Overview of the Institute of Medicine's Persian Gulf Activities
The Institute of Medicine (IOM) has undertaken several activities focusing on the potential health implications of deployment in the Persian Gulf War and the efforts of DoD and the VA to respond to health concerns. The IOM Medical Follow-up Agency conducted a project focused on the health consequences of service in the Gulf and developed recommendations for research and information systems. The first report of this group (IOM, 1995b) concluded that there had been a fragmented attempt to solve the health problems of Persian Gulf veterans and that "sustained, coordinated, and serious efforts must be made in the near term to focus both the medical, social, and research response of the Government and of individuals and researchers." (See Appendix B for a complete set of recommendations.) The second report of the Medical Follow-up Agency (IOM, 1996b) detailed 16 recommendations with accompanying findings concerning research and information systems needed regarding the health consequences of service during the Persian Gulf War (Appendix C).
In 1994, DoD asked the IOM to assemble a group of medical and public health experts to evaluate the adequacy of the CCEP. The first committee met four times and prepared three reports between October 1994 and January 1996 (IOM, 1994, 1995a, 1996a). The committee concluded that although overall "the CCEP is a comprehensive effort to address the clinical needs of the thousands of active-duty personnel who served in the Gulf War," specific recommended changes in the protocol would help to increase its diagnostic yield. The committee also concluded that the CCEP is not appropriate as a research tool but that the results could and should be used to educate Persian Gulf veterans and the physicians caring for them, to improve the medical
protocol itself, and to evaluate patient outcomes. A complete list of the first CCEP committee's recommendations appears in Appendix D.
Late in 1995, DoD asked the IOM to continue its evaluation of the CCEP with special attention to three issues: (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. The committee was also to consider whether there are medical tests or consultations that should be added systematically to the CCEP to increase its diagnostic yield. A new committee was convened to address these issues. Most members of the newly formed committee were also members of the first IOM CCEP committee.
In defining the tasks included in this review, the committee noted what was not included in its charge. It was not this committee's charge to determine whether there is such an entity (or entities) as Persian Gulf Illness, nor was it this committee's charge to determine whether there are long-term health effects from low-level exposure to nerve agents. These questions are more properly the subject of extensive scientific research.
A series of workshops was planned to obtain information on these topics. Given the urgency surrounding the question of health problems of those who may have been exposed to low levels of nerve agents, DoD asked the committee to address this topic first, separately and as rapidly as possible. A 1-day workshop was held on December 3, 1996, during which information was gathered from leading researchers and clinicians about the effects of exposure to nerve agents and chemically related compounds, as well as about tests available to measure the potential health effects of such exposures. (See Appendix E for the workshop agenda and list of participants.)
The committee reviewed extensive clinical and research results regarding the effects of nerve agents, including those presented at the workshop as well as in the literature. In its report Adequacy of the Comprehensive Clinical Evaluation Program: Nerve Agents (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. For a complete set of recommendations, see Appendix F.
Over the course of the project, the committee heard presentations, reviewed written material, and received comments from leading scientific and clinical experts; representatives of the Department of Defense and the Department of Veterans Affairs; the Presidential Advisory Committee; the General Accounting Office; and representatives of veterans' groups. The committee also held two public workshops (see Appendix G for workshop agendas and participant lists).