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1 Introduction On August 2, 1990, Iraq invaded the independent nation of Kuwait. In rapid response the United Nations passed Resolution 678, which directed that "all necessary means" be used to get Iraq out of Kuwait. Within 5 days the United States had begun to deploy troops to the Persian Gulf in Operation Desert Shield. Intense air attacks against the Iraqi forces began on January 16, 1991 (Operation Desert Storm). A ground attack was launched on February 24, and within 4 days Iraqi resistance crumbled. Almost 700,000 U.S. troops participated in the Persian Gulf War. Following the fighting the number of U.S. troops in the area began to decline rapidly. By June 1991 fewer than 50,000 U.S. troops remained. The demographic characteristics of the Persian Gulf troops differed from those involved in previous military engagements. Overall, they were older, a large proportion (about 17%) were from National Guard and Reserve units, and almost 7% of the total forces were women. U.S. casualties during the Persian Gulf War were low. There were 148 combat-related deaths, with an additional 145 deaths due to disease or accidents. Despite the low numbers of U.S. fatalities and injuries, deployed personnel were exposed to a number of stressors. The rapid mobilization for military service led to the sudden disruption of the lives of large numbers of people. The involvement of large numbers of reservists and National Guard personnel created particular concern because in addition to their rapid mobilization and deployment, they would be returning directly to civilian life at the conclusion of the war. Stressors to which U.S. troops were exposed included oil smoke, diesel and jet fuel, solvents and other petrochemicals, CARC (chemical agent resistant 15
16 ADEQUACY OF THE VAPE~IANGULF=GISTRYANDUCAP coating) paint, depleted uranium, sand, endemic infections such as leishmaniasis, the extreme heat, and primitive living conditions. In addition, some soldiers were given anthrax and botulinum vaccines and some soldiers ingested Pyridostigmine Bromide pills to protect against chemical warfare agents. Other stressors affecting the troops were the unfamiliar character of the region, the requirement that U.S. military personnel have virtually no interaction with the indigenous populations, the wait for the fighting to begin, the fear that chemical warfare agents would be used by the Iraqis, and the immense destruction visited on the whole nation of Iraq, including exposure to dead and mutilated Iraqis. After the war most veterans returned home and resumed their normal activities. Within a relatively short time, however, some active-duty military personnel and veterans began to report various health problems that they believed were connected to their service in the Persian Gulf. Symptoms commonly described included fatigue, memory loss, severe headaches, muscle and joint pain, and rashes (Iowa Persian Gulf Study Group, 1997~. In 1992, the Department of Veterans Affairs (VA) developed and implemented the Persian Gulf Registry. Its original purposes were to ease returning veterans into the VA health care system, to create a registry containing medical and other data on Persian Gulf veterans that would assist in addressing questions about possible future effects of air pollutant exposure and other environmental agents, and to serve as the basis for future medical surveillance. Exposures, particularly those associated with the oil well fires, were included as part of the history taking. As time passed it became apparent that a number of exposure issues and a host of symptoms needed further investigation. As concern escalated over the health problems of those deployed to the Persian Gulf, the Department of Defense (DoD) also decided to develop and implement a Persian Gulf clinical program. DoD and VA met, used experts to develop clinical protocols, and by 1994 both had implemented similar and parallel clinical evaluation programs. VA's in-depth clinical program is called the Uniform Case Assessment Protocol (UCAP) whereas DoD's is called the Comprehensive Clinical Evaluation Program (CCEP). By early 1994 over 20,000 veterans had been examined as part of VA's Persian Gulf Registry program. There were concerns, however, about whether those veterans were being appropriately diagnosed and cared for under the VA program. In response to those concerns, in 1994 the Congress passed P.L. 103- 446 which stated: "In each year after the implementation of the protocol, the Secretary shall enter into an agreement with the National Academy of Sciences under which agreement appropriate experts shall review the adequacy of the protocol and its implementation by the Department of Veterans Affairs." In September 1996, VA charged the Institute of Medicine (IOM) with evaluating the adequacy of the UCAP and its implementation. The expert
INTRODUCTION 17 Committee on the Evaluation of the VA Uniform Case Assessment Protocol was convened to review the VA Persian Gulf clinical protocol and data collection, the adequacy of its implementation of the programs, outreach efforts to veterans, and the education of providers.