[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]





                    GULF WAR ILLNESS: THE FUTURE FOR
                         DISSATISFIED VETERANS

=======================================================================

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 27, 2010

                               __________

                           Serial No. 111-94

                               __________

       Printed for the use of the Committee on Veterans' Affairs













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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota           CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey            BRIAN P. BILBRAY, California
JOHN J. HALL, New York

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.








                            C O N T E N T S

                               __________

                             July 27, 2010

                                                                   Page
Gulf War Illness: The Future for Dissatisfied Veterans...........     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    38
Hon. David P. Roe, Ranking Republican Member.....................     2
    Prepared statement of Congressman Roe........................    38
Hon. Zachary T. Space............................................     3

                               WITNESSES

U.S. Department of Veterans Affairs:
    Hon. Charles L. Cragin, Chairman, Advisory Committee on Gulf 
      War Veterans...............................................    18
      Prepared statement of Mr. Cragin...........................    54
    John R. Gingrich, Chief of Staff.............................    30
      Prepared statement of Mr. Gingrich.........................    61

                                 ______

American Legion, Ian C. de Planque, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission..........................     6
    Prepared statement of Mr. de Planque.........................    43
Hauser, Stephen L., M.D., Professor and Chair of Neurology, 
  University of California, San Francisco, School of Medicine, 
  and Chair, Committee on Gulf War and Health: Health Effects of 
  Serving in the Gulf War, Update 2009, Board on the Health of 
  Selection Populations, Institute of Medicine, The National 
  Academies......................................................    20
    Prepared statement of Dr. Hauser.............................    56
Research Advisory Committee on Gulf War Veterans' Illnesses, 
  James H. Binns, Chairman.......................................    23
    Prepared statement of Mr. Binns..............................    59
Veterans for Common Sense, Paul Sullivan, Executive Director.....     8
    Prepared statement of Mr. Sullivan...........................    49
Veterans of Modern Warfare, Donald D. Overton, Jr., Executive 
  Director.......................................................     4
    Prepared statement of Mr. Overton............................    39

                       SUBMISSIONS FOR THE RECORD

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director, statement................................    67
Desert Storm Battle Registry, Crawford, TX, Kirt P. Love, 
  Director, statement............................................    76
Gold Star Wives of America, Inc., Vivianne Cisneros Wersel, 
  Au.D., Chair, Government Relations Committee...................    77
National Gulf War Resource Center, James A. Bunker, President, 
  letter.........................................................    80
National Vietnam and Gulf War Veterans Coalition, Major Denise 
  Nichols, RN, MSN, USAFR (Ret.), Vice Chair, statement..........    81
Research Advisory Committee on Gulf War Veterans' Illnesses, 
  Anthony Hardie, Member, Gulf War Steering Committee, U.S. 
  Department of Veterans Affairs; and Gulf War Illness Research 
  Program Integration Panel, Congressionally Directed Medical 
  Research Program, U.S. Department of Defense, statement........    85

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, 
      Ranking Republican Member, Subcommittee on Oversight and 
      Investigations, Committee on Veterans' Affairs, letter 
      dated July 28, 2010, and VA responses......................    89

 
                    GULF WAR ILLNESS: THE FUTURE FOR
                         DISSATISFIED VETERANS

                              ----------                              


                         TUESDAY, JULY 27, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:08 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Mitchell, Space, Walz, and Roe.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning, ladies and gentlemen. The 
Committee on Veterans' Affairs' Subcommittee on Oversight and 
Investigations' hearing on Gulf War Illness: The Future of 
Dissatisfied Veterans will come to order. This meeting is held 
on July 27, 2010.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and that statements may 
be entered into the record. Hearing no objection, so ordered.
    Last year, this Subcommittee held two hearings on Gulf War 
Illness. Our first gave us an overview of the purpose, 
research, and methodology that the U.S. Department of Veterans 
Affairs (VA) utilized to determine the parameters relating to 
Gulf War Illness.
    Our second hearing evaluated the scientific information and 
analyzed the different schools of thought on Gulf War Illness 
research.
    In both of these hearings, it has become clear that 
veterans are suffering from symptoms related to service in the 
Gulf and that they are continuing to struggle for the health 
care, treatment and benefits they deserve.
    For our third, and hopefully final, hearing today, we will 
hear from the Department on how they plan to move ahead and 
implement the culture, care, benefits, research, outreach, and 
education efforts for our Gulf War veterans.
    Next month will mark the 20th anniversary since the United 
States deployed almost 700,000 troops to the Persian Gulf. With 
a growing number of these veterans developing undiagnosed and 
multi-symptom illnesses, they have looked to the people who 
promised them the care worthy of their sacrifice when they 
returned home. Still to this day, many of our Gulf War veterans 
have yet to see this care and are finding themselves fighting 
the VA for service-connected claims and proper compensation.
    Under the new leadership of Secretary Shinseki, a new 
vision and a new mission has been created at the Department. I 
know that Members on both sides of the aisle are eager to see 
how the VA will use this new vision to ensure that our veterans 
are receiving the best possible care.
    As part of this new vision, Secretary Shinseki's creation 
of the Gulf War Veterans Illness Task Force in 2009 is bold and 
shows the Department's dedication to our Gulf War veterans.
    However, with this new task force, we need to begin to see 
results. Even though the VA has put forward motions to better 
serve our veterans, it is not a substitute for results.
    We all understand the arduous task of ensuring that the 
proper research and data is collected, but our veterans have 
waited too long. While I appreciate the VA's attempt to change 
the culture at the Department regarding Gulf War Illness, there 
must also be strides to change the care and compensation these 
veterans have waited so long for.
    The Department of Veterans Affairs is the second largest 
agency in our system of government and they must be held 
accountable for the timely care of our Nation's veterans. There 
is a culture of complacency that does not serve anyone, 
especially our men and women in the Armed Forces.
    VA needs to take action to begin to implement a plan to 
provide transparency and answers to our Gulf War veterans. 
Without a unified central VA effort to provide appropriate care 
to this population, these veterans and their families will have 
to wait that much longer and grow that much sicker.
    I trust that this hearing will begin to lay out a unified 
plan for the care of our Gulf War veterans as well as instill 
hope that these veterans are not forgotten and that the 
promises we made to care for them are kept.
    Before I recognize the Ranking Republican Member for his 
remarks, I would like to swear in our witnesses.
    [The prepared statement of Chairman Mitchell appears on 
p. 38.]
    Mr. Mitchell. I would ask that all witnesses stand from all 
panels and raise their right hand.
    [Witnesses sworn.]
    Mr. Mitchell. Thank you.
    Now I recognize Dr. Roe for opening remarks.

             OPENING STATEMENT OF HON. DAVID P. ROE

    Mr. Roe. Thank you, Mr. Chairman.
    And I noticed in the back of the room here, we have some 
guests. The Boy Scouts are having their 100th anniversary. I 
being an Eagle Scout would like to welcome you to our hearing 
today and thank the leaders for the leadership that you give 
these young men. Thank you for being here.
    Thank you, Mr. Chairman.
    It is fitting as we approach the 20th anniversary of the 
start of Operation Desert Storm and the beginning of the Gulf 
War that we proceed with this final hearing in our three-part 
series on Gulf War Illness.
    On this day, it is important for us to look to the future 
of care for our veterans who fought and served in this conflict 
and now suffer from various illnesses from unknown causes.
    I believe it will be interesting to listen to the views of 
each of the panels and what they perceive is the cultural 
perception of Gulf War Illness as well as both the medical and 
benefit side of the equation on the care for these veterans.
    On April 9th, 2010, the Institute of Medicine (IOM) issued 
its most recent report on Gulf War and health which made 
additional recommendations on how we can best support the 
veterans from this conflict.
    I look forward to hearing from Dr. Hauser who Chaired the 
Committee on Gulf War and Health, Health Effects of Serving in 
the Gulf War on how the VA can use the information in this 
report to improve care to these veterans and also to hear what 
progress VA has made since we last met in July.
    I am curious to hear the VA's response to the Research 
Advisory Committee's (RAC) September 2009 report and what 
changes are coming about as a result of our hearings as well as 
the Advisory Committee's report.
    We must never forget the reason that we are having these 
hearings. It is to help our Nation's veterans.
    In the past, we have explored the research behind 
presumptions, the medical indicators leading to the diagnosis 
or lack thereof and we learned most importantly that the 
documentation of undiagnosed illnesses is a large contributor 
leading to a presumption of Gulf War Illness.
    I believe we can use the information we have compiled 
through these hearings to really come to a better understanding 
of Gulf War Illness and through that knowledge better serve 
these veterans who have sacrificed so much for our country.
    The information gleaned from the upcoming report from the 
Secretary's Gulf War Veterans Illness Task Force as well as the 
reports issued by the Research Advisory Council and the 
Institute of Medicine will help us serve those veterans from 
the Gulf War.
    It is my hope that we will also take the lessons learned 
through these hearings as well as the reports and apply them to 
the current Operation Iraqi Freedom/Operation Enduring Freedom 
(OIF/OEF) veterans and future veterans down the road to better 
serve their needs.
    I am pleased that the VA Chief of Staff, John Gingrich, has 
brought with him representatives from both the Veterans Health 
Administration (VHA) and the Veterans Benefits Administration 
(VBA) who can respond to the type of care and benefits being 
provided to our Gulf War veterans.
    And I look forward to the hearing and the testimony of all 
witnesses.
    And, again, Mr. Chairman, thank you for holding this 
hearing.
    [The prepared statement of Congressman Roe appears on p. 
38.]
    Mr. Mitchell. Thank you.
    Mr. Space.

           OPENING STATEMENT OF HON. ZACHARY T. SPACE

    Mr. Space. Thank you, Mr. Chairman.
    I want to thank the witnesses for coming and talk about 
this topic of immense importance to our veterans.
    Gulf War Illness is a serious issue plaguing thousands of 
veterans in this country. And I sincerely hope that this 
hearing will bring to light steps that the VA is and has been 
taking in working for the best quality care for the men and 
women who fought in the Gulf War.
    For years, the seriousness of this condition was 
unfortunately overlooked because of the lack of understanding. 
I want to commend Secretary Shinseki for dedicating new 
resources to redefine how veterans suffering from Gulf War 
Illness are compensated and to begin getting them the services 
they need.
    This war has been over for 19 years. And I believe that the 
VA is finally on the right track toward alleviating the source 
of the debilitating effects that the Gulf War has had on our 
veterans.
    I encourage the Veterans Administration to continue taking 
all steps necessary to provide assistance for veterans 
suffering from this illness and I would like to ensure that we 
will do all we can to make the necessary tools available to you 
so that you can fulfill your mission in taking care of our 
Nation's heroes.
    And with that, I yield back. Thank you, Mr. Chairman.
    Mr. Mitchell. At this time, I would like to welcome panel 
one to the witness table. Joining us on our first panel is 
Donald Overton, Jr., Executive Director for the Veterans of 
Modern Warfare (VMW); Ian de Planque, Deputy Director of the 
Veterans Affairs and Rehabilitation Commission for the American 
Legion; and Paul Sullivan, Executive Director for the Veterans 
for Common Sense (VCS).
    I ask that all witnesses stay within 5 minutes of their 
opening remarks. Your complete statements will be made part of 
the hearing record.
    I would like to recognize Mr. Overton.

   STATEMENTS OF DONALD D. OVERTON, JR., EXECUTIVE DIRECTOR, 
VETERANS OF MODERN WARFARE; IAN C. DE PLANQUE, DEPUTY DIRECTOR, 
   VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN 
  LEGION; AND PAUL SULLIVAN, EXECUTIVE DIRECTOR, VETERANS FOR 
                          COMMON SENSE

              STATEMENT OF DONALD D. OVERTON, JR.

    Mr. Overton. Thank you, Chairman Mitchell, Ranking Member 
Roe, and distinguished Members of the Subcommittee on Oversight 
and Investigations.
    On behalf of Veterans of Modern Warfare, a 501(c)(19) 
National Wartime Veteran Service Organization, I thank you for 
the opportunity to present our views on Gulf War Illness: The 
Future for Dissatisfied Veterans.
    My name is Donald Overton and I testify today from a dual 
perspective, first as Executive Director for VMW, also as a 100 
percent service-connected combat-disabled veteran of the first 
Gulf War.
    Nearly 20 years have passed since the start of the 
deployment and combat operations. Since then, an estimated 
250,000 veterans of our conflict have endured adverse health 
consequences and suffer from the potentially debilitating 
consequences of undiagnosed multi-symptom illness.
    We contend these are distinct illnesses and the large 
numbers of veterans affected have been disenfranchised and 
under-served by the Department of Veterans Affairs.
    To date, VA has historically failed to recognize our 
conditions, opting to emphasize stress or other psychiatric 
disorders in its research funding, clinician training 
materials, and public statements, although scientific research 
clearly indicates otherwise.
    We must work with due diligence in order to stop allowing 
the lives of Gulf War veterans to be stolen and make no mistake 
about it, that is exactly what is taking place.
    Last year, the VA impeded, and then canceled, a 
Congressionally mandated contract for unparalleled Gulf War 
Illness research at the University of Texas Southwestern 
(UTSW).
    This year, VA used those funds to buy an $11 million piece 
of lab equipment of dubious value to Gulf War veterans.
    The recent announcement by VA to fund yet another stress 
management study and portray it as somehow providing meaningful 
treatment to Gulf War veterans is discouraging.
    VMW urges Congress to work with the VA to reinstate the 
UTSW study, which would be highly regarded by all Gulf War 
veterans as well as advancing funding towards effective 
treatments of Gulf War Illness.
    The area of greatest controversy for Gulf War veterans 
remains our inability to obtain disability compensation. 
Currently there are only three ill-defined presumptive 
conditions for Gulf War veterans, chronic fatigue syndrome, 
fibromyalgia, and irritable bowel syndrome.
    Our written testimony clearly illustrates the contorted 
rules Gulf War veterans face regarding these disability claims. 
VMW urges Congress to consider expanding VA regulations which 
could authorize extra scheduler ratings for Gulf War veterans 
suffering from undiagnosed multi-symptom illness.
    Clearly defining the conditions, which constitute 
undiagnosed illness as well as preventing generic labeling of 
conditions based on closely-related symptoms must be mandated.
    Additionally, VMW urges Congress to enact legislation 
granting indefinite presumptive eligibility for undiagnosed 
illness.
    Please consider removing all sunset provisions in title 38 
of the United States Code at sections 1117 and 1118 so health 
care and benefits are for the life of every Gulf War veteran 
and every surviving beneficiary.
    VMW strongly endorses granting a presumption of service-
connection for our Gulf War veterans who deployed to the war 
zone and are diagnosed with autoimmune diseases such as 
multiple sclerosis and Parkinson's disease based on their 
unusual prevalence amongst our cohort.
    Establishing tiger teams within the Veterans Benefits 
Administration comprised of highly-trained environmental 
exposure claims specialists would expedite and enhance the 
myriad claims-related issues plaguing the Agency.
    Due to significant limitations in the VA's Gulf War 
Veterans Information System, it is extremely difficult to 
accurately portray the experiences of Gulf War veterans, let 
alone our respective disability claims or health care issues.
    Based on this fact, it would appear that the recently 
completed Gulf War Veterans Illness Task Force report was based 
solely on the presumptions of task force members which 
unfortunately limits the credibility of the report's findings.
    Overcoming the VA's established culture towards Gulf War 
veterans will not be an easy task, but under Secretary 
Shinseki's bold leadership and cultural transformation, it can 
and must be accomplished now. Acknowledging the relevance of 
Gulf War veterans within VA would serve to reinvigorate 
research and medical care. Enhancing education of benefits 
counselors, medical staff, and various stakeholders will serve 
to increase the effectiveness of this cultural transformation.
    Gulf War veterans swore by a common creed as do all members 
of our Armed Forces to leave no one behind. We are proud to 
proclaim we left no one behind. Unfortunately, our country has 
abandoned us.
    Those charged with our care and well-being continue to 
neglect us. We have been lost in the shuffle. Now our fate 
rests in the hands of Congress, in your hands. Please help us 
as we continue to struggle to get all the way back home after 
our military service.
    Mr. Chairman, VMW thanks you for this opportunity to 
express our views today and we will be pleased to answer any 
questions you or your distinguished colleagues may have. Thank 
you.
    [The prepared statement of Mr. Overton appears on p. 39.]
    Mr. Mitchell. Thank you.
    Mr. de Planque.

                 STATEMENT OF IAN C. DE PLANQUE

    Mr. de Planque. Good morning, Mr. Chairman and Members of 
the Committee. I would like to thank you on behalf of the 
American Legion for the opportunity to testify today on the 
future of this Nation's policy towards Gulf War veterans.
    Traditionally, servicemembers are called upon to place 
themselves in hazardous situations to protect our country. 
While it is easy to think of these hazards in simple terms of 
bullets and bombs, over the last half of the previous century, 
we have learned many hard lessons about the environmental 
hazards faced as well.
    Of course, these are not new lessons. On the battlefields 
of World War I, the world learned lessons about the terrifying 
effects of chemical weapons. Through World War II and the Cold 
War, we slowly began to understand the devastating effects of 
ionizing radiation.
    Over 40 years after the Vietnam War, we still struggle to 
keep pace with the after effects of the chemical herbicide 
Agent Orange. Throughout this time, the American Legion has 
fought for a better understanding of these effects and to 
ensure that those veterans affected by these hazards receive 
the treatment and compensation that is their due for their 
service under these conditions.
    Throughout history when soldiers have gone to war, the 
mission comes first and little thought is given to the after 
effects. Complete the mission, engage and destroy the enemy, 
these are the driving motivations of war fighting. Whatever 
tools exist at our disposal are employed to that end and it is 
only later in retrospect that we begin to understand the impact 
that will resonate throughout the lives of these veterans.
    To this end, the American Legion supports several 
considerations for these Gulf War veterans. The current 
presumptive period for Persian Gulf War undiagnosed illnesses 
under title 38 of the Code of Federal Regulations, section 
3.317 will expire on January 1st, 2012. It is well within 
appropriate authorities to extend this deadline and the 
American Legion recommends extending this period indefinitely.
    As has been shown through the hard lessons still being 
learned with relation to Agent Orange, medical science will 
continue to identify and isolate new conditions as after 
effects of exposure to environmental hazards. There stands no 
reason that an arbitrary period should be enforced for the 
cessation of these presumptive periods. An indefinite period 
will ensure that research of the effects of the Gulf War will 
continue to provide meaningful treatment and compensation to 
these veterans.
    Perhaps most concerning is the finding of the Research 
Advisory Committee on Gulf War Veterans' Illness November 2008 
report that, ``The Federal Gulf War research effort has yet to 
provide tangible results in achieving the ultimate objective, 
that is to improve the health of Gulf War veterans.''
    This must be the driving goal of our government's efforts. 
To this end, the American Legion recommends several parts to an 
attack to achieve this goal.
    First, we fully support robust funding for scientific 
research to continue to track the effects of Gulf War exposure. 
Sound scientific study is the priority to develop a medically-
based understanding for the treatment of these veterans. 
Continued funding for all research in this area must remain a 
top priority.
    Second, the American Legion encourages the VA to continue 
to provide appropriate medical examinations and treatment 
including follow-up treatment to all veterans of the Gulf War 
who report signs or symptoms that may be associated with 
diseases endemic to that war region and other conditions 
related to the experience.
    To this end, the American Legion has long advocated for 
Congress to reinstate Gulf War veterans' status in Priority 
Group 6 for medical treatment. Eligibility for Gulf War 
veterans in Priority Group 6 of the Department of Veterans 
Affairs health care system established by the Veterans 
Healthcare Eligibility Reform Act of 1996 expired in 2002. 
Although VA has continued to treat ill Gulf War veterans 
despite the expiration of its authority to do so, lack of 
Congressionally-mandated authority to treat these veterans 
could mean abrupt discontinuation of the treatment that is 
currently available.
    Continuation of care for ill Gulf War veterans would 
provide invaluable data that could be used to examine the 
nature of Gulf War Illness, provide for better care for all 
other Gulf War veterans, and provide preparation for treatment 
of future servicemembers who may become ill after deployments 
in the southwest Asia theater of operations.
    As a final note, the American Legion wishes to stress that 
there are growing concerns regarding the specific Gulf War 
effects on women veterans and research into these areas must 
not fall by the wayside. Because the health concerns of women 
can in some cases differ from a more generalized conception of 
veterans, research must ensure that these areas are 
specifically addressed and remain a fundamental part of Gulf 
War Illness analysis.
    As always, the American Legion thanks the Committee for the 
opportunity to provide testimony today and we would be happy to 
answer any questions the Committee may have.
    And we would like to add one final note. As I mentioned 
earlier, we stand 40 years, over 40 years after our deployments 
to Vietnam and we are still struggling with the after effects 
of Agent Orange. We are now looking at 20 years with continued 
deployments to the Gulf War theater of operations. The clock is 
ticking for these veterans and we cannot afford to make the 
same mistakes we did with Agent Orange.
    Thank you.
    [The prepared statement of Mr. de Planque appears on p. 
43.]
    Mr. Mitchell. Thank you.
    Mr. Sullivan.

                   STATEMENT OF PAUL SULLIVAN

    Mr. Sullivan. Veterans for Common Sense thanks Subcommittee 
Chairman Mitchell and Ranking Member Roe, and Members of the 
Subcommittee for inviting us to testify here today.
    VCS is here to present our recommendations for improving VA 
policies for our Nation's 250,000 ill Gulf War veterans.
    Before I begin, I want to recognize Steve Robinson, a 
fellow Gulf War veteran, in the audience, Thomas Bandzul, our 
Associate Counsel, and with me is my daughter, Megan, to learn 
how Washington works.
    Why are we here today, Mr. Chairman? We are here today 
because Gulf War veterans are deeply dissatisfied and 
disappointed with VA staff actions for the past 2 years. We 
concur with the comments of Veterans of Modern Warfare and the 
American Legion and their specific points and much of them are 
repeated in our written statement, so I am going to cut those 
parts out of my oral testimony to focus on a couple of new 
things.
    Let me put this to you simply, Mr. Chairman. VA staff does 
not listen to our concerns. VA staff does not listen to 
advisory panels or expert scientists. VA staff does not even 
listen to Congress. VA staff actions for about the last 20 
years have been, and remain, disastrous for our veterans.
    I am here today sending up a red star cluster. That is an 
emergency. That is a warning. VCS is urging VA's new leadership 
here in the room today to stop and listen to the veterans, as 
you pointed out, before time runs out.
    Why, sir? It is because VA's bureaucratic delays are slowly 
killing us veterans. The mismanaged research prevents us from 
finding answers about why we are ill and obtaining care.
    Today, VCS officially petitioned VA to issue regulations so 
our 250,000 Gulf War veterans can learn why we are ill, obtain 
medical care, and receive the disability benefits that we need 
for our conditions linked to service in the Gulf War.
    The two things we do not want, Mr. Chairman, are more false 
promises and more stress research from VA.
    Today if VA's Chief of Staff, who is here today, fails to 
deliver assurances to veterans and this Subcommittee that VA 
will begin comprehensive research and reform, then VCS is 
asking you here today to take action.
    Why are we making such specific requests in our petition to 
VA and to this Subcommittee? It is pretty clear. We have waited 
20 years for answers about why we are ill, for treatment, and 
for benefits. We will no longer tolerate waiting and watching 
our friends die. I have been to too many funerals, listened to 
too many of my friends talk to me over the phone over the years 
about problems. And there seems to be VA promises and then they 
disappear like fog when the sun comes up. That needs to stop.
    The VA and military policy about delay and deny actually 
began in March 1991, the day of the Gulf War cease fire. That 
is when the military wrote a memo urging staff to hype the 
military effectiveness of depleted uranium (DU). The same 
military memo urges the government to downplay adverse health 
impacts of DU, a toxic and radioactive waste used as ammunition 
in the Gulf War.
    This is very important today because on August 19, 1993, 
then Army Brigadier General Eric Shinseki signed a memo 
confirming medical testing was, in fact, ordered for hundreds 
of thousands of Gulf War veterans exposed to DU. Unfortunately, 
Dr. Roe, the military never did the DU medical testing for the 
700,000 soldiers.
    VCS has written VA. We have spoken with VA's Chief of Staff 
and urged them to launch DU research and they have not done so.
    Of particular note is that in 1999, the U.S. Department of 
Defense (DoD) and VA leaders met in private and confirmed that 
Gulf War veterans are, in fact, sick from DU inhalation and 
embedded fragments. Some of the members of that meeting are 
here today.
    So what we are trying to get to the bottom of is we need 
depleted uranium research and other toxic exposure research so 
we can find the answers and get treatment.
    The real coup de grace came just last week, Mr. Chairman, 
when VA announced $2.8 million in stress research. Now, the 
research may be good and well-intended to help some veterans, 
but it sent the message that VA staff was still in control, 
that the message was that Gulf War Illness is stress and VA is 
not going to move forward on this issue.
    So we are asking you here today if Secretary Shinseki and 
the VA Chief of Staff will not launch aggressive research, 
especially into DU, then Congress needs to intervene. We need 
to end VA's policy of do not look, do not find. That is where 
VA will not look for a problem because that way, they do not 
have to do anything if they find something.
    We want you to please hold more hearings on this subject to 
see how VA implements whatever policies they may announce today 
because, yes, time is running out.
    And I'd like to ask one last comment and VA will be the 
last panel here. I think it would be very constructive if the 
Chairman and Ranking Member ask some Gulf War veterans here 
today to comment on what VA is announcing after they have made 
their announcements so we can close the loop and we do not walk 
away from here today saying, well, VA offered all this new 
stuff, everything looks fine. We need some feedback for VA 
immediately so they know if they are going in the right 
direction and they do not have to wait months for another 
hearing, Mr. Chairman.
    Thank you. That concludes my comments.
    [The prepared statement of Mr. Sullivan appears on p. 49.]
    Mr. Mitchell. Thank you.
    The first question I have is for Mr. de Planque. In your 
written testimony, you state that people are looking for the 
cause and not the solution, that even to this day, everyone is 
looking for the diagnosis rather than the successful treatment.
    Why do you believe this is mutually exclusive and how will 
the VA know when it reaches the point of successful treatment 
for this generation of veterans?
    Mr. de Planque. Well, there are twofold reasons for looking 
at it that way. And certainly finding the causes is not 
unimportant because that can help to protect future generations 
of veterans who may be exposed to things. And those are 
important.
    But the ultimate reasoning behind it, you need to treat the 
people who have the conditions. And in some cases, if you can 
find an effective treatment, even if you do not know the exact 
cause, it is far more important to be actually utilizing that 
treatment and improving the quality of life of the veterans who 
are suffering from that.
    Now, you know, obviously as a medical expert, you can sit 
there and debate about the specifics of this causes this and so 
that is how we eliminate that. But rather than getting too far 
down into the weeds and spending all of the effort chasing the 
ghost of what exactly caused it when it could be, in fact, a 
combination of seven, eight, ten different things in 
combination with each other rather than one specific root 
cause, if you look to actually treating the people with the 
problems, that is where we feel that it needs to be a priority.
    Ultimately the veterans are the people who are suffering 
and if we can find causes and eliminate them from future 
exposures to veterans, then that is certainly very helpful 
because that protects future generations.
    But right now there is an immediate focus because veterans 
are suffering from these conditions and finding a treatment for 
those conditions is to us far more important than actually 
arguing about what the blame is for them.
    Mr. Mitchell. Thank you.
    Mr. Sullivan, if the VA does not do the things that it 
states it will do to make progress in finding the solution to 
Gulf War Illness, what would you like to see Congress do?
    Mr. Sullivan. Mr. Chairman, Congress would need to do a 
couple of things. Congress would first need to bring VA in and 
ask what are you doing, what are the results. Also bring in 
veterans and say what are your impressions, what are the 
results of VA's actions.
    And then Congress would also need to introduce legislation 
to fill in the areas where VA failed to act. Let me give you 
examples.
    First, VA did not want to keep track of Gulf War veterans. 
Congress legislated the creation of reports to monitor 
veterans. What has VA done? They have stopped producing the 
reports.
    Congress ordered VA to conduct research into Gulf War 
Illness with the University of Texas Southwestern contract 
money after VA refused to do the research. That was in 2005.
    In 1998, Congress had to act with the Persian Gulf Veterans 
Act because VA refused to listen to any outside scientists. We 
had to call in the Institute of Medicine, the National Academy 
of Science. We had to create the Research Advisory Committee. 
All of those things happened, Mr. Chairman, because VA refused 
to act. It is a few staff stuck in key positions that are 
blocking change.
    So if the current Administration, which is now promising to 
make improvements, to bring change, is not able to do it, we 
have to find out who exactly in the VA staff is preventing it 
from happening. And that can happen when you bring in VA, call 
them on the carpet, and say what is going on. So oversight 
hearings and legislation, Mr. Chairman.
    Mr. Mitchell. Mr. Sullivan, you mentioned a couple of areas 
where Congress forced or passed legislation for the VA.
    What were the results of those? What did the VA do with 
those?
    Mr. Sullivan. Well, when Congress ordered the creation of 
the Research Advisory Committee, VA dragged its feet for about 
4 years and it could not put it together. It took Congress 
writing letters and the intervention of philanthropist Ross 
Perot to actually have the Research Advisory Committee created.
    In another example for undiagnosed illness, Congress passed 
a law in 1994 to provide benefits for those conditions. VA 
essentially denied 94, 96 percent of the claims. So the intent 
of Congress to provide service-connected status for Gulf War 
veterans so that they get free health care was being thwarted 
by VA.
    There were several hearings about that and now VA approves 
about 25 percent of the Gulf War claims. It is still a disaster 
because that means 75 percent of the Gulf War veterans with 
undiagnosed illness claims do not get the free health care that 
they need.
    So VA over and over again when Congress launches 
legislation that tells them to do something, they do not do it. 
And they have to be dragged in here kicking and screaming.
    For 20 years, we have been hearing about these promises of 
change and now we have the Chief of Staff in here. Let us make 
sure that we hear that he is actually going to deliver on some 
of the things they are promising because last week, Mr. 
Chairman, when VA said that they wanted to do more stress 
research, the phone calls I received from Gulf War veterans 
were unbelievable.
    They were furious that VA appeared to be preempting this 
hearing by saying Gulf War Illness is stress and it looked like 
VA was doing something. And we have been down that road for 
almost two decades and it has to stop now. We need assurances 
from VA in the room that they are going to provide the care and 
launch the research now.
    Mr. Mitchell. Thank you.
    My time has expired. Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    And, first of all, thank you all for your service.
    Mr. de Planque, just a couple of comments. The way the VA 
may, and they can speak for themselves, but as a doctor, 
treating a symptom is very, very difficult. You need to know 
the etiology of something.
    I would argue that if you know what caused something, it is 
a lot easier to treat it than if you are just treating symptoms 
because I have done that many times. When you do not have a 
cause of an illness, it makes it very difficult to give an 
effective treatment. You cannot.
    And I have chased symptoms in patients that I could not 
diagnose and never felt good about the treatment they were 
getting. So we do need to do both.
    I think a question I would ask, and I certainly would agree 
with you all 100 percent, and I have forgotten which one in the 
testimony, but I think Mr. de Planque, by extending this 
deadline, we need to do that. That is easy to do. And it should 
be done.
    And the reason it should be done is, and Mr. Sullivan is 
absolutely correct, we are still learning about, I am a 
Vietnam-era veteran, and we are still learning about things 
that occurred 40, 50 years ago.
    So absolutely we need to do that. That is one talking point 
I will leave here with today and we will make sure we at least 
try to get that done for you.
    One of the things, and I am not again defending, they will 
be here in a minute, but a couple of weeks ago, we had a 
Subcommittee hearing on suicide prevention outreach and we 
discussed efforts to outreach towards veterans that were 
contemplating suicide. And obviously that is an issue with 
veterans across the board if you look at those numbers.
    But communicating with veterans should not be just limited 
to that. And both of you or many of you brought up concerns 
about the lack of communication from the VA with Gulf War 
veterans on issues that concern these veterans. Mr. Sullivan, I 
think, did.
    What do you recommend the VA do to better communicate with 
Gulf War veterans?
    Mr. Sullivan. Mr. Ranking Member, thank you for raising 
that subject of outreach to Gulf War veterans.
    The first thing VA needs to do is actually sit down and 
start speaking politely with Gulf War veteran leaders. Then VA 
can have some focus groups of Gulf War veterans to make sure 
what it is that Gulf War veterans are looking for and how to 
have the message tailored.
    Then the next thing the VA can do is actually start 
delivering the outreach message based on professional input, 
based on input from veterans, and, of course, VA staff to make 
sure they are saying the right thing to the right audience 
rather than just throwing something up at the wall and hoping 
it sticks.
    But the first step, Mr. Ranking Member, Dr. Roe, is for VA 
to bring Gulf War veterans into the room and sit down and speak 
with us. And, frankly, they have refused to do so.
    Mr. Roe. Okay. Well, I think that ought to be easy to do 
also.
    I think one of the things that has bothered me during this 
whole discussion, that has confused me is to put my finger on 
exactly what the cause of this is so we know what treatment to 
do.
    Do you all have any numbers about how many Gulf War 
veterans are currently being treated with undiagnosed illness? 
How many have been given disability or treated at the VA?
    You brought up so many of them could not get in. I think 
you mentioned of the 690,000, Mr. Overton mentioned that served 
in his written testimony I read last night, 250,000 veterans 
are being treated now or, Mr. Overton, did I misread you?
    Mr. Overton. No, you did not misread me. Right now the 
current statistical numbers that we see out of the Institute of 
Medicine is 250,000 that are affected. Unfortunately, many Gulf 
War veterans left VA care at the onset because every time they 
entered a VA medical center for care, they were instantly 
referred to a psychiatrist and it was deemed a psychological 
condition as well as the limitations of the Gulf War Veterans 
Information System, we have no statistical numbers to build 
anything off of. We cannot get that data. It does not seem to 
exist. There were coding errors and it is just not being made 
available to us.
    So the internal numbers we do not know. Anecdotally we can 
tell you that most Gulf War veterans left VA care because 
nobody was providing any care.
    Mr. Roe. Well, you know, I mean, I got that. Do you know 
how many have gone through the Veterans Benefits Administration 
and are receiving benefits? Do you all have any numbers on 
that?
    Mr. Overton. Yeah. I will touch on that briefly because we 
know that, too, off of the system. But one of the things to 
keep in mind with that, one of the things that we pulled over 
the last several years when we could get data is, you know, 
when you take a Gulf War veteran and you look at receiving 
benefits, the majority are receiving a ten percent for tinnitus 
of hearing loss or ringing, roaring, rushing sensation of the 
ears.
    So when we start trying to look at the other data, I know 
Paul has probably the closest statistics available, so I will 
yield to him for some of those additional numbers.
    Mr. Sullivan. I regret to say, Mr. Ranking Member, that I 
did not bring my glasses up here, so I cannot see the number in 
my fine print written statement. So I will get an accurate 
number to you.
    To the best of my knowledge, approximately 300,000 Gulf War 
veterans who served in 1990 to 1991 have sought care and/or 
filed a disability claim against the Department of Veterans 
Affairs.
    I was the person who helped create those reports. When I 
left VA in 2006, they were well-received and reviewed by VHA, 
the Office of the General Counsel, the Office of Congressional 
and Legislative Affairs. They all concurred with the 
methodology and the statistics in the report.
    However, after I left VA about 4 years ago, the report fell 
into disarray, frankly because VA wants this subject to go 
away.
    You know, when there are more hearings on this, more Gulf 
War veterans go in for care. And if VA does not have funding to 
provide for additional care for new patients, then VA sees this 
as a no win situation. They just want this to go away.
    So we can sit here and give you all the statistics in the 
world, Dr. Roe, but here is the bottom line. Gulf War veterans 
might still be going to VA, but they are not getting treatments 
for the conditions that we are complaining about mainly because 
VA never launched the research to find out why we are sick and 
never really launched the research to provide treatments.
    And that is why we are here 20 years later, an enormous 
staff failure that is continuing to kill our vets. We need to 
keep our eyes on that. The numbers are huge.
    Mr. Roe. I yield back, Mr. Chairman. Thank you.
    Mr. Mitchell. Thank you.
    Mr. Walz.
    Mr. Walz. Well, thank you, Chairman and Ranking Member, for 
this continued series of important hearings. I very much 
appreciate it.
    And point out again, I think we were talking at the first 
set of hearings, we pointed it out, the Majority Counsel, 
Colonel Herbert, is a Gulf War veteran himself and was in the 
midst of many burning oil wells and other things. So we 
appreciate his insight into this.
    I want to thank each of you for being here.
    I wanted to hit on, I think that both the Chairman and the 
Ranking Member brought up the point on this epidemiology, of 
finding out where this comes from is critically important. I do 
not want to misstate where you were at, but I think it is 
important.
    And I think the VA is right to explore where things came 
from for two reasons, as Dr. Roe clearly pointed out, in 
treatment, but I also think is, is that so it does not happen 
in the future. If our current warriors in the Middle East are 
being exposed to the same triggers, knowing where they came 
from is critically important. So I appreciate where you are all 
coming from on that.
    As frustrated as you are, the one thing I would say, I 
know, Mr. Sullivan, you spent a lot of time on this. You have 
been a great voice and we appreciate it. I do not get the same, 
I guess, feeling from the VA. I think they want to solve this 
thing. I do not think they want it to go away. I get the 
feeling they are trying to get it, but I know it is a 
frustrating situation.
    I was going to ask and just factually because I think you 
can support some of the things and say, well, why is this not 
happening, why is this not happening. The staff gave me a memo 
from 1993 in response to a U.S. Government Accountability 
Office report of exposure to DU. And in here, it said provide 
that the, this is a Department of the Army memo, would provide 
adequate training for personnel who may come in contact with DU 
contaminated equipment, two, complete medical testing of 
personnel exposed to DU contamination during the Persian Gulf 
War.
    Did that happen?
    Mr. Sullivan. Congressman, no, it did not happen.
    Mr. Walz. Okay.
    Mr. Sullivan. And the people responsible for not making it 
happen are in this room today.
    Mr. Walz. Okay. Now, these are the type of things that I 
want to get at to try and understand of why this did not 
happen. It was clearly a directive coming out of the Army.
    The one thing I can tell you is that I know happened from 
being a First Sergeant at the time, I was responsible for 
pushing the play button on the 15-minute DoD DU exposure video 
and that was it. That was all that was talked about. And as an 
artilleryman, that was a big issue. But that was the end of it.
    And so I, too, have a concern if any of this is moving 
forward. I cannot speak recently, but I know from that time of 
the mid-1990s up until my retirement in 2005, I never broached 
the subject again that I can recall.
    Is that true to the best of your knowledge?
    Mr. Sullivan. Congressman, you are really close on that. 
The bigger issue here is that the Department of Defense likes 
depleted uranium as ammunition. So it hypes the effectiveness 
of the weapon and really it does not need to be hyped. I was 
there on the battlefield as a scout in the invasion and I can 
tell you that DU rounds work. They tore through Iraqi tanks 
like nobody's business.
    However, the military did not follow-up with the testing. 
It is their do not look, do not find policy.
    Mr. Walz. I do have a follow-up Department of Defense memo 
from 1995, a year and a half later, that talked about the 
allegation of this being totally false, apparently presented in 
a manner designed to mislead, presented out of context, and 
exhaustive studies of all materials concluded there was no 
evidence, yada, yada, so forth.
    So your contention on this is that we never did get at the 
heart of this? We never made the full effort to try and decide 
what the exposure looked like even though the directive was 
made clear in the 1993 memo that we should have done so?
    Mr. Sullivan. Yes, Congressman, and it still needs to be 
done today.
    Mr. Walz. Okay. Before my time expires, for each of you on 
this across the board, and I think maybe, Mr. Sullivan, you 
have expressed that, but for our other two panelists, what do 
you feel like? Why are we not moving on this? Why are we not 
doing it? Have we not made the determination that Gulf War 
Illness is real and why are we not moving satisfactorily in 
your opinion?
    Mr. Overton. Two parts, Congressman Walz. I wanted to touch 
first on the initial point you made on epidemiological studies. 
You know, we can fix this real easy.
    We have new electronic medical records and we can put a 
full military history inside of that record that could track 
the trends and patterns of units. It is a simple database 
concept and it would drop down and we would take the 
information of who served where, when, how, and why were you in 
combat operations. And it would provide our primary care 
providers to track trends, see effective treatment.
    So on that front, I believe that could be highly effective 
and moving forward, especially for our younger service-conn/OIF 
cohorts.
    I do not think we want the answers. Every time we see a 
research study that comes close to finding an answer, it seems 
as if there is some little mechanism that has been buried 
inside of it to shut it down.
    So, again, going along with what Paul says, I mean, we do 
not want to find this. If we find this, unfortunately, as much 
as I hate to say it, it becomes a bottom line budget matter. We 
have to compensate veterans.
    My mentality on this is if we can fund the war, we need to 
fund the war fighter. That is all we can do. We have to take 
care of those of us that went down range in defense of this 
great Nation and came home broken.
    And it is the cause and the charge of these agencies to 
provide that care for us. And it cannot be a matter of we do 
not have the budget. It is not fair. It is unconscionable and 
it needs to end now.
    Mr. Walz. Who do you think puts pressure on them, and I 
will let Mr. de Planque finish, but who puts pressure on them 
to do that because when they come to us, we ask them what do 
you need, tell us what you need to care for our veterans? And I 
have heard all of us say that time and time again. Who is 
putting the pressure on them to not ask for it?
    Mr. Overton. And is that not the frustration because we sit 
here and listen to that and walk out just absolutely dismayed 
when we say why are we hearing that the budget is not there, 
but we know that the budgets have been provided and put into 
place.
    You know, I do not want to put all this on VA. VA 
unfortunately gets the aftermath. The Department of Defense has 
much responsibility here and I would hope to see in the near 
future that both the House Armed Services Committee and 
Veterans' Affairs Committee can come back together to begin to 
address this because it really does start at active duty. And 
if DoD, and that is another part of our concern with the report 
and the way that VA is moving forward is a strong relationship, 
are they going to be dependent upon DoD to give them the 
information and DoD has not done that in the past.
    Mr. Walz. Well, this is another problem of lack of seamless 
transition causing problems?
    Mr. Overton. That is correct, sir.
    Mr. Walz. Mr. de Planque, if you would finish quickly.
    Thank you, Chairman. I am sorry I went over my time.
    Mr. de Planque. And just to finish quickly, and I agree 
completely that if you are going to fund the war, you have to 
fund the war fighter and you have to fund all of the after 
effects.
    I think some of the reluctance to address things like this 
stems from almost an embarrassment. People do not want talk. It 
is something people do not want to talk about. It is something 
they do not want to think about and that is in an even 
generalized sense about people as a whole, society as a whole 
in that they do not want to focus on what the after effects 
were to soldiers.
    They want to look the other way when they see an amputee 
soldier struggling through an airport. But at the same time, 
they want to be sympathetic. They do not know how to deal with 
it and so they are embarrassed. And so it kind of gets shifted 
into the fringes and the poor veterans are left sitting out 
there with questions and they do not know where to turn for 
answers.
    And the information component, getting good, accurate 
information out to the veterans that was mentioned earlier, 
that is a key component and telling them it is okay to step 
forward.
    For Gulf War Illnesses, we have talked recently about post-
traumatic stress disorder (PTSD) and removing the stigma from 
that and saying it is okay for veterans to go forward and seek 
help. And I do not want to tie that in and conflate it because 
I know, you know, we have talked about, you know, mixing it 
with stress stuff, but it is a similar situation in that it is 
a situation that nobody wants to talk about and nobody wants to 
tell people it is okay to be suffering from this. These things 
happen. We just need to find a treatment for it.
    And I agree with what Dr. Roe was saying also about 
etiology is important. And we are not trying to say that 
finding the causes of these things are important. What we were 
trying to say is you can sit around trying to point fingers and 
find the blame, what is the blame for this, what is the blame 
for this, and argue about that until you are blue in the face, 
but you are not looking for the solution.
    Sometimes finding the cause of it is a part of the solution 
and we completely agree with that. But spending all of the time 
devolving into it has got to be this and subgroups championing 
that I believe this is the cause and I believe this is the 
cause. They fight with each other over which should get the 
lion's share of the research.
    And so the whole approach, how do we fix the veterans, is 
ultimately that is why we believe it is more important----
    Mr. Walz. I appreciate it.
    Mr. de Planque. Thank you.
    Mr. Walz. Chairman, I am sorry for overusing time.
    Mr. Mitchell. One last question from Dr. Roe.
    Mr. Roe. Just one brief question. I know we had many 
people, Nations in the coalition during the Gulf War, much more 
than now. And Kuwait is a small country.
    Have we studied the population of Kuwait where a lot of 
this action took place and the southern part of Iraq and the 
cohort Nations in England, Canada, Australia? Have they shown 
similar things?
    Mr. Sullivan. Dr. Roe, I understand that there were some 
studies in the early 1990s of Kuwaitis who remained in the 
theater and they showed increases in respiratory problems, 
heart problems, and other stuff like that when there were 
scientific research panels in the Middle East. However, when 
the U.S. Government decided to look at what was going on, it 
did a very surface review of that.
    I do know one thing is that some Nations did not have some 
of the problems we have because they did not have some of the 
exposures we had, for example, pesticides, pyridostigmine 
bromide (PB), depleted uranium, and whatnot.
    So you actually have different exposure populations. And 
that is why it is important to find out which one of these 
issues or multiple may be behind it because at the end of the 
day, we want to make sure we are providing the right kind of 
treatment, so we can do both. That is the perfect world.
    And after 20 years of VA saying it is not this or not that 
and delaying research, we have actually got to do both now. If 
we do not get that answer from VA that they are going to look 
into treatments and research for the causes, we have struck out 
here.
    Mr. Overton. And I would like to just add briefly I 
disagree briefly with Paul. We have had coalition forces over 
attending the Research Advisory Committee meetings seeing 
similar disease patterns within their soldiers.
    The Norwegians were here recently. The interesting thing is 
it is a much smaller cohort, but also taking the pyridostigmine 
bromide and having similar exposures and similar conditions.
    They look to you and to our Nation as the leaders, as the 
leaders in science and as the leaders in what they are doing to 
take care of their soldiers, sailors, airmen, and Marines. So 
it all begins here.
    The UK has been waiting for our answers, German troops. The 
world is really waiting for us to come up with a proper answer 
and a proper approach for this. The difference being they are 
providing compensation and benefits to their affected soldiers. 
They are taking care of their own.
    Mr. Sullivan. And I stand corrected, Don. You are right on 
that information. Thank you.
    Mr. Mitchell. Thank you. Thank you very much.
    I would like to welcome the second panel to the witness 
table. For our second panel, we will hear from the Honorable 
Charlie Cragin, Chairman of the Advisory Committee of Gulf War 
Veterans; Dr. Stephen Hauser, Professor and Chair of Neurology 
for the University of California, San Francisco, School of 
Medicine, and Chairman of the Committee on the Gulf War and 
Health for the Institute of Medicine; and Mr. Jim Binns, 
Chairman of the Research Advisory Committee on Gulf War 
Veterans' Illnesses.
    Again, I would like to ask each panelist to limit their 
remarks to 5 minutes and your complete statement will be 
submitted to the record.
    I would like to recognize Mr. Cragin.

    STATEMENT OF HON. CHARLES L. CRAGIN, CHAIRMAN, ADVISORY 
  COMMITTEE ON GULF WAR VETERANS, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; STEPHEN L. HAUSER, M.D., PROFESSOR AND CHAIR OF 
 NEUROLOGY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, SCHOOL OF 
 MEDICINE, AND CHAIR, COMMITTEE ON GULF WAR AND HEALTH: HEALTH 
 EFFECTS OF SERVING IN THE GULF WAR, UPDATE 2009, BOARD ON THE 
  HEALTH OF SELECTION POPULATIONS, INSTITUTE OF MEDICINE, THE 
  NATIONAL ACADEMIES; AND JAMES H. BINNS, CHAIRMAN, RESEARCH 
       ADVISORY COMMITTEE ON GULF WAR VETERANS' ILLNESSES

              STATEMENT OF HON. CHARLES L. CRAGIN

    Mr. Cragin. Thank you. Mr. Chairman, Members of the 
Subcommittee, thank you for inviting--press to talk, a 
marvelous piece of technology--thank you very much for inviting 
me to testify before the Subcommittee this morning. I am 
Charles Cragin of Raymond, Maine, and I had the honor of 
serving as Chairman of this Advisory Committee on Gulf War 
Veterans throughout its tenure from April 2008 through 
September of 2009. It was a privilege to serve with the fine 
men and women of the Committee.
    As you know, the Committee was chartered by the Secretary 
of Veterans Affairs to examine the health care and benefits 
needs of those who served in the southwest Asia theater of 
operations during the 1990, 1991 period of the Gulf War and to 
advise the Secretary on the issues that are unique to these 
veterans.
    And I should emphasize that the Committee saw its 
assignment to conduct information gathering, assess the current 
situation, and then provide advice to the individual who 
requested it, namely the Secretary of Veterans Affairs.
    I would like to recognize the Department of Veterans 
Affairs for the work it has done recently with respect to the 
Gulf War Task Force.
    I was encouraged to find many of the recommendations of the 
Committee referenced within the action plans. I look forward to 
the Department implementing the plans it has outlined and I 
offer my support if they would like it to help them in its 
implementation.
    In general, Mr. Chairman, the Committee's findings are 
summed up in the title of its report, ``Changing the Culture, 
Placing Care Before Process.'' This was a resounding theme. 
Pockets of people trying to do their best stymied by process or 
lack of vital information.
    Many of those who came to VA in the early days after Gulf 
War I were turned away. In many cases, health care 
professionals were not able to connect the symptoms experienced 
by these veterans to defined or known illnesses.
    Consequently veterans were not able to access medical care 
and treatment and their claims for service-connected 
disabilities were often denied.
    The process served as an impeding wall preventing veterans 
who were hurting from getting over the wall to take advantage 
of the care they needed and deserved.
    Consider for a moment that all the fine men and women were 
considered in excellent health and deployable when they went to 
war. In many instances, shortly after their return home, these 
veterans began complaining of feeling ill and seeking help. 
Many were turned away as malingerers or having a psychosomatic 
illness.
    Why did a department of government designed to care for 
veterans not identify that something was happening to men and 
women who had recently been healthy who now were sick? The 
common denominator being that they had deployed in the Gulf 
War.
    The process should have been constructed in such a way that 
these folks could have immediately been welcomed into the 
system rather than rejected because the process required a 
diagnosable service-connection.
    These veterans were not engaged in a massive national 
conspiracy to defraud the government. Rather, they were sick, 
sought help, and in many instances were rebuffed by the agency 
established to care for them. The process became a wall rather 
than a door.
    The Committee has discovered many programs and initiatives 
within the Department of Veterans Affairs to assist Gulf War I 
veterans. Unfortunately, these programs and initiatives are not 
easy to find and it is often incumbent upon the veteran to ask 
the right question.
    As I mentioned, the lack of data contributed to the 
frustration of the Committee and prevented us from conducting 
any substantive analysis. The Committee discovered that the one 
database that had come to be relied upon as the authoritative 
source of information, the Gulf War Veterans Information 
System, had been corrupted. To date, the issues with this data 
system have not been addressed. The last valid report to be 
generated by the system was in February of 2008.
    How can policy be constructed without an underpinning base 
of valid data?
    Dr. Roe, you asked a question concerning numbers and in my 
final few seconds, let me call the Committee's attention to our 
total report. On page 14 of that report, we observed that 
approximately 700,000 U.S. servicemembers deployed to the 
Persian Gulf during the conflict. Of that number, 248,000 are 
enrolled in VA health care. Approximately 290,000 veterans have 
filed claims for benefits with 74 percent receiving some level 
of disability compensation.
    Mr. Chairman, I would request that the Committee 
incorporate our report into the proceedings of this hearing. I 
thank you very much for the opportunity to be with you this 
morning and I look forward to your questions.
    [The prepared statement of Mr. Cragin appears on p. 54.]
    Mr. Mitchell. Thank you. And the report will be 
incorporated.
    [The report entitled, ``Changing the Culture: Placing Care 
Before Process,'' dated September 2009, submitted by Advisory 
Commit-
tee on Gulf War Veterans, will be retained in the Committee 
files. The report can also be accessed online at http://
www1.va.
gov/gulfwaradvisorycommittee/docs/AdvisoryCommitteeonGulfWar
VeteransFinalReport-September2009.pdf.]
    Dr. Hauser.

              STATEMENT OF STEPHEN L. HAUSER, M.D.

    Dr. Hauser. Good morning, Mr. Chairman and Members of the 
Subcommittee. My name is Stephen Hauser.
    Since 1992, I have served as Professor and Chairman at the 
University of California at San Francisco, Chairman of the 
Department of Neurology. We are trainable, but it takes a 
while. I am trained in internal medicine, neurology, 
immunology, and genetics. I am an elected member of the 
Institute of Medicine.
    I am here today because I served as Chair of the Committee 
that worked on the IOM or Institute of Medicine report, Gulf 
War and Health, Update of Health Effects of Serving in the Gulf 
War. The sponsor of the study was the Department of Veterans 
Affairs. The report was released to the VA and Congress on 
April 8th of this year.
    I would like to focus on three major points in my 
testimony, first to discuss the study process of the IOM 
report, second to summarize our findings and conclusions, and 
perhaps most germane to present briefly our recommendations for 
a path forward and for future research that hopefully will 
address the continuing health concerns of our Gulf War 
veterans.
    The IOM is part of the National Academies, a private, 
nongovernmental organization that provides independent, 
science-based advice to policymakers and the public. The long-
established study process followed throughout the Academies 
ensures that Committee Members are balanced for any biases and 
free from actual or perceived conflicts of interest.
    Important to note that the sponsoring organization does not 
participate in any portion of the preparation and review of the 
IOM report.
    This current report is an update of the earlier Gulf War 
and Health report, Volume IV, ``Health Effects of Serving in 
the Gulf War,'' which was published in 2006.
    The specific charge for our Committee was to review, 
evaluate, and summarize the literature on a number of health 
outcomes that were noted in the earlier report as possibly 
being related to deployment in the Gulf.
    We also reviewed, unlike the earlier report, cause specific 
mortality. We began our charge by holding two public sessions 
where interested parties such as representatives from veterans 
service organizations (VSOs), Gulf War veterans were invited to 
speak. We learned a lot and these meetings affected us deeply.
    The Committee also invited representatives from the VA 
Research Advisory Committee of Gulf War Veterans' Illness, the 
RAC Committee. Mr. Binns will follow me representing the RAC 
Committee to present the findings and conclusions from their 
report which was published in November 2008.
    In order to draw conclusions on the strength of evidence 
for an association between deployment to the Gulf and health 
outcomes, we use categories of association. These have been 
used by prior committees and are widely accepted and familiar 
to Congress, the VA, and veterans' groups.
    We also took a weight of evidence approach to weighing the 
evidence and confidence in the evidence presented by individual 
studies. And I would like to now summarize our findings.
    We found sufficient evidence to conclude that a causal 
relationship exists between being deployed to the Gulf War and 
post-traumatic stress disorder. This was the only outcome 
placed in this causal category.
    Also of note, sufficient evidence for an association exists 
between deployment to the Gulf War and the following health 
outcomes, other psychiatric disorders including generalized 
anxiety disorder, depression, and substance abuse, particularly 
alcohol abuse. These psychiatric outcomes can persist for at 
least 10 years post-deployment.
    Sufficient evidence for an association was also seen for 
gastrointestinal symptoms consistent with functional 
gastrointestinal disorders such as irritable bowel syndrome and 
functional dyspepsia, sufficient evidence for multi-symptom 
illness and sufficient evidence for chronic fatigue syndrome.
    There was limited evidence in support of an association for 
a number of other health outcomes including amyotrophic lateral 
sclerosis, ALS, Lou Gehrig's disease, and fibromyalgia.
    I would like to elaborate a little bit more on how we 
evaluated multi-symptom illness also referred to as Gulf War 
Illness and Gulf War syndrome. Numerous studies have documented 
that those deployed to the Gulf War have had increasing 
prevalence of a disabling complex of self-reported symptoms 
such as fatigue, musculoskeletal pain, sleep disturbances, 
cognitive dysfunction, moodiness among other symptoms.
    Our Committee accepted that multi-symptom illness was 
indeed a diagnostic entity. And we examined the literature to 
make conclusions regarding its association with deployment to 
the Gulf War.
    Some research has identified an association between multi-
symptom illness and self-reported exposures to several 
chemicals that inhibit the neurotransmitter, the chemical in 
the brain cholinesterase. This is an enzyme that is critical 
for proper functioning of the nervous system. Pyridostigmine 
bromide is an example of a cholinesterase inhibitor as are 
pesticides.
    In the appendix to our report, the Committee described how 
Gulf War veterans may have been exposed to cholinesterase 
inhibitors including evidence possibly linking these exposures 
to multi-symptom illness.
    After careful examination, however, of both animal studies 
and human studies, our Committee concluded that there was 
insufficient evidence to link possible exposures to 
cholinesterase inhibiting chemical agents to the multi-symptom 
illness seen in Gulf War veterans.
    The Committee believes that the path forward for Gulf War 
veterans consists of two branches, science and applied 
medicine.
    First, we call for improved studies of Gulf War veterans 
designed and conducted to more accurately characterize 
deployment and potential adverse environmental influences 
associated with deployment and to address also possible 
confounding factors of which there are many. Smoking is one.
    However, we feel that further studies based solely on self-
reports may not contribute substantially to our scientific 
knowledge at this point so far removed from that original 
conflict.
    Mr. Mitchell. Dr. Hauser, could you speed it up a little 
bit?
    Dr. Hauser. Yes, I will.
    Mr. Mitchell. Your written statement will be put into the 
record.
    Dr. Hauser. Very good. Let me just finish with a couple of 
comments.
    We need very robust cohorts to identify disorders that 
might occur many decades later, Parkinson's disease, perhaps 
ALS, perhaps some forms of cancer.
    We also believe that a major branch of inquiry needs to be 
launched at the bedside to develop better evidence-based 
therapies for people with Gulf War Illness. We were surprised 
how little evidence-based therapy exists right now that can 
help guide our clinicians at the bedside to care for these 
veterans.
    We believe that a large collaborative venture perhaps 
involving a consortium between the National Institutes of 
Health, the Department of Defense, and the Veterans 
Administration would be one way whereby we could engage the 
very best scientists and the best physicians in this area.
    So on behalf of the Committee Members, I would like to 
thank you for your trust and confidence in our ability to 
assist you with this most important task. Thank you.
    [The prepared statement of Dr. Hauser appears on p. 56.]
    Mr. Mitchell. Thank you.
    Mr. Binns.

                  STATEMENT OF JAMES H. BINNS

    Mr. Binns. Chairman Mitchell, Ranking Member Roe, Members 
of the Committee, I am honored to address you again as Chairman 
of the Research Advisory Committee on Gulf War Veterans' 
Illnesses. I thank you for holding this series of hearings.
    There has been a dramatic change in the recognition of this 
problem in the year since the last hearing and much of it can 
be attributed to your spotlighting attention on it.
    Great credit must also be given to two other people who 
will address you today as VA Chief of Staff, Mr. John Gingrich, 
has personally led a task to reexamine VA Gulf War policy from 
top to bottom, bringing to this effort the urgency and concern 
for his troops he demonstrated as a Battalion Commander during 
the war.
    Dr. Stephen Hauser has Chaired a courageous new Institute 
of Medicine Committee which refused to limit its review to the 
narrow assignment given by VA stuff. The Research Advisory 
Committee and the IOM are now in agreement on major scientific 
conclusions, that chronic multi-symptom illness is a diagnostic 
entity, that it is associated with service during the Gulf War 
affecting as many as 250,000 veterans, that it cannot be 
ascribed to stress or other psychiatric disorders, that it is 
likely the result of genetic and environmental factors, and 
that a major national research program is urgently needed to 
identify treatments.
    As you heard, the IOM Committee did not feel the data were 
strong enough to identify specific environmental causes while 
our Committee did, but that is a relatively minor difference.
    The question before us this morning is what the government 
will do now that the problem has been recognized. VA 
leadership's decision to open the draft task force report to 
public comment was wise. There is much in the report that is 
good, but there is also much that reflects old attitudes the 
report was supposed to change. The tests will come in the final 
draft of the report and how its recommendations are 
implemented.
    I will focus my comments on research. Now that there is a 
scientific consensus that Gulf War Illness is real, important, 
and soluble, we have arrived where we should have been in 1995. 
The task remains to mount an effective national research 
program, ``A well-planned top-down program employing the best 
in American science run by people who go to bed at night and 
wake up in the morning thinking about this problem,'' if I may 
paraphrase what Dr. Hauser told me a few weeks ago on the 
telephone,'' his Committee envisioned.
    This country is not doing that. At VA, there are some 
individual researchers doing excellent work. And VA is in the 
process of launching a new program and hiring a toxicologist to 
staff it. They have issued requests for proposals that include 
most topics recommended by the Research Advisory Committee's 
report. They have appointed a Steering Committee of outside 
scientists to guide this program. There is a plan being 
developed for a major genetics component.
    It all sounds very positive. However, the new RFAs 
(Requests for Advice) have failed to attract much interest from 
the VA research community. There is no comprehensive research 
plan. The places that VA has found to invest most of the funds 
committed this year are not for priority research topics. 
Research involving the psychological aspects of chronic illness 
is again being favored.
    The new Steering Committee was not consulted on several new 
research studies announced last week. The press release 
announcing the studies carried the old message that Gulf War 
veterans' problems are mainly psychological.
    In short, VA's new research program resembles far too much 
VA's old research program.
    To mount an effective program, the Office of Research and 
Development must create a comprehensive plan focused on 
priority research topics under the leadership of a scientist 
who understands the problem, who harbors no doubts about its 
nature, and who goes to bed at night and wakes up in the 
morning thinking about how to solve it.
    Assuming that VA makes these major necessary changes, it 
cannot do the job alone. Yet, the Department of Defense, which 
has historically funded two-thirds of Gulf War Illness 
research, has eliminated this research entirely from its budget 
for many years. This action is tragically shortsighted given 
the major implications of this research to current and future 
military personnel at risk of multi-symptom illness and toxic 
exposures.
    Congress has responded by establishing a Gulf War Illness 
Research Program within the DoD Congressionally Directed 
Medical Research Program (CDMRP). This well-managed program is 
open to all researchers. However, it is grossly underfunded 
having received just $8 million in fiscal 2010. Congressional 
supporters have proposed $25 million for this program in fiscal 
2011.
    Compare these figures to the billions of dollars recently 
calculated to cover the care and disability of Vietnam veterans 
exposed to Agent Orange. How much better for ill Gulf War 
veterans, current and future U.S. military personnel, and the 
public treasury to cure this illness rather than to allow 
veterans' health to deteriorate.
    I urge you to make this bipartisan issue a priority and to 
press upon your colleagues the vital importance of adequate 
funding for Gulf War Illness research at CDMRP.
    I would also encourage you to support Gulf War Illness 
reform at VA. As last week's press release makes clear, there 
is still push-back within the bureaucracy to the initiative 
Secretary Shinseki and Chief of Staff Gingrich have begun. 
Bureaucrats remain while appointed leaders come and go. I urge 
you to consider legislation to ensure the permanence of 
reforms. I urge you to hold annual follow-up hearings to keep 
the spotlight on.
    It is important to close on a positive note. Twenty years 
into this battle, the objective is finally clearly in sight. It 
is time for leaders and resources adequate to accomplish the 
mission. It is within reach. It is a matter of choice.
    [The prepared statement of Mr. Binns appears on p. 59.]
    Mr. Mitchell. Thank you.
    Mr. Cragin, in your testimony, you mentioned one of the 
frustrations of your Committee was the Gulf War Veterans 
Information System and how this database had been corrupted. 
Today you say the issue with the database has not been 
addressed. A couple of questions with that.
    Why do you think this is so and what detrimental impact 
would there be should this database remain corrupted? And if it 
is something as seemingly simple as fixing a database, why has 
this not been corrected and what larger problem do you think 
there is left that is broken?
    Mr. Cragin. Well, Mr. Chairman, I cannot obviously speak 
for the Department of Veterans Affairs. But during the time 
that the Committee was in existence and was trying to get data 
and on occasions there was great reticence within the 
Department to provide us with information on a timely basis, 
something that we observed in our report, it became apparent to 
the Committee that the data was changing before our very eyes, 
had become corrupted, and finally we were able to get the 
guardians of the data, so to speak, to concur that, yes, in 
fact, it was corrupted.
    I inquired recently as to whether there had been any change 
within the Department with respect to this Gulf War Veterans 
Information System and they advised that they were not going to 
try to fix this corruption which had occurred as a result of a 
transition from a Legacy System to a ``newer system,'' but 
were, in fact, going to invent a new system.
    We will have to wait and see. The concerns of the Committee 
and I think the concerns of veterans generally is you need good 
data in order to make good policy first and foremost.
    Secondly, really that was the only database that identified 
this cohort of Gulf War veterans because the Gulf War is still 
on. And this cohort has never ever been tracked within the 
medical community, for example, at VHA as a specific cohort. So 
physicians are not necessarily trained to recognize one of 
these vets when they walk in the door, when they get in the 
door, and to be able to make an evaluation based upon their 
particular profile and history.
    That is why I mentioned it in my testimony because it was 
so frustrating to the Committee. I have worked in the 
government for a number of years and if you do not have good 
information, you cannot make good decisions.
    Mr. Mitchell. Mr. Binns, in your testimony, you state that 
there is also much in the task force report that reflects old 
attitudes that the report was supposed to change.
    Could you elaborate a little more on what the old attitudes 
are contained in the report.
    Mr. Binns. The best example that comes to mind, and this 
was in the draft task force report, I understand that VA has 
made substantial revisions, so we look forward to those, but in 
the draft task force report, the introduction presented these 
problems as perceptions of veterans, the perception of veterans 
that VA somehow was not doing all it could or should, and it 
neglected to mention all of the facts that have been presented 
to you today about care, about research, and so on that 
reflected an attitude that did exist in the Department of 
Veterans Affairs for many years and in some quarters still does 
today that this is not a serious problem that should be 
addressed seriously.
    So that was one clear example. And I look forward to seeing 
if that is corrected in the new version. I do think it was a 
very positive step that the Department did to put this report 
out for public comment.
    Mr. Mitchell. Again, Mr. Binns, why do you feel that the 
new requests for advice, the RFAs, have failed to attract much 
interest in the VA research community?
    Mr. Binns. Well, just as veterans have been told that this 
is not a serious problem or that it is just a collection of 
symptoms, so VA researchers and VA doctors have been told that. 
And when you are a researcher and you are deciding what to 
invest your time on and your career on, you naturally want to 
do it on something that is important, that is recognized by 
your mentors as important.
    So it is going to take a very emphatic effort on the part 
of VA leadership and VA research leadership to indicate that 
they have changed their approach on this, that this is a very 
important problem if they are going to get their researchers to 
respond.
    Mr. Mitchell. Thank you.
    My time has expired. Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    Dr. Hauser, you made some interesting points. And I commend 
the Institute of Medicine for digging into this very, very 
difficult subject, and the more I read and the more I read 
about where you got your information and so forth to 
specifically bring out the conclusions, and I am going to talk 
about those in just a minute.
    How many reports and studies and so forth did you all do at 
the IOM to come to your conclusions that you brought out here 
just a moment ago?
    Dr. Hauser. How many reports did we review, sir? Yes. We 
initially--excuse me. She turned it on for me.
    Mr. Roe. You all are using all my time up punching the 
button.
    Dr. Hauser. I am not used to this button. We initially 
looked at over 1,000 and decided that 400 were significantly, 
were substantially serious contributions that we studied those 
in detail.
    Mr. Roe. Okay. And you mentioned cause-specific mortality. 
Could you discuss that in a little more detail?
    Dr. Hauser. Yeah. So we tried to capture the death records 
that we could from various sources and I think the time is 
still probably too early to have robust data in the area of 
cause-specific mortality.
    We need to go further for that, to have strong data in 
terms of excess mortality beyond what had been noted in the 
earlier report, increased mortality from automobile accidents, 
particularly in the early years after the conclusion of the 
first Gulf War.
    Mr. Roe. And I think Mr. Cragin makes your point about the 
database not being there. I think you are absolutely dead on 
right about that. Without that information, you draw an 
erroneous conclusion.
    And what is helping me is what we have done with the 
Vietnam era veterans and Agent Orange. In this particular group 
of men and women who served, you had the causal for PTSD and 
that is causal. We were okay with that. The GI 
(gastrointestinal) symptoms, that is also causal. And is that 
correct? You mentioned you had evidence----
    Dr. Hauser. I believe that GI symptoms were an association 
that was sufficient but not causal.
    Mr. Roe [continuing]. Not causal. Okay.
    Dr. Hauser. Yes, sir.
    Mr. Roe. Sufficient, but not causal. And causal was PTSD. 
The multi-symptom illness, could you define that to me what 
that is, multi-symptom illness, Gulf War Illness? I have been 
trying to figure out what that is so if someone asked me, I 
could explain it.
    Dr. Hauser. I think, sir, you have not been able to define 
it yourself because different definitions are used in the 
literature. And we really do not have a single definition that 
people have agreed upon to define this constellation of 
symptoms that overlap with other disorders prevalent in the 
civilian community, chronic fatigue syndrome, chronic 
unexplained fatigue, fibromyalgia, widespread pain syndromes.
    You know, there are 81 million Americans who suffer from 
chronic pain. That is an important component to this. Headache, 
bowel symptoms, cognitive disturbances, musculoskeletal pain, 
tingling, and the symptoms vary in different individuals.
    And one of the problems that came up in earlier analyses 
was that the symptoms were so broad that an easily recognized 
diagnostic entity could not be identified using a method known 
as cluster analysis.
    Mr. Roe. Okay. That is what I thought. You did not have a 
statistical significance of four symptoms or five symptoms you 
could put together? Me, when the patient came to see me, I 
could listen to that history and there are no biomarkers you 
can draw from----
    Dr. Hauser. That is correct, sir. And I think that also 
made it very difficult to interpret what different researchers 
meant by Gulf War syndrome or chronic multi-symptom illness.
    Mr. Roe. I agree. I think what you have done is put some 
more smoke in the room. It is difficult to define. And so you 
have Gulf War Illness. I am beginning to get a little bit 
better idea. It is a very broad set of symptoms.
    Dr. Hauser. Yes.
    Mr. Roe. Very broad set of symptoms. But there is no clear 
concise conclusion from experts about what that is?
    Dr. Hauser. That is correct.
    Mr. Roe. And that is why what Mr. Cragin is saying is so 
absolutely vitally important because you can get, over time, 
you can get that information.
    And I think it was Mr. Overton that mentioned about the 
electronic medical record, having this data in there that you 
can peel this back and look at it with thousands of people or 
hundreds of thousands of people to come to some reasonable 
conclusion because right now you cannot.
    Dr. Hauser. It is having the data available, but also 
making certain that the proper data is encoded in the medical 
record. The content of what is in the record needs also to be 
standardized.
    Mr. Roe. And then once you do that, it is to try to figure 
out how to adequately and properly treat these patients----
    Dr. Hauser. Yes, sir.
    Mr. Roe [continuing]. After you have that. I yield back, 
Mr. Chairman. Thank you.
    Mr. Mitchell. Thank you.
    Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    What Dr. Roe hit on, I know I am a broken record on this, 
it does go back to seamless transition. Our ability to be able 
to coordinate across the spectrum on records and everything 
else is a frustrating situation to me.
    I, too, would like to comment on the research. And, Dr. 
Hauser, my home district is the Mayo Clinic area, so I have 
become somewhat familiar with the IOM and how things are 
carried out.
    How would you characterize how Gulf War Illness or the 
issues you are hearing has been addressed compared to other 
issues out there? How were the studies done in your opinion?
    Dr. Hauser. In my personal opinion----
    Mr. Walz. Right.
    Dr. Hauser [continuing]. There has been, I think, a lack of 
a top-down approach that could be very helpful in this 
situation. I think that big science is needed to have 
definitive answers for this type of problem. Analogies might be 
the polio effort or more recently the effort that was centrally 
coordinated against HIV to find the cause and then the 
therapies for AIDS.
    We are in a very different place. Modern genetics, modern 
cell biology, and imaging combined with informatics and 
clinical trials creates a wonderful opportunity to have a 
coordinated effort informed by the very best science and the 
very best bedside medicine.
    Mr. Walz. Dr. Hauser, would you concur with Mr. Binns that 
those very best folks are not going to do this on the RFA? Do 
you think----
    Dr. Hauser. The RFA is a great mechanism for creative 
science by individual investigators and perhaps less useful for 
this very large top-down effort that may be needed here.
    Mr. Walz. Okay. Very good. That is helpful to me because I 
am trying to get this in my--as I said, coming from the Mayo 
and in my own doctoral studies.
    Mr. Binns, you said something interesting and I know this 
is what I am trying to get at. Everybody in this room wants the 
best care for these veterans. Something is happening to them.
    I am really glad, Mr. Cragin, you are pointing out there is 
not a national conspiracy to defraud the government from these 
folks. These are warriors and heroes and did their job and came 
back.
    And in a minute, I am going to ask you too if you believe 
there is a massive conspiracy to deny their claims, because 
there is the other side of this, and if I could come back.
    But, Mr. Binns, you mentioned that we want these best 
people there, but you said you wanted somebody in research with 
no doubt. It has been my conclusion that doubts are at the core 
of research, of trying to get there, that you find that is 
where you need to start from. I say that because I think there 
is a belief among some veterans that there is a preconceived 
notion on this.
    So I would ask you, Dr. Hauser, were you under any pressure 
to come up in that IOM study with a preconceived or 
predetermined outcome?
    Dr. Hauser. No, sir.
    Mr. Walz. Okay. Mr. Cragin, were you in your research, did 
you have a predetermined outcome that you were supposed to come 
up with?
    Mr. Cragin. Absolutely not, sir.
    Mr. Walz. So there was no conspiracy to deny the claims on 
this that you could tell from your position?
    Mr. Cragin. No, Mr. Walz. But I think perhaps to be more 
responsive to your question, there are some great people who 
work at the Department of Veterans Affairs.
    I was parachuted into the Department in 1990 as the first 
presidentially appointed, Senate confirmed Chairman of the 
Board of Veterans' Appeals. And I must admit that I found a 
group of people who want to do it their way or not do it. My 
management approach is lead, follow, or get out of the way. 
And, unfortunately, I think leadership sometimes in 
organizations has to confront and spend an inordinate amount of 
time dealing with those folks who decline to get out of the 
way.
    Mr. Walz. Well, I am appreciative. And I, in all full 
disclosure, my colleagues heard me say this, I am a cultural 
studies teacher, so this issue of culture always comes back to 
me on this and I believe it is at the heart of many things that 
we do.
    And what I am struggling with is, is that we are trying to 
do the science, we are trying to do it unbiased, we are trying 
to do it in a caring, passionate manner with the realization 
that we have folks here who are experiencing a degradation of 
their daily lives because of most likely either causal or 
sufficient evidence or association-wise with this and we are 
trying to balance this all out to get it there.
    So for me, the one thing I would say is you did a really 
nice study. You got this all done. It is 10 months into it. You 
made some recommendations.
    Have we reinstated authority to enroll Gulf War veterans in 
Group 6?
    Mr. Cragin. Not to my knowledge, but it is my understanding 
that Mr. Gingrich and his task force is working on that issue 
at the present time.
    Mr. Walz. Okay. I will save us the time to do this. If I 
read down through this whole list of recommendations, have any 
of them been implemented yet?
    Mr. Cragin. Sir, not to my knowledge.
    Mr. Walz [presiding]. Okay. I yield back.
    Mr. Roe. You are yielding to yourself. You are the Chairman 
now. Make sure we have our next panel.
    Mr. Walz. Mr. Roe, you have a follow-up?
    Mr. Roe. I do not.
    Mr. Walz. If there are no follow-ups, then I personally 
want to thank all of you for the work you are doing. Thank you 
for sharing this with us and I look forward to working together 
in the future. We appreciate it. Thank you all.
    For our third panel, we are going to hear from John 
Gingrich, Chief of Staff and Chairman of the Gulf War Task 
Force for the Department of Veterans Affairs. Mr. Gingrich is 
accompanied by Dr. Victoria Cassano, Director of Radiation and 
Physical Exposures, Veterans Health Administration; Dr. Joel 
Kupersmith, Chief Research and Development Officer, Veterans 
Health Administration; and Brad Mayes, Director of the 
Compensation and Pension Service for the Veterans Benefits 
Administration.
    Thank you all for your time here. I think when you get 
situated, we will go ahead and hear from Mr. Gingrich first.

STATEMENT OF JOHN R. GINGRICH, CHIEF OF STAFF, U.S. DEPARTMENT 
  OF VETERANS AFFAIRS; ACCOMPANIED BY VICTORIA CASSANO, M.D., 
MPH, DIRECTOR, RADIATION AND PHYSICAL EXPOSURES SERVICE, ACTING 
DIRECTOR, ENVIRONMENTAL AGENTS SERVICE, OFFICE OF PUBLIC HEALTH 
AND ENVIRONMENTAL HAZARDS, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; JOEL KUPERSMITH, M.D., CHIEF 
   RESEARCH AND DEVELOPMENT OFFICER, OFFICE OF RESEARCH AND 
DEVELOPMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; AND BRADLEY G. MAYES, DIRECTOR, COMPENSATION 
  AND PENSION SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Mr. Gingrich. Chairman Mitchell, Ranking Member Roe, 
Members of the Subcommittee, thank you for holding this hearing 
today.
    I also want to thank the preceding panels for their candor 
and insights into the challenges that we face. Regardless of 
our position, we understand there is a lot of work that remains 
to be done.
    Our task force relied heavily on the outstanding 
contributions of the Advisory Committee on Gulf War Veterans 
and the Research Advisory Committee on Gulf War Veterans' 
Illnesses.
    I would like to publicly recognize Charlie Cragin and Jim 
Binns for their superb leadership and unwavering support of our 
veterans.
    I vividly remember two experiences from my Gulf War 
deployment, the physical reaction to PB pills and the chemical 
alarm sounding in the battalion area. We were told the physical 
reaction was due to heat and the alarms were malfunctioning 
even though they seemed to not malfunction during training.
    In our last days, a soldier in the operations center became 
extremely sick. Our medical personnel could not explain the 
cause. Eventually he was medivacked. Today he is undeniably 
physically suffering multiple illnesses.
    Despite being in the same unit with similar exposures, I am 
not ill and he is and I do not know why.
    This hearing is entitled ``The Future of Dissatisfied 
Veterans.'' It is understandable why some are dissatisfied. 
They are sick and sometimes have been given misinformation and 
answers and cures are not readily available.
    For years, they were told their symptoms were a mental 
condition or they were not taken seriously. In trying to get 
the benefits they earned, they were denied or delayed in the 
process. Given all this, it is understandable why some lack 
trust in DoD and VA.
    We recognize the frustration that many veterans and their 
families experienced on a daily basis, people who only want to 
have their quality of life restored. It is our responsibility 
to rebuild and earn their trust.
    VA is challenging the way we do business and changing in 
many ways. It is already changed and we have become more 
proactive advocates for Gulf War veterans, in fact for all 
veterans. While there is more to be accomplished, the task 
force is among the first steps in that change and it will not 
be the last.
    My accompanying witnesses, Dr. Cassano, Mr. Mayes, and Dr. 
Kupersmith, serve as members of the task force. They bring over 
50 years of experience in health care, benefits delivery, 
service to our Nation and its veterans.
    Dr. Cassano, a Navy veteran, returned last night from 
teaching an exposure seminar to VA clinicians in Portland to 
improve direct clinical care, a theme being developed for our 
next report.
    She is also key to our Joint Medical Surveillance Program 
for veterans at Qarmat Ali, Iraq. This program is the first of 
its kind, DoD and VA proactive medical surveillance to ensure 
that the current generation can avoid some of the problems 
plaguing Gulf War I veterans. In fact, notification phone calls 
are underway to enroll veterans, civilians, and servicemembers 
as of today. It is a joint DoD/VA effort.
    Mr. Mayes, a 19-year VA employee, was hands-on in 
developing 22 rules and regulations helping veterans, as well 
as training letters for claims adjudicators to use in deciding 
environmental exposures. He is at the forefront of our effort 
to break the back of the disabilities backlog and our fast-
track presumptive claims processing program and our southwest 
Asia veteran system or data bank system that will be 
established and operational no later than October 2010.
    Dr. Kupersmith led 49 new studies to find the sources of 
and develop treatments for Gulf War Illnesses. He is working to 
improve VA partnership with RAC to establish a Gulf War 
Research Steering Committee and to install a new Director for 
service-related illnesses in the Office of the Research and 
Development to oversee all programs.
    VA is adding combat experienced advisors to the National 
Research Advisory Committee. All these actions improve our 
research and development program and change the culture.
    Secretary Shinseki charged the task force to conduct a 
comprehensive review of all VA programs and services for Gulf 
War veterans to seek opportunities to better serve those 
veterans, to engage these veterans with genuine transparency 
and measurable accountability for the care and services we owe 
them and to earn their trust.
    The task force was designed as an interdisciplinary matrix 
team charged with being candid, aggressive, innovative as we 
investigated allegations and perceptions, analyzed the facts, 
developed the recommendations. The result is a unified, 
comprehensive organizational plan.
    While our primary focus was on the veterans deployed in 
1990 and 1991 Gulf War period, we sought a broader new view by 
applying the lessons we learned to improve practices and 
policies in the support of all veterans including the current 
conflicts in Iraq and Afghanistan.
    We took the unprecedented step of posting the report online 
for public comment. The response was strong. One hundred and 
fifty suggestions were submitted, 300 additional comments, and 
more than 2,100 votes were cast by 189 unique public 
respondents. I have personally reviewed every comment. They 
provide great insights.
    Our action plans are our initial road map to transform the 
care and services we deliver, as well as provide new and 
improved tools for VA personnel. The report is not a panacea 
for caring for Gulf War veterans, but we have made every effort 
to establish a strategy and an execution plan for the weeks, 
months, and years ahead.
    We are not waiting for the release of the report to execute 
the recommendations. We are moving out now. We are not waiting 
because the veterans have waited long enough. We will not 
disband the task force. Our work will continue. We will issue 
annual reports capturing progress and addressing new areas of 
focus. VA will reach out to all Gulf War veterans who were 
turned down for care and services to make them aware of the 
changes and encourage them to apply for care and benefits.
    We know that not everyone agrees with the report or the 
actions we are taking just as we recognize the mistrust and 
misperceptions some have. We encourage all of our stakeholders, 
internal and external, to set aside individual differences to 
continue and further develop our collaboration.
    Speaking as one of the VA leaders and a Gulf War combat 
veteran, we must work together, share the challenges, and stay 
focused on helping our veterans and find the right solutions.
    We welcome your recommendations and even criticisms in our 
ongoing constructive dialogue. Our goal is to continue gaining 
veterans' trust in VA. I know that is our shared goal.
    This concludes my opening statement and we look forward to 
your questions. Thank you.
    [The prepared statement of Mr. Gingrich appears on p. 61.]
    Mr. Walz. Dr. Roe, if you are ready, I am going to yield to 
Dr. Roe to start out as our medical expert on this and then 
come back.
    Mr. Roe. Thank you for that.
    Mr. Walz. Absolutely.
    Mr. Roe. I guess, Colonel, one of the things that we have 
here they just handed me was a Gulf War review. And the way it 
works for us, the Sergeant Major, I am sure, has had a similar 
experience, what happens to us is I will go this week to the 
Bowmantown fish fry. And somebody is going to walk up to me and 
they are going to say during that fish fry, Doc, I have been 
having these symptoms, what should I do. And I tell them try to 
get an appointment to the VA.
    And it says right here disability compensation. And what 
will happen is I will say, well, call Ann at my Morristown, 
Tennessee, office and talk to her. And you talk to Ann. You get 
all the things filled out and then it gets denied. And then we 
refile it and it gets to Nashville. And then it gets to 
Washington and then it gets denied. And that is sort of what 
happens. I have had that experience many times.
    And I think one of the problems has been is there is not a 
clear definition of what really qualifies so that when someone 
comes in that they know that they can get these particular 
benefits. So I know when you do this right here, this is a nice 
piece of paper, but I am going to jump through a thousand hoops 
and so is my office when we come up with the very next veteran. 
I promise you when I get home this weekend, something will 
happen just like this.
    And how is that going to be different with what you just 
said?
    Mr. Gingrich. There are several things that are being done, 
Dr. Roe, and I do not want to make it sound too simplistic 
because it is complex. But one of the things we have done is we 
just announced the fast track for processing presumptive 
claims. We have already put three presumptives in the process. 
Those are the Agent Orange presumptives. The next priority, the 
Gulf War. Those presumptive claims we say that we will process 
in 60 days or less.
    Totally automated. You go to the Web site. You download a 
medical questionnaire. You take that medical questionnaire to 
any clinician in the country. The clinician fills out the 
questionnaire answering all the questions on the questionnaire. 
They prove military service and the role it had in it. If they 
actually have the illness, we will process the claim.
    This is different than what we currently do. These 
questionnaires, there are 67 of them and we have three done and 
we are in the process of getting all 67 of them done by the 1st 
of October.
    Mr. Roe. I am going to find out about that. That sounds 
pretty easy, but I am going to absolutely try that. I will let 
my Veterans' Affairs person in my Congressional office try it, 
and I just bet you it will not be that simple.
    Mr. Gingrich. Sir, that is just one step we are making in 
the process, but these questionnaires, the advantage of this 
questionnaire is it allows you to take the questionnaire to a 
non-VA clinician and get it filled out. That has not been done 
before.
    Mr. Roe. No.
    Mr. Gingrich. The questionnaires have been worked with VHA 
and VBA and the Board of Veterans' Appeals to make sure that we 
have all the questions that we need to have to evaluate that 
disease, Parkinson's, for example, or ischemic heart disease.
    Mr. Roe. When this is all filled out, when it gets to the 
person that makes the decision, they will be able to make a 
decision affirmative or negative based on this questionnaire 
and based on what?
    Mr. Gingrich. Based on the proof of military service and 
the disease.
    Brad.
    Mr. Mayes. Yes, in the case of the Agent Orange 
presumptives, because the nexus burden is relieved and that is 
the essence of creating a presumption of service-connection, if 
the veteran has ischemic heart disease and the service 
indicates that it is qualifying for the purposes of extending 
the presumption, in other words, they stepped foot in Vietnam 
or served on its inland waterways, then we would certainly be 
able to make that connection quickly.
    The disability benefits questionnaires are really helping 
the veteran to participate in the process by getting a private 
examiner to provide the evidence that allows us to give the 
veteran the proper evaluation, and determine the rating, as 
opposed to having them come in to a VA medical center and be 
examined. It would streamline the process.
    Mr. Roe. And my time is about up, but one more question 
briefly. Do you feel like that the DoD/VA needs more resources? 
That is what we need to know up here at this dais. Do you need 
more resources to study this issue or do you have enough 
information to make the decisions you need right now? I think 
that is the takeaway I am going to leave from here with.
    Mr. Gingrich. To answer your question about right now that 
is I think we do. Do we need to continue this research into the 
project and what we need to get done and develop more action 
plans? Yes, sir, we do. And when we get those developed, we 
will have a better appreciation for where we are.
    But we just added in the, if Congress approves the 
President's budget, $377 million into VBA to get at the claims 
process, to go aggressively after it. So right now I would say 
yes, but I do not want to close the door on coming back later.
    Mr. Roe. I guess one of the comments that someone in the 
first panel mentioned was wanting to sit down with VA and have 
an open door. Is that a possibility?
    Mr. Gingrich. Yes, sir, it is a possibility.
    Mr. Roe. It would be reasonable to me to do.
    Mr. Gingrich. Yes, sir. In fact, we have shared this 
report. The draft report was open to the public and it was 
shared with veterans service organizations before, individual 
VSOs, and we have their comments back.
    Mr. Roe. Okay. Thank you.
    I yield back.
    Mr. Walz. Well, again, I thank you all for being here. And 
I want to be absolutely clear that I understand everyone in 
this room wants what is best for our veterans and that is what 
we are trying to get to.
    But I would be remiss to say one of the issues here is the 
perceived lack of attention that our veterans say they believe 
they are getting. This panel requested Deputy Secretary Gould. 
He declined to come.
    Do you think that sends the right message, Mr. Gingrich?
    Mr. Gingrich. Chairman, I am not getting into the internal 
things that happened back then. But I will say the message sent 
is this is a priority of the Secretary and this is a priority 
of the Deputy Secretary.
    I think if you would go by Secretary Shinseki's record, he 
is serious about advocacy for veterans or he would not have 
taken on the Gulf War question, the Agent Orange challenges of 
presumptives. He would not have approved the nine presumptives 
for Gulf War.
    He is about to announce the Volume VIII and Volume VII 
results that were at the task force. We brief him regularly. 
What he has done is he has divided the efforts of the 
organization and he said, to me, you very well represent Gulf 
War veterans because you served yourself and I want you to 
personally take----
    Mr. Walz. Well, I certainly do not want to, and I do not 
mean that derogatory to you, you are a great resource for us, 
you have been here, I just think this perception of bringing 
this back together is critically important.
    I would come back again. Dr. Roe asked the question about 
funding. Just a couple months ago on the views and estimates, 
not one penny was requested for Gulf War Illness Research.
    What message does that send us?
    Mr. Gingrich. The President's budget was passed by Congress 
for 2010 was a significant increase, in fact the most 
significant increase in decades.
    Mr. Walz. So it was enough?
    Mr. Gingrich. It was enough for what we have in----
    Mr. Walz. How does that Mr. Roe just asked----
    Mr. Gingrich. As he said I do not know what the final 2011 
budget is going to be. But based on what we know about the 2011 
budget, they are putting $377 million into VBA to work on the 
claims process. I believe it is enough to jumpstart us of 
getting at the backlog and getting at the medical research that 
we need to do because in the report when we publish it, it will 
show where the money comes for the initial elements that we 
want for----
    Mr. Walz. So that $2.8 million recently announced is 
enough?
    Mr. Gingrich. That is not enough. We already have more 
money and we are going to make more announcements in 2010 and 
2011.
    Mr. Walz. Well, I want to get at this. You heard Mr. Cragin 
say that, and we were talking with the last group, and I asked 
the recommendations that Mr. Cragin's group, these are being 
implemented then? We are prepared to do so?
    Mr. Gingrich. We are prepared, I cannot say all of them off 
the top of my head, but 80 percent of the recommendations that 
were presented to us by the two Committees are in this report.
    Mr. Walz. And what is the timeline on that?
    Mr. Gingrich. Sir, we have already started on some of them, 
some of the research.
    Mr. Walz. Okay.
    Mr. Gingrich. Having the Steering Committee was worked out 
with Mr. Binns, the fact that we needed a Gulf War Research 
Steering Committee so that the RAC and our research people 
could sit down and work it out. I think Mr. Binns would be or 
at least understand when we said we have created a new person, 
a new position for a Director to look at combat-related 
illnesses.
    That Director is to take these programs, pull them 
together, and look at them to get at what the previous panels 
talked about when they said you need an overarching plan----
    Mr. Walz. Yes.
    Mr. Gingrich [continuing]. To go after it. That is being 
implemented right now. We are going to start. We are out 
looking for a person to fill that position. So there are things 
in here that we have already done.
    And I really do appreciate the two Committees and the other 
panelists that came up because we are looking at every one of 
these issues and some of them we have already done and some of 
them we are working on.
    Mr. Walz. Mr. Gingrich, do you feel that the first panel 
was an unfair criticism of where we are on this or do you think 
it stems from a frustration of 20 years of waiting? There were 
some pretty pointed comments about what is not happening. And 
these are folks, they themselves, that are, as you, part of 
this cohort.
    So how do you respond? I mean, I think we owe a response to 
the first group and I owe you the opportunity. As I said, the 
commitment you have to our veterans is never in question.
    Mr. Gingrich. Congressman, let us go back to your days as a 
Sergeant Major. You know that you and I have experience in a 
unit. When trust is broken, the unit becomes dysfunctional. And 
what we are saying is the trust has been broken and it is our 
job to put the trust back.
    And I cannot expect the first panel to come in here and 
expect the Chief of Staff who, as they made it very clear, is 
an appointee is going to come in and change 20 years of history 
or, as they were referring to, 40 years of history. But I think 
Secretary Shinseki has made it very clear that our job is to be 
the advocate for veterans 24/7 and we are trying very earnestly 
and with all heartfelt effort to make that happen. And I 
believe that the people who are sitting here with me have taken 
this on in a great effort to say we are going to do this 
differently.
    One of the things that the Secretary charged us with is do 
not make this so that it leaves when you leave, John. You have 
to set this up so that it is here, it is institutionalized. 
That is why we are putting it in regulations. That is why we 
are putting it into the governance process of VA.
    The Deputy Secretary in his monthly performance reviews is 
going to get briefed on where we are in the task force. That is 
why it has been put into the budget process for 2012. So----
    Mr. Walz. Mr. Gingrich, I am appreciative of everything you 
do. Do you think if we are here a year from now that the first 
panel will be able to see a difference in the lives of those 
warriors that were there? Do you think they will be able to see 
an appreciable difference in how we are caring for them or how 
the culture is working or how the research is moving? Do you 
think that is a reasonable expectation?
    Mr. Gingrich. Yes, sir.
    Mr. Walz. So if we reconvene or, as you said, whether you 
and I are here at that time, it is important that the 
institutions that care for them are still there, so whoever is 
here at that time, they will be able to see that?
    Mr. Gingrich. I am absolutely convinced, sir.
    Mr. Walz. All right. Well, I thank you all. And, again, 
thank you for your work.
    Dr. Roe, if you have any further comments.
    Mr. Roe. Just very briefly.
    First of all, I thank all of the panel Members. You have 
done a great job and have actually--it is a very complicated 
problem that I am trying to get my arms around. I think just a 
statement that we as a country or the VA or the DoD need to do.
    I heard, Colonel, you say trust has been broken. We did 
that in Vietnam. It looks like we have done that with the Gulf 
War. We need to stop doing that. We need to have, when veterans 
come home, whether they are intact as I was when I came home 
from overseas duty or whether you do not come home intact, we 
have an obligation. I believe the VA does. And I know that my 
own VA in my hometown does. I really honestly believe that in 
my heart. Do they get it all right? No. But as a country we 
have to stop doing that.
    And we have conflict going on now in Afghanistan and Iraq 
that we are going to be paying the penalty of that for years to 
come and we need to start right now doing it right. And I think 
I have gotten a pretty good idea about how we can do that. But 
as a Nation, I believe we are obligated to our warriors to do 
that. And we owe that obligation.
    We saw a young warrior last night on the House floor that 
lost both legs and his hand. I cannot do enough for him. 
Personally I cannot do enough for that warrior. So we have to 
accept that, I think, as a Nation. As a philosophy we have is, 
we are going to do right by them when they are in war and we 
are going to do right by them when they are home.
    And I appreciate, Mr. Chairman, you all holding this. The 
hearing has been very informative for me.
    Mr. Walz. Thank you, Dr. Roe.
    Final question on the Gulf War review that is going out and 
we are getting them. How are you disseminating that? How do we 
know who we are targeting with that and how are they getting 
the information?
    Mr. Gingrich. We have 200,000 plus in our database. We also 
put it on our Web site. All 300 of our Web sites will have a 
link to this report. We will also take and distribute it.
    I only know of one Gulf War 20th reunion or 20th 
celebration or whatever you want to call it, recognition. We 
are going to that. You talk about engaging the veterans. We are 
going to go to that. I am going. We are going to run an hour 
and a half discussion. We will also set up a benefits where 
they can talk to the benefits folks. They can talk to the VHA 
folks. They can talk to a cross-section of the VA. So there 
will be two sessions set up on the Saturday. So we are walking 
out and reaching out and saying, okay, we will meet you at this 
event.
    Mr. Walz. We appreciate that. And I would follow up with 
Dr. Roe. These are the things that we steer people to, but he 
is right. If we are going to see this, there is going to need 
to be action and we are going to need to be partners in that.
    Mr. Gingrich. Right.
    Mr. Walz. Well, again, I thank you all for being here and 
all our panels. I think all of us know this was a series that 
will not end. This job will not be done. And I continue to say 
it and I know Dr. Roe believes it also, this is a zero sum game 
and if one veteran falls through the crack of care, that is one 
too many. So our obligation is unwavering as is we know yours. 
And I look forward and am hopeful that we are changing in the 
right direction.
    So with that, this hearing is adjourned.
    [Whereupon, at 12:02 p.m., the Subcommittee was adjourned.]









                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Harry E. Mitchell, Chairman,
              Subcommittee on Oversight and Investigations
    Thank you to everyone for attending today's Oversight and 
Investigations Subcommittee hearing entitled, Gulf War Illness: The 
Future for Dissatisfied Veterans.
    Last year, this Subcommittee held two hearings on Gulf War Illness. 
Our first hearing gave us an overview of purpose, research and the 
methodology that the VA utilized to determine the parameters relating 
to Gulf War Illness. Our second hearing evaluated the scientific 
information and analyzed the different schools of thought on Gulf War 
Illness research. In both these hearings, it has become clear that 
veterans are suffering from symptoms related to service in the Gulf, 
and that they are continuing to struggle for the healthcare, treatment 
and benefits they deserve. Our third and hopefully final hearing today, 
we will hear from the Department how they plan to move ahead and 
implement the culture, care, benefits, research, outreach, and 
education efforts for our Gulf War veterans.
    Next month will mark the 20th Anniversary since the United States 
deployed almost 700,000 troops to the Persian Gulf. With a growing 
number of these veterans developing undiagnosed and multi-symptom 
illnesses, they have looked to the people who promised them the care 
worthy of their sacrifices when they returned home. Still to this day, 
many of our Gulf War veterans have yet to see this care and are finding 
themselves fighting the VA for service connected compensation.
    Under the new leadership of Secretary Shinseki, a new vision and a 
new mission has been created at the Department, and I know that Members 
on both sides of the aisle are eager to see how the VA will use this 
new vision to ensure that our veterans are receiving the best possible 
care. As part of this new vision, Secretary Shinseki's creation of the 
Gulf War Veterans Illness Task Force in 2009 is bold and shows the 
Department's dedication to our Gulf War veterans. However, with this 
new Task Force we need to begin to see results. Even though the VA has 
put forward motions to better serve our veterans, it is not a 
substitute for results. We all understand the arduous task of ensuring 
that the proper research and data is collected, but our veterans have 
waited too long. While I appreciate the VA's attempts to change the 
culture at the Department regarding Gulf War Illness, there must also 
be strides to change the care and compensation these veterans have 
waited so long for.
    The Department of Veterans Affairs is the second largest agency in 
our system of government and they must be held accountable for the 
timely care of our nation's veterans. It is a culture of complacency 
that doesn't serve anyone, especially our men and women in the armed 
forces. VA needs to take actions to begin to implement a plan to 
provide transparency and answers to our Gulf War veterans, and without 
a unified central VA effort to provide appropriate care to this 
population, these veterans and their families will have to wait that 
much longer and grow that much sicker.
    I trust that this hearing will begin to lay out a unified plan for 
the care of our Gulf War veterans, as well as instill hope that these 
veterans are not forgotten and that the promises we made to care for 
them are kept.

                                 
  Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
              Subcommittee on Oversight and Investigations
    Mr. Chairman, thank you for yielding me time.
    It is fitting as we approach the twentieth anniversary of the start 
of Operation Desert Storm and the beginning of the Gulf War that we 
proceed with this final hearing in our three-part series on Gulf War 
Illness. On this day, it is important for us to look to the future of 
care for the veterans who fought and served in this conflict and now 
suffer from various illnesses from unknown causes. I believe it will be 
interesting to listen to the views of each of the panels on what they 
perceive is the cultural perception of Gulf War Illness, as well as 
both the medical and benefits side of the equation on the care for 
these veterans.
    On April 9, 2010, the Institute of Medicine issued its most recent 
report on Gulf War and Health, which made additional recommendations on 
how we can best support the veterans from this conflict. I look forward 
to hearing from Dr. Hauser who chaired the Committee on Gulf War and 
Health: Health Effects of Serving in the Gulf War, on how VA can use 
the information in this report to improve care to these veterans, and 
also to hear what progress VA has made since we last met in July. I am 
curious to hear VA's response to the Research Advisory Committee's 
September 2009 report, and what changes are coming about as a result of 
our hearings, as well as the Advisory Committee's report.
    We must never forget the reason we are having these hearings. It is 
to help our nation's veterans. In the past year, we have explored the 
research behind presumptions, the medical indicators leading to 
diagnosis or lack thereof, and we learned most importantly that the 
documentation of undiagnosed illnesses is a large contributor leading 
to a presumption of Gulf War Illness. I believe we can use the 
information we have compiled through these hearings to really come to a 
better understanding of Gulf War Illness, and through that knowledge, 
better serve these veterans who have sacrificed so much for their 
country.
    The information gleaned from the upcoming report from the 
Secretary's Gulf War Veterans Illnesses Task Force, as well as the 
reports issued by the Research Advisory Counsel and the Institute of 
Medicine will help us serve those veterans from the Gulf War. It is my 
hope that we will also take the lessons learned through these hearings 
as well as the reports, and apply them to the current OIF/OEF veterans, 
and future veterans down the road to better serve their needs.
    I am pleased that VA Chief of Staff John Gingrich has brought with 
him representatives from both the Veterans Health Administration and 
the Veterans Benefits Administration, who can respond to the type of 
care and benefits being provided to our Gulf War veterans, and I look 
forward to hearing the testimony of all the witnesses.
    Again, Mr. Chairman, thank you for pursuing this issue, and I yield 
back my time.

                                 
   Prepared Statement of Donald D. Overton, Jr., Executive Director,
                       Veterans of Modern Warfare
    Chairman Mitchell, Ranking Member Roe, and Distinguished Members of 
the Subcommittee on Oversight and Investigations, on behalf of Veterans 
of Modern Warfare (VMW) National President Joseph Morgan we thank you 
for the opportunity to present our views on ``Gulf War Illness: The 
Future for Dissatisfied Veterans.'' My name is Donald Overton and I 
currently serve as Executive Director for VMW.
    I testify today from a dual perspective. First, as Executive 
Director for Veterans of Modern Warfare (VMW) a 501(c)19 National 
Veterans Service Organization founded in 2006 by Gulf War veterans. VMW 
represents Active-Duty, National Guardsmen, Reservists and Veterans who 
have served honorably within our nation's armed forces from August 2, 
1990 through a date to be prescribed by Presidential proclamation or 
law.
    I also testify as a 100 percent service-connected combat disabled 
veteran of Operations Desert Shield/Desert Storm. I served with the 3rd 
Battalion 505th Parachute Infantry Regiment 82nd Airborne Division. 
While some may view my injuries as devastating, particularly my 
blindness, I consistently contend I am one of the fortunate warriors 
that served during this conflict. My conditions, unlike those of so 
many of my battle buddies, could not be refuted by the Veterans 
Benefits Administration (VBA), thus affording me access to VA health 
care and benefits programs.
    Although I was wounded in the line of duty during combat operations 
my claims for post-traumatic stress disorder (PTSD), undiagnosed multi-
symptom illness (UDX) and various other combat related conditions 
remain denied by the VBA. I have dedicated the past 16 years to veteran 
advocacy and representation within multiple veteran service 
organizations. We have come a long way over the past 16 years, yet the 
scope of health care and disability challenges facing our Gulf War 
veterans remains very real and ever increasing. We must act now, with 
urgency, if we are ever to assist this generation of veterans to get 
all the way back home after military service. Together we can right the 
wrongs of the past 20 years and finally stop allowing antiquated 
systems to steal the lives of our Gulf War veterans.
Cultural Perception of Gulf War Illness
    Nearly 20 years have passed since the start of the deployment and 
combat operations known as Operations Desert Shield and Desert Storm. 
Since then, many veterans of that conflict have endured adverse health 
consequences from the war. Of the 696,842 servicemembers who served in 
the conflict an estimated 250,000 veterans suffer from the potentially 
debilitating consequences of undiagnosed multi-symptom illness. We 
contend these are distinct illnesses and the large numbers of veterans 
affected have been disenfranchised and underserved by the VA.
    The excess of unexplained medical symptoms reported by deployed 
1990-1991 Gulf War veterans cannot be reliably ascribed to any known 
psychological disorder. This was recently substantiated by the 
Institute of Medicine (IOM) April 9, 2010 report ``Gulf War and Health: 
Volume 8 Health Effects of Serving in the Gulf War.'' Unfortunately, to 
date, VA has historically failed to recognize this and has consistently 
emphasized in its research funding, clinician training materials and 
public statements, that these illnesses were related to stress or other 
psychiatric disorders, when scientific research indicates otherwise.
    This apathetic cultural perception of Gulf War Illness (GWI) by VA 
can and must be changed via fully implemented policy initiatives. The 
recently convened Gulf War Veterans Illness Task Force (GWVI-TF) within 
VA is a step in the right direction. The GWVI-TF has the ability to 
improve coordination within VA overseeing policy, training, research, 
benefits, and outreach for Gulf War-related issues. The data 
limitations experienced by the GWVI-TF should serve to establish a 
mandate to fully fund and resume the Gulf War Veterans Information 
System (GWVIS) as required by Public Law 102-585. The system was 
suspended by VA in 2008 due to internal data collection issues, which 
undermines any notion of transparency in regard to Gulf War veterans 
and their utilization of VA services.
    Overcoming the VA's established culture of the past 20 years will 
not be an easy task, but under Secretary Shinseki's bold leadership and 
cultural transformation it can be accomplished. Acknowledging the 
relevance of Gulf War veterans within VA, which has been partially 
accomplished by convening the GWVI-TF, will also serve to reinvigorate 
research and medical care for this cohort. Enhanced education of 
benefit counselors, medical staff and various stakeholders will serve 
to increase the effectiveness of this cultural transformation.
Research
    VMW urges Congress and the VA to embark upon a multi-faceted 
approach that recognizes the urgency of understanding GWI causation, as 
well as finding new treatments for ill Veterans of the 1990-1991 Gulf 
War. We recommend maintaining funding levels for Gulf War research to 
at least the $15M per year recommended in the report language of the 
appropriation bill for VA Medical and Prosthetics Research. We also 
recommend funding the Congressionally Directed Medical Research Program 
(CDMRP) to at least the $25M recommended in the report language of the 
pending FY 2011 NDAA.
    While research funding is a major concern for Gulf War veterans, 
oversight and transparency in funding allocations are paramount. VA 
proclaims participation in Federal research efforts on behalf of GWI 
totaling more than $152.1 million from VA and $400.5 million in total 
Federal commitment to date. We contend that these figures are an 
example of VA R&D spending money on studies only partially or even 
tangentially related to GWI, then classifying it as GWI spending to 
beef up annual research and research spending reports to Congress, the 
Research Advisory Committee on Gulf War Veterans Illness (RACGWVI), and 
the public. The following is but one example of our concern.
    Last year, the VA impeded and then canceled a Congressionally 
mandated contract for unparalleled GWI research at the University of 
Texas Southwestern (UTSW). This year, the VA has used the Gulf War 
research funds designated for UTSW to buy an $11 million piece of lab 
equipment of dubious value to Gulf War veterans. While VA eventually 
reclassified the Weiner/Tesla equipment buy to ``only'' $5+ million (of 
the fiscal year's total spending of $8 million) this appears to be 
crass disregard of moral and ethical principles by those charged to 
prevent such conduct.
    To further elaborate, Dr. Michael Weiner of the San Francisco VA 
Medical Center recently gave a public presentation to the RACGWVI on 
June 28 entitled, ``Effects of Military Service on the Brain,'' in 
which he suggested that his research findings show PTSD is the culprit 
for Gulf War veterans' illnesses, much to the disagreement of many 
other scientists on the RAC reviewing his results, who noted that he 
could not even reproduce his own study results.
    VMW urges Congress and the VA to guarantee the funding allocated to 
conclude the UTSW study will retrieve any and all data/specimens 
collected to date and avail said to ongoing GWI research programs. The 
absolute loss of these materials would be unacceptable and an abuse of 
taxpayer monies. Continued efforts to resurrect this program would be 
highly regarded by all Gulf War veterans. If VA continues to refuse, 
perhaps the CDMRP with VA endorsement will fund.
    VMW commends the VA for their recently approved $2.8 million to 
fund three new research projects that focus on testing or developing 
new treatments for illnesses affecting veterans who served in the 1990-
1991 Gulf War. We hope this shift in funding to treatments will serve 
to enhance the quality of the lives of those who served during this 
conflict. We also encourage the VA to consider issuing Requests for 
Applications (RFA) to regularly request submission of new proposals and 
revisions of previously reviewed, but not funded, applications.
Benefits and Health Care
    The area of greatest controversy for Gulf War veterans remains the 
enormous difficulty we face obtaining disability compensation benefits 
from the Veterans Benefits Administration (VBA). Currently, there are 
three ``ill-defined'' illnesses that are presumptive for Gulf War 
veterans. They are: Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM), 
and Irritable Bowel Syndrome (IBS). We believe that these presumptions 
are appropriate, and are consistent with countless peer-reviewed 
scientific studies that have concluded that these conditions and/or 
their symptom sets have high, unusual prevalence among veterans of the 
1990-1991 Gulf War.
    The first of three presumptive conditions for Gulf War veterans, 
Chronic Fatigue Syndrome (CFS), can currently be rated as high as 100 
percent depending upon the level of debilitation. We believe this is 
appropriate and should remain as it is. However, the second of the 
three conditions, Fibromyalgia (FM), can only be rated at a maximum of 
40 percent under the current rating schedule, even though chronic 
fatigue and other debilitating symptoms can be totally and permanently 
disabling. And, because CFS is a diagnosis of last resort, a diagnosis 
of FM excludes a diagnosis of CFS, even if the veteran is clearly 
suffering from both debilitating chronic widespread pain and 
debilitating chronic fatigue. In other words, veterans who may be the 
worst off can only receive a maximum 40 percent rating if they have the 
diagnosis of FM, even with all the symptoms of CFS.
    VA should review these contorted rules so that veterans with FM can 
be rated as high as 100 percent, depending upon the level of 
debilitation. For the third of the three current presumptive 
conditions, Irritable Bowel Syndrome (IBS) can be rated to a maximum 
rating of 30 percent. This rating can be made in conjunction with a 
rating for CFS or FM (but not both, as previously stated). VA should 
also review the rules governing the maximum rating for this condition 
to allow for higher ratings relative to the actual level of 
debilitation.
    Individual ``undiagnosed'' symptoms are still the basis of Gulf War 
veterans chronic multi-symptom illness claims, making it incredibly 
difficult for these veterans to be found substantially or totally 
disabled for their multi-symptom illness. Addressing this issue, so 
that these veterans could be rated for their entire multi-symptom 
illness rather than reviewing and approving individual undiagnosed 
symptoms and the defined illnesses (CFS, FM, IBS) one by one would save 
VA hours of time on each Gulf War veteran's claim and help countless 
veterans get better, more logical, and more appropriate claims results.
    VMW urges Congress to consider expanding VA regulations which 
authorize a rating of total disability based on individual unemployment 
if a veteran is unable to obtain, or maintain, substantially gainful 
employment because of service-connected disabilities. This is an extra-
schedular benefit resulting in compensation paid at the 100-percent 
schedular rate for veterans who have been awarded a single 60-percent 
or a combined 70-percent disability rating and are unable to work as a 
result of their service-connected disability. The benefit is also 
available based on a VA administrative review, if the schedular 
requirements are not met. For those Gulf War veterans presenting with 
two or more presumptive, or multi-symptom undiagnosed illnesses, VBA 
should automatically trigger an administrative review and apply the 
extra-schedular benefit when warranted.
    VMW believes Congress should enact legislation granting a 
presumption of service connection for our Gulf War veterans who 
deployed to the war zone and who are diagnosed with auto-immune 
diseases, such as Multiple Sclerosis (MS), and Parkinson's disease. 
Additionally, VBA must identify the estimated 15,000 Gulf War veterans 
previously denied disability compensation for Fibromyalgia, Chronic 
Fatigue, and Irritable Bowel Syndrome from 1991 through 2010 that 
should have otherwise been granted benefits by Public Law 107-103. When 
approved, VBA benefits should be retroactive to 2001.
    Additionally, VMW urges Congress to enact legislation granting 
indefinite presumptive eligibility for undiagnosed illness for our Gulf 
War veterans. Please remove all sunset provisions in 38 U.S.C. 
Sec. 1117 and 38 U.S.C. Sec. 1118, so health care and benefits are for 
the life of every Gulf War veteran and every surviving beneficiary. 38 
CFR Sec. 3.317 requires a change to clarify the law's intent with 
respect to compensating veterans with Gulf War-related disabilities. 
Current claims processing procedures for VBA Regional Office personnel 
and C&P examiners do not specify the unique circumstances surrounding 
the handling of claims related to multiple environmental exposures.
    While accessing benefits has proven to be a daunting challenge for 
Gulf War veterans, gaining access to the Veterans Health Administration 
(VHA) is equally challenging. Often, this access is contingent on VBA 
granting disability benefits. Extending health care to Gulf War 
veterans at the VHA by automatically enrolling all servicemembers who 
deployed since August 2, 1990 into Priority Group Six at the time of 
their discharge would ensure our veterans can obtain care as treatments 
and research evolve.
    Additionally, the outdated clinician training programs still posted 
to VA's Gulf War website have the capacity to do more harm than having 
nothing at all. VMW strongly recommends VA immediately remove these 
training materials until new ones can be developed and put in place. 
The new training materials should be reviewed and approved by the 
RACGWVI, ensuring Gulf War examinations follow a uniform best practices 
protocol.
    VMW strongly urges VHA to develop and implement a full military 
history feature within the new electronic medical records. The current 
Gulf War registry is nothing more than a mailing list and lacks the 
ability to function as an epidemiological medical tool. The new 
military history feature can be utilized by primary care providers to 
track potential environmental exposure trends enhancing treatment 
options, as well as validating potential exposures for the VBA, thus 
expediting claims processing time and accuracy. Longitudinal studies 
can then be initiated to further understand exposure patterns across 
time.
Education and Outreach
    The Veterans Health Administration (VHA) utilizes a series of 
clinician training programs, titled Veterans Health Initiative (VHI), 
to prepare clinical staff to treat veterans. The understanding of Gulf 
War Illnesses has grown over time, but there is much yet to be learned. 
The wide range of illnesses and multisystem manifestations pose 
significant challenges to VA's capacity to maintain clinicians' 
proficiency and familiarity. VA health care is not always responsive to 
the needs of Gulf War veterans because health care providers are not 
fully educated on managing the Gulf War veterans' health-related needs 
or their potential hazardous exposures. Major revision of training 
materials for all VA providers is warranted.
    Although each VA Medical Center (VAMC) provides access to 
environmental health clinicians and coordinators, there is variability 
in knowledge and practice among VAMCs as to when and how to conduct 
exposure assessments. There are few subject matter experts in exposure-
related disease within the VA system. Many providers may not be trained 
to recognize or diagnose exposure-related disease, nor are they aware 
of the types of exposures typically encountered in the combat theater 
especially in South West Asia. Expansion of the VA War Related Illness 
and Injury Study Center's (WRIISC) referral processes, enabling more 
veterans to be evaluated and eventually treated for their environmental 
exposures should be considered as a viable solution to the limited 
subject matter experts within VAMCs.
    Additional training is needed for VA Regional Office (VARO) 
personnel on proper application of law governing disability benefits 
for Gulf War veterans. The training should focus on issues related to 
adjudicating disability claims based on Gulf War undiagnosed illnesses 
and medically unexplained chronic multi-symptom illnesses, as defined 
by law. The laws directing benefits for disabilities resulting from 
Gulf War service are found at 38 U.S.C. Sec. 1117 and 38 CFR 
Sec. 3.317. Additionally, the requirement for Gulf War veterans to 
provide new and material evidence to substantiate their undiagnosed 
illnesses and medically unexplained chronic multi-symptom illnesses 
should be eliminated.
    The absence of open lines of communication can quickly lead to 
misinformation, mistrust, and confusion. There is a general lack of 
knowledge within the veteran community about the recent modifications 
to the rating schedule and presumptions related to Gulf War veterans' 
illnesses. This lack of knowledge includes those that serve the veteran 
population, VA employees. The current VA system for informing veterans 
of such changes does not reach the entire affected community. New 
methods of communication are needed immediately.
    Traditionally, VA relied upon the Gulf War Review to inform Gulf 
War veterans of all things relevant to this cohort. Unfortunately, VA 
has failed to publish this resource consistently, if at all. The 
current VA Gulf War website should be more interactive for 1990-1991 
Gulf War veterans, to both educate and inform potentially eligible 
beneficiaries and stakeholders about Gulf War veterans' illnesses, 
benefits and services. This interactive site should be equipped with a 
human element (a Gulf War veteran, or veterans capable of responding to 
inquiries), not just a dumping ground of data. Websites with no human 
capacity are not outreach mechanisms and should not be confused as 
such.
    Resources designed specifically for Gulf War veterans should be 
updated and made available at all VA facilities to include; VA Medical 
Centers, Community Based Outpatient Clinics, Vet Centers, Regional 
Offices and service delivery points for homeless veterans and veterans 
re-entering society after incarceration. Consideration should be given 
to digitizing these resources and making them available on an external 
keychain-sized flash memory device with a USB interface. Attention 
should be given to historic dates relevant to Gulf War veterans with 
coinciding public service announcements and outreach campaigns aimed at 
welcoming Gulf War veterans to VA facilities for ``stand down'' like 
events.
VA's Gulf War Task Force Report
    In March 2010, a final draft of the Gulf War Veterans Illness Task 
Force (GWVI-TF) report was released for public comment to ensure the 
needs of Gulf War veterans were being met and improve their level of 
satisfaction with VA services. The report outlined seven areas where VA 
can improve upon their current level of services to this cohort. These 
areas include; partnerships, benefits, clinician education and 
training, ongoing scientific reviews and population based surveillance, 
enhanced medical surveillance of potential hazardous exposures, 
research and development and outreach. We addressed these areas in our 
testimony, but would like to elaborate on some potential general 
shortcomings of the report.
    First, there appears to be an over dependence on the ability of VA 
and DoD to work effectively in regard to mitigating environmental 
exposures for past, present and future generations of veterans. DoD's 
ongoing denial of Gulf War veteran exposures, coupled with the 
inability of each agency to effectively communicate data via electronic 
medical records and various other data sharing initiatives, bodes badly 
for the effectiveness of this strategy. Should DoD fail to fulfill 
their obligation will VA subsequently be allowed to shun their 
responsibilities?
    Second, the Gulf War Veterans Illness Task Force, which was 
convened by Secretary Shinseki, appears to dissolve with the 
appointment of a new Secretary. What faith, if any, should Gulf War 
veterans have in the ability of the Department of Veterans Affairs to 
carry on this initiative across time? Will we ever see any of the 
report's outcome measures, or are we once again being led astray? There 
must be some level of permanence in order to have any confidence in the 
report. Many of the findings will require significant time commitments 
and followthrough.
    Third, due to significant limitations in the VA's Gulf War Veterans 
Information System (GWVIS) and the reports generated from the various 
data sources used by GWVIS, it is extremely difficult to accurately 
portray the experiences of this 1990-1991 Gulf War cohort/group and 
their respective disability claims or health care issues. It would 
appear that the report is based solely on the perceptions of Task Force 
members, which obviously limits the credibility of the report's 
findings.
Conclusion
    Mr. Chairman, VMW again thanks you for this opportunity to express 
our views here today, and will be pleased to answer any questions you 
or your distinguished colleagues may have.

                                 
       Prepared Statement of Ian C. de Planque, Deputy Director,
    Veterans Affairs and Rehabilitation Commission, American Legion
    Chairman Mitchell and Members of the Subcommittee, The American 
Legion would like to thank you for the opportunity to testify today and 
strongly appreciates the Subcommittee's commitment to addressing this 
issue. In many ways, this generation of wartime veterans can identify 
with the veterans of previous generations exposed to other 
environmental hazards, such as radiation and Agent Orange. This kinship 
comes from the suffering, hardships, and challenges they faced in 
dealing with the very government that placed them in harm's way.
    As servicemembers, veterans are trained to fight and defeat the 
enemy. For those Gulf War veterans with an array of medical conditions 
not easily diagnosed, they were not prepared for the battle ahead with 
both the Department of Defense and the newly-created Department of 
Veterans Affairs. Fortunately, these veterans had an ally--The American 
Legion.
    Today, The American Legion would like to address the cultural 
perception of Gulf War Illness: the research; the care (both medical 
and benefits wide); and finally the education and outreach to Gulf War 
veterans.
                   For Most: A Military Success Story
    The Southwest Asian War was historic in many aspects. Each military 
operation from start to finish truly demonstrated the greatest military 
force the world had ever seen. Over a six month period, from August to 
February, the military buildup was textbook and unprecedented. The 
airpower unleashed in January of 1991 softened the Iraqi military and 
inflicted tremendous damage prior to what was predicted to be a major 
ground action. The ``100-hour War'' had no equal in the United States 
military history. Military losses were minimal. Clearly, noncombat 
injuries far outnumber the combat wounded on the battlefield. The 
anticipated threat of chemical or biological warfare never 
materialized. The multi-nation Coalition Forces, working in harmony, 
successfully freed Kuwait and confined Saddam Hussein within the Iraqi 
borders. Servicemembers returned home from Operation Desert Storm to 
warm welcomes and parades.
                        For Others: An Adventure
    Back home, thousands of National Guard and Reserve personnel were 
being federalized for deployment to augment their active-duty 
counterparts. That meant refresher training on such activities as 
Nuclear, Biological and Chemical (NBC) Warfare Protection; 
Decontamination Activities; Combat First Aid; Prisoner of War 
processing and confinement; Geneva Convention; Weapons Qualification; 
and physical training. Going through the mobilization for deployment 
meant medical and dental checkups; wills; powers of attorneys; cleaning 
and packing equipment; inoculations; medications; and more training. As 
unit after unit were deemed combat-ready, they were deployed.
    When servicemembers began arriving in Saudi Arabia, they found 
themselves in unfamiliar surroundings. Most were still wearing their 
``Woodlands Green'' camouflage fatigues in the desert surrounding. 
Daytime temperatures soared and nighttime temperatures dropped. Diets 
changed according to locations. Some still had access to hot meals 
prepared in field kitchens or makeshift dining halls, while others 
began their Meals Ready to Eat daily regimen. Once in Saudi Arabia, 
servicemembers began taking their malaria pills until their issued 
allotment was depleted.
    Training resumed with increased emphasis on NBC conditions. Efforts 
to break the boredom resulted in volleyball, basketball, baseball or 
football games while wearing the protective mask, protective suits, 
protective boots, and protective gloves. Hydration was emphasized at 
every turn. Then there were the ``other'' shots, as prescribed 
(botulism and anthrax) and the additional medication (Pyridostigmine 
Bromide--PB) with or without instructions.
    Some units were deployed to the desert locations living in ``tent-
cities,'' while others remained in quarters, such as Kobar Towers--an 
underutilized community house project built by the Saudi Arabian 
government for their nomadic citizens. At Kobar Towers, underground 
parking garages were converted into assembly areas, stores, call 
centers and dining facilities.
                      For Others: A Long Nightmare
    Before long the environment began to change. Pesticides were used 
by the individual servicemembers to repel insects--mostly flies and 
fleas. At times, a commercial sprayer (contracted) dispensed pesticides 
via a ``fog machine'' as it drove around the compound. Personal hygiene 
was emphasized depending on the location. In the desert, some had 
access to field showers--gravity-fed setups next to tanker trucks. 
Latrines were ``cleaned'' daily with the body waste normally burned off 
by use of diesel fuel. Kerosene stoves were often used inside the tents 
for heat at night. Small diesel generations provided power for lighting 
the tents. Much larger generators provided power for kitchens, dining 
areas, and recreational areas. In addition, garbage was disposed of in 
``pile it and burn it'' landfills--little to no quality control over 
these burning activities--most were civilian operated.
    Then the oil well fires began. The density of the smoke varied 
based on location from extremely heavy (blocked out the sun) to light 
(a haze). Wind direction also played a major role. When it did rain, 
there were times that the rain drops left spots on clothing and skin as 
it penetrated the clouds.
    Chemical detection equipment was strategically dispersed on 
vehicles and on the ground to give early warning of the presence of 
chemical agents. Unfortunately, they seem to go off frequently, very 
frequently--almost all the time. In fact, some servicemembers just 
remained in their NBC protective clothing (except the mask and gloves) 
between alarm activations. It was almost a ``crying wolf'' situation--
servicemembers did not consider them reliable. It was reported that 
some were even disabled because of the repeated ``false alarms.''
    Next SCUD missiles were launched, which were normally greeted by 
two Patriot missiles launched to intercept them. Explosions were 
impressive and debris was visible as it dropped from the sky and could 
be heard when they fell to the ground. The psychological impact of not 
knowing whether the SCUD missile was carrying a chemical or biological 
warhead weighed heavy on many servicemembers. Each time a siren 
sounded, protective NBC gear was donned and worn until the all clear 
was announced. Unfortunately, the very last SCUD launched reportedly 
did the most damage. It hit a barracks not far from Kobar Towers, 
killing some National Guard and Reserve personnel from Pennsylvania.
                           So Why Am I Sick?
    Not long after the war, The American Legion Service Officers began 
getting complaints from returning Gulf War veterans about medical 
problems they encountered either while in country or upon return from 
Southwest Asia. The symptoms were wide-ranging, but fatigue, joint 
pain, skin rashes, memory loss, and mood swings appeared to be met with 
a common diagnosis--``it is all in your head'' or ``it is stress-
related'' by both Department of Defense (DoD) and Department of 
Veterans Affairs health care professionals. Some ill servicemembers 
were prescribed medications such as Prozac or other mood altering 
drugs. Some servicemembers were even accused of malingering.
    Some servicemembers going to VA medical facilities were told to go 
back to the Military Treatment Facility, but since they were no longer 
on active duty they were told to go back to the VA or their private 
health care providers. Those who went to private doctors were told to 
go to the VA or Military Treatment Facility because their medical 
conditions were clearly service-connected.
    None of the health care providers denied that the symptoms existed; 
they just didn't know what was causing them and treatment was pretty 
much non-existent. Some were diagnosed as the flu--for months. Others 
were given anti-fungal medications proven to be ineffective. 
Frustration began to set in. Repeated complaints seem to fall on deaf 
ears, except family members who were also beginning to become very 
angry with the lack of answers or medical treatments. Veterans were 
only seeking medical treatment from health care professionals in the 
military, Veterans Affairs, and the private sector--getting few answers 
to the question ``Why am I sick?'' and little to no treatment.
                        Building of a Data Base
    Soon The American Legion began compiling a list of ill Gulf War 
veterans. As our unofficial list grew, acting VA Secretary Anthony 
Principi authorized VA to begin collecting names on an initial Gulf War 
Registry--not treatment, no compensation--just begin collecting names. 
Once The American Legion had collected over 100 names, former 
Representative Joe Kennedy (MA) agreed to listen to the complaints of 
ill Gulf War veterans and their families. As a member of the Veterans' 
Affairs Committee, he held the meeting in this very hearing room. What 
started out as a meeting, ended up being a hearing chaired by the late 
Representative ``Sonny'' Montgomery. Veteran after veteran told his or 
her story, in some cases, the spouse had to speak on a veteran's behalf 
because of illness prohibited the veteran from attending. It became 
increasingly clear a much larger number of veterans were ill compared 
to what VA and DoD were reporting to Congress.
    When other Congressional hearings began, both DoD and VA agreed 
that there was no evidence of anything that would be making these 
servicemembers sick. However, when one of the Members of Congress, 
Representative Steve Buyer (IN), showed them the medications he was 
taking since his return from the Gulf War, the tone of Congress, DoD 
and VA began to slowly change. Congress became more aggressive, while 
DoD and VA became more defensive. From this pivotal moment, the issue 
of Gulf War Illness became a national issue of concern.
                     Looking for the Silver Bullet
    At this point, everyone was looking for the ``cause'' not the 
``solution.'' That remains the situation today, still looking for the 
``diagnosis'' rather than ``successful treatments.'' Among the first 
suspects was a disease called Leishmaniasis (a parasitic disease) since 
a few servicemembers had actually been diagnosed with it, but that was 
ruled out as ``the cause.'' Then the issue of depleted uranium (DU) 
surfaced, but it too was determined not to be ``the cause.'' Then the 
inoculations, to include anthrax, were suspected, but they were also 
determined to be ``safe.'' The PB pill became a new theory, which has 
not been completely ruled out at this point. Some pointed to the oil 
well fires or the diesel exhaust or poorly ventilated tents, but none 
seems to be the right cause.
    In the Senate, the list of chemicals provided to Iraq by many 
different companies, including US companies reveals the very real 
possibility of the presence of a toxic chemical environment. That 
coupled with the thousands and thousands of ``false alarms'' by our 
military chemical detection equipment.
    About this time, the question of possible low-level chemical 
exposure began to receive more consideration. While DoD definitively 
claimed that there was no presence of chemicals on the battlefield, 
there were actually reports of detection of Sarin on the battlefield (a 
Marine FOX vehicle and a Coalition Forces chemical detection team). 
Then reports of the demolition of a munitions storage complex at 
Khamisiyah, by U.S. servicemembers was validated via video footage 
taken by an ill servicemember. ``Seeing is believing.'' However, even 
this ``suspect'' after years of analysis was determined not to be the 
cause of undiagnosed medical conditions.
                          Seeking Health Care
    From 1990 until 1996, access to care in the VA health care delivery 
system was strictly limited to service-connected disabled veterans and 
economically disabled veterans. Access to care was very confusing and 
complex. However, since 1996 more than 8 million veterans have enrolled 
in the VA health care delivery system and nearly 6 million are ``unique 
patients.'' Unfortunately, by this time many ill Gulf War veterans 
seemed to have lost faith in VA's health care delivery system. Their 
biggest complaint was the lack of urgency, sincerity and compassion in 
dealing with their medical conditions. Both VA and DoD had created 
registries, but by this time, all Gulf War veterans were being added to 
the registries whether the veteran was ill or not.
    However, to find the exact number of ill Gulf War veterans 
receiving treatment for their diagnosed medical conditions would be a 
major challenge and results were extremely disheartening. Many of the 
initial Gulf War veterans seeking health care from VA for their 
undiagnosed medical conditions just walked away. Some went to private 
health care providers. Some just tried to accept their fate and suffer 
their pain in silence. The trust in VA was lost. The confidence is 
minimal.
    The stigma of being an ill Gulf War veteran is real. There did not 
seem to be a standard protocol in dealing with these veterans by the 
system. Even as legislation was passed addressing undiagnosed illness, 
public law did not successfully translate into proper care and 
treatment of ill Gulf War veterans. Veterans searched for health care 
professionals who believe they were sick--whether in the public or 
private sector. Regrettably, there is still no treatment prescribed for 
ill Gulf War veterans.
    Once a doctor described Gulf War Illness as ``being shot with a 
bullet made of ice. The damage is done, but the evidence has melted 
away. The absence of evidence doesn't mean that the evidence is 
absent.''
                    ``Placing Care Before Process''
    Members of The American Legion were asked by the former Secretary 
of Veterans Affairs, James Peake, to serve on the Advisory Committee on 
Gulf War Veterans. The Advisory Committee produced a report entitled: 
``Changing the Culture: Placing Care Before Process.'' This title 
represents the collected thought of that Advisory Committee--America 
has an obligation to the men and women of the Armed Forces that exceeds 
the existing bureaucratic paradigm.
    The American Legion would highly recommend you and your colleagues 
review the recommendations made by this Advisory Committee to VA 
Secretary Shinseki.
    Nearly every Gulf War veteran who addressed the Committee addressed 
their frustration and dissatisfaction with the way they were initially 
treated--or mistreated--within VA. Veterans who were not easily 
diagnosed were treated as liabilities and pushed aside. We even learned 
of biases within the health care profession that found undiagnosed 
illness as simply a desire for disability compensation. If the answer 
is not obvious, quit looking or send them to mental health. Nearly 
every Gulf War veteran who appeared before the Advisory Committee had 
pretty much given up on VA ever making a diagnosis or providing 
treatment.
    Had the medical conditions existed prior to deployment, most of 
symptoms ill Gulf War veterans identified would have likely made them 
``unfit for duty'' and would have cancelled their deployment orders to 
Southwest Asia. Clearly, they would have probably been released from 
the Reserves or Nation Guard for being ``unfit for duty.'' That is why 
the ill Gulf War veterans find it is so unacceptable--that the failure 
of two Federal health care delivery systems to have failed returning 
veterans with such disregard.
             Gulf War Veterans Illness Task Force (GWVI-TF)
    The Gulf War Veterans Illness Task Force (GWVI-TF) recently 
published a report of their findings after a comprehensive review of 
all VA programs and services that serve the Gulf War cohort of 
veterans. The task force focused its efforts on veterans who were 
deployed to the Operation Desert Shield or Operation Desert Storm 
components of the 1990-1991 Gulf War period. However, as part of the 
task force charge to develop innovative and forward-looking solutions, 
it identified lessons learned from past practices and policy that can 
be applied to today's programs and services supporting the Operation 
Enduring Freedom/Operation Iraqi Freedom cohort.
                  Service-Connected Disability Ratings
    One of the greatest concerns facing veterans from the Gulf War era 
who have filed for disability is that some veterans were continuing to 
suffer from symptom clusters that could not be attributed to known 
diseases or disabilities through conventional medical diagnostic 
testing and that these veterans were ``falling through the cracks'' 
within the current disability compensation scheme. The existing VA 
system of benefits was designed with a more traditional understanding 
of medical conditions, and was not initially equipped to deal with the 
unexplained illnesses that began to surface from Gulf War veterans.
    Due in part to the recommendations of the GWVI-TF, rule-making is 
underway to add additional diseases to the list of those subject to the 
presumption of service connection based on qualifying Gulf War service. 
Based on evidence provided by the National Academy of Sciences on 
chronic diseases associated with service in Southwest Asia, additional 
rules to ensure that veterans can efficiently access the benefits 
they've earned may also be forthcoming. The American Legion stresses 
that the lessons learned from the long uphill battle faced by Vietnam 
veterans in dealing with the aftereffects of the herbicide Agent Orange 
must continue to be implemented with the new spate of conditions 
resulting potentially from environmental hazards. As is the case with 
Agent Orange, research must be continuously examined, and where sound 
medical principles support the addition of new presumptive conditions 
or new understandings of existing conditions VA must adjust their 
procedures to ensure these veterans receive equitable benefits.
    Recently, the VBA Compensation and Pension (C&P) Service has 
developed two training letters designed to inform and instruct regional 
office personnel on development and adjudication of disability claims 
based on Southwest Asia service. Training Letter 10-01, titled 
``Adjudicating Claims Based on Service in the Gulf War and Southwest 
Asia'', was released on February 4, 2010. This training letter provides 
background information on the Gulf War of 1990-1991, and explains the 
initial 1994 and subsequent 2001 legislation found in Title 38 United 
States Code, Section 1117, which was a response to the ill-defined 
disability patterns experienced by returning Gulf War veterans. It 
explains the terms ``undiagnosed illness'' and ``medically unexplained 
chronic multi-symptom illness'' used in the legislation, and stresses 
that service connection may be granted for other diagnosed chronic, 
multi-symptom illness in addition to chronic fatigue syndrome, 
fibromyalgia, and irritable bowel syndrome, which are identified as 
examples in the legislation. It also provides step-by-step procedures 
for procuring supporting evidence and for rating a disability claim 
based on Southwest Asia service under Section 3.317 of the Code of 
Federal Regulations.
    The training letter includes a separate memorandum to be sent with 
the VA medical examination request so that examiners are informed of 
the issues related to qualifying chronic disabilities and better able 
to evaluate a Gulf War veteran's disability pattern. Here, The American 
Legion cannot state more firmly that coordination between VBA and VHA 
elements in the understanding of these disorders must be consistent. 
All too often in American Legion Quality Review visits to Regional 
Offices, we see apparent disconnect between VBA and VHA elements in the 
claims process. Without a full understanding by both sides of the 
equation, veterans' claims will suffer from poor interpretation and 
these veterans will continue to slip through the cracks.
    VA is additionally providing information on environmental hazards 
in Iraq and Afghanistan, as well as other areas, and is working in 
close coordination with DoD. This should enhance the understanding of 
environmental hazards associated with Gulf War and Southwest Asia 
service outside of the original Gulf War. They are discussing airborne 
toxic substances resulting from the widespread use of burn pit fires to 
incinerate a variety of waste materials in Iraq and Afghanistan, as 
well as hexavalent chromium contamination at the Qarmat Ali water 
treatment plant in Basrah, Iraq, from April through September 2003.
    With regard to the growing understanding of these environmental 
contaminations, not only overseas but also with regard to situations 
such as the groundwater contamination at Camp Lejeune in North 
Carolina, The American Legion's Comprehensive Resolution on 
Environmental Exposure could not be more clear: veterans must be 
provided examinations and treatment which is thorough and appropriate, 
and that all necessary action be taken by the Federal government, both 
administratively and legislatively as appropriate, to ensure that 
veterans are properly compensated for diseases and other disabilities 
scientifically associated with a particular exposure. This requires 
close monitoring of the development of all ongoing research on the 
long-term effects of all environmental exposures and point out to the 
proper officials any perceived deficiencies or discrepancies in these 
projects; and ensuring that government committees charged with review 
of such research are composed of impartial members of the medical and 
scientific community.
                         Education and Outreach
    The American Legion continues to encourage ill Gulf War veterans to 
seek timely access to quality health care within VA through numerous 
venues--pamphlets, articles in The American Legion Magazine, Department 
Service Officers, and word of mouth. In 1996, with enactment of 
eligibility reform, The American Legion aggressively encouraged all 
veterans to enroll in the VA health care delivery system. Enrollment 
quickly grew yet still many ill Gulf War veterans continued to resist 
returning to VA medical facilities.
    VA's outreach was limited to a sporadic publishing of a periodical 
entitled the Gulf War Review and information on their website. Each 
provides updates as to developments on Gulf War Illness related issues.
    VA has moved forward to some extent with increased internal 
education of their medical and benefits related staff; however the 
mission of increasing understanding of the medical factors involved for 
the actual veterans who have served still lags far behind what is 
necessary. Veterans Service Organizations must pick up the slack with 
their own advocacy efforts. To be sure, The American Legion is 
positioned well within the community to provide information to veterans 
through materials such as our pamphlets on ``Gulf War Era Benefits & 
Programs'', and our Department Service Officers are trained annually to 
ensure the information they provide to veterans is the most current. 
However, actions such as these do not void VA's responsibility to 
provide this information directly to veterans. All too often when we 
are able to convey information to veterans, the response we receive is 
that this is the first time they have heard much of the material. This 
cannot be allowed to happen. This information should come straight from 
the horse's mouth to the veteran. VA cannot continue to rely on 
veterans' groups as the near sole provider of this valuable information 
to our nation's veterans.
                               Conclusion
    The most revealing comment we have heard from the ill Gulf War 
veterans that we have talked to was their answer to one simple 
question, ``If you had it all to do over again and your unit was 
deployed to the Persian Gulf, would you go?''
    The answer was unanimous--``Absolutely!''
    Mr. Chairman and Members of this Subcommittee, these young men and 
women did not fail us--we, as a nation, have failed them. However, we 
continue to be engaged on this battlefield and the battle is not lost. 
VA must move forward to elevate their attention to these conditions in 
a manner that learns the hard lessons of the battle against Agent 
Orange-related disease. The time to act is sooner, not later. The more 
aggressively we attack this problem in the now, the less we will 
struggle with solutions in the future.

                                 
        Prepared Statement of Paul Sullivan, Executive Director,
                       Veterans for Common Sense
    Veterans for Common Sense (VCS) thanks Subcommittee Chairman 
Mitchell, Ranking Member Roe, and Members of the Subcommittee for 
inviting us to testify about our recommendations for improving 
government policies for our nation's 250,000 ill Gulf War veterans. 
Congress remains a loyal friend of our Gulf War veterans by holding 
hearings, passing legislation, and conducting vital oversight hearings.
    With me today is my good friend Steve Robinson, a fellow Gulf War 
veteran and the former Executive Director at the National Gulf War 
Resource Center, a position I once held. Also with me is Thomas 
Bandzul, our VCS Associate Counsel. Steve, Thomas, and several ill Gulf 
War veterans assisted VCS with preparing this statement.
    VCS is here today because Gulf War veterans are dissatisfied and 
disappointed with the actions of the Department of Veterans Affairs 
(VA). VA is not listening to our concerns about our illnesses 
associated with our deployment to the 1991 Gulf War. VA does not listen 
to advisory panels created by Congress or VA. VA does not listen to 
expert scientists. VA does not even listen to Congress. Two decades of 
inaction have already passed. Gulf War veterans urgently want to avoid 
the four decades of endless suffering endured by our Vietnam War 
veterans exposed to Agent Orange. VA's actions are unfortunate and 
disastrous for our nation's 250,000 ill Gulf War veterans.
    Veterans for Common Sense sends up a red star cluster for Congress, 
VA, and America to see. In military terms, VCS asks VA for cease fire. 
VCS urges VA leadership to stop and listen to our veterans before time 
runs out, as VA is killing veterans slowly with bureaucratic delays and 
mismanaged research that prevent us from receiving treatments or 
benefits in a timely manner.
    VCS is here urging VA to issue regulations so Gulf War veterans can 
learn why we are ill, obtain medical care, and receive disability 
benefits for our medical conditions scientists agree are associated 
with our Gulf War deployment during 1990-1991.
    After 20 years of war, we are done waiting. VCS urges VA to act now 
and provide research, treatment, and benefits. As a Gulf War veteran, I 
have watched too many of my friends die without answers, without 
treatment, and without benefits. In a few cases, veterans completed 
suicide due to Gulf War Illness and the frustration of dealing with VA. 
VCS asks Congress and VA to keep this in mind when evaluating VA 
policies.
    Our statement contains a copy of our formal petition to VA 
Secretary Eric Shinseki urging to VA promulgate regulations under the 
Administrative Procedure Act (5 U.S.C. Section 551) so our veterans can 
obtain answers to the questions about why 250,000 veterans remain ill, 
treatment for veterans' conditions, and benefits so our veterans do not 
fall through the economic cracks due to disabilities.
    VCS asks Congress to intervene if VA fails to act now. VCS asks 
Congress to continue holding oversight hearings and to pass legislation 
to implement our petition if VA continues ignoring the needs of our 
veterans, ignoring the laws passed by Congress, and ignoring the peer-
reviewed and published findings of our nation's top scientists.
Gulf War Illness
    VCS is here today urging action by Congress because the scope of 
the healthcare and disability challenges facing our Gulf War veterans 
is real and increasing in size. VA officially reports 265,000 of the 
veterans deployed between 1990 and 1991 sought medical care and 248,000 
filed disability claims by 2008, the last time VA released official 
statistics about veterans from the 1991 conflict.
    VCS estimates VA spends up to $4.3 billion per year for Gulf War 
veterans' medical care and benefits. However, VA has never actually 
revealed the financial costs, and VA has indicated no intention the 
agency plans to release those facts. VA's failure to release 
information about the human and financial costs of war reveal VA 
remains without the fundamental facts needed to monitor Gulf War 
veteran policies.
    In 2008, VA's Research Advisory Committee on Gulf War Veterans' 
Illness (RAC) estimated as many as 210,000 Gulf War veterans suffer 
from multi-symptom illness. In 2009, the Institute of Medicine (IOM) 
agreed the exposures and illnesses are real, impacting as many as 
250,000 veterans of the 1991 invasion of Iraq. Both the RAC and IOM 
studies were mandated by the ``Persian Gulf Veterans Act of 1998.''
    Gulf War veterans are hoping for improvements with the new 
administration. In August 2009, VA created a new Gulf War Task Force 
under the leadership of Gulf War veteran and VA Chief of Staff John 
Gingrich. We look forward to VA's testimony today with the hope that VA 
will offer new, substantive regulations for our Gulf War veterans who 
need answers, healthcare, and benefits. We do thank VA for taking the 
precedent-setting initiative of proposing policy via the Federal 
Register on April 1, 2010. VCS submitted detailed comments to VA about 
the Draft Task Force report on May 3, 2010.
    However, VCS recommendations to VA's Chief of Staff John Gingrich 
appear to have fallen on deaf ears. The only VA action since January 
2009 was a paltry $2.8 million for stress research announced on July 
21, 2010. Only VA's Research Office, in a vacuum without input, wants 
this research. VA's systemic failures reveal significant problems 
remain at VA. If VA Secretary Shinseki won't fix VA's Research Office, 
then Congress must intervene and place Gulf War research outside of 
their area of responsibility.
    VCS also urges Secretary Shinseki to investigate the improper and 
arbitrary termination of essential Gulf War Illness research. A July 
15, 2009 VA IG report concluded $75 million in Gulf War Illness 
research at the University of Texas Southwestern Medical Center (UTSW) 
was ``impeded'' by VA (page iv, IG ``Review of Contract No. VA549-P-
0027''). Without any reasonable scientific basis, VA arbitrarily 
terminated UTSW research, potentially undermining more than 15 years of 
critical inquiry. VCS remains outraged VA's Research Office has not 
been held accountable.
    On November 19, 2009, VCS filed Freedom of Information Act (FOIA) 
requests with VA to determine the extent of the VA internal sabotage. 
VA has not released any information about who ``impeded'' Gulf War 
Illness research. On June 29, 2010, VCS filed a formal appeal under 
FOIA with VA's General Counsel to obtain documents about the cabal of 
VA staff intentionally delaying research and treatment for our 
veterans.
    VCS also urges VA to investigate the adverse health impact of 
depleted uranium, a radioactive toxic waste used as ammunition. On 
August 19, 1993, then-Army Brigadier General Eric Shinseki signed a 
memorandum confirming that on June 8, 1993, the Deputy Secretary of 
Defense ordered the Army Secretary to ``Complete medical testing of 
personnel exposed to DU contamination during the Persian Gulf War.'' No 
medical testing was performed. VCS urges VA Secretary Shinseki to take 
the rare opportunity for a second chance and complete the research 
ordered 17 years ago. In February 2010, VCS President Dan Fahey 
requested DU research during a conference call with VA Chief of Staff 
John Gingrich. To date, VA has not conducted DU research.
    Third, other than a VA-VCS conference call in February 2010, VA has 
excluded Veterans for Common Sense from participating in any 
meaningful, consistent dialog on the issue of Gulf War Illness. The 
communication from VA is almost always one direction: telling veterans 
what VA will do with little or no input from veterans until after VA 
has reached a final, irreversible decision. VA's continued insulation 
is the main reason why VCS urges VA to create a permanent Gulf War 
Veteran Advocacy office.
Conclusion
    The needs of our veterans are detailed in two decades of scientific 
research reviewed by the RAC and IOM as well as countless Congressional 
investigations, hearings, and reports. However, VA's Research Office 
has failed Gulf War veterans for two decades. This absolutely vital 
hearing represents VA's last chance to get it right so Gulf War 
veterans have a reasonable chance at answers, treatments and benefits 
in our lifetime.
    After 20 years of waiting, we refuse to wait on more empty promises 
from VA. The first step is for Secretary Shinseki and Chief of Staff 
Gingrich to immediately clean house of VA bureaucrats who have so 
utterly and miserably failed our veterans for too long. Our bottom line 
is clear: we urge VA Secretary Shinseki to quickly implement the 
recommendations we make in our petition sent to VA today. If VA does 
not immediately take action, we urge Congress to continue holding 
hearings and passing legislation so VA is held accountable for taking 
care of our veterans. Our waiting must end now.
    VCS presented the following petition to VA for new Gulf War veteran 
regulations:
    VCS Petition to VA to Improve Regulations for Gulf War Veterans

                                          Veterans for Common Sense
                                                    Washington, DC.

The Honorable Eric Shinseki
Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Shinseki:

    Under the Administrative Procedures Act (5 U.S.C. Section 551), 
Veterans for Common Sense (VCS) petitions the Department of Veterans 
Affairs (VA) to promulgate regulations to improve the delivery of 
healthcare and benefits for the 3.1 million U.S. servicemembers 
deployed to Southwest Asia since August 2, 1990.
    VCS supports the goals of VA leaders to ensure our Gulf War 
veterans receive answers to the questions about why Gulf War veterans 
remain ill as well as prompt access to treatment for our medical 
conditions and disability benefits. We thank you for forming a Gulf War 
Task Force and for naming your Chief of Staff, John Gingrich, a Gulf 
War veteran, to lead it. VCS asks VA to issue regulations based on 
these laws:
    Public Law 102-1, enacted on January 14, 1991, authorized the 
President to start the Persian Gulf War, known at the time as Operation 
Desert Shield and Desert Storm. Offensive U.S. military action against 
Iraq began on January 17, 1991.
    Public Law 102-25, enacted on April 6, 1991, retroactively 
established the start date of the Gulf War as August 2, 1990, the date 
Iraq invaded Kuwait. Neither Congress nor the President have ever ended 
the Gulf War, and the conflict continues through the present in the 
geographical area defined by 38 CFR 3.317.
    Public Law 102-85, enacted on November 4, 1992, authorized the 
creation of the Gulf War Registry as well as the Gulf War Veterans 
Information System (GWVIS). VA began preparing GWVIS reports in 2000, 
and VA ceased producing the reports in 2008 after VCS observed that 
VA's GWVIS reports were incomplete. VA has since confirmed that it 
failed to update computer programming to identify all disabled Gulf War 
veterans.
    Public Law 103-210, enacted on December 20, 1993, requires VA to 
provide healthcare on a priority basis (Priority Group 6).
    Public Law 103-446, enacted on November 3, 1994, expanded access to 
VA disability benefits so ill Gulf War veterans could obtain VA medical 
care under what is commonly referred to as the Undiagnosed (UDX) 
illness law. Congress found, as a matter of law, Gulf War veterans were 
exposed to a long list of toxins, including depleted uranium:

       Fumes and smoke from military operations, oil well fires, diesel 
exhaust, paints, pesticides, depleted uranium, infectious agents, 
investigational [experimental] drugs and vaccines, and indigenous 
diseases, and . . . multiple immunizations.

    Public Law 105-277, enacted October 22, 1998, significantly 
expanded the list of toxins it presumed Gulf War veterans were exposed 
to during deployment to Southwest Asia, and mandated contracts between 
VA and the National Academy of Science's Institute of Medicine (IOM) to 
determine if there were associations between deployment and medical 
conditions suffered by Gulf War veterans.
    Public Law 105-368, enacted November 11, 1998, created the Research 
Advisory Committee on Gulf War Veterans' Illness (RAC) and expanded 
Public Laws 103-210 and 103-446. VA was unable to form the RAC until 
2002.
    Public Law 109-114, enacted November 20, 2005, appropriated $75 
million for Gulf War Illness research at the University of Texas 
Southwestern Medical Center (UTSW) because VA staff steadfastly refused 
to conduct research into the adverse impact of toxic exposures by 
claiming veterans were not exposed, not ill, and suffering only from 
stress. VA objected to the use of a contract to implement this law. 
However, VA made no effort to convert the contract to grant, thereby 
revealing VA opposed the research.
VCS List of Ten Recommended VA Actions Regarding Gulf War Veterans

     1.  VA Regulations Acknowledge Scope and Nature of Gulf War 
Illness

    When VA issues regulations regarding Gulf War Illness, VCS urges VA 
to confirm 250,000 Gulf War veterans from the 1990-1991 deployment 
period remain ill after deployment to Southwest Asia during 1990-1991, 
a conclusion supported by thousands of peer-reviewed scientific 
articles. VA should specifically cite the following three major 
sources:

       IOM: April 2010 findings of the Institute of Medicine (IOM), 
``Gulf War and Health: Volume 8. Health Effects of Serving in the Gulf 
War.'' After an exhaustive review of peer-reviewed, published research, 
the IOM concluded as many as 250,000 Gulf War veterans still suffer 
from multisymptom illness, and the cause is not post-traumatic stress 
disorder (PTSD): ``The excess of unexplained medical symptoms reported 
by deployed Gulf War veterans cannot be reliably ascribed to any known 
psychological disorder.''

       RAC: November 2008 report by the Research Advisory Committee on 
Gulf War Veterans Illnesses (RAC), ``Gulf War Illness and the Health of 
Gulf War Veterans: Scientific Findings and Recommendations,'' concluded 
that between 175,000 and 210,000 Gulf War veterans still suffer with 
multisymptom illness.

       VA: Dr. Han Kang, is credited with the important conclusion that 
one-in-four Gulf War veterans remains ill, in his study, ``Health of 
U.S. Veterans of 1991 Gulf War: A Follow-Up Survey in 10 Years,'' 
published in the Journal of Occupational and Environmental Medicine in 
April 2009.

     2.  VA Issues Improved Undiagnosed Illness (UDX) Regulations

    VCS supports the goals of VA's new instructions on handling Gulf 
War veterans' claims for Undiagnosed Illness (UDX) benefits. VCS asks 
VA Secretary Shinseki to use his rule-making authority to transform 
VA's temporary instructions issued in a ``Fast Letter'' as permanent VA 
regulations that can be reviewed and commented on by advocates in a 
transparent manner.
    In 2002, VA staff conducted a thorough review of granted and denied 
claims among Gulf War veterans at the diagnostic code level. VA staff 
concluded that VA regional offices with large claim backlogs and 
without training on UDX claims under 38 CFR 3.317 approved few (about 4 
percent) of Gulf War veterans claims. In contrast, VA regional offices 
with small backlogs that received training from VA Central office 
approved far more UDX disability benefit claims (about 30 percent). At 
present, VA has no idea how many UDX claims have been granted or 
denied.

     3.  VA Notifies As Many Gulf War Veterans as Possible About 
Changes

    Using VA's Gulf War Master Record listing of nearly all military 
servicemembers, VA should mail information to each veteran where VA has 
an address. And VA should use all available national and local VA 
public relations staff to conduct outreach to the media and veterans 
about changes in laws and regulations. The information should include a 
brief description of presumed toxic exposures, research, treatment, and 
benefits.

     4.  VA Pays Retroactive Benefits for UDX Claims

    VA should re-open the disability claim of any Gulf War who asks. VA 
should pay, when appropriate, retroactive benefits to the earliest 
possible date allowed under the law starting with the veteran's first 
claim against VA. VA should do this based on VA's illegal act, in 2001, 
of failing to notify Gulf War veterans about changes in benefits laws 
(Public Law 107-103) that would have granted access to healthcare and 
disability compensation for tens of thousands of veterans. VA's act was 
illegal because it violated the spirit and intent of the Veterans 
Claims Assistance Act, where VA is obligated to help veterans with 
compensation and pension claims. VA should also consider paying any 
out-of-pocket expenses veterans incurred due to VA's deliberate policy 
of failing to notify veterans about the change in law and VA 
regulations.

     5.  VA Requests Permanent Gulf War Veteran Advocacy Office

    VCS urges VA to create a permanent Gulf War Veteran Advocacy Office 
and staff it with at least five ill, previously deployed Gulf War 
veterans among a staff of at least nine. The office will serve as the 
sole clearing house coordinating all Gulf War veteran related matters, 
reporting directly to the Secretary. Staff will provide input and 
monitor research, advisory panels, treatment trials, benefit programs, 
and outreach. VA leaders need a permanent, pro-veteran office to avoid 
repeating past mistakes. In our view, the needs and voices of Gulf War 
veterans have been excluded for too long, especially when VA's Research 
Office intentionally ignores both veteran and scientific input.

     6.  VA Expands Definition of Gulf War Service

    VCS asks the Secretary to use his rule-making authority to update 
the definition of Gulf War service so it is accurate and conforms with 
the actual war zone nations and bodies of water where our 
servicemembers deployed to conflicts on or after August 2, 1990, the 
official start of the Gulf War.
    VA should add Turkey to the list of nations shown in CFR 3.317. DoD 
records indicate tens of thousands of U.S. servicemembers supporting 
the 1990-1991 Gulf War and subsequent military operations through the 
present were based in Turkey. The military also lists Turkey as an 
eligible deployment location for the Southwest Asia Service Medal 
(SWASM). However, VA excluded Turkey from the definition of the Gulf 
War theater of operations.
    VCS urges VA to add Operation Enduring Freedom (the Afghanistan 
War, including all nearby nations and bodies of water) as well as 
Operations Iraqi Freedom and New Dawn (the Iraq War) to the definition 
of the Gulf War deployment zone so there is no confusion when VA staff 
are making healthcare and benefit eligibility determinations.

     7.  VA Benefit Eligibility Covers All Deployed Troops Since August 
2, 1990

    VA should apply scientific findings from IOM, RAC, or other 
research studies to apply to all veterans deployed to the war zone 
since August 2, 1990. For example, when a study finds an association 
for a condition for Operation Desert Storm veterans, then VA 
regulations should apply to all 3.1 million servicemembers deployed to 
the war zones since August 2, 1990.

     8.  VA Issues New Regulations for Multisymptom Illness

    VCS asks VA Secretary Shinseki to use his rule-making authority to 
promulgate new regulations expanding disability compensation benefits 
to veterans with multisymptom illness. In April 2010, the IOM concluded 
that as many as 250,000 Gulf War veterans remain ill with multisymptom 
illness associated with their deployment to Southwest Asia. In November 
2009, the RAC reached a similar conclusion.
    Based on scientific evidence, if a Gulf War veteran can show they 
were deployed to the Gulf War theater on or after August 2, 1990, and 
if the Gulf War veteran has a diagnosis of a multisymptom condition, 
then VA should automatically grant disability benefits and access to 
medical care.

     9.  VA Issues New Chronic Fatigue Syndrome, Fibromyalgia and 
Irritable Bowel Regulations

    VCS asks Secretary Shinseki to use his rule-making authority to 
amend the VA benefits rating manual as it pertains to three chronic 
multisymptom illnesses presumptive for Gulf War Veterans under 38 CFR 
3.317. The first of the three presumptive conditions, Chronic Fatigue 
Syndrome (CFS), can currently be rated as high as 100 percent depending 
upon the level of debilitation. VCS agrees CFS ratings should go up to 
100 percent because CFS can be totally disabling.
    However, Fibromyalgia (FM) can only be rated at a maximum of 40 
percent under current VA rules, even though it can be totally and 
permanently disabling. Since CFS is a diagnosis of last resort, a 
diagnosis of FM excludes a diagnosis of CFS, even if the veteran is 
clearly suffering from both debilitating chronic widespread pain and 
debilitating chronic fatigue. Veterans who may be the worst off may 
only receive a maximum 40 percent FM rating, even with all the symptoms 
of CFS. VCS calls for Secretary Shinseki to review these contorted 
rules so that veterans with FM can be rated as high as 100 percent, 
depending upon the severity of symptoms and the level of disability.
    Currently, Irritable Bowel Syndrome (IBS) can only be rated 
currently to a maximum rating of 30 percent. An IBS rating can be made 
in conjunction with a rating for CFS or FM (but not both, as previously 
stated). VCS asks Secretary Shinseki to also review the rules governing 
the maximum rating for IBS condition to allow for higher ratings 
relative to the actual severity of symptoms and the level of 
disability.

    10.  VA Issues New Regulations for Upper Respiratory, Lower 
Respiratory, Digestive, and Neurological Conditions

    Based on scientific evidence, VCS asks Secretary Shinseki to issue 
regulations and grant presumptive service-connection for upper and 
lower respiratory, digestive, and neurological conditions to grant 
presumptive service-connection for these conditions, including but not 
limited to Gastro-Esophageal Reflux Disease (GERD), diagnosed 
respiratory disorders including but not limited to asthma, bronchitis, 
bronchiolitis, and chronic obstructive pulmonary disease (COPD), and 
diagnosed neurological disorders involving pain, cognition, and other 
widely reported symptoms among Gulf War veterans.
    In practical terms, this action item is of enormous significance to 
ill Gulf War veterans without access to VA care because they are not 
service-connected. Our goal in requesting new regulations is to allow 
VA to grant service connection for these conditions so our ill Gulf War 
veterans can receive the VA medical care they need and earned for 
conditions scientists concluded are associated with their military 
service.
    VCS respectfully asks VA to respond, in writing, to our formal VCS 
petition in a timely manner so Gulf War veterans can have the answers 
they seek, the treatment they need, and benefits they earned without 
further delay.

            Sincerely,

                                                      Paul Sullivan
                                                 Executive Director

                                 
    Prepared Statement of Hon. Charles L. Cragin, Chairman, Advisory
  Committee on Gulf War Veterans, U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman, Ranking Member and Committee Members. 
Thank you for the opportunity to discuss with you the findings of the 
Department of Veterans Affairs (VA) Advisory Committee on Gulf War 
Veterans and our recommendations for improvements.
    I had the honor of serving as Chairman of this Advisory Committee 
throughout its tenure from April 2008 through September 2009. It was a 
privilege to serve with the fine men and women of this Committee. As 
you know, the Committee was chartered by the Secretary of Veterans 
Affairs to examine the health care and benefits needs of those who 
served in the Southwest Asia theater of operations during the 1990-1991 
period of the Gulf War and to advise the Secretary on the issues that 
are unique to these veterans. I should emphasize that the Committee saw 
its assignment to conduct information gathering, assess the current 
situation, and then provide advice to the individual who requested it, 
namely, the Secretary of Veterans Affairs.
    I would like to recognize the VA for the work it has done with 
respect to the Gulf War Task Force. I was encouraged to find many of 
the recommendations of the Committee referenced within the action 
plans. I look forward to the VA implementing the plans it has outlined 
and offer my support and assistance in reaching our shared goal of 
improving service and benefits to Gulf War and all veterans.
    During its tenure, the Committee held eight public meetings in 
Washington, DC; Baltimore, MD; Seattle, WA; and Atlanta, GA. Due to the 
lack of reliable data concerning Gulf War I veterans, the Committee was 
forced to base the majority of its findings on scattered scientific 
research and anecdotal information. Because of the reliance on such 
information, the Committee took extra efforts to contact veterans, both 
users of VA services and those who did not use VA services, and invited 
them to come before the Committee and report on their personal 
experiences. The Committee, in an additional effort to open 
communications, broadcast its meetings over toll-free telephone lines 
and maintained an active, up-to-date Committee web site.
    In general, the Committee's findings are summed up in the title of 
its report: Changing the Culture: Placing Care Before Process. This was 
a resounding theme, pockets of people trying to do their best, stymied 
by process or lack of vital information. Many of those who came to VA 
in the early days after Gulf War I were turned away. In many cases, 
health care professionals were not able to connect the symptoms 
experienced by these veterans to defined or known illnesses. 
Consequently, veterans were not able to access medical care and 
treatment and their claims for service-connected disabilities were 
often denied. The process served as an impeding wall preventing 
veterans who were hurting from getting over the wall to take advantage 
of the care they needed and deserved. Consider for a moment that all of 
the fine men and women were considered in excellent health and 
``deployable'' when they went to war. In many instances, shortly after 
their return home, these veterans began complaining of feeling ill and 
seeking help. Many were turned away as ``malingerers'' or having a 
``psychosomatic illness.'' Why did a department of government designed 
to care for veterans not identify that something was happening to men 
and women who had recently been healthy who now were sick, the common 
denominator being that they had deployed in Gulf War I? The process 
should have been constructed in such a way that these folks could have 
immediately been welcomed into the system, rather than rejected because 
the process required a diagnosable service connection. These veterans 
were not engaged in a massive, national conspiracy to defraud the 
government. Rather, they were sick, sought help, and in many instances 
were rebuffed by the agency established to care for them. The 
``Process'' became a wall, rather than a door.
    The Committee has discovered many programs and initiatives within 
the Department of Veterans Affairs to assist Gulf War I veterans. 
Unfortunately, these programs and initiatives are not easy to find and 
it is often incumbent upon the veteran to ask the ``right question.'' 
This is not how these men and women should be treated. As the Committee 
observed, ``newer approaches to more systematic health evaluation of 
servicemembers' pre- and post-deployment and newer approaches to more 
effectively organizing and integrating care and benefits for veterans 
with health problems have been very beneficial for veterans of more 
recent conflicts, but have not been inclusive of Gulf War I veterans. 
There is a clear need to move beyond the somewhat narrow and 
restrictive confines of treating diagnosable illness to addressing the 
broader functional limitations which remain as ongoing problems 
requiring health and social interventions.''
    As I mentioned, the lack of data contributed to the frustration of 
the Committee and prevented us from conducting any substantive 
analysis. The Committee discovered that the one database that had come 
to be relied upon as the authoritative source of information, the Gulf 
War Veterans Information System, had been corrupted. To date, the 
issues with this data system have not been addressed. The last valid 
report to be generated by the system was in February 2008.
    Gulf War I veterans view themselves as the forgotten era of 
veterans. Because the military operations were relatively short and 
successful, the residuals of the war were not at the forefront of the 
American consciousness. They are a relatively small group by war era 
standards and are easily eclipsed by the larger, more vocal coalitions 
of veterans. Because these veterans are not uniquely identified in VA 
systems and databases, many who work for VA may have no idea who these 
veterans are nor have VA employees been educated in the special issues 
related to this deployment.
    The Committee had the opportunity to meet with Dr. Steve Hunt in 
Seattle and see first hand the Post-Deployment Integrated Care clinic 
VA had there. The Committee was impressed with the model of integrated 
care designed to recognize and respond to the post-combat needs of 
veterans. The Committee recommended that Gulf War I veterans be 
included in the Post-Deployment Integrated Care Initiative and that VA 
track and evaluate the utilization and effectiveness of the program for 
Gulf War I veterans. The Committee further recommended that individuals 
with training in neurology and neuropsychology be included on the 
integrated care team. In the alternative, the Committee felt that the 
Department may want to consider expanding the current Environmental 
Agents Service to perform clinical evaluations of Gulf War I veterans.
    Concerns about the health of these veterans and the consequences of 
their exposures continue to exist today. The Institute of Medicine 
continues to issue reports on Gulf War and Health and I encourage VA to 
respond to these reports in a timely manner and to establish new 
presumptions as they are warranted. VA should keep in mind that the 
difficulty in determining the causes of the illnesses experienced by 
Gulf War I veterans has contributed to the ongoing lack of treatments. 
Gulf War I veterans want to be healthy.
    The Committee developed several recommendations contained in the 
report. I will not go into all of them in this testimony, but on behalf 
of the Committee I ask that the entire report be submitted for the 
record. I would like to take this opportunity to briefly highlight a 
few more of the recommendations contained in the report.
    The Committee recognizes that a culture change is necessary within 
VA and that such a change does not happen overnight. The Committee 
recommended, as part of the foundation of the transformation effort 
underway, that VA implement special programs to educate VA and contract 
medical personnel on Gulf War I medical issues, research, and 
regulations. To improve care and the delivery of benefits, staff needs 
to be aware and knowledgeable about medical issues that may be related 
to service in the Gulf War. Training of staff should be mandatory and 
conducted annually. An educated work force will serve to assist 
veterans as they navigate VA's complex system of health care and 
benefits.
    The Committee also recommended that the end date for the 
presumptive period for compensation for Undiagnosed Illness in Gulf War 
I veterans be extended indefinitely. The presumptive period for 
compensation for undiagnosed illness in Gulf War I veterans will expire 
on December 31, 2011. This presumptive period demonstrates VA's 
recognition that, although not yet officially named, Gulf War I 
veterans are experiencing adverse health consequences. There are 
servicemembers who fought in Gulf War I who have not left service yet, 
and who may experience these same symptoms in the coming years. VA 
should not confine Gulf War veterans to a timetable not supported by 
medical science. Veterans must receive the benefit of the doubt with 
respect to undiagnosed illness while VA awaits the conclusions of Gulf 
War Illness research.
    Technology can also help bridge the gaps. The Committee recommended 
mandatory clinical reminders be established in the system to trigger VA 
medical professionals to ask specific follow-up questions for Gulf War 
I veterans. This would require that Gulf War I veterans have a unique 
identifier in the VA system. VA should also build upon the good work 
begun early in its response to Gulf War I. VA should contact veterans 
who participated in the original Gulf War Registry Exams and invite 
them back for follow-up exams. This will not only be beneficial to the 
veterans, but provide valuable information about the evolution of Gulf 
War I veterans physical and mental conditions over the past 18 years.
    With respect to outreach, VA has a real opportunity to try to make 
up for the lack of outreach and awareness that has been afforded this 
cohort of veterans. VA should use the 20th anniversary of the Gulf War 
as a positive opportunity to attract Gulf War I veterans back to the 
VA.
    VA should increase its responsiveness to veterans and other 
stakeholders. The Committee experienced a number of delays in getting 
responses from VA on questions pertinent to our charge. Again, this had 
a negative affect on the analysis and review we were able to conduct.
    In general, VA learned many valuable lessons from Gulf War I 
veterans and those lessons have substantially improved the treatment 
received by Operation Iraqi Freedom and Operation Enduring Freedom 
(OIF/OEF) veterans today. VA needs to include Gulf War I veterans in 
the improved programs and initiatives it offers returning OIF/OEF 
veterans.
    Obviously, the report, in its entirety, represents the work of the 
Committee and the direction which it has recommended that the 
Department travel in its mission to serve Gulf War I veterans. 
Recently, the Department of Veterans Affairs provided a written 
response to the recommendations made by the Committee. I would like to 
thank VA for its responses and encourage VA to continue efforts to 
improve benefits and services to Gulf War I veterans.
    Thank you for inviting me to participate in this hearing 
representing my colleagues on the Committee. I am available to answer 
any questions you may have.

                                 
        Prepared Statement of Stephen L. Hauser, M.D., Professor
    and Chair of Neurology, University of California, San Francisco,
   School of Medicine, and, Chair, Committee on Gulf War and Health:
        Health Effects of Serving in the Gulf War, Update 2009,
             Board on the Health of Selection Populations,
             Institute of Medicine, The National Academies
    Good morning Mr. Chairman and Members of the Subcommittee. My 
thanks to Congressman Mitchell and Members of the Subcommittee on 
Oversight and Investigations, House Committee on Veterans' Affairs for 
your concern regarding Gulf War veterans' health.
    My name is Stephen Hauser. Since 1992, I have served as professor 
and chair of the Department of Neurology at the University of 
California, San Francisco. I am trained in internal medicine, 
neurology, and immunology. I am also an elected member of the Institute 
of Medicine. I am here today because I served as Chair of the Committee 
that worked on the Institute of Medicine (IOM) report Gulf War and 
Health: Update of Health Effects of Serving in the Gulf War. The 
sponsor of the study was the Department of Veterans Affairs (VA). The 
report was released to the VA and Congress on April 8th of this year.
    I will focus on three main topics in my testimony. First, I will 
briefly discuss the overall IOM study process followed by the Committee 
in developing our report and the Committee's approach to its charge, 
including the process the Committee used to draw its conclusions 
regarding the association between deployment to the Gulf War and 
specific health outcomes. Second, I will summarize our specific 
findings and conclusions. And finally, I present the Committee's 
recommendations for future research to help address the continuing 
health concerns of Gulf War veterans.
    The IOM is a part of The National Academies, a private, non-
governmental organization that provides independent scientific-based 
advice to policymakers and the public. Among the IOM's signature 
products is the consensus report produced by expert individuals from 
universities, nonprofit organizations, and other types of 
organizations. The long established study process, followed throughout 
the Academies, ensures that Committee Members are balanced for any 
biases and free from actual or potential conflicts of interest. 
Additionally, during Committee meetings and deliberations, there is no 
sponsor oversight; the sponsoring organization does not participate in 
any portion of the preparation and review of the IOM report. In 
instances when the Committee requests information from the sponsor, 
those materials are made publicly available. After the Committee 
develops a draft consensus report based on a detailed review of 
available literature, hearing from additional experts, and internal 
deliberation, the draft report undergoes a formal external peer-review 
process. The reviewers are anonymous to the Committee and IOM staff. 
They are asked to read the report and provide comments on whether the 
Committee has addressed its charge, the strength of the evidence for 
and the validity of the Committee's conclusions, and clarity and flow 
of the report. All reviewer comments must be addressed by the Committee 
and the report must be approved by The National Academies Report Review 
Committee before it can be released to the study sponsor and the 
public.
    The current report is an update of the 2006 report Gulf War and 
Health, Volume 4: Health Effects of Serving in the Gulf War. It 
examines the relevant literature published since 2005, the time of the 
last literature search for the 2006 report, on the health of veterans 
related to deployment to the Persian Gulf in 1990-1991. As requested by 
the VA, the specific charge to our update Committee was to review, 
evaluate, and summarize the literature on the following health outcomes 
that were noted in the 2006 report as having high incidence or 
prevalence in the Gulf War deployed veterans: cancer (particularly 
brain and testicular cancer), amyotrophic lateral sclerosis (ALS) and 
other neurologic diseases (such as Parkinson's disease and multiple 
sclerosis), birth defects and other adverse pregnancy outcomes, and 
post-deployment psychiatric conditions. In addition, and as recommended 
by the 2006 report, the Committee also reviewed studies on cause-
specific mortality in Gulf War veterans.
    The Committee initially examined over 1,000 potentially relevant 
references from peer-reviewed publications for the Update report. After 
an assessment of the titles and abstracts, 400 of these references were 
considered particularly relevant and thus reviewed in depth by the 
Committee. In addition, to ensure a comprehensive approach, all the 
epidemiologic studies included in Volume 4 were also reviewed by this 
Committee in order to draw conclusions about the strength of 
association between deployment to the Gulf War and particular health 
outcomes. The Committee held two public sessions where interested 
parties, such as representatives from veteran-service organizations and 
Gulf War veterans, were invited to speak. As requested by VA Secretary 
Shinseki, the Committee also invited representatives from the VA 
Research Advisory Committee of Gulf War Veterans' Illness (RAC) to 
present the findings and conclusions from their report, Gulf War 
Illness and the Health of Gulf War Veterans: Scientific Findings and 
Recommendations, which was published in November 2008.
    In order to draw conclusions on the strength of the evidence for an 
association between deployment to the Gulf War and a health outcome, 
the Committee used categories of association. The following five 
categories are long established and have been used by previous 
Committees on Gulf War and Health and other IOM Committees evaluating 
topics such as vaccine safety and Agent Orange. They are widely 
accepted by and familiar to Congress, the VA, and veteran groups. The 
categories are:

      Sufficient evidence of a causal relationship, that is, 
the evidence is sufficient to conclude that between being deployed to 
the Gulf War causes a health outcome.
      Sufficient evidence of an association; that is, a 
positive association has been observed between deployment to the Gulf 
War and a health outcome in humans.
      Limited/suggestive evidence of an association; that is, 
some evidence of an association between deployment to the Gulf War and 
a health outcome in humans exists.
      Inadequate/insufficient evidence to determine whether an 
association exists; that is, available studies are of insufficient 
quality, validity, consistency or statistical power to permit a 
conclusion regarding the presence or absence of an association.
      And finally, limited/suggestive evidence of no 
association; that is, several adequate studies are consistent in not 
showing an association between deployment and a health outcome.

    In order to reach consensus and determine the category of 
association assigned for each health outcome, the Committee took a 
weight-of-the-evidence approach based on the studies and their 
classification as primary or secondary.
    Listed below is a summary of the Committee's findings. Sufficient 
evidence was found to conclude that a casual relationship exists 
between being deployed to the Gulf War and posttraumatic stress 
disorder (PTSD)--the only outcome placed in this category. Also of 
note, sufficient evidence suggests an association exists between 
deployment to the Gulf War and the following health outcomes: other 
psychiatric disorders, including generalized anxiety disorder, 
depression, and substance abuse, particularly alcohol. These 
psychiatric outcomes can persist for at least 10 years post deployment. 
Sufficient evidence of an association was also seen for 
gastrointestinal (GI) symptoms that are consistent with functional GI 
disorders such as irritable bowel syndrome and functional dyspepsia; 
for multi-symptom illness; and for chronic fatigue syndrome.

                               __________

           Summary of Findings Regarding Associations Between
        Deployment to the Gulf War and Specific Health Outcomes
Sufficient Evidence of a Causal Relationship
      PTSD.
Sufficient Evidence of an Association
      Other psychiatric disorders, including generalized 
anxiety disorder, depression, and substance abuse, particularly alcohol 
abuse. These psychiatric disorders persist for at least 10 years after 
deployment.
      Gastrointestinal symptoms consistent with functional 
gastrointestinal disorders such as irritable bowel syndrome and 
functional dyspepsia.
      Multisymptom illness.
      Chronic fatigue syndrome.
Limited/Suggestive Evidence of an Association
      ALS.
      Fibromyalgia and chronic widespread pain.
      Self-reported sexual difficulties.
      Mortality from external causes, primarily motor-vehicle 
accidents, in the early years after deployment.
Inadequate/Insufficient Evidence to Determine Whether an Association 
        Exists
      Any cancer.
      Diseases of the blood and blood-forming organs.
      Endocrine, nutritional, and metabolic diseases.
      Neurocognitive and neurobehavioral performance.
      Multiple sclerosis.
      Other neurologic outcomes, such as Parkinson's disease, 
dementia, and Alzheimer's disease.
      Incidence of cardiovascular diseases.
      Respiratory diseases.
      Structural gastrointestinal diseases.
      Skin diseases.
      Musculoskeletal system diseases.
      Specific conditions of the genitourinary system.
      Specific birth defects.
      Adverse pregnancy outcomes such as miscarriage, 
stillbirth, preterm birth, and low birth weight.
      Fertility problems.
Limited/Suggestive Evidence of No Association
      Peripheral neuropathy.
      Mortality from cardiovascular disease in the first 10 
years after the war.
      Decreased lung function in the first 10 years after the 
war.
      Hospitalization for genitourinary diseases.

    I would like to elaborate a bit more on how the Committee evaluated 
``multi-symptom illness,'' also referred to as Gulf War Illness or Gulf 
War syndrome. Numerous studies have documented that those deployed to 
the Gulf War have an increased prevalence of a disabling complex of 
self-reported symptoms such as fatigue, musculoskeletal pain, sleep 
disturbances, cognitive dysfunction, and moodiness, among others. The 
Volume 4 Committee looked at this symptom reporting by deployed Gulf 
War veterans and attempted to determine whether a unique illness could 
be defined by these symptoms but our Committee accepted that multi-
symptom illness was indeed a diagnostic entity and examined the 
literature to make conclusions regarding its association with 
deployment to the Gulf War. We did not attempt to determine if the 
multisymptom illness seen in Gulf War veterans was a disease unique to 
them.
    Research has identified an association between self-reported multi-
symptom illness and self-reported exposures to several chemicals that 
inhibit cholinesterase, an enzyme that is important for proper 
functioning of the nervous system. Pyridostigmine bromide (PB) is one 
example of a cholinesterase inhibitor as are many pesticides. In the 
appendix to our report, the Committee described how Gulf War veterans 
may have been exposed to cholinesterase inhibitors, including evidence 
potentially linking these exposures to multi-symptom illness. After 
careful examination of both animal studies and human studies, the 
Committee concluded that there was insufficient evidence to link 
possible exposures to cholinesterase-inhibiting chemical agents to the 
multi-symptom illness seen in Gulf War veterans.
    The Committee believes the path forward for Gulf War veterans 
consists of two branches, and has made recommendations accordingly. 
First, as with numerous other Gulf War and Health reports, the 
Committee calls for improved studies of Gulf War veterans that are 
designed and conducted to more accurately characterize deployment and 
potential related adverse environmental influences, and that address 
possible confounding factors, such as smoking. However, the Committee 
feels that further studies based solely on self-reports may not 
contribute to the scientific evidence or accurately reconstruct 
exposures that occurred 20 years ago in the Persian Gulf. The Committee 
recognizes that establishing Gulf War veterans' physical and mental 
health baseline status is a challenge. Robust cohorts need to be 
followed to track the development of ALS, MS, brain cancer, psychiatric 
conditions, and other health problems, such as cancers, cardiovascular 
disease, and neurodegenerative diseases that manifest later in life. 
Some large, well-characterized cohorts have already been established, 
such as the US cohort studied by the VA, the two UK cohorts, and the 
Australian cohort. In the future, these cohorts might provide 
information on diseases with low prevalence, such as ALS and brain 
cancer.
    The Committee also recommends a second major branch of inquiry 
regarding the effort to further define the diagnosis of and develop 
effective treatments for multisymptom illness. As our understanding of 
genetics, molecular science, and brain imaging expands, it should be 
possible to carry out large-scale, well-designed studies to identify 
the differences in veterans with persistent medical symptoms as 
compared to their healthy deployed counterparts. These differences 
include genetic variants; molecular profiles of gene expression; 
markers such as changes in DNA structure as a result of exposures to 
chemicals or viruses; immune system activation; and changes in the 
brain. The committee believes that useful biomarkers may be indentified 
to help diagnose and treat unexplained symptoms such as chronic 
fatigue, muscle and joint pain, sleep disturbance, difficulty in 
concentration, and depression.
    Finally, the Committee believes it would be valuable to undertake 
high quality clinical trials that may result in identifying effective, 
evidence-based treatments for multisymptom illness. In short, with the 
progress in scientific capabilities, well organized efforts to 
accurately diagnosis and clinically treat multisymptom illness and 
other unexplained illnesses would be most valuable to help our 
suffering veterans.
    On behalf of the Committee on Gulf War and Health: Health Effects 
of Serving in the Gulf War, Update 2009, I thank you for your trust in 
our ability to assist with you with your important work on veterans' 
health and for asking me to testify before this subcommittee. I look 
forward to answering any questions you may have.

                                 
            Prepared Statement of James H. Binns, Chairman,
      Research Advisory Committee on Gulf War Veterans' Illnesses
    Chairman Mitchell, Ranking Member Roe, Members of the Committee, I 
am honored to address you again as Chairman of the Research Advisory 
Committee on Gulf War Veterans Illnesses. The Committee was created by 
Congress in 1998 to provide advice to the Secretary of Veterans Affairs 
on the conduct of Federal Gulf War health research. Its membership 
includes the most experienced researchers in this field, some of the 
most respected neuroscientists in the country (including the head of 
the CDC neurotoxicology research laboratory and a former president of 
the American Academy for the Advancement of Science), and several Gulf 
War veterans. I thank you for holding this third hearing in your series 
on Gulf War Illness. There has been a dramatic change in the 
recognition of this problem in the year since the last hearing, and 
much of it can be attributed to your spotlighting attention on it.
    Great credit must also be given to two other people who will 
address you today. As VA Chief of Staff, Mr. John Gingrich has 
personally led a Task Force to re-examine VA Gulf War policy from top 
to bottom, bringing to this effort the urgency and concern for his 
troops he demonstrated as a battalion commander during the war. You 
will not hear him say, as the VA representative testified at your first 
hearing, that ``Gulf War veterans are suffering from a wide variety of 
common and recognized illnesses.''
    Dr. Stephen Hauser has chaired a courageous new Institute of 
Medicine Committee which refused to limit its review to the narrow 
assignment given by VA staff and which has forcefully recognized this 
problem. Unlike what you heard at your second hearing, the Research 
Advisory Committee and the IOM are now in agreement on major scientific 
conclusions: that chronic multisymptom illness is a diagnostic entity; 
that it is associated with service during the Gulf War, affecting as 
many as 250,000 veterans; that it cannot be ascribed to stress or other 
psychiatric disorders; that it is likely the result of genetic and 
environmental factors; and that a major national research program is 
urgently needed to identify treatments. The IOM Committee did not feel 
the data were strong enough to identify specific environmental causes, 
while our Committee did, but that is a relatively minor difference.
    The question before us this morning is what the government will do, 
now that the problem has been recognized. The Task Force is a major 
initiative to reform VA system-wide, and VA leadership's decision to 
open its draft report to public comment was wise. There is much in the 
report that is good, but there is also much that reflects old attitudes 
the report is supposed to change. The test will come in the final draft 
of the report and how its recommendations are implemented.
    I will focus my comments on research. Now that there is a 
scientific consensus that Gulf War Illness is real, important, and 
solvable, we have arrived where we should have been in 1995. The task 
remains to mount an effective national research program--``a well-
planned, top-down program, employing the best in American science, run 
by people who go to bed at night and wake up in the morning thinking 
about this problem,'' as Dr. Houser described to me what his IOM 
Committee felt was necessary.
    This country is not doing that. At VA, there are some individual 
researchers doing excellent work, and VA is in the process of launching 
a new program to replace the one cancelled at the University of Texas, 
Southwestern, and hiring a toxicologist to staff it. They have issued 
requests for proposals that include most topics recommended by the 
Research Advisory Committee's 2008 report. They have appointed a 
steering committee of outside scientists to guide this program, 
including several from the Research Advisory Committee. There is a plan 
being developed for a major genetics component. It all sounds very 
positive.
    However, the new RFA's have failed to attract much interest from 
the VA research community, which is not surprising after nineteen years 
of denial regarding this problem. There is no comprehensive research 
plan. The places that VA has found to invest most of the funds 
committed this year are not for priority research topics. Research 
involving the psychological aspects of chronic illness is again being 
favored. The new steering committee was not consulted on several new 
research studies announced last week. The press release announcing the 
studies carried the stale old message that Gulf War veterans' problems 
are mainly psychological.
    I am confident that this message was not approved by the 
Secretary's office, but regardless of their intentions, VA's new 
research program resembles far too much VA's old research program. To 
mount an effective program, the Office of Research and Development must 
engage its new steering committee to create a comprehensive plan, 
focused on priority research topics, under the leadership of a 
scientist who understands the problem, who harbors no doubts as to its 
nature, and who goes to bed at night and wakes up in the morning 
thinking about how to solve it. Marginal improvement is not enough. The 
program must be built for success. Or the successors of everyone in 
this room will be having this same conversation twenty years from now 
and wondering why we didn't act.
    Assuming that VA makes these major necessary changes, it cannot do 
the job alone. Yet the Department of Defense, which historically has 
funded two-thirds of Gulf War Illness research, has eliminated this 
research entirely from its budget for many years. This action is 
tragically shortsighted, given the major implications of this research 
to current and future military personnel at risk of multisymptom 
illness and toxic exposures.
    Congress has responded by establishing a Gulf War Illness research 
program within the DoD Congressionally Directed Medical Research 
Program (CDMRP). This well-managed program is open to all researchers. 
However, it is grossly underfunded, having received just $8 million in 
FY2010. Congressional supporters have proposed $25 million for this 
program in FY2011, and I support that request, as necessary to the 
scope and importance of the problem.
    Compare these figures to the billions of dollars recently 
calculated to cover the care and disability of Vietnam veterans exposed 
to Agent Orange. How much better for ill Gulf War veterans, current and 
future U.S. military personnel, and the public treasury, to cure this 
illness rather than to allow veterans' health to deteriorate. I urge 
you to make this bipartisan issue a priority and to press upon your 
colleagues the vital importance of adequate funding for Gulf War 
Illness research at CDMRP.
    I also encourage you to support Gulf War Illness reform at VA. As 
last week's press release and the undesirable parts of the draft Task 
Force report make clear, there is still push-back within the 
bureaucracy to the initiatives Secretary Shinseki and Chief of Staff 
Gingrich have begun. The bureaucrats believe that they will remain 
while appointed leaders come and go. I urge you to consider legislation 
to ensure the permanence of reforms. I urge you to hold annual follow-
up hearings to keep the spotlight on.
    Finally, I urge you to reaffirm the purpose of the Research 
Advisory Committee to provide independent advice to the Secretary on 
the conduct of Gulf War research, as intended by Congress. Recently VA 
staff have attempted to change the charter of the Committee to make us 
dependent on VA staff--in the name of standardization. In other words, 
the people whose work we review would staff our meetings, our reports, 
and our recommendations. I am sure this is not what Congress had in 
mind when it directed our Committee to review Federal Gulf War 
research.
    It is important to close on a positive note. Twenty years into this 
battle, the objective is finally in sight. It is time for leaders and 
resources adequate to accomplish the mission. It is within reach. It is 
a matter of choice.

                                 
        Prepared Statement of John R. Gingrich, Chief of Staff,
                  U.S. Department of Veterans Affairs
    Chairman Mitchell, Ranking Member Roe, and Members of the 
Subcommittee, thank you for holding today's hearing. I am John 
Gingrich, Chief of Staff for the Department of Veterans Affairs (VA), 
and Chairman of the Gulf War Veterans' Illnesses Task Force (GWVI-TF, 
or ``Task Force''). Joining me today are Dr. Victoria Cassano, 
Director, Radiation and Physical Exposures Service, and Acting 
Director, Environmental Agents Service, Office of Public Health and 
Environmental Hazards, Veterans Health Administration (VHA); Dr. Joel 
Kupersmith, Chief Research and Development Officer, Office of Research 
and Development, VHA; and Bradley Mayes, Director, Compensation & 
Pension Service, Veterans Benefits Administration (VBA). Dr. Cassano, 
Dr. Kupersmith, and Mr. Mayes also serve as members of the Task Force.
    I am pleased to come before you today to provide an overview of the 
Task Force mission, accomplishments, and recommendations contained in 
its report. The Task Force represents a bold step forward in how VA 
considers and addresses the challenges facing not just veterans of a 
specific era, but the challenges facing all veterans.
    Our ability to address the challenges facing 1990-1991 Gulf War 
veterans is not applicable just to that cohort of veterans, it is 
representative of VA's commitment to all our veterans. We welcome the 
opportunity to work with the Congress, Veterans' Service Organizations 
(VSOs), and all stakeholders in applying the lessons we have learned in 
caring for Gulf War veterans across the spectrum of care and benefits 
for all veterans.
Task Force Mission, Efforts, and Approach
    The Task Force was formed in August 2009 to provide a unified and 
cohesive organizational instrument to address the concerns and needs of 
Gulf War veterans, especially those who suffer from unexplained chronic 
multisymptom, or undiagnosed illnesses. From the outset, VA recognized 
that this was a complex issue with many people deeply invested in its 
resolution. We recognized the frustrations that many veterans and their 
families experience on a daily basis as they look for answers, and seek 
benefits and health care.
    In order to meet these challenges, the Task Force was designed as a 
matrix organization within VA that meets regularly to investigate 
allegations and perceptions, analyze facts and data, coordinate and 
review findings and proposals, and collaboratively develop 
recommendations. The Task Force includes staff from the Office of the 
Secretary (OSVA), VHA, VBA, Office of Public and Intergovernmental 
Affairs (OPIA), Office of Policy and Planning (OPP), and the Office of 
Congressional and Legislative Affairs (OCLA). The staff from these 
offices represented a broad spectrum of subject matter expertise and 
stakeholder perspectives necessary to ensure success. Members were 
charged with defining the key areas of review, consulting key experts 
and relevant stakeholders, and capturing the issues, data, programmatic 
and performance information necessary to inform their recommendations.
    From the outset, I expected Task Force members to be candid and 
thorough during the review process. In order to meet the Task Force 
goals, and develop results-oriented proposals, members were asked to be 
aggressive and innovative. They met those expectations. Although the 
report the Task Force produced is but the first of many steps in a 
dynamic and still unfolding plan to address the needs of Gulf War 
veterans, I am confident that we are moving in the right direction.
    The Task Force was charged with conducting a comprehensive review 
of all VA programs and services that serve the Gulf War cohort of 
veterans. The Task Force was further charged to identify gaps in 
services as well as opportunities to better serve this veteran cohort, 
and then develop results-oriented recommendations to decisively advance 
VA's efforts to address their needs. The Task Force considered a 
successful mission outcome as a coherent, comprehensive and facts-based 
action plan, which considers and integrates appropriate viewpoints from 
stakeholders and subject matter experts.
    The Task Force focused its efforts on veterans of the conflict in 
Operation Desert Shield or Operation Desert Storm, components of the 
1990-1991 Gulf War period. However, as part of the Task Force charge to 
develop innovative and forward-looking solutions, it identified lessons 
learned from past practices and policy that can be applied to today's 
programs and services supporting the Operation Enduring Freedom/
Operation Iraqi Freedom cohort.
    The Gulf War is legally defined as beginning on August 2, 1990, and 
extending through a date to be prescribed by Presidential proclamation 
or law. The term ``Gulf War Veterans'' could refer to all veterans of 
conflicts in Southwest Asia during this period, including Veterans of 
Operation Iraqi Freedom, and subsequent conflicts in this theater. We 
considered these possibilities when developing our recommendations, in 
the hopes that this report would serve as a foundation for treating the 
unique wounds of war of the present conflicts. We were also mindful 
that this cohort of veterans includes significant percentages of women 
and minority veterans; and so we worked diligently to ensure that we 
addressed their needs.
    The Task Force report reflects an unprecedented VA approach to 
problem solving. The approach uses an interdisciplinary team of subject 
matter experts from across multiple horizontal domains of VA, to 
include direct senior leader participation. The GWVI-TF worked over 
several months to develop a comprehensive plan of action consistent 
with the challenge inherent in Secretary Shinseki's pledge to all 
veterans in his comments before the National Society of the Sons of the 
American Revolution on 9 January 2010: ``At VA, we advocate for 
veterans--it is our overarching philosophy and, in time, it will become 
our culture.''
Task Force Objectives
    The report's action plans form an initial roadmap to transform the 
care and services we deliver to the Gulf War cohort. Execution of these 
plans will deliver the critical tools for frontline staff to address 
issues raised by VA and Gulf War veterans, Veteran Service 
Organizations, Congress, and other external stakeholders.
    Due to significant limitations in VA's Gulf War Veterans 
Information System (GWVIS) and the reports generated from the various 
data sources used by GWVIS, it is extremely difficult to accurately 
portray the experiences of the 1990-1991 Gulf War cohort and their 
respective disability claims or health care issues. That said, this 
shortfall did not prevent the GWVI-TF from identifying gaps in services 
as well as opportunities to better serve this veteran cohort.
    The Task Force developed action plans to deliver new and improved 
tools for VA personnel based on seven core themes:

      Partnerships: Partner with the Department of Defense 
(DoD) to improve communication and subsequently the care and services 
VA delivers to veterans;
      Benefits: Reassess and revise benefit policies as needed 
and empower and train VA compensation personnel to better secure the 
benefits veteran clients have earned;
      Clinician Education and Training: Empower clinical staff 
to better serve veteran needs through a new model of interdisciplinary 
health education and training;
      Ongoing Scientific Reviews: Ensure long-term population-
based surveillance efforts for improved care for veterans;
      Medical Surveillance: Transition from reactive to 
proactive medical surveillance to identify and better manage possible 
adverse health outcomes of veterans' potential hazardous exposures;
      Research and Development: Strengthen the foundation today 
for tomorrow's more comprehensive short and long-term program for 
research and development; and
      Outreach: Enhance outreach to reconnect veterans to VA 
care, services, information and databases.

    These action plans are not meant to be the definitive panacea for 
caring for Gulf War veterans. While a starting point, this veteran-
centric care will require continued efforts and vigilance on the part 
of all stakeholders. Implementing the recommendations in this report 
will provide VA staff with the means to continue to advocate and care 
for all Gulf War veterans.
Task Force Recommendations
    The Task Force report is organized around the seven themes, 
previously mentioned. These themes drive action plans for the way 
ahead.
    Partnerships: Veteran care is profoundly influenced by how well DoD 
and VA share information and resources in the areas of deployment 
health surveillance, assessment, follow-up care, health risk 
communication, and research and development. VA is dependent on DoD to 
identify environmental hazards and Servicemembers who were possibly 
exposed to those hazards.
    VA and DoD already collaborate through the Deployment Health 
Working Group (DHWG). The report proposes to leverage the DHWG as the 
principal mechanism for VA to receive data on environmental exposures 
of Servicemembers, but this proposal has not been coordinated yet with 
the DHWG. Additionally, the report proposes using the DHWG to provide 
regular progress reports on data sharing efforts to the VA/DoD Health 
Executive Council. As of July 1, 2010, a draft Data Transfer Agreement 
is being reviewed by DoD and VA.
    Benefits: The Task Force received input from veterans and veterans' 
stakeholders concerning the benefits and services targeted to Gulf War 
veterans. Specifically, there was concern that some veterans were 
continuing to suffer from symptom clusters that could not be attributed 
to known diseases or disabilities through conventional medical 
diagnostic testing and that these veterans were ``falling through the 
cracks'' within the current disability compensation scheme.
    As a result, the Task Force reviewed the current legislative and 
regulatory provisions unique to the Gulf War cohort of veterans. Rule-
making is also underway to establish the presumption of service 
connection for nine infectious diseases identified in the National 
Academy of Sciences' report titled ``Gulf War and Health Volume 5: 
Infectious Diseases'' issued on October 16, 2006.
    To further assist Gulf War veterans, VBA Compensation and Pension 
(C&P) Service published two training letters designed to inform and 
instruct regional office personnel on proper development and 
adjudication of disability claims based on Southwest Asia service. 
Training Letter 10-01, titled Adjudicating Claims Based on Service in 
the Gulf War and Southwest Asia, was released on February 4, 2010. This 
training letter provides background information on the Gulf War of 
1990-1991, and explains the initial 1994 and subsequent 2001 
legislation found in Title 38 United States Code, Section 1117, which 
was a response to the ill-defined disability patterns experienced by 
returning Gulf War veterans. It explains the terms ``undiagnosed 
illness'' and ``medically unexplained chronic multisymptom illness'' 
used in the legislation, and notes that VA plans to amend its 
regulations to clarify that the three currently listed medically 
unexplained, chronic, multisymptom illnesses, chronic fatigue syndrome, 
fibromyalgia, and irritable bowel syndrome, are only examples of 
chronic unexplained multisymptom illnesses and not an exhaustive list 
of conditions subject to the presumption of service connection. It also 
provides step-by-step procedures for procuring supporting evidence and 
for rating a disability claim based on Southwest Asia service under 
section 3.317 of title 38 of the Code of Federal Regulations. The 
training letter includes a separate memorandum to be sent with the VA 
medical examination request so that examiners are informed of the 
issues related to qualifying chronic disabilities and are better able 
to evaluate a Gulf War veteran's disability pattern.
    Additional assistance was provided in Training Letter 10-03, titled 
Environmental Hazards in Iraq, Afghanistan, and Other Military 
Installations, which was coordinated with the Veterans Health 
Administration and DoD. This training letter provides regional office 
personnel with information on environmental hazards associated with 
Gulf War and Southwest Asia service. It discusses airborne toxic 
substances resulting from the widespread use of burn pit fires to 
incinerate a variety of waste materials in Iraq and Afghanistan, as 
well as hexavalent chromium contamination at the Qarmat Ali water 
treatment plant in Basrah, Iraq, from April through September 2003. The 
training letter was sent to VBA's regional offices on April 26, 2010.
    In addition to Southwest Asia environmental hazards, the training 
letter provided details of the contaminated drinking water situation at 
Camp Lejeune, North Carolina, from the 1950s to the 1980s. The purpose 
of this information is to alert regional office personnel to the 
potential for disability claims based on exposure to any of these 
environmental hazards. The training letter outlines development and 
rating procedures for such claims and provides ``fact sheets'' for VA 
medical examiners that explain each hazard. We will continue to 
coordinate with DoD to ensure that VA claims processing personnel 
remain informed about future environmental hazard exposures as 
additional information becomes available.
    Clinician Education and Training: VHA has historically used a 
series of clinician training programs, titled Veterans Health 
Initiative (VHI), to prepare clinician staff to treat veterans. 
However, the current programs are unwieldy, information is out-of-date, 
the format is not user-friendly, and the process for updating these 
training programs lacks agility.
    In order to address this training deficit, an interdisciplinary 
team of VA subject matter experts met on December 8 and 9, 2009, to 
rewrite and reorganize the Gulf War veterans' Illnesses training 
program. This was the first time that such a wide array of policy 
makers, subject matter experts, and clinicians in the field were 
brought together to review every facet of a training program. A 
conference call on December 28, 2009, was held to continue editing the 
content. A two-day offsite meeting on February 1 and 2, 2010, finalized 
the content. The training program is now ready for review by the peer 
review board. The target date for on-line availability is October 31, 
2010.
    And while primary care providers currently do an excellent job of 
providing patients with work-ups based on symptoms, they do not always 
have the necessary tools to provide thorough exposure assessments. An 
initial seminar was developed in August 2009 in conjunction with Mount 
Sinai Medical Center and the New Jersey War Related Illness and Injury 
Study Center (WRIISC) to overcome this deficiency.
    Lessons learned from prior conflicts, including the 1990-1991 Gulf 
War, were coupled with the lessons learned at the August 2009 seminar 
to build more comprehensive training for VA staff. This past month, VHA 
conducted two exportable workshops in exposure evaluation and 
assessment to update VA clinicians on the unique exposure concerns of 
returning OEF/OIF veterans, and to provide educational and clinical 
tools for evaluation of exposure risk and the health outcomes relevant 
to these risks. Additional seminars are being planned for fiscal year 
(FY) 2011. In addition, later this year, a segment of this workshop 
seminar will be offered as a satellite broadcast available to all VA 
providers.
    Recent training provided to VBA field stations included guidance 
for VA medical professionals who conduct compensation and pension 
examinations for conditions associated with Gulf War-related exposures. 
VA's War Related Illness and Injury Study Center (WRIISC) program is 
fully operational with facilities located in Washington, DC, East 
Orange, NJ and Palo Alto, CA. The WRIISCs, staffed by teams of 
multidisciplinary clinicians uniquely qualified to evaluate veterans 
with deployment-related health concerns, provide a clinical ``second 
opinion'' resource to veterans via a referral process based on 
geographic location.
    Ongoing Scientific Reviews: VA recognizes the need to leverage 
additional resources available to us and our partners to provide the 
kind of attention to Gulf War veterans that they deserve.
    We will continue to support the long-term Institute of Medicine 
(IOM) scientific reviews of health outcomes related to veterans' 
service in Gulf War combat theaters. VA is collaborating with the 
Centers for Disease Control and Prevention (CDC) to incorporate de-
identified veteran-specific data collection and analyses into three 
major longitudinal health-related national surveys: National Health and 
Nutrition Examination Survey (NHANES); National Health Interview Survey 
(NHIS); and National Immunization Survey (NIS). VA staff has had 
several discussions with investigators on the NHANES and NHIS. Staffs 
from both surveys have expressed willingness to include veteran-
specific questions and to plan for oversampling of the veteran 
population to ensure an adequate number of veterans to allow for 
comparisons to the adult U.S. population.
    As of July 1, 2010, VA has submitted to NHANES and NHIS staff 
specific questions that, when answered, will identify veteran study 
subjects beginning in 2011 in both these National surveys. This effort 
will enable contrasts to be made between current disability and health 
status of veterans and non-veterans. Additionally, these questions will 
enable VA to assess the health of veterans during multiple periods and 
eras of service.
    To prepare for and address future needs, in June 2009, we announced 
the National Health Study for a New Generation of U.S. Veterans to 
study the health status of 60,000 veterans who have separated from 
active duty, Guard, or Reserves, half of whom served in either Iraq or 
Afghanistan and half who did not. Women veterans are being oversampled 
to permit appropriate comparisons.
    Medical Surveillance: DoD has discussed with VA events or 
situations when Servicemembers may have been exposed to hazardous 
substances during the current conflicts in Iraq and Afghanistan. These 
possible exposure events include exposure to hexavalent chromium, burn 
pit smoke, and other contaminants.
    Unfortunately, medical surveillance has not been extensive for 
1990-1991 GW veterans, despite the efforts of DoD's Comprehensive 
Clinical Evaluation Program, which was not focused on exposure related 
disease. One of the lessons learned from the first Gulf War is that VA 
must get information regarding potentially exposed troops as soon as 
available from DoD, in order to provide ongoing medical surveillance of 
veterans who may be at risk of adverse health outcomes. A program is 
being developed for those veterans who may have been exposed to sodium 
dichromate while performing duties at Qarmat Ali, Iraq. This model will 
be used to develop medical surveillance programs for the other exposure 
events. The event at Qarmat Ali is the most well-defined event in that 
there is a relatively small number of potentially exposed veterans, 
there is only one offending chemical, and the exposure has ceased.
    Among Gulf War veterans, there are known instances where 
Servicemembers were hit by coalition fire and are believed to still 
have depleted uranium (DU) fragments present in their bodies. The need 
to monitor the effects of long-term DU exposure still exists. The 
Depleted Uranium follow-up program was started in 1993 at the Baltimore 
VA Medical Center (VAMC). This program periodically re-evaluates 
Servicemembers who have known embedded DU fragments. In 2008 the Toxic 
Embedded Fragment Study Center was established to clinically evaluate 
all Servicemembers with any type of embedded fragment. These programs 
have been supported by the Division of Biophysical Toxicology at the 
Armed Forces Institute of Pathology (AFIP). The Joint Pathology Center 
(JPC), authorized in NDAA 2008, will serve as the new Pathology 
Reference Center for the Federal Government providing pathology 
consultation, education, research, and oversight of the vast Tissue 
Repository housed at AFIP, which will close in 2011. VA will continue 
to support the work of the JPC to maintain these vital programs for 
Veterans with Toxic Embedded Fragments of all kinds.
    Research and Development: There has been significant Federal 
support for research on Gulf War veterans' illnesses that has answered 
many epidemiological questions and studied a number of potential 
biological indicators of illness in Gulf War veterans. Effective 
treatments and objective diagnostic tests, however, have not yet been 
identified. We know that this is of particular frustration to veterans 
and their families.
    The most recent IOM Report, Gulf War and Health: Volume 8, 
concluded that while PTSD was causally linked to traumatic war 
experiences associated with GW deployment, the excess of unexplained 
medical symptoms reported by GW veterans cannot be reliably ascribed to 
any known psychiatric disorder. Although the precise cause for these 
symptoms remains unknown, the fact that some GW veterans are ill and 
suffer adverse effects on their daily lives remains unquestioned.
    VA agrees with the recommendation of the VA Research Advisory 
Committee on Gulf War Veterans' Illnesses in its 2008 report that a 
renewed Federal research commitment is needed to identify effective 
treatments for Gulf War Illnesses and address other priority Gulf War 
health issues. VA remains committed to conducting research to identify 
new treatments for ill GW veterans. Clinical trials have examined new 
therapies for sleep disturbances and gastrointestinal problems, and 
tested the feasibility of performing cognitive behavioral therapy via 
telephone. Additionally, VA researchers are conducting clinical trials 
funded through the Congressionally Directed Medical Research Program 
managed by DoD in hopes of finding new treatments for GW veterans.
    VA's Office of Research and Development (ORD) issued three new 
Requests for Applications (RFAs) on November 10, 2009, which 
incorporated more than 80 percent of the research recommendations the 
Research Advisory Committee on Gulf War Veterans' Illnesses made in 
their 2008 report. Three of the 13 applications received, focused on 
testing or developing new treatments for ill Gulf War veterans, have 
been selected for funding. These RFAs will be re-issued twice a year to 
regularly request submission of new proposals and revisions of 
previously reviewed, but not funded, applications.
    The results of VA's short term plans to move forward are 
encouraging that the goal of identifying effective treatments will be 
met. Previous VA-funded clinical trials have examined new therapies for 
sleep disturbances, cognition, pain, fatigue and gastrointestinal 
problems, and tested the feasibility of performing cognitive behavioral 
therapy via telephone. Another major focus of VA's current research 
portfolio is to identify biomarkers, or biological indicators, that can 
distinguish ill Gulf War veterans from their healthier counterparts.
    In addition, ORD's long-term plans include the design of a new 
study of a National cohort of Gulf War veterans under the auspices of 
VA's Cooperative Studies Program, which has extensive experience in 
developing multi-site VA clinical trials and clinical studies. The 
design of this new study will include a Genome Wide Association Study 
(GWAS) and other elements, based on evaluation of the existing body of 
scientific/clinical knowledge about the illnesses affecting Gulf War 
veterans.
    Let me also take this opportunity to say clearly that our decision 
to not exercise the two option years of the contract with the 
University of Texas Southwestern Medical Center (UTSW) was because of 
our commitment to ensuring that Gulf War veterans receive only the best 
care. Our decision was based on persistent noncompliance with contract 
terms and conditions, and numerous performance deficiencies documented 
by the Contracting Officer, the Contracting Officer's Technical 
Representative, and the Office of the Inspector General. Unobligated 
funds from FY 2009, the third UTSW contract period, have been retained 
for use in FY 2010 and FY 2011 for modifications and close-out costs of 
previously approved contract task orders and for data transfer costs at 
the conclusion of the contract. VA will maintain funding levels for 
Gulf War research as close as possible to the $15 million per year 
recommended in the Senate Committee on Appropriations' report language 
which accompanied the FY 2010 Military Construction and Veterans 
Affairs and Related Agencies Appropriation Bill.
    Even with the unanticipated decision to stop accepting new task 
orders during the latter portion of FY 2009 and to not exercise the 
third option year (FY 2010) of the contract, VA exceeded the $15 
million target for FY 2009 and is currently projecting $9.7 million for 
FY 2010. It is anticipated that additional VA research projects focused 
on the illnesses affecting Gulf War veterans will be identified for 
funding in FY 2010 and beyond as a result of the short- and long-term 
plans described above. Although we are aware that some of our 
stakeholders viewed our decision regarding the UTSW contract as a 
disservice to Gulf War veterans, let me say it again: We are committed 
to the best possible care for this cohort of veterans.
    Outreach: There is a general lack of engagement on, and knowledge 
of, the efforts VA is taking to address the issue of Gulf War veterans' 
illnesses. Additionally, VA has not been consistent in conducting 
targeted outreach, nor in building awareness about Gulf War Illnesses 
and research among the general public and professional communities. VA 
needs a more robust outreach plan which will ensure that there is a 
more inclusive approach when communicating to the Gulf War veteran 
community. In addition, VA should communicate Department-wide to its 
employees about the changes to the rating schedule and presumptions 
related to Gulf War veterans, and will execute an outreach program to 
interested scientists and clinicians in conducting Gulf War Illness 
research.
    As part of the renewed effort to acknowledge and engage Gulf War 
veterans, the GWVI-TF has formulated a proactive outreach strategy that 
combines consolidated strategic communication initiatives with 
educational resources to ensure that Gulf War veterans are informed of 
the benefits and services available to them. We will also be reaching 
out to you, our partners in Congress, to help us provide this 
information to your Gulf War veteran constituents.
Partnering With Our Stakeholders
    VA reviewed and evaluated all the public comments related to the 
draft findings for subsequent inclusion into the final written report 
to the Secretary. This was an unprecedented step for VA to take for any 
task force report, but we believe this course of action was both 
necessary and beneficial to the process.
    The Task Force completed the draft written report on March 29, 
2010. On April 1, 2010 VA released the written report for public 
comment. This was the first initiative in which VA provided two ways 
for veterans to submit feedback on policy proposals. The public was 
notified per a Federal Register notice and a simultaneous outreach 
campaign support by VSOs. The public could make comment two ways: via 
the Your Gulf War Voice Website, or a formal written submission 
directly to VA. The public comment period closed on May 3, 2010.
    The public response was one of the largest in VA's history to a 
proposed rule, regulation, or policy with over 150 suggestions 
submitted, 300 additional comments, and more than 2,100 votes were cast 
by 189 unique public respondents. Despite this outreach effort and the 
robust public response to the draft written report, VA did not reach as 
many veterans as it wanted to reach. Based on the public comments to 
the draft written report, many veterans believed the opportunity to 
comment on this report should have been be posted in all VA facilities 
at the point of service (i.e. waiting areas and vet centers). VA will 
publish subsequent findings and recommendations of the Task Force in a 
public forum for comment and review, and we will consider ways to post 
future Gulf War information in VA facilities.
Conclusion
    In developing this report, VA made every effort to be transparent 
and aggressively advocate for veterans. We strived to hold ourselves 
accountable for our shortcomings, and build on our successes. VA's team 
views this report as a foundation upon which we can collectively build 
iterative future improvements in the care and services VA delivers by 
leveraging the lessons learned by this Task Force across the full 
spectrum of all veteran communities and their families.
    We are keenly aware that not every stakeholder will agree with 
everything in the report. We recognize that there is mistrust among 
some of our stakeholders, and there are many misperceptions. 
Regardless, VA encourages all stakeholders to avoid letting individual 
differences prevent further collaboration or progress for Gulf War 
veterans. We welcome your recommendations and criticisms in the hopes 
of forming a constructive dialogue that results in better services for 
our veterans. VA looks forward to partnering with all stakeholders in 
implementing the Task Force recommendations and devising new strategies 
with the members of the Task Force as they continue to refine the way 
ahead--always with the goal of serving our Gulf War veterans.
    Mr. Chairman, this concludes my testimony. I will be happy to 
respond to any questions from you and the other Members of this 
Subcommittee.

                                 
            Statement of Adrian Atizado, Assistant National
            Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this important hearing to offer our views on the future of 
veterans suffering from Gulf War Illnesses (GWI). The DAV was asked to 
address the following issues in our testimony: the cultural perception 
of GWI; GWI research; Department of Veterans Affairs (VA) medical care 
and benefits for ill Gulf War veterans; education and outreach efforts 
to Gulf War veterans; and the VA's Gulf War Veterans' Illnesses Task 
Force report.
CULTURAL PERCEPTION
    The DAV believes the American people honor and respect the courage 
and contributions of military members, especially those who have made 
the ultimate sacrifice of life or injury as a result of their service. 
Americans strongly support programs that address the needs of the men 
and women who become ill or injured as a consequence of military 
service. To meet those needs, sick and disabled veterans should be 
provided: high quality health care; adequate compensation for losses 
resulting from such service-connected disabilities; vocational 
rehabilitation and/or education to help disabled veterans prepare for, 
and obtain, gainful employment; enhanced opportunities for employment 
and preferential job placement so that the remaining abilities of 
disabled veterans can be adapted or used productively; and effective 
outreach to ensure all veterans are aware of, and receive the benefits 
they have earned.
    Despite the commitment of the American people and Congress, past 
history is replete with examples that the needs of sick and disabled 
veterans have gone wanting, with cynicism, denials, delays, and 
resistance. This is especially true when the wounds of war are not 
visible or well understood. Although one need only look to the latest 
conflicts in Iraq and Afghanistan, one can cite myriad examples from 
the World Wars, Korea, and Vietnam of an absence of beneficence. 
Veterans have faced consistent and strident challenges in gaining 
official recognition of the health consequences of occupational 
exposures that occurred as a result of military service to their 
country. This is especially true of Gulf War veterans and their 
illnesses.
    Articles continue to be published, including those funded by VA and 
the Department of Defense (DoD), that minimize, confuse, or conceal 
information that this Subcommittee has received in testimony at 
previous hearings. These articles claim that symptoms reported by ill 
Gulf War veterans are similar to those experienced by veterans of other 
eras. Yet scientific studies such as those conducted by Dr. Han Kang, 
the principal investigator for the ``Longitudinal Health Study of Gulf 
War Era Veterans,'' \1\ consistently show about 25 percent of Gulf War 
veterans suffered from multi-symptom illnesses compared to non-deployed 
era veterans. His study also found that Gulf veterans reported more 
functional impairments, more limitations on employment, and more health 
care utilization than their non-Gulf veteran peers. However, almost two 
decades after the Persian Gulf War began, still-unanswered questions 
abound about the pain, illnesses, and disabilities afflicting Gulf War 
veterans. We do not have a clear understanding of the risks, causes, 
treatments or long-term outcomes of illnesses suffered by Gulf War 
veterans. These issues require corrective action.
---------------------------------------------------------------------------
    \1\ Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 
10 Years. Journal of Occupational and Environmental Medicine 2009 Apr; 
51(4):401-410.
---------------------------------------------------------------------------
    In VA's rush to restore the health of our latest combat heroes of 
Operations Enduring and Iraqi Freedom (OEF/OIF), VA has not maintained 
a steadfast commitment and adequate efforts to explore the unanswered 
questions of older era veterans. We at DAV are committed to be the 
voice of ill and injured veterans of all eras. We believe that VA must 
retain a steady focus on, and a commitment to find answers to the 
health consequences of military service, especially the illnesses and 
injuries resulting from combat service, including those of the Persian 
Gulf War.
    Congress has many champions who have and continue to fight to 
better the lives of ill Gulf War veterans. Further, the DAV is 
encouraged by the current Secretary of Veterans Affairs, who has 
publicly committed to transform the VA culture to better serve 
veterans; however, it has been a challenge to point to a clear champion 
in this Administration, or a clear plan that will address all the well-
known health concerns associated with our nation's ill Gulf War 
veterans.
GULF WAR ILLNESS RESEARCH
    Each year since the dramatic decline in overall research funding 
for GWI in 2001, the DAV has urged Congress to increase funding for VA 
and DoD research on GWI. The DoD's Congressionally Directed Medical 
Research Program (CDMRP) has managed the Gulf War Illness Research 
Program (GWIRP) since fiscal year (FY) 2006. This program did not 
receive funding in FY 2007, but a $10 million appropriation renewed the 
GWIRP in FY 2008, and $8 million was appropriated for FY 2009 and 2010. 
This year, DAV again supports a recommendation to provide $25 million 
for the GWIRP in FY 2011.
    Mr. Chairman, the CDMRP has funded nine treatment studies, now 
underway, compared to three in the entire previous history of Federal 
GWI research. It focuses on small pilot studies of promising treatments 
already approved for other diseases and is open to all researchers on a 
competitive basis. The DAV urges the Members of this Subcommittee to 
support, and the full House Committee on Appropriations to meet the 
recommended funding level of the Senate for the Gulf War Illness 
Research Program.
                   Diluting Gulf War Illness Research
    The DAV previously testified before this Subcommittee about our 
ongoing concern similar to those issues raised by the Research Advisory 
Committee on Gulf War Veterans' Illnesses (RACGWVI), a committee that 
is directed to evaluate the effectiveness of government research on 
GWI. The RACGWVI has questioned the nature of some VA-funded research 
as to whether these research projects will directly benefit veterans 
suffering from GWI by answering questions most relevant to their 
illnesses and injuries.
    Moreover, we are concerned about expanding the target population 
for GWI research to include veterans who served much more recently in 
OEF/OIF. Although ill Gulf War veterans and OEF/OIF veterans have 
similar concerns about their potential exposures to environmental 
hazards, and while it is true that we are maintaining a continuing 
military presence in Southwest Asia, DAV believes these are 
insufficient reasons to link research in these distinctly different 
populations. We believe research on OEF/OIF health concerns are co-
equally important to that of GWI veterans, but rigorous scientific 
evidence, not assertions, should establish the basis that proves 
expanding the target population of these research efforts does not 
confound results or otherwise diminish the focus on improving the 
health status of ill Gulf War veterans.
    One of the lessons learned from the GWI experience is that 
attention to documentation of environmental and military occupational 
exposures is of utmost importance to our understanding of the health 
consequences of combat exposure. We dramatically reduce our ability to 
find effective casualty prevention measures as well as the chances of 
understanding the causes and linkage to illnesses of combat veterans 
when adequate attention is not devoted to monitoring exposures. The DoD 
made a commitment to correct its deficiencies in documenting and 
monitoring unit locations and potential exposures after the Persian 
Gulf War. However, evidence is growing that this promise has not been 
kept and that DoD has failed to do adequate exposure monitoring once 
again in the wars in Afghanistan and Iraq. Whether it is the magnitude 
of local blast impacts; screening after exposure to blasts; or air, 
water, and soil environmental monitoring, potential exposures have not 
been adequately measured. The DoD should be required to take immediate 
action to correct these deficiencies.
MEDICAL CARE AND BENEFITS FOR ILL GULF WAR VETERANS
              Health Care Benefit Workload and Utilization
    In 1997, VA created the Gulf War Veterans Information System 
(GWVIS) reports to comply with Public Law 102-585, for the purpose of 
identifying Gulf War veterans and monitoring their benefit claims 
activity. Beginning in 2003 these reports included data from VHA \2\ to 
provide some semblance of tracking VA health care utilization.
---------------------------------------------------------------------------
    \2\ February 2003--Gulf War veteran mortality data; May 2003--
Cumulative numbers of inpatient and outpatient health care encounters 
for deployed Gulf War veterans; February 2005--Number of unique Gulf 
War veterans who sought care at Vet Centers; February 2005--Number of 
unique Gulf War veterans enrollment by Priority Group.
---------------------------------------------------------------------------
    As this Subcommittee is aware from a previous hearing, concerns 
regarding the integrity of benefit claims data in the GWVIS reports 
have been confirmed by VA, noting discrepancies in migrating records 
from the Department's legacy database to the new corporate database 
(VETSNET). In addition, VA indicated in its post-hearing response to 
the Subcommittee's question that a review of this migration and 
subsequent erroneous reporting was to be completed by the end of FY 
2009. DAV has not been given the opportunity to be briefed by VA on 
this matter nor have we received the promised reports with accurate 
data that were to be published by the beginning of FY 2010. The DAV 
believes the new reporting will remain suspect until the Department 
provides full disclosure to Congress and the veterans service 
organization community on the specific business rules that caused the 
discrepancy in data migration, the limitations of the new reports, and 
how they differ from reports based on VA's Benefits Delivery Network 
(BDN). In addition to compensation and pension benefits, veterans may 
be eligible for education and training benefits, vocational 
rehabilitation and employment, home loans, dependents' and survivors' 
benefits, life insurance, and burial benefits. Unfortunately, 
information regarding utilization of these benefits by Gulf War 
veterans is unavailable even on GWVIS reports.
    We also note there was a limited run of reporting from May 2003 
until August 2006 of crude but potentially worthwhile data on VA 
inpatient stays and outpatient visits of Gulf War veterans. DAV 
believes VA is capable of producing a more meaningful report on health 
care utilization of GWI veterans. Notably, VA's Office of Public Health 
and Environmental Hazards issues the ``Analysis of VA Health Care 
Utilization Among US Global War on Terrorism (GWOT) Veterans.'' This 
report provides a fairly detailed description of the trends in health 
care utilization and workload of OEF/OIF veterans, diagnostic data, and 
their geographic location with respect to the VA health care system. We 
believe such information should also be gathered on Gulf War veterans 
to allow VA to tailor its health care and disability programs to meet 
the needs of this veteran population. Such information should include 
updated workload and utilization of VA's Vet Centers as well as its War 
Related Illness and Injury Study Centers (WRIISCs).
    The GWVIS reports are the only public reports available regarding 
the VA health and benefits activity of Gulf War veterans. Due to the 
lack of data integrity and granularity, the GWVIS quarterly report 
should be made more comprehensive, since many unanswered questions 
remain that can better describe whether VA benefits are meeting the 
needs of ill Gulf War veterans and whether such veterans are receiving 
the VA benefits they have earned and deserve.
                   Compensation and Pension Benefits
                    Expiration of Presumptive Period
    Public Law 103-446 was enacted in 1994, and serves as hallmark 
legislation to ensure Gulf War veterans suffering from unexplained 
chronic conditions receive just compensation. However, faced with what 
appears to be a dismal record of adjudicating claims based on 
presumptive service connection for GWI without proper analysis by VA, 
and considering that other conditions should be included in the list of 
conditions to be presumptively service-connected due to military 
service in the Persian Gulf War, the delegates to our most recent 
National Convention passed DAV Resolution No. 010, urging the passage 
of legislation to extend indefinitely the presumptive period for 
service connection for ill-defined and undiagnosed illnesses. We urge 
this Subcommittee to ensure this period that, under current law, ends 
on December 31, 2011, does not expire.
                  Delivering All the Benefits Entitled
    Through our corps of highly trained professional National Service 
Officers, who assist veterans and their families in filing claims for 
VA disability compensation, rehabilitation and education programs, 
pensions, death benefits, employment and training programs, and many 
other programs, the DAV has witnessed first-hand how ill Gulf War 
veterans are denied benefits they have earned and deserve.
    DAV applauds the Veterans Benefits Administration's (VBA's) 
issuance of Training Letter 10-01 dated February 4, 2010, to clarify 
VBA's past erroneous interpretations of Section 202 of Public Law 107-
103. This Act established presumptive service connection for GWI 
veterans based on an array of disabling signs and symptoms. The letter 
also affirms past VA variability in applying 38 CFR Sec. 3.317 yielding 
decisions adverse to GWI veterans. In the Training Letter, VBA 
personnel were instructed to recognize that chronic disabilities 
claimed by ill Gulf War veterans, fall under two categories: 
undiagnosed illnesses and ``diagnosed medically unexplained chronic 
multi-symptom illnesses.''
    Medical personnel in general and physicians in particular are 
trained to produce a diagnosis as a basis for treatment. However, such 
a diagnosis is not grounds for denying the claim, since medically 
unexplained chronic multi-symptom illnesses are diagnosable. According 
to VBA, regulations will be proposed to amend Sec. 3.317 to clarify 
that chronic fatigue syndrome, irritable bowel syndrome, and 
fibromyalgia are not the only disability patterns that can be 
considered diagnosable medically unexplained chronic multi-symptom 
illnesses.
    We look forward to the proposed regulations that will also include 
service in Afghanistan and Iraq as qualifying service under all laws 
related to Gulf War and Southwest Asia service. DAV is cautiously 
optimistic the Training Letter and the accompanying regulatory 
amendment will lead to more equitable and favorable resolution of 
claims based on GWI. Equally important, we look forward to measures VBA 
will adopt that will finally address data integrity issues so that data 
gathering and reporting will indeed help determine if these new 
instructions will produce awareness, consistency, and fairness in VBA's 
handling of disability claims from veterans with service in Southwest 
Asia.
                              Health Care
                    ``Special Treatment'' Authority
    In 1993, Congress saw fit to provide ``special treatment 
authority'' in Public Law 103-210 for VA to provide health care to 
veterans who served in the Persian Gulf War in the Southwest Asia 
theater of operations who were exposed to toxic substances or 
environmental hazards. This special treatment authority is similar to 
that given to Vietnam veterans who may have been exposed to 
herbicides.\3\ In 1997, Public Law 105-114 eliminated the requirement 
that the veteran had to be exposed to toxic substances or environmental 
hazards, and only required service in the Southwest Asia theater of 
operations during the Persian Gulf War. In 1998, the authority was 
extended through 2001,\4\ and Public Law 107-135 (115 Stat. 2446) 
provided for another extension through 2002.
---------------------------------------------------------------------------
    \3\ Public Law 97-72 (95 Stat. 1047).
    \4\ Public Law 105-368 (112 Stat. 3315).
---------------------------------------------------------------------------
    We thank the Members of this Subcommittee and of the full Committee 
for reporting S. 1963, the Caregivers and Veterans Omnibus Health 
Services Act of 2010, and we thank the full Congress for enactment of 
that bill, now Public Law 111-163, to address the lapse in this special 
treatment authority that ended in 2002 by making it permanent. Studies 
have found prescription drugs and over the counter (OTC) medicines were 
by far the most common treatments that were used for multi-symptom 
illness of Gulf War veterans. Treatment by relaxation therapy, mental 
health providers (psychologist, psychiatrist, and trained counselor), 
herbal medicine, sleep study, and therapeutic massage have been found 
to be the most common treatments that reduced GWI symptoms. This 
permanent authority will allow ill Gulf War veterans continued access 
to VA health care and specialized services provided through the VA's 
WRIISCs.
              Need for Effective Evidence-Based Treatment
    Over 18 years after the war, studies continue to indicate that few 
veterans with GWI have recovered, or have substantially improved over 
time. To address this matter, VA providers who are treating Gulf War 
veterans' illnesses must have effective evidence-based treatment 
protocols supported by research studies. The myriad symptoms 
experienced by Gulf War veterans make it very difficult for physicians 
to diagnose and treat a specific illness. Correspondingly, Gulf War 
veterans who experience little to no relief from their unique health 
problems are frustrated at best.
    Although more is known today about the nature and causes of GWI, 
important questions remain about improving the lives of ill Gulf War 
veterans. As this Subcommittee is aware, an important gap in our 
knowledge exists about effective evidence-based treatment for GWI. The 
DAV believes more research is needed to advance the knowledge, and 
promote innovative and effective evidence-based care, to improve the 
health and quality of life of ill Gulf War veterans. Notably, the 8th 
report in the Gulf War and Health series from the Institute of Medicine 
(IOM) recommends a renewed research effort to identify and treat multi-
symptom illnesses in Gulf War veterans. While we are hopeful the FY 
2010 GWIRP will identify and provide effective interventions for 
veterans with GWI with additional appropriations being recommended in 
the FY 2011 Defense Appropriations Act, the IOM noted inadequate 
numbers of clinical trials have been undertaken to develop more 
effective and evidence-based treatments for multi-symptom illness.
    We thank the Subcommittee for holding hearings last year to explore 
concerns raised by the veteran community and the RACGWVI on GWI 
research that influences efforts by the research community to, among 
other things, identify effective treatments for GWI. Since this 
hearing, the RACGWVI and the IOM have come to an agreement that chronic 
multisymptom illness is a diagnostic entity associated with service 
during the Gulf War, and affecting approximately 250,000 veterans. 
Chronic multisymptom illness is likely the result of genetic and 
environmental factors and cannot be attributed to stress or other 
psychiatric disorders. Finally, both agree a major national research 
program is urgently needed to identify treatments.
    These agreements are critical toward establishing a much needed 
comprehensive plan to address specific priority research topics. 
Accordingly, DAV is concerned with VA's announcement funding $2.8 
million for three new research projects without such a plan. Moreover, 
we are concerned the new steering committee established to guide VA's 
research program on GWI was not consulted prior to the Department's 
announcement and that the projects would not favor research involving 
psychological aspects of chronic multisymptom illness in light of the 
agreement on this matter by the RACGWVI and the IOM.
                        Tailoring VA Health Care
    Gulf War veterans are being diagnosed and treated for a wide 
variety of illnesses and injuries that we believe are consequential to 
their military service. The DAV has learned that it is important to 
distinguish the poorly understood, multi-symptom conditions defined as 
GWI from other diagnosable medical conditions suffered by Persian Gulf 
War veterans. GWI is a complex of chronic symptoms found at high rates 
in Gulf War veterans that is not easily explained by standard medical 
tests and diagnoses. Other health issues that are associated with 
Persian Gulf War service include amyotrophic lateral sclerosis (ALS) 
and brain cancers in servicemembers who were exposed to the Khamisiyah 
demolitions. The RACGWVI estimated that as many as 175,000 veterans, or 
one in four of those who deployed in the Persian Gulf War, remain ill 
after their service. Given the magnitude of the problem and the numbers 
of veterans affected, DAV is concerned the Veterans Health 
Administration (VHA) is not focusing appropriate efforts and resources 
to address the needs of this population.
    For example, in 1999, the National Academy of Science (NAS) 
recommended that VA establish centers for the study of war related 
illnesses similar in structure to VA's Geriatric Research Education, 
and Clinical Centers to apply a proven model of care, research, and 
education to the issue of deployment health. Such centers would, if 
established, contribute greatly to the advancement of knowledge in this 
area.
    The DAV applauded the establishment of VA's WRIISCs located at VA 
medical centers in Washington, DC, East Orange, New Jersey, and Palo 
Alto, California. These centers offer tertiary medical consultation and 
clinical programs staffed with multi-disciplinary teams of clinicians 
focused on the deployment health concerns of combat veterans, including 
those with difficult-to-diagnose or medically unexplained symptoms. The 
WRIISCs are tasked with assisting VA providers to understand veterans' 
deployment-related health challenges, provide lessons learned to 
deliver optimal person-centered care, and perform cutting edge 
investigations and research.
    The WRIISCs have a central and important role in VA's health care 
program for veterans with post-deployment health problems. Despite this 
important role, VA has not devoted adequate attention or resources to 
the education of its staff, or outreach to veterans, to make them aware 
of these programs. We hear time and again from ill Gulf War veterans 
that their VA or private sector providers did not make them aware of 
the information, consultation opportunity, and expertise of the 
WRIISCs. We believe this VA national resource remains largely 
unrecognized and underutilized. As a practical matter, DAV believes 
clinical reminders should be used to prompt VA primary care providers 
to ensure the military history of ill Gulf War veterans is made part of 
the electronic medical record, exposure examinations are conducted and 
open pathways to the WRIISCs are provided.
    VA's core missions are to provide comprehensive prevention, 
diagnosis, treatment and compensation services to veterans who suffer 
from service-related illnesses and injuries. Service-related illnesses 
and injuries, by definition, are military occupational conditions. 
Accordingly, we believe VA should devise systems, expertise, and 
recruit and train the necessary experts to deliver these high quality 
occupational health services.
    Occupational Health is a medical specialty devoted to improving 
worker health and safety through surveillance, prevention, and clinical 
care activities. Doctors and nurses with these skills could provide the 
foundation for VHA's post-deployment health clinics, enhanced exposure 
assessment programs, and improve the quality of disability evaluations 
for VBA Compensation and Pension (C&P) Service. VA should consider 
establishing a holistic, multi-disciplinary post-deployment health 
service, led by occupational health specialists, at every VA medical 
center. Moreover, these clinics could be linked with the WRIISCs in a 
hub-and-spoke pattern to deliver enhanced care and disability 
assessments to veterans with post-deployment health concerns. To 
achieve this ideal arrangement, the WRIISCs and post-deployment 
occupational health clinics would be charged to----

      Work collaboratively with DoD environment and 
occupational health programs;
      Identify and assess military and deployment-related 
workplace hazards;
      Track and investigate patterns of military and veterans' 
work-related injury and illness;
      Develop training and informational materials for VA and 
private sector providers on post-deployment health;
      Provide assistance to other VA providers to prevent work-
related injury and illness; and
      Work collaboratively with DoD partners to reduce service-
related illness and injury, develop safer practices and improve 
preventive standards.

    Likewise, VA needs to improve the capability of its primary care 
providers to recognize and evaluate post-deployment health concerns. VA 
and DoD jointly developed the Post-Deployment Health Clinical Practice 
Guideline to assist primary care clinicians in evaluating and treating 
individuals with deployment-related health concerns and conditions. 
This guideline uses an algorithm-based, stepped care approach, which 
emphasizes systematic diagnosis and evaluation, clinical risk 
communication, and longitudinal follow-up.
    On July 26, 2007, VA's testimony before the Subcommittee on 
Health's hearing included how a health care provider treats a veteran's 
GWI. VA stated that a provider must, ``go through a very long list of 
clinical possibilities, take them one at a time, and examine each one 
fully and do the right diagnostics and try and treat them one at a 
time.'' Anecdotal reports and Departmental data indicate that VA 
primary care providers are already stretched thin to deliver routine 
acute, chronic and preventive care within their short clinic visits. 
The complex, chronic conditions afflicting veterans with GWI cannot be 
adequately addressed in a routine visit with a stressed primary care 
provider. We believe VA providers must gain the opportunity to refer 
such patients to specialized post-deployment occupational health 
clinics, and to the WRIISCs for the most complex problems of war-
exposed veterans with GWI. Veterans suffering from GWI require a 
holistic approach to the care they receive to improve their health 
status and quality of life. VA must establish a system of post-
deployment occupational health care if it is to meet its mission and 
deliver on veteran-centered care.
GULF WAR VETERAN EDUCATION AND OUTREACH
    Education and outreach is only effective if the information 
provided is timely and accurate, and it penetrates and permeates the 
target audience. The DAV recently had the opportunity to assist a North 
Carolina veteran suffering from GWI. His primary care physician had 
attempted to treat the veteran's symptoms, to no avail. The veteran 
contacted our office for assistance and we recommended the veteran ask 
his physician to seek assistance from the WRIISC located in Washington, 
DC. Unfortunately, the veteran and his physician were not aware of the 
WRIISC or how to contact that center. They were not aware of the 
information available on the internet \5\ regarding the WRIISC's 
national referral program allowing the veteran to self-refer, nor that 
the primary care physician is able to use the WRIISC referral template 
in VA's Computerized Patient Record System.
---------------------------------------------------------------------------
    \5\ http://www.warrelatedillness.va.gov/.
---------------------------------------------------------------------------
    While in the case of the veteran above, telehealth consultation 
between the WRIISC, the veteran, and his primary care provider was used 
to improve the treatment being provided, DAV is concerned that this one 
example, combined with 2007 VA data showing only 344 veterans have been 
evaluated between the East Orange, New Jersey, and Washington, DC, 
WRIISCs since 2001, is indicative of underutilization of this national 
resource.
    We continue to receive reports from ill Gulf War veterans who 
remain confused about specific VA health care programs for GWI. For 
example, recently we were contacted by a veteran who was under the 
impression that the Persian Gulf War Registry and examinations for 
entry on the Registry had been halted. We have no doubt other Gulf War 
veterans maintain this perception due to a number of factors.
    The individual responsible for the Gulf War Registry program at 
each VA medical center was previously called the ``Persian Gulf 
Coordinator.'' Soon after OEF/OIF began, this position was renamed the 
``Environmental Health Coordinator.'' The change in name sought to 
recognize the environmental exposures that affected Persian Gulf War 
veterans may also affect OEF/OIF veterans since they are deployed to 
the same general region. Moreover, OEF/OIF veterans were also exposed 
to other toxins such as Hexavalent chromium (at the Qarmat Ali water 
treatment plant in Basra, Iraq), burn pit smoke in several theater 
locations, and other contaminants.
    While the Environmental Health Coordinator is responsible for the 
administrative management of the Gulf War Registry, schedules veteran 
patients for exposure examinations, and monitors timeliness compliance, 
the Environmental Health Clinician is responsible for the program's 
clinical management and performs the actual examinations. Although each 
VAMC provides access to environmental health clinicians and 
coordinators, there is variability in knowledge and practice among 
VAMCs as to when and how to conduct exposure assessments.
    The DAV is appreciative of the work done by VA's Office of Public 
Health and Environmental Hazards' website to make access more user-
friendly and provide pertinent information that may be useful to ill 
Gulf War veterans and their health providers. Now available to the 
public is a directory of local VA Environmental Health Coordinators & 
Health Clinicians at http://www.publichealth.va.gov/exposures/
eh_coordinators.asp. Direct telephone numbers to the Environmental 
Agents Service is also on this webpage for veterans to call with any 
questions or concerns regarding this program.\6\
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    \6\ (202) 461-1013 or (202) 461-1014.
---------------------------------------------------------------------------
    To assist ill Gulf War veterans seeking benefits and medical care, 
VA has made available a VA Gulf War Information Helpline 1 (800) PGW-
VETS (1-800-749-8387). As a veteran of the Persian Gulf War, I called 
this Helpline four times in October 2009 to ask for information on 
whether VA had specific treatments for GWI. This telephone service 
offers an automated message providing health care information, specific 
to Khamisiyah and other Gulf War exposures, and eligibility information 
was also provided. When I was able to speak to three individuals on 
three separate telephone calls, all asked if I had participated in the 
Gulf War Registry and if I had filed a claim for compensation benefits. 
When I asked whether VA had specialized treatments or a specialized 
center or clinic for veterans suffering from GWI, one indicated that if 
I were to enroll into the VA health care system that I would most 
likely be seen by a local VA specialist based on each physical 
complaint. The other two stated that the local VA clinic or hospital 
would see to my specific health concerns. Only one mentioned my 
contacting the Gulf War Coordinator at my local facility. None, 
however, mentioned the WRIISCs or referred me to VA's website for the 
Office of Public Health and Environmental Hazards cited above.
    Notably, these calls are routed to one of eight VA call centers,\7\ 
which VA's Office of Inspector General (OIG) audited in 2009 and issued 
Report No. 09-01968-150 on May 13, 2010. The OIG concluded that any one 
call placed by a unique caller had just a 49 percent chance of reaching 
an agent and getting correct information.
---------------------------------------------------------------------------
    \7\ Cleveland, OH; Philadelphia, PA; Columbia, SC; Nashville, TN; 
Muskogee, OK; St. Louis, MO; Phoenix, AZ; Salt Lake City, UT.
---------------------------------------------------------------------------
    VA's Gulf War Information Helpline has now been merged with a 
resource that assists surviving spouses seeking VA benefits, and is now 
called the Survivors Call Center and Veterans Special Issues Help Line. 
I recently called the toll free number. It prompts the caller to select 
assistance for survivor benefits or exposure issues, including those 
related to the Gulf War. A caller's selecting Gulf War issues brings an 
automated message with information regarding exposure to nerve agents 
from Khamisiyah and provides information on VA's special exposure 
examination and benefits as well as an online computer bulletin board.
    If not directly routed to an agent, the automated help line offers 
four options for information on Persian Gulf benefits and services, 
including medical benefits, disability compensation, and an option to 
speak with a representative. Having called four times, two agents 
referred me to my local VA medical center and regional office, with one 
urging me to file an informal claim over the phone if I had not already 
done so. The other two agents mentioned the Persian Gulf War Registry 
and provided the telephone number and extension of the respective 
Environmental Agents Coordinators. Mr. Chairman, while not perfect, 
this is an improvement towards standardization of responses and quality 
of information provided from the calls I made nine months prior.
GULF WAR VETERANS' ILLNESSES TASK FORCE (GWVI-TF)
    This Subcommittee asked DAV to provide our position on the March 
29, 2010, GWVI-TF draft report which was subject to a notice with a 
request for comments by May 3, 2010 in the Federal Register. After VA's 
review of all comments and recommendations related to the draft report, 
an updated version of the report will be released. We appreciate the 
effort taken by the GWVI-TF to produce the recommendations under seven 
broad categories: Partnerships, Benefits; Clinician Education and 
Training; Ongoing Scientific Reviews and Population Based Surveillance; 
Enhanced Medical Surveillance of Potential Hazardous Exposures; 
Research and Development; and Outreach.
    This draft report is subject to change pending review of public 
comments, but DAV generally agrees with its overarching goal to improve 
services to meet the needs of veterans of the Persian Gulf War. As 
stated above, DAV believes VA must aggressively pursue answers to the 
health consequences of veterans' Gulf War service and that the 
Department must not reduce its commitment to VHA programs that address 
health care and research or VBA programs that meet the unique needs of 
ill Gulf War veterans.
    We note some of the recommendations made in the draft report are 
not new and have been the subject of inaction for several years without 
appreciable results. For example, both DoD and VA are required to 
exchange health information and to develop systems that allow for 
interoperability of information between the two agencies. However, both 
departments have been working toward electronic medical record 
compatibility for more than a decade. While progress has been made and 
the departments are sharing more information, such as exchanging 
computable pharmacy and drug allergy data, according to the Government 
Accountability Office, the departments were not sharing all electronic 
health data, including for example, immunization records and history, 
data on exposure to health hazards, and psychological health treatment 
and care records. Moreover, although VA's health information was all 
captured electronically, not all health data collected by DoD were 
electronic--many DoD medical facilities still use paper-based health 
records.\8\
---------------------------------------------------------------------------
    \8\ GAO-09-268.
---------------------------------------------------------------------------
    As this Subcommittee is aware, there are two plans that contain 
objectives, initiatives, and activities related to further increasing 
health information sharing, the VA/DoD Joint Executive Council 
Strategic Plan (VA/DoD Joint Strategic Plan) and the DoD/VA Information 
Interoperability Plan (IIP). We are concerned the recommendations in 
this draft report do not link to these two plans, which are key 
documents in defining planned efforts to provide interoperable health 
records. We do agree with the recommendation to establish partnerships 
particularly with the Joint Interagency Program Office, to function as 
a single point of accountability for accelerating the exchange of 
health information between VA and DoD.
    The draft report also makes recommendations regarding the claims 
processing procedures and training of personnel related to adjudicating 
disability claims based on Gulf War undiagnosed illnesses and medically 
unexplained chronic multi-symptom illnesses. We direct the 
Subcommittee's attention to our views on this matter in this testimony 
under the heading, ``Delivering All the Benefits Entitled.''
    Another longstanding issue on which DAV has called for action is 
revamping the outdated and ineffectual education and training tools 
regarding Gulf War exposures, health outcomes and research that are 
currently used to prepare VHA and VBA personnel in caring for and 
assisting ill Gulf War veterans. The Veterans Health Initiative on Gulf 
War Veterans' Health is an independent study guide developed to provide 
a background for VA health care providers on the Gulf War experience 
and common symptoms and diagnoses of Gulf War veterans. We note, this 
guide was released and last revised in 2002. The information in the 
guidebook must be reviewed and revised to include the latest research 
findings and clinical guidelines. In addition, VA must assess the 
effectiveness of this guidebook and determine if another format should 
be used that would be more easily accessed and consumed by VHA and VBA 
personnel.
    Additionally, while the GWVI-TF agrees with the RACGWVI that 
identification of new treatments for ill Gulf War veterans is a high 
priority, it is not highlighted or reflected as a central issue in the 
draft report. The need for effective treatment is a central issue 
identified by the IOM, the RACGWVI, and the 25 to 32 percent of the 
700,000 deployed Gulf War veterans suffering with multi-symptom 
illnesses. We direct the Subcommittee's attention to our views on this 
matter in this testimony under the heading, ``Need for Effective 
Evidence-Based Treatment.''
    Along the same lines as identifying effective treatment of GWI and 
disseminating such information to VA providers to improve the 
Department's clinical care focus on GWI, DAV believes VA should 
consider establishing a post-deployment health service led by 
occupational health specialists at every VAMC and that these clinics 
could be linked in a hub-and-spoke pattern with the WRIISCs to deliver 
enhanced care and disability assessments to veterans with post-
deployment health concerns. VA must establish a system of post-
deployment occupational health care if it is to meet its mission and 
deliver on veteran-centered care to veterans suffering from GWI and 
other veteran population suffering from other hazardous environmental 
and other toxic exposures.
CONCLUSION
    Mr. Chairman, it is apparent to DAV that VA has a number of 
programs aimed at patients and providers to assist ill Gulf War 
veterans. However, VA's approach to the needs of this veteran 
population has become parochial and fragmented. DAV believes much work 
remains to ensure Federal benefits and services are adapted to meet the 
unique needs of veterans suffering from GWI. VA must find ways to meet 
its obligation to care for the newest and prior generations of disabled 
veterans without diverting its attention from the actions needed to 
find the means to diagnose, treat, and cure GWI. DAV believes the 
answers lie in medical surveillance, high quality health care, and 
research. Where cure remains elusive, VA must provide timely, 
accessible, responsive, and equitable benefits and compensation for 
those who suffer chronic illnesses and disability. Our nation requires 
no less.
    Veterans suffering from GWI who file claims for service connection 
for undiagnosed illness must contend with a slow process that has a low 
success rate. Moreover, if they seek care at VA, they often receive a 
combination of piecemeal interventions and symptom-based treatments, 
about which all longitudinal studies that have evaluated the health of 
veterans suffering from GWI have reported little improvement.\9\
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    \9\ Research Advisory Committee on Gulf War Veterans' Illnesses. 
Gulf War Illness and the Health of Gulf War Veterans: Scientific 
Findings and Recommendations. Washington, DC: U.S. Government Printing 
Office, November 2008.
---------------------------------------------------------------------------
    We believe many ill Gulf War veterans have stopped turning to VA or 
worse have simply given up seeking any type of assistance. We hope some 
of the recommendations made in this testimony will be seriously 
considered. Otherwise, providers can only try to teach ill Gulf War 
veterans how to choose a lifestyle adapted to their disabilities 
incurred in service in the Persian Gulf War without substantial 
improvements in their health. As stated at the beginning of this 
testimony, there is a great need for a true champion from the 
Administration who will challenge VA to provide a clear path for 
progress to systematically address GWI issues and ensure that Federal 
programs aimed at meeting the extraordinary needs of veterans suffering 
from GWI are adapted to meet them.
    Mr. Chairman, DAV thanks the Subcommittee for the opportunity to 
testify and for your efforts in highlighting the needs of our nation's 
ill Gulf War veterans. This concludes my statement. I will be pleased 
to respond for the record of this hearing to any questions you may wish 
to ask with respect to these issues.

                                 
                  Statement of Kirt P. Love, Director,
               Desert Storm Battle Registry, Crawford, TX
    Dear Distinguished Committee Members:
    My name is Kirt Love, and I served in the Army as part of C. Co. 
141 Signal Battalion while in Operation Desert Shield/Desert Storm in 
1990-1991. At this time I am 60 percent service connected but only 
after a long 8-year fight with VA to do so. There had been two 
Presidentials involved in my case and finally a meeting with Sec. 
Anthony Principi staff after a VBA appeal hearing in DC to get what 
little I have. It shouldn't have been that way to begin with.
    My protracted illness was gradual and by 1993 I was having such 
health problems that I lost my home. I moved in with a kind friend as I 
lingered in much of 1993 and 1994 in a death bed. By then food was like 
broken glass, and water like battery acid--I was passing my intestinal 
lining in sheets as a host of other problems made this worse. The 
doctors of that day had no clue, and only after trying an old 
veterinarian remedy did I improve enough to regain some function. VA 
never figured out what was affecting me then or now.
    By 1996 I wanted to understand what had happened to me and started 
looking into what happened to our unit during the war. I learned of 
OSAGWI and began digging on their Web site to find out more. By 1997 I 
launched a Web site of my own to find other vets and compare their own 
experiences with my own. I called my effort the ``Desert Storm Battle 
Registry'' to see if the other ground troops had similar issues.
    By late 1997 I inventoried the whole DoD OSAGWI declass file server 
and sent them a list of the over 400 files they had pulled from that 
server. This became my battle cry as it turned out there were over 
6,000,000 files they would not release, and only a heavily censored 
43,000 the public would see. At a staggering cost of $150,000,000 to 
declassify that project and then conceal it from the public. Without 
those records veterans such as myself had no real substantive evidence 
in support of what we saw during the war. Like the massive chemical 
weapons demolitions around my unit in March 1991 that DoD still to this 
day wants to ignore.
    Around 1999 I was meeting with multiple entities on the Hill such 
as the IOM, GAO, Pentagon, PSOB, MHVCB, OSAGWI, and others concerning 
our plight. The tone was different then because there was oversight all 
around us. By 2000 that all changed, and by 2001 grass roots groups 
were no longer welcome at the Pentagon. That would lead to a 10-year 
decline as veterans were cut off and kept at bay. This I would witness 
first hand and up close as OSAGWI stopped meeting with veterans. Why, 
oversight was gone. VA and DoD took advantage of that.
    By 2002 the GW Research Advisory Committee would be the only entity 
left that had any input in Gulf War issues. But, they were only 
research and this didn't help with the benefit/healthcare issues. The 
years would pass and VA would make sure that anything related to Gulf 
War was invisible. Programs would go largely ignored and the title 
removed so that veterans couldn't figure out how they changed. i.e., A 
Gulf War Referral Center would become a War Related Illness and Injury 
Study Center. Well, we still couldn't get a referral if we didn't know 
it existed.
    After hounding the RAC for years it became necessary to push for 
another entity. I started in 2006 by proposing the need for another GW 
coordinating board which is listed in PL 105-368. Others talked me down 
to an Advisory Committee, and by 2007 the RAC finally made the 
recommendation to VA for this. The support was soft and they failed to 
get it. I repackaged this, and sent it through Rep. Chet Edwards. Sec. 
James Peake agreed to the idea. Of which I then pushed to get on this 
Committee. I did, and then started the slow process of collecting data.
    Problem here was VA took advantage of the way the proposal was made 
to give the Committee an 18-month lifespan and then put ringers on it. 
Namely, choosing a former Undersecretary of Personnel and Readiness at 
the Pentagon to Chair the Committee. Many didn't understand, at one 
time he was in charge of OSAGWI but not quite in the same capacity as 
former Bernard Rostker. This would become apparent when the Committee 
toured and its fact finding was passive at best. It showed that the 
Chairman had his own agenda and wanted this Committee disbanded as 
quickly as possible. So the results were thin, rushed, and the 
Committee was quickly disbanded before its deadline without so much as 
a press release at the end. I was so displeased with the report I 
dissented at the end, but kept it simple and cited the PDICI as my 
primary complaint. In truth, much of what I wanted didn't make it into 
the report and I found myself largely censored as well as continuously 
chastised by Cragin to scare the others into duplicity with his 
desires. It was a mostly good ole boy network of former friends of his 
which gave him controlling interest in the final votes.
    By Feb 2009 VA would release its August 2008 GWVIS report. Within 3 
hours of its release I found numerous problems with the report. 
Comparing it back to the February 2008 report there were massive 
numerical changes. Rather than 290,195 files claimed by Gulf war vets, 
VA was saying it had gone down to 258,317. A loss of 31,878 vets who 
had applied for benefits. There would be over 8 categories of similar 
numerical changes of 10 percent or more to the negative. So I wrote VA 
and told them of what I had found. I told my Committee and they didn't 
care. From Feb 11th 2009 to April 6th 2008 VA ignored my letter. Even 
tried to tell me to start from scratch on my request for that data. My 
committee also ignored this until finally Gerald Johnson dropped the 
ball that then got passed to Thomas Kniffen. This by then had gotten 
silly enough that Chairman Cragin saw the need to step in. By June 30th 
2009 a subcommittee of the ACGWV met with VBA to discuss the GWVIS.
    VBA made promises to revamp the whole GWVIS structure and reports. 
Well, a year has passed since the promise and even today they do not 
have anything to show your committee on the progress of how these 
reports have improved. They were to be published July 27th 2010 and I 
called VBA to find it won't happen.
    Our committees last meeting would be with Chief of Staff John 
Gingrich. He announced the Gulf War Illness Task Force that he would 
Chair. There would be a continuing Gulf War presence at VA and then 
there would be a report of their own shortly. But, the Task Force was 
comprised only of 25 internal VA staff that did not have to share their 
daily work with the public. There would be no Web site, public 
meetings, or interaction with them externally. By the time they 
published that report it was painfully apparent that it was being 
controlled by legacy government personnel providing bad input to send 
things backwards. The heavy IOM influence and the desire to bring the 
invisible Deployment Health Working Group was a severe blow of past 
dysfunction trying to be resurrected. If it didn't work before, how 
would it improve by bringing it back. Fortunately, the COS would allow 
public comments of the report which over 200 of us would provide over 
250 pages of materials to that effect. I myself posted the first 10 
ideas online within hours of this Web site launch, and pushed hard over 
30 days to get others to do the same.
    All said and done, July 22nd 2010 VA announces Gulf War medical 
research studies. An exercise study, anti depressant study, mind based 
stress reduction study. It's like 1997 all over again. There are no new 
specialized external clinics, no new programs, and anything related to 
our plight that is no more visible now than in 2009. I myself have 
great reason to be distressed as 20 years after the war find my own 
current VA medical care no better than when I started my odyssey back 
in 1993. That despite my best efforts to say the obvious to VA and 
fight its upper ranks they still don't listen. Rather than be more 
public they are now more reclusive and invisible than ever. I can't get 
straight answers from VA after having been on a Federal committee. They 
have ignored Rep. Chet Edwards' request that I be included in the Task 
Force work as a subject matter expert.
    This letter could have been 20 pages long with a tremendous amount 
of other details. This has been condensed for the sake of this hearing. 
But, it's high time that one of Congress' Committees needs to step in 
and take a hard stance with VA on its very form and function. Gulf War 
veterans deserve better and we should have a voice in our medical care 
as well as benefits. This hearing will not be enough to do that fact if 
you base it solely on what data you collect today. We need an oversight 
body attached to VA on GW issues that doesn't go away in 18 months. 
Without oversight our issue will languish another 20 years. Thank you 
for your time.

            Sincerely,

                                                       Kirt P. Love
                                                     Director, DSBR
                                               Former member: ACGWV
                                    52D-C. Co. 141 Signal Battalion

                                 
          Statement of Vivianne Cisneros Wersel, Au.D., Chair,
    Government Relations Committee, Gold Star Wives of America, Inc.
       ``With malice toward none; with charity for all; with firmness 
in the right, as God gives us to see right, let us strive to finish the 
work we are in; to bind up the nation's wounds, to care for him who has 
borne the battle, his widow and his orphan.''
        . . . President Abraham Lincoln, Second Inaugural Address, 
March 4, 1865

    Mr. Chairman and Members of the Subcommittee, I am Vivianne Wersel, 
the Chair of the Gold Star Wives' Government Relations Committee. Thank 
you for the opportunity to submit this statement for the record on 
behalf of Gold Star Wives of America. I am the surviving spouse of Lt 
Col Rich Wersel, Jr. USMC who died suddenly on February 4, 2005, one 
week after he returned from his second tour of duty in Iraq.
    Gold Star Wives of America, Incorporated, founded in 1945, is a 
congressionally chartered organization of spouses of servicemembers who 
died while on active duty or who died as the result of a service-
connected disability. Our current members are widows and widowers of 
military members who served during World War II, the Korean War, the 
Vietnam War, the Gulf War, the conflicts in both Iraq and Afghanistan, 
and every period in between.
    Gold Star Wives is an organization of those who are left behind 
when our nation's heroes, bearing the burden of freedom for all of us, 
have fallen. We are that family minus one; we are spouses and children, 
all having suffered the unbearable loss of losing our spouses or 
fathers/mothers. We are those whom Abraham Lincoln referred when he 
made the government's commitment ``to care for him who shall have borne 
the battle, and for his widow, and his orphan''.
    Today, we highlight important areas of concern regarding survivors 
of those servicemembers who died as the result of an illness from the 
Gulf War.
         Gulf War Illness: The Future of Dissatisfied Veterans
    We would like to speak to you on behalf of Gulf War veterans who 
can't speak for themselves. They either died during that conflict, or 
died later of a service connected illness or injury. GSW represents 
their survivors.
    The Secretary of the Veteran's Administration should revisit the 
Persian resulting from their service Gulf War Veterans Registry that 
was established under Title 38, Part 2, Chapter 11, Subsection 11, 
Section 107, ``Evaluation of Health Status of Spouses and Children of 
Persian Gulf Veterans.'' The program was established to evaluate the 
health status of spouses and children of Persian Gulf War veterans of 
1990-1991. The program was funded to not exceed $2,000,000 and covered 
a period of time from November 1, 1994 to December 31, 2003. According 
to the report: Gulf War Illness and the Health of Gulf War Veterans: 
Scientific Findings and Recommendations published in November 2008, 
``No information from VA's Gulf War family registry program has ever 
been issued.'' Most military families do not have access to Federal 
Register publications to receive government information, much less 
reply within a specified period of time. Certain spouses and children 
of this war continue to suffer illnesses and disorders, as written in 
the media and reported by veterans and their families. The registry 
should be revisited and the results made available to those who 
registered, or need to be registered. VA should publicly broadcast the 
opening of such a registry to veterans, spouses and children.
    We are pleased that the Secretary has recognized that the Gulf War 
veteran's illness is real, and is providing Gulf War veterans the same 
respect given to Iraq/Afghanistan veterans at VA clinics and hospitals. 
Full honor and respect should be given to all veterans in need of 
medical care. No servicemember should suffer a long term illness and/or 
death because of denied medical care, and no family should witness such 
a death.
    We acknowledge improvements on the handling of medical claims and 
evaluations of veteran's ratings for compensations. However, more work 
needs to be done for the surviving spouses and children. It is our 
sincere and strong desire to see the repeal of the SBP/DIC offset for 
surviving spouses of Gulf War veterans. The offset is an injustice that 
has been recognized by Congress, The Military Coalition, and the 
National Military and Veterans Alliance.
    Many Gulf War veterans' claims were inappropriately processed and 
the veterans received a much lower disability rating than they should 
have received. In some cases, veterans who were inappropriately rated, 
or even worse yet, whose claims were denied, died of the service 
connected cause within a short time. Their survivors were left without 
the entitled benefits or had to re-file the claim after the death of 
the loved one, if they even knew to do so.
    GSW applauds Congress for the recent legislation that benefits 
caregivers of wounded warriors who were injured on active duty after 9-
11-2001. However, we are unhappy that wounded warriors and the 
caregivers of wounded warriors from past wars were excluded from this 
legislation. Such exclusions demean the contributions and service to 
this country of those who served in past wars and sacrificed their 
health to serve this country. Many of those who were injured or ill 
from past wars are in need of caregiving assistance as much as those 
injured or ill after 9-11-2001.
    Children born to those who served in the Gulf War, who were once 
referred to as Desert Stork Babies, are now of college age. These 
children, who lost a parent who was serving in the military or due to 
that service, are eligible for education benefits under Chapter 35, 
Dependents Educational Assistance. Chapter 35 benefits do not provide 
enough to cover today's college tuition and expenses. Under the New GI 
Bill, children of servicemembers who died on active duty after 9-11-
2001 are eligible for the Gunnery Sergeant John David Fry Scholarship 
which provides adequate financial support for 36 academic months. The 
children whose parent died prior to 9-11-2001 were not included.
    The Survivor Benefit Plan (SBP) annuity for surviving spouses is 
offset dollar-for-dollar by the amount of Dependents Indemnity 
Compensation (DIC) a surviving spouse receives. The surviving spouses 
of those who died on active duty after 9-11-2001 are allowed to assign 
the SBP benefit to the children of the servicemember; the children 
receive the benefit until they reach the age of 22. Once again, the 
children of those who died on active duty or as a result of their 
service prior to 9-11-2001 were not included in this option.
    Children of those who died on active duty after 9-11-2001 receive 
active duty TRICARE coverage and dental insurance until they reach the 
age of 23 (if enrolled full-time in school), but children of 
servicemembers who died on active duty prior to 9-11-2001 had 3 years 
of transitional active duty TRICARE, and then were switched to retired 
TRICARE coverage and had to pay premiums or deductibles. Children of 
those who died in retirement receive retired TRICARE and must also pay 
cost shares, deductibles and co-pays.
    Appropriate VA bereavement counseling is often not available or 
readily accessible. The only other option available for bereavement 
counseling is to use TRICARE or CHAMPVA; those who use TRICARE or 
CHAMPVA must not only pay a fee for each visit, but bereavement 
counseling results in a diagnostic code for either situational 
depression or clinical depression. These diagnoses can later be 
detrimental to the individual when applying for a job or schooling. 
Mental health counseling using TRICARE Prime requires co pays of $17 
(group session) or $25 (individual session) per visit, if seen outside 
the military treatment facility. Those on TRICARE Extra or TRICARE 
Standard, incur co pays of 15 percent and 20 percent respectively. For 
a family with a surviving spouse and three children the cost can be 
prohibitively expensive.
    Many of these surviving spouses and children not only participated 
in the care of the veteran, but also witnessed the death. Caregivers 
often suffer from a form of PTSD due to the care they provide for the 
disabled veterans. No counseling or support is provided for the 
caregivers who care for veterans who were disabled as the result of 
service prior to 9-11-2001.
    All surviving spouses should have a casualty assistance officer 
assigned to assist them with planning the funeral and in obtaining the 
benefits that are due to them. While surviving spouses of those who die 
on active duty are assigned a casualty assistance officer, surviving 
spouses of those who died of a service connected disability and/or in 
retirement are not assigned a casualty assistance officer. As a result, 
these surviving spouses often are not aware of the benefits for which 
they are eligible or the time limits for filing claims.
    The Army has established Survivor Outreach Service (SOS) offices 
that assist survivors with benefits and finances. SOS will help any 
military surviving spouse regardless of the spouse's branch of service; 
however, SOS offices are located on Army installations and therefore 
are not readily available to survivors outside those areas.
Conclusion:

      The DIC offset to SBP needs to be removed so the 
surviving parent has enough income to support college age children and 
avoid financial hardship themselves.
      The spouses of those with a severe service connected 
disability who provide caregiving for their disabled spouses need 
assistance and support while they are doing the caregiving.
      Children of those died on active duty before 9-11-2001 
and children of those who died of a service connected disability in 
retirement need to be afforded the same medical and dental benefits as 
the children of those who died on active duty after 9-11-2001.
      Surviving spouses and children need bereavement 
counseling without a diagnosis of clinical or situational depression, 
and they should not have the financial burden of paying fees for each 
counseling session.
      Surviving spouses of those who die after retiring need 
assistance in obtaining the benefits to which they are entitled. A 
casualty assistance officer should be assigned to every surviving 
spouse.
      Chapter 35 education benefits need to be increased to the 
level of the education benefits available to children whose parent died 
on active duty after 9-11-2001.

        Surviving children of those who died on active duty 
after 9-11-2001 have until age 36 to use educations benefits; surviving 
children of those who die of a service connected cause in retirement 
should also be allowed to use education benefits until they reach the 
age of 36.
        Surviving spouses who were full-time caregivers cannot 
be expected to use education benefits while caring for a disabled 
veteran 24/7. The time limit on education benefits needs to be 20 years 
after the death of the military spouse or, better yet, the time limit 
needs to simply be removed.

      Programs such as Marine Corps and Army Long Term Case 
Management and the Army's SOS program need to be available to the 
surviving spouses and children of all branches of military service.

    Thank you for your attention.

                                 

                                  National Gulf War Resource Center
                                                         Topeka, KS
                                                      July 26, 2010

Chairman Robert Filner
House Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, D.C. 20515
(202) 225-9756

Dear Chairman Filner and Members of the House Committee on Veterans' 
Affairs,

    The National Gulf War Resource Center (NGWRC) regrets that we will 
not be able to be at the hearings on July 27th due to other 
commitments. I would like this opportunity to submit a written 
statement for the record. The NGWRC is a non-profit organization based 
in Topeka, Kansas, focusing on issues related to Gulf War Illnesses. 
The NGWRC leads the battle in identifying problems facing veterans of 
Southwest Asia and their families, along with finding practical 
solutions.
    NGWRC requests that Congress enact legislation that would add to 
CFR Title 38 a standard for all raters to be trained and tested on 
undiagnosed illness, TBIs, and PTSD claims. The sending out of training 
letters is not working; most all of the raters have little to no time 
to read them due to their workload. The backlog of claim will only be 
reduced by having well trained raters. To take 3 to 5 days a month for 
classroom training and test will do more in six months than any 
training letter.
    We have worked with veterans and their service officers all over 
the country whose claims were denied because the rater did not know or 
would not follow the law regarding these claims. I have seen claims 
turned down for the following presumptive illnesses: Chronic fatigue 
syndrome, Fibromyalgia, and Irritable bowel syndrome. Being a 
presumptive for their service in the gulf, the veteran only needs to 
show they served in the gulf and that they had the illness on or before 
31 December 2011 ratable to 10 percent or more. In the last 2 months, 
we have worked with over 200 veterans where the regional office had 
denied the claim stating that it did not start in service. This is one 
example of many more claims we have worked around our country.
    We need a mandatory training program set up for all adjudicators 
and their supervisors to attend. By making it mandatory we will take 
care of a large problem of many adjudicators not going to any training 
after they get their job. As a part of this training, there needs to be 
a closed book test on the classes. Everyone that fails the test will 
need to redo the class and take the test until they pass. Once an 
adjudicator is certified to work an undiagnosed TBI or PTSD claim, then 
that adjudicator will be allowed to rate those types of claims. There 
should also be a quality control system so that as an adjudicator's 
claim comes back, either as a notice of disagreement or as a remand, 
the adjudicator must be retrained in that area again and retested. As 
before he will need to pass the test before he can rate claims in that 
area.
    The NGWRC asks the House Veterans' Affairs Committee to work 
closely with the House Armed Services Committee and the Appropriations 
Committee to insure that the Congressionally Directed Medical Research 
Program (CDMRP) to not only budget, but also is appropriate $30,000,000 
for the purpose of funding treatments for the estimated 200,000 Gulf 
War veterans suffering from chronic multi-symptom illnesses. This money 
will once again go into the DoD Congressionally Directed Medical 
Research Program. With many of the returning veterans starting to show 
problems too, the number of sick is much higher.
    NGWRC supports the program because the (CDMRP) is an innovative, 
open, peer reviewed program focused on identifying effective 
treatments, with first priority for pilot studies of treatments already 
approved for other diseases, so they could be put to use immediately. 
Nearly 20 years since the start of the war, one-third to one-fourth of 
Gulf War veterans continue to suffer from chronic multi-symptom 
illness, according to the IOM report released this year, and there are 
still no effective treatments.
    We would like $10,000,000 of the funding to go back to Dr. Haley's 
research being done in Texas. The Congress approved $75,000,000 for his 
research at UTSWMC over a five year time frame. With the VA now 
redirecting the funding to different studies and the last of Dr Haley's 
studies needing to be completed, this money is needed now. To see the 
importance of the finding, we also ask that you do a joint hearing to 
hear from Dr. Haley on what his research has found and how it will help 
the veterans. We were not happy when the VA spent $11 million of the 
$15 million on a piece of equipment that is not for the use of research 
into Gulf War treatment.
    NGWRC requests that Congress remove the presumptive deadlines in 
the CFR 38 section 1117. By removing the deadline for Gulf War Illness, 
you would be doing what was done for the veterans of Vietnam and their 
exposure to Agent Orange. We still have veterans coming home from 
Southwest Asia that are getting sick. Researchers still do not know 
fully why we are sick, but they do believe it most likely is due to the 
different chemicals. In many of the briefings from researchers, they 
all say that as time goes on, there will be even more problems 
affecting us.
    NGWRC would like Congress to enact legislation granting a 
presumption of service connection for our Gulf War veterans who 
deployed to the theatre of operation and who are diagnosed with auto-
immune diseases, such as multiple sclerosis (MS), Parkinson's disease, 
and auto-immune diseases that act like MS but cannot be diagnosed as MS 
yet. VA has granted service connection based on the Secretary's 
authority under existing regulations. These grants should be made 
permanent for existing and future veterans so that these very sick and 
highly vulnerable veterans aren't needlessly forced to fight diligently 
when the science is so clear. The November 2008 VA report does show the 
three leading causes for the chronic multi-symptom illnesses are 
chemicals. We are just now starting to understand how these chemicals 
cause these different auto-immune disorders. While strong evidence 
linked ALS and brain cancer to Gulf War deployment, we believe the 
research on auto-immune disorders similar to ALS shows the same 
results.
    In conclusion, the NGWRC would like to thank you for your continued 
interest in this important subject. We regret we are not able to appear 
in person. We look forward to working with you on these critical issues 
identified here as well as on other issues impacting our Gulf War, Iraq 
War, and Afghanistan War veterans, their immediate access to the VA's 
high-quality healthcare, and the prompt receipt of disability 
compensation benefits.

            Thank you,

                                                    James A. Bunker
                                                          President
                                                       866-531-7183

                                 
 Statement of Major Denise Nichols, RN, MSN, USAFR (Ret.), Vice Chair,
            National Vietnam and Gulf War Veterans Coalition
    Thank you for accepting my for the record testimony in relationship 
to the hearing on July 27, 2010 on the Gulf War veterans.
    I come to you with issues, that are probably not being addressed in 
this hearing but are significant and need to be identified and 
assessed. This will be addressed as a listing to at least have on the 
record of other outstanding needs identified by Gulf War veterans and 
Gulf War veteran advocates in the community.
    We wish to recognize the VA recent efforts to address the Gulf War 
Illness, Research, and Benefits. But we want to be on record that more 
Gulf War veterans from outside the VA system and all veteran 
organization have equal abilities to interact from the beginning and 
throughout the process. WE wonder why the Task Force had to be limited 
to internal VA and not open meetings. We are so willing to interact and 
help to make the issues more clear and address so many issues that have 
not been covered or discussed.
    We thank them for the efforts to have a task force, to have a draft 
and to have a chance to submit written comments. But this does not go 
far enough. Meetings need to be open and available to listen in on if 
we can not be there and a way to interact as the process occurs all the 
way through. It would be a step forward to use all the internet and 
telecommunications that are now available in every department/agency in 
the government. Our President campaigned on full transparency and in 
response the doors need to be opened wide. We also encourage an open 
phone line to be available to have our comments heard because our Gulf 
War veterans with significant neurological cognitive problems have 
trouble in writing their comments but are still able to verbalize! It 
could be like the crisis lines now being used by the VA but lines 
devoted to input of suggestions and problems that don't just affect one 
veteran.
    We feel that the VA hospitals could be used i.e. live telephone 
audio visual hook up in their auditoriums and that way feedback could 
occur with Gulf War veteran patients, family members, veteran groups, 
health care professionals, doctors, researchers, benefits personnel, 
and other concerned personnel. This would truly be dynamic process and 
result in getting a wealth of ideas and ways to improve.
    The final changes to that draft should have also been open before 
the final product for input for that report and for future areas that 
need to be addressed. It is through opening the process completely that 
we will get the full range of suggestions for changes.
    Personally during that time my family faced a major health problem 
and I did not offer as much in feedback as I could have at the window 
of opportunity. But this happens to others too, so why just have one 
window of opportunity? Obviously the draft was changed several times 
after the initial feedback time period.
    Again I encourage VA to open the door to more veterans and 
organizations that would want a chance to serve yet again and have a 
more active dynamic communication.
    Now for problems that still need to be addressed.

     1.  One area of concern is that veterans and doctors do not have a 
list of tests that need to be done as a minimum for Gulf War Illness. 
This list of tests needs to be a main item on the front page of the VA 
website. Suggestions for additions and or changes need to be addressed.
     2.  The Gulf War veterans must also see any new guidelines that 
are being provided to the medical staff concerning Gulf War Illness. WE 
suggest that to be available on the internet the draft of changes and 
the final product. Many veterans have been health care providers and 
could input suggestion for changes.
     3.  A couple of areas that we have had many veterans discussing is 
the ability to be seen and evaluated re dental problems, vision, and 
hearing problems. WE at least need to have those problems assessed and 
then a team of the appropriate specialist need to review these 
assessments, to write reports, articles for professional journals to 
evaluate if there is unidentified needs that relate to the whole health 
of the veterans of Gulf War even if they are not rated!
     4.  We also are hearing from veterans that have had significant 
spinal problems re disc degeneration and we wonder if data is being 
compiled on this significant problem. And how is that information being 
shared not only within the VA but outside the VA and to the Gulf War 
veterans. We also get reports of significant skin problems/rashes/
infections, other body system problems, and diagnosed illnesses. We 
feel that sharing of this information points out several health care 
problems and that adequate complete communication among health care 
providers and the veterans concerned are not being shared and compiled. 
A system needs to be developed within and outside the VA on problems 
that are being seen by all the health care providers within the VA and 
civilian health care professionals that also see Gulf War veterans. 
Communications to the Gulf War veterans and their family members is 
also absent.
     5.  There are no support groups at each VA local that veterans, 
their families, health care professionals and social workers can attend 
monthly. There is a severe need for this type of function. An example 
would be to compare it to cancer patients or heart patients and 
civilian CFS support groups. The family members and the veterans have 
identified this as a real need. They feel alone and need this type of 
support!
     6.  There is a problem that has surfaced concerning the deaths 
that have occurred within the Gulf War veteran community. The problem 
is originally and still is that it has been easier to get rated for 
PTSD while significant health problems--CFS, fibromyalgia, all the 
other symptoms--were not rated and or denied.
     7.  One of the problems is that veterans that had claims and had 
been rated through years of difficulty (Gulf War Illness) have died. 
One example is that the individual veteran was in process of trying to 
have other physical problems rated, he was rated for PTSD but he died 3 
months short of ten year period and therefore his widow and dependent 
children are denied DIC. To leave dependent children without DIC 
benefits is simply cold hearted! Another veteran had been rated PTSD 
but had the neurocognitive problems and had an accident on a tractor 
that killed him and his dependents are being left without DIC. The Gulf 
War veterans who are dying are not being honored and their dependents 
are left out in the cold. Again visible wounds get all the attention 
while more invisible illnesses are being ignored, brushed off, not 
rated and then the survivors suffer with no DIC. These are just two of 
the most recent families/survivors of Gulf War veterans that I 
personally was made aware of in just the last couple of weeks!

         The survivors and dependents of deceased Gulf War veterans 
that suffered from illnesses after the war get no focus or attention as 
compared to those with visible wounds.

     8.  There needs to be a triage system set up for claims! Those 
that are at risk of dying i.e. more complex multiple symptoms, cancers, 
diagnostic problems re cardiac, blood disorders, renal and liver 
problems need a fast tracking for benefits as well as those homeless 
veterans or veterans that are in dire financial status. WE have triage 
in medical care, why don't we have a nation wide triage for benefits? A 
coding system could be developed in which the veteran and/or family 
member can self identify, the medical care provider can rate, the 
social worker can rate, or other professionals including their service 
officer if they have one--when the claim needs a special triaging.
     9.  Aid and Attendance or Nursing Assistance care available thru 
Social Workers at the VA needs to be updated for the Gulf War veterans 
that need assistance at home. Many spouses have not been working when 
they could have if they had someone to be there for their veteran 
spouse that are having neurocognitive problems, balance problems, 
mobility problems. Many veterans are without spouses and need 
assistance at home. One veteran is having to rely on their children to 
help them. It is interesting that programs have been developed for the 
severely visual injured of OIF/OEF but these regulations have not been 
revamped for the invisible wounds of environmental exposures.

         This needs to be done ASAP and a widespread communication 
process developed to the health care professionals, social workers, and 
the veteran patients and families to get them the help they have needed 
for many years. One veteran that has severe multiple problems and the 
overwhelming fatigue (which is not an adequate term for us that suffer 
with this) told me that it took all they had to make it to the grocery 
store and that it may take a week for them to get the groceries just 
into their house! One veteran identified the problem re the income 
factor on Aid and Assistance needs to be adjusted for the younger Gulf 
War veterans where they may have VA and SS benefits and a spouse that 
is still able to work gainfully but can't in order to care for the ill 
Gulf War veteran spouse.

    10.  The system including health care and benefits need to get rid 
of the antagonistic situation that has existed for 20 years at least 
particularly for those with environmental illnesses/Gulf War Illness. 
The Gulf War veterans need to have a faster track to handle benefit 
problems. The veterans and their families are suffering on a large 
scale and it has lasted 20 years without adequate corrective actions.
    11.  It is not a problem just involving benefits personnel that 
need training on rating Gulf War Illness but also health care 
providers! I was a professional nurse and was not aware of the problems 
with undiagnosed illnesses, ME, CFS, multi symptom complex diseases 
until I experienced my illness. Doctors are the same and that affects 
the diagnoses, care, and treatment of the Gulf War veterans. The VA 
could be the role model and network with medical universities that 
train physicians to make a change that would benefit veterans and 
civilian sufferers of CFS, ME, Fibromyalgia.
    12.  The time is critical now in the past year with the information 
of a potential XMRV retrovirus that was discovered in research and 
published almost a year ago. The research to replicate that discovery 
has to be fast tracked and Gulf War veterans with Gulf War Illness need 
to be included in those research studies.
    13.  The areas of research that the veterans of the Gulf War 
deployed and nondeployed feel need further research involves DU (inhale 
and ingested), vaccines (not limited to anthrax but the whole list of 
vaccines used in the Gulf War period), sand/silica in the deserts of 
Saudi, Iraq, and now OEF veterans, and contamination from returning 
equipment. WE do want the biomarkers, diagnostic tests and treatment 
research but we as a group feel the other factors have not had adequate 
research for the potential of health problems whether singularly or as 
synergistic effects. We are invigorated with the VA RAC GWI effort and 
the recent NAS IOM report that finally are showing progress in finding 
some answers and finally getting away from stress theories.
    14.  We want more research based on physiological and no more 
stress psychological research. We want researchers and health care 
professionals to have a means to interact more and share on a frequent 
basis!
    15.  There is a need for a bulletin board or blog that is 
interactive between researchers and physicians. One funded VA 
researcher has been trying to interact with more of the health 
professionals seeing Gulf War veterans and other specialized physicians 
at his own VA and he told me it is a catch as catch can method. They 
need the internet system and educational cross sharing. There needs to 
be real time and archival taping and audiovisual interactive sharing of 
the VA RAC GWI Committee meetings to each VA Hospital. This way 
clinicians, researchers, and the Gulf War veterans can get the 
information and education needed as a starting point. Only thru the 
ability to communicate will the needs of the Gulf War veterans be met 
quicker.
    16.  We cannot just have researchers separate from the clinicians 
and the patients, the veterans! WE need the concept of units set up in 
at least one VA in each State and/or regionally that addresses research 
and clinical practice in an interactive setting for research to 
clinical practice to occur more rapidly for Gulf War veterans or 
environmentally exposed veterans. WE have polytrauma, spinal cord, MS, 
etc specialty care centers in the VA why not environmentally exposed 
specialty care centers. And the WRIIS that are on the east coast and 
west coast do not meet the needs. They were set up as second opinion 
and just have not met the needs of the Gulf War veterans on the whole.
    17.  There needs to be not only a task force at the central VA 
headquarters but a Task Force involving each VA hospital or at least 
one in each State and then a Regional Task force. We need a robust 
system at each level and that is absent.
    18.  The Environmental Health Headquarters at the central VA needs 
to be evaluated. The staffing needs to include an office and veteran 
staffing labeled Gulf War Illness/syndrome/ill defined conditions. It 
needs to have a complaint area, a resource center, medical research, a 
benefits staff specific for Gulf War Illnesses, and a health care 
professional and physician to deal with health care issues.
    19.  The recently named Gulf War Steering Committee charter, 
mission, duties, and members has not even been featured on the VA 
website!
    20.  Each of these areas within the VA should open their doors to 
input and assistance from the Gulf War veteran advocate community at 
large and not just to VSOs or to Gulf War veteran organizations that 
have been outspoken. There are many talented Gulf War veterans that 
seek to be involved in helping improve the situation and solve 
problems. We have many Gulf War veterans that were health care 
professionals that want to help, just open the door!
    21.  The Gulf War veteran community was outraged that the funding 
and work at the UTSW medical school, a VA collaborative research effort 
was stopped. This was a program we all agreed should be continued. The 
researcher's effort to find the best testing for Gulf War veterans that 
could be passed on to the VA at large was a huge setback and we 
encourage the situation to be resolved and the research and work to be 
funded. The recent announcement of what was funded is a slap in our 
face. The research project was truly ready to make major gains in being 
able to study other groups of Gulf War veterans besides the Navy 
Seabees. In this means the replication of what was found in one cohort 
could have been expanded. This in itself is a loss that can not be 
explained satisfactorily. Work out the problems identified or else the 
whole Gulf War veterans affected population suffers as an outcome of VA 
OIG actions. What is the greater need?
    22.  We need the VA to also accept help from physicians on the 
civilian side that have worked on the issues of CFS/ME/Fibromyalgia not 
just for health care but in accepting their input for rating of 
benefits. The Gulf War veterans need their expertise and ability to 
educate VA physicians.
    23.  For Congress and the Senate: The process of hearings on Gulf 
War Illness needs to be not only for the House and or Senate but 
jointly. Joint sessions i.e. hearings would be the ideal approach to 
keeping both Houses fully informed and engaged.
    24.  We complement you on having this hearing but we would like to 
offer a suggestion that one hearing a year is not sufficient to address 
the Gulf War Illness that affects such a huge percent of the troops 
that served. We also strongly suggest that individual Gulf War veterans 
and Gulf War veterans' advocates be included in all these hearings not 
just the VSO's, but the veteran advocates that you are not having 
testify, formally in this way, if done including the other advocates 
you will get a more complete listing of problem areas that have yet to 
be discussed and examined. We also think that the information on 
hearings and witnesses has almost become like top secret and feel the 
open communication to all veterans and veterans advocates begs for 
improvement.
    25.  I would be remised if I didn't also address the nondeployed 
Gulf War veterans that have experienced ill defined illnesses the same 
as deployed, they are truly being lost in the process.

    Thank you, for your consideration of the most recent 25 items that 
Gulf War veterans and Gulf War veteran advocates have been discussing. 
We hope you will include this as submitted testimony for the record.

                                 
         Statement of Anthony Hardie, Member, Research Advisory
Committee on Gulf War Veterans' Illnesses; Gulf War Steering Committee,
   U.S. Department of Veterans Affairs; and Gulf War Illness Research
  Program Integration Panel, Congressionally Directed Medical Research
                  Program, U.S. Department of Defense
    Thanks you to the Subcommittee for holding this third hearing in a 
very serious series seeking solutions on the Gulf War Illness issues 
that have plagued so many thousands of Gulf War veterans for nearly 20 
years. As you already know, I am one of those 250,000 veterans affected 
by Gulf War Illness issues. I particularly thank Chairman Mitchell and 
Ranking Member Roe for your bipartisan, professional, committed 
leadership on this issue.
    I also want to thank VA Secretary Eric Shinseki and VA Chief of 
Staff John Gingrich for their courageous, principled stance on 
championing issues related to Gulf War veterans. As veterans 
themselves, we look to them with hopeful anticipation and continue to 
wish for their encouragement in achieving so many long-overdue and 
deeply needed goals on our behalf.
    From my own experience helping to lead one of the largest State 
veterans agencies in the country, I know that this leadership can 
sometimes mean battling those within your own organization, who can 
range from well-intentioned to apathetic to resistant to change to even 
those who think they know better than leadership and believe they and 
their ideas and ways of doing things will be there long after the 
latest batch of appointees are gone.
    But I also believe from my personal experiences and from meeting 
with VA leadership that their vision of culture change at VA can indeed 
be achieved.
    Much of what needs to be said has been said already elsewhere, 
including in public comments to the current and former VA advisory 
committees, VA's new, internal Gulf War Veterans' Illnesses Task Force, 
and during the many Congressional hearings held over the last two 
decades on issues related to the health and well being of Gulf War 
veterans.
    And, I continue to have faith in the new VA leadership, and I 
continue to believe that they will be effective on these issues as long 
as they keep them directed at the high level they are currently 
directed, right from the Office of the Secretary.
    Instead, I want to take this opportunity to highlight just some key 
issues.
    New National Research Project. First, from my experience serving on 
various federal research advisory committees related to Gulf War 
veterans' illnesses, it is clear that what is needed most urgently is 
fulfillment of the Institute of Medicine's recommendation for a 
Manhattan Project style, nationally directed research program focused 
on finding and funding the best science to unlock the etiology of, and 
effective treatments for the toxin- and other environmental agent-
induced illnesses of veterans of the 1991 Gulf War. And, as has been 
previously shown in other hearings and testimony, much of the hundreds 
of millions of dollars of previous research was misdirected, misspent, 
and made no difference in the health and lives of Gulf War veterans. 
Continuing to fund Gulf War Illnesses research piece-meal, without a 
broader strategy, is inefficient and best and may well be ineffective 
at worst, leaving Gulf War veterans to continue to try to endure 
without effective treatments to improve our health and lives. This 
large-scale research project most likely cannot be created without 
Congressional action.
    New Kinds of Research. Second, I have become convinced from my work 
with the brilliant scientists next to whom I have served on these 
various committees that the key to success lies in funding 
interdisciplinary, multi-focused, consortium-type research projects 
rather than funding one lone scientist testing a single theory.
    Simplifying Gulf War Illness claims. Third, with regards to 
benefits, we as a nation can and must achieve better results with 
regards to the service-connected disability claims of veterans of the 
1991 Gulf War. VA must clarify, or Congress must enact legislation to 
clarify the current disability claims eligibility contained in 38 CFR 
3.117. Veterans with chronic multi-symptom illness should be rated for 
``chronic multi-symptom illness'' as a single entity, not have to prove 
each individual symptom, ensure that each symptom subset is 
``undiagnosed,'' and then be subjected to separate ratings for each 
symptom or set of symptoms.
    Correcting flaws in Gulf War presumptive rating schedule. Fourth, 
in previous testimony and public submissions, I have provided details 
of highly problematic issues related to service connection for 
fibromyalgia, a presumptive condition for Gulf War veterans under 38 
CFR 3.117 which is currently only allowable to a maximum of 40 percent 
when it should be allowable to 100 percent. And, the symptoms of severe 
irritable bowel syndrome, a second presumptive condition for Gulf War 
veterans can be substantially or even totally disabling should not be 
limited to just 30 percent as it is currently under 38 CFR 3.117. And, 
the diagnosis of fibromyalgia should not preclude service-connection 
for chronic fatigue syndrome (a third presumptive condition for Gulf 
War veterans that is allowable by itself up to a 100 percent rating, as 
it should be) as it currently does. While I have already made specific 
recommendations to VA on these issues, implementing the change 
suggested in my third point, above, would be another way to alleviate 
these issues of overlap and unfairness.
    VA Staff Accountability. Finally, VA staff must be held accountable 
for implementing the changes called for by Gulf War veterans, the 
scientific community, Congress, and VA appointees. Even still, the 
advisory committees on which I serve are not always consulted on issues 
within their purview, advised of decisions made independently by VA 
staff without advisory committee consent, or heeded in the sound 
recommendations they make.
    These issues internal to VA and the U.S. Department of Defense have 
been at the root of many of the concerns of Gulf War veterans, and have 
surfaced repeatedly, including as recently as last week with the 
issuance of VA's new press release on funding $2.8 million in new Gulf 
War health research.
    As a member of VA's new Gulf War Steering Committee (GWSC) and the 
Congressionally-chartered VA Research Advisory Committee on Gulf War 
Veterans' Illnesses, I was surprised to learn of VA's newly funded 
research related to the health of Gulf War veterans, not from VA staff 
as a member of these committees, but from a writer from the Veterans 
Today news website who emailed me the news, which was most surprisingly 
issued in the form of a press release.
    As a member of these committees and a typical ill Gulf War veteran, 
I also find the nature of the studies funded to be of concern. None 
appear to be related to treatments for exposures from among the nearly 
comprehensive list of potentially hazardous exposures detailed in the 
Persian Gulf War Veterans Act of 1998.
    I find it extremely disappointing that not only were the two 
committees with oversight and advisory roles yet again not provided 
input or even advance notice of these decisions (yet again, same as 
always in the past), but even the news of these funding decisions was 
not provided by anyone at VA (and still has not been provided) to our 
members on the VA's GWSC and the VA's RACGWVI.
    As Congressional and VA leaders know, these committees have 
substantial, Congressionally- and VA-chartered responsibilities related 
to overseeing VA's performance of research related to ill Gulf War 
veterans. These ``oversights'', if we generously call these serious 
issues by that name--imply that VA officials at several levels and in 
several capacities within VA do not take seriously the oversight and 
advisory roles of these committees.
    Indeed, the message from these actions is that VA staff can and 
will simply disregard the oversight and advisory committees created 
specifically, in part, to help prevent the range of problematic issues 
described in this letter. This appears to be in direct contravention to 
the culture change and policy changes advocated by Sec. Shinseki and VA 
Chief of Staff John Gingrich.
    Additionally, I found at least one statement of fact in the VA's 
press release that is cause for substantial concern.

      Number of Gulf War veterans with Gulf War Illnesses 
Downplayed. The VA press release says, ``In the years since they 
returned, nearly a quarter of these Veterans have experienced chronic 
symptoms . . . known collectively as `Gulf War Veterans' illnesses.' '' 
This statement contradicts the VA-contracted Institute of Medicine 
Volume 8 study on Gulf War Veterans' health, released in April 2010, 
and cited later in the press release, which states the number of 
veterans at 250,000--at 35.9 percent, this number is substantially 
higher than VA's claim in the release of, ``nearly a quarter''. For 
many years, VA has downplayed the severity of Gulf War veterans' 
serious and disabling illnesses, and this latest instance is 
unacceptable and should be corrected immediately in the online version 
of this press release.

    But most importantly of all, the substance of the three studies is 
deeply concerning. Instead of focusing on known Gulf War toxic 
exposures (as shown in the list in the Persian Gulf War Veterans Act of 
1998) and ameliorating the range of health effects known to be 
associated with those exposures, instead, one of the three VA studies 
is still, after 20 years of criticism for this kind of focus, focused 
on stressand psycho-social adaptation to disability without treating 
the underlying physical health conditions (``mindfulness-based stress 
reduction''). To put it simply, of course mindfulness training provides 
some small bit of health to people in their personal adaptation to 
conditions of pain and disability and no new, expensive study is needed 
to show that--but most importantly this adaptation has absolutely no 
bearing on the underlying and all too real physical health of the 35.9 
percent of Gulf War veterans still suffering from Gulf War Illnesses. 
To portray this stress management study as somehow providing meaningful 
treatment to veterans is deeply disappointing, disingenuous, and a 
disgrace to all 250,000 Gulf War veterans still suffering from very 
real physical illness related to their toxic exposures.
    Similarly, a second of the three announced studies is about 
exercise to alleviate pain in Gulf War veterans. Again, this area has 
been excessively studied by VA, DoD, and the scientific community, and 
even non-scientist health writers regularly note that exercise helps 
people with fibromyalgia and chronic pain, but worsen the fatigue and 
others symptoms in people suffering from chronic fatigue. Gulf War 
veterans hardly need a new, expensive study to tell them more about 
what is already known.
    The third of the three VA announced studies is an animal study 
conducted over four years to assess the efficacy of drugs with anti-
depressant, anti-oxidant, and anti-inflammatory properties. At the end 
of those four years, presumably it will take some time to publish the 
results, after which, if success is found, new multi-year studies to 
study the efficacy of the treatments in humans will be required. It is 
incomprehensible why, after 20 years of waiting, these treatments are 
not being tried in ill Gulf War veterans directly rather than in study 
design that will require more studies thereafter before treatments ever 
reach the Gulf War veterans who need them. Even if this study of anti-
depressants turns out to be effective, instead, this study will take 
years before any potential benefit can pave the way for yet another 
study, meaning many more years of waiting by the 35.9 percent of Gulf 
War veterans still suffering from Gulf War Illnesses.
    In addition to the fact that adaptations to disability purporting 
to be ``treatment'' have already been excessively studied by VA and DoD 
over the last 20 years at costs ranging into the millions of dollars, 
to put it simply, after so many years of VA missteps, these latest 
missteps by VA are simply unacceptable, as I am sure Sec. Shinseki and 
you would agree. Most importantly, these kinds of missteps are fully 
preventable if the oversight and advisory bodies cited above are 
actively engaged by VA staff and their recommendations heeded. But 
again, these committees were not only not consulted; they still haven't 
even been informed of these decisions made without their input on 
issues directly within their purview.
    All these issues suggest that despite all the expressed good 
intentions, staff inside VA continue through their actions--whether 
intentional or not--to undermine these efforts. Perhaps they want to do 
things the way they've always done them, perhaps they believe that what 
they're doing is ``right,'' perhaps they want this Administration to 
fail, perhaps they have their own agendas, or perhaps they just don't 
get it.
    In any case, given all of these facts and circumstances, on behalf 
of my fellow Gulf War veterans, I gave the following specific questions 
to VA leadership--questions I believe any reasonable person would have 
given the circumstances:

     1.  What specific corrective steps are being taken immediately by 
VA leadership to ensure that the stated oversight and advisory roles of 
the GWSC and RACGWVI are respected and followed by VA staff at all 
levels? These bodies cannot perform their intended functions when they 
are completely bypassed by VA staff.
     2.  When will VA begin a treatment-focused research program--as 
called for in the more than a decade-old Persian Gulf War Veterans Act 
of 1998--that is based on alleviating the known health effects 
associated with the known toxic exposures of the 1991 Gulf War? VA 
officials note in this press release, ``The IOM report noted that the 
illnesses seen in Gulf War Veterans cannot be ascribed to any 
psychiatric disorder and likely result from genetic and environmental 
factors,'' yet not one of these new expensive new studies focuses on 
environmental or genetic factors that caused 250,000 Gulf War veterans' 
illnesses.
     3.  When will VA correct the factual error in the press release? 
Again, in one place in VA's press release VA cites the number of the 
696,842 Gulf War veterans still suffering from Gulf War Illnesses as 
``nearly a quarter,'' when the Institute of Medicine, contracted by VA, 
shows this number to be far, far higher--at least 250,000, or 35.9 
percent. That's one-third again higher than ``nearly a quarter''. More 
broadly, this latest instance of downplaying the severity of Gulf War 
Illness appears to be indicative of a continuing, long term trend 
within VA.
     4.  When will VA provide the rewritten press release to every 
Member of the two VA Committees that have oversight over Gulf War 
veterans' health issues? (GWSC and RACGWVI)

    For the last year, I have been using my leadership role to reassure 
my fellow ill Gulf War veterans--including through the Gulf War health 
news website I publish, 91outcomes.com, which has had more than 25,000 
readers in the mere 16 months since it was created--that change is 
coming, and that VA has a new focus and a dramatic culture shift that 
will almost certainly lead to effective treatments for Gulf War 
veterans' toxin-induced disabilities.
    For most of us, like any other disabled veteran, all most of us has 
ever wanted is our health restored to a state as close as possible to 
its pre-war state. Science tells us that may very well be possible, 
that effective remedies are within our reach--but the choices made in 
selecting these three studies do not reflect the direction that the 
scientists tell us should be the way forward.
    VA's serious factual, procedural, and research-focus errors have 
shaken my growing trust in the new VA. But, I look to VA leadership to 
take immediate, good-faith steps to remedy these serious issues. And, I 
remain optimistic that VA Secretary Eric Shinseki and VA Chief of Staff 
John Gingrich can find ways to effectively cause VA staff to conform to 
their stated vision of the ``culture change'' desperately needed by the 
at least 35.9 percent of Gulf War veterans still suffering from the 
life-long effects of their Gulf War toxic exposures--a vision that so 
many of us out here share with great hope and expectation.
    If ever there was leadership that can indeed get this right, I 
believe it is them, aided by the able, committed, and professional 
leaders in Congress including you on this Committee. Please, don't let 
us down now when the end is finally in sight.
    Again, thank you for holding today's hearing, for all that you have 
done for all veterans, and all that you continue to do.
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                       Subcommittee on Oversight and Investigations
                                                    Washington, DC.
                                                      July 28, 2010

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Shinseki:

    Thank you for the testimony of John R. Gingrich, Chief of Staff, 
U.S. Department of Veterans Affairs, accompanied by Victoria Cassano, 
M.D., MPH, Director, Radiation and Physical Exposures, Office of Public 
Health and Environmental Hazards; Joel Kupersmith, M.D., Chief Research 
and Development Officer; and Bradley Mayes, Director of the 
Compensation and Pension Service, Veterans Benefits Administration at 
the U.S. House of Representatives Committee on Veterans' Affairs 
Subcommittee on Oversight and Investigations hearing that took place on 
July 27, 2010, entitled ``Gulf War Illness: The Future for Dissatisfied 
Veterans.''
    Please provide answers to the following questions by Friday, 
September 10, 2010, to Todd Chambers, Legislative Assistant to the 
Subcommittee on Oversight and Investigations.

     1.  American Legion's testimony describes veterans' frustration at 
how Gulf War vets from the 1991 Gulf War were initially treated. It 
goes on to describe a perceived bias at the VA for this group of 
veterans: ``if the answer is not obvious, quit looking or send them to 
mental health.'' Can you please address this perceived bias?
     2.  Recently, the VA announced $2.8 million for research projects 
related to Gulf War Illness. The VA has repeatedly stated that the care 
of our Gulf War veterans is a top priority of the Department. Do you 
believe that the research money you have invested thus far for Gulf War 
Illness is reflective of this sentiment?
     3.  What can the VA say to those Gulf War veterans out there who 
have pretty much given up on VA ever making a diagnosis or providing 
treatment?
     4.  In the Veterans of Modern Warfare testimony, they discuss the 
disparity of the presumptive condition of Fibromyalgia. Fibromyalgia 
can only be treated at 40 percent under the current rating schedule. Do 
you think the VA should review this rule so that veterans with this 
condition could be rated higher?

        a.  Can you guarantee today that the VA will review this rule 
and get back to us about your decision and how you reached your 
conclusion?

     5.  VMW's testimony discusses the concern of the Gulf War Task 
Force report's effort of Secretary Shinseki dissolving with the 
appointment of a new Secretary. What can you say to veterans who have 
concerns about what faith should Gulf War veterans have in the ability 
of VA to carry on this initiative across time?
     6.  One of the frustrations of the Advisory Committee was that the 
Gulf War Veterans Information System database had been corrupted. To 
date, according to Mr. Cragin, the issues with this data system have 
not been addressed. Can you please validate this and explain why this 
database has not yet been fixed?

        a.  And if something as seemingly simple as fixing a database 
has not been corrected, what larger problem do you think are left 
broken?

     7.  How much interest has the new RFA's attracted from the VA 
research community?

        a.  And does the VA have a comprehensive research plan?

     8.  Given the problems and opportunities we're hearing, is VA 
prepared to rethink its research program and make it successful in 
curing this terrible illness?
     9.  Can you assure us that nothing will be done to jeopardize the 
independence of the Research Advisory Committee from the VA regular 
staff?
    10.  How will the Department apply the lessons learned from the 
history of developing presumptions for Agent Orange for those who 
served in Vietnam to issues found in veterans who served during the 
Gulf War as well as in the current conflict?
    11.  What progress is being made to improve dialogue and 
information sharing between the Department of Defense and the VA, when 
servicemembers are potentially exposed to harmful bio-toxins, and other 
materials?
    12.  If, as stated during testimony, the term ``Gulf War Veterans'' 
could refer to all veterans of conflicts in Southwest Asia during this 
period, including veterans of Operation Iraqi Freedom and subsequent 
conflicts in this theater, what is the Task Force doing to also involve 
the Department of Defense in order to make certain that exposures which 
have occurred and may still be occurring in this theater are not missed 
by the Task Force?
    13.  What is the timeline the Department has planned for building 
the partnerships with the Deployment Health Working Group (DHWG), and 
the Data Transfer Agreement?
    14.  What efforts are being made to ensure that the training 
letters being issued on the exposures during the Gulf War conflicts are 
used to help benefits offices in adjudicating claims for veterans?
    15.  When do you anticipate publishing the final report of the Task 
Force?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers. If you have any 
questions concerning these questions, please contact Martin Herbert, 
Majority Staff Director for the Subcommittee on Oversight and 
Investigations at (202) 225-3569 or Arthur Wu, Minority Staff Director 
for the Subcommittee on Oversight and Investigations at (202) 225-3527.

            Sincerely,

                                                       David P. Roe
    Harry E. Mitchell
                                          Ranking Republican Member
    Chairman

    MH:tc

                               __________

                        Questions for the Record
                 The Honorable Harry Mitchell, Chairman
           The Honorable David Roe, Ranking Republican Member
              Subcommittee on Oversight and Investigations
                  House Committee on Veterans' Affairs
       ``Gulf War Illness: The Future for Dissatisfied Veterans''
                             July 27, 2010
    Question 1: American Legion's testimony describes veterans' 
frustration at how Gulf War Vets from the 1991 Gulf War were initially 
treated. It goes on to describe a perceived bias at the VA for this 
group of veterans: ``if the answer is not obvious, quit looking or send 
them to mental health.'' Can you please address this perceived bias?

    Response: The Department of Veterans Affairs (VA) has not received 
any complaints from patients of the type of bias towards veterans of 
the Gulf War cited above. There are many avenues to gain input from 
veterans including but not limited to Patient Advocates, Veteran 
Service Officers meetings, and local VA Consumer Councils. While VA has 
not heard this concern expressed until this request, we will follow up 
with the American Legion to better understand this issue and engage in 
identifying ways to improve communications and address this concern, 
since we do not believe it is an accurate depiction of VA's approach to 
care. VA orientation to care has been, and continues to be, providing a 
thorough and comprehensive clinical assessment of the problems 
presented by a veteran and treating those problems as effectively and 
efficiently as possible. This orientation to care is reinforced by VA 
policy to provide a comprehensive assessment of both the physical and 
mental health issues of all veterans who present to VA for care. If 
veterans present with problems in thinking, emotions or behavioral 
problems, VA providers should undertake a mental health and 
psychosocial assessment and provide treatment as needed. While 
diagnosis is important in developing treatment approaches, VA assesses 
and addresses the specific problems presented by each veteran, even if 
he or she does not fit a specific diagnostic category. This has been 
VA's approach before, during and after the Gulf War.
    VA Clinical Practice Guidelines for Major Depression, Post-
Traumatic Stress Disorder (PTSD) and Substance Use Disorders (SUD), 
first published in 1996, provide evidence-based guidance for assessing 
and treating veterans with these disorders. Currently, veterans of all 
service eras are screened for PTSD, depression and alcohol problems 
when they present to VA for care. A comprehensive medical history and 
physical examination is a part of this comprehensive assessment. VA has 
established three War Related Illness and Injury Study Centers across 
the country to provide comprehensive assessments for veterans with 
complex or difficult to diagnose conditions.

    Question 2: Recently, VA announced $2.8 million for research 
projects related to Gulf War Illness. The VA has repeatedly stated that 
the care of our Gulf War veterans is a top priority of the Department. 
Do you believe that the research money you have invested thus far for 
Gulf War Illness is reflective of this sentiment?

    Response: VA's goal is for ill Gulf War veterans to become well, 
and we will continue to encourage more research to achieve this 
objective. VA is committed to maintaining funding levels for Gulf War 
research as close as possible to $15 million per year. VA exceeded the 
$15 million target for fiscal year (FY) 2009, and currently projects at 
least $9.7 million in Gulf War research spending for FY 2010. Previous 
VA-funded Gulf War research conducted clinical trials of new therapies 
for pain, fatigue, cognitive deficits (attention, concentration and 
memory), and gastrointestinal problems; made significant contributions 
to our understanding of the scope and persistence of chronic symptoms 
experienced by Gulf veterans; examined biomarkers (imaging, genetic, 
biochemical) that may be developed into objective diagnostic tests for 
ill Gulf War veterans; and used animal models to examine underlying 
causes of Gulf War veterans' illnesses and identify therapeutic targets 
for development of new treatments.
    VA recently issued a request for applications for research studies 
focused on Gulf War veterans' Illnesses. This request is the most 
recent phase of an ongoing VA effort to identify the causes and 
treatments for these complex illnesses. The three studies funded by the 
recently announced $2.8 million will focus on testing or developing 
treatments for chronic pain, fatigue and cognitive function (including 
attention, concentration and memory problems), which are among the most 
common and debilitating symptoms of Gulf War veterans' illnesses. These 
treatments have been used for medical conditions with similar symptoms 
(including chronic fatigue syndrome, fibromyalgia, and chronic cancer 
pain).

    Question 3: What can the VA say to those Gulf War veterans out 
there who have pretty much given up on VA ever making a diagnosis or 
providing treatment?

    Response: It is very important for VA to restore any Gulf War 
veteran's trust and confidence in VA's health care system that may have 
been lost since the start of the Gulf War. Many Gulf War veterans have 
been extremely frustrated about not receiving a specific diagnosis for 
their illnesses. We are, nevertheless, absolutely committed to 
providing the best health care for all Gulf War veterans even if we 
cannot provide a specific diagnosis for their health problems. VA has 
made significant progress and will continue to work to develop 
diagnoses and treatments for veterans with undiagnosed or difficult to 
diagnose conditions. In the meantime, VA has developed treatment and 
management approaches for many of the symptoms Gulf War veterans 
report. VA is also trying to make the process of applying for 
compensation and care easier for these veterans by creating presumptive 
service connection for several conditions. In sum, VA believes it is 
the best source for veteran-centered care for all veterans, including 
those of the Gulf War. It is VA's obligation to serve as advocates for 
veterans whether they be seeking health care, benefits or other 
services from the Department. Through its actions, VA has demonstrated 
its commitment to advocating for veterans including Gulf War veterans.

    Question 4: In the Veterans of Modern Warfare testimony, they 
discuss the disparity of the presumptive condition of Fibromyalgia. 
Fibromyalgia can only be treated at 40 percent under the current rating 
schedule. Do you think the VA should review this rule so that veterans 
with this condition could be rated higher?

    Response: VA conducted a public Musculoskeletal Forum on August 10, 
2010, as part of VA's active effort to revise the Musculoskeletal 
portion of the VA Schedule for Rating Disabilities (VASRD). We are 
currently reviewing the findings. VA will propose any changes to the 
VASRD that are necessitated by current medical science and earnings 
loss information in a proposed regulation. This will include any 
changes to Fibromyalgia.

    Question 4(a): Can you guarantee today that the VA will review this 
rule and get back to us about your decision and how you reached your 
conclusion?

    Response: VA cannot make any specific guarantees as to results or 
outcomes; however, VA is committed to systematically reviewing the 
VASRD and incorporating any updates that are necessitated by current 
medical science and earnings loss data.

    Question 5: VMW's testimony discusses the concern of the Gulf War 
Task Force report's effort of Secretary Shinseki dissolving with the 
appointment of a new Secretary. What can you say to veterans who have 
concerns about what faith should Gulf War veterans have in the ability 
of VA to carry on this initiative across time?

    Response: The Report of the Task Force on Gulf War Veterans 
Illnesses was not simply an analysis of the situation and 
recommendations, rather it is a plan of action based on a culture 
change that can and will be sustained. It embodies VA's philosophy that 
we serve as advocates for veterans.
    The Task Force's recommendations will become part of VA's 
governance. The action plan will be incorporated in strategic planning, 
training, and budgeting as appropriate. VA has already begun to 
implement key recommendations and has put forward changes and 
improvements in regulations, clinician and claims adjudication 
training, and medical surveillance programs.
    While key positions of the Task Force will remain in place, the 
ultimate goal of the Task Force is to change VA's culture to the point 
that top-down leadership is not necessary to see its implementation. 
The Task Force remains in place and will continue to actively address 
the concerns raised by Gulf War veterans and provide an annual report 
on its progress.

    Question 6: One of the frustrations of the Advisory Committee was 
that the Gulf War Veterans Information System database had been 
corrupted. To date, according to Mr. Cragin, the issues with this data 
system have not been addressed. Can you please validate this and 
explain why this database has not yet been fixed?

    Question 6(a): And if something as seemingly simple as fixing a 
database has not been corrected, what larger problem do you think are 
left broken?

    Response: VA is no longer using Gulf War Veterans Information 
System (GWVIS). GWVIS will be replaced by the Southwest Asia Veterans 
System (SWAVETS) which will be used to generate statistics on both Pre-
9/11 and Post-9/11 Gulf War Era Veterans. The new database system will 
integrate both VA benefits and health care utilization information. The 
first pre-9/11 Gulf War Era report will contain utilization information 
for VA compensation, pension, and health care. Over time, other VA 
benefit information such as education, vocational rehabilitation and 
employment, and home loan guaranty will be integrated into the system.
    Representatives from VA Office of Policy and Planning (OPP), Office 
for Information and Technology (OI&T), the Veterans Benefits 
Administration (VBA), and the Veterans Health Administration (VHA) have 
collaboratively worked together to conduct operational assessments and 
develop the necessary processes, framework, and system architecture 
required to generate the two integrated reports.
    An initial report for the pre-9/11 Gulf War Era cohort using 
SWAVETS is planned for completion by September 30, 2010. Also by 
October 1, 2010, VA will have a DoD-verified database of pre-9/11 Gulf 
War Era veterans for report and analysis uses.

    Question 7: How much interest has the new Requests for Applications 
(RFA) attracted from the VA research community?

    Question 7(a): And does the VA have a comprehensive research plan?

    Response: VA leadership has brought about a cultural attitude shift 
by encouraging research related to Gulf War Veterans' Illnesses. This 
has a multiplier effect, as more information on Gulf War Veterans' 
Illnesses brings in more interested and qualified researchers. VA saw a 
considerable increase in the number of applications in response to the 
most recent request for applications. These proposals underwent peer 
review to assess whether they were scientifically meritorious and 
responded to the needs of our veterans. Three proposals were considered 
ready and were funded. All of the investigators received written 
critiques, which will allow those not selected for funding in this 
round to improve their proposals and submit them again.
    VA has made it a priority to conduct research on illnesses 
affecting Gulf War veterans, so it will continue to provide incentives 
to encourage our researchers to focus on these issues. VA plans to 
release subsequent Gulf War requests for applications every 6 months, 
and as an added incentive to bring new investigators into the field, 
the maximum annual budget allowed for submissions to these RFAs was 
raised from $150,000 to $500,000.
    VA has a two-fold approach for increasing research relevant to Gulf 
War veterans. In the short term, VA will address the immediate urgency 
of understanding and finding new treatments for ill veterans of the 
1990-1991 Gulf War. VA included more than 80 percent of the Research 
Advisory Committees on Gulf War Veterans' Illnesses (RAC) report and 
Institute of Medicine (IOM) recommendations for the requests for 
applications. The new studies already approved under this recent 
request for applications meet those needs. In the long-term, VA will 
develop a new National cohort of Gulf War veterans of a significantly 
large size to conduct long-term studies and ensure the most 
scientifically rigorous and advanced research possible. VA plans to 
conduct genetic studies to determine which veterans may be especially 
susceptible to exposures and design treatments for them. VA is also 
expanding the Gulf War Biorepository to collect a broad variety of 
tissues from Gulf War veterans. The Biorepository is currently focused 
on brain and spinal cord from patients diagnosed with amyotrophic 
lateral sclerosis (ALS).
    VA recently formed a Gulf War Steering Committee which reports back 
to the Research Advisory Committee on Gulf War Veterans' Illnesses 
(RAC) and the National Research Advisory Committee (NRAC). VA will 
utilize advice from the Gulf War Steering Committee, NRAC, and RAC, as 
well as information from IOM, to manage the direction and scope of VA's 
Gulf War research program, including collaborations with other Federal 
agencies to ensure its research portfolio on Gulf War Veterans' 
Illnesses is appropriate.
    Lastly, VA is hiring a new Director of Deployment Health who will 
coordinate deployment health activities in VA's Office of Research and 
Development. The new director will be designated to coordinate specific 
activities in collaboration with various DoD and other Federal 
Government agencies. VA funds a variety of studies on deployment health 
issues and the expertise and ability to provide high-level scientific 
knowledge across these broad areas of deployment health will be an 
important role. This person will be keenly aware of emerging issues 
while also remaining aware of the range of issues that affect veterans 
of all ages.
    The new Director of Deployment Health will also be responsive to 
veterans and their needs as a result of deployments.

    Question 8: Given the problems and opportunities we're hearing, is 
VA prepared to rethink its research program and make it successful in 
curing this terrible illness?

    Response: Gulf War research is a priority for VA, and our response 
to Question 7 provides considerable detail regarding the breadth of 
work the Department is doing in this area.

    Question 9: Can you assure us that nothing will be done to 
jeopardize the independence of the Research Advisory Committee from the 
VA regular staff?

    Response: VA greatly values the work of the RAC and its advisory 
role in helping to guide VA on the needs of Gulf War Veterans' 
Illnesses. The RAC and its independence are integral to VA's work, and 
the Department will continue working with the RAC so that Gulf War 
Veterans receive the best care possible.
    The RAC serves as a Federal Advisory Committee (FACA) to VA and 
therefore, operates under the authorities and rules of a FACA 
Committee. As a FACA Committee comprised of individuals external to VA, 
VA is responsible for the payment of expenses incurred by the 
Committee. Also, RAC must meet publicly with a designated Federal 
official from the VA present, compile reports and make recommendations 
to the VA. According to the RAC charter, ``The Committee is charged 
with reviewing previous medical research and other relevant medical 
knowledge, and with making recommendations for future research.'' VA 
uses RAC recommendations in addition to the Institute of Medicine 
(IOM), a wide array of scientific literature and input from veterans to 
guide its research priorities. All documents, meeting minutes and 
recommendations produced by the RAC are open to the public as are the 
Committee meetings. The appropriate checks and balances are in place to 
ensure the RAC remains independent while meeting its obligations to VA 
in assisting to guide research priorities for Gulf War veterans.

    Question 10: How will the Department apply the lessons learned from 
the history of developing presumptions for Agent Orange for those who 
served in Vietnam to issues found in veterans who served during the 
Gulf War as well as in the current conflict?

    Response: As an advocate for veterans, VA has adopted a proactive 
posture toward potential toxic battlefield exposures. For example, the 
Department has developed a comprehensive and collaborative program with 
the Department of Defense (DoD) to identify, screen, and follow 
servicemembers and veterans exposed to sodium dichromate at the Qarmat 
Ali water purification plant in Iraq. By developing contemporaneous 
medical surveillance programs for veterans with known environmental and 
occupational exposures, VA will be able to provide more timely 
diagnoses related to exposure; ameliorate the effects of these 
exposures; and drive preventive efforts by DoD to help avoid such 
exposures in the future.
    When looking at the history of presumptions related to Agent 
Orange, as well as those applicable to the first Gulf War, VA must 
acknowledge that such presumptions have evolved to their current state, 
in part, because of a lack of accurate exposure data. Therefore, the 
resulting presumptions must be fairly applied to all veterans who 
served in the respective theater, irrespective of actual of exposure 
and the level thereof. While this problem still exists in the current 
conflict (such as those exposed to burn pit toxins), DoD has made 
advances in tracking individual troop locations, thereby enhancing 
their knowledge of individual exposure data.
    Further, DoD is actively engaged in sharing certain exposure data 
with VA, such as through the VA/DoD Deployment Health Working Group 
(DHWG). VA was able to use selected information obtained through this 
venue to publish its training letter (TL 10-03) on environmental 
hazards in Iraq and Afghanistan. VA was also able to establish its 
Qarmat Ali medical surveillance program with information obtained 
through the DHWG.
    Essentially, one of the most important lessons learned from 
widespread exposure events in past conflicts is that DoD must 
accurately track troop movement and hazardous exposures, and relay such 
information to VA. VA must then utilize such information to inform its 
healthcare providers and its claims adjudicators in order to provide a 
better path to direct service connection, as opposed to presumptive 
service connection. Consequently, VA can target presumptions, if 
appropriate, at those veterans with confirmed hazardous exposure when 
medical data supports a relationship between their current disability 
and the hazardous exposure.

    Question 11: What progress is being made to improve dialogue and 
information sharing between the Department of Defense and the VA, when 
servicemembers are potentially exposed to harmful bio-toxins, and other 
materials?

    Response: The lessons learned from Agent Orange and the first Gulf 
War (Operations Desert Storm/Desert Shield) resulted in a significant 
improvement in communications between DoD and VA. We are working 
closely to evaluate exposures both from an environmental and a clinical 
perspective. The medical surveillance program for Qarmat Ali veterans 
and DoD active and civilian personnel clearly shows how this 
cooperation can benefit veterans and their family members. Furthermore, 
VA and DoD cooperation in long-range epidemiologic investigations, such 
as the Millennium Cohort Study, allows for much more robust information 
gathering that will improve our ability to detect health trends in 
veterans in the future.

    Question 12: If, as stated during testimony, the term ``Gulf War 
Veterans'' could refer to all veterans of conflicts in Southwest Asia 
during this period, including veterans of Operation Iraqi Freedom and 
subsequent conflicts in this theater, what is the Task Force doing to 
also involve the DoD in order to make certain that exposures which have 
occurred and may still be occurring in this theater are not missed by 
the Task Force?

    Response: VA is in the process of better identifying separate 
cohorts that are considered part of the ``Gulf War Veteran'' 
population. Dividing this population by period of service (e.g. 
conflict 1990-1991; stabilization 1991-1997 etc.) will certainly help 
in correlating conditions to specific place and time. DoD is moving 
forward with better area and individual monitoring for environmental 
hazards. VA and the veterans we serve will greatly benefit from this 
increased ability of DoD. In addition, VA remains actively engaged with 
DoD through the DHWG to obtain as much information as possible about 
veterans' exposures and translate that information into programs and 
services of benefit to veterans. One example of this is the medical 
surveillance program for veterans affected by exposures at Qarmat Ali 
(as discussed in the response to Question 11).

    Question 13: What is the timeline the Department has planned for 
building the partnerships with the Deployment Health Working Group 
(DHWG), and the Data Transfer Agreement?

    Response: There is an overarching Data Use Agreement already in 
place. The Data Transfer Agreement is currently being developed 
cooperatively through the DHWG. Despite the fact that this agreement is 
not final, DoD and VA have shared necessary information on exposures 
and individuals potentially exposed to environmental hazards when 
situations requiring such sharing arise. Two examples of this sharing 
include the Camp Lejeune ``Historical Drinking Water'' database, and 
the names and contact information of veterans potentially exposed to 
sodium dichromate at Qarmat Ali.

    Question 14: What efforts are being made to ensure that the 
training letters being issued on the exposures during the Gulf War 
conflicts are used to help benefits offices in adjudicating claims for 
veterans?

    Response: VA took significant steps to ensure that all appropriate 
personnel received training. In addition to issuing the training 
letters to all VA claims adjudicators, VA also conducted two nationwide 
training sessions on processing disability claims from Gulf War 
Veterans based on undiagnosed illnesses and diagnosed medically 
unexplained chronic multi-symptom illnesses. Sources of exposure to 
environmental hazards, as well as evidence gathering and medical 
examination scheduling, were explained. These training sessions were 
conducted live via Microsoft Live Meeting and attendance at the 
training was mandatory.

    Question 15: When do you anticipate publishing the final report?

    Response: The Report is in the final stages of Executive Branch 
clearance and will be released as soon as it is completed.