the protocol would help to increase its diagnostic yield. (See Appendix D for a complete set of recommendations.)

Late in 1995, DoD asked the IOM to continue its evaluation of the CCEP with special attention to the adequacy of the protocol as it related to (1) difficult-to-diagnose individuals and those with ill-defined conditions; (2) the diagnosis and treatment of patients with stress and psychiatric conditions; and (3) assessment of the health problems of those who may have been exposed to low levels of nerve agents. It is important to note what was not included in the committee charge. It was not the committee's charge to determine whether or not there is such an entity (or entities) as "Persian Gulf Illness" nor was it this committee's charge to determine whether or not there are long-term health effects from low-level exposure to nerve agents. These questions are more properly the subject for extensive scientific research.

Given the urgency surrounding the last question—the health problems of individuals with possible exposure to low levels of nerve agents—the committee addressed this issue first and separately, releasing its report, Adequacy of the Comprehensive Clinical Evaluation Program: Nerve Agents, in April 1997. The committee concluded that although the CCEP continues to provide an appropriate screening approach to the diagnosis of disease, certain refinements would enhance its value. A complete set of recommendations is found in Appendix F.

To complete the remaining portions of its charge, the committee convened two workshops on the relevant topics, heard presentations, reviewed written material, and received comments from leading scientific and clinical experts, representatives of DoD and the VA, the Presidential Advisory Committee, the General Accounting Office, and representatives of veterans groups.

A great deal of time and effort has been expended evaluating DoD's Comprehensive Clinical Evaluation Program. It has been reviewed by the President's Advisory Committee, the General Accounting Office, the Office of Technology Assessment, the Institute of Medicine, and manys other organizations. As more is learned, it becomes easier to focus on the kinds of questions the CCEP should be asking. As Dr. Penelope Keyl said in her workshop presentation on the development of good screening instruments, progress made over time will necessitate new generations of screening instruments. This does not imply that the first instrument developed is bad, but rather that time leads to new knowledge, which leads to the ability to improve the instrument.

Such is the case with the CCEP. Over time, the CCEP and other programs have generated information that has increased our understanding and led us to focus on areas of importance for those concerned about the health consequences of Persian Gulf deployment. This information has enabled us to take a closer look, to make a more thorough examination of the system, and to identify areas in which change will be of benefit. The committee believes that such change is



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