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Witness Testimony of Dr. Victoria Davey, Chief Officer, Office of Public Health and Environmental Hazards Veterans Health Administration U.S. Department of Veterans Affairs

Good morning, Mr. Chairman, Madam Ranking Member, and Members of the Subcommittee.  Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA) efforts to identify, diagnose, and treat Gulf War-era Veterans.  I am accompanied today by Dr. Maureen McCarthy, Deputy Chief Patient Care Services Office, Dr. Stephen Hunt, Persian Gulf Registry Physician, and Dr. Gavin West, Physician, Salt Lake City VA medical center (VAMC).

VA focuses on all eras of Veterans and recognizes unique aspects of service associated with each era.  In 2009, Secretary Shinseki established a Gulf War Veterans Illnesses Task Force (Task Force), headed by VA’s Chief of Staff (COS), a Gulf War Veteran.  The Task Force's mission is to ensure that VA maintains a focus on the unique needs of Gulf War Veterans.  It was chartered to conduct a comprehensive review of VA’s programs to support this population of Veterans; develop an overarching action plan to advance service to them; and ultimately to improve their satisfaction with the quality of services and support VA provides.  The Task Force has prepared three annual reports detailing concrete steps VA has taken, and continues to take, to improve care and services to Gulf War Veterans.  The Secretary and COS believe that ultimately, the Task Force's efforts must become a part of the culture and ongoing operations of VA―and not simply the purview of a special Task Force.  

At this time, Mr. Chairman, I would like to focus on the efforts the Veterans Health Administration has made in response to both the guidance of the Task Force and the needs of Gulf War Veterans, to improve their health and well-being.
VA is proud to offer continuing treatment as well as evaluation of the nearly 700,000 men and women who served in Operations Desert Shield and Desert Storm.  My purpose today is to communicate the personalized and compassionate care that VA strives to deliver to fulfill the unique needs of the men and women who served in these Operations.
Many Gulf War Veterans are affected by a debilitating cluster of medically unexplained chronic symptoms that can include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems.  

These symptoms can wax and wane, and may have lasted since deployment in some Veterans.  Unfortunately, we yet do not know the cause, but a complex combination of environmental hazards, exposures, and individual genetic characteristics may be behind these symptoms.  We refer to the illness that these Veterans describe as chronic multisymptom illness or ‘CMI’.  

Terminology like ‘CMI’ helps us define the populations of concern, plan treatments, and drive research.  However, VA’s fundamental approach to health care has evolved over the first decade of the 21st century.  We believe the person, not the disease or the terminology, is the center of importance in the health care relationship.  We want to meet the patient where he or she is in life, and develop with the patient a health plan of care that returns the patient to his or her highest possible level of health and enjoyment of life.  As with every other Veteran, VA seeks to provide Veterans with CMI personalized, proactive, patient-driven care.  As part of our services to Gulf War Veterans, VA offers a number of programs and services that are uniquely designed to meet their needs.  

VA facilities throughout the Nation are working on bold, innovative programs that combine primary care and specialty care services.  One such program links primary care services with specialty medical treatment models specific to Gulf War Veterans, in order to produce a seamless, patient-centric model that will improve patient care, safety, and satisfaction, as well as provider knowledge.  This program is creating a system of care, which leverages VA’s Patient-Aligned Care Team (PACT) concept.  Through PACT, providers and staff members from multiple disciplines, outlooks, and experiences work together to provide the best possible care.  Patients and family members are considered part of their own PACT.

VA has linked PACT teams working with Gulf War Veterans with a specialty care capability that focuses on treating the unique health care requirements of Gulf War Veterans.  The program includes teaching aids, referral networks, and other types of collaboration.  Front-line clinicians have been educated through monthly community of practices conference calls, informational meetings, pocket cards, and Web sites.  The meetings are led by clinicians trained in issues specifically related to the integration of primary and specialty care.

Facilities involved in the program have seen improvement in their recent customer service scores; an improvement that has been corroborated in VA-led focus groups.  VA is currently preparing a social media campaign to improve feedback on the program from Veterans, to keep Veterans involved in the progress of the program, and to allow Gulf War Veterans served by the program to communicate more easily.

VA providers being trained in clinical issues related to the Gulf War include family medicine and internal medicine doctors in training, nurse practitioner students, and those intending to become physician assistants.  Many practitioners at participating VA hospitals and Community-Based Outpatient Clinics (CBOC) have noted a substantial increase in their knowledge about Gulf War Veterans issues, and have found it significantly easier to find information they require about the subject.  Veterans have also noted that clinicians involved in the program are now more knowledgeable about their issues.  

Another program specifically for Gulf War Veterans is our registry program, begun by VA in August 1992.  The program offers a health examination at any of our health care facilities to any Veteran with Gulf War service.  To date, about 130,000 Gulf War Veterans have undergone a registry exam, allowing their health concerns to be evaluated by VA physicians, and enabling them to be referred for additional care when needed.  The comprehensive health exam includes an exposure and medical history, laboratory tests, and a physical exam.  VA health professionals discuss the results
face-to-face with Veterans and in a follow-up letter.

Since 2001, the War Related Illness and Injury Study Centers (WRIISC) have supported specialized care for Gulf War Veterans, and conducted cutting-edge research, clinician education, and a Veteran referral program. VA’s three WRIISC locations have teams of clinicians ready to evaluate Gulf War Veterans with deployment-related concerns.  Based on a comprehensive evaluation, the WRIISC team develops an individual, holistic treatment plan for Veterans with CMI or other ill-defined conditions, through a referral process based on geographic location.

Primary care physicians throughout VHA contact the WRIISC to refer Veterans to one of the three regional centers, using the consult process in VA’s computerized patient record system.  VA recently developed this streamlined specific interfacility consult for the Veteran’s integrated team to use to seek help from the WRIISC for consultation and development of a coordinated treatment plan.

The WRIISC is not the only way in which the special needs of Gulf War Veterans are met throughout VA’s health care system.  VA conducts special educational programs for health care providers, Veterans, and their families.  These include
in-person training sessions, webinars, Web sites, and publications for both patients and providers on topics including assessments of environmental exposure and difficult-to-diagnose conditions.

VHA’s Office of Public Health (OPH) holds quarterly conference calls with Environmental Health coordinators and clinicians located at every VA hospital.  These coordinators and clinicians are subject matter experts for Veterans and VA staff, offering advice on environmental exposure experience during military service.  The conference calls provide coordinators and clinicians with ongoing training, allowing them to share patient care questions, challenges, administrative issues, and solutions that have come up at their facilities and provide an opportunity to discuss the latest information on environmental health.

Recently, OPH developed an Environmental Exposure pocket card that includes questions for practitioners to ask Veterans about their health concerns, including those related to Gulf War deployments.  It also provides contacts Veterans can use to obtain information about additional VA resources and benefits to which they may be entitled.  The card is available at http://www.publichealth.va.gov/docs/exposures/environmental-exposure-pocket-card.pdf.

VA now is in the process of developing additional innovative training resources, such as a mobile device and internet application that will provide real-time information on environmental exposures, associated symptoms and conditions, and potential treatments beneficial for clinicians in treating these Veterans.

Mr. Chairman, in accordance with Public Law 105-277, VA contracts with the National Academy of Sciences to independently examine and evaluate the medical and scientific literature regarding illnesses and deployment in support of the Gulf War.  Since 2000, the Academy’s Institute of Medicine (IOM) has provided its scientific conclusions on the strength of the evidence for associations between such exposures and illness.  VA uses IOM’s reports to help inform policy decisions regarding whether certain diseases or illnesses, called presumptive diseases, are related to qualifying military service.

VA recently engaged IOM to convene a committee to comprehensively review, evaluate, and summarize the available scientific and medical literature regarding the best treatments for CMI among Gulf War Veterans.

On January 23, 2013, IOM released a study containing recommendations to VA on how to recognize and treat Gulf War Veterans with CMI.  IOM based
its recommendations on a review of 47 existing studies.  IOM provided a working definition of CMI, as “the presence of a spectrum of chronic symptoms” in at least two of six categories, including fatigue; mood and cognition (such as memory difficulties); musculoskeletal; gastrointestinal, respiratory, and neurologic issues.  IOM indicated that the symptoms of conditions that are already defined, such as chronic fatigue syndrome; fibromyalgia; functional gastrointestinal disorders; In addition, co-morbid conditions, such as depression and anxiety, may overlap those of CMI.

IOM made recommendations to VA in five categories, including how to:  treat CMI; improve systems of care and management of care for Veterans with CMI; provide information throughout VHA about care for Veterans with CMI; improve the collection and quality of data on care outcomes and satisfaction with care for Veterans who have CMI; and how to conduct future research on diagnosing and treating CMI and on evaluating programs to treat the illness.

VA welcomes this opportunity to address these recommendations in an effort to improve how we meet the clinical needs and expectations of Gulf War Veterans.  VA shares IOM’s concern that Veterans experiencing CMI be managed compassionately and that they experience personalized, proactive, patient-driven care specific to their needs.  Actions that we already are taking include a pilot program to provide every Veteran with a full health assessment when he or she separates from service.  This is a combined VA-DoD separation health assessment.  The Secretaries of Defense and Veterans Affairs acknowledged their commitment to full implementation of a universal, standardized separation health assessment for all transitioning Servicemembers (SMs) was supported through the resources of both DoD and VA in December 2012.  Currently, VA and DoD representatives are drafting the memorandum of agreement (MOA) which will be ready for coordination by end of March 2013.  The MOA will formally establish roles, responsibilities, standard exam criteria, and monitoring requirements. DoD and VA staff have been meeting weekly to discuss implementation options along with the drafting of the MOA.  A pilot is taking place at the Washington, DC VAMC to test the processes related to performing the standardized health assessment elements as part of a VA disability exam in support of a claim for benefits.;

Moreover, other actions include VA’s addition of a clinical reminder to its computerized patient record system to prompt clinicians to ask all Gulf War separating Servicemembers whether they may have symptoms consistent with CMI; and the special PACT program for Gulf War Veterans described previously in this testimony.  We are improving communication among VA health care providers and with patients; improving patient satisfaction measurement tools, and training our staff to better recognize CMI.  We are also developing a champions program and additional webinars, and taking steps to strengthen research protocols submitted for funding in complementary and alternative medicine.

IOM notes in its report that the impacts of CMI are wide-ranging, and extend far beyond the health of individual Veterans.  CMI has personal, occupational, and social consequences that impact not only Veterans and their families but also their employers and the communities in which they live.  VA understands this.  We remain committed to providing evidence-based, compassionate care for these Veterans, and for all of the Veterans it is our privilege to serve.  VA intends to continue our ongoing efforts to improve our abilities to provide health care for Gulf War Veterans; to better educate our health care providers; and to expand the evidence basis for the treatments we provide for Gulf War Veterans, and all Veterans.

Mr. Chairman, this concludes my testimony.  We appreciate the opportunity to appear before you today to discuss this important issue.  My colleagues and I are prepared to answer your questions.