LESSONS LEARNED AND RECENT INITIATIVES

It is critical that our Nation ensures that the health-related lessons learned resulting from the review of Gulf War activities be identified and implemented. The Federal Government is committed to learning from the mistakes and shortfalls that characterized the issues surrounding Gulf War illnesses, and making the needed corrections for the benefit of our veterans in future deployments. Consequently, numerous efforts have been taking place to ensure these concerns are fully addressed.

Military and Veterans Health Coordinating Board (MVHCB)

A key component of the PAC’s Final Report relating to lessons learned was the recommendation to task the White House’s National Science and Technology Council to develop an interagency plan addressing health preparedness and readjustment of veterans and families after future deployments. In August 1998, the National Science and Technology Council/Presidential Review Directive-5 (PRD-5), entitled A National Obligation: Planning for Health Preparedness for and Readjustment of the Military, Veterans, and their Families after Future Deployments, was published. PRD-5 reflects a strong interagency commitment to implement the health-related lessons learned from the Gulf War and other more recent deployments.

PRD-5 also called for the establishment of a new board to coordinate interagency activities supporting strategies identified in the directive. On November 11, 1998, President Clinton directed the Secretaries of DoD, HHS, and VA to establish the Military and Veterans Health Coordinating Board. The mission of the MVHCB, which is co-chaired by the three Secretaries, is to ensure permanent, continuing interagency coordination to enhance force health protection and medical care of our military, veterans, and their families.

The MVHCB was established in December 1999, with the subsequent formation of three working groups: research, deployment health, and health risk communications. The executive director and staff initially supported both the PGVCB and the MVHCB. In order to achieve greater efficiencies in the operations of the two boards, and to ensure that the lessons learned from the Gulf War were fully addressed for future deployments, the functions of the PGVCB were incorporated into the newer MVHCB. Prior to merging the two boards, VSOs and congressional staffs were consulted to ensure that this merger would continue to benefit all concerned parties. With general consensus, the ongoing functions of the PGVCB Clinical Working Group and Disabilities and Benefits Working Group were folded into the responsibilities of the MVHCB. Likewise, the PGVCB Research Working Group’s emphasis on Gulf War illnesses research was incorporated into the broader research venue of the MVHCB Research Working Group, which was established to provide coordination to better protect personnel during future deployments. The Deployment Health Working Group is tasked with monitoring and coordinating interagency activities related to force health protection and medical surveillance, including medical record-keeping, which was a problem during the Gulf War. The Health Risk Communications Working Group is the third working group of the MVHCB. Its purpose is to coordinate an interagency process to ensure honest, open, and clear communications on deployment health-related topics with military personnel, veterans, families, health care providers and the public.

In addition, an interagency information management/information technology (IM/IT) task force works closely with the working groups to ensure all necessary information management requirements have been identified to support their focus areas. The IM/IT task force also ensures that those requirements are passed to the appropriate agency for inclusion in the information systems being developed.

Institute of Medicine (IOM)

The IOM emphasized that the experiences after the Vietnam and Gulf Wars have shown that the immediate post-deployment period is crucial for medical screening and evaluation, and for providing appropriate care for returning service members. In addition, VA and DoD physicians have identified the need for standardized guidelines for treating patients who may have deployment-related health concerns. The Veterans Benefit Improvement Act of 1998 (Public Law 105-368) now routinely provides service members who served in combat missions eligibility for medical care for a period of two years after the date of separation from the service. The provision for this care without the need for establishing service connection provides a valuable opportunity to identify the health needs of this population. Rather than developing a special deployment-specific registry, the IOM concluded that veterans should receive care as needed, with evaluation, follow-up, and patient management focused in the primary care setting.

In early 1999, VA and DoD convened a group of experts to review the IOM recommendations and develop a plan for implementation. The challenge to them from the Assistant Secretary of Defense for Health Affairs and the Under Secretary for Health (VA) was to develop a post-deployment clinical evaluation program focused in the primary care setting. The consensus was to develop an evidence-based redeployment clinical practice guideline to assist health care providers in evaluating service member health concerns and to develop specific clinical guidelines for the most important conditions. This effort, which will greatly benefit our veterans, is currently ongoing.

The Millennium Cohort Study

DoD identified in the report on Effectiveness of Medical Research Initiatives Regarding Gulf War Illnesses (to the House of Representatives Committee on National Security and the Senate Armed Services Committee) the need for a coordinated capability to apply epidemiological research to determine whether deployment-related exposures are associated with post-deployment health outcomes. The Millennium Cohort Study responds to this need, and to recent recommendations from Congress and the IOM to systematically collect population-based demographic and health data to evaluate the health of service personnel throughout their military careers and after leaving military service. The Millennium Cohort Study will serve as a foundation upon which other routinely captured medical and deployment data may be added to answer future questions regarding the health risks of military deployment, military occupations, and general military service.

OSAGWI’s Lessons Learned Implementation Directorate (LLID)

In August 2000, OSAGWI completed the second full year of the Lessons Learned Implementation Directorate. Set up to examine the knowledge derived from OSAGWI investigations in the context of current and future force health protection, the LLID has made substantial and concrete suggestions to DoD for improvements in several areas of concern. Investigations uncovered weaknesses and deficiencies in policies, procedures, doctrine, training, and equipment. The establishment of the LLID was the result of a determination to see that DoD agencies adopt, implement, and enforce the changes designed to correct these weaknesses and reduce risk to troops in the future.

Stress. Although comparatively few participated in actual combat during the Gulf War, an important lesson learned was that DoD underestimated the impact of exposure to deployment-related stressors. The unexpected and rapid nature of the deployment to the Persian Gulf created anxiety over family separation and other personal hardships that especially impacted the large numbers of reserve service members. Other stressors among deployed service members included fear of missile attack, prolonged anticipation of chemical and biological weapon attack, anxiety over false-positive chemical weapon alarms,and witnessing death and civilian atrocities. In the 1999 RAND report on stress, a strong case is made that the stress of combat, or simply deploying to the theater of war, can have both immediate and long-term physical and psychological consequences. RAND further stated:

Although it is inappropriate to rely upon stress exposure as a default explanation for the myriad health problems reported by Gulf War veterans, in the absence of a thorough review of research concerning all plausible causes, we think it equally inappropriate to assume that stress played no role. To do so would ignore what the scientific literature shows about the relationship between stress and health.

In spite of the results of numerous studies, RAND concluded there is still resistance to the concept that stress can cause debilitating physical symptoms:

The scientific study of stress and its mpact on health has made enormous advances in recent years. Unfortunately, these scientific strides have generally not been accompanied by an evolution in popularly held misconceptions about stress. The societal stigma associated with stress as an explanation of poor health and disease has contributed greatly to the politicized environment that sometimes characterizes public discourse concerning the health problems suffered by Gulf War veterans.

In June 2000, the LLID hosted an operational stress conference to bring together military experts from the medical, religious and combat communities to craft a coherent joint strategy to deal with the issue of operational stress management. The focus was on the impact stress has on our service members’ health, and how it affects operational effectiveness. OSAGWI is identifying the follow-on actions required to formalize these findings. These findings will provide an excellent foundation for future policy on how to better train current and future leaders to prevent and manage operational stress. They will also build on the current DoD initiative to minimize combat stress as outlined in DoD Directive, DODD 6590.5, Combat Stress Control Program.

Joint Staff Force Health Protection (FHP) Initiative

DoD implemented a far-reaching "lessons learned" concept in 1998 when the Joint Staff (JS) developed a Force Health Protection (FHP) strategy that describes the integrated preventive and clinical programs that are necessary to protect the "total force." Working with the Assistant Secretary of Defense for Health Affairs, the JS specified preventive actions that must take place before, during, and after deployments to assure better health protection and properly documented health care. In August 1997, DoD issued DODD 6490.2, Joint Medical Surveillance, and its accompanying instruction, DODI, 6490.3, Implementation and Application of Joint Medical Surveillance for Deployments, which addressed many shortfalls in the force health protection program. In November 1999, the JS published its FHP Vision document, which closely follows the recommendations of PRD-5 and which identifies an implementation roadmap for this new DoD concept. The JS is now developing a plan that supports the FHP roadmap to ensure progress is being made toward achieving the factors put forth in the Vision document. FHP is a significant departure from conventional combat medicine because it:

  • Institutes programs to develop and support healthy and fit service members and families;
  • Emphasizes prevention of injury and illness while maintaining an exceptional casualty management system; and
  • Employs concepts that call for only essential care in the theater and evacuation to definitive care outside the theater of operations.

Office of the Special Assistant for Gulf War Illnesses, Medical Readiness and Military Deployments (OSAGWI-MRMD)

In August 2000, Defense Secretary William S. Cohen ensured the lessons learned from OSAGWI’s investigations would be applied to current and future deployments by broadening the scope of DoD’s focus on Gulf War illnesses. In doing so, he created the Office of the Special Assistant for Gulf War Illnesses, Medical Readiness and Military Deployments. This is not an end to DoD’s concern for Gulf War veterans’ illnesses, but an expansion to respond to other situations that might arise from current or future deployments. OSAGWI’s more than 30 investigational and information papers on potential exposures to hazardous materials in the Gulf War had convinced Defense officials that the Pentagon was not well structured to handle the medical consequences of non-traditional combat situations. Since very few of the deployment situations encountered during the Gulf War are truly unique to that war, it became apparent that DoD needed a resource to maintain focus on veterans’ needs for both today and into the future. This new organization will ensure that the environmental hazards and health issues, including better record-keeping, that face modern military forces remain on commanders’ priority lists.


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