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FEBRUARY 2, 2000







Mr. Chairman and members of the Committee, I am pleased to be here today to provide testimony before this subcommittee on our current clinical and research efforts to understand and treat illnesses among Gulf War veterans.
I am Dr. John F. Mazzuchi, Deputy Assistant Secretary of Defense, Clinical and Program Policy, Office of the Assistant Secretary of Defense for Health Affairs. Within the Department of Defense, the primary role of Health Affairs is to ensure medical services and support to members of the Armed Forces during military operations, and to provide medical services and support to members of the Armed Forces, their dependents, and others entitled to DoD medical care. Our interface with the Departments biomedical research programs derives primarily from our role as Co-chair, along with the Director, Defense Research and Engineering, of the Armed Services Biomedical Research Evaluation and Management Committee, which facilitates consideration of DoD biomedical research.
The Assistant Secretary of Defense for Health Affairs also serves as the principal alternate member and primary DoD liaison official to the Military and Veterans Health Coordinating Board and is a voting member of the Research Working Group, along with the Director, Defense Research and Engineering.
The Gulf War in 1991 was the last critical test of military medicine during full-scale ground and air combat operations. By nearly all measures, this war was a victory not only for United States combat troops and its allies but also for the military health care system. The Department of Defense (DoD) was able to deploy an extensive clinical care and preventive medicine infrastructure rapidly to a distant, desert environment. As a result of these efforts and prevention programs established before the war, the disease and non-battle injury rate among deployed U.S. forces was lower in this war than in previous major conflicts.
Despite the success of military medicine in the Arabian Gulf, the general perception almost ten years later is considerably different because of unresolved questions about the health of Gulf War veterans. In particular, some veterans have experienced fatigue, joint pains, sleep problems and other diverse symptoms that have not been definitively explained. Gulf War health questions have resulted in controversy over potentially hazardous exposures during the deployment, the possibility of adverse affects from preventive health measures, and the role of stress in causing chronic illness.

Deployments present unique and difficult challenges. Through many years of research and progress in military medicine, tremendous strides have been made in the medical protection and care provided to soldiers, sailors, airmen, and marines. The medical consequences of the Gulf War made it clear, however, that some threats remain poorly understood and inadequately addressed. Despite few combat causalities and low rates of disease and non-battle injuries during both the build-up to the war and the war itself, veterans have since reported health problems, including medically unexplained symptoms, that followed their service in the Gulf War. These unexplained illnesses have proved to be frustrating to diagnose and treat.

Although further research is in progress, much information on veterans' health already has been provided by an extensive research effort. Systematic clinical examinations have not identified a unique syndrome or a characteristic organic abnormality among over 100,000 U.S., British, and Canadian Gulf War veterans. Additionally, the overall mortality rate of Gulf War veterans has been less than half that of the civilian population (adjusted standardized mortality ratio of 0.44), and deaths due to medical causes have not increased. Only deaths due to accidents have been higher, as similarly observed after previous wars. Moreover, there has been no overall increase in hospitalizations among Gulf War veterans or birth defects among their children.
Efforts within the Department to care for Gulf War veterans have reinforced our appreciation of the seriousness of their health complaints, and military physicians fully recognize that these veterans require careful evaluations and appropriate therapeutic programs.
The Comprehensive Clinical Evaluation Program (CCEP) has provided an in-depth medical evaluation to Department of Defense beneficiaries who are experiencing illnesses which may be related to their service during the Gulf War. The clinical protocol of the CCEP currently involves a three-phase evaluation process developed in close coordination with the Department of Veterans Affairs (VA). The initial phase of the protocol consists of a physical examination, supplemental baseline laboratory tests, and clinically directed specialty consultations available at the local MTF. Patients with unexplained symptoms who lack definitive diagnoses are referred to one of fourteen TRICARE Regional Medical Centers (TRMCs) where they progress to the second phase for further evaluation according to an established clinical protocol. Patients with unexplained symptoms or symptoms not completely explained by the second phase diagnoses, can be referred to the Specialized Care Center at Walter Reed Army Medical Center. The CCEP protocol provides a framework for diagnostic evaluation and is not all-inclusive or restrictive.
The Specialized Care Center at Walter Reed Army Medical Center is available to members of the armed services and family members with persistent symptoms who have completed the first and second phases of the CCEP. This program is a three-week intensive outpatient program that emphasizes treatment over evaluation. The Specialized Care Center at the Walter Reed Army Medical Center continues to offer a more intensive therapeutic program for those veterans on active duty or in the reserves with more disabling health problems related to their Gulf War service.
The CCEP has highlighted the need to develop a comprehensive medical surveillance system that is capable of monitoring the health outcome of individuals upon return from deployments. On January 14, 1995 the ASD(HA) announced a medical surveillance plan for the deployment to Bosnia which reflects many of the “lessons learned” from the Department’s experiences in the aftermath of the Gulf War. Guidelines for implementation of a medical surveillance system which features pre-deployment education, enhanced capability to assess health hazards in theater, standardized pre- and post-deployment health screening, and monitoring of health consequences were promulgated in August 1997, in DoD Directive 6490.2 and DoD Instruction 6490.3. A Joint Preventive Medicine Policy Group has been established to work implementation of these guidelines.
Health problems among Gulf War veterans, however, persist. Therefore the Department remains engaged in a comprehensive, coordinated effort to respond to the health concerns of Gulf War veterans; our veterans and their families deserve no less. The Departments of Defense (DoD), Veterans Affairs (VA), and Health and Human Services (HHS) are committed to finding answers to Gulf War veterans’ questions. To address these complicated issues, we will continue to solicit advice from independent scientists and experts.
In response to health questions following the Gulf War and the increasing demands of a series of hazardous deployments, the military health system has undergone a fundamental reorientation. A new strategy has been developed and is being implemented to protect U.S. forces against foreseeable physical and psychological threats. DoD’s "Force Health Protection" strategy balances the military’s key responsibilities to: 1) promote and sustain health and wellness throughout each person's military service; 2) prevent acute and chronic casualties; 3) rapidly stabilize, treat, and evacuate casualties; and, 4) perform medical surveillance, longitudinal health studies, and ensure adequate medical records documentation and clinical follow-up for deployed forces. The Force Health Protection strategy has played a key role in further reductions in illness and injury rates since the Gulf War.
The development of sound health policy for Force Health Protection has to rely on a rigorous standard of scientific proof to improve clinical care and preventive medicine practices. Preferably, such proof should be based on peer-reviewed science published in leading medical journals; because of the limitations of individual studies, research findings require expert review and confirmation before conclusions are adopted. Multiple and sometimes conflicting hypotheses and suggested changes are continually being advanced by clinicians, scientists, advocates, and concerned citizens, both in and out of the military and federal government. These diverse ideas have to be evaluated by rigorous scientific methods to provide the best possible health care for military service members and veterans.
The Department of Defense is committed to an aggressive program of Force Health Protection. A comprehensive approach to health care and prevention has been implemented that will coordinate the activities within DoD and among multiple federal agencies. New DoD and VA deployment health clinical and research centers are being established that will actively investigate potential health risks and medical, psychological, and reproductive outcomes. DoD has recognized the need for proactive health risk communication as an essential part of the force health protection strategy. Specific Force Health Protection initiatives include:

  • Documentation of health status, including mental health assessments, blood sample collections, and health threat briefings before deployment.

  • Improvement in medical record keeping, including tracking of immunizations and other preventive countermeasures, during deployment.

  • Assessment of health status -- individual and force - after deployment.

  • Improvement of health risk communication efforts.

  • Prospective cohort studies of deployed military personnel.

The Department and our Federal partners are committed to resolving Gulf War veterans’ health concerns and preventing similar occurrences among our service men and women as a consequence of future deployments. The challenges are great and while there may be no quick solutions, we are committed to responsible and aggressive pursuit and resolution of these problems.

The lack of predeployment health and deployment exposure data is recognized as a chief limitation in evaluation of Gulf War veterans’ illnesses. Numerous improvements have or are being made to document and analyze health data regarding future US military deployments. These efforts include capturing better service-entry health data, pre- and post-deployment health data, environmental and morbidity data during deployments, improved communications to troops regarding deployment risks, and focused clinical evaluation and epidemiological research programs of deployed populations.
In the 1998 report to Congress, Effectiveness of Medical Research Initiatives Regarding Gulf War Illnesses,
DoD identified the need for a coordinated capability to apply epidemiological research to determine whether deployment-related exposures are associated with post-deployment health outcomes. Subsequent to this report, Congress authorized the Secretary of Defense to establish a center devoted to “…longitudinal study to evaluate data on the health conditions of members of the Armed Forces upon their return from deployment…” On 30 September 1999, Dr. Sue Bailey, the Assistant Secretary of Defense for Health Affairs directed establishment of DoD Centers for Deployment Health, creating a research center at the Naval Health Research Center, San Diego, with the mission of “…longitudinal study to evaluate data on the health conditions of members of the Armed Forces upon their return from deployment…” A clinical center was established at the Walter Reed Army Medical Center, to oversee the Departments clinical evaluation programs for deployed service personnel.
One of the many lessons of the Gulf War is that the lack of ongoing population-based longitudinal health studies has limited our capabilities to identify deployment-related health outcomes. Additionally, the only way to determine health status change is through prospective monitoring of health and health outcomes. Recognizing the challenges of conducting such studies, DoD and VA asked the National Academy of Sciences, Institute of Medicine, to establish a committee to consider these questions and suggest appropriate scientific and practical methodologies. In response, the Institute of Medicine recommended in the report Gulf War Veterans: Measuring Health, that DoD and VA initiate longitudinal cohort studies of both Gulf War and deployed veterans.
DoD and VA have initiated planning to develop a research program of ongoing longitudinal studies with the specific aim of determining how the health of US military veterans changes over time. This study - the Millennium Cohort Study - will focus upon US military cohorts of the future, yet be constructed so as to enable comparisons to military cohorts of the recent past. A concurrent program will use similar data collection methods to study a comparable Gulf War veteran population.
Our goal for the two studies is to determine how the health of several veteran cohorts changes over time. The specific goal of the Millennium Cohort Study is to identify and prospectively follow health outcomes in future US military cohorts beginning in the year 2001. In this study we intend to adapt and coordinate the numerous dynamic medical information systems that are currently being developed such that future investigators will not have to rely as much on special investigative studies to determine the effects on health of military deployments.
We appreciate the interest this Committee and others have shown in the health of the men and women who serve and have served this nation in our armed forces. The health and fitness of military personnel have long been concerns of those responsible for ensuring troop readiness and effectiveness. The Military Health System wants to achieve its goal to take care of those men and women and their families, and protect their health. We recognize that our commitment to keeping our veterans healthy does not end when they leave active service. We will maintain a strong post deployment evaluation and care program in coordination with the VA and continue to move forward to strengthen our Force Health Protection Program as well as the total Military Health System.
Again, we appreciate the opportunity to testify before this Committee, and look forward to answering your questions.

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