The Department of Defense (DoD) created the Office of the Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses (OSAGWI) when it became apparent DoD's initial assessment-no American military personnel were exposed to chemical agents during the Gulf War-most likely was incorrect. By the fall of 1996, DoD clearly needed a broader focus, an expanded effort, and a strategy for systematically examining the various theories on the nature and cause of undiagnosed illnesses among Gulf War veterans. The Department also needed a plan to effectively communicate DoD's findings to our veterans and the American people.
On November 12, 1996, Dr. John White, then Deputy Secretary of Defense, established OSAGWI, giving it broad authority to coordinate all aspects of DoD's Gulf War investigations. He asked the new Special Assistant to focus on the war's operational aspects and future force protection issues. He emphasized the need for a communications program that would reach out to the veterans and learn from them what went on during the Gulf War. He stipulated health-related programs-specifically the clinical and health research programs-would remain the responsibility of the Office of the Assistant Secretary of Defense for Health Affairs.
OSAGWI's mission statement emphasized three goals: Gulf War veterans of the would be appropriately cared for; DoD would do everything possible to understand and explain the undiagnosed illnesses among Gulf veterans; and DoD would change existing military doctrine, policies, and procedures to minimize any future hazard from biological and chemical agents. Since DoD Health Affairs continues to care for our servicemembers still on active duty and the Department of Veterans Affairs continues to be the primary health care provider for those who have left service, OSAGWI's paramount concern is to find out what happened during the war and make sure any lessons learned are reflected in future force protection.
This mission charges OSAGWI to do everything possible to understand and explain Gulf War illnesses, inform Gulf War veterans and the American people of our progress, and then ensure DoD makes the required changes in equipment, policy, procedures, and doctrine. Our purview is not limited just to the possibility of chemical or biological exposures, but includes a broader inquiry into other possible causes of Gulf War illnesses. Over the past three years, our focus has expanded from investigations of chemical weapons to a more balanced inquiry that includes work on pesticides, oil well fires, and depleted uranium. To ensure the changes to policy, procedures, and doctrine are implemented, OSAGWI established a lessons-learned directorate.
In accordance with its mission statement, OSAGWI has undertaken an aggressive outreach program that centers around "GulfLINK" and "GulfNEWS," our case narrative series, our hotline and e-mail programs, and visits to military bases and town hall meetings. During the last 3 years, we have published 18 case narratives, 8 information papers, and 3 environmental exposure reports. In 1997, OSAGWI commissioned the RAND Corporation (RAND), a federally funded research and development center, to prepare reviews of medical literature. RAND has published five of these reviews-four during 1999. In addition, we have produced three closeout reports in which available evidence indicated no need for further investigation. We visited 20 installations, conducting 17 town hall meetings at those installations, and attended an additional 13 town hall meetings throughout the country sponsored by veterans service organizations. We have answered approximately 11,500 hotline calls, fielded 6,991 e-mail letters, and sent notification letters to some 162,500 veterans who served in the Gulf. We also continue to work with Gulf War veterans to help them obtain their out-patient records from the National Personnel Records Center in St. Louis, Missouri.
From the very beginning, we understood public confidence in our office and in the Department of Defense would have to be earned. DoD, after all, established OSAGWI when many were calling for an investigation independent of the Department of Defense. Notwithstanding the work over the past three years, everything that we do, every report we write, every group we meet with, can be of value only if the American people have absolute confidence in the objectivity and integrity of this office.
This third year of operation could be characterized as the "year of oversight." On February 24, 1998, President Clinton signed an Executive Order creating the Special Oversight Board for Department of Defense Investigation of Gulf War Chemical and Biological Incidents, known as the Presidential Special Oversight Board (PSOB). During the same year, the General Accounting Office (GAO) completed its review of OSAGWI's operations.
OSAGWI's hallmarks are the case narratives, information papers, and environmental exposure reports designed to provide our veterans and their families with the information they need to understand what happened during the Gulf War and how it might have a bearing on their health. From the beginning, Gulf veterans provided the ultimate feedback on our reports. This is why OSAGWI has published all reports as interim reports, with a cover sheet requesting anyone with additional information to contact us by calling our 800 number. Careful review by outside organizations is also part of this process. During 1998, the Senate Special Investigations Unit reviewed our work, which was discussed in last year's (1998) Annual Report. This year, 1999, both the GAO and the PSOB reviewed our work. Their findings are reported here.
The General Accounting Office
The GAO undertook a year-long examination of OSAGWI at the request of Lane Evans, the ranking minority member of the House of Representatives' Committee on Veterans Affairs. The objects of GAO's inquiry were to: "(1) describe DoD's progress in establishing an organization to address Gulf War illnesses issues, and (2) evaluate the thoroughness of OSAGWI's investigations into and reporting on incidents of veterans' potential exposure to chemical or biological warfare agents during the Gulf War." In the course of intensely reviewing six case narratives, the GAO:
The GAO found DoD had "made progress in addressing Gulf War illnesses issues...[and] significant progress in establishing communications with veterans and others." However, GAO did note some "investigative and reporting weaknesses" in three of the six case narratives it examined in detail, but found no fault with the three others. Despite these weaknesses, the GAO agreed with our assessment in five of the six case narratives, stating, "Despite the weaknesses we noted, in all but one case...[we] found no basis to question OSAGWI's determinations of the likelihood that chemical warfare agents were present."
In the sixth case narrative, the GAO asked us to reconsider our assessment that chemical agents were unlikely to be present during the Marine Corps's breaching operation. The GAO noted it did not find proof chemical agents were present, but said only some new information "increased the potential that some might have be been present." We agreed to the re-assessment, which will appear in the republished case narrative with a discussion of the GAO's concerns. (Previously, the Senate Special Investigations Unit found Khamisiyah and An Nasiriyah "appear to be the only locations in the Kuwaiti Theater of Operations where chemical weapons were fielded during the Gulf War." The Marine breaching operation was nowhere close to these locations.)
In March 1999, the GAO initiated a review of issues relating to the use of depleted uranium (DU) in munitions and tank armor during the Gulf War. To determine the scientific understanding of DU's health effects, the GAO closely analyzed RAND's 1999 report on DU, examining its methodology and quality assurance measures. In addition, the GAO reviewed the Toxicological Profile for Uranium prepared by the Agency for Toxic Substances and Disease Registry and consulted with doctors at the Baltimore Veterans Affairs (VA) Depleted Uranium Follow-up Program. Finally, the GAO reviewed the methodology and underlying assumptions the US Army Center for Health Promotion and Preventive Medicine used in preparing exposure and risk assessments for the Special Assistant's office.
GAO's review, conducted from March 1999 through January 2000, noted the scientific literature reviews by RAND and the Agency for Toxic Substances and Disease Registry (ATSDR ) "concluded that current evidence suggests that radiation from inhaled or ingested depleted uranium is an unlikely health hazard." While pointing out certain anomalies (the clinical significance of which remains unknown) in a few of the many medical tests given to the Baltimore VA DU Follow-up participants, the GAO enumerated many of RAND's and ATSDR's findings which, taken as a whole, support the conclusions in our 1998 DU Environmental Exposure Report. That is:
Based on data developed to date, the Office of the Special Assistant believes that while DU can pose a chemical toxicity and radiological hazard under specific conditions, the available evidence does not support claims that DU caused or is causing the undiagnosed illnesses some Gulf War veterans are experiencing.
After interviewing both the scientists conducting the DU exposure and risk assessment and the researchers performing the tests on which these assessments were based, the GAO determined there was a potential problem with interpreting the original test data. We directed the Army to conduct new live-fire DU tests to fill in any missing information.
While we agree our case methodology can be improved, we believe the GAO inquiry was very positive about the veracity of our investigative system. For example, the GAO actually re-interviewed "71 individuals interviewed by OSAGWI that were key sources of information and requested that they verify the accuracy and completeness of both the OSAGWI case narrative and the OSAGWI write-up of the investigator's discussion," and did not report any anomalies. The GAO also noted OSAGWI already had taken steps to improve our methodology.
The Presidential Special Oversight Board
On February 19, 1998, the President created the PSOB (consisting of seven members under the chairmanship of former US Senator Warren B. Rudman) to:
[p]rovide independent oversight of the remaining investigations being conducted by the Department of Defense ... into possible detections of, and exposures to, chemical or biological warfare agents and environmental and other factors that may have contributed to Gulf War illnesses.
In its Interim Report, the Board highlighted OSAGWI's outreach program:
Perhaps most noteworthy is OSAGWI's sustained effort to provide veterans and the public with as much information as possible through the Internet, a telephone hotline, and town hall meetings. In addition, OSAGWI has increasingly used veterans' service and military service organizations (VSOs and MSOs, respectively) to provide information to Gulf War veterans.
The Board also noted, "Identifying lessons learned ranks among OSAGWI's most important work," and made several suggestions to strengthen that function.
The Board's primary focus during 1999 was reviewing OSAGWI's case narratives and environmental reports. The Board asked OSAGWI to present more fully in its case narratives what evidence carries the greatest weight and why OSAGWI discounts or dismisses other contrary evidence. Further, the Board asked OSAGWI to clarify the methodology used to digest and evaluate the information leading to the reports' conclusions. Accordingly, we added this language to our narratives' methodology section:
Once the investigation is complete, the investigator evaluates the available evidence in order to make a subjective assessment. The available evidence is often incomplete or contradictory and thus must be looked at in the total context of what is known about the incident being investigated. Physical evidence collected at the time of the incident, for example, can be of tremendous value to an investigation. Properly documented physical evidence would generally be given the greatest weight in any assessment. The testimony of witnesses and contemporaneous operational documentation is also significant when making an assessment. Testimony from witnesses who also happen to be subject matter experts is usually more meaningful than testimony from untrained observers. Typically, secondhand accounts are given less weight than witness testimony. When investigators are presented with conflicting witness testimony, they look for other pieces of information supporting the statements of the witnesses. Investigators evaluate the supporting information to determine how it corroborates any of the conflicting positions. Generally, such supporting information will fit into a pattern corroborating one of the conflicting accounts of the incident over the others. Where the bulk of corroborating evidence supports one witness more than another, that person's information would be considered more compelling.
In addition to reviewing case narratives and environmental exposure reports, the Board recommended we close out several reports and suggested additional lines of inquiry in others. The Board asked us to report in September 1999 on "all case narratives currently scheduled, programmed, or under analysis for potential investigation and recommend to the Board those investigations and activities that are candidates for discontinuation." The Board recommended OSAGWI "cease work on all information papers" because "the papers do not directly address incidents of potential chemical exposure or possible causes of Gulf War illnesses."
Following the Board's request, in September 1999 OSAGWI provided the Board with recommendations for revising, re-issuing, completing, or discontinuing case narratives and environmental exposure reports. In a November 16, 1999 letter to the Secretary of Defense, the Board noted it had requested OSAGWI provide such an assessment because "few medical or scientific studies to date definitively link GW [Gulf War] chemical and biological events to servicemembers' or veterans' health problems," and the Board "wanted to explore the DoD's plan to shift focus from retrospective investigations."
The Board approved OSAGWI's recommendations to continue and publish several case narratives and environmental exposure reports, but also to discontinue several ongoing investigations, which became the subject of Close-Out Reports. Importantly, the Board based its actions on this rationale:
The findings of both the United Nations (UNSCOM) and the Central Intelligence Agency (CIA) conclude that no chemical weapons were known to be or found to have been shipped south of Khamisiyah, Iraq. No information, including case narratives published by OSAGWI, has been discovered or published to either refute or challenge the UNSCOM or CIA conclusions. These findings support both the Special Assistant's recommendations to the Board and the Board's actions (on these recommendations) as enumerated in this report.
REPORTS DURING 1999
This past year, OSAGWI published one case narrative and three information papers, and the RAND Corporation published four papers.
Summary of the Cement Factory narrative, April 1999:
On March 12, 1991, outside Kuwait City, a team of 2nd Marine Division chemical warfare and ordnance disposal specialists inspected an industrial area known as the cement factory. A Fox Nuclear, Biological, and Chemical (NBC) reconnaissance vehicle alerted for blister and nerve agents within half a mile of the cement factory's buildings. NBC units took soil samples for further analysis, and a second Fox vehicle surveyed the area. The second Fox also alerted for chemical warfare agents. The Marines again took samples and printed records of both alerts. No other evidence indicated chemical warfare agents were present, and there were no reported casualties. The Marines turned over the samples to a special joint command service unit, which sent the samples to the Army Chemical Research, Development Engineering Center in Edgewood, Maryland, where they arrived approximately six days later for analysis.
The analysis of these samples at Edgewood indicated diesel engine exhaust probably contaminated the soil. Approximately two weeks after the Marines took the samples, the laboratory communicated its findings to the special joint command service unit, but the Marine specialists were never informed of these results. In 1998, the US Army Soldier and Biological Chemical Command analyzed one of the Fox vehicle alert record tapes and reported the chemical compound present was not a chemical warfare agent.
The evidence leads investigators to assess it unlikely chemical warfare agents or munitions were present at the cement factory. Likewise, it is unlikely US armed forces were exposed to chemical warfare agents there.
Summary of the Inhibited Red Fuming Nitric Acid information paper, August 1999:
During and immediately after the war, some Gulf War veterans reported incidents in which they encountered or observed colored clouds and mist characterized by strong odors. They experienced immediate burning sensations to the eyes, skin, nose, and throat, and in some cases, respiratory irritation, nausea, and vomiting. There is no evidence these veterans were exposed to chemical warfare agent, although they may have been exposed to weapons-system components and industrial chemicals (e.g., liquid rocket fuel and oxidizers).
Inhibited red fuming nitric acid (IRFNA) is such an oxidizer. IRFNA contains mostly nitric acid, nitrogen oxides, a small percentage of water, and a halogen compound inhibitor (e.g., hydrogen fluoride or iodine), an additive to prevent the acid from eating through its metal storage tank. During the Gulf War, Iraq used IRFNA as the oxidizer in several weapons systems (e.g., Scud, Guideline, Silkworm, and Kyle missiles) located and fired within the Kuwait Theater of Operations.
Servicemembers might have encountered fumes, vapor, or residue from missile fuels and oxidizers on the battlefield in four major ways:
The information paper discussed inhibited red fuming nitric acid's properties, including:
Summary of the M256 information paper, August 1999:
The M256 series Chemical Agent Detector Kit, including both the M256 and M256A1, is an essential element of chemical warfare agent defensive measures. The M256 tests for the presence of hazardous concentrations of both blood, nerve, and blister agent vapors and liquid nerve and blister agents. The M256 has two primary test components-the vapor sampler and M8 detection paper. Similar to a miniature chemistry set, the vapor sampler contains all the solids and liquids required to test vapors and aerosols. M8 detection paper is similar to litmus (pH) paper but is designed to react specifically to liquid nerve and blister agents.
In some instances, the M256 kit can produce either a false positive or false negative. Extensive testing with known chemicals and compounds normally found on a battlefield indicate a false negative detection, although possible, is unlikely. However, a false positive detection can occur if the kit is used improperly, outdated, or inadvertently exposed to some battlefield pollutants.
Summary of the Medical Record-Keeping information paper, August 1999:
This paper discusses problems with military medical record-keeping during the Gulf War. It examines policies and practices, explores future initiatives, and addresses three broad categories of medical record-keeping issues: content, consolidation, and custody.
At the time of the Gulf War, the Army, Navy, and Air Force surgeons general tended to publish their own, service-specific medical record-keeping policies. These policies derived primarily from peacetime record-keeping and did not foresee the difficulties of wartime record-keeping. The Army and the Air Force, for example, deployed soldiers and airmen with abbreviated medical records in lieu of complete health records. For security reasons, the Pentagon coded the documentation of certain investigational vaccines. All the services experienced deficiencies in fully documenting the care provided in the Gulf; after the war, all the services had problems consolidating and storing medical records.
Because of the problems during the Gulf War, the Department of Defense (Health Affairs) and Joint Staff now are improving record-keeping procedures-focusing, for instance, on force health protection, standardizing policy among the services, and documenting the medical surveillance activities of the continuing Bosnian and Southwest Asian operational deployments. The Departments of Defense and Veterans Affairs and the National Archives and Records Administration now are increasingly cooperating on issues involving medical record transfer and storage. Additionally, the DoD medical community is laying the groundwork for developing a future personal information carrier and computer-based medical record. DoD views these steps as technological solutions to both Gulf War medical record-keeping deficiencies and the President's mandate to create a new force health protection program with a comprehensive, life-long medical record for each military servicemember.
Summary of Military Use of Drugs Not Yet Approved by the FDA for CW/BW Defense, April 15, 1999:
This report examined:
Both before and during Operation Desert Storm, the Department of Defense gave substantial attention to countermeasures to protect troops against chemical and biological weapon attacks. Besides warning devices and protective garments, the prophylactic drug pyridostigmine bromide (PB) provided protection against the nerve agent soman. Protection against biological agents included the anthrax (AX) vaccine and the botulism vaccine, botulinum toxoid.
These drugs are considered investigational new drugs, a legal term the Food and Drug Administration (FDA) uses to distinguish between licensed and unlicensed drugs. "Investigational" is not synonymous with experimental. Normally, the FDA requires informed consent from those receiving an investigational new drug. The Interim Rule waives this requirement, allowing DoD to administer these drugs to US troops to protect them against the chemical and biological weapons the Pentagon expected to encounter during the Gulf War.
The Interim Rule raised three sets of issues:
The controversy surrounding the Interim Rule was resolved by a modified version of the Byrd amendment, included as Section 731 of the Strom Thurmond National Defense Authorization Act for Fiscal Year 1999. This amendment, "Process for Waiving Informed Consent Requirement for Administration of Certain Drugs to Members of Armed Forces for Purposes of a Particular Military Operation," allows "the administration of an investigational new drug or a drug unapproved for its applied use to a member of the armed forces in connection with the member's participation in a particular military operation." It provides the requirement of prior consent for receiving such a drug under the FDCA "may be waived only by the President."
Summary of Depleted Uranium, April 15, 1999:
After an extensive review of the scientific literature, the RAND Corporation released a report on the potential health effects of depleted uranium (DU) in Gulf War veterans. This report, commissioned by the Office of the Special Assistant, indicated that at the low exposure levels experienced by Gulf War veterans, the scientific literature did not indicate negative health effects from the chemical toxicity of DU. In addition, the literature review did not reveal negative health effects in humans from the exposure to ionizing radiation from depleted or natural uranium.
RAND had recognized experts review the literature, including Dr. Naomi Harley, an authority on radiation and health physics, and Dr. Ernest Foulkes, a heavy metal toxicologist. Their review encompassed literature published or accepted for publication in peer-reviewed journals, books, government publications, and conference proceedings about both radiation and toxicity risks.
RAND's researchers found very little literature directly addresses the health effects of DU. However, they found a wide body of literature dealing with natural and enriched uranium. That literature is relevant because experts say the toxicological effects of natural uranium are identical to those of depleted uranium, while depleted uranium's radiological effects are less pronounced because it is less radioactive than natural uranium. In short, their research found heavy metal toxicity is regarded as a more serious risk than radiation.
Their report presented these conclusions:
Although any increase in radiation to the human body can be calculated to be harmful from extrapolation from higher levels, there are no peer-reviewed published reports of detectable increases of cancer or other negative health effects from radiation exposure to inhaled or ingested natural uranium at levels far exceeding those likely in the Gulf. This is mainly because the body is very effective at eliminating ingested and inhaled natural uranium and because the low radioactivity per unit mass of natural and depleted uranium means that the mass of uranium needed for significant internal exposure is virtually impossible to obtain. Large variations in exposure to natural uranium in the normal environment have not been associated with negative health effects.
Although RAND's conclusions indicate no evidence of harmful effects directly linked to DU exposures, their report urges continued research because DU likely will be used more in future conflicts.
Summary of Stress, May 19, 1999:
This paper evaluates the available evidence about the link between stress and health problems in general, and the role of stress as experienced by Gulf War veterans in particular. RAND defines stress as a real or perceived imbalance between environmental demands required for survival and an individual's capacity to adapt to these requirements. Over time, stress can increase the likelihood of illness symptoms-rapid heart rate, increased perspiration, and gastrointestinal distress, etc.-and may eventually heighten the risk of illness.
RAND completed a wide-ranging literature review to make its determinations. This review included 250 general articles, books, and technical reports, approximately 55 studies of in-theater and post-war psychiatric evaluations, and approximately 60 articles and technical reports bearing directly on the link between stress and health problems.
RAND concluded although these studies generally show persons who went to the Gulf War reported more health problems than those who did not, they do not clarify whether these differences result from stress, other possible exposures, or pre-existing conditions. The study suggests stress is associated with post traumatic stress disorder, but little evidence connects stress to the physical symptoms reported by Gulf War veterans.
Summary of The Health Effects of Pyridostigmine Bromide, October 19, 1999:
This paper examined the safety and effectiveness of pyridostigmine bromide (PB), used during the Gulf War as a prophylactic to protect military personnel from the nerve agent soman, an extremely potent, lethal nerve agent with limited antidotes. At the start of the war, intelligence analysts suspected Iraq had munitions loaded with this chemical agent. The paper covers theories or hypotheses that might link PB to Gulf War veterans' illnesses. The review presents two major conclusions. First, on PB's safety, while medical research has not established PB as a cause of Gulf War illnesses, it "cannot be ruled out as a possible contributor to the development of unexplained or undiagnosed illnesses in some [Gulf War] veterans." Second, further research is needed to determine the effectiveness of the current PB dose against soman.
To resolve the remaining questions about PB's effectiveness against soman, more than 26 peer-reviewed research studies (with Federal funding in excess of $22 million) currently are under way. These studies' focus ranges from the toxic interactions of prophylactic drugs and pesticides to the individual differences in the neurobehavioral effects of PB.
Although the Food and Drug Administration (FDA) has not approved any effective protection against soman, DoD believes animal research indicates that PB, combined with other antidotes, may be effective in preventing human casualties. Most US troops received PB pills during the war-DoD estimates approximately 250,000 personnel took at least some PB. The FDA has approved pyridostigmine bromide for two civilian uses: treating myasthenia gravis, a neuro-muscular disorder, and reversing some anesthetic drugs' effects. However, PB is considered an investigational drug when used as a pre-treatment against chemical warfare agents. Evidence of PB's effectiveness as the pre-treatment for soman is based solely on animal studies because it is unethical to intentionally expose people to lethal nerve agents to test a drug's effectiveness.
WORKING WITH VETERANS
The Office of the Special Assistant for Gulf War Illnesses conducts an outreach program as a one-of-a-kind effort by the Department of Defense to respond to the needs and concerns of Gulf War veterans, active duty members, and their families. The program began in 1997 with 13 town hall-style meetings sponsored by the American Legion and Veterans of Foreign Wars (VFW). The outreach team visited 7 military installations in 1998 and 13 in 1999 to reach all known locations where 6,000 or more Gulf War veterans reside. In addition, OSAGWI's participation in more than 27 conferences, conventions, educational seminars, and other events hosted by veterans and military service organizations (VSOs and MSOs) has become a new focus of outreach efforts.
VSOs and MSOs
The outreach to the VSOs and MSOs has provided important information to these organizations' nearly 10 million members about DoD's effort to respond to Gulf War veterans' concerns. The regular meetings with the VSOs and MSOs address issues important to their members, including depleted uranium, oil well fires, anthrax immunization policy, and in-patient medical records. In September, VSO and MSO members attended a morning-long, on-site visit. The VSOs and MSOs met with staff members and observed the flow of information and the analytical process. The PSOB praised the outreach work of OSAGWI's Public Affairs Office, noting, "Its personnel have enabled OSAGWI to develop a closer rapport with VSOs and MSOs, a noteworthy achievement considering OSAGWI's initial missteps with these organizations."
To ensure VSOs and MSOs promptly received our reports, we provided special briefings before releasing case narratives, environmental exposure reports, and information papers to the public. In addition, we developed an electronic mailing list and forwarded all GulfLINK news releases as they were available. OSAGWI now regularly sends information displays and veteran contact managers to major VSO and MSO national and regional conventions. OSAGWI provides information to Gulf War veterans through VSO and MSO publications (e.g., AMVETS Magazine) and receives VSOs' support for its town hall meetings.
Base Visits and Town Hall Meetings
We expanded our outreach efforts to include the Total Force-Gulf War veterans, active duty soldiers, Reservists, National Guard members, retired and separated personnel, DoD civilians, and family members-at military installations. We met with veterans and the public nationwide in an effort to communicate the results of our investigations. The PSOB maintains these meetings have greatly enhanced OSAGWI's credibility. The PSOB Interim Report praises the Special Assistant for "selecting the sites based on his determination to reach as many veterans as possible, even when hostile activists were expected."
The itinerary for these visits included a four-day information exchange in which subject-matter experts briefed the troops, leadership at all levels, medical staff, Gulf War veterans, family members, community groups, service organizations, and installation staff. To reach those unable to attend the briefings, our staff now operates conference-style displays placed in high-traffic areas (e.g., installation exchanges, commissaries, and hospitals). The staff demonstrates DoD's "GulfLINK" web site at these displays. At the installations' requests, we added special evening sessions for family members.
A part of any public communications program includes the news media. During outreach visits, we contacted all local newspapers and television and radio stations for inclusive coverage of our efforts. Since OSAGWI is the central point of contact for official information on Gulf War illnesses, we responded in the media to numerous questions about the military use of depleted uranium and DoD's anthrax vaccination program.
The town hall meetings covered topics spanning a broad range of interests, including the results of investigations into possible exposures from chemical or biological weapons, DoD force health protection efforts, and information on resources available to Gulf War veterans and their families. Because many veterans' concerns fall under the purview of the Department of Veterans Affairs (VA), OSAGWI invited the VA to participate at the town hall meetings as well. The PSOB has recommended the VA make a formal commitment to routinely participate in OSAGWI's outreach and town hall meetings.
Through these outreach visits we have received more than 4,100 requests for copies of our investigative reports and 3,424 people asked us to add them to the "GulfNEWS" mailing list, increasing its original distribution of 2,000 copies in 1997 to nearly 20,000 in 1999.
To date, our outreach program has reached nearly 50,000 veterans, service members, their families, and the American public during the installation visits and other outreach efforts. A similar outreach effort to large military communities with several installations (e.g., San Antonio, Texas) is planned in calendar year 2000. Multiple briefing and display teams, newspaper interviews, and radio and television call-in talk shows will enable us to take our message to 70,000 more Gulf War veterans, their family members, VSO and MSO members, and many more active duty forces.
PSOB staff members have attended several of these visits, and OSAGWI has incorporated the Board's comments in an ongoing effort to optimize the effectiveness of our presentations.
Visits to Our Coalition Allies
Some members of the PSOB and its staff joined OSAGWI on recent trips to England, France, and Germany, during which OSAGWI updated our Coalition partners on the status of our investigations and conducted an outreach visit and town hall meeting with our forces in Germany. OSAGWI presented briefings to Coalition partners on current case narratives and medical research. We also shared information on the success of our national outreach program, which is of interest in their own post-Gulf War programs.
In November 1999, OSAGWI led a team of researchers from the Uniformed Services University for Health Sciences, the Naval Health Research Center, and the Centers for Disease Control to Riyadh, Saudi Arabia to begin a joint project with the Saudi Arabian National Guard (SANG). This project will use the hospitalization database, established in 1983, at the SANG hospital in Riyadh to compare SANG members assigned to the Al Kafji area during the Gulf War and those assigned to Riyadh. Frequency and causes of hospitalization before and after the Gulf War will be analyzed. Additionally, the causes for SANG family-member
hospitalization before and after the war will be analyzed to search for any trends.
The Internet, the newsletter, telephone hotlines, and personal correspondence are other sources of valuable information. This year, we expanded both our web site and newsletter.
"GulfLINK," our web site (www.gulflink.health.mil), is a highly successful, useful tool for communicating with our veterans. "GulfLINK" typically receives more than 60,000 "hits" weekly, peaking when we publish information of great interest. In our second year we added a mail-list service that electronically notifies subscribers when we post new information to the site. In May 1998, Government Executive Magazine selected "GulfLINK" as one of the "Best Feds on the Web," an achievement recognized by Vice President Gore. We continue to look for innovative ways to improve the site.
"GulfNEWS," our bi-monthly, four-page, newsletter in both print and electronic formats, continues to highlight events of interest to Gulf War veterans and presents timely features based on our ongoing or released case narratives and information papers. In our January 1998 issue, for example, we discussed the $12 million joint DoD and VA award for Gulf War health research studies. Other 1998 "GulfNEWS" issues covered our environmental exposure reports on the Kuwait oil well fires and depleted uranium, the Defense Department's Gulf War document declassification efforts, and DoD's mandatory anthrax vaccination program. In 1999, along with reviews of released information papers and case narratives, "GulfNEWS" addressed medical research, collaborative US-Saudi Arabian investigations, and other issues of interest to Gulf War veterans. Among other topics in 1999, "GulfNEWS" covered the unlikely exposures to chemical warfare agents at the cement factory and reviewed the uncertainty of the link between stress and Gulf War illnesses and RAND's reports on depleted uranium and the nerve agent drug study.
Veterans Data Management
The veterans data management division (VDM), which consists entirely of veterans, applies the human touch to OSAGWI's work, reaching out to veterans who call or write with questions and comments and assisting them in many, often intangible, ways. The VDM increased the number of veterans it stays in touch with by 4,310 to 15,970 and contacted 3, 856 veterans since last year, averaging 78 interviews per week. Of this population who initially contacted OSAGWI, the total percentage VDM has contacted or attempted to contact increased from 86 to 89 percent. Unsolicited calls directly to the toll-free 800 number (not the Defense Manpower Data Center Hot Line) increased dramatically. Most resulted from word-of-mouth recommendations from one veteran to another, from the VA, from the VSOs, and from other sources.
VDM participated in outreach visits to Forts Benning, Bliss, Bragg, Carson, Hood, Knox, Polk, and Stewart and the Marine Corps Air Ground Combat Center Twentynine Palms and paid a second visit to Andrews Air Force Base. It also supported outreach efforts at the Pentagon, the Reserve Officers Association, the California and Pennsylvania National Guards, AMVETS, VFW, Disabled American Veterans, the National Guard Enlisted Association, the American Legion national conventions, and the Oklahoma American Legion state convention-signing up more than 1,800 for the Gulf War Registry and conducting 1,669 interviews in the last year from all outreach efforts. The VDM toll-free hotline has fielded more than 11,500 veterans' calls, with many lasting several hours.
Notifications to Veterans
Starting in April 1997, we began working closely with the Department of the Army's US Armed Services Center for Unit Records Research (USACURR). In 1998, we continued bringing together former Army Gulf War operations officers (S3/G3s) from division- and brigade-sized units to verify, validate, and add unit locations in the Persian Gulf Registry. As mandated by Public Laws 102-190 and 102-585, the Army (DoD's executive agent) reviewed approximately six million pages of Gulf War records to build and maintain the Persian Gulf Registry, which contains unit location and personnel information for all the services during the war. By June 1998, we had held 19 week-long conferences, in which 163 active, reserve, and retired operations officers returned to work on their respective units' location data. As a result of their efforts, USACURR's original location database more than doubled the number of known unit locations, to more than 800,000 for all services. The Office of the Special Assistant for Gulf War Illnesses relies on this database to identify veterans and units potentially involved in incidents we are investigating. Additionally, we greatly appreciate the opportunities to gather insights and information through direct contact with these Gulf War operations officers and veterans.
We continue to notify individual veterans in conjunction with releasing case narratives and environmental exposure reports. In 1998 we sent more than 4,000 letters to Gulf War veterans; since our office began operations three years ago, we have sent 162,504 such letters. In the case of possible depleted uranium exposure, we took this notification process one step further. Based on operational information, analysts identified those people who had the most extensive exposure to the heavy metal. Analysts and veteran contact managers telephoned 192 of these veterans, gave them the needed information, answered questions, and invited them to participate in a depleted uranium medical monitoring program. We mailed letters to those we could not reach by phone.
Medical Issues Division
In addition to releasing the military medical record-keeping information paper, the Medical Issues Division identified 27,680 Gulf War in-patient medical records stored at the National Personnel Records Center in St. Louis, Missouri. Our medical division created a database to assist in retrieving these records for veterans who require copies to file service-related claims with the Department of Veterans Affairs or for other needs. The staff copied the database for the Department of Veterans Affairs to assist in speeding processing of veterans' claims.
Many Gulf War veterans who were unable to locate their in-patient hospitalization medical records after the War assumed the records were lost. During our investigation into in-patient medical record-handling during the War, we learned after the War the services sent most in-patient records to the National Personnel Records Center in St. Louis, Missouri, where the Army had developed an index by name, Social Security number, and medical facility for 13,842 persons hospitalized in Army hospitals. Augmented by Army Reservists, our staff examined more than 2,000 boxes identified as Air Force and Navy Gulf War hospital records and discovered an additional 11,187 Air Force and Navy and 2,651 Army in-patient hospital records. By building on the Army's work, we were able to create a consolidated database to retrieve hospital records for many patients treated in Army, Navy, and Air Force Gulf War hospitals. This service has provided many veterans with information that has enhanced the quality of their medical treatment.
COMPLETING OUR INVESTIGATIONS
The work we plan to accomplish during the first year of the 21st Century will add substantially to the foundation of trust we began building three years ago. We will complete several narratives and information papers that will answer some of the vexing questions posed by America's Gulf War veterans. We will publish our re-analysis of the Khamisiyah ammunition depot destruction, with a refined estimate of the chemical warfare agent released and dispersed there. We will publish comprehensive reports on depleted uranium, pesticide use, chemical agent resistant coating (CARC paint), the air campaign, and Scud missile attacks. As with the Khamisiyah narrative, some of the coming year's publications will review cases we released during our first year because new information-often from Gulf War veterans-helped us refine our initial findings.
We will continue to work closely with the Presidential Special Oversight Board, which already has offered substantial comments and suggestions for our papers. The PSOB serves as a critical check on our investigative progress toward better understanding Gulf War illnesses and in accounting for our work to America's Gulf War veterans. We believe continued dialogue between our office and the Oversight Board enables us to do the best job for our veterans. The Board monitors our publication process, helping us determine where we should redirect our efforts, how much we yet need to do, and when we have been sufficiently thorough.
LOOKING AHEAD: LESSONS LEARNED
The Special Assistant established the Lessons Learned Implementation Directorate (LLID) in late 1998 to ensure the system failures identified in our investigations-weaknesses and deficiencies in policies, procedures, doctrine, training, equipment, etc.-are corrected, institutionalized, implemented, and enforced to enhance the readiness and force health protection of future deployed servicemembers. The PSOB's interim report pays tribute to the value of this endeavor, noting, "Identifying lessons learned ranks among OSAGWI's most important work."
During our third year, the first full year of work by the LLID, we identified almost 40 lessons learned in 7 reports. We shared these insights with DoD, the services most affected, and other offices of primary responsibility to help characterize and correct previous deficiencies and gaps. Similarly, the LLID has spearheaded an initiative that brought together key decision makers from the US Army Training and Doctrine Command and the Office of the Surgeon General to share relevant knowledge and insights gained from OSAGWI's investigational efforts. These offices in turn are committed to ensuring Gulf War lessons learned, once validated, are corrected in current and evolving guidance, doctrine, policies, training, etc.
The Effectiveness of the Services Lessons-Learned Process
Our experience addressing Gulf War veterans' illnesses clearly shows Cold War-oriented policies, guidance, and training failed to adequately address exposures to chemical warfare agents. The lack of attention to these issues-the absence of a determined effort to learn from our experiences and be consistent and candid in our public statements and interactions-substantially contributed to the erosion of public trust and confidence in DoD's capability or will to adequately safeguard deployed military members' health and safety. Our assessment of the Department of Defense's lessons-learned capabilities revealed the Department's existing resources do not adequately address the perceptions and concerns of the individual and collective military members, veterans, and their families. A significant number of military members and veterans believe biased, inaccurate sources (e.g., the Internet) more than they believe their chain of command or other official channels of information. The LLID has spent the last year building bridges between the lessons learned and force development processes to ensure the services adequately and appropriately recognize and address troops' expectations as we modernize our forces.
OSAGWI's Lessons Learned Process
OSAGWI realized lessons learned are generally formed only after retrospective assessments and analyses have identified what went wrong and the associated causes and effects. Therefore, LLID began by developing a clear understanding of the operative guidance and systems currently in place to protect against chemical, biological, environmental, or occupational hazards and risks. With the benefit of hindsight and a thorough study of current knowledge and guidance, this understanding allows us to determine what should have happened, compared to what actually happened. LLID then examines and refines the knowledge derived from OSAGWI investigations in the context of current and future force health protection. LLID then can make substantial, concrete suggestions for improvement in areas of concern (e.g., doctrine, organizations, training, leader development, and materiel).
Depleted Uranium Awareness Training
A premier example of OSAGWI and LLID's process involves the case of depleted uranium (DU). OSAGWI's investigation of DU use in the Gulf highlighted numerous shortcomings in US forces' readiness to recognize and respond to battlefield DU contamination. Among the ground troops most likely to encounter DU contamination, an awareness of its use and the associated risk factors was unacceptably low, causing many needless exposures to DU "dust." Misinformation containing misleading, inflammatory, baseless charges about the military's use of DU and its effects on human health and the environment circulated on the Internet and in the media; these charges fanned veterans' and their families' subsequent concerns about these exposures.
To address these DU training and awareness shortfalls, OSAGWI worked directly with top DoD, Joint Staff, and service authorities to come to a common understanding of the challenges and requirements that needed to be met in this area. LLID convened a meeting of representatives from the services' relevant medical, safety, training, and operational communities, with Joint Staff participation, to address the inconsistencies in the information and the emphasis found in their DU awareness training programs. After agreeing on the health concerns posed by DU's heavy metal toxicity and mild radioactivity, the services began to develop and field improved DU awareness training. They incorporated the latest available medical and scientific findings aimed at responding to some common fears and misconceptions associated with the military use of DU.
One of the occupational hazards of any war is stress. Combat stress and its possible role in Gulf War illnesses have been a sensitive issue since the very beginning of LLID's work. Veterans generally are not receptive to any suggestion stress-a legitimate factor in many illnesses-might have a role in some of the symptoms associated with Gulf War illnesses. Leaders need to be trained in how to recognize and respond to operational stress in both themselves and their units. To assist in meeting this objective, in June 2000 the Assistant Secretary of Defense for Health Affairs, the Director of the Joint Staff, and OSAGWI will co-sponsor the Leaders and Operational Stress Conference.
Chemical and Biological Defense Training and Doctrine
Our investigations substantiate the Pentagon's belief the US deterred Iraq's offensive use of chemical or biological weapons against Coalition forces. Khamisiyah represents the only known potential exposure of US forces to chemical warfare agent. Yet many Gulf War veterans continue to believe they were exposed to chemical or biological warfare agents while in the Kuwait Theater of Operations. After analyzing all our investigations of reported chemical or biological warfare agent incidents and talking to thousands of veterans, we have concluded this belief has been nourished and perpetuated when the participants did not get timely or accurate information to address their concerns. We encountered similar problems when circulating the accurate message about the effects of DU. We could have prevented these information wars through proper training and feedback.
Consequently, we have asked the Army Training and Doctrine Command (TRADOC) to develop responses to these evolving and potential future information needs. We expect TRADOC to recommend responsive changes in organizational structure, leadership development, equipment requirements, and policies. TRADOC started in October with the identified lessons learned from the Gulf War and supporting documentation and soon should complete its analysis and begin to implement its findings. The other services can expect similar efforts.
The PSOB supports OSAGWI's "efforts to incorporate these lessons into the appropriate military doctrine, training, management, and operational disciplines." But the Board believes OSAGWI's lessons learned team must be formally integrated into the existing military service and Joint Staff lessons-learned infrastructure if these lessons are going to be implemented.
A PLAN FOR THE FUTURE: A NEW ORGANIZATION
Beginning in the summer of 2000, we expect changes in the operations of the Office of the Special Assistant for Gulf War Illnesses. Our investigation of Gulf War operations and our work with Gulf War veterans about their concerns with battlefield exposure to hazards in post-Gulf War conflicts demonstrate the need for a new organization focusing on any military deployment's long-term implications.
In response to the direction from the Presidential Special Oversight Board and the mandate of Presidential Review Directive 5, which provides a blueprint for coordinating actions to improve military readiness and health care for servicemembers, veterans, and their families, we are developing a strategy to replace the Special Assistant for Gulf War Illnesses with a more all-encompassing Special Assistant for Military Deployments.
Sharing many similarities with the current office, this proposed office would undertake several endeavors. We will continue outreach efforts to the Total Force, veterans and military service organizations, veterans, their families, and the public to respond to their concerns about past and potential deployment issues, including exposures affecting health. We will strive to determine what happened during deployments and on the battlefield to account as fully as possible for those events. We will complement the Office of the Assistant Secretary of Defense for Health Affairs and the Joint Staff in monitoring and investigating the full spectrum of deployment-related activities, including doctrine, policy, readiness, medical research, and force health protection. From veterans' accounts and the new organization's own investigations, we will develop lessons learned and ensure the Department institutionalizes them in doctrine, organizations, training, materiel, policies, and future issues to achieve the utmost in health protection and readiness for our servicemembers. Providing information to veterans should be one of the new organization's most important missions. Only by maintaining a robust outreach program will we be able to maintain the legacy of our work for access by Gulf War veterans.
We believe more issues resembling Gulf War issues will arise and that without an organization dedicated to working with veterans, the Department of Defense is bound to relive the experience of Gulf War illnesses. Over the past three years, the Department has invested significant resources on behalf of Gulf War veterans who have health concerns related to their Gulf service. The new organization will build on OSAGWI's competencies. In the new organization, DoD's capability to communicate with Gulf veterans will continue through the toll-free hotline, interactive e-mail, and written correspondence. In addition, we will transmit all we have learned so far to tomorrow's fighting forces. We are obliged to equip them with the best possible information about the kinds of threats to readiness and combat they most certainly will face during future deployments-realistic scenarios of the battlefield and cultural conditions they can expect to face and the training that will enable them to meet these situations. In the new organization, we will uphold our responsibility and extend our commitment to ensure all our Gulf War veterans receive the care they deserve.
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