HISTORY OF THE OFFICE

Soon after the Gulf War, some American veterans, as well as veterans from other nations, reported a variety of illnesses and symptoms. One issue raised early in the search for causes was the possible exposure to chemical or biological agents. In testimony before the Congress, and in press interviews, senior Department of Defense (DoD) officials asserted that Iraq did not use chemical or biological weapons. To many observers, however, these statements were difficult to reconcile with a number of firsthand reports by US and foreign chemical detection teams that chemical warfare agents were present on the battlefield. In the eyes of many in Congress, the media, and many Americans, the Department of Defense was not telling the truth.

When President Clinton established the Presidential Advisory Committee on Gulf War Veterans� Illnesses (PAC) in 1995, he also ordered the departments of the Federal Government to reexamine the possibility of exposures to chemical or biological agents during the Gulf War. DoD and the Central Intelligence Agency (CIA) initiated new reviews of operational, intelligence, and medical records, including captured Iraqi documents and debriefings of Iraqi POWs and defectors. In March 1995, Deputy Secretary of Defense, Dr. John Deutch, established a Senior Oversight Panel and created the Persian Gulf Illnesses Investigation Team within the Office of the Assistant Secretary of Defense for Health Affairs.

Four years earlier, in March of 1991, US Army Engineers had captured a huge Iraqi munitions storage area at Khamisiyah, in southern Iraq. In accordance with standard procedures, US Explosive Ordnance Disposal and Combat Engineer personnel set demolition charges that blew up the tons of artillery shells and rockets stored in bunkers on the site. The huge resulting blasts created a pall of smoke that drifted many miles downwind, including over areas where US servicemembers were located.

In September 1995, a reassessment of information by the CIA indicated Khamisiyah as a possible chemical agent release site. A May 1996 United Nations Special Commission on Iraq (UNSCOM) inspection of Khamisiyah documented that 122 mm chemical rockets were in a destroyed bunker. In June 1996, DoD determined that it was likely American troops had unknowingly destroyed some sarin- and cyclosarin-filled 122 mm rockets in the March 1991 demolition at Khamisiyah.

In September 1996, the new Deputy Secretary of Defense, Dr. John White, referring to Khamisiyah as a "watershed," asked Dr. Bernard D. Rostker, Assistant Secretary of the Navy (Manpower and Reserve Affairs), to assess everything the Department was doing about Gulf War illnesses and to recommend a future course of action. Dr. Rostker determined that DoD needed a broader focus, an expanded effort, and a strategy for systematically examining the theories about the nature and cause of Gulf War illnesses, as well as a plan to effectively communicate DoD�s findings to veterans and the general public.

On November 12, 1996, Dr. White directed the establishment of the Office of the Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses (OSAGWI) with broad authority to coordinate all aspects of the Department�s programs. Dr. White concluded that the Department had not placed sufficient emphasis on the operational aspects of the war and the implications of those operations. He appointed Dr. Rostker as the Special Assistant and requested a new focus on operational issues and issues of future force protection. Responsibility for health-related programs, specifically the clinical program and the health-research program, remained with the Office of the Assistant Secretary for Health Affairs.

The Office of the Special Assistant would emphasize DoD's commitment to those who served in the Gulf, focusing on operational impacts on health and future force protection. OSAGWI operated under a three-part mission statement:

• Gulf War veterans will receive appropriate medical care;
• DoD will do everything possible to understand and explain Gulf War illnesses; and
• DoD will put in place all required military doctrine, personnel, medical policies, and procedures to minimize any future problems from exposure to biological and chemical warfare agents and other environmental hazards.

OSAGWI changed the way DoD approached the issue of Gulf War illnesses. First, it focused on the Gulf War veterans and listened to their concerns and problems in order to incorporate what they were saying into its investigations. Second, it developed an outreach program to effectively communicate with veterans. Third, it significantly expanded the formal investigation process for researching possible chemical and biological agent exposures. And fourth, it expanded the investigations beyond chemical and biological warfare agents to include potential environmental and occupational causes of Gulf War illnesses.

Probably the two most important investigations during the tenure of the Special Assistant focused on the release of low levels of the nerve agents sarin and cyclosarin at Khamisiyah and the health effects of using depleted uranium (DU).

The events at Khamisiyah dominated the first year�s activities. The inquiry into those events focused on three questions:

• What happened at Khamisiyah?
• Why did it take so long for DoD and the CIA to realize chemical munitions were destroyed in an open pit there in early March 1991?
• Who was exposed to what levels of nerve agents from the detonation of sarin- and cyclosarin-filled 122 mm rockets at Khamisiyah?

DoD and the CIA undertook extensive ground testing of 122 mm rockets filled with a sarin simulant at the Army�s Dugway Proving Ground to determine the effects of detonating rockets in the open. Investigators linked computer simulation models with weather models and chemical agent transport models. They also researched and plotted the movement and location of troop units in the area, and they located and collated regional weather observations from classified and unclassified sources to include in the analysis. By combining the results of all of these efforts, OSAGWI estimated which units were most likely exposed and the levels of that exposure.

In July 1997, the Office of the Special Assistant and the Department of Veterans Affairs (VA) notified those US servicemembers who were potentially exposed. Approximately one hundred thousand American troops and an unknown number of coalition and Iraqi troops may have been exposed to low levels of nerve agent from the detonated stacks of sarin- and cyclosarin-filled rockets in the open pit.

In total, OSAGWI and the CIA issued six reports on Khamisiyah. An additional independent report by the Army Inspector General substantiated published reports about the events at Khamisiyah. In 1998 the Special Investigations Unit (SIU) of the US Senate Committee on Veterans� Affairs also concluded that:

Depleted uranium became an important issue when some veterans claimed that the Gulf War battlefield was heavily contaminated by DU, a mildly radioactive heavy metal, and that contamination might be the cause of the unexplained illnesses. The Special Assistant's report on DU was the culmination of nearly two years� investigation and analysis involving hundreds of interviews with veterans, reviews of scientific literature, reviews by government and non-government agencies, and discussions with scientists in the fields of health physics, nuclear medicine, and occupational health. OSAGWI�s report highlighted the follow-up being conducted by the VA on veterans known to have been exposed to DU during the Gulf War.

The analysis indicated that some American soldiers were exposed to DU through wounds, inhalation, or ingestion. It also identified and addressed significant shortcomings in the way the Pentagon trained US troops to operate in environments where DU was present and identified lessons learned that can be applied to future operational deployments.

Several organizations (the National Institutes of Health, the National Academy of Science�s Institute of Medicine (IOM), the PAC, the US Senate Committee on Veterans� Affairs Special Investigations Unit (SIU), the General Accounting Office (GAO), the RAND Corporation, the Presidential Special Oversight Board (PSOB), and the Agency for Toxic Substances and Disease Registry) have reviewed the limited existing medical literature on DU and the much more voluminous literature on natural uranium, and all concur. Based on the data developed to date, OSAGWI 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.

CONTINUING THE MISSION

The Office of the Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses has now completed the fourth year of investigations into the possible causes of Gulf War veterans� unexplained illnesses. During this year we published additional Gulf War narratives, information papers, and environmental exposure reports, and we talked to thousands of veterans during base visits and town hall meetings. We also laid the foundation for a new organization to continue the oversight of health-related matters for past, ongoing, and future deployments. The new Office of the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness and Military Deployments (OSAGWI-MRMD) will continue to support appropriate health care for Gulf War veterans and determine what happened in the theater of operations, while promoting changes in existing military doctrine, policy, and procedures that will minimize any future hazardous exposures during deployments. To ease the transition, OSAGWI will provide the new office with the knowledge and lessons learned from our previous investigations.

For the past four years, we have remained committed to doing everything possible to understand what happened during the Gulf War and responding to veterans� questions and concerns. Our focus moved from investigating reports of chemical warfare agent exposures to investigating oil well fire exposures, chemical agent resistant coating (CARC) exposures, depleted uranium exposures, and pesticide exposures. This year we published reports on the air campaign and Scud missile attacks, among others. Throughout our investigations we identified the mistakes made during the Gulf War from which our military must learn and, therefore, avoid repeating. To this end, OSAGWI�s lessons learned directorate ensures that we change policy, procedures, and doctrine. The Gulf War taught us that the Departments of Defense and Veterans Affairs need ways to more effectively communicate with our veterans. In response, DoD developed an extensive outreach program to respond to the needs and concerns of Gulf War veterans, servicemembers, their families, and the American public. As we move forward, it is imperative that we remain as committed as ever to helping Gulf War veterans by continuing to address their health issues, informing and apprising them of new information, and providing the utmost in health protection and readiness for future deployments.

During its tenure, the Office of the Special Assistant produced eighteen interim and six final case narratives, nine information papers, five interim and one final environmental exposure reports, and four close-out reports. The RAND Corporation, under contract to OSAGWI, published five reports reviewing the medical and scientific literature on the known health effects of substances to which Gulf War veterans may have been exposed. Gulf War veterans and the American public have relied on these investigations to answer many of the questions surrounding the unexplained illnesses of Gulf War veterans.

Before DoD established our office, the absence of accurate information about what happened to servicemembers on the battlefield meant DoD could not provide our veterans with the information they needed to make informed health- related decisions. From the beginning, we have developed and implemented a methodology to reach objective assessments using available information. The GAO, the SIU, and various reviewers have helped us refine the procedures we use to reach our assessments. More recently, to ensure that the thoroughness and veracity of our investigative system is maintained, President Clinton created the Presidential Special Oversight Board for Department of Defense Investigations of Gulf War Chemical and Biological Incidents (PSOB) to provide independent oversight of our findings.

THE PRESIDENTAIL SPECIAL OVERSIGHT BOARD

The PSOB�s role has served as a critical check on our investigative process and our progress toward understanding undiagnosed illnesses among Gulf War veterans. Since its inception in February 1998, the Board has helped us determine where to focus our attention, which questions cannot be answered, and when to finalize our reports.

As evident in the discussion below of our publications, the PSOB has closely monitored our processes and investigative work. After the publication of any interim report, the Board reviews both the process and the product. The PSOB staff often checks on leads and references we used in an investigation to assure that the details presented, such as laboratory test results or interviews with veterans, are accurate and fair. Their continuous oversight of all OSAGWI's investigations and processes assures that when we publish a case narrative, information paper, environmental exposure report, or close-out report, it contains the best information available at the time of publication.

The Board has also recommended that we republish reports in final form when sufficient time has passed for public comment and review and no new information has come to light, or if new information reflects only minor changes that do not change the assessment. Publishing a final report, however, does not mean we reject new information on the case. Our office continues to welcome information pertinent to any case and will revisit any case in response to new information, even in reports published as final. This year, the Board asked us to address additional questions and open new lines of inquiry for some investigations, and directed us to close out several ongoing investigations.

Four directorates within OSAGWI worked with the PSOB to accomplish our mission. The Investigation and Analysis Directorate (IAD) was at the forefront of our investigative efforts to determine what happened on the battlefield and define the hazards our servicemembers were exposed to. The Medical Outreach and Issues Directorate (MOI) worked with agencies responsible for medical care, policies, and research arising from the Gulf War and kept health-care providers up to date on issues and treatments. The Public Affairs Directorate managed an extensive outreach and liaison program to convey the scope and substance of our work to veterans� service organizations, the media, veterans, and the public. The Lessons Learned Implementation Directorate (LLID) identified our past mistakes so we may better protect the health of those serving now and in the future.

THE INVESTIGATION AND ANALYSIS DIRECTORATE

This year, as part of our continuing Gulf War mission, we published 20 final, close-out, or interim reports. Each of these published reports is summarized below. Although no new investigations have yet resulted from our expanded mission, we are already providing information to veterans of other deployments.

Camp Monterey. Originally published in May 1997, this narrative detailed the investigation of a reported detection of a chemical warfare agent at Camp Monterey, Kuwait. The investigation revealed that the substance detected was actually the riot control agent, CS (tear gas). The GAO reviewed the original narrative and had no comments on it. The PSOB reviewed the narrative and recommended republishing it as final. The final narrative reflects additional information veterans provided, which elaborated on the event, but did not alter the findings. OSAGWI published the final report in January 2000.

Tallil Air Base, Iraq. Initially published in November 1997, this narrative found it unlikely that Iraq stored chemical warfare agents at Tallil Air Base before or during Operation Desert Storm and that no agents were present during the post-war US occupation of the base. Since then, we have received no new information that would alter that assessment. Additionally, after reviewing the report, the PSOB recommended republishing it as a final report. The final report, published in May 2000, complies with that recommendation.

Possible Chemical Agent on a Scud Missile Sample. Initially published in August 1997, this narrative found that analysis of a Scud missile piece presented to the PAC did not reveal the presence of chemical warfare agents or their breakdown products. Since the initial publication, no new information has been received, nor have any additional leads developed that would change the report's assessment. The PSOB reviewed the narrative and recommended that it be published in final form. OSAGWI published the final report in July 2000.

Chemical Agent Resistant Coating (CARC). Initially published in February 2000, this environmental exposure report discussed CARC painting activities during the Gulf War, described the possible health effects of exposure to CARC, and recommended improvements in CARC painting policies. It was republished as a final report in July 2000 in compliance with the PSOB's recommendation.

An Nasiriyah Ammunition Storage Point. Originally published in August 1998, this narrative found Iraq might have stored chemical weapons at the An Nasiriyah Southwest Ammunition Storage Point at some time during the war; although it was unlikely any chemical weapons were at the site during US occupation. After reviewing the initial publication, the PSOB recommended publishing the report as final. However, after the final report publication in January 2000, the PSOB provided additional information about the investigation. Consequently, although the conclusion did not change, we republished the revised final report in September 2000 to include the new information.

Cement Factory. Originally published in April 1999, this narrative described testing for chemical warfare agents at a former cement factory in Kuwait after the Gulf War. Evidence from Fox Nuclear, Biological, and Chemical (NBC) Reconnaissance Vehicles and analyses of samples collected at that site indicated chemical warfare agent presence was unlikely. Since the publication of the initial narrative, we have received no new information or additional leads to change that narrative�s assessments. The PSOB reviewed the narrative and recommended that we republish it as final, which we did in September 2000.

Close-out Reports

This year marked the first publication of close-out reports. These reports resulted from a public hearing before the PSOB in September 1999. At that hearing, the Board requested that OSAGWI provide a summary of all pending investigations. If, in the Board�s opinion, the emerging results of an investigation did not help us understand a potential cause of the unexplained illnesses some Gulf War veterans suffered, and the anticipated outcome of further investigation would not improve that understanding, the Board recommended terminating the investigation. The Board requested we complete a close-out report to summarize the collected data, document the evidence found, and present the findings compiled to that point of the investigation.

Water Use. This was the first close-out report to comply with the PSOB's recommendation. This report, published in February 2000, found there is no credible evidence to link contaminated water to the long-term unexplained illnesses suffered by some Gulf War veterans.

ARCENT Suspected Chemical Weapons Sites. Published in March 2000, this report covered a US Central Command task to its Army component, ARCENT, to investigate 17 sites that were potential chemical weapons storage areas. The PSOB recommended terminating this investigation because it had been the subject of investigation by the CIA in July 1997. The Board maintained that no new information had been discovered to refute that investigation's finding�namely, Khamisiyah and An Nasiriyah were the only two sites US forces occupied where Iraq stored chemical weapons during Operation Desert Storm.

Retrograde Equipment. This close-out report, published in March 2000, outlined the findings from reports of potential adverse health effects caused by US equipment returned from the Gulf War. Except for dermatitis caused by contact with chromium at one depot and short-term symptoms medically diagnosed as caused by workplace conditions, no evidence exists linking retrograde equipment to the unexplained illnesses some Gulf War veterans are experiencing. Emerging results indicated further research would probably not increase our understanding of these illnesses. Consequently, the PSOB recommended we terminate the investigation and report on the information collected at the time of termination.

Possible Post-War Use of Chemical Warfare Agents Against Civilians by Iraq. Published in May 2000, this report focused on whether Iraq used chemical warfare agents to suppress the post-war Shiia rebellion, and whether such use exposed US forces to chemical warfare agents. Doctors who treated wounded Iraqi civilians thought it unlikely chemical warfare agents caused the injuries. However, since the injuries occurred in areas not occupied by Coalition forces or covered by their chemical detection equipment, it is impossible to retrospectively determine what caused the Iraqi civilians� injuries. Since further investigation would not provide additional insight into this investigation, the Board recommended we terminate the investigation and publish a close-out report.

Chemical Agent Resistant Coating (CARC). Published in February 2000, this interim report discussed the CARC painting activities that occurred during the Gulf War. See the final report summary above.

Oil Well Fires. Originally published in November 1998, this environmental exposure report covered the possible short- and long-term health effects from exposure to the numerous oil well fires started by Iraq�s forces. The report found the contaminant concentrations from the oil fires were lower than those known to cause short- or long-term health effects. The second interim report, published in September 2000, updated the original by incorporating review comments and adding changes the PSOB recommended. In addressing the PSOB�s recommendations, this report added a purpose statement and expanded the text to state who prepared the report�s findings and conclusions and how they were prepared. It also identified areas where further research or additional work is required to more fully address exposures to oil well fire smoke.

Fox Alerts in 24^th Infantry Division. Published in February 2000, this interim narrative discussed Fox vehicle initial alerts for chemical warfare agents in the 24^th Infantry Division sector during the Gulf War. The investigation found no corroborating evidence indicating chemical warfare agents were present. To date, we have not received any additional information on this case. The PSOB reviewed the report and recommended republishing it as final. We will publish this final report early in 2001.

Air Campaign: Modeling and Simulation in the Planning of Attacks on Iraqi Chemical and Biological Warfare Targets. Published in February 2000, this information paper provided background information on how the air campaign planners used modeling and simulation in planning Coalition air attacks against suspected chemical and biological facilities in Iraq�i.e., to estimate aircraft losses, the effects of Iraq�s chemical weapons use against Coalition forces, the best weapons combinations to destroy Iraq�s bunkers, and ways to minimize collateral damage during the bombing. The paper found planners did not use modeling and simulation to predict the dispersal of Iraq�s chemical or biological warfare agents ensuing from Coalition bombing.

Possible Chemical Warfare Agent Incident Involving a US Marine. This interim report focused on a Marine corporal who developed blisters on his forearm after handling the personal equipment of enemy prisoners of war. Although the Marine suffered an injury, all evidence indicated it was unlikely chemical warfare agents caused it. Since publication in March 2000, we have received no new information on this case. The PSOB reviewed the interim narrative and recommended we publish it as a final report.

US Marine Corps Minefield Breaching. Published in May 2000, this interim report was an update of the July 1997 interim report about the 1^st and 2^d Marine Division minefield breaching (path clearing) operations of February 24, 1991, which initiated the ground phase of the campaign to liberate Kuwait. In addition to new information provided by veterans, this second report also addressed the recommendations of a GAO report asking us to investigate other aspects of the operations. The evidence this investigation gathered indicated it was unlikely Marines traversing the minefield breaches in the 1^st and 2^d Marine Division areas were exposed to chemical warfare agents.

Iraq�s Scud Ballistic Missiles. Published in July 2000, this information paper provided a basic understanding of the characteristics, capabilities, and use of Iraq�s Scud missiles.

Possible Mustard Release at Ukhaydir. This interim case narrative, published in July 2000, focused on a possible mustard agent release caused by Coalition bombing of the Ukhaydir Ammunition Storage Depot. Using US intelligence community reports, UNSCOM reports, and computer modeling and simulations, this investigation determined that if Coalition bombing produced a release, the resulting hazard area would not have reached US troops, making their exposure to chemical warfare agents unlikely.

Particulate Matter. Published in July 2000, this environmental exposure report focused on the exposure of US personnel to silica (sand) and soot particles from the oil fires in Kuwait during the Gulf War and the possible health effects from their exposure. For this investigation, we commissioned independent civilian scientists to search medical literature and assess the effects of exposure to these particles. The scientists found the total dosages of silica and soot were below human health protection standards and therefore chronic, long-term effects would not be expected. Although some servicemembers may have experienced temporary, reversible, short-term effects, the report suggests there is no link between exposure to soot and silica in the Gulf and the unexplained illnesses some Gulf War veterans are experiencing.

THE MEDICAL OUTREACH AND ISSUES DIRECTORATE

OSAGWI�s mission has always been first and foremost ensuring veterans get the health care they deserve. During the past year, the Medical Outreach and Issues Directorate (MOI) supported that mission by interacting with a variety of military and government agencies, including the Institute of Medicine (IOM), Congress, the Department of Health and Human Services (HHS), the VA, and various DoD organizations, including numerous medical facilities. MOI has been active in the weekly interagency teleconference in which DoD, VA, HHS, and National Security Council representatives share and coordinate information about research, public affairs, and legislation.

Although OSAGWI does not directly provide health care to veterans, the MOI staff supported the OSAGWI mission to help veterans get needed medical care by responding directly to veterans� and their families� e-mails, telephone calls, Congressional requests, and face-to-face requests at outreach meetings. MOI�s efforts often helped servicemembers obtain better access to care, get a second opinion, or simply provided them with the information or reassurance they failed to receive from their usual healthcare providers.

The MOI identified and catalogued nearly 28,000 Gulf War inpatient treatment records archived at the National Personnel Records Center (NPRC) in St. Louis, Missouri, making it possible for veterans to request and receive copies of their medical records. Many veterans could not obtain records because they were filed by the name of the hospital that retired the records and the veterans could not furnish the NPRC with the name of the field hospital to which they were admitted. The MOI staff created a cross-referenced index to all of the records from the Gulf War hospitals so it could match any hospitalized veteran with the admitting field hospital. Upon request, the MOI staff sent veterans the standard form for requesting copies of NPRC records. Two hundred and forty-one Gulf veterans have located their records in this manner. This documentation can be crucial to veterans� applications for benefits such as medical care and disability compensation. MOI has made this cross-referenced index available to the VA.

In addition, MOI physicians regularly responded to questions from veterans participating in Walter Reed Army Medical Center�s Special Care Program. The MOI staff provided information to help Gulf War veterans living in Germany (but no longer connected to the military) obtain VA registry medical evaluations. Other important activities included informing veterans, scientists, health care providers, and the press of the findings and implications of newly-published research results through briefings, interviews, printed abstracts of journal articles, and by posting abstracts on OSAGWI�s web site, GulfLINK.

Although OSAGWI does not conduct medical research, the MOI staff made important contributions to the government research program aimed at explaining illnesses among Gulf War veterans. MOI interest in this program came from working with veterans and listening to their concerns, which proved important in guiding the research agenda. The MOI staff strives to keep veterans abreast of what is being learned from research about undiagnosed illnesses among Gulf War veterans. MOI was instrumental in initiating several research efforts.

In 1997, the director of the Saudi Arabian National Guard (SANG) Hospital in Riyadh offered Dr. Rostker access to their electronic hospitalization database. MOI brought together a research team from DoD, the Centers for Disease Control, and the Saudi Arabian National Guard to evaluate the SANG hospital�s database and determine whether SANG members stationed in a combat zone had greater hospitalization, cancer, and mortality rates than those stationed in a non-combat zone. The results of this study will be compared with studies of illnesses among Gulf War veterans from the US and other Western forces in the Coalition.

MOI did initial exploratory work for the VA national study of a possible association between amyotrophic lateral sclerosis (ALS)�known as Lou Gehrig's disease�and service in the Gulf War. When the family of a Gulf War veteran with ALS asked our office how many Gulf War veterans had this disease, the staff looked at the DoD hospitalization data and the Physical Evaluation Board data and identified 15 Gulf War veterans diagnosed with ALS from 1990 to 1998. This information was shared with the VA and other federal agencies, which are conducting a one-year nationwide study to see if ALS occurs at a higher-than-expected rate among Gulf War veterans.

The Special Assistant expressed an interest in all research that seemed to have promise for Gulf War veterans. Consequently, the MOI staff identified research efforts that appeared to be at the frontier of modern science. As a result, when the Special Assistant learned that Dr. Haley had undertaken research centered on the 24^th Naval Mobile Construction Battalion at Al Jubayl, he arranged special funding to underwrite this promising research, with the understanding that all such work would be peer reviewed. Conducted at the University of Texas Medical Center, this project was believed meritorious by MOI and the Research Working Group, which monitored the progress and results on behalf of OSAGWI to assess its meaning for ailing Gulf War veterans.

The Special Assistant supported funding of a special scientific study of Dr. Nicloson�s novel laboratory methods to detect bacteria in Gulf War veterans. After carefully following the progress of research into the hypothesis that mycoplasma infections were responsible for undiagnosed illnesses among Gulf War veterans, MOI arranged for OSAGWI to fund a study of the reliability and reproducibility of Nicolson�s methods to detect the possible presence of this bacterium in ailing veterans. MOI has worked closely with the Army to evaluate the validity of these laboratory methods.

As a follow-up to the cross-indexing of the NPRC paper records of hospitalizations during Operations Desert Shield and Desert Storm, MOI staff conceived and executed a project to put into a computerized database the contents of those medical records. This database will allow DoD and other scientists to perform future research into the causes and treatments for illnesses and injuries that resulted in hospitalization in the Gulf.

MOI assisted and advised IAD staff in arranging for an OSAGWI-funded study to compare the ability of several laboratories to measure depleted uranium and its constituent isotopes in laboratory-prepared specimens. There is no national or international organization to establish standards.

An MOI staff member served as the DoD�s Contracting Office Technical Representative, overseeing the 3-year, $6 million contract with the IOM to develop "Strategies to Protect the Health of Deployed US Forces." At the end of 1999, the IOM published a 4-volume set of findings and recommendations from its four subcommittees. In 2000, a new IOM committee integrated the first four committees� work into a final report focusing on the areas where DoD must make improvements for protecting and monitoring personnel health during and after deployments.

MOI also contributed through various other means to the government�s interagency research collaboration. The staff directed veterans� and scientists� ideas for research to the Research Working Group (RWG) of the Persian Gulf Veterans Coordinating Board (PGVCB)�re-designated the Military and Veterans Health Coordinating Board (MVHCB)�and actively participated in the RWG�s meetings. MOI physicians helped plan and execute the annual interagency Research Conference on Gulf War Veterans� Illnesses and helped identify veterans� cohorts for study in research projects. The latter included assisting the collaboration between DoD and the VA in assessing veterans with definite or possible DU exposures�particularly in the ongoing Baltimore VA study of Gulf veterans with embedded DU from friendly-fire incidents. The OSAGWI staff that wrote the DU environmental exposure report identified 102 DU friendly-fire veterans and contacted 99 to inform them about the VA study.

An important function of the MOI staff is reviewing the documents (case narratives, information papers, environmental exposure reports, correspondence, e-mail, press releases, etc.) other OSAGWI elements generate to ensure they are consistent with current scientific knowledge and appropriately communicate medical risks. All OSAGWI publications receive this careful medical review.

In supporting OSAGWI activities, MOI physicians reviewed current scientific literature and summarized in abstract form the articles� contents and significance. The MOI printed these summaries for distribution during outreach efforts and placed them on OSAGWI�s web site, GulfLINK. Publications reviewed include journal articles from US and foreign scientists, government monographs, and the OSAGWI-commissioned RAND reports on specific topics in the literature. The topics span the breadth of studies about the possible nature, causes, and treatment of illnesses among Gulf War veterans.

In support of our public affairs� efforts to keep media reports about illnesses among Gulf War veterans as accurate and current as possible, the MOI staff participated in interviews with a wide range of newspapers, radio and television stations, and internet news sources in this country and abroad. The MOI�s involvement in public affairs also included participating in all outreach efforts at military installations and communities.

MOI staff physicians actively visited numerous military installations and communities in both the US and Germany. On such outreach visits, the physicians briefed health care providers, family members, and veterans, and also supported other presenters, responding to the audience�s medical and scientific questions. A physician always accompanied the Special Assistant to address medical questions during town hall meetings. In addition, the MOI gave medical briefings during other special trips to military installations, medical facilities, and VA hospitals and conferences.

The MOI assessed the impact of OSAGWI outreach visits by counting the number of new requests for Comprehensive Clinical Evaluation Program (CCEP) evaluations at visited locales. CCEP data showed the rate of requests increased an average 490 percent in the month following an OSAGWI outreach visit.

THE PUBLIC AFFAIRS DIRECTORATE

The Total Force Outreach program is DoD�s comprehensive effort to respond to the needs and concerns of Gulf War veterans, active duty members, reservists, and their families. Beginning in 1997 with a focus on Gulf War veterans, we developed the Total Force Outreach in 1998; to date, it has reached nearly 70,000 veterans, servicemembers, their families, and members of the general public. We provided more than 20,000 Gulf War veterans the opportunity for one-on-one interaction with our staff during Total Force Outreach and other outreach efforts (including veterans service organization and military service organization conferences and conventions, and educational seminars). The Public Affairs outreach teams visited 56 military installations in 2000 and participated in 20 conferences, conventions, and other events hosted by veterans and military service organizations. Participation in such events provides important information to these organizations� nearly 10 million members about DoD�s efforts to respond to Gulf War veterans� concerns. During 2000, Public Affairs reached about 5,700 veterans by telephone, and responded to more than 9,000 e-mail inquiries and 800 letters.

The Year 2000 Total Force Outreach itinerary included two- to four-day information exchanges in which experts briefed servicemembers, leadership at all levels, medical staff, Gulf War veterans, family members, community groups, community service organizations, installation staff, and the general public. Public Affairs outreach teams offered special evening sessions to maximize participation. To reach those unable to attend the briefings, team members manned several displays placed in high-traffic areas, such as the installation exchange, commissary, and hospital, and demonstrated DoD�s Gulf War web site, GulfLINK, at many of the displays.

Topics addressed at the briefings and town hall meetings spanned a broad range of interests, including the results of investigations into possible exposures from chemical or biological warfare agents, 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, staff members from the local and regional VA offices participated at the town hall meetings as well. Many Public Affairs outreach presentations also included representatives from the DoD�s Anthrax Vaccine Immunization Program to address servicemembers� concerns.

The outreach visits during 2000�conducted at 35 Army posts, 10 Navy bases, 2 Marine Corps bases, and 9 Air Force bases�provided the team an opportunity to contact and talk with large numbers of Gulf War veterans. During these visits, the Public Affairs team personally met with more than 9,000 total force members. We received more than 200 requests for copies of our investigative reports and added more than 3,000 people to the mailing list for OSAGWI�s newsletter, GulfNEWS, increasing the bimonthly circulation from its original 1997 total of 2,000 readers to more than 27,000 current readers. We expect the 2001 outreach schedule to continue this ongoing success story.

Over the past four years, we have held 32 Town Hall meetings to listen to veterans and to try to answer their questions and help them with access to healthcare. Veterans service organizations arranged the first 13 town hall meetings. We then changed the venues to military bases, with the town hall meetings open to the public and advertised on local radio, television, and in local newspapers. At these 19 town hall meetings, local Veterans Affairs representatives, local military base leaders, and local military hospital leaders joined our outreach teams. At each town hall meeting we spent three or more hours answering questions and concerns from Gulf War veterans, their families, and the general public. For some questions there were no answers, but we were able to share information on how the federal government is conducting a large medical research program to try to find answers. For many veterans, the VA or military medical personnel present were able to respond to their personal issues and concerns. It was important to those Gulf War veterans to have their voices heard and to learn that work is continuing to try to understand why some are ill.

Regular meetings with veterans service organizations (VSOs) and military service organizations (MSOs) addressed issues important to their members�the Gulf War air campaign, Khamisiyah, depleted uranium, pesticides, particulate matter, among others.

To ensure the VSOs and MSOs received our reports promptly, Public Affairs provided special briefings before publicly releasing case narratives, information papers, and environmental exposure reports. We sponsored ten VSO or MSO meetings in 2000. In addition, we continued to use an electronic mailing list and sent all GulfLINK news releases as they became available. Team members also staffed conference-style displays in high traffic areas during annual VSO and MSO conventions�particularly those of the largest national veterans organizations (e.g., Veterans of Foreign Wars, The American Legion, and Disabled American Veterans). Plans for 2001 are underway; we hope, however, to continue attending the national VSO and MSO conventions.

GulfLINK, our web site (www.gulflink.health.mil), continued to be a successful, useful tool for communicating with our veterans. Typically, GulfLINK receives more than 60,000 "hits" weekly, a number that peaks when Public Affairs publishes information of great interest. Additionally, the direct e-mail connection on the GulfLINK site allows anyone visiting the site to ask questions (more than 1,500 every year) or make comments. GulfLINK will remain in operation after the office transitions to the new organization in 2001, and updates on Gulf War-specific issues will continue to appear on GulfLINK in addition to the archived material. GulfLINK will also be linked with the new DeploymentLINK web site, which will be devoted to contemporary medical readiness and deployment health issues.

In GulfNEWS, our bimonthly, four-page, print and electronic newsletter, Public Affairs highlights events of interest to Gulf War veterans and presents timely features based on our case narratives, information papers, and environmental exposure reports. In 2000, for example, we featured articles on the "Tallil Air Base" and "Injured Marine" case narratives and the streamlined VA disability claims process. Other GulfNEWS issues covered the release of depleted uranium research and a study on the effects of low-level exposure to nerve agents.

In 2001, Public Affairs will launch a new publication encompassing the Gulf War deployment, subsequent deployments, and future deployments. GulfNEWS will cease publication and current subscribers will receive the new publication, which will continue to address Gulf War illnesses issues. The format and publication schedule for the new newsletter are still being developed.

Public Affairs continues to notify individual veterans in conjunction with the release of certain case narratives, information papers, and environmental exposure reports and solicit information from veterans to aid investigations. So far this year, Public Affairs has sent 142,214 letters to Gulf War veterans about CARC, the M256A1 chemical agent detector kit, and the revised Khamisiyah report. During the past four years, we sent out 398,568 notifications.

Public Affairs dedicated significant resources and effort in responding to requests from Congress. Actions included testifying before several committees on topics of interest to the legislators. In addition, we aided Members of Congress in responding to constituents� needs, from providing information about specific issues relevant to Gulf War illnesses, to directly interceding with Government agencies on behalf of individuals. In conjunction with the MOI, we assisted the GAO�s investigations on behalf of individual Members and committees.

In addition to the Total Force Outreach, Specialized Care Program participants benefited from individualized meetings as part of OSAGWI�s outreach mission in 2000. Public Affairs invited veterans enrolled in the DoD Comprehensive Clinical Evaluation Program who had progressed to the Phase III Specialized Care Program at Walter Reed Army Medical Center to visit OSAGWI�s offices. The monthly visits included an orientation briefing, a meeting with the Deputy Special Assistant, and a tour of the facilities, where we explained the various organization functional areas.

THE LESSONS LEARNED IMPLEMENTATION DIRECTORATE

In 2000, OSAGWI�s Lessons Learned Implementation Directorate (LLID) completed its second full year of operation. Established in late 1998 to apply the knowledge derived from OSAGWI investigations to current and future force health protection, the LLID makes substantial, concrete suggestions for improvement in several areas of concern. Our investigations uncovered weaknesses and deficiencies in policies, procedures, doctrine, training, and equipment. The LLID arose from our determination to ensure that DoD corrected these system failures and then institutionalized the corrective action as doctrine to prevent recurrence. The LLID�s impact on future force deployments cannot be overstated. As the PSOB�s interim report notes, "Identifying lessons learned ranks among OSAGWI�s most important work."

The LLID has supported DoD programs aimed at identifying, preventing, and controlling injury and disease due to occupational and environmental threats, operational stress, and other dangers to the health and readiness of military personnel. This has led to concrete improvements in the Department�s ability to heed the lessons learned from the Gulf War and more recent deployments, and to correct deficiencies in medical readiness, force health protection, and DoD�s responsiveness to military members, veterans, and their families.

Building on the success of institutionalizing DU awareness training, the LLID began 2000 by aggressively working with several organizations to institutionalize potential NBC defense lessons and other medical lessons identified in OSAGWI narratives. The overall effort, "Campaign Plan USA," was an OSAGWI and Department of the Army initiative that began in late 1999 with an OSAGWI, Army Training and Doctrine Command (TRADOC), and Medical Command (MEDCOM) working group meeting to assign responsibility for assessing and resolving identified issues. The working group assigned key participants responsibility to analyze potential lessons OSAGWI identified and to develop and validate solutions using the established functional areas of doctrine, organizational structure, training, leader development, and materiel. Since most OSAGWI investigations have focused on reported chemical or biological agent detections, the working group chose NBC defense as the first area for review.

While a systematic, thorough review of NBC defense-related doctrine, training, and policy is far from complete, Joint Staff and multi-service NBC defense doctrine manuals are beginning to re-address numerous chemical and biological defense issues and related medical issues. Looking ahead, LLID will continue to monitor emerging doctrine, new training, deployments, and deployed personnel�s experiences to assess if DoD is improving knowledge and awareness among line commanders, their staffs, and their units. Since many already-identified issues reach beyond traditional NBC defense concerns, we also are focusing on other areas (e.g., toxic industrial chemicals) that could benefit from similar change.

Another important Gulf War lesson was that DoD underestimated the impact of deployment stress. Although comparatively few participated in combat during the Gulf War, many servicemembers deployed to the Gulf, both combatants and non-combatants, were exposed to a wide range of stressful circumstances.

The unexpected, rapid nature of the deployment to the Gulf and the protracted assembly of up to nine months in the harsh desert environment created personal and family hardships. Other stressors included fear of missile attacks, prolonged anticipation of chemical and biological weapon attacks, and anxiety over false-positive chemical weapon alarms�as well as witnessing deaths, civilian atrocities, and other customary consequences of war. Further, a lack of communication about what happened on the battlefield led many veterans to believe they were exposed to harmful substances.

LLID had worked on hosting an operational stress conference since the fall of 1998. The concept for the conference was to bring together subject matter experts from the medical, spiritual, and combat arms communities to craft a joint strategy to deal with operational stress management. Partnering with the Office of the Assistant Secretary of Defense for Health Affairs and the Joint Staff, OSAGWI hosted the DoD Leaders and Operational Stress Conference on June 20 and 21, 2000, at Fort McNair, Washington DC. More than 260 personnel, representing the Army, Navy, Air Force, Marine Corps, Coast Guard, and several allied nations participated in the conference.

The conference�s theme was the changing nature of combat and combat stress. Key discussion topics included the potential for stress casualties, the combat leader�s role in reducing this potential, and managing these casualties. The conference emphasized the role of leadership in developing strategies, and also educated commanders, medical personnel, and chaplains about the need to enhance current prevention approaches. The conference revealed that strong leadership and effective management are crucial factors in identifying problems and taking corrective action to protect servicemembers� health.

The Special Assistant is identifying the follow-on actions required to formalize these findings, which provide a foundation for future policy on how to better train today�s and tomorrow�s leaders to prevent and manage operational stress.

A BROADER MISSION�THE NEW ORGANIZATION

A significant lesson learned from the Gulf War is that the Department of Defense is not well structured to deal with the non-traditional issues occurring after every deployment. The Gulf War experience revealed significant shortcomings in our understanding of modern war health stressors. For instance, the Gulf War highlighted the need for an increased focus on chemical doctrine and on improving the design of chemical agent detection equipment. The number of false alarms from detection equipment created confusion and concern among Gulf War veterans. Properly training military personnel in the use of chemical detection equipment, and about safety precautions for depleted uranium, pesticides, and other chemical hazards are issues that became problematic during the Gulf War and will eventually confront future deployments.

A major shortcoming was inadequate communication between DoD leadership and deployed personnel concerning health risks. Many veterans had unanswered health-related questions about smoke from oil well fires, battlefield exposures to depleted uranium, unexplained vaccines and medications, alarms sounding from nearby chemical detectors, Scud rockets impacting or flying close overhead, and incomplete medical records. When Gulf War veterans reported a myriad of undiagnosed symptoms and illnesses after their return, DoD did not provide explanations or respond in a prudent manner. Faith in the government's commitment to safeguarding servicemembers' and veterans' health and providing responsive care became seriously eroded.

Since none of these shortcomings were unique to the Gulf War, it became apparent to this office, the PSOB, the IOM, the VSOs and the MSOs that DoD needed to make a sustained effort to concentrate on veterans� current and future needs. To this end, Defense Secretary William S. Cohen broadened the scope of DoD�s focus on Gulf War illnesses by creating a permanent Office of the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness and Military Deployments. DoD has not concluded its concern about Gulf War veterans� illnesses, but has expanded it to confront other situations that might arise from current or future deployments.

Sharing many similarities with OSAGWI, the new Office of the Special Assistant will undertake several endeavors. We will build on and expand the work OSAGWI originally started. Providing information for all those involved in deployments will be one of the new organization�s most important missions. We will continue to work with and deliver information to veterans service organizations, military service organizations, individual veterans, their families, and the public regarding their concerns about past, current, and future deployment exposures affecting their health. We will work with the Office of the Assistant Secretary of Defense for Health Affairs and the Joint Staff to assure that servicemembers and their families understand what is being done on their behalf. We will work with the VA to see that health-related information about those who served is readily available to VA medical care and benefits sections. We will play a key role in working with other DoD organizations to integrate deployment health-related lessons learned with future doctrine and policy. We will keep the environmental hazards, exposures, and the health issues facing modern military forces on commanders� and DoD�s priority lists. We will create a partnership with the unified Commanders-in-Chief and their subordinates to support appropriate implementation of their shared responsibilities for force health protection measures before, during, and after deployments.

We believe issues resembling those of the Gulf War may arise from current and future deployments, and without an organization dedicated to working with veterans, the Department of Defense could revisit the Gulf War experience. Over the past four years, the Department has gained competence in dealing with the health concerns veterans believe are related to their Gulf War service. The new organization will build on its past expertise to provide the best support possible for veterans of future deployments. Through the Office of the Special Assistant�s toll-free hotline, interactive e-mail, and written correspondence, DoD will be able to communicate with all veterans. We are obligated to provide the most accurate information about the health risks servicemembers have faced and will face during future deployments�the health risks arising from realistic scenarios of the battlefield and environmental conditions they can expect to encounter. We owe them the information that will enable them to react and cope with these situations. In the new Office of the Special Assistant we will uphold our responsibility and extend our commitment to ensure veterans of all deployments, including the Gulf War, receive the care they deserve.