VETERANS AFFAIRS (VA) COMPENSATION AND BENEFITS

Gulf War Veterans’ Compensation

With more Gulf War veterans requesting disability compensation than veterans from other periods, VA found its claims processing strained. Veterans filing claims for unexplained illnesses were initially hampered because the law only allowed VA to compensate veterans for diagnosable conditions. This was later remedied through the legislation described below.

As of July 2000, Gulf War veterans had filed about 186,000 compensation and pension claims with VA, but not all of them were directly related to service in the Persian Gulf. Many of the claims were for medical conditions that either existed before deployment to the theater or occurred after the war. VA has processed 165,000 compensation and pension claims of which 143,000 have been granted. Of those claims granted, about 3,000 have been for veterans whose disabilities could not be attributed to a diagnosable medical condition. VA has searched for responsive, innovative ways to meet the health care, compensation, and outreach needs of Gulf War veterans and is building upon this experience to better help veterans from past and future conflicts, as well as other types of missions.

Compensation for Undiagnosed Illnesses. Veterans, veterans service organizations (VSOs), and members of the public have demanded that the Federal Government develop new ways of responding to Gulf War-related health care needs. In response, VA requested and was given authority under Public Law 103-446, signed November 2, 1994, to compensate any Persian Gulf veteran suffering from a chronic disability resulting from an undiagnosed illness. In March 1997, VA extended through December 2001, the compensation eligibility period during which the signs and symptoms must become evident.

Training VA Compensation Service Providers. Since the cease-fire in 1991, VA has made considerable effort to provide comprehensive training to VA employees who process Gulf War claims. Monthly reviews at facilities located throughout the U.S. are accomplished now by a special quality improvement review of a sample of claims, with results reported to the VA Central Office. In 1998, VA began a new accuracy study designed to provide a current profile of Gulf War claims and assess the accuracy of their claims evaluation process. This program has shown that the special training, communication, and continuing reviews have had a positive impact on the quality of the claims processing.

VA has sponsored nationwide satellite broadcasts on Gulf War issues, including one specifically focused on disability examinations for Gulf War veterans. Hearing officers at VA regional offices previously trained in Gulf War issues are used as subject matter experts who assist claims examiners.

Fair Compensation Policy. In June 1998, VA asked the IOM to help assess the scientific literature linking Gulf War environmental exposures to potential health problems. This effort was modeled after the successful process VA has used since the early 1990s to establish a sound and scientifically based compensation policy for Vietnam veterans exposed to Agent Orange. Environmental exposures are classified according to the strength of their association with specific diseases or categories of disease. Four months later, Congress supported this effort with legislative mandates, including the "Veterans Programs Enhancement Act of 1998" (Public Law 105-368) and the "Persian Gulf War Veterans Act of 1998" (Public Law 105-277). Public Law 105-277 requires the Secretary to determine, based on IOM reports, whether particular illnesses warrant a presumption of service connection and, if so, to set compensation regulations establishing such a connection for each illness.

Institute of Medicine (IOM) Involvement. The Secretary of Veterans Affairs requested that the National Academy of Sciences’ Institute of Medicine (IOM) provide an independent scientific review of the evidence regarding associations between diseases and exposure in the military service to selected risk factors encountered during the Gulf War. On September 7, 2000, the IOM issued a report, Gulf War and Health: Volume 1: Depleted Uranium, Sarin, Pyridostigmine Bromide, Vaccines (www.nap.edu/html/gulf_war). The IOM limited its initial review to an analysis of the health effects of depleted uranium (DU), the chemical warfare agent sarin, vaccinations against botulinum toxin and anthrax, and pyridostigmine bromide (PB) — the agents of most concern to veterans and their representatives. The review took into account the strength of scientific evidence and the appropriateness of the methods used to identify associations. It included an assessment of the biologic plausibility of any exposures that may be associated with Gulf War veterans’ illnesses. The IOM made recommendations for additional scientific studies to resolve areas of uncertainty. The MVHCB Research Working Group is closely evaluating these recommendations to ensure the research portfolio adequately addresses the IOM’s concerns.

In reporting its findings, the IOM included one exposure in the category "Sufficient Evidence of a Causal Relationship": exposure to sarin and dose-dependent acute poisoning effects that are evident promptly (seconds to hours) after exposure, and resolve in days to months. Acute poisoning effects short of death include constricted pupils, runny nose, increased sweating and salivation, weakness, headache, blurred vision, nausea, diarrhea, cessation of breathing, and convulsions.

The IOM included three entries in the category "Sufficient Evidence of an Association": 1) PB administration and short-lasting, immediate effects primarily gastrointestinal in nature (nausea, diarrhea) in doses normally used in treatment and for diagnostic purposes; 2) anthrax vaccination and short-lasting, immediate local and systemic effects (redness, swelling, fever); and 3) botulinum toxoid vaccination and short-lasting, immediate local and systemic effects (redness, swelling, fever, headache, nausea diarrhea, hives, blurred vision dizziness).

The IOM placed one item in the category "Limited/Suggestive Evidence of an Association": exposure to sarin at doses sufficient to cause acute signs and symptoms of nerve agent poisoning and subsequent long-term effects (psychological and/or neurological).

Approximately half of the IOM conclusions were in the category "Inadequate/Insufficient Evidence to Determine Whether an Association Does or Does Not Exist." These included: 1) exposure to uranium and lung cancer at high levels of cumulative exposure; 2) exposure to uranium and lymphatic cancer; bone cancer; nervous system disease; nonmalignant respiratory disease; or other health outcomes; 3) PB and long-term adverse health effects; 4) exposure to sarin at low doses insufficient to cause acute poisoning signs and symptoms, and subsequent long-term adverse health effects; 5) anthrax vaccination and long-term adverse health effects; 6) botulinum toxoid vaccination and long-term adverse health effects; and 7) multiple vaccinations and long-term adverse health effects.

The IOM included two items in the final category "Limited/Suggestive Evidence of No Association": 1) exposure to uranium and lung cancer at cumulative internal low doses; and 2) exposure to uranium and clinically significant kidney dysfunction.

By law, the Secretary of VA must determine whether a presumption of service connection is warranted for each illness covered in the IOM report. Service connection is warranted if the Secretary determines a positive association between exposure to a biological, chemical, or other toxic agent, environmental or wartime hazard, or preventive medicine or vaccine known or presumed to be associated with service in the Persian Gulf War, and the occurrence of diagnosed and undiagnosed illness in humans or animals. A positive association under the law is considered to exist if the credible evidence for the association is equal to or outweighs the credible evidence against the association. If the Secretary of VA finds a positive association, then VA has the authority to grant automatic service connection for the associated illness. As of the date of this document, the Secretary of VA had not yet made any determination of positive associations for these exposure agents.

The September 2000 IOM Report is only the first phase in what will be a lasting effort for Gulf War veterans. IOM reports on other Gulf War risk factors will follow, and the IOM and VA have a long-term commitment to study many more of the agents to which veterans may have been exposed. In addition, both are committed to issuing updated reports as new evidence appears.


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