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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM 3 The DoD should consider developing a comprehensive document for use in the CCEP that describes the potential physical, chemical, biological, and psychological stressors that were present in the Persian Gulf theater. If the CCEP physicians could obtain a clearer picture of the possible range of exposures, they might be able to counsel their patients more effectively. Walter Reed Army Medical Center staff have developed the Specialized Care Center (SCC) for the evaluation, treatment, and rehabilitation of a small, select group of seriously impaired patients who have been referred from regional medical centers. The committee's review should be considered preliminary because the program is still early in its development. The committee believes that the DoD has taken a serious approach to the treatment and rehabilitation of these impaired patients who have treatable, chronic diseases. If the SCC program is successful in improving the health and functional status of its patients, perhaps the elements that are most effective in enabling the patients to cope with their symptoms could be identified. It might then be possible to disseminate some of these elements to the DoD medical treatment facilities, which are close to where the CCEP patients live and work. INTRODUCTION Since their return from service in the Persian Gulf region during Operations Desert Shield and Desert Storm, a number of active-duty military personnel and veterans have reported a variety of health problems that they perceived to be associated with their service in the Persian Gulf. In response to continuing concerns about these problems, the U.S. Department of Defense (DoD) instituted the Comprehensive Clinical Evaluation Program (CCEP) in June 1994. The program's main objective is the diagnosis and treatment of these active-duty military personnel who have medical complaints that they believe could be related to their service in the Persian Gulf. In the CCEP, each individual receives a comprehensive medical evaluation that is based on a standardized clinical protocol (DoD, 1995a). In July 1994, Assistant Secretary of Defense for Health Affairs Stephen Joseph asked the Institute of Medicine (IOM) to convene a group of national medical and public health experts to complement the DoD's efforts with their analysis and to offer a channel for broader public comment and suggestions. In particular, the IOM committee was asked to evaluate the protocol for the clinical evaluations and to comment on the interpretation of the CCEP results that have been obtained so far. The committee was also asked to make recommendations relevant to the conduct of the clinical evaluations in the future and on the broader program of the DoD Persian Gulf health studies, if appropriate.

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4 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM The DoD published its first results for the CCEP on December 13, 1994, in a report entitled Clinical Evaluation Program for Gulf War Veterans Preliminary Status Report on the First 1,000 Patients (DoD, 19941. In April 1995, the DoD published its second report, entitled Clinical Evaluation Program for Gulf Veterans Second Interim Report on 2,076 Participants (DoD, l995b). The DoD also provided an unpublished draft DoD report to the IOM committee entitled Comprehensive Clinical Evaluation Program (CCEP) for Gulf War Veterans Report on 10, 020 Participants, dated June 7, 1995 (DoD, 1995c). The DoD then revised this report and released it to the public, with the same title, on August 1, 1995 (DoD, l995d). The IOM committee held its first meeting on October 24, 1994. It released its first interim report on the CCEP, which was based on the DoD presentations prepared for the first DoD report, on December 2, 1994 (IOM, 19941. The committee held its second meeting on March 10, 1995, during which several DoD clinicians discussed the results in its second report on 2,076 patients, as well as administrative aspects of the CCEP. The IOM committee held its third meeting on June 8 and 9, 1995. The purpose of the meeting was to review the unpublished draft DoD report on 10,020 CCEP participants, dated June 7, 1995 (DoD, l995c). In addition, several physicians who were involved with the CCEP gave presentations on the clinical results, and the committee made a site visit to the Specialized Care Center at the Walter Reed Army Medical Center in Washington, D.C. The committee released its second interim report on August 7, 1995, which commented on the unpublished draft DoD report and on the presentations at the June 8 and 9 meeting (IOM, 1995a). The IOM committee held its fourth meeting on September 6, 1995, to draft and discuss the current report. The purpose of this report on the CCEP is to evaluate the major issues that the committee has identified since its first meeting in October 1994. The major topics of the two interim reports are incorporated here. The report consists of six sections on (1) the goals and procedures of the CCEP, (2) the implementation of the CCEP, (3) the analysis and interpretation of the results of the CCEP, (4) specific medical diagnoses, (5) use of the CCEP results for education, for improvements in the medical protocol, and for outcome evaluation, and (6) a summary of epidemiological research relevant to the CCEP.