NOTE: UNEDITED DOCUMENT
UNITED STATES OF AMERICA
PRESIDENTIAL ADVISORY COMMITTEE
ON GULF WAR VETERANS' ILLNESSES
TUESDAY, NOVEMBER 7, 1995
EPIDEMIOLOGICAL RESEARCH ISSUES PANEL
The panel met in the Green Room, San Francisco War Memorial Building
401 Van Ness Avenue, San Francisco, California at 10:00 a.m,
JOYCE C. LASHOF, M.D., Committee Chair, presiding.
PANEL MEMBERS PRESENT:
JOYCE C. LASHOF, M.D., Committee Chair JOHN BALDESCHWIELER, Ph.D, Committee Member
ANDREA KIDD TAYLOR, Dr.P.H., Committee Member
MARK BROWN, Committee Staff
HOLLY GWIN, Committee Staff
LOIS JOELLENBECK, Committee Staff MICHAEL KOWALOK, Committee Staff
PAGE NUMBER OPENING REMARKS:
JOYCE C. LASHOF, M.D. 4
San Francisco, CA 6
Santa Cruz, CA 16
Santa Cruz, CA 23
Berkeley, CA 32
Sacramento, CA 48
Silverado, CA 56
Monterey, CA 61
Elk Grove, CA 68
Winters, CA 74
Oakland, CA 80
Sutter Creek, CA 88
San Francisco, CA 94
San Francisco, CA 101
HEALTH ASSESSMENT OF PERSIAN GULF VETERANS FROM IOWA
DR. DAVID SCHWARTZ
University of Iowa
Principal Investigator 106
DR. MICHELE MARCUS
Department of Epidemiology
Rollins School of Public Health
Emory University 121
MR. DENNIS GOODEN
Disabled American Veterans, Iowa
Member, Iowa Study Public Advisory
QUESTIONS FROM THE PANEL 131
UNEXPLAINED ILLNESSES AMONG PERSIAN GULF WAR VETERANS
IN AN AIR NATIONAL GUARD UNIT (PENNSYLVANIA STUDY)
DR. WILLIAM REEVES
Division of Viral and Rickettsial
National Center for Infectious Diseases
Center for Disease Control and
DR. WARREN WINKELSTEIN, JR.
Division of Population Biology and Epidemiology
School of Public Health, University of
Member, Scientific Advisory Panel 171
QUESTIONS FROM THE PANEL 175
DEPARTMENT OF DEFENSE -- ARMED FORCES EPIDEMIOLOGICAL BOARD REVIEW OF THE COORDINATING BOARD'S Working Plan for Research on Persian Gulf Veterans' Illnesses
DR. MICHAEL ASCHER
California Department of Health Services Member, Armed Forces Epidemiological
QUESTIONS FROM THE PANEL 213
2 10:05 a.m.
3 DR. LASHOF: Good morning. I'm Dr.
4 Joyce Lashof, Chair of the Presidential Advisory
5 Committee on the Gulf War Veterans' Illnesses. I
6 would like to thank all of you for coming to this
8 This meeting is a subcommittee of our
9 full committee, and the hearing today is directed
10 primarily at a review of the epidemiological studies
11 so that the Committee can get a better understanding
12 of the scope and direction of the various studies
13 which have been undertaken. But as always at our
14 meeting, subcommittee or full committee, we begin
15 the meeting with first an opportunity for veterans
16 or others who wish to make public comment concerning
17 the Gulf War veterans' illnesses, the work of the
18 VA, the DOD, or the Committee.
19 I want to thank all of you for coming,
20 and specifically to those of you who have requested
21 to testify, we're pleased to be able to hear from
22 you this morning. We have scheduled the morning
23 session in such a way that each one of the public
24 comments will be limited unfortunately to five
25 minutes, and five minutes allotted for questions by
1 the Committee and staff. However, we are always
2 happy to receive additional written testimony,
3 either today at the time of the hearing, or it can
4 be sent to the Committee offices in Washington at
5 any time that those -- any of you wish to
6 communicate with us.
7 So without further ado -- well, let me
8 first introduce the people at the head table here.
9 They are both Committee members and staff, and maybe
10 I'll ask each of them to just introduce themselves.
12 MR. BROWN: Thank you, Joyce. My name
13 is Mark Brown. I work on the Committee staff.
14 DR. BALDESCHWIELER: My name is John
15 Baldeschwieler, and I'm a professor of chemistry at
16 Cal Tech.
17 MS. JOELLENBECK: I'm Lois Joellenbeck.
18 I'm on the Committee staff.
19 MR. KOWALOK: My name is Mike Kowalok.
20 I'm with the Committee staff, and if you have any
21 written remarks for testimony I'll be happy to take
22 them later today.
23 DR. TAYLOR: I'm Andrea Kidd Taylor.
24 I'm an industrial hygienist with the United Auto
25 Workers Health and Safety Department in Detroit.
1 I'm a member of the Advisory Committee.
2 MS. GWIN: I'm Holly Gwin of the
3 Committee staff.
4 DR. LASHOF: All right. Thank you. Our
5 first commentor is Mr. Dan Fahey from San Francisco.
6 Mr. Fahey?
7 MR. FAHEY: Good morning. My name is
8 Dan Fahey, and I just have a question. You stated
9 that we had five minutes to speak. I was under the
10 understanding that each person had ten minutes to
12 MR. KOWALOK: There's a total of ten
13 minutes, some of which -- preferably five minutes,
14 would be reserved for questions and answers.
15 MR. FAHEY: Okay.
16 Again, my name is Dan Fahey, and I am a
17 Navy veteran. My training included learning how to
18 -- included attending a school where I learned how
19 to fire the CLOSIN weapon system, which is a Navy
20 gun that shoots depleted uranium bullets.
21 I'm currently a case manager and claims
22 representative at Swords to Plowshares, a veterans'
23 rights organization here in San Francisco, and a
24 member of the Depleted Uranium Network of the
25 Military Toxics Project. I'm going to talk today
1 about depleted uranium and the need for objective
2 research and analysis.
3 Munitions made of depleted uranium metal
4 were used for the first time in warfare by the
5 United States military during Operation Desert
6 Storm. Thousands of large caliber and close to one
7 million small caliber armor piercing depleted
8 uranium rounds were fired by American tanks and
9 aircraft. In addition, depleted uranium was
10 employed as armor on the main U.S. battle tank, the
11 M1A1 Abrams. After just a few weeks of intense
12 warfare, more than 350 tons of depleted uranium lay
13 scattered in fragments and small particles on the
14 battlefields of Kuwait and Iraq.
15 While a variety of weapon systems were
16 employed against the Iraqi army, depleted uranium
17 projectiles are credited with the destruction of at
18 least 1400 Iraqi tanks, as well as an unknown
19 quantity of armored personnel carriers and other
20 equipment. Conversely, the depleted uranium armor
21 on U.S. tanks was impenetrable to Iraqi fire,
22 although depleted uranium rounds penetrated depleted
23 uranium armor in several friendly fire incidents.
24 The battlefield advantage provided by
25 depleted uranium weaponry during the Gulf war was
1 widely recognized, but such recognition will likely
2 make this a short-term advantage. The proliferation
3 of depleted uranium weaponry, spearheaded by the
4 U.S. government and defense contractors, is likely
5 to level the playing field in future conflicts.
6 Although the radiation emitted by
7 depleted uranium is cause for concern, particularly
8 among crew members in tanks equipped with depleted
9 uranium armor, the internalization of depleted
10 uranium particles poses the greatest danger to human
12 When a depleted uranium particle strikes
13 a hard surface, up to 70 percent of the penetrator
14 is oxidized and scattered as small particles in, on,
15 and around the target. A fact sheet issued by the
16 U.S. Army Armament, Munitions and Chemical Command
18 "When a DU penetrator impacts a target surface,
19 a large portion of the kinetic energy is
20 dissipated as heat. The heat of impact causes
21 the DU to oxidize or burn momentarily. This
22 results in smoke which contains a high
23 concentration of DU particles. These uranium
24 particles can be inhaled or ingested and are
1 Inhaled depleted
2 uranium particles concentrate in the lungs, while
3 ingested particles favor the kidney, liver, and bone
4 marrow. Because depleted uranium is both chemically
5 and radiologically toxic, just a few particles
6 trapped in the kidney or lung greatly increase the
7 risk of cancer or other illness over time.
8 A message issued by the
9 U.S. Army Armament, Munitions and Chemical Command
10 on March 7, 1991 stated, "Any system struck by a DU
11 penetrator can be assumed to be contaminated with
12 DU." They later added,
13 "If a burned out vehicle must be entered,
14 precautions must be taken to avoid inhaling or
15 ingesting DU particles. Respirator or
16 protective mask should be worn at minimum,
17 along with gloves. Ideally, protective
18 clothing should be worn as well. After exiting
19 the vehicle, hands should be washed thoroughly.
20 All dust should be brushed off of clothing or
21 protective clothing should be discarded."
22 According to the
23 results of a survey of 10,051 Desert Storm veterans
24 conducted by Vic Sylvester and the Operation Desert
25 Shield/Desert Storm Association between 1991 and
1 October 1, 1995, 82 percent of veterans "Entered
2 Captured Iraqi Vehicles." That number is consistent
3 with my own experience talking to veterans who
4 climbed on and/or entered destroyed vehicles to pose
5 for pictures, look for souvenirs or remove
7 However, not one of the
8 veterans I have talked to donned a respirator,
9 gloves, or protective clothing before approaching
10 damaged vehicles, or thoroughly washed their hands
11 or face afterwards, as Army guidelines prudently
13 The lack of awareness
14 among U.S. troops about the use of and dangers posed
15 by depleted uranium weaponry is described in the
16 January 1993 General Accounting Office report aptly
17 titled OPERATION DESERT STORM: Army Not Adequately
18 Prepared to Deal With Depleted Uranium
20 Based on the Army's
21 admission that vehicles struck by depleted uranium
22 penetrators are contaminated, the fact that over 350
23 tons of depleted uranium were used to destroy more
24 than 1400 Iraqi tanks and other equipment, and a
25 survey showing that four out of five vets entered
1 Iraqi vehicles, the number of U.S. military
2 personnel who potentially inhaled or ingested
3 depleted uranium particles could reach into the
4 hundreds of thousands. Yet curiously, the
5 Department of Defense counts those at risk from
6 depleted uranium exposure at fewer than 100.
7 According to the Army,
8 only a few dozen soldiers wounded in friendly fire
9 incidents involving depleted uranium, plus a small
10 number of personnel who recovered contaminated U.S.
11 vehicles, are likely to have internalized depleted
12 uranium particles.
13 In their June 1994
14 Summary Report to Congress on the Health and
15 Environmental Consequences of Depleted Uranium Use
16 by the U.S. Army, the U.S. Army Environmental
17 Policy Institute concluded,
18 "It is unlikely that significant internal
19 exposures occurred to other individuals who
20 either had incidental contact with contaminated
21 vehicles or breathed smoke from the plumes from
22 burning vehicles impacted by DU penetrators.
23 These scenarios, however, should be evaluated
24 to quantify the risks."
25 They go on to say,
1 "The potential for major environmental impact
2 from DU contamination on battlefield sites is
3 low. Additional environmental modeling and
4 data are needed, however, to support this
6 Such ambiguity about the risks posed by
7 the use of depleted uranium weaponry can be
8 explained by the Army's reluctance to criticize
9 weaponry that it very much values. Just as they
10 legitimized the use of Agent Orange during the
11 Vietnam War, the Department of Defense now
12 legitimizes the use of the depleted uranium weaponry
13 because they place more importance on short-term
14 battlefield advantages than on the long-term health
15 and well-being of their own troops.
16 While exposure to depleted uranium
17 affects the health of an uncertain number of U.S.
18 veterans, the impact of its use may be most heavily
19 felt by civilians living near the battlefields on
20 which it was used. In fact, on May 24, 1995, Iraq
21 formally complained to the United Nations that the
22 widespread use of depleted uranium during the Gulf
23 War was causing serious illness and death among
24 Iraqi civilians.
25 As if anticipating such a complaint,
1 the Army Environmental Policy Institute Summary
2 Report to Congress stated, "(i)t should be noted
3 under current international law, there is no
4 requirement to remediate -- or clean up --
5 environmental damage to battlefields."
6 Legal requirements notwithstanding, as
7 Americans, and as human beings, we have a moral
8 responsibility to acknowledge the dangers associated
9 with the use of depleted uranium weaponry, and to
10 discontinue the use of such weaponry which, due to
11 its chemical and radiological properties, will turn
12 future battlefields into vast, unusable toxic waste
13 sites, and threaten the health of people who
14 encounter it for literally billions of years to
15 come. Depleted uranium projectiles and armor are
16 Pyrrhic Weapons, whose long-term health and
17 environmental costs outweigh the short-term
18 battlefield advantage they provide.
19 In conclusion, the Presidential
20 Advisory Committee on Gulf War Veterans' Illnesses
22 One, recommend the establishment of a
23 peer review committee of leading radiation health
24 experts from the civilian sector that would act as a
25 "Citizens Watchdog Authority" over Department of
1 Defense and Department of Veterans Affairs' studies
2 of depleted uranium;
3 Two, recommend independent health
4 studies for Persian Gulf war veterans and civilian
5 personnel at or near depleted uranium manufacturing
6 sites to determine the toxic and radiological
7 effects of exposure to depleted uranium. These
8 studies should expand the number of veterans and
9 civilians considered at risk to include: all tank
10 crew members; anyone who climbed on, entered, or
11 passed within 30 meters of a vehicle which may have
12 been contaminated by depleted uranium; anyone with
13 imbedded depleted uranium fragments; anyone who
14 cleaned, transported, or buried tanks or other
15 equipment hit by depleted uranium penetrators;
16 anyone who manufactured, tested, transported,
17 loaded, or otherwise handled depleted uranium
18 munitions; anyone within a 25 mile radius of the
19 July 1991 ammunition fire at Doha, Kuwait, in which
20 an unknown quantity of depleted uranium rounds
21 burned; anyone currently deployed to areas in Kuwait
22 and Saudi Arabia that may be contaminated with
23 depleted uranium. Additionally, the role of
24 depleted uranium in reproductive problems and birth
25 defects among children of Gulf War veterans should
1 be evaluated;
2 Three, recommend the issuance of
3 appropriate radiation clothing to soldiers and
4 workers who are exposed to the possible inhalation
5 or ingestion of depleted uranium oxide particles
6 during production, testing, training, or wartime
8 Four, recommend an international
9 agreement to ban depleted uranium weapons.
10 Thank you.
11 DR. LASHOF: Thank you very much. We
12 only have about a minute left for questions, because
13 you did take about nine of your ten minutes. Are
14 there questions from -- Andrea?
15 DR. TAYLOR: Mr. Fahey, are there
16 members of your network who have experienced any
17 kind of symptoms related to using depleted uranium,
18 and do you know?
19 MR. FAHEY: Yes. We have one of --
20 there's 22 veterans who have imbedded DU fragments
21 from the friendly fire incidents. We have one of
22 those who is working with us in the DU network. We
23 also have a nurse who has been experiencing health
24 problems that she believes was related to the fact
25 that she -- when she was on the battlefields,
1 depleted uranium weapons were used to take out some
2 Iraqi tanks, and she was very close by.
3 DR. TAYLOR: What kind of health
4 problems are they experiencing?
5 MR. FAHEY: Respiratory problems is
6 one. Fatigue. A lot of the symptoms are the same as
7 what a lot of other Gulf veterans are experiencing,
8 but because the Department of Defense and the VA
9 consider those at risk so small, the studies aren't
10 really being done to determine what the connection
11 between the uranium exposure and the current health
12 problems are.
13 DR. LASHOF: Any other questions?
14 (No response.)
15 Thank you very much.
16 MR. FAHEY: Thank you.
17 DR. LASHOF: The next person is Dean
18 Lundholm from Santa Cruz.
19 MR. LUNDHOLM: Thank you and good
21 I don't have any prepared statements.
22 I mostly came here to let you know who I was, and
23 give you some perspective of how a Desert Storm
24 veteran feels.
25 I testified at the National Institute
1 of Health symposium on the Gulf War Syndrome. I
2 testified at Senator Riegle's hearings on Desert
3 Storm in '93. I was one of the original plaintiffs
4 on a lawsuit out of Texas, and I since then have
5 really backed off from being an activist in this
6 Desert Storm scenario.
7 We are angry white males. There's no
8 doubt about it. We -- I personally -- I'll speak
9 for myself today. I was asked to sign waivers
10 before I went over. I came back. There were no
11 jobs. This country has a tendency to promise you
12 the world, and deliver nothing, as we see from our
13 Vietnam vets.
14 In Portland, one of the Presidential
15 Advisory Committees came to me and said, well,
16 that's what's wrong with you, you shouldn't be
17 smoking. And, you know, I kind of laughed it off,
18 and it's all right, but that's the attitude we
19 receive from the people that are in the position to
20 do something about Desert Storm Syndrome, and Desert
21 Storm veterans that are suffering.
22 People are dying. I mean that's --
23 that's what's going on. When we send people into
24 war, we send people to kill people, and we do it.
25 And we do a good job of it here in the United
1 States, you know. We have men and women dedicated
2 to defending this country, but when we come back,
3 and we get spit on, we get heckled -- it upsets you.
4 It has a deep seated anger.
5 I looked -- I didn't hear any of you
6 say that you were veterans, you know. From what I
7 understand -- I didn't hear, but none of you are
8 veterans. How can I relate an experience like going
9 to Desert Storm; like fighting; like being sick;
10 being hospitalized in Desert Storm; being
11 unconscious for several days; coming back having my
12 girlfriend become ill; going to the VA hospitals;
13 being told it's in your head; seeing friends die;
14 seeing friends sick; and being told it's in your
16 I'd love to take any questions.
17 DR. LASHOF: Questions?
18 DR. TAYLOR: I'll start with the same
19 question. What kind of health symptoms have you
20 experienced since your return?
21 MR. LUNDHOLM: Quite often I'll wake up
22 dry heaving. Gastrointestinal difficulties.
23 Burning in the throat, diarrhea, muscle spasms,
24 chronic fatigue, joint aches, muscle aches, as well
25 as quite a bit of psychological -- and stress,
1 incredible stress.
2 DR. TAYLOR: Where were you stationed
3 in the Gulf?
4 MR. LUNDHOLM: I was in the town called
5 Haboral Badhan which is 15 miles from the Iraq
6 border, and about 30 miles north of Kuwait. I was
7 EPW guard, and we had 27,000 Iraqi PW's in our camp.
8 We had five major riots that never hit the media,
9 that, for the most part, the general public is
10 unaware of. During these riots two prisoners were
11 shot. Our vehicles were damaged by the stones being
13 DR. TAYLOR: Do you remember any
14 chemical exposures or other exposures that might
15 have occurred?
16 MR. LUNDHOLM: Yes. I -- the date
17 eludes me. I think it was around April -- the first
18 of April.
19 A chemical alarm went off. I was in
20 the shower, and didn't have my gas mask. I masked
21 up as soon as I could. After the alarms went off,
22 we were ordered to take the perischime bromide --
23 you know, another attempt by the Department of
24 Defense to help its troops in the chemical
25 biological and it -- as a result we see that these
1 perischime bromide has actually ended up hurting a
2 lot of people.
3 I took the perischime bromide for three
4 or four days. I developed a crick in the neck --
5 you know, you sleep on your neck wrong, and you get
6 a crick? That crick went down, gave me paralysis on
7 the right side. I was hospitalized unconscious for
8 three days. I spent a week and a half in the
9 hospital, was released back to my unit, completed my
10 tour, came back. Those medical records are now
11 gone. Nobody seems to know where they are.
12 I had a full bird colonel who came up
13 to me at the National Institute of Health who said,
14 "You weren't in my hospital. You lied. You weren't
15 there." And I was able to pull out the form with
16 one of his doctor's signatures on it, and say at
17 least I was here. At least I have the paper that
18 says that I was there, now go back and check your
19 work, you know.
20 That's the attitude we get from the
21 upper echelon. And you wonder why we're angry white
23 DR. LASHOF: Were you in the Reserve or
24 in the active, prior to --
25 MR. LUNDHOLM: I was part of the 49th
1 Military Police Brigade here in California. It's a
2 National Guard unit. It was Reserve. I was not
3 called to active duty. I volunteered for active
5 In the military I was a general
6 officer's chauffeur, and personally I had a lot of
7 difficulty with our line units being taken out of
8 the brigade, the battalions being taken out of the
9 brigade, and myself staying back and using my
10 privileged position not to go. I felt that if my
11 line units were going, I was going to go, so I was
12 -- I was a Reservist.
13 DR. LASHOF: Since you've returned,
14 have you been to the VA hospital, or where have you
15 sought treatment?
16 MR. LUNDHOLM: Yes, I've been to the VA
17 hospitals, the mental health clinics in Oakland,
18 Palo Alto, Martinez, and then just recently in
19 Roseburg. I went to a PTSD clinic. It was a four-
20 week clinic to deal with stress. At the end of
21 three and a half weeks, the team of psychologists,
22 psychiatrists, came to me and said I was too angry
23 to participate in the program. I kind of relate
24 that to being too fast to run in a race, you know.
25 You're too stressed to be in a PTSD clinic. It just
1 really -- it's a double standard.
2 The VA SOP, standard operating
3 procedure, is to immediately prescribe Zoloft,
4 Prozac, Trazodone, Erythromene, and say it's a
5 psychological problem. I do not deny there are
6 psychological ramifications from going to a war,
7 serving in a war, coming back from a war, and going
8 through the motions of dealing with the system.
9 It's a very emotional, very stressful, very
10 monotonous process.
11 But certainly there are other things
12 going on than stress alone, and that's -- that's the
13 point that really has to come out in all this, that
14 veterans that went over there that served -- we are
15 the first volunteer army, volunteer service, in the
16 history of this United States. You know, you
17 drafted in Nam, you drafted in World War II, Korea,
18 World War I. You didn't have to have a draft,
19 because we were there. We were there. We were
20 getting paid $1,700 dollars a month in some cases to
21 go die for our country. We come back -- now $1,700
22 dollars a month is not a lot of money, particularly
23 not in this area.
24 Myself, I was getting $100 dollars a
25 month to be a part of the National Guard, and they
1 want to turn it into money? I -- $100 dollars a
2 month doesn't even put groceries on your table for a
4 DR. LASHOF: Thank you very much. I'm
5 afraid our time has run. Erika Lundholm?
6 MS. LUNDHOLM: I have copies of a
7 statement here for you all.
8 DR. LASHOF: Could you lower the mike
9 so that you -- thanks.
10 MS. LUNDHOLM: Good morning. My name
11 is Erika Lundholm. I'm the co-founder and Executive
12 Director of the California Association of Persian
13 Gulf Veterans, and co-founder and member of the
14 Board of Directors of the National Gulf War Resource
15 Center in Washington, D.C. I have been working on
16 the issue of ill veterans, civilians, and family
17 members since May of 1994.
18 First, let me tell you a little bit
19 about who I am, and my connection to this issue. I
20 am the sister of a Persian Gulf veteran. My
21 brother, as he explained, experienced SCUD attacks
22 and chemical alarms while in the Gulf. He
23 subsequently spent three days unconscious, and two
24 weeks in an EVAC hospital, although he was not
25 diagnosed with any disorder. His military medical
1 records from that incident are missing.
2 Over the next three years he became
3 progressively more ill, and he lived with me
4 immediately after returning from the Gulf for
5 several months, and brought all his equipment with
6 him. In January of '94 he returned to live with me,
7 because he was too ill to work. He has been
8 repeatedly denied adequate treatment at the VA, and
9 I have accompanied him there many times, and he's
10 been denied any compensation from the VA. He is now
11 homeless, and without any means of support.
12 In May of 1994, I became significantly
13 ill with most of the symptoms veterans are
14 describing. I was on complete disability for one
15 year and am now on partial disability from my
16 position with a county health department. At first,
17 I was very skeptical that there was any connection
18 with my illness to what was going on with the Gulf
19 War Syndrome. Over time I went through a real
20 revision of thought as to the causes of my illness.
21 After researching the subject and talking to many
22 people across the country, I found I was one among
23 many, many civilians that were ill.
24 What I found is that one of the real
25 problems addressing the issue of ill civilians is
1 the dearth of information. I would like to be able
2 to present data and statistics showing the
3 occurrence and extent of illnesses among civilians
4 and their relationship to exposures from the Gulf.
5 Unfortunately, no preliminary or comprehensive data
6 has been collected, nor are any epidemiological
7 studies being planned that include the majority of
8 civilians who are ill.
9 We don't know the total numbers of
10 civilians affected, how they are affected, who is
11 treating them, or how many have died. However, what
12 we do know is that the health status of civilians
13 has been, and is continuing to be, negatively
14 affected by events in the Persian Gulf War.
15 Through my research on this topic, I
16 found there seems to be four main classes of ill
17 civilians. Each has different risk factors for
18 exposure to chemical and biological warfare agents,
19 endemic infectious diseases, and other known health
20 hazards resulting from the war. The four classes
21 include civilian participants, civilian non-
22 participants, spouses and children, and close living
24 Civilian participants were present in
25 the Gulf area during the war, and had many of the
1 same exposures as military personnel to chemical,
2 biological and nuclear contamination, endemic
3 infectious diseases, and other toxic materials.
4 They include news media personnel, such as from CBS,
5 has had personnel with illnesses; DOD contracting
6 companies, such as Affes Company of El Paso, Texas,
7 which has around 60 ill civilians; also Bell
8 Helicopter at Ft. Hood, Texas; Red Cross workers are
9 ill; and Iraqi and Kuwaiti civilians living in the
10 area seem to have a very high rate of illness.
11 And looking at the Iraqi and Kuwaiti
12 medical research you find that they have been
13 experiencing severe health effects. Some of the
14 research shows Dr. Walid al-Tawil of the College of
15 Medicine at Baghdad has published a paper showing an
16 increase in environmental related illnesses. Dr.
17 Barhouti and Dr. al-Tawil performed a cross-
18 sectional study of patients and found a significant
19 increase in seminal fluid abnormalities.
20 Dr. Muna Elhassani of the Iraqi Cancer
21 Registry has found that in the Basra province in the
22 south of Iraq the leukemia rate has risen 56 percent
23 in the last five years. Dr. Selma al-Taha, a
24 consultant geneticist at the Saddam Medical City in
25 Baghdad, has stated that after the war the clinic
1 had fewer patients, but more cases of malformations
2 and genetic diseases. They also had many new cases
3 not seen before the war, including phocomelia. This
4 was especially true for those from the south of
6 Dr. Ahmad Harith al-Salihi of the ENT
7 Department at College of Medicine, University of
8 Baghdad, has stated that the Iraqi researchers have
9 found many undiagnosed illnesses. In one
10 manifestation, he has seen epidemic numbers of
11 patients presenting with temporary, partial
12 blindness followed by headaches and numbness. And a
13 visiting German doctor has stated that he observed a
14 higher rate of premature births. He also states
15 that he observed immune system suppression.
16 Civilian non-participants were not
17 present in the theater of war. However, they worked
18 in direct close contact, both during and after the
19 war, with either military personnel or military
20 equipment used in the war. Therefore, they might
21 have been exposed to infectious diseases or
22 chemically or biologically contaminated personnel or
24 The governmental response to these ill
25 civilian non-participants has been minimal.
1 Although some may be eligible for Workman's
2 Compensation, proof that exposure occurred through
3 contact with contaminated personnel or equipment is
4 difficult to prove without scientific studies, and I
5 know of no studies currently being planned.
6 The medical personnel include -- I'm
7 sorry. The civilian non-participants include
8 medical personnel, airline stewards, and civilian
9 contract workers. For instance, at Anniston,
10 Alabama, they repaired returned tanks, and many are
11 ill; at Ft. Bragg, North Carolina, they repackaged
12 used, returned parachutes, and many are ill; at Ft.
13 McCoy, Wisconsin, they cleaned and painted returned
14 equipment, and many are ill; at Ft. Riley, Kansas,
15 they sorted and cleaned equipment, and many are ill;
16 at military hospitals in England they removed
17 clothing and equipment from personnel, and many have
18 become ill. In Portland, Oregon, non-deployed
19 troops were on ships that had just returned from the
20 Gulf, and became ill; at Sacramento Army Depot they
21 cleaned and repaired returned equipment, and they
22 are ill; at Travis Air Force Base they cleaned and
23 repaired returned airplanes. They also were
24 stewards on planes that ferried troops home, and
25 they, too, are ill.
1 The third category is spouses and
2 children, and I know the committees have heard
3 numerous testimonies from spouses about their health
4 problems. Certainly many had the opportunity, as
5 did civilian non-participants, to become exposed to
6 various infectious diseases. As in Iraq, the
7 saddest part is the children exposed prior to birth
8 to toxins and the resultant birth defects.
9 Although some studies are currently
10 being planned and conducted by the DOD and VA to
11 investigate the health status of families, the
12 results of these studies need to be closely
14 And the fourth category is the close
15 living contacts. I have talked to numerous people
16 throughout the country, including parents of
17 veterans, siblings of veterans, housemates of
18 veterans, and partners -- girlfriends and such, who
19 have had health problems similar to the veterans.
20 If the veterans did return with contaminated
21 equipment or infectious diseases, it makes sense
22 that the close living contacts could well have been
23 exposed. Unfortunately, I know of no studies that
24 are planning to include these close contacts in any
25 of their research.
1 Civilians in general -- the civilians
2 I've talked to have the same symptoms as the
3 veterans, including the fatigue, the joint pain, the
4 diarrhea, the headaches, a lot of the muscle spasms.
5 Women also seem to be experiencing burning semen, as
6 I've noted previously, and an increase in
7 gynecological infections. And at this point very
8 little is being done by the DOD or the VA to address
9 this problem, except for some family related studies
10 and some birth defect studies.
11 The attitude of the DOD and VA seems to
12 be: if we don't look for any type of connection,
13 there won't be any found. And so I have some
15 One is to charge the Persian Gulf
16 Illness Coordinating Board with creating and funding
17 a registry to include all civilians who believe they
18 may have been exposed to illnesses, either in the
19 Persian Gulf, by contact with those returning from
20 the Gulf, or by contact with equipment returned from
21 the Gulf. It would include exposure questionnaires,
22 histories, medical evaluations, and treatment. It
23 would also include an outreach program to inform
24 possibly affected civilians of their eligibility.
25 I suggest the registry be managed by
1 the CDC, and an independent review body composed in
2 part by ill civilians should have oversight
4 The second recommendation is to include
5 ill civilians who may have PGI in any government-
6 funded epidemiology or research studies on the
7 health effects of the war.
8 And the third is to establish a
9 government liaison through the CDC who will become a
10 member of the Persian Gulf Veterans Coordinating
11 Board. The liaison will be responsible for
12 providing medical diagnostic and treatment
13 information to ill civilians and to their treating
14 medical personnel, and to oversee medical,
15 scientific, and epidemiology research on civilians,
16 and coordinate information with respective agencies.
17 Thank you.
18 DR. LASHOF: Thank you.
19 Are there questions from any of the
20 Committee members?
21 (No response.)
22 You indicated that you have had a lot
23 of contact, and talked with lots of people. Do you
24 have -- does your organization have a list now of
25 people who are spouses or relatives or family? Do
1 you have numbers at all? Even though granted
2 they're not epidemiologically done or anything like
4 MS. LUNDHOLM: Well, we have not done
5 an official survey. We do have throughout the
6 groups -- as you know, the National Gulf War
7 Resource Center is coordinating information from
8 about 21 veterans' groups across the country right
9 now, and we are compiling lists of names. I do have
10 some names of people in California, but there is no
11 -- at this point we don't have a complete registry,
12 although we are working on preparing a quite
13 widespread study.
14 DR. LASHOF: Thank you.
15 Any other questions?
16 Thank you very much. Our next
17 presenter is Howard Umowitz from Berkeley.
18 MR. UMOWITZ: Thank you for pronouncing
19 my name correctly.
20 I'm Howard Umowitz. I'm a micro-
21 biologist, a Ph.D. I'm an entrepreneur. I started
22 a biotech company up, and was interested in Gulf War
23 Syndrome because it fits a lot of the models that
24 we're looking at. I want to first thank the
25 Committee, and President and Mrs. Clinton for
1 allowing us the opportunity to express our views
3 I do my best talking with cartoons, and
4 so I've brought some with me. This is the world of
5 -- first slide. Basically this is the world I deal
6 with. It's a jungle in there, and we are charged
7 with understanding how the immune system has to
8 interact with all of these bacteria, funguses, and
10 I'd like to use this illustration to
11 simply point out three things we've learned in the
12 last five years.
13 The first is that the immune system is
14 a balance. We have what is known as cell-mediated
15 immunity and humoral immunity. That's skin tests
16 and antibodies, and they're mutually exclusive, and
17 so that's point one.
18 Point two is that we now know that
19 infectious organisms can exist without the
20 particles. That is to say that infectious nucleic
21 acid can be transmitted through semen, and a recent
22 example is the agent that's associated with Kaposi's
23 sarcoma, the human herpesvirus 8. It took molecular
24 biology to find that.
25 And the third is that I applaud the
1 efforts of the Center for Disease Control, of which
2 I'm a big supporter, in relooking at -- redefining
3 the case definition to fit things like chronic
4 fatigue syndrome and Gulf War Syndrome, because
5 clearly we don't have increased deaths, and we don't
6 have increased hospitalizations.
7 I think the DOD did a pretty good study
8 on that, but the evidence of absence is not the
9 absence of evidence. I like the fact that the
10 Center for Disease Control has now a case definition
11 we can use and go forward. We see pain and
12 suffering. That's what we're dealing with here.
13 So this is an immunologic balance, and
14 this is important to note, because it's the basis of
15 my topic, and I have handed the Committee my notes.
16 I don't expect you to read it today, but it is a
17 balance, and you must realize that the body must
18 always move between cell-mediated immunity and
19 humoral immunity as it decides to fight viruses and
21 But let's face it, it's really a lot
22 more complicated than that. If we had another ten
23 minutes I'm sure we would all understand this slide,
24 but in fact this is what I deal with every morning,
25 and I enjoy doing it.
1 The bottom line is this is my battle
2 plan of how to attack diseases, and I'm looking for
3 the weakest link, and maybe we've found something.
4 It may be anecdotal.
5 I'd like to define for you then that I
6 believe that we're dealing with an immune system
7 imbalance syndrome, not a deficiency, and I define
8 it as a group of symptoms that characterize an
9 abnormal condition with demonstrated imbalance in
10 the immune system. And I put into that category --
11 and I'll show you limited research, but we can talk
12 about this later -- Persian Gulf War related
13 illnesses. I throw AIDS and cancer, and autoimmune,
14 and neurologic disorders into this group.
15 We believe that imbalance happens
16 because of interactive infections. We wrote this
17 several years ago, that the old guard of using
18 Koch's postulate -- which has saved a lot of our
19 lives -- that one bug causes one disease, works for
20 staph infections and strep infections, but I think
21 in chronic illnesses we're dealing with a
22 multiplicity of interacting substances, and we
23 define those substances in the three major important
25 We have triggers -- and please forgive
1 me, I follow in the foots of some very fine people,
2 Dan Fahey, Erika Lundholm, Dean Lundholm, and people
3 to follow me, Debbie Judd and the like, I applaud
4 their efforts.
5 What we've found is, I've simply put up
6 multiple vaccines and chemical agents. We clearly
7 know that there was contaminated water, oil, field
8 fires, depleted uranium, parasites-carrying sand
9 flies, desert sand, and nerve agent pre-treatment
10 drugs. That's a heavy dose for the human body.
11 I think it was to help us be prepared
12 for the war, but it does put a lot of impact on the
14 But that in itself, the human body can
15 get over. I think the key thing here is the fact
16 that there's a progressor, and we believe, in the
17 chronic illnesses, it's opportunistic infections,
18 and the one thing that's greatly been missed is host
19 genes. I hate this word, but it's in the literature
20 -- human endogenous retro viruses. They are not
21 retro viruses, they are normal human genes, and it's
22 one percent of your genome.
23 And we have written a paper on this
24 subject, which will come out in January in two
25 months, and the bottom line is that we simply did a
1 survey. We are not commercializing this test, the
2 point is simply a research essay.
3 I'll show you the data. It's nothing
4 more than just a silly little plate that has a bunch
5 of yellow wells. Yellow means there's a positive
6 antibody response. White means -- clear means
7 there's no antibody. And what we were looking for
8 was, if you make antibodies to your own gene
9 proteins, that's called an autoantibody. It's an
10 autoimmune antibody. You shouldn't have it.
11 I'm simply going to go through this
12 quickly, not because I'm trying to do
13 prestidigitation, only because ten minutes is not a
14 lot of time. But the bottom line is we've done most
15 of our studies in looking at HIV disease. We
16 believe HIV is the major trigger in AIDS, and if you
17 look at asymptomatics, people who have no AIDS
18 defining illnesses at all, you can see the red bars
19 are the antibodies to HIV, which you would expect.
20 This is in a 24 hour period. But you see no green
21 bars anywhere, which is antibodies to these cellular
22 genes. They haven't turned them on. They haven't
23 progressed. But that's not the case with people
24 with AIDS or symptoms.
25 You can see that at least -- a green
1 bar in each of these graphs, which tells you that
2 not only is HIV present, but you turn on these
3 autoantibodies, and they also have opportunistic
4 infections, and most of these people have gone on to
6 In this study there was simply a
7 survey, and the limitations here are -- we simply
8 run these as research essays. We have not done
9 deploy groups of proper epidemiology, which is
10 what's called for here, but this simply was to give
11 us the clue of where to look next.
12 And we have here 13 out of 15 Gulf War
13 vets, this is from a group in Portland, Oregon; 13
14 out of 15 vets, as you can see, have very high
15 titers of antibodies to their own gene proteins,
16 eight out of ten spouses and four out of five
17 children; these people, of course, were all ill.
18 And, of course, limitations studies to do groups
19 that were non-deployed.
20 But I argue that this has been an
21 historical reference that antibodies to your own
22 proteins is just an abnormal state.
23 Given that as it may, it simply was
24 used as a directional post for where to go next, and
25 it provided us with the notion that these people
1 were in imbalance, the fact that they've turned on
3 We then next looked at the usual
4 suspects. The paper that I wrote with Bill Murphy -
5 - I am proud to know Bill for the last 25 years --
6 he was the first individual to isolate Mycoplasma
7 fermentans from childhood leukemia 30 years ago
8 from bone marrow. Luke Machinae, who also is a
9 friend of mine and colleague, just isolated it from
10 AIDS patients.
11 And now we hear in Texas that they're
12 finding the genes in Gulf War symptoms. Gee, do you
13 think there's a pattern? I do.
14 I think Mycoplasma fermentans is one
15 of these bugs that just persists in long-term
16 infections, and make super antigens alike, and can
17 turn on these genes and certainly make progression
18 towards chronic illnesses.
19 Let's not discount Epstein-Barr Virus,
20 cytomegalovirus, microsporida, and cryptospordia --
21 all these things we know are associated with Gulf
22 War related illnesses.
23 Well, theories are all fine and good,
24 and whether I'm right or wrong is not the issue; the
25 issue is what are we going to do with this. And
1 because of our position that we found the imbalance.
2 (Slide change)
3 This gentleman and his wife found us in
4 Berkeley. This is him in the Gulf War. In March of
5 this year, he saw me at my keynote address, which I
6 was honored to give in Houston at the International
7 Conference on AIDS in America, and he was in a
8 wheelchair, and he was probably never going to walk
10 We looked at him. He had all the
11 symptoms of a mycoplasma infection, so we asked his
12 doctor to treat aggressively with doxycycline, which
13 is a known antibiotic that helps.
14 (Slide change)
15 This is Tom four weeks later with his
16 daughter and father-in-law, carrying his own weight.
17 (Slide change)
18 And this is Tom in Portland, Oregon.
19 And I'm happy to announce that they want to let me
20 know one hour ago that Tom just carried a 125-pound
21 deer a quarter mile after shooting it, and doing his
22 favorite sport of deer hunting, which I believe
23 President Clinton enjoys also.
24 This man believes he's cured. I
25 believe it's a happy moment, but I don't call it a
1 cure, and he has to live on doxycycline because,
2 when he goes off it, he's back in the wheelchair
4 This is my recommendations to you. I
5 think this is -- I like to look for successes.
6 That's what we should build on. My recommendations
7 are very simple, and I have provided the Committee
8 with things that you just pull off the Internet, our
10 I believe that we should provide
11 individuals with guidelines for avoiding
12 opportunistic infections. Here in the absolutely
13 fantastic preparation -- a lot of work went into it
14 -- for the Center for Disease Control and U.S.
15 Public Health System, it's called the MMWR Reports
16 and Recommendations, Prevention of Opportunistic
17 Infections in Persons Infected with Human
18 Immunodeficiency Virus. This is not AIDS, but it
19 is opportunistic infections. That's my belief, and
20 that's my position.
21 And I believe that we need to charge
22 scientists, both in the VA and outside the VA, to
23 diagnose and treat opportunistic infections, not
24 willy-nilly but, I think, intelligently and
25 medically to find these chronic diseases that we
1 know about.
2 And by the way this is the guideline
3 that I provide you with. It's a beautiful report,
4 and has some very good things I think should be
5 distilled down to non-medical terms, and it's done a
6 very good job.
7 And the last thing I would like to tell
8 you about is that we have provided on the Internet
9 for scientists, physicians, and patient advocates,
10 of which I'm a big fan of, is that we believe all
11 these chronic diseases have a trigger progressor and
12 human genome component to it, at least that's what I
13 get up in the morning for, and I'm trying to build
14 diagnostic tests for, and that we're happy to give
15 out the Web site address to anybody who is
17 And we also invite members of the
18 Commission to please, if you wish to, publish the
19 results, or editorials, or a message to the world.
20 Hand it over to us -- we'd be happy to put it on the
21 net. Thank you again for allowing me to speak.
22 DR. LASHOF: Thank you very much.
23 Questions? Andrea?
24 DR. TAYLOR: I have a question. How
25 many Gulf War veterans have you actually seen thus
1 far? You said something about 13 and 15, and I
2 wanted to --
3 MR. UMOWITZ: Oh, we did about 40 vets
4 in the study that we did up in Portland, and we ran
5 them double blinded in our facility with AIDS
6 patients, low-risk patients from the life insurance
7 industry, and the like, so they were just all mixed
8 up, and that was the curve you saw.
9 DR. TAYLOR: Okay. And these all had
10 opportunistic infections?
11 MR. UMOWITZ: The vets that we selected
12 all had complaints of chronic fatigue syndrome,
13 joint/muscle pains, you know, the list of the case
14 definition that's being generated by the Centers for
15 Disease Control now.
16 DR. TAYLOR: The other question is, for
17 those patients, did you actually treat them with the
18 same antibiotic as this last person that you showed?
19 MR. UMOWITZ: I'm but a humble
20 microbiologist. I can't --
21 DR. TAYLOR: Well --
22 MR. UMOWITZ: -- recommend a specific
24 DR. TAYLOR: -- treatment or --
25 MR. UMOWITZ: But I do provide to
1 physicians, the Journal of the American Medical
2 Association, that shows the aggressive treatment
3 with doxycycline; but we believe that just standard
4 medicine should be used as medical practice.
5 DR. TAYLOR: Okay. But now those that
6 were recommended treatment through their physicians,
7 do you know of any of those getting better from --
8 MR. UMOWITZ: Well, I've interviewed
9 personally 12 of about 100 that have been
10 recommended in Houston. I have simply just started
11 randomly calling them, asking them a lot of
12 questions, and the 12 out of 12 all said the same
13 thing. Within about four to eight weeks -- it takes
14 a long time, because remember these are slow-growing
15 bacteria, much like Lyme Disease -- it takes a long
16 time, a long course of antibiotics, before you start
17 seeing ablation of symptoms.
18 DR. LASHOF: Do you know of any double
19 blinded clinical studies on doxycycline for Gulf War
20 veterans' illness?
21 MR. UMOWITZ: I'm here to tell you that
22 we're going to get started with the Martinez VA in
23 about two months to do such a study. You must do
24 these studies to really ask the question, is it that
25 the doxycycline or is it, in fact, just helping the
1 inflammatory response and has nothing to do with the
2 microbes? These are all very important questions to
4 But I think that I like to build from
5 successes. Anecdotally I know of 12 people that
6 have done very well by this treatment. I'd
7 certainly encourage the group to work with us to do
8 such studies. I think they're important.
9 DR. LASHOF: Recently the Department of
10 Defense and the VA put out a call for proposals for
11 research in different areas including clinical
12 illness. Have you applied for --
13 MR. UMOWITZ: I've been up all night
14 writing these things. I just enjoy writing
15 proposals, and we're going to get it in.
16 DR. LASHOF: Okay. You haven't heard
17 anything yet then?
18 MR. UMOWITZ: All I've heard is that I
19 better get it in pretty quick.
20 DR. LASHOF: Okay. Thank you.
21 Any other questions? John?
22 DR. BALDESCHWIELER: Let me be sure I
23 understand your hypothesis.
24 You say that an immune imbalance is the
25 -- allows opportunistic infection, and actual
1 symptoms are those of the opportunistic infection.
2 What is the cause of the immune imbalance?
3 MR. UMOWITZ: Oh, I believe it's the
4 triggers that we see. For example, in HIV, which is
5 a retro transposon generator, that if, in fact, you
6 can cause these jumping genes, which they are -- I'm
8 DR. BALDESCHWIELER: Presumably there
9 is an immune imbalance which is caused by exposure
10 to something in the Gulf?
11 MR. UMOWITZ: Oh, I'm sorry. When we
12 sent them over there with the multiple
13 immunizations, as you know in the literature, immune
14 paralysis -- when you give multiple immunizations it
15 makes people sick.
16 When I came back from Gulf War Unity
17 Conference in March, I pulled up a beer, sat on my
18 couch, and watched Magombo, where Clark Gable was
19 looking at a friend who just came by and said,
20 "Geez, you really look bad; is it from the
21 vaccines?" We know that vaccines put people in a
22 TH-2 mode, which is, in fact, the antibody mode, and
23 it does in fact turn on human endogenous retro virus
24 genes, so people get over it.
25 I mean, it's -- you get the discomfort.
1 We always recommend before you go abroad that you
2 get vaccinations a month or two in advance so that
3 you can get over the flu-like symptoms, if you will.
4 But you had the flu-like symptoms, you had the nerve
5 gas, the PB pills, if you will, contaminated water,
6 and the like, but I think that perhaps the -- what
7 I'm hearing and what I'm seeing is the fallout --
8 the chemical fallout from the bombing of the
9 munition plants is probably the most deadly of all
10 the encounters. I think that really may have been
11 the trigger that just pushed everything into immune
12 imbalance. That's my guess from what I'm reading.
13 DR. BALDESCHWIELER: Because people in
14 their normal lives in the United States are exposed
15 to an enormous variety of challenges.
16 MR. UMOWITZ: Yes. That's why we call
17 them opportunistic infections. It is when the
18 immune system is crippled, that's when these things
19 take over.
20 DR. BALDESCHWIELER: And so then you
21 would hypothesize that it was the panel of
22 vaccinations before they left?
23 MR. UMOWITZ: Vaccines, depleted
24 uranium, chemical fallout, contaminated water, sand
25 flies leishmania, it's -- I just don't think it's
1 any one thing. I think it's just that when you're
2 -- the human body is faced with that much,
3 something's going to give, and I think that it just
4 happens so far and so long that we're just starting
5 to see now how opportunistic infections took hold,
6 and they're just hard to get rid of. We can't
7 resolve these infections right now. We've got to
8 look to antibiotics. That's my hypothesis.
9 DR. LASHOF: Thank you very much.
10 DR. BALDESCHWIELER: Thank you.
11 DR. LASHOF: I'm afraid we're running
12 out of time. The next person is Richard Reyes from
14 MR. REYES: Good morning.
15 My name is Richard Reyes. I was a
16 Reservist activated for the Gulf War in January of
17 1991, and we were stationed at King Kalid
18 International Airport near the city of Riyadh, and
19 during that time we were consistently attacked by
20 SCUD missiles, and we were in an evacuation
21 hospital, and we estimated that we evacuated 800
22 patients from our facility. Patients who were never
23 decontaminated, who came to our facility exactly as
24 they had been out in the field.
25 My -- the reason that I'm here this --
1 today is again to -- like I said in my letter to you
2 that I believe that there are quite a few active
3 duty National Guardsmen and reservists that will not
4 come forward to present their illnesses, or present
5 their complaints, and there's a lot of reasons for
7 But if I were to use myself as an
8 example, that when I first started having my
9 symptoms back in 1993, I did the right thing. It
10 said to go to the VA hospital and get put on a
11 registry, and I went and did that, and it's been --
12 I regret doing that to this day. It's just been
13 something that's turned my whole life into one --
14 one VA visit after another, and it's almost like
15 you're trapped, because then once you stop going
16 then the VA says that you're refusing treatment.
17 And it just seems like I've -- you keep
18 telling them about the Gulf War Syndrome, but
19 they're more interested in some of the other
20 symptoms that you have, and they -- I've never
21 really had anyone really say that the Gulf War
22 caused any of the problems that I've had.
23 I've had a lot of gastrointestinal
24 problems. As soon as I came back from the war my
25 right hand was numb, and the VA -- when I got my
1 separation physical from the Air Force, the doctor
2 put down ligament strain, and that was the diagnosis
3 that stayed on my record until 199 -- 1994 when
4 ulnar nerve compression was finally diagnosed, and
5 since 1994 I've had two operations on the nerve and
6 my hand continues to be numb, and I've continually
7 told the VA that my left arm has also been numb, and
8 that I've had problems with my knees and my
9 shoulder. But they just never seem to concentrate
10 on that. Right now they're just looking, and it's
11 just been very frustrating.
12 So again I just want to say that, for a
13 lot of young people that I talk to that they're
14 having a lot of the same symptoms that I've had,
15 especially with the numbness in the hands, and these
16 are active duty personnel, reservist National
17 Guardsmen, that through a network they seem to find
18 out that I'm a veteran, and they call me, and then
19 the first thing that they tell me is, well, I'm not
20 going to do it, because, hey, I like -- I like the
21 reserves. I like active duty. I don't want to
22 jeopardize my career.
23 And that's one of the things that I
24 guess I want to stress this morning is that I joined
25 the reserves when I was 17 years old. I've been in
1 the reserves now for 18 years, and I can just
2 imagine someone who is 24, 25, and is really
3 enjoying their participation in the military, and
4 it's very difficult for you to come forward and to
5 say something's wrong with my body that's going to
6 jeopardize your continued participation in the
7 military, because for people that haven't been in
8 the military it's something that -- it's kind of
9 hard to explain at times why people are willing to
10 risk their lives.
11 People are willing to get on Navy
12 transports, willing to get on aircraft carriers,
13 airplanes, to serve their country, but people do it,
14 and people love what they do. And it's very
15 difficult when you went to serve your country, and
16 you're having these problems, and then when you
17 start talking to veterans that have been exposed to
18 the VA -- I just recommend for them just to -- not
19 to go anywhere near the VA, that if they have their
20 own personal doctor for them to concentrate with
22 Because I was self-employed before I
23 went to the Gulf, and since I came back from the
24 Gulf I've lost my health insurance. I was not
25 eligible for my disability insurance, because it was
1 an act of war, and they said even if it was an
2 undeclared act of war, so it's been very difficult
3 for me to provide an income for my family. And I
4 just wanted to stress that, that there are quite a
5 few especially active duty -- a lot of active duty
6 fliers that I come in contact with in my reserve
7 duty that periodically -- they're bi-monthly, or in
8 a quarter of the year will come down with symptoms
9 of -- where they will have to go to the emergency
10 room and get pumped with IV fluids, and have a lot
11 of gastrointestinal problems -- the nausea, the
12 dizziness, and again they just go through and active
13 duty never really makes the connection that they
14 were participants in the Persian Gulf War.
15 So I just wanted to make that for --
16 it'll be quite some time I think before these young
17 -- these young military personnel finally will come
18 forward and say, well, I had -- this occurred to me
19 back in 1992 or in 1993, where I could just envision
20 the VA saying, well, you know, you're out of luck.
21 You should have came by when we put out the call for
22 you to come by.
23 So I just wanted to let you know that
24 this morning, and I also wanted to note that right
25 now what we just learned is that the Department of
1 Defense is making provisions now for income
2 protection, especially for some of our doctors that
3 went, but also for a lot of people who are self-
4 employed, like in my case, that we -- we've lost our
5 income when we were activated in the war, and since
6 that time our ability to make a living has been
7 greatly affected, so those -- but I would just like
8 to say that the use of active duty reserves and
9 National Guardsmen -- I really don't believe that
10 the Department of Defense was prepared for a lot of
11 the special needs that reservists and National
12 Guardsmen were facing, and face even to this day.
13 I think that they talk a good game
14 about the total force policy, about integrating
15 active duty and reserves, and I believe that as you
16 -- there's a call up right now for 25,000 men to go
17 to Bosnia, and a few of them will be reservists. I
18 really still don't think that the military looks at
19 the reserves and their special needs, and their
20 special requirements for their family, for their
21 income, for their medical, legal, and I think that
22 these are issues that maybe you should look at.
23 And the final thing that I would just
24 like to say is that back in 1992 when I returned
25 from the Gulf, I knew right away that I was having
1 problems with my memory and my concentration, so I
2 accelerated my scholastic goals and I obtained my
3 Bachelor of Science in 1993, and I obtained my
4 master's degree in 1994. And since that time I'm
5 glad that I did, because I know that I wouldn't be
6 able to carry a full load, or even be able to
7 participate in any sort of structured classroom
8 setting any longer.
9 But it seems now that the VA holds that
10 against me, because they look at me and they see
11 somebody who's 35 years old, has a master's degree,
12 and should be doing something with their lives, and
13 you're trying to tell them, hey, I can't do anything
14 with my life. I can't go to a job and have to tell
15 them, well, you know, I have to go to the bathroom
16 every so often, or I have to have frequent visits to
17 the doctor, and I take medication that sometimes
18 makes me ill, and so it's been just very difficult.
19 And I believe that the VA is just not -- again, just
20 wasn't prepared for the needs of reservists and
21 active duty personnel that they are treating.
22 And so that the main reason that I'm
23 here is that it seems like the VA treatment -- the
24 doctors that I look at that look me over -- they're
25 very dedicated individuals, but it seems like the VA
1 -- the administrative end -- the ones that handle
2 the compensation and the pension issues -- they're a
3 whole different ball game. I don't know what their
4 rationale is. I don't know what -- if they're out
5 to deny everyone, and just have this -- they have it
6 in as part of their policy that all these guys are
7 faking it, and then let's just make life as
8 difficult for them as possible, but I think that
9 these things need to be addressed, because they make
10 it very frustrating.
11 And you talk with VA -- Vietnam era
12 veterans, and I get a lot of encouragement from
13 them, because they tell you just never give up.
14 That that's exactly what the VA wants you to do is
15 just to get frustrated with all the ins and outs,
16 the paperwork, the run around, so that you can --
17 then they can say, well, you withdrew, you didn't
18 come to this appointment, you didn't bring in this
19 form in a timely fashion. And then you're out your
20 pension, or you're out your compensation.
21 So I really want to again thank the
22 Vietnam veterans that I've been talking to, because
23 they've really been to me a support, and they've
24 really told me or really have identified to me how
25 to deal with the VA, and just how almost hideous
1 they are at times in their treatment of veterans'
3 So that that would be my statement, and
4 also with -- add that my wife has also been ill, and
5 the VA just doesn't have anything in place for my
6 wife's illness, and it's almost like it doesn't
8 DR. LASHOF: All right. Thank you very
10 Are there any questions? No?
11 Thank you very much.
12 The next person is Garold
14 MR. SCHWARTZENBERGER: Good morning.
15 My name is Gary Schwartzenberger, and
16 I'm one of those Vietnam vets, okay? First of all
17 the symptoms people are talking about here today are
18 exactly the same things that I talked about, minus
19 the spent uranium rounds, okay?
20 To get on with what I'm here to say,
21 the subject of thiamine, B1, and its successful
22 treatment of exposure to toxic chemicals at warfare
23 has been reported to this committee previously.
24 However, the primary cause creating this Gulf War
25 Syndrome, Agent Orange Syndrome, or shall we say
1 toxic chemical exposure in warfare, has been
2 discovered by myself and my associates.
3 With the help of Mr. Edward Hill and
4 with myself as a primary test subject, we found
5 damage to five points on my chromosome structure,
6 hypervitaminosis B1 at one point,. hypervitaminosis
7 D as another.
8 In the second victim tested these same
9 five points were also found to be damaged. Both of
10 us have had our DNA altered by toxic chemical wash
11 in warfare.
12 With the second subject, by treating
13 the damaged chromosomes directly with alternative
14 medicine, the length of treatment was reduced from
15 one and a half hours to five minutes. The interval
16 between treatments was extended from one day to two
17 weeks. The second subject was also able to go back
18 to work within the first two weeks after treatment
19 for damaged chromosomes.
20 Now let's get into the cost. The cost
21 of manufacturing given away free to all the victims
22 of toxic chemical exposure, all the sublingual, B1,
23 B1 complex they need, military and otherwise, in
24 this entire nation -- the budget of this committee
25 is greater. The product thiamin is so cheap to
1 produce that few chemical companies will bother.
2 That is the problem. There is no profit potential.
3 It costs VA hospitals to not treat the
4 victims of toxic chemical exposure. I'm talking
5 about from the Korean War vets I've talked to, the
6 Vietnam vets, and the Gulf War vets. It's all the
7 same. There's no difference. The cost not to treat
8 the victims of toxic chemical exposure, but wait for
9 opportunistic diseases to manifest themselves, is
10 conservatively estimated between $15- and $20
11 billion to the VA alone, and that's a very
12 conservative figure.
13 The costs escalate exponentially when
14 you consider all the victims in federal, state,
15 county and city hospitals, private medical programs,
16 military and our general population -- which lately
17 about ten percent of the people I work with are of
18 the general population, they have nothing to do with
19 the military.
20 Add on to those who are classified and
21 enforced misdiagnosed categories, which we've heard
22 one testify today -- possible cancer, possible MS,
23 possible lupus, possible rheumatoid arthritis, and
24 on and on. And don't forget our skid rows, our
25 prisons, state and county jails, where so many sick
1 victims languish, wind up going untreated and die.
2 The total cost to the private and
3 governmental sector is so vast that it boggles the
4 mind even to figure out -- to try to figure out how
5 to add up the hundreds of billions of dollars wasted
6 and the tens of thousands dead.
7 In the majority of the untreated toxic
8 chemical exposure victims, the misdiagnosed medical
9 conditions are very long-term, very expensive, and
10 the treatment is of little or no value, but they are
11 very, very profitable, and very deadly.
12 In 1885, when Mr. Emile Zola wrote in a
13 letter to France about the Dreyfus case and about
14 truth, and I quote him:
15 "Truth must come out. Nothing can prevent it.
16 Despite all ill will, every step taken will be
17 mathematically a step forward when the right
18 hour strikes. Truth possesses a power within
19 itself which overwhelms every obstacle, and
20 should you stop a road, should you succeed
21 during a shorter or a longer period of time in
22 burying her below the Earth, the power augments
23 and becomes an explosive force, which on a day
24 that it breaks loose will carry everything
25 before it, and try on this occasion to wall it
1 up with lies, to keep it behind closed doors,
2 and you will see whether you do not prepare for
3 the future the most reverberating of
5 And I have for this Committee a copy of
6 this statement that I have also obtained from
7 retired Admiral E.R. Zumwalt, Jr., Chairman of the
8 Agent Orange Coordinating Committee for the
9 Scientific Advisory Board, Executive Committee
10 Meeting, U.S. Environmental Protective Agency, dated
11 September 21st, 1995. That less than six weeks ago.
12 And this document speaks, and I quote him,
13 "This is a devastating indictment of our past
14 president's and government's complicity in
15 promoting the atrocities and deaths confronting
16 our veterans, and the general population of the
17 world environment today. The mechanisms
18 installed by these perpetrators are still in
19 place... " --
20 We're talking about the ones that
21 installed it against the Agent Orange and Vietnam
22 vets. They're still in place.
23 "...and they are coming into play against our
24 returning Gulf War veterans."
25 Thank you.
1 DR. LASHOF: Thank you.
2 Are there questions? Andrea?
3 DR. TAYLOR: I might have missed it at
4 the very beginning, but did you say that you served
5 in the Gulf War?
6 MR. SCHWARTZENBERGER: No. I was a
7 Vietnam vet.
8 DR. LASHOF: Any other questions?
9 Thank you very much.
10 The next person is Mr. Robert Olson
11 from Monterey. Oh, we are? I'm sorry. Okay.
12 We were going to take a break, yes.
13 I'm sorry. We are going to take a brief break, and
14 during the break let me say that Room 212 at the end
15 of the hallway has been set aside for veterans and
16 the others in attendance today. There's coffee, and
17 additional information is available there, so you
18 can avail yourself of that in the break. And we
19 will resume at 11:30. Thank you.
20 (Whereupon, a brief recess was taken.)
21 DR. LASHOF: I think we're ready to
22 resume hearing the testimony.
23 I ask Dr. Robert Olson to come forward.
24 DR. OLSON: Good morning, ladies and
1 May I first of all thank you for
2 allowing me to address this important panel this
3 morning. I'm a retired Air Force physician, and
4 obstetrician/gynecologist by specialty, and have
5 personally consulted and treated thousands of
6 military personnel during my Air Force career.
7 About two months ago a friend who
8 served in the Persian Gulf complained of classical
9 symptoms of the Gulf War Syndrome. These
10 complaints, namely intermittent chronic fatigue,
11 recurring rash, generalized malaise, and similar
12 symptoms that have been well described in the
13 literature and to this panel in the past.
14 I must admit I do have a great deal of
15 skepticism regarding the issue. I had essentially
16 gained all of my knowledge on the subject from the
17 lay press, and been led to believe that there was
18 really no validity to these complaints, since the
19 Department of Defense had repeatedly denied the
20 presence of bacteriological, chemical, or other
21 exposures to significant medical toxins by our
23 Because of my interest in obtaining
24 more information on this subject, I was invited to
25 attend the West Coast Conference on Persian Gulf
1 Syndrome in Portland, Oregon last September. There
2 were nearly 100 veterans and families attending with
3 stories and complaints that convinced me beyond any
4 doubt that a very serious chronic illness has indeed
5 resulted from Gulf War exposures. And, in fact,
6 that although the DOD denied the presence of various
7 toxic elements, the Freedom of Information and the
8 Senate Committee on Banking, Housing and Urban
9 Affairs reported a report of May 25, 1994, recently
10 uncovered evidence to the contrary.
11 I was amazed that this meeting in a
12 room filled with young Persian Gulf veterans all had
13 essentially the same story to tell, that is, they
14 all seemed to have the same cluster of symptoms
15 typical of the Gulf War Syndrome. But even more
16 impressive to me was the consistent and recurring
17 complaint against the Veterans' Administration
18 regarding their medical care, or more accurately
19 described the lack thereof.
20 It appears that there is a constant
21 trifling of these complaints. It seems that the
22 veterans are constantly told they are suffering from
23 stress or some ill-defined psychiatric disorder.
24 In addition, your Commission has
25 already heard many spouses and family members
1 express similar complaints, and their children are
2 being delivered with serious birth defects. The
3 marriages and family integrity of many of these are
4 being challenged by these chronic medical
6 I have recently accessed a military
7 forum on Compuserve and Internet sources, and am
8 receiving similar complaints from veterans all over
9 the United States, and, in fact, from several NATO
11 As a physician and a former hospital
12 commander of several Air Force facilities, I can
13 attest to the fact that I, too, had complaints
14 regarding medical services rendered at my
15 facilities, but that the vast majority of my clients
16 were satisfied with the services rendered them.
17 This does not appear to be the case for our
18 Veterans' Administration.
19 As an American citizen and a physician,
20 I am ashamed that we as a nation can deploy our men
21 and women overseas to fight in foreign wars with
22 much fanfare and patriotic gestures, but they are
23 essentially abandoned when serious medical problems
24 arise upon their return. The Agent Orange issue and
25 now the Gulf War issue medical complaints are two
1 recent examples of inadequate response to war
2 induced medical problems.
3 I would urge the following steps be
4 recommended to President Clinton regarding these
5 problems. Number one, insist that the VA and DOD
6 hold a series of meetings throughout the United
7 States similar to this one, but invite veterans and
8 their families to vent their complaints and listen
9 to their recommendations regarding possible
10 solutions to their many medical and social problems.
11 Number two, insist that the VA begin
12 circulating a patient satisfaction survey, so that
13 they can begin to receive and analyze feedback
14 regarding the poor image they allegedly now receive.
15 Number three, seek additional funding
16 to not only begin providing adequate medical
17 services to our Gulf War veterans, but their
18 affected families as well. We need to answer the
19 question of how can this be paid for? As an
20 example, during the recent Defense budget hearings,
21 our Congress allocated more money to the Defense
22 Department than they requested. This is therefore
23 not a question of lack of funds, but rather a matter
24 of priorities. I believe our veterans serving in
25 the Gulf War or any conflict deserve better.
1 Finally, thank you again for allowing
2 me to present my impressions regarding the Gulf War
3 Syndrome. I know you realize you not only have an
4 awesome responsibility in your deliberations, but
5 also an opportunity as well to be able to influence
6 our political leadership and insist that they assign
7 the highest priority in addressing the important
8 issue of the Gulf War Syndrome.
9 Thank you.
10 DR. LASHOF: Thank you, Dr. Olson.
11 Are there questions for Dr. Olson from
12 the panel?
13 DR. TAYLOR: I have a short one. Do
14 you actually have a number of patients that you've
15 actually seen who have exhibited symptoms similar to
16 the ones --
17 DR. OLSON: I have to admit I'm very
18 new to this issue. I really got involved primarily
19 in September at the Portland encounter where the
20 room was filled up with maybe two or three times as
21 many people, and they were all -- almost all
22 veterans from the Persian Gulf, and their families,
23 and they were all, you know, informally giving me
24 the same information as to -- and so I don't have
1 DR. TAYLOR: You didn't see actual
2 patients in your --
3 DR. OLSON: No, no. I have not.
4 DR. LASHOF: Are you in active practice
5 now, or are you retired?
6 DR. OLSON: I am licensed to practice
7 in California, but I am retired, but I'm going to do
8 everything in my power in my time to try to resolve
9 this very serious problem.
10 DR. LASHOF: Thank you.
12 DR. BALDESCHWIELER: You mentioned a
13 report from the Senate Committee on Banking, Housing
14 and Urban Affairs, which provided evidence for
15 exposure --
16 DR. OLSON: That was a hearing by
17 Senator Riegle, and that information is public
18 information now. I'd be glad to furnish you with
19 that if you're interested.
20 DR. BALDESCHWIELER: Do we have that?
21 DR. LASHOF: Yes. We have. Thank you.
22 Thank you very much.
23 DR. OLSON: Thank you.
24 DR. TAYLOR: Thank you.
25 DR. LASHOF: Debra Judd, Elk Grove?
1 MS. JUDD: Good morning.
2 My name is Debbie Judd, and I'm a
3 Registered Nurse. I served in the Air Force as an
4 Air Evacuation Staging Nurse in Saudi Arabia during
5 the Persian Gulf War.
6 Shortly after entering the theater of
7 operations I became ill, and have experienced
8 deteriorating health problems since that time. My
9 primary reason for interest in the Persian Gulf
10 illness issue is to identify those who are ill, and
11 ensure they receive adequate, competent, and quality
12 medical care.
13 In an attempt to locate and identify
14 ill veterans, a number of veterans advocacy groups
15 have formed nationally and internationally. I am
16 the founder of the Northern California Association
17 of Persian Gulf Veterans, which now has
18 approximately 150 members; as well as that, I am on
19 the Board of Directors of the National Gulf War
20 Resource Center.
21 The information I'll be presenting
22 today is the survey results of one of our fellow
23 advocacy groups, the Operation Desert Shield/Desert
24 Storm group. This group was formed in November of
25 1990 in support of the 1115th Transportation Company
1 out of Ft. Eustis, Virginia. The group's located in
2 Odessa, Texas.
3 ODSA received its first call for help
4 from an ill veteran in August of 1991. Due to the
5 large volume of calls received, a questionnaire was
6 subsequently developed to record information
7 gathered from the veterans. Between August of 1991
8 and October 1st, 1995, the number of calls received
9 were 10,051 sick veterans. And what I would like to
10 just briefly go over is to show the results of the
12 The methodology -- all the data was
13 provided by Mr. James Sylvester of Operation Desert
14 Shield/Desert Storm, which is headquartered in
15 Odessa. All the veterans who phoned ODSA between
16 August of 1991 and October of 1995 were asked a
17 standard series of questions regarding their
18 service, exposures and symptoms. Copies of the
19 questionnaire and the criteria are attached in the
21 The percentages are based on the total
22 number of calls received or surveys completed at
23 their group meetings. The verified surveys indicate
24 that they were able to prove to the medical facility
25 providing treatment and they were contacted, or that
1 the veteran was able to bring their medical records
2 to the meeting. Medical records from active duty
3 personnel were not verifiable due to military
5 The total number of surveys was 10,051,
6 and the ones that they were able to verify through
7 medical facilities or medical records was 46
9 DR. BALDESCHWIELER: Excuse me. Can
10 you tell me what "verify" means?
11 MS. JUDD: "Verify" was that they were
12 either able to -- the person -- the recorder taking
13 the -- doing the interview was able to contact the
14 medical establishment the person was being seen at,
15 and verify that they were being seen, or they
16 personally saw them and carried their medical
17 records into one of the meetings.
18 On the family questionnaire section, 65
19 percent of the 10,000 were married, 51 percent of
20 those stated that their spouse was having problems,
21 and 22 percent stated their children were having
23 For the environmental questionnaire --
24 part of the questionnaire, 82 percent entered
25 captured enemy vehicles, 78 percent was in the area
1 of SCUD attack, 67 percent came under Iraqi
2 artillery fire, 64 percent entered captured enemy
3 bunkers, and 62 percent entered captured enemy
4 ammunition dumps.
5 Concerning the N/B/C questions part of
6 the survey, 84 percent of the 10,000 indicated that
7 while they were there the gas alarms went off, and
8 that they went into MOPP status and wore protective
9 gear; 65 percent witnessed dead animals that were
10 not -- did not have artillery wounds. They could
11 not see apparent causes for the dead animals. There
12 were 65 percent that witnessed these dead animals.
13 And those who entered buildings that had marked
14 radiation warnings was nine percent.
15 Specific to the oil in the environment
16 there, those breathing or enveloped in oil fire
17 smoke was 96 percent; within clear visual area of
18 the oil fires was 90 percent; worked in, lived in,
19 or made travel through the burning oil fields was 72
20 percent; washed in water with an oily sheen was 68
21 percent. Those having oily taste to their food was
22 66 percent, and those with oily taste to the
23 drinking water was 65 percent.
24 On the environmental section of the
25 questionnaire, this was indicated to note local
1 environment, to wherever you were stationed in the
2 country. Those who ate local economy food was 87
3 percent, bathed in local water that was either
4 brought in or well water was 78 percent, those who
5 either entered or worked in the landfills or the
6 garbage dumps was 76 percent, and those who drank
7 local water was 69 percent.
8 In relationship to investigational
9 drugs, the recorder termed that as drugs that --
10 they were either not written on their shot records,
11 or that they had not given informed consent to be
12 given. That was 94 percent of the 10,000 veterans
13 indicated that they had had them.
14 On the symptoms questions, 95 percent
15 indicated that they had sleep problems --
16 DR. LASHOF: For the sake of time, I
17 think we could all see them, and it probably isn't
18 helpful for you to read them. It would be more
19 helpful for you to leave that slide up, and let us
20 ask you some questions at this point.
21 MS. JUDD: Okay. All right. That's
23 DR. LASHOF: Are there questions?
24 Well, one question I would like to ask you -- of the
25 -- you indicated that the families had health
1 problems. Now this symptomatology -- does that
2 refer only to the veteran himself, or is that the
3 family's symptomatology as well?
4 MS. JUDD: No. That is only to the
5 veteran themselves.
6 DR. LASHOF: All right. Do you have
7 any data on the symptomatology of the family or the
9 MS. JUDD: No, I do not.
10 DR. LASHOF: Okay. Thank you.
11 Other questions? Andrea? Mark?
12 MR. BROWN: Thank you. You probably
13 said this and I just missed it, but it wasn't clear
14 to me how you solicited this group of 10,000 people.
15 What did they -- how did they come to hear about
16 your organization's efforts, and what were they
17 responding to?
18 MS. JUDD: When Mr. Sylvester formed --
19 originally when he formed the group out of Ft.
20 Eustis, his son was in that particular group, and so
21 the word got out that he was forming a support
22 group, which actually formed while we were gone to
23 the war, and he continued to form that, and as
24 people started trickling back his -- he was really
25 the first person to have formed a group -- people
1 started calling him for support, and questions, and
2 so he -- by the number of phone calls he was getting
3 he started the questionnaire, and then he asked the
4 same questions of each phone call that he received.
5 DR. LASHOF: Did he personally carry
6 out the interviews of 10,000 interviews?
7 MS. JUDD: Yes, he did.
8 DR. LASHOF: Very impressive.
9 Questions? Okay.
10 You have one minute left if you wanted
11 to show one more --
12 MS. JUDD: I have this one last slide
13 to show.
14 (Slide change)
15 DR. LASHOF: Okay. These are the other
16 -- okay. Thank you very much.
17 MS. JUDD: Thank you.
18 DR. LASHOF: Next person is Corkey
19 Junkin from Winters.
20 MAJOR JUNKIN: Good morning. My name
21 is Major Corkey Junkin. I've been a nurse for 22
22 years in the Air Force. I've served in both Vietnam
23 and Saudi Arabia. I was forced to retire a year and
24 a half ago because of illnesses that had to do with
25 Persian Gulf exposure.
1 While in the theater of operation I was
2 stationed in both Riyhad and Dhahran. I hold an
3 AFFC, which is our breakdown of the jobs that you
4 do, in general duty nursing, mental health, and
5 surgical nursing. I was activated with my group
6 from Travis Air Force Base in January of '91, and
7 sent to Saudi Arabia.
8 Because of short-term memory loss in
9 addition to my problems with asthma, I was forced to
10 give up my civilian job as a surgical nurse and take
11 another that had fewer benefits and less pay.
12 I was forced to have a hysterectomy due
13 to bleeding problems, which became evident in the
14 Persian Gulf. No women in my family have ever had
15 GYN problems, nor had I until I went over there. I
16 have no children.
17 When I returned to Travis Air Force
18 Base I was given a physical exam that more closely
19 resembled pencil whipping. The doctor who was
20 assigned to the exam informed me that I had no
21 problems. "You didn't have any respiratory,
22 psychiatric, orthopedic problems, did you?" I could
23 do a better history and physical when I was taking
24 Nursing 101. It was very evident he didn't want to
25 find anything.
1 In fact, I had been treated for
2 respiratory difficulties and for a neurological
3 problem while in country. I had passed out, had to
4 be carried to the hospital, and was treated for five
5 days as an inpatient. Their diagnosis was a
6 migraine headache. There's no family history of
7 migraine or vascular headaches, nor have I ever had
8 one prior to this.
9 After my discharge from active duty, I
10 took a routine physical exam for a promotion in the
11 California Department of Corrections, which is my
12 civilian employer. They had found a spot on my
13 lung, and advised me to have it checked out. I was
14 told that there was no room in the pulmonary clinic
15 for five months. I advised my chief nurse of this,
16 and she stated that I could either go to my HMO, or
17 I could put on my uniform and sit in the waiting
19 Because I could get no help from my
20 squadron, I was forced to go to the IG, and at his
21 intervention the clinic saw me and determined that
22 the spot was gone.
23 I did not get the job as a correctional
24 officer, even though I passed the test twice before
25 with the second highest score they'd ever had. I
1 ended up going to my HMO for my bleeding problem.
2 They could find no alternative except for a
3 hysterectomy. While I was on the gurney on the way
4 to the OR they found the spot on my lung, and
5 immediately canceled the surgery. It was then
6 performed two months later.
7 My HMO did not send me to Saudi Arabia.
8 My government did.
9 Prior to being activated I was very
10 physically active. I hiked the circumference of Mt.
11 Rainier, swam a mile a day, and was the OIC of the
12 Travis Color Guard. Since that time, I've been
13 forced to dramatically curtail my outdoor
14 activities, retire from the Air Force, and carry
15 respiratory equipment at all times. I go no further
16 than the length of an extension cord.
17 I feel I've served my country without
18 question in two wars. I should be entitled to
19 quality comprehensive care without question.
20 I'm done.
21 DR. LASHOF: Thank you very much.
23 DR. TAYLOR: You said that you served
24 in Saudi Arabia. Were you near any kind of chemical
25 warfare at all, or possible chemical exposures that
1 you know of?
2 MAJOR JUNKIN: The first day that we
3 were there, while we were still on the tarmac off-
4 loading the aircraft, we had a SCUD alert and we
5 went into full chem. gear. There was one night
6 where we had five chemical alert sirens. In fact,
7 it got to the point where you just slept in your
8 chem. gear. So, yes, I was exposed.
9 Also, in Dhahran, it was very close to
10 where they were burning the oil fields.
11 DR. TAYLOR: Do you know of others in
12 your unit who are experiencing some of the similar
13 health symptoms and problems that you are?
14 MAJOR JUNKIN: Oh, absolutely.
15 DR. TAYLOR: And you've had a chance to
16 talk with them more?
17 MAJOR JUNKIN: Yes. My asthma is now
18 triggered -- I had never had asthma before. It's
19 now triggered by insecticides, floor stripper,
20 strange and wonderful things that come up in daily
21 life. Changing the antifreeze on my car will get me
23 DR. LASHOF: And you indicated that
24 your HMO found this spot on your lung also, --
25 MAJOR JUNKIN: Yes.
1 DR. LASHOF: -- and deferred surgery
2 because of that. Was there a final diagnosis as to
3 that spot on the lung? Is it still there?
4 MAJOR JUNKIN: No. They did a CAT
5 scan, determined that it was not anything that
6 should interfere with the surgery, and went ahead.
7 And I'm being treated now by my HMO.
8 DR. TAYLOR: What was the diagnosis of
9 the spot, and was there a --
10 MAJOR JUNKIN: They're still working on
12 DR. TAYLOR: Okay.
13 MAJOR JUNKIN: My HMO -- I mean, I'm
14 getting most of my medical care from my HMO, and I'm
15 very thankful I have it, but Kaiser didn't send me
16 to Saudi.
17 DR. LASHOF: Are you able to work now
18 at all?
19 MAJOR JUNKIN: Yes. I am working. I'm
20 probably one of the few that's still working. I
21 work for the Department of Corrections.
22 DR. LASHOF: You do work for the
24 No further questions?
25 Thank you very much. Duane Mowrer?
1 MR. MOWRER: Good morning.
2 My name is Duane Mowrer. I'm the
3 President and Chairman of the Persian Gulf War
4 Veterans' Association of America. We're a loose
5 group of about 400 veterans, family members, and
6 related friends spread throughout seven western
8 Before I go any further I'd just like
9 to thank you guys for taking the time to serve on
10 this Committee. In talking about it to some friends
11 of mine the other day I realized that you're going
12 to get a lot of heat for this, and we just wanted to
13 let you know that we appreciate the time you've
14 taken. I know you didn't have to.
15 Persian Gulf War Veterans of America
16 was founded based on a unit -- Army reserve unit
17 from Montana that is in a very rural area of that
18 state that I was attached to during the Gulf War.
19 Because I live in Oakland, and am just a few blocks
20 away from the VA office there, they often ask me to
21 help them by going around and picking up forms for
22 them or whatever. As time went on we got more and
23 more involved in this, and finally decided to give
24 ourselves a name. It's spread by word of mouth, and
25 we now have, like I said, about 400 members spread
1 across the country.
2 I'm also in an Army reserve unit. I'm
3 a staff sergeant. I teach basic non-commissioned
4 officer and combat skills, including N/B/C defense,
5 and related subjects of that type. Part of the
6 N/B/C class that I teach is recognizing symptoms of
7 N/B/C exposure, and all I can say is Gulf War
8 Syndrome -- if someone came up to me on the
9 battlefield with these symptoms I would have to say
10 we probably have an N/B/C problem here.
11 First what I want to talk to you about
12 today -- and I want to emphasize that I'm not at my
13 best today. Excuse me for not being as lucid as I
14 would like to be, I didn't get much sleep last
15 night, but I'm going to prepare a written report
16 that I'll be able to send to you with all the
17 documentation for the things that I'm about to tell
18 you now.
19 Our Montana veterans in particular are
20 having some severe problems getting treatment from
21 the VA. It's not necessarily the VA's fault. They
22 live in a very rural section of Montana. The
23 nearest VA facility is eight hours away, one way.
24 Very few of those veterans have been able to get any
25 VA assistance whatsoever, because they're farmers,
1 loggers, people that make their living off the land.
2 They can't take a couple days off often to go to the
3 VA. Most of the people in that unit -- it amounts
4 to about 120 people -- are ill, and are showing
5 symptoms, both physically and mentally. We have had
6 a couple suicides from that unit alone through PTSD,
7 and what I would like to see for them is possibly
8 for the VA to be able to have a clinic in that area
9 a couple times a year for one or two days, or use
10 local doctors to help them.
11 Our reasoning for this is actually
12 quite simple. If the Army is willing to have a unit
13 in a rural area during peace time and during war
14 time, then they need to take care of that unit after
15 they've returned from a war.
16 We're also having problems locally with
17 the VA, and in other states as well. For example,
18 just this summer at VA San Francisco, Persian Gulf
19 veterans were being turned away at the doors saying
20 we cannot treat you. You have not had a disability
21 rating yet, therefore you are ineligible for care.
22 This went on apparently from the time the Gulf War
23 ended until this summer when they happened to do it
24 to someone that is in my group. They came to me,
25 and we were able to get it taken care of, but it
1 took us two weeks to even get VA San Francisco to
2 admit that they had been doing this. The same thing
3 has been going on in Boise, Idaho, and in Phoenix,
5 That's the VA. What about the DOD?
6 Well, our veterans and our members have
7 shown a very major lack of trust with the Department
8 of Defense, both in their treatment and in the study
9 that they've done. Most vets who went in for the
10 treatment in Department of Defense hospitals have
11 said to me something like, "They decided before we
12 got there that we didn't have Gulf War Syndrome.
13 When I personally went to Oak Knoll Naval Hospital
14 in Oakland, the head doctor of the program told me
15 when I arrived there is no such thing as Gulf War
16 Syndrome, but we're going to find out what's wrong
17 with you anyway.
18 The basic feeling was that there's no
19 way that a doctor would diagnose anything unique
20 that they did find, but that they would simply try
21 to find some normal disease they could pin it on.
22 The DOD study -- I don't know if any of
23 you saw this report last week. In fact, you may
24 have far more information on this than we do, but
25 there was a report in the newspapers last week which
1 I again will include in my written documentation to
2 you. It said that the control group that the DOD
3 used in their study to compare how sick veterans
4 were as opposed to a normal population used people
5 significantly older than Gulf War veterans, as many
6 as 25 to 30 years older. We don't think that this
7 is a valid study at all.
8 One thing that most of our veterans
9 have described is when they go to the VA or the
10 Department of Defense they walk in the door, and
11 they're immediately sent to a psych. ward. In fact,
12 VA's policy for a long time has been that all
13 Persian Gulf veterans as part of their treatment
14 will be psychologically evaluated, which is fine if
15 that's all it was, but it seems that most of the
16 symptoms are pinned on that psychological
17 evaluation. Many of our veterans have wanted to go
18 deeper than this. In fact, many of us have talked
19 for many months about having neurological tests done
20 on a civilian site.
21 I traveled to Great Britain last year
22 and talked to the British Gulf War Veterans'
23 Association, and they were setting up a program at
24 that time to do just that, so I came back and
25 decided to try to get some of our vets into a
1 similar program.
2 What we've done is we've tried to get
3 civilian neurologists to do a neuro/psych.
4 evaluation on our veterans. It is very expensive.
5 In my case it cost $3,000 dollars, only half of
6 which was paid by insurance. It's very involved as
7 well. It takes two days. Therefore, at this point
8 we haven't had a whole lot of veterans we've been
9 able to send through it, but there has been a
10 significant number. If you take the total veterans
11 in both countries, there's over 100 so far that have
12 gone through this. Virtually all of them have come
13 back positive for the exact same thing. This thing
14 that they have come back positive for, which once
15 again will be in my written report to you, is so
16 rare that it occurs in less than one percent of the
18 So the Army has either recruited people
19 that have the exact same genetic birth defect, or
20 something happened over in Southwest Asia.
21 When the VA doctor saw this, his
22 reaction to me when I showed him my test was, "Are
23 you involved in that lawsuit?" After that -- after
24 his talking to his superiors -- and I went there
25 three times to this same VA neurologist in Oakland
1 -- they said that they could not do anything for me,
2 and I would not be seeing a neurologist again.
3 I also showed it to my DOD doctor at
4 Oak Knoll, and after a long time talking to each
5 other they explained it away, saying that I still
6 had an IQ of 120. What was I complaining about? My
7 IQ prior to the Gulf War was 140.
8 So what caused this problem? We don't
9 know. What we do know is this -- the VA and DOD is
10 pretty much pinning everything on our stress. Are
11 we stressed? Yes. Actually, I'm stressed right
12 now. But we went to war. We killed somewhere
13 between 100,000 and 200,000 enemy soldiers in a very
14 short time period. You can't do that and come back
15 normal. Of course we're stressed.
16 Our problem is this. If we went over
17 there and got shot, we would come back, they would
18 treat the gunshot wound, and our PTSD. But it seems
19 like now we come here, and we show these symptoms,
20 and all they treat is the PTSD. It seems that many
21 doctors, both civilian and VA and DOD, are hesitant
22 to treat any new kind of illness, or to diagnose a
23 new illness. We've seen this before. Parkinson's
24 Disease, Legionnaire's Disease, AIDS -- all these
25 things took years to finally be recognized by
1 western medicine. Even today such diseases as lupus
2 or many childhood learning disabilities don't get
3 diagnosed many times right away.
4 It just seems there's this hesitancy in
5 our medical community to go after these new
6 diseases, and we think that actually that's one of
7 the major things that we're fighting right now,
8 because the symptoms that we show are somewhat
9 similar to symptoms that you would find with PTSD.
10 However, I mentioned that I teach N/B/C defense to
11 the Army. Symptoms are even closer to N/B/C
12 exposure than they are to PTSD.
13 When we talk about --
14 DR. LASHOF: Could you try to finish
15 up? You're running short.
16 MR. MOWRER: Actually, everything else
17 that I have could say could probably be better
18 summarized in my written report to you. I just
19 wanted to emphasize that the recommendations that we
20 have are very, very simple. We just don't want to
21 rely on a DOD study. Many of these other studies
22 that have been done by CDC and others have relied in
23 large part on the DOD study, and we think that it is
24 flawed. We would like to see studies done outside
25 of DOD. We would also like to see the doxycycline
1 test on a larger scale to involve more veterans, and
2 family members as well.
3 DR. LASHOF: Thank you very much.
4 Are there questions for --
5 MR. MOWRER: Thank you.
6 DR. LASHOF: Noel Stewart?
7 MR. STEWART: Thank you for allowing me
8 to testify to your group. I am one of the few
9 Desert Storm veterans that came from the IRR. In
10 case you don't know what that means, that means
11 Individual Ready Reserve. There were 600 of us
12 there. They called, we went, and now I feel much
13 like the soldiers in the Civil War, left out without
14 anyone coming to our aid.
15 I was fortunate. I was what they call
16 a desert rat. In case you don't know what that
17 means, that means somebody in the unit is given the
18 job to go out and scrounge. At first my first
19 station was Dhahran. What does that mean? We were
20 given a shot, not told what it was, but everyone on
21 the plane, their gums began to bleed and their hair
22 began to fall out.
23 When I came in at Dhahran, I spent 28
24 days in a steel cold barracks with less than
25 anything to sleep, and hardly any food, but somebody
1 found out that I had a maritime license, so I was
2 the only Army reservist in the whole United States
3 that was stationed on a tugboat. I have now been
4 given more license than most people had ever gotten
5 during the war.
6 I basically got a license to scrounge,
7 go and steal anything I wanted. I got to see
8 different units from different places all around. I
9 got to go places that people don't get to see. I
10 got Marine Corps, Navy, Army units. Everyone that
11 ever needed anything got to come to me. And what
12 I'm about to express to you is sorrow only in my
14 I went to the hospital many times about
15 the bleeding gums, why my hair was falling out, why
16 I had pneumonia after this shot that no one seems to
17 ever -- still explain to me what I had, but I did my
18 job for my country. I can never forget the moment
19 that we left Ft. Jackson when a general, and a Saudi
20 Arabian and a Kuwait prince said how well -- that
21 they were proud of us IRR individuals who were ready
22 to go and fight for a country that we didn't even
23 know, but what we were told was that we were going
24 to defend a country that had been taken over, and
25 somehow we would defend the free rights of the
2 Let alone did I know when I came back
3 to this country the shame would come about me.
4 But now what I'm about to tell you
5 becomes much of a more horror story. Why weren't we
6 told? Why did you keep everything such a secret
7 from us? Because now I'm going to start revealing
8 to you what I saw as this scrounge that got to go
9 into different units that most people never got to
10 see. But when you're a scrounge you get to go
11 places that most people never get to see, because
12 you're trying to trade for steel or a flashlight, or
13 whatever it is. You're trying to do that.
14 The first exposure is that they didn't
15 have a use for me in Dhahran so that after that they
16 sent me up to al-Jabal. Al-Jabal was the central
17 supply station for the war. After the war it was
18 now the returning station. The units, in case you
19 don't know it -- for every man that's out in the
20 field is supported by 25 men in the rear. I think
21 that this should shock all of you, because those men
22 that came back from the war zones brought diseases,
23 anthrax, gases -- all souvenirs, but the men at al-
24 Jabal did not know what they were bringing back in
25 to these camps.
1 I know, because for one week and
2 another two-week period, I was asked to do drawings.
3 I did drawings for the MRL missile systems that
4 would be transported back. They kept pretty much
5 the information secretive. In case any one of you
6 don't know that the group that we are now supporting
7 that was against us in the war -- their ammunition
8 was destroyed at al-Jabal. Chemical weapons and men
9 just went up into the fuel depots and burned without
10 any protection. They would come back, and we were
11 exposed to things that perhaps we should not have
12 been exposed to. I recently read the Life Magazine
13 issue, and it talked about the tanks.
14 I would like -- I brought a picture of
15 my tank. There were 200 Iraqi tanks that we were
16 walking around that probably had nuclear shells
17 bombarded on them. I'd like to show you one of my
18 pictures. I don't know how to use your overhead
19 projector. Okay.
20 But in these tanks were atrocities,
21 dirt, filth, something that you would see in the
22 dirtiest slums. But they were there. And everybody
23 in al-Jabal wanted their picture taken near it. We
24 all piled inside of it. Why, two weeks later, did
25 they feel that -- did they take yellow ribbon and
1 stop people from going in it, and have MP sentries?
2 No one knew why. I knew why, because they had found
3 anthrax in some of these tanks, and nuclear
4 exposure, but they didn't tell anybody.
5 I wasn't supposed to know, but what do
6 you do when you're drafting a MRL missile carrier
7 system, and you're there?
8 I think this should all shock you.
9 Shock you to the point that men are now in a field,
10 and they're crying out. If these men had been
11 desecrated in the field of Iraq, you all would have
12 been horrified, but now because they're all one
13 individual somewhere out there crying for help, no
14 one wants to help them any more.
15 Our medical report was a joke. A
16 complete and utter joke. We were supposed to land
17 in Ft. Jackson. We weren't sent back to Ft.
18 Jackson. We were sent back to Ft. Dix where a
19 general wanted to, because he lived in Philadelphia.
20 Our medical records disappeared. Disappeared. We
21 went into the hospital in Ft. Jackson, and that
22 physical was not very much. When we came back to
23 Ft. Dix it was, "Are you okay?"
24 I stayed two extra days to have my
25 records filled out, but most people left in less
1 than one hour. It wasn't fair. Our treatment was
2 not fair. We came back to a yellow ribbon parade,
3 and now we are forgotten, because we're out there
4 alone. We are not Vietnam veterans. We are not
5 Desert Storm heroes, as the Vietnam veterans would
6 have us believe. Will you leave us out in a field
7 to die, or will you take courage? I would like you
8 to have the same courage our country had in 1934
9 when they formed the VA, when they realized the
10 World War I veterans had been exposed to biological
11 warfare; and, through their efforts -- the World War
12 I veterans -- the VA was formed.
13 You now must have a greater courage
14 than ever before, because our Constitution formed a
15 different kind of nation, and we have been examples
16 throughout the world. Now is your time to be that
17 example. I wish that I could tell you all. My time
18 is coming up. I hope that in all consciousness that
19 you will do what you need to do, and be brave as we
20 were brave, and I hope that you will be the hand
21 that comes out into the field and not be the general
22 that tells us how brave we were. Thank you.
23 DR. LASHOF: Thank you very much.
24 Questions? All right.
25 The next speaker is Patricia Axelrod.
1 MS. AXELROD: Good morning -- good
2 afternoon, ladies and gentlemen of the Committee.
3 My name is Patricia Axelrod. You have
4 before you, or you are now receiving, an article
5 that I actually wrote in 1993, which was published
6 in International Perspectives in Public Health, and
7 subsequently used, I might add, in 1993. The
8 findings contained in this article were subsequently
9 used in a report published by U.S. Senator Donald
10 Regan in September 9th of 1993.
11 I first would like to compliment every
12 speaker that I've heard who has spoken articulately,
13 brilliantly, and I would first like to ask of you to
14 review the article. You will see that as early as
15 1993 at the request of the National Institutes of
16 Health, I conducted a research guide, a literature
17 review, sponsored in part by the John D. and
18 Catherine T. MacArthur Foundation, I might add. At
19 that time I found, as you will note, a number of
20 factors contributing to Desert Storm Syndrome, each
21 of which has been gone over today.
22 They include as follows: the use of
23 experimental vaccines, to include anthrax and
24 pyridostigmine; the effects of depleted uranium,
25 which I might add is an oxymoron -- the term
1 depleted uranium -- in fact, there is radiation
2 exposure upon the use of a depleted uranium
3 artillery projectile --smoke and chemical
4 pollutants; Old World Leishmaniasis and visceral
5 leishmaniasis; pesticides and insecticides; the
6 allied destruction of Iraqi chemical, nerve, and
7 biological warfare weapons, as well as allied and
8 Iraqi use of chemical and biological warfare agents;
9 and the effects of electromagnetic radiation.
10 I completed this guide in 1993. It was
11 subsequently crushed by the National Institutes of
12 Health, who chose not to publish these
13 findings.Fortunately, they were in fact published by
14 International Perspectives in Public Health.
15 With that said, I would say to you that
16 each of you is a scholar, and I would presume that
17 although each of these speakers is brilliant, that
18 you have had access to this information and more, as
19 in fact on your panel is General Franks, a man who
20 was there. First hand knowledge. I would presume,
21 and I would hope, that each of you have questioned
22 him quite exhaustively, as you have on your panel a
23 very valuable resource.
24 With that said, I shall not belabor the
25 findings contained in this report, but will ask you
1 instead to read them at your leisure. I will,
2 however, ask you folks some questions. I'm going to
3 take this opportunity to ask you some questions.
4 Who amongst you is an epidemiologist?
5 Who amongst you is an epidemiologist?
6 This is an -- are you an epidemiologist?
7 DR. LASHOF: Let me say that I've had
8 training in epidemiology. I'm not an active
9 practicing epidemiologist at this time.
10 MS. AXELROD: Do you know how to model
11 a study? Do you know how to prepare a survey or a
13 DR. LASHOF: Yes.
14 MS. AXELROD: Why is it, ma'am, that
15 you do not have an epidemiologist on your
17 DR. LASHOF: We do. He is not here
18 today, but he is a member.
19 MS. AXELROD: I've looked through --
20 DR. LASHOF: Dr. Phillip Landrigan.
21 MS. AXELROD: And with what school is
22 he associated?
23 DR. LASHOF: Mt. Sinai Medical College
24 in New York.
25 MS. AXELROD: Okay. Let me ask you
1 this as well. What is your budget?
2 DR. LASHOF: I don't know it offhand.
3 MS. AXELROD: Can you give me --
4 DR. LASHOF: It's adequate --
5 MS. AXELROD: I beg your pardon?
6 DR. LASHOF: I said it's adequate for
7 our task.
8 MS. AXELROD: Will you be sending out a
9 questionnaire or a survey to each and every person
10 who served in Desert Storm, and will that
11 questionnaire include questions to be asked of their
13 DR. LASHOF: Let me say that you have
14 to become familiar with the charge of this
16 We are not to conduct any original
17 research. It is our charge to look at all the
18 research that is being done, and make
19 recommendations to the President as to whether or
20 not everything that needs to be done is being done
21 or what additional studies should be done. We will
22 not be taking -- we will not be developing any
23 research tools of our own.
24 MS. AXELROD: Ma'am, I say this most
25 respectfully. As a researcher in this field, a
1 person who has worked in this field since day one of
2 Desert Shield, I want you to know, ma'am, that my
3 phone rings night and day with dying people. There
4 are some 70,000 people according to VA records who
5 have registered as victims of Desert Storm Syndrome.
6 As to the date -- as of now -- there
7 are an estimated 7,000 deaths which can be
9 I want to ask you another question if I
10 may. Are you folks planning on going to the Middle
11 East? I have. If you have not, does this in fact
12 fall under the category of original research? Will
13 you in fact -- and I say this respectfully -- I do
14 not wish to be rude to you, but you must understand
15 that people are dying, that they came home from the
16 war, they walked home, and they walked through a
18 I ask for your indulgence in this,
20 They walked through a parade, and they
21 walked right to a sickbed, many of them, and many of
22 them are dying.
23 I am in fact taking the liberty of
24 speaking with you passionately, but there are cold
25 hard facts to support this data. If in fact the VA
1 and the Department of Defense chooses to, even I
2 might add to what I did in 1993, which was to
3 conduct a literature review of every factor and
4 ailment that these people could have potentially
5 been exposed to. It's a miracle any of these folks
6 are walking.
7 I take this liberty of telling you to
8 tell the President of the United States, who even
9 now as we speak is perhaps ordering troops to
10 Bosnia. I saw the other day on the front page of
11 USA Today an American soldier with a gas mask on,
12 and it sent chills through my body, as I know full
13 well that American soldiers and allied soldiers were
14 exposed to chemical warfare agents, and you know as
15 well, as does General Ronald Frank. I'm sure you're
16 in contact with him. You all know that. You all
17 know there's an overwhelming data base already.
18 Already compiled.
19 You will today receive I am sure many
20 articulate pleas from many veterans who will beg for
21 your help. I am begging you, and I am also telling
22 you that it is the President's responsibility to
23 take care of these people, and to do it now. I do
24 not want my phone to continue to ring from a Candy
25 Lovett or a Selena Nelson, who tells me she's
1 desperately ill. She can't breath. She's gone to
2 the VA. Nobody will help her. That's what happens.
3 I'm sorry if I've taken this
4 opportunity perhaps to be dramatic, but each and
5 every one of these people should be saying this to
6 you, and I beg of you, give them the chance.
7 If you are in fact conducting an
8 epidemiological study, I should recommend to the
9 President of the United States that, number one, on
10 the basis of the data that you've heard presented
11 here today, and on the basis of the NIH study, and
12 on the basis of countless other studies that have
13 been conducted, on the basis of that, I would
14 recommend that you tell the President of the United
15 States to be sure that every one of these veterans
16 is treated and now, and that every one of them get
17 the very best care available to them, number one.
18 And number two, while you do that, in
19 your leisure, you can conduct a epidemiological
20 study. You can send out a survey, and you can send
21 out a questionnaire, and then you can compile the
22 data, and crunch the numbers. But these folks
23 aren't numbers. These are real human beings who are
25 So I beg your indulgence, and I am now
1 available to questions. And I want to tell you one
2 other thing. I'm going to give you a little hint.
3 You should speak with people from the graves
4 registration detail. These are the people who bury
5 the dead. The dead of Iraq. The soldiers of Iraq,
6 and the civilians of Iraq.
7 I want you to know that in the course
8 of my trip to Baghdad after the war I found that
9 300,000 civilians died. What did they die of?
10 Number one. And number two, and you've heard this
11 as well -- in Jordan, just as in Assad, there was an
12 increased propensity in childhood leukemias and
13 defects -- birth defects.
14 So I'm now open to questions.
15 DR. LASHOF: Are there questions? No.
16 Thank you very much.
17 MS. AXELROD: I wish you all the best,
18 and I ask that you act quickly. Please.
19 DR. LASHOF: Thank you.
20 We will hear from the final -- the
21 final testimony is by Mr. Denver Mills from the VA
22 -- from the Vet Center.
23 MR. MILLS: Thank you.
24 My name is Denver Mills. I'm a Vietnam
25 veteran. I have a son that's a Persian Gulf
1 veteran, and I have another son that's in the
2 military at this time.
3 And although it's probably dangerous to
4 admit it here today, I do work for the VA. I am a
5 team leader of the San Francisco and Rohnert Park
6 Vet Centers, which is part of the Veterans'
7 Administration's readjustment counseling service. I
8 also provide services in Mendocino, Lake and Sonoma
9 County. I have approximately 350 clients in my case
10 load now, which I am supervising. That's with a
11 core staff of four clinicians.
12 After Desert Storm, readjustment
13 counseling service began providing treatment to
14 Persian Gulf vets. Our primary treatment is for
15 combat related and sexual assault related post
16 traumatic stress disorder. Approximately five to
17 six percent of the veterans that we have seen since
18 Persian Gulf vets became eligible have been Persian
19 Gulf vets. Their primary reasons for coming to us
20 have been for employment, and for readjustment
21 counseling for post traumatic stress disorder.
22 Of the Persian Gulf vets that we have
23 seen, approximately 25 percent of them have self-
24 disclosed symptoms of Persian Gulf Syndrome. When
25 we have a Persian Gulf vet come in, we refer he or
1 she to the VA Medical Center to go through the
2 Persian Gulf vet health screening, and be entered on
3 the register. One of
4 the main concerns that I have that I would like to
5 address to this Committee is something that echoes
6 the past, the problems of Agent Orange exposure
7 among Vietnam veterans. When I came back from
8 Vietnam and started working with Vietnam veterans we
9 didn't know about Agent Orange, and there would be
10 symptoms show up. We would not know what it was.
11 We would think it was just something we ate.
12 In our questioning the Persian Gulf
13 vets that come into our service, most of them are
14 unaware of the symptoms of the Persian Gulf
15 Syndrome. This causes me concern, because with the
16 lack of reporting it may affect the studies that you
17 are undertaking. You may be underestimating the
18 degree or the widespread effects of the Persian Gulf
20 I thank you for your concern, and your
21 commitment to helping this problem with the Persian
22 Gulf vets. I encourage you to spread the word about
23 Persian Gulf Syndrome, so that those veterans out
24 there that may be sick, and may not relate it to
25 their Persian Gulf experience, are aware that they
1 should come in, and we can at least take a look at
3 Thank you.
4 DR. LASHOF: Thank you very much.
5 Are there any questions? If not, let
6 me thank everyone who came here this morning to
7 testify, and assure you that the Committee will take
8 into consideration all of the testimony you have
9 given to us, and all the written materials you
10 provide us with.
11 We will adjourn now, and we will resume
12 our session this afternoon at 1:45, and we will be
13 devoting this afternoon and tomorrow into a review
14 of the epidemiologic studies that have been
15 undertaken by the VA and DOD and CDC. Thank you
16 very much.
17 (Whereupon, at 12:30 p.m., the meeting was
18 recessed, to reconvene at 1:45 p.m. the same
2 1:53 p.m.
3 DR. LASHOF: I'd like to bring the
4 afternoon session to order.
5 If we may, I'd like to ask Mr. Dennis
6 Gooden, Dr. Michele Marcus, and Dr. David Schwartz
7 to come forward to the --
8 Thank you very much for coming this
10 By way of introduction for this
11 afternoon's session, can we just say that we're
12 going to be hearing about some epidemiologic
13 studies, some that are just beginning, another that
14 has progressed to a certain point of developing some
15 research hypotheses.
16 I think we should make clear that the
17 goal of this -- of the Presidential Advisory
18 Committee is to try to understand what studies are
19 ongoing, what questions the various studies can hope
20 to answer, what questions they can answer, so that
21 we can overall come up with some assessment of
22 whether additional studies need to be done or not.
23 I think we all recognize that
24 epidemiologic studies are difficult, are fraught
25 with a number of problems, confounding variables,
1 and we just really want to understand the study
2 design, the difficulties the study may be facing,
3 and what can hope to learn from a specific study,
4 and what we recognize one cannot learn.
5 So by that type of relatively brief and
6 not very complete discussion of epidemiology as a
7 science, we'll start with a presentation on the
8 health assessment of Persian Gulf veterans from
10 Dr. David Schwartz of the University of
11 Iowa is the principal investigator, and will present
12 information. Dr. Michele Marcus from the Department
13 of Epidemiology of the Rollins School of Public
14 Health at Emory University is on the Review Panel
15 that's advisory to this study, and Mr. Dennis Gooden
16 of the Disabled American Veterans of Iowa is a
17 member of the Iowa study Public Advisory Committee,
18 and this is a unique situation where this study has
19 had a Public Advisory Committee, and we've asked a
20 member of that group to share their thoughts with us
21 as well. Dr. Schwartz, would you begin?
22 DR. SCHWARTZ: I'd like to thank the
23 Committee for inviting us to come present our study
24 design here today. The way we've organized this
25 presentation is I'll present some general comments
1 about the study. I'll give you an idea of what we
2 think are the strengths and weaknesses of the study,
3 and then talk a little bit about the advice and the
4 response to the advice from both the Scientific
5 Advisory Committee, as well as the Public Advisory
6 Committee, and then I'll turn it over to Michele
7 Marcus to talk about the Scientific Advisory
8 Committee, and Dennis Gooden to talk about the
9 Public Advisory Committee.
10 So my comments will be brief. I'll try
11 to speak for no more than 15 minutes. Can I have
12 the first slide please?
13 The Iowa Persian Gulf
14 War Study is a cooperative agreement, and the
15 agreement is between the Centers for Disease Control
16 and the Iowa Department of Public Health, and the
17 University of Iowa serves as a subcontractor to the
18 Iowa Department of Public Health to carry out and
19 coordinate the various aspects of the study. A very
20 important component of that cooperative agreement is
21 the absence of the Veterans' Administration and the
22 Department of Defense in this agreement, and in the
23 funding for this study, and the fact that we are
24 independent of a military organization in terms of
25 this particular study.
1 (Slide change)
3 The design of the study is kind of
4 unique. It's a hybrid study, and this will
5 introduce us a little bit more to epidemiology, but
6 it will identify the study population as a
7 retrospective cohort of individuals that were in the
8 military between August of 1990 and July of 1991,
9 and all of those individuals put Iowa as their home
10 of residence.
11 So that's how the study population was
12 established, and then we're in the process of cross-
13 sectionally surveying those individuals, so this
14 really does not represent a longitudinal follow-up
15 study. It also doesn't represent a case control
16 study, and it has elements of a cohort design in it,
17 which may be valuable to us in terms of a follow-up
19 The selection of the study subjects for
20 the different study groups -- the exposed and
21 unexposed groups -- are population based. They're
22 from this very large cohort of individuals that were
23 in the Armed Forces, and put Iowa as a home of
24 residence, and we randomly selected our study
25 subjects from within that cohort. This is a
1 controlled study in that we have a population of
2 individuals who were in the military, but were not
3 deployed to the Persian Gulf, as our reference
4 population -- as our comparison population.
5 And another important feature of this
6 study is that this is going to be a -- the survey
7 will be administered through a telephone interview,
8 a structured telephone interview.
9 So far we have completed 1,200
10 interviews, so we're well on our way to completing
11 the study, and we are -- our total study population
12 is approximately 3,000. And because of the nature
13 of a telephone interview, we have a very high rate
14 of participation. The rate of participation is
15 approximately 93 percent presently, and that's
16 somewhat typical of telephone interviews. That's
17 why we chose the telephone interview to conduct the
19 (Slide change)
20 I'm just going to stand up for these --
21 for this particular slide. This slide shows how we
22 structured the study population to address the goals
23 of the study, and military personnel who were
24 involved in the Persian Gulf War, or military
25 personnel who didn't go to the Persian Gulf. And
1 we're going to survey 1,500 in each of those groups.
2 We also are concerned with how the
3 regular military differed from the National Guard
4 and reserve, and that's why we have an equal number
5 of individuals within each one of these four strata.
6 So the main goal of this study is to compare the
7 current health status of the Persian Gulf War
8 veterans, at least 1,500 individuals, and the
9 military personnel who were not deployed to the
10 Persian Gulf -- at least 1,500 individuals. And
11 that's the primary goal of the study.
12 However, --
13 DR. LASHOF: Dr. Schwartz, we are
14 recording, so we have to ask that you use a mike.
15 DR. SCHWARTZ: Sorry. However, we do
16 have secondary goals for this study. We're going to
17 be able to compare the regular military, between the
18 Persian Gulf regular military, and those who didn't
19 go to the Persian Gulf. We're going to make
20 comparisons also between the National Guard and
21 reserve, between those who went to the Persian Gulf,
22 and those who didn't.
23 And then, importantly, among the
24 Persian Gulf War veterans, we're going to be able to
25 compare the regular military to the National Guard
1 and reserve in terms of some general health
3 (Slide change)
4 Our primary health concerns that we're
5 specifically looking at were developed as a result
6 of many of the reports that have come out that have
7 reported data from the Persian Gulf War registries
8 and the Department of Defense Registry. Our primary
9 health concerns include depression, post traumatic
10 stress disorder, chronic fatigue, airway disease,
11 and cognitive dysfunction. And we have very
12 specific questions that will address all of these
13 disorders, and these are from standardized
14 instruments that are imbedded within our telephone
16 (Slide change)
17 We also are going to be looking at
18 general health concerns, functional health status,
19 reproductive health, cancer, fibromyalgia, multiple
20 chemical sensitivity, substance abuse, anxiety and
21 injuries. And I should point out that in looking at
22 and addressing the issue of how confident we are in
23 terms of being able to address these health concerns
24 with our primary and secondary health outcomes,
25 we've performed sample size calculations based on
1 the prevalence that we anticipate for our primary
2 health outcomes within the unexposed group, which is
3 somewhere between five and ten percent, and then we
4 looked for a two-fold excess risk among those who
5 went to the Persian Gulf, and we have at least an 80
6 percent power in being able to address our primary
7 health concerns.
8 (Slide change)
9 So the strengths of this study are
10 several. It's a hypothesis-driven study. We have
11 clear ideas of the diseases that we're looking at or
12 the health concerns that we're looking at, and we
13 also have clear ideas about the comparisons between
14 populations, and also in terms of looking at
15 differences between the regular military, and the
16 Guard and reserve.
17 This is a population-based study, so
18 our findings will be generalizable to the larger
19 population that we're selecting our study subjects
20 from, which is the Iowa population. We have a
21 control unexposed study group. This is a telephone
22 interview. We expect the information to be highly
23 reliable, and we also expect to have a high degree
24 of participation in this study. It's a standard --
25 our telephone interview includes several
1 standardized survey instruments that are imbedded
2 within our telephone interview -- instruments that
3 have been validated for telephone surveys. We also
4 have a validation component to this study.
5 We're going to be looking at birth
6 defects, looking at objective data through birth
7 defect registry, and also by surveying the births of
8 all of the individuals that were residents of Iowa.
9 We're going to be looking at the
10 presence of cancer through the cancer registry, and
11 comparing that to the information we get from the
12 Persian Gulf War -- from the military through this
13 survey. We're also going to be looking at records
14 through the VA hospital, and looking at the number
15 of visits to the outpatient and inpatient setting,
16 and compare that to the number of visits that the
17 individuals say that they've had in each of these
18 different locales. So those are the three ways we
19 plan to validate our results.
20 And lastly we have a very strong
21 investigative team. We have over 20 investigators
22 from the University of Iowa involved in this study,
23 several investigators from the Centers for Disease
24 Control, one investigator from the Iowa Department
25 of Public Health, and each one of them serves a
1 different unique role and has contributed to the
2 study, epidemiologists, biostatisticians, data
3 managers, psychiatrists, infectious disease
4 specialists -- so we've covered many of the
5 methodologic, as well as the disease oriented
6 problems that are related to this particular study.
7 (Slide change)
8 However, there are several weaknesses
9 related to this study. First, this is an Iowa based
10 study, so the concern that needs to be raised is
11 whether our results would be generalizable to people
12 outside of Iowa, and I think that that's a fair
13 concern to be raised. However, there's no clear
14 reason why people from Iowa should be all that
15 different from people at least from the rest of the
17 Although we have a validation component
18 to the study, it's a limited validation component
19 and it's based largely on survey data, except for
20 the birth defect information. For the birth defect
21 information we will go through hospital records to
22 validate that information. We'd like to include an
23 exam component -- a physical examination component
24 -- to many of these health concerns, and that's
25 something that we might consider doing at a later
2 And I think the biggest weakness of
3 this study is that we're not -- given the nature of
4 our study population, we're not going to be able to
5 address the concerns -- the many concerns of women
6 and minorities that played an important role in
7 terms of the Persian Gulf build-up, as well as the
8 conflict. And that may also require an additional
9 follow-up study to address those very special needs.
10 (Slide change)
11 So, we have two outside advisory
12 committees. The -- oh, I do want to address one
13 other weakness, which I failed to put down, but I
14 did write on my piece of paper here.
15 (Previous slide)
16 It is that we don't have access to
17 objective exposure data, and this is something that
18 I would hope the Committee could help us with.
19 There is classified information that the Department
20 of Defense has regarding troop movement, as well as
21 vaccine use, information that we haven't been able
22 to get hold of, and yet information that would be
23 critically important in terms of investigating
24 exposure response outcomes, exposure symptom or
25 exposure disease outcomes.
1 And I think that we're going to need a
2 great deal of help in trying to get some of this
3 information, and the information that we're most
4 interested in obtaining is vaccine use, as well as
5 troop movement.
6 (Slide change)
7 So the first advisory committee that I
8 want to discuss is the Public Advisory Committee.
9 We have 19 members involved in this advisory
10 committee. Dennis Gooden is one of those members.
11 This is largely made up of individuals from a
12 variety of different veteran organizations around
13 Iowa, and this group assists us with public support
14 of the project, and they have been instrumental in
15 marshalling the forces in Iowa to look at this as a
16 very positive study, a very independent and
17 objective assessment of the problem, and I think
18 that they're largely responsible for the very high
19 rate of participation that we've experienced thus
21 (Slide change)
22 We've also involved the Public Advisory
23 Committee all along the way, and I've forgotten
24 whether we've had three or four meetings, but we've
25 met with them regularly, and Dennis is going to go
1 into this a little bit later. Two issues that they
2 brought up that we've tried to address -- one was
3 assurance of confidentiality. They made it very
4 clear to us that veterans would not be willing to
5 participate unless they were absolutely certain that
6 the Department of Defense or other organizations
7 wouldn't be able to get hold of that data.
8 As a result of their concern, and also
9 as a result of the concern raised by the Centers for
10 Disease Control, we filed for and obtained a 301-D,
11 which will protect the information that we get from
12 this survey.
13 Another very important issue that was
14 brought up was the issue of substance abuse, and
15 concern was raised that the veterans wouldn't be
16 willing to share information about substance abuse.
17 We were also concerned whether this -- whether we'd
18 obtain valid information in this regard. We decided
19 to include this in our piloting that we did prior to
20 the OMB submission, and the piloting actually went
21 very well, and it turned out that a number of
22 individuals were more than willing to give
23 information about substance abuse, both inside as
24 well as outside the military.
25 We discussed this issue further with
1 our Scientific Advisory Committee, and we decided to
2 go ahead and continue to include those questions
3 about substance abuse, and then we brought that
4 issue back to the Public Advisory Committee and
5 discussed that with them prior to submitting the
6 proposal to OMB, and they were comfortable with that
8 (Slide change)
9 The Scientific Advisory Committee
10 includes six senior scientists, and I'm not going to
11 go over the details of these individuals. You have
12 that in the write-up, but this Scientific Advisory
13 Group has been very, very helpful to us. They've
14 advised us and consulted with us, and reviewed and
15 critiqued the study design, survey instruments,
16 outcome measures, analytic methods, and will help us
17 with the reporting strategies, and also future
18 research initiatives.
19 We've met twice with this committee,
20 once by phone and once face to face, and these
21 meetings have been very, very productive, very
22 helpful. They helped shape some of the initial
23 proposal that we submitted to OMB, and then they
24 helped shape some of the things we're thinking of in
25 terms of the analysis. And I'll go into some of the
1 specific suggestions now.
2 (Slide change)
3 One of the things that came up
4 initially was the issue of response bias. Would the
5 individuals who went to the Persian Gulf respond to
6 the questionnaire differently than the individuals
7 who didn't go to the Persian Gulf? We decided to
8 address this issue by readministering the
9 questionnaire to five percent of the study subjects
10 on a random basis, and the questionnaire will be
11 readministered to individuals within two to four
12 weeks of the original survey. We've also included a
13 social desirability scale, which will help us assess
14 the validity of some of these responses.
15 Issues were raised about the absence of
16 questions related to traumatic events, and also
17 military training, and we added specific questions
18 related to both of these concerns. Concern was
19 raised over the validation of birth defects, and
20 along with help from the Centers for Disease
21 Control, we developed a complete validation study
22 for birth defects where we're going to be going to
23 the individual hospital where the birth occurred in
25 We're going to review those records for
1 both normal babies, as well as babies that were
2 found to have birth defects, and we'll be able to
3 validate the information related to birth defects.
4 The assessment of exposure intensity
5 was raised, because initially we were just asking
6 questions about the types of exposures, and as a
7 result of that we changed the question to ask
8 whether individuals developed physical problems when
9 they were exposed to certain agents that could have
10 been acutely toxic to those individuals to get a
11 clear sense of the dosing of exposure.
12 And finally the initial analysis plan
13 that we developed did not include the possibility of
14 a Persian Gulf Syndrome, in other words, a
15 constellation of symptoms that were not part of our
16 primary or secondary outcomes. And as a result
17 we've modified the initial analytic plan to
18 incorporate a Persian Gulf Syndrome, and to do some
19 exploratory analyses to see whether symptoms cluster
20 in individuals, and to construct our analysis so
21 that we're deriving it from a random sample of the
22 population, and then testing it on a subsequent
23 portion of the population.
24 I think this will be very, very helpful
25 in identifying whether the Persian Gulf Syndrome is
1 something unique, or represents a disease that we
2 know a lot about.
3 So at this point I'd like to conclude
4 my formal comments, and I'd be happy to turn it back
5 over to the Chair.
6 DR. LASHOF: I think we'll proceed by
7 asking Michele to speak, and then Dennis, and then
8 we'll open it up for questions and discussion
9 between the three of you, and the panel here.
10 So, Dr. Marcus?
11 DR. MARCUS: Yes. Thank you.
12 I'd like to thank the panel for
13 inviting me to be here, and I am here representing
14 the Scientific Advisory Committee to the Iowa
15 Persian Gulf Research Project.
16 The charge to the Scientific Advisory
17 Committee is to provide scientific advice and
18 consultation to the investigators of the study. In
19 this capacity we have reviewed the overall design of
20 the study, and all of the draft data collection
21 instruments. We had a lengthy telephone review last
22 spring before the final questionnaires were
23 developed, and sent in to OMB for approval, and we
24 met in Iowa on October 12th to review the study
25 design with particular attention to the definition
1 of the health outcomes.
2 We found the Iowa investigators to be
3 responsive to our comments and suggestions, and we
4 believe the study has benefitted from our input.
5 This study will make an important contribution to
6 our understanding of the health of the Gulf War
8 I was a member of the NIH panel that
9 examined the evidence regarding Gulf War illnesses
10 in April of 1994, and one of the questions put to
11 the panel at that time was, was there an excess of
12 illness among the Gulf War veterans? And the data
13 available to us at that time was not adequate to
14 answer that question, and I'm very happy to see now
15 that a number of studies are being undertaken in
16 order to gather the data to answer that question, as
17 well as the question of what exactly are the types
18 of illnesses that are occurring among the Gulf War
19 veterans, and are these illnesses that we've seen
20 before, or are there some distinct syndromes that
21 are unique to deployment to the Gulf War.
22 And I think that this study will answer
23 a very fundamental and important question, which is,
24 did the men and women who served in the Gulf War
25 have more illnesses than expected for such a group
1 of men and women, and what is the nature of those
3 Some of the strengths of the study --
4 and these David has already summarized most of the
5 issues that we discussed and some of the strengths
6 of the study. I'd just like to add that they have
7 developed a very complex and careful sampling scheme
8 in order to draw a representative sample of the Iowa
9 veterans, and they will be able to draw conclusions
10 regarding the population in a very representative
11 way of each of the four groups that they sample.
12 Unfortunately the number of women and
13 minorities in this ten percent sample will be small,
14 and one of the recommendations of the Scientific
15 Advisory Committee was to do an additional study or
16 to supplement this study by including all of the
17 women and minorities who served in the Gulf in order
18 to get stable estimates of their experience. This
19 is one of the first times that women were deployed
20 in such large numbers in a combat theater, and I
21 think it would be very important to document their
23 Another strength of the study is that
24 they are using standardized and validated
25 instruments for their symptom outcomes, and although
1 these instruments have been used in epidemiologic
2 studies before, we need to keep in mind that these
3 symptom complexes are not the same as clinical
5 And another one of our recommendations
6 was to do some nested case control studies where the
7 symptom complexes could be validated among the cases
8 with medical exams and appropriate tests as
9 needed.Their statistical power is very good for the
10 primary health outcomes.
11 Another strength of the study is the
12 range of adverse exposures that they are
13 ascertaining by questionnaire. They basically have
14 a fairly extensive list, and based on what the
15 veterans reported as their concerns when I was on
16 the NIH panel, this is a fairly comprehensive list.
17 Unfortunately, it is just based on self-report, and
18 again it would be very useful to supplement this
19 study with nested case control studies, where the
20 exposures could be documented by troop movement
21 information, and information on vaccinations, and
22 the pyridostigmine medication that was given to the
24 I'd also like to make a comment on the
25 design of the study, which has features of both a
1 cross-sectional study and a cohort study, and David
2 spoke a little bit about this. They will be able to
3 ascertain cases of illness which occurred since the
4 Gulf War, and have persisted until this time. What
5 they will be missing are incident cases that have
6 not persisted, so it's very important to recognize
7 that they'll be looking at prevalent cases of
8 illness, and will be missing those incident cases
9 that have resolved before the time of the survey.
10 I don't think is an important
11 limitation, however because the concern -- there's
12 more of a concern about illnesses that have
13 persisted until this time. Illnesses that have
14 resolved are of less public health importance.
15 One exception to this limitation is the
16 reproductive history information, which will be
17 obtained for the entire time period since the Gulf
18 War, so they will be able to look at rates of
19 spontaneous abortion and birth defects for all
20 pregnancies occurring since the Gulf War, and that
21 is a strength of the study and, as David said, they
22 will be able to validate the birth defects for those
23 births that occurred in Iowa.
24 Okay. That's -- those are, you know,
25 my general remarks. We have made some very specific
1 comments about the definition of symptom complexes
2 and outcomes, and the investigators have been very
3 responsive to our suggestions in that regard. And
4 we feel very comfortable that the study as currently
5 designed will make an important contribution to
6 answering these questions.
7 Thank you.
8 DR. LASHOF: Thank you very much.
9 Mr. Gooden? May we hear your comments?
10 MR. GOODEN: Yes, ma'am, thank you.
11 Madam Chair, ladies and gentlemen of
12 the Commission, first of all I'd like to thank you
13 for the opportunity to address such a distinguished
14 panel. Coming from Iowa -- Iowa is a good state,
15 but we don't get a chance to talk to people like
16 this often.
17 As a National Service Officer for the
18 Disabled American Veterans I've been given the
19 opportunity and the privilege of serving on an
20 Advisory Committee for the Health Assessment of
21 Persian Gulf War Veterans in Iowa. Quoting from our
22 operational guidelines,
23 "The purpose for the advisory committee for the
24 health assessment of Persian Gulf war veterans
25 from Iowa is the creation of a representative
1 and knowledgeable body of citizens to review,
2 comment, advise, and recommend on an ongoing
3 basis during the development and administration
4 of the study. In addition, the Committee will
5 disseminate information regarding the status of
6 the study to its constituents that they
8 This advisory committee is, as Dr.
9 Schwartz brought up, made up of 19 representatives,
10 including representatives from service
11 organizations, a spouse of a Persian Gulf War
12 veteran, a spouse of a deceased Persian Gulf War
13 veteran, Gulf War veterans, as well as members of
14 the Department of Veterans' Affairs. The diversity
15 of this committee is by design. It was meant to
16 allow for a broader representative cross-section of
17 interested persons.
18 To date we've had a total of three
19 meetings. First was to familiarize the Advisory
20 Committee with its responsibilities and purposes.
21 At that meeting we also elected a Co-Chairman, Mr.
22 Tim Striley, who himself couldn't be here today, and
23 he's a Gulf War veteran. Since that time we have
24 had two other meetings during which we had
25 presentations by the different medical and
1 scientific advisors to the committee.
2 The presentations by the experts have
3 been exceptional. They have been -- they haven't
4 been condescending in any way, and they've been open
5 to any questions or comments we might have. We also
6 discussed the time frame of the study, and we were
7 asked for our input concerning the initial set of
8 questions for the survey. There were several
9 comments made by the group, many of which were
10 incorporated into the final survey.
11 Some of the recommendations we made
12 included simplifying the wording of the questions,
13 and incorporating safeguards to ensure
14 confidentiality. Confidentiality was probably the
15 first issue the Committee discussed in any great
16 detail. We were all very concerned with the
17 question of how a study of this nature, which
18 includes active duty military service men and women,
19 could be honestly answered given the present
20 atmosphere in the active military services. We were
21 concerned that if military personnel answered the
22 questions concerning their health, and the use of
23 drugs and alcohol while they were in the Persian
24 Gulf, their careers could be jeopardized if those
25 answers were revealed to their commanding officers.
1 We are assured that the Department of
2 Defense has given full cooperation to the research
3 group, and that confidentiality would be maintained.
4 At our last meeting we were informed that the
5 initial questions have been redone, and also that a
6 more sophisticated protocol had been established.
7 Another concern the Committee addressed
8 was having our organization's and personal views
9 used as a marketing device for the findings of the
10 Committee. No advisor on the Committee is willing
11 or able to speak for their national organizations.
12 We also believe it is important that no organization
13 phrases this research in such a way that it could be
14 misconstrued as an endorsement by that organization
15 of this specific study.
16 We are all very aware of the still
17 present cloud of Agent Orange, and we do not want
18 the research concerning Persian Gulf illness to
19 suffer the same fate. We are most interested in
20 making sure that the correct information is
21 gathered, and that the information is used in a most
22 appropriate and effective way. There are also
23 concerns that the information gathered in any survey
24 may not be politically correct, and will be stifled
25 or ignored even when it is based on solid research
1 and sound scientific and medical principles. We
2 hope that this Advisory Committee will be able to
3 disseminate accurate and complete information to our
4 constituents and to the general public.
5 On the other side of the coin we want
6 to be sure that as much as possible the information
7 gathered by different research groups is not used to
8 grant benefits cart blanche for any illness, real or
9 perceived. It is particularly important to service
10 organizations that the veterans from the Persian
11 Gulf be given every benefit they are entitled to.
12 However, it is also of paramount importance that
13 benefits not be granted solely because of public
14 pressure or political correctness.
15 The present system that allows the VA
16 to compensate Persian Gulf veterans for symptoms of
17 as yet unidentified illness is a huge departure from
18 normal VA procedures. While we believe these
19 veterans have earned their compensation, we are also
20 aware that for the first time the cost of this
21 compensation is being borne by other service
22 connected disabled veterans by the rounding down of
23 future COLA increases.
24 I believe that advisory committees such
25 as ours should play an important role in any
1 research aimed at discerning medical problems
2 suffered by Persian Gulf veterans, and that all the
3 research be done in an honest, scientific and open
4 atmosphere to minimize political pressure or
5 manipulation. We hope that this advisory group will
6 lend credibility to the Iowa study, and we feel
7 privileged to serve with such a distinguished group
8 of doctors and scientists in their search for any
9 medical problems the veterans of Iowa may have
10 suffered as a result of their service during the
11 Persian Gulf war.
12 This concludes my statement, and I'll
13 be glad to answer any questions you may have.
14 DR. LASHOF: Thank you very much.
15 I think that gives us a fairly good
16 overview, and I'll open it up to questions from the
17 panel. Andrea?
18 DR. TAYLOR: I have a question for Dr.
19 Schwartz, two, actually. One is regarding the
20 sample size. He selected 3,000 veterans.
21 Was there -- I didn't understand quite
22 the reasoning for just 3,000 from the population
23 group that you had.
24 DR. SCHWARTZ: Well, we were weighing
25 the economics of each additional individual versus
1 the statistical power inherent in the design of the
2 study. We believe that if something is going to be
3 important in terms of a public health concern in
4 this population -- now this is an assumption -- that
5 it will be occurring twice as frequently in
6 individuals who went to the Persian Gulf versus
7 those who didn't go to the Persian Gulf, so instead
8 of maybe five percent in the population it's ten
9 percent in the individuals who went to the Persian
10 Gulf in terms of, let's say, depression.
11 And given that assumption, we found
12 that we needed 3,000 individuals to have a very high
13 likelihood of being able to find that result within
14 our study, and that's the basics of how we did that
15 sample size calculation.
16 Now if we went to maybe 4,000 or 5,000
17 individuals in the entire study population, our
18 chances of finding a positive result may have
19 increased from 80 percent to 90 or 95 percent, but
20 these telephone surveys are very, very expensive to
21 conduct, and our thinking was that we wanted to
22 spend the money as best we could for the outcomes
23 that we were looking at, and those are the
24 assumptions that we made in that calculation.
25 DR. TAYLOR: The second question I had
1 is regarding the exposure data, or accessibility to
2 the exposure data, because the questionnaire of
3 course is all self-reported.
4 Have you requested information from DOD
5 regarding actual -- or are you thinking you might
6 get this information?
7 DR. SCHWARTZ: Yes. We're still in a
8 data processing mode in that -- or gathering mode in
9 that we haven't really identified exactly who in DOD
10 is responsible for that data, or how to request data
11 from DOD. What we've been told, and this is again
12 through the grapevine, is that there is no
13 centralized source of data for vaccine use or
14 vaccine administration, and that that is a series of
15 individual medical records, and sometimes the
16 vaccines are not even recorded on the medical
18 We're starting -- in terms of vaccine
19 use -- to work locally, and that we may be able to
20 get access to medical records at a local level and
21 identify vaccine use within our study subjects. So
22 that's the first way we're going to approach vaccine
24 In terms of troop movement, we're told
25 that there is a process occurring within DOD to
1 systematize and compile the troop movement of all
2 the individuals who were involved in the Persian
3 Gulf. Again, we don't have clear verification of
4 that going on, and I can't really begin to tell you
5 who in the Department of Defense or Pentagon is
6 responsible for developing that data base, but
7 that's something that we absolutely plan to look
8 into this year.
9 Our initial goal was to develop the
10 study design, develop the questionnaire, get it
11 through OMB, and start administering the
12 questionnaire. So that is definitely a goal of this
13 next year to find out what information DOD has, and
14 who is responsible at DOD for that information.
15 DR. TAYLOR: Okay. Thank you.
16 MS. GWIN: We got a presentation on
17 that at our last full committee meeting, --
18 DR. SCHWARTZ: Yes.
19 MS. GWIN: -- and we can help you with
20 that information.
21 DR. SCHWARTZ: That would be terrific.
22 DR. LASHOF: Holly, do you have
23 questions? I think we'll just go straight down the
25 MS. GWIN: I'm curious about the --
1 whether the coordinating board, the Persian Gulf
2 Veterans' Coordinating Board that's put together by
3 the VA, DOD, and HHS, whether they've played any
4 role in helping you design your study or share your
5 study design problems or anything with the other
6 agencies, or researchers that are conducting
7 epidemiologic studies?
8 DR. SCHWARTZ: Well, to a certain
9 extent, yes. I've not directly participated with
10 the Persian Gulf Coordinating Board. I've not been
11 invited to one of their meetings, and I've -- I'm
12 not a member of that board.
13 There is an individual involved with
14 our study, Leslie Boss, from the Centers for Disease
15 Control. Dr. Boss is involved with the Persian Gulf
16 Coordinating Committee, and there is information
17 that gets passed back and forth through Dr. Boss.
18 And actually she was very helpful in designing some
19 questions that addressed the issue of discomfort
20 during intercourse, which is a major concern that
21 veterans have, and there was a lot of discussion, I
22 believe, through the Persian Gulf Coordinating
24 And Dr. Boss, if you want to correct
25 me, feel free to.
1 That discussion through the Persian
2 Gulf Coordinating Committee concerning that issue
3 was translated to us, and then we incorporated some
4 of those questions into the questionnaire.
5 The Office of -- the OMB in reviewing
6 our proposal was reviewing the VA proposal at the
7 same time, and there were some questions that are
8 shared on both of -- both their mail-out survey and
9 our telephone survey, so that we'll be able to
10 validate across the two different studies. And I
11 think that that will be particularly helpful to us
12 to see how similar our population is to their
13 population, which may help in the generalizability
15 MS. GWIN: Thank you.
16 DR. LASHOF: Following up on that
17 aspect, the CDC, of course -- and we're going to
18 hear next on the Pennsylvania study, is your
19 questionnaire pretty compatible with the CDC
20 Pennsylvania study?
21 DR. SCHWARTZ: I'm not familiar with
22 that at all. I'm not familiar with the
23 questionnaire from the Pennsylvania study.
24 Dr. Barrett, do you know about that?
25 DR. DRUE BARRETT: (inaudible comment
1 from an unmic'ed location.)
2 DR. LASHOF: I do have a concern that,
3 if we're doing a number of different epidemiologic
4 studies, that the questionnaires were similar, that
5 does increase the power or the size. And we are
6 going to hear a little bit later about a case
7 definition that Pennsylvania has come up with.
8 And I'm wondering if it's going to be
9 -- whether you will be able to take that case
10 definition as presented by CDC from Pennsylvania,
11 and apply it to your group, and see whether -- how
12 many people would fall into that case definition,
13 both among the deployed and non-deployed.
14 But maybe you can't answer that until
15 you hear Pennsylvania, and I should ask you again
16 after this.
17 DR. SCHWARTZ: Yes, we'd have to see
18 their case definition to see if we have questions
19 that address their case definition. But if we did,
20 we certainly would be able to apply that within our
21 study population, or within our analysis.
22 DR. LASHOF: Another question about
23 location of troops. Do you know -- even though you
24 don't know the specific troop location information
25 -- do you know whether the members of the armed
1 forces and reserve from Iowa who were deployed were
2 pretty well deployed in the same general area as
3 everyone else, and that they weren't sent off to one
4 particular spot, and that therefore they are apt to
5 be fairly represented?
6 DR. SCHWARTZ: We don't even know that
7 piece of information in terms of troop movement or
8 in terms of troop deployment. We do have the units
9 that individuals were members of, and we should be
10 able to get at that exact information -- where a
11 person was deployed within the Persian Gulf, and
12 then where they served during that time that they
13 were in the Persian Gulf.
14 DR. LASHOF: Now we expect that we will
15 have the information or the DOD will have the
16 information on geographic location by the end of
17 December, I believe, and so we can help you be sure
18 that you get that information.
19 DR. SCHWARTZ: Okay.
20 DR. LASHOF: Lois?
21 MS. JOELLENBECK: It seems to me that
22 -- and as you said, your primary goal is really
23 looking at a comparison of the prevalence of these
24 symptoms, and that that is what you might reasonably
25 expect to begin to address with this study.
1 The exposure issues, and looking at
2 maybe causal links, is that really a goal of this
3 study as you are setting out to do it? How much do
4 you hope to be able to contribute to that?
5 DR. SCHWARTZ: It depends on what
6 information we get from the Department of Defense.
7 Right now we're focusing on the comparison between
8 those who were deployed to the Persian Gulf, and
9 those who weren't deployed to the Persian Gulf, and
10 trying to establish some basic very important
11 epidemiologic data, which will allow follow-up
12 studies to not only validate the health concerns in
13 terms of examinations and more specific studies, but
14 will also allow us to look at issues like what's
15 causing those health concerns. What was the
16 etiology? What was the -- what were the clustering
17 of exposures that were related to the all these
18 health concerns?
19 And we thought that just undertaking
20 this very broad question, which is, do Persian Gulf
21 War veterans have different health concerns than
22 non-Persian Gulf War veterans, was a fundamental
23 initial step in this process.
24 So we are getting some self-reported
25 information on exposure, and we'll look at that
1 self-reported information on exposure in relation to
2 disease outcome. However, then you're relying on
3 two self-reported pieces of information, both
4 exposure as well as outcome, and they're clearly
5 going to influence each other. So that brings up
6 yet another reason why this information from the
7 Department of Defense is so critical.
8 MS. JOELLENBECK: Yes. The self-report
9 aspect is a challenge in many of the studies that
10 we'll be looking at.
11 I had a question about the health data
12 that you'll be asking about in your questionnaire.
13 You, among the questions, are asking whether people
14 have certain conditions, which would be conditions
15 that usually a physician would diagnose, then later
16 there are lists of symptoms. How will you respond
17 if a person responds that they have a certain
18 condition, but then their description of symptoms
19 doesn't match up? Would that cause some
20 difficulties in deciding how you kind of categorize
21 that person?
22 DR. SCHWARTZ: Well, we'll be reporting
23 those separately, and when we report those findings
24 we'll be very specific about how those symptoms are
25 collected, versus how the medical conditions are
1 assessed in terms of the reported conditions.
2 I think that this is a very important
3 issue related to validity, and can only be addressed
4 by doing the kinds of studies that Dr. Marcus
5 suggested, which are the nested follow-up studies to
6 try to identify what those symptoms really mean in
7 terms of medical diseases.
8 We're not going to be able to diagnose
9 medical diseases, nor can we rely entirely on the
10 history that we obtain from these individuals, but
11 again it's a starting point that will point us in a
12 direction that needs further or more specific forms
13 of investigation to get at issues like doctor
14 diagnosed diseases, or medically validated
16 DR. MARCUS: I'd just like to add
17 something to that.
18 I think one of the issues here is that
19 many of the veterans, both those deployed in the
20 Gulf and those not deployed, have had a different
21 experience in terms of their health-care-seeking
22 behavior, and also their access to different levels
23 of specialty care. And it would be very difficult
24 to rely even on physician diagnoses, because not
25 everyone has been evaluated to the same extent. And
1 I think it would be very important to make sure that
2 -- that these diagnoses are validated with a
3 consistent work-up.
4 MS. JOELLENBECK: Thank you. Just one
5 other quick question.
6 You said that you had gotten a 93-
7 percent participation rate so far, which is
8 excellent. I wondered how many -- how far are you,
9 and how many attempts have you made at this point?
10 DR. SCHWARTZ: We've interviewed -- the
11 last count was about 1,200 individuals. Is that
12 what you were asking?
13 MS. JOELLENBECK: You have already made
14 telephone interviews with them?
15 DR. SCHWARTZ: We've interviewed 1,200
16 individuals so far, and we started September 20th --
17 21st. Now you have to remember that those are --
18 those are -- that's 93 percent of the individuals
19 that we've been able to contact by telephone, so
20 those are the easy ones. There are a number of
21 individuals that we haven't yet been able to contact
22 by telephone for a slew of reasons, and those
23 individuals will take a lot more time to get hold
24 of. We anticipate the same rate of participation
25 once we -- once we contact an individual.
1 DR. LASHOF: I guess the question then
2 is what percentage of those you've attempted to
3 contact you've been able to contact at this point in
5 DR. SCHWARTZ: Yes. It's about 65
7 DR. LASHOF: Okay.
8 DR. MARCUS: I'd like to make a comment
9 in that one of the things that we discussed at this
10 meeting with the Scientific Advisory Committee was
11 whether or not next-of-kin information might be
12 available from the Department of Defense for people
13 who have moved, and are difficult to locate, it
14 might be possible to get next-of-kin information,
15 and contact the next-of-kin to find out where the
16 person currently resides so that they could be
18 DR. SCHWARTZ: So actually, that's one
19 of the things -- one of the suggestions that we've
20 followed up on. We're in the process of looking at
21 the data sources in the Department of Defense to
22 identify whether next-of-kin exists in those data
24 Now inevitably that has to exist to
25 contact individuals when something -- when something
1 unexpected happens to an individual in the military,
2 so we're trying to identify where that source is,
3 and whether that can be incorporated into our data
4 base so that we can send a letter to those
5 individuals, or contact those individuals by phone.
6 DR. BALDESCHWIELER: Several things I
7 didn't understand. One, I thought you said that OMB
8 had not yet given you approval for your particular
10 DR. SCHWARTZ: No, I didn't say that.
11 They have given us approval. We submitted the
12 application to OMB in the beginning of June, and we
13 received approval, I believe, September 19th or 20th
14 or 21st.
15 DR. BALDESCHWIELER: So you are
16 literally under way at this point?
17 DR. SCHWARTZ: Oh, yes.
18 DR. BALDESCHWIELER: Okay. And then on
19 the sampling, you, David, said that your sample was
20 a random sample out of a larger number of those who
21 had served, and those who had not served.
22 And, Michele, I thought you said that
23 there was some sampling strategy or -- I wonder if
24 we could have a resolution of that.
25 DR. SCHWARTZ: It's a stratified random
1 sample, so we have 30,000 individuals who were in
2 Iowa, as Iowa as their home of residence, and either
3 were in the Gulf or not in the Gulf. Of those
4 individuals we stratified them across men and women,
5 and minorities, age distribution, greater than 25 or
6 less than 25. We also stratified them according to
7 branch within the military, and within those strata
8 -- and it turned out that there were 64 strata
9 within each of our study groups. Within those 64
10 strata, we randomly selected individuals to be
11 included in the study.
12 And that presents a little bit of a
13 problem because, if you think about a woman, black
14 officer in Iowa, there's probably just a few of
15 those individuals, so all of those individuals would
16 be selected to participate in the study.
17 So some of these strata are over-
18 represented, because they're -- they're a sparse
20 DR. MARCUS: And I just want to add to
21 that, that they will be able to adjust for that by
22 doing a weighted analysis, so they can reconstitute
23 the composition of the target population in the
24 final analysis.
25 DR. BALDESCHWIELER: And then I
1 wondered if either of you might be willing to
2 speculate on the potential systematic differences
3 between the control and the Gulf War groups. As
4 with a survey of this kind I'm presuming there's
5 going to be some elements of bias.
6 DR. SCHWARTZ: I think that the big
7 concern between the exposed and the unexposed group,
8 those who went to the Persian Gulf and those who
9 didn't go to the Persian Gulf, is the possibility
10 that individuals who were deployed to the Persian
11 Gulf, or units who were deployed to the Persian
12 Gulf, were different than units -- were more ready
13 to participate in military activity than those who
14 didn't go to the Persian Gulf.
15 That's something that we've been
16 assured by the military is not true, but we're still
17 in the process of trying to determine whether in
18 fact there were systematic differences between those
19 who were deployed and those who weren't deployed in
20 terms of unit readiness -- combat readiness.
21 I think one of the other big concerns
22 that we have is whether this recall bias -- whether
23 the individuals who went to the Persian Gulf will
24 recall information differentially from individuals
25 who didn't go to the Persian Gulf, and I've alluded
1 to a few ways we're going to test that in terms of
2 readministration of the questionnaire, the inclusion
3 of a social desirability scale, which will get at
4 the validity of the responses
5 But I think that the only way of really
6 getting at that issue is to do these follow-up
7 nested, case control studies where we can begin to
8 validate the symptom complexes in terms of more
9 objective medical screening.
10 DR. LASHOF: Mark, do you have any
12 MR. BROWN: Thank you, yeah. We have a
13 few more minutes here.
14 Dr. Marcus, when you talked about the
15 study and your role as -- I'm sorry -- as being on
16 the Scientific Advisory Board, you seemed to
17 express, you know, a fair amount of confidence that
18 this study was going to get at -- I guess the real
19 basic question that everyone wants to know about is
20 are veterans more sick? Are they experiencing more
21 illnesses, and what's the nature of their illnesses?
22 And I -- so I interpret that when I
23 hear that to mean that when the study is done that
24 we're going to have a pretty good idea, you know,
25 are veterans more ill? Are they actually more ill
1 than some appropriate control group? Are we going
2 to have some idea maybe about what's causing it, and
3 what particular exposures may be a cause, which is
4 -- I mean, that's great. That's what we want.
5 But then I'm wondering if there's a
6 danger in stating it like that. There seems like --
7 are you -- is there a danger that you're promising
8 too much, because I hear -- and the reason I'm
9 concerned is I hear then there's some issues --
10 there's obviously some very serious issues about
11 exposure assessments, and self-reported exposures
12 with the difficulties in validating them. And then
13 there's some lesser issues, but nevertheless some
14 issues, surrounding the nature of diagnoses --
15 validating diagnoses. You're going to use some
16 registries to try and diagnose some of the birth
17 defect data.
18 It's not clear to me what are you going
19 to do -- what will happen if there are
20 discrepancies, for instance, between what the
21 registry data tells you and birth defects, and what
22 you actually poll in these telephone surveys? And I
23 guess I'm just wondering -- I don't know if there's
24 an answer to this, you know. It's not a yes or no
25 question, but is there --
1 DR. MARCUS: I have an answer.
2 MR. BROWN: -- there's an issue of
3 what's going to happen, you know, what can you
4 really promise? How much confidence do you have in
5 what you can promise this study ultimately is going
6 to tell us? That's my question.
7 DR. MARCUS: Okay. Let me respond to
8 that, and perhaps put it in a little bit more
9 context, and also perhaps clarify what I meant by my
11 First of all, when I say that the study
12 will be able to tell us whether there are more
13 illnesses reported by the Gulf War veterans than a
14 non-deployed comparison group, I mean that it will
15 tell us whether, by self-report, there are more
16 illnesses, and that is an important step forward.
17 As I said, when I was on the NIH panel
18 a year and a half ago, we couldn't even answer that
19 question. All we had basically was numerator data.
20 In other words, there were veterans who had reported
21 to the Persian Gulf registry, and so we had "x"
22 number of people who had various illnesses, and we
23 had no way of knowing whether that was what we would
24 expect in such a population.
25 I mean, when you deploy 600,000 people,
1 a number of them are going to be ill. So we didn't
2 have appropriate denominator information, and we
3 didn't have comparison information. So I think that
4 this study is the first step. It's not going to
5 provide all the answers, but it will address the
6 first step, which is do the Gulf War veterans -- are
7 they reporting more symptoms than other veterans?
8 And then I think we need the next step, which will
9 give us much more detail on medical diagnoses and
10 exposures to supplement that.
11 MR. BROWN: Okay. I think I agree with
12 that. But your point then is that a study, such as
13 the one that we've talked about here, is really just
14 the first step -- that it logically will lead to
15 decisions about additional studies that one might
16 really need to really resolve this.
17 DR. MARCUS: Absolutely.
18 MR. BROWN: I think that's an --
19 DR. MARCUS: Absolutely.
20 MR. BROWN: -- important point though,
21 because I think, you know, there's a danger of over-
22 promising what a study such as this might deliver.
23 Or does that --
24 DR. MARCUS: I absolutely agree. We
25 spent a lot of time talking about this in the
1 Scientific Advisory Committee, and with the Iowa
2 investigators, and I guess I didn't make myself
3 clear, because in fact that was one of the points
4 that I had wanted to make, which I guess I either
5 missed or didn't explain clearly in my remarks.
6 But as an epidemiologist, one of the
7 things that I have stressed in this whole discussion
8 was that there is not going to be one study that's
9 going to answer all of these questions, and that it
10 will be an iterative process, and that we need to
11 take one step at a time, and each study will build
12 on the knowledge gained from the previous one before
13 we can have all of the answers.
14 MR. BROWN: It sounds like this is an
15 argument for further funding for epidemiology.
16 DR. MARCUS: Well, I just don't think
17 it's possible to address such a complex question as
18 this with one study.
19 DR. LASHOF: I think we're all in
20 agreement on that. In trying to get the most we can
21 out of any one study is one of the questions why I'm
22 so anxious to see if the questionnaires are
23 compatible among the various studies that are going
24 on, and seeing how much we could do by meta-analysis
25 after we have a series of studies.
1 In regard to the validation question, I
2 wonder whether you're asking when you -- in your
3 questionnaire whether the veterans are in the
4 registry, either the VA registry or the DOD
5 registry, of comprehensive clinical evaluation
6 protocol, because if you can get that information in
7 your survey, you then could at least go to that
8 registry and see what they had found on clinical
10 DR. SCHWARTZ: We do ask those
11 questions. The problem with that
12 is that we don't have those exams on individuals who
13 didn't go to the Persian Gulf, so it again suffers
14 from the problem of numerated data. However, it
15 will help us validate some of the clinical concerns
17 DR. LASHOF: Yes, validation.
18 DR. SCHWARTZ: -- raised about
19 objective data, yes;I agree with that.
20 Now whether we're be able to get a hold
21 of the registry data is yet another issue.
22 DR. LASHOF: We can help you with that.
23 DR. SCHWARTZ: And that would help.
25 DR. LASHOF: Are there other questions?
1 MS. GWIN: I wanted to ask about the
2 Public Advisory Committee.
3 Was that mandated by the statute that
4 created this study, or was that something you came
5 up with?
6 DR. SCHWARTZ: No, it was included in
7 the RFP related to this -- to this proposal.
8 MS. GWIN: But was it mandated by the
9 public law, or just an idea that you had that you
10 thought it would be useful?
11 DR. SCHWARTZ: I'm going to let the CDC
12 address that issue.
13 DR. BARRETT: (inaudible comment from
14 an unmic'ed location.)
15 DR. LASHOF: But it wasn't written into
16 the legislation. It was CDC's decision. We're just
17 trying to get at which things the -- because this is
18 a study that was actually legislated. Let's make
19 that clear.
20 DR. BARRETT: (inaudible comment from
21 an unmic'ed location.)
22 DR. SCHWARTZ: Good for CDC.
23 MS. GWIN: Is this common in CDC
24 studies to use a Public Advisory Committee?
25 DR. BARRETT: (inaudible comment from
1 an unmic'ed location.)
2 DR. SCHWARTZ: I just want to say that
3 for this study the Public Advisory Committee has
4 been extraordinarily helpful, and I would recommend
5 it to any large-scale epidemiologic study. That's
6 not to downplay the contribution of the Scientific
7 Advisory Committee.
8 DR. TAYLOR: It actually helps us to
9 put together the questionnaire so that people can
10 understand it.
11 MS. JOELLENBECK: I had a question,
13 I thought maybe, once the study is
14 completed and you're thinking about how to get the
15 information out, that maybe the Public Advisory
16 Committee could play a role in advising you on the
17 best ways to spread the word.
18 DR. SCHWARTZ: Yeah, we've already
19 begun those discussions with the Public Advisory
20 Committee, and we've also discussed with the
21 Scientific Advisory Committee, or have begun to
22 anyway, how to get this information out to the
23 scientific community at the same time as when we're
24 releasing it to the public sector.
25 So there's going to be a very
1 complicated reporting problem, because we'd like to
2 make this information publicly available, but we
3 also want to get it peer-reviewed at the same time
4 and be published in a peer review journal.
5 DR. LASHOF: What is the time table now
6 for completing the questionnaire, the interview, and
7 the validation? What's the time frame?
8 DR. SCHWARTZ: Yes. We anticipate that
9 we'll be able to complete the administration of the
10 questionnaire by the end of February of '96, and
11 that we'll be able to compile all the data by the
12 end of March of '96.
13 And we are receiving -- will receive
14 batches of the data in three different bundles
15 throughout the study period, so we'll begin analysis
16 probably in December or January of this year.
17 Probably January of next year is when we'll begin
18 analysis of the study, just to make sure that our
19 analytic programs are working correctly, and that
20 our data is being compiled correctly.
21 We anticipate that we'll be able to
22 report the findings of this study in August of '96,
23 and hopefully -- we're in the process of negotiating
24 with medical journals. Hopefully these results will
25 be released in the scientific literature at the same
1 time as it's released in the lay press in August of
3 DR. LASHOF: That's very good. I think
4 you're being very far-sighted to begin to work with
5 the journals now to do that, and I think that is
6 very important, because there is a real problem with
7 studies like this that are high visibility -- of
8 importance to a large group that you want to get it
9 out to the public, and yet we want to respect the
10 ability to put it in the scientific literature.
11 Are there other questions?
12 Are there any other final comments
13 you'd like to make? I think we've got about two
14 minutes left for you to say -- make any other final
16 DR. SCHWARTZ: I don't really have -- I
17 guess the one thing that I'd like to stress is the
18 cooperative nature of this study.
19 This study, from the principal
20 investigator point of view, has been really
21 rewarding in terms of being able to coordinate large
22 groups of people, both scientists as well as
23 interested public, in terms of giving input into the
24 study, and responding to that input, and the
25 investigative team alone is made up of individuals
1 at the University of Iowa, CDC, and Iowa Department
2 of Public Health. That has been a very cooperative
4 And it's been a rewarding experience to
5 work with this large group of individuals, and yet
6 look at each individual in that group and know what
7 they have contributed to the progress of the study.
8 So, I could say that for the investigators as well
9 as the advisory committees.
10 DR. LASHOF: Well, thank you very much.
11 I appreciate your appearing, and let me assure you
12 that the staff will be available to you or the
13 Committee to help you in any way they can, and
14 whether it's getting data from DOD or anything else
15 -- keep us posted on the progress, and we'll be glad
16 to help in any way we can. Thank you very much.
17 DR. SCHWARTZ: Thank you.
18 DR. MARCUS: Thank you.
19 DR. LASHOF: I think we'll take a 15-
20 minute break, and we will resume again at 3:15.
21 (Whereupon, a brief recess was taken.)
22 DR. LASHOF: We're going to now resume
23 our session with a report from Dr. William Reeves,
24 and comments from Dr. Warren Winkelstein on the CDC
25 Pennsylvania study.
1 Dr. Reeves?
2 DR. REEVES: I, too, will speak from
3 slides. Could I have the first one?
4 DR. LASHOF: Is somebody going to hand
5 those slides?
6 DR. REEVES: My kid got away. What I'm
7 going to do is comment on what we call EPI-AID 95 --
8 DR. LASHOF: Can you check whether your
9 mike is operating?
10 DR. REEVES: Okay.
11 I'm going to talk on EPI-AID 9518,
12 which is a disease clustered in a Pennsylvania Air
13 National Guard Unit. The Committee should have
14 handouts on this -- an MMWR article which came out,
15 and some copies of slides we gave before. I'll
16 briefly go through some background material, and
17 then deal with stuff that has not been published
19 In November of 1994, two Veterans
20 Administration physicians reported that 60 members
21 of the 193rd Pennsylvania Air National Guard were
22 ill with what they termed Persian Gulf Mystery
23 Illness, and they defined the illness as
24 characterized by irritable bowel syndrome, large
25 polyarthralgia, clustular dermatitis, and a variety
1 of other physical findings or signs. And they
2 indicated that the illness was associated with
3 deployment to the Gulf War, exposure to sand and
4 sand flies.
5 (Slide change)
6 Based on this report, which was
7 reported both to the VA Expert Scientific Advisory
8 Committee, and to the Inter-Science Conference on
9 Anti-microbials and Chemotherapy, the veterans --
10 the Department of Veterans' Affairs, Department of
11 Defense and the State of Pennsylvania requested that
12 CDC work up this reported cluster or outbreak. This
13 was done in what we call the EPI-AID mechanism.
14 It was to specifically look at this one
15 reported cluster, and to be done as an EPI-AID one,
16 this basically needs to be a problem of public
17 health importance, require a timely response,
18 require epidemiologic methods and have epidemiologic
19 assistance requested by appropriate officials. The
20 request specifically asked CDC to do this
21 independently of the VA and DOD's overall response
22 to Gulf War issues.
23 (Slide change)
24 The questions that we posed at the
25 outset of the epidemic were first of all, was the
1 report true? If it was true, what were, in fact,
2 the clinical characteristics? Were they what was
3 reported? Was the illness, in fact, a cluster of
4 illness in the 193rd Pennsylvania Air National Guard
5 unit? Was it related to service in the Gulf War?
6 How -- what illness was there in fact? How could
7 the illness be defined for study purposes, and what
8 were the associated risk factors?
9 And the way we approached this was in
10 a three stage study design.
11 (Slide change)
12 I will talk about just Stages 1 and 2
13 at this point. Stage 3 field work is complete. The
14 data is not complete yet.
15 (Slide change)
16 Stage 1 was a clinical series. We
17 evaluated a series of patients from the reported
18 cluster just to see if there was anything happening,
19 and to get the clinical characteristics.
20 Stage 2 was a population survey of the
21 index and comparison units to determine if, in fact,
22 there was a cluster in the comparison unit, were
23 cases more prevalent in that unit than in comparison
24 populations to determine if Persian Gulf deployment
25 was a risk factor, and to develop a working case
1 definition for study purposes.
2 Stage 3 is a case control study looking
3 for risk factors, both risk factors by
4 questionnaire, risk factors by detailed physical
5 examination and record review, risk by examination
6 of various bodily fluids.
7 Stage 1 was written up in the MMWR.
8 They stated the conclusions were that the Persian
9 Gulf War veterans that we examined, which were all
10 under care of the Veterans' Administration Hospital
11 at Lebanon, Pennsylvania, in fact reported multiple
12 symptoms, and malingering was not, in our opinion, a
13 factor in any of this. The symptoms were similar to
14 those in other studies. They were chronic. They
15 began either during or soon after the war.
16 (Slide change)
17 Although we found isolated disorders
18 and abnormalities, we did not find any
19 characteristic abnormalities. For example, one
20 patient had Crohn's Disease diagnosed well before
21 the war. One patient had Addison's Disease. One
22 patient had visceral trophic leishmaniasis, which
23 was treated. But besides those few isolated things,
24 there were no characteristic physical findings.
25 There were no characteristic laboratory
1 abnormalities. There were no characteristic
2 diagnoses that were made. There was no mystery
3 illnesses described.
4 Specifically, we also examined
5 patients. There was no evidence of skin disease,
6 either on examination or in consultation with
7 dermatologists. There was no organomegaly, no
8 splenomegaly, no hepatomegaly, no lymph node
10 The subjects reported by the physician,
11 which we called typical subjects, did report in fact
12 more symptoms, but they were the same as far as
13 physical examination went.
14 And we also surveyed hospitals in the
15 area to see if there were other Persian Gulf War
16 veterans that might not have been in the registry or
17 not be seen at the VA Medical Center. We didn't
18 discover any evidence of this in a rather complete
19 survey of hospitals in the Lebanon, Pennsylvania
21 (Slide change)
22 We then went on to Stage 2, which we
23 conducted between January and April of '95 putting
24 field teams into the field. We took the index, the
25 193rd Air National Guard Unit, and comparison air
1 units to determine again if illness clustered in the
2 index unit, determine if it was related to Persian
3 Gulf deployment, and develop a working case
5 (Slide change)
6 Now this was reported in an index unit,
7 which is in blue, the 193rd Air National Guard
8 Special Operations Group, a guard unit special
9 operations unit located in Pennsylvania five years
10 after the war. Pennsylvania is obviously a unique
11 geographic place in the U.S.
12 There's a variety of illnesses that
13 cluster geographically -- Giardia, cryptosporidia,
14 Lyme Disease. So we chose two comparison units in
15 Pennsylvania, and two comparison units well
16 separated geographically, and with different
17 geographic factors. We wish to control for
18 geography. We wish to control for Air Force
20 So in Pennsylvania, our geographic
21 controls, we took a fighter wing, and an air
22 refueling wing. In Florida, the two other units, we
23 took both Special Operations Groups, so their
24 missions were similar. We used three Guard units,
25 and one regular Air Force unit to attempt to control
1 for being Guard or part-time soldier, and being
2 full-time. Those were our comparison groups.
3 (Slide change)
4 The survey procedures were to go to
5 each group, and during their unit training exercise,
6 which is the weekend they meet every month to
7 attempt to assemble the entire unit, explain the
8 study, ask for volunteers, and then administer a 15-
9 to 45-minute questionnaire to try to get at signs,
10 symptoms and various risk factors and descriptive
11 information. The attempt was to do this in a one-
12 shot thing while they were all there at their unit
13 training activity. The volunteers when we were able
14 to explain it to them -- virtually everybody in the
15 room volunteered to take the questionnaire and did
16 not leave.
17 (Slide change)
18 Nonetheless, participation results --
19 and we may wish to come back to this -- varied
20 greatly by unit. We had no participation from the
21 111th Fighter Wing, less than satisfactory from the
22 Air Refueling Wing, and I think quite good
23 participation in the three Special Operations Units.
24 (Slide change)
25 Again, you've seen a summary of the
1 symptoms early in the study, and the MMWR article.
2 I'll just hit some highlights.
3 Persian Gulf War veterans clearly
4 reported significantly more symptoms than non-
5 veterans. The prevalence of symptoms was indeed
6 higher in the index unit, but the index unit had
7 almost twice the deployment rate of other units, and
8 when we controlled for deployment, essentially that
9 is what accounted for the apparently higher rates in
10 the index unit. The only exception was chronic
11 diarrhea, which was reported more often by Persian
12 Gulf War veterans than the index unit, and I will
13 not deal with that more, but that's an important
14 point of the case control study.
15 (Slide change)
16 A major goal of Stage 2 was to identify
17 what was occurring, or to develop a working case
18 definition of the illness. The primary purpose of
19 this --
20 DR. BALDESCHWIELER: Excuse me. Can
21 you give us a feeling for the numbers?
22 DR. REEVES: There's about 4,000.
23 DR. BALDESCHWIELER: Pardon?
24 DR. REEVES: Approximately 4,000
25 individuals participated in the survey. 3,600 and
2 DR. BALDESCHWIELER: In the entire
4 DR. REEVES: That's correct.
5 DR. BALDESCHWIELER: Both the control
6 and the --
7 DR. REEVES: What we did is we would go
8 to a unit, and we asked everybody in the unit to
9 participate, whether they had gone to the Gulf or
10 not, whether they were ill or not, and the total end
11 -- there was about 1,000 per group. So it's close
12 to 4,000 -- not quite 4,000.
13 (Slide change)
14 Obviously major considerations of this
15 approach are that we're dealing with symptoms, but
16 we had physical exam data in Stage 1. There were
17 obviously a lack of objective abnormalities in Stage
18 1, so again we're dealing with symptoms, and issues
19 related to the validity of any definitions based
20 solely on symptoms.
21 (Slide change)
22 Okay. We used two methods -- and I
23 left the slide out for this -- to come to our case
24 definition. I will not deal with them in depth, but
25 we used a clinical epidemiologic approach and factor
1 analysis. We devised case definitions by both of
2 these approaches. We compared the two case
3 definitions together. They agreed slightly 81
4 percent by the capa statistic, and this is the case
5 definition that we selected based on the comparisons
6 of those two.
7 A case of illness is defined by at
8 least one chronic -- that means persistent for at
9 least six months or longer -- symptom from two or
10 more of the following categories: category of
11 fatigue; category of mood and cognition-related
12 symptoms, depression, difficulty remembering or
13 concentrating, feeling moody, et cetera; and
14 musculoskeletal symptoms. So if one -- if a subject
15 endures a symptom from any two of those, they were
16 considered a case.
17 (Slide change)
18 We further stratified cases into severe
19 cases or mild/moderate cases. In a severe case,
20 each of the case defining symptoms had to be defined
21 by the patient as severe in nature. A mild or
22 moderate case were the other ones.
23 (Slide change)
24 This is a look at the prevalence of
25 case and other sub-groups by deployment status. Now
1 I've added two other groupings in here on the left,
2 so-called controls. These are individuals who
3 complained of none of the symptoms in the case
4 definition, symptomatic not a case, or those
5 individuals who perhaps complained of a symptom on
6 the list but were not themselves a case, mild or
7 moderate cases, and severe cases.
8 And I think you can see very clearly
9 that looking particularly at the cases that six
10 percent of Persian Gulf War veterans across the
11 units and independent of units were defined as
12 severe cases, compared to one percent of those not
13 deployed, which has a prevalence ratio of eight,
14 highly statistically significant.
15 Mild to moderate cases had a somewhat
16 less large relative risk, and were endorsed or fit
17 by 36 percent of those who were deployed, and 12
18 percent of those who were not deployed. And I think
19 the background in the not-deployed is very
20 important. Symptomatic not a case -- we have
21 similar numbers in both groups.
22 (Slide change)
23 This is a look at the age-stratified
24 case prevalence. We have small numbers in the
25 severe cases, but I think it's very clear that age-
1 specific prevalence goes up in the older age
2 populations, in particular with mild and moderate
4 (Slide change)
5 This is a look at the entire population
6 of cases and other sub-groups by sex. What's
7 interesting here is that there is a slight increase
8 in women fitting the severe case definition.
9 However, -- and this is women and men whether they
10 went to the war or not -- significantly fewer women
11 in our sample were deployed to the war than men.
12 (Slide change)
13 We've reanalyzed this looking just at
14 those who were deployed, and I think it's important
15 to note that, when one looks at this, fully 15
16 percent of women who were deployed to the Gulf
17 compared to five percent of men were defined as
18 severe cases, for a relative risk of approximately
20 (Slide change)
21 Overall summary of Stage 2 findings and
22 analysis to date -- we've produced a working case
23 definition of illness. It was based on two
24 independent methods. We've sub-grouped cases into
25 'severe' and 'mild/moderate'. We've showed that
1 illness overall and illness as defined is more
2 frequent in Persian Gulf War veterans, but also
3 occurs at rather substantial levels in the non-
5 (Slide change)
6 This is a comparison, which may not be
7 completely fair to do, looking at the case
8 definition in those who were deployed and not.
9 You've seen the top two lines before, and a random
10 digit dialing population survey we just completed in
11 San Francisco involving 18,000 participants as part
12 of our chronic fatigue syndrome research.
13 We fit the overall case definition of
14 Persian Gulf War to that sample, and we fit the
15 definition of chronic fatigue syndrome, which is
16 quite similar to the definition that we've developed
17 for this, but requires substantially more severity
18 to the Gulf War population. And what one sees is
19 that in all cases, not stratifying by severity, 45
20 percent of the deployed and 14 percent of the non-
21 deployed -- the prevalence is the same in non-
22 deployed military of this case definition as it is
23 in the city of San Francisco.
24 Looking at the most severe end of this
25 disease, which would appear exactly like chronic
1 fatigue syndrome, five percent of those deployed
2 would fit that case definition pending a physical
3 examination, compared to .23 percent of those not
4 deployed, which is again identical to the prevalence
5 of chronic fatigue syndrome-like illness in the
6 adult population of San Francisco.
7 (Slide change)
8 We feel this indicates factors
9 associated with deployment are not the only risk
10 factors associated with illness. There's illness as
11 a background, risk of illness increases with age,
12 and to a lesser degree with female sex.
13 And that will conclude my remarks of
14 where we are to date on Stages 1 and 2.
15 DR. LASHOF: Thank you very much.
16 I'll think we'll ask Dr. Winkelstein to
17 make some comments, and then we'll open it for
18 questions by the panel.
19 DR. WINKELSTEIN: Okay. Thank you,
20 madam Chairman.
21 I'd like to start out by pointing out
22 that the CDC has a great deal of experience in the
23 investigation of what might be called new diseases
24 or emerging diseases, and so they have developed an
25 approach to this kind of investigation, which is
1 highly structured, unique and rigorous, and that's
2 represented by Dr. Reeves' presentation of these
3 three stages. This is how they go about it when
4 they are faced with a new epidemic, and they
5 frequently have encountered this situation, not only
6 in this country, but abroad as well, and it's been a
7 very effective approach.
8 So the Stage 1, which is basically to
9 confirm the existence of a problem, and we describe
10 how that was done. Stage 2 is, if you will, a
11 preliminary epidemiological investigation, and Stage
12 3, which the data is not available yet, is a case
13 control study. So that this approach is highly
14 organized, and was likely to produce a good result.
15 So I think that's -- we need to take
16 that into account in evaluating this investigation.
17 Secondly, as Dr. Reeves pointed out,
18 the EPI-AID activity has a limited objective, and he
19 described that I think very well, so one cannot
20 expect, as it were, a comprehensive answer, nor is
21 it an a priori approach to looking at etiology of
22 this particular situation.
23 Now the problem with all of these
24 studies -- I think the central problem lies in the
25 way the study population is obtained. In this case,
1 and in most of the other studies of Gulf War
2 effects that I've seen, the study populations are
3 composed of volunteers.
4 Now if participation in a study is in
5 any way related to the effect of deployment or --
6 and if it's related to the existence of symptoms, we
7 have a situation which is potentially biased,
8 because of the confounding that's going on. And we
9 notice here that the participation rates were quite
10 different. Ranging from zero, and I think we -- I
11 think the Commission ought to hear why one of the
12 units didn't participate at all, one in which there
13 was only 36 percent participation. The other three
14 had pretty good participation rates ranging from 63
15 percent to 78 percent.
16 The method -- I should also mention in
17 relation to the way that CDC goes about these
18 investigations, and that is that generally speaking
19 they use epidemic intelligence service officers in
20 the field, and I believe that was the case here.
21 And these are highly trained usually, but not
22 always, medical personnel who are very sensitive to
23 the issues of data collection, so I think that the
24 quality of the data is going to be of a very high
1 It's hard to find very much beyond that
2 to be critical of. I mean, you could be critical of
3 a few minor points. I'd like to mention though that
4 one of the things about this study, which I think
5 has bearing on many of the other studies, and I've
6 heard it several times this afternoon, talking about
7 standardized questionnaires.
8 CDC constructs their questionnaires
9 basically in the field, and I think that's a very
10 sound approach. I think you have to be very
11 cautious if there's too much standardization between
12 studies, especially when you're beginning to look at
13 a new disease. There should be questions and
14 information that overlaps from one study to another,
15 but standardized questionnaires are, I think, a trap
16 waiting to close, because if you only have one
17 approach, then when you don't know what you're
18 looking for you're bound by the -- that uniform
19 approach to the investigation.
20 I was going to ask Dr. Reeves whether
21 they had looked at the correlation actually within
22 the study of people who had severe symptomatology
23 according to the constructed definition, and also
24 conformed to the chronic fatigue syndrome definition
25 as well.
1 I really don't have anything more to
2 say at this point.
3 DR. LASHOF: Thank you.
4 Do you want to respond to Warren's last
5 question, and also his earlier one as to why there
6 were zero volunteers in that one unit, and then
7 we'll open it up to other questions?
8 DR. REEVES: Okay. I'll respond to the
9 chronic fatigue syndrome question first.
10 We began the EPI-AID was done through
11 my branch, which is the Viral Exanthema and Herpes
12 Virus Branch. It's a branch in the National Center
13 for Infectious Diseases. Our area of expertise is
14 infectious disease, and that sort of clusters. My
15 research program is also responsible for chronic
16 fatigue syndrome research at the Centers for Disease
18 We were struck at the beginning by how
19 close these appeared. The case definition for
20 chronic fatigue syndrome, and I'll just read it so
21 that people will know it, is that,
22 "One have clinically evaluated and unexplained
23 fatigue of a new or definite onset, six months
24 or greater in duration, not the result of
25 ongoing duration, not substantially alleviated
1 by rest, that causes substantial reduction in
2 occupational, educational, social, and personal
4 And that as a given, it must be first
5 unexplained medically. We obviously don't know that
6 in this case, except that from Stage 1 it would
7 appear that that would be true. One to be diagnosed
8 as chronic fatigue syndrome must have four
9 additional symptoms, which are impairment in short-
10 term memory and concentration, myalgia, multi-joint
11 arthralgia without swelling, and new headaches,
12 unrefreshing sleep, sore throat, tender cervical
13 auxiliary nodes and post-exertional malaise greater
14 than 24 hours.
15 The key to that definition is
16 substantial reduction in everyday activities.
17 Clearly most people did not fit that, and we had to
18 go back within the data set and try to reconstruct
19 that out of the data. We feel we're very close, but
20 to be defined as chronic fatigue syndrome they will
21 require a complete medical evaluation, which is
22 going to happen in Stage 3.
23 With respect to participation rates, it
24 is always difficult doing research with military
25 units, because the unit's commander, who is
1 responsible for everyday activities and unit
2 readiness, may not perceive medical investigations
3 with the same degree of urgency that the
4 investigator does. The one unit that we got no
5 participation in, the commanding officer refused to
6 let us on base, because it did not fit with his
7 mission at that time. The unit that had 36-percent
9 We had a problem that was a mutual
10 problem administering the test at the beginning, and
11 we had some confusion about how we were going to get
12 people together. We wanted to come back at a
13 subsequent unit training activity. The unit
14 commander felt that was incompatible with their unit
15 mission, and we were unable to do that.
16 But I think a problem with any research
17 involving the military, and involving active duty
18 military, will -- must address concerns of the
19 commanding officer, whose concerns may be quite
20 different that medical concerns.
21 DR. LASHOF: Thank you very much.
22 Do you want to go ahead, Andrea?
23 DR. TAYLOR: In Stage 3, the case
24 definition, what are you using actually to identify
25 those three populations for illness? What are you
1 calling it? Is this chronic fatigue syndrome or --
2 DR. REEVES: What name do we have for
4 DR. TAYLOR: Yes. What name do you
6 DR. REEVES: We don't give it a name,
7 and I would be just as happy not to do that. It
8 would appear that this is part of the continuum of
9 fatiguing illness of which chronic fatigue syndrome
10 is one extreme. Basically this is a disease defined
11 by fatigue, by neurocognitive symptoms, and by
12 musculoskeletal symptoms. Those are, in fact, the
13 same things that are in the definition of chronic
14 fatigue syndrome.
15 DR. TAYLOR: So those are the cases
16 then? That would be --
17 DR. REEVES: That's how we would define
18 a case based on the data from this investigation.
19 And again, I think the important thing is that there
20 are a substantial number of cases depending on
21 severity in the population that was not deployed.
22 The relative risk goes up substantially with
23 deployment in this group with this case definition,
24 but it is not something which would appear to be
25 unique to Persian Gulf War service. There obviously
1 -- there are other factors, and that is one of the
3 DR. TAYLOR: How many participants do
4 you actually have or are anticipating in the case
5 control study?
6 DR. REEVES: The case control study has
7 approximately 300 participants. What we did in the
8 case control study is, when we were doing our
9 questionnaire in the index unit, the 193rd, which is
10 completely anonymous, we asked for volunteers to
11 participate in the case control study. We got 300 -
12 - we had decided because the disease -- our case
13 definition is highly linked to the Persian Gulf, the
14 case control study will use only those who were
15 deployed to the Gulf, and attempt to see what the
16 risk factors are among those deployed for fit in the
17 various case definitions versus not fitting the
18 various case definitions, and there were
19 approximately 300 participants. That phase is over.
20 The participants required about three
21 hours each. They got structured questionnaires,
22 getting at risk factors. They got structured
23 psychiatric interview schedules -- the DIS, the
24 Beck's, the interview for post-traumatic stress
25 disorder. They had complete and standardized
1 physical examinations. They had complete
2 blood/urine analysis to rule out routine diagnosable
3 diseases, as we have in our protocol for chronic
4 fatigue syndrome. They had complete stool cultures,
5 and studies for most of the pathogens that we're
6 aware of. They had antibody studies in their serum
7 for all of the agents we felt they might be exposed
8 to in the Gulf, including leishmaniasis, including
9 sand fly fever viruses, which would be surrogates
10 for sand fly exposure, including anthrax and
11 botulina antibody, which would be surrogates for
13 DR. TAYLOR: What about the women in
14 the survey -- in the case control? Was that
15 representative of what you found before?
16 DR. REEVES: The women are
17 unfortunately going to be under represented, and
18 again because of the anonymous nature of this, and
19 because of the fact that we were asking for
20 volunteers. Again, one must remember that the
21 objective of this was to try to look at a cluster in
22 a unit and try to work that up. We were
23 specifically not beginning this initially as an
24 investigation, or to answer the questions of all
25 Persian Gulf War veterans' illnesses.
1 I'll also mention, because I assume
2 someone will ask me, that we have closely shared
3 this information with the Veterans' Administration
4 -- Department of Veterans' Affairs Expert Scientific
5 Advisory Board, on which I sit. I report on the
6 study each time we do it. We have shared the
7 information and worked very closely with our
8 colleagues at CDC at the National Center for
9 Environmental Health at all stages, including
10 developing questionnaires. We have reported this to
11 the -- at the various meetings that have been held
12 by the coordinating board, and we have reported the
13 results at the APHA meeting.
14 DR. LASHOF: The case control study,
15 can you tell me a little bit -- I mean, I heard all
16 the tests that are going to be done. There are 300
17 people, all of whom have been deployed, 150 who fit
18 your case definition, 150 who do not.
19 Is that what we're dealing with?
20 DR. REEVES: That's going to be the
21 approximate numbers.
22 DR. LASHOF: Yes.
23 DR. REEVES: Yes.
24 DR. LASHOF: The case definition
25 clearly developed around this cluster. How
1 applicable do you feel that case definition is to
2 the group at large that we're trying to look at in
3 defining whether there is or isn't a Persian Gulf
4 War Syndrome?
5 DR. REEVES: I can't answer that
6 precisely. My answer would involve two things.
7 First of all, the symptoms that we have
8 seen in this cluster, which clearly cannot be
9 generalized beyond at the most huge jump the Air
10 Force, but indeed the groups we looked at are the
11 same symptoms that have been reported by every
12 single study. I mean, there is nothing unique here.
13 Every study is seeing these exact symptoms. Every
14 study is having problems with ICD diagnoses.
15 I feel that this approach to symptoms
16 should be used by the various studies. It would be
17 my hint as an epidemiologist, and not necessarily as
18 a spokesman for the government, that this is indeed
19 probably what's happening, but it needs to be looked
20 at in a similar fashion, I believe, in other
21 studies. I think the approach to the case
22 definition that Dr. Fakuta developed is a very
23 unique and unusually elegant approach.
24 DR. LASHOF: So that you would, let me
25 emphasize, recommend that the other studies apply
1 this case definition and see whether they get
2 similar results in the population they're looking
4 DR. REEVES: I would recommend that
5 they apply the definition and that they also apply
6 the methodology used to derive the definition, which
7 was to carefully listen to symptoms that people
8 enunciate, and then use the types of methods we did
9 to derive a case definition, and see how close it is
10 to what we've derived from this.
11 DR. LASHOF: You're familiar with the
12 VA and the DOD Registry, and their comprehensive
13 clinical evaluation protocol. Do those two
14 registries lend themselves to the same methodology
15 and the same application of a case definition?
16 DR. REEVES: I really can't answer
17 that. I would suspect that it might be difficult.
18 I would suspect that the questions have not been
19 phrased in exactly the same way that would allow
20 them to do that, but I can't really -- I've not gone
21 through their data collection forms.
22 DR. LASHOF: Could we get back to you
23 and ask you to take a look and help us on that?
24 DR. REEVES: Sure.
25 DR. LASHOF: Thank you.
2 MS. JOELLENBECK: I had a question.
3 Given that what you're defining as the
4 case in this population, you're also seeing in the
5 non-deployed and in the civilians, would that mean
6 that in your case control you would be ruling out
7 exposures that are unique to the Gulf?
8 DR. REEVES: What we're trying to do in
9 the case control, and again using chronic fatigue
10 syndrome as a model if one has visceral trophic
11 leishmaniasis that precludes a diagnosis for chronic
12 fatigue syndrome. I mean, that doesn't mean you
13 can't have it, but you've got something worse. If
14 somebody has cancer, that precludes a diagnosis of
15 chronic fatigue syndrome. If one has hypothyroidism
16 successfully treated, it does not. And so to do the
17 diagnoses. And in fact to rule out explainable
18 diseases, one must do as we're doing in the case
19 control study, a careful physical examination,
20 routine background studies and a careful medical
21 record search, and you attempt to rule out no
22 undiagnosable, treatable, organic diseases that
23 could preclude that diagnosis.
24 MS. JOELLENBECK: Will you then be --
25 as far as exposures are you relying on self-reports,
1 or how can you get at exposure?
2 DR. REEVES: Well, one that relies both
3 on self-reports, which has been discussed previously
4 -- some of the exposures, for example, biting
5 insects. If in fact one is exposed to biting
6 insects and they're vectoring a disease, it should
7 be possible to measure antibodies to that disease,
8 which we're doing through the Ft. Collins facility
9 of the Centers for Disease Control.
10 Leishmaniasis has been an important --
11 actually visceral trophic leishmaniasis is a new
12 agent really or disease due to an agent unraveled
13 due to war in the Gulf. Unfortunately the serologic
14 tests for exposure to leishmaniasis are not good,
15 however the same insects that vector sand fly fever
16 viruses vector leishmaniasis.
17 So by measuring the antibodies to sand
18 fly fever viruses one has a surrogate for exposure
19 to leishmaniasis that deals with self-reports of
20 exposure to insects. Self-reports of vaccination
21 are an even more difficult issue. The two vaccines
22 of greatest controversy in the Gulf War have been
23 botulina and anthrax, for which antibody tests
24 exist. So by measuring for antibodies to those
25 agents, one has a surrogate for a vaccination and/or
1 exposure to biologic warfare agents. I suspect
2 those will be negative in this case.
3 MS. JOELLENBECK: Thank you.
4 DR. LASHOF: John?
5 DR. BALDESCHWIELER: Are there other
6 occupational groups, for example, which show high
7 levels of a similar complex of symptoms?
8 DR. REEVES: In our study in San
9 Francisco, again which was addressing chronic
10 fatigue syndrome, but which we were able to go back
11 and reapply this definition to, we did not see
12 evidence in the study from again approximately
13 16,000 to 18,000 randomly selected people in San
14 Francisco of fatiguing illness clustering by a
15 particular population.
16 DR. BALDESCHWIELER: Population or
18 DR. REEVES: I meant occupation. It
19 was higher actually in blacks and Hispanics, but it
20 did not -- and women, but it did not cluster. There
21 was no indication in that survey of any particular
22 occupation being at higher risk.
23 DR. LASHOF: Mark?
24 MR. BROWN: Let me just see if I
25 understand what you found here. I'm not an
1 epidemiologist, so I could be a little bit ignorant
2 here maybe, but you found this using -- you found a
3 case definition by using clinical examinations and a
4 cluster analysis. When you applied that to your
5 control you found something that looked -- which you
6 think looks like CFS -- looks like chronic fatigue
8 Is that -- and to bolster that argument
9 you found that it occurred at the same -- your
10 control population and the general population, you
11 found this syndrome that looks like chronic fatigue
12 syndrome at this -- occurring at the same rate?
13 DR. REEVES: It's not exactly how I
14 would have put it, but what we found in our study
15 was that there was an unusually high occurrence of a
16 variety of symptoms in those individuals that we
17 surveyed that went to the Gulf. Those symptoms were
18 those symptoms that other people have applied. We
19 then decided how could we make a -- try to make a
20 case definition. These were purely symptoms.
21 We chose two methods to make that case
22 definition. The clinical epidemiologic approach
23 said if something is associated say with the Gulf,
24 it should be chronic and persistent, which all these
25 have been said to be. If one was to be really
1 conservative, it should occur in at least a quarter
2 of the people who went, and if one wanted to be
3 really conservative, there should be at least a 2.5
4 relative risk.
5 And when we did that with the clinical
6 diagnosis what came up were fatigue, neurocognitive
7 and musculoskeletal. Now that is kind of circular,
8 because you've already assumed that they went.
9 Factor analysis, which is the mathematical
10 statistical approach that we applied, looks for
11 clustering of factors to define illness, and it's
12 independent both of clinical judgement and it's
13 independent of whether one was deployed or not, or
14 whether one -- factor analysis we did in a very
15 complex way, in which we divided the population in
16 half randomly. We applied factor analysis to both
17 halves of the population, and the entire population,
18 and we looked at all the factors. And what happened
19 was that two factors, factors one and two, were the
20 same factors one and two all the way as we cut it.
21 Factors one and two were -- factor one was fatigue,
22 neurocognitive, and factor two was musculoskeletal.
23 When we then compared individuals diagnosed in those
24 two ways, they were exactly the same, and that's how
25 we came to our case definition.
1 MR. BROWN: Well, I guess what I'm
2 trying to do here is draw you out a little bit on
3 your -- on this concept, the symptoms that you
4 identified in this method to come up with a case
5 definition, look something like CFS. That you had
6 to tweak the CDC definition of what CFS is a little
7 bit to get it, because some of the factors didn't
8 quite add up, but nevertheless am I correct, and did
9 I understand you to say that nevertheless the
10 symptom that you identified as your case definition
11 -- the cluster of symptoms that you identified as
12 your case definition looked a lot like CFS?
13 DR. REEVES: With the exception of
14 numbers of symptoms, with the exception of severity,
15 it is the case definition of CFS.
16 MR. BROWN: And does CFS have any
17 environmental cause?
18 DR. REEVES: As far as we know -- we
19 would be really happy if we knew of one. We do not
20 have specific -- the risk factor that we are finding
21 most highly associated with chronic fatigue syndrome
22 -- with slow onset chronic fatigue syndrome -- are
23 multiple major lifetime stresses in the year before
24 one becomes ill.
25 MR. BROWN: What then would the -- what
1 would you expect to get out of looking for
2 correlating different exposures to this case
3 definition if it's like CFS, and CFS doesn't have a
5 DR. REEVES: Well, we obviously don't
6 know if it is or not, and so we need to look at what
7 the exposures were, --
8 MR. BROWN: I see.
9 DR. REEVES: -- if nothing else then to
10 rule them out.
11 MR. BROWN: If you found an exposure
12 that correlated to that --
13 DR. REEVES: We have not analyzed the
14 data from Stage 2.
15 MR. BROWN: I mean, if you did, then
16 you would be less likely to call it CFS. You'd want
17 to call it something else presumably.
18 DR. REEVES: We would be ecstatic, and
19 I don't know what we would call it -- what it was.
20 MR. BROWN: Okay. Thanks.
21 DR. BALDESCHWIELER: Is there any way
22 to quantify stress? That is, for example, could one
23 make the case that certain units then had added
24 stress because of either their particular role, or
25 their leadership, or issues in the general conflict?
1 DR. REEVES: Some of the --
2 unfortunately, again I'm in the Viral Exanthema and
3 Herpes Virus Branch, and my forte is not stress or
4 psychology or psychiatry. We're applying rather
5 general, but standardized instruments to measure
7 I think interestingly, and I think
8 something which may be forgotten in issues of the
9 Gulf War -- again, remember this is a study of Air
10 Force people. This is a study of Air Force people
11 in a Special Operations Group. It is not the group
12 that drops bombs. It's not the group that goes in
13 and takes out SCUD missile sites. It is not a group
14 at all similar to forward deployed Marines, to
15 Seabees or to other units, and I think that stress,
16 you know, is a very encompassing area, and the
17 stress again that the military is exposed to is
18 quite different.
19 There may be some stresses that are
20 very similar in the various military populations
21 dealing with family at home, dealing with
22 deployment, dealing with other issues that are major
23 lifetime stresses in addition to whatever those
24 stresses are in the Gulf. We've tried to measure
25 those with standardized instruments, and again some
1 things we've thought up on our own.
2 DR. WINKELSTEIN: Epidemiologists have
3 addressed this problem in recent years with respect
4 to a number of different diseases, for example,
5 coronary heart disease, high blood pressure, and so
6 forth, and defined stress in a variety of different
7 ways depending on the particular situation that
8 they're looking at, so one could define stress in
9 terms of mobility -- residential mobility. In the
10 current study of blood pressure in bus drivers in
11 San Francisco, one of the stressors is keeping up
12 with a schedule, and then there are all kinds of
13 different -- different strategies for addressing the
14 stress issue in epidemiological studies.
15 DR. LASHOF: Though you've made the
16 point that this is a unique unit, this is the Air
17 Force, you've applied it to this, you think we ought
18 to try this definition in the other studies that are
19 going on, what study would you like to do most if
20 you had your druthers at this point to try to
21 further elucidate the presence or absence of a Gulf
22 War illness or the cause of a Gulf War veterans'
24 DR. REEVES: I think it would -- is
25 going to be extremely important that studies like
1 the Iowa study and other studies which are doing
2 similar population approaches get on with and get
3 terminated and written, but I think the important
4 thing is, can this or something similar to it be
5 replicated in other population based studies. I
6 think that's probably the most important thing.
7 And then I look upon this as in many
8 ways a pilot study, and I think it needs to be
9 replicated. It needs to be looked at again in other
10 population-based studies, of which the Iowa study is
11 a very good example, and I think that case control
12 studies collecting biologic material as well as
13 questionnaire information also need to be done in a
14 variety of populations to see if we're seeing pretty
15 much the same things.
16 DR. LASHOF: Thank you. Other
17 questions? Holly?
18 MS. GWIN: I want to pursue this idea
19 that you don't want over standardization of the
20 questionnaires a little bit. Do you mean they
21 shouldn't go out with a pre-prepared set of
22 questions, or --
23 DR. WINKELSTEIN: What I meant by that
24 was if you're studying a disease about which you
25 know very little, then it seems to me it's important
1 to have different approaches, different hypotheses
2 to be tested, and that a multi-factorial, if you
3 will, approach is likely to give -- be more
4 revealing when you know very little or nothing.
5 This was a big argument at the
6 beginning of the AIDS epidemic when the multi-center
7 AIDS study was being designed. The argument was,
8 should we have one large study using a standardized
9 questionnaire, or should we have five smaller
10 studies, but with different approaches? And it just
11 seems to me important that, when you're looking,
12 that you don't get too highly standardized at the
13 beginning, because then you won't be able to see if
14 there are other things going on, or alternative
15 answers to the question.
16 So I think it's very important that
17 studies be able to be compared, but they not all do
18 exactly the same thing. That they have different
19 sampling techniques, and so forth. That's what I
20 tried to convey.
21 DR. LASHOF: Questions?
22 DR. WINKELSTEIN: Could I just offer
23 one other thing?
24 DR. LASHOF: Sure.
25 DR. WINKELSTEIN: To add to Dr. Reeves'
1 last point, I think one of the -- as I mentioned
2 earlier, one of the big problems is the rate of
3 participation in these studies, because the lower
4 the rate of participation, the more likely -- or the
5 more possible it is that biases can be introduced,
6 so I think there should be a great deal of emphasis
7 on characterizing the non-participants. So -- and
8 that can be done, although many times it's a rather
9 costly and intensive effort to do, but in the
10 studies that I've seen, including the Pennsylvania
11 study, it hasn't been possible or the investigators
12 have not adequately investigated, in my opinion, the
13 non-participants to see how they compare with the
14 people who participate, even on simple
15 characteristics. Because, if you can establish that
16 the non-participants are very much like the
17 participants, then you have a lot more confidence in
18 the results that you get.
19 DR. REEVES: I would make two comments
20 on that.
21 In our study -- there is a problem with
22 these sorts of studies, and one is -- and again,
23 particularly in ours doing the study completely
24 anonymously, there was a high degree of suspicion,
25 particularly among the members of the 193rd
1 Pennsylvania Air National Guard that they would get
2 kicked out of the guard, be found unfit for service
3 medically, if they were in fact complaining of
4 Persian Gulf War related illness; so basically the
5 response bias can be both ways.
6 That meant we had to do the studies,
7 and I think other ones, very anonymously, which
8 makes it impossible to collect direct information on
9 the non-participants. We were in our study,
10 however, to at least get information on the
11 participants, and compare that to the overall
12 demographics and various information of the unit,
13 and there's no difference between our participants
14 and the unit as a whole in any of those cases.
15 DR. LASHOF: Let me ask one more
17 We've heard obviously anecdotal
18 information over the several meetings that this
19 committee has had about various treatments that
20 people have undergone for this disease, and you've
21 heard some this morning about doxycycline. Are any
22 of the studies that you're familiar with looking at
23 all about what treatment people have gotten, and
24 whether they've responded or not? Or has that not
25 been included in your surveys?
1 DR. REEVES: That's not been included
2 in our survey, and I think obviously the flaw with
3 all of the studies of treatment is that they're
4 numerator-based studies, they're accumulated case
5 series, and they really have no meaning whatsoever
7 DR. LASHOF: Any other closing remarks
8 either of you would like to offer to us?
9 DR. REEVES: We're open for advice.
10 DR. LASHOF: Thank you very much;
11 appreciate it.
12 Okay. I think I'll move now to Dr.
13 Michael Ascher, who is a member of the Armed Forces
14 Epidemiological Board. That board has reviewed the
15 overall coordinating board's work plan for research
16 on the Persian Gulf War Veterans' Illnesses, and
17 will offer us some general assessment or summary
18 really of the Armed Forces Epidemiologic Board's
19 review of the current studies, which also close out
20 the day, but might be an introduction to tomorrow.
21 A summation of today and an introduction of
22 tomorrow, if you will.
23 Presentation by Dr. Michael Ascher
24 DR. ASCHER: Thank you, Dr. Lashof.
25 DR. LASHOF: Thank you.
1 DR. ASCHER: Thank you for the
3 I'm a little bit hampered in my
4 assignment by the fact that the two major study
5 groups that we are supposed to talk about are
6 actually going to be presented tomorrow and the
7 investigators aren't here, so I'd like to maybe even
8 reserve some time after that and be around to make
9 some further comments.
10 DR. LASHOF: That would be fine. We'd
11 appreciate it if you could be here tomorrow, and be
12 able to comment.
13 DR. ASCHER: I'll take the lead of your
14 comment and perhaps try to summarize maybe the day's
15 activities, and I'll refer back to some of the
16 proceedings earlier in the morning and other things
17 to try to make some speculation, and talk a little
18 bit as well about what the key role of the Armed
19 Forces Board is, which is to prevent this happening
20 in the future.
21 The Armed Forces --
22 DR. LASHOF: Is that to prevent the
23 wars, or --
24 DR. ASCHER: All of the above.
25 DR. LASHOF: I'm sorry.
1 DR. ASCHER: Okay. The Armed Forces
2 Epidemiologic Board was formed in 1941, obviously in
3 response to the issues of World War II, particularly
4 in reference to infectious disease prevention and
5 control. It had immediate assignments, as you can
6 imagine, in areas of respiratory disease,
7 streptococcal disease, malaria, and all the big
8 infectious problems due to our widespread deployment
9 and things like that.
10 It had a very long record of managing
11 these problems through this process, and actually
12 has to that day -- to this day written all of the
13 policy recommendations and reviewed all of the
14 issues of diseases, and now other issues, of the
15 active reserve and other forces.
16 For example, in recent years we've
17 written the testing policy for HIV. We wrote all
18 the policy for the use of vaccines for prevention of
19 biological warfare casualties and continue to do
20 that. We evaluate all new vaccines. We're working
21 on injury prevention. We talk about things like
22 sickle cell disease, and all those sorts of things
23 as well.
24 I'm the Chair of Disease Control. My
25 term on the Board just expired so I can be a little
1 free in my comments. I'm also wearing a second hat.
2 I'm an active medical officer reservist in a unit
3 about 15 miles from here in Oakland. I'm an
4 infectious disease officer. I was not deployed to
5 the Gulf. I was on annual training during the
6 invasion in Walter Reed, and returned home and sat
7 waiting by the phone.
8 The Armed Forces Epidemiologic Board
9 has had really, until the referenced statement in my
10 assignment and in the title of my talk, had no
11 official involvement in this problem. Now you might
12 want to know why that is. This is something that --
13 from my historical comments might have been
14 something that the Board might have taken on as a
15 first class assignment, and the answer is that I
16 think basically there were too many other people in
17 the soup at the time, so we were sort of sitting
18 back and were never really given an assignment.
19 But from that perspective I'm going to
20 go through some of the material that had come across
21 our desks at these various meetings, and kind of
22 highlight some of the issues that I don't think
23 you've had full exposure to, and particularly some
24 comments today.
25 We first had information about the
1 problem as it was occurring in a presentation in May
2 of 1992 from the Preventive Medicine Officer of the
3 Army. Now the meetings work is all the Preventive
4 Medicine Officers bring up all the problems of
5 concern, and there are usually formal questions
6 raised, to which the Board writes responses. But
7 this was all informational, so we were just
8 interested in seeing what was happening.
9 When Colonel Erdtmann reported that, in
10 an Indiana reserve unit that had been deployed to
11 Saudi Arabia, there were complaints of headaches,
12 aching joints, diarrhea, and other generalized
13 symptoms, several putative agents were involved, and
14 merited the sending of an EPI-CON team. The team
15 interviewed all 94 soldiers.
16 Findings indicated there were several
17 units involved, not a single unit, not confined to
18 one region, located in different places, et cetera,
19 et cetera. Examination of blood tests showed
20 nothing particular.
21 One common thread was an indication of
22 situational stress difficulties particularly due to
23 being removed from their civilian jobs, placed upon
24 -- into a wartime situation, and then reinjected
25 into a civilian environment. A combat stress team
1 will be deployed to pursue these issues.
2 In the Q and A fashion, Dr. Kuller, the
3 President of the Board, recommended that results be
4 published to preclude attempting to develop studies
5 for diseases, which according to the preliminary
6 study do not exist. Dr. Dowdle, then Acting
7 Director of CDC, noted that the review of the data
8 by the Board as an outside advisory group enhances
9 the credibility of the results.
10 So in May of '92, we on the Board at
11 this private meeting had a kind of an overview that
12 gave us a considerable bias as to what the problem
13 was, particularly as it related to the issue of the
14 fact that this appeared in a reserve force. And
15 remember I told you, I'm a reservist.
16 Now I want to come back to that in a
17 second, but I want to sort of tell you what some of
18 the other things that came along as we were going
19 through the process.
20 We had a very excellent presentation by
21 the Chief of Psychiatry at Walter Reed, Dr. Marlow.
22 If you haven't heard from him, you should invite
23 him. He presented the stresses and psychological
24 consequences of Operation Desert Storm/Desert
25 Shield. This was a prospective study. Dr.
1 Baldschwieler's question about assessing stressors
2 was actually the basis of this presentation, and he
3 made some interesting findings.
4 First, as Dr. Reeves said, that there
5 is, in any baseline population, a frequency of a
6 complex that you can call a variant of post-
7 traumatic stress or chronic fatigue or any
8 variation, and this was clearly enhanced by the
9 total process of service in this activity. But an
10 interesting finding of the report was that six
11 months to one year after return, the major sources
12 of stress reported by most soldiers involved issues
13 in their unit, their families and other life events,
14 only ten percent attributed their current situation
15 to things that happened in the Gulf War, and 30
16 percent cited problems at home during and after
17 Operation Desert Storm.
18 Now, this was interesting finding as we
19 saw it epidemiologically, because it suggested that
20 there was more than deployment involved in this
21 situation, and we began to think a little bit in
22 some of the other data we had heard, particularly
23 from my own personal experience, that this exercise
24 was a continuum of activity, everything from taking
25 active forces overseas, to taking reservists to an
1 activatable state, to activating reservists to their
2 home unit where they live, to activating reservists
3 and put them somewhere else in the United States, to
4 activating reservists and sending them overseas.
5 And I would like you to consider the
6 possibility, particularly in the Iowa study and
7 others, that the stresses and other things are not
8 purely a function of the life events associated with
9 service in the Gulf; and if we ignore the fact that
10 taking a physician out of practice in San Francisco
11 and placing him in Colorado where there's no
12 specialty work of his type produces significant life
13 stress, particularly when he has a divorce and loses
14 his practice.
15 So there are issues of the backlash of
16 this problem if you limit your discussion to
17 considering only the exposures, and only the
18 stresses of combat. And paradoxically I would
19 maintain that there might be a case made that some
20 of the people who had the experience I just related
21 might actually have a worse outcome than individuals
22 who actually did something in combat.
23 And I caution a backlash that might
24 occur if somehow in the findings that you evaluate
25 that you say there is a illness associated with
1 deployment that is limited to people that served in
2 the sand, and somehow the individuals who were --
3 whose life stresses were the same in terms of their
4 family and personal and job situations were -- are
5 not excluded on the basis of the fact that you had
6 to go to Saudi. Particularly because we don't
7 really know who went in many cases, and that's going
8 to be a complicated story.
9 Now I'm going to turn to the review of
10 the material that will be presented tomorrow, and I
11 said it's a little complicated because we haven't
12 heard it, but in general our cover letter indicated
13 just basically some of the stuff I just mentioned.
14 We suggested important changes in the
15 program as presented, more emphasis on behavioral,
16 psychologic stressors, as I mentioned; recommended
17 doing a comparison with deployed forces from other
18 countries. Now the reason for that -- and I've
19 talked to Mark Brown about that -- is that the
20 British liaison officer, Colonel Leach had presented
21 at several Board meetings the fact that the British
22 forces deployed 70,000 people, and had several -- I
23 think you said 50,000 were still active, and they
24 had 33 individuals appear for evaluation of some
25 related illness. And I asked him the question did
1 he think that the fact that Britain has a national
2 health care system had anything to do with it, and
3 he said absolutely.
4 And the bell went off for many of us in
5 the audience, which I will elaborate on in a second,
6 that we had a very, very strange story here in this
7 deployment. And the strange story was that we had
8 changed from the concept of having an active duty
9 Army, Navy and Air Force that would cover an
10 activity of this type to something called total
11 force. Total force is where you depend on reserve
12 components for up to 100 percent of support
13 activities, such as sky-ops water purification,
14 people that do legal affairs -- they're all in the
15 reserves. Medical, 70 percent in the reserves. So
16 now you have a deployment that for the first time
17 ever takes many, many people from a reserve
19 Now, a lot of people on the Board when
20 I mentioned this did not know that reserve component
21 soldiers do not have health care benefits in any way
22 shape or form. When they are mobilized, deployed to
23 the Gulf War, the day they hit the street back in
24 their home station they are not eligible for health
25 care, the only access to care is through a
1 disability linked process that involves the
2 Veterans' Administration.
3 And, if you follow my train of thought,
4 what actually happened because of this big gap in
5 coverage is that process got activated through a
6 public law that there was no way for people to get
7 care. Now if you look at the past as we've looked
8 at various other kind of national problems of this
9 magnitude, and the one I like best of all is the
10 shuttle disaster, everyone talked about climate, and
11 waves in the ocean, and mental fatigue, and engineer
12 problems, and Richard Fineman got up and broke an
13 O-ring on television, and everybody said, "I got it.
14 It wasn't any of that stuff, it was cold and the
15 O-ring broke."
16 The problem in this syndrome or in this
17 complex of illness is access to health care. We
18 have a system that relies on reservists, that puts
19 them in harms way, and drops them back on the street
20 with no coverage. It is not a surprise that almost
21 all the participants in your public hearing were
22 reservists: Mr. Fahey, no jobs; Eric Lundholm,
23 denied treatment; Richard Reyes, lost health
24 insurance, lost disability insurance; Major Junkin
25 -- Major Junkin, telling us about bouncing from
1 health care system -- one to another. She's a
2 reservist. She is not eligible for care. She is a
3 retired reservist. She is not eligible for care
4 until she reaches the age at which retired
5 reservists get care, which is 60 or 62. So there's
6 a big gap in the system.
7 So, what's the fix? We'll talk about
8 that in a second.
9 So, what is the bottom line in terms of
10 my most -- big concern about this experience? Well,
11 the bottom line is from my own reserve experience
12 the effect that it's had on decimating some of the
13 capability that we have in our armed forces. The
14 people who went through this, in addition to
15 complaining and having the problems that we've heard
16 about, have left in droves. And recruitment,
17 particularly for medical officers and other people,
18 is hopeless. We cannot fill medical plans. No one
19 wants to join. They heard what happened. So we
20 have a real problem at the level of how to fix the
21 system, and I can't answer that. The fix I have for
22 that does not include the simple issue of health
24 The other thing that I comment on, and
25 I welcome other panel questions on this, is the fact
1 that this got linked to compensation through the VA
2 process is really to me an aberration, and not the
3 VA's fault in any way. It was the fact that there
4 was no other system available to respond.
5 But right now I think we've heard that
6 the VA is not the place to solve the problem. The
7 VA does not really know under this circumstance how
8 to respond to this. The people that have testified
9 that have been to the VA don't like it. They're
10 being mis-labeled I think to some extent in terms of
11 what they might need.
12 And I agree with Patricia Axelrod in
13 terms of her comment about all of the epidemiologic
14 studies and everything else that we're planning, she
15 said, "Get the best care available first." We have
16 to get the care for the people in a meaningful way,
17 and if I've heard that the way the VA handles people
18 is send them to the psych ward and put them on
19 Prozac -- I'm concerned about that. That doesn't
20 seem to be a full response.
21 And I will cite to you only one other
22 sort of document that you might have seen, and it's
23 a magazine called Soldiers, and it's what the Army
24 provides. It's an official Army magazine. And they
25 reported Dr. Joseph's epidemiologic study in here,
1 as we've all heard, about the findings from that,
2 but they also relayed in here a very interesting
3 program at Walter Reed for the evaluation and
4 treatment of Gulf War veterans experiencing illness,
5 and it relates to a holistic approach, where diet
6 and other factors are included, and they basically
7 rehabilitate people in a very comprehensive way
8 other than sending them to a psych evaluation and
9 starting them on Prozac.
10 So I would be concerned that we do not
11 have the people in the right hands, and if we could
12 emulate anything I would emulate the program that
13 the Army has done, no questions asked, and get
14 people back on their feet.
15 Prevention -- the Armed Forces Board
16 has a primary role in that. Now I don't think that
17 anybody here would have to be told that physical
18 fitness for a deployable military is critical. You
19 can't be disabled and be in the reserves, or in any
20 active component. It's one of the requirements.
21 Well, at this point in time from our
22 experience we could also say there are people whose
23 life situations, given their jobs, given their home
24 situations, really put them at risk for serving in a
25 situation where they might be pulled out of that and
1 sent somewhere. And we really have to reevaluate
2 the fact of having all these individuals in sort of
3 a mixed situation, where -- when the result of doing
4 this, adding job stress, life stress, to exposures
5 to a new environment, add up to the outcome that
6 we've had.
7 I agree with Dr. Olson. There are
8 distressed individuals. I know many of them. I
9 agree with Dr. Reeves that it is an amplification of
10 something that is in the background of our
11 population as a consequence of all these stressors.
12 But in summary don't leave out the fact that the
13 stressors include service other than the Gulf,
14 components other than pyridostigmine and depleted
15 uranium. It's a continuum of exposure to a large
16 scale exercise, and if we can learn one thing from
17 it I would hope we would learn that we might want to
18 consider selection in some way against this in the
20 Now, is the system fixed right now?
21 What happens if we do it again? To some extent,
22 yes. Through the downsizing of the military, and
23 self-selection, those of us that are still in have
24 been told eyeball to eyeball, you understand you're
25 going to go if we go again. The answer is yes.
1 We're not going to have surprises again. So if you
2 are seriously in the military you have to accept
3 that. And the half the military that has left in
4 recent years due to downsizing is probably the self-
5 selected component that was really less prepared to
6 be deployed.
7 I'm not suggesting psychological
8 testing in terms of whether you can be deployed or
9 not, but it certainly would be a useful thing to
10 have out in the open so people understand what are
11 the forces, and particularly if people really don't
12 understand the effects of this on their family and
13 their home situation.
14 Back to one further point, and then
15 I'll quit and let you ask some questions. The
16 experience that I'm relating about deployment within
17 the United States, or what I call the third control
18 group, is from my own reserve unit, which I did not
19 get activated with, that was deployed to Colorado.
20 This was a hospital unit that had originally been
21 scheduled to Germany, and because of some changes in
22 downsizing was sent to Colorado.
23 It was a complete change of plans, and
24 the people were there with nothing to do. Life
25 stresses, extraordinary; the number of people who
1 had severe problems, extraordinary, all through
2 conversations with a friend of mine who was there.
3 So it's clear that those kinds of
4 things are part of the continuum. Don't exclude
5 those people. That's my major message about that
7 I'll answer any questions, and I hope
8 to comment further tomorrow on some of the issues
9 about the studies as they are presented. Thank you.
10 DR. LASHOF: Thank you very much,
11 Doctor Ascher.
12 Do you have any questions?
13 DR. TAYLOR: I guess it's one question
14 that I have. It's clear that post traumatic stress
15 disorder is one that should be investigated as well,
16 but I guess my point to you -- I'm trying to figure
17 out if you're saying that or suggesting that most of
18 the symptoms reported are by reservists, and that
19 indeed may mean that most of them have psychological
20 related problems, and that it's more stress related
21 than anything else?
22 DR. ASCHER: No, I don't think -- I
23 don't think that's the case. The issue of reporting
24 symptoms on the active duty side is a very hard one
25 to evaluate, because there are no questions asked
1 about medical care. You have a headache, you have
2 diarrhea, you have anything after being in the Gulf
3 War, you walk in your troop clinic and you're cared
4 for. So there's no question at all.
5 I think there were a lot of people who
6 came back on the active side who were stressed, and
7 who had some of these things as a consequence. I
8 don't like the term psychological or in your head,
9 or anything else. I think what we're talking about
10 is reaction to a combination of personal,
11 occupational, environmental, and other stresses that
12 play out as a series of things, manifest anything
13 from diarrhea, to headache, to sleep disorder, to
14 depression, to fatigue -- all of which if you stress
15 an individual enough, he will produce this sort of
16 complex. It is not in your head. It is not
17 psychological. It is a stress reaction.
18 DR. TAYLOR: So, is this a stress
19 reaction to all the exposures that occurred,
20 including the vaccines, the environmental exposures,
21 the pyridostigmine, all of that?
22 DR. ASCHER: Right, but as I said, if I
23 can cite you evidence that going to Colorado without
24 vaccines, without pyridostigmine, produced about the
25 same frequency of difficulty in terms of people's
1 life situation when they returned, that would
2 suggest that it's a bigger picture than the minor
3 issues of pyridostigmine.
4 DR. TAYLOR: And this is based on a
5 population in Colorado of how many people?
6 DR. ASCHER: This is anecdotal. But
7 I'm saying -- to be concrete with you. I'm sorry it
8 isn't clear.
9 For the Iowa study, the Iowa study
10 could have had a third control group that had
11 individuals who were activated and sent somewhere
12 else, but never left the country. I'm saying that
13 life events -- to leave your job, to leave your
14 family, has those two components in isolation, as
15 opposed to adding the exposure to the Gulf scenario,
16 and there is actually a published study that says
17 the individuals who went over had less difficulty in
18 certain regards than the people who were left behind
19 for that reason, because people felt they were doing
20 something useful, rather than sitting in Colorado
21 with nothing to do, and that is stressful.
22 Now the other thing that came up, and
23 I'm not going to beat on it, is the issue of
24 evaluating the treatment. We've heard that probably
25 for a good -- in good faith, there is an ongoing
1 program to use certain drugs and certain therapeutic
2 modalities in the VA from the registry program. I
3 would suggest that they ought to add very quickly an
4 evaluation of that, because that's something that
5 would be very, very important to see.
6 DR. TAYLOR: Evaluation of --
7 DR. ASCHER: Evaluation of those
8 therapies. They've sort of evolved a therapy for
9 certain people who manifest the more -- like
10 depression, for example. You know, the standard
11 treatment of depression and how that actually works.
12 I don't think there are very many studies that could
13 be as good as that to evaluate how some of those
14 things do work.
15 DR. LASHOF: Holly?
16 MS. GWIN: In the Board's report to Dr.
17 Joseph you raised some pretty serious concerns about
18 self-reported exposures, and self-reported
19 symptomology, and seemed to suggest that maybe
20 animal studies might be more appropriate at this
21 time than some of the EPI studies. Can you comment
22 on that? Am I misinterpreting the report?
23 DR. ASCHER: Right. The question was
24 in relation to trying to assess the environmental
25 factors like pyridostigmine or Gulf -- or smoke
1 exposure, or things like that.
2 Yeah, it was felt that based on self-
3 reported exposure, which cannot be validated, and
4 the symptomatology, which in some cases is hard to
5 validate, that it would be better if you wanted to
6 know what the long-term effects of something like
7 the exposure to pyridostigmine or smoke, that you
8 would do that in a controlled animal model -- that
9 it's unlikely to give you the information.
10 There is another interesting twist, and
11 Dr. Schwartz, I believe, laughed, but the military
12 is trying to determine who went where in the Gulf,
13 and one of the first things that the Board -- our
14 board found out was that it was even hard to
15 determine who went. It's even hard to determine who
16 was activated.
17 The data base for some of this is not
18 in the best of shape, but what is being developed at
19 Aberdeen, Maryland, where our most recent meeting
20 was held, is a data base trying to put unit
21 movements of people that were actually in the Gulf,
22 and overlay that on the oil smoke plumes.
23 And that has a limited use in terms of
24 understanding the oil smoke, but it also has the
25 ability to actually place people in the area, and so
1 that that's the way they're approaching the data
2 base of who went where, and that's in development.
3 But it is very difficult to get that information.
4 When Dr. Schwartz said something was
5 classified about who got vaccines -- I don't believe
6 that. It's not classified, just nobody knows.
7 There are no centralized records that have any of
8 that information.
9 When you lose a medical record or a
10 shot record wasn't used at the time of a shot,
11 there's no information, so it is really a problem in
12 getting that stuff. And it is a problem that the
13 Board has addressed long-term in terms of the
14 military trying to get their computer systems to
15 talk to each other, but it's going to be a long time
16 before that works properly.
17 There have been assurances to the Board
18 that the next time this happens, God forbid, that
19 the computers will work a little better. I would
20 think the other backlash of that is, if in the
21 course of validating the Gulf War registry of the
22 70,000 veterans that have signed up, it was found
23 that a significant proportion of them never left the
24 country. There are two approaches to that. You
25 say, well, you don't qualify because you never left
1 the country. Or, as I said earlier, you do qualify
2 because you have the same symptom complex for
3 reasons that I've tried to explain, or at least one
4 of the explanations that's possible.
5 DR. LASHOF: Thank you.
7 MS. JOELLENBECK: Oh, I was just
8 surprised to hear you say that you thought they
9 didn't have a good sense of who was over there. I
10 was under the impression that the Defense Manpower
11 Data Center had now a good listing of the folks who
13 actually --
14 DR. ASCHER: They're -- it's 1995.
15 We're talking about 1992. It took them awhile to
16 get it together. That's what I'm saying.
17 DR. LASHOF: But they do.
18 DR. ASCHER: Yes. They do have it now.
19 They're working on it, but it has been driven
20 predominantly by this issue that they have been able
21 to put it together. It was not a very high priority
22 or well organized thing. That's astonishing, but it
23 is basically true. It's not a data base that you
24 maintain for some reason.
25 DR. BALDESCHWIELER: Let me try to
1 understand the gap in the medical care that you've
2 identified. When a reservist comes off active duty
3 -- when he's on active duty he has the same access
4 to DOD medical facilities --
5 DR. ASCHER: Including his family.
6 DR. BALDESCHWIELER: Including the
7 family. But the instant he is released from active
8 duty, he's back on reserve status, and so his
9 medical coverage is --
10 DR. ASCHER: Zero.
11 DR. BALDESCHWIELER: Does he have
12 access to the VA?
13 DR. ASCHER: No. Unless he has a
14 disabling condition that he is able to qualify for,
15 in this case, by the Bill that was passed to make
16 undiagnosed illness a qualifying condition.
17 DR. TAYLOR: It seems like we heard
18 something different before. I'm not sure.
19 DR. LASHOF: Well, I think the -- to
20 clarify this, prior to the passage of that Bill, if
21 you didn't have a service-connected illness you were
22 not eligible for care.
23 DR. ASCHER: That's correct.
24 DR. LASHOF: You're now eligible for
25 care if you have an illness that has occurred since
1 going to the Gulf, and within two years of having
2 returned from the Gulf.
3 DR. ASCHER: That's right.
4 DR. LASHOF: And you don't have to be
5 means tested. You don't have to prove it's service-
6 connected. But that's for an illness that started
7 since the Gulf War. If you had some condition that
8 got aggravated, --
9 DR. ASCHER: Right.
10 DR. LASHOF: -- it's very questionable
11 whether you're eligible for care.
12 DR. ASCHER: But in the two- or three-
13 year period till they passed that bill, if you came
14 back and had a complaint, you had to go through the
15 hoop, as mentioned this morning, of getting
16 qualified in the VA, and that's a separate process
17 than getting care.
18 You have to get an eligibility
19 determination, which is a very, very different step
20 than getting care. You walk in a VA -- you're a
21 reservist, you're sick, you walk in Letterman
22 Hospital and they say, "You have the wrong color
23 card, we can't take care of you." You walk in the
24 VA, they say, "You have no letter of eligibility."
25 You're completely lost. There is no -- was no care
2 Now, I don't know how I would feel in
3 that situation, but it might make me angry,
4 particularly if that -- now, we had a briefing about
5 this by one of the reserve component people from
6 Georgia to my reserve unit, and I asked him
7 specifically the question: If you come back from a
8 deployment, and you are ill, is there somebody you
9 can call? And he gave the 800 number. There is now
10 such a number.
11 DR. LASHOF: Yes.
12 DR. ASCHER: And I asked the question:
13 Before this experience, was there anybody you could
14 call? And he said no.
15 DR. LASHOF: I think we will be digging
16 into this issue in greater depth at a future meeting
17 of the Board when we're having review of the medical
18 care issues, the access, the care. We have a
19 separate subcommittee looking at that, and we will
20 be holding separate hearings and dealing with that.
21 We're running short now, so --
22 DR. ASCHER: This was our major
23 criticism of the studies that will be presented
24 tomorrow, that we can anticipate in advance, that we
25 would like to have had social factors assessed as
1 well as some of the questions that were asked. We
2 would like to know who lost their job? Who lost
3 their spouse? Who lost their health care? Who lost
4 their disability insurance? And those variables
5 were not included in some of those questionnaires,
6 it was not considered an issue.
7 And so those were major criticisms that
8 I'd like to have responded to tomorrow, because I
9 think we could all see how this would play out. And
10 Dr. Lashof says this will be a whole other topic --
11 DR. LASHOF: Well, now it's fine to
12 raise it in relation to the epidemiology, and I hear
13 you loud and clear that you have concerns that the
14 survey does not address these issues, and that it
15 should address them. All I'm saying is the broader
16 issue of access to care, and so forth, we will be
17 covering at another time, but addressing it in the
18 questionnaire as a stressor is certainly relevant to
19 our discussion today, and I appreciate your raising
21 DR. ASCHER: And of course you realize
22 that the issue of health care access was all --
23 universal health care was on the table during all of
24 this, so you had people saying, am I going to get
25 it, am I not, and nobody knew the answer. So you
1 couldn't make a case for going to the military and
2 saying, "Put special case health care in for
3 reservists," and they'd say, "Oh, just wait a few
4 months, everyone will have it."
5 I asked in my reserve unit on Saturday,
6 among some young people who are in their twenties --
7 the typical reservists, college students -- what did
8 I feel about a high deductible health care plan for
9 them similar to what is given to college students.
10 It probably costs 25 bucks a month through an HMO.
11 The guy turned to me and he said number one issue
12 for retention, number one issue for recruitment.
13 We have a decimated force. What would
14 bring people in? We give young recruits a GI Bill
15 college fund, we give them life insurance, we have
16 no provision for health insurance. It's not the
17 nightmare that you might think. It's not the $300 a
18 month what we have to pay, or what we would pay.
19 It's healthy young kids. It's cheap. They're
20 healthy. So, it's an easy fix. A cheap fix.
21 DR. LASHOF: Mark, do you have any
22 further questions?
23 MR. BROWN: How are we doing for time
25 DR. LASHOF: Well, we have about five
1 minutes left, and then we're going to hear from --
2 MR. BROWN: Just one question. I'm
3 sorry? Oh.
4 You're a medical doctor, right?
5 DR. ASCHER: Yes.
6 MR. BROWN: I just have one question.
7 In your opinion -- it wasn't clear to me from your
8 remarks what your thoughts about this were, but in
9 your opinion -- in general, if you can make such a
10 generalization, the medical effects that you would
11 expect from stress -- from the high types of stress
12 that we're talking about here, the medical effects,
13 psychological effects, and physiological effects,
14 would you consider that, in general, serious
15 effects, or are these more trivial?
16 DR. ASCHER: In terms of overall
17 hazard --
18 MR. BROWN: As compared to other types
19 of effects that might cause illness and problems in
20 people compared to this. Or other types of organic
21 diseases, I mean, are these -- I mean, my question
22 is --
23 DR. ASCHER: Oh, it's very stressful.
24 MR. BROWN: In your opinion is the
25 effects of stress a serious issue --
1 DR. ASCHER: Oh, absolutely.
2 MR BROWN: -- or of serious
3 consequences or --
4 DR. ASCHER: I mean, these are
5 disabling conditions. I mean, these are people as
6 we've all had that don't sleep, that are prone to
7 all sorts of drug and alcohol problems, that have
8 various difficulties with depression, and it's a
9 loop you can't get out of. It's a horrible
10 situation to be in.
11 We had an earthquake here several years
12 ago. A lot of people talked about it afterwards.
13 People were very, very disturbed by it. It's a
14 variation of that.
15 No, it's one of the worst things that
16 can possibly happen to you, and I'm very sympathetic
17 to the people that have it, and I'd like to prevent
18 it in the future, and I'd like to get them care now,
19 as we've said this morning. Figure out what works.
20 I don't know whether they're higher in frequency. I
21 don't know what the cause is, but I know they're
22 sick people, and I think they should be getting care
23 for it right now.
24 DR. LASHOF: If there are no other
25 further questions -- thank you very much, Dr. Ascher
1 -- and we'll stand adjourned and reassemble tomorrow
2 morning. And we're beginning at -- we're beginning
3 at 8:30 with further epidemiologic studies.
4 (Whereupon, at 4:44 o'clock p.m., the meeting
5 in the above-entitled matter was adjourned to
6 reconvene at 8:30 o'clock a.m., Wednesday,
7 November 8, 1995.)