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OCR for page 1
Evaluation of the U.S. Department of
Defense Persian Gulf Comprehensive
Clinical Evaluation Program
EXECUTIVE SUMMARY
In July 1994, the U.S. Department of Defense (DoD) asked the Institute of
Medicine (IOM) to establish a committee to evaluate its Comprehensive Clinical
Evaluation Program (CCEP). Since their return from service in the Persian
Gulf region during Operations Desert Shield and Desert Storm, some active-duty
military personnel and veterans have reported a variety of health problems that
they perceived to be associated with their senice in that region. The DoD
instituted the CCEP in June 1994 to evaluate and treat the health problems of
these active-duty personnel. The DoD then asked the IOM committee to
evaluate the protocol for the clinical evaluations and to comment on the
interpretation of the CCEP results that have been obtained so far. In addition,
the committee was asked to make recommendations relevant to the conduct of
the clinical evaluations in the future and to the broader program of the DoD
Persian Gulf health studies, if appropriate. The purpose of this report on the
CCEP is to provide a comprehensive evaluation of the major issues that the
committee has identified since its first meeting in October 1994.
The CCEP is a compassionate and comprehensive effort to address the
clinical needs of thousands of active-duty personnel who served in the Persian
Gulf War. The CCEP clinical protocol is a thorough, systematic approach to
the diagnosis of a wide spectrum of diseases. A specific medical diagnosis or
diagnoses can be reached for most patients by using the CCEP protocol. The
DoD has made conscientious efforts to build consistency and quality assurance
into this program at the many medical treatment facilities and regional medical
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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN
GULF COMPREHENSIVE CLINICAL EVALUA TION PROGRAM
centers across the country. This nationwide effort was implemented relatively
quickly. The committee commends the DoD for its efforts to provide high-
quality medical care in the CCEP and the success it has achieved to date in
developing the infrastructure necessary to efficiently contact, schedule, refer, and
track thousands of patients through the system.
Of the first 10,020 CCEP patients, 37% were diagnosed with a psychiatric
condition, most commonly depression or posttraumatic stress disorder. Many of
the psychiatric diseases found in the CCEP population have both physical and
psychological symptoms and manifestations. The IOM committee encourages the
DoD to emphasize in its future reports that psychosocial stressors can produce
physical and psychological effects that are as real and potentially devastating as
physical, chemical, or biological stressors. The committee also encourages the
DoD to emphasize that effective treatments exist for many of these psychiatric
disorders.
There is currently no clinical evidence in the CCEP for a previously
unknown, serious illness among Persian Gulf veterans. If there were a new or
unique illness or syndrome among Persian Gulf veterans that could cause serious
impairment in a high proportion of veterans at risk, it would probably be
detectable in the population of 10,020 CCEP patients. On the other hand, if an
unknown illness were mild or only affected a small proportion of veterans at risk,
it might not be detectable in a case series, no matter how large. The DoD and
the U.S. Department of Veterans Affairs (DVA) are sponsoring several large
research studies that may provide more definitive answers as to whether there is
a new, unique Persian Gulf Syndrome.
The CCEP was not, however, designed to answer epidemiological questions.
Instead, it was designed as a medical evaluation and treatment program. In a
recent report on 10,020 patients, the DoD compares the symptoms and diagnoses
in the CCEP with the symptoms and diagnoses in several community-based and
clinically based populations. The committee concludes that interpretations based
on comparisons with other populations should be made with great caution and
only with the explicit recognition of the limitations of the CCEP as a self-
selected case series. The CCEP results do have considerable clinical utility, and
they could be used to address many important questions from a descriptive
perspective.
The results of the CCEP can and should be used for several purposes
including ( 1) educating Persian Gulf veterans and the physicians caring for them,
(2) improving the medical protocol itself, and (3) evaluating patient outcomes.
The medical findings of the CCEP should be distributed promptly to all CCEP
primary care physicians. The medical findings of the CCEP would also be of
considerable value and interest to physicians in the DVA system and in the
community.
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