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. 3 HEALTH CARE PROBLEMS AND CONCERNS OF PERSIAN GULF WAR VETERANS: THE RESPONSE OF THE DEPART- MENT OF VETERANS AFFAIRS AND THE DEPARTMENT OF DEFENSE AND RELATED ISSUES ^Y 4. V 64/3: 103-33 Health Care Problens and Concerns o. . HEARING BEFORE THE SUBCOMMITTEE ON 0\^RSIGHT AND IM^STIGATIONS OF THE COMMITTEE ON VETERANS' AFFAIRS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION NOVEMBER 16, 1993 Printed for the use of the Committee on Veterans' Affairs Serial No. 103-33 U.S. GOVERNMENT PRINTING OFFICE 3-904CC WASHINGTON 1995 : ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments.CongressionalSalesOffice,Washington.DC 20402 ISBN 0-16-046657-1 ] HEALTH CARE PROBLEMS AND CONCERNS OF PERSIAN GULF WAR VETERANS: THE RESPONSE OF THE DEPART- MENT OF VETERANS AFFAIRS AND THE DEPARTMENT OF DEFENSE AND RELATED ISSUES Y 4, V 64/3: 103-33 Health Care Problens and Concerns o... HEARING BEFORE THE SUBCOMMITTEE OX OVERSIGHT AND IM^STIGATIONS OF THE COMMITTEE ON VETERANS' AFFAIRS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION NOVEMBER 16, 1993 Printed for the use of the Committee on Veterans' Affairs Serial No. 103-33 -? s U.S. GOVERNMENT PRINTING OFFICE 0-904CC WASHINGTON 1995 : ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments.CongressionalSalesOffice.Washington,DC 20402 ISBN 0-16-046657-1 COMMITTEE ON VETERANS' AFFAIRS G.V. (SONNY) MONTGOMERY, Mississippi, Chairman DON EDWARDS, California BOB STUMP, Arizona DOUGLAS APPLEGATE, Ohio CHRISTOPHER H. SMITH, New Jersey LANE EVANS, Illinois DAN BURTON, Indiana TIMOTHY J. PENNY, Minnesota MICHAEL BILIRAKIS, Florida J. ROY ROWLAND, Georgia THOMAS J. RIDGE, Pennsylvania JIM SLATTERY, Kansas FLOYD SPENCE, South Carolina JOSEPH P. KENNEDY, II, Massachusetts TIM HUTCHINSON, Arkansas GEORGE E. SANGMEISTER, Illinois TERRY EVERETT, Alabama JILL L. LONG, Indiana STEVE BUYER, Indiana CHET EDWARDS, Texas JACK QUINN, New York MAXINE WATERS, Cahfomia SPENCER BACHUS, Alabama BOB CLEMENT, Tennessee JOHN LINDER, Georgia BOB FILNER, California CLIFF STEARNS, Florida FRANK TEJEDA, Texas PETER T. KING, New York LUIS V. GUTIERREZ, Illinois SCOTTY BAESLER, Kentucky SANFORD BISHOP, Georgia JAMES E. CLYBURN, South Carolina MIKE KREIDLER, Washington CORRINE BROWN, Florida Mack Fleming, StaffDirector and ChiefCounsel SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS LANE EVANS, Illinois, Chairman MAXINE WATERS, CaUfomia THOMAS J. RIDGE, Pennsylvania BOB FILNER, California SPENCER BACHUS, Alabama LUIS V. GUTIERREZ, Illinois TERRY EVERETT, Alabama JAMES E. CLYBURN, South Carohna JACK QUINN, New York MIKE KREIDLER, Washington JILL LONG, Indiana (II) CONTENTS Page OPENING STATEMENTS Chairman Evans 1 Hon. Jack Quinn 2 Prepared statementofCongressman Quinn 103 Hon. Thomas J. Ridge 5 Hon. Mac CoUins 6 Prepared statement ofCongressman CoUins 106 Hon. Joseph P. Kennedy II 6 Hon. Spencer Bachus 11 Prepared statement ofCongressman Kreidler 104 Prepared statement ofCongresswoman Brown 105 WITNESSES Albuck, Troy, accompanied byKelUAlbuck, Barrington, IL 19 Prepared statement ofTroy and Kelli Albuck 168 Blanck, Maj. Gen. Ronald R., Commanding General, Walter Reed Army Medi- cal Center 72 Brown, Hon. Jesse, Secretary, Department ofVeterans Affairs; accompanied by Dr. John T. Farrar, Acting Under Secretary for Health; Dr. Susan H. Mather, Assistant Chief Medical Director, Environmental Medicine and Public Health; Dr. Susan Ritter, Ph.D., MPH, Persian GulfFamily Support Program Coordinator, Persian GulfHealth Advisory Clinic Co-Director, VA Medical Center, Birmingham, AL, R.J. Vogel, Deputy Under Secretary for Benefits; J. Gary Hickman, Director, Compensation and Pension Service, Veterans BenefitsAdministration; and Mary Lou Keener, General Counsel 82 CuUinan, Dennis, Deputy Director, National Legislative Service, Veterans. ofForeign Wars ofthe U.S., accompanied by Brian Martin, Niles, MI 31 Prepared statement ofMr. Cullinan 176 Egan, Paul S., Executive Director, Vietnam Veterans ofAmerica 33 Prepared statement ofMr. Egan appears 184 Gelband, Hellen, Senior Associate, Health Program, Office ofTechnology As- sessment, accompanied by Maria Hewitt, Senior Analyst, Health Program, and Clyde J. Behney, Assistant Director, Health, Life Sciences and the Environment 3 Prepared statementofMs. Gelband 157 Hollingsworth, Kimo S., Assistant Director, National Legislative Commission, TheAmerican Legion 31 Prepared statementofMr. Hollingsworth 179 Jackson, Dr. Charles, Environmental Physician, StaffPhysician, StaffPhysi- cian, VA Medical Center, Tuskegee, AL 58 Prepared statement ofDr. Jackson 218 Martin, Brian, Niles, MI 25 Shayevitz, Dr. Myra B., Director, Cardio-Pulmonary Laboratory, Pulmonary Rehabilitation Program, VA Medical Center, Northampton, MA 56 Striley, TimothyJames, Fulton, IL 22 Prepared statement ofMr. Striley 171 (III) IV MATERIAL SUBMITTED FOR THE RECORD Documents: Analysis and amendment to H.J. Res. 15 44 Written committee questions and their responses: Chairman Evans to DepartmentofVeterans Affairs 221, 223 Congresswoman Long to DepartmentofVeterans Affairs 237 Chairman Evans to Dr. Myra Shayevitz 238 Chairman Evans to Department ofDefense 243 Chairman Evans to Veterans ofForeign Wars 263 Chairman Evans to Dr. CharlesJackson 265 HEALTH CARE PROBLEMS AND CONCERNS OF PERSIAN GULF WAR VETERANS: THE RESPONSE OF THE DEPARTMENT OF VET- ERANS AFFAIRS AND THE DEPARTMENT OF DEFENSE AND RELATED ISSUES TUESDAY, NOVEMBER 16, 1993 House of Representatives, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, Washington, DC. The subcommittee met, pursuant to call, at 9 a.m., in room 334, Cannon House Office Building, Hon. Lane Evans (chairman of the subcommittee) presiding. Present: Representatives Evans, Montgomery, Gutierrez, Ken- nedy, Long, Kreidler, Ridge, Bachus, and Quinn. Also Present: Representatives Browder and Collins. OPENING STATEMENT OF CHAIRMAN EVANS Mr. Evans. The hearing will come to order. On June 9, the Subcommittee on Oversight and Investigations conducted a nine-hour marathon hearing on the health care problems and concerns of Persian Gulf War veterans. From veterans and their loved ones, we learned that many who served are now chronically ill. These heroes of the Persian Gulf War are shackled by a wide array of health problems and symptoms. They had been healthy and physically fit before their Gulf services. Now, they cannot re- sume the active and productive lives they led before serving in the Gulf. These ongoing health problems were reemphasized last week when the full committee, at the request of Congressman Joe Ken- nedy, conducted a special hearing and received added testimony from more than a dozen individuals. In June, we also learned veterans and active duty servicemen and women were not always receiving priority medical attention for their health problems. In some cases, veterans were reportedly told they would not receive care until they made a copayment. In other cases, repeated efforts to get help from their government produced only repeated failure. Some Gulf War veterans turned elsewhere for help. Others simply gave up. Witnesses representing VA and DOD told the subcommittee some GulfWar veterans did have health problems, but a diagnosis had been elusive. More research was needed. Gulfveterans' health (1) problems were not a mystery to several private physicians who ap- peared before the subcommittee. But while they identified cause, diagnosis and treatment, their answers were not the same. In the 5 months since the June hearing, what has been done and what has been learned about these health care problems? How have the VA and DOD responded and how have they worked together? What research has been conducted and what new information has been gained? What treatment is being provided and is it suc- cessful? What has been learned from the Gulf War Registry programs? Do we know what happened in the Gulf and the causes of these health care problems? Has all the information which might be essential for effective treatment been provided? These and many other related subjects are the issues before the subcommittee today. I am very pleased at this point to recognize the distinguished chairman ofthe full committee, Sonny Montgomery. Mr. Montgomery. Thank you very much, Mr. Chairman. As you said in your statement, we need to get all of the information and all of the facts we can about chemical weapons that could have been used or not used in the Persian Gulf. I commend you for having this hearing, and I commend you for starting on time. Mr. Evans. Following your leadership, Mr. Chairman. The gentleman from New York. OPENING STATEMENT OF HON. JACK QUINN Mr. QuiNN. Thank you, Mr. Chairman, and thank the chairman of the full committee, Mr. Montgomery, for reminding the three of us that we are on time. Mr. Chairman, I appreciate more than any the work you have done on this issue, and look forward to hearing testimony this morning. It seems that each and every week more information comes to light on this matter, and the important thing for all of us to recognize and to keep in the forefront of our minds is that we don't fool around and wait with this thing. Time is of the essence, and the sooner we get to it the better. I think all ofus agree with that. I will have an opening statement for the record, but I appreciate the time [The prepared statement of Congressman Quinn appears at p. 103.] Mr. Evans. It will be included in its entirety, and we salute you for being here at the beginning, as you are regularly. Mr. Quinn. Thank you. Mr. Evans. The subcommittee's first witness today is Hellen Gelband, Senior Associate, Health Program, Office of Technology Assessment. She is accompanied by Maria Hewitt and Clyde Behney. Hellen, your entire statement will be made part of the hearing record, without objection, and you may proceed when you are ready. Ifyou care to summarize, you may do so. STATEMENT OF HELLEN GELBAND, SENIOR ASSOCIATE, HEALTH PROGRAM, OFFICE OF TECHNOLOGY ASSESSMENT, ACCOMPANIED BY MARIA HEWITT, SENIOR ANALYST, HEALTH PROGRAM, AND CLYDE J. BEHNEY, ASSISTANT DI- RECTOR, HEALTH, LIFE SCIENCES AND THE ENVIRONMENT Ms. Gelband. Thank you, Mr. Chairman, for the opportunity to participate in this hearing. PubUc Law 102-585 charged the Director of OTA with assessing the potential utihty of the DOD and VA Registries for "scientific study and assessment of the intermediate and long-term health consequences ofmilitary service in the Persian Gulf." Our first report, issued 2 months ago, focused on the Department of Veterans Affairs Persian Gulf Veterans Health Registry, which is the examination program initiated by the VA for Persian Gulf veterans. We also started to look at how the Defense Department is carry- ing out its mandate, developing a geographic information system linking troop locations with exposure to oil well fires. When Congress directed the VA to create a Registry for health examinations of Gulf veterans, the greatest potential hazard ap- peared to be the smoke pouring from hundreds ofoil wells that had been set on fire by the Iraqis. The Defense Department mandate also centered on assessing the risk to health posed by the fires. Once completed, the DOD system may be used in various ways to consider possible health damage from oil fire smoke. DOD will be able to tell individual veterans about his or her level ofexposure by using daily company locations and modeled estimates of air pol- lutant concentrations, although it will be difficult to explain just what those exposures mean in terms of the veteran's health. The DOD system also could be used to identify cohorts of individuals with relatively high and relatively low exposures to the oil fire pol- lutants should it be decided that it is necessary to do in depth studies. The emphasis on oil fires as the exposure around which both DOD and VA conducted their activities, however, means that it will be much less useful for exploring other potential hazards. The limi- tations ofDOD's and VA's mandated activities are worth noting. The VA Registry can provide only descriptive information about the individuals who requested an examination either because they are sick or because they fear potential ill effects of their Gulf service. The hope is that the individuals who do come will serve as sen- tinels for health problems that might be emerging among Persian Gulf veterans more widely, but no valid conclusions about cause and effect can be made on the basis of the Registry population alone. The task ofdeciding whether to pursue a possible health problem in a separate study will be the big challenge and one for which there is no set ofrules to follow. The judgments ofexperts in medicine and epidemiology will have to be relied on and strong dif- ferences ofopinion about what to do are guaranteed. The DOD system will be used mainly for studying the effects of oil fires and possibly also for other geographic variables, but al- ready there are concerns about inoculations, depleted uranium, ve- hicle paint, diesel fumes, and chemical warfare agents to name a few, and these will benefit relatively little from DOD's Registry ac- tivity. Whether or not these represent real threats, they must at least be acknowledged and considered for further evaluation and that work will have to proceed on an ad hoc basis in addition to the mandated Registry. Decisions about whether epidemiologic studies should be under- taken will be made ultimately on the basis ofexpert opinion offered by the Institute of Medicine's Medical Follow-up Agency, and, of course, also by VA and DOD. But there is no neat formula for them to make those decisions. The lOM's job could be made easier however, by making sure that they have an accurate historical record of troop activities in the Persian Gulf and that there is a clear idea ofwhat information about possibly hazardous exposures exist in personnel and other military records. This information is not now easily available, as we found out when we were asking to get records ofthat sort. OTA's report includes the following suggestions: (1) that specific changes be made in the Department of Veterans Affairs' examination protocol; (2) that coordination between DOD and VA be strengthened, perhaps by appointing a single advisory board to oversee both activities, which would be independent of VA and DOD and would include technical experts and veterans representatives; (3) that the Department of Defense assemble information about the Persian Gulf Conflict, including the specific activities of military units and the distribution ofother potential exposures and experiences. Next, that DOD and VA each catalog and describe other medical information available for Persian Gulfveterans from before, during and after their tours of duty, such as their intake examinations, blood samples that may have been stored and other medical examinations. And finally, that VA and DOD standardize the terminology that they are using in their activities. We believe that that is relatively simple and should be happening now. We are working on our second mandated report which will focus on DOD's Oil Fire Modeling Project. This includes the development of a geographic information system which comprises satellite map- ping, atmospheric monitoring, modeling of contaminant concentrations, and health risk assessment, all being carried out currently in a pilot phase by the Army Environmental Hygiene Agency. The Army expects to report on the pilot project at the end of the calendar year, and OTA's report is due in February. Those efforts will eventually incorporate troop location data being assembled by the U.S. Army and Joint Services Environmental Support Group. OTA will report on the technical merit of each major component and on how the system will work together. A particular concern and one that requires coordinated effort between VA and DOD now is how information about individual risks will be communicated to veterans. Thank you again for the opportunity to appear here, and we will be happy to answer any questions. [The prepared statement ofMs. Gelband appears at p. 157.] Mr. Evans. Thank you very much.