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Executive Summary
On August 2, 1990, a large Iraqi armed force invaded the independent nation
of Kuwait. Five days later, U.S. troops began deployment in Operation Desert
Shield, and within two months, 200,000 troops had been added to those already in
Southwest Asia. By February 1991, more than 500,000 U.S. troops were in the
field, facing the Iraqi army. Intense air attacks against the Iraqi armed forces,
beginning on January 16, 1991, opened the phase of operations known as
Operation Desert Storm (ODS). ODS ended after a brief, but destructive (to the
Iraqi forces), ground war from February 24 to February 28, at which time Iraqi
resistance was largely ineffective and peace was restored. The number of U.S.
troops in the area then declined more rapidly than it had grown. By June 1991,
fewer than 50,000 U.S. troops remained. The total number of U.S. military
personnel present at one time or another during this interval of Operation Desert
Shield/Storm (ODS/S) was about 697,000. The U.S. troops deployed in this war,
compared with other conflicts, included a higher proportion of those who were
older, were from reserve and guard units, or were female.
The experiences of service personnel were nearly as varied as the individuals
deployed, and individuals have responded to their experiences in various ways.
The majority of men and women who served in the Gulf returned home and
resumed their normal activities with little noticeable difficulty. For others,
however, a wide range of physical, chemical, and psychological stressors and
exposures appear to have had health effects disproportionate to the brevity of
active combat and the relatively low combat casualty rate.
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2
HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
As reports of illnesses and individual complaints increased, so did public
concern about a "mystery illness" or "Gulf War Syndrome" (GWS) associated
with service in the Persian Gulf (PG). Both the Department of Defense (DoD) and
the Department of Veterans Affairs (DVA) were involved from the beginning in
tracking and investigating these reports of unexplained signs and symptoms.
Efforts in both clinical care and research were initiated, and these have grown in
size, complexity, and number.
Speculation about the existence and possible causes of a GWS have
involved several federal agencies and numerous research investigators. Many
expert opinions have been offered, and a considerable amount of money has
been spent. The designation of GWS itself has been controversial. Even
without the stress of war, among approximately 697,000 people over a period of
several years, there will be poorly understood ailments and a number of obscure
diseases.
The work of the committee was determined by its charge, which is derived
from Section 706 of Public Law 102-585, in which Congress directed the
secretaries of DVA and DoD to seek an agreement with the Medical Follow-up
Agency of the Institute of Medicine to review existing scientific, medical, and
other information on the health consequences of military service in the PG
theater of operations during the Persian Gulf War (PGW).
The committee was charged to assess the effectiveness of actions taken by
the secretaries of DVA and DoD to collect and maintain information that is
potentially useful for assessing the health consequences of military service
referred to in subsection (a) of Public Law 102-585 (PG theater of operations
during the POW); to make recommendations on means of improving the
collection and maintenance of such information; and to make recommendations
as to whether there is a sound scientific basis for an epidemiologic study or
studies of the health consequences of such service and the nature of the study or
studies.
To meet this charge, the committee heard presentations and reviewed
written materials from representatives of DVA and DoD through May 1996;
reviewed relevant scientific literature, protocols, reports of findings, and other
documents; held a public meeting; reviewed unsolicited materials received; and
attempted through staff updates to keep abreast of relevant PG health-related
activities, including activities of other groups.
The committee released a first report in January 1995 with a focus on data
and databases, coordination and process, and considerations of study design
needs. Little research was under way at that time, and research results were
sparse. The first report and this report were written to stand independently, and
the recommendations of each are based on the findings and material presented
in the individual report.
The committee's charge is specific to DVA and DoD, and the focus of our
review of data collection methods and research is specific to those agencies.
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EXECUTIVE SUMMARY
3
Many other activities are being conducted by private individuals, but a
comprehensive review of that body of work is beyond the scope of our charge.
To make appropriate and relevant recommendations concerning future research
activities, the committee believes that a review of federal research activities and
plans is appropriate and within the charge. The committee recognizes and
agrees that there are veterans who are sick. They must have proper diagnosis
and care for their illnesses, including compassionate and expert attention to the
full range of their health concerns. However, it is beyond the scope of this
committee's work to evaluate issues related to access, responsibility, quality and
scope of health care, or possible impact of compensation policies. We believe
that this separation of issues is appropriate and that matters of medical care and
compensation should be examined separately from issues related to potential
causes of illnesses, their treatment, and their prevention in any future conflicts.
Individuals deployed during the PGW were at risk of exposure to a myriad
of environmental, occupational, medical, psychological, and battle-related
health risks. Some exposures may have occurred in a setting recognized as
health threatening; others were unlikely. Some were primarily threats to
psychological health; others were threats to physical health. Some potential
health effects would be immediate; others would become manifest in the
medium term; still others might take years or decades to surface. Within these
dimensions, there could be many specific manifestations of symptoms and signs.
During and after service in the PGW, veterans did begin to experience adverse
health effects. Some of the individuals would have experienced illness during
this period whether or not they were in the PGW, whereas the health complaints
of others might be a result of their PGW service. However, there is no way to
determine which veterans fall into the former group, and research may shed
some light on, but not necessarily prove, which may be in the latter group.
Our overarching themes are that reliable and relevant data are essential, that
both the broad and the fine details matter a great deal, and that developing an
understanding of the range of uncertainty of a risk assessment, while possibly
discomforting, may be of greater importance than highlighting best-guess
conclusions.
Several good research studies are now under way; attempts are being made
to link potential exposures with troop locations; information systems are being
improved with regard to data capture (including in-theater tracking), data
quality, and intersystem linkages; and the clinical registries of DVA and DoD
are obtaining standardized, relevant data.
Even when considering the difficulties and cautions in interpreting research,
the committee believes that there is a sound basis for epidemiologic studies, as
well as basic science studies, relevant to an understanding of the health
consequences of service in the PGW.
There have been special concerns about a range of both naturally occurring
and either purposeful or accidental environmental exposures of troops during the
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
POW. Objective indicators of harmful environmental exposures in the PG were
limited in scope during the POW and are not readily usable for research
purposes. Monitors of air and soil contaminants were not operating for the full
period of ODS/S, and other kinds of exposures were not measured. Exposure
indicators of other than air or soil were not available. Autopsies of animals and
humans, and follow-up examinations of military working dogs, have not
indicated the presence of excessive toxic or heavy metals, particularly when data
before and after the oil well fires are compared. Official reports of acute health
consequences from exposure to air pollutants were rare.
It is clear from written descriptions and reports by veterans that the PG was
a hostile environment. Desert conditions, the absence of amenities,
uncomfortable temperatures and humidities, extremes in rainfall, blowing sand,
insects, animals, fumes, and smoke all contributed to adverse living
conditions. In addition, wartime conditions, including measures uniquely
designed to protect the troops, necessitated other exposures such as vaccines
against possible biological warfare agents, pyridostigmine bromide to protect
against possible chemical warfare agents, and pesticides to protect against bites
from insects carrying diseases such as sandily fever and leishmaniasis.
Depleted uranium, used in munitions and tank armor, was a limited but real
wartime exposure. Unfortunately, there was no systematic accumulation of data
on these exposures, making research into their possible health effects
exceptionally difficult, if not impossible.
In the midst of these adverse environmental and wartime-related exposures,
soldiers were vulnerable to all of the exposures connected with their particular
occupations in the Gulf, such as chemical-agent-resistant coatings, solvents, and
vehicle exhaust fumes. Information about "unofficial" exposures, such as the
combustion products of leaded fuels in heaters that were sometimes unventilated
or nonregulation, wearing flea collars to protect against insect bites, and
ingesting alcohol substitutes in the absence of approved alcohol consumption is
available only from self-reports.
Not surprisingly, the above scenario creates a picture of an extremely
stressful environment, filled with the dangers and trauma of war, combined with
a hostile living and work environment. Contributing to this stress were the lack
of sanitary conditions and privacy (particularly when men and women were
serving together); the speed of being "called-up" to duty and thrown into this
environment; "watchful waiting" for the shooting war to begin or SCUD
missiles to explode; apprehension heightened by drills and training exercises
relating to the threat of chemical and biological warfare; intense workloads; and
sleep deprivation. Additionally, issues related to unit cohesion, leadership,
morale, and knowledge of family stresses back home varied among individuals
but are important for fully understanding the experience of the entire deployed
cohort.
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EXECUTIVE SUMAl4RY
5
Although a wide range of possible exposures might be associated with
adverse health outcomes in PG veterans, data on these exposures are often not
available; when they are available, they are poorly documented. This lack of
exposure information is at the core of the frustration in obtaining answers from
epidemiologic studies. Self-reports of exposure and estimation of individual
exposures from unit-level measurements will be subject to so much error that
they are likely to yield inconclusive results and additional questions.
With the broad question of what adverse health consequences veterans have
suffered as a result of their service, the range of relevant experiences is also very
broad. The strength of evidence for or against increased risks of specific health
outcomes among those who served in the PG depends in part on what research
studies have been conducted, and hence, on numerous explicit and implicit
decisions made by large numbers of research investigators and funding
agencies, often acting individually with little perspective on overall needs and
priorities. As a result, the research record is of uneven depth and quality. Our
task is to summarize the data available to date that appear relevant to our charge
of examining possible health consequences of PGW service and recommend the
nature of future studies that would provide more and better- answers to this
question.
Although medical scientists often can use clinical data and individual
reports of health experiences to identify areas of concern, such data and reports
cannot in themselves provide proof of cause and effect about the health
outcomes of PGW service. No matter how well documented an illness may be,
or how moving a personal story, unexplained illnesses also occur in the civilian
population and in troops not deployed to the Gulf. A basic question regarding
the connection between illness in veterans and their service is not whether
specific illnesses or adverse health experiences occurred, but whether the
frequency or severity of such outcomes was increased over what occurs in
otherwise similar populations that were not in the PG.
The range of possible PGW-related health effects that can be studied at this
time is intrinsically limited. Illnesses and symptoms that occurred during the
deployment and were transient in nature were not studied or monitored
systematically then and are very difficult or impossible to study retrospectively
now. For example, possible temporary decrements in lung function associated
with exposure to pollutants from the oil well fires were not evaluated at the
critical time and are not very amenable to study now, although they may be
important.
Likewise, health effects that first come to light years after the precipitating
exposure cannot easily be studied. Many of the known causes of chronic
diseases, such as cancer and coronary artery disease, operate over longer periods
than have passed since the PGW and, therefore, cannot yet be evaluated in Gulf
War veterans. For example, it is commonly believed that most cancers have a
minimum 10-year latent period between exposure and detection of the first extra
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
cases of disease. Thus, although no excess adverse cancer effects have yet been
reported, delayed effects that have not yet come to light are still possible. What
can be examined now are effects that appear early and are persistent or become
manifest at some time up to several years after the relevant exposure.
Concerns about unusual illnesses among PGW veterans arose initially
through reports of individuals and then through "outbreak" studies, in which
teams of epidemiologists studied groups of soldiers who reported a high
prevalence of a cluster of symptoms later proposed to be characteristic of a
GWS.
This report reviews three such studies. In each case, the unit came to
medical attention because of a report of what appeared to be an unusually high
rate of unexplained illness. These studies came to the similar conclusion that
troops reported high rates of a variety of nonspecific symptoms, including
fatigue, joint pain and stiffness, disturbed or unrefreshing sleep, some
gastrointestinal complaints, and a variety of complaints suggestive of mood and
musculoskeletal disorders. Thus, although these outbreak studies were
successful in demonstrating a common pattern of perceived health problems
across a range of military units deployed to the Gulf, they were not successful in
demonstrating that these symptoms occurred at a higher rate among PGW
veterans than among PG-era veterans (those who did not serve in the PG) or that
these symptoms could be linked to specific medical diagnoses or exposures.
To provide some support to those veterans concerned about their health, to
enable them to receive a clinical work-up, and to gather information on a
possible connection to service in the PG, the DVA and DoD created registries
and voluntary referral programs for troops, including DVA's National Referral
Center and Persian Gulf Health Registry (PGHR) and DoD's Comprehensive
Clinical Evaluation Program (CCEP).
Veterans who have voluntarily participated in these registries have not been
found to have any unusual rates of diagnosable conditions but do report a
pattern of symptom complaints similar to that seen in the outbreak studies. For
example, the five most commonly reported symptoms among registrants in the
PGHR were fatigue, headache, skin rash, muscle and joint pain, and loss of
memory or other cognitive problems. The registries also share the scientific
limitations of the outbreak studies, in that participants are self-selected,
symptoms are self-reported, exposures are self-reported and could not be
validated, and there is no suitable control group.
Because of these limitations, the committee has concluded that the
information on veterans' health that exists in the registries cannot serve alone as
a basis for scientific study of the health effects of the PGW. The committee
does consider these registries and their affiliated clinical referral programs as
useful in assisting veterans who need clinical services and possibly useful as a
source of hypotheses regarding the nature and extent of health problems
experienced by PGW veterans.
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EXECUTIVE SUMMARY
7
The DVA and various units of the DoD have undertaken a variety of
scientific studies of the health status of PGW veterans. The number and scope
of these studies have increased rapidly over the past several years, but few
studies had been completed as of May 1996. Most of these studies are limited
by the absence of detailed exposure information related to individual troops or
units. Consequently, studies have had to be designed to seek effects that are
sufficiently widespread to be evident when comparing troops who served in the
Gulf with those who did not (PG-era veterans).
In seeking evidence for specific effects of service in the PGW, a
combination of studies has shown increased rates of symptoms among groups of
veterans (many of these being self-selected), with no identified medical
diagnosis or exposure. Along with these are studies of mortality and
hospitalization rates, in the PG veteran cohort as a whole, that show no
consistent differences relative to rates in PG-era veterans. Given this overview,
the committee has not identified scientific evidence to date demonstrating
adverse health consequences linked with PGW service other than the
documented incidents of leishmaniasis, combat-related or injury-related
mortality or morbidity, and increased risk of psychiatric sequelae of
deployment. At the same time, the committee recognizes that studies provided
to us thus far do not comprise a comprehensive scientific investigation of the
health consequences of service in the PGW.
The single most troublesome problem encountered in attempts to conduct
epidemiologic studies of illnesses among PGW veterans has been the inability to
retrieve information on medical care events such as hospitalizations, outpatient
visits, and diagnoses and treatments from DoD and DVA medical records in a
uniform and systematic manner. Lack of uniform and retrievable - medical
information concerning reserve, National Guard, active, and separated forces
has greatly inhibited systematic analysis of the health effects of mobilization.
DoD and DVA have different and only partially automated inpatient hospital
record systems. Neither DoD nor DVA has automated outpatient record
keeping, although the committee has recently learned that a database with
outpatient records will be available in the near future from DVA. Current
systems are fragmented, disorganized, incomplete, and therefore poorly suited
to support epidemiologic and health outcome studies.
In addition to the PGHR and CCEP mentioned previously, DoD established
two other PG database programs: the Troop Exposure Assessment Model
(TEAM) and the Registry of Unit Locations (RUL).
The committee finds that the PGHR and CCEP are useful for clinical
evaluation of the health problems of PGW veterans but cannot be utilized for
research because they include only self-selected individuals who volunteer to
participate in these programs. TEAM and RUL also will have limited utility for
epidemiologic studies since they provide information at the unit level rather than
at the individual level.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
Whereas no system of medical record keeping can or should be designed to
provide the information needed to address every unanticipated issue regarding
the health consequences of either military service in general or a specific
military conflict, health information systems can be established to facilitate
epidemiologic studies of such service. The committee has identified several
changes in health information systems for military personnel that will enhance
the capability of the military to evaluate the health consequences of future
deployments and service. These changes include creation of a uniform medical
record, including data from civilian providers; full implementation of the
Defense Medical Epidemiological Database system; and completion of the
Army's Patient Accounting and Reporting Real-Time Tracking System
(PARRTS), including expansion to the other branches of service
Medical care and health surveillance (for persons who may need medical
attention now) and epidemiologic evaluation of potential threats to the health of
service personnel (for research to prevent future problems) will be greatly
strengthened by the development of a system that provides access to the entire
medical history of each member of the armed services and facilitates linkage to
other sources of data. Such a system would provide substantial benefits to the
service member and veteran, to future service persons whose health will be
better protected, and to DoD or any agency that needs healthy personnel.
As far back as World War I, and perhaps antiquity, every war has left a
proportion of service personnel and veterans with serious medical complaints
that cannot be explained on the basis of known health hazards or identified
physical illnesses. This pattern is so consistent, and the health problems are so
important, that databases and health information systems should be designed
and implemented now to deal with and mitigate similar problems that are likely
to arise in future conflicts.
Two categories of health and exposure information systems are discussed in
this report: (1) those established in response to health concerns related to
service in the PGW and (2) those developed to improve the future capability to
evaluate military-service-related health issues.
Several systems exist for collecting health and exposure information. Some
are relevant to clinical evaluations, others are relevant to research, and some are
relevant to both. Not all of these information systems are appropriate for use in
research activities, nor do they have to be. Some of these systems, such as
inpatient hospitalization data, were available at the time of the PGW; others,
such as the PGHR, were established shortly thereafter; still others, such as
PARRTS, have been developed or extended since the PGW. Some of these
systems will be useful for collecting data that strengthen future military health
preparedness to address research questions.
The committee considers four steps the development of a uniform
medical record, (2) the improvement of data collection on exposures and health
status of deployed service personnel, (3) the provision of supplementary data on
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EXECUTIVE SUMMARY
9
occupational and environmental exposures, and (4) the inclusion of early
detection medical teams during major deployments to be important elements
of a Military Health Surveillance System that would increase the nation's
capacity to address questions about acute and chronic health consequences of
deployments of U.S. military service personnel.
In our attempt to investigate comprehensively the health-related
consequences of service in the PG, we have encountered numerous hypotheses,
often provided by independent investigators, that have suggested a wide variety
of associations among agents and exposures, circumstances that existed in the
Gulf, and adverse clinical outcomes. These hypotheses have had varying
degrees of plausibility and supporting research. Some investigators brought
their work to the attention of the committee. In each case, the material
presented by individuals and groups, in person or in documents, was evaluated
by the entire committee and considered as we formed our overall impression of
the health consequences of service in the Gulf. The many investigations (both
federal and private) and the putative causal associations that we evaluated
demonstrate the vexing nature of the medical problem presented by what some
have referred to as a Gulf War Syndrome, and we refer to here as unexplained
illnesses (UI).
A precis of many of the hypotheses and much of the supporting evidence
that the committee received is provided in the report. Most of this material was
not solicited. Thus, this list is not intended to be exhaustive or complete but
rather to illustrate the issues that faced both the investigators and the committee.
The number and variety of hypotheses call attention to the variety of different
types of abnormalities that have been reported and the strong likelihood that no
single hypothesis could account for all of these, whether or not the illnesses
result from service in the POW.
The committee-has been troubled by news stories about activities to
promote the treatment of clinically evident manifestations of UI. These raise
ethically troublesome questions about the lack of documented efficacy, and
some of these interventions could even prove harmful to individual patients.
Since placebo treatment of patients with almost any ailment (psychological or
otherwise) will often result in marked improvement in symptoms or even
physical signs of disease, well-designed clinical studies must be employed to
understand the efficacy of any medical intervention.
Finally, although the committee has not identified an explanation for the
unexplained illnesses in PG veterans, we do not doubt that many individuals
reporting such illness are seriously affected. We recognize that many illnesses
in the population at large lack explanation according to current medical
understanding and also require an open mind. Continuing efforts to explore all
possible avenues to increase our knowledge of such illnesses, and to reduce
suffering and disability, are certainly indicated. The fact that work of the
tentative nature summarized in the report continues 6 years after cessation of the
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
PGW underscores the importance of taking seriously the reports of ill health
among active and returning troops. Those involved in future conflicts must
anticipate the need to integrate into DoD and DVA planning at all stages high-
quality research on the health consequences of combat and of deployments to
hostile environments.
The committee makes recommendations in this report regarding the
collection and maintenance of information that is potentially useful for assessing
the health consequences of military service in the PGW. These
recommendations support completion of certain data sets, prompt reporting of
research findings and submission for publication in peer-reviewed journals,
strengthened medical and epidemiologic research capabilities of the armed
forces, and strengthening the decision-making processes for study selection.
We also give considerable attention to information systems that would be
useful in future conflicts. These recommendations are based largely on
experience with systems in place for the PGW that have shown some gaps and
defects that can be remedied.
The committee believes that there is indeed a sound basis for epidemiologic
studies, and recommendations follow. However, the committee does not
recommend an additional nationwide epidemiologic study of PG veterans,
because such a study is likely to be of limited scientific value at this time.
Those large studies that are currently under way should be completed as quickly
as possible, while continuing to meet high scientific standards, including a high
response rate and- a thorough investigation of potential biases, as recommended
below.
The recommendations are listed here without their associated findings. The
reader is referred to the full report for the associated and specific findings
supporting each recommendation.
RECOMMENDATIONS
Recommendation 1. The DoD, the branches of the armed services, and the
DVA should continue to work together to develop, fund, and staff medical
information systems that include a single, uniform, continuous, and retrievable
electronic medical record for each service person. The uniform record should
include each relevant health item (including baseline personal risk factors, every
inpatient and outpatient medical contact, and all health-related interventions),
allow linkage to exposure and other data sets, and have the capability to
incorporate relevant medical data from beyond the DoD and DVA institutions
(e.g., U.S. Public Health Service facilities, civilian medical providers, and other
health care institutions). Appropriate consent and protection of individual privacy
must be considered for information obtained and included.
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EXECUTIVE SUMMARY
11
Recommendation 2. The DoD and DVA should conduct further studies,
with appropriate statistical and epidemiological support, to identify risk factors
for stress-related psychiatric disorders among military personnel (active and
reserve) and to develop better methods to buffer and ameliorate the psychiatric
consequences of modern training, deployment, combat, demobilization, and
return to daily living.
Recommendation 3. Studies being conducted by DoD and DVA that have
included longitudinal follow-up of the mental health of veterans who served in
the PG should be supported with continued follow-up, after appropriate peer
review of study methods. Follow-up in these studies should be sufficient to
provide at least a decade of information comparing the mental health status of
those deployed with those not deployed.
Recommendation 4. The DoD should ensure that military medical
preparedness for deployments includes detailed attempts to monitor natural and
man-made environmental exposures and to prepare for rapid response, early
investigation, and accurate data collection, when possible, on physical and natural
environmental exposures that are known or possible in the specific theater of
operations.
Recommendation 5. Research is needed to determine whether differences
in personal characteristics or differences in policies and procedures for
mobilization, deployment, demobilization, and return of reserves, National
Guard, and regular troops are associated with different or adverse health
consequences. If there are associations, strategies necessary to prevent or
reduce these adverse health effects should be developed.
Recommendation 6. The mortality experience of PG veterans should
continue to be monitored for as long as 30 years, on a regular basis, including
comparisons with that of PG-era veterans. (PG-era veterans have been defined
as those in military service at the time of the POW, but assigned or deployed
elsewhere.) Research investigators should focus on the reported excess
mortality from unintentional injury, on mortality from specific illnesses, and on
evidence of elevation (or reduction) in the risk of death from other causes.
Recommendation 7. The DVA should exert greater effort to improve
understanding of the reasons for excess mortality from unintentional injury.
Detailed evaluation is needed beyond death certificate data concerning the
circumstances surrounding fatal injury, through more focused case-control
studies to identify both individual risk factors and remediable causes.
Recommendation 8. The Defense Medical Epidemiological Database
system should be continued, expanded as planned, expedited to develop the
proposed integrated information management system, linked to other key systems,
and evaluated regularly.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
Recommendation 9. The DoD should complete development of
information systems to expeditiously and directly pinpoint unit locations at a
high level of disaggregation in space and time (that is, fine detail) and to
document local environmental conditions, including appropriate data quality
checks, with direct data entry into the system. There is likely to be a need for a
similar information system during and after any future conflict, and DoD should
prepare and continually update plans for such a nonpaper system. A manual for
use of the information systems by research investigators should be compiled,
with the strengths and limitations identified.
Recommendation 10. For every specific question posed to the current
TEAM, DoD should assess the strengths and limitations of the TEAM as a
resource for evaluating the health significance of geographically defined
exposures of troops, including those in the POW and those in conflicts that may
develop in the future. Evaluations and recommendations for possible
modification of the TEAM should be reported to the PG Coordinating Board,
Research Working Group.
Recommendation 11. The DoD and DVA should ensure that studies of the
health effects of deployment, including effects on PGW veterans, include
evaluation of the exposures, experiences, and situations of both women and
men, with attention to their age, prior military service, marital and parental
status, and other gender-specific parameters.
Recommendation 12. The DoD and DVA should conduct studies of the
health consequences of assigning men and women to serve together in combat
or under the threat of enemy action. Such work should be undertaken with a
focus on prevention and amelioration of any added stresses.
Recommendation 13a. The Naval Health Research studies in San Diego
should be completed and results published as designed and scheduled.
Recommendation 13b. The DVA National Health Survey should be
completed and results published as designed and scheduled.
Recommendation 13c. Evaluation of predictors of enrollment in the DVA
PGHR should be promptly completed and results published. Included, if
possible, should be information on type of care requested, required, and
received.
Recommendation 14. The epidemiologic capabilities of the armed forces
should be strengthened rather than reduced. The command structure should be
kept informed about the reasons for and the results of this recommendation and
its relevance to military preparedness and effectiveness, and should be
encouraged to support appropriate epidemiologic work in the theater of
operations and in the postdeployment period.
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EVECUTIFE SUMMARY
13
Recommendation 15. The DoD and DVA should adopt a policy that
internal and contract-supported reports on health research will be submitted for
publication in the peer-reviewed scientific literature in a timely manner.
Recommendation 16. The Congress, DVA, and DoD should adopt a
policy that unless there are well-specified, openly stated reasons to the contrary,
requests for proposals for research related to unexplained illnesses or other
needed health-related research will be publicly announced and open to the
scientific community at large, that proposals will be reviewed by panels of
appropriately qualified experts, and that Finding will follow the
recommendations of those experts.
Representative terms from entire chapter:
gulf war
