Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action

Committee to Review the Health Consequences of Service During the Persian Gulf War

Medical Follow-up Agency

Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, D.C.
1995



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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Committee to Review the Health Consequences of Service During the Persian Gulf War Medical Follow-up Agency Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1995

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this study was provided equally by the Department of Veterans Affairs and the Department of Defense (contract no. V101(93)P-1417). Library of Congress Catalog Card No. 94-74965 International Standard Book No. 0-309-05241-6 Additional copies of the report are available in limited quantities from: National Academy Press Box 285 2101 Constitution Avenue, N.W. Washington, D.C. 20055 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area) B522 Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo-type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action COMMITTEE TO REVIEW THE HEALTH CONSEQUENCES OF SERVICE DURING THE PERSIAN GULF WAR JOHN C. BAILAR III,* Chairman, Professor, Department of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Canada CHRISTOPHER C. GREEN, Director, Technology Research Partnerships, General Motors Corporation, Warren, Michigan RICHARD B. HORNICK, Vice President of Medical Education, Orlando Regional Healthcare System, Medical Education Administration, Orlando, Florida KARL T. KELSEY, Associate Professor of Radiobiology and Occupational Medicine, Harvard School of Public Health, Boston, Massachusetts WAYNE M. LEDNAR, Medical Director, Rochester Medical Services, Eastman Kodak Company, Rochester, New York THOMAS A. LOUIS, Professor and Head, Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota GARY M. MARSH, Professor, Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania DAVID P. RALL, * Institute of Medicine Foreign Secretary, Washington, D.C. PHILIP K. RUSSELL, Professor, International Health, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland DAVID A. SAVITZ, Professor, Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, North Carolina G. MARIE SWANSON, Professor, Department of Medicine and Director, Cancer Center Michigan State University, East Lansing, Michigan GUTHRIE L. TURNER, Jr., Chief Medical Consultant, Division of Disability Determination Services, Department of Social and Health Services, Olympia, Washington MARK J. UTELL, Professor of Medicine and Environmental Medicine, Department of Medicine, Pulmonary and Critical Care Unit, University of Rochester School of Medicine, Rochester, New York JAMES H. WARE, Dean, Academic Affairs Harvard School of Public Health, Boston, Massachusetts DAVID H. WEGMAN, Professor and Chair, Department of Work Environment, University of Massachusetts, Lowell, Massachusetts *   Member, Institute of Medicine

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action LOUIS JOLYON WEST, Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, School of Medicine, Neuropsychiatric Institute, Los Angeles, California ELIZABETH WILLIAMS, Department of Internal Medicine, James Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee NANCY FUGATE WOODS,* Director, Center for Women's Health Research, Professor, School of Nursing, University of Washington, Seattle, Washington Study Staff DIANE J. MUNDT, Study Director and Senior Program Officer AMANDA E. HULL, Research Assistant CARLISS PARKER-SMITH, Project Assistant

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Preface The Committee to Review the Health Consequences of Service During the Persian Gulf War was appointed in December 1993 by the Medical Follow-up Agency of the Institute of Medicine (IOM), in response to Public Law 102-585. In response to the IOM role directed in this law, the committee is to provide: "(a) an assessment of the effectiveness of actions taken by the Secretary of Veterans Affairs and the Secretary of Defense to collect and maintain information that is potentially useful for assessing the health consequences of the military service . . . [in the Persian Gulf theater of operations during the Persian Gulf War]; (b) recommendations on means of improving the collection and maintenance of such information; [and] (c) recommendations on whether there is sound scientific basis for an epidemiological study or studies on the health consequences of such service, and if the recommendation is that there is sound scientific basis for such a study or studies, the nature of the study or studies." The joint and equal sponsors of this review, as mandated in the law, are the Department of Veterans Affairs (VA) and the Department of Defense (DoD). The DoD retains responsibility for all medical care of veterans who remain on active duty or retire; the VA is responsible for caring for those who have served in but left the military. The committee understands that the primary objective in a military operation is to successfully complete the mission, which the DoD accomplished with great distinction in the Persian Gulf. Scientific research is not and cannot be a high priority in the midst of armed conflict. The committee feels that the DoD and VA did and now do a creditable job in addressing the potential health is-

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action sues, given the time pressures and public concerns. The committee recognizes that these two agencies experienced various difficulties in meeting the highest scientific standards during the conflict and it is understandable that the results of these gaps still persist, but we believe that some of the most critical problems can still be rectified. This interim report provides constructive criticism of a number of areas that require immediate action. The task before the IOM committee is expected to take three years; however, there are some matters that could be settled earlier and some findings and recommendations that should be provided immediately because they have implications for ongoing research. This report is the result of the committee's deliberations and conclusions regarding certain issues for which findings are sufficient to make recommendations at this time. The report also includes an overview and some commentary on ongoing activities in the background section of the report. A second, final report should be available by September 1996. Several topics that the committee has chosen not to include in this first report are on the agenda for further consideration and review for the final report. Among the topics for future consideration are the issues of chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity, and psychosocial outcomes. Readers should understand that the absence of discussion of some of these topics does not mean that the committee is ignoring them. Committee members were drawn from several areas of expertise. During our work we have heard from veterans, spouses, and concerned individuals in a public meeting, and through letters, phone calls, and individual contacts. Without prejudging any technical matters, we are impressed by the concern of veterans and their relatives, friends, and organizations about those who are sick and about their dedication to finding the causes of and remedies for the evident human suffering. This concern has deepened as American troops have been deployed to two more distant areas as this report was being finalized. We hope that this report will be valuable to the VA, DoD and Congress in focusing research in appropriate and effective ways. In the process of writing this report, the committee received valuable assistance from several people who we would like to thank at this time: Ms. Laura Baird, Mr. Michael Edington, and Ms. Rosa Kasper. JOHN C. BAILAR III, Chair

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Contents     INTRODUCTION   1     Organization of the Report   2     History of Events in the Persian Gulf War   3     FINDINGS AND RECOMMENDATIONS   7     Data and Databases   8     Coordination/Process   10     Considerations of Study Design Needs   11     BACKGROUND   18     Boards and Committees   19     General Comments on Study Design   22     Population-Based Activities   23     Health-Outcome-Based Activities—Completed or Well Underway   24     Health-Outcome-Based Activities—New or Just Beginning   37     Assessments of Exposure   43     REFERENCES   63     APPENDIXES   69 A   Putative Outcomes and Exposures   69 B   Invited Presentations   71

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action C   Portions of PL 102-25, PL 102-190, and PL 102-585   73 D   Meetings of the IOM Committee   80 E   Activities (as of September 1994) Related to Potential Health Consequences of Service in the Persian Gulf   82 F   Timeline of Relevant Events   88     ACRONYMS   91

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Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action

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