In August 1998, the Executive Office of the President, National Science and Technology Council, Office of Science and Technology Policy, issued Presidential Review Directive 5 (PRD-5), A National Obligation. Planning for Health Preparedness for and Readjustment of the Military, Veterans, and Their Families after Future Deployments. PRD-5 established broad goals for achieving progress in the area of military health and deployment. On Veterans Day 1998, the President directed the creation of the Military and Veterans Health Coordinating Board (MVHCB) with the specific task to focus on "issues associated with deployment health, research, and communications regarding health risks."¹ Creation of the MVHCB satisfied the specific PAC Special Report recommendation that "DoD, DVA, and DHHS should complete the comprehensive risk communication program for Gulf War veterans, as well as for forces deployed in the future; community-based outreach should receive particular focus." The MVHCB was thus an initial step toward institutionalizing goals and objectives for achieving the progress that PRD-5 outlined. Although the MVHCB is an advisory body, it has demonstrated its importance in military deployment and health matters by serving as a focal point for the many activities and programs required by PRD-5 and ongoing within DoD, VA, and DHHS.

In September 2000, the MVHCB conducted a plenary session that reviewed the institutional progress that the government has made in addressing the documented requirements of PRD-5 and the implied requirements of the President in his "leave no stone unturned" directive to investigate the potential causes of veterans� Gulf War illnesses. The following programs and/or topics were discussed:

The MVHCB proposed the establishment of the Health Enrollment Assessment Review, a DoD standardized instrument for self-reporting health information. While some administrative issues hamper the program (e.g., enrollee noncompliance), the continued development of this data collection program offers the potential to support the life-cycle health record of the military servicemember. The Board recommends that OSAGWIMRMD be an active participant in the development and implementation of the life-cycle military health record.

The Assistant Secretary of Defense for Health Affairs established this program to capture information on hospitalizations, outpatient visits, reportable diseases, HIV results, immunizations, deaths, and other health-related events for the purpose of detecting, characterizing, and countering threats to the health and well-being of military members. The Army Medical Surveillance Activity conducts the program as an element of the Defense Medical Surveillance System. The Board recommends that DoD increase its emphasis on recording deployment data.

The expansion of the role of the reserve components in mission performance and the increased utilization of the Presidential Selected Reserve Call-up Authority have resulted in increased demands on the health care system to provide medical and dental care for reservists. PRD�5 called for development of a plan to satisfy these unmet needs. Section 746 of the National Defense Authorization Act of 1997 directed DoD to conduct a study and report to Congress on the means of improving the provision of uniform and consistent medical and dental care to members of the reserve components. DoD presented its report to Congress in October 1999, and DoD has implemented numerous initiatives to improve health care for reservists before, during, and after deployment. However, funding, mobility of reserve component members, medical data collection, and multiplicity of health care providers are potential issues in the implementation of a comprehensive DoD strategy for the health care of the reservists. The Board recommends that OSAGWIMRMD and the MVHCB support this effort.

DoD Directive 6490.5 on Combat Stress Control mandates and outlines the requirements for all Defense agencies. The Board recommends the MVHCB incorporate deployment stress as a major area of emphasis.

Mental disorders clearly affect military readiness. These factors are the second leading cause of hospitalization, the leading cause of inpatient bed days, and the leading medical cause of attrition from the military service. Mental disorders are also the most important cause of medical and occupational morbidity among active duty U.S. military personnel. The Walter Reed Army Institute of Research (WRAIR) will begin research on these factors in Fiscal Year 2001.

PRD-5 mandated a cooperative DoD, VA, and DHHS plan to respond promptly to the health needs and concerns of veterans returning from deployments. DoD established three activities in response to this recommendation:

• The Deployment Health Clinical Center at the Walter Reed Army Medical Center, Washington, D.C.;
• The Deployment Health Research Center at the Naval Health Research Center, San Diego, California; and
• The Deployment Health Surveillance Center at CHPPM, Aberdeen, Maryland.

The Board feels these centers offer great promise for improved understanding of the health consequences of future deployments. OSAGWIMRMD should establish close relationships with these centers.

Family matters can affect military readiness through their effect on the individual service member and on his or her unit. Continued attention to family housing, unit family support groups during deployments, installation family centers, and DoD school system initiatives indicate the Department�s awareness of the importance of family matters, particularly as they relate to deployments.

Current or planned studies in the U.S. Army include:

• Impact of operations tempo on the military family,
• Deployment and stress in the Army Reserve Component, and
• Soldier-family stress contagion in deployable active and reserve component units.

The results of these studies are expected to be applicable to the other military services. The MVHCB and OSAGWIMRMD should ensure the dissemination of any lessons learned to the other military services.

The VA will establish two Centers for the Study of War Related Illnesses. The four program components of these centers�veterans health issues, outreach and risk communications, clinical care, and education�will focus on development of strategies to minimize illness and injury following future conflicts, including both combat and peace-keeping operations. They will also develop new approaches for improvement of the health care of active duty personnel and veterans with war-related illnesses.

The VA has also initiated the Veterans Health Initiative (VHI), a program that recognizes the connection between certain health effects and military service, allows better documentation of military medical history; prepares health care providers to better serve their veteran patients, and establishes a data base for further study.

PRD-5 recommended DoD possess the capability to collect and assess data associated with anticipated exposures during deployments and to respond to newly identified threats. In 1997, DoD began to develop new risk assessment tools for operational risk management. The National Academy of Sciences has endorsed parts of these plans as a means to provide future capabilities for exposure and risk assessments. The inability to accurately conduct exposure and risk assessments during the Gulf War has inhibited efforts to identify the causes of undiagnosed illnesses.

The Board believes that the complexity of accurate assessment tools and epidemiological standards have inhibited progress in this area of environmental health research. The Board recommends that DoD develop and implement a system for applied toxicological research based on prioritized lists of environmental and occupational substances, as suggested in PRD-5.

The Armed Forces Medical Intelligence Center provides environmental health intelligence assessments to the preventative medicine community, operational forces, and DoD policy makers. Based on first-hand observation, the Board is satisfied that the lessons of the Gulf War with respect to environmental and health conditions and hazards are being incorporated into operational planning for deployment of our military forces.

PRD-5 called for a comprehensive effort to identify the health effects of low-level exposures to chemical and biological warfare agents, environmental agents, and other factors. The DoD has historically focused on the lethal effects of CWA. The National Defense Authorization Act of 1999 directed DoD to determine the effects of chronic and low-dose exposures to CWA. Peer review of DoD�s plan has resulted in recommendations designed to improve and strengthen the plan. The Board recommends that OSAGWIMRMD and the MVHCB closely monitor the development and resourcing of DoD�s plan and make recommendations as appropriate to ensure continued progress in this area.

PRD-5 called for establishment of an interagency program for medical defense against chemical and biological warfare agents. In 1994 the military services outlined a Joint Services Agreement plan to coordinate and integrate each respective service�s nuclear, biological, and chemical defense efforts. The Chemical and Biological Defense Program and the Joint Service Agreement demonstrate to the Board that the Department is responsive to this PRD-5 recommendation. Fiscal Year 2001 funding is programmed at $17 million, which includes requirements for development, training, and acquisition.³

This demonstration project responds to the requirement to have the capability to determine exposure to low levels of CBW agents and/or toxic industrial chemicals. DoD is developing a smaller, lighter, simpler, more sensitive device to serve both as a real time alarming chemical detector and as an individual passive chemical sampler for archiving low-level exposures. However, issues such as concept of operations and operational scenario must be addressed before this concept is advanced and tested.⁴

DoD�s Chemical and Biological Defense Program directly responds to the PRD-5 recommendation for development of wide area standoff technologies to detect the battlefield presence of CWA in all physical states. Current upgraded, refined, and developmental systems such as the Fox M93A1 NBC Reconnaissance System, the Joint Service Lightweight Standoff Chemical Agent Detector, the Chemical Warfare Directional Detector, and the M21 Remote Sensing Chemical Agent Alarm demonstrate DoD progress in force health and operational protection in the chemical warfare environment. The Department continues to study low-level exposure scenarios, data analysis, and operational impacts, and the Board commends the Department for meeting these PRD-5 requirements. The Board does not support or recommend hastily conceived, inadequately tested, and quickly fielded approaches in the area of chemical and biological weapons detection and response. While progress may appear to be slow, the Board finds that both the spirit and the intention of the presidential directives are being satisfied with respect to health protection for our forces.

The MVHCB is participating with the DoD, VA, and DHHS to implement the PRD-5 risk communication requirements. The Board recommends continued support and extension of the MVHCB charter and encourages the respective departments to provide senior level endorsement, participation, guidance, funding, and staffing support to the MVHCB.

DoD fully recognizes the difficulties in coordinating the 1,770 military personnel management systems that collect and maintain information on DoD personnel. The Defense Integrated Military Human Resources System (DIMHRS), the 1,771^st system, is being designed to resolve the information collection deficiencies. This system may be operational by 2007. The Board recommends that the MVHCB and OSAGWIMRMD monitor developments in this area.

These initiatives derive from a critical lesson learned from the Gulf War. Many service member and veteran health issues were not verifiable due to lack of detailed documentation of pre-deployment health status. DoD and VA have recognized this shortcoming and are attempting, through the Recruit Assessment Program, to collect routine baseline health data from U.S. military recruits. The program will establish baseline health information for use in future longitudinal research studies to evaluate health problems among servicemembers and veterans after they leave military service and to address post-deployment health questions. This program requires the continued support of the DoD senior leadership both in concept and in application of resources. The IOM has also endorsed the program concept. Pilot program development and testing are under way at the Marine Corps, Navy, and Air Force recruitment and training commands. The Board recommends that OSAGWIMRMD include the "cradle to grave" health record concept for all U.S. military members in its top-ten priorities list.

The military health system is a complicated enterprise consisting of "sustainment" base operations (TRICARE, claims, pharmacy, retiree and dependent health care, contractors, hospitals, clinics), deployment medicine (battlefield medicine, casualty care, medical logistics, command and control, readiness), and an exhaustive list of activities that include integrated record keeping, responsiveness, immunization, research, information system requirements, and health care delivery. Longitudinal information on separating military servicemembers must be transferred to the VA if the veterans� health care system is to avoid the problems that Gulf War veterans experienced. Development of a computer-based patient record that satisfies the "sustainment" and operational base requirements of the military health care system, that simultaneously meets the VA�s legal and operational requirements for client records, and that can be integrated with a government-wide computer-based patient record (as directed by the President) represents a monumental undertaking. The Board believes that the ongoing efforts of DoD, VA, and DHHS satisfy both the spirit and the letter of the President�s directive and the lessons learned from the Gulf War experience. The Board recommends that the departments continue to apply lessons learned to their program developments in this area, and that the MVHCB be integrated in an ex officio status into the planning activities for the government computerized, multi-department patient record concept.

The Board believes that its recommendation that DoD institutionalize its investigative and historical research into the circumstances and events of the Gulf War, as they relate to the veteran and military service member population, is a critical element in the planning and programming efforts directed at the future health of servicemembers and their families. The implementation of this recommendation and the efforts of the OSAGWIMRMD will have a direct influence on the conduct of future military operations.

The Board observes that most of the above programs are new initiatives in response to the Gulf War, PRD-5, and the President�s directive to "leave no stone unturned." Individually, none of these programs will remedy the health problems of Gulf War veterans. However, collectively they represent a substantial beginning to future efforts to address health matters of our servicemembers before, during, and after deployment.

The Board recognizes the critical need for coordination and oversight of the many complex scientific, military, medical, veteran, family, and occupational programs and research activities under way in DoD, VA, and DHHS. The Board recommends that the MVHCB perform that coordinating mission with the assistance, as needed, of OSAGWIMRMD. The Board recommends that the MVHCB remain the focal point for the collective efforts of its chartering sponsors, and that the recommendations of the MVHCB represent a synthesis of the individual departmental efforts.

__________