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Introduction

This first report by the Institute of Medicine (IOM) Committee to Review Health Consequences of Service during the Persian Gulf War is the result of our review of the current activities related to potential health consequences of service in the Persian Gulf. Our recommendations for actions that should be taken immediately, are the committee's response to concerns by Congress and veterans. In our second report, the committee will focus on reviewing issues requiring additional scientific evaluation, and recommendations will follow from that review.

The IOM committee is issuing these initial findings and recommendations because of the urgent concerns of Persian Gulf War veterans and of society in general, and because some steps can—and should—be taken promptly. The actual scope and nature of the health problems of Persian Gulf veterans have not yet been ascertained. We have not limited our discussions to a narrow interpretation of the charge, but rather have chosen to broaden the scope of our study of health outcomes and related research efforts, to include women's health and reproductive issues, infrastructure and procedures for data collection, health services influences, nutritional problems of military personnel, the role of psychiatric diagnosis, the review of Persian Gulf boards and coordination groups, as well as issues stemming from involvement in the Persian Gulf region that might have relevance to possible future conflicts.

To gather information for this report, committee members listened to invited presentations (see Appendix B), examined the voluminous materials prepared for use by the IOM staff, talked with physicians responsible for treating



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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action 1 Introduction This first report by the Institute of Medicine (IOM) Committee to Review Health Consequences of Service during the Persian Gulf War is the result of our review of the current activities related to potential health consequences of service in the Persian Gulf. Our recommendations for actions that should be taken immediately, are the committee's response to concerns by Congress and veterans. In our second report, the committee will focus on reviewing issues requiring additional scientific evaluation, and recommendations will follow from that review. The IOM committee is issuing these initial findings and recommendations because of the urgent concerns of Persian Gulf War veterans and of society in general, and because some steps can—and should—be taken promptly. The actual scope and nature of the health problems of Persian Gulf veterans have not yet been ascertained. We have not limited our discussions to a narrow interpretation of the charge, but rather have chosen to broaden the scope of our study of health outcomes and related research efforts, to include women's health and reproductive issues, infrastructure and procedures for data collection, health services influences, nutritional problems of military personnel, the role of psychiatric diagnosis, the review of Persian Gulf boards and coordination groups, as well as issues stemming from involvement in the Persian Gulf region that might have relevance to possible future conflicts. To gather information for this report, committee members listened to invited presentations (see Appendix B), examined the voluminous materials prepared for use by the IOM staff, talked with physicians responsible for treating

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action patients listed in the Department of Veterans Affairs (VA) Persian Gulf War Veterans Health Registry (subsequently referred to in the text as the Persian Gulf Health Registry), and looked at some of their case records. We also talked with other physicians interested in this case material, including one who has helped a few of these patients at her own expense. We have also followed the coverage of unexplained illnesses referred to as the ''mystery illness'' or "Gulf War Syndrome" (GWS) by the public media. ORGANIZATION OF THE REPORT Following the introduction, this report contains two additional chapters. In the second chapter, the committee presents findings and recommendations that should be implemented as soon as possible. Implementing these recommendations is necessary only to enable certain critical research on the health effects associated with service in the Persian Gulf War (PGW), and to establish infrastructure and procedures to support health studies related to possible future military encounters. The chapter is divided into three sections: "Data and Databases," "Coordination/Process," and "Considerations of Study Design Needs." This chapter precedes the supporting background chapter because the committee believes its findings and recommendations are the most important part of the report. The third chapter provides a general overview and discussion of the actions taken and the steps involved in defining the Persian Gulf health arena. The chapter is divided into the following sections: "Boards and Committees," "Population-Based Activities," "Health-Outcome-Based Activities—Completed or Well Underway," "Health-Outcome-Based Activities—New or Just Beginning," and "Exposure-Based Activities." Appendix A comprises the putative outcomes and exposures that the committee has been, and will continue to, evaluate and modify as additional information becomes available; Appendix B is a listing of invited presentations; Appendix C contains relevant portions of the laws that are mentioned in this report. Included in Appendix D are the dates of each IOM committee meeting, a list of persons who presented or submitted testimony for the committee's public meeting, and a list of persons who have subsequently sent materials to the IOM committee. Appendix E includes a list of activities known to this committee to be related to the Persian Gulf health experience, as of September 1994 and Appendix F includes a timeline of events beginning with the invasion of Kuwait and continuing with events and activities related to this report.

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action The second report from this committee will build on materials presented here, and will report additional recommendations that may evolve from deliberations on issues that have not been resolved for this report. HISTORY OF EVENTS IN THE PERSIAN GULF WAR On August 2, 1990, Saddam Hussein's Iraqi troops invaded Kuwait. In response to this invasion, U.S. Naval forces were strengthened in the area to enforce trade sanctions, and an aircraft carrier with 2,100 Marines was sent to join other carriers in the area. More U.S. ground troops were deployed to Southwest Asia (SWA) theater of operations (Persian Gulf, Iraq, Kuwait, Saudi Arabia. Red Sea, Gulf of Oman, Gulf of Aden, portion of Arabian Sea (northern), Oman, Bahrain, Qatar, and United Arab Emirates), beginning on August 7, 1990. This deployment of troops was known as Operation Desert Shield. By August 22, 1990, the president announced the mobilization of reserve forces, including many Army noncombat personnel. The build up continued, and on November 8, 1990, President George Bush announced the deployment of additional troops to join the troops already stationed in SWA. On November 29, 1990 the United Nations (UN) Security Council passed Resolution 678, which authorized the UN member states to use "all necessary means" to remove Iraqi troops from Kuwait. On January 12, 1991 Congress passed House Joint Resolution 77, which authorized President Bush to use armed forces in the region to implement UN resolution 678. On January 14, this resolution was signed into law as Public Law (PL) 102-1. On January 16, 1991, the coalition air forces began attacking Iraqi targets. These actions have been termed Operation Desert Storm (ODS). Oil fires in Kuwait started burning on February 20, 1991. The ground war began on February 24, 1991, as the coalition forces attacked Iraqis in Kuwait and southern Iraq. By February 28, 1991, the war was over, and the last troops to have participated in the ground war returned home on June 13, 1991. The last oil field fire was extinguished by early November 1991. This history of events in the Persian Gulf was condensed from a chronology report to Congress (CRS, 1992). In all, a total of approximately 700,000 U.S. troops had been deployed to the Persian Gulf theater for Operation Desert Shield/Desert Storm (ODS/S). As troops were being deployed, others were returning home; the maximum number of troops located in the Persian Gulf was in February 1991, with a rapid return of troops after March 1991. The number of reserve and active duty troops located in the theater of operations, by month, is shown in Figure 1. A timeline of these events and subsequent activities relevant to this report is in Appendix F.

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Since the earlier days of this operation the U.S. government, and military and civilian personnel assigned to the Persian Gulf, and their families have been concerned about the possible health consequences of serving in the Persian Gulf theater of operations. Following the Persian Gulf War, Congress mandated, through PL 102-190, that the Department of Defense (DoD) establish the Persian Gulf Registry, to determine the location of members of the Armed Forces exposed to burning oil fumes during Operation Desert Storm. Subsequently, in PL 102-585, passed on November 4, 1992, the Persian Gulf Registry mandate to DoD was expanded to include the location of "any other members who served in the Operation Desert Storm theater of operations during the Persian Gulf conflict." Records of the DoD register are designed to include service members' names and other relevant identifying information, the grid location of their service in the Gulf, and the prevailing atmospheric and other environmental conditions, including length of time exposed to burning oil fumes. In addition, PL 102-585 also mandated that the Department of Veterans Affairs establish a Persian Gulf War Veterans Health Registry, and that it record relevant medical data on members of the Armed Forces who served in the Persian Gulf theater of operations during the Persian Gulf War. This registry contains names and selected other personal and health data, and includes PGW veterans who have sought VA care or medical examination, or who claim disability based on PGW service; active duty service members seeking similar health examinations because of PGW service from DoD medical facilities; and veterans for whom beneficiaries have filed claims (see Appendix C). PL 102-585 also requires the Secretary of Veterans Affairs and the Secretary of Defense jointly to seek to enter into an agreement with the Medical Follow-up Agency (MFUA) in the Institute of Medicine, in the National Academy of Sciences (NAS), to report on "(a) an assessment of the effectiveness of actions taken by the Secretary of Veterans Affairs and the Secretary of Defense to collect and maintain information that is potentially useful for assessing the health consequences of the military service . . . [in the Persian Gulf theater of operations during the PGW]; (b) recommendations on means of improving the collection and maintenance of such information; [and] (c) recommendations on whether there is sound scientific basis for an epidemiological study or studies on the health consequences of such service, and if the recommendation is that there is sound scientific basis for such a study or studies, the nature of the study or studies" (see Appendix C). The contract with the IOM was funded jointly by VA and DoD beginning on September 30, 1993. The IOM Committee to Review the Health Consequences of Service during the Persian Gulf War was approved December 31, 1993, by the IOM and National Research Council (NRC), which is the operating arm of the NAS. The efforts of the committee from January 1994 through

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action this writing in September 1994, have focused on reviewing Persian Gulf (PG) related activities to date, and making recommendations based on that review. The process has included five committee meetings prior to the release of this report and a review of numerous documents sent to the committee for consideration. The second meeting, which took place on the afternoon of February 28 and the morning of March 1, 1994, included a public meeting in Washington, D.C. to allow presentations from anyone who wished to address the committee members. Additional written materials received after the public meeting were made available to the committee members to review (see Appendix D). Although the products of oil well fires were the initial focus of concern about the health effects of the PGW, attention has shifted to a complex of ill-defined and often poorly characterized symptoms and signs of illness. In response to the growing concern about unexplained illnesses, several boards were established by federal government agencies, composed of representatives from VA, DoD, Environmental Protection Agency (EPA), and Department of Health and Human Services (HHS). The VA's Persian Gulf Expert Scientific Committee is reviewing all aspects of patient care, and medical diagnoses, and is providing professional consultation as needed. A DoD Task Force of the Defense Science Board (DSB) reported on the cause and effect of the full range of low-level chemical exposure, environment pollutants, endemic biologics, and other health hazards that might have affected Persian Gulf veterans (DSB, 1994). The Persian Gulf Veterans Coordinating Board, chaired by the Secretaries of Defense, Veterans Affairs, and Health and Human Services, oversees the coordination of all efforts in research, clinical care and disability determination/compensation for illness related to service in ODS/S. The Persian Gulf Interagency Research Coordinating Council serves as the research working group of the Persian Gulf Veterans Coordinating Board, which coordinates all Persian Gulf health consequences research activities of the Executive Branch of the Federal Government. In April 1994, the Persian Gulf Interagency Research Coordinating Council sponsored a Technology Assessment Workshop held at the National Institutes of Health (NIH) entitled "The Persian Gulf Experience and Health." This workshop, and the boards mentioned above are discussed in greater detail in chapter 3.

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Figure 1. Number of U.S. troops in the Persian Gulf Theater of operations by month. SOURCE: Information provided by the Defense Manpower Data Center.