The statement of Victor Gordan, MD before the U.S. House of Representatives, Committee on Veterans’ Affairs - October 26, 1999.  325 Cannon House Office Building Washington, DC  20515.

Mr. Chairman,

My name is Victor Gordan.  I am a staff physician at the VA Medical Center in Manchester NH and I am in charge of the Persian Gulf Registry and the Primary Care Gulf Clinic.  Thank you for giving me the opportunity to testify before the Committee.

            I will describe my experience and express my opinion on the undiagnosed illnesses experienced by the Persian Gulf war veterans under my care at the VA Medical Center in Manchester, NH.  I will also present to you some explanations and clarify as best as I can how many physicians attribute similar signs and symptoms of these poorly defined illnesses to a diagnosed condition and not to an undiagnosed condition.

            I have evaluated 668 Persian Gulf war veterans.  I have followed the majority of these veterans over the years in the Primary Care Gulf clinic.

            Approximately 3% of these veterans have no symptoms but they decided to enroll in the Persian Gulf Registry.  The rest of these veterans do present symptoms, which are now so familiar to us.  The average number of symptoms per person is 8.  This number is similar to the average number of symptoms per person presented by the British and Canadian researchers at the annual conference on Gulf war illnesses, organized by the DOD and the VA at Palm Beach CA in 1996.

            I divided my Gulf veterans who presented with symptoms into two subgroups: one subgroup which contains the majority, have only undiagnosed illnesses.  The second subgroup, which is rather small, contains veterans who are older than 50 years and have both undiagnosed and diagnosed illnesses.  Examples of diagnosed illnesses are: Degenerative Joint Disease proved by x-ray findings; hypertension, proved by blood pressure measurements; diabetes, proved by blood sugar measurement; post traumatic stress disorders (PTSD), diagnosed by required clinical criteria, etc.  I would like to strongly emphasize that these veterans, besides having these diagnosed illnesses, present other symptoms and signs, which do not fit into the frame of the diagnosed illnesses.  Therefore, the symptoms which do not fit into the frame of the diagnosed illnesses, and for which I could not find an explanation, constitute undiagnosed illnesses.

            In conclusion, all the veterans, (100%), evaluated by me who have symptoms have undiagnosed illnesses and a small subgroup I have just described have both diagnosed and undiagnosed illnesses.  Less than 0.5% were found to have alcohol and drug problems.

            Allow me now to concisely elaborate on how I reach the conclusion of an undiagnosed illness in a person.  The protocol I use in this process is the one, which was devised by the VA Central Office and is called Uniform Case Assessment Protocol (UCAP).  This consists of taking patient’s history, meaning listening to the patient’s complaints and symptoms.  Recording the health status of the veterans before deployment, which invariably ranges from very good to excellent to perfect, is also part of the patient’s history.  The history of exposure to various environmental hazards, vaccinations, medication is also addressed in detail.  The laboratory workup, which includes blood tests, and various types of x-rays, CT scans Magnetic Resonance Imaging (MRI) as indicated in individual situations.

            If this part of the evaluation does not support the identification of a diagnosed illness, then the veteran is referred for a consultation with specialists i.e. neurology, psychiatry, gastroenterology, rheumatology, cardiology, pulmonary disease, etc. 

            Some of the veterans who have health insurance coverage prefer to be evaluated by specialists in the private sector.  If the specialists are not able to establish the presence of diagnosed illnesses, then the veteran is considered to have an undiagnosed illness or illnesses.

            In many cases, the diagnostic workup described above is not based on only one evaluation.  This is an ongoing process involving followup visits, repeat laboratory tests and referrals to specialists.

            Based on this approach, I am certain in my judgement when I attribute these ill- defined symptoms and signs to an undiagnosed conditions(s).

            In order to clarify the issue of diagnosed versus undiagnosed illness in Gulf war veterans, I will mention two facts: At the annual conference on Gulf War Illnesses held in Baltimore MD in 1995, which was organized by the DOD and VA, I learned from the DOD research presentation that only 12% of the individuals still in active duty and who were deployed to Gulf Theater have undiagnosed illnesses and the rest of 88% have diagnosed illnesses.  At the same conference, the VA researchers communicated their research results, which found that 24% of Gulf war veterans have undiagnosed illnesses and 76% have diagnosed illnesses.  Several months later, the VA changed its initial statistics i.e. 24% versus 76% of undiagnosed and diagnosed illnesses respectively to 12% undiagnosed illnesses and 88% of diagnosed illnesses.  As you can clearly see, the latter statistics are identical to the DOD statistics.  I do, not know the reasons for this significant statistical change on the part of the VA.

            If the initial VA statistics were scientifically correct, then the subsequent changes can not be explained by the medical science rules.

            I challenged these statistics during that conference.  I asked the presenters to describe to the audience the scientific methods used in order to support these statistical results.  No scientific methods were presented.  The presenters instead gave explanations to support their statistical numbers.  These explanations were far from the medical science and I could not accept them as scientifically valid.

            The second fact which I will describe, involves approximately 25 to 30 Persian Gulf war veterans from outside the state of New Hampshire who were evaluated in the Persian Gulf Registry elsewhere.  These veterans came to me for a second opinion concerning their symptoms.  They also brought to me copies of their Persian Gulf Registry records.  In none of these records could I find the mentioning of undiagnosed illnesses.  Instead, all these young veterans were considered to have diagnosed illnesses such as arthritis, irritable bowel syndrome, post traumatic stress disorders (PTSD), somastisation disorders, carpal tunnel syndrome, eczema, migraine headaches etc.  I could not find any clinical or laboratory date to support these diagnoses.  Because no scientific evidence was presented at the 1995 Conference in Baltimore MD and because no clinical or laboratory support could be found by me in the Persian Gulf Registry records of those who came to me for a second medical opinion from other states, I am left only with postulations on how and why the VA researchers and other VA physicians attributed the ill-defined veterans’ illnesses to diagnosed diseases.

            In order to be able to clarify this complex issue of diagnosed versus undiagnosed illness in Gulf war veterans, I will present to you a representative not hypothetical case from the group of the Persian Gulf war veteran under my care: A 23 year old male from US Marines Corp who presents the following symptoms which he developed within 6 months of his return from Gulf war: headaches, joint pains, numbness in hands, dropping objects from hands, memory loss and lack of concentration, mood swings with depression, sleep problems, skin lesions, diarrhea, palpitations, disorientation and spacing out spells, profuse sweats and hot flashes, rectal bleedings, fatigue, brittle teeth and loss of teeth.  Examination of the patient and lab results is negative.  As you can see, this young veteran has 15 symptoms.  If one takes individual symptoms or lumps together several of these described symptoms one can easily come up with descriptive labels of diagnosed diseases.  When these labels are not supported by clinical criteria or laboratory tests, these remain just labels or false diagnoses. 

            A diagnosed disease has a code whereas an undiagnosed disease has no code.  I am going now to play a labeling game with these 15 ill-defined symptoms and as a result of this game I will come up with 10 diagnosed diseases.  Let’s start:

Headache is migraine headache, which has code.  Joint pains, (negative x-ray), is arthritis, which has code.  Numbness in hands and dropping objects from hands is carpal tunnel syndrome, which has code.  Memory loss, lack of concentration, mood swings and sleep problems is post-traumatic stress disorder (PTSD), which has code.  Skin lesions is eczema, which has code.  Diarrhea is irritable bowel syndrome, which has code.  Disorientation, spacing out spells, profuse sweats and hot flashes is panic disorder, which has code.  Rectal bleedings are hemorrhoids, which are not found on examination but has code.  Fatigue is chronic fatigue syndrome, which has code.  Brittle teeth and loss of teeth is periodontitis, which has code.  In conclusion, this 23-year old who rated his health status before his deployment to Gulf war as being perfect, came down in a very short period of time with 10 diagnosed diseases as a result of my labeling game.  If this veteran truly came down with 10 diagnosed diseases, then we would be encountering an epidemic outburst of diagnosed diseases in 88% of the Persian Gulf war veterans with symptoms, according to DOD and the VA statistics.  This would involve tens of thousands of young veterans.  This would constitute an unprecedented epidemiological event in the history of medicine.

            Putting labels of diagnosable disease on ill understood, ill-defined medical conditions is a high temptation for many physicians for selfish reasons. The few doctors like myself who have the courage to say to the patient, yes you have symptoms which are real but I am not able to formulate a diagnosis is not easy.  However, this is professional honesty.

            In conclusion, we are dealing with ill-defined illnesses, which appear to be the expression of dysfunction multi-organ systems of the human body, in young individuals whose health status before deployment to Gulf war is rated by them from very good to excellent to perfect.  To use labels of diagnosed diseases on these illnesses, will only cover the tragic reality, the reality of the presence of undiagnosed illnesses in the Persian Gulf war veterans.

            Before I conclude my statement, I would like to make two remarks:  #1.  Before the implementation of the PL 103-446, the most common reason for claim denials in Gulf veterans was that the veteran has undiagnosed diseases.  After the implementation of PL 103-446, the most common reason for claim denials is that the veteran has diagnosed diseases and not undiagnosed illnesses.  Quite a dramatic flip-flop!  #2.  I propose that PL 103-446 should be changed because the way the law is formulated authorizes the VA to award SC% status for undiagnosed illnesses only if these illnesses reach the minimum 10% of disability.  The formulation of this law should be change in order to authorize the VA to award also 0% SC for undiagnosed illnesses as the VA does for diagnosed conditions such as scars.  Many veterans’ claims are denied even when the rating board admits that the veteran has an undiagnosed illness but because he disability from the undiagnosed illness does not reach the minimum of 10% the claim is denied.  I made this proposal more than once before.

            Thank you very much for listening to me.  I am ready to answer questions.

                                                       VICTOR GORDAN, MD, FACP