Submission For The Record of Adrian Atizado, Disabled American Veterans, Assistant National Legislative Director
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to testify at this important hearing to offer our views on the future of veterans suffering from Gulf War Illnesses (GWI). The DAV was asked to address the following issues in our testimony: the cultural perception of GWI; GWI research; Department of Veterans Affairs (VA) medical care and benefits for ill Gulf War veterans; education and outreach efforts to Gulf War veterans; and the VA’s Gulf War Veterans’ Illnesses Task Force report.
The DAV believes the American people honor and respect the courage and contributions of military members, especially those who have made the ultimate sacrifice of life or injury as a result of their service. Americans strongly support programs that address the needs of the men and women who become ill or injured as a consequence of military service. To meet those needs, sick and disabled veterans should be provided: high quality health care; adequate compensation for losses resulting from such service-connected disabilities; vocational rehabilitation and/or education to help disabled veterans prepare for, and obtain, gainful employment; enhanced opportunities for employment and preferential job placement so that the remaining abilities of disabled veterans can be adapted or used productively; and effective outreach to ensure all veterans are aware of, and receive the benefits they have earned.
Despite the commitment of the American people and Congress, past history is replete with examples that the needs of sick and disabled veterans have gone wanting, with cynicism, denials, delays, and resistance. This is especially true when the wounds of war are not visible or well understood. Although one need only look to the latest conflicts in Iraq and Afghanistan, one can cite myriad examples from the World Wars, Korea, and Vietnam of an absence of beneficence. Veterans have faced consistent and strident challenges in gaining official recognition of the health consequences of occupational exposures that occurred as a result of military service to their country. This is especially true of Gulf War veterans and their illnesses.
Articles continue to be published, including those funded by VA and the Department of Defense (DoD), that minimize, confuse, or conceal information that this Subcommittee has received in testimony at previous hearings. These articles claim that symptoms reported by ill Gulf War veterans are similar to those experienced by veterans of other eras. Yet scientific studies such as those conducted by Dr. Han Kang, the principal investigator for the “Longitudinal Health Study of Gulf War Era Veterans,” consistently show about 25 percent of Gulf War veterans suffered from multi-symptom illnesses compared to non-deployed era veterans. His study also found that Gulf veterans reported more functional impairments, more limitations on employment, and more health care utilization than their non-Gulf veteran peers. However, almost two decades after the Persian Gulf War began, still-unanswered questions abound about the pain, illnesses, and disabilities afflicting Gulf War veterans. We do not have a clear understanding of the risks, causes, treatments or long-term outcomes of illnesses suffered by Gulf War veterans. These issues require corrective action.
In VA’s rush to restore the health of our latest combat heroes of Operations Enduring and Iraqi Freedom (OEF/OIF), VA has not maintained a steadfast commitment and adequate efforts to explore the unanswered questions of older era veterans. We at DAV are committed to be the voice of ill and injured veterans of all eras. We believe that VA must retain a steady focus on, and a commitment to find answers to the health consequences of military service, especially the illnesses and injuries resulting from combat service, including those of the Persian Gulf War.
Congress has many champions who have and continue to fight to better the lives of ill Gulf War veterans. Further, the DAV is encouraged by the current Secretary of Veterans’ Affairs, who has publicly committed to transform the VA culture to better serve veterans; however, it has been a challenge to point to a clear champion in this Administration, or a clear plan that will address all the well-known health concerns associated with our nation’s ill Gulf War veterans.
GULF WAR ILLNESS RESEARCH
Each year since the dramatic decline in overall research funding for GWI in 2001, the DAV has urged Congress to increase funding for VA and DoD research on GWI. The DoD’s Congressionally Directed Medical Research Program (CDMRP) has managed the Gulf War Illness Research Program (GWIRP) since fiscal year (FY) 2006. This program did not receive funding in FY 2007, but a $10 million appropriation renewed the GWIRP in FY 2008, and $8 million was appropriated for FY 2009 and 2010. This year, DAV again supports a recommendation to provide $25 million for the GWIRP in FY 2011.
Mr. Chairman, the CDMRP has funded nine treatment studies, now underway, compared to three in the entire previous history of federal GWI research. It focuses on small pilot studies of promising treatments already approved for other diseases and is open to all researchers on a competitive basis. The DAV urges the members of this Subcommittee to support, and the full House Committee on Appropriations to meet the recommended funding level of the Senate for the Gulf War Illness Research Program.
Diluting Gulf War Illness Research:
The DAV previously testified before this Subcommittee about our ongoing concern similar to those issues raised by the Research Advisory Committee on Gulf War Veterans’ Illnesses (RACGWVI), a committee that is directed to evaluate the effectiveness of government research on GWI. The RACGWVI has questioned the nature of some VA-funded research as to whether these research projects will directly benefit veterans suffering from GWI by answering questions most relevant to their illnesses and injuries.
Moreover, we are concerned about expanding the target population for GWI research to include veterans who served much more recently in OEF/OIF. Although ill Gulf War veterans and OEF/OIF veterans have similar concerns about their potential exposures to environmental hazards, and while it is true that we are maintaining a continuing military presence in Southwest Asia, DAV believes these are insufficient reasons to link research in these distinctly different populations. We believe research on OEF/OIF health concerns are co-equally important to that of GWI veterans, but rigorous scientific evidence, not assertions, should establish the basis that proves expanding the target population of these research efforts does not confound results or otherwise diminish the focus on improving the health status of ill Gulf War veterans.
One of the lessons learned from the GWI experience is that attention to documentation of environmental and military occupational exposures is of utmost importance to our understanding of the health consequences of combat exposure. We dramatically reduce our ability to find effective casualty prevention measures as well as the chances of understanding the causes and linkage to illnesses of combat veterans when adequate attention is not devoted to monitoring exposures. The DoD made a commitment to correct its deficiencies in documenting and monitoring unit locations and potential exposures after the Persian Gulf War. However, evidence is growing that this promise has not been kept and that DoD has failed to do adequate exposure monitoring once again in the wars in Afghanistan and Iraq. Whether it is the magnitude of local blast impacts, screening after exposure to blasts or air, water, and soil environmental monitoring, potential exposures have not been adequately measured. The DoD should be required to take immediate action to correct these deficiencies.
MEDICAL CARE AND BENEFITS FOR ILL GULF WAR VETERANS
Health Care Benefit Workload and Utilization
In 1997, VA created the Gulf War Veterans Information System (GWVIS) reports to comply with Public Law 102-585, for the purpose of identifying Gulf War veterans and monitoring their benefit claims activity. Beginning in 2003 these reports included data from VHA to provide some semblance of tracking VA health care utilization.
As this Subcommittee is aware from a previous hearing, concerns regarding the integrity of benefit claims data in the GWVIS reports have been confirmed by VA, noting discrepancies in migrating records from the Department’s legacy database to the new corporate database (VETSNET). In addition, VA indicated in its post-hearing response to the Subcommittee’s question that a review of this migration and subsequent erroneous reporting was to be completed by the end of FY 2009. DAV has not been given the opportunity to be briefed by VA on this matter nor have we received the promised reports with accurate data that were to be published by the beginning of FY 2010. The DAV believes the new reporting will remain suspect until the Department provides full disclosure to Congress and the veterans service organization community on the specific business rules that caused the discrepancy in data migration, the limitations of the new reports, and how they differ from reports based on VA’s Benefits Delivery Network (BDN). In addition to compensation and pension benefits, veterans may be eligible for education and training benefits, vocational rehabilitation and employment, home loans, dependents' and survivors' benefits, life insurance, and burial benefits. Unfortunately, information regarding utilization of these benefits by Gulf War veterans is unavailable even on GWVIS reports.
We also note there was a limited run of reporting from May 2003 until August 2006 of crude but potentially worthwhile data on VA inpatient stays and outpatient visits of Gulf War veterans. DAV believes VA is capable of producing a more meaningful report on health care utilization of GWI veterans. Notably, VA’s Office of Public Health and Environmental Hazards issues the “Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans.” This report provides a fairly detailed description of the trends in health care utilization and workload of OEF/OIF veterans, diagnostic data, and their geographic location with respect to the VA health care system. We believe such information should also be gathered on Gulf War veterans to allow VA to tailor its health care and disability programs to meet the needs of this veteran population. Such information should include updated workload and utilization of VA’s Vet Centers as well as its War Related Illness and Injury Study Centers (WRIISCs).
The GWVIS reports are the only public reports available regarding the VA health and benefits activity of Gulf War veterans. Due to the lack of data integrity and granularity, the GWVIS quarterly report should be made more comprehensive, since many unanswered questions remain that can better describe whether VA benefits are meeting the needs of ill Gulf War veterans and whether such veterans are receiving the VA benefits they have earned and deserve.
Compensation and Pension Benefits
Expiration of Presumptive Period
Public Law 103-446 was enacted in 1994, and serves as hallmark legislation to ensure Gulf War veterans suffering from unexplained chronic conditions receive just compensation. However, faced with what appears to be a dismal record of adjudicating claims based on presumptive service connection for GWI without proper analysis by VA, and considering that other conditions should be included in the list of conditions to be presumptively service-connected due to military service in the Persian Gulf War, the delegates to our most recent National Convention passed DAV Resolution No. 010, urging the passage of legislation to extend indefinitely the presumptive period for service connection for ill-defined and undiagnosed illnesses. We urge this Subcommittee to ensure this period that, under current law, ends on December 31, 2011, does not expire.
Delivering All the Benefits Entitled
Through our corps of highly trained professional National Service Officers, who assist veterans and their families in filing claims for VA disability compensation, rehabilitation and education programs, pensions, death benefits, employment and training programs, and many other programs, the DAV has witnessed first-hand how ill Gulf War veterans are denied benefits they have earned and deserve.
DAV applauds the Veterans Benefits Administration’s (VBA) issuance of Training Letter 10-01 dated February 4, 2010, to clarify VBA’s past erroneous interpretations of Section 202 of Public Law 107–103. This Act established presumptive service connection for GWI veterans based on an array of disabling signs and symptoms. The letter also affirms past VA variability in applying 38 C.F.R. § 3.317 yielding decisions adverse to GWI veterans. In the Training Letter, VBA personnel were instructed to recognize that chronic disabilities claimed by ill Gulf War veterans, fall under two categories: undiagnosed illnesses and “diagnosed medically unexplained chronic multi-symptom illnesses.”
Medical personnel in general and physicians in particular are trained to produce a diagnosis as a basis for treatment. However, such a diagnosis is not grounds for denying the claim, since medically unexplained chronic multi-symptom illnesses are diagnosable. According to VBA, regulations will be proposed to amend § 3.317 to clarify that chronic fatigue syndrome, irritable bowel syndrome, and fibromyalgia are not the only disability patterns that can be considered diagnosable medically unexplained chronic multi-symptom illnesses.
We look forward to the proposed regulations that will also include service in Afghanistan and Iraq as qualifying service under all laws related to Gulf War and Southwest Asia service. DAV is cautiously optimistic the Training Letter and the accompanying regulatory amendment will lead to more equitable and favorable resolution of claims based on GWI. Equally important, we look forward to measures VBA will adopt that will finally address data integrity issues so that data gathering and reporting will indeed help determine if these new instructions will produce awareness, consistency, and fairness in VBA’s handling of disability claims from veterans with service in Southwest Asia.
“Special Treatment” Authority
In 1993, Congress saw fit to provide “special treatment authority” in Public Law 103-210 for VA to provide health care to veterans who served in the Persian Gulf War in the Southwest Asia theater of operations who were exposed to toxic substances or environmental hazards. This special treatment authority is similar to that given to Vietnam veterans who may have been exposed to herbicides. In 1997, Public Law 105-114 eliminated the requirement that the veteran had to be exposed to toxic substances or environmental hazards, and only required service in the Southwest Asia theatre of operations during the Persian Gulf War. In 1998, the authority was extended through 2001, and Public Law 107-135 (115 Stat. 2446) provided for another extension through 2002.
We thank the members of this Subcommittee and of the full Committee for reporting S. 1963, the Caregivers and Veterans Omnibus Health Services Act of 2010, and we thank the full Congress for enactment of that bill, now Public Law 111-163, to address the lapse in this special treatment authority that ended in 2002 by making it permanent. Studies have found prescription drugs and over the counter (OTC) medicines were by far the most common treatments that were used for multi-symptom illness of Gulf War veterans. Treatment by relaxation therapy, mental health providers (psychologist, psychiatrist, and trained counselor), herbal medicine, sleep study, and therapeutic massage have been found to be the most common treatments that reduced GWI symptoms. This permanent authority will allow ill Gulf War veterans continued access to VA health care and specialized services provided through the VA’s WRIISCs.
Need for Effective Evidence-Based Treatment
Over 18 years after the war, studies continue to indicate that few veterans with GWI have recovered, or have substantially improved over time. To address this matter, VA providers who are treating Gulf War veterans’ illnesses, must have effective evidence-based treatment protocols supported by research studies. The myriad symptoms experienced by Gulf War veterans makes it very difficult for physicians to diagnose and treat a specific illness. Correspondingly, Gulf War veterans who experience little to no relief from their unique health problems are frustrated at best.
Although more is known today about the nature and causes of GWI, important questions remain about improving the lives of ill Gulf War veterans. As this Subcommittee is aware, an important gap in our knowledge exists about effective evidence-based treatment for GWI. The DAV believes more research is needed to advance the knowledge, and promote innovative and effective evidence-based care, to improve the health and quality of life of ill Gulf War veterans. Notably, the 8th report in the Gulf War and Health series from the Institute of Medicine (IOM) recommends a renewed research effort to identify and treat multi-symptom illnesses in Gulf War veterans. While we are hopeful the FY 2010 GWIRP will identify and provide effective interventions for veterans with GWI with additional appropriations being recommended in the FY 2011 Defense Appropriations Act, the IOM noted inadequate numbers of clinical trials have been undertaken to develop more effective and evidence-based treatments for multi-symptom illness.
We thank the Subcommittee for holding hearings last year to explore concerns raised by the veteran community and the RACGWVI on GWI research that influences efforts by the research community to, among other things, identify effective treatments for GWI. Since this hearing, the RACGWVI and the IOM have come to an agreement that chronic multisymptom illness is a diagnostic entity associated with service during the Gulf War, and affecting approximately 250,000 veterans. Chronic multisymptom illness is likely the result of genetic and environmental factors and cannot be attributed to stress or other psychiatric disorders. Finally, both agree a major national research program is urgently needed to identify treatments.
These agreements are critical toward establishing a much needed comprehensive plan to address specific priority research topics. Accordingly, DAV is concerned with VA’s announcement funding $2.8 million for three new research projects without such a plan. Moreover, we are concerned the new steering committee established to guide VA’s research program on GWI was not consulted prior to the Department’s announcement and that the projects would not favor research involving psychological aspects of chronic multisymptom illness in light of the agreement on this matter by the RACGWVI and the IOM.
Tailoring VA Health Care
Gulf War veterans are being diagnosed and treated for a wide variety of illnesses and injuries that we believe are consequential to their military service. The DAV has learned that it is important to distinguish the poorly understood, multi-symptom conditions defined as GWI from other diagnosable medical conditions suffered by Persian Gulf War veterans. GWI is a complex of chronic symptoms found at high rates in Gulf War veterans that is not easily explained by standard medical tests and diagnoses. Other health issues that are associated with Persian Gulf War service include amyotrophic lateral sclerosis (ALS) and brain cancers in service members who were exposed to the Khamisiyah demolitions. The RACGWVI estimated that as many as 175,000 veterans, or one in four of those who deployed in the Persian Gulf War, remain ill after their service. Given the magnitude of the problem and the numbers of veterans affected, DAV is concerned the Veterans Health Administration (VHA) is not focusing appropriate efforts and resources to address the needs of this population.
For example, in 1999, the National Academy of Science (NAS) recommended that VA establish centers for the study of war related illnesses similar in structure to VA’s Geriatric Research Education, and Clinical Centers to apply a proven model of care, research, and education to the issue of deployment health. Such centers would, if established, contribute greatly to the advancement of knowledge in this area.
The DAV applauded the establishment of VA’s WRIISCs located at VA medical centers in Washington, DC, East Orange, New Jersey, and Palo Alto, California. These centers offer tertiary medical consultation and clinical programs staffed with multi-disciplinary teams of clinicians focused on the deployment health concerns of combat veterans, including those with difficult-to-diagnose or medically unexplained symptoms. The WRIISCs are tasked with assisting VA providers to understand veterans’ deployment-related health challenges, provide lessons learned to deliver optimal person-centered care, and perform cutting edge investigations and research.
The WRIISCs have a central and important role in VA’s health care program for veterans with post-deployment health problems. Despite this important role, VA has not devoted adequate attention or resources to the education of its staff, or outreach to veterans, to make them aware of these programs. We hear time and again from ill Gulf War veterans that their VA or private sector providers did not make them aware of the information, consultation opportunity, and expertise of the WRIISCs. We believe this VA national resource remains largely unrecognized and underutilized. As a practical matter, DAV believes clinical reminders should be used to prompt VA primary care providers to ensure the military history of ill Gulf War veterans is made part of the electronic medical record, exposure examinations are conducted and open pathways to the WRIISCs are provided.
VA’s core missions are to provide comprehensive prevention, diagnosis, treatment and compensation services to veterans who suffer from service-related illnesses and injuries. Service-related illnesses and injuries, by definition, are military occupational conditions. Accordingly, we believe VA should devise systems, expertise, and recruit and train the necessary experts to deliver these high quality occupational health services.
Occupational Health is a medical specialty devoted to improving worker health and safety through surveillance, prevention, and clinical care activities. Doctors and nurses with these skills could provide the foundation for VHA’s post-deployment health clinics, enhanced exposure assessment programs, and improve the quality of disability evaluations for VBA Compensation and Pension (C&P) Service. VA should consider establishing a holistic, multi-disciplinary post-deployment health service, led by occupational health specialists, at every VA medical center. Moreover, these clinics could be linked with the WRIISCs in a hub-and-spoke pattern to deliver enhanced care and disability assessments to veterans with post-deployment health concerns. To achieve this ideal arrangement, the WRIISCs and post-deployment occupational health clinics would be charged to—
- Work collaboratively with DoD environment and occupational health programs;
- Identify and assess military and deployment-related workplace hazards;
- Track and investigate patterns of military and veterans’ work-related injury and illness;
- Develop training and informational materials for VA and private sector providers on post-deployment health;
- Provide assistance to other VA providers to prevent work-related injury and illness; and
- Work collaboratively with DoD partners to reduce service-related illness and injury, develop safer practices and improve preventive standards.
Likewise, VA needs to improve the capability of its primary care providers to recognize and evaluate post-deployment health concerns. VA and DoD jointly developed the Post-Deployment Health Clinical Practice Guideline to assist primary care clinicians in evaluating and treating individuals with deployment-related health concerns and conditions. This guideline uses an algorithm-based, stepped care approach, which emphasizes systematic diagnosis and evaluation, clinical risk communication, and longitudinal follow-up.
On July 26, 2007, VA’s testimony before the Subcommittee on Health’s hearing included how a health care provider treats a veteran’s GWI. VA stated that a provider must, “go through a very long list of clinical possibilities, take them one at a time, and examine each one fully and do the right diagnostics and try and treat them one at a time.” Anecdotal reports and Departmental data indicate that VA primary care providers are already stretched thin to deliver routine acute, chronic and preventive care within their short clinic visits. The complex, chronic conditions afflicting veterans with GWI cannot be adequately addressed in a routine visit with a stressed primary care provider. We believe VA providers must gain the opportunity to refer such patients to specialized post-deployment occupational health clinics, and to the WRIISCS for the most complex problems of war-exposed veterans with GWI. Veterans suffering from GWI require a holistic approach to the care they receive to improve their health status and quality of life. VA must establish a system of post-deployment occupational health care if it is to meet its mission and deliver on veteran-centered care.
GULF WAR VETERAN EDUCATION AND OUTREACH
Education and outreach is only effective if the information provided is timely and accurate, and it penetrates and permeates the target audience. The DAV recently had the opportunity to assist a North Carolina veteran suffering from GWI. His primary care physician had attempted to treat the veteran’s symptoms, to no avail. The veteran contacted our office for assistance and we recommended the veteran ask his physician to seek assistance from the WRIISC located in Washington DC. Unfortunately, the veteran and his physician were not aware of the WRIISC or how to contact that center. They were not aware of the information available on the internet regarding the WRIISC’s national referral program allowing the veteran to self-refer, nor that the primary care physician is able to use the WRIISC referral template in VA’s Computerized Patient Record System.
While in the case of the veteran above, telehealth consultation between the WRIISC, the veteran, and his primary care provider was used to improve the treatment being provided, DAV is concerned that this one example, combined with 2007 VA data showing only 344 veterans have been evaluated between the East Orange, New Jersey, and Washington, DC, WRIISCs since 2001, is indicative of underutilization of this national resource.
We continue to receive reports from ill Gulf War veterans who remain confused about specific VA health care programs for GWI. For example, recently we were contacted by a veteran who was under the impression that the Persian Gulf War Registry and examinations for entry on the Registry had been halted. We have no doubt other Gulf War veterans maintain this perception due to a number of factors.
The individual responsible for the Gulf War Registry program at each VA medical center was previously called the "Persian Gulf Coordinator." Soon after OEF/OIF began, this position was renamed the "Environmental Health Coordinator." The change in name sought to recognize the environmental exposures that affected Persian Gulf War veterans may also affect OEF/OIF veterans since they are deployed to the same general region. Moreover, OEF/OIF veterans were also exposed to other toxins such as Hexavalent chromium (at the Qarmat Ali water treatment plant in Basra, Iraq), burn pit smoke in several theater locations, and other contaminants.
While the Environmental Health Coordinator is responsible for the administrative management of the Gulf War Registry, schedules veteran patients for exposure examinations, and monitors timeliness compliance, the Environmental Health Clinician is responsible for the program’s clinical management and performs the actual examinations. Although each VAMC provides access to environmental health clinicians and coordinators, there is variability in knowledge and practice among VAMCs as to when and how to conduct exposure assessments.
The DAV is appreciative of the work done by VA’s Office of Public Health and Environmental Hazards’ website to make access more user-friendly and provide pertinent information that may be useful to ill Gulf War veterans and their health providers. Now available to the public is a directory of local VA Environmental Health Coordinators & Health Clinicians at http://www.publichealth.va.gov/exposures/eh_coordinators.asp. Direct telephone numbers to the Environmental Agents Service is also on this webpage for veterans to call with any questions or concerns regarding this program.
To assist ill Gulf War veterans seeking benefits and medical care, VA has made available a VA Gulf War Information Helpline 1 (800) PGW-VETS (1-800-749-8387). As a veteran of the Persian Gulf War, I called this Helpline four times in October 2009 to ask for information on whether VA had specific treatments for GWI. This telephone service offers an automated message providing health care information, specific to Kamisiyah and other Gulf War exposures, and eligibility information was also provided. When I was able to speak to three individuals on three separate telephone calls, all asked if I had participated in the Gulf War Registry and if I had filed a claim for compensation benefits. When I asked whether VA had specialized treatments or a specialized center or clinic for veterans suffering from GWI, one indicated that if I were to enroll into the VA health care system that I would most likely be seen by a local VA specialist based on each physical complaint. The other two stated that the local VA clinic or hospital would see to my specific health concerns. Only one mentioned my contacting the Gulf War Coordinator at my local facility. None, however, mentioned the WRIISCs or referred me to VA’s website for the Office of Public Health and Environmental Hazards cited above.
Notably, these calls are routed to one of eight VA call centers, which VA’s Office of Inspector General (OIG) audited in 2009 and issued Report No. 09-01968-150 on May 13, 2010. The OIG concluded that any one call placed by a unique caller had just a 49 percent chance of reaching an agent and getting correct information.
VA’s Gulf War Information Helpline has now been merged with a resource that assists surviving spouses seeking VA benefits, and is now called the Survivors Call Center and Veterans Special Issues Help Line. I recently called the toll free number. It prompts the caller to select assistance for survivor benefits or exposure issues, including those related to the Gulf War. A caller’s selecting Gulf War issues brings an automated message with information regarding exposure to nerve agents from Kamasiya and provides information on VA’s special exposure examination and benefits as well as an online computer bulletin board.
If not directly routed to an agent, the automated help line offers four options for information on Persian Gulf benefits and services, including medical benefits, disability compensation, and an option to speak with a representative. Having called four times, two agents referred me to my local VA medical center and regional office, with one urging me to file an informal claim over the phone if I had not already done so. The other two agents mentioned the Persian Gulf War Registry and provided the telephone number and extension of the respective Environmental Agents Coordinators. Mr. Chairman, while not perfect, this is an improvement towards standardization of responses and quality of information provided from the calls I made nine months prior.
GULF WAR VETERANS’ ILLNESSES TASK FORCE (GWVI-TF)
This Subcommittee asked DAV to provide our position on the March 29, 2010, GWVI-TF draft report which was subject to a notice with a request for comments by May 3, 2010 in the Federal Register. After VA’s review of all comments and recommendations related to the draft report, an updated version of the report will be released. We appreciate the effort taken by the GWVI-TF to produce the recommendations under seven broad categories: Partnerships, Benefits; Clinician Education and Training; Ongoing Scientific Reviews and Population Based Surveillance; Enhanced Medical Surveillance of Potential Hazardous Exposures; Research and Development; and Outreach.
This draft report is subject to change pending review of public comments, but DAV generally agrees with its overarching goal to improve services to meet the needs of veterans of the Persian Gulf War. As stated above, DAV believes VA must aggressively pursue answers to the health consequences of veterans’ Gulf War service and that the Department must not reduce its commitment to VHA programs that address health care and research or VBA programs that meet the unique needs of ill Gulf War veterans.
We note some of the recommendations made in the draft report are not new and have been the subject of inaction for several years without appreciable results. For example, both DoD and VA are required to exchange health information and to develop systems that allow for interoperability of information between the two agencies. However, both departments have been working toward electronic medical record compatibility for more than a decade. While progress has been made and the departments are sharing more information, such as exchanging computable pharmacy and drug allergy data, according to the Government Accountability Office, the departments were not sharing all electronic health data, including for example, immunization records and history, data on exposure to health hazards, and psychological health treatment and care records. Moreover, although VA’s health information was all captured electronically, not all health data collected by DoD were electronic—many DoD medical facilities still use paper-based health records. 
As this Subcommittee is aware, there are two plans that contain objectives, initiatives, and activities related to further increasing health information sharing, the VA/DoD Joint Executive Council Strategic Plan (VA/DoD Joint Strategic Plan) and the DoD/VA Information Interoperability Plan (IIP). We are concerned the recommendations in this draft report do not link to these two plans, which are key documents in defining planned efforts to provide interoperable health records. We do agree with the recommendation to establish partnerships particularly with the Joint Interagency Program Office, to function as a single point of accountability for accelerating the exchange of health information VA and DoD.
The draft report also makes recommendations regarding the claims processing procedures and training of personnel related to adjudicating disability claims based on Gulf War undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses. We direct the Subcommittees attention to our views on this matter in this testimony under the heading, “Delivering All the Benefits Entitled.”
Another longstanding issue on which DAV has called for action is revamping the outdated and ineffectual education and training tools regarding Gulf War exposures, health outcomes and research that are currently used to prepare VHA and VBA personnel in caring for and assisting ill Gulf War veterans. The Veterans Health Initiative on Gulf War Veterans' Health is an independent study guide developed to provide a background for VA health care providers on the Gulf War experience and common symptoms and diagnoses of Gulf War veterans. We note, this guide was released and last revised in 2002. The information in the guidebook must be reviewed and revised to include the latest research findings and clinical guidelines. In addition, VA must assess the effectiveness of this guidebook and determine if another format should be used that would be more easily accessed and consumed by VHA and VBA personnel.
Additionally, while the GWVI-TF agrees with the RACGWVI that identification of new treatments for ill Gulf War veterans is a high priority, it is not highlighted or reflected as a central issue in the draft report. The need for effective treatment is a central issue identified by the IOM, the RACGWVI, and the 25 to 32 percent of the 700,000 deployed Gulf War veterans suffering with multi-symptom illnesses. We direct the Subcommittee’s attention to our views on this matter in this testimony under the heading, “Need for Effective Evidence-Based Treatment.”
Along the same lines as identifying effective treatment of GWI and disseminating such information to VA providers to improve the Department’s clinical care focus on GWI, DAV believes VA should consider establishing a post-deployment health service led by occupational health specialists at every VAMC and that these clinics could be linked in a hub-and-spoke pattern with the WRIISCs to deliver enhanced care and disability assessments to veterans with post-deployment health concerns. VA must establish a system of post-deployment occupational health care if it is to meet its mission and deliver on veteran-centered care to veterans suffering from GWI and other veteran population suffering from other hazardous environmental and other toxic exposures.
Mr. Chairman, it is apparent to DAV that VA has a number of programs aimed at patients and providers to assist ill Gulf War veterans. However, VA’s approach to the needs of this veteran population has become parochial and fragmented. DAV believes much work remains to ensure federal benefits and services are adapted to meet the unique needs of veterans suffering from GWI. VA must find ways to meet its obligation to care for the newest and prior generations of disabled veterans without diverting its attention from the actions needed to find the means to diagnose, treat, and cure GWI. DAV believes the answers lie in medical surveillance, high quality health care, and research. Where cure remains elusive, VA must provide timely, accessible, responsive, and equitable benefits and compensation for those who suffer chronic illnesses and disability. Our nation requires no less.
Veterans suffering from GWI who file claims for service connection for undiagnosed illness must contend with a slow process that has a low success rate. Moreover, if they seek care at VA, they often receive a combination of piecemeal interventions and symptom-based treatments, about which all longitudinal studies that have evaluated the health of veterans suffering from GWI have reported little improvement.
We believe many ill Gulf War veterans have stopped turning to VA or worse have simply given up seeking any type of assistance. We hope some of the recommendations made in this testimony will be seriously considered. Otherwise, providers can only try to teach ill Gulf War veterans how to choose a lifestyle adapted to their disabilities incurred in service in the Persian Gulf War without substantial improvements in their health. As stated at the beginning of this testimony, there is a great need for a true champion from the Administration who will challenge VA to provide a clear path for progress to systematically address GWI issues and ensure that federal programs aimed at meeting the extraordinary needs of veterans suffering from GWI are adapted to meet them.
Mr. Chairman, DAV thanks the Subcommittee for the opportunity to testify and for your efforts in highlighting the needs of our nation’s ill Gulf War veterans. This concludes my statement. I will be pleased to respond for the record of this hearing to any questions you may wish to ask with respect to these issues.
 Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 10 Years. Journal of Occupational and Environmental Medicine 2009 Apr; 51(4):401-410.
 February 2003 – Gulf War veteran mortality data; May 2003 – Cumulative numbers of inpatient and outpatient health care encounters for deployed Gulf War veterans; February 2005 – Number of unique Gulf War veterans who sought care at Vet Centers; February 2005 – Number of unique Gulf War veterans enrollment by Priority Group.
 Public Law 97-72 (95 Stat. 1047)
 Public Law 105-368 (112 Stat. 3315)
 (202) 461-1013 or (202) 461-1014
 Cleveland, OH; Philadelphia, PA; Columbia, SC; Nashville, TN; Muskogee, OK; St. Louis, MO; Phoenix, AZ; Salt Lake City, UT
 Research Advisory Committee on Gulf War Veterans’ Illnesses. Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations. Washington, DC: U.S. Government Printing Office, November 2008.