PROGRESS OF RESEARCH ON UNDIAGNOSED ILLNESSES OF PERSIAN GULF WAR VETERANS

THURSDAY, MARCH 9, 1995

House of Representatives,

Subcommittee on Hospitals and Health Care,

Committee on Veterans' Affairs,

Washington, DC.

The subcommittee met, pursuant to call, at 9 a.m., in room 334, Cannon House Office Building, Hon. Tim Hutchinson [chairman of the subcommittee], residing.

Present: Representatives Hutchinson, Smith, Quinn, Bachus, Stearns, Ney, Flanagan, Edwards, Kennedy, Clement, Tejeda, Gutierrez, Baesler, Bishop and Doyle.

Also Present: Representatives Buyer and Evans.

OPENING STATEMENT OF CHAIRMAN HUTCHINSON

OPENING STATEMENT OF HON. CHET EDWARDS

STATEMENTS OF DR. KENNETH W. KIZER, UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF DR. STEPHEN JOSEPH, ASSISTANT SECRETARY FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE

STATEMENT OF DR. RICHARD JACKSON, DIRECTOR, NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. PUBLIC HEALTH SERVICE

STATEMENT OF DR. RICHARD MILLER, DIRECTOR, MEDICAL FOLLOW-UP AGENCY, INSTITUTE OF MEDICINE

OPENING STATEMENT OF HON. JACK QUINN

OPENING STATEMENT OF HON. SANFORD BISHOP

STATEMENT OF STEVE ROBERTSON, LEGISLATIVE DIRECTOR, THE AMERICAN LEGION

OPENING STATEMENT OF CHAIRMAN HUTCHINSON

Mr. Hutchinson. The subcommittee hearing on the progress of research related to undiagnosed illnesses of Persian Gulf War veterans will now come to order.

And I would like to take this opportunity to welcome our distinguished panel of witnesses, most of whom are here, some of whom are, we're hoping, going to make it with the inclement weather this morning. We thank you for taking time to testify before our subcommittee this morning. And I look forward very much to hearing your testimony so that we can determine the progress of the research with regards to the multitude of undiagnosed illnesses being experienced by our Persian Gulf veterans.

I would also like to welcome two members that we expect to be here for the subcommittee hearing this morning, Representative Steve Buyer and Lane Evans, both of whom are not members of the subcommittee but have been at the forefront on this issue since it was first made public 4 years ago.

Mr. Steve Buyer is a Persian Gulf veteran who came home to experience many of the symptoms being felt by many of his colleagues. Mr. Lane Evans was Chairman during the 103rd Congress of the Veterans' Affairs Oversight and Investigation Subcommittee. In that capacity he held a number of hearings on this issue. His assistance was vital in the passage of the three Persian Gulf illness-related pieces of legislation that were signed into law during the last 2 years. We warmly welcome their participation this morning.

I am pleased that our first subcommittee hearing deals with this very important matter. There are dozens of studies currently being conducted to determine the causes of these baffling ailments. I look forward to hearing this testimony so that we can learn the status of many of these research projects.

Persian Gulf veterans deserve, in expeditious fashion, to be told why they are experiencing these problems. And I am hopeful that the Federal Government is doing all in its power to find these answers and that money directed for Persian Gulf research will not be to the detriment of other VA research priorities.

This subcommittee also welcomes the President's recent commitment to get to the bottom of this puzzle. I trust that this subcommittee and the full committee will be working with the administration to ensure that money going to pay for research is spent in the most effective manner. The American taxpayer deserves no less, and our veterans deserve no less.

The Veterans' Affairs Committee has led the way in providing assistance to those veterans whose sicknesses are attributable to service in the Gulf. Three separate pieces of legislation were passed by our committee and signed into law during the 103rd Congress. Public Law 103-210 authorizes health care on a priority basis for Persian Gulf veterans. Persian Gulf 103-452 extends the eligibility for care for Persian Gulf veterans for covered conditions until December 31, 1995, and Public Law 103-446 permits the Secretary of Veterans' Affairs to compensate Persian Gulf veterans for undiagnosed illness, requires the development of a uniform medical evaluation protocol and case definition or diagnoses, and requires the Secretary to evaluate the health status of spouses and children of Persian Gulf veterans. Our job is not complete until the questions are answered, the mystery is solved, and the anxious minds of suffering veterans are eased.

I would like to give special recognition to Bob Stump and to Sonny Montgomery, who have worked together on a bipartisan basis and have really exemplified the kind of bipartisan spirit that has historically characterized and been the hallmark of the Veterans' Committee and whose diligence and hard work guaranteed that Persian Gulf veterans would be given priority attention as we try to find a reason or reasons for these illnesses.

Once again, I welcome each of our witnesses, and I look forward to your testimony this morning. I would now like to recognize the subcommittee's ranking member, Chet Edwards of Texas.

OPENING STATEMENT OF HON. CHET EDWARDS

Mr. Edwards. Thank you, Mr. Chairman. Let me first congratulate you on this being your first meeting as Chairman of this important subcommittee. It is a great responsibility, and I know you'll carry it out very well. I look forward to working with you.

I think it's a compliment to you, and I hope it sends a message to veterans across this country that the subject of your first committee meeting is on the Persian Gulf illness problem. There are dozens of issues that deserve hearings that we will have hearings on, but I think the fact that you chose this, put this at the top of the list, is a compliment to you, Mr. Chairman, and says, I think for members on both sides, how important this issue is to all of us.

Let me also congratulate Mr. Kennedy, Mr. Buyer, and Mr. Evans, who is not here, but members who on their own have made this a real cause and brought the problems of this situation to the attention of other members of this committee through their leadership. I know we don't always agree on every issue, but I think in this case these particular members have been real leaders in helping our veterans that served in the Gulf War.

Let me just finally say that to me the bottom line is that we simply cannot rest until we have done everything possible to understand and to successfully treat the illnesses of American men and women who answered the call of duty to fight for freedom in Desert Shield and Desert Storm. That's the purpose of our meeting.

Mr. Chairman, thank you for recognizing me. We look forward to hearing the witnesses.

[The prepared statement of Congressman Edwards follows:]

S6621 Prepared statement of Hon. Chet Edwards

Thank you, Mr. Chairman, for scheduling this session, which represents the tenth hearing on issues relating to the health status of Persian Gulf veterans held by the full Veterans Affairs Committee or one of its subcommittees.

Today's hearing represents a particularly important step in our efforts to advance research on undiagnosed illnesses among Persian Gulf War veterans. Its timing signals the priority we give this issue. More important, I hope this session will provide a framework for achieving consensus on directions the Federal Government should be charting in our common search for answers.

For the sake of our new members, the first in this series of ten hearings was held in September 1992. As the chairman indicated, since that time Congress has enacted several pieces of legislation. Among these are measures providing for establishment of the Persian Gulf Registry (Public Law 102-585), priority treatment for Persian Gulf veterans (103-210), and most recently, compensation for those individuals who are seriously ill but are still undiagnosed (Public Law 103-446). In Public Law 102-585, we laid the foundation for the Institute of Medicine to provide recommendations on future directions for Federal research relating to the health of veterans of Persian Gulf service.

In focusing today on the IOM's assessment and on the status of Federal research efforts, I look forward to this morning's testimony.

Q04

S6602

Mr. Hutchinson. Thank you, Chet. I really am delighted to have you as the ranking member and look forward to working with you on a many projects in this Congress. I cannot think of anybody that I'd be more delighted to serve with. Thank you for those kind words as well.

I want to welcome the witnesses on Panel 1. We're glad to have you here this morning. It looks like, Dr. Jackson and Dr. Joseph, have arrived, and we're delighted. I would like to begin by having Dr. Kizer come up to the witness table. We would remind you that your full statement will be included in the record. If possible, please keep your comments under 10 minutes.

Thank you, Dr. Kizer.

Dr. Kizer. Thank you, Mr. Chairman, and members of the subcommittee. I certainly appreciate this opportunity to discuss with you this morning the various Department of Veterans Affairs activities relating to Persian Gulf veterans and the illnesses that have been experienced by some of those veterans.

STATEMENTS OF DR. KENNETH W. KIZER, UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY DR. STEPHEN JOSEPH, ASSISTANT SECRETARY FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE; DR. RICHARD JACKSON, DIRECTOR, NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. PUBLIC HEALTH SERVICE; DR. RICHARD MILLER, DIRECTOR, MEDICAL FOLLOW-UP AGENCY, INSTITUTE OF MEDICINE

STATEMENT OF DR. KENNETH KIZER

Dr. Kizer. Let me first reaffirm the VA's commitment to provide high-quality compassionate medical care to our Persian Gulf veterans, our commitment to compensate those veterans who have become disabled as a result of their service to the nation in this conflict, and our commitment to pursue research that may lead ultimately to an understanding of the cause, or causes, of the illnesses experienced by those who have served in Desert Shield and Desert Storm.

Let me also take this opportunity to emphasize President Clinton's personal commitment to the Persian Gulf veterans and especially his concern for and commitment to finding answers to why some of the veterans have become ill. His commitment in this regard was again demonstrated earlier this week when he announced the formation of a Presidential advisory committee to broaden the involvement of independent scientists, physicians, and veterans in this complex issue.

In 1993, the President named the Secretary of the Department of Veterans Affairs to coordinate Government research efforts to find the cause of health problems being experienced by Persian Gulf veterans. To date, the coordination of research activities has been provided by the Interagency Research Coordinating Council, a working group of the Persian Gulf Veterans Coordinating Board. This Board coordinates the research, clinical, and compensation issues related to Persian Gulf veterans. It is composed of Secretaries Brown, Perry, and Shalala. The Research Coordinating Council is chaired by the VA. It monitors the activities and work products of various research efforts and recommends future research directions.

Mr. Chairman, as you know, I'm new to the VA, having been on the job now about 4 months. Much of the time that I've been here has been spent learning about the myriad of programs conducted by the VA as well as in drafting a plan to restructure the Veterans Health Care Service so as to fundamentally change how it conducts its business. This plan should be submitted to Congress within 2 weeks.

I've also spent a considerable amount of time learning about all that's been done to try to understand the problems experienced by our Persian Gulf veterans, especially with regards to the various investigative efforts that are underway or that are planned.

I've also focused attention on some gaps in our research program and our infrastructure in dealing with the problem. With regards to the latter, I might note that I've done a number of things, including elevating the Office of Public Health and Environmental Hazards. This is the VA program office that is principally responsible for Persian Gulf issues. I've elevated it so that it reports directly to me, and I've also augmented its staff by four FTEs. Currently I am looking to see if additional staff is needed in that office as we expand our activities in this area.

I've also asked the Research Coordinating Council to develop a tactical plan for future research activities, and I have shared with them some of my thoughts about what I see as further research needs. If we have time, I'll be happy to discuss some of those with you this morning.

We have also intensified our educational and information dissemination efforts, as well as our efforts to reach out to nongovernment investigators so as to benefit from a broader input to our efforts.

One of the things that I found in coming into this is that the overall strategy or overall game plan, if you will, is not perhaps as well-articulated as it should be. And in the remaining few minutes that I have this morning, I thought it might be useful to walk through the strategy as I see it, or at least conceptually how I've organized and how I hope to pursue our efforts in this regard, focusing especially on the research issues since that is a subject of this morning's hearing.

In brief, we have a four-pronged effort or approach to the Persian Gulf veterans. The first prong involves providing medical care. This involves providing priority care, which you touched on in your opening comments as well as the Registry exam program for those veterans who are either ill or not ill but wish to have their condition documented for the record. We have also named several VA referral centers, and I do expect to increase the number of such centers in the days and weeks ahead.

The second prong of the overall strategy is one of outreach and education. We have targeted particularly three audiences: first, professional care-givers, i.e., our physicians and others who need education, to standardize the exam and what it is they're being asked to look at. If you consider the problem you will see why this is so important. There is a fundamental difficulty in how a physician is goint to approach the diagnosis of undiagnosable conditions. And so we've tried to take some steps to standardize the approaches and make sure that our physicians and other care-givers around the country are approaching things in a uniform manner.

We have also targeted the general public, as well as patients, and have recently increased the number of information vehicles that we have available to provide to patients or the public.

In addition to printed materials, we have turned to the media and have focused on not only professional literature contributions but also things that can go in newspapers and other public forums. We also have established the few hotline which I know you are familiar with. The hotline has been very well-received and has fielded literally tens of thousands of calls already.

The third prong of our overall approach is disability evaluation and compensation. These fall into two categories: those who are handled in the routine manner and those that fall into the under-diagnosed illness category.

And, finally, the fourth prong of the effort has to do with research. Here, again, I conceptualize our research activities into four areas. The first is the epidemiologic studies that are being pursued and some additional areas that need to be pursued in the future. This includes both descriptive epidemiologic studies as well as hypothesis-driven epidemiologic investigations.

We have a number of basic science projects underway, and we are looking at additional ones that may compliment what is already being done.

There is an array of clinical investigations underway; these investigations focus on pulmonary problems or other organ-specific problems, as well as behavioral, neuropsychiatric, and other clinical conditions.

And, finally, the last category of research has to do with the environmental concerns per se. There are various research activities in this arena.

Instead of taking the time to detail each and every project that the VA is undertaking or to usurp what others may say after me, I would just note for you that we have provided a listing of these projects for you. This includes an outline of our overall plan that we'll make available both for the record and for individual members. Attached to this plan is a synopsis of the various research activities being undertaken by the VA and Department of Defense, including a description of the individual research project being undertaken by our three environmental hazards research centers. The latter which ncludes time lines for when those projects will be completed so that you will have a better indication of when we can expect to have answers in the future to the different projects that are being pursued; finally, we are providing a one-page sheet that depicts the overall oversight structure and describes how the Coordinating Board and the Research Coordinating Council fit into the overall effort.

And with that, let me conclude these comments. I will be happy to answer questions either now or later.

[The prepared statement of Dr. Kizer, with attachments, appears on p. 66.]

Mr. Hutchinson. Thank you, Dr. Kizer. The documents to which you refer will be entered into the record without objection.

(See p. 74.)

Mr. Hutchinson. We will hold our questions until the entire panel has testified. We certainly look forward to working with you in your new job, and we welcome you.

The chair recognizes Dr. Joseph.

Dr. Joseph. Thank you, Mr. Chairman, distinguished members of the subcommittee, first let me apologize for getting here in just under the wire. It is an honor to be here before this subcommittee to talk about our medical and research efforts related to the Persian Gulf War.

STATEMENT OF DR. STEPHEN JOSEPH

Dr. Joseph. For the past 2 years, the Clinton administration has been heavily engaged in caring for our Persian Gulf troops and in trying to solve the difficult puzzle sometimes known as Persian Gulf illnesses.

Just this Monday the President, in a speech before the VFW, described the collaboration between the agencies on our very aggressive programs of research and care. But, as he said, we need to go further. And, the President announced that we will step up our treatment efforts and launch new research initiatives.

The departments, as Dr. Kizer has already begun to tell you, will be funding millions of dollars in new research initiatives. We will be opening specialized care centers to push forward our diagnostic and treatment efforts, particularly for those Gulf War veterans whose illnesses have proven most difficult to diagnose. And, as Dr. Kizer mentioned, the President announced that he will be forming a presidential advisory committee to look into medical research and other aspects of this problem.

I want to frame our efforts, both clinical and research, in an analogous way to what Dr. Kizer has done. And, I'll summarize my testimony, but will be happy to go back into the details as you wish.

As you know, we deployed almost 700,000 people to the Persian Gulf. And it's important to recognize that the vast majority of these people came back healthy. In fact, our DNBI, our disease non-battle injury rate, in the Persian Gulf was lower than with any conflict deployment in the military's history. But we all know that soon after the ending of the Gulf War, veterans began to complain of a variety of symptoms that were not readily explainable.

To try and sort through to the bottom of this, I established in DOD the Comprehensive Clinical Evaluation Program (CCEP) in June of 1994. We were attempting to seize the needle, rather than the whole haystack. We wanted to start with the patients, provide to them the care and caring that is our responsibility. At the same time, that we were diagnosing their individual symptoms and illnesses, we began to get some sense of direction, and leads, into what might be the overall causes of their problems.

We set up a national hotline. Since that time in June, we have had over 15,000 people registered through that hotline. About 12,000 of them wished to enter into the systematic tiered process of medical evaluation. We have between eight and nine thousand persons in that medical evaluation process now. We have completed a comprehensive evaluation on over 4,000. And we have scrubbed the data and entered into our clinical database data now on over 2,000.

When I made my first preliminary report in December, we had 1,000 people in the database. We now have 2,000. And our expectation is that we will have fully between eight and nine thousand comprehensive medical evaluations finished by late spring this year.

I need to enter a word of caution here. The CCEP was not designed as a sophisticated research or epidemiological program. It was designed primarily to provide care and diagnoses to our individual patients. This is the way to start with a needle: to work back from those individual diagnostic and treatment efforts, while providing care to our people, to develop leads, hypotheses and insights into what may be key questions to ask.

I can say that based on the findings now of over 2,000 patients, that over 84 percent have a clear diagnosis or diagnoses which explain their condition. And, that probably is the largest number of people ever subjected to this kind of comprehensive medical evaluation in this sort of setting with an ill-defined and mysterious set of symptoms.

The most important thing about that is that those diagnoses represent essentially the entire spectrum of medical diagnoses. And they range all the way across that medical spectrum.

Infectious disease accounts for relatively few of these diagnoses. Less than 3 percent of those first 2,000 patients have an infectious disease. About 20 percent of those patients have psychologically related medical conditions. Most of these conditions are relatively common in the general population. And indeed the distribution of all of these diagnostic categories is quite common and quite reflective of the general population. In this group they include such diagnoses as depression, anxiety, tension headache, and dstress-related disorders.

These patients have been provided appropriate treatment, and many have responded well. I think it's very important to underscore that these people are hurting just as much from their symptoms as if they had diabetes or arthritic knees. The good news is, as with most of the patients whose diagnoses we're able to establish, that we are able to provide treatment. Most of these patients are finding significant relief.

Now, about 16 percent of those first 2,000 patients have less clearly defined symptoms. We are not yet able to establish a definitive diagnosis or diagnoses. That's the group that represents the mystery. That's the group that we need now to go further on through our specialized care centers, and see if we can whittle down those ill-defined conditions into firm diagnoses.

The diagnostic proportions as we said in December when we issued the first preliminary report on the first 1,000, haven't changed in the second 1,000. And there is no clinical evidence to date for a new or unique agent causing illnesses among Persian Gulf veterans.

That preliminary finding is entirely consistent with what the National Institutes of Health workshop found. I'll just quote from their report, ``No single disease or syndrome is apparent but rather, multiple illnesses with overlapping symptoms and causes,'' end quote. That really has been the finding of every group that has looked at the issues and patient data, and our findings to date are consistent with that.

It's important to say right away that is not a statement that says we stop looking. That is not a statement that says we close the book or rule out any particular cause of symptoms or illnesses. We've got to keep working. We've got to keep investigating. And our principle is we look at all possibilities and we let the chips fall where they may as we find things to rule in or to rule out.

I won't repeat what Dr. Kizer has said about the coordinated research activities and the Persian Gulf coordinating boards. We are in a very intensive research program. And in 1995 we will be spending in DOD an additional $10 million on a variety of research activities. These fall into three large areas: epidemiologic research looking at the distribution of symptoms in large populations, including reproductive health issues; affects of pyridostigmine, the pretreatment preventative for chemical warfare attacks that some have thought might be related to these symptoms; and clinical research, research that will look at ways to better treat and identify symptoms in individual patients and groups of patents.

The first $5 million of these $10 million will be spent on peer-reviewed independent investigator activities. And the second $5 million will be spent partly that way and partly in research conducted within the Federal Government.

All that research is worked through the coordinating board, as Dr. Kizer said.

There's one last area that I want to touch on in my introductory remarks: the issue of chemical and biological exposure, which has been the subject of intense media coverage and public interest. Let me summarize what we know of the exposure of our troops to chemical and biological weapons.

Hundreds of false chemical alarms that were activated due to dust, heat, smoke, and low batteries have led many to believe that chemical agents were used.

I'm sure you all saw the statement in USA Today in the last week where General Schwartzkopf is quoted as saying, quote, ``There's absolutely no evidence that we ever ran into during the war or anything that's come up since the war that I know of that says they used them.'' And that really summarizes what our position is.

This has been looked at by a number of groups: Defense Science Board, our internal looks, the declassification efforts. And we have found no evidence that would lead to the conclusion that chemical or biological warfare agents were used in the Gulf.

But, again, this is not a statement that says we stop looking. We look everywhere. We pursue all leads. And we let the chips fall where they may.

So let me close by reiterating the President's personal commitment to the Persian Gulf vets and quote his words at the VFW meeting this week, ``We must listen to what the veterans are telling us and respond to their concerns. We will leave no stone unturned. And we will not stop until we have done everything that we possibly can for the men and women who, like so many veterans in our history, have sacrificed so much for the United States and our freedom.''

We're committed. I think we're on the right track. I think we do have to focus on the needles and not the haystack. And we fully intend to pursue this to the best possible conclusion

Thank you, Mr. Chairman.

[The prepared statement of Dr. Joseph appears on p. 111.]

Mr. Hutchinson. Thank you, Dr. Joseph.

The chair recognizes Dr. Jackson.

Dr. Jackson. Good morning. Thank you, Mr. Chairman, members of the subcommittee.

STATEMENT OF DR. RICHARD JACKSON

Dr. Jackson. I am Dr. Richard Jackson. I am the newly appointed Director of the National Center for Environmental Health at the Centers for Disease Control and Prevention, CDC.

We're pleased to have the opportunity to meet with the subcommittee on our efforts and those of the Department of Health and Human Services in evaluating the health status of Persian Gulf veterans. The health of our military personnel and veterans is an important issue with the administration, as evidenced by Monday's announcement of the formation of the presidential advisory committee.

As you know, CDC has a long history of involvement in veterans' issues, dating back to the formation of CDC as the Communicable Disease Center after World War II.

I'd like to go through a number of the activities CDC has pursued in relation to this. One was our first involvement. This was in response to concerns about the health effects of exposure to smoke from the burning oil wells.

Beginning in April 1991 researchers from several Federal agencies went to the Persian Gulf to assist the Kuwait government officials in developing a research project to determine if the air pollution created by the burning oil wells had potential to cause health problems.

We surveyed a cross-section of workers in Kuwait City in May of 1991 and of fire-fighters in the oil fields in October of 1991. Blood samples were tested for 31 volatile organic compounds. These are the fumes that you would smell, for example, when you put gasoline in your car. And we compared the blood levels for these chemicals with a reference group of Americans, people living in the United States. This is a reference group that we get from every 10 years' survey of the American people.

As would be expected, the fire-fighters had more of these chemicals in their blood than did the average American. But the chemicals remain in the blood only for a short period of time. And the long-term health effects on the fire-fighters are unknown.

We also examined blood levels of soldiers who were not fire-fighters. Blood levels of these volatile organic chemicals were about the same or lower than those found in the American reference group.

In addition, our laboratory collaborated with the Department of Defense in a study of 30 members of the 11th Army Cavalry Regiment. Only one compound, tetrachloroethylene, was found to be elevated. This compound is not associated with emissions from oil fires, but, rather, is a substance found in degreasing agents. In other words, it's used as a dry cleaning solvent. It's used to clean weapons.

Another question that has been raised is whether an infection called Leishmaniasis could explain some of these symptoms. Leishmaniasis is a disease somewhat like malaria. It's spread by sand fleas.

When personnel returned from Operation Desert Storm, CDC published an article in its February 1992 weekly report that described cases of Leishmaniasis identified in persons who had served in the region. The article identified federal organizations to contact for information regarding Leishmaniasis, and we worked with the staff at Walter Reed Army Medical Center and others to get information out to the medical, public health, and lay communities.

From December 1991 through February 1995, CDC received 1,632 specimens from persons who served in the Persian Gulf region. Most of them, 93.5 percent of the specimens, tested were negative. Six and a half percent showed low levels of reactivity.

The next question we were asked is: Is there some issue around reproductive outcomes, birth outcomes? In December 1993, CDC met with Congressman Sonny Montgomery regarding reports of a cluster of infant health problems among children born to Persian Gulf veterans in Mississippi. CDC and the Mississippi Department of Health assisted the VA Medical Center in Jackson, MS in the investigation of this reported cluster.

The investigation found no increase in expected rates in the total number of birth defects or the frequency of premature birth and low birth weight. The frequency of other health problems in the children, such as respiratory infections, gastroenteritis, and skin diseases, also did not appear to be elevated.

There's a caveat on this. This is a small group. And when you have small groups, it's very hard to get an accurate assessment as to whether this really reflects a much larger population. You're only looking at about 50 children.

I'd like to talk briefly about an investigation that's underway right now in Pennsylvania. We are conducting an investigation of a reported cluster of illnesses of about 60 members of the 193rd Pennsylvania Air National Guard. All those affected have been deployed to the Persian Gulf during Operation Desert Shield and Desert Storm.

The investigation is being conducted in three phases. The first phase will describe the clinical signs and symptoms and health concerns among a sample of the ill Persian Gulf veterans. This is being done at the Lebanon, PA VA Medical Center.

Phase II is a survey of the Air National Guard unit in comparison to other units to document the prevalence of health problems.

The third phase is what's called a case control study, where you interview people who are ill and you interview people who are well and you compare their histories and what they report to see if we can find risk factors for this unusual cluster of disease.

The last is an assessment of the health status of Persian Gulf veterans from Iowa. After a request from Congress, CDC is implementing a telephone survey of Persian Gulf veterans who listed Iowa as their home of record. This study is being conducted in collaboration with the Department of Public Health in Iowa and the University of Iowa. It includes a detailed assessment of Persian Gulf veterans' health concerns as well as questions about the health of family members.

This study will consist of a random sample of 2,000 military personnel who served in the Gulf theatre of operations and 2,000 Gulf era military personnel who served at other sites. We expect to begin data collection in July and to have a final report for you in the Summer of 1996.

In addition to these studies, CDC has been active as a participant in the Persian Gulf Veterans Coordinating Board. Health and Human Services has been involved in fostering coordination and communication among the Federal agencies involved in the research, and has detailed a staff member to the Persian Gulf Veterans Coordinating Board. The person will serve as a liaison to the Coordinating Board and to the other agencies, including Department of Defense.

We also have staff participating in the Department of Veterans Affairs Persian Gulf Expert Scientific Committee and, of course, are looking forward to working with the new presidential advisory committee.

I'll briefly touch on future research needs. Studies should be conducted on representative samples of Persian Gulf veterans with complete assurance of confidentiality. Obtaining data on a comparable control group of veterans is essential. It's often easy to get information from people who have identified themselves as ill, but you need to ask those same questions of people who are not ill.

The VA is planning a mail and telephone survey of a nationally representative group of Persian Gulf War veterans. And our CDC Iowa study will complement the VA study and provide in-depth information on Persian Gulf War veterans' health status. These will tell us if the prevalence of illnesses among the veterans is higher than expected.

I'd like to close with a few recommendations. All of these studies will contribute to our understanding of the effects of military service in the Gulf theatre of operations. However, most of our studies are limited by their retrospective nature. We're going back and asking people to recollect their exposures from 3, 4, 5 years ago. This has been true of previous CDC studies of military personnel, be it Agent Orange or others.

Baseline data on the health of military personnel is often lacking. And it limits the ability to conduct definitive studies. One way to fix this problem is to take a more proactive approach in evaluating the veterans' concerns, health concerns. It would call for much closer consultation with the Departments of Defense and Veterans Affairs as to what baseline data would be useful in evaluating the health of military personnel further on down the line.

We'd like to have improved information on the number of troops deployed during a military conflict, information on potential exposures, surveillance systems to address health outcomes and identification of risk factors for stress-related reactions.

Health and Human Services believes that the health of our veterans should be a very high priority. And we will work energetically with the other Federal agencies who deal with these issues.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Jackson appears on p. 119.]

Mr. Hutchinson. Thank you, Dr. Jackson.

Dr. Miller, you're recognized.

Dr. Miller. Good morning, Mr. Chairman and members of the subcommittee.

STATEMENT OF DR. RICHARD MILLER

Dr. Miller. My name is Dr. Richard Miller. I am the Director of the Medical Follow-Up Agency, a division of the Institute of Medicine in the National Academy of Sciences.

Public Law 102-585 directed the Secretaries of Veterans Affairs and Defense to seek to enter into an agreement with the National Academy of Sciences to establish an expert committee. That committee's task is to assess how the VA and DOD have collected and maintained information potentially useful for evaluating the health consequences of service in the Persian Gulf War and to make recommendations concerning whether there is a sound scientific basis for epidemiologic studies of those health consequences.

The IOM committee released a first report on January 4th of this year. The intention of the report was to describe initial findings and make initial recommendations to the VA and DOD regarding potential Persian Gulf War health effects research and related issues.

There are many research projects that have been completed or are now underway within the VA and DOD related to health consequences of Persian Gulf War service. And the IOM committee reviewed approximately 50 of these as of September of last year, when the report was finalized.

The earliest research activities within the DOD were focused on the effects of the burning oil well fires, while the VA conducted early studies in response to Public Law 102-25 assessing the occurrence of post-traumatic stress disorders. Subsequent efforts were generally in response to local outbreaks or clusters of undiagnosed illness.

The IOM committee felt that while all of these activities have been appropriate and credible, efforts now need to be focused on answering carefully formulated and highly specific research questions.

The VA was also required by Public Law 102-585 to establish the Persian Gulf veterans health registry. Although the information in this registry is of little use for research purposes because of the self-selected nature of the participants, the IOM committee agreed that it was important that the data be reviewed on a regular basis for possible sentinel events.

The report made initial recommendations in three categories: data and databases; coordination and process; and, finally, consideration of study design needs. The data and database recommendations reflected the IOM committee's concern with the database resources that are necessary to conduct research, including the lack of a data system linking medical information on an individual during active duty and continuing into the era of VA-provided services.

Also the IOM committee recommended prompt completion of the DOD's geographical information system that will provide potentially useful information on troop locations to be used in future research. The location of troops can provide a surrogate for potential exposures received in the Persian Gulf theatre, essential information in evaluating health outcomes.

The initial recommendations involving coordination reflected the IOM committee's concern that new projects need to contribute substantively to the total Persian Gulf health research agenda, that they be actively and fully coordinated between the VA and DOD, that they be focused in design, peer-reviewed, and not duplicative of efforts of other agencies.

The IOM committee felt that specific research questions should be addressed with input from epidemiologists as well as subject matter experts. The research that the IOM committee recommended included: a VA-DOD collaborative population-based survey to obtain data on symptom prevalence and health status; evaluation of potential health effects from exposure to lead; a long-term study of the mortality of Persian Gulf War veterans; well-designed studies of potential adverse reproductive outcomes, laboratory studies of possible interactions of pyridostigmine bromide, DEET, and permethrin; and further work in the area of diagnosis of Leishmania tropica infections and the study of the epidemiology and ecology of those infections.

The IOM committee met in January of this year with representatives from the Persian Gulf Veterans Coordinating Board to discuss the IOM report recommendations and the VA/DOD response. The meeting was useful for all parties involved, and the IOM committee agreed that genuine efforts are being made to respond to their recommendations.

The IOM committee will continue to evaluate the research efforts for the coming year and a half and will review progress in the areas of concern in the final report. The committee is, in fact, meeting today for the seventh time. And their final report will be available in late Summer of 1996.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Miller appears on p. 130.]

Mr. Hutchinson. Thank you, Dr. Miller. I want to thank the panel. For some of us, we may yearn for Dr. Rowland to be back. Much of the testimony is very technical but we appreciate it. I know the members will have a lot of questions.

I do want to for the benefit of the members, that members who were present before the gavel went down will be recognized by seniority, Republican, Democrat alternating. Those members who came in after the gavel went down, will be recognized in the order in which they appeared following the long tradition of the full committee. We will be operating under the 5-minute rule.

Dr. Kizer, both the Department of Defense and the Defense Science Board Task Force on the Gulf War Health Effects have concluded that no chemical or biological warfare agents were used in the Gulf War. We've heard that assertion here during the testimony this morning.

Dr. Kizer, you recently remarked in USA Today that you lack confidence in Pentagon assertions that troops were not exposed to chemical or biological agents. What is the basis for that assertion?

Dr. Kizer. Let me try to respond to that. That was a comment that was made when I was having a wide-ranging, free, and open discussion with our expert advisory panel a couple of weeks ago or thereabouts.

My comment was in no way intended to mean that I don't believe DOD officials or that the DOD has not been fully forthcoming. What it was intended to focus on was the fact that I have not yet reviewed that data personally. So I can only rely on what I have been told.

I also have some questions about what exactly were the exposures that occurred over there, not necessarily biological/chemical warfare, but the whole array of potential environmental exposures. It's not clear to me, at this point, that anyone has rigorously documented what exactly were the environmental conditions that were confronted by our troops.

And, as I said, being relatively new to this job, I have not yet had the benefit of hearing some of the DOD briefings and other things that Dr.Joseph and I have talked about. Hopefully I'll be hearing more about those in the weeks and months ahead.

Again, I think there are some questions about what actual exposures occurred and whether we had all the monitoring that would have been necessary to document that. I'm withholding judgment, I guess, until I've heard more.

Mr. Hutchinson. In your mind you were expressing, not prejudging that the jury was still out as far as you were concerned,. You wanted to look at exactly what the evidence was?

Dr. Kizer. That's correct. Again, I was talking to what I viewed as peer scientists and investigations. I'm withholding judgment until I've had the opportunity to become more personally knowledgeable myself.

Mr. Hutchinson. Let me ask this question of the panel in general. Any of you can respond to this. The Journal of the American Medical Association August 3, 1994 states that ``A collaborative Government-supported effort on Persian Gulf illnesses has not been established'' and there is not a uniform protocol across the military, VA, and civilian physicians. Could you respond to that, comment on that?

Dr. Joseph. I'd be delighted to respond to that. I think that statement is inaccurate. It's inaccurate on both the research and the clinical sides.

I've said in my testimony, and I know we've said it many places before, the clinical protocols for DOD and the VA have been worked together, developed together. They're virtually identical. We have joint bodies that review all research proposals, plan the research studies, and that look at the clinical data as well.

I guess I'd have to say, Mr. Chairman, that it's an easy shot. An easy shot that one can always say about every Government activity. And, we can talk about whatever level of detail you want.

I've never known of an interagency activity in Government that has had as intensive and close coordination, particularly between VA and DOD, as this one has.

Does that mean that everything is perfect and that we never disagree on something? Of course not. But if you look at the number of actions working and the results, the way that the research is funded and conducted, and the way the clinical studies are funded and conducted, I think that statement in JAMA is just inaccurate.

Mr. Hutchinson. Would any of the rest of you want to comment on that? [No response.]

In Arkansas we had a lot of our reservists who were involved in the Gulf War. The 142nd in my district performed admirably. The fact is that 50 percent of those afflicted with Persian Gulf illnesses have been reservists. Are studies looking at factors such as age and physical conditioning as a possible difference in the levels of psychological preparedness as a basis for the current research?

Dr. Joseph. Yes, we are, sir. Certainly on the clinical side, in both the preliminary report we put out in December and the next version, which you'll see shortly, we do all the demographic cuts: Reserve, active duty, gender, age, branch of Service, et cetera.

I would like to drop back to something that__

Mr. Hutchinson. Before you leave that__

Dr. Joseph. Yes.

Mr. Hutchinson (continuing). Is there any correlation that has been found?

Dr. Joseph. No significant correlation. There really is nothing. If you look at the two groups, among veterans in the comprehensive clinical evaluation program, our CCEP, they are slightly older than the representation of age in Gulf service as a whole. There are small differences, but there's nothing that leaps out at you. And I would also say_again, this is preliminary data, but it is 2,000 people_we have found no clustering by unit of service in that initial 2,000.

Dr. Kizer mentioned, and I think Dr. Miller also mentioned something that is going to be one of the most important pieces of this puzzle. That's the study the Army is working on to give us a geographic location by small unit by every day, every place in the Gulf.

Army has been working on that about 18 months now. The study will not be completed until sometime next spring, not this spring. It's a very complicated job.

Once we have what is essentially a map by location and by time of all small units in the Gulf, we then can take any of these questions, whether it's Reserve, active duty, gender, particular symptoms in a group, particular histories of exposure, et cetera, and lay it over that map and come up with whatever leads there are. That's probably the key study and it takes that amount of time to get it done. When we have it, we can give you discrete answers for a lot of the questions you pose.

Dr. Kizer. If I might, your question also raises an issue, again as someone new coming in and looking at this, that points to whether there are differences between the reservists versus the regulars. But there's another group that, in my judgment, we should be looking at. That's our coalition forces.

They came with different backgrounds. In many cases they had different preparatory or prophylactic measures. It occurs to me that there were significant numbers of them and that we should be looking in a collaborative way with the governments of the countries involved: Britain, France, Canada, et cetera, for what has happened in their troops, whether they have the same experience as our troops, and whether their different preparatory and prophylactic measures in any way correlate with the symptomatology being found in those groups of soldiers.

Mr. Hutchinson. Thank you.

Let me yield to Mr. Edwards.

Mr. Edwards. Thank you, Mr. Chairman. Since Mr. Kennedy has been so active on this issue, I'd like to yield my 5 minutes of time to him for questions.

Mr. Hutchinson. Mr. Kennedy, you're recognized.

OPENING STATEMENT OF HON. JOPEPH P. KENNEDY II

Mr. Kennedy. Thank you very much.

First of all, I want to thank Mr. Edwards for his consideration in yielding. I really appreciate it, Chet, very much. Thank you.

I also want to thank the chairman, Tim Hutchinson, for holding this important hearing this morning. I think it was really significant that you chose to make this one of your first hearings. And I think for many of who serve on the committee who felt that this issue has not gotten the attention that it needs in the past, it really is telling an important demonstration of your commitment, Tim. So I really appreciate the fact that you've chosen this morning to hold this hearing.

I want to thank our panelists as well for coming forward. I think that there are a number of questions that I have after listening to your testimony. First of all, Dr. Joseph, you talked with some emotion about the fact that this is the most coordinated and comprehensive effort that you've seen in your experience in terms of interagency coordination and the like. And, yet, I think Dr. Kizer just pointed out what from at least my perspective has been a disturbing pattern that has developed over the course of the last few years, which is that as each one of these issues develop, there's always resistance on behalf of the Department of Defense towards accepting the notion that there might be some kind of issue here.

Now, I don't suggest for a second that at the moment there hasn't been a growing awareness on the part of the Pentagon that there is a problem, but it has been like pulling teeth, I mean, just hearing Dr. Kizer mention the fact that there is a potential of the coalition forces.

I mean, I remember when I tried to bring up the fact that we were hearing testimony, we were hearing from people overseas, there was a great deal of resistance on behalf of the department to take that into account.

We've since heard, I've gotten letters, people have called my staff, of people in the news media that were serving in the Persian Gulf who themselves are now having many of the same kinds of physical complaints.

There was a great deal of scorn that was directed at the family members of individuals that served in the Persian Gulf and the kinds of transfers that at least wives that did not serve, of people that did serve, and husbands of women that served were beginning to complain of some of these illnesses. And that again was treated with a great deal of scorn.

The problem is, as I'm sure you're well-aware, that there has been a certain lag time in recognition and in acceptance of the fact that there might be a problem. And when you talk about your numbers of 8 or 9 thousand people in toto, of 1,000 people being processed_right? Well, I didn't quite get it because I thought you said 2,000 people went through but there are only 1,000 people__

Dr. Joseph. I'll be happy to repeat that. I don't want to interrupt you.

Mr. Kennedy. Okay. Well, I guess my concern is that, as I understand it, there are over 15,000 people who have registered in the Department of Defense registry. There's something on the order of 43,000 people who have registered in the VA registry.

Now, that's not to say that every single one of those people has these direct complaints, but is an indication if somebody others to sign up with a registry that, maybe, in fact, they came in and registered because they do have something that they're concerned about.

And so it seems like there's a much larger universe out there. Okay. Well, you're shaking your head. So why is that not true?

Dr. Joseph. Let me focus on what's a wide-ranging question. I'll first talk about the universe, and then I'll talk about the lag time that you alleged.

What I said in my testimony is that on the DOD side we set up the hotline last summer and we've had 15,000 people register through that hotline. Of those 15,000 people, about 3,000 say they have no symptoms but they just want to be on the register. Of the 12,000 who have called in with symptoms, we already have in the medical examination process between 8 and 9 thousand. And we have completed that medical examination process for over 4,000.

We then take the completed exams and scrub the data: go back and quality check all the lab data and the rest. We have scrubbed the data on the 2,000. So it goes 15, 12, 9, 4, 2. The 1,000 number is where we were 3 months ago, in December. We were at that same final point, if you will, on only 1,000 people. We've doubled that number between December and now.

Mr. Kennedy. I see. So let me just ask you: When you__

Dr. Joseph. So I think we're reacting to that universe, I think, quite effectively.

Mr. Kennedy. Okay. When you talk about the 2,000, you say in your testimony 84 percent of those 2,000__

Dr. Joseph. That's correct.

Mr. Kennedy (continuing). Have explicable illnesses.

Dr. Joseph. That's right.

Mr. Kennedy. Do you attribute any of those explicable illnesses to chronic fatigue syndrome?

Dr. Joseph. No, we would not consider chronic fatigue syndrome in that grouping. What we have done__

Mr. Kennedy. Can you break it down? Because when you broke it down, it didn't exactly add up to 200. You get 20 percent or something. I wrote it down. You said 3 percent have infectious illnesses. Twenty percent have psychological problems. But where did the rest of the 70 or whatever__

Dr. Joseph. Musculoskeletal problems, skin disorders, gastrointestinal disorders, whatever.

Mr. Kennedy. Wouldn't musculoskeletal problems, skin disorders and things like that be the kinds of illnesses that people are complaining about?

Dr. Joseph. Yes, of course. Of course.

Mr. Kennedy. So you're saying that you would have a skin disease and absolutely make assurances it has no relationship to this inexplicable illness__

Dr. Joseph. Well, the word ``inexplicable''__

Mr. Kennedy (continuing). Because of the symptom?

Dr. Joseph. That's right.

Mr. Kennedy. It would have absolutely no relationship to service in the Gulf, you're saying?

Dr. Joseph. No, I'm not. I'm most clearly not saying that.

Mr. Kennedy. Oh, okay. I'm getting confused.

Dr. Joseph. Let me try to ``unconfuse'' you, then.

Mr. Hutchinson. Your time has been extended.

Mr. Kennedy. Thank you very much, Chairman.

Dr. Joseph. Let's try to take a diagnostic spectrum. Let's suppose you served in the Gulf and you fell off a ``Humvee'' and injured your right knee. Now you have chronic arthritis in that knee. You have an explicable, clear, garden variety medical diagnosis that is clearly related to your service in the Gulf. That's way over here.

Way over at the other end is this 15 percent of people that I'm saying we're most concerned about. They came back from service in the Gulf, have chronic fatigue, trouble sleeping, aches and pains, et cetera, and are symptomatically ill with these symptoms. And, we don't have yet an explanation or a diagnosis to fit them.

Mr. Kennedy. And you have cleared having any psychological problem as well?

Dr. Joseph. In that group?

Mr. Kennedy. In that group.

Dr. Joseph. At least at present we can't identify what the specific, clear diagnostic problem is. That's way over on the other end. And, there are numerous people in the middle.

Suppose you served in the Gulf and you're back now 4 years. You have diabetes and you noticed the onset of the symptoms of your diabetes while you were serving in the Gulf. There it might be a more open question whether that__

Mr. Kennedy. I appreciate that.

Dr. Joseph. So what I'm trying to say is there is an entire spectrum in that group.

Mr. Kennedy. I appreciate that. I'm just trying to understand. In terms of the overall numbers, you still leave a very large range. And I'm trying to understand. You're saying about 16 percent of the people have this illness that is inexplicable, 20 percent of the people have psychological, 3 percent of the people have the__

Dr. Joseph. Right.

Mr. Kennedy (continuing). Infectious illness. And so the rest of the people have illnesses. The only question I really have is that the rest of those people, there are 60-70 percent of the people you talked about, do they fall off a truck and hurt their knees or is there some group_I mean, I just remember General Blanck testified last year that 25 percent of the people had chronic fatigue syndrome. So I'm trying to understand what that larger category is__

Dr. Joseph. Right.

Mr. Kennedy (continuing). And whether or not there is any open discussion. You've got 15,000 people in your registry. The VA has 43,000 people. And I don't want to make any presumptions. You say it's all so well-coordinated. I'm just concerned that, in fact, there's a hell of a lot more people out there, Doctor, than, in fact, we have been able to take into account, which then leads me to another question that I want to ask Dr. Kizer.

But, in any event, I'm pointing out that there seems to be the potential for a gap in your numbers that leaves very much open to debate what has actually happened to that 60 or so percent that has yet to be specifically accounted for.

Dr. Joseph. I don't think so.

Mr. Kennedy. Okay.

Dr. Joseph. I'll be happy to share, or send up later, the specific diagnostic categories and percentages.

Mr. Kennedy. Right.

Dr. Joseph. There is one more thing I want to say. In referring to that 16 percent for which we still don't have a clear diagnosis, you used the words ``this illness.'' What all our experience is showing us to date is that in that 16 percent, it is probably not a question of this illness, but rather these illnesses.

Mr. Kennedy. I appreciate your__

Dr. Joseph. That's a very important differential.

Mr. Kennedy. No. I understand. I think all of us understand the perspective that you're bringing, Dr. Joseph. And what you've got is Dr. Kizer sitting right next to you saying that he is still open to the notion that there might be a specific cause of these illnesses if you want to choose to describe it that way.

And so what you've got again is, instead of coming across as having an open mind to the notion that there might, in fact, be a specific event, a specific bug, a specific exposure, a specific kind of_whether chemical, biological, whether it's some bacteria that lives in the desert, hell, I don't know, but there might well be something that our troops and everybody in the theatre was exposed to that affects a certain number of people a certain kind of way and has a multiple myriad of different symptoms that can be brought upon a human being as a result of that exposure. That is something that Dr. Kizer I think is still open to and something that I think I'm concerned that we still haven't created a playing field that is actually going to allow us to make that ultimate determination.

So let me just ask Dr. Kizer while I've still got my yellow light whether or not there is in your opinion right now a study that will end up enabling us to draw that conclusion at some point? Whether it's 2, 3, 4 years from now, but at some point will we be able to draw that conclusion given what we have going on today?

Dr. Kizer. I don't think any of the individual studies by itself will be able to give you a definitive answer. I think in the composite, though, that we'll certainly be able to narrow the issues down. I also believe that out of the 40-plus studies that are currently being pursued, there will be some new hypotheses that will further open up avenues or potential areas that will need to be explored in the future.

I'm not sure whether we'll ultimately find an answer, or a series of answers, that will explain this. I think the studies have to be done, and we have to judge the results based on where they point us to in the future.

Mr. Kennedy. I appreciate the chairman's indulgence. Thank you.

Mr. Hutchinson. Thank you, Joe.

We recognize Mr. Tejeda. The order will be Jack Quinn then Steve Buyer. The gentleman from Texas, Mr. Tejeda, is recognized.

Mr. Tejeda. Mr. Chairman, what I'd like to do is submit some questions for the record and yield the balance of my time to Mr. Kennedy.

Mr. Hutchinson. Without objection.

(See p. 149.)

Mr. Kennedy. Thank you very much, Frank. I didn't know I was going to get__

Dr. Joseph. Could I come back on that__

Mr. Kennedy. Sure.

Dr. Joseph (continuing). Mr. Kennedy, if I might? I think we're talking a bit at cross-purposes because I agree with every part of the statement you just made with reference to leaving these issues open.

I said in my testimony three or four times that we've got to be very careful. We are very determined not to foreclose any possibilities and not to say that we have ruled out any particular cause or causes until that is absolutely scientifically clear.

I think where our cross-purposes discussion comes in is that I believe that all the data on the table tell us one very important thing_I think I hear you saying this_that whatever series of causes there are for whatever groups of illnesses in the people who served in the Gulf, there is no one unique, single overriding cause for all or most of that series of illnesses. That is the essential thing that we know fairly definitively so far.

Mr. Kennedy. And all I'm saying is I don't know that. I don't know what I think that there are_in my district, Massachusetts Institute of Technology, I have spoken with multiple chemical sensitivity experts, some of the top people in the field in this country. And they will tell you that you can be exposed to a myriad of different chemicals and that those chemical exposures potentially can provide a wide range of different symptoms that the human body can then demonstrate.

So I just don't know, Doc. I don't know what happened out there. I know that the Department of Defense had a whole bunch of different instruments that kept going off. It scares the hell out of people that we're serving in the theatre because they don't know whether or not they were exposed.

I know and I couldn't agree with you more that I don't think there's any evidence to suggest that Saddam Hussein sent in a chemical warfare agent that exploded in one particular theatre because a hell of a lot more people would have been exposed in that particular area. But whether or not something exploded in the air, whether or not there were shelters that could have been hit by bombs that then created some_whether there were bugs in the sand, I don't know.

And I guess I would look to somebody like Dr. Jackson to just sort of come in at a certain point here and kind of set the record straight as to how you conduct an epidemiological study that ultimately would enable us to capture whatever knowledge the human race has been able to develop and bring that to bear on the range of exposures that these individuals had in this particular area for a particular period of time and enable us to draw some conclusions so that we're not feeling_and I don't think you're doing anything evil, Doc, Dr. Joseph. I just think you're taking 15,000. Kizer has got 43,000.

We can talk about Leishmaniasis. We can get bogged down on whether or not there were chemical or biological agents. Hell, I don't think any of us know. But it does seem to me that it should be possible to be able to conduct a universal study, look at all of these guys we're serving, all the troops we're serving, everybody there was serving, the kinds of illnesses and exposures that they're having, and be able to draw some kind of conclusion.

The VA is now treating the people in terms of their illnesses, whether they be physical or psychological. That's great. They're getting some money from the Government for their disability. That's great. But all they really wanted to know was whether or not there was something that they were exposed to that could have drawn this conclusion. There's no sense in us pretending that they might not have been exposed to anything that could have happened out there.

Is it possible? Dr. Jackson, is this appropriate for you to answer, whether it's possible to create a universal study that will enable_Dr. Kizer said that even with what we've got to date we might be able to come to a conclusion. But we might not be able to. Is it possible to create a study that would enable us to make this determination once and for all?

Dr. Jackson. Congressman, I don't know how one could do a survey of 700,000 individuals, look at all their exposures everywhere they had gone, compare those with 700,000 other individuals, that level of detail. What's really needed is a scientifically based sound sample of individuals, just the way a poll looks at the profile of the American people before an election.

If you do a random survey of the population, you interview those individuals. You find out where they were, what were your exposures, and you draw some conclusion from that sample. And that's what we're proposing to do with__

Mr. Kennedy. Isn't that exactly the opposite of what Dr. Joseph_Dr. Joseph is saying you find the needle in the haystack, and you're saying you look at a haystack.

Dr. Joseph. You do both of these.

Mr. Kennedy. Okay.

Dr. Joseph. You do both.

Mr. Kennedy. I'm just repeating what you said. Isn't that true? He's saying you look at the guys who are sick, and you're saying you look at a comparison.

Dr. Joseph. No, sir. I'm saying you start with the people who are sick. You start with the needle so then you can know what questions to ask about the haystack. That's my comment.

Dr. Jackson. May I just comment quickly on the questions you ask because it's very important how you word the questions? Number one, the population you interview is very important. People that call up and self-refer are different from people who don't call up. And you need to get that sample that's an actual profile of the population. That's what the Iowa study is doing.

Number two, the questions. We've got two advisory committees that will be working on that. One is a science advisory panel, which obviously you need, but the other is a veterans' panel, people who actually have real life experience with this that will help us formulate the questions, make sure that we're asking about exercise training or whatever questions are needed.

We've already had one meeting of one of those panels already. So we'll be including all of those as well.

Mr. Kennedy. Well, is your conclusion that you're going to have the data, you'll be able to make the best presumption possible, the best answers possible or__

Dr. Jackson. If I may, I don't want to raise false hopes. At the end of this, we will be able to say, one, are the rates higher than people who did not serve in that theatre?

Number two, if they are higher, how are the people that had higher rates of symptoms different, different age, different level of training, different areas that they worked in? We're going to refer that over to the geographic systems that would look at that. That's about as much as we'll get out of that.

Mr. Kennedy. Thank you, Mr. Chairman.

Mr. Hutchinson. Thanks, Joe.

The gentleman from New York, Mr. Quinn, is recognized.

OPENING STATEMENT OF HON. JACK QUINN

Mr. Quinn. Thank you, Mr. Chairman. I, too, want to, Tim, say to you that I appreciate the effort that you've put in to make sure that this is one of our first hearings this year and want to suggest, Mr. Chairman, that we continue this line of questioning with some other panels, as I know you plan to do this year, and would ask unanimous consent to insert into the record some opening remarks.

Mr. Hutchinson. Without objection.

[The prepared statement of Congressman Quinn follows:]

S6621 Prepared statement of Hon. Jack Quinn

Thank you, Mr. Chairman for calling this hearing.

I am pleased that one of our first hearings is focusing on the troubling experiences of some of our Persian Gulf War veterans. I think we need to continue to pay special attention to the servicemen and women who have returned and are experiencing unexplained illnesses.

Research efforts appear to be well underway. While I understand few projects have come up with definitive conclusions, I hope today will give this subcommittee more information on planning and investigations phases.

The witnesses who have come to testify before us this morning will help me respond the many questions and concerns of the veterans and their families in my district.

The unexplained illnesses_fatigue, rash, muscle pain, stomach ailments_and the particularly troubling reports of problems among vets' spouses and children. The biggest obstacle seems to be that there is no common or underlying problem that can be identified. We owe it to our vets to keep trying to find one.

I am pleased to note that a researcher at University of Buffalo is involved in one of the multi-project efforts. I look forward to hearing more about these efforts this morning.

President Clinton recently formed an advisory panel to advise him on the issue of Persian Gulf Syndrome and requested a $13 million increase in research money. We can see we have a commitment from the Administration, VA, DOD and other agencies.

I am glad to be here this morning_so that our vets will know there is also a commitment by the Veterans' Affairs Committee and all of our colleagues in Congress.

S6602

Mr. Quinn. I at the same time want to mention a gentleman that I represent, upstate New York, Buffalo, NY_and I'm pleased to note that one of the researchers at the University of Buffalo is involved in one of the multifaceted projects. And we've been in touch with him as well as some people at the Buffalo VA and others in our end of the world up there in Buffalo and western New York.

I guess a couple of reactions and then maybe a general question to the entire panel for my benefit this morning. I guess I've sat here now for a little over 2 years on the committee and want to make special note of the work that Joe Kennedy and Lane Evans and Steve Buyer have done in this regard.

Just to say as an observer a little bit until about now, when I plan to jump in a little bit more what the gentlemen have begun, we're not making this stuff up. I mean, we hear from constituents. We hear from people back home. We hear from people all over the country who are concerned.

I've sat this in this room around this table and have heard from vets and their families, men and women, who have explained to us absolute horror stories of their experiences and their fears, fears of the unknown. I see some young people joined us in the back of the room a few minutes ago. They're fearful for their children and other things.

So we're not going around trying to make this stuff up or to look for these kinds of concerns. They come to us. You gentlemen_and the other thing I want to mention before I make is an observation that I'm pleased to see after some prodding here some headway being made. I think the President's announcement of an advisory panel and some money to this effort is something we all should support. And I want to do that.

I think the fact that we have the four of you here this morning from four different areas shows that we're working on it from a couple of different directions. And I think that's very helpful.

But the four of you represent work for the American people, I think, remind us all that you work for the American people. In a sense so do we back in our districts. We have oversight over that. And our job in representing the American people is to make sure that those of you who do work for them are doing the best you possibly can.

Mr. Chairman, when we do some more of these hearings later on this year, one of the things we might suggest is since we're not the only ones hearing from all different sides, that we invite some of the panelists back to hear those mornings when we hear from the servicemen and servicewomen and their families firsthand what's going on. I'm sure you've heard it in your interviews over the course of the last couple of years.

I just would ask you for some advice, each of you this morning. When we go back home or we pick up the phone or we answer letters from people who say to us along the line of the questioning that Mr. Kennedy just hit, ``What's taking so long? How many studies do you have to do for me to convince you that I'm sick, that things aren't going very well for me?''

I'm a school teacher. I understand that you can't rush into these things. I understand that overnight you can't decide what's wrong and what's right without some study, some science, some medical information to give you that.

What advice would you give me or anybody else around the table this morning on a response to these people? When the chairman calls them back again this year to testify on the Hill, they'll say ``Here we go again. We'll go back to Washington, and we'll sit in front of the panel. We'll tell them again what we told them last year and the year before.''

Dr. Kizer, I ask you to start and work your way across. What advice would you give me to give to my constituents?

Dr. Kizer. First I would encourage you to tell them to come into the VA, and we're going to take care of them. That is one of the things that's fundamentally different about how this problem is being approached than other problems in the past, such as problems with Agent Orange and others.

We have decided that it makes much more sense to take care of people, to treat their conditions, to give them the best care that we can, even though we may not know exactly what's causing it or even in some cases if it can't be clearly linked to what may have happened.

Having been involved very closely with the AIDS epidemic and with other problems in the past, we've heard these same questions there. We're 15 years into the AIDS epidemic. Why don't we have answers? We still don't have answers. The war on cancer was declared 35 years ago. We don't know what causes most types of cancer. And you can go down the list of other medical conditions that we don't have answers to.

The research that needs to be takes time. If you're going to do good research and get good results, you can't rush it. We need to explore all possibilities. I think we need to keep a very open mind. And anything that's reasonable needs to be pursued. And that is indeed the approach that hopefully we're taking.

But, again, I would go back to what I said at the outset. What's different here is that we're saying you don't have to wait until science has those answers because we don't know when that's going to be. It may be years. It may be never.

But in the meantime let's take care of the people. They served the country. Let's take care of them in the best way that we can. And so I think for your constituents, you need to encourage them to come in and get the care that they deserve.

Mr. Quinn. Thank you. The only difference when we talk about this kind of illness and AIDS or cancer, of course, is that we have heard from some people who said that the reason they're ill in the sickness is because they were in the service of their country.

A mother said that she sent away a 19-year-old son who was the star of the football team. And then 11 months later she told us he was dead. And there's some connection to the service to our country in there. And that's why we're interested. That's why we all should be interested.

Dr. Kizer. Sure. And I understand that. But from a science point of view, it's not that much of a difference.

Mr. Quinn. May I take just an additional minute to get a response from the other members, Mr. Chairman?

Dr. Joseph. Here's how I'd answer your constituent, ``The number of studies we have to do before we're convinced that you're sick is zero.'' What Ken Kizer has just said, and what I've said about our clinical program is strong encouragement to them to come in so that we can take care of what ails them and try to figure out what is causing it.

I would not be quite as pessimistic as Dr. Jackson about how soon we will learn or how fully we will learn what this whole puzzle looks like. Although he's right that we are unlikely to get a complete perfect answer, I think a number of the studies now going on will help: the VA survey, the Naval studies that look at comparisons between hospitalization rates, mortality rates, other kinds of exposures and reproductive issues. The way imperfect science and medicine work is that you probe an issue from many different directions. You don't get a full or a perfect answer from any one of those probes, but you begin to get knowledge that enables you to move on and work with it.

So, I'm a little more optimistic. Although I think he's right in a perfectly scientific sense. I think that's the answer to the constituent. We don't know, but we're moving in the right direction. Each year we'll have more to say about how much we do know. That takes time.

Mr. Quinn. Dr. Jackson, can you add a brief comment?

Dr. Jackson. People that are ill need to be taken care of. And science may give us some answers that may take a long time. You want to make sure people get the care that they need before they'll not wait for the science to come in.

Mr. Quinn. Dr. Miller.

Dr. Miller. My only comment is that we have on our committee one Persian Gulf vet who reminds the full committee frequently of the urgency of these issues and pushes them very hard.

Mr. Quinn. I appreciate you. Dr. Kizer, for your line to explore all opportunities and to keep an open mind I think is key to all of us and all of our efforts in this area.

I appreciate the time, Mr. Chairman.

Mr. Hutchinson. Thanks, Jack.

The gentleman from Illinois, Mr. Flanagan, is recognized.

Mr. Flanagan. Mr. Chairman, I ask unanimous consent to place a statement in the record.

Mr. Hutchinson. Without objection.

[The prepared statement of Mr. Flanagan appears on p. 60.]

Mr. Flanagan. Good morning, gentlemen. I thank the chairman for having these meetings. And I thank Mr. Kennedy for his commentary and his questioning.

I have a couple of questions for Dr. Miller along the same vein that we have been pursuing with Mr. Kennedy, and that is the coordination of the efforts and the value and efficacy of what has gone before and our plans for the future to continue to deal with this in relation to your study with the Institute of Medicine.

Your statement before this committee and the report of the Institute of Medicine as issued indicate a somewhat critical review for the research efforts that the Department of Defense and the VA have recommended a better focus to coordinate their efforts. How can these departments better coordinate their information-gathering and research efforts?

Dr. Miller. I think the committee in the report made highly specific recommendations for coordination, and realizing that those were made last September and that I think they feel somewhat better now than they felt at that time.

But their emphasis on coordination was not only information-sharing, but something beyond that to ensure integration and a lack of duplication across the research program. And I think their recommendations were very clear and they have been taken to heart by the VA and the DOD.

Mr. Flanagan. Well, I'm glad it's that because Dr. Kizer this morning was talking about the fact that he did not have a comprehensive research organization insofar as it applied to the ensure spectrum of the number of people he has to look at for the Gulf coordinating boards and the difficulties and benefits that have been gleaned from that. I'm glad that we're moving in that direction.

Dr. Miller, you have also alluded to the fact that the Department of Defense and the Veterans Administration should focus their efforts on specific research questions. Could you elaborate on what those questions might be?

Dr. Miller. I think the specific research questions were detailed in the testimony. And I will reiterate.

Mr. Flanagan. Could you extrapolate on those a little bit because we're learning a little bit today about not just what they're called, but what they're doing, too?

Dr. Miller. All right. I will go more slowly over the collection of recommended studies, the first of which was a collaborative population-based survey to obtain data on symptom prevalence and health status and evaluation of potential health effects from lead; a long-term study of the mortality of Persian Gulf War veterans; well-designed studies of potential adverse reproductive outcomes; laboratory studies of potential interactions of pyridostigmine bromide, DEET, and permethrin, three substances that were widely used during the Gulf War; and further work in the area of diagnosis of Leishmania tropica infections and the study of the epidemiology and ecology of this tropica Leishmaniasis.

Dr. Joseph. If I might jump in here for a minute?

Mr. Flanagan. Yes, please, because I read the testimony and I heard you repeat it again now. Could you ell us something about what these specific research questions are going to do and how we're going to get a little closer to the answers we're looking for?

Dr. Joseph. I believe with the possible exception of lead, every one of those categories is either currently funded research or is in the 1995 plan. I'm not sure about lead. Somebody will remind me in a moment. But each of the others I believe we have moved to fund.

Mr. Flanagan. All right. Well, I have been listening through most of the morning and Mr. Kennedy's 15 minutes, Mr. Quinn particularly. I must say that the level of urgency to find the root cause of the problem does not seem to be there at the level that we have it.

I know that you're scientists and you operate on a much more elevated plane and there are methodologies by which you approach and where you're going, but you are responsible to the same American people that we are. And they need an answer.

I remain still uneasy as to the direction we're going, not just the speed by which we're getting there, but the efforts that are being expended to get there. I remain without a concrete warm fuzzy feeling inside saying ``We're going to get there eventually.'' It might take 30 years or 40 years or longer. I remain very uncomfortable that we're moving in the right direction.

I think we're collecting a lot of information in a duplicative, difficult, cumbersome fashion without a lot of coordination. And I'm not sure that that's taking us where we want to go. We are just doing something. Perhaps I'll give each of you a chance to throw a bomb back at me and make me feel better about that.

That's where I stand now. And I'm deeply uneasy about this.

Dr. Kizer. Well, I don't think that that is a fair characterization of the projects that are underway. Some of the things that were talked about earlier are indeed being done.

For example, you asked ``Well, what are they going to show?'' Well, the project underway is looking at 15,000 Persian Gulf veterans and 15,000 of a control group of veterans to determine whether there are differences in the symptoms in those two groups to determine whether there is a different array of illnesses occurring in those who served and who didn't. This is fundamental, threshold-type question that needs to be answered.

And you can go down the list of other projects. Some of them are much more narrowly focused. Others are more broadly focused. But they're all part of answering the big picture question of why and what it is we actually do or don't know.

Mr. Flanagan. Thank you, gentlemen.

Thank you, Mr. Chairman.

Dr. Joseph. If I might, I would invite you__

Mr. Flanagan. Yes, sir. I'm sorry.

Dr. Joseph. I would invite you to interview one of the 40 or 50 military physicians who are working full time going from ground zero to__

Mr. Flanagan. No one is demeaning anybody's efforts in getting this done by__

Dr. Joseph. It's 9,000 people against__

Mr. Flanagan. It's the coordination efforts involved in the information data collecting and actually congealing that into some sort of level of solutions. Without specific research questions or without a direction in which we're going that we've talked about, my concern is not misplaced. I really have a problem with whether we're flying to get to the answer or not and not the level upon which the work is being done or the information is being collected.

Dr. Joseph. I guess I'm responding to your comment about sense of urgency. I think if you talk to some of the people, you might get a sense of our sense of urgency.

Mr. Flanagan. Thank you, Doctor.

Mr. Hutchinson. Thank you, Mike.

The gentleman from Indiana, Mr. Buyer. Steve. Earlier we recognized your great commitment to this issue and your personal involvement in it. We are glad to have you join the subcommittee today. And you are recognized.

Mr. Buyer. Thank you, Mr. Chairman. And let me congratulate you and our ranking member_again, I think everyone is saying it_for making this the first hearing. It shows your commitment. I appreciate it from both of you. I give special recognition to Joe Kennedy and Lane Evans. Joe took on this issue early on.

When I came to the Congress, I learned very quickly about institutional barriers within the medical community, whether it was the private medical community, whether it was VA, whether it was the DOD. And I think even by what I've heard today, some of the downward pressures still exist. And I'll get into that, Dr. Joseph.

Let me make a couple of comments. One I'll be very careful and tactful in the comment, especially based on a conversation that Mr. Tejeda and I had in making sure that we keep the Veterans' Committee in a bipartisan spirit.

I appreciate President Clinton getting involved. As a matter of fact, I'll welcome anyone in America to get involved in the issue of Gulf War veterans. If the President were here, I would say ``Mr. President, what took you so long?''

So I know all four of you like to reach out and put your arms around the President's statement. Let's not forget who it was said, when it was said, and why it was said. So let's not forget about political theatre involved in a very sensitive issue of policy.

When you think about how far, in fact, we've had to go in the last 2\1/2\ years, any time when you're trying to pioneer a new issue, you're out there plowing up that ground, there's always somebody behind also putting the soil right back in the furrow.

I'm calmer today than what I was in December. And that's fine. You can take shots at us in December, when we're out of session. I understand that things like that happen and occur.

I have some specific questions. Let me get to them. One that puzzled me, Dr. Jackson, your comment puzzled me when you said that baseline data is difficult. When you say baseline data is difficult, the confusion to me is we're dealing with a pool of individuals here who are perhaps the most physically fit in the country because we only take the most physically fit. We have a drug-free environment. They're all HIV-tested. And you're saying that we have a difficult baseline data to begin with. Confuse me.

If you're having problem getting information, I'm sure that Dr. Joseph would be more than happy to cooperate with you. If not, call me. I'm sure that Jesse Brown would be more than happy. Jesse has been very cooperative in this effort. So please explain that to me.

Dr. Jackson. Sir, what I meant to convey is to find out what the individuals who were not ill, what their exposures were, where they were, their background, demographics, other such information in this survey in Iowa, and compare those answers of the well individuals with individuals who became ill by the baseline in that. What is the background rate of how many times do they take pyridostigmine, other such things, the ill compared to the well? So I was looking for information from the well population.

Mr. Buyer. Are you having difficulty getting that information from DOD?

Dr. Jackson. No. We're doing this through the interview survey. We're actually interviewing the veterans themselves, both the individuals in the theatre and veterans who did not serve in the theatre. This is the Iowa study.

Mr. Buyer. All right. To Dr. Joseph, here's part of the problem that I've had for a long time. And I had this conversation with Dr. Blanck in December. First you make the comment that the CCEP, the purpose is to go in in regard to the treatment. So I salute you. I mean, that's part of the struggle that we had.

How do we get those who are suffering from physical ailments for which they themselves don't know what happened to their bodies? So we worked very hard. We got them access into the VA. And I congratulate you for setting up the program.

I shifted the focus when all of us were focusing on the veteran side. I jumped over to the active duty side. I remember when I talked about the downward pressure, I remember that at that time, even at the meeting we had over at the Pentagon and by the testimony of the Surgeons General, was that we only had like 167 on active duty.

Steve, that's it, 167. I didn't believe it. Joe didn't believe it. And now your testimony is we've got 15,000. That's less than a year since that last hearing.

So when you say that 84 percent have clear diagnosis of their conditions, let's only focus in on the other 16 percent. Here's where my difficulty with this whole issue, Dr. Joseph, has been. We've had this conversation. I'm not a doctor. You're a physician. You're trained for known diagnoses. Sometimes you need to take a step back and go ``Time out.''

What happened here? What happened to all of these soldiers? When they go to the Gulf and they're physically fit and then they come home and begin to have problems with their bodies, you can treat all the flu. You can treat their respiratory problems. You can treat pneumonia. I mean, you have specific diagnoses for those problems. But somehow you have to just take a step back and go ``Well, what is all of this?

What caused all of it?'' So I agree with you when you can say 84 percent have clear diagnoses. My own physical problems have very clear diagnoses. And I'm one of the lucky ones because I have improved so much over the last 2 years. I mean, I can run up to 3 miles now. And I did a stationary bike for an hour last night. I was so thrilled and excited. And I can play basketball and do things. But I still have some of the respiratory problems. I still have asthma. And I'm allergic to everything green, very clear diagnosis. I'm just as puzzled as anyone else out there what happened.

I've also, you know, been an advocate_Mr. Chairman, may I__

Mr. Edwards. If I could ask unanimous consent, Mr. Chairman? You were very gracious in letting Mr. Kennedy on our side, who has been involved in this issue so personally, have extra time, let us yield to him. I'd like to ask unanimous consent to give Steve an extra 5 minutes so he also can continue.

Mr. Hutchinson. If there's no objection. Gentlemen?

Mr. Buyer. Help me here. When you say that you only want to focus on the 16 percent, tell me that's not true.

Dr. Joseph. No. That's not true. I didn't say ``only.'' Let me let you finish.

Mr. Buyer. No, no. That's part of my question to you, that I want to be reassured here today that whatever research efforts we're doing, it's for a larger picture__

Dr. Joseph. Of course.

Mr. Buyer (continuing). And that part of this, in your questioning, hopefully you can tell me: How are you labeling these discharges from the active duty side? Okay. Tell me what you're labeling them. And for the disabilities now, what are you calling them? So are you calling them your known diagnosis?

And when you do that, you're giving up the big picture. I mean, there's a tendency right now, ``Let's not call it the Gulf War syndrome. Let's get away from that.'' So help me out here.

Dr. Joseph. Somebody asked me last night a pointblank question, ``Is there a Gulf War syndrome?'' My answer was, ``Of course there is. Because, any collection of illnesses and/or symptoms that relate to a particular focus you can call a syndrome.''

If they had asked me the question ``Is there a Gulf War illness?''; I would have said ``Everything we know so far says there is not.'' What there is in this large group of people, in these 15,000 people_I agree with you entirely; I mean, we looked, and that's what we found_is a collection of illnesses and symptoms. Some of which are quite easily explainable, some of which are frustratingly unexplainable at the moment. Then there's a whole spectrum in between.

When I said we're now going to concentrate on the 16 percent that are way off on this end, didn't mean ``only.'' I meant that that's where we've got to go to try and find whatever root causes, not root cause, root causes, are to be found in that 16 percent. That's certainly the way to hit pay dirt more quickly than to go back and look in the things that are more easily explained, that fit into our_if imperfect, at least kind of understandable_system of medicine.

Yes, there is a syndrome. No, I don't believe there is an illness. And yes, we have to keep pressing on. I think in one of the first conversations you and I had, I likened this to trying to peel away the layers of an onion: take the easiest ones first, the most explainable first, and keep working in towards the center.

Whether or not there's going to be a core at that center that we never explain, I don't know. I don't think anybody can.

Mr. Buyer. Does any of the research mirror that theory?

Dr. Joseph. I think that it does. I think it mirrors it in several ways. First, I've said several times that the clinical approach gives us an idea of what the needles might be and where to look in the haystack.

Then, second, there have been_and these have come in for some criticism from the IOM_a series of research probes to look at things that either people are very concerned might be root causes, like pyridostigmine, or that, for one reason or another, might be a root causes, like the oil fires.

The third mirror, the most important one, is these broad population-based studies that look at comparing hospitalization rates in people who went to the Gulf with people who didn't go to the Gulf, at reproductive outcomes and miscarriage rates, et cetera, et cetera.

As I said earlier, when we have that geographic map to lay all of this research over, then we will really see if things pop out. It's that combination of approaches; learn from the clinical program what you can in terms of which directions to go, pursue the specific leads, and then do the larger, broad-based epidemiology that Dr. Jackson is talking about to try to put it into perspective.

Mr. Buyer. To answer the question that I asked earlier, how are those on active duty_what do you call it when you're discharging?

Dr. Joseph. Well, you remember that Under Secretary Dorn issued a policy that no one was to be discharged against their will who did not have a diagnosis. That policy is still in effect. I will double check to be sure I'm right, but I believe if someone has a firm diagnosis coming through the CCEP_let's take an easy one, way over here, chronic arthritis of the right knee_and would be boarded out on that basis, that would be the discharge diagnosis.

Mr. Buyer. All right. See, there is a reason I wrote that right into law. I mean, I wrote that in the law because, to my colleagues, I was so incredibly frustrated.

And the whole idea of giving_I mean, this is an incredible radical idea to give compensation to undiagnosed illnesses. And I didn't mean doing that on the active duty side. That's where we forced the issue first.

And the frustration that I share in the challenge that I think we share at the moment is they say ``Well, we're not going to discharge those who are the unknown diagnosis.'' In other words, we didn't want these guys kicked off of active duty. We want to extend our compassion and care to them, make sure they're taken care of and not just thrown out into Dr. Kizer's care. Okay?

The challenge here is, ladies and gentlemen, to make sure that when they say it's a known diagnosis, are we losing a bigger picture here? And that's why I want to make sure that we're not just sending them out the door on a catch-all diagnosis because that's what we've had from the very beginning. So I want to make sure to my colleagues there's a bigger picture out here, too.

It's a difficult challenge that you face, Doctors. It really is because of the efforts, actually from a lot of us, that want there to be the cause. What was the cause? What was the cause? Causation is very, very difficult, especially when illness is multifaceted.

If I could, can I have just one last, Mr. Chairman?

Mr. Hutchinson. Without objection.

Mr. Buyer. Dr. Kizer, before you arrived with the Veterans Affairs, I had had a conversation with Jesse Brown. And he contacted NIH in the research to look at the cocktail mix of the inoculations. So I'm curious as to where that particular study is going. And so, Doctor, if you know that or whomever can answer that one.

And to Dr. Kizer: If you would tell me that of the $250 million in the research and development budget of the VA, how much is devoted to this issue?

Thank you, Mr. Chairman.

Dr. Kizer. Let me try to answer your latter first. We will be spending at least $5 million of the research budget for Persian Gulf issues next year, but I would hasten to add that I believe we will be spending more than that.

I am currently reviewing our whole research budget and what it's allocated for. I'll be looking at not only what we're spending on Gulf War issues and concerns, but what we're spending in a number of other areas. I may be making some adjustments in the future.

So while we are committed to spending at least $5 million, that may increase in the future as we look at other studies that may need to be funded.

Mr. Buyer. And to the cocktail mix?

Dr. Kizer. I'm sorry?

Dr. Joseph. I think I can speak to that. The initial set of studies looking at the possible interactions between pyridostigmine, insecticides, et cetera, are underway and will be completed this year, I think towards the middle of the year.

The studies looking at the possible effects of vaccines and immunizations and other issues, pyridostigmine, are in the 1995__

Mr. Buyer. Dr. Dorn had testified to us, this particular committee, my colleagues, that the inoculations that were given were the five series of shots they took to Vietnam. They had no idea what the effect is on the human body. They give you all those shots.

On top of it, some of these guys take botulism. They take two shots of Anthrax. You take your nerve agent pills, change the dye, put you under stress. They have no idea what that does to the human physiology.

So I know you said you wanted to also look at the insecticides. I think that's a good idea. But I want to make sure that they are in the 1995__

Dr. Joseph. All of that is going to be done. Well, one, Mr. Buyer, those are in the 1995 research proposal as independent investigator peer-reviewed research.

Two, I wouldn't agree with Dr. Dorn that we have no idea what the effects of multiple immunizations are. We have a lot of information and knowledge about that.

Mr. Buyer. And when you say that ``you'' are going to do that, DOD has a__

Dr. Joseph. Everything runs through the coordinating research__

Mr. Buyer. So NIH out there isn't doing something on its own?

Dr. Joseph. I'm sorry. That I can't answer. I don't know what's in the NIH budget with regard to vaccine effect research.

Mr. Buyer. I'll check that out.

Dr. Joseph. I'm speaking about VA and DOD.

Mr. Buyer. Okay. I appreciate the indulgence of my colleagues. Thank you, Mr. Chairman.

Mr. Hutchinson. Thanks, Steve.

The gentleman from Georgia, Mr. Bishop, is recognized.

OEPNING STATEMENT OF HON. SANFORD BISHOP

Mr. Bishop. Thank you. Let me just briefly again thank the chairman for this hearing. I think it's certainly appropriate for us to have a progress report. I'd like to thank Mr. Kennedy, Mr. Evans, Mr. Buyer for their leadership in seeing that this issue stays on the front burner.

My concerns I think have already been raised, but they really are underscored. And I think I can't underscore it enough. And the veterans that I have in my district and that I hear from across the country are asking ``Why is it taking so long? Why is it that the process that we understand is being undertaken is taking so long and moving so slowly?''

Could you isolate for us those factors that have contributed to what some of our veterans and their families consider to be the snail's pace at which it is developing? I know that putting this in perspective certainly would suggest that we are much further along than we were, for example, in dealing with Agent Orange following the Vietnam conflict.

But could you shed some more light on it? Because I just don't know what to say to my veterans when they continue to ask over and over again ``Why is it taking so long? What is the problem? We know that we have been affected? Why are they stonewalling? Why are they stalling?''

That's, of course, unfair to you. And I'm not suggesting that you have not been moving with dispatch. But could you please give me some guidance there on how I can respond to those kinds of questions that I repeatedly get?

Dr. Kizer. Certainly. And I'll defer to my colleagues here to follow up on my comments. I would certainly tell you that you can tell your constituents that if they have some ideas on how the research can be done more quickly or better, we are very open to hearing those ideas.

We have a wide array of some of the best minds in the country, the best scientists in the country working on this. They are doing the best they can. Good science takes time. I think it's imperative that you and your constituents, understand that.

This condition is not unlike many other conditions where despite lots of money, and lots of research projects, we still don't have answers to basic questions. And we're certainly open to considering any ideas that you, your colleagues, or your constituents might have that could speed the process up, because we'd like to find the answers quicker, too.

Dr. Joseph. I don't think there's any snail's pace on the diagnostic and treatment side. We want anybody who is still out there. This goes both for the VA and DOD, I know. Anybody who is still out there who is ill, who is symptomatic, we want them in so we can help figure out what ails them and treat that.

I really have nothing to add to what Dr. Kizer said about the research side. Good science takes time. You don't necessarily get more good science with more money, although sometimes you do. It takes time to figure out what questions to ask, then to do the research_particularly when it's large population-based research, and then to interpret the answers. That's often frustrating, but that is the reality.

Dr. Jackson. Sir, every doctor knows people who have suffered because a patient was given a wrong diagnosis, someone rushed to a judgment, gave them the wrong pills or sent them for the wrong surgery. I think it's very important that we get good medicine to these folks. That's what's being talked about, number one.

Number two, especially in the area of environmental health, there have been many arenas where science was half-baked and ended up making a decision that turned out not to be the right decision later on as further information came in, not saying that_I am suggesting that it is a slow and sometimes cumbersome process.

Could it be improved? Probably always.

Dr. Miller. Sir, I have nothing helpful to add to what has already been said.

Dr. Kizer. I'd like to add just a couple of points that I think are relevant. And some of it goes back to what Mr. Buyer was saying, that insofar as these studies can