FINAL REPORT

President Clinton established the Special Oversight Board by Executive Order 13075 in response to a recommendation from the Presidential Advisory Committee on Gulf War Illnesses (PAC). The Board's charter (Appendix C) called for it to "provide advice and recommendations [and oversight] ... of Department of Defense investigations into possible detections of, and exposures to, chemical or biological weapons agents and environmental and other factors that may have contributed to gulf war illnesses ... [and to provide an] overall evaluation of DoD's plan for and progress toward the implementation of the 12 recommendations contained in the PAC's Special Report" (see Chapter 5).

Board operations began in June 1998 by focusing on the work of the Office of the Special Assistant for Gulf War Illnesses (OSAGWI), the primary DoD agency responsible for coordinating DoD's Gulf War investigations in this area of concern. The Board solicited the opinions of veterans groups, individual veterans, and scientists researching the etiologies of Gulf War illnesses. Since the release of its Interim Report in August 1999, the Board has conducted four public hearings and eight monthly meetings that have included presentations from DoD and Department of Veterans Affairs agencies (VA).

This final report addresses:

• the transition from OSAGWI to OSAGWIMRMD (Office of the Special Assistant for Gulf War Illnesses, Medical Readiness, and Military Deployments),
• OSAGWI case narratives,
• OSAGWI environmental exposure reports,
• Presidential Advisory Committee Special Report recommendations,
• an overview of Gulf War illnesses (GWI),
• the role of stress as a contributing factor in Gulf War undiagnosed illnesses,
• lessons learned from the Gulf War and ongoing initiatives, and
• Board findings, recommendations, and observations.

The Deputy Secretary of Defense established OSAGWI on November 12, 1996, following DoD revelations that U.S. and coalition forces may have been exposed to low-level nerve agents from the destruction of Iraqi ammunition stores at Khamisiyah, Iraq. OSAGWI endeavored to determine the causes of Gulf War illnesses, to ensure that veterans were receiving proper care, and to recommend to the Secretary of Defense changes in doctrine, policy, and procedures to reduce the risks to troops during future deployments. OSAGWI has published seventeen case narratives and four environmental exposure reports as a result of its investigations into possible chemical and biological incidents and into environmental factors that may have contributed to adverse health outcomes. In addition, OSAGWI has devoted considerable effort to providing veterans, military personnel, and the public with timely and accurate information regarding Gulf War illnesses and related issues. Because of the success of OSAGWI's efforts and the need for continued research into the causes of Gulf War undiagnosed illnesses, the Board recommended that DoD create a follow-on organization to OSAGWI. This new organization, OSAGWIMRMD, will not only continue to focus on Gulf War illnesses but also will examine future force health protection issues.

As of November 30, 2000, the Board has reviewed fourteen original and nine revised case narratives released by OSAGWI and OSAGWIMRMD (see Appendix F). The Board finds OSAGWI made assessments that were consistent with available evidence in all of its case narratives regarding the presence of chemical and biological warfare agents. The only known potential exposure of U.S. personnel to chemical warfare agents remains the accidental low-level release of nerve agents during demolition operations at Khamisiyah, Iraq, in March 1991.

As of November 30, 2000, the Board has reviewed three original and two revised environmental exposure reports (see Appendix F). The Board finds OSAGWI made assessments in each of its reports regarding environmental exposures that were consistent with available evidence. In particular, the Board concurs with the conclusions in the report on depleted uranium (DU) that available evidence does not support claims that DU caused or is causing the undiagnosed illnesses (or diagnosed illnesses) from which some Gulf War veterans still suffer. The Board agrees with the report on Chemical Agent Resistant Coating (CARC) that this special camouflage paint posed a health hazard only to the approximately 200 personnel who participated in spray-painting operations. The Board concurs with the reports on oil well fires that contaminant concentrations (less particulate matter) in the smoke were below those known to cause short- or long-term health effects and that, except for the possibility of exacerbating some pre-existing respiratory conditions, long-term health effects are unlikely. However, ongoing research must be completed and assessed before OSAGWIMRMD can make a final determination on oil well fires.

The Board addressed the twelve PAC recommendations during several of its monthly meetings. Representatives from DoD, VA, and the Department of Health and Human Services (DHHS) described each agency's efforts to implement the recommendations. The Board has determined that DoD properly implemented ten of the recommendations. The Board advised DoD to take no further action on two recommendations:

The Board reviewed numerous published scientific studies on Gulf War illnesses. The Board also heard direct testimony from many of the primary authors of these studies. Based on this information, the Board evaluated ten potential exposures possibly associated with Gulf War illnesses. These exposures include: biological warfare agents; chemical warfare agents; depleted uranium; indigenous infectious diseases; oil well fires; pesticides; pyridostigmine bromide; sand; vaccines; and stress.

The Board makes the following conclusions:

• A substantial number of Gulf War veterans suffered significant illness, impairment, and disability following their deployment to the Persian Gulf.
• Studies published to date have not identified a cause of undiagnosed Gulf War illnesses.
• The symptoms of Gulf War undiagnosed illnesses are similar to those found in the general population and are similar to those of veterans returning from combat duty in previous wars and from contemporary peacekeeping duties.
• The symptoms of Gulf War undiagnosed illnesses are similar to those of patients suffering from chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity.
• Deployment stress is a likely causal or potentiating factor in at least some Gulf War veterans' illnesses.
• Epidemiological studies of Gulf War veterans are compromised because exposure estimates for many factors are of poor quality or are nonexistent. Self-reported exposures, which are subject to recall bias, misinformation, or other confounding variables, are often the only exposure data available.
• Further research is necessary to evaluate the potential relationship between toxic exposures and symptoms of undiagnosed Gulf War illnesses.

The Board concludes that stress is likely a primary cause of illness in at least some Gulf War veterans; it is a likely secondary factor in potentiating other causes of undiagnosed illnesses among some Gulf War veterans. The Board recognizes that veterans suffering from undiagnosed illnesses, even if caused by deployment stress, have real medical problems that pose a significant disruption in their lives.

An unfortunate reluctance exists on the part of the American public, some members of Congress, and especially among some members of the veteran community to recognize the impact that stress can have on an individual. These attitudes stem from a misunderstanding of the very real physiological and biochemical impact that stress can have on the human body. Stress can lead to genuine illnesses. No physician or researcher familiar with the effects of stress minimizes the suffering that patients often experience. The symptoms are indeed real; they are not imagined and they are not "all in the head." The fact that stress is a likely factor in some Gulf War veterans' illnesses does not imply that other potential exposures played no role. This issue requires continued research. The Board commends DoD for recognizing the role of stress in deployment and in combat and for developing and implementing programs to address this issue.

The Board commends the Departments of Defense, Veterans Affairs, and Health and Human Services for the many programs that they have initiated or will shortly implement to promote the health of service members and their families following future deployments.

These programs include:

• Periodic Health Assessments (DoD)
• Deployment Medical Surveillance Assessment Status (DoD)
• Unmet Health Needs of Reservists (DoD)
• Prevention/Treatment of Deployment Related Stress (DoD)
• Predisposing Psychiatric Problems/Risk Factors (DoD)
• Responding to Health Needs/Concerns of Returning Troops (DoD)
• The Family�s Role Related to Deployment (DoD)
• Deployment-related Health Issues/Veterans Health Initiative and Veterans� Health Programs for Latent Post-war Illnesses (VA)
• Environmental and Occupational Health Programs and Research and Deployment Occupational/Environmental Health Surveillance (DoD)
• Role of Medical Intelligence and Detection of Potentially Hazardous Environmental Exposures (DoD)
• Research on Health Effects of Low-Level CW Agents (DoD)
• Interagency Medical Defense Program Against CBW Agents (DoD)
• Medical Force Protection: Advance Concepts and Technology (DoD)
• Detecting/Mapping Potential Hazardous Health Exposures and Detecting Potential Biological Agents (DoD)
• Interagency Health Risk/Research Communication Program (DoD, VA, DHHS)
• Personnel Record Keeping/Tracking (DoD)
• Documenting Recruits� Health Status and a Lifetime Health Record (DoD)
• Automated System to Collect Pertinent Personnel/Health Data and Data Dictionary for Comprehensive Health Record (DoD and VA)

Findings

• The Department of Defense and OSAGWI have worked diligently to fulfill the President's directive to "leave no stone unturned" in investigating the possible causes of Gulf War illnesses.
• DoD has made no effort to deliberately withhold information from the general public or from veterans concerning its investigations or findings related to Gulf War illnesses. On the contrary, DoD has made an extraordinary effort to publicize its findings through the publication of reports and newsletters, public outreach meetings, briefings to veterans and active duty servicemembers, the creation of a toll-free hotline, and the creation of an actively updated website.
• In each of its case narratives, OSAGWI made assessments regarding the presence of chemical and biological warfare agents that were consistent with available evidence.
• In each of its environmental exposure reports, OSAGWI made assessments regarding environmental exposures that were consistent with available evidence.
• Following a recommendation of the Board in its Interim Report, OSAGWI revised its case narrative methodology statement to fully explain its procedures, resulting in an accurate method for assessing the likelihood of chemical warfare agent exposures during the Gulf War.
• The Department of Defense appropriately implemented the recommendations contained in the PAC's Special Report.

Recommendations:

• The Board recommends that OSAGWIMRMD suspend its installation visits until it can devise a more efficient vehicle for conducting town hall meetings while maintaining its informative world-wide web site, 1-800 toll-free operators, and other existing outreach initiatives. The VA should assume the lead for Gulf War illness-focused town hall meetings because veterans' questions have centered on that department�s services. OSAGWIMRMD should assume a supporting role in such meetings, and the Military and Veterans Health Coordinating Board (MVHCB) should facilitate the transfer of responsibility from DoD to VA for Gulf War illness-focused town hall meetings. OSAGWIMRMD should use those meetings to inform the public about its new responsibilities and use DoD news media, installation visits, and other initiatives to ensure that the active and reserve components of each military service also understand the organization�s enhanced mission. (Chapter 2)
• The Board concurs with Dr. Harold Sox, chairman of the recent Institute of Medicine (IOM) study on Gulf War exposures, that combat stress should be investigated by the IOM with the same academic and scientific rigor that was used to evaluate other Gulf War exposures whose investigation Congress mandated. (Chapter 7)
• The Board recommends that OSAGWIMRMD be an active participant in the development and implementation of the life-cycle military health record. (Chapter 8)
• The Board recommends that OSAGWIMRMD and the MVHCB develop their mission requirements in support of meeting the needs of the reserve components. (Chapter 8)
• The Board recommends continued support and extension of the MVHCB concept, charter, and strategic plan and further encourages the respective departments to provide senior level endorsement, participation, guidance, funding, and staffing for the MVHCB. (Chapter 8)
• The Board recommends that the MVHCB and OSAGWIMRMD monitor developments by the Defense Integrated Military Human Resources System (DIMHRS) to resolve deficiencies and duplication in personnel management systems. (Chapter 8)
• The Board recommends that DoD and OSAGWIMRMD include the "cradle to grave" health record concept for all U.S. military members in its top-ten priorities list. This should include the computerized health record currently under development. (Chapter 8)
• The Board recommends that DoD, VA, and DHHS continue to apply lessons learned to their efforts to create a comprehensive health record for each veteran. The Board recommends that the MVHCB be integrated into the planning activities directed at the government computerized multidepartmental patient record concept in an ex officio status. (Chapter 8)
• The Board recommends that OSAGWIMRMD and the MVHCB closely monitor the development and resourcing of DoD�s research on the health effects of low-level CWA exposures and make recommendations as appropriate to ensure continued progress in this area. (Chapter 8)
• The Board recommends that the MVHCB remain the focal point for the collective efforts of its chartering sponsors and that the recommendations of the MVHCB represent a synthesis of the individual departmental efforts. (Chapter 8)

Observations:

• The Department of Defense has acted responsibly, decisively, and in good faith in responding to the President�s charge to "leave no stone unturned" in the search for the cause(s) of the undiagnosed illnesses from which some Gulf War veterans still suffer.
• Science alone should determine whether a Gulf War illness or syndrome exists. To date, research has not validated any specific cause of these illnesses, and the general population experiences the same symptoms associated with the undiagnosed illnesses of some Gulf War veterans.
• Government agencies must continue to address the challenging Gulf War veterans issues of medical research, health care delivery, and disability claims processing.
• The Board strongly believes that efforts to fund non-peer-reviewed research projects do not serve the best interest of the nation or of its Gulf War veterans. Researchers and clinicians who advocate "alternative" diagnostic and treatment methods, as well as those proposing more conventional approaches, should be encouraged to respond to Requests for Proposal and Broad Area Announcements with well-constructed proposals capable of passing vigorous and independent peer review.
• The Board notes that the executive and legislative branches of government do not have a mechanism to budget and to appropriate funding for health care, rehabilitation, and disability compensation costs that arise after every major conflict or military deployment involving hostile fire. The two branches should develop a budgetary process that automatically incorporates funding for these post-deployment services into the operational costs of a deployment. For example, when the Secretary of Defense estimates to the President the cost of a major operational mission (e.g., Desert Storm/Desert Shield), the estimate should include an allowance for follow-on medical care and treatment for the U.S. Government participants (military and U.S. Government civilian, not contractors). This cost, when funded, could serve as a mechanism for the DoD and VA to provide medical care for veterans and military personnel suffering from illnesses of unknown etiology which were not present or identified prior to the operation or deployment.
• The Board believes that DoD should fully support the Millennium Cohort Study and that the service members selected to participate in the program should cooperate fully. This twenty-year research project will significantly enhance the Federal Government�s and the medical community�s understanding of the long-term health consequences of military service and facilitate improved clinical care and force health protection for members of the Armed Forces. The study will provide better insight into the possible health effects of service in Bosnia, Kosovo, Southwest Asia, and future deployments and also contribute to VA�s development of services that will meet the needs of veterans who have participated in overseas operations.
• The Board notes that DoD and VA do not share a core set of questions used in Gulf War illness studies, especially epidemiological studies. The two agencies should consult with the Centers for Disease Control and Prevention's National Center for Health Statistics to design a core set of questions that will result in responses that are comparable with those from other national surveys (i.e., NHIS or NHANES). DoD and VA lose the advantage of comparability of response to survey data from the general population when their questionnaires are not compatible with existing surveys.
• The Board believes that DoD and/or VA should conduct a time series geographical information system analysis from a random sample of deployed Gulf War veterans to identify whether any health outcome clusters occurred in the Kuwaiti Theater of Operations.
• The Board notes that the U.S. Government�s haste to respond to media and public expectations for definitive answers to the unintentional release of chemical warfare agents at Khamisiyah stimulated distrust of the government among many veterans and others as inaccurate initial estimates gave way to a flurry of increasingly more accurate, yet ever changing, revisions. The Board strongly believes that the public has the right to receive timely, accurate, and supposition-free information on matters of such grave import. Accordingly, the government must acknowledge when it possesses insufficient information to make an accurate assessment and resist the temptation to make definitive statements in the absence of reliable environmental and meteorological data, in-depth modeling, and careful analysis. Failure to do so will cause some veterans and others to falsely accuse the government of a cover-up and prompt many veterans to attribute their illnesses to exposures that did not occur, could not have occurred, or were too small to cause even transient observable effects.

The Board included twelve recommendations in its Interim Report. DoD and OSAGWI have complied or are complying with the eight recommendations that remain valid.

• The Board recommends that the Special Assistant (OSAGWI) report to the Board within sixty days (from the July 13, 1999, Board hearing) identifying 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. (Interim Report, Chapter 1)
• The Board recommends that the MITRE Report¹ regarding intelligence collection and analysis during the Gulf War be issued in an unclassified form. (Interim Report, Chapter 2)
• The Board recommends that OSAGWI should clearly demonstrate how it digests and evaluates the information it amasses to reach the conclusions presented in its reports. (Interim Report, Chapter 4)
• The Board recommends that OSAGWI should develop a policy for determining when and by what criteria interim reports should become final. (Interim Report, Chapter 4)
• The Board recommends that OSAGWI include in the rewrite of its DU environmental exposure report the exposure parameters (such as quantity of DU, duration of exposure) for the thirteen exposure scenarios (presented in Table 1, page 8) to establish that Level I scenarios represent the highest exposure levels. (Interim Report, Chapter 4)
• The Board recommends that OSAGWI extend the external review of its environmental exposure reports to other appropriate agencies and subject matter experts. (Interim Report, Chapter 4)
• The Board recommends that in assessing the likelihood of the presence of chemical or biological agents OSAGWI should present in its reports the evidence, its expert opinion, and the assumptions it used to weigh the pieces of evidence in reaching its conclusions. (Interim Report, Chapter 4)
• The Board recommends that the Department of Defense continue to review new information and modeling results, and take action as necessary and appropriate. (Interim Report, Chapter 5)

The Board believes that the other four recommendations no longer apply due to policy changes and other factors:

• The Board recommends that the Assistant Secretary (C³I) respond to this recommendation [adding a position location capability to the Personal Information Carrier] and report to the Secretary of Defense and the Board, within thirty days of this report, as to the progress on this matter as reported by the Chairman of the Joint Chiefs of Staff. (Interim Report, Chapter 1)
• The Board recommends that OSAGWI cease work on all information papers except those due to be released within sixty days of the publication of this report. (Interim Report, Chapter 3)
• The Board recommends that any continuation of the "lessons learned" activity at OSAGWI be supported by a plan, approved and directed by the Secretary of Defense, that addresses and recognizes the formal integration of the OSAGWI lessons learned team into the existing Military Service and Joint Staff lessons learned infrastructure. (Interim Report, Chapter 3)
• The Board recommends that the Secretary of Defense obtain a formal commitment from the Secretary of Veterans Affairs for routine participation and representation by VA in support of OSAGWI�s outreach and town hall meetings. (Interim Report, Chapter 3)

This report, entitled Iraqi Chemical Warfare: Analysis of Information Available to DoD, is also known as the Mitre Report. The report was commissioned by the Office of the Assistant to the Secretary of Defense for Intelligence Oversight.