauma counseling and legislation on the war-related programs.
We have Dr. Garthwaite accompanied by Dr. Murphy, Joan
Furey, Andrea Van Hom, and Mr. Christopherson accompanied by
Dr. Mazzuchi. And we welcome the second panel. And I think we'll
start with the opening comment of Dr. Garthwaite.
STATEMENTS OF THOMAS L. GARTHWAITE, M.D., DEPUTY
UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETER-
ANS AFFAIRS; ACCOMPANIED BY FRANCES MURPHY, M.D.,
DIRECTOR, ENVIRONMENTAL AGENTS SERVICE, DEPART-
MENT OF VETERANS AFFAIRS; JOAN FUREY, DIRECTOR,
CENTER FOR WOMEN VETERANS, DEPARTMENT OF VETER-
ANS AFFAIRS; ANDREA VAN HORN, CNP, WOMEN VETERANS'
COORDINATORIPRIMARY CARE NURSE PRACTITIONER, VA
MARYLAND HEALTH CARE SYSTEM; GARY
CHRISTOPHERSON, ACTING ASSISTANT SECRETARY OF DE-
FENSE FOR HEALTH AFFAIRS; PRINCIPAL DEPUTY ASSIST-
ANT SECRETARY FOR HEALTH AFFAIRS, DEPARTMENT OF
DEFENSE; JOHN F. MAZZUCHI, Ph.D., DEPUTY ASSISTANT
SECRETARY FOR CLINICAL AND PROGRAM POLICY, DE-
PARTMENT OF DEFENSE
STATEMENT OF THOMAS L. GARTHWAITE
Dr. GARTHWAITE. Thanks. Mr. Chairman and members of the
committee, I'm pleased to be here to discuss draft legislation to ex-
tend and improve our authorities for responding to the health
needs of Gulf War and future conflicts veterans. As requested, I
will also comment briefly on existing programs to respond to the
health needs of Gulf War veterans and will also provide an update
concemirlg VA's sexual trauma counseling program.
First, VA generally supports the draft bill. After periods of war
or hostilities, veterans have experienced illness that current medi-
cal knowledge cannot fully link to a causative agent. Some of these
health problems can become chronic. The draft bill would ensure
that VA can provide health care for such illnesses to war zone vet-
erans while research is conducted to determine the causes, mecha-
nisms, and treatments of these illnesses. The current draft provides
 22
this authority 5 years following discharge from military service. An
alternative construction could be to extend this authority for 5
years following the veteran's departure from the combat theater.
VA supports granting a higher enrollment priority to veterans
seeking care for disabilities possibly associated with exposure to
Agent Orange or ionizing radiation, or with service in the Gulf War
or a future war or conflict. These veterans, who are currently
placed in enrollment priority six, would be elevated to priority four
under the draft bill. It is entirely appropriate for war zone veterans
to have a higher priority for care during the time it takes to assess
the relationship between their illnesses and service.
We also support extending the authority for VA to furnish health
care to Gulf War veterans with disabilities possibly associated with
such service. As you know, there's ongoing research into health
problems of Gulf War veterans, and it is appropriate to continue
their treatment authority while this research effort is in progress.
We also support the establishment of a national center for the
study of war-related illnesses. Historically, ill-defined post-war
health problems occur following every war. We should anticipate
their occurrence after future conflicts, be prepared to provide
health care and treatment, and develop methods to prevent post-
war health problems in the future. A National Center for Study of
Gulf War-Related Illnesses would enhance our ability to create a
comprehensive VA program for post-war clinical care, medical edu-
cation, health risk communication, and research.
Mr. Chairman, VA testified before the full committee on Feb-
ruary 5, 1998, and provided information on our Gulf War health
care and research efforts. My formal statement provides an update
on that previous testimony.
The VA has sought broad scientific and other input to help in-
form us about the best course of action with regard to Gulf War
health care and research. As we have gained knowledge and infor-
mation, we have continued to consult the best scientists available.
As lead agent for federally-sponsored Gulf War research, VA has
developed a structured research portfolio to address .the currently-
recognized highest priority medical and scientific issues. Over 120
federally-sponsored research projects are pending, underway, or
have been completed. My formal statement provides an update on
key research activities and detailed information regarding each
study as provided in the just released annual report to Congress
for federally-sponsored research on Gulf War veterans' illnesses.
Mr. Chairman, you also requested an update on VA's sexual
trauma counseling program. Over the last 6 years, VA has under-
taken a focused effort to expand and improve sexual trauma coun-
seling services at our health care facilities. To date, more than
18,000 women veterans and 200 male veterans have accessed sex-
ual trauma counseling services. The number of veterans accessing
the sexual trauma counseling program has increased each year
since its inception.
VA research indicates sexual trauma is more prevalent among
women veterans seeking services at VA health care facilities than
we had previously thought. And the negative impact of sexual trau-
ma experiences on the physical and mental health of affected veter-
ans is significant. Therefore, VA is committed to continuing this
 23
program and has submitted a legislative request to extend VA's au-
thority to provide this care through December 31,2003.
Mr. Chairman, that concludes my comments. My colleague and
I are happy to respond to any questions you or the Committee
members may have.
[The prepared statement of Dr. Garthwaite appears on p. 78.]
Mr. STEARNS. Thank you. Dr. Mazzuchi.
Dr. MAzZUCHI. We want--
Mr. STEARNS. Oh, okay. We'll switch you to over there. Mr.
Christopherson?
STATEMENT OF GARY CHRISTOPHERSON
Mr. CHRISTOPHERSON. Thank you very much. Mr. Chairman,
members of the committee, I'm coming here today both as the Act-
ing Assistant Secretary as well as the Principal Deputy. Well talk
about for just a couple few moments our Force Health Protection
program, the health experience of our military personnel deployed
overseas since the Gulf War, and our current Gulf War illnesses re-
search efforts.
Dr. Mazzuchi will speak to both the research efforts, and he'll
also speak to the issue of the sexual counseling/responding to sex-
ual trauma problems.
Mr. Chairman, as I've testified before this committee and others,
it is no doubt at all that mistakes were made during the Gulf War.
We learned a lot from those mistakes and we apply a lot of those
new lessons today. In Bosnia, we made substantial improvements.
We still need to do even more. In Southwest Asia, making more im-
provements; again, more lies ahead of us. Many lessons learned;
many lessons need to still be applied.
We have changed our policies significantly over the last 8 years,
including putting in place a major Force Health Protection Pro-
gram, which we recommended to the President and the President
adopted. As part of the lessons under the Force Health Protection
programs we are now doing pre-deployment, deployment and post-
deployment health assessments. We're improving recordkeeping.
We're doing more work in terms of looking at the risk of deploy-
ment. We're looking at better work in terms of risk communication.
We're also looking for better medical countermeasures to deal with
biological and chemical warfare agents. We are also looking at
issues of more extended research programs, working very closely
with the VA.
And I think another key other element that came out is the need
to have a much closer working relationship right from the begin-
ning with both VA and DOD especially, but also with the Depart-
ment of Health and Human Services. That is in place, and that is
operating today.
We have also put into place, as part of this program, our medical
surveillance directive clearly laying out for all future major deploy-
ments that we will be looking at surveillance and making sure we
understand better what goes on during any kind of major war and
what the sort of consequences might be that we may have to deal
with in the post-war period.
We are also looking at better coordinating mechanisms. The ex-
perience of the Persian Gulf Coordinating Board has been very
 24
positive, but we are building upon that experience and looking to
create a Military and Veterans' Health Coordinating Board which
would again bring together both VA and DOD and HHS to formal-
ize many of the initiatives we are working on in the clinical, re-
search and medial surveillance.
Our CCEP, our Comprehensive Clinical Evaluation Program,
continues and will stay in place as long as necessary, having served
over 42,000 veterans of the Gulf War. And, again, in the clinical
program we will continue to work closely with VA on that program
as well to make sure we are ready for any future war situations,
where, again, we need a comprehensive clinical program to support
that experience.
But again, clearly, all that is not enough. There are some areas,
for example, in the chemical and biological warfare agent area,
where we need to do more. We need to find better medical counter
measures out there. It's an area that we and the Food and Drug
Administration are working very closely now in trying to find bet-
ter tools to bring that into play.
In closing my part of the remarks before turning it over to Dr.
Mazzuchi, we will maintain a strong post-deployment evaluation
and care program. We will continue to move forward and mature
and strengthen our Force Health Protection Program as well as our
total Military Health System. We will continue a strong program
for the prevention of sexual trauma and aid to victims of sexual
trauma.
And we appreciate the opportunity to testify before the commit-
tee. And we'll be prepared to answer your questions as well.
With that, let me turn to Dr. Mazzuchi.
[The prepared statement of Mr. Christopherson and Dr.
Mazzuchi appears on p. 89.]
STATEMENT OF JOHN MAZzucm
Dr. MAzzUCHI. Mr. Chairman, good morning. And good morning
to members of the committee. It's my privilege to appear before you
this morning to talk about Persian Gulf-related research and sex-
ual trauma counseling in the military.
The coordination and management of our research efforts on be-
half of Gulf War veterans has required the establishment of an
overall research policy framework linking each department's re-
search management hierarchy. This essential linkage is provided
through the Research Working Group of the Persian Gulf Veterans
Coordinating Board. The DOD has two individuals permanently as-
signed to work with this board on research matters.
Research in Gulf War veterans' illnesses is a complex undertak-
ing that involves a number of different approaches. The Federal re-
search effort addressing this problem involves scientists in the Fed-
eral, academic, and private institutions both in the United States
and abroad. The entire Federal research portfolio consists of over
120 projects-with a total research investment to date of approxi-
mately $115 million. Of these, 39 projects have been completed, 78
are ongoing, and 4 have been newly awarded and are awaiting
start up. Additional research projects are at various stages of
planning.
 25
The DOD expenditure for Gulf War veterans' illnesses-specific re-
search from fiscal year 1994 through fiscal year 1998 totals $62.6
million dollars. The full report of our research activities has re-
ceived final departmental clearance and, as Dr. Garthwaite has
mentioned, is on its way to the Hill for your review.
The path of science is difficult, expensive and often time-consum-
ing. Historically, though, the match of scientific merit and program
needs has been the foundation upon which our national leadership
in medical science has been built. Over half of our research projects
involve non-government scientists who received Federal funding for
their research through a vigorous, competitive peer review process.
Our experience in the Gulf War has focused attention on the im-
portance of strategies for prevention of diseases and illnesses, early
intervention when exposures take place, and effective treatment.
Medical surveillance has been recognized as the critical element for
force protection and a medical surveillance reporting framework
has been developed by the Joint Staff.
With respect to sexual. trauma, sexual trauma and sexual abuse
are serious problems in our society with long-term health con-
sequences. In the United States, a woman has about a 20 percent
lifetime chance risk of being raped, yet only 5 to 15 percent of
these are reported to police. Rape-trauma syndrome is a type of
posttraumatic stress disorder. Researchers demonstrated that
about 55 percent of people with PTSD have two or more common
psychological problems, including depression, anxiety disorder, and
eating disorders.
People with a history of childhood or adolescent sexual abuse or
exposure to family violence are significantly higher risk for devel-
oping PTSD or being victimized again. Studies suggest that a his-
tory of attempted and completed rape in childhood may be far more
widespread among female service members than among women liv-
ing in the community at large.
Research has shown that military personnel have a significant
history of preexisting sexual trauma and subsequent risk of devel-
oping PTSD. A recent Navy study of basic trainees found that 45
percent of women trainees had been either victims of rape or at-
tempted rape prior to their entry onto active duty. An Army study
of female active-duty soldiers showed a lifetime history of sexual
assault to be about 51 percent, with 81 percent of these occurring
prior to entrance to active duty. In addition, almost 41 percent of
females and nearly 39 percent of male trainees have been victims
of childhood physical abuse. The results of these studies suggest
that it may be cost-effective to develop treatment, education, and
intervention programs for military recruits.
The Navy has developed a trial 3-hour intervention program for
Naval recruits. The focus of the program for females is how not to
be victimized. The focus of the program for males deals with in-
formed consent issues.
The Services have programs for prevention and treatment of sex-
ual assault and family violence. The Sexual Assault Victim Inter-
vention Program, or SAVI Program, is an innovative program de-
veloped by the Navy at the installation level. A specifically-trained
coordinator establishes installation prevention training, a system of
victim advocates, and develops the best counseling programs for
 26
victims by utilizing the best resources available in the community,
both military and civilian.
Since 1992, the VA has provided sexual trauma counseling for
women who have experienced sexual trauma while on active duty.
The information is provided to departing service members through
our Transition Assistance Program, and in addition, the Office of
the Assistant Secretary of Defense for Health Affairs published a
policy memorandum requiring each medical treatment facility to
review its ability to provide counseling to this group of patients and
to utilize VA sexual trauma counseling programs as appropriate to
meet the needs of the service members.
In addition, VA has developed a Memorandum of Understanding
to expand the systemwide cooperative use of the sexual trauma
counseling services for active-duty personnel. This Memorandum of
Understanding is currently under departmental review. It would
formalize reimbursement issues as well as facilitate reporting of co-
morbid, psychiatric diagnoses to the services. These co-morbid diag-
noses could have significant impact on command responsibilities for
security and personnel management issues. The agreement, once fi-
nalized, would provide a valuable adjunct source of services for
treatment for those who may not be appropriately treated in the
military setting.
But we will continue to work with the Department of Veterans
Affairs to ensure that the Government meets its commitment to
victims of sexual trauma while in the military and after they
retire.
That concludes my statement.
Mr. STEARNS. Thank you. Dr. Murphy and Dr. Garthwaite, I'd
like to ask the same question that I asked the earlier panel of Dr.
Hyams about the proposed legislation to merge the databases-ac-
quire databases from both DOD, Veterans' Administration, and pri-
vate health insurance to carry out this study. What is your reaction
to the legislation offered by Mr. Kennedy and Mr. Evans?
Dr. GARTHWAITE. Well, I think from a theoretical standpoint, as
someone who also used to legitimately earn a living by~Laugh
ter.karing for patients, I would say that computerization of pa-
tient records offers great opportunities for improving the quality of
care in doing the kind of epidemiologic resear~h that will be very
helpful in the future.
There's a variety of problems with getting from the theoretical
piece to the practical piece. Everything from confidentiality of pa-
tients' records and safeguarding what is teally a patient's informa-
tion, to how to get doctors to type, how to get them to agree on
what definitions of various physical findings and symptoms are,
how to get the same software or standards for moving data to all
those individual doctor offices around the country. I think there are
just enormous issues.
I think a great piece in this is what was alluded to in the pre-
vious panel is that the Department of Defense, Department of Vet-
erans Affairs, the Indian Health Service, and the Louisiana State
University have signed an agreement to develop a Government
computerized patient record. And I think that will force some
standardization to occur. We'll begin to collect the data and collect
the patient information in a way that allows patient records to
 27
move transparently with a patient when they want it to. And I
think that's a tremendous stride in getting a computerized patient
record that will benefit veterans over time. I, also, don't underesti-
mate the enormity of the task of doing that while keeping the cur-
rent system completely functional because we depend on it.
I think the suggestion is that we're not doing any health out-
comes research which I don't think is true. I think that health care,
in general, isn't doing as much health outcome measurement in a
non-research setting as it needs to do. And the VA, I think, is com-
mitted to do that. And we can show you a significant amount of
data where we've used HEDIS like measurements and other meas-
urements of patient outcomes to try and assess the quality of care
we are providing. We are also trying to over-sample Gulf War vet-
erans in those efforts to try to understand better what their health
status is, and we expect to have some data in the next several
months.
In addition, we are doing research studies, we're in phase three
of the Gulf War veteran study, which is more systematically look-
ing at health outcomes of veterans. I wouldn't say that any health
care system has gotten to the point where we know for any given
individual, or every individual, their outcome, and the quality of
their care. But I think we're beginning to do that better, and I
think in the VA we've made tremendous strides.
Finally, we've asked the Institute of Medicine to give us some
feedback on how we might better study the outcomes for Gulf War
veterans, and I think next week, or the week after, is their first
meeting beginning to attack that problem.
Dr. COOKSEY (presiding). Good. Thank you. I know that Con-
gressman Stearns appreciates the support of his bill, but do you
have any recommendations for fine-tuning his conceJ?t of a national
center for war-related illnesses other than what you ve just covered
in terms of electronic medical records?
Dr. GARTHWAITE. Well--
Dr. COOKSEY. Or does this bill already have everything covered,
all the bases covered? Do you think it's a good bill as it is?
Dr. GARTHWAITE. May--
Dr. COOKSEY. He's not here, so you can tell me what you really
think. (Laughter.)
Dr. GARTHWAITE. Right. We have some experience in putting to-
gether centers which have been dedicated to research, education,
and clinical care of specialized populations of veterans. We've done
that in geriatrics. We have just awarded some grants, or support,
for mental illness-related centers-or MIRECC's, as we call them.
So I think we have some history. But we also, I think, have at-
tempted in the last 3 years to get broad input. And so my assump-
tion is that we will put together a draft request for proposals out-
lining what we would like to see in these centers, and then get the
input of a variety of people both inside and outside of Government,
including various Service organizations and others, so that as we
design a center we'll have that kind of input. I think critical to that
~rk!t is the Department of Defense. I mean, very clearly, we're
'ng about the health continuum of patients who start with the
Department of Defense and that we take through the rest of their
lives.
 28

So, I think it's going to require multiple inputs to get a very di-
verse look at this so we can design it right from the outset.
Dr. COOKSEY. And so you feel like this piece of legislation would
accomplish what its goals are as it is presently drafted, then? Pret-
ty good shape?
Dr. MURPHY. Specifically, on the National Center for Study of
Post-War lllnesses, we were very supportive of the current draft.
We were happy to see the mandate for interagency coordination be-
cause we feel that DOD needs to be an active partner in that cen-
ter. They have expertise with military occupational medicine as
well as VA. But they, also, maintain some of the databases that
would be really key to be able to do quality research and epidemio-
logic studies in this area.
Dr. MAzZUCHI. I'd like to add to that, that one of the improve-
ments, I think, that's coming very rapidly is new DOD policy which
requires pre-deployment, during, and post-deployment medical sur-
veillance. And, as we begin to capture those data electronically,
we11 be able to share with VA much more readily information for
its center that will deal with the exact health status of the service
member prior to and during the deployment, or right after deploy-
ment. You're going to get a nice continuance of records that's-it's
not just something that you see as the person who has left the mili-
tary service and has been 2 or 3 years out, and then you really
can't capture those data. So, I think our new deployment surveil-
lance effort is going to go a long way to feeding into that center.
Dr. COOKSEY. Good. I know during the Vietnam period they're
were so anxious to get physicians in that I had a colleague that ac-
tually was a resident, senior resident, ahead of me when I was in
medical school who only had one eye. He had an artificial eye and
a God-given eye. But he not only went into the military, he went
to Vietnam. And yet today, I think that the military is able to be
a lot more selective in all their personnel, in not taking people who
have any kind of a health problem, because I know there are peo-
ple that would like to get into the volunteer services right now that
have health problems. These need to be screened out and that
needs to be done.
Let me move into another area. I have three daughters, no sons.
We never learned how to have boys. (Laughter.)
But I am very biased toward women. And I was surprised, and
my colleague, Dr. Gutierrez, was surprised, at the numbers you
gave us about the number of people that go into the military that
have had preexisting or childhood sexual trauma. Do you really
think those numbers are accurate-accurately reflect the makeup
of the military? And what is your source for acquiring that
information?
Dr. MAzZUCHI. These are basically studies of the Navy Training
Center and a study that was conducted by the Army. They are not
generalizable to the entire population. But I'm not surprised that
the numbers are high, that they are as high as they are. I'm some-
what surprised in whether they would hold for the entire popu-
lation; I don't know. But, clearly, we have a group of people coming
into the military who, because of past experiences, either sexual
trauma or family violence, are at greater risk for continuing these
 29
problems. People who have been victimized once are much more
easily victimized a second time.
Dr. COOKSEY. So these studies were done on Navy personnel,
then?
Dr. MAzzUCHI. Yes, at their recruit centers.
Dr. COOKSEY. Well, this past ;year we had two generals at our
home for dinner, and I had my dIstrict directbr there who was also
in the Air Force, and I commented to him that the Air Force usu-
ally has to bale out the Army. Well, a little while later-this was
in the time period they were trying to get a Chairman of the Joint
Chiefs of Staff. Well, the two generals-one of them got me back,
and he said, "Well, you know, we don't worry about the Chair of
the Joint Chiefs of Staff being anybody from the Air Force because
they can't find anyone in the Air Force that hasn't committed adul-
tery." (Laughter.)
So I would hope that we that these numbers that you're reflect-
ing are a little bit-are inaccurate, because it's really a-it would
be a concern if I felt that everybody that went into the military had
that kind of history, because my contact with people in the military
is that they're a lot of good people, well adjusted people that are
committed to doing the right thing, and very professional people.
And yet when these problems occur in childhood-I know people
cannot prevent it a lot of times and it's unfortunate. But it's sur-
prising numbers.
Mr. Gutierrez.
Mr. GUTIERREZ. Thank you. Well, it's good to see that we are
moving in the direction of-I just thought in order to have your
tonsils taken out, they've got to give you all these tests, and it's a
pretty simple procedure that most of us go through. And you can
go to war and not have any medical records. I certainly hope that
this leads us in that direction of having at least the medical
records that someone who's tonsils got taken out. It is a pretty rou-
tine experience in youth. I don't remember a lot of people who kept
them. That's certainly good.
Let me just ask Dr. Garthwaite-I want to, first of all, thank
him and commend the work of the VA in establishing the com-
prehensive sexual trauma counseliIlg program. And Dr.
Garthwaite, on November 25, 1997, the Under Secretary of Health
circulated a letter to VA medical facilities clarifying the eligibility
criteria for VA health care to veterans seeking counseling and
treatment for sexual trauma. This letter was based on a VA Gen-
eral Counsel opinion from earlier that year which deemed that the
minimum length service requirement contained in section 5303(a)
of title 38 doesn't apply to the provision of sexual trauma counsel-
ing; thus, to receive this vital care a veteran no longer has to serv-
ice 24 months of active duty.
Doctor, as you may be aware, this General Counsel ruling is
similar to provision contained in legislation I introduced last July.
It exempted veteran seeking sexual trauma counseling for mini-
mum service requirement. I believe it's important. Many of the in-
cidents of sexual violence in the military occur prior to 24 months
of service and where the requirement would come in.
Doctor, since the clarifying letter was distributed throughout the
VA, has the VA medical practitioners and administrators been ad-
 30
mitting for trauma care veterans who did not serve the minimum
service requirement? And could you--
Dr. GARTHWAITE. My understanding--
Mr. GUTIERREZ (continuing). Start with some of your experiences
and numbers?
Dr. GARTHWAITE. It is my understanding that's true. I'll ask Joan
if she has some more specific information.
Mr. GUTIERREZ. Sure.
Ms. FUREY. Yes, Congressman. We don't actually have numbers
on the number of people we are seeing since that clarification and
interpretation has gone out to the field. However, we have been in
contact with our clinician providers, and they have pretty much
told us that it is no longer a problem that they are encountering
with people seeking the counseling under the provisions of the law.
Mr. GUTIERREZ. So, we're working on guaranteeing that every-
body knows about this new ruling and that's it's being imple-
mented?
Dr. GARTHWAITE. One of the advantages we have is that we have
women's veteran health coordinators in our medical centers. We
have Ms. Van Hom, from Baltimore-or the, I guess, VA Maryland
Health Care System.
Mr. GUTIERREZ. The experience in Baltimore, what happened
after November of 1997 that used to be the trauma center-the
sexual trauma center and if you--
Ms. VAN HORN. I think I can quote our numbers from the VA
Maryland Health Care System for all of 1997. We saw 80 patients,
male and female. As of October 1997 to date, last week, we've al-
ready seen 78 veterans. So, we've doubled already in 6 months our
experience with veterans.
If I may address a question that Dr. Cooksey added, we, in Balti-
more, did a study looking at the enrolled women in 1994. We had
close to 900 women enrolled. We did a survey and, subsequently,
wrote a paper which was published in "Military Medicine" in 1996.
In fact, it was published 2 weeks before Aberdeen, which made it
pretty clear that we have had a sexual abuse problem in the mili-
tary for quite awhile.
One of the questions that we did ask was when did this act hap-
pen? And we asked specifically about age groups. Our experience
was that 50 percent of our women veterans had been sexually
abused as children. Our experience was also that 50 percent of
those who went into the military were re-victimized. And this is
the experience that the DOD is, I think, addressing at this point
with many programs including the SAVI (Sexual Assault Victim
Intervention Program) program which is, I think, one of the best
programs that the Navy has at the present time.
Dr. MAzZUCHI. One clarification and it's a question as to you, but
also a comment to the committee is my understanding that it de-
pends on how you view the definition of attempted rape. I think
many people are victims of date rape, of being placed in situations
where they feel threatened, and this is not a consensual act. I
think most people, when they look at attempted rape, and conjure
images of, you know, someone jumping out from the bushes with
a knife or gun or something like that. There are many forms of
 31
ra~~;"kd I believe that those are included in all of these numbers.
I t ' that's an important fact to have out.
Mr. GUTIERREZ. But if you compare it to the general population,
is it higher?
Ms. FuREY. Yes, I'd just like to make a couple of comments.
Mr. GUTIERREZ. Sure.
Ms. FuREY. Certainly I think, in general, we see this-I think it
was mentioned earlier that about 13 percent of women in the gen-
eral population self report being victims of assault. And our data
shows somewhere between 15 to 20 percent of women on active
duty report having had these experiences of assault while they
were on active duty, not in childhood. So, I think the perception
and the numbers that we have in the VA is that this is a problem,
and remains a problem in the active duty military.
One comment I would like to address about this study that was
mentioned of the Navy recruits and the military recruits. I always
get concerned when numbers are given about the percentage of
women who were victims of assault rape and violence during child-
hood or premilitary service, and not talk about the findings of men
who, I think, have also been the victims of violence and physical
abuse in childhood prior to their admission into the military; or
how that dynamic may impact future interactions. I think it's im-
portant that we don't just select out the women as having had
some of these negative experiences. And I would be interested to
know what the data is for the negative experiences or abuse experi-
ences of men, of the male recruits. Was that involved in this study?
Dr. MAzZUCHI. No, it was. I mentioned it. It was 38 percent were
victims of childhood physical abuse.
Mr. G~RREZ. Men?
Dr. MAzzUCHI. Yes.
Mr. GUTIERREZ. Good. We'll just keep going as people feel about
the different questions. Mr. Cooksey, if you don't mind?
Going back to Dr. Garthwaite, the General Counsel's rulings ba-
sically interpret the laws that Congress pass for Executive agen-
cies, but they don't carry the weight of law, do they? That
means--
Dr. GARTHWAITE. We try to carry them out once they rule.
Mr. GUTIERREZ. Once they rule?
Dr. GARTHWAITE. Right.
Mr. GUTIERREZ. They don't carry the weight of law?
Dr. GARTHWAITE. We try to carry them out.
Mr. GUTIERREZ. I understand.
Dr. GARTHWAITE. We try to follow all their advice the best we
can.
Mr. GUTIERREZ. That's what it is. It's good advice, but it's not the
law that you have to follow. So in the future, the VA could choose
to permit veterans who have served less than 24 months not to re-
ceive sexual trauma care. In fact, unless you codify into law. Let
me move back to a situation where veterans get discharged before
the 24 months and not eligible. Could that happen?
Dr. GARTHWAITE. I think, given their interpretation, it would be
unlikely.
Mr. GUTIERREZ. It would be unlikely, but-so you can't see a sit-
uation where, I don't know, Aberdeen kind of goes off the, you
 32
know, I would say the public spectrum scale and, you know, it's not
an issue that's being raised and it's a new administration. You
know, one not obviously not headed by Dr. Cooksey, because he'd
continue doing this stuff, but headed by a new administration
where they just think, you know, this isn't an important issue-
isn't one. So they don't have to do it. I mean there are budgetary
concerns here, aren't there? I mean it is not a requirement. It is
not required even that I receive this kind of treatment is there?
Anybody can answer that question.
Ms. FuREY. My understanding, and I think certainly it's some-
thing that we can get a clearer opinion on; is that the General
Counsel's opinion is an interpretation that we act as being a legal
interpretation, and it will be the regulations that we will follow.
Mr. GUTIERREZ. Yes, and you can have a new General Counsel
issue, a new opinion, but you can't have-the VA can't simply uni-
laterally change its mind about what the Congress of the United
States dictates. They don't have that latitude or discretion. Would
that be fair?
Ms. VAN HORN. Correct.
Dr. GARTHWAITE. That's fair.
Mr. GUTIERREZ. Okay. So--
Dr. COOKSEY. Could I comment on this point? It states here the
Secretary shall give priority to the establishment and operations of
the program to provide counseling and care services under sub-
section and on and on. So "shall" is a mandate, I would think. So
I think there is a definite requirement there that the Secretary of
Defense do this and it be carried out. Am I - -
Dr. GARTHWAITE. That's the way we are interpreting it, yes.
Mr. GUTIERREZ. And we just want to-let me ask then, that's the
way you're interpreting it. Before that interpretation that you
made in 1997, was it a requirement for the Veterans' Administra-
tion to have to treat and have to personnel to treat victims of sex-
ual trauma? Anyone who demanded the service?
Ms. FuREY. I'd be glad to address that, sir. I think initially we
did have some difficulty in implementing the provision of Public
Law 102-585 and its amendments, and that it was open to inter-
pretation at individual facilities. I think the reason that we went
forward and requested the General Counsel opinion on the eligi-
bility, and, also, the may/shall interpretation was that it was
brought up by our Advisory committee. Dr. Kizpr did send an inter-
pretation to the field that basically said: this was something that
the VA would provide, that the Secretary had determined we would
provide it and, therefore, it was not an option. So, I think at this
point in time today, as we sit here today, we feel we are in very
good shape with the program. We have very little problem in terms
of people being denied who meet our eligibility requirements. Cer-
tainly that was not always the case. But I think the steps that
we've taken in developing this new program, interpreting the eligi-
bility criteria, and reinforcing the commitment of the agency to pro-
viding the service in the field, has really demonstrated in improve-
ment. Certainly the force of the Secretary and Dr. Kizer's commit-
ment to the program has been significant in helping us accomplish
that. .
 33
Mr. GUTIERREZ. I'm very happy to hear that since we have testi-
mony of members of the military forces who did not complete the
24 months of service who were denied treatment-sexual trauma
treatment, and indeed, and others.
Last question for Dr. Garthwaite: In my research of the issue, I
found that many women, veterans specifically, were poorly in-
formed about sexual trauma programs. And I know that you've
stepped up your efforts of late. I'm just raising one last concern
with you about the extent to which women know about the pr(r
gram. That is, that when they come in they obviously give them
the testimony of Ms. Van Hom in Baltimore, the services are in-
creasing, and so that's good. And I'm just wondering what is being
done so that they know it's there? So that they know to access it,
not just because there's a higher incidence of the problem that ~
pIe are coming up and askin~l~k the service?
Dr. GARTHWAITE. Sure, I t ' there are a lot of outreach efforts.
I think they're detailed in the GAO report that I read last night,
I think maybe Ms. VanHorn could comment.
Ms. VAN HORN. Additionally, Secretary Brown last year, in the
early part of the summer, sent a letter out to over 400,000 women
veterans across the United States. The women veterans' program-
health care programs have designed a question-and-answer tri-fold
that is available at every VA facility. It has been distributed widely
at health fairs, at women's meetings, at every venue that we
Women Veteran Coordinators can use to address any female popu-
lation about the availability of services that we have at most of the
VA centers. And, of course, the mandate approximately a year ago
to set up sexual trauma treatment programs at each medical divi-
sion has been accomplished. And this is generally under the juris-
diction of the women veteran coordinator using licensed social
workers, psychologists, and psychiatrists to deliver the acute care,
or the crisis intervention, and then the therapy that's necessary for
them subsequent to their call.
An 800-number was set up and monitored last year after a cou-
ple of television shows actually. It think it was' "20120;" "60 Min-
utes" did a piece, And, in fact, Ms. Furey was just on about a
month ago on The Bryant Gumble Show.
Again, we're taking every avenue that we can-newspaper st(r
ries, anything that we can us~to say we know that the VA used
to be a male bastion; we now have female services and that does
include medical services, mammography, pap smears, and sexual
trauma counseling.
Mr. GUTIERREZ. And then let me say to Ms. Furey-by the way,
it's always good to see you. Sorry I didn't say hello. (Laughter.)
Let me try to ask a general question, see if we can't get-what,
given your experience, can be improved in terms of expanding what
gaps? What women out there in the military-what gaps exist out
there that who-this is shall and may, and who may not be getting
the service but they are part of our armed forces?
Ms. FuREY. Yes, I would just like to tag on one other thing to
what Ms. Van Hom said before I answer your question, Congress-
man--
Mr. GUTIERREZ. Sure.
 34
Ms. FuREY (continuing). Which is, the other thing that we have
done has been working very diligently with the veterans' service of-
fices and the national leaders to }.!rovide their membership and
their counselors with information. We do go to their conventions.
We go to their re~onal trainings, and really get the word out so
that they'll get this information out to their membership, as well.
I also think it's im~rtant to mention that it is not just women
who access these sel'Vlces. I think we tend to forget that sometimes
in talking about it. Certainly our clinicians have shared with us
that they're seeing more men coming in every year to access these
services. And you'll recall in 1994, I think, the Congress did pass
a law to make that a gender-neutral bill.
Since we received the interpretation about the 24 months, we
have not had a problem. Those individuals are now being seen
under that General Counsel interpretation. I think, as has been
discussed, and as you are aware, one of the issues that has been
brought to our attention from clinicians and from the women veter-
ans' community is that, women veterans or women who have been
in the Reserves and are on active duty for training, who have these
experiences happen to them, currently cannot access our services.
They have presented that as a concern regarding eligibility. We are
aware that you have a provision in your bill to address that, and
the agency is studying it and is preparing, its position in response
to what impact that change in eligibility would have on the agency
or its ability to ~rovide the services (the resource impact, et cetera).
But certainly, I think that is the population that we are not able
to provide services to right now.
Mr. GUTIERREZ. And how about National Reserves, National
Guard?
Ms. FuREY. Well, that-yes. We actually can provide services to
individuals who are activated, for service in Bosnia, or the Persian
Gulf, et cetera.
Mr. GUTIERREZ. So what happens i f l - -
Ms. FuREY. It's the group of mdividuals who have this experience
while they're on active duty for training. This status is excluded in
the title 38 definition of veteran. .
Mr. GUTIERREZ. So, I go for my month of active duty; something
happens. I have to stay on active duty in order to be able to get
the service.
Ms. FuREY. Yes.
Mr. GUTIERREZ. Because when I go back to my civilian job, I'm
no longer on active duty and cannot access this?
Ms. FuREY. And by law, you're not considered a veteran. That is
my understanding.
Mr. GUTIERREZ. Right, and you're not considered a veteran. So
when you activate groups of people, we have to try to figure out
a way to get them back mto the thing.
I'd like to ask Dr. Van Hom just that it seems to me that-I
wanted to say that, you know, the Baltimore program is a great
program, and it's one that I hope Dr. Garthwaite and everybody
else at the VA is going to continue to duplicate throughout the sys-
tem. Just a question, what is the level of service? Is the level of
service as good in Wyoming, in California, in Chicago, and in Mis-
sissippi as it is in Baltimore? Is there the same level of service and
 35
quality service and access to that service throughout the VA health
care system?
Ms. VAN HORN. First, thank you for my promotion, but I'm a
nurse practitioner. (Laughter.)
Mr. GUTIERREZ. And you're welcome. (Laughter.)
Ms. VAN HORN. We are across the Nation, as a very active group
both with the women veteran coordinators in VBA, the Veterans'
Benefits, and the Veterans' Health, trying very hard. And all of the
program directors within the women's health services are striving
to give the same services, or at least contract the same services if
they're not available at smaller VA medical centers.
Yes, I'm prb:t proud of the Baltimore program, as you well
know. But I t ' there are many, many programs across the Na-
tion that are accomplishing the same things. The women are get-
ting excellent services. And I think that once the women come in,
or once they are identified, I have to say that the care is excellent.
Yes, the reason for our program, and for this paper I should say,
was that I had had so many responses to, "Have you ever been sex-
ually abused?" And the women would say, "I've never been asked
that before"-and open up this floodgate of historical happenings.
We would get them into therapy, and these are women that per-
haps were over-utilizing medical care-and substance abusing-
and all of a sudden we ask the question, they get into therapy, and
we have now identified the woman and we know why she has this
chronic pelvic pain, why she has the chronic headaches, why she
has the chrome gastrointestinal problems. We treat the psycho-
logical sequela of this trauma, and she's a well person who's back
to work.
We are finding that, once we'd get a woman, or male, back into
therapy, they're back into a normal life within a year to a year and
a half, two years max. Without this identification-and it's very dif-
ficult for anyone who has been raped to come forth because it's
such a degrading happenstance-that once we ask the question,
open it up, get them into therapy, they're pretty well.
So we're finding that it's a very successful program, and what
we're trying to do right now is, not only say, sure, those of us who
know the problem, we knew to ask, but to ask every physician out
there to ask the question, every primary care provider to ask the
question, and then utilize the services that have been set up
through each of the medical centers, that's our goal right now.
Mr. GUTIERREZ. I see that Mr. Bilirakis has joined us and Mr.
Cooksey has been more than kind in expanding the time, so I'm
going to ask-that's very good Ms. Van Hom, but if anyone could
answer the question, is the level of treatment available to women
and men to sexual trauma equal? Is it just as good? Is the quality
of service there? Is the availability there equal from region to re-
gion or are there lapses in this-in the body of the VA health care
system?
Dr. GARTHWAITE. Mr. Gutierrez, I would be the first to tell you
that when you run a system as large as the VA, that absolute uni-
formity and consistency of care is difficult to achieve in every re-
gion in evel7. medical center every day of the year. It is that guar-
antee of uniformity of care is, in large part, a major focus of the
effort that Dr. Kizer and I and many other people in the VA have
 36
been putting forward in the last 3 years. We've begun to measure,
as I answered Dr. Cooksey, that we're beginning to measure the
patient's satisfaction with care and their outcomes from care. We
have more measures than we've ever had which get at the issue of
what is the outcome from care and what is the quality of those
experiences .
.I think today more than ever in the history of the VA we can sit
here and tell you that we've improved morbidity and mortality
from surgery over the past 3 years, that we've improved patient
satisfaction, our courtesy scores went up significantly, statistically
significantly in every network last year around the country. We can
tenJOu the major cohorts of medical illnesses have improved sur-
viv rates-the top nine medical diagnoses studied since 1992 to
1997.
If you say you can find someone who had a bad experience one
day at one VA medical center, that may have happened. We are
hoping to learn from that and prevent it from happening. But I
think from a broad perspective, we have measures in place which
have moved us in a very positive direction and we can tell you
today that patients tell us when randomly sampled that they're
happier with their care and that our data has shown that it's
better.
Mr. GUTIERREZ. And that's not really the focus of my question.
And I'm just going to thili~DkoU all for being here this morning.
We'll continue you this. I . you are making excellent strides at
the Veterans' Administration in this-in our goal for providing
services to men and women. My question is-I know that if I have
a cold, I can go to any VA facility and I bet they got somebody who
can treat me for my cold. If I break my finger, I bet there's some-
body who can treat me for breaking by finger. You know--
Dr. GARTHWAITE. True.
Mr. GUTIERREZ. You get what I'm saying? I just want to make
sure that if I need sexual trauma counseling--
Dr. GARTHWAITE. Right, well, I think we have over 2,000 people
trained and providin~ these services.
Mr. GUTIERREZ. It s just that-I mean, I don't-know that we're
going to have the top cardiologists everywhere--
Dr. GARTHWAITE. Right.
Mr. GUTIERREZ (continuing). You know--
Ms. FuREY. Right.
Mr. GUTIERREZ (continuing). Or the top throat, theoretically, an
individual should be able to access this service if they need it.
Mr. GUTIERREZ. Well, that's my only point, because as you have
said, they go back. As Nurse Van Hom suggested, within 2 years
at max, they're productive and back and that their prognosis is a
very good one in terms of getting back and being productive once
again. And, you know, I just think they're so many things you said
here today. I mean there's an increase in the number of people say-
ing, "I want the service." You're telling people about it. It's being,
when they get the service, it seems like it might, you know, that
it's good; that, unlike other traumatic experiences that need health
intervention, this is one in which we can intervene and bring some-
body back to a healthy situation vis-a-vis the Gulf War syndrome
which we're still trying to figure out. It would be really nice if we
 37
said that everybody who had Gulf War syndrome ailment, right, in
2 years you could put them back to shape; we'd stop the hearings
and give somebody a Nobel Peace Prize. I'm serious. That's what
would happen. It would be so great. That's my only point.
And thank you very much, Dr. Cooksey.
Dr. COOKSEY (presiding). I want to pose a question for the record.
I do not have the answer. I assume you don't have the answer. But
I'm still intrigued by your comments. If there are so many people
that go on active duty in the military that have had adverse child-
hood experiences, should these people be precluded from being in
the military? If you have had back surgery, they will not accept you
in the military. If lou've got bad vision, they won't accept you in
the military. I don t know the answer to that. Does anyone want
to touch it? It's something we should think about.
Dr. MAzzUCHI. It's something we should think about. It's clear
that psychological screening techniques need refinement. We do
have standards that are very high for coming into the military
service, but we don't demand that people have-that they come in
without any problems of any kind. So, obviously, it depends on
where on the continuum these problems are.
I think it's very important for the military to develop early iden-
tification and early intervention programs for these people. But I
think along the whole area of psychological problems that people
mayor may not have been experiencing as young people, we
couldn't have a policy excludin~ someone who had every problem
because we would have nobody In the military then. And we really
have to make sure that these people would be treatable, would be
able to serve on active duty, and finish a term of enlistment. I
mean that comes to the critical piece for us. So exactly where on
the continuum and how traumatic an experience was, and how se-
rious the psychological problem, and how much ~!lychological dam-
age that is done, all that needs to be assessed. We attempt to do
that in our overall psychological screening, but psychological
screening is not a very perfect art as you know.
Mr. CHRISTOPHERSON. Let me bring up a little more on that.
Dr. COOKSEY. Yes. There are a lot of answers to my questions,
aren't there?
Mr. CHRISTOPHERSON. There are, but let me go to the more basic
part of it. I think, in general, you would not want to use sexual
trauma as a reason for somebody not to come in to the military.
I think that would be to identify a victim who would be victimized
twice and that would be too unfair. I don't think our experience
today here is that this is something that should eliminate a will
to serve well the military. And so I would not want to see us go
down that road.
Dr. COOKSEY. Good. Would one of the ladies like to comment?
Ms. Furey or Dr. Murphy?
Dr. MURPHY. I'd like to comment. We know that childhood trau-
ma is a significant risk factor for development of future problems
including PTSD, especially with re-exposure to a traumatic
stressor, but this isn't 100 percent predictive. Not every individual
who has had childhood trauma develops those difficulties, and it
would be discriminatory to exclude all individuals with any history
of childhood trauma, whether sexual or physical, from military
 38
service. I think that would be a bad policy. A better policy would
be to make sure that, if identified in recruit training camps, that
the preventive therapy that we know works is offered to military
members.
Ms. FuREY. I'll just make a brief comment, sir. I think that when
you hear the kind of data that's presented, it would automatically
make one think that maybe we should keep these people out. I
think, then, we forget that there are many people who have come
from disadvantaged backgrounds who have actually benefited tre-
mendously from military service both in their social, educational,
economic, and occupational abilities. I think it's an area that cer-
tainly needs to be questioned and studied and looked at in terms
of what happens in the environment that can either assist them or
perhaps create some other problems.
I, personally, would be very cautious to make any kind of blanket
statement regarding screenin~ these individuals out, particularly
knowing the level of psycholOgical screening available right now.
Dr. COOKSEY. Well, it's a very serious concern. Your presentation
has been good. I'm glad we're having open discussions, and I think
it should be available for everyone in the military from the, you
know, the entry-level person all the way up through the ranking
officers, maybe even the Commander-in-Chief.
I will turn this over to Mr. Bilirakis. I have got to give a speech
somewhere in a little while. And I'll let him ask his questions from
th~position of the chair.
Thank you very much. You've been excellent witnesses.
Okay, if there are no other questions, thank you again for com-
ing, and we'll have the next panel.
Mr. BILIRAKIS (presiding). The last panel will consist of Mr. Ste-
phen Backhus, Director of Veterans' Affairs and Military Health
Care Issues with HHS, General Accounting Office, accompanied by
Shelia Drake, Assistant Director of Veterans' Affairs and Military
Health Care Issues, the General Accounting Office, and Veronica
A'Zera, National Legislative Director of AMVETS.
Welcome, Ms. Drake, Ms. A'Zera, and Mr. Backhus. Stephen, will
kick it off with you.
STATEMENTS OF STEPHEN BACKHUS, DmECTOR OF VETER-
ANS' AFFAIRS AND MILITARY HEALTH CARE ISSUES,
HEALTH, EDUCATION AND HUMAN SERVICES DIVISION,
GENERAL ACCOUNTING OFFICE; ACCOMPANIED BY SHELIA
DRAKE, ASSISTANT DIRECTOR OF VETERANS' AFFAIRS AND
MILITARY HEALTH CARE ISSUES, HEALTH, EDUCATION AND
HUMAN SERVICES DIVISION, GENERAL ACCOUNTING OF-
FICE, AND VERONICA A'ZERA, NATIONAL LEGISLATIVE DI-
RECTOR, AMVETS
STATEMENT OF STEPHEN BACKHUS
Mr. BACKHUS. Mr. Chairman and Mr. Gutierrez. We are pleased
to be here today to discuss VA's sexual trauma counseling pro-
grams. M>.' remarks will focus on work we have undertaken for this
subcommittee, that Shelia led, to describe the extent to which sex-
ual trauma counseling services are available in the VA, their out-
reach and training efforts, the extent to which women veterans use
 39
these services, and what VA is doing to assess the effectiveness of
its counseling programs. The work was conducted at six VA facili-
ties and included discussions with, not only VA health care person-
nel, but with women veterans.
Regarding the extent to which sexual trauma counseling is avail-
able, VA now offers services in all of its hospitals and in 62 of its
206 Vets' Centers. Four VA hospitals-Boston, Brecksville, Lorna
Linda, and New Orleans-also offer specialized programs for
women who have been more severely affected by the stress or sex-
ual trauma they experienced while in the military. These special-
ized programs are conducted by women veteran stress disorder
teams that generally employ much more intense treatment proto-
cols and include such treatment services as individual psycho-
therapy and crisis management. At those Vet Centers that do not
offer sexual trauma counseling services, the staff do provide psy-
chosocial assessments and do make referrals to other VA centers
as appropriate.
The VA has conducted a number of outreach efforts to increase
staff awareness, and inform women veterans about available sexual
trauma counseling services. For example, it has implemented a
multi-faceted training program to educate and sensitize health care
administrative personnel about sexual trauma. It has also informed
many women veterans about the availability of counseling and
treatment services. For example, it has sent letters to over 400,000
women veterans informing them of their services. It routinely pro-
vides information on available services and arranges for these serv-
ices through a toll-free telephone number. And its services, as
you've heard before, were highlighted as part of a national tele-
vision network news documentary on sexual trauma in the
military.
Turning now to utilization, the number of women veterans who
seek sexual trauma counseling has dramatically increased over the
past several years. Between just fiscal year 1993 and fiscal years
1997, the number of veterans receiving sexual trauma counseling
has almost quadrupled from 2,300 to over 9,000. Over this same
period, more than 18,000 women have been treated for sexual trau-
ma by VA. And between just 1996 and 1997, the number of women
receiving sexual trauma counseling services increased 20 percent.
Not surprisingly, staff associated with the counseling programs
we visited expressed some concern about their ability to continue
to adequately respond to the increasing demand for counseling
services. However, the women veterans we talk to are generally
satisfied with the care and the services they have received through
the VA and like having the different options available to them. A
few though have expressed the desire to receive counseling on a
more freq,uent basis.
The pnmary complaints we heard about the VA sexual trauma
services are directed at the process for awarding compensation.
While documentation of sexual trauma is not required to received
counseling, it is required for compensation claims. Since personal
assaults often go unreported, there is commonly no documentation
to support a claim for compensation. We understand, though, that
VBA has developed guidance it helps will alleviate some of these
problems by accepting information other than service medical and
 40
personnel records-in other words, personal diaries or statements
of other people.
Regarding the effectiveness of sexual trauma counseling pro-
grams, later this fiscal year, VA plans to initiate an evaluation of
its four women veterans' stress disorder teams using a protocol
similar to that which they've used to evaluate the effectiveness of
intensive PrSD programs. And Vet Centers are currently evaluat-
ing the effectiveness of their programs. While these evaluations are
positive steps, only about one-fourth of the counseling services pro-
vided to women veterans occur through either Vet Centers or the
stress disorder treatment teams. Most counseling is provided by VA
hospitals and outpatient facilities, and at this time, VA has no
plans to systematically evaluate the effectiveness of its counseling
programs provided at these locations.
Mr. Chairman, this concludes by statement. Shelia and I will be
happy to respond to any questions you and other members of the
subcommittee may have.
[The prepared statement of Mr. Backhus appears on p. 78.]
STATEMENT OF VERONICA A'ZERA
Ms. A'ZERA. Thank you, Mr. Chairman. I'm Veronica A'Zera. I'm
the National Legislative Director with AMVETS, and I'm accom-
panied today by Carol Rutherford from the American Legion, Joy
Ilem from DAV, and Kelly Willard-West from VVA.
On behalf of AMVETS, Disabled American Veterans, Vietnam
Veterans of America, and the American Legion we want to thank
you for the opportunity to express our views on the sexual trauma
counseling program at the Department of Veterans Affairs.
We want to congratulate Congress and VA for having insight to
establish such an essential program. We are here to evaluate the
current program and make some suggestions on what improve-
ments can be made when Congress re-authorizes the sexual trau-
ma counseling program.
The first thing is, and as Congressman Gutierrez brought up in
his opening statements earlier, that we would like to see it opened
up to Reservists and National Guard members. ,Current law re-
quires 2 years of active duty service in order to be deemed a vet-
eran for the purpose of seeking general VA health care. Yet, a VA
Under Secretary for Health's information letter dated November
25, 1997, regarding eligibility criteria for VA health care to veter-
ans seeking counseling or treatment for sexual trauma indicates
that the minimum length of service requirement does not apply to
the provision of these sexual trauma benefits. Members of the Na-
tional Guard and Reservists who are called to active duty are eligi-
ble for this program. However, they are not eligible if trauma/har-
assment happened during their training. The law excludes active
duty from training from the definition of their active duty. We be-
lieve that this presents some potential ambi~ties, and we also
fear a different and perhaps more restrictive mterpretation in the
future, particularly if resources become more and more constrained.
Because of this unique circumstance surrounding sexual trauma
or harassment in the military, some men and women victims' serv-
ice careers may be abbreviated. Some of the individuals involved in
the situation at Aberdeen, for example, may have left the service
 41
as a result of these incidences during or shortly after their train-
ing. Also, members of their Reserve component called to active duty
during the Persian Gulf War may not have fulfilled the 2 years of
active duty service to qualify for these needed treatments.
While current VA interpretation of the law seems largely appro-
priate, we want the statue to be modified to reflect the Under Sec-
retary's policy and further allow Reservists and members of the
National Guard traumatized while on training exercises to be eligi-
ble for the VA sexual trauma counseling program.
Because this is current VA practice, based on ~e letter, we do
not anticipate a significant cost increase that would be associated
with providing this statutory authority, and this would help to en-
sure that men and women in these categories do not fall through
the cracks.
A second recommendation is to make the program permanent. In
a perfect world, this program would not be necessary. Unfortu-
nately, we don't live in a perfect world. According to the Center for
Women Veterans' at Department of Veterans Affairs, 20 percent of
all women veterans report they have been raped or sexually as-
saulted. In order to protect those who served, we need to have this
program and continue beyond 1998.
Along with making it a permanent authority, reporting require-
ments and outreach records should be kept and reports made to
Congress each year by VA and the Department of Defense on the
incidents that have occurred as well as how many people have par-
ticipated in the program. Currently, these records are not kept and
are sketchy at best.
We would like to DOD and VA maintain and compare data. Cur-
rently, DOD cannot detail how many men and women were as-
saulted last year. There's no tracking system. This needs to be
corrected.
We would also like to see sexual trauma listed in the next edition
of the "National Survey of Veterans" produced by VA. They track
several medical conditions, and we would like to also see them
track sexual trauma.
No matter how great the program is, if no one knows that it ex-
ists, it won't benefit anyone. We credit the VA for its efforts in get-
ting the message out. We, as veterans' service organizations, also
have the ability to help in this area and ask for a more coordinated
communication plan.
One misconception about this program is that some individuals
will use sexual trauma counseling as a way to get into the VA sys-
tem and then "milk it" for other services such as medical, dental,
compensation. There is no incentive to do such a thing. All this Act
entitles a veteran to is counseling and care as required because of
the trauma. It does not entitle them to get anything extra, nor does
it guarantee compensation. The very remote potential of people
misusing the system is no reason to preclude the program improve-
ments that we advocate.
In conclusion, we all believe that this program with some minor
modifications warrants being made a permanent program within
the VA. H.R. 2253 introduced by Congressman Gutierrez addresses
all of our concerns, and we are all supporters.
 42
We appreciate the opportunity to testify on this issue, and I'll ad-
dress any questions you may have.
[The prepared statement of Ms. A'Zera appears on p. 105.]
Mr. BILIRAKIS. Thank you, Ms. A'Zera.
Let's see. Ms. Drake, I know you're not really a member of the
panel, but since you are here is there anything you'd like to add
very briefly?
Ms. DRAKE. No, I'm just here to help Steve answer some ques-
tions if I need to. Thanks.
Mr. BILIRAKIS. Okay, great. Maybe you'll have that opportunity.
(Laughter.)
All right. Ms. A'Zera, obviously you're supportive the sexual trau-
ma program. I think we all are supportive of a sexual trauma pro-
gram. It might be what we now have, it may be an expanded pro-
gram, but-I guess my question is, do you have any data or infor-
mation regarding its effectiveness?
Ms. A'ZERA. Well, I think it has been reported through GAO and
with the VA on how many people have used it. And also, we have
gotten letters from women veterans, specifically after the letter
went out from Jesse Brown inviting people to come out to the VA
for these kind of services. We, also, did receive letters from women
veterans who said, ''We went out to the hospital and there wasn't
anything there for us." So, we've gotten those kind of feedback.
:But as far as the statistics of how many people have used it, the
VA and the GAO have those statistics. And it is, according to their
reports, that it's increased.
Mr. BILIRAKIS. All right.
Ms. A'ZERA. It is being used-utilized.
Mr. BILIRAKIS. But AMVETS really is going on record as saying
that they think it's effective?
Ms. A'ZERA. Yes. Yes, sir.
Mr. BILIRAKIS. Okay. I know Ms. Van Hom-I came in during
the time that she responded to a question, and she indicated
incidences when an awful lot of people were able to become produc-
tive and that sort of thing. And that's obviously good to hear.
Mr. Backhus, have you been able to compare the quality of any
of the VA sexual trauma counseling programs with the kind of
intervention quality, etc., that would be available through non-VA
providers? I mean, how do they compare? Do you have any opinion
in that regard?
Mr. BACKHUS. Well, we didn't have that as part of our study.
Mr. BILIRAKIS. Yes, I can understand that probably it was prob-
ably not requested, srecifically.
Mr. BACKHUS. So, really, I have no firsthand knowledge of that.
However, I do know of people who have commented that there is
at least comparability.
Mr. BILIRAKIS. There is comparability?
Mr. BACKHUS. Yes, with what's available outside the VA. Also,
I know that the VA occasionally contracts out, of course, for this
service.
Mr. BILIRAKIS. Yes, so you've gotten sort of that information even
though it hasn't been part of your study?
Mr. BACKHUS. Correct.
 43

Mr. BILlRAKIS. Okay. Let me ask you-and I know that the focus
here, as it should be, is on the counseling programs and are they
effective, and should they be improved, etc. I guess there's always
room for improvement, no matter how well any program is going
on.
Going back to prior days, Korea, people-men and women in the
military during the Korean days, Vietnam, to those decades-let's
say the 1950's, the 1960's. It may seem like ancient history to you
all, but for people like myself who was in back at that time, it isn't.
All of the years really fly. And I know that sexual abuse and sexual
harassment is just not limited to women, but for the most part-
there are a lot more women in the service now than there were
back in those days. But on a per-capita basis, if you will, did we
have as many problems in this regard back then as we do today?
Mr. BACKHUS. Well--
Mr. BILIRAKIS. In the process, Mr. Backhus, of your research, and
what-not, any opinion in that regard?
Mr. BACKHUS. The only information I have-and it doesn't really
very clearly get to your question-is that it wasn't until the early
1990's, earlier in this decade, that people began to talk about this.
So, I would conclude from that---
Mr. BILlRAKIS. So are you saying, then, the problems were prob-
ably there but people Just didn't talk about it?
Mr. BACKHUS. That s what I would say, yes.
Mr. BILIRAKIS. Yes, and any further comments, Ms. Drake or Ms.
A'Zera?
Ms. DRAKE. We don't know to what extent it happened back
then. It seems to be more prevalent now. When we were out talk-
ing to some of the veterans, at one of the regional offices, they did
have a veteran who had been sexually traumatized back in 1948.
And, then, we did meet with a couple of other women veterans who
had been sexually traumatized maybe about 20 years ago. So, it did
happen back then but I still don't know to what extent it hap-
pened--
Mr. BILIRAKIS. Yes.
Ms. DRAKE. But it seems to be more prevalent now, as Steve
said, because maybe it's more in the forefront and people are more
willing to talk about it.
Mr. BILlRAKIS. Yes, that's reasonable. Ms. A'Zera, anything to
add?
Ms. A'ZERA. I would just add that there weren't any statistics
kept so it's kind of hard to do that, to look back and see that.
Bu~-
Mr. BILlRAKIS. There weren't any statistics kept?
Ms. A'ZERA. DOD, right now, can't tell you how many people
have been assaulted at any given time now, within a year. They
can do surveys; they've done a survey on military members who
have experienced it, but they don't keep the records as far as like
each base, how many. have been as's aulted, or anything like that.
They don't keep anything like that.
But when I did-I did an article for AMVETS a while ago, and
on the veterans, and I went back through the history and talked
to several women veterans from different eras, and they had all
had stories about some sexual assault or abuse that had happened
 44

to them during their time or knew of some people that had. So I

think it's been prevalent all along. I think we just now are-it's
brought up to awareness.
Mr. BILIRAKIS. Well, thank you. Mr. Gutierrez.
Mr. GUTIERREZ. Thank you very much, Mr. Bilirakis. And wel-
come, Mr. Backhus, Ms. Drake, and Ms. A'Zera. Good to have you
all here.
Well, No.1, you said it quadrupled, the use from 1993 to the
present?
Mr. BACKHUS. Yes.
Mr. GUTIERREZ. So what about the number of women serving in
the military? Do you have any correlation--
Mr. BACKHUS. I do.
Mr. GUTIERREZ (continuing). Correlation between the number of
women increase and those asking for the service?
Mr. BACKHUS. I do, but I don't have it memorized here.
Mr. GUTIERREZ. Okay.
Mr. BACKHUS. In 1980-here it is-in 1982 there were about
740,000 women veterans. By 1996 there were 1.2 million. So, it's
not quite a doubling.
Mr. GUTIERREZ. But it seems to be--
Mr. BACKHUS. But for a much longer period of time.
Mr. GUTIERREZ. Is there any projection of what's going to happen
in the military--
Mr. BACKHUS. Yes.
Mr. GUTIERREZ (continuing). In terms of women?
Mr. BACKHUS. Yes.
Mr. GUTIERREZ. What's going to happen--
Mr. BACKHUS. Yes-I have that, too.
Mr. GUTIERREZ (continuing). In the future? What do you know
about it?
Mr. BACKHUS. By the year 2010, it is estimated that there will
be about 1.3 million veterans. And you know, I had it out to 2040,
or Shelia did, and I said that's too far out. (Laughter.)
So now I forget what the number is.
Mr. GUTIERREZ. All right. (Laughter.) .
So that's very good. Well, I think it answers the question pretty
well for the committee, so we do know that there are more women
seeking the service, quadrupling of seeking of service. It's more
now and people need it. And it's one that they like, for the most
part, they like. And that we hear from the VA that it's a very pro-
ductive intervention. Do you find that their interventions-that
your study show that their intervention leads people to successful
kind of reentry into life?
Mr. BACKHUS. Well, you know, we didn't look at that specifically.
However, in the conversations with the women veterans that's how
they tended to portray the outcome of the service. We make men-
tion in the testimony that there really isn't anything more than
what I woul,d call antidotal accounts of the program's effectiveness.
There are efforts underway though to try to do something in a
more systematic way to find out-for example at least at the Vet
Centers and the special trauma teams that are taking care of the
more severely ill patients. I tend to agree, though, that if there
wasn't some sort of a ground swell of support among the women
 45

veterans that we wouldn't have seen the demand increase as it has.

And that suggests to me that people are getting a lot out of it.
Mr. GUTIERREZ. So we have increase, and we will continue to in-
crease the number of women veterans through the foreseeable fu-
ture. And the people that are using the program, it's productive.
People are getting food benefit out it. Let me ask you some yes or
no, otherwise, I wil certainly take up a lot of more than 5 minutes
between the two of you.
So, now, do you believe that more women's veterans stress dis-
order treatment teams should be established by the VA? Should
they establish more of them?
Mr. BACKHUS. I haven't seen any unmet demand for that at this
time.
Mr. GUTIERREZ. You have not seen any unmet demand. So that
you don't see any reason to have an additional ones?
Mr. BACKHUS. Not at this time.
Mr. GUTIERREZ. In the hospitals and the Vet Centers that you
visited as part of your report, did you find uniformity of care pro-
vided to veterans? And how consistent is the care offered for sexual
trauma?
Mr. BACKHUS. Dr. Garthwaite answered that, I think, similar to
how I'm going to answer it. Like any other health care issue in VA,
if you've gone to one VA facility, you've seen one VA facility. They
vary; there's variation around the country as to how well these pro-
grams are run and how well supported they are resource wise.
Some are more able to treat than others.
Mr. GUTIERREZ. Just so there isn't uniformity?
Mr. BACKHUS. There's not.
Mr. GUTIERREZ. Not?
Mr. BACKHUS. No.
Mr. GUTIERREZ. There's not uniformity in terms of the care? You
can receive better care at some facilities then at other facilities?
Mr. BACKHUS. Clearly.
Mr. GUTIERREZ. That's why I just wanted to establish that. I
think both--
Mr. BILIRAKIS. If the gentleman would yield, should there be or
is that a - -
Mr. GUTIERREZ. I believe there should be. I believe that a - -
Mr. BILIRAKIS. Well, I - -
Mr. GUTIERREZ (continuing). Women should be. And my point is
if I have a sore throat-I bet if I ask the same question of Mr.
Backhus and the same question of Dr. Garthwaite, I bet you I
could list a series of ailments, a series of medical conditions, that
there would be more uniformity than not in terms of the availabil-
ity of drugs, pharmaceutical, and doctors to take care than this
particular issue. And since the hearing is about this particular
issue, I'm concerned about this particular issue because I want to
raise it to be just as important, if not more important, than a cold.
And the reason I bring a cold and a broken-that's my few times
I visited-(Laughter.)-and it was like any hospital could take care
of me in the city of Chicago, and any health care plan would have
covered me. It's kind of universal-colds and broken bones.
Mr. BILIRAKIS. I would suggest to you though, sir, that a cough-
and you've just coughed-a cough or a cold or what not could be
 46
something more serious than just, you know, a cough or the flu or
something of that nature. So, I'm not sure that we really want the
uniformity that you talk about there.
Mr. GUTIERREZ. No, no. It's no~
Mr. BILIRAKIS. And this was on your time. I guess my question,
though, was to Mr. Backhus and you responded to it. (Laughter.)
Do you think there should be uniformity?
Mr. BACKHUS. Well, I think there's a value in establishing that
as a goal or something to strive toward. I don't think it's possible,
though. I'm not a clinician, but in speaking with those clinicians
that work in this program, it's a very complicated issue. You treat
people individually, depending on the circumstances, and there has
to be variability in how you treat those people. The consistency
that I see possible is in, the resources that are made available to
people, not so much in the protocols that are established in--
Mr. BILIRAKIS. Yes. So what you're saying is there should be con-
sistencies a far as resources being available.
Mr. BACKHUS. Right.
Mr. BILIRAKIS. Which I know is what you're certainly very anx-
ious to--
Mr. GUTIERREZ. It's exactly, Mr. Bilirakis, my point. My point is
pretty simple. A cold is a cold, is a cold. And if a cold is something
other than a cold, then it's not a cold. But a cold is a cold, and I've
been treated for a cold many times and it wasn't anything other
than a cold because I'm still here. (Laughter.)
And I didn't go back to get treated for anything else. And a bro-
ken finger is a broken finger, is a broken finger. And so my only
point is that there are things that are what they are. Now let me
just-watch, I'll ask Mr. Backhus. Has the VA improved over the
last 5 years, their services to men and women in terms of sexual
trauma treatment?
Mr. BACKHUS. I would say definitely, yes.
Mr. GUTIERREZ. They have improved? Is there room for improve-
ment?
Mr. BACKHUS. Of course.
Mr. GUTIERREZ. Of course there's room for improvement. I'll rest
my case. I would like to, if I could, ask Ms. A'Zera a couple of
questions.
Mr. BILIRAKIS. A couple of questions with a couple of quick an-
swers, please.
Mr. GUTIERREZ. Fine. That's why I'm only the ranking member.
(Laughter.)
Ms. A'Zera, welcome again, and allow me to thank you and the
member of AMVETS and your colleagues and the veterans' service
organizations for your assistance and support in this issue.
The GAO earlier testified that the VA's outreach efforts to
women veterans-do you believe the VA has done everything it can
or enough to inform women about sexual trauma services that they
can receive?
Ms. A'ZERA. I think that, after hearing all the comments from
Joan Furey and everyone, that they are certainly doing what they
can. And I think that there's always room for improvement. And,
as I've said in my statement, there's also room for the veterans'
service organizations and other agencies to help them get that
 47
word out. And I think that we all need to work together on doing
a better job at that. Yes.
Mr. GUTIERREZ. Current law authorizes the VA to establish a
sexual trauma program but does not mandate that this be done or
continued. Is that your understanding?
Ms. A'ZERA. Yes.
Mr. GUTIERREZ. Today the VA has established a viable sexual
trauma counseling program throughout the VA network that people
are accessing, quadrupling. They're the numbers from 1993 for-
ward. Nevertheless, because this program is discretionary, uniform
access to these services is not guaranteed for the future. Do you be-
lieve that we should revise the law to require that the maintenance
of this vital program and to make the provision of this care a prior-
ity for veterans in need? And why do you believe it's important?
Ms. A'ZERA. Of course, and because there's clearly-they've
shown the need is there by the fact that the numbers have quad-
rupled, and from what we heard from our women veterans and our
members, that the need is there for it. And with the expansions
and the improvements that we've suggested, as far as opening it
up to the Reserves and National Guard, I think that you'll see the
desire to use it will expand even further.
Mr. GUTIERREZ. Last question: Do you believe the authority to
establish the sexual trauma program should be extended perma-
nently? And is that the position of your organizations and any
other veterans' organizations that you might know of?
Ms. A'ZERA. That's back to my perfect world situation. Yes, we
would like to see it permanently.
Mr. GUTIERREZ. And AMVET supports permanent. And are there
any other veterans' organizations that you know of that support it
being permanently extended?
Ms. A'ZERA. The ones that I'm here representing today, yes,
that's our case.
Mr. GUTIERREZ. Thank you very much, and thank you very much
Mr. Bilirakis.
Mr. BILIRAKIS. The gentleman, Mr. Stearns,Chairman Stearns.
Mr. STEARNS. Thank you for doing such an able job.
Mr. BILIRAKIS. Well, I'm not sure if Mr. Gutierrez would agree
with that. (Laughter.)
In any case--
Mr. GUTIERREZ. For the record, I do. (Laughter.)
Mr. BILIRAKIS. Okay. In any case, we thank this panel. You
know, this is a tough, complex subject. I know that there isn't any-
one in this room, or elsewhere, who would not agree with that, and
a willingness to work on it, address it, to solve it, you know, that
sort of thing. Whether Mr. Gutierrez's legislation A through Z is
the answer; whether-are there answers? I don't know. But cer-
tainly that's what these hearings are all about. And we could not
never really come to any kind of conclusions without the type of
testimony we've heard from you. Thank you very much for being
here.
Mr. BILIRAKIS. The hearing is adjourned.
[Whereupon, at 12:08 p.m., the subcommittee adjourned subject
to the call of the chair.]
 APPENDIX

PREPARED STATEMENT OF HON. LANE EVANS

Thank you, Mr. Chairman. We have a full agenda ahead of us today looking at
draft legislation for war-related illnesses and reviewing VA and DOD programs for
sexual trauma counseling so I will make my remarks brief.
I am pleased that the members of this Committee, from both sides of the aisle,
have demonstrated such a si~ficant interest in Persian Gulf War Illnesses. The
draft legislation we will be dIscussing today offers another approach to addressing
the problems veterans of the Persian Gulf continue to experience seven years after
their military service. But, I would add, it is just one of the approaches that has
been offered to the House Committee on Veterans' Affairs for review. While I am
eager to hear the experts from the scientific and government agencies discuss this
proposal, I am equally anxious for other bills including my own comprehensive Per-
sian Gulf bill, H.R. 3279, and Mr. Kennedy's H.R. 3361, to have a fair hearing. I
hope that the Chairman of the full Committee will work with me to ensure that our
Committee can consider more of these measures before it chooses which course is
most appropriate for action.
I commend you, Mr. Chairman for reviewing DOD and VA's outreach and sexual
trauma counseling programs. While I realize this is an oversight hearing, my ~ood
friend, Luis Gutierrez, has worked closely with the veterans' service organizations
and the VA to identify the needs of the existing program. Rep. Gutierrez and many
of the advocates of the sexual trauma program have identified some legislative ex-
pansions that respond more fully to the needs of veterans and other former
servicemembers or reservists who were harassed during military service or training
exercises.
GAO's testimony indicates that the VA is doing a good job reaching and serving
the women who are eligible for this service. It also documents a growing need for
these services. Based on GAO's review and "the testimony of VA and the veterans'
service organizations, I encourage the Subcommittee to extend authority for this
valuable service, and take action on H.R. 2239 to amend and improve existing
authority.
Mr. Chairman, thank you for the opportunity to address the Subcommittee today
and for scheduling this hearing to examine these important issues.

(49)
 50

Representative Helen Chenoweth

Statement to the Veterans Affairs
Subcommittee on Health
April 23, 1998

Thank you, Mr. Chairman, for holding this hearing today. I look
forward to hearing from today's witnesses about the future of research
and treatment for war-related illnesses and the VA sexual trauma
counseling program.

I believe strongly that the Veterans Affairs Committee should

make every effort to ensure that victims of Gulf War Illness and soldiers
who may contract unknown illnesses in the future receive the care they
deserve. I also recognize the importance of reviewing the effectiveness
of the VA sexual trauma counseling program which has been in place
since 1992. I,t is important that the VA continue to provide quality,
efficient services to the veterans which they are committed to serving.

It is of vital importance that the VA be given the authorization to

continue treatment for victims of the various unknown Persian Gulf
Illnesses. When Americans ask men and women to serve in our nation's
armed forces, we make them certain promises. One of the most
important is the promise of proper health care, but tragically, for many
veterans of Operation Desert Stonn, that promise has been broken.

We have the opportunity, through these hearings and through

proposed legislation, to extend the authority of the VA to research and
provide treatment for Persian Gulf veterans. In addition, we can clear
the way to ensure that we will not repeat the same mistakes made in the
care of our Persian Gulf veterans. It is my hope that this hearing will
lead to administrative and legislative measures that enable victims of
Gulf War Illnesses to receive the care they need and deserve.

Again, thank you Mr. Chainnan, and 1 look forward to the

testimony today.
 51

NOT FOR PUBLICATION UNTIL

RELEASED BY THE BOUSE
VETERANS' AFFAIRS C~TTEE

STATEMENT OF

CAPTAIN KENNETH CRAIG HYAMS, MEDICAL CORPS

UNITED STATES NAVY

BEFORE THE

HOUSE VETERANS' AFFAIRS SUBCOMMITEE

ON

HEALTH

23 APRIL 1998

NOT FOR PUBLICATION UNTIL

RELEASED BY THE BOUSE
VETERANS' AFFAIRS COMMITTEE
 52

Good Morning Mr. Chairman. My name is Kenneth Craig Hyams.

I am a Captain in the Medical Corps of the u.s. Navy.

Currently, I am the Head of the Infectious Diseases Threat

Assessment Division of the Naval Medical Research Institute in

Bethesda, Maryland. I am a physician, board certified in

internal medicine and infectious diseases, and I have a degree

in public health from Johns Hopkins University. I am also an

author on over 130 scientific publications. The following

testimony represents my scientific and personal opinion and does

not necessarily reflect the official views of the

Administration, the Department of Defense (DoD) or the u.s.

Navy.

My involvement in Persian Gulf war health care began in

August 1990, when I deployed to the Persian Gulf to help set up

a diagnostic laboratory. With the support of numerous military

scientists and preventive health officers, and the u.s. Naval

Medical Research Unit No. 3 in Cairo, Egypt, the Navy Forward

Laboratory was established in Al-Jubayl, Saudi Arabia. The Navy

Forward Laboratory served as the theater-wide, infectious

diseases reference laboratory during Operations Desert Shield

and Desert Storm. Our job was to evaluate clinical specimens

and environmental samples for infectious disease threats. We

were able to identify the most important infectious disease

problems during this war, which led to improved clinical care

and preventive health efforts among coalition troops.

The diagnostic and surveillance activities of the Navy

Forward Laboratory have also helped prioritize and direct

medical research programs since the war. The U.S. Army, Navy,

and Air Force maintain an extensive medical research program

which:
 Conducts epidemiological studies to determine the major

health threats for our troops;

Develops improved preventive health measures;

Develops new diagnostic tests; and,

Develops new drugs and vaccines.

The military's medical research program has played a major

role in the government's effort to understand the health

problems of Gulf war veterans. The first large-scale

epidemiological studies of hospitalizations and birth defects

among Gulf war veteran populations were conducted at the Naval

Health Research Center, San Diego, California, and a new form of

parasitic infection, viscerotropic leishmaniasis, was identified

in 12 Gulf war veterans at the Walter Reed Army Institute of

Research, Washington, DC .

In December 1993, I was ~etailed to the Tri-agency Persian

Gulf Veterans' Coordinating Board and spent over two years at

the Department of Veterans Affairs (VA) assisting in the

evaluation of veterans' unexplained symptoms . One of the

earliest questions we had to address was whether similar

illnesses had occurred after previous wars. In a collaborative

study between DoD and VA (Dr. Robert Roswell, VISN 8 Director),

we conducted an extensive search for scientific publications

dealing with prior war-related illnesses. Initially, we

expected to find psychological problems, like post-traumatic

stress disorder (PTSD), to be cornmon after wars; what we

discovered was a much more complicated picture of veterans'

health problems.

In addition to well-known stress-related conditions, we

found that similar unexplained symptoms have been associated

with armed conflicts since at least the u.s. Civil War. War

veterans have repeatedly suffered from fatigue, shortness of

 54

breath, headaches, sleep disturbances, and impaired memory and

concentration. These symptoms have been categorized as distinct

syndromes, which have been variously called DaCosta's syndrome,

soldier's heart, neurasthenia, effort syndrome, and most

recently Gulf war syndrome.

Our research also revealed one other unifying factor: war

syndromes have been repeatedly defined, explained, and studied

in a similar manner since the U. S. Civil War. These postulated

syndromes have been identified by diverse physical symptoms,

which do not fit easily into well-recognized diagnostic

categories. In addition, war syndromes have remained

unexplained, ~ven after decades of medical follow-up of veterans

who were definitely ill, because unique physical abnormalities

were not identified. Lastly, there have been extensive

governmental efforts in the United States, Great Britain, and

Canada to understand war syndromes and provide clinical care and

assistance to veterans. Despite these concerted efforts, the

existence and causes of distinct war-related diseases have not

been conclusively determined, which has resulted in over a

century of unresolved public and scientific controversy.

When all available clinical and research data is carefully

weighed, it is clear that war veterans have suffered from a

broad variety of medical and psychological illnesses, which were

due to complex and frequently unknown factors. There are two

principal reasons for the continued uncertainty about the causes

of these health problems . For one, epidemiological studies

cannot be conducted in the midst of a chaotic and unpredictable

battlefield, where the overriding objective has to be the defeat

of the enemy . Consequently, it has not been possible to collect

the extensive risk factor data needed to conclusively answer all

post-war health questions. Also, it is not possible in a

 55

research laboratory to re-create the exact combination of

events, exposures, and experiences during a war to prove whether

a potential health risk is the cause of illness.

The other principal reason why it has not been possible to

explain war syndromes is that we are dealing with fundamental,

unanswered health questions shared by every adult population.

Symptoms such as chronic fatigue and pain are frequent causes of

suffering a"nd disability in all civilian populations, yet the

underlying causes and most effective treatments for these

symptoms remain largely unknown.

The findings of our study of war syndromes clearly

demonstrates that more research is needed to understand the

causes of chronic physical symptoms. Basic scientific research

is essential, as is increased surveillance of military personnel

and veterans - before, during, and after hazardous deployments.

Just as clearly, our research demonstrates that some veterans

may require specialized health care after life-threatening

deployments. Because it may not be possible to verify an

association between ill health and wartime exposures, even with

well-designed research studies, requiring individual veterans to

prove causation following future conflicts may be unrealistic.

Although active duty military personnel automatically receive

health care within the Military Health System and Gulf War

Veterans are covered by legislation; future reservists, National

Guard personnel, and troops who leave active duty soon after

hazardous deployments will have to establish financial need or

service-connection before the VA can legally provide medical

care. Given the unanswered scientific questions involving post-

war health problems, the requirement for service-connection can

be very hard to meet, resultinq in a frustratinq process tor ill

veterans, their families, and health care providers.

Mr. Chairman, I will be happy to answer any questions you

or other committee members wish to ask.

 57

STATEMENT FOR TIfE RECORD

BY

RICHARD N. Mll..LER, M.D., M.P.H.

DIRECTOR, MEDICAL FOLLOW-UP AGENCY

INSTITUTE OF MEDICINE

NATIONAL ACADEMY OF SCIENCES

BEFORETIfE

SUBCOMMITTEE ON HEALTH

COMMITTEE ON VETERANS' AFFAIRS

U.S. HOUSE OF REPRESENTATIVES

April 23, 1998

 58

Mr. Chairman, Members of the Subcommittee:

I am Dr. Richard Miller, Director of the Medical Follow-up Agency, at the National Academy of
Sciences. I speak as the director ofa small organization that is part of the Institute of Medicine
and that has been carrying out research on veteran' s health issues for more than 50 years since
our agency's founding by Dr. Michael DeBakey in 1946.

It is appropriate to point out that I am the principal investigator of a study jointly funded by the
Departments of Veterans Affairs and Defense ('1A and DOD) into the health perceptions and
health care seeking behaviors of Persian Gulf War veterans enrolled in the VA Persian Gulf
Health Registry and the DOD Comprehensive Clinical Evaluation Program. lhls study involves
examining the health records of individuals who were on active duty during a one year period
prior to the Persian Gulf War. The number and type of outpatient visits during that one year
period are being compared between veterans enrolled in the two registries with poorly defined or
undiagnosed conditions and a comparable group of Persian Gulf War veterans who did not enroll
in the registries. lhls study seeks to determine if those veterans who enrolled with poorly
defined or undiagnosed illnesses had patterns of illness and health care seeking prior to the war
that differed from control veterans who did not enroll. All results will be aggregated, and no
individual veteran will be identified when the results are published or presented.
Further, we intend to submit one or more proposals to the VA and DOD in the near future to
conduct other studies of war-related illnesses. I am, therefore, a knowledgeable but involved
witness.

I will also testify as a veteran of29 years of active duty in the U.S. Anny who now receives a
portion of his medical care at a VA Medical Center and as a physician who has cared for both
military and civilian patients. Most of my military career was spent at the Walter Reed Anny
Institute of Research doing population-based medical studies of military populations.

I do not feel qualified to comment on the portion of the bill dealing with health care for veterans
except to make a personal observation that at least some of these war-related illnesses appear to
be associated with psychological stress, and that a significant stressor is uncertainty about the
availability of medical care. There could, therefore, be a paradoxical reduction in the
requirement for medical care produced by assurances to veterans that care is available. An
additional personal speculation is that the provision of routine care to recent war veterans may
well obviate the need for complex and expensive registries and evaluation programs such as the
Persian Gulf Health Registry.

All remaining comments will deal with the proposed National Center foiStudy of War-Related
Illnesses which I believe is an excellent and long overdue effort to elucidate the causes of a major
portion of veteran illnesses.

Wars pose unique combinations of psychological and environmental exposures. A center

organized around the phenomenon of war-related illnesses, rather than a single discipline or
disease, can bring together the appropriate mix of expertise and foster appropriate collaborations.
Cooperative efforts between psychologists, psychiatrists, toxicologists, environmental medicine
physicians, and other specialties may bring new insights and perhaps help combat the stigma of
psychological illness in.the minds of some by treating war-related stress as just another
unavoidable risk factor associated with going to war. I particularly like Dr. Hyams' term "war
syndrome" since it connotes an occupational hazard for our nation's warriors and not the
judgment, so disliked by veterans, that these government doctors are saying it' s not a real illness.
I hope that this new center will, as the draft Bill says, fund studies of the causes of war-related
illness. Epidemiologic studies of risk factors for developing war-related illness with the goal of
preventing them or at least ameliorating their effects are essential.
 59

The recently published work of Dr Hyams and his colleagues indicate that the problem of war-
related illnesses is much more complex than originally believed and has been with us after most
major military deployments. Sometimes. as after the Persian Gulf War. medically unexplained
illnesses constitute the majority of the resulting medical problems of veterans. The lack of a
ready answer to the causes of these illnesses suggests the need to look at the problem in new
ways. The assignment ofICD-9 disease classification codes to a collection of symptoms and
calling them diagnoses is misleading. Equally misleading is diagnosing a condition that does not
really explain the patient' s complaints. Saying that a minority of the veterans on the registries
have not been diagnosed implies a level of understanding of war-related illness that does not
exist.

The work ofa National Center for Study of War-Related illnesses may have major implications
for civilian health care. It is clear that medically unexplained illnesses are by no means limited to
veteran populations. Any physician who has practiced primary care or family medicine is aware
of the burden of lDlexplained illness for patients. clinic staff. and for those who pay the ever-
increasing costs of medical care.

Mr. Chairman. I will be happy to answer questions.

 60

INSTITUTE OF MEDICINE
NAllONAL ACNJM'( OF SCIENCES
2101 CONSTrTVTION AVENUE WASHNGTON, D.C. zo.cUI

TE:LIEPtCIf'oE: 202/33 ... 282S

"AX: 2O:tJ33 ...2685

April 20, 1998

The Medical Follow-up Agency has received since October I, 1995 the following
amounts in support of these contracts or grants: Health Consequences of Military Service
in the Persian Gulf Theater of Operations (VA and DoD, VI01(93)P-1417), Prisoners of
War Mortality Study (V A, VI0l(93)P-15SI), Strategies to Protect The Health of
Deployed US Forces (DOD, DASWI-97-OO78), Long Term Sequelae of Hemorrhagic
Fever with Renal Syndrome in Veterans (HHS/CDC, N664602161), Patterns of Health
Care Seeking prior to Onset of Persian Gulf War Related 111ness(VAlDOD, VIO\(93)P-
1417):

VA $718,000
DOD $1,098,000
HHS $113,000

~'M.P.H.
Director
 61

CURRICULUM VITAE

RICHARD N. MILLER. M.D.

Director. Medical Follow-up Agency. Institute of Medicine.
National Academy of Sciences

GENERAL: Address: 2101 Constitution Avenue. NW

Washington. DC 20418
Telephone: (202)334-1774
Fax: (202) 334-2685
Email: rlniller@nas.edu

EDUCATION:
Loras College. Dubuque. IA
University of Iowa. Iowa City. IA (MD 1963)
Harvard School of Public Health. Boston. MA (MPH 1967)

GRADUATE MEDICAL EDUCATION:

Straight Medicine Internship. Washington Hospital Center. Washington. D.C . 1963-64.

Residency. General Preventive Medicine. Walter Reed Army Institute of Research.
Washington. DC. 1967-69.

CERTIFICATION and LICENSURE:

American Board of Preventive Medicine (General Preventive Medicine. 1977. #40513)

American Board of Preventive Medicine (Occupational Medicine. 1978. #21557)
West Virginia License #14937

MILITARY ASSIGNMENTS:

Public Health Officer. Third Civil Affairs Detachment. Canal Zone.

Republic of Panama (1964-66).
Chief. Preventive Medicine Activity. USARSUPTHAI. Bangkok. Thailand (1970-72).
Chief. Preventive Medicine Activity. USAMEDDAC. Frankfurt. Germany (1972-75) .
Regional Preventive Medicine Consultant (South). Fort McPhefson. Georgia (1975-79).
Director. Division of Preventive Medicine. Walter Reed Army Institute of Research.
Washington. DC (July 1979-June 1993).

TEACHING APPOINTMENTS:

Director. Residency Program in General Preventive Medicine. Walter Reed Army

Institute of Research. Washington. DC (July 1979-July 1988. July 1991-1993).
Director. WRAIR Annual Tropical Medicine Course (July 1979-1993).
Assistant Professor. Department of Preventive Medicine and Biometrics. Uniformed
Services University of the Health Sciences (May 1981-June 1993).
 62

PROFESSIONAL SOCIETIES AND COMMITI'EES:

American College of Epidemiology

American Society of Tropical Medicine and Hygiene
Society for Epidemiology Research
Preventive Medicine Residency Advisory Committee. Walter Reed Army Institute of
Research. Washington, DC.

AWARDS:

Army Commendation Medal (1966)

Army Commendation Medal. OC (1972)
Meritorious Service Medal (1979)
Army Surgeon General's" A " PrefIX
George W. Hunter ill Award (1991)

PUBLICATIONS:

Wisseman C. Miller RN . First report of human body lice resistant to malathion in Burundi.
Trans Roy Soc Trop Med & Hyg 1972; 66:372-375.

Lemon SM, Lednar WM. Bancroft WH. Cannon HG, Benenson MW. Park lH. Churchill FE,
Tezak RW. Erdtmann FJ. Kircbdoerfer RG. Lewis PO, James 11. Miller RN . Etiology of
viral hepatitis in American soldiers. Am J Epidemiol 1982; 116:438450.

Takafuji ET. Kirkpatrick IW. Miller RN. Karwacki II. Kelley PW. Gray MR. McNeill KM.
Timboe HL. Kane RE. Sanchez IL. An efficacy trial of doxycycline prophylaxis against
leptospirosis. N Engl J Med 1984; 310:497-500

Lemon SM. Miller RN, Pang LW. Prier RE. Bernard KW . Failure to achieve predicted
antibody responses with intradermal human diploid cell rabies vaccine. Lancet 1984; i:
1098-1100

Pappas MG. Ballou WR. Gray MR. Takafuji ET. Miller RN. Hockmey"er WT. Rapid
serodiagnosis of leptospirosis using the IgM-specific dot-EUSA; Comparison with the
microscopic agglutination test. Am J Trop Med Hyg 1985; 34:346-354.

McNeil 10. Lednar WM. Stansfiels SK, Prier RE. Miller RN . Central European Tick-borne
encephalitis: Assessment of risk for persons in the armed services and vacationers. J Infect Dis
1985; 152:650-651.

Gardner U. Redfield RR, Lednar WM. Lemon SM. Miller RN . Occupational and geographic
risk factors for hepatitis B among US Army enlisted personnel during 1980. Am J Epidemiol
1985; 123:464-472.
 63

Kelley PW, Takafuji ET, Tramont EC, Redfield RR, Brundage IF, Herbold JR, Miller RN.
The importance ofHN infection for the military. In: Wonnser GP, Stahl RE, Bottone EJ, eds.
Acquired immune deficiency syndrome. New Jersey: Noyes Publications, 1987:67-85.

Brundage JF, Scott RMcN, Lednar WM, Smith OW, Miller RN. Building-associated risk of
febrile respiratory disease in Army trainees. JAMA 1988; 259:2108-2112.

Kelley PW, Takafuji ER, Wiener H, Milhous W, Miller R, Thompson NJ, Schantz P, Miller
RN. An outbreak of hookworm infection associated with military operations in Grenada.
Milit Med 1989; 154:55-59.

Gardner LI, Brundage JF, Burke OS, McNeil 10, Visintine R, Miller RN. Spatial diffusion
of the human immunodeficiency virus infection epidemic in the United States, 1985-87. Ann
of Assoc of Am Geographers 1989; 79:25-43.

McNeil JG, Brundage JF, Wann ZF, Burke OS, Miller RN, et. al. Oirect measurement of
human immunodeficiency virus seroconversions in a serially tested population of young adults
in the United States Army, October 1985 to October 1987. N Engl J Med 1989;
320:1581-1585.

Gardner LI, Brundage JF, Burke OS, McNeil 10, Visintine R, Miller RN. Evidence of
spread of human immunooeficiency virus epidemic to low prevalence areas of the United
States. J AlOS 1989; 2:521-532.

Brundage JF, McNeil JG, Miller RN, Gardner LI, Burke OS, et. al. The current distribution
of CD4 + T -lymphocyte counts among adults in the United States with human
immunodeficiency virus infections: estimates based on the experience of the U.S. Army. J
AIDS 1990; 3:92-94.

Kelley PW, Miller RN, Pomerantz R, Wann ZF, Brundage IF, Burke OS. Human
immunodeficiency virus seropositivity among members of the active duty U.S. Army. Am J
Public Health 1990; 80:405-410.

Cowan ON, Pomerantz RS, Wann ZF, Goldenbaum M, Brundage JF, Miller RN, Burke OS,
Carroll CA. Human inuninodeficiency virus infection among members of the reserve
components of the US Army: Prevalence, incidence, and demographic characteristics. JID
1990; 162:827-836.

Brundage JF, Burke OS, Gardner LI, Kelley PW, McNeil 1M, Goldenbaum M, Visintine R,
Redfield RR, Peterson M, Miller RN. Tracking the spread of the HIV infection epidemic
among young adults in the U.S.: Results of the first four years of screening among civilian
applicants for U.S. military service. J AIDS 1990; 3:1168-1180.
 64

McNeil 1M. Brundage IF. Gardner LI. Wann ZF. Renzullo PO. Redfield RR. Burke OS.
Miller RN. Trends of human immunodeficiency virus seroconversion among young adults in
the US Army. 1985 to 1989. lAMA 1991;265:1709-1714 . .

Cowan ON. Brundage IF. Pomerantz RS. Miller RN. Burke OS. Human immunodeficiency
virus infection among US Army Reserve ComponenlS members with medical and health
occupations. lAMA 1991; 265:2826--2830.

Cowan ON. Brundage IF. Pomerantz RS. Gardner LI. Miller RN. Wann ZF. HIV infection
among members of the Army reserve componenlS residing in New York City. NY State I Med
1991; 91:479-482.

Sanchez IL. Oiniega BM. Small IW. Miller RN. Andujar 1M. Weina PI. Lawyer PG. Ballou
WR. Lovelace IK. Epidemiological investigation of an outbreak of cutaneous leishmaniasis in
a defined geographic focus of transmission. Am I Trop Med Hyg 1992; 47:47-54.

Gunzenhauser 10. Brundage JF. McNeil 1M. Miller RN. Broad and persistent effeclS of
benzathine penicillin G in the prevention of febrile. acute respiratory disease. no 1992;
166:365-373.

Partin AW. Page WF. Lee BR. Sanda MG. Miller RN. Walsh PC. Concordance rates for
benign prostatic disease among twins suggest hereditary influence. Urology 1994; 44:646-650.

Walsh PC. PartinAW. Page WF. Lee BR. Sanda MG. Miller RN. Concordance rates for
benign prostate diseases among twins suggest hereditary influences. Journal of Urology. 151.
1994. p. 294A.

Smoak BL. McClain 18. Brundage JF, Broadhurst LE. Kelly OJ, Oasch GA. Miller RN.
An Outbreak of Spotted Fever Rickettsiosis in U.s. Army Troops Oeployed to Botswana
Emerging Infectious Diseases 1996; 2(3):217-221. .

Broadhurst LE. Kelly OJ. Chan C. Smoak BL. Brundage 18. McClain 18. Miller RN.
Laboratory evalustion of a dot-blot enzyme immunoassay for serological confmnation of illness
due to Rickettsia conorrii. In press Am J Trop Med Hyg 1998.
 65

MATTHEW L. PUGUSI
ASSISTANT DIRECTOR FOR GULF WAR VETERANS
VETERANS AFFAIRS AND REHABIUTATION COMMISSION
THE AMERICAN LEGION
BEFORE THE
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES

APRIL 23. 1m

Mr. Chainnan and distinguished members of the Committee:

Thank you for providing The American Legion the opportunity to participate in today's
hearing regarding research on, and treatment of, war-related illnesses, and draft
legislation to provide authority to fumish priority health care to treat illnesses which
may be attributable to future wartime service. This is your third hearing in this
Congress regarding Gulf War veterans' illnesses. Your leadership and energy have
provided the public and Congress with the facts regarding the health effects of the Gulf
War, and a lucid analysis of the federal govemment's reaction to veterans' health
complaints. The draft bill applies the knowledge gained through the Subcommittee's
exhaustive investigation of Gulf War veterans' illnesses, and investigations of illnesses
found after past wars. If passed, it would represent a histOric step in addressing the
health problems of today's veterans, and tomorrow's as wall. It would also be a bright
display of how Congress can leam lessons from the nation's experience in preceding
wars. This coukl signal another step forward in the nation's evolving commitment of
caring for its war veterans, and hes the enthusiastic support of the nation's largest
veterans service organization.

Executlye Summary

Background

Since late 1991 thousands of veterans retuming from combat service in the Persian
Gulf heva reported a broad range of symptoms, syndromes, and diseases. The
possible causes of these illnesses have been summarized In a series of committee
reports (Department of Veterans Affairs, Institute of Medicine, Presidential Advisory
Committee). Now, seven years later, many veterans still feel ill and seek answers that
will help them feel better. Increasingly, the question is where they, and future re-
deployed veterans, shoukl receive health care. Returning veterans have reported
similar symptoms after previous wars (Hyams, et. al., 1996), symptoms that ware
chronic, disabling and medically unexplained. In spite of the appaarance of 'Medically
Unexplained Symptom Syndromes' (10M 1997) after all our wars since at least 1860,
the federal goverM18nI has not responded with programs that would anticipate these
illnesses and provide access to health care for these veterans. That would change with
the passage of this draft bill.

The Health C~ of We(

Combat in World War II predicted that in the 15 years after the war a veteran would
experience 8 2.85-foId increase in physical decline or death. There was no evidence
that the eI'fect of combat was more pronounced among men of different ranks, theaters
of engagement (with the exception of POWs), or levels of seIf-'MHth before the war
(Elder, et. 81., 1997). The post-war experience of Vietnam veterans appears to be
 66

-2-

similar, in that their post-war health was poorer than their peers who did not deploy to
Vietnam (Stellman, et. aI., 1988). The health consequences of the Gulf War appears to
be no different from these earlier wars (Kang, 1996; Iowa, 1997). These wars were
fought during different periods, against different foes, and with different waapons. Yet
all shared something in common: combat and environmental exposures found in war
theaters.

The Health Consequences of the Gulf War

Thousands of Gulf Wer veterans are ill. The population of deployed Gulf War veterans
is significantly more ill than the non-<leployed Gulf War era population (Iowa, 1997).
They appear to use the health care system more frequently for a broad range of
problems, from asthma to "ill defined conditions." Some of these represent identifiable
diseases commonly treated in primary care settings. Some veterans are commonly
seen, but not treated well, by primary care phYSicians who have little training in
veterans health.

The Draft Bill

Patients in primary care settings often seek halp from their physicians for symptoms
that are not easily explained (Kroenke 1990), including back pain and fatigue. Primary
care phYSicians have long spent much of their time addressing non-specific symptoms
and screening out diseases. As health care financing in tha US has changed,
physicians have had less opportunity to spend time with their patients, listen carefully
and patiently, and sometimes await the self-healing of patients.

With VA moving towards a primary care model, it should be better suited to treat
veterans of Mure wars more appropriately than it has treated Gulf War veterans. It will
not accomplish anything, however, unless Mure veterans have ready access to VA
health care. This draft bill would provide that access.

Natjonal Center for the Study of War-Related Illnesses

The creation of such a center neturally follows from the realization that war syndromes
have been reported since the Civil War. It would be an innovative and appropriate step
for VA to designate such a focal point of leaming. Such a center would provide the
medical knowledge for VA to improve its treatment of post-war illnesses, and therefore
enable VA to provide effective medical treatments for veterans eligible' to take
advantage of this benefit after our next war,

The American Legion Enthusiastically SuPPOrts the Draft Bill

The American Legion has long held the view that the most pressing issue facing sick
Gulf War veterans was the development of effective medical treatments for their
illnesses. Thera have been obstacles in the way, the most apparent being the failure to
recognize that Medically Unexplained Symptom Syndromes may be a natural
consequence of participating in a war. Another was ,that 'Gulf War veterans were only
gradually given access to health care, when the medical literature is clear that the
sooner interventions occur the more likely a sick patient will get better, This bill
overcomes these obstacles. First, it provides health care for Gulf War veterans
(through 2001), and Mure war veterans. Secondly, it will eventually enable VA to
effectively treat these illnesses through medical knowledge developed at a National
Center on War-Related Illnesses. The bill not only is a key part of VA's current efforts
to determine which medical approaches effectively treat these illnesses, but it will help
create a VA system ready to "hit the deck running" after our next war,Thebili provides
VA with the opportunity to address the next "Gulf War Syndrome" competently,

At the height of the Second World War, veterans of the First World War sat in Legion
Posts across the United States and talked about the hardships they faced upon thair
 67

-3-

return from France in 1919. These discussions turned into ideas, and soon into action.
Congress passed the Serviceman's Readjustment Act, the GI Bill of Rights, before the
war had ended. Discharged veterans didn't return home unemployed while the federal
government slowly decided what could be done for them. Instead, the GI Bill enabled
these veterans to attend college and buy homes, and it generated the greatest era of
prosperity in the nation's history.

This bill, although much more modest in scale than the GI Bill, para"els its vision. It
applies the lessons learned from our recent, and distant, past. It implements policies
before they are needed by veterans. This will enable sick war veterans to return from
Mure wars and be given every chance to recover their health and lead productive
lives.
 68

-4-

Research On. And Treabnent Of. War-Related Illnesses And Draft

Legislation To Provide Authorttv To Furnl,h Prlorttv Health Care To
Treat IIIn"", Which May Be Attributable To Future Wartime Service
VA's APproach to Gylf War Veterans' Illnesses' A Seven Year (and Counting) Evolution

VA expected large numbers of disabled veterans in the wake of the Gulf War. The war
ended quickly, however, and with ' - casualties. VA then focused on two types of
significant problems that it anticipated: illnesses resulting from oil well fire smoke; and
illnesses resulting from exposure to traumatic stress. In early 1991 VA moved to create
a tracking system to begin following Gulf War veterans health in light of their exposure
to oil well fire smoke and liquid petroleum. VA also collaborated with the Department of
Defense (000) and Health and Human Services (HHS) in order to determine the
possible health effects from such exposure.

VA sought authority from Congress to create a health registry to track veterans health
because of their exposure to oil well fire smoke. On November 4, 1992 Congress
passed Public Law 102-585, 'Persian Gulf War Veterens' Health Status Act. ' The law
mandated the Secretary of Veterans Affairs to establish and maintain a Persian Gulf
Registry, and provide health examinations and counseling for eligible veterans. The
original code sheet and examination focused on exposure to oil and smoke (or both), or
regional diseases (VA, 1992).

While VA was focusing on the most obvious risk factors encountered in the Persian
Gulf (particularly the one television was best able to transmit to those in the US, smoke
from oil well fires), Gulf War veterans were reporting a wide array of symptoms that
could not be explained by exposures to smoke, petroleum. or regional infectious
diseases.

Public Law 103-446, among other things, authorized the Secretary of Veterans Affairs
to provide priority care to Gulf War veterans. VA was obligated to provide care to a
Gulf War veteran who believed that his current health complaints were somehow
connected with his service in the Persian Gulf, and a VA physician could not prove
otherwise. This essentially opened VA up to many Gulf War veterans with health
complaints.

By the fall of 1995, VA created a revised Registry examination that was much more
comprehensive in light of what VA had learned from the thousands of Registry
examinations conducted since the creation of the program. VA had begun to recognize
that the illnesses found in the Gulf War veterans population were complex. Hyams,
and other iiwestigators, heve since reported that these illnesses have occurred after all
the nation's wars since 1860.

Hindsight provides one with the luxury of looking back and observing the VA as a
"giant' moving clumsily in the dark. It reminds one of the proverb of the blind men who
came upon an elephant. VA at first expected the obvious: PTSD and respiratory
problems. It found both. However, it also found a wide array of health complaints once
it began to look beyond the conditions it expected. During this process where VA's
approach to Gulf War veterans' illnesses evolved and improved, many veterans were
left feeling ill. This draft bill would avoid this learning process after our next war, and
provide Mure war veterans the opportunity to seek care as soon as they become ill.
 69

-5-

Why Are Gulf War Veterans III?

Since the first meeting on Gulf War Illnesses (TAP JAMA 1994), war-related stress has
been under consideration as a potential cause for this problem. Clinical experience
and literature from this century (Textbook of Military Medicine: War Psychiatry 1994)
has given rise to systematic approaches to war-related stress. This knowledge has not
been incorporated into the VA screening and diagnostic procedures. More recently,
Hyams (1996) summarized psychological consequences of war in volunteer armies.
After each war since 1860, he identifies a syndrome that cannot be explained in terms
of pathophysiology as we currently view the body unless one resorts to depression and
autonomic dysfunction. He argued that prior wars had caused similar syndromes, and
that most diseases could be explained by either physiologically based or other
psychologically determined mechanisms. The recognition of these syndromes, long an
integral part of practiced military psychiatry, relies on well-defined guidelines for
management (Takla 1993). These guidelines have included, since World War I,
"proximity, immediacy, and expectancy." That is, soldiers should be treated wherever
they are identified with a psychological response, rather than referred on to speCialists
(psychiatrists) or other locations. They should be treated as soon as pOSSible, rather
than undergoing referrals. Finally, labeling the problem as a psychological disorder
rather than a normal response to an abnormal Situation, even for soldiers, is associated
with adverse long-term consequences and disability.

Epidemiological studies in Gulf War veterans do suggest some consistent features, i.e.,
women, those with combat experience, and subjects who describe higher rates of war-
related stress describe higher rates of symptoms (Wolfe 1998; Iowa 1997; Haley
1997). In addition, individuals with self-reported exposure to nerve gas are clearly
more symptomatic (Haley 1997; Wolfe 1998).

What is the Significance of Stress as a Plausible Risk Factor?

Stress is a Significant risk factor because of its ubiquity on battlefields. It's obvious that
at least one component of war that has not changed is stress. If stress is the common
thread that could somehow explain why veterans have developed syndromes as
described by Hyams, then the nation must squarely face this possibility. If these
syndromes have always happened after every war, then they will always happen after
future wars. This draft bill recognizes, at least, that some part of the population of
future war veterans will become ill with "Medically Unexplained Symptom Syndromes,"
as recently described by the Institute of Medicine.

The American Legion is in the business of advocating for a thorough investigation of

the illnesses and all their possible causes. As advocates who seek adequate medical
treatments and compensation for disabled Gulf War veterans, we know that an
exhaustive investigation must occur. Stress, however, is not the only risk factor under
investigation.

Neurotoxic Effects

A recent triad of papers (Haley 1997: a, b, c) documents clusters of symptoms in a

group of veterans deemed consistent with neurotoxic disorders, including a peripheral,
a central, and an autonomic syndrome. These veterans were involved in a SCUD
missile attack and report exposure to nerve gas. A more detailed comparison of
symptomatic and asymptomatic veterans suggests the presence of subtle physiologic
abnormalities, which may be considered objective markers of effect. One of these
markers has been used as a marker of neurotoxicity from organophosphates (Sack
1993), although it is also considered a marker of anxiety (Furman 1996), whether as a
marker of susceptibility or as a consequence of the syndrome. In addition, Jamal et. al.
 70

-6-

(1997) document abnormalities in Gulf War veterans consistent with peripheral

neuropathies. That same group of authors have used these techniques to document
the presence of peripheral neuropathy in farmers exposed to sheep dip even in the
absence of documented clinicel poisoning (Jamal, unpublished data), as have others
(Beach 1996, Stephens 1995).

Persian Gulf War veterans have described myalgias as a common symptom, with 21 .8
percent reporting muscle pain, although only 0.8 percent reported it as their chief
complaint. Conflicting evidence supports these symptoms as representing a
phenomenon with a biologicel explanation. Data often support the presence of some
poorly defined biologicelly measureble abnormalities (Schlesinger 1997; Amato 1997),
although the appropriate interpretation of relatively minor abnormalities remains open
to question.

Chemical warfare agents, like stress, will very likely be present on many future
battlefields. Although the science supporting an association between low-level
chemical exposure and long term adverse health effects is currently controversial , a
great many studies are underway that should clarify any association. The draft bill,
however, addresses this contingency on future battlefields. If low-level chemical
exposure is a cause of some of the illnesses currently afflicting Gulf War veterans, one
can presume that Mure veterans are at great risk of similar illnesses. The armaments
of potential adversaries with their chemical weapons, make this so.

VA missed the possibility that Gulf War veterans were ill because of low-level
exposures because of the unavailable science, and the denials of the Department of
Defense until 1996 that chemical weapons were present in the Kuwaiti Theater of
Operations. Veterans who may be sick because of these exposures did not have their
health complaints adequately addressed. The draft bill, by opening up the system to all
Mure veterans, would let these veterans have access to care as soon as they begin to
suffer illnesses.

Pyrjdostigmine Bromide (pBl

The Surgeons General of the US Armed Forces have developed a policy that suggests
the prophylactic use of pyridostigmlne bromide in situations that make exposure to the
chemical werfare agents soman and tabun likely. The recommended dosage is 30 mg
every eight hours. One study suggested that only 1 percent of airmen (Keeler 1991)
hed symptoms requiring medical attention and only 0.1 percent had symptoms requiring
discontinuation. Reasonable concem wes voiced on one of the committees (VA) that
such large scale administration of any drug is likely to cause unrecognized adverse
reactions, possibly not previously described.

Several recent studies have examined the toxicology of PB. It appears to increase core
temperature by itself, and to cause some measurable muscle weakness (Cook 1992)
even without appearing to cause symptoms. Several studies suggest that at least in
rats, fasciculation from overdosage predict the development of a chronic myopathy
(Adler 1992). A chronic dose of 90 mg/kg causes myopathy in rats (Schuschereba
1990). These doses are substantially higher than those used in prophylactic
administration. Nevertheless, given knowledge of interactions. and the albeit weak
evidence for muscle aches and abnormal muscle enzymes in the blood. this remains an
interesting finding.

Controversy has arisen because of case reports that genetic deficiency of serum
(butyryl) cholinesterase is associated with some chronic disease, as yet poorly
characterized (Loewenstein-Lichtenstein 1993). Several cases in Haley's exposed
cohort similarly had cholinesterase deficiency, although there was no significant
difference in mean levels of enzyme. Pyridostigmine bromide is a well-known drug
used in the treatment of myasthenia. It is known to require individual dosage
 71

-7-

edjustment. Some myasthenics are very 'brittle' and may easily develop signs of
poisoning, including weaknesa. Their management is at times very difficult. PB was
not given alone in the Persian Gulf. Several other agents were present that could
theoretically increase its toxicity, including diethyltoluamide (OEET) and permethrin.
Recently published data (Abou-Donia 1996; McCain 1997; Matthew 1994) suggest that
these agents together, or in combination with heat, may have substantially more toxicity
than any individual agent. Similarly, interactions between PB and caffeine (Chaney
1997) may explain some worsening toxicity. Finally, Friedman et. al. (1996)
demonstrated that PB absorption may Increase dramatically, with clearly documented
consequences in neure-irnaging and enzymatic activity, after rodent exposures in
stress studies. An unpublished (Ottenweller ) animal study suggests that PB exposure
may leed to earlier development of hypertenSion in genetically hypertension-prone rats.

These studies, together, suggest thet some combination of drug interactions, coffee,
and heat might leed to worsening toxicity. No data have been provided thet supports
this hypothesis for veterans. The provision contained in the draft bill would again
enable VA to care for future war veterans. If this theory of chemical interaction and
illness in Gulf War veterans were to be supported by scientific evidence, then one can
expect future war veterans to be exposed to those risk factors.

Research: H.R. 3279. 'The Persian Gulf Veterans Act of 1998'

The American Legion supports H.R. 3279, the Persian Gulf Veterans Act of 1998,
introduced by Representative Lane Evans (IL-17). This legislation represents a
comprehensive approach to the study of the environmental exposures, as well as the
symptoms and illnesses experienced by the newest generation of wartime veterans.
H.R. 3279 would place the enalysis of the completed scientific studies in the hands of
the National Academy of Sciences, the nation's premier independent scientific
institution. This proposal is modeled after an extremely effective Public Law 102-4, the
Agent Orange Act of 1991.

Whet is the ApproPriate Treatment?

Many Gulf War veterans continue to suffer from illnesses caused by their combat
service. They use the health cara system more frequently for a broad range of
problems, from asttvna to 'i11 defined conditions.' Some of these represent identifiable
diseases convnonly treated in primary care settings. Some are commonly seen but not
treated well by primary care phYSicians who have little training.

Patients in primary care settings often seek help from their physicians for symptoms
that are not easily explained (Kroenke 1990). Primary care physicians heve long spent
much of their time addressing non-specific symptoms and screening out diseases. As
health cara financing in the US has changed, physicians have had less opportunity to
spend time with their patients, listen carefully and patiently,

In this context, several groups of investigators have attempted the use of cognitive
behavioral therapy (CBT) as a formalized treatment to help patients return to productive
states. For example in the Chronic Fatigue Syndrome patients often feel disabled
although there are few data to explain their inability to work. Wesselly et. ai, (Bonner
1994) demonstrated mild benefits in a small trial, criticized because it was uncontrolled,
Friedburg and Krupp (1991) showed some improvement in depression but not in fatigue
in such patients. More recently, Beale et al. (1997) hes demonstrated a parallel 70
percent return-te-work rate using 17 sessions of CBT. Such sessions require
approximately 1.5 hours of the traater's time. Such treatmant is meanwhile covered by
the National Health Service in the UK on the strength of these data,

Such treatments, which take a great deal of time and effort, would be difficult to
implement in todays health care system in the US Managed care discourages such
time consuming and labor intensive treatments. VA and DoD, however, are exploring
 72

-8-

this very approach, among others, to treat Gulf War veterans' illnesses. The draft bill
would creates a mechanism where VA could continue to determine the best medical
treatment for these iIInessas, and some form of CBT may be one of the treatments.

At present, the causa of symptoms of fatigue or inability to perform in various activities

among veterens remains unclear. Treatment guidelines on war syndromes suggest
that long-term health outcomes may be better if soldiers are treated without labeling.
Cognitive behavioral therapy can be applied to individuals whether they have Chronic
Fatigue-like Syndrome, a somatoform disorder, or need support in adjusting to a
chronic disability from a nerve gas. Especially for the latter, no other treatment is
appropriate.

Review of the prectices of primary cere physicians suggest that they may not follow all
treatment guidelines published by federal agencies. It may be unreasonable to expect
veterans to acquire adequate sarvices after redeployment unless thesa are provided by
the VA. The draft bill sats VA on the path to better prepare itself to treat these
illnesses, and it gives veterans ready access to that care.

The Americen Legion Enthusiasticelly SupPOrts the Draft Bill

The American Legion has long held the view that the most pressing issue facing sick
Gulf War veterans was the development of effective medical treatments for their
illnesses. There have been obstacles in the way, the most apparent being the failure to
recognize that Medically Unexplained Symptom Syndromes may be a natural
consequence of participating in a war. Another was that Gulf War veterans were only
gradually given access to health care, when the medical literature is clear that the
sooner interventions occur, the more likely a p[patient will become wall. This bill
overcomes thesa obstacles. First, it provides health care for Gulf War veterans
(through 2(01) and Mure war veterans. Secondly, it will enable VA to effectively treat
these illnesses through a National Center on War-Related Illnesses. The bill not only
is a key part of VA's current efforts to determine which medical treatments effectively
treat these illnesses, but it will help create a VA system ready to "hit the deck running'
after our next war. The bill provides VA with the opportunity to address the next "Gulf
War Syndrome' competently.

At the height of the Second World War, veterans of the First World War sat in Legion
Posts across the United States and talked about the hardships they faced upon their
return from France in 1919. These discussions turned into ideas, and soon into action.
Congress soon passed the Serviceman's Readjustment Act, theGI Bill of Rights,
before the war had ended. Discharged veterans didn't return home unemployed while
the federal government slowly decided what could be done for these veterans. Instead,
the GI Bill enabled these veterans to attend college and buy homes, and it generated
the greatest era of prosperity in the nation's history.

This bill, although much mora modest in scale than the GI Bill, parallels its vision. It
applies the lessons learned from our recent, and distant, past. It implements pOlicies
before they are required by veterans. This will enable sick war veterans to return from
Mure wars and be given every chance to recover their health and lead productive
lives.

Thank you again for the opportunity to review and comment on this historic legislation.
The American Legion strongly supports the draft bill, and looks forward to its passage
this year.

Mr. Chairman, this concludes my testimony. I will be happy to answer any questions.
 73

-9-

REFERENCES

Abou-Oonia M.B., Wilmarth KR. , Jensen KF., Oehme FW., Kurt T.L. Neurotoxicity
Resulting from Coexposure to Pyridostigmine Bromide, DEET, and Permethrin:
Implications of Gulf War Chemical Exposures. Joumal of Toxicology & Environmental
Health. 1996; 48: 35-56

Adler M., Hinman D., Hudson C.S. Role of Muscle Fasciculations in the Generation of
Myopathies in Mammalian Skeletal Muscle. Brain Research Bulletin. 1992; 29: 179-87

Amato AA , fkVey A, eha C., Matthews M.D., Jackson C.E., K\eingo..rlther R , Worley L.
eorrvn.-.E., Kagan-HalIet, K Evaluation of Neuromuscular Sympioms in Vetenlns of the
Persian Gulf War. Neurology 1997; 48: 4-12

Beach J.R., Calvert lA, Spurgeon A., Levy L.S., Stephens R , Harrington J.M.
Abnormalities on Neurological Examination Among Sheep Farmers Exposed to
OrganophosphoJOus Pesticides. Occupational & Environmental Medicine. 1996; 53:
520-5.

Bou-HoIaigah I. , Kan J., Rowe P.C., Calkins H. The Relationship Between Neurally
Mediated Hypotension and the Chronic Fatigue Syndrome. Joumal of the American
Medical Association. 1995; 274: 961-7.

Bonner D., Ron M., Chalder, Butker S. Wesslely S. Chronic Fatigue Syndrome: A
FollOw-up Study. Joumal of Neurological Psychiatry. 1994; 57: 617-21

Butler S., Chalder, Ron M., Wesslely S. Cognitive Bevaiorial Therapy in the Chronic
Fatigue Syndrome. Joumal of Neurological Psychiatry 1991; 54: 153-8

Chaney L.A, Hume AS., RocI<hold B.W., Moss J.I., Mozingo J.B. Potentiation of
Pyridostigmine Bromide Toxicity in Mice by Selected Adrenergic Agents and Caffeine.
Vaterinary & Human Toxicology. 1997; 39: 214-9.

Cook JE., Kolka MA, Wenger C.B. Chronic Pyridostigmine Bromide Administration:
Side Effects Among Soldiers Working in a Desert Environment. Military Medicine.
1992;157:250-4

Deale A , Chalder A, Marl<s I., Wessely S. Cognitive Behaviori81 Therapy for Chronic
Fatigue Syndrome: A Randomized Clinical Trial. American Joumal of Psychiatry 1997;
154: 408-14.

Elder G.H., Shanahan M.J., Clipp E~ C . Unking Combat and Physical Health: The
Legacy of World War /I in Men's Lives. American Journal of Psychiatry. 1997; 154:
330-6.

Friedberg F., Krupp L.B. A Comparison of Cognitive Behaviorial Treatment for Chronic
Fatigue Syndrome and Primary Depression. Clinical Infectious Disease. 1994; 1B
(SuppI1): S105-S110.

Friedman A, Hendler, Kaufer D., Soreq H., Shemer J, ur-Kaspa. Pyridostigmine Brein
Penetretion Under Stress Enhances Neuronal Excitability and Induces Early Immediate
Transcriptional Response. Nature Medicine. 1996; 2: 1382-5.

Furman J.M., Turner S.M., Durrant J.D. Penic, Agoraphobia, and Vestibular
Dysfunction. American Journal of Psychiatry. 1996; 153: 503-12.
 74

-10-

Gray G.C., Quate B.D., Anderson C.M., Kang H.K , Berg S.w., Wignall F.S., Knox J.D.,
Berret-Connor E. The Post-War Hospitalization Experience of US veterans of the
Persian Gulf War. New England Journa1 of Medicine. 1996; 338: 1505-13.

Haley, RW. Is the Gulf War Syndrome Due to Stress? The Evidence Reexamined.
American Journal of Epidemiology. 1997; 146: 695-703.

Haley, RW., Kurt! T.L. Self-Reported Exposure to Neurotoxic Chemical Combinations

in the Gulf War. Joumal of the American Medical Association. 1997; 277: 231-7.

Haley, RW., Hom, J. Evaluation of Neurologic Function in Gulf War Veterans: A Case-
Control Study. Joumal of the American Medical Association. 1997; 277: 223-30

Hearst, N., Hulley, S.B., Newman, T.B. Delayed Effects of the Military Draft on
Mortality: A Randomized Natural Experiment. New England Joumal of Medicine. 1986;
314: 620-4.

Hyams, KC., Roswell, R, Wignall, FS. War Syndromes and Their Evaluation: From
the U.S. Civil War to the Persian Gulf War. Annals of Internal Medicine. 1996; 125 (5):
3~.

Institute of Medicine. Health Consequences of Service During the Persian Gulf War.
National Academy Press, Washington, DC. 1996.

Institute of Medicine. Adequacy of the Comptehensive Clinical Evaluation Program.

National Academy Press, Washington, DC. 1997.

Iowa Persian Gulf Study Group. SeIf-Reported Illness and Health Status Among Gulf
War Vetenlns. Journal of the American Medical Association, 1997; 266: 23~5.

Jamal, GA, Hansen, S., Apartopoulos, F., Peden,A. The "Gulf War Syndrome." Is
There Evidence of Neurological Dysfunction in the Nervous System? Joumal of
Neurological Psychiatry, 1996; 60: 441-49.

Jones, F.D., Sparacino, L, Wilcox, V.L, Rothberg, J.M., Stokes, J.w. Military
Psychiatry: Preparing in Peace for War. Textbook of Military Medicine, 1994.

Joseph, S. and CCEP Evaluation Team. A Comprehensive Eval~ation of 20,000

Persian Gulf War Veterans. Military Medicine, 1997. 162: 149-55.

Kang, H.K, Bullman, T.A. Mortality Among US Veterans of the Persian Gulf War. New
England Joumal of Medicine, 1996; 338: 1496-502.

Keegan, J. The Face of Battle. Viking Press, London., 1982.

Keegan, J. A History of Warfare. Viking Press, London. 1993.

Keeler, J.R, Hurst, C.G., Dunn, M.A. Pyridostigmine Used as a Nerve Agent
Pretreatment Under Wartime Conditions. Joumal of the American Medical Association ,
1991 ; 266: 693-5.

Kroenke, K, Arrington, M., Mangelsedorff, AD. The Prevalence of Symptoms in Medical

Outpatients and the Adequacy of Therapy. Archives of Internal Medicine, 1990; 150: 1685-
9.

Loewenstein-lichtenstein, Y., Norgaard-f'edersen, B., Schwarz, M., Zakut, H., Glick, D.,
Soreq, H. GeneIic Predisposition to Adverse Consequences of Anti-Cholinesterases in
.AtypicaI' BCHE Caniers. Nattxe Medicine, 1995;1:1062-5.
 75

-11 -

McCain, W.C. ,Ferguson, JW., Lee, R., Beall, P., Johnson, M.S., Leach, G. , Whaley, J.E.
Acute Oral Toxicity Study of Pyridostigmine Bromide, Permethrin, and DEET in the
Laboratory Rat. .IolmaI ofToxic:otogy and Environmen Health, 1997; 50: 113-24.

Matthews, C.B., Bowers Jr., W.O., Glenn, J.F., Navara, D.K Cholinergic Drug Interactions
and Heat Toleralce. Life Sciences, 1994; 54: 123745.

Mechanic, D. Social Psychologic Factors Affecting the Presentation of Bodily Complaints.

New England Journa/ofMedicine, 1992; 25: 1132-9.

Ott, M.G., Messerer, P., Zober, A Assessment of Past Occupational Exposure to 2,3,7,8
TCDD Using Blood Lipid Analyses. Internal Archives of Occupational Envirorvnental
Heelth, Hi93; 65: HI.

Persian Gulf Veterans Coordinating Board. Unexplained Illnesses among Desert Storm
veterans. A Search for Causes, Treatment, and Cooperation. Archives of Internal
Medicine. 1995; 155: 262-8.

Presidential Advisory Committee on Gulf War Veterans Illnesses. Final Report. United
States Government Printing Office, December 1997.

Richter, E.D., Shkolnik, I., Kowalski, M., Lerman, S., Leventhal, A , Zahavi, H., Grauer,
F., Bashari, A, Marzouk, J, et. al. Illness and Excretion of Organophosphate
Metabolites Four Months after Household Pest Extermination. Archives of
Environmental Heelth, 1992; 47: 135-8.

Rowe, P.C., Bou-Holaigh, I., Kan, J.S., Calkins, H. Is Neurally Mediated Hypotension
an Unrecognized Cause of Chronic Fatigue? Lancet, 1995; 345: 623-4.

Sack, D., Rice, C., Linz, D., Bhattacharya, A, Shukla, R. , Suskind, R. Health Status of
Pesticide Applicators: Postural Stability Assessments. Journal of Occupational
Medicine, 1993; 35(12): 1196-202.

Schuschereba, S.T., Bowmen, P.O., Vergas, JA, Johnson, T.W ., Woo, F.J., McKinney,
L. Myopefflic Alterations in Extraocular Muscle of Rats Subchronically Fed
Pyridostigmine Bromide. Toxicologic Pathology. 1990; 18: 387-95.

SchleSinger, N., Baker, D.G., SchumaCher, H.R. Persian Gulf War Myalgia Syndrome.
Journal of Rheumatology, 1997; 24: 1018-9.

Shorter, E. From Paralysis to Fatigue. University of Toronto Press. Toronto, 1992.

Sidell, F.R. Clinical Effects of Organophosphorous Compounds. Journal of Applied

Toxicology, 1994; 14: 111-113.

Sidell, F.R. , Borak, J. Chemical Warfare Agents: Nerve Agents. Annals of Emergency
Medicine, 1992; 21 : 865-71 .

Sloan, P., Arsenault, L., Hilsenroth, M., Handler, L., Harvill, L. Rorschach Measures of
Posttraumatic Stress in Persian Gulf War Veterans: A Three-Year Follow-up Study.
Journal of Personality Assessment. 1996; 66: ~.

Southwick, S.M., Morgan 3rd, CA, Darnell, A, Bremner, D., Nicolaou, A.L., Nagy,
L.M., Charney, D.S. Trauma-Related Symptoms in Veterans of Operation Desert
Storm: A 2-year Follow-up. American Joumal of Psychiatry, 1995; 152: 1150-5.
Spurgeon, A , Gompertz, D., Harrington, J.M. Occupational and Environmental
Syndromes. Occupational and Envirorvnantal Medicine, 1996; 53: 361~.
 76

-12-

Stellman, J.M., Sommer, J.F., Stellman, S.D. Utilization: Attitudes, and Experiences of
Vietnam Era Veterans with Veterans Administration Health Facilities: The American
Legion Experience. Environmental Research, 1988; 47: 193-209.

Stellman, S.D., Sommer, J.F. , Stellman, J.M. Health and Reproductive Outcomes
Among American Legionnaires in Relation to Combat and Herbicide Exposure in
Vietnam. Environmental Research, 1988; 47: 150-74

Stellman, J.M., Sommer, J.F. , Stellman,S.D. Social and Behavioral Consequences of

the Vietnam Experience Among American Legionnaires. Environmental Research,
1988; 47: 129-49.

Stellman, S.D., Stellman, J.M. Estimation of Exposure to Agent Orange and Other
Defoliants Among American Troops in Vietnam: A Methodological Approach. American
Journal of Industrial Medicine. 1986; 9 (4): 305-21 .

Stretch, RH., Bliese, P.O., Marlowe, D.H., Wright, KM., Knudson, KH., Hoover, C.H.
Physical Health Symptomatology of Gulf War-Era Service Personnel from the States of
Pennsylvania and Hawaii. Military MediCine, 1995; 160: 131-6.

Sulker, P.B., Uddo, M., Brailey, K., Vasterling, J.J., Errera, P. Psychopathology in
War-Zone Deployed and Nondeployed Operation Desert Storm Troops Assigned
Graves Registration Duties. Journal of Abnormal Psychology. 1994; 103: 383-90.

Sulker, P.B., Davis, J.M., Uddo, M., Ditta, S.R. Assessment of Psychological Distress
in Persian Gulf Troops: Ethnicity and Gender Comparisons. Journal of Personality
Assessment, 1995; 64: 415-27.

Szurdoki, F., Zheng, J., Jaeger, L., Stoutamire, D.W ., Harris, A., Sanborn, J.R , Kido,
H., et, al. Rapid Assays for Environmental and Biological Monitoring. Journal of
Environmental Sciences Health Bulliten. 1996; 31 : 451-8.

Takla, NK, Koffman, R, Bailey, DA Combat Stress, Combat Fatigue, and Psychiatric
Disability in Aircrew. Aviation, Space and Environmental Medicine, 1994; 65: 858-65.

Department of Veterans Affairs, Veterans Health Administration Manual M-10,

"Environmnetal Medicine," Part III, "Persian Gulf Program ," Chapters 1 and 2.

Verger, P., Cordier, S., Thuy, L.T., Bard, D., Dai, L.C., Phet, PH , Gonnord, M.F.,
Abenhaim, L. Correlation Between Dioxin Levels in Adipose Tissue and Estimated
Exposure to Agent Organce in South Vietnamese Residents. Environmental Research
1994;65:226-242

Viola, J.M., McCarthy, D.A. An Eclectic Inpatient Treatment Model for Vietnam and
Desert Storm Veterans Suffering From Posttraumatic Stress Disorder. Military
Medicine. 1994;159:217-20

Ware, N.C. Society, Mind And Body In Chronic Fatigue Syndrome: An Anthropological
View. Ciba Foundation Symposium. 1993;173:62-73; discussion 73-82, 1993.

Ware, N.C., Kleinman, A Culture And Somatic Experience: The Social Course Of Illness In
Neurasthenia And Chronic Fatigue Syndrome. Psychosomatic Medicine. 1992;54:546-60

Wegman, D.H., Woods, N.F., Bailer, J.C. How Would We Know A Gulf War Syndrome "
We Saw One? Amer ican Jolmal of Epidemiology, 1997; 146: 704-11 .

Writer, J.V., DeFraites, R.F., Brundage, J.F. Comparative Mortality Among US Militatry
Personnel In The Persian Gulf Region And Worldwide During Operations Deset Shield And
Desert Storm. Journal of the American Medical Association, 1995; 275: 118-121 .
 77

-13-

Wolfe, J., Proctor, S.P., Davis, J.D., Borges, M.S., Friedman, M.J. Health Symptoms
Reported By Persian Gulf Veletans TMO Y88IS After Retum. American Journal of Internal
Medicine, 1998; 33: 104-13.

Zung, WW., Roth, M.E., Broadhead, W.E. Prevalence Of Depressive Symptoms In

Primary Care. Journal of Family Practice, 1993; 37: 337-44.
 78

STATEIIENTOF
THOMAS L GARTHWArrE, II.D.
DEPUTY UNDER SECRETARY FOR HEALl1i
DEPARTMENT OF VETERANS AFFAIRS
BEFOREllfE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
HOUSEOFREPRESENTA~S
APRIL 23.1998

Mr. Chairman and Members at the Comm~:

-
We are pleased to be hare to discuss Il draft bin being considered by the
Subconvnlttee. This bill would -
_utitorize VA to fumish health care for H1nesses that might be attributable to future
combat service,
~ existing authority to furnishhealth carete Gulf War veterans,
-grant a higher enrollment priority to velerans seeking care for disabilities possibly
associated with exposure to Agent Orange, ionizing radiation, or with service in the Gulf
War or a Mure war or combat.
_nd establish a National Canler for the study at War-Related Illnesses. Our
testimony addresses the draft bin provided to US by the Subcommittee staff. You also
asked that we discuss issues associated with the Departmenfs research and treatment of
war-related illnesses and VA's sexual trauma counseling program.

DRAFT BILL
As you are aware, the draft bi. has four basic provisions. My testimony will review
VA's assessment of these elements. First. the proposed legislation would enhance the
eligibility for care for two groups of veterans; It would authorize VA to provide health care
to those veterans who serve on active duty In a theater of combat operations durtng a
pertod of war after the Vietnam era and to veterans at future combat against a hostile force
during a period of hostilities. Both groups would be provided health care for any Illness
that might be aUributable to such service, for a period of up to five years after their
discharge. The Secretary would be required to submit to Congress a report on VA'f$
experience under that authority. Second, the draft bUI would grant a higher enrollment
priority to veterans seeking care for disabilities possibly associaled with exposure to Agent
Orange. ionizing radiation, or with service In the Gulf War or a future war or combat. Third,
the draft bID would extend WItII December 31,2001. the authorfty for VA tofumlsh health
care to Gulf War V8terans with disabilities possibly assodated with 8uclr.arvlce. Finally,
the biD would direct VA to establish a National Center for the Study at Wlr-Related
Illnesses.
 79

New.Special TreatrllentAuthorttY

After periods of war or hostilities, veterans have experienced illnesses that current
medical knowledge cannot fully Hnk to a causative agent. Some of these health problems
can become chronic. The draft bill would ensure that VA can provide health care for such
iIIn8$HS to war zone veterans while research is conducted to determine the causes,
mechanisms; and treatment of their Illnesses.

In 1981, Congress authorized VA to provide care and aervic:es for any disability to
Vtetnam-era veterans who _ra exposed to Agent Orange and to thoae veterans exposed
to radiation during weapons testing, or at the close of World War II. Congress authorized
this special treatment authority notwithstanding the absence of a clear association
between the disability and the exposure. In 1993, Congress pnMded a special treatment
authority for Gulf War veterans who were exposed to toxic substance or environmental
hazaR:! while SCHVing on active duty. In each of these three situations, VA was specifically
diracted to provide cera and services unless a VA physic::Ian afIitmatIveIy determined, In
accordance with VA guidelines, that the veteran's disability resulted from a cause other
than such mcpo6U1'e. In 1997, the Congress broadened the special treatment authority for
Gulf War veterans to anow care for any disability poasibly related to their service in the
theater of operations, rather than requiring evidence of particular exposures. The draft bID
would establish a similar treatment authority for veterans of future armed conflicts.

VA would be authorized to provide health care to veterans who served on active

duty In a theater of combat operations during a period of war after the VIetnam era or In
future combet against a hostile foR:e during a period of hostilities, for any illness that might
be attributable to that service. This authority would extend for up to five ye&nI after their
discharge from serva. These veterans would be able to receive care for any liness
unless a VA physician determines In accordance with VA guidelines that the oondltlon
resulted from a cause other than such service. ThIs Is consiatent with the apecIaI eligibility
for care of Gulf War vaIerIinS.for medical oonditions that IU8 poMi)Iy related to their
service In the theater of operations rather than requiring evidence of particular
exposure(s). The draft bill would obviate the need for adcIltionallegislation to authorize VA
action on behalf of veterans for each future military conftlct. It also would eliminate
possible delays In providing necessary medical care In VA facilities. i It should be noted
that this bill would measure eligibility bued on discharge from servioe, which may be
many years after a veteran has been In the combat theater. An altematlve construction
could be to extend medical care to veterans within five years of departure from combat
theatBr.

Enrollment Priority

In 1996. Congress directed VA to establish a system of annual patient enrollment

~In the limits of
for use In managing the provision of hospital care and medical services
appropriated funds. The Seaetary was directed to manage the enrollment of patients In
accordance with a list of seven priorities:

-2-
 80

(1) Veterans with service-c:onnected disabilities ratIId 50% or greater;

(2) Veterans with 8efVic:IHnnected dlsablflties rated 30% Of 40%;
(3) Former prisoners of war, veterans with service<onneded dlsabHities rated 10%
or 20%, veterans discharged or released from active military S8fVice for a disability
that was incurred or aggfllVllted In the line of duty, and veterans who are In receipt
of section 1151 benefits;
(4) Veterans who are In receipt of Increased pension based on a need of regular aid
and attendance or by reason of being permanently housebound and other veterans
who 8AI catastrophically disabled;
(5) Veterans who have annual Income and net worth below the so-called "means
test" threshold;
(6) All other eligible veterans who are not required to pay a copayment for their
care; and
(7) Veterans who must pay a copayment for their care.

The draft bal would grant a higher enrollment priority to veterans seeking care for
disabilities possibly auoc:lated with exposure to Agent Orange Dr ionizing radiation, or with
service in the Gulf War or a future war or conflict. These veterans, who are currently
placed In enrollment priority sbc, would be elevated to priority four under the draft bill. We
support this provision. It Is entirely appropriate for war zone veterans to have a higher
priority for care during the time it takes to assess the relationship between their Illnesses
and service.

Extension of Gulf War Treatment Authority

The draft bill would extend until December 31, 2001, the authority for VA to furnish
health care to Gulf War veterans with dlsablfJties pOssibly associated with such service.
Under existing law, the authority will expire on December 31, 1998. As you know, there Is
ongoing research into the health problems of Gulf War I18terans. By extending their
special eligibility for care, the draft bill would recognize our ongoing responsibility to Gulf
War veterans during this continuing research effort. VA supports the three-year extension
of the Gulf War treatment authority.

National Center for the study of War-RelatBd Illnesses

As a further matter, the draft bill calls for the establishment no later than October 1,
1999, c:l a National CentBr for the Study of War-Related Illnesses. The oenter would be a
focal point for reH8rch, particularly Into the development of treatments for war-related
illnesses, education and training. This center would complement our current Interagency.
efforts by helping to coordinate ali research on war-related illnesses. In the put, when
deaUng with GulfWar-related Illnesses, the Federal Government has demonatratad its
ability to coordinate an extensive Interagency research program. I wllhliseusB this effort
more fully later In my testimony.
 81

Historically, IIkIeftned post-war health problems occur following tNery war. We

should anticipate their ocx:urrence after Mure contIicts, be prepared to pmvIde health care
and treatment, and develop methods to prevent post-war health problems In the Mure. For
this reason, VA supports the concept of a National Center for the Study of War-Relatecl
Illnesses. We envision that the Center will provide a focal point for activity related to the
development of investigations of risk factors, preventive measures, treatment, and basic
research on wartime elCpO$ures, Including physiological and psychological streSSOI'S. In
previous congressional testimony, Veterans Health Administration's (VHA) Under
Secretary for Health has expressed his views that an Interagency research etI'ort should be
considered to investigate the health e1I'acts of Iow-level chemical exposures, alone and In
combination with other toxicants. These wiU be Important public health Issues for the 2111
century battlefield, as well 11$ our civilian workplaces, homes and communities. Focused
research in the area of war-related R1nesses would be competitively awarded to
investigators who apply to wor1t at the Center. Such research could include the full range
of rasearch from basic to applied.

A National Center for the Study of War-Related Illnesses would enhance our abUity
to create a comprehensive VA program for post-war clinical care, medical education,
health risk communication and research. ActIve DoD and HHS partnership and
collaboration Inthe Center would be a key to optimal performance. The Center should be
designated as a VA repository for transfer of DoD deployment health and environmental
surveillance data. These databases would provide the basis for future research on
preventive medicine, risk factor analysis, and epidemiologic studies. An education
function at the Center would share best prac:tlces and lessons learned concerning clinical
strategies and treatment for IIl-defined war-reiatad illnesses with the feeleral and non-
federal medical community.

VA has significant experience with centers such as the one proposed. The Geriatric
Resean:h, education, and Clinical Centers (GRECCs) and the National Center for Post
Traumatic Stress Disorder (PTSD) have served similar functions with regard to developing
our approach to care of aging veterans and veterans suffering with PTSD. We believe a
Center such as tIie one proposed has the potential to significantly enhance the medical
communitYs ablrlty to address the needs of Mure wartime veterans.

TREATMENT OF AND RESEARCH ON GULF WAR-RELATED ILLNESSES

Mr. Chairman, VA testlfted before the full Committee on February 5,1998, and
provided information on our Gulf War health care and research eftbn.. I would rlke to
reference our previous testimony and provide an update on VHA's Gulf War veterans'
health care and research programs.

BackSround
-,.".
The Department of Veterans Affairs began planning to provide health care and
benefits to the service membens deployed to Operations Desert Shield and Desert Storm
as soon as the first soldiers entered the theater of operations. VA's Gulf Registry Health
 82

examination Program was the first component of VA's c:omp!ehensNe Gulf War response.
VA developed the ReglstJy in 1991, and Congress passed authorizing legislation in 1992.
The Gulf War Registry was established primarily to assist Gulf War veterans to gain entry
Into the continuum of VA health care services by providing them with a free, complete
physical examination with basic laboratory studies; and to act as a health screening
database. VA staff are instructed to encourage all Gulf War veterans, symptomatic or not,
to get a Registry examination. The Registry's database, which In addition to allowing VA
to communicate with Gulf War vet8l8ns via periodic Il8W$Jetters, provides a mechanism to
catalogue possi)Ie exposures and prominent symptoms and to report diagnoses present at
the time of the examination. This record of symptoms, diagnoses and expost,lres makes
the Registry valuable for health surveillance purposes; however, the voluntary, self-
selected nature of the database means that the experiences, illnesses and health profiles
of those In the Registry cannot be generalized to represent those of aU Gulf War veterans.
The Registry was neither designed nor Intended to be a research tool. H was also not
envisioned to be a "at&nd-elone" health care program, a mechanism to assess treatment
effectiveness, or a mechanism to monitor the health outcomes of Gulf War veterans
through longitudinal fOllow-up.

Since the ReglstJy examination program was Initiated, VHA's Gulf War programs
have grown to encompass a comprehensive approach to health services, addresSing
relevant medical care, research, outreach and educational Issues. In 1993, at the request
of VA, Congress passed legislation later enacted as Public law 103-210, gMng Gulf War
veterans special eligibility (pI1ority) for VA health care. This law gave VA the authority it
requested to treat Gutf War veterans who have health problems which may have resulted
from exposure to a toxic substance or environmental hazard during Gulf War service. We
are also pleased that Congress passed legislation subsequently enacted as P.L 105-114,
which expands a Gutf War veteran's ef.g1bRlty for health care. for any condition that might
be associated with the veteran's service In the Gulf War. VA now provides Gulf War
Registry health examinations and hospital and outpatient follow-up care at its medical
facilities nationwkfe, spec:lalized evaluations at four regional Referral Centers, and
readjustment and sexual trauma counseling at Vet Centers and VA medical facilities
nationwide to Gulf War veterans. To date, almost 67,000 Gulf War veterans have
completed ReglstJy examinations; more than 2.5 miUion ambulatory care visits have been
provided to 221,225 veterans; more than 22,000 Gulf War veterans have been hospitalized
at VA medical facilities; there have been almost 500 admissions to specialized Referral
Centers; and more than 83,000 Gulf War veterans have been counseled at VA's Vet
Centers. VA Is committed to continue to provide, and Improve, health care services
available to Gulfveterans.

Health Status of Gutf War Veterans

As was discussed during the February 5 hearing, VA has contracted with the
National Academy of Sciences, Institute of Medicine (10M), to provld&.advlce on the
optimal methods to assess the health status of Gulf War veterans anct.ti1e etrectiveness of
treatments being delivered by the Department. The 10M has scheduled a workshop in
washington, DC, on May 7. and will produce an interim report following the WOrkshop.
 83

Case Management and Demonstration projects

In response to Public law 105-114, VA will initiate clinical demonstration projects

for case management and mUltidisciplinary clinical care for Gulf War veteran .

Last year, the Under Secretary for Health implemented a new case management
initiative aimed at improving services to veterans with complex medical problems. In its
Spec/al Report, the Presidential Advisory Committee on Gulf War Veterans Illnesses
supported our efforts to Implement case management. Significant progress has already
been made. In addition, performance measures for the Network Directors have been
established to ensure that the appropriate resources are devoted to these efforts at aU
facilities.

The demonstration projects are an important component of this effort. The projects
wiD use obJec:tive outcome measures to assess whether health care for Gulf War veterans
is improved by multidisciplinary clinics or case management approaches. A Request For
Proposals for the demonstration projects was issued on April 14, 1998. Funding will be
awarded for the demonstration projeds In July 1998. These projeds will be funded as
two-year studies and VA looks foIward to reviewing the resulbi.

Education

To maintain the quality of health care provided to Gulf War veterans and keep our
health care providers Informed about the latest developments related to Gulf War veterans'
health, VHA has utilized a wide array of communication methods, Including periodic
nationwide conference calls, maKings, satellite video-teleconferences and annual on-slte
continUing medical education (CME) conferences. On March 5, 1998, VBA and VHA
broadcast a joint teleconference regarding enhanced guidelines for compensation
examinations of Gulf War veterans with dissbility due to undiagnosed Illnesses. On
March 25,1998, VHA produced a satellite video teleconference on Depleted Uranium (DU)
and the new DU protocol examination. The most recent national training program, Gulf
War CME Conference, was held on June 3-4, 1997, in Long Beach, Califomia. This year
VHA will hold a joint conference to update clinical and research staff on the latest scientific
developments in Gulf War veterans' health.

VA's past Internal educational efforts have been primarily aimed at developing a
cedre of well-lnformec:l Registry physicians and staff, who in tum provide a source of
education and consultation to other health care providers at their facilities. However, with
the universal implementation of primary care and the growing re~nition that the health
problems of Gulf War veterans span all medical subspeclalties, we are expanding our
educational programs to encompass other medical personnel. Our goal is that all VA
health care providers will have a wor1<.ing understanding of Gulf War exposures and health
Issues and will be able to discuss with their Gulf War patients how these issues could
Impact on their current or future health statuI>. As a first step to meet this challenge, in
March 1998 VHA published a self.tudy Gulf War CME program that has been distributed
 84

to every VA physician. We will make this educational tool available to aU health care
providers via the In1em8t. ThIs can serve to improve the health C8Je available to Gulf
veterans In VA, DoD, and civilian settings nationwide.

Status of Gulf War Veterans Research

In order to get the best assessment of the health status of Gulf War veterans, a
carefully designed and well-executed research program i5 necessary. VA, as lead agent
for Federally sponsored Gulf War research, has laid the foundation for such a program.
Under the auspices of the Persian Gulf Veterans Coordinating Board Research Working
Group, VA has developed a structured research portfolio to address the currently
recognized, highest priority medical and scientific issues. Over 120 Federally sponsored
research projects are pending, underway or have been oompIeted. More than half of
these projects are being canied out by non-FederallnvestigatorS. Thlrty-nlne of the 121
projects are completed. Seventy-eight are ongoing, and four have been awarded funds
but are pending start-up. VA's own research programs related to Wnesses of GuJfWar
veterans Include more than 40 research projects, amounting to a cumulative expenditure
of research dollars projected from FY 1994 through FY 1998 of approximately $27 million.
Federally funded researchers have, to date, published approximately 60 papers In the
peer-revJewed literature, including neariy 40 from VA Investigators alone. The research
portfolio of VA encompasses a variety of research approaches, including epidemiology,
basic research, clinical research, and applied research, applied to a vast array of potential
exposures and health outcomes. In addHlon, VA research Is embartdng on some important
steps toward the assessment of etfectIve treatments for Gulf War veterans' Illnesses.
Detailed information regarding the studies Is provided in the Annual Report to Congress for
FedereUy Sponsoted Rese8lCh on Gulf War Veterens' Illnesses.

There has been signmcant progress on a number of key VA research studies. The
0fTIce of Research and Development has awarded funding for Phase III of the National
Health Survey of Gulf War Veterans, and preliminary site selection has begun. It is
expected that physical examinations will begin In the near future. As you may recall, the
National Survey is designed to determine the prevalence of symptoms and illnesses
among a random sampling of Gulf War veterans across the nation. The Survey is being
conduCted in three phases. Phase I was a poputation-based mail survey of the health of
30,000 randomly selected veterans from the Gulf War era (15,000 Gulf War veterans and
15,000 non-Gulf War veterans, males and females). The data collection phase Is complete
and analysis of the data continues. Phase" consisted of a telephone interview of 8,000
non-respondenls from Phase I (4,000 deployed and 4,000 non-deployed veterans) to
determine if there are any response differences between respondents and non-
respondents to the mail survey. Additionally, 2,000 veterans from each of the deployed
and n~eployed groups (1,500 mail respondents and 600 telephone Interview
respondents) will be selected to validate their health questionnaire responses (mail or
telephone) against their medical records. Phase Ills nearing completian. In Phase III.
2,000 veterans who responded to the postal survey or underwent .'teIephone Interview will
be invited, along with their family members, to participate In a comprehensive physical
examination protocol. These examinations will be conducted at 18 VA medical centers

-7-
 85

nationwide and Involve specialized examinations, including neurological, rheumatoIogical,

psychological, and pulmonary evaluations. Completion of data collection Is anticipated
around mid-1999. At that time, we should have a more complete picture of the prevalence
of symptoms and Illnesses among veterans who served In the Gulf War.

The VA OffIce of Research and Development has Initiated the planning stages for a
multi-slte randomized clinical trial to assess the effectiveness of treatments for Chronic
Fatigue Syndrome (CFS) and Flbromyalgla (FM) In Gu/fWar veterans. These conditions
appear to significantly overlap with the types of symptoms and illnesses reported by many
Gulf War veterans. Such a study Is possible because these conditions have c1ear1y
defined case definitions along with proposed treatments that have undergone preliminary
evaluation. This study will be carried outin collaboration with the Department of Dehtnse
and conducted at multiple VA and DoD health care facilities. VA and DoD are Investing up
to $5 mHlion each to conduct this trial. Because of HHS' experience and research on the
characteristics of these diseases, we plan to consult with NIH and CDC In the development
of these research protocols. In addition, the VA Office of Research and Development has
Issued a Program Announcement, or general invitation to VA cllnlcianalsclentists, to
propose additional multHite trials to eva\uatie the effectiveness of different treatment
strategies. The planned treatment trial, along with any trials proposed In response to the
Program Announcement. will undergo rigorous scientific peer review by VA's federally
chartered Cooperative Studies Evaluation Committee. These treatment trials are In
response to the mandate in P.L. 105-114 to estabUsh demonstration project& to test new
approaches to treating and improving satisfaction with treatment of Gulf War veterans who
suffer from undiagnosed and IIJ-deftned disabilities.

The OffIce of Research and Development has taken a number of steps to expand
research on the neurobIological effects of stressors. FIrst, VA and DoD have Issued a
request for Intral1'l4lral proposals valued at $5 million tor research on the neurobiology of
stress and stress-reJated disorders. Proposals will undergo sc:IentifK< review by a joint
VNDoD appointed panel of experts, and programmatic review by the Research Working
Group. Proposals will undergo peer review this spring, with the award and funding of
projects expected by July 1, 1998. Second,In June 1997, VA funded a muJti..center
cooperative study examining the effectiveness of computerized batteIy of
neuropsychological tests that could Improve the accuracy of the diagnosis of PTSD and
enable clinicians to better assess the presence or absence of central nervous system
dysfunction. Third, In July 1996, VA funded a new mu\ti-centertreatment trial Investigating
the efficacy of a highly structured and traumatic event foculed approach to group therapy
In the treatment of PTSD. In addition, VA issued a Program Announcement in August
1997 requesttng proposals for additional muJti..center trials of PT~D treatment studies will
ellaluate methodologies which include new, non-pharmacologic approaches to treatment.

Improving Care and Reeearch

VHA has undertaken several initiatives aimed at Improving thePatient satisfactIOn

and quality of care for .Gulf War veterans. VHA has conducted focus groups and
developed a new customer satisfaction survey, which Includes a statistically significant
 86

sample of Gulf War veterans. This national survey was sent to veterans In the faU of 1997.
The analysis of the customer satisfaction survey results was completed In March 1998. A
final report was provided to the Network Directors, Service Evaluation and ActIon Teams
(SEATS), and Veterans Affairs Medical Centers (VAMCS) for their review. A copy has
also been pawided to the Committee.

I have Just described VA's extensive treatment and research efforts on behalf of
Gulf War veterans. Research related to the illnesses of Gulf War veterans is highly
complex, and this is equally true of outcomes research. VA Is committed to meeting these
challenges and providing quality health care and the most e1fective treatments to Gulf War
veterans. We wiD continue to solicit the advice of scientific experts, oversight groups and
thIS Committee to Improve our programs for veterans and will take steps to improve the
program when weaknesses have been identified. VA health care providers are dedicated
to providing compassionate care and answering Important medical questions. We believe
the approaches being pioneered for these veterans wfll benefit others in the future.
President Clinton has made It clear that no effort should be spared In this regard.

SEXUAL TRAUMA COUNSEUNG PROGRAM

The Veterans Health Care Act of 1992, P. L 102-585, authorized VA to establish

programs to improve health care services for women veterans, including the provision of
priority counseling for the treatment of the psychological consequences of sexual trauma
experienced by veterans while on active duty. In 1994, Public Law 103-452 amended this
authority to aDow VA to provide treatment for the physical consequences of sexual trauma
experiences, and extended this care and counseling to male veterans. This authority
expires December 31, 1998.

OVer the last six years, VA has undertaken a focused effort to expand and improve
sexual trauma counseling services at our health care facilities. Through a National
Training Program Initiated in 1992, approximately 2000 VA mental health professionals
and other health care providers have developed expertise In the diagnosis, assessment,
and treatment of the physical and mental health consequences of sexual trauma. They
have also gained an appreciation of the unique aspects of sexual trauma that occurs in the
context of military service and an understanding of the eft'ect of these experiences on the
health of the veteran.

To date, more than 18,000 women veterans and 200 male veterans have accessed
sexual trauma counsefmg services. Last year (FY 1997), the number of ~ clients
seeking counseling for such experiences increased 20% over FY1996 (Attachment). At
least two published VA research studies have found that 15 to 20% of women veterans
seeking VA services report having suffered a rape or other form of sexual assault while on
active dutY, white 35 to 50% report having suffered at least one se)C\J8-"'rassment
experierlce during their military career. The 1995 DOD survey on sex\'Ja1 assault and
harassment experiences of military peraonnellndicated that 14% of the men and 55% of
the women surveyed reported having suffered one or more Instances of sexual
 87

harnsment during the prior year, while 8% of the women anet fewer than 1% of the men
reported having suffered an actual sexual assault experience. These findings indicate that
sexual h~rassment/assautt of women service members remains a serious problem for the
active duty military.

In summary, the number of veterans accessing the sexual trauma counseling

program has increased each year since its Inception. VA research indicates sexual trauma
is more prevalent among women veterans seeking services at VA health care facilities
than we had previously thought, and the negative impad of sexual trauma experiences on
the physical and mental health of affected veterans is significant. Therefore, VA is
committed to continUing this program and has submitted B legislative request to extend
VA's authortty to provide this <:are through December 31, 2003.

CONCLUSION

Mr. Chairman, that concludes my prepared atatement. My colleagues and I will now
be happy to respond to any questions Committee members may have.

-10-
 88

ATTACIlMEM'l'

The following tables reftect the number d W!b!nIns seen lor sexual trauma CDUnSI!IIng
In eadt d .these programs rNf6 the last 5 years.
 89

DEPARTMENT OF DEFENSE

STATEMENT OF

GARY A. CHRISTOPHERSON
ACTING ASSISTANT SECRETARY
OF DEFENSE
(HEALm AFFAIRS)

AND

JOHN F. MAZZUCHI, Ph.D.

DEPUTY ASSISTANT SECRETARY
OF DEFENSE
(CLINICAL AND PROGRAM POLICY)

BEFORE THE
SUBCOMMITTEE ON HEALTH
OF mE
COMMITTEE ON VETERANS AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES

APRIL 23, 1998

NOT FOR PUBLICATION

UNTIL RELEASED BY THE
COMMITTEE ON VETERANS AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES
 90

Mr. Chairman and members of the Committee. we are pleased to be here today to
provide testimony before this subcommittee on the Department' s Force Health Protection
program for current and future deployments. the health experience of military personnel
deployed overseas since the Gulf War and our current Gulf War illnesses research efforts.
In addition. we have been asked to provide an overview of the Department ' s counseling
and treatment programs available to Service personnel who are victims of sexual trauma.

I will address the Force Health Protection program and Dr. Mazzuchi will speak
to the Department's Gulf War Illnesses research efforts and our sexual trauma treatment
and counseling programs.

As I have testified before. mistakes were made during the Gulf War and it is our
responsibility to avoid making those mistakes again. In Bosnia. we made substantial
improvements. but we still need to do even more. Many lessons have been learned; many
lessons need to be applied.

Let me address how we have changed our policies over the past eight years to
reflect the mistakes made during the Gulf War and the lessons learned. On November 8,
1998, the President vowed that we would use the knowledge gained from the Gulf War
experience to "improve the health of our veterans. their families and all who serve our
nation. now and in the future." As we recommended. the President directed "the
Departments of Defense (DoD) and Veterans Affairs (VA) to create a new Force Health
Protection Program."

With respect to force health protection. the lessons we learned led to the
establishment of the following actions:

Documentation of pre-deployment health assessments.

Improvement in medical record keeping. including record keeping and
tracking of immunizations and other preventive countermeasures. in theater.
Improvement in medical surveillance in theater.
Improvement in exposure assessments and record keeping in theater.
Documentation of health assessments at redeployment.
Identification of better products for biological and chemical warfare medical
countermeasures.
Improvement of health risk communication efforts.
Assessment offorce health post-deployment.
Improvement in VAlDoD coordination during and after deployment.
Additional peer-reviewed research on a range of high priority issues.

Based on these lessons learned from the Gulf War. we have incorporated a
number of changes into subsequent deployments to Somalia. Rwanda, Haiti. and Bosnia.
In August 1997, the Department issued DoD Directive 6490.2 "Joint Medical
Surveillance" and DoD Instruction 6490.3 "Implementation and Application of Joint
Medical Surveillance for Deployments." The directives establish the Department's
policy and requirements that will improve health assessments. surveillance. and record
 91

keeping during deployments. The directives require: pre-deployment and post-

deployment health screenings, including mental health assessments; blood sample
collections; health threat briefings; and the collecting, analyzing, and documenting of an
expanded range of health surveillance data during deployments.

We worked closely with the Joint Staff and the Services to develop these policies
and implement them in Bosnia even before we had a formal Department Policy Directive.
The Joint Staff and the Services are moving ahead to implement these requirements into
routine operations and planning. Currently, joint publications are being rewritten to
include changes in doctrine regarding force health protection. Additionally, the
warfighting Commanders in Chief are revising theater operations plans to include the
force health protection requirements. For the current operation in Southwest Asia, the
Joint Staff will address specific requirements and actions for force health protection that
are being implemented. Further, the Office of the Secretary of Defense has issued
specific policy on vaccination programs and other force health protection measures for
the current operation that are explicit regarding the requirements a) to document, retain,
and, if appropriate, archive individual medical information, and b) to provide information
to the service men and women before, during and after the deployment about the force
health protection measures.

To support medical record keeping during deployments and throughout the

Military Health System, we are establishing the needed information systems. The
computer-based patient record, the Theater Medical Information Program, and the
personal information carrier are major information system initiatives designed to create
an effective medical tracking system and health record before, during, and after
deployments. Our goal, in partnership with the Department of Veterans Affairs, is an
individual, comprehensive, life-long medical record for each military member of all
illnesses and injuries, all health care (including vaccinations and preventive measures),
and exposures to different occupational and battlefield hazards. These record s will help
both Departments provide care, prevent illnesses, and improve our knowledge of the
health of our military members and veterans throughout their lives.

The Department of Defense is working closely with the V A regarding our

preparations to protect the health of our U.S. forces during future deployments, and
prepare for their health needs upon their return home. The senior health leadership of
both organizations meets regularly and we have active interagency working groups
addressing health care, medical record keeping, risk communication, and deployment and
re-deployment health programs. In conjunction with the Departments of Veterans Affairs
and Health and Human Services (HHS), we have proposed the establishment of a
Military and Veterans Health Coordinating Board to continue and formalize these
initiatives. It has been a very good partnership; one, which we believe, will become even
stronger.

We must be ready to address health concerns of veterans and their families when
our service men and women return from a conflict. Our Comprehensive Clinical
Evaluation Program (CCEP) for Gulf War veterans remains active. To date, over 32,000

2
 92

veterans and their family members have been provided CCEP health evaluations. As
appropriate, and in close coordination with the V A, we will utilize that program to
address any health issues that may arise out of current or future deployments.

Following the Gulf War, DoD established a Defense Medical Surveillance System
(DMSS). This system receives, validates, and integrates personnel, military, medical,
and deployment-related data in a rapidly analyzable, central medical surveillance
database. DMSS contains rosters of service members who participated in selected joint
overseas operations, including operations in Somalia, Rwanda/Zaire, Kuwait, Haiti, and
Bosnia. Since the beginning of Operation Joint Endeavor in Bosnia, the DMSS has
received nearly real-time reports of all in-theater hospitalizations, thus we are now
capable of conducting analysis of hospitalization experiences (overall and for specific
diagnoses) of deployed service members - prior to, during, and following their
deployment participation. A comprehensive analysis of hospitalizations for Operation
Joint Endeavor in Bosnia for all participants from all Services is underway.

The Department's emphasis on force health protection is making a difference.

Routine in-theater outpatient disease non-battle injury (DNB!) surveillance and reporting
has been conducted by each of the Services during selected joint overseas operations.
Dedicated joint task force (JTF) surveillance teams under the control of the respective
JTF Surgeon have operated field-oriented surveillance systems. Data from each reporting
site is reviewed for trends and recommendations made for control of noted health
problems.

But this all is not enough if we cannot better protect our troops against the threats
of chemical and biological warfare agents. Our goal, and our charge is to take care of our
people in uniform as they serve our nation. As a nation, we are morally obligated to
provide the best protection we are capable of providing to our troops against known and
dangerous threats. To do this, we need better and approved products for Biological and
Chemical WarfaTe medical countermeasures.

Our research and development people are working on more safe and effective
medical countermeasures. The Army Medical Research and Materiel Command, the
Joint Staff and our office have an ongoing effort with the Food and Drug Administration.
We are discussing how we can use current products, such as pyridostigmine bromide and
botulinum toxoid vaccine, when they are not yet fully approved and -how we can develop
and achieve approval of those and future products more expeditiously. The critical issue
for the Department of Defense and the Food and Drug Administration is how, in a timely
fashion, to make available the safest and most effective medical countermeasures for our
troops.

The Department remains engaged in a comprehensive, coordinated effort to

respond to the health concerns of Gulf War veterans; our veterans and their families
deserve no less. DoD, HHS and VA are committed to finding answers to Gulf War
veterans' questions. To address these complicated issues, we will continue to sOlicit
advice from independent scientists and experts

3
 93

It has not yet been 5 years since formation of the Persian Gulf Veterans'
Coordinating Board-Research Working Group to coordinate Federal research into the
health consequences of service in the Persian Gulf War. The genuine concern and
recognition of the magnitude and consequences of the challenges before us are reflected
by our commitment to work in a productive and cooperative manner that exploits our
individual Department's scientific .strengths and unifies them into a productive,
responsive and fully integrated research effort. The path of science is difficult,
challenging. expensive and time consuming. Easy and complete solutions to complex
health problems are exceptionally attractive and extremely rare. This truth is especially
disappointing to those of us who see those veterans and non-veterans who suffer the
consequences of prolonged. often incapacitating, illnesses of uncertain or unknown
origins and for whom medical science offers little in the way of long-lasting relief or a
cure.

The Federal research effort addressing this problem involves scientists in Federal,
academic. and private institutions, both in the United States and abroad. It involves
research sponsored by the V A, 000. and DIffiS . The coordination and management of
this extensi ve. international research effort on Gulf War veterans' illnesses have required
the establishment of an overall research policy framework linking each Department's
research management hierarchy. This essential linkage is provided through the Research
Working Group (RWG) of the Persian Gulf Veterans Coordinating Board.

Over half of the research projects have involved non-government scientists who
received federal funding for their research through rigorous. competitive peer review
processes. In their final reports of extensive reviews of the research programs managed
by the RWG. the Institute of Medicine and the Presidential Advisory Committee on Gulf
War Veterans' Illnesses endorsed the research directions of the RWG.

The 000 expenditure for Gulf War veteran's illnesses specific research from
FY94 through FY98 totals $62.6M . The annual investment has increased by
approximately $14M since FY94. From FY98 through FY02, the Department estimates
investing approximately $20M per year in Gulf War related illnesses specific research
and thereby bringing the total since FY94 through FY02 to $142.6M. The entire Federal
research portfolio currently consists of 121 projects with a total research specific
investment to date of approximately $115 million. Of these 121 projects. 39 have been
completed. 78 are ongoing. and 4 have been newly awarded and are awaiting startup .
Additional research projects are at various stages of planning. There are 14 identified
research focus areas ranging from the effects of service in the Gulf War on the brain and
nervous system to the potential health consequences of low-level exposure to chemical
warfare agents. Approximately one-third of the projects are epidemiological. one-third
are clinical. and one-third are basic research. This funding profile does not include
related funds for health care delivery or our investments in highly relevant. core science
and technology programs (e.g .. medical chemical defense) which are already established,
continuing programs that will likely have direct benefits for the Gulf War veteran ' s
illnesses research program.

4
 94

This investment has been effective in providing new information on the impact of
military service in the Gulf War on health-related problems, providing new areas of
research exploration, and prompting new force protection initiatives that provide for
medical surveillance during future operations. With specific reference to Gulf War
veterans' illnesses, the investment and findings have highlighted the need for improved
prevention, intervention, and treatment approaches, and the national program has
responded to these needs both in its approaches for veterans' health care and in the
Research Working Group' s emphasis on its research investment strategy.

We are committed to sustaining a sound and responsive working plan, against

which scientifically meritorious proposals will be evaluated for relative programm~tic
merit. Historically, the match of scientific merit and program relevance has been basis
for establishing research priorities. There are no more reliable means to progress of
which I am aware.

The Depanment and our Federal panners are committed to resolving Gulf War
veterans' health concerns and preventing similar occurrences among our service men and
women as a consequence of future deployments. The challenges are great and while
there may be no quick solutions, we are committed to responsible and aggressive pursuit
and resolution of these problems.

We appreciate the interest this Committee and others have shown in the health of
the men and women who serve and have served this nation in our armed forces. The
health and fitness of military personnel have long been concerns of those responsible for
ensuring troop readiness and effectiveness. The Military Health System wants to achieve
its goal to take care of those men and women and their families, and protect their health.
We recognize that our commitment to keeping our veterans healthy does not end when
they leave active service. We will continue to work with you and the VA to ensure the
government meets its commitment to our veterans.

The Depanment of Defense is very aware and concerned about sexual

victimization of service personnel. It is clear that sexual abuse and sexual trauma are
serious problems in our society generally. Following the initial and definitive recognition
of rape-trauma syndrome, a type of Posttraumatic Stress Disorder (PTSD), in the mid-
1970s, significant data have emerged concerning the prevalence of childhood sexual
abuse and sexual trauma in adolescents and adults (i.e., adults not unCommonly
experience PTSD as a result of childhood trauma). As is evident from professional
repons, rates of both childhood sexual abuse and adolescent and adult sexual trauma are
significantly higher than had been previously thought. A national survey revealed that in
the US general population the lifetime prevalence ofPTSD was 7.8%, with women being
significantly more likely to have suffered from PTSD than men. Research has also
indicated that a high number of people with PTSD also have other psychological
disturbances, such as depression, anxiety disorders, or eating disorders. With such
prevalence in the general population. it seems likely that similar patterns are present in
military populations.

5
 95

The Services have performed research on their basic trainee population to

adequately assess the extent of exposure of childhood sexual trauma and family violence.
An Army study identified a significant incidence offamily violence in basic trainees and
a Navy study of basic trainees found that 45% of the women trainees indicated that they
had been the victim of attempted or completed rape prior to entering the service.
Identification of basic prevalence rates is necessary for the adequate planning and
provision of health-care services. This ongoing research has resulted in a trial, three-hour
intervention program designed by the Navy for both male and female basic trainees. The
focus of the program for female trainees is how not to be victimized while male trainees
are instructed on consent issues. Although the research on this program is not yet
completed, this program is extremely promising and demonstrates the commitment of the
Services to meet the needs of their members by early intervention and to minimize future
issues.

Because disorders such as PTSD, depression, and anxiety can be severe enough to
affect performance in the general population, it is especially important that such disorders
be examined in the military popUlation, which is tasked with the nation's defense.
Research on mental health disorders in military personnel has shown that while the
lifetime prevalence of most psychiatric disorders was comparable to national prevalence
rates, current or annual rates for most disorders was lower. One notable exception was
PTSD. The lifetime prevalence ofPTSD in military personnel was 12%, compared with
1-9"10 found in civilian research. However, both lifetime and annual rates in military
personnel were similar to those observed in a representative national sample of women.
Additionally, 56% of personnel with at least one psychiatric disorder were found to have
2 or more disorders. These numbers are comparable to national studies that reflect this
same incidence of comorbid conditions.

While the Services are committed to preventing sexual trauma, they recognize the
need to provide the highest level of care for their service members and their family
members who are victims of sexual trauma. The Services have programs for prevention
and treatment of sexual trauma and family violence. The Sexual Assault Victim
Intervention, or SA VI program, is an innovative program developed by the Navy to deal
with sexual trauma. Installations have a SA VI coordinator who provides prevention
training and also establishes a system of victim advocates at the site who accompany the
victim through the acute phases of medical and legal interventions .. The SAVI
coordinator also coordinates counseling through the Family Service Centers or in the
local community. The SAVI coordinator is able to evaluate all available resources and
set up a system that makes sense for the local community. These types of innovative
programs exist in each of the Services and reflect the proactive approach of each Service
to deal with this critical issue.

The V A has a program in place to provide full- and part-time counselors for
veterans who are suffering psychological trauma as a result of sexual assault, rape, or
harassment that occurred while on active duty. These services are provided in DV A

6
 96

Medical Centers and their community Veterans Centers. This information is provided to
outprocessing Service Members through the Transition Assistance Program.

The V A has provided sexual trauma counseling services since 1992 to veterans
who experience sexual trauma while on active duty. A Health Affairs policy, dated
November 1997, required each Medical Treatment Facility (MTF) to perform a needs
assessment to include a review of local V A and MTF resources to determine the
adequacy of such care for this area of treatment. This policy calls for the development of
a Memorandum of Understanding (MOU) between the MTF and the local VA that would
allow active duty service members to seek counseling at V A facilities if a local need
existed. This local MOU would outline access issues, medical record issues, and
reimbursement rates. Other issues, including command and control issues and treatment
of co-morbid psychiatric issues should also be addressed in these local agreements.

In addition, the DVA has developed a Memorandum of Understanding to expand the

system-wide, cooperative use of these sexual trauma-counseling services for active duty
personnel. This MOU, which is currently in coordination with the Service MR&As, would
formalize reimbursement issues as well as facilitate reporting of co-morbid, psychiatric
diagnoses to the services. These co-morbid diagnoses could have significant impact on
command responsibilities for security and personnel management issues. This agreement, once
finalized, would provide a valuable adjunct source of treatment to a group of individual service
members that may not be appropriately treated within the military healthcare system.

Commands have a legal responsibility to deal with sexual harassment/trauma in

the unit. This responsibility includes providing a unit environment that promotes
equality . It will be difficult for the chain of command to deal with an environment of
harassment if they are not notified of an incident in the unit. Command responsibilities
for security issues related to personnel should not be compromised. A Commander' s
knowledge ofa service member' s psychiatric treatment is essential in high-risk programs
such as Nuclear Surety and the Personnel Reliability Programs. Treatment of associated
psychiatric diagnoses is a major issue. As stated above, 56% of patients with PTSD are
likely to be diagnosed with two or more disorders. These conditions may make patients
unfit for service or represent a security risk. It is important, therefore, to insure that the
unit commander be informed of and involved in the prevention, identification, and
provision of treatment for these cases.

The Department of Defense is committed to providing the highest quality

of care to our service members. In the case of sexual trauma counseling, this care
involves early identification and intervention of high-risk groups as early as basic
training, continuing throughout the service member's career, as well as provision of
counseling for acute sexual trauma. We recognize that our commitment to keeping our
veterans healthy does not end when they leave active service. We will continue to work
with you and the VA to ensure the Federal government meets its commitment to our
veterans.

7
 97

We will maintain a strong post deployment evaluation and care program. We will
continue to move forward. mature and strengthen our Force Health Protection Program as
well as the total Military Health System. With the help of all of our colleagues in the
Executive Branch, as well as this Committee. I am fully confident that we can better
protect the health of our troops during deployment and in garrison. Be assured that we
will continue a strong program for the prevention of sexual trauma and aid to its victims.

Again. we appreciat~ the opportunity to testify before this Committee. and look
forward to answering your questions. .

8
 98

United States Genenu Accounting Office

Testimony
GAO
Before the Subcommittee on Health,
. Committee on Veterans' Affairs, House of
Representatives

For Releaae OD Delivery

Expected at 9:30 a.m.
'lbunoday, April 23, 1998
WOMEN VETERANS'
HEALTH CARE

VA Efforts to Respond to
the Challenge of Providing
Sexual Trauma Counseling

Statement of Stephen P. Backhus, Director

Veterans' Affairs and Military Health Care I88ues
Health, Education, and Human Services Divi8ion

GAOIl'-BEBS-98-138
Mr. ChaInnan and Members of the SubcommlUee:

We .re pleased to be here toda to dIlIcuss sexual tramna COUIl8eIIng !leMces for women
veterans In the Department of Veterans Affairs (VA). In the early 199Os, repeated alleptIons of
sexual - * while serving on active duty were made by women veterans of the U.S. umed forces.
A nmnber of the8e women llUffer from sexual trawna, including poet-traumatlc stress dI80rder
(PTSD), and experience emoUonal and physical symptoms such as Increased stress, impaired
concentraUon, and nightmares, which can Impede their dally lives.

WhIle women represent a small segment of the nadon's veteran populat1on-le11s than 6
pen:ent.-thejI' nmnbera are npIdIy IfOwIng. In 1982, there were about 740,000 women veterans; by
1996, that number had almOllt doubled to <M!I' 1.2 mJDIon. It Is expected that by 2010, the number of
WOIIIen veterans wIlllncrealle an additional 7 percent to 1.3 million, which would ~t 6.4
percent of all veterans. Thus, It Is poIIIIIble that more women veterans will be diagnosed with PTSD
and other mental and health problems related to sexual tramna.

To help ensure these veterans receive the counseling care and !leMces they require, the
Congress enacted the Veterans Health Care Act of 1992 (p.L. '102-586), which In addlUon to
authorizing new and expanded health care !leMces, authorized VA to provide sexual tramna
counseI1ng for women veterans through 1996. The sexual tramna counseling provllllons of thls act
were amended by the Veterans Health Programs Extension Act of 1994 (P.L. 103-462), wh1ch
extended sexual trawna counseling care and !leMces to all eJlg1ble veterans, not Just women, through
December 1998.

My remarks today will focus on (1) the extent to which sexual trawna counseling !leMces are
available In VA, (2) the extent to whlch women veterans use the8e !leMces, and (3) what VA Is doing
to assess the effecUvenesa of Its sexual tramna counseI1ng programs. My tesUmony Is based on our
~ ot VA poIlcy d1rectIves and VA sexual trawna counseling statistiCS; dlscus!I1ons with 01'ftc1als
and starr In VA medical facIIit1es, the Real\lustment CounselIng ServIce's Vet Centers, the Veterans
Health AdJn1nlsIndIon (VHA), and the Veterans Benellts AdmInlstr3t1on (VBA); and dlscus!I1ons with
women veterans at live of the six locations we visited. (See app. I.)

In 9UJII1II8lY, VA, whlch began offering sexual trauma counseling services In 1993, offers these
services at all ot Its 172 h09Pitsls and 62 of Its 206 Vet Centers. Four VA h09Pitsls offer spedaIIzed
sexual tramna counseling prognuns through Women Veterans Stress Dlsorder Treatment Teams.
These counseling programs provide care to women veterans who have been more severely atrected
by their traumaUc experiences. VA has also conducted a nmnber of outreach efforts to Increase starr
awarenesa and Inform women veterans about available sexual trawna counseling services. These
efforts have Included segments on a nadonal televlslon program and letters to women veterans.
FInally, to tadIitate accesslbWty to sexual trawna coUl1llellng, VA has provided a toll-free nmnber tor
women veterans to obtsln lnformaUon about available counseling services and has designated women
veteran coordinators at medical facWUes and VBA regional ol'ftces to assist women veterans In
obtaining the8e services.

Ita a ~ of VA', efforts, women veterans are lncrea8In8IY ua1ng VA's sexual tramna
counseI1ng !leMces. Between IIscal year 1993 and IIscal year 1997, the number of women veterans
receiving sexual trauma counseling has almost quadrupled, from about 2,360 to about 9,000.
AlthoUlh not yet done, VA pWw to systematically eYaluate the effecUvenesa ot the sexual tramna
counseI1ng prl>llf8lllll provided by the four Women Veterans Stress Dlsorder Treatment Teams and Its
Vet Centera.

VA'S PBOYJSlON OF SEXUAL

TRAUMA COlJNS'fiI.lNG
VA has made sexual trawna counseling !leMces available In all of Its h09Pitsls and nearI,y a
third ot Its Vet Centers. VA also has provided training on sexual trawna for Its cJIn1clans and support
starr to sensitize them to the lssue and provide guidance on how to Interact with trawna v1cUms. In
tuIIIll1n8 Its reeponsI.blllty tor providing sexual tramna counseling for women veterans, VA conducted
outreach campaIjpI8 to Inform women veterans of the counseI1ng services available to them.

GAOII'-HEHS-98-138
 100

VA OlIeg Wgmea VeterapI Op!iorut (1M'

Sexua! Trauma Cgumo:!!nB Seryi<:ea
VA orten IelDmI tnuma COUI1IeIIng eemces It III of its 172 hoepItaIs. WItbIn VA boIIpItaIs,
aexUIII tnuma COIIIIIIeIInC Is avIIlIb&e In either Its JllelUlIIemtb c:IInIc&-pIIyc:hlltry, Jl81chology, 01"
both-!M' In the _ ' . dInIc. SelrusI tnuma COUIIII!IInIIs ~ proyIcIed both indlvlduaiiy and
In Jl"OIIP COUI1IeIIng III!IIIJions. Four 01 its ho8pItaJ&...8oIIton, M.-huaetts; BrecksvIlle, OhIo; Lama
UncIa, c.JItomla; and New Orleans, LouIsIan.-aIao have Women Vet.enna Stress DIsorder Treatment
Teuna, wbIch are spedaJIzed prosnms that provide aexUIII trauma cOWUJellng.

The Women Veteruw Stress DIaol"der TreaIment Teams wen! t!IItBbIIIIIIed In IIl113 .. put of a
pO JIIOIIJaDIIn accordance wUh the Veteruw Hellth care
Act of 11182 and are reserved (1M'
IndIvic:IuIIIa who have cIeftloped more aeven dIaonIen, IIUCb .. PI'SD, .. a reIIIIlt of the ~ 1M'
aexUIII tnuma they experienced. The Womea Veteruw Stress DIsorder TreItment Teams generally
employ moce Intenee trealment protocols and Include IIIclI treatment eemces .. lndlvIdual
psychothenpy, crIU mmagement, drug thenpy, and Jl"OIIP thenIpy.

In IddIUoo, 62- 30 percent-of VA's 206 Vet Centers orter aexUIII tnuma COIJII8eI1n8. Vet
Centers that do not have a COIIIUII!lOl" quaIHIed to provide treatment tor eexuaI tnuma provide
JIII7Choeod8I-.ta and make appropriate reternl&
VA Pxgylj!a Scm'" Trauma
DldnIns IIMI Etn"dt oo
In 1983, VA bepn a muJlItacetecI IraInInI PfOIIl1IIII to educate medical f8dIi1)' bealth care

a_
penonneI-W:Iud1n8 mental health COIIIIIIelon, Vet Center cl1nIcIIn8, and prinwy care pndlUoner&-
.. well .. .tmInIaIntive penonneI; vetenM and their fmnIIIea; and the ..-nl public Ibout aexUIII
tI'Iuma. 'l'raInIII& tor cIInIduw Includea modules 011 undenUndInI the factors that Inftuence the
.-nent, cbpoerIs, and treltment 0 1 _ veter.. who have been victims of IIeXUIIl -u.
The tnInIna Is 8180 deaI8ned to nIiIe of and Incn!aR IIlII8IUvII)' to eexuaI tnuma 8I'Rong
the ..-nl public. These IraInInIInItIIttves Include face..to..face preeentatIooa, IIIIeIIlte broadcasts,
c:onterence calla, educatioaaI videos, and printed matertaIa. In addItIoa, to Incn!aR the eJrecUvenesa
of women vetermw' coordInatore-who pIq a key role In helping women vetenM obtain COUII8eIIng-
VA Implemented a IIIIIIoNlIraInInI procram to CmIIIWIze coonIInaton with _ vetenM' IaIUes
IIId Incn!aR a_ 01 their roles.

VA 0utrwI! EIIorta
In M-,y 1l1li6, VHA published a directive to Implement the pnMaon of P.L. lCJ3.41i2, wbIch
required that information 011 COIUIBeIIng I!II!lYices fOl" vetenna. who have experienced IelDmI tnuma In
the mlIIt8ry be provided bytelephone. VA UIIed its senenl beneftta 1nf0l1l\lti0ll toIt.free nUlllber to
dI.mIInate thIIIlnformatlOl). WIlen a veteran ~ eeeIdI1g lnformaIiOll Ibout IelDmI tnuma
III!rYices, the callis routed to the women vetenM' COOI'dInItoI" It the IIl!In!8t VBA reatooaI omce. U
the veteran wIabes to contact a VA hoIpttII, a refenalis made to the women vetenM' coordInatoc It
the VA boIpltal 1M' the Vet <;enter team leader, If the Vet Center oera aexUIII tnuma COIJII8eI1n8.

Women veterwIII' coordInatorI are VA employees wbo have been tB8ked with conducting
outreaclI to women vetenM and lIeIpIn& them obtain VA benellts and 1!II!lYices. VA Increaaed the
time IIIotted flM' _ women veterwIII' coordInatorI to perfocm theee duties by 'c:reItIn8 IIlOI'e full..
time JK)IIlUonI. As of JanUuy 1998, Ibout 40 percent of the _ _ vetennII' coordInIton In VA
medIcIl fIIdIItIeII wen! fu11..Ume. Women vetenM' coordInIIton and VA cIInIduw have beaun to
ICfteII _ veterans fO(" aexUllllI'IIIIn....aId them If they experienced eem..a
tnuma wIIIle 011
active duI-wben they come to VA for odIer IIemtb care I!II!lYices. The 8CneIIInC proce. bB8 been m
In\poI'tInt and productive tool In IIlowInC VA to ~ tnuma vlctImB, eapecIa\lJ IIiDce women
veterans often do not revNl that they have been 8I!XUIIIJJ traumatiIed.

In NOYeIIIber 1l1li6, a IIIIIIoNl teIevIIIon network', weekly ne. . JIIOIIJaDIIired two II!lID*Its
0II1UUJ1 trIUma In the mUllaly. In IddIUoo, VA lent !etten to 400,000 women vetenM lnfonnInI
them of the couneeIIn8 aerYiceI av.u.bIe to thoee who had esperIenced eexuaI trIUma wIIIle 011
active duI.

2 GAOfl'HEHS-98-138
 101

TIlE NUMBER OF WOMEN VETERANS

BECEMNG SEXUAL T1WJMA
COJ!NSEJJNG CON'1'lNlJF:! TO INCREASE
The number of women veterans who seek sexual trauma coUIlllellng bali dramaUcaIIy
Increased over the pa8t BeYeI'IIl years. ThIs InCl'e8lle has C8WIed concern among some sexual trauma
counselon that they IIIlI not be able to meet the demand for care and services. However, women
veterans who have recetved counseling are generally satIsIled with the care and services they have
recetved through VA.

Between ft!cal year 1993 and ft!cal year 1997, the total nmnber of women veterans receiving
sexual trauma counseling Incre~ over 280 percent. The nmnber of women veterans receiving
sexual trauma coUIlllellng services from VA hoepitals and outpatient c1In1cs Increased almost 230
percent, from about 2,100 to 6,900. The number who recetved coUIlllellng from Vet Centers Increased
about 376 percent, from about 270 to over 1,270. Between ft!cal year 1994 and ft!cal year 1997, the
number of women veterans receiving coUIlllellng from the Women Veterans Stress DIsorder
Treatment Teams Increased over 220 percent from about 270 to 870. (See app. n.)

Staff 8IIIIOCiated with the sexual trauma coUIlllellng programs at one of the live VA hoepitals
and two of the three Vet Centers we vllllted expresaed some concern about thetr ablllty to adequately
respond to the demand for sexual trauma COUIIIIeIIng. Staff at one VA hospital explained that their
workload Is not decreasing. because sexual trauma patients remain In counseling for some time.
Although It Is too early to esUmate how long sexual trauma patients will need to receive counseling,
one c1In1c1an told us that uterature suaeats they would probably receive coUIlllellng for an average of
about 2 years. The other locations we vllllted seemed to be I1\8I1lIIIIn8 their sexual trauma workload
fa1J1y well.

Women veterans we talked with Uked having the different options available to them for sexual
trauma counseling. Some veterans Uked receiving their counseling In the women's c1In1cs because
they felt more comfortable going there than the mental health c1In1c. Their view was that mental
health c1In1cs were fOl" 'crazy" people and they were not crazy. Several women veterans preferred
the more private, Informal setUng at the Vet Centers.

The women veterans we talked with told us they are grateful for the counseling services they
have recetved and beDeve the counseling Is helping them. One vetersn commented that the
coUIlllellng has saved her ute. However, a few veterans expresaed the desire to receive coUIlllellng
more frequently than once a month. One vetersn told us that she sometimes has ditftcult periods
and linda It hard to get an appointment before her next scheduled visit. Yet she has found that the
counselOl" Is very committed and has helped her through crisis periods over the phone when an In-
oMce appointment was not possible.

The primary complaints we heard about VA sexual trauma services were directed at VA's
cIstms process for awarding compenasUon related to sexual trauma. While documentation of sexual
trauma Is not required to receive counselIn& It Is required for ftlIng cIstms for compensation. A
women veterans' coordinator at V8A explained that it Is sometimes d1fIlcul~ to docmnent sexual
trauma cases since personal assault Is otten not reported. V8A has developed guidance It hopes will
help alleviate some of the problems 8IIIIOCiated .with the documentary evidence that Is required to
apply for compensation related to sexual trauma. Veterans are now asked to provide any
documentation that will help to substantiate their cIstms, which can cover primary evidence-such as
service medical records and personnel recorcls-or alremat1ve sources, including clviUan medical
records, pollce reports, statements from others, or personal diaries.

VA PLANS TO EVALUATE TIlE

EFFEC'Jl\1ENESS OF SOME OF ITS
SEXUAL TRAUMA COUNSELING PROGRAMS

The etfecUveness of VA's various sexual trauma coUIlllellng programs Is not yet known.
Currently, VA plans to evaluate the effectiveness of its four Women Veterans Stress DIsorder
Treatment Teams and Its Vet Center sexual trauma counseling programs. Based on ftscal year 1997
data, these evaluations would cover about 24 percent of the sexual trauma counseling services
provided to women veterans. At this time, VA has no plans to systematically evaluate the
etfecUveness of the sexual trauma counseling programs provided by VA hospitals and outpatient
facilities.

3 GAM-HEHS-98-138
 102

The Northeast Program Evaluation Center (NEPEC) will evaluate the effectiveness of the four
Women Veterans Stress DIsorder Treatment Teams. According to NEPEC's National DIrector of
PTSD Program Evaluations, it Is dIftlcult to assess the effectiveness of mental health programs,
including sexual trawna CO\lll8eUng, because treatments for sexual trawna counseIIng-llke PTSD-are
still evolving; therefore, absolute outcome standards have not been established. In addition, sexual
trawna coUll8ellng effectiveness evaluat1oll8-l1ke other effectiveness studies-are dIftlcult to conduct
because of the llCientiftc challenges they present, such as Implementing data collection In real-world
settings as well as measuring anlndlvldual's emotional status. Further, It Is dIftlcult to define the
treatment and determine whether a treatment-and not time or some other ocCUlTence-cauaed the
particular outcome.

To evaluate the effectiveness of the Women Veterans Stress DIsorder Treatment Teams,
NEPEC plans to \I8e a protocol similar to the one It used to evaluate the effectiveness of VA's
specialized Intensive PTSD programs. NEPEC will \I8e several data collection instruments that will
be administered at admission and 4- and 8-month follow-up Intervals to collect socIodemographlc,
symptom, social functioning, and military and cUnlcal background Infonnallon. NEPEC will also
collect (1) more extensive data re8Jlldln3 traumatic exposure In the mllItsIy, (2) Infonnallon
re8JIldIn3 personall~ characteristics and health beliefs, and (3) Infonnallon on the number and ~
of VA and non-VA individual and group 8eS8ions received In the 4 months prior to admission to the
specialized program. VA anticipates It will begin lis evaluation some time during ftscal year 1998.

To determine the effectiveness of Its coUll8ellng programs, Vet Centers will \I8e the Global
Assessment of FunctIoning (GAF) rating and a psychosocial rating. GAF rates a client's overall
functioning, including psychological, social, and OCCUPational. Vet Center staff will compare each
veteran's GAF score before and after completing the sexual trawna coUII8eIIng progrsm. Vet Center
staff will also compare women vetenuls' before and after psychosocial ratings, which assess the
speclftc cUnlcal problem areas addressed In the coUll8ellng 8eS8ion, their severt~, and the level of
resolution achieved. In addition, Vet Centers will conduct aattsraction IIII1'Vey8 upon termlnatton of
sexual trawna counseling.

Mr. ChaInnan, this concludes my statement. I would be happy to respond to any questions
you or the other Subcommittee Members IIl8 have.

GAOfl'-HEHS-98-138
 103

APPENDIX I APPENDIX I
VA FACILl'11ES VJSITED

Women Veterans Comprehell8ive Health Center

Women Veterans StreIIs DI80nler Treatment Team

Bay PInes. florida

Women's ClInlc

Tampa. florida
Women Veterans CompreheIl8ive Health Center

St, Peteqbur& florida

Vet Center (Tampa Vet Center repreeentatIve liiio participated)

New 0rI.,.. Lmdsl'M

Women'lI QInIc
Women Veterans StreIIs DIsorder Treatment Team
VBA regloII8l oMce
Vet Center

WIIIhIpcton. D,C.

Women'lI QInIc
VBA regloII8l omce

5 GACYl'HBBS-98-138
 104

APPENDIXD APPENDIXD
SEXUAL TRAllMA OOJ/NSR.JJffi CAMS
Table D l' Ipmw in Ntpntw pi Sm,e' Trauma CO"_UM Pew Between f1pI Yw Igga and
f1pIXw 1997

FI8eaI'JMr
801Ifte of It93 lIN It1t11 1_ 1997 m-
trMUIeIIt "1993-"1997
(pereeat)
VA hoIIpttIIs 8lId 2,090 3,627 4,789 4,707 6,867 228.~
outpdent dInlaI
.
Vet Centers

Women VelerwW
.
268 1,442
271 816
1,863
906
1,273
870
376.0

221.0
sa- DI80nIer
Tremnent Teams
Total 1,318 1,340 1,801 7,'" 9,010 lSI.l

"Women Veterans Stre8s DIsorder Tremnent Teams were not established unUl 1993.
"Included In the VA hoIpIt.l and outpmient clinic totals except for SIn Antonl.o.
Source: Depanment of Veterans AffaIrs, Veterans Health AdmInIstration, Oftlce of Women Veterans
Health Pfo8nm.

(406139)

6 GAOtT-HEIfS.98-138
 105

STATEMENT OF

Veronica A' Zera

AMVETS National Legislative Director

before the
Subcommittee on Health
House Veterans Affairs Committee

Sexual Trauma Counseling Program

Thursday, April 23, 1998

9;30 A.M.
334 Cannon
 106

Mr. Chairman, on behalf of AMVETS, Disabled American Veterans, Vietnam

Veterans of America and the American Legion, we want to thank: you for the
opportunity today to express our views on the Sexual Trauma Counseling Program
at the Department of Veterans Affairs.

Neither AMVETS nor the VSO's listed have received any federal grants or contracts
during the fiscal year 1998 or in the previous two fiscal years.

We want to congratulate Congress and VA for having the insight to establish such
an essential program. We are here to evaluate the current program and make
suggestions on what improvements can be made when Congress reauthorizes the
Sexual Trauma Counseling Program.

First of all, we want to acknowledge what the program does right:

1. It authorizes counseling and treatment for sexual trauma for both women
and men.
2. The program authorized VA to provide treatment services for sexual
trauma, in-house and contractually, through December 31, 1998.
3. It mandates that the Secretary shall give priority to the establishment and
operation of the program to provide counseling, care, and services.

Even with all these accomplishments, there are some things we would like to see
improved or changed.

Open up to reservists and nadoDal pard members

Current law requires two years of active duty service in order to be deemed a
"veteran" for the purposes of seeking general VA bealthcare. A VA Under
Secretary for Health's 1Df0rmation Letter dated November 25, 1997, regarding
"Eligibility Criteria for VA Healthcare to Veterans Seeking Counseling or Treatment
for Sexual Trauma" indicates that "the minimum length of service requirement in
section S303A does not apply to the provision of these (sexual trauma counseling)
benefits. "

Second, members of the National Guard and reservists who are called to active duty
are eligible for this program. However, they are not eligible if the
traumalbarassment happened during training-"the law excludes active duty for
training from the de(injtion of 'active duty'."

We believe that this presents some potential ambiguities and we also fear a different,
and perhaps more restrictive, interpretation in the future - particularly if resources
become more and more constrained. Because of the unique circumstances
surrounding sexual trauma or harassment in the military, some men and women
victims' service careers may be abbreviated. Some of the individuals involved in
the situation at Aberdeen, for example, may have left the service as a result of these
incidents during or shortly after their training. Also, members of a reserve
component called to active duty during the Persian Gulf War may not have a full
two-years of active duty service to quality for these needed treatments.
 107

While current V A interpretation of the law seems largely appropriate. we want

the statute to be modified to reflect the Under Secretary's policy. and further allow
reservists or members of the National Guard traumatized while on training exercises
to be eligible for VA's sexual trauma counseling program. Because this is current
VA practice (based upon the November 25. 1997 letter). we do not anticipate a
significant cost increase that would be associated with providing statutory authority.
And this would help to ensure that men and women in this category do not fall
through the cracks.

Make the program permanent

In a perfect world. this program would not be necessary. Unfortunately. we do not
live in a perfect world. According to the Center for Women Veterans at Department
of Veterans Affairs. 20 percent of all women veterans report that they had been
raped or sexually assaulted. In order to protect those who served. we need to have
this program continue beyond 1998.

Along with making it a permanent authority. reporting requirements and outreach

records should be kept and reports made to Congress each year by V A and
Department of Defense on the incidents that have occurred as well as how many
people have participated in the program. Currently. these records are not kept or
are sketchy. at best. We would like to see DoD and VA maintain and compare data.
Currently. DoD can not detail how many men and women were assaulted last year.
There is no tracking system. This needs to be corrected. We would also like to see
sexual trauma listed in the next edition of the National Survey of Veterans produced
by VA. They track several medical conditions and we would like to see them also
track sexual trauma.

No matter how great the program is. if no one knows that it exists. it won't benefit
anyone. We credit the VA for its efforts in getting the message out. We as veterans
service organizations also have the ability to help in this area and ask
for a more coordinated communication plan.

One misconception about this program is that some individuals will use sexual
trauma counseling as a way to get into the VA system and then "milk it" for other
services such as medical. dental. compensation. etc. There is no incentive to do
such a thing. All this act entitles the veteran to is counseling and care as required
because of the trauma. It does not entitle them to get anything extra nor does it
guarantee compensation. The very remote potential of people misusing the system
is no reason to preclude the program improvements that we advocate.

In conclusion. we all believe that this program. with some minor modifications.
warrants being made a permanent program within the VA. H.R.2253. addresses all
of our concerns and we have signed on as supporters. Whether this bill becomes
law or not. the fact remains that sexual trauma counseling is a viable program and
we hope it is here to stay.

We appreciate the opportunity to testify on this issue. Thank you.

2
 lOS

Vietnam Veterans of America, Inc.

1224 M Street. NW . Washington. DC 2000S-SI83 Telephone (202) 628-2700
F...., Maio (202) 621'110 1\4_(202) _ 7 C_ _ (202) 713..941 Fi_(202) 621-'1111

A. NoI-ForProfit V~t~rans Serviu O,ganiztllion 'Chan~'~d by tM Unit~d Stal~S Cong,~ss

Stmmentof

VIETNAM VETERANS OF AMERICA

Submitted for the Record By

ToTbc

House Veterans' Affaiis Subcommittee on Health

April 23. 1998

 109

TABLE OF' CONTENTS

INTRODUCTION ......................................................... 1

NEEDED CHANGES TO CURRENT LAW .................................... 1

LACK OF INCENTIVE TO "MILK THE SYSTEM" ................................ 5

CONCLUSION ............................................................. 6

Attachments:

Biography - Kelli R. Willard West, Director of Government Relations

FUDding Statement - April 23, 1998

 110

INTRODUcnON

Chairmam Steams IIDd manbers of tile VettnD1I A1IiIiIs Subcommittee on Health, Vietuam
Veteraus of America (!IVA) is pleucd to submit testimony for this hearing rqarding the VA's
sexual trauma counseling program. Because the VA's authority to provide this counseling expires
this year, VVA believes it is an appropriate time to review efficacy to date and ensure that access
to this program is not blocked by obscure provisions of law.

NEEDED CHANGES TO CURRENT LAW

VVA's WOlk in this _leads lIS to beliew that where sexual trauma counseling is available
within tile VA. it is bigb1y effective IIDd oftm has a very beneficial impaI:t on tile assaultlbarassment
victims utilizing these trCatments. Much of this therapy is provided tbrQugh the Readjustment
Counse1ing (RCS), vet Center pro~ Which is a very cost-effective'settingllDd modality for
providing such care.

Male and female veteraus who were victimized ~ this way ~e in .the military often
describe the experience as something that virtually desIroyed their lives. Suicides and/or substance
abuse III'e frequent outcomes. The individual's entire base of trust and personal security is usually
completdy obliterated by the incidcnt(s) in which the abuser took advantage of powa--relationships,
the military authority structure or individual vulnerability. Many victims never discuss their
experiences for many years - they feel they III'e entirely alone and III'e ashamed of their victimiDtioo.
We have beard testimonials from individual veterans who felt compelled to come forward IIDd seek
help only after hearing the stories ofTailhook. Aberdeen or other incidents that become public.
They want help for themselves. And they want to prevent this from happening to others.

There III'e a few shortcomings in the current law governing VA's sexual trauma counseling
program limiting individual eligibility and there is potential for certain segments of the veteran
population to fiill through the cracks. In some respects, the statute limits which veterans can access
 111

SemaI Tn..... ColUIIeIiag

VA', sexual trauma couuse1ing prosrIIDI in ways that are inappropriate given the cimmJstances of
the sexual trauma or harassment itself.

Current law requires two years of active duty service in order to be deemed a "veteran" for
the purposes of seekiDg geoeral VA bealth care. A VA UDder Secretary for Health's
lDformatioD Letter dated No~ 25, 1997, rcgantina "Eligibility Criteria for VA
HeaItbcare to Veta.w SeekiDg CouIIIeliDg or TreatmeDt for Sexual Trauma" indicates that
"thc: minimum Ieo&th of service mpIiraneDt in section 5303A does not apply to the
provision of tbeIc [sexual trauma COUIIlIeIiDg] beoefits. "

Second, members of the National Guard end reservists.whoare called to active duty are
eligible for this program. However, they are notcljgible.ifthe ~ happened
during training - "the law excludes active duty for training from the definition of 'active
duty'."

VVA feels that this JR8CDts some potaJtiaI ambiguities and we also fear a different, and
pabIps man: resIrictive, inlaj&Ctlllioo in the futun: - pIIIticuIady if reaoun:a become more
IIDd more coostniDed. 8ecIuse of the unique cimImstIm!les surrounding sexual trauma or
harassment in the mili1ary, some IDCIl end women victims' service careers may be
abbreviated. Some of the individwds involved in the situation at Aberdeen, for example,
may have left the service as a result of tbeIc incidents durins or shortly after 1beir training.
Also, members of a reseivc COIIIJIODeIlt called to active duty durins the p~ Gulf War
may not have a full ~years of active duty service to qualify ~or tbeIc needed treatments.

While cuneot VA interpretation of the law seems Iarae1y appropriate, VVA believes the
statute should be IJl(ldified to reflect the UDder Secretary's po~cy, ,1IDd further allow
reservists or members of the National Guard traumatized while on training exercises to be
eligible for VA's sexual trauma counseling program. Because this is current VA practice

2
 112

(baed upoo tbe Nowmbc:r 25, 1997 leUer), we do DOt IDticipate a liinmc:aat cost inc:Iease
would be assoc:ided with providiua statutory authority. ADd this would help to easun: that
men IDIl women in this catcaorY do DOt fall through the cracks.

8ecauIe this JlI'OIP8ID is discretiouuy uadr:r tbe C1Il'I'aIt Sllltute,it is DOt Ullivasally avan.ble.
Some veteras may be daDed _ for this disliDcdy Iervice-rebded 1I'IIuma if it is
~ at a pmic:ular &ciJity, or ifsufficieat _ _ _ DOt aYIIilabIe. VVA Ib"oIJiIy
belieYa tbIIt tbe I&mItDrj lIaa1IIIC IbouIcI be cbaDpd from "may" to "1balI," in Older to
emureuaifonD _ to VA .axuaI U - CXIIIIIIIIIIin& ei1ber cIiIectly or CCIDCrId or OCher
aervic:e modality.

VVA IIrOII8lY beIieYes VA IIIXUIl ~ CouIIIeIiDa IbouIcI be readboriadpa........y.

Recail"eVeaIs with tbe.-. at . . U.s. Army AbeIdeal ProYidiIIt 0IuuDd _ 0Iben IIIIIke
it ~ tbIIt .axuaI b.u.ma.t iad IIX1IIl ...at naIIiD ierious coa&:cnII wi1biIi "the
AImed Services, well. dIrouIboUt~. We c:.aDiIt expect this p"ObJem to diIIppcIr
witbiDtbe JIal,ar, two,... or fiw,-.. EWD if tile JDiJMy wen able 10 ~
cndicate tbe pubIem, .-y weer.. fiDeI that their PTSD sympkJmI ..&ce or JeqUire
lleatmeat ,.... t.ter. A peimImat JIIOIPIIl aIIbarity would ImIl a IIIoa& ....... 10
....._ adiw: duly miIi1Iry palOllDel dIIIl Coapas recopi2Iea the problem 1DIl_
..,....10 emure tbIltrcmaeat wiD be 1MIiIIbIe.

VVA ill pIe-.I to CDdonc IU. 2253, ......ed by RaakiDa Member Luis 0uIieInz oflbia
IIIi M"hinee 1biI biB wouId ..... tbe . . . ow.'" ClCIDCfIDI_ would..., ...... VA_
DOD to COOl. . . 0UIIeacb ill arder to provide beaefits iublllllliw to.,., ".... wbo may Med
tbeIe.w:cs. The . . . . 10 Caapaa wbicb would be JeqUinid by H.R. 2253 Ihauld be a UIdUI
tool ill -ma JIIOPIIIl efI'ec:dwaeII_ .... Ift:fed ...,.ovemeaIL

3
 113

Viebwa veteraus of America SenaI Trauma CCMIIIIeIiq

VVA also recommends that the Committee seek guidance from the VA Office of Women
Veterans and the VA Advisory Committee on Women Veterans, both of which have done
considerable work and analysis of these issues.

VVA further advocates that the Department ofDefeose be required to keep centralized data
on the numbers of assaultlharasSment cases reported each year by branch of service and by duty
station. It is our understanding that no universal data is currently kept by OOD on sexual
assaultlharassment incidents. Therefore, when one considers that sexual assaultJbarassment often
goes UIIIepOrtcd, the fact that no c:cnt:ralized data is maintained by OOD certainly leads us to believe
this problem is largely hidden. These reports should be aggregate numbers only, rather than
descriptive information, in order to protect the privacy of involved service personnel. This
information should also be made available to Congtesson a routine (protiably annual) basis, in order
to assist with Congress' oversight of these delicate issues and to assess overaUpiogress in combating
sexual assaultlharassment within the military. This analysis can also help our military leaders to
target particular problem _ with corrective and preventive actions.

As our nation's attention is drawn toward prosecuting the offenders in military sexual
barassmentltrauma cases, we must also be mindful of the needs of the victims - female or male
veterans whose lives and careers may have been destroyed by their experience of harassment or
abuse. While some leaders in Congress, the military and the media have c:hosen to focus on wbetber
or not co-ed training is good for the military, VVA is very pleased that Rep. Gutierrez bas chosen
to focus on providing appropriate care to the victims.

Vietnam Veterans of America bas been at the forefiont of advocating for the needs ofwomen
veterans since the Vietnam War. And we have seen a number of positive changes in the way the VA
treats women who served in the military. Sexual harassment and misconduct have long been
problems in the military. Holding high standards for conduct across-the-board - for both men and
women - is the best solution. And just as we expect to have appropriate counseling and medical

4
 114

Scmal Tn.... ColIIIIeIiq

services available to c:iviliaos who are barused or assaulted, military and VA programs should also
be available to victims of sexual trauma or barassmalt in a military setting.

LACK OF INCENTIVE TO "MILK THE SYSTEM" .

Some might argue that it is unwise oc inappropriate to euact certIIin p-ovisioos ofKR. 2253,
because some vetenms will use this program as a foot in 1be door for ~ VA benefits. VVA
c:aauot lee bow this would happen OIl any widespread scale, because the incentives just doD't exist
to attempt to manipulate 1be system in this way. H.R. 2253 does not address access to IDOIICtary
rompeasation beoefits whatsoever, and it does not open the door for the broad array ofbealth care
beoefits. The bill deals exclusively with IeXUIIl trIIuma COUoseIing iDd medii:ally DeCeSIIIlY care for
related bealth cooditioDS. '. . ..

It is extnme1y difIicult to imaaiDe wterans - women oc meil- lying about being raped oc
harassed in ~ to get free group oc individual couoselin& for this coaditioo. 1bae Idods of
therapy are deeply emotioaIl. paiIIfuI expericocea. Most people who do not aeed the tJaImcDt
would IIIMr c:boose to subject themselws to this therapy process. In additioD, therapists are well
traiDed aad sbouId be able to euiIy detect impoIIas.

VVA does DOt believe tbIIt 1be very remote poteatial of IlWillpretlIDiausioa 1be )JI'OpIIIIl
is a valid _ to preclude die minor adjuItmcIdB cmtemplaled in KR. 2253. 1bae propIIIl
moditicadoas are oecessary to eusun: access to ~ V * ' - in aeed of ~ trauma treGmeDt.

s
 115

VietDam Veteratll of America Saul Trauma ColIDHIiDg

CONCLUSION

We are hopeful that the Congress will enact H.R. 2253 to extend VA's authority to provide
sexual trauma counseling permanently and to eliminate restrictions on who can and cannot access
this therapy. Rep. Gutierrez' bill will address the inconsistencies of current law by making this a
uniformly avai1able, requiml VA program - not dependent upon whether or not a specific facility
provides the care. And it would make the program available to any veteran - male or female - who
is deemed by a menIIII. health professional to need this care.

Women represent a growing percentage of the total ~.S. military personnel. While women
are not the only intended beneficiaries of this proposed program extension, it is evident that there
cont,ip.ues.to bea problem of sexuallwassment and abuse in the military, and most victims are
women. The nature of existing redress mechanisms makes it difficult for many victims to report
these crimes - both within the military and throughout civilian wodd'on:e. VVA feels confident that
over time this situation will improve as women's roles become more integrated into the fabric of the
armed services and our broader society. However, until that seemingly utopian circumstance exists,
we must ensure that appropriate medical and mental treaIments are available to veterans who
experience sexual harassment or trauma during their mi1itary service. Congress must send strong
guidance on these points.

VVA appreciates this opportunity to submit views on the sexual trauma counseling program,
and loob forward to working with this Committee to successfully address this issue. We would
be very pleased to respond in writing to any questions the Committee may have.

6
 116

CD.
Vietnam Veterans of America, Inc.
1224 M Street, NW, Washington, DC 200055183 Tclcphone (202) 6282700

r::r . _ . - p;
"':1_......,., .
F.... : Maio (202) 6215180 Ad.....y(102)621-6997 ~(202)71)"912' _(202)62858.'
Worl4 Wid< 11'<b: E.-J 71154.101"_ _. _

A NotFor-Profit V~t~nms S~rvic~ Organization Chan~r~d by th~ Unit~d State. Congr

KELLI WILLARD WEST

DIrector of Govcmmeat Relatiou

KeUi Willard West became Directm-ofGovemment Relations in 1995, after serving within
the VVA govamnent relations department sinre in 1993. She is rcspcIlISible for coordinating VVA
govemment relations and legislative activities; advising VVA leaders on strategy; and overseeing
and training VVA's nationwide network of legislative coordinators in support of national VVA
advocacy goals. In addition, West keeps the gencral VV A mcmbersbip informed through reports
in 1he WA Veteran.

In la previous positiollS as VVA Legislative Assistant and subsequently Deputy Director

for Oovemment Relations, Ms. West was responsible for health care. Agc:ntOrange, PTSD and
reIaIed issues. 1il1994, West served as VVA's cbiefbcslth care advoCate during thenationa1 health
care reform debate, participating in the Departmeut of Veterans Affairs'Nationai Health Care
Reform Veterans Servi<:e Organization Working Group. Prior to joining the staff of Vietnam
Vetcrans of America, she served as Legislative Assistant in the U.S. House of Representatives, to
a Member ofCongrcss from ber home state of Iowa.

In 1997, Kelli Willard West was pn:sented with the WA Go1Iunment Affairs Distinguished
Service Award in recognition ofber extraordinary and tenacious commitment and service to VVA
and all Uoited States veterans. West bas testified before both the U.S. Senate Veterans' Affairs
Committee and the U .S. House of Representatives Committee on Veterans Affairs. On behalf of
VV A. she sits on the President's Committee on the Employment of Persons with Disabilities
Subcommittee on Disabled Veterans, as well as the Secretary of Labor's Advisory Committee on
Veterans Employment and Training.

KcIli received her B.A. with Honors in Global Studies from the Uoiversity of Iowa. She
resides in Alexandria, Virginia, with her husband Rich, who is COmmuoications Director for a
House member from Missouri.
 117

D
(D
_..... __ [l
Vietnam Veterans of America, Inc.
1224 M Street. NW. Washington. OC 2000S-S183 Telephone (202) 628-2700
Fua: MoioIlOZI621-SIIO' Ad.......,.1lOZI6ZS-699' C_oic:"_1102171J-4942' Fi___ 1lOZl621-S881

A NOI-For-Profir V~r~rans S~rvic~ OrgafJi'DliOll Cha"~r~d by r"~ U"ir~d Sraus Congrus

FUNDING STATEMENT
April 13, 1998

The aatiooaI orpnizaIion Viecuam VdI:DIIS of America, IDe. (VVA) is a IJOIl1lIOfit wtcnos
mcmbasbip orgaaiDtionregislr:rcd as a SOI(cXI9) wilh the Imemal RlMnue Service_ VVA is also
appropriately registc:red wilh the Secretary of the SeDate and the Clerk of the House of
Replelartatives in compliauce with the LobbyiDg Di8closme Act of 1995.

VVA is not curmrtly in RCeipt of 1liiY fedenl grant or CODtI1ICt, other than the routiDe
a1loc:ation of office space aod aaocWccl _ _ in VA Regioaal Offices for 0UIIadl and dinct
services through its Veterans Bcoefits Program (Service Representatives). This is also true of the
previous two fiscal years.

For Further Information, ConbIct:

Director of 00vI:mment ReIIdions,
Viecuam Veterans of America, Inc.
(202) 628-2100. extcasion 127
 118

Statement ofPlllrick G. Eddington

Executive DiRctor, Veterans for Integrity in Government
. to the
Health subcommittee of the Committee on Veterans Affairs
United States House of Representatives
23 April 1998

Mr. Cbairman, members of the committee. On behalf of Veterans for I'ntegrity in

Government (VlG), I want to thank. you for the opportunity to express our views on the
draft Gulf War illness legislation being considered today by the committee. As a national,
individual-member veteran advocacy organization, we are deeply concerned about the
plight of our ailing Desert Storm veterans. I applaud your efforts and those of your
colleagues to address this extremely important issue.

We have reviewed the draft bill provided to us, and we have a number of
observations regarding it's focus and content:

Pl'elWllptioa of IervKe COIlJIeetjoa for ilHlefiDed iIIII_

We applaud the committee's effort to come to grips with this difficult issue. We
would suggest, however, that the committee reconsider the five-year post-discharge
window for veterans to make claims regarding undiagnosed illnesses. VIG believes
stronaJy that any final bill passed by the Congress must not contain any "sunset"
provisions regarding presumption of exposure to battlefield toxins. The effects of some
toxic exposure&-Such as depleted uranium-may take decades to manifest themselves
as cancers or other serious medical disorders. Our Atomic veterans and Agent Orange
veterans know this painful lesson all too well.

Consider for a moment the question of depleted uranium exposures during and
after the Gulf War. Depleted uranium ammunition was fired by M-I tanks, M-2 Bradley
Fighting Vehicles, and A-I0 Warthog ground attack aircraft. The amount of depleted
uranium dispersed over the Desert Storm battlefield was unprecedented. The House
Government Reform and Oversight subcommittee report issued last year by your
Republican colleague, Mr. Shays of Connecticut, noted that

"This amount [6 tons of depleted uranium aerosol particles) in 4 days [of

the ground war) is more than 10,000 times greater than the maximum airborne
emissions of depleted uranium allowed in the air over Albany in 1 month."I

Based on the experience of our Atomic veterans, it may be years before a large
number of cancers begin to manifest themselves in Gulf War veterans. Even a "sunset"
provision that extends presumption of exposure through 2001 would likely still leave a
Jarge number of Gulf War veterans and their family members exposed to the ravages of
service-connected cancers without the ability to claim service connection. These same
concerns apply to the bill's provision to extend the existing period of presumption for
Gulf War veterans through December 31,2001 . It is very unlikely that all of the potential
cancers or 0Iher serious medical disorders associated with toxic exposures will have
manifested themselves by that time.

PrIority _ _ for IIeaItil care for Galf War vetenu

VIG welcomes the committee's initiative in this area and fully supports this
provision of the bill.

NatloDal Cster lor tile Stwdy of War-Related III.a_

This committee recommendation is a novel and intriguing approach to post-war

health care. To ensure it's success, however, will require careful implementation. VIG
 119

believes that the continuing efforts on the part of the Defense Department and the VA to
continue to c:aIqOriz.e Gulf War ilIncsses IS psychosomatic or SII'ess related show 1111
in<:unble institutional bilS. The IaIcst example arc the theories of "war-related
syndromes" being advanced by Captain Craig Hyams of the U.S. Naval Medical
Research Institute. On the PBS program FronJliM in Il11luary 1998, Captain Hyams made
the following staICIIICnt:

"If you read the medicalliteraturc, with all major wars the troops suffer from
psychological problems after the wars. Anyone who's been traumatized, their life
has been thrcatcncd, is going to have some problems afterwards.'

In reality, a two-year investigation by your colleague Mr. Shays found that "TIIen Is
ItO crdlbk etIitIDtu tIuJt stress or PTSD C/III.Sa 1M m - npolVtl by ...., Gulf
W.,.~. ,;J In VIG' s view, the Defense Department and the VA arc seeking to shift
the blame for Gulf War illnesses from the exccutive bran<:h (which allowed vctcrIIIls to
be exposed to these toxins) to the vctcrllllS (by claiming the vctcrIIIls arc "stressed" or
mentally unstable). Such characterizations arc not only medically insupportable, they arc
demClllling and insulting. Thus, VIG believes that neither the Defense Department nor
the Department of VctcrIIIlS Affairs arc the appropriate entities to create and maintain the
proposed Center.

We recommend that the Congress consider creating the Center IS a separate,

multidisciplinary research institute with no direct ties to either the Defense or VctcrIIIlS
Affairs dcpIIrtmcnts. VIG believes that lilly such Center should be staffed by medical
researchers, civilillll military specialists, and scientists who have shown a genuine
willingness to challenge prevailing views of war-related ilIncsscs IS stress-relatcd or
psychosomatic disorders. We urge the Congress to catcgoricaUy reject any attempt by the
Pentagon and the VA to promote Icgislative proposals that emphasize !Rating SII'ess over
dealing with the real physical i1Incsscs plaguing Gulf War vctcrllllS.

AIIiItia& Gll1fWar veteraaa: a pIaD of aetiota

VIG firmly believes that only strong, continuous Congressional oversight will
result in real changes in existing executive bran<:h Gulf War illness policy. The latest
example of the success of this approach is the March 3, 1998 GAO report (also requested
by Mr. Shays) entitled Gulf W.,. VI!tmIIU: l~ of n.-n 0umDt Be ReIJIIbIy
~ FI'O.. A~ DtW.4 As the rcpon makes abundantly clear, existing
Pentagon and VA databuc policies will Ulldcrslate the likely prcvaIence of can<:crs
among Gulf War vctcrIIIls. The continuing failure of DoD and the VA to deal openly and
honcst1y with the issues surrounding Gulf War Syndrome is why VIG and other vctcrIIIls'
advOC8())' organizations strongly favor removing the Pentagon and the VA from the dar-
to-day management of Gulf War illness research and databuc maintenance. Only a
research organization outside of the DoD-VA structure will have the ability to restore the
trust and confidence of the vctcrIIIls' community.

To ac:hicvc this goal, VIG favors the National Institutes ofEnvironmcntal Health
Sciences (NIEHS) because of its focus on toxic exposures and adverse health outcomes.
As the Gulf War experience has forcefully demonstrated, the modem battlefield will
contain ever-adlier weapons with potentiallifc-Iong after effccts for both the vctcrllll
tuuI his farnily---cbcmical and biological weapons; depIcted urmium; etc. In light of this
new military reality, it is imperative that the federal government IIIld private sector
medical communities focus more of their time and efforts on these new threats. VIG
believes that NIEHS--tn pu1Dcrship with the leading private sector medical research
institutions-providcs the best vehicle for meeting this challenge. This approach is
embodied in HR 3661, 11w PnrIa Gulf W.,. V'*'-IU' HesItIt IIIfIl MNiaII Rnarcll
Act 0/1"', offered by your committee colleague, Mr. Kennedy of MassachusctlS. We
urge you to hold a bearing to consider the merits of HR 3661, and to wort with Mr.
Kennedy to devise a compromise mcuure that combines the best clements of your draft
bill with those ofHR 366\.

2
 120

Mr. Chairman, let me conclude my remarks by thanking you and your colleagues
for your efforts to address the medical problems of our Gulf War veterans. I look forward
to working with you and your colleagues on the committee towards a measure that will
help restore the dignity and health of our Desert Storm warriors.
I GIll/War VelmJlu'llbtu6u: VA, DoDC_IO&sistSlrollgEvIdmce LInIdng TOIlic Caue. to
Chronic HeaJtIJ F,jfocI&. Houle Report IOS-388, Second Report by the Committee on 0 0 _
CMniabt II1II Refunn toptber with AdditionoI V-.. November 1, 1991, p. 114.
2 TIIIIICript of the 20 Jamwy 1991 F.-Jhw JII"OIIfIIII.

GIll/War V.-'II_ _: VA, DoD C _ to RniSl SIroIIg EYIde_ Unldng TOIlic Caue.rlo
ChronIc HIIIII F,jfocI&. Houle Report 105-388, Second Report by the Committee on Government
Owniabt II1II Refunn toaetber with AdditionoI V-.. Nowmber 1, 1991, p. 92.
GAOINSJAD..98..89.

3
 121
WRITTEN COMMl'ITEE QUESTIONS AND THEIR RESPONSES
CONGRESSMAN EVANS TO CAPl'AIN CRAIG HYAMS,M.D., U.S. NAVY,
INFECTIOUS DISEASES DEPARTMENT, NAVAL MEDICAL RESEARCH
INSTITUTE
CAPT Craig Hyams
House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 1

QUESTION: Your research concludes that the phenomenon, of

war itself may cause veterans' health problems post war. How
would it be possible to disprove this theory without alternative
explanations for veterans' illnesses after wars?
ANSWER: The research we conducted did not find the
"phenomenon of war itself" causes veterans' health problems. Our
research found:
a. Veterans of previous wars reported somatic (physical)
symptoms similar to those being reported by Gulf War veterans,
particularly fatigue, headaches, sleep problems, and
concentration and memory difficulties. These symptoms are also
reported frequently in all adult populations, especially among
individuals who are under physiological stress or have undergone
a traumatic experience. The etiology of chronic physical
symptoms and the most effective treatments for them are not well
understood.
b. While veterans of prior military conflicts reported a
variety of poorly understood somatic symptoms, a recurring, war-
related organic disease was not identified despite concerted
efforts taken after previous wars by the U.S., British, and
Canadian governments to explain the symptoms and to provide
medical care and assistance. Stress-related illnesses, like
combat fatigue, adjustment reaction, and post-traumatic stress
disorder (PTSD), have been associated with all wars.
 122

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 2

QUESTION: Would you recommend a new VA Center to study

"war-related illnesses" or can VA draw on its expertise in PTSD,
stress, and environmental hazards to address this issue?
ANSWER: This is a question more appropriately directed to
the Department of Veterans Affairs (VA), which has a better
understanding of its capabilities than I do. However, I think
that DoD should be involved in any program studying war related
illnesses because the participation of DoD researchers with
direct experience of wartime events would be invaluable in any
research effort. We have a previously unequaled opportunity to
study war-related health problems because more medical data was
collected during and after the Persian Gulf war than in prior
wars.
 123

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 3

QUESTION: Several epidemiological studies have done

"factorial analysis" to develop syndromes that can be found in
deployed and non-deployed populations. Have you attempted to
group syndromes you have found post-war in a scientifically
significant way? Have you compared veterans' post war syndromes
to those found in other populations?
ANSWER: Yes. In a collaborative study with British
researchers, we are currently evaluating pension records
maintained in the United Kingdom since the Boer war for possible
symptom patterns among veterans. However, there are serious
limitations to this type of approach. It is not possible to
specifically define a unique organic disease, as opposed to
psychological illnesses, using symptoms alone - objective "siyas'
of organic pathology, like abnormal laboratory test results, are
required to define a disease.
Attempts by the medical profession to use symptoms to define
postulated diseases began more than a century ago with the work
of Dr. George Beard to identify a unique fatigue-associated
disease, then known as neurasthenia (Beard G. Neurasthenia, or
nervous exhaustion . The Boston Medical and Surgical Journal
1869;3:217-20). More recently, extensive research efforts have
been directed toward defining "chronic fatigue syndrome," but a
specific and widely accepted case-definition has yet to be
developed. Consequently, the existence, etiology, and prevalence
of a distinctive chronic fatigue syndrome remains controversial.
Another major problem with factor analysis is that this
technique does not take into account reporting bias or
confounding from other causes of symptoms and is subject to
differing results depending on how the technique is performed an d
interpreted (Gould SJ . The Mismeasure of Man; chapter 6, Fact o r
analysis and the reification of intelligence. New York: W.W.
Norton' Co., Inc. 1981).
 124

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 4

QUESTION: Why do you suppose the somatic symptoms you

identified for different combat groups differed somewhat from
group to group?
ANSWER: It is difficult to determine why these common
complaints differed from group to group because symptoms are
subjective impressions of bodily sensations and therefore cannot
be quantified or easily counted and compared . Even with
demonstrable disease, self-reported symptoms are not consistently
related to physical impairment (Lane RS, et al. Discomfort and
disability in upper respiratory tract infection . Journal of
General Internal Medicine 1988;3 : 540-6). People tend to respond
to organic pathology in very different ways, which is one of the
reasons why it has not been possible to define unique diseases
using symptoms alone.

4
 l~

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 5

QUESTION: I asked you during the hearing for an opinion

about how compensation awards should be granted in VA. In your
testimony, you stated that basing service connection upon proof
of causation following future conflicts may be unrealistic and
that requiring a veteran to determine an association between ill-
health and wartime exposure may be "unrealistic." .
ANSWER: My statements related only to the need for medical
care after wartime conflicts and not to matters related to
compensation, like policy or guidelines for compensation. As a
000 researcher, I do not deal with compensation awards or
regulations. My comments reflect my personal opinion that war
veterans should have ready access to medical care from physicians
who understand veterans' health problems. The provision of g ood
health care requires more than diagnosis and treatment but also
includes answering patients' questions about their health
concerns. Veterans who participate in combat understandably have
numerous health concerns, which are related not only to stress
but also to many other potential exposures. If arrangements are
made before military conflicts to have veterans' health concerns
addressed and questions answered by qualified health care
providers, much uncertainty and unnecessary worry and suspicion
could be prevented in future conflicts. Waiting until a
hazardous deployment begins to initiate health care programs may
be too late because of the time required to authorize and
establish access to health care.
 126

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 6

QUESTION: Would you make the same comment about PGW

veterans.
ANSWER: Yes, I . believe that war veterans should have ready
access to medical care from physicians who understand veterans'
health problems .

6
 127

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 7

QUESTION: If it is unrealistic to expect veterans to prove

causality, as a scientist, how would you determine service
connection?
ANSWER: I am not qualified to address the multiple factors
that determine service connection but I can discuss the
scientific concept of causality, which I understand is not used
to establish service connection.
In a strict scientific sense, it is never possible to
demonstrate causality afteroa war because each war is a complex,
one-time event that cannot be duplicated or recreated in a
laboratory. There is too much uncertainly after a unique event
for retrospective research studies to rule out all possibilities
and conclusively determine causality; this is true for any
scientific question and not just Gulf war health questions.
"Evidence" of causality, however, can be obtained in
retrospective epidemiological studies. I would consider evidence
of causality to be good for a particular risk factor of organic
disease if the following were present:
a. The risk factor was postulated to be important before the
onset of any study and at least two independent research studies
of different subsets of a population found the risk factor to be
significantly and independently associated with a disease, with
an odds ratio (or relative risk) of three or greater, after
ruling out confounding and bias (selection, reporting, recall,
etc.); and,
b. The risk factor was related to a biological mechanism
that had been "demonstrated" to produce the same type disease in
question at presumed exposure levels rather than just
hypothesized to cause the disease. For example, assuming that
there is an underlying immune or neurological abnormality
producing disease is not sufficient without conSistent, objective
findings that patients actually have this abnormality.
These criteria for establishing evidence of causality are
widely used in biological science. Strict standards for
determining causality are necessary because: 1) computer programs
have been developed with data-dredging techniques that can
identify an unlimited number of possible associations in any
large data set; and, 2) e~roneous assumptions about causality can
lead to harmful treatments and changes in personal b~havior.

7
 128

CAPT Craig Hyams

House Veterans Affairs, 23 Apr 98
FY99 Health Issues
Q. 8

QUESTION: This Subcommittee has heard about research

conducted by Dr. Robert Haley that refutes the argument that
stress underlies Persian Gulf veterans' health problems.
Specifically referencing your study, he suggests that
"researchers did not have access to the types of epidemiological
and neurobiology research methods required to discover the nature
and causes" of complex problems suffered by veterans of the past
and that "officials adopted psychological explanations by
default." Would you like to comment on the Baley findings?
ANSWER: Dr. Haley is correct in pointing out that past
researchers did not have the research methods available today.
However, they did have one decisive advantage over modern
researchers: Past researchers had decades to follow their veteran
populations to identify any new or unique diseases. Serious
pathological processes generally do not remain stable but
progress, particularly as person ages and becomes less healthy.
If veterans of prior wars had had a serious, chronic, war-related
disease, it should eventually have manifested itself among some
veterans. But there are no SCientific reports of new diseases
being identified among veterans with unexplained symptoms . To
more thoroughly explore the possibility of a unique war-related
syndrome, I am collaborating with British researchers on a study
of prior war veterans that is using pension records maintained in
the United Kingdom.
In the clinical evaluation of prior war veteran populations,
psychological diagnoses were not arrived at just by default but
were based on decades of observation. The one consistent cause
of post-war health problems has been stress, because stress is an
unavoidable risk factor in any military conflict. However, Dr.
Haley is correct in concluding that PTSD can explain not all
post-war health problems, which is only one possible
manifestation of stress. Many different types of ~edical and
psychological problems were found among veterans evaluated for
somatic symptoms after prior wars.
Additionally, I would like to comment that I found the
previous questions well thought out and germane - the questions
go to the heart of the Gulf war health issue. Unfortunately, I
am unable to provide definitive responses because these issues
involve fundamental, unsolved health questions shared by all
adult populations. As stated by Sir Thomas Lewis in 1919 when
commenting on the war syndrome of the WWI era: "We are in the
borderland between health and disease __ ._..When we understand the
syndrome in all patients, we shall have knowledge which extends
throughout the domain of medicine." (Lewis T. The Soldier's
Heart and the Effort Syndrome. New York: P.B. Hoeber, 1919).

8
 129

8>
DEPARTMENT OF VETERANS AFFAIRS
WASHINGTON DC 20420

August 20, 1998

The Honorable Lane Evans

Ranking Democratic Member
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Congressman Evans:

Enclosed are the Department's responses to post-hearing questions 1-7

and 13-17, you submitted in your letter of April 24, 1998, concerning the April 23,
1998, hearing. We previously sent you the answers to questions 8-12 and 18-20
on June 11, 1998.

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

If we can be of further assistance, please contact me or Doug Dembling at

202-273-5628.

Sincerely,

JJtlt~J (jvA;'L Jl1(j{/~~

Sheila Clarke McCready
Principal Deputy Assistant Secretary
for Congressional Affairs
Enclosure
 130

~a.-tIona
c-rnIng the AprtI23, 1. . HIerIng

for
Dr. ~ GerIhw.n.
Deputy under SecnItIIry for Health
o.p.rtment of V n _ Affal,.

from
T1Ie Honorable ..... EVIUItI
RMkIng DemocnItIc Member
CornmIttM on VeIIInln.' Mal,.
U.S. Hou.. of Repraaentatlv.

1. Dr. GerIhw..... VA ellpl'MWd neither support nor oppoeItIon for the

propotI8I to euthoIta, for five yMr iM*-c:ombet, VA health cera treetment
for veteran. from future cornbet or war perIocIe. Ie VA aupportlve of auch e
propoaeI?

Reepon. .: Yes, VA supports the draft bill. However, ~ should be noted that the
draft bill under discussion on April 23, 1998, measured eligibility based on
discharge from service, not postcombat. It is clear from an historical review, that
every war in this century has been followed by reports of postwar Illnesses
among combat service members. VA Is committed to providing healthcare to
veterans with illnesses ralated to their mH~ry service. In studies of Vietnam and
GuH War veterans, higher morbidity and mortality has been reported during the
first five years of post-combat service.

In 1993, Public law 103-210 was -aed to 8stablish "priority" care for
certain GuH War veterans. (Similar legislation on behalf of Vietnam
veterans was enactad In 1981 and extended many times.) The 1993
legislation authorizes VA to furnish inpatient and outpatient care to
veterans for disebilMies poasI)Iy related to ellPOSUre to toxic substancas or
environmental hazards. during aClive duty service in the Southwest Asia
theatre of operations dUring the GuH War. Subsequent legislation signed
into law by President Clinton elCP8nded this authority to include all
disebllMies that are possibly related to GuH War service.

In view of tha precedent and facts described above, we believe it would be

reasonable to modHy eligibility law to provide VA health care servicas for
veterans from future combat or wars for five years post-discharge from service.

2. BeIng supportive of NatIonal Center for the Study of W.....ReIeIed

01 _ _ to Imply thai the w.,e~'" common ,eIementa
whether the ......... piece In V1eInem, GrenecIe, or the PersIan Gulf.

3. What do you believe _ the common eIem8nta of _ ? Would you give

lie a conc:reee example of expoeww thai ".......In VleInam and the
PersIan Gulf may have had In common?

Rnpon8e (2 and 3): Certain elements are unique to each mil~ry conflict;
others are similar. The most obvious element that Vietnam veterans and GuH
War veterans shared Is combat, which resulted in great stress (and in some
veterans: post-traumatic stress disorder, anxiety disorders, or depression, as
well as physiological problems). Some similar vaccinations were given to
veterans in both eras, although Vietnam veterans did not receive pre-treatment
for chernlcal/biological warfare agents.

Chemical exposures, Including from pasticldes and petrochemicals, are common

to GuH War and Vietnam veterans. These factors alone or in combination may
result In adverse health consequences 01 wartime service.
 131

4. In whIIt types 0I.auctr would you _ _ a c.nIer . . . .nv?

RHponee: We are beginning to leam that the variety of elCPQSUr&S elq)8rienced

by seIVice members during war can create significant alterations in their
physiological state. Although these alterations may not lead to readily definable
or det8ctable pathology, they can potentially lead to Illness and altered quality of
life. The proposed Center would focus Its research efforts on the oonftuenca of
wartime exposures (environmental. chemical, and psychological) and their
consequenoes to human health. Basic and clinical research would likely include
studies of the complex Interactions of the nervous system, the endocrine system,
and immune systems that can lead to altered health states. Research would
include approaches to better define these illnesses and their pathophysiology,
study potentlelly effective treatments, and develop improved preventive
measures. The Center would be a focal point for researoh, particUlarly Into the
development of treatments for war-related illnesses, education and training.

We envision that the Center would provide a focal point for actMty related to the
development 01 investigations of risk factors, preventive measures, treatment,
and basic research on wartime exposures, Including physiological and
psychological stressors. Also, a National Center for Study of War-Related
Illnesses would enhance our ablHty to create a comprehensive VA program for
post-war cOnical cara, medical education, health risk communication and
research. Active. DoD partnership and collaboration In the Center would be a key
to optimal performance. We believe that the Center could also be designated as
a central repository for maintenance of all joint VAIDoD deployment health and
environmental surveillance databases. These databases would provide the basls
for future research on preventive medicine efforts, risk factor analysis, and war-
related epidemiologic studies. An 4ducation and health risk communication
function at the Center would sAAr.. best practices and lessons learned
conceming clinical strategies a..d treatment for Ul-detined war-related Illnesses
with the Federal and non-Federal medical community. Center activities would be
coordinated with Health and Human Services and oCher appropriate Federal
agenCies throujtl the MilllaryNeterans Health Coordinating Board.

5. Dr. Garthw..... 1appIec:I* the filet that VA has not had ....... ttrna
to ...... an ~...apon.. to the PwaI8n Gulf IegIsIaIIon 1have
Introduced. 1kmMyou . . _ that H.R. 3271 ..... a kay component
01 the dndt lagI8IatIon thai VA oIIIcIaI. chcuaad with the V......,. ,..,.....
CommItIaa..........,. aatabIIahlng an ongoing IIdvIaorJ raIatIonahlp with
the InatItuta of IIacIIc!na at the _ldatIon of the "-IdanIIaI
Mvlamy CommIeaIon on ParaIan Gulf W. 1 1 _. .., biD ampIo,.
anOlhar _ _ MIatIon of that ComrnIaIon-uaing ~ . . a
modal for ct.IarmInIng c:ompanuIIon. rd lib your COI..... '1a on .....
aapKtaofH.R.327I.

Raaponaa: The Department Is currently developing its views on H.R. 3279.

After clearance by the Mnlnletrallon, we wit provide them 10 you .

... Your IMtInDty racommancIa ttwta VA c.nIer for the StudJ of W.

RaIIIIad ....... loa dMIgnaIad .. a rapoaItoI, for DOD dapIOJn .... haaIIh
and anvIroI_ .... .."aIIanca data. 0 - VA currantIJ have the
apprcIpItata mix of cInIcIana and r chara to ~ thI8 effort?
How couId1uCh dIIII anIIanca VA'. abIIIly to _ for WIarane?

Raaponaa: VA has the appropriate mix 01 clinicians and researchers 10

Implement the propoeiIl for a Center for the Study of War-Related 11IrIaMs. The
Fon:e Health Protection Plan Includes development of a lifelong health racon:J,
IncIlldingthe VNDoD Recruit Asses8ment Program (RAP). Under the RAP,
there would be routine collection of baseline hNlth data from aU military recruits
during the fInIt Week 01 recruit training. WIh this information, VA could more
accurately_luate-the Impact 01 military service on each veteran, dewIop

2
 132

prewntive medicine strategies, and provide clinical .care based on identified

veterans' needs.

7, I apprecIn the brOlld ICOpe of InvutlgatloM VA II Wldllrtaldng to look

at tIM eff~ of ... hIIIth caN trutmInt.nd _ PerIIIn Gulf
w_,..' MIIIf8ctIon with VA.-vIeet. Hal VA IIIIIdI any ettempII to look
at _ " . . , . . with PwIIan Gulf U I _ . , . not ulliIg VA .-vices?
RIIpon..: Thus far, we have focused our survey efforts on veterans who have
utilized our health care services. In this regard we have undertaken several
initiatives to improve patient 68tisfaction and the quality of care for Gulf War
veterans. In order to solicit specific opinions of Gulf War veterans a new national
customer satlsfaction survey 'Ambulatory Care Gulf War Era Veterans, 1997
National Survey Report" was mailed in the fall of 1997. The analysis of the
survey results was completed in March 1998. When survey partiClpants were
asked to rate the overall quality of their VA care during the past two months, 38%
of Gulf War veterans answered 'excellent' or 'very good.' Among the VA
general inpatient and outpatient populations, percentages of 'excellent' and
'very good' have been approximately 65% for this question. When asked if they
would want to be treated In the VA ewn if they could get free care in the private
sector, 24% of Gulf War veterans answered that they 'defin~eIy would' and
another 37% said that they 'probably would.' Among the VA general inpatient
and outpatient populations, percentages of 'derlll~eIy would' have been in the
middle SO's for this question. In general, the survey results Indicate that GulfWar
veterans who have utilized VA outpatient services find the overaU coordination
and continuity of care more problematic, and access to care and provider
courtesy less problematic. We anticipate that this national survey will generate
adequate statistical power from which to draw valid conclusions about these data
for quality improvement.

one can only speculate at this point why III Gulf War veterans 'are not using VA
services.' Our approach has been to study the reason for lack of satisfaction in
the veterans who usa VA Meith cera and attempt to improve our performance in
those areas (e.g., continuity of care, coordination of care, waiting times for
medical care and accesa to care). Veterans seeking Meith care, like consumers
In general, now expect and demand better service. We ara aware of the
expectations expressed by Gulf War veterans elCp8riencing medical difficuMies
and will continue to work diligently to providelhese Individuals with timely,
compassionate medical care.

(a..uonl ...12 refwIIacI ..xuaI trIumI ' -. The quMtlone and

_ _ _ WIfII'WI1C)Wd from thII ~ 8IId provldlcl ~ the CommItIM
on June 11, 1",,)

13. Would DOD eupport. VA Cent for tIM Study 01 WIfoAeIad ........
being dIIIgned . . . NpOIItory for DOD dIpIoyment hIIIth 8IId
IrIVIronrnentaI eurwllIance data? How would you forelM DOD working
with VA on IUCh .... effort?

RIIpon..: 000 support for this proposal Is a question you may wish to direct to
000. However, based on preliminaly dlscussioos (but not formal agreement)
with DoD officials, we think that DoD would support a VA Center for the Study of
War-Related Illnesses being desVlated as a (but nof an elCClusive) repository for
000 deployment health and environmental surveillance data. The VA Center
would be one of several sites within VA and 000 where this Information would be
compiled and readily available. In addition 10 the Meith and environmental
surveillance data, we will encourage DoD to share information about Its research
on weapons and defense against biological and chemical warfare agents.
 133

14. If 80khra __ deployed to the Gulf again next month, would the
be8ellne _ of health statu. - the _Inga, the "*ItII1 MeIth
118M8811181'1t', and blood ..".,... - you ref.r to In your tHtImony be
documented?

Raapon. .: Pre-depIoyment screening perfonned by DoD has been improved

but is still not optimal. Health screening questionnaires and blood samples are
currently being obtained. Baseline recruH assessment resutts are not currently
accessible from a standardized, centralized computer database. The proposed
VAlDaD Recruit Assessment Pr~ (RAP) mentioned in response to Question
No. 6, provides for the routine collection of baseline health data from all milHary
recruits during the first seven days of recruit training. The RAP would create a
computerized tracking database available to both VA and DoD by collecting
baseline health data using scannable questionnaires. UntU RAP and other health
surveillance systems are fuRy implemented there will be gaps in deployment
health surveillance information systems.

15. How long will h taka to ..... theM beaallne fll8HUraa and the
lurwlll8nce tool. r.quIraclarw In pIKe to an..,..
.n affectIw medlcel
tracking .yatem?

ReaponM: Necessary elements of the RAP could be eslablished within 24

months with full funding and backing. The tlmellne could easily expand or
contract depending on the priorHy the project is given by VAlDaD. It is absolutely
essential that a medical tracking system have baseline data to be effective. The
following development schedule is offered as an example:

a. 6 months -- InHial questionnaire development and preliminary pilot

testing.
b. 12 months -- Pilot testing, organization of questionnaire, and
establishment of a demonstration program in at least one recruH camp.
c. 18 months -- Full implementation of the program DoD-wide.

At this time, RAP is a proposal under consideration by VAlDaD. It has not yet
been approved or funded.

16. Do you bell.ve. Natlon.1 Center for the Study of W.r-Reletecllllne....

would bring c:apabllhy to find anaw.... about Meith conaequencea
euffarwd by PerIIen Gulf veterans end other era veterans that does not
currently exlet In DOD .nd VA?

Raapon. .: Research on the health consequences of war has historically

involved studies of isolated exposures and their outcomas. Research on combat
casuatties, Infectious disease, and PTSD are examples. These Isolated
approaches are necessary because the single exposures are so .dominant as
health threats that other exposures are less important a consideration in their
individual study. However, the whole experienca of war as a health threat has
never been the focus of a concerted Clinical, education, and research enterprise.
The aftermath of the GuH War, the Vietnam War and other wars in the past has
demonstrated the significant health Impact of war extending well beyond more
readily identifiable health efIects such as infection and wounds. The focus of the
proposed Center on the entire wartime experience would be unique in both VA
and DoD.

A National Center for the Study of War-Related Illnesses would provide a

conSOlidation of expertise and a focal point for clinical, research, and education
activHies. The Center would complement our current interagency efIorts by
cocrdinating all research on war-related Illnesses and expedHe the development
of health care and treatment methods to prevent future post-war health problems.
The Center would increase the likelihood of finding answers - but cannot
guarantee answers.

4
 134

17. What unique roIM might IUCh centIr play?

RMponar. By focuaIng on the heaIIh consequences 01 the entire wartime

elCp8rience, the proposed Center would be In a unique position to significantly
advance our understanding of war-related Illnesses, foster the development of
effective tnNltments for Ihe8e Illnesses, and Improve through education of health
care providers, the quality 01 care provided to Y8t8lllllS who may be experiencing
Ihe8e IIInesMs alone and In addition to other disease states.

We envision that the Center would provide a focal point for activity related to the
devaIopment of InWIatlgations of risk factors, preY8IItlYe m8ll8Ure8, tnNltment,
and basic _n:h on wartime 8JCpoSUr&8, including physiological and
psychological atreesors. The Center should be dee9lated as a VA coHectlon
point for complation 01 relevant DoD deployment '-Ill and enYIronmental
SUMllIance data. n- databasM would provide the basis for future _n:h
on prewncIve medicine, risk factor analysis, and epidemiologic studies. An
education function at the Center would share best practJoes and IeI80ns Ieamed
oonoemIng cIinIcallllnltegies and treatment for UkIefined war-f9lated IIInesus
with the Federal and non-Fedanll rnedcaI community.

(~I1I-20 ,.,...1C8CI ....... trauma ....... 11Ie.-aona and

_ _ _ _ NIIIOftCI from tIIIa PKUgI and pnMdad to IIIe CommIIIM
on June 11. 1".)
 135

DEPARTMENT OF VETERANS AFFAIRS

WASHINGTON DC 20420

JUN 111998

The Honorable Lane Evans

Ranking Democratic Member
Committee on Veterans' Affairs
U.S. House of Representatives
Washington. DC 20515

Dear Congressman Evans:

Enclosed is an interim response to post-hearing questions you submitted

in your letter of April 24. 1998. regarding the April 23. 1998 Subcommittee on
Health hearing on GuH War issues and sexual trauma counseling.

The answers provided will address the sexual trauma related questions
only. The other questions (1-7 and 13-17) will be answered in a separate
document as soon as possible.

Please have a member of your staff contact me if we can be of further

assistance.

Sincerely.

~61-'-
Acting Assistant Secretary
for Congressional Affairs
Enclosure
 136

Post-hearlng Questions
Concerning the April 23, 1998 Hearing

for
Dr. Thomas Garthwaite
Deputy Under Secretary for Health
Department of Vaterans Affairs

from
The Honorable Lane Evans
Ranking Democratic Member
Committee on Veterans' Affairs
U.S. House of Representatives

8. The testimony offered today, both yours and GAO's, Indicate that there
Is a growing need for sexual trauma counseling services. Your testimony
Indicates that VA Is supportive of extending VA's authority to provide
sexual trauma counseling until 1213112003.

Response: Yes, we support extending this authority.

9. Do you believe the program requires additional legislative

enhancements?

Response: The only additional Legislative enhancement necessary is an

extension of authority to continue the program. We believe we are able to
continue conducting a successful sexual trauma counseling program with our
current authority. VA is currently preparing comments on H.R. 2253, a bill that
was introduced by Rep. Gutierrez, Ranking Democratic Member, Subcommittee
on Health, House Veterans' Affairs Committee. H.R. 2253 would give VA the
authority to accept National Guard Members and Reservists for sexual trauma
counseling. When our views are complete, we will forward them to you
conceming that legislative proposal.

10. Ms. Furey and Dr. Van Horn, do you share this view? (You may answer
this question from a personal perspective).

Response: Both Ms. Furey and Dr. Van Hom are officials of the Department
with official responsibilities for VA's Sexual Trauma Counseling Program. It
would not be appropriate to have them providing un-official views on pending
legislation that directly concems their official duties.

11. How does VA distinguish "shall" provide and "shall give priority to the
establishment and operation of the program for sexual trauma counseling?

Response: We feel that the two terms both indicate the priority need
for a program for sexual trauma counseling in VA.
 137

12. How would VA change ..rvIce delivery H the program W88 made
mandetory?

Response: We feel that there would be no change from the existing

program in which counseling and related medical care for sexual
trauma are widely available throughout the system.

18. Is your central sexual harassment reporting hotllne stili

operating? Is there any Indication that the McKinney verdict has
had a dempenlng effort on the reporting of sexual harassment?

Response: Yes. Based on monthly conference calls with the field-

based Deputy Directors of the Women Veterans Health Program, there
has been no dampening effect on reporting sexual trauma to the VA.

19. Are you aware of how many active duty members aeek VA sexual
trauma counseling and treatment services? Are you . .are of the number
of local Memorandums of Understanding that have been approved by VA
and DOD treatment facilities?

Response: A number of local DODNA Memorandums of Understanding (MOU)

for providing sexual trauma counseling for active duty military are under
development across the system, however, none are final at this tine.

It is important to note that we are working with DOD to develop a national

VAIDOD MOU to provide sexual trauma counseling for active duty military that
would significantly expand availability of our services for active duty members.

20. It sounds like Inclvlduals seeking sexual trauma counseling through

VA may be severely penallz8d. perhaps putting their jobs at risk, H
Commander8 view aeeklng such coun..llng as evidence of PTSD and other
psychiatric dlsordera. How can an Individual seek counseling without fear
of reprlsel at the work place? .. there a way that Inclvldual8 can ...k
needed counseling without risking their careera?

Response: Records of care provided by VA are confidential. Of course, the

active duty individual must seek permission to go to the VA for treatment and
sharing agreements allow th. payer to review some care to the benefICiary for
audit and other purposes. This information Is protected from re-release to
persons who do not have a "need-to-know. Protection of these Individuals r9lt
to confidentiality would ultimalely have to be the responsl>ility of the Department
of Defense.

2
 138

CongresllllWU1 Evans to Richard Miller, M.D., M.P"H., Director, Medical

Pollow-up Agency, Institute of Medicine, National Academy of Sciences

I. Dr. Miller,)'OUl' -a.-y iDdicMM!bIt IlUdielIIIIIIeatUeIl by a NaIiaaaI c - fOr

Study of War-Related m - could have significaot implications fOr civiliaDs. Do you
believe there is a cJistinct neocI to eumIne mecJicaJJy unexpJainecl rnne.- in the combat-
exposeclvetenns' community? Could lludies of mec1ically unexpJainecl rnne.-Ibat are
equally relevant be performed IIIina data &om civiJian popuIatioaI?

Pem.ps, but COIIClusiOlll drawn &om civiJian lludies would have to be coofumecI in
miliwy popuJatiooa which have di1fereut demop-apbic and !:XIJOI1II'C cbaracteriJIica. The
greatest value of studiea of mecJicaJJy unexpJainecl i1IDeas data &om civilian popuIaticos
would be to cIeveIop hYJlOll-s for tesIina in miliwy and _ popuIlIicoa Combat-
exposecI_ will COIIIIitule a aufticieally Jarae pup to prOvide the required
statisticaJ powa-. Larae numbers of cocnpmabJe, unexposed c:aatroIa with uniform
opportunities fOr medica1 follow-up II VA mec1icaJ lilcilities will be avaiJahIc. In Ihe
abIeDce of a nationa1 health care system, DO civilian agcucy or reoean:b. JIIOIIP i. u _u
pl8cecl to study theM i1IDeases. 11Ua b partkuIarly true if VA and DOD are IUCCCllfuI in
developing the seamless, COIIIpUIerized medica1 record Ibat lhey are diICUSIing.

2. In your opinion, what are war-rellled i1IDeases and what should a center devoted to lheir
study cover?

The term "war-rellled iJlneuea" means the eotire spectrum of m- and _-hattie
injuries resulting &om hostilities, and the National Ceotel' IIbouId be prepuecI to exploit
targets of opportuDity in lDy area ofwar-related i1IDeas. But, hiItorically. the ~
portion of theM rn-. particu1uIy Ihe 0DeI with delayed 011IIII, remainllIIIClqIJainecI
A NaIiaaaI Ceoter for Study ofWar-RelIIecI m-Ibould IIddreu, u a priority
miuiOG, theM delayed 011IIII, mecJicaJJy UDCXpJainecI dIroaic umea-.

3. Will you explain )'OUl' staterDeIIt: "Saying Ibat a minority oflhe _ on Ihe reptries
have DOt heeo cIiapoeed implies .1evel of uocIentaDdins of war-Nlated i1IDeas Ibat does
not exist."

Published information coacemlng the POHR. and CCEP Itatea !bit moot resiatrmta fit
into certain diagnoIIic cateaories IIIdl u mUICuloIkeletal diseues or diseue of tile skin
and suhclllllDeolll tissue. 11Ua hu led some readers to coo1iJsem- clauifi~oD and
cJiseue cJiagnosis. ICD-9 codes are DOt cJialll'oses; they are coaveoieDt clUlifi~OIII
often for aclministnrtive rather than mec1icaJ plllpOlCS. AclcJitjoaally; to make a diaanoois
of acne in a patient complaining of insomnia, increased fatigability, and recurrent
hadacbea does DOt offer ID adequaIe expImotion of the patient'l health problems. The
VA and DOD ofticiala II1d researchers are DOt trying to miIlead ..yooe. but IDIDY
reacIers have tile mistaken impreuion !bit only 18% to 20% of ~ are clleaorized
u "SympIDms, ligna, and ill-clefined coacJitioos" and therefOre mecJicaJJy unap1ained.
11Ua IiIct hu DOt heeo llUfficieotly empbuizecl.

4. How do you think we should cJauify mec1icaJly UIIdiajpIoIecI rnne.- if DOt throuah
cIiqDOstie codes and other t001l o1rady existing in Ihe mec1icaJ community? Is there no
value in Ipplyins theM codes to study pOIIible Iymptom syndromes or identify profiles
ofpopulati0D8? What's the alternative?

There is value in classifying illness using ICD-9 codes u long u one recognizes Ibat
these are lugely symptom classifi~OIII and DOt diagnoIIic categories u DequentJy
stated. An adcJitionaJ mocJifier should be required for esch m- code stating whether.
in the opinion of the examining physiciaD, this m- code explains the patieot'. chief
complaint IDd usociated lymptomI and lips. Such. req~ would reveal the true
frequeDcy of mecJicaJJy unexpJainecl i1lneuC1 u a subset of war-related i n -.
 139

s. What do you believe are the most important ~ fiDdinp about Penim Gulf War
vetenos' heUtb ccmsequences to date?

The most striking fiDdinp are the Depliw resulta from well conducted studies of
hospiWizatiODS, birth cIefects, IIOd mortUity. These fiDdinp haw fon:ed us to recognize
that we are experiencing _large outbreak of medically unexplained iIIDeaaea following a
major deploymeut, IIOd a1most cen.inly DOt for the tint time.

6. Do you believe this group experienced UDique exposures that may have adversely
impIcted their heUtb or are they most suffering from syudromes charlcteristic to veterans
of other wan or within the civilian population.

There appears to be no unique exposure affecting Persian Gulf War Veterans. The
reviews of Dr. Hyams' and othen have indicated that epiclemica ofmedicaUy
unexplained iIIDeaaea follow most ~or bosIilities. The work of Dr. Kroeuke2 show that
civilian primary care clinic patieota, IIOd even DOlI-patient popuIatioOI interviewed in
community surveys, haw high mea of symptom complaints similar or identic81 to those
of Persian Gulf War Veterans. Life u indeed "dim vast vale ofteara'" whether one is a
warrior or not> What u 11IIknown is how much the mea of medically unexplained
illnesses are elevated by the -.on associated with war IIOd to wbat _ they can be
prevented. Is the risk of developing i11Deas in respoose to war-associated stressors
uniformly dUlributed among mi1itary personnel, or are there amaUer subsets that are at
undue risk? Can tbeae individuals be identified and immllllizecl againat tbeae 1lIreIson?
Is it ethical to send tbeae individuals into combat? These are ooly _ few of tile important
questiOJll that might profitably be Iddreased by ~ at Naticmal Center for Study of
War-Re1atecl111Desses.
I. Hyams CH, W"qpWI FS, _ R. w. syDdromeo ooc1their evo\uoIloa: &om tbo US Ciw W.to tbo
PcnImOUlfW. AIm-"Med.I996; 125:398-405.

2. KroeIIb K, Price RIC. Symptoms iD tbo CommuaIty: I'mIIeuI:e, Coal_on, ooc1 ~

Comorbidity. An:h.1Dem. Med. 1993;153: 2A7....2AIO.

3. SboIIey PD. Hymn to iDIeI\ecluoIlIeouly H.

 140

House Committee on Veterans' Affairs

Subcommittee on Health
April 23, 1998
Hearing on Persian Gulr Issues
Chairman SWRtpi:'.- "'""'-"I
Gary A. Christopherson
Question 1

Question 1: Would DoD support a V.~ cemer for the study of War Related Illnesses being
designated as a reposirory for DoD deploymem health and environmemal surveillance data'
How would you foresee DoD working with VA on such an effort')

Answer: No. DoD does not support a V A cemer being the repository for DoD deployment
health and environmental surveillance data. The U.S. Army Center for Health Promotion and
Preventive Medicine (USACHPPM) is the DoD Executive Agent for medical surveillance
databases. USACHPPM is responsible for planning. coordinating and conducting epidemiologic
analysis of deployment medical surveillance data. Because of operational imperative and
timeliness of reporting. maintenance of such databases should be under DoD control at DoD
facilities. DoD does support datasharing agreements with V A and considers cooperation and
joint research efforts critical to the success of the proposed National Center for Study of War-
Related llInesses.

The Department of Defense is working closely with the V A regarding our preparations to protect
the health of our U.S. forces during furure deployments. and prepare for their health needs upon
their rerum home. The establishment of this Center with participation of DoD researchers and
clinicians with direct experience of wartime events would be invaluable in any clinical. research
or educational effort. Epidemiologic srudies of risk factors for developing war-related illness
with the goal of preventing them or at least ameliorating their effects are essential.

The work of a National Center for Study of War-Related llInesses may have major implications
for civilian health care. It is clear that medically unexplained illnesses are by no means limited
to veteran populations.
 141

House Committee on Veter.lns Affairs

Subcommittee on Health
April 23, 1998
Hearing on Persian Gulf Issues
ChainnanStulRp ~....,...;)
Gary A. Christopherson
Question 2

Question 2: If soldier5 were deployed to the Gulf again next month. would the ba5eline
me:l5ures of he:llth status you refer to in your testimony be documentedry (i.e. the screenings. the
mental health assessments. and blood samples)

Answer: 000 is carrying out the requirements for pre- and post-deployment health assessments
and the related medical recordkeeping. On February 20, 1998, CENTCOM updated their
deployment policy to implement comprehensive joint medical surveillance measures for
deployment into the CENTCOM area of operation (AOR). The CENTCOM requirements follow
the requirements in the August 1997 DoD Instruction 6490.3. Implementation and Application of
Joint Medical Surveillance for Deployments. The CENTCOM policy includes completion of
pre-deployment health assessments and serum sampling; completion of post-deployment health
assessments; daily and weekly dise:lSe and non-battle injury (DNBO reporting; environmental
monitoring of the air, water, soil, and radiation based on assessment of actual and/or potential
health threats in deployed locations: oversight of individual and unit preventive medicine
measures; and immunization tracking with enhanced focus on the anthrax vaccine. Other
Unified Commands are implementing the joint medical surveillance requirements, including
deployment health assessments, for major deployments. The Joint Staff is providing direction to
coordinate the requirements and procedures among the Unified Commands.

During the past year, over 31,000 military members deploying to Southwest Asia have
completed pre-deployment health assessments, wbich include questions to assess mental health
status. in CONUS or in theater. Military members who have spent more than 30 days in the
CENTCOM AOR are completing post-deployment health assessments upon their return. DoD is
using this recent experience and the "lessons learned" to revise and refine the deployment health
:lSsessment questionnaires and procedures.

There is an active program of DNB! surveillance and environmental monitoring in the

CENTCOM AOR. Joint medical surveillance teams (JMSr, are in the CENTCOM AOR to
closely monitor and report on compliance with force medical protectionl~urveillance initiatives.
including vaccinations administered in theater.
 142

House Committee on Veter.ms' Affairs

Subcommittee on Health
April 23, 1998
Hearing on Persian Gulf Issues
Chairman ~ >tLA-O
Gary A. Christopherson
Question 3

Question 3: (If no. suggesled follow up:) How long will il lak~ 10 ensure Ihese baseline
measures and Ihe surveillance lools required are in place 10 ensure an dfeclive medical Iracking
syslem"

Answer: Refer 10 queslion 2.

 143

House Committee on Veterans' Affairs

Subcommittee on Health
April 23, 1998
Hearing on Persian Gulf Issues
Chairman .......C.,.lo...-va
Gary A. Christopherson
Question 4

Question 4: Do you beii~ ';~ a National C~nter for the Study or War-Relat~d Illnesses woulJ
bring a capability to find answers about health consequences suifered by Persian Gulf veterans
and other era veterans that does not currentl y exist in DoD and V.A:?

Answer: Yes. DoD agrees that establishment of this Center with coordination and participation
by DoD clinical and research entities could and would contribute to ongoing studies of risk
factors for developing war-related illness with the goal of preventing them or at least
ameliorating their effects. This Center would likely contribute to and augment existing efforts
ongoing in VA and provide a locus of activity augmenting existing DoD and VA collaborative
efforts.
 144

House Committee on Veterans' Affairs

Subcommittee on Health
April 23, 1998
Hearing on Persian Gulf Issues
Chainnan i'lI...,
C'Ut:>",,:r
Gary A. Christopherson
Question 5

Question 5: (If yes) What unique ro!es might such a Center play'~

Answer: A primary role of the proposed :-.Iational Center for Study of War-Related Illnesses
should be study of risk factors for developing war-related illness with the goal of preventing
them or at least ameliorating their effects. Wars pose unique combinations of psychological and
environmental exposures. A center organized around the phenomenon of war-related illnesses.
rather than a single discipline or disease. can bring together the appropriate mix of expenise and
foster appropriare collaborations. This locus of activity could bring new insights and resources
for studying the c:wses of war-related illness.

The recently published work of Dr Hyams and his colleagues indicate that the problem of war-
related illnesses is much more complex than originally believed and has been with us after most
major military deployments. As has been the case with the Gulf War. in future conflicts
medically unexplained illnesses might constitute the majoriry of the resulting medical problems
of veterans. The lack of a ready answer to the causes of these illnesses suggests the need to look
at the problem in new ways.

The work of a National Center for Study of War-Related illnesses may have major implications
for civilian bealth care. It is clear that medically unexplained illnesses are by no means limited
to veteran populations.
 House Veterans' Affairs Committee
Subcommittee on Health
Research on and Treatment of War-Related Illnesses
Sexual Trauma Counseling
April 23, 1998
Mr. Gary A. Christopherson
Question 7

Question 7: .~re you aware of how many active duty members seek VA sexual trauma
counseling and treatment services'! Are you aware of the number of local Memorandums 0['

Understanding that have been approved by VA and DOD treatment facilities'!

Answer: Traditionally. our Active Duty service members have received their health care through
our direct care system of over 100 military hospitals (the Military Treatment Facilities (MTFs))
and several hundred clinics. We do not have a mechanism in place to track active duty members
who seek sexual trauma counseling and treatment services from the VA.

A Health Affairs policy. dated November 1997. required each MTF to perform a needs
assessment to include a review of local VA and MTF resources to determine the adequacy of
such care for this area of treatment. Feedback on the results of these needs assessments are not
complete. However. several military treatment facilities have reported that a Memorandum of
Understanding (MOV) with the loCal VA is currently being pursued for sexual trauma
counseling.
 146

House Veterans' Affairs Committee

Subcommittee on Health
Research on and Treatment of War-Related Illnesses
Sexual Trauma Counseling
April 23, 1998
Mr. Gary A. Christopherson
Question 8

Question 8: It sounds like individuals seeking sexuai trauma counseling through V..1. may be
severely penalized-perhaps putting their jobs at risk-if Commanders view seekIng such
counseling as evidence of PTSD and other psychiatric disorders. How can indi\'iduals seek
counseling without fear of reprisal at the work place" Is there a way that individuals can seek
needed counseling without risking their careers?

Answer: The Department is committed to providing the highest quality of care to our service
members; both in the military direct care system as well as health benefits provided through
agreements with other care providers, including the VA. Individuals are encouraged to seek
needed counseling without fear of risking their careers. Information shared between a patient
and their provider is considered confidential. Our service members have a right to expect that all
communications be considered in confidence. All individual identifiable medical information is
protected and use is restricted for health care purposes only. Only upon a clear legal basis for
disclosure is information made available outside this arena. However, our system still must
focus on the mission readiness of our troops. Military unique mission readiness creates some
special exceptions for Active Duty personnel in our system. Command responsibilities for
security issues related to personnel shoUld not be compromised. Nuclear Surety and Personnel
Reliability Programs require knowledge of psychiatric treatment The confidentiality of the
individual's medical information will continue to be balanced with the Commanding Officer's
need to know the health status of his command.
 147

B-28OO37

Mq21, 1998

'11Ie HoIIonIlIe LIne Evaw

RanIdJIc MinoIit ~
Canm!ttee 00 VeWme' AmlIn
Houle of Repreeentatlves

~ WQIIMII V......... 1fea!th Cvt; VA Ecrgrta to J!eeood to the

A'"." of PmuIcIpc 8'1"" Tpgg. QomeIInf

Dear Mr. EvIns:

'11Ie encloIed InronnIIion reIJII(JIIds to ,our follow-up quesIIoos about our

teIIdJnoo.J before the SubeoaImlttee 00 HesIth 00 AIJdl23, 1l1li8, 00 VA.. 1IelI.Ual
trauma eouneeIIDg prosnms laid IIJIlI)IementI tbIt~. We will make
copies of tbIs COClespondeace avadIabIe to otber IntereIted JIIltieII 00 nquest.

If JOG .... II\)' ~ or would lib to ~ tblllIIfonIudion fIIrther,

. . . . eonIICt _ 011 (202) 612-7101.

9IDcenlJ' JOUIlI,

~~
DIreetOI', V. . . .' ADIn laid
MiItIrJ BeIIIh c.e J . -
EDdoIure
 148

ENCLOSURE ENCLOSURE

stm DfflNTN. INFORMATION ON VA'S

SEXUAL 'I'RA1JMA COUNSELING PROGRAMS
1bIs encIoIIure details your questions and our responses, which 9Upplement Infonnation In
our teallmooy before the Subcomm1ttee on Health, Women Veterans' Health Care' VA
morts to JWmnd to the CbaIIenae of Proyld!ng Sexual Trauma Cowwllnc (GAOIT
HElJS.98.138, Apr. 23, 1998).

I. Did ~ ....e attempt. to eoatact womea veteraD.l' eoonllDaton at medical

fadIld_ 01' recloaal om_ dudq J01I1' 8tDdJT Bow aeee.lble by plaoae
are tIteJT Would ~ ~ tIaat VA dtlldpate more fIIll-dme
COCII'dIDatonI?

11K! acope of our won did not Include calling women veterans' coordinators to
detennIne tbeD' ~ by phone IlOI" did we try to determine whether VA needs
mon fuB.Ume women veterans' coor"dInatonI. 11K! olUect1ves of our study were to
determine (1) the extent to which sexual trauma counseling services are available, (2)
the extent to which women veterans are U8Ing these services, and (3) what VA Is doing
to evaluate the effectlveness of its sexual trauma counseling programs. Before IltartIng
our 1Itudy, we neither !mew that the accessIbI11t of women veterans' coordinators was a
concern, nor did women veterans indicate that they had 9Uch concerns during our
discussions with them. The WOIJleII veterans' coordinators at the medlcat centers we
visited were full-time coordinators. The women veterans' coordinators at the two
regtooal otrIces we vIBlted, however, were part time; although both expreesed a desire to
bave mon time for outreach efforts, they did not indicate that they could not respond to
women veterans' concerns and calls.

Z. DId J08 ....e IUI7 effort to .,..,..ucally evaluate lDdlYiduala' prefereuee

for eo-ua& aenleee Ia VA, lD Vet Center&, or by CODtract? WIIat were
J01I1' ftaclIDaB aboIlt tile adYutaaee or cllAdYutaaee to cue lD eaela
IM!UIq?

We did not evaluate individuals' preferences for counseling services In VA, Vet Centers,
or by contract. We asked women veterans what they liked and disliked, however, about
the bealth care and counseling eervIces available to them. 'lbe women we spoke with
were generally pleued with the eervIces they were receiving regardless of the !letting.
'lbe women veterans who were receiving counseling In Vet Centers liked the less formal
atmoaphere and thoUllht the Center save them more privacy. One veteran commented
that IIhe worked for VA and felt lite could better keep her collllgellng conftdentlal at the
Vet Center.

3. 181t GAO'. oplDloa tIaat VA .... adeqaate reeo1l1'ee8 to addreM die powlq
deauld for tIaeIIe eenleee?

Our review of VA's sexual trauma counseling program did not Include an analy9Is of VA's
resources so we cannot evaluate the adequacy of VA's funding for sexual trauma
counseling services. It Is dIftlcult to IdenW) the resources allotted for sexual trauma
counseling because funding for most of VA's sexual trauma counseling programs Is not
eannarll:ed or spedftcaIly IdenWled. Although Vet Centers mq possibly be able to
ldenW) sexual trauma counseling resources because they IdenW) the counselors
dedicated or quaII1Ied to provide this coUlUlelln& this Is not the case for medlcat centers.
Sexual trauma collllgellng Is one of many services provided with reeources allocated for
medlcat centers' mental health care. We did note In our testimony, however, that staff
IIJSOCIated with the sexual trauma collllgellng programs at three locations we visited
eJqIf"e&I!Ied some concern about their ablIIt to adequately respond to the demand for
COIIIIIJeIIng.

Did J08 _ _ aeede for IUI7 eDIlaDeed &1ltlaorl~ for VA eexual tnl1llll&
eo1lll8ellq eenleee dDrilll you ltady?

Our won revealed that (1) reservIsI8 and NIUooaI Guard personnel traumatized wt1IIe
IIerVIng 011 actM! dut for trIIInIn8 and (2) individuals traumatized while on actM! dut

2 GAOOIEII8-98-1'l'lR VA 8enal Truuu Co1lll8ellq

 149

ENCLOSURE ENCLOSURE

but seplll'llted from the mlI1tary with less than 2 years of aervlce are not eJISIble for'
8eJlUII trauma counseling. AceordIna to 11\ opUUon by VA'. omce 01 the General
CounIeI, leIIaIaIM amendment would be needed to make tbe8e veterww eJISIble rill'
aemal trauma counaeIII1t AIthougb we do not know to wIuIt eztent thIa presents
problem rill' tbe8e veterww lII&Ionwtde, VA otIldIIs told 111 that IIOIIIe of tbe8e
IndIvIduIIs have UIIIIICcelISfII 80Ulht care In the VA syatem. 'lbIa is one area that IIU\Y
wurant cloeer auenuon and addIUonal ewluIIIon.

(406163)

3 GA0iJIEII.S..98-1T1R VA Sena1 Tra..a CouueIIDI

 150

-.-
For God and Country
* WASHINGlON OFFICE * 1608 "K" STREET. N.W. * WASHINGTON. O.C. :zoooa.2847 *

May21,1998
(202) 8812700 * FAX (202) 881-2728 *

The Honorable Lane Evans

Ranking Democratic Member
Committee on Veterans Affairs
333 Cannon House Office Building
Washington, DC 20S IS

Re: Ouestjons Re!ated to Hearing on Am 23 1998

Dear Congressman Evans:

Thank you for inviting The American Legion to testify at last month's hearing
concerning Gulf War Dlnesses. Attached please find The American Legion's response to your
written questions.

Sincerely,

~~;<L-:.
MATIHEW c.puGUSI
Assistant Director
Persian Gulf Task Force
 151

I. W1IaI are the UgioIt 's lriglwstlegislative prlorltiaJOr PenimI Gulfvetmms?

~ The American Legion's bighest legislative priority is 10 encourage Congress 10

pus a bi-putisan bill that includes provisiona from HR 3279 (Penilm GulfYetuaIIs Act of 1998)
and the draft bill writIien by Congreuman Clift'StJems. Each billlllcldes dilTen:nt problems that
Gulf War veIaaDI, and tidure veII:nnI, cum:atIy conftoot.

2. W1IaI are the most iIIfportIIItI antIS ofresarch YA IUId otherfet/DrJl agenda C<IIt pursue?

~ Clinical trials designed 10 cIetamine elTective medical1reatments for sick Gulf

War vetams are the most impor1ant inveatipliOllll that the federaI government can pursue.
Helping sick Gulf War vetams IIOW, while the basic science is learned, is the most appropriate
course of action. The clinical trials currently unc1envay, thanks 10 language you included in last
year's authorization bill, will belp address !his n=.

3. The veterans' CO/IIIIIU1Iity has been disinclined to accept the uw. that stress may play a
significallt role in tire physical symptoms many veteran.r experience in the aftermath ofwar, yet,
your testimony s_to mpport tills as a liJr.eIy riskfactor. Severa/.commwions have been
strollgly criticizedJOr drawiltg tills same conclusilm. Ifjimue studies iltdictlle stress is liJr.eIy to
cause IIIIUIJ' poor health _ in veteran.r, how would you advise researchen to publicize
this fouling ill a way thai veteran.r deem more responsive?

~ The vetams' community, on the contrary, bas recognized the role _ plays
in the physical symptoms that many veterans experience after wars. The vetams' community
recognized the existence of Posttraumatic Stress Disorder (PTSD) long before the Department of
Veterans Affairs did. Physical symptoms are associated with PTSD, and with other mental
illnesses Ions ackoowledged 10 be caused by combat service. The psychological consequences of
combat are well known 10 vetams.

The conIroversy in the case of Gulf War vetams heslth is not wbetber any of them
suITer from PTSD or other mental illnesses as a result of their combat service. There are Gulf
War vetams who have been diagnosed with these illnesses, as one would expecl The heslth
registries nut by VA and the Department of Defense thoroughly screen patients for mental
illness. The controversy is over the possible link between lIOn-traumatiC s~s and adverse
physiological heslth outcomes in sick Gulf War veterans who do not have mental illnesses.

The research on !his topic is in its early stages. The Presidential Advisory Committee's
Filial Report recognizes this fact by carefully explaining that "scientists are beginning 10 IIIII1lvel
the physiological connection between tile brain and various parts of tile human body," and,
furthermore, that "some researchers suspect that the inadequate production of stress hormones
and _ response occurs in some (not all) humans with CFS [Chronic Fatigue Syndrome) and
PTSD." Suspicions are not data or research fmdings. and tile PAC's finding that stress is a likely
cause of GWI is premature at best The PAC is not alone, however, as you point out in your
question. Nevertheless, one of the nation's leading PTSD experts commented last year that
'''Iikely' should not be used by the PAC 10 deacn"be stress. Not yet"

My testimony bighlighted tile scientific findings 10 date regarding aeveraI risk factors that
may cause Gulf War Illnesses. Stress was amoog them. but The American Legion does not
support _ as a more likely risk factor than any other under investigation.

The American Legion's position on the investigation of possible risk factors that Gulf
War veterans were exposed 10 is that they all should be investigated. This includes stress. The
American Legion does not favor one risk factor over another, nor will it reject one before the
scientific studies are completed. It cautions tile research community, as it did the PAC, 10 not
jump 10 conclusions regarding any of the possible risk factors until the over 100 scientific studies
are completed.

The American Legion believes tltst the Veterans Service Organizations (VSOS) have an
obligation 10 publicize research findings in a responsible manner. Researchen have an obligation
10 perform scientifiCally sound investigations. Researchers who may publish findings regarding
any risk factor, including stress. and poor heslth in Gulf War vetams should ensure that their
findings are valid and can be generaIized 10 tile entire Gulf War vetams population. The peer
review process should ensure !his outcome. It is the job of tile VSOS 10 explain the significance
of the findings after they are published, not the resean:hen.
 152

4. You suggatlabelillg IIIIJ)' ilrlpair ~ of'-1lll. Haw do)lOtl avoUi labcliltg tIIId still
give MertIIU IIt/01'7lfllll0fl tIIey ...,.., about t1teir IteaJIh can co1UlitiOll$?

ADImI: The clinical medicalli1ll:ralme repnIs non-labeling as III effective way to help
certain sick patients return to aood health. Patients with difficult to diaJPlOlC conditiona are
found in every hospitallllCl mcdicaI prKtice, not just VAMCs. Medical cIocton have found that
instead of labeling such patients with diqnoaia that IIIIJ)' fit, the beat method i. to not offer a
diagnoais. The phyaician sbouId acknowlcdae that the patient', pain ot fatigue is real, IIICI work
to UIiat the patient in aettin& well. The phyIiciIII could prcacribe medications, ot tach the
patient coping aechaiquca. The f _ is OIl healing. Sick veterans already know that they Arc ill.
They WIllI. diqaoIia. but they WIllI to gel bella' even _

o
 ISBN 0-16-057507-9