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-
Charge to the CommiDee:
Its Findings and
Recommendations
OVERVIEW
In this chapter we summarize the findings and principal recommendations
of the Committee to Review the Health Consequences of Service During the
Persian Gulf War (POW). Most of the findings are discussed at greater length in
the chapters that follow.
Our task was to respond to three specific charges. Each finding is linked to
at least one of the charges, and for each we note the principal connection.
Recommendations follow each of the findings. The committee was charged as
follows:
THE COMMITTEE'S CHARGE
Charge 1
Assess 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 military service
referred to subsection (a) [of PL 102-585, Persian Gulf (PG) theater of
operations during the POW].
The committee makes four recommendations (recommendations 13-16) in
this report regarding the collection and maintenance of information that is
26
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FINDINGS AND RECOMMENDATIONS
27
potentially useful for assessing the health consequences of military service in
the POW. 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.
Charge 2
Make recommendations on means of improving the collection and maintenance
of such information.
The committee makes five recommendations (recommendations 1, 4, and
8-10) on the collection and maintenance of information on the health
consequences of service in the PG. 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
POW that have shown some gaps and defects that can be remedied.
Charge 3
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
if the recommendation is that there is [a] sound scientific basis for such a study
or studies, the nature of the study or studies.
The committee believes that there is indeed a sound basis for epidemiologic
studies, and eight recommendations follow (recommendations 2, 3, 5-7, and
11-13~.~ 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 meeting
high scientific standards, including a high response rate and a thorough
investigation of potential biases, as recommended below.
~ Recommendation 13 has been counted as applicable to both Charge 1 and Charge
3, and therefore appears with both.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
FINDINGS AND RECOMMENDATIONS
Finding
Recent military deployments, especially in Vietnam and in the Persian Gulf,
have demonstrated that concerns about the health consequences of participation
in military action may arise long after deployment has ended and that the
evaluation of those concerns and the provision of health care to affected
personnel may present formidable challenges both to epidemiologists and to
medical caregivers. Although some of these challenges can be attributed to the
intrinsic difficulty of evaluating poorly understood clusters of events that were
not among the expected consequences of combat or of environmental
conditions, they also may be attributed in part to limitations of the systems used
to collect and manage data regarding the health and service-related exposures of
military personnel. No system of record keeping can be expected to provide the
information needed to address every unanticipated research issue, including
those regarding the health consequences of military service. Nevertheless, the
committee has identified several possible improvements in the systems and
practices for collecting information on the health and service-related exposures
of military personnel. Such changes would increase the ability of the military
services to pursue appropriate investigations in the future. Such changes also
would increase the capacity of the services to evaluate the efficacy of
mobilization-supporting health services (including approaches and
methodologies for disease prevention employed before, during, and after
mobilization) and would aid in providing the best possible medical care to
military service personnel and veterans (Charge 2~.
Recommendation 1. The Department of Defense (DoD), the branches
of the armed services, and the Department of Veterans Affairs (DVA)
should continue to work together to develop, filed, 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 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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FINDINGS AND RECOMMENDATIONS
29
Finding
The number and variety of studies regarding consequences of the PGW are
already considerable. To date, most health-related studies specifically involving
PGW veterans have focused on short-term mental health consequences of
deployment, the role of combat exposure, and other stressors experienced in the
theater of operations and, to a lesser extent, on problems relating to
demobilization and readjustment to civilian life among reservist and National
Guard personnel. A few reports have included limited longitudinal follow-up
data concerning men and women who served in the PG. Important information
may be gained through longer follow-up of some of these groups, particularly
since at least one of these groups was first to arrive in the theater, and precombat
data are available. Also needed are studies of risk factors in modern
deployments predictive of combat stress reactions, posttraumatic stress disorder
(PTSD), and other psychiatric disorders of military personnel and veterans.
Studies relevant to the trauma of war and the ensuing mental health
consequences should concentrate special attention on improving efforts in
prevention, intervention, and follow-up (Charge 3~.
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.
Finding
The military dominance of U.S. forces in the PGW increased the relative
significance of physical and natural environmental exposures as important sources
of potential morbidity and mortality, compared with combat injuries. This is likely
to recur in future deployments (Charge 2~.
Recommendation 4. The DoD should ensure that military medical
preparedness for deployments includes detailed attempts to monitor
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HEALTH CONSEQUENrCES OF THE PERSIAN GULF WAR
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.
Finding
National Guard and reserve component personnel may differ substantially
from active duty personnel in average age, level of training, occupational
specialties, family status, and readiness for deployment. Further, it is unclear
whether either policies and procedures or the manner in which they are
implemented differs between activated reserve or National Guard units and
active duty troops for mobilization, deployment, demobilization, and return. All
of these factors may affect the health consequences of deployment (Charge 3~.
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.
Finding
Completed studies have described the mortality experience of troops
deployed to the PG during the period of deployment and in the 2-year period
after deployment. These studies have documented a consistent pattern of
increased risk of death from unintentional injury for the cohort of deployed
troops compared with those not deployed to the PG. However, death rates from
disease were not significantly increased. Continued monitoring and further
study of mortality rates among veterans of the POW will be of value in
assessing the long-term health consequences of deployment (Charge 3~.
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.
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FINDINGS AND RECOMMENDATIONS
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.
31
Finding
The armed services and the DVA together are developing a shared basic
epidemiological data system, the Defense Medical Epidemiological Database
(DMED) (Charge 2~.
Recommendation 8. The DMED system should be continued, expanded
as planned, expedited to develop the proposed integrated information
management system, linked to other key systems, and evaluated
regularly.
Finding
Considerable effort has been devoted by DoD to the development of a
Troop Exposure Assessment Model (TEAM) for describing the POW
experience of veterans. This has included the completion of an information
system designed to establish the geographic location of each unit from January
15, 1991, until the unit departed from the Gulf theater. This system has the
potential to be linked to data on regional environmental conditions but will
necessarily be devoid of most individual data (such as pesticide exposure or
individual health risk factors) (Charge 2~.
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.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
Finding
The power and complexity of analyses based on space-time geographical
information system (GIS) data require careful attention to data quality and the
limits imposed by various data items. Quality improvement and assessment of
limits are continuous processes and depend on detailed evaluation of data needs
for specific analytic questions (Charge 29.
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 fixture. Evaluations and
recommendations for possible modification of the TEAM should be
reported to the PG Coordinating Board, Research Working Group.
Finding
Given the unprecedented numbers of women serving in the PG, especially
those in largely new roles, including combat support, it is important to specially
evaluate the health consequences and needs for health services of women who
served in the PG. Preliminary findings from studies being conducted at the
Boston VA Medical Center (VAMC) indicate that additional research in this
area is needed. Additional research is also needed on the health effects of
having male and female personnel serve together in combat or under threat of
combat (Charge 3~.
Recommendation 11. The DoD and DVA should ensure that studies
of the health effects of deployment, including effects on POW veterans,
include evaluation of 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.
Finding
Several important studies are currently under way. Worthwhile data are
being collected and prepared, and the studies should be completed promptly,
with the necessary personnel and funding to collect the additional data needed,
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FINDINGS AND RECOMMENDS TIONS
33
to conduct appropriate analyses, and to evaluate potential biases. Findings from
these studies are likely to provide leads as to whether or not additional research
along these lines is required to produce more specific findings (Charges 1 and
3~.
· The Naval Health Research Center at San Diego has undertaken a series
of studies under the general title of "Epidemiologic Studies of Morbidity
Among Gulf War Veterans: A Search for Etiologic Agents and Risk Factors."
These studies hold promise for answering some important questions about the
health of PGW veterans after demobilization and about the possibility that
veterans and their spouses may experience an excess risk of adverse pregnancy
outcomes as a result of service in the PGW. The studies are being carried out
with care, excellent planning, and proper pilot efforts to determine feasibility.
Upon completion, these studies should provide important guidance concerning
whether veterans have experienced hospitalization at rates in excess of their
nondeployed peers, have developed specific symptoms or illnesses related to
their PGW experience, or have experienced risks that have resulted in adverse
reproductive outcomes related to their service in the Gulf.
Recommendation 13a. The Naval Health Research studies in San
Diego should be completed and results published as designed and
scheduled.
· Although there are significant problems with the DVA National Health
Survey, the investigators have designed additional phases of the study that will
be important to complete. The physical examinations and follow-up of
nonrespondents to the mail survey will be an important step toward describing
potential biases and evaluating signs and symptoms of both PG and PG-era
study participants.
Recommendation 13b. The DVA National Health Survey should be
completed and results published as designed and scheduled.
· The DVA-DoD study that was designed to examine predictors of
enrollment in the DVA PG Health Registry (PGHR) may provide useful
information as to what objectively measurable factors contribute to self-
selection into the registry. In addition to the proposed analysis of associations
among demographics, past health experiences, and health behaviors as possible
predictors of enrollment, information on the eligibility of individuals for health
care, as well as the type of health care, could generate additional hypotheses to
be investigated.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
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.
Finding
The armed forces have had small but high-quality and effective capabilities in
epidemiology. Recent cutbacks have reduced these capabilities, with potentially
serious effects on both military preparedness and the health care of veterans. The
Theater Area Medical Laboratory (TAML) is an example of how specialists can
respond rapidly to potential health problems of troops deployed in various areas of
the world and provide immediate and useful information necessary to maintain the
military readiness of the armed forces. In addition, well-trained epidemiologists
and preventive medicine specialists are necessary for conducting the relevant
population-based epidemiologic studies, with comprehensive exposure assessment,
that have the greatest likelihood of being informative about the health
consequences of any future deployment. Such capability should permit studies
that extend beyond the time of an individual's active duty service and that are
capable of responding to questions of delayed effects that may emerge only
years, or even decades, after a military operation (Charge 1~.
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.
Finding
Much good work on symptom complexes and other matters discussed in
this report has been done by DoD, DVA, and their contractors. However, it is
evident from the references cited in this report that many are in the "gray
literature" available to those who know they exist and how to ask for them,
but not published in the open, peer-reviewed scientific literature where they will
be fully indexed and readily available, with some assurance that they meet at
least minimal scientific standards. Even this committee, with the contacts and
expertise it developed over time, had difficulty in identifying and obtaining
some of these reports. The committee also is concerned about the high cost of
much recent research and the necessity for maximizing the nation's overall
return on that investment. In summary, the committee believes that health
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FINDINGS AND RECOMMENDATIONS
35
related research is not finalized until it is published and readily accessible in
peer-reviewed journals (Charge 1~.
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.
Finding
Some research directed toward reports of unexplained illnesses after the
POW was flawed in the questions posed, populations studied, or research
design. We believe that these defects could have been identified before research
projects were funded if requests for proposals had been announced generally
and had been open to the scientific community at large and if fully developed
research proposals had been reviewed by panels of qualified expert peers. Some
research was announced and reviewed in this manner, but much more could be
so treated, to the benefit of both veterans and the public (Charge 1~.
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 funding will follow the recommendations of those experts.
Representative terms from entire chapter:
persian gulf
