[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
PROTECTING THE HEALTH OF DEPLOYED FORCES: LESSONS LEARNED FROM THE
PERSIAN GULF WAR
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
EMERGING THREATS AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
MARCH 25, 2003
__________
Serial No. 108-54
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
______
89-544 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
CHRIS CANNON, Utah DIANE E. WATSON, California
ADAM H. PUTNAM, Florida STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma C.A. ``DUTCH'' RUPPERSBERGER,
NATHAN DEAL, Georgia Maryland
CANDICE S. MILLER, Michigan ELEANOR HOLMES NORTON, District of
TIM MURPHY, Pennsylvania Columbia
MICHAEL R. TURNER, Ohio JIM COOPER, Tennessee
JOHN R. CARTER, Texas CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota ------
MARSHA BLACKBURN, Tennessee BERNARD SANDERS, Vermont
(Independent)
Peter Sirh, Staff Director
Melissa Wojciak, Deputy Staff Director
Rob Borden, Parliamentarian
Teresa Austin, Chief Clerk
Philip M. Schiliro, Minority Staff Director
Subcommittee on National Security, Emerging Threats and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
MICHAEL R. TURNER, Ohio
DAN BURTON, Indiana DENNIS J. KUCINICH, Ohio
STEVEN C. LaTOURETTE, Ohio TOM LANTOS, California
RON LEWIS, Kentucky BERNARD SANDERS, Vermont
TODD RUSSELL PLATTS, Pennsylvania STEPHEN F. LYNCH, Massachusetts
ADAM H. PUTNAM, Florida CAROLYN B. MALONEY, New York
EDWARD L. SCHROCK, Virginia LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee C.A. ``DUTCH'' RUPPERSBERGER,
TIM MURPHY, Pennsylvania Maryland
WILLIAM J. JANKLOW, South Dakota CHRIS BELL, Texas
JOHN F. TIERNEY, Massachusetts
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Thomas Costa, Professional Staff Member
Kristine McElroy, Professional Staff Member
Robert A. Briggs, Clerk
David Rapallo, Minority Counsel
C O N T E N T S
----------
Page
Hearing held on March 25, 2003................................... 1
Statement of:
Moxley, Dr. John H., III, managing director, North American
Health Care Division, Korn/Ferry International; Dr. Manning
Feinleib, professor of epidemiology, Bloomberg School of
Public Health, Johns Hopkins University; and Steven
Robinson, executive director, National Gulf War Resource
Center, Inc................................................ 77
Winkenwerder, William, Jr., M.D., M.B.A., Assistant Secretary
of Defense for Health Affairs, Department of Defense,
accompanied by Michael E. Kilpatrick, Deputy Director for
the Deployment Health Support Directorate, Department of
Defense; Robert H. Roswell, M.D., Under Secretary for
Health, Department of Veterans Affairs, accompanied by K.
Craig Hyams, Chief Consultant, Occupational and
Environmental Health, Department of Veterans Affairs....... 14
Letters, statements, etc., submitted for the record by:
Burton, Hon. Dan, a Representative in Congress from the State
of Indiana, prepared statement of.......................... 130
Feinleib, Dr. Manning, professor of epidemiology, Bloomberg
School of Public Health, Johns Hopkins University, prepared
statement of............................................... 97
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio:
Letters dated November 27, 2002 and February 27, 2003.... 7
Letter dated February 27, 2003........................... 41
Maloney, Hon. Carolyn B., a Representative in Congress from
the State of New York:
Pages from ``Saddam's Bombmaker,''....................... 44
Prepared statement of.................................... 13
Moxley, Dr. John H., III, managing director, North American
Health Care Division, Korn/Ferry International, prepared
statement of............................................... 80
Robinson, Steven, executive director, National Gulf War
Resource Center, Inc., prepared statement of............... 111
Roswell, Robert H., M.D., Under Secretary for Health,
Department of Veterans Affairs, prepared statement of...... 26
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut:
Letter dated January 20, 2003............................ 57
Prepared statement of.................................... 3
Winkenwerder, William, Jr., M.D., M.B.A., Assistant Secretary
of Defense for Health Affairs, Department of Defense:
Followup questions and responses................ 50, 60, 62, 67
Prepared statement of.................................... 18
PROTECTING THE HEALTH OF DEPLOYED FORCES: LESSONS LEARNED FROM THE
PERSIAN GULF WAR
----------
TUESDAY, MARCH 25, 2003
House of Representatives,
Subcommittee on National Security, Emerging Threats
and International Relations,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2 p.m., in
room 2247, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Present: Representatives Shays, Turner, Lewis, Murphy,
Janklow, Kucinich, Maloney, Bell and Tierney.
Staff present: Lawrence Halloran, staff director and
counsel; Thomas Costa and Kristine McElroy, professional staff
members; Robert A. Briggs, clerk, Joe McGowen, detailee; David
Rapallo, minority counsel; and Jean Gosa, minority assistant
clerk.
Mr. Shays. I would like to call this hearing to order, this
hearing entitled, ``Protecting the Health of Deployed Forces:
Lessons Learned from the Persian Gulf War.''
When the war in Iraq is over, we will mourn our dead, and a
grateful Nation will welcome home legions of battle-tested men
and women who fought for freedom in a far-off place. Some will
be well. Some will be wounded. We may not always be able to
tell the difference.
Not all the casualties of modern warfare are apparent.
Injuries and illnesses linked to exposures to chemicals,
pathogens, and toxins may not manifest symptoms until months or
years after the victory parades. But those wounded are as much
our responsibility to prevent or treat as those caused by
bullets and bombs on the battlefield. Today we ask if the
health of deployed forces is being effectively monitored and
adequately protected against the insidious but often avoidable
perils of their very hazardous workplace.
Gulf war operations in 1991 could have taught us much about
the dose-response relationship between wartime exposures and
delayed health effects, but essential health data was never
recorded. The Department of Defense [DOD], took years to
acknowledge obvious deficiencies in Gulf war-era health
protections for deployed forces. Since 1997, the Pentagon has
issued impressive volumes of directives and joint staff
policies on improved medical recordkeeping, battlefield
environmental monitoring, troop location data, and health
surveillance before, during and after deployments. External
panels of experts have echoed those recommendations to
standardize and integrate service-specific protocols and
systems. The 1998 Defense Authorization Act directed the
Department to implement many of the recommended improvements to
medical tracking and disease prevention.
Witnesses today will describe substantial progress in
applying the lessons learned during Operation Desert Storm
about force health protection, but questions remain whether the
ambitious plans and proposals of peacetime will be able to
pierce the fog of war and yield the detailed real-time
information needed to assess health effects after the battle.
Do the pre and postdeployment questionnaires now being
administered meet the statutory mandate for medical
examinations? Will the brief, hastily administered surveys
capture the data required by DOD and the Department of Veterans
Affairs [VA], to reach valid epidemiological conclusions about
service-connected health effects?
VA Secretary Anthony Principi recently concluded, much of
the controversy over the health problems of veterans who fought
in the 1991 war could have been avoided had more extensive
surveillance data been collected. We agree. There should be no
mysterious Iraq war syndrome after this victory. Veterans of
this era should not go empty-handed into battle to prove
deployment exposures caused or contributed to their postwar
illnesses.
In modern warfare, smart weapons dominate the battlefield
and minimize collateral casualties. By far the smartest, most
complex, most elegant system we send into battle is the human
body. Accurate timely information is the life-cycle maintenance
log of our most precious military asset, freedom's sons and
daughters, brothers and sisters, fathers and mothers. We look
to those entrusted with their care to protect them.
We welcome our witnesses this afternoon, and we look
forward to their testimony.
[The prepared statement of Hon. Christopher Shays follows:]
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Mr. Shays. At this time I'd like to call on our vice
chairman of the committee.
Mr. Turner. I don't have an opening statement. I look
forward to hearing their testimony. This certainly is an
important issue for us.
Mr. Shays. I thank the gentleman.
Mr. Kucinich, I know you just walked in. Do you have a
statement you'd like to make, or shall we just swear them in?
Mr. Kucinich. I'd like to make a statement.
Mr. Shays. You've got it.
Mr. Kucinich. Thank you, Mr. Chairman. Good afternoon, Mr.
Chairman. Welcome to the witnesses.
The first Gulf war was 13 years ago, but as a country,
we've not yet implemented the lessons that we've learned since
that time. I believe that this failure may bring harm to our
troops now in Iraq, and that is unacceptable.
Part of this delay, unfortunately, was caused by a series
of misstatements perpetuated by the Defense Department itself.
Mr. Chairman, as you know, it took one group of dedicated
veterans over 4 years to force the Pentagon to reveal that
Iraqi stocks of sarin gas at Khamisiyah had been blown up by
U.S. troops, exposing over 140,000 American soldiers.
Steve Robinson, who will testify before us later, said in a
recent interview, ``that was the first lie. Then the Pentagon
said, maybe 100 soldiers had been exposed. Then it was maybe
1,000. Lie after lie. Now it's up to 140,000.''
Similar concerns were raised about depleted uranium. Again,
dedicated veterans spent years filing Freedom of Information
requests to obtain information about friendly fire incidents
involving depleted uranium. Although the Pentagon first said
only 35 soldiers were exposed, this number soon increased to
122, then to 932, and then to thousands who breathed in
depleted uranium.
Unfortunately, it appears that Dr. Winkenwerder, who will
also testify here today, has become part of the cycle. In
January he issued a press release, which I would like to make
part of the record. In the press release he made this
statement, ``the U.S. military is prepared to protect its
personnel against the use of biological weapons.'' In fact,
many Pentagon and White House officials have declared that
troops are prepared for war in Iraq. While they understand the
desire to provide assurance that a problem is being addressed,
broadly claiming total preparedness in the face of evidence to
the contrary is reckless.
Last year the Army's own audit agency identified what it
called, ``a breakdown in the Army's primary control for
ensuring the maintenance and sustained operability of chemical
and biological equipment.'' They found that 62 percent of gas
masks and 90 percent of chem-bio detectors didn't work. They
said soldiers at 18 of 25 units they reviewed weren't
proficient and couldn't operate basic equipment.
GAO has also testified before this committee about
shortages of critical items. One military wing, for example,
had only 25 percent of the protective masks required. In
addition, the GAO discovered--the General Accounting Office
discovered, amazingly, that some military units were selling
their protective suits on the Internet for $3, while other
units were desperately clamoring for these critical items. In
fact, the Pentagon's own inspector general raised these
concerns, stating that, ``420,000 suits were not on hand as
recorded in the inventory balance.''
For these reasons, Congresswoman Jan Schakowsky, a former
member of this subcommittee, wrote to Defense Secretary
Rumsfeld to ask him do the troops going to Iraq have the
minimum required levels of chem-bio protective equipment. She
asked him to certify this to Congress. On February 27, just 3
weeks before the war in Iraq began, she got her answer, and
that answer was no. The Defense Department refused to certify
to Congress that it had provided to troops in Iraq the minimum
levels of chem-bio equipment as those levels were established
by the Pentagon itself. And I would like to ask that this
letter also be included into the record.
[The information referred to follows:]
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Mr. Kucinich. If the Secretary of Defense won't certify
that the troops are prepared, I'm at a loss as to how anyone in
the administration can do so. Perhaps it depends on what their
definition of ``prepared'' is. In this case, it does not appear
to mean meeting the minimum required levels of critical
equipment or training. This certainly does not bode well for
the larger question of medical surveillance.
We must also examine how we are treating veterans of the
first Gulf war. We must honor those who have fought for this
Nation by taking care of their health needs. However, as our
Armed Forces are ordered to implement this new war, the
administration is proposing sweeping new cuts to veterans'
health. The administration's 2004 budget for VA would restrict
access to care and increase cost. It would halt the enrollment
of all new priority 8 veterans, denying them any access to VA
care. According to data from the VA, this proposal will deny
care to 173,000 veterans nationwide.
This administration would also charge all priority 7 and 8
veterans a new $250 annual enrollment fee as a new policy for
VA, which has never charged an enrollment fee.
The administration would also increase copayments. VA
estimates that 55 percent of all enrolled priority 7 and 8
veterans, over half will drop out of the VA system altogether.
Overall the administration's proposals would force 1.25 million
enrolled veterans, including 425 active patients, out of the VA
health care system.
The administration's budget also fails to provide any
additional service-connected disability benefits resulting from
the present war with Iraq. As we know from the last conflict in
the Gulf, war results in adverse health effects and claims for
service-connected disability compensation. What message do we
send to our troops in Iraq, knowing that many won't receive
health benefits when they come home? Congress is to receive a
$75 billion war supplemental request from the President. Why is
there not a single dime for veterans' health benefits in that
$75 billion? It's hard to believe that this war will not
increase the cost to the veterans' health system, yet the
administration is solely focused on war to the exclusion of its
effect on our troops, our veterans or our economy.
Mr. Chairman, our men and women in uniform, both Active
Duty and Retired, deserve more than empty assurances. They
deserve the best protection we can provide, and frankly, we're
not living up to that promise. Thank you, Mr. Chairman.
Mr. Shays. Thank the gentleman.
At this time the Chair would recognize Mr. Murphy, if he
has a comment to make.
Mr. Murphy. Nothing yet. Thank you.
Mr. Shays. Thank you. I'll just go down.
Mr. Janklow.
Mr. Lewis.
Thank you.
Mrs. Maloney, we're kind of getting to you as you're
walking in.
I have a feeling, knowing you, you have a statement you want to
make.
Mrs. Maloney. I'm looking forward to the testimony. I'll
put my statement in the record in the interest of time.
Mr. Shays. Thank you very much.
[The prepared statement of Hon. Carolyn B. Maloney
follows:]
[GRAPHIC] [TIFF OMITTED] T9544.007
Mr. Shays. I would like to first take care of some business
and ask unanimous consent that all members of the subcommittee
be permitted to place an opening statement in the record and
that the record remain open for 3 days for that purpose. And
without objection, so ordered.
I ask further unanimous consent that all witnesses be
permitted to include their written statements in the record.
And without objection, so ordered.
We have two panels. Our first panel is Dr. William
Winkenwerder, Assistant Secretary of Defense for Health
Affairs, Department of Defense; accompanied by Dr. Michael
Kilpatrick, Deputy Director of the Deployment Health Support
Directorate, Department of Defense; accompanied by Dr. Robert
H. Roswell, Under Secretary for Health, Department of Veterans
Affairs. Excuse me. I'm sorry. Dr. Robert H. Roswell will be
making a statement, accompanied by Dr. K. Craig Hyams, Chief
Consultant, Occupational and Environmental Health, Department
of Veterans Affairs. And Dr. Roswell is Department of Veterans
Affairs as well for Under Secretary for Health.
At this time, gentlemen, I will swear you in. Now, if there
is anyone who might be behind you that might need to respond to
questions, I'd like them to respond as well so we can swear
them in, if you have anyone you want to direct to stand. So if
you'd rise, I'll swear you in. Raise your right hands.
[Witnesses sworn.]
Mr. Shays. Note for the record that our witnesses have
responded in the affirmative.
Am I pronouncing your name Roswell--is that--I'm sorry. I'm
a tennis fan. I think we'll start with you, Dr. Winkenwerder.
STATEMENTS OF WILLIAM WINKENWERDER, JR., M.D., M.B.A.,
ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT
OF DEFENSE, ACCOMPANIED BY MICHAEL E. KILPATRICK, DEPUTY
DIRECTOR FOR THE DEPLOYMENT HEALTH SUPPORT DIRECTORATE,
DEPARTMENT OF DEFENSE; ROBERT H. ROSWELL, M.D., UNDER SECRETARY
FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY K.
CRAIG HYAMS, CHIEF CONSULTANT, OCCUPATIONAL AND ENVIRONMENTAL
HEALTH, DEPARTMENT OF VETERANS AFFAIRS
Dr. Winkenwerder. Thank you, Mr. Chairman. Mr. Chairman,
members of the subcommittee, thank you for the opportunity to
appear here today. With your permission, I will summarize my
written statement. And also with me today to answer questions,
if that is acceptable to you----
Mr. Shays. That is fine.
Dr. Winkenwerder [continuing]. Is Dr. Michael Kilpatrick,
whom you've already introduced.
I want to begin----
Mr. Shays. Let me just ask, can you all hear in the back of
the room? No. I need you to speak up a little louder. Thank you
very much. It is the silver mic that projects your voice.
Dr. Winkenwerder. All right. Thank you.
I want to begin by adding my condolences to those of
President Bush and the Secretary of Defense for the families'
of the U.S. casualties since operations began last week. Each
of you is in our prayers. Our country's ultimate weapon against
any enemy is the valor of the men and women in our armed
services who serve the cause of freedom. They comprise the most
powerful force on Earth, and, in this particular case today, a
force for peace and liberation of the Iraqi people.
On behalf of all the men and women in medical service to
our Armed Forces, I want to recognize the cause for which many
have now given their lives and the efforts to ensure the safety
of everyone engaged in this conflict. The courage, skill and
discipline of our military medical personnel is matched only by
the high-quality, swift and effective medical care that they
provide.
You have already seen reports by embedded media of heroic
acts by U.S. Armed Forces medics to save lives; for example,
the MediVac crews and surgical teams that have gone into very
dangerous situations. We can be assured that today such acts
will continue, and they will continue until our final mission
is accomplished. In Operation Iraqi Freedom we have more than
sufficient capability to move casualties from their point of
wound to any level of care their injuries might require. We
have more than sufficient medical supplies, including blood
supplies, for all of our troops operating in the field, and all
of this is regulated by an integrated logistics system in the
theatre.
Our medical medics and soldiers are trained, equipped and
prepared to operate in the contaminated environment, if
necessary, with equipment decontamination and antidotes. We are
prepared for what Saddam Hussein might attempt to deliver to
U.S. forces.
As the Assistant Secretary of Defense for Health Affairs,
safeguarding the health and safety of our military members is
my highest priority. Our force health protection program has
made great strides based on the lessons learned from the Gulf
war and subsequent deployments. I believe our efforts are in
line with your own objectives, as these have been expressed in
public law.
The Department is committed to providing an ongoing
continuum of medical service to service members from entrance
into the military through their separation and as many
transition to the Department of Veterans Affairs after their
service.
The vigorous requirements of entrants' physical exams,
periodic physical examinations, periodic HIV screening, annual
dental examinations, routine physical training and periodic
testing and then regular medical record reviews are all part of
this continuum.
We've established a comprehensive program to sustain and
document our service members' health and fitness for duty. All
deploying personnel are required to complete individual
predeployment health assessments. These health assessments are
coupled with a review of medical and immunization records. We
look at whether there is a DNA sample on record, and if a blood
serum sample has been drawn within the prior 12 months. This
information is considered, along with the availability of
personal protective and medical equipment. Predeployment
briefings on deployment-specific health threats and
countermeasures are also provided. All personnel complete
postdeployment health assessments when they return.
Any indication of health concerns results in an individual
health review and, if appropriate, referral for further medical
evaluation or testing. These health assessments are to be
maintained in the individual's medical records and centrally in
electronic format in the defense medical surveillance system.
Additionally, all immunizations are tracked by service-
specific systems, and the data are fed into a central data
base. We're currently transitioning from paper-based medical
records to automated medical records for patient encounters and
reporting of nonbattle and disease events.
Health care focused on postdeployment health concerns is
available through both military and VA providers who are using
jointly the postdeployment health clinical practice guidelines.
These guidelines were designed to ensure that the medical
providers render effective and appropriate responses to the
medical concerns of our deployed service members and their
families upon return.
We've established three deployment health centers. One
focuses on deployment-related health care, one on related
health surveillance, and the third on health research. All are
working toward prevention, treatment and understanding of
deployment-related health issues.
Desert Shield, Desert Storm taught us knowledge of the
environment is vital if we're to protect the health of our
service members. Today the Army's Center for Health Promotion
and Preventive Medicine conducts environmental health
assessments that enable intelligence preparation of the
battlefield before and during deployments. This unit employs
equipment to monitor the combat environment, and it samples
soil, air and water. They also perform extensive environmental
assessments of staging areas and base sites. This information
is used to make determinations of where we can safely put our
military people. We also archive that information so that we
can go back amend, look at it later to evaluate for correlation
between an area of known or suspected exposure and illness that
may appear in the future.
In the past few months, we've been working to develop and
have implemented a joint medical workstation. This is an
important development. We're using a Web-based force health
protection portal to our classified system, and DOD now has the
electronic capability to capture and disseminate real-time and
near real-time information to commanders about in-theatre
medical data, patient status, environmental hazards, detected
exposures and critical logistics information like blood, beds
and equipment availability.
The transition from paper-based processes to automated
systems offers us a much greater opportunity for collecting and
analyzing medical information that is useful in real time. We
proceed with that work with an awareness of operational
security and personal security for our service members who
expect their medical records to remain confidential.
When we deploy, we bring a formidable medical capability.
This includes far-forward surgical care, and we've seen this on
the battlefield just in the past few days; medical evacuation
assets, with the ability to provide intensive care, ICU care,
inside an airplane; and ship-based medical capabilities.
In the event of a biological or chemical attack, we also
maintain significant decontamination equipment and the ability
to treat both chemical and biological casualties. All services
have made training improvements, and they've been significant
to do that, to assure that their medical personnel can work
successfully in a contaminated environment and decontaminate
and rapidly evacuate their patients to safer environments.
Much has been accomplished in the past decade. Our level of
effort and our capability to protect our forces is
unprecedented in military history. However, today we face new
and deadly threats and the possibility that a brutal regime
would use chemical or biological weapons.
As military professionals and as health professionals,
we're well aware that war, and particularly this war, involves
real risks, but our message to you, to our service members, to
their families, to the American people is that we're prepared,
and we have extraordinary capability to protect and care for
our people.
Mr. Chairman, I thank you again for inviting me here today.
I'm pleased to answer your questions, and I know there will be
many. Thank you.
Mr. Shays. I thank you.
[The prepared statement of Dr. Winkenwerder follows:]
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Mr. Shays. Dr. Roswell. I'm going to ask you to bring the
mic a little closer. I know it's got a bulky platform to it.
Dr. Roswell. Mr. Chairman, I'm pleased to be here to
testify before the subcommittee today. With me, as you
indicated, is Dr. Craig Hyams, who is the VA Chief Consultant
for Occupational and Environmental Health.
The VA today is better prepared to provide high-quality
health care and disability assistance than at any other time in
history. And let me begin by dispelling two concerns raised in
his opening remarks by Mr. Kucinich. First of all, let me point
out that Public Law 105-368 authorizes 2 full years of medical
care for any veteran serving in a combat zone for any possible
condition related to the military service. So despite the
constraints of our current budget, despite an unprecedented
demand for VA health care, I want to assure this committee that
no veteran serving in the current conflict with Iraq will go
untreated by the VA upon their return, should they need such
care.
Let me also point out that disability compensation was
authorized following the Desert Storm/Desert Shield war for
even undiagnosed illnesses when those became problematic for
many of the men and women who served in the Persian Gulf war.
Special legislation authorized VA to provide disability
compensation for undiagnosed claims, and because the Persian
Gulf war has never officially ended, that same authorization
exists today and will exist and be available for anyone
currently serving in the conflict in Iraq.
Since the operation of Desert Shield and Desert Storm in
1991, a number of improvements have been put in place to better
allow us to meet the health care needs of our veterans. VA has
implemented an innovative new approach to health care known as
the Veterans Health Initiative. This is a comprehensive program
designed to increase recognition of the connection between
military service and certain health effects, better document
veterans' military and exposure histories, improve patient care
and establish a data base for further study.
In 2002, VA established two war-related illness and injury
centers to provide specialized health care for veterans for all
combat and peacekeeping missions who suffer difficult to
diagnose, but disabling illnesses. These centers provide
research into better treatment and diagnoses and develop
education programs for health care providers.
The Gulf war made clear the value of timely and reliable
information about wartime health risks. VA has already
developed a brochure that addresses the main health concern for
military service in Afghanistan and is currently preparing
another brochure for the current conflict in the Gulf.
VA has recently developed new clinical practice guidelines
based on the best scientifically supported practice that will
give health care providers the needed structure, clinical tools
and educational resources that will allow them to diagnosis and
manage patients with deployment-related health concerns. It's
our goal that all veterans who come to VA will find their
doctors to be well informed about specific deployment and
related health hazards.
We're also working very closely with the Department of
Defense to improve care and interagency coordination of health
information. As you know, governmental coordination plays a
critical role in addressing health problems of veterans.
In fiscal year 2002, a special deployment health working
group of the VA, DOD Health Executive Council, was established
to ensure interagency coordination for all veteran and military
deployment health issues. This group continues the efforts
begun by the Persian Gulf Veterans Coordinating Board and the
Military and Veterans Health Coordinating Board.
DOD with VA support is developing the Recruit Assessment
Program to collect comprehensive baseline health data from all
U.S. military recruits. As the first module of a lifelong
military veteran and health record, this program will help DOD
and VA evaluate health problems among service members and
veterans and address post-deployment health questions and
document changes in health status.
VA and DOD are collaborating on several important health
applications that will permit the departments to offer a
seamless electronic medical record system, a lifelong medical
record system. Key initiatives are the Federal Health
Information Exchange and the Healthy People Federal Project.
Mr. Chairman, a veteran separating from military service
and seeking health care today will have the benefit of VA's
decade-long experience with Gulf war health issues, but the
real key to addressing long-term needs of veterans is improved
medical recordkeeping and environmental surveillance.
For VA to provide optimal health care and disability
assistance after the current conflict with Iraq, we will need a
complete roster of veterans who served in designated combat
zones; and second, we will need any data from predeployment,
deployment and postdeployment health evaluation and screening.
Furthermore, in the event Iraq uses any weapon of mass
destruction, it's vital that VA have as much health and
environmental information as possible on potential exposure and
their health effects. This information will allow us to provide
appropriate health care and disability compensation for
veterans of this conflict.
Mr. Chairman, this concludes my statement. Dr. Hyams and
myself would be happy to answer any questions you may have.
Mr. Shays. Thank you very much.
[The prepared statement of Dr. Roswell follows:]
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Mr. Shays. We've been joined by Mr. Bell and Mr. Tierney,
and we have a full group of Members here. We're going to do the
5-minute rule. Usually we do 10 minutes, because it allows us
to get a little deeper, but we'll have a second round. And I am
going to start off this time.
I want to ask why the Department of Defense is not taking
actual physicals of every member who goes into conflict
overseas. When we passed Public Law 105-85, the medical
tracking system for members deployed overseas--that is section
1074, subsection (a), the system required, the Secretary of
Defense shall establish a system to assess the medical
conditions of members of the Armed Forces, including members of
the Reserve components who are deployed outside the United
States or its territories or possessions as part of a
contingency operation, including a humanitarian operation,
peacekeeping operation or similar operations, or combat
operations.
And subsection (b), elements of system, a system described
in subsection (a) shall include the use of predeployment
medical examinations and postdeployment medical examinations,
including an assessment of mental health and the drawing of
blood samples to accurately record the medical condition of
members before their deployment and any changes in their
medical condition during the course of their deployment.
I'm pretty clear, when we voted on this law, what that
meant to me. I'm just curious to know why we're not seeing it
implemented. And, Dr. Winkenwerder, would you kind of tell me
why not?
Dr. Winkenwerder. We believe that we are following the law,
and that we're doing it in a way that makes sense. As you
read--and I think it is very helpful to read the actual
language of the law here--you note the fact that we're required
to develop a system to assess the medical condition. I think
that's the operative point. It is to understand what is the
baseline health, and when one is looking at a young generally
healthy population, the most useful information to ask--or to
determine the health status of that individual is a set of
questions. I think, from my experience as a physician, that
history-taking is really the most useful information to get a
picture of the health status of the individual, not so much a
hands-on physical examination. Usually those types of
examinations are of very limited value.
We do perform periodic full physical examinations, along
with the drawing of blood, but it is our view that we are
meeting the letter and the spirit of the law----
Mr. Shays. Let me just tell you, from my standpoint, you're
not meeting the letter of the law clearly, and I don't even
think you're meeting the spirit of the law.
So I'd like to know where it says that this examination
should be a self-assessment. Where in the law do you read self-
assessment?
Dr. Winkenwerder. Well, it is not only a self-assessment.
There is a review by a medical provider with questioning by the
medical provider that gets at the history of the individual,
the medical history of that individual.
Mr. Shays. The challenge that I have is that we've had
countless numbers of hearings since Gulf war, because our folks
came home sick; 125,000 are registered with the VA out of
700,000. And it started out when we had our hearings that the
government officials would respond and say, no one came home
sick, and our second panel were people who were sick, and you
knew they were sick just looking at them. Then when you heard
their history--so we then reversed it. So we had them go first
and then had the VA and DOD come second and be the second
panel.
What I'm struggling with right now is we didn't accept
self-assessment when our VA folks--when our military folks came
back. We gave them a physical. We didn't ask them to fill out a
questionnaire. We gave them a physical. I can understand you'd
have them fill out a questionnaire, but doesn't the law say
that there's supposed to be a medical examination?
Dr. Winkenwerder. Well, again, medical examination and
physical examination are not synonymous. Some may have read
that to be the same, but as a physician, I would say that
they're not the same.
Mr. Shays. You know----
Dr. Winkenwerder. What we're attempting to do to really--to
answer your question, which I think is a very fair question, is
to ensure that we have a good baseline of information for every
individual that gives us what we need to know about the health
status of that individual.
Now, I'll stop at that. I was going to go into the issue of
the postdeployment.
Mr. Shays. Well, I'm sure you'll have an opportunity.
Let me just say before I recognize Mr. Kucinich that one of
the challenges with the concept of medical examination versus
physical examination is that it reminds me of what was alluded
to by Mr. Kucinich when we went to DOD and questioned whether
our troops had been exposed to chemical weapons, and we found
them using the word, they weren't exposed to offensive use of
chemicals.
Then we had a hearing in which we had a video of the
blowing up of Khamisiyah, and DOD has a press conference on
Friday at 4 o'clock before our Tuesday hearing to disclose that
our troops were exposed to defensive chemical exposure. I just
hope we're not getting a play on words here.
So at any rate, Mr. Kucinich, you have the floor.
Mr. Kucinich. Thank you very much, Mr. Chairman. Again, I
want to thank you for demonstrating your concern for the men
and women who serve by calling this hearing.
Dr. Winkenwerder, I would like to ask you about the press
release that you issued in January. In it you made a broad
statement. You said the U.S. military is prepared to protect
its personnel against the use of biological weapons. That's a
direct quote. You stated that, ``America's troops are well
trained and protected with a robust multilayered set of
defenses against bioweapons.''
Now, you say the troops are prepared. Does your definition
of prepared include training in a realistic environment?
Dr. Winkenwerder. Yes.
Mr. Kucinich. But, Dr. Winkenwerder, the GAO testified
before this subcommittee last fall, ``no realistic field
exercises for medical personnel of chemical and biological
defense have been conducted.'' None. How can you say that
you're prepared with no chem-bio field exercises for your
medical personnel?
Dr. Winkenwerder. That study, if it is the same one that I
believe you're referring to, was in 2001. That is the time when
that information was collected was approximately 2 years ago.
And I can just tell you that since that time there has been an
intensive effort to train a large number of people, both
nonmedical and medical.
When I took my position about 18 months ago and then was
before this committee about 14 months ago or 13 months ago, I
think, now, I committed to you that this matter of training
people would be one of my highest priorities.
Mr. Kucinich. Thank you.
Dr. Winkenwerder. And let me just say, we issued----
Mr. Kucinich. Doctor, I've got a question here that is a
followup, and I appreciate you taking this time to answer the
question, but I have another question.
Dr. Winkenwerder. OK.
Mr. Kucinich. And that is that are you familiar with the
war game called Millennium Challenge 2002?
Dr. Winkenwerder. Generally. So yes, I----
Mr. Kucinich. You say we're talking about 2001. Now let's
go to 2002. That was the largest war game in American history,
and it was also the most expensive at $250 million. It involved
over 13,000 soldiers, sailors, airmen. But when the commander
claimed the enemy wanted to simulate the use of chemical
weapons, he was told to disclose his troop locations and be
destroyed. He told the Army Times that instead of testing
against the most urgent threats, the game was rigged. Now, how
can you say, 2002, that you're prepared, when from this report
realistic field testing had not been done?
Dr. Winkenwerder. I'm not going to try to speak for our
commanders in the field, Army officers that planned and
conducted those exercises.
Mr. Kucinich. But how do you answer the question, though?
Do you have an answer to that question?
Dr. Winkenwerder. Well, I can't answer your question,
because I'm not in a position----
Mr. Kucinich. Let me move on to the next question if you
can't give me an answer.
Dr. Winkenwerder. Well, let me just stay this. I stand by
what I've said in terms of the preparation of our medical
personnel to operate in those environments, the preparation and
training to care for people, whether there's been exercises----
Mr. Kucinich. Doctor, Doctor, with all due respect, you
said you stand by what you said, but I gave you an example that
contradicted what you said, but you still stood by what you
said. Now, I just want that on the record.
Does your definition of ``prepared'' include providing
troops with the minimum level of necessary chem-bio equipment
as said by you and the Defense Department?
Dr. Winkenwerder. The minimum level of equipment to protect
people would be part of being prepared, absolutely.
Mr. Kucinich. And in light of all the equipment shortages
identified by the GAO, the critical deficiencies identified by
the Army audit agency and the false inventories identified by
the inspect general, tell me, Doctor, how can you assert that
you're prepared?
Dr. Winkenwerder. The first thing I would say to you is
you're bringing up issues that are not directly within my area
of responsibility, but I will tell you, based on my
conversations with other people in the Department of Defense
who do have some responsibility in that area, that the concerns
about suits and equipment have been addressed, and that there
is confidence, a high level of confidence, that the issues that
you refer to have been addressed and that people believe that
we are prepared.
Mr. Kucinich. Mr. Chairman, thank you. I just want to
conclude with this. Now, the doctor has said that the problem
has been fixed, and we were told this as well, and that's why
Congresswoman Schakowsky, who was part of our last committee,
wrote to Secretary Rumsfeld and asked him to certify to
Congress that these minimum required levels of chem-bio
equipment have been met. She got her answer 3 weeks before the
war, and her answer was no.
Dr. Winkenwerder. I'm not sure--I might respond, because I
think this is an important issue.
Mr. Shays. Sure. I do want you to respond. And I would like
the gentleman to put on the record the letter. I think the
letter didn't say no. I think it said they had two JSLIST
suits, which then you could interpret as not meeting the
minimum requirement. The JSLIST suits have 30 days each to
them.
Dr. Winkenwerder. Right.
Mr. Kucinich. Mr. Chairman, here is the letter.
Mr. Shays. We'll put that in the record.
[The information referred to follows:]
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Mr. Kucinich. Here's the letter, here's the response, and
it's very clear the answer was no.
Mr. Shays. For the record, since this is so technical, find
where the no is on that letter.
Mr. Kucinich. The text of this does not answer the question
as far as certification.
Mr. Shays. OK.
Mr. Kucinich. She asked for certification. If the Secretary
of Defense will not certify that these suits are OK, the
American people have a right to know that. The answer was no.
Mr. Shays. I got the same letter, and my interpretation of
it was that he was certifying that they would have--well, I
first have to make sure I have the same letter. I'll look at it
and then----
Dr. Winkenwerder. I want to attempt to answer your
question, even though I want to be clear that the issues you're
talking about are not within my area of responsibility, but I
don't want to avoid trying to answer the issue that is in front
of us.
Mr. Shays. I realize we have a 5-minute rule, but I will
extend a little more time if a Member, you know, is nervous
that the answer is a little long. But I don't want to have the
answer not be thorough enough to respond.
Dr. Winkenwerder. The issue with respect to chemical
protective suits, I believe you're referring to, is the number
of them, and each service member has been issued at least two,
and I'm told--the information I have is that each will have
three within a matter of less than a week.
Now, obviously that's to reach 100 percent. So they've been
moving toward that target obviously for the last several weeks.
And then I think there was another issue with some defective
suits, and, again, I'm going to relate to you my best
understanding of that, but my understanding is that those have
been removed from the inventory, and there was a very
deliberate, scrupulous effort to remove all of those suits, and
they are not being used in this situation today.
Mr. Shays. Well, we'll be here for a bit, so we can nail
this one down.
Mr. Turner.
Mr. Turner. Dr. Winkenwerder, I just recently met with
representatives from the Ohio National Guard, and they were
talking to me about the issue of National Guard Reservists that
do not have continuous health care coverage. They have
indicated numbers between 20 and 40 percent of the Reservists
do not have continuous health care coverage for insurance.
To what extent do you have a concern that might have an
impact on the medical condition of those deployed?
Dr. Winkenwerder. If I might just ask you, the 20 to 40
percent, is this without health insurance coverage, and they're
sort of private----
Mr. Turner. Correct. Correct.
Dr. Winkenwerder. My hope is that it would not impact upon
their health status. We do have a check on that, however, and
that is that we require a certain level of medical readiness
before people come on to Active Duty, and so we would hope to
screen for and identify individuals who are not medically ready
to serve.
Obviously the issue of health insurance or the lack thereof
among certain members of the population is an ongoing problem.
I will say that with respect to caring for National Guard
and Reservists and their families, when they come on Active
Duty, they are eligible for the military health system benefit
program, TRICARE. We've made--in a change that we had just 2
weeks ago, made it easier for them to gain coverage for their
families. There had been a glitch in the system where if a
person was living, for example, in one part of the country and
got deployed from another, that because they weren't residing
with their family--or their family wasn't residing with them,
they would not be eligible. We changed that. They're now
eligible right then and there. There was also a hurdle that one
had to be activated for 180 days. We changed that and said they
only need to be active for 30 days. So all those benefits are
commensurate between reservists and Guard and our ongoing
Active Duty.
And we gladly did that. Our Reservists and Guard are
playing a very important role in this conflict, and
particularly so in the medical area. So it's important that we
take care of them.
Mr. Turner. Thank you.
Mr. Shays. Thank you. I think we will go to Mrs. Maloney.
Mrs. Maloney. A few, Mr. Chairman, and I want to be
associated with your comments and those of the panel in
appreciation of our men and women who are serving in the armed
services.
I would like to ask some questions that were raised in this
book, Saddam's Bomb Maker. It was written by Khidir Hamza, who
says that he was in charge of Saddam's efforts to secure
materials from foreign governments to build nuclear bombs, and
he also talks about their chemical and biological weapon
program. And I would like permission to place in the record
page 244 and page 263.
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Mrs. Maloney. And he raises really an alarming statement,
and I would like to just quote from his statement here. He
says, ``the Gulf war syndrome was well known to everyone in
Iraq, but Saddam remained silent. In this he had a secret ally,
the U.S. Pentagon, which continued to deny that there was proof
of a war-based disaster--war-based disease despite growing
evidence to the contrary. But evidence soon leaked of allied
forces blowing up chemical dumps during the war and of the U.S.
Government efforts to suppress repeated efforts of reports of
the contamination of our troops.''
He also on page 244 talks about Saddam's effort to put
biological--or that he did put, according to him, biological
and chemical weapons into missiles that he was going to fire on
the U.S. military if they went into Baghdad, but that he had a
more sinister plan in that he buried chemical and biological
weapons in southern Iraq, knowing that the tactics of the U.S.
military would be to blow up the bunkers; therefore, they would
release the contaminated material, they would not even know
that they were affected, and that they would then be laden with
chemical and biological disease from these terrible weapons.
I'd like to ask you if you, No. 1, have read the book; No.
2, your comments on what Saddam's bomb maker, Mr. Hamza, who
has defected to the West and I understand is working with our
military and has been very outspoken against Saddam in
hearings, publicly and so forth.
Dr. Winkenwerder. I have not read the book, Congressman. I
have heard of the book. And by all accounts, it is a--from what
I understand, is a reliable piece of information.
Mrs. Maloney. Are you aware that our troops were exposed to
these biological weapons? The allegation that he makes that our
Pentagon knows, that Saddam knows, that people in Iraq know
that our troops were exposed to these terrible chemicals in the
Gulf war?
Dr. Winkenwerder. Well, from all the information that I've
been presented during my tenure, no one has ever indicated to
me that there is any knowledge of an acute exposure or the
exhibiting of symptoms that would suggest an acute exposure to
chemical or nerve agents during that conflict.
Mr. Shays. Would the gentlelady yield? I'll make sure she
gets additional time.
Mrs. Maloney. Sure.
Dr. Winkenwerder. That is a separate question, an acute
exposure, someone who is acutely ill, than the issue of whether
there were low levels of exposure----
Mrs. Maloney. Were there low levels of exposure?
Dr. Winkenwerder. Well, that is what the whole Khamisiyah
incident is about.
Mr. Shays. This is very important, and I don't want--since
this is testimony under oath, I do want to make sure. There are
really two issues, but one issue is sites. The only one that
the Department of Defense has acknowledged is Khamisiyah. So I
would love it if you would ask the question of whether there
were other sites, and then get into this other shoe. But I want
to make----
Mrs. Maloney. Were there other sites besides Khamisiyah
where they were exposed to chemical weapons?
Dr. Winkenwerder. Not to my knowledge.
Dr. Kilpatrick.
Dr. Kilpatrick. I can answer that. In looking at----
Mr. Shays. A little closer to the mic, Doctor.
Dr. Kilpatrick. In looking at the air war campaign, it's
very clear that at his storage sites at Al Muthanna and
Mahamadia there were releases of chemical agents. In one
location we have no indication there were American troops in
the area where that plume would have gone, and the other area
there were possibly up to 70 Special Forces people in that
area, but there were no coalition forces or American forces in
that area.
Then Khamisiyah is the third area, and that's been widely
publicized and put out, and certainly we've identified the
101,000 American forces who were in that hazard area that was
determined.
Mrs. Maloney. Well, Mr. Hamza alleges that Iraqis were
likewise exposed, and women gave birth to deformed children.
People died of cancer early. People had Parkinson's-like
neurological problems. And he blamed it all on malnutrition,
according to this professor, and he likewise said that the same
symptoms--or he alleges are now in the troops who regrettably
were exposed to these terrible chemicals in the war.
If you have any other information, if you could get back to
the chairman on it, on how many troops we think were exposed,
where they were exposed and what chemicals--what chemicals do
we think they were exposed to? Do you have an idea of what the
chemicals were or biological weapon they were exposed to? Do
you have an idea what it was?
Dr. Winkenwerder. Yes.
And Dr. Kilpatrick.
Dr. Kilpatrick. In all three areas, sarin--cyclosarin were
the agents that we were concerned about. As far as biological
agents, we don't have any indication that American troops were
exposed to biological agents. We do know that bombs and rockets
filled with biological agents were found by the United Nations
Special Commission, but we have no indication that they were
ever launched against Americans.
Mrs. Maloney. Excuse me. Go ahead, Mr. Chairman. My time is
up. I'd like to continue with this questioning.
Mr. Shays. Why don't you ask the next question, and then
we'll----
Mrs. Maloney. If you have another question.
Mr. Shays. I just want to say to you that it's a little
unsettling to me, because we've had so many instances--DOD has
insisted that the only place that our troops were exposed was
at Khamisiyah, and now we're hearing that we had other troops
that were nearby. So I'm not sure whether I should consider
this new information or old information, but it is a little
unsettling to me, because either way it's new to me. And so I
want to be clear that you have said that--there were two other
sites. I want you to say what those sites were, and I want you
to be very clear as to what level of the amount of chemicals we
think were onsite and compare them to Khamisiyah.
Dr. Kilpatrick. Those reports we released in the last 2
years, and I can get you specific details. Al Muthanna is one
site, and Mahamadia is the other site. These were large
production storage sites in Iraq near Baghdad, and they were
damaged during the air war. We don't know exactly which day,
because the bombing runs in each of those sites were over some
17 days. We don't know whether the release was at one time or
over multiple periods of time. The determination of the hazard
area assumed a release of all agent at one time, and the amount
of agent is information that we receive from CIA, and they have
recently released a report to give that amount. We can provide
that to you.
Mr. Shays. Well, I understand we have the GAO looking at
this, but--the plume modeling--but one thing I want to ask you
would be then how many American troops do you think--first off,
it's unsettling no matter what humanity was there, but how many
Americans do you think were at----
Dr. Kilpatrick. At Al Muthanna, we don't believe there were
any Americans in the area. At Mahamadia, we believe that there
were up to 70 Special Forces, and we have identified them and
notified them.
Mr. Shays. And have you notified the VA?
Dr. Kilpatrick. And that's been done also, yes.
Mr. Shays. OK. I thank the gentlelady for asking those
questions.
Mrs. Maloney. Mr. Chairman, could I followup with other
sites that----
Mr. Shays. Yes. Why don't we do that real quick.
Mrs. Maloney. They mentioned that they had it really as a
war strategy, burying these chemicals knowing we might bomb
them. The symptoms would not arise until weeks, months later.
They would not know where it came from.
But he mentions that they were buried, thousands of
chemical weapons in southern Iraq at Basra, Nasiriyah, Simawa,
Diwaniyah, and Hilla, the likely routes of the allied invasion.
And he says that that's what they did, and that we walked into
that trap.
Dr. Winkenwerder. I think you can conclude that this
provides a good window into the twisted mind of Saddam Hussein.
Mr. Shays. But is that an answer that is a yes?
Dr. Winkenwerder. We will take that information for the
record, and certainly----
Dr. Kilpatrick. And I have no information at this time to
be able to comment positively or negatively. I have no
knowledge that in fact is true.
Mrs. Maloney. Just very briefly, for years, literally, the
Pentagon denied that they were exposed to chemical weapons, and
he says that in the book. Why did we do that when we knew that
they were exposed? And when did we acknowledge in the timeframe
that they were exposed to chemical weapons?
Dr. Winkenwerder. Let me just say this. I cannot speak for
those who had my responsibility or were associated with those
responsibilities 5, 6, 7 years ago, at the time the information
began to come to light.
Mrs. Maloney. But can you get us that information?
Dr. Winkenwerder. Well, what I can tell you is that I am
committed to getting that kind of information out and making it
available, and that we know what happened. I think it is in
everyone's interest, our service members, their families.
Mrs. Maloney. And you will get that information to the
chairman, so we can----
Dr. Winkenwerder. We will take your request. But I just
want you to know that I am committed to making that kind of
information--and we have sought to establish a track record
with this for the release of the information regarding the
SHAD.
Mr. Shays. Let me just say. You are not just taking the
request. You are going to get us the information, correct?
Dr. Winkenwerder. We will.
Mr. Shays. Thank you.
[The information referred to follows:]
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Mr. Shays. Mr. Murphy, thank you for being so patient.
Mr. Murphy. Thank you, Mr. Chairman. Are there differences
between British troops and American troops in the Gulf war
syndrome incidents?
Dr. Winkenwerder. I am going to turn to Dr. Kilpatrick for
that.
Dr. Kilpatrick. I think the research that has been done to
date shows that there is tremendous similarity, not really
difference. As far as numbers of British troops, the numbers of
course are smaller. They had deployed some 50,000 and they've
had some 3,000 people go through their health assessment
program, which is very similar to our clinical--comprehensive
clinical evaluation program, the VA's Persian Gulf registry
program.
Mr. Murphy. Is anybody still pursuing the line--I found the
article from Pain and Central Nervous System Week from a year
ago, a year ago last week, saying that research teams
identified clusters of postcombat syndrome, some debilitating
syndrome from the Boer war and the First World War, somatic
disorder focused on the heart from the First and Second World
Wars, and neuropsychiatric syndromes, in essence saying that
every war seems to have those.
Are people still following that or has that been seen as
not scientifically valid to say that perhaps Gulf war syndrome
is similar to what is seen after every war?
Dr. Winkenwerder. My answer to that is that even though
different kinds of issues and maybe even some similar kinds of
issues do occur in all wars, we saw something and later better
understood something coming out of the Gulf war that was a
constellation of symptoms and complaints that were quite real,
that were occurring in higher proportion among those people who
were deployed than among those who didn't deploy.
So I would distinguish what we saw there from what maybe
had occurred in other, prior wars.
Mr. Murphy. I have also read some studies that have looked
at animal studies of some chemicals used for example for insect
control and other things, particularly DEET, permethrin, and an
antinerve gas agent, pyridostigmine bromide--I hope I am
pronouncing that right--PB, which was administered to both
British and U.S. troops; and have found a number of problems--
cell degeneration, cell death, animal behavior differences--and
have found that those things were exacerbated more when the
animals were under stress, etc.
Given that these were--there also seems to be an additive
effect, a multiplier effect, that any individual chemical, when
used alone, doesn't have that, even when the dosage of those
chemicals is low. But when you add them together, you end up
with some pretty severe outcomes.
With those, that kind of data, have there been changes in
how the military is using such things as immunizations, insect
control agents, and other things in dealing with the Gulf war
now?
Dr. Winkenwerder. First of all, let me just say that the
area that you are talking about is an area of research that we
continue to support and believe is very important to better
understand whether a variety of simultaneous or near-
simultaneous insults from low-level agents produces these
effects. And that is very important work. It is ongoing. We are
supporting that.
I would distinguish that from immunizations. From my
perspective, particularly with respect to the use of the
anthrax vaccine, we have had millions of doses given. We have
followed all of that very closely for the last several years,
and from my perspective, don't believe that there is any--and I
think others would corroborate this, experts, outside experts,
Institute of Medicine--that there is any association between
the use of that vaccine and any of the symptoms that we saw.
Mr. Murphy. Not even an interactive effect with these
agents?
Dr. Winkenwerder. Not with respect to the vaccine.
But I think your other point is very well taken in terms of
low-level chemical exposure, nerve agents and pesticides. The
way they work in the body is similar, and so you could
hypothesize or theorize that there might be this additive
effect. And I think that is important work that is ongoing, and
we are supporting that.
Mr. Murphy. Is that changing, though, how--a lot of what is
being done that we are talking about here is the epidemiology
of exploring pre and post-data. But I am just wondering if
there has been a difference in handling things like
insecticides and knowing that there may be nerve agent
exposure.
Dr. Winkenwerder. There have been some changes in the use
of pesticides and pesticide management policy, and I think the
long and short of that is that they are used more sparingly and
more carefully, and with a lot better documentation and
control. So that is something that we had already begun to
respond to and change practice.
Mr. Murphy. One other factor I want to ask, perhaps because
of my background as a psychologist. But what I see frequently
in these studies is the impact or the interactive effect of
stress upon any of these.
Can you comment on how that works?
And it also relates to some of the comments--you talked
about soldiers who are in the actual theater of war and those
who remain home.
Dr. Winkenwerder. I think it is certainly plausible that
stress could add to any sort of physiologic--yeah, and as Dr.
Roswell was saying. But I would distinguish that from saying
that stress alone is responsible for the symptoms; I don't
happen to believe that.
Mr. Murphy. I understand. I just think as we discuss these
things, as one is looking at pre and post-histories, that
getting some understandings of the mental health, which is
oftentimes extremely difficult to get from just a self-
disclosing questionnaire, is very important.
That is not to say that these folks have mental illness,
that is not--although some may have post-traumatic stress
syndrome. It is important to understand that stress has an
impact on many diseases, cancer being one on which there has
been extensive amounts of research. And one that you can't
build a cure to protect you from that, but it is one that we
need to be aware of, how we help soldiers with that.
Dr. Winkenwerder. We agree with you.
Mr. Murphy. Thank you, Mr. Chairman.
Mr. Shays. Thank you, Mr. Bell, for your patience. You now
have the floor.
Mr. Bell. Thank you very much, Mr. Chairman.
I want to followup on some lines of questioning that were
begun by my colleagues, Congresswoman Maloney and Congressman
Kucinich. I want to begin with this letter that Congressman
Kucinich referred to, since we didn't really--I know it's been
offered for the record, Mr. Chairman, but we didn't really get
to delve into the text.
And I would disagree with my colleague that it was a no;
actually, it was a little more disturbing than that in that it
was a non-answer completely. And Representative Shakowsky had
asked a very direct question in her letter to the Department,
requesting information on the suits and would they provide
protection for our troops. And I am not going to read the
entire letter since it has been entered in the record, but
where you come to the paragraph where he could easily answered
the question yes or no, he says, instead: ``since Operation
Desert Storm, the Department of Defense has fielded a new and
improved CD, defense detection equipment and individual
protective equipment. Every service member, to support near-
term operations in Southwest Asia, will carry at least two of
the newer, joint service lightweight integrated suit technology
JS list suits and will have an additional two suits in
contingency stocks. The contingency suits will be the battle
dress overgarments, BDOs, until replaced by JS list suits.''
So we know what they will have in terms of supplies, but we
have no idea whatsoever whether they are safe because nowhere
in the letter of response does it say that they are safe. And I
think the frustration felt by me and some of my colleagues in
recent weeks is that it is hard to get a direct answer.
And the purpose of this hearing is to focus on lessons
learned from the Persian Gulf. Persian Gulf war syndrome was
not something that was immediately announced after the Persian
Gulf war, if I recall correctly. I was not--obviously not
serving as a Member of Congress at the time, but if memory
serves, it took months, perhaps years in some cases, for all
the information regarding that syndrome to filter out regarding
what people had been exposed to.
And we are highly critical of our enemies in this conflict
as to their propaganda machine. And I am not saying that our
information system compares to that in any way, shape, or form,
but it does seem that we do engage in misinformation sometimes.
And I would like for your comments on that and whether you
think that we could learn a lesson from the Persian Gulf war
and perhaps do a better job of educating both Members of
Congress and the American people as to the risk we face.
Because I don't think any right-thinking individual in this
country believes that we don't face very serious risk by going
forward with this conflict.
Dr. Winkenwerder. Congressman, I can just assure you there
is no thought of misinformation or trying to misinform either
our service members or the public. That does not serve any of
us in the short run or the long run.
I think that, from my review of what transpired in the
past, it did take months and years to find out more about what
happened. I do believe that has informed a lot of action and
activity on the part of the Congress, as well as DOD and VA, to
put into place better recordkeeping, better tracking, better
equipment, better monitoring detection across the whole board.
And my conclusion is that we are prepared. However, we face
an enemy that is prepared to use some of the most lethal and
awful weapons we have ever known, and that is a daunting
situation. So I don't think there is any effort to tread
lightly over this issue or to not acknowledge the seriousness
of the risks that are out there. These are very serious risks
that we face.
Mr. Bell. And I think that is a very important statement,
because by putting a statement on the record that we are
prepared, basically you put yourself in a position that, if we
come up against something that we really didn't know we were
going to come up against during the course of this conflict,
then you are in a box if we come back and face something and
you have to say, well, we weren't prepared completely for that.
But aren't we in a situation, Doctor, where it is almost
impossible--based on your statement about what he is prepared
to do, almost impossible to completely prepare for what we
might face?
Dr. Winkenwerder. That's a judgment. I think we have very
good information about what the threats are. We have good
information about the detection capabilities. We have good
information about the protective capabilities of the equipment
and suits. We have good information about the protective
capability of medical countermeasures. So I think that we are
prepared.
There are certain situations, there are circumstances that
one can envision where an enemy can create harm and damage, and
we have already seen that in the war thus far. So being
prepared does not mean being able to completely prevent any
adverse outcome in every single service member serving.
Mr. Bell. Can I ask one more question?
Mr. Shays. Sure.
Mr. Bell. As far as the lessons-learned category, are we
prepared, after we face whatever we are going to face in this
conflict, to come back and say, this is what we are looking at,
this is what we are testing our troops for?
Dr. Winkenwerder. Yes.
Mr. Bell. And to treat that instead of trying to pretend
that we didn't face any of those things?
Dr. Winkenwerder. Absolutely. We will be looking at people
very carefully after deployment. And we have a process in
place. We are looking at and currently evaluating that system
to ensure that it will collect all the information in a timely
way that we want and think that we might need.
Mr. Bell. Thank you very much, Doctor.
Thank you, Mr. Chairman.
Mr. Shays. Thank you.
Just for the record, the committee's counsel reminds me
that all three sites had been discussed. The only thing that we
think is a bit new is that maybe we had Special Forces near one
of those sites, but that the committee is trying to determine
where those plumes went. So I just want the record to state
that.
Also say--Dr. Winkenwerder, you are getting all the
questions right now.
Dr. Roswell, you are going to get some.
But you have, for the record, turned over some stones and
have been very cooperative and very helpful with this
committee. So these are big issues. But I do want the record to
note that you have been pushing DOD to be more candid, to be
more open, and to treat these very serious questions that you
are being asked with a lot more attention than has been done in
the past. I do want the record to note that at well.
Dr. Winkenwerder. Thank you.
Mr. Shays. Mr. Janklow.
Mr. Janklow. Thank you very much, Mr. Chairman.
You know, let me, if I can, ask questions kind of like we
used to take our English lessons--what, where, when, how, why,
and to what extent--if I can.
Let's talk about the current war that we are in. In order
to try and make sure that we don't have some of the problems
that--and nobody wants to repeat the problems of Desert Storm.
One, is it--will it be difficult at all--and you used the
phrase before, production areas, storage areas. Would it be
difficult now, if we come across any production areas in the
country, to document, using GPS, GIS, whatever, exactly where
these locations are; two, exactly what storage facilities we
come across within the country; three, exactly where
utilization of chemical, biological types of weapons are used;
and four, to the best extent possible, identifying, if not the
individuals, at least the units that are in the area so that
all of these kinds of problems that we have wrestled with from
Desert Storm don't have to be revisited?
Is there a plan in place to deal with it that way?
Dr. Winkenwerder. I will try to give you the best answer I
can. But I will note that, again, you are asking very good
questions. They are out of my----
Mr. Janklow. Are they out of your bailiwick?
Dr. Winkenwerder. They are really, truly are out of my area
of responsibility.
Mr. Janklow. OK. If they are, then could you find somebody
that could--could you at least take the message back?
And I've got to believe they're doing this. It isn't that
they operate in a vacuum over there. They are the best there
are.
Dr. Winkenwerder. Absolutely.
Mr. Janklow. This is a way to try and obviate some of these
kinds of problems.
Dr. Winkenwerder. I can just tell you from my exposure to
those types of discussions, there is an exquisite level of
sensitivity to the issue of how to deal with the issues that
you brought up and to avoid any inadvertent or any kind of
contamination.
Mr. Janklow. Doctor, based on your position, your
experience, your background, are you satisfied that we have a
good baseline on the troops that are currently in the field or
will be going to the field over in Iraq?
Dr. Winkenwerder. I am.
Mr. Janklow. In terms of a medical baseline for them?
Dr. Winkenwerder. Yes, sir, I am.
Mr. Janklow. And Mr. Roswell, are you satisfied that within
the President's budget, the existing budget or the supplemental
request, there are sufficient funds to take care of the medical
liens, medical needs that are reasonably foreseen--and I
realize we could argue about terms--but the medical needs that
are reasonably foreseen, that may be necessary for these
soldiers, sailors, airmen, Marines when they come home? Or,
obviously, in the field, but when they come home?
Dr. Roswell. Certainly, based on the current availability
of resources we have concerns. But given their high priority, I
have no reservation about our ability to----
Mr. Janklow. When you say that, is there any anticipation
at all that you will be bumping other people that are currently
eligible out of the system or aside to take care of these folks
when they come home?
Dr. Roswell. That is a contingency that the Secretary of
Veterans Affairs, in exercising his statutory authority as
mandated by this Congress, would have to consider. So it is
possible that if there was an unpredicted demand for care from
the Department of Veterans Affairs, by law, Secretary Principi
would have to consider other lower priorities of veterans and
their ability to continue to enroll in and receive a full
health care benefit.
Mr. Janklow. Mr. Chairman, can I see that letter for a
second? I guess I have it here, the one that was mailed to you.
I am unfamiliar with these letters, until today, that have been
talked about. But one of the letters I saw is a letter from Mr.
Eldridge--or an E.C. Eldridge, Jr., I am sorry, I assume that
is a Mr. Eldridge--to Representative Shays; and in it--I am
sorry, one signed by Mr. Eldridge on February 27, 20O3.
And in that one, Mr. Eldridge says to--excuse me--Ms.
Schakowsky that every member of Desert Storm will carry at
least two--excuse me--every member support near-term operations
in Southwest Asia will carry at least two of the new joint
service lightweight integrated, the J list suits, and will have
an additional two suits in contingency stocks.
Is that the case for the people currently operating in
Iraq?
Dr. Winkenwerder. That is my understanding. Yes.
Mr. Janklow. OK.
Thank you, Mr. Chairman. I have no more questions right
now.
Mr. Shays. Thank you very much. We are going to put both
letters in the record. But the bottom line is, that was the
response to my request and also Ms. Schakowsky's.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T9544.029
Mr. Shays. Mr. Tierney, you have the floor for a generous 5
minutes.
Mr. Tierney. Thank you, Mr. Chairman.
Mr. Chairman, thank you for the long series of these
hearings that you've had over the years. I think they have
served to benefit the men and women that are there now. I don't
think that without having had the hearing on the condition of
our protective suits, that they would have the two new suits;
and so I appreciate that, and I am sure their families do.
Mr. Shays. It has been a team effort on both sides of the
aisle.
Mr. Tierney. Doctor, Dr. Winkenwerder, let me ask you for a
second: One of the concerns that we had in doing the homeland
security measures was that if there was a contamination, the
people responding to that, the medical personnel who oftentimes
found themselves unprepared, sometimes exacerbated the
situation and completely knocked out an entire medical unit
because they hadn't been prepared to separate the contaminated
folks out from the others.
My understanding is that, in the Gulf, most of the medical
people, the doctors and nurses sent over there, are Reservists,
which would raise the specter that their training is 1 weekend
a month or 2 weekends a month and 2 weeks in the summer; and I
would guess that would probably be barely enough to keep up on
their training for medical treatment in the field.
Can you give us some assurance that those Reservists have,
in fact, been properly trained to meet what might happen in
terms of a chemical or biological attack?
Dr. Winkenwerder. We expect every service to be trained
equally to the Active Duty to take care of those situations.
Mr. Tierney. How is that happening if they are getting 1
weekend a month and 2 weeks in the summer, and in that period
of time have to keep up with their own medical treatment? How
are they getting this additional training? Where are they
getting that in a fashion that would give us the comfort that
they are really prepared and ready?
Dr. Winkenwerder. Well, there are a variety of training
courses that we offer. And it is part of this overall
requirement that I set into place last year that for every
medical person in the military health system, professional,
that depending upon his or her level, there should be training
to deal with chemical and biological events.
And so we expect that. That is a responsibility of each of
the services, to provide that training and to ensure that we
meet the standards.
Mr. Tierney. Have you been monitoring that?
Dr. Winkenwerder. Yes, we have been.
Mr. Tierney. And how much additional training other than
that 1 weekend a month and 2 weeks a summer are these personnel
getting?
Dr. Winkenwerder. Well, I had some figures that we recently
generated from the three services, and I want to be careful
with this, to describe it as accurately as my recollection will
allow. But the percentages are in the high double digits now as
opposed to the low single digits, what they were a couple of
years ago.
So there has been----
Mr. Tierney. Double digits? Single digits? What?
Dr. Winkenwerder. That means like somewhere between 60 and
80-something percent. And again, there has been an effort to
make sure that those that are deploying are the ones that get
the training. So when I describe those statistics, that is
across the whole system.
Obviously, not everybody is going, so the training has been
targeted more toward people that are serving. But I will--I
understand the gist of your question and we will try to get
back with that information.
Mr. Tierney. Would you get that information?
Dr. Winkenwerder. Yes, sir. We would be glad to.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T9544.030
Mr. Tierney. Thank you.
And again, because I continue to have concerns about those
suits, and even though you've now told me how many suits they
have, in my reading anyway, it indicates that that may well not
be enough depending on how long this conflict goes.
But you put out the impression at least, that Mr. Kucinich
mentioned earlier, about the people being ready; and I am
wondering, can you give us the assurance that Secretary
Rumsfeld, through Under Secretary Aldridge, was not able to
give us? Can you give us the assurance here today that the
troops have sufficient equipment to protect them against
chemical and biological attacks in quantities sufficient to
meet the minimum required levels previously established by the
Department of Defense?
Dr. Winkenwerder. Certainly, from a medical standpoint; and
by that I mean the medical countermeasures, the antibiotics,
the vaccinations and all of that; those are the issues that
come directly under my area of responsibility. The others, my
understanding from recent conversations with--Dr. Anna Johnson
Winegar, who is the chief responsible person within the Office
of the Secretary of Defense for those matters and has testified
before this committee and others, has indicated that she
believes that we are well prepared on the issues that you have
just raised.
Mr. Tierney. Well, your impression at least was not
contained just to the medical end; it also involved the
protective suits. Or did it not?
Dr. Winkenwerder. That is not--and I know from your
perspective, as well it should be, you should be concerned
about everything, and so I don't want to be bureaucratic here.
But----
Mr. Tierney. I appreciate that.
Dr. Winkenwerder. It is not directly within my area of
responsibility. It is another area that does work under Mr.
Aldridge. We work closely, very closely with those people. The
responsibility for executing those policies resides within each
of those services.
Mr. Tierney. Thank you.
And just to finish up my generous 5 minutes, the reason I
raised the initial question was that we had an exchange here in
committee with Dr. Kingsbury, Nancy Kingsbury, at some point in
time; and her answer indicated, to me at least, that in
instances of mass casualties she did not believe that the
exercises that have been done so far indicated that we could
deal with those appropriately.
So whatever assurances you could give the committee in
terms of medical personnel being ready would be greatly
appreciated.
Dr. Winkenwerder. We will do that.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T9544.031
Mr. Tierney. Thank you.
Mr. Shays. Thank the gentleman.
We are going to do a second round here, and I just want to
ask--so we can close up the issue of the questionnaire, I want
to know why our men and women aren't given physicals when they
go into battle, so that we know. What is the logic of that?
Mr. Janklow. Aren't given what, sir?
Mr. Shays. Aren't given physicals. They are given
questionnaires, but they aren't given physical examinations.
Dr. Winkenwerder. I think, Mr. Chairman, that the logic is
that a hands-on physical examination yields not a great deal of
information in terms of the baseline health status of young,
healthy individuals. And far more important and relevant is a
series of questions that are asked that can go into greater
detail if a flag goes up that indicates that there is some
problem with that person's health.
Mr. Shays. First off, I am not going to concede that we
didn't intend that they weren't going to have physicals. So I
understand your doing the questionnaires, and I understand when
we talk about a medical examination versus a physical
examination, you have decided that you have some flexibility
there.
But what about the Reservists and the National Guard folks
who simply, you know, might be eating a little differently,
might--you get my gist. Why wouldn't they have physicals? They
might be older. They might not have been active for a while.
Why treat them all the same?
Dr. Winkenwerder. Why treat them all the same?
Mr. Shays. Why treat them all the same? Why not have a
little bit more of an interest in giving a physical to someone
who may not have been in the Active Service?
Dr. Winkenwerder. You raise a good point. I think it is
something we could certainly take a look at.
Dr. Kilpatrick.
Dr. Kilpatrick. If I could, for the Reservists that are
called to Active Duty, there is a more stringent process put in
place to look at them, having physical examinations, their
periodic physical examinations.
For Reservists under 40, they need to have one every 5
years; over 40, every 2 years. I think there is a recent GAO
report that showed that people were not meeting the mark--I
mean, the numbers were terrible--on doing that. So when people
are called to Active Duty at that mobilization center, if they
have not had a physical within the last 5 years for under 40 or
the last 2 years over 40, they have to have a physical before
they go, so they are caught up.
Mr. Shays. Why not at least draw blood?
Dr. Kilpatrick. And I think the drawing of blood is--we do
make sure that everyone has an HIV screening sample done within
the previous 12 months prior to deployment. That serum sample
is banked in a serum bank. It is kept permanently. There is no
sort of portfolio of tests to do on a serum sample, but that is
kept in the eventuality there is an exposure, either recognized
or unrecognized, and then a determination of a set of tests
that could be done. So the serum sample is saved, but there is
no testing done, prior to leaving, for levels of any agents.
Mr. Shays. Dr. Roswell, how are you involved in the
predeployment questionnaire? How much involvement did you have
in this questionnaire?
Dr. Roswell. Relatively little, Mr. Chairman.
Mr. Shays. Does relatively little mean, really, I didn't
have much involvement at all?
Dr. Roswell. The survey was shared with us. We have
effective communication through the Health Executive Council
that Dr. Winkenwerder and I cochair. So there is an active
sharing of information.
Mr. Shays. But this was basically designed by DOD, Dr.
Winkenwerder?
Dr. Kilpatrick. Yes.
Dr. Winkenwerder. Designed in 1997.
Mr. Shays. 1997. OK. We have a letter that Principi--
Principi; I'm sorry, I went to a college called Principia, so I
have a bit of a problem with that name--where the Secretary had
written. And he said--and this is a letter he drafted to Mr.
Rumsfeld on--Secretary Rumsfeld on February 14 of this year;
and the second page says, ``In the event of hostilities, VA
further requests more extensive postconflict health data.
Within the first month after hostilities cease, VA recommends
administration of a detailed postwar health questionnaire to
accurately document the health status and health risk factors
and health in Gulf war troops immediately after the conflict.''
Can you explain that a little to me?
And, Dr. Winkenwerder, can you respond?
Dr. Roswell. I think what Secretary Principi was asking for
was to get risk assessment and self-reporting----
Mr. Shays. Excuse me. Let me just say for the record, with
just three members, I am going to roll to a 10-minute question.
So you'll have 10, and we'll go from there.
Thank you. Go ahead.
Dr. Roswell. Our concern is that particularly with
Reservists and National Guard, when they are demobilized, the
immediate concern--and it's true of Active Duty as well--is to
get home to family and loved ones. But unlike the Active
component, when the Reservists are demobilized, they may be
lost to followup, and it may be difficult to get information.
We learned, painfully so, in the Gulf war that when we
surveyed service members who had separated from military
service months or years after their service in the Gulf war,
that there was a high level of what we would call ``recall
bias.'' They don't really remember the specifics, it is hard to
recall a specific date. A service member might not remember an
actual grid coordinate or an actual physical location.
So I think what Secretary Principi was asking Secretary
Rumsfeld was that, in the event of possible exposures, we get
as much information as possible at the time military members
are demobilized and separated from service. That would help us
evaluate possible symptomatic exposures and health consequences
that might have----
Mr. Shays. So there's logic to doing this.
Let me just ask, Dr. Winkenwerder, do you--we had in 1997,
you have this--developed this questionnaire we are using today.
Do you have a postsurvey questionnaire that was done in
1997, or is that still a work in progress?
Dr. Winkenwerder. That was developed in the same timeframe.
Mr. Shays. We are asking that questionnaire be updated and
improved.
Dr. Roswell.
Dr. Roswell. The postdeployment survey that Dr.
Winkenwerder speaks of would certainly be helpful. Obviously,
we'd seek more complete information if there was a documented
or suspected exposure.
Mr. Shays. It's just a two-page document?
Dr. Roswell. Correct.
Mr. Shays. It doesn't even look as extensive. I guess it's
the same as--both are two pages.
I would hope, Dr. Winkenwerder, that you will give
tremendous consideration to Principi's letter and request, and
absolutely determine that our troops, shortly after--not after
they are sent back home, but you know, a month or two after the
conflict ends, that they are going to have this kind of
questionnaire.
I am seeing the nodding of heads. I would love to know if
you could put something in that we could transcribe here.
Dr. Winkenwerder. Yes. Well, I share the objective of
getting accurate information in a timely way.
Mr. Shays. And do you believe that maybe a more than just
two-page questionnaire would be helpful?
Dr. Winkenwerder. I have already initiated an effort to
reassess this survey tool to see if it collects all the
information that we think it ought to collect.
Mr. Shays. Do you give some weight to the Secretary of
Veterans Affairs, who ultimately has to deal with this, that--
--
Dr. Winkenwerder. Oh, absolutely.
Mr. Shays. OK.
Dr. Winkenwerder. Yeah, absolutely. So I've, No. 1, done
that.
And second, ideally, if we could collect that information
even before people come back to the United States, it would be
great. Logistically, we are still looking at that. Obviously,
we have to have a lot of cooperation and assistance from many,
many people to----
Mr. Shays. You may have to do some physicals. You may have
to add more than physicals to the questionnaire, and you may
have to have more of these folks actually take a physical when
they leave.
Dr. Winkenwerder. Well, I would expect, with a good
detailed questionnaire that whenever people gave any reason for
concern, they would then be very carefully evaluated.
Mr. Shays. OK.
Mrs. Maloney.
Mrs. Maloney. Thank you, Mr. Chairman. I would like
permission to place in the record an article written by Judith
Coburn entitled Suited for war, and it is very thought
provoking. In it, she alleges----
Mr. Shays. Without objection, that will be put in.
Mrs. Maloney. Thank you. In it, she alleges that it took a
4-year struggle of Gulf war veterans from Georgia before they
got the Pentagon to declassify documents which revealed that
Iraq's stocks of sarin gas stored in Khamisiyah had been blown
up, and that roughly 140,000 American troops were exposed.
I realize, Dr. Winkenwerder, this did not happen on your
watch, but I fail to understand the mentality or the mind frame
of a department that would withhold valuable information on the
exposure to chemicals that could hurt people.
And I understand this was not on your watch, but if you can
find any documentation on what they were thinking about or
what, in their minds, they thought they couldn't reveal to our
men and women, that they may have been exposed, I would love to
get that back in writing.
But my question--and Ms. Coburn further goes on.
Mr. Shays. Let me be clear. What do you want back in
writing?
Mrs. Maloney. Why the Pentagon fought the release of
information on men and women being exposed to sarin gas when
they knew they were exposed in that particular area.
Mr. Shays. The record will note that they acknowledged that
our troops were exposed, before our hearing, at a press
conference. Then there was a question as to how many troops
were ultimately exposed, and the numbers kept going up.
And so what would be helpful is if, in fact, additional
information was held and for how long and why. And that will
be--it is just not a wish, it is a request that--Dr.
Kilpatrick, you are nodding your head--you will get back to us
on.
Dr. Winkenwerder. Yes. There is a great deal of
information. We will pull out all together and provide it.
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Mrs. Maloney. She further states that 148 Americans died in
the war, but that roughly 160,000 have fallen ill; and that
11,000 have died since the Gulf war--much higher than other men
and women in the military--and that they have collected a
series of 57 symptoms for which there is no known cause, which
is the Gulf war syndrome.
I would want to ask what we are doing to protect the health
of the men and women that were exposed and the possibility, God
forbid, that they may be exposed yet again. And I am the
cochair of the Parkinson's Disease Task Force, along with Fred
Upton; it is a bipartisan effort. And my father suffered from
Parkinson's.
But it has been reported that some of the Gulf war veterans
have suffered symptoms similar to Parkinson's. And each year we
have been working with the Defense Department, and we have
received funding for Parkinson's research on neurotoxin
exposure, seeing if that is a reason for the brain damage that
causes Parkinson's. But I would argue that, likewise, it may be
a study for what we can do to help the men and women that may
have been exposed to chemicals.
So my question right now is more of a proactive one of,
what are we doing in research?
As I understand it, we have no cure for Gulf war syndrome.
And what are we doing to find--are we spending some of our
research dollars in trying to find a cure for neurotoxin
disease that may be caused by the sarin gas or other things?
What are we doing? I am very thankful to the Department of
Defense for funding the Parkinson's research.
My question is, is this likewise connected to the Gulf war
syndrome?
Dr. Winkenwerder. To your general question of what are we
doing? We are continuing to fund with millions of dollars
ongoing research into many of these questions that you have
raised. As I alluded to earlier, it's difficult to determine
with the levels of certainty that one would like in this case,
if one is talking about evaluating these individuals that
served, when the baseline of information and what was collected
and what people may or may not have been exposed to is not
good.
The information is not good, so--by definition, to do good
research, you need good information. That shouldn't prevent us
from funding additional research, as we have done, to look at
some of these questions of what would low levels of exposures
do to laboratory animals. Certainly we would never do this to
any individual on an experimental basis. But studying what
happens with animals and looking at some of these things is
very important.
Mrs. Maloney. Specifically, is the Parkinson's research
that you are funding--and I thank you for that research. Is
that connected to the Gulf war syndrome?
Dr. Winkenwerder. I am going to turn to Dr. Kilpatrick.
Dr. Kilpatrick. Let me just address it. It is being pursued
in two directions.
One is a clinical basis, looking at people; and then that
is very tightly tied to a program looking at chemical nerve
agents in particular and the effects that they have on brain
function. There are projects funded at $5 million a year over
the next 3 years; 1.5 million is looking at repeated low-level
exposures of animals to sarin nerve agent, to look at long-term
health consequences. That is very applicable to what Gulf war
veterans' concerns are.
The other part of the money each year is spent toward what
we call the high end of low-level exposure, below symptomatic
response to nerve agents, one exposure, and then seeing what
are the physiological responses.
And those data from those research sets are really very
closely shared with people looking at Parkinson's disease,
because they are really looking at the same pathway potentially
as far as disease cause.
Dr. Roswell. If I may respond to that from a combined
perspective.
Since the Gulf war, over $200 million in federally funded
research has been focused on possible causes for Gulf war
syndrome. I would like to set the record straight.
One of those studies has looked at death rates in veterans
in the Gulf war, and in fact, the overall death rate for
veterans who served in the Gulf war is not increased compared
to their military counterparts who were deployed outside the
theater of operations. If you look at specific-cause mortality
in veterans who served in the Gulf war, there is a very slight
increase in death due to trauma, such as automobile accidents.
But other than that, the mortality rate is not increased in any
subcategory, and the overall mortality is not increased.
And I certainly wouldn't want to create a fear for the men
and women currently serving in Iraq.
Let me point out that Parkinson's disease is one of several
neurodegenerative diseases that DOD and VA are currently
studying. VA recently funded the creation of a neuroimaging
Center of Excellence for neurodegenerative diseases to look not
only at Parkinson's but also other diseases, even when
unpublished data suggested that there might be an increase in a
degenerative disease known as amyotrophic lateral sclerosis, or
Lou Gehrig's disease.
Secretary Principi moved quickly to presumptively service-
connect veterans who suffered from that illness and served in
the Gulf war, so that they received disability compensation.
I would also point out that 160,000 veterans of the Gulf
war have received approved disability claims. But most of those
claims are for diseases that we would expect to see in a
military age population, and it is a relatively small number
for undiagnosed illnesses or the Gulf war syndrome you spoke
of.
Mrs. Maloney. When you mentioned the clinical trials, are
you doing them on our veterans? Are we tracking our veterans
and seeing if--particularly those that we know were exposed to
sarin gas? That would be helpful to see, because some of them
apparently--I am talking to doctors that treat Parkinson's.
They have told me that they are developing Parkinson's-like
symptoms.
Dr. Roswell. We have extensively reviewed literature for
symptomatic exposures to the organophosphate, which is the
class of compounds that sarin nerve gas falls into. The study
suggests that there is cognitive impairment in people who
suffer symptomatic exposures, but I am not aware of evidence
that conclusively links any kind of organophosphate or nerve
agent exposure to Parkinson's disease specifically.
Some investigators have reported a possible
neurodegenerative disorder that involves part of the
vasoganglia, which are structures that are affected in
Parkinson's, but in a way different than in Parkinson's
disease, which is why we've funded the neuroimaging center.
Mrs. Maloney. Where is the neuroimaging center?
Dr. Roswell. Actually, there are several within the VA.
There is one in San Francisco; there is--a final selection for
the designated center has not yet been made, however.
Mrs. Maloney. Well, thank you for investing in research for
coming up with some cures. And thank you for your testimony. My
time is up.
Mr. Shays. We have just two more members who will ask some
questions, and then we are going to get to the next panel.
Mr. Janklow.
Mr. Janklow. Thank you very much, Mr. Chairman.
Help me, if you could. With the testimony--the hearing is
about lessons learned from the Gulf. My question is, both of
you in your capacities, you, Dr. Roswell, and you, Dr.
Winkenwerder, have you looked into the history of why was this
so secret so long? With everybody clamoring for information,
why did it take so long to get the information out? Why did it
have to be dragged out of people? What was the reason for the
mystery?
I guess--have you ever been able to find out, or have you
ever looked as to the reason for the mystery? It couldn't have
been national defense secrets.
Dr. Winkenwerder. I can't give you a good answer. I will
give you the best answer I know, and that is that in many cases
it took months and even years for symptoms to develop with
people. And that, combined with the poor record base, made it
very difficult to do research or to even develop good,
plausible mechanisms, causal-related mechanisms.
Mr. Janklow. Have those problems been solved?
Dr. Winkenwerder. In my judgment, we have a far superior
baseline of information. We have a far improved recordkeeping
system. We have a far improved ability to surveil and actually
keep records in the theater. We have these pre and
postdeployment assessments. So our information base, by all
accounts, should be far, far better in our current situation.
Mr. Janklow. Doctor, I believe you said you have been in
your position about 18 months.
Dr. Winkenwerder. Yes, sir.
Mr. Janklow. And for you, is there anything, at least at
this point in time in your tenure in this position, where we
have a lesson we haven't learned?
Dr. Winkenwerder. Well, I hope we don't have one that I am
not attending to.
Mr. Janklow. Are there any--do you know of any that concern
you or that we ought to be concerned about?
Or you Dr. Roswell?
Either one of you, are there any lessons we haven't
learned?
Dr. Roswell. If I could, I think the Gulf war was an
unprecedented conflict. The breadth and nature of military
occupational exposures had never been experienced by our men
and women in any prior conflict. So part of the delay, if you
will, the confusion--I think, in retrospect, it is fair to say
there was some confusion about exposures and possible health
consequences--was because we didn't recognize that a vast
number of unprecedented exposures could be factors: the anthrax
vaccine, the pyridostigmine bromide that was used, the dense
oil fire smoke, the fine particulate sand in the desert, the
use of petroleum products to cut down on the blowing sand, the
use of permethrin and DEET to protect people from insects--
there were so many exposures--the use of depleted uranium as
both an armour-piercing munition and a firearm plate, even
chemical agent-resistant coating paint, which was applied to
vehicles to make them resistant to chemical agents--were just
some of the possible exposures that were investigated
methodically, consistently over time to try to ferret out
possible causes for the illnesses we saw in Gulf war veterans.
And I think that, to me, if there is a lesson learned, it
is that we have learned that all of these exposures, singly or
in combination, as has been pointed out in this hearing, could
be factors in the development of illness. Certainly, every
major conflict that U.S. men and women have served in has
yielded unexplained illnesses.
But that doesn't obviate our need to methodically and
thoroughly investigate each and every exposure. And that is why
we are committed to do that, and I think that is the
partnership that VA and DOD, through the Deployment Health
Working Group, are vested in right now.
Mr. Janklow. Dr. Kilpatrick, are there any unlearned
lessons that you know of lingering from the Gulf war?
Dr. Kilpatrick. I think one of the hardest ones is
communication. It doesn't matter how good a job you do, you can
always do it better.
And I think one of the issues that we are working at very
hard now is to make sure that leaders in the field are
communicating to their troops that they are concerned about
these various exposures and their health. They are concerned
about documenting where they are. They are concerned about
making sure they have that access to health care when they come
home--I think DOD and VA share the same concern for those who
are getting off Active Duty; they will be looking perhaps to
the VA for health care--that they understand that, in fact,
there is the ability for them to have 2 years of health care
coming out of a combat zone now. That was not present after the
Gulf war in 1991. And I think that is--getting that
communicated to people, so they know they have that access to
health care, is so important.
So I think that is one of the areas where, as good a job as
I think we are doing, we always need to look to say, how can we
do it better. And I think doing that, through even this
hearing, is very helpful to those men and women who are serving
today.
Dr. Winkenwerder. And if I might add to that to say, you
know, you never know when you haven't learned a lesson until--
there are many times you don't until you've learned it, which
to me speaks to the need culturally to have an open mind, be
open to learning things that you didn't know before.
And so if there is one thing that I would continue to hope
to convey to our people it is a continued vigilance about
different sources and causes of illness and ways to improve. It
is sort of a culture of learning and getting better.
Mr. Janklow. Assuming we have the baseline data that we
need for the current war that we are in, recognizing that our
troops could be exposed to biological or chemical warfare, do
we have the systems in place?
I mean, that is the key thing. Do we have the systems in
place to be able to get the information about the individuals
and about the chemical or the agents or the toxins that are
being--that they have been exposed to, so that we will have the
data base of information to address it without all the types
of--new types of frustration that we will have to go through in
order to find out whether or not there are or aren't legitimate
reasons for illnesses or problems that people have after the
war?
Am I making sense to you?
Dr. Winkenwerder. Yes.
Mr. Janklow. Do we have a system in place, is what it comes
down to. I realize we had no history before the Gulf war. We
now have a history.
Dr. Winkenwerder. I believe we do have the system in place.
Mr. Janklow. Is there anything we can do to make it better?
Dr. Winkenwerder. Yes.
Mr. Janklow. What?
Dr. Winkenwerder. One of the things that we can do to make
it better is to ensure that there is 100 percent compliance
with all the policies and all the procedures, the training we
have talked about.
Mr. Janklow. Have those orders gone out to the military?
Dr. Winkenwerder. Absolutely.
Mr. Janklow. Is there any reason that the military would
have for not following orders from above that are lawful?
Dr. Winkenwerder. No. I have no reason to believe that
people have not taken this issue extremely seriously.
Mr. Janklow. Do they understand that if they violate
direct, lawful orders from a superior, that it sometimes is far
more serious in the military than it is in civilian life?
Dr. Winkenwerder. Yes. I think there is a good
understanding of that.
Mr. Janklow. Those are all the questions I have, sir.
Mr. Shays. Thank you.
Mr. Tierney.
Mr. Tierney. Thank you. I have only a followup question.
We know that this 2004 VA budget, Dr. Roswell, has several
provisions that are going to restrict the ability of certain
classifications of veterans, priority 7 and priority 8, to get
treated and to get the cost of care covered--I can't get this
thing to stop moving up and down.
Isn't that one of the lessons we've learned, though? If we
have incidents that are not really showing signs of symptoms or
illnesses for several years after people get out of the
service, being covered for the first 2 years may not be
sufficient. And haven't we learned through some of the Gulf war
syndrome incidents that it can be any number of years before
people start coming down with these symptoms?
So having learned that lesson, we put out a budget that
still doesn't seem to address these people's concerns.
What are your concerns about that, and what can we do about
the fact that some of these people may not exhibit symptoms in
the first couple of years? And how is the VA going to deal with
those people without excluding them from coverage?
Dr. Roswell. Well, certainly one way to do that is to
authorize special access for care for people who have illnesses
that occur following a conflict.
We actually had that authority that just expired in 2002
for veterans of the Gulf war. It would be obviously, depending
upon the outcome of the current conflict, appropriate for this
Congress to consider special authorization for priority care
for veterans who have served in this conflict.
The 2 years is a minimum. It would certainly continue
beyond that if an identified need were discovered during that
period or if an illness, injury, or disability associated with
military service were identified that led to a service
connection.
Mr. Tierney. I think your first recommendation is probably
one that we ought to look into, and that is making sure that we
provide some sort of flexibility or ability to cover those for
people that may be coming out of this conflict, and I
appreciate that.
Mr. Chairman, I have no other questions at this time. I
want to thank our witnesses for their thoughtful answers and
for their assistance here today. Thank you.
Mr. Shays. Thank the gentleman. Let me just do a few little
minor points for the record.
Dr. Roswell, we are looking at VA data and reports on
mortality in the Gulf war. And its recent reports, based on VA
data, have been late. There was one report that showed kind of
a real spike in deaths, and it was called back and we are
curious about that.
So we are going to invite the VA back to have a dialog
about this, but I just kind of feel your comment about not
showing much difference is something that this committee has a
big question with.
And I would also just say, Dr. Winkenwerder, that I have
some specific questions about the status of the Armed Forces
Radiobiology Research Institute and their work on a drug to
counteract the effects of radiation exposure.
And we're going to send these questions in writing to your
office and ask that you respond. I don't think we need to take
time to do that now, we think.
Dr. Winkenwerder. We'd be glad to do that.
Mr. Shays. Dr. Hyams, you have the biggest challenge here,
and I have a theory and it never fails me that the person who
says the least has the greatest contribution at the end to
make. So I'm going to just ask--no, I'm not going to do it
quite that way. But I'm going to say to you that I would like
you to put on the record anything that you think needs to be
put on the record or any observation that you would like to put
on the record, and then we'll get to the last panel.
And Dr. Hyams, I would also invite you as well. I'm not
being facetious. I know all four of you have expertise here,
and we didn't ask Dr. Roswell as many questions so you didn't
need to jump in, but I'm happy to have all four of you make any
final comment. I'll start with you, Dr. Kilpatrick.
Dr. Kilpatrick. Well, I think that the Department of
Defense is very focused from the lessons learned in the Gulf on
how do we better take care of our men and women in harm's way
today. I think the Force Health Protection Program is that
cascade effect of programs that will protect health. It does
depend on good leadership and cohesive units. We believe we
have that. We see that in action today, and it is our duty to
make sure from a medical standpoint that those men and women
have their health concerns addressed, and our medical
department stands by waiting to make sure that their health
concerns, whether they are related to the deployment or any
other concern, get addressed with facts about exposures we know
occurred.
Mr. Shays. Thank you.
Dr. Winkenwerder. Mr. Chairman, I'd just say we appreciate
the opportunity to be here today. I think this has been a
productive exchange of information. I hope you've found it that
way and useful.
My first comment is just to say that I deeply appreciate
the sacrifice that our men and women in uniform are making, and
I also deeply appreciate the outstanding job that our medical
people are doing. I think we've seen from the TV reports and
all just the incredible job they're doing. They've made us all
very proud.
We are absolutely committed to trying to protect our people
who are taking on a very challenging situation, a brutal regime
that has terrible weapons. We've done everything that we know
we can do to protect them. We will continue throughout this
conflict and after the conflict is over to ensure that we look
after people's health care needs and that we do right by them
for the good service that they've done. So I'm committed to
that.
Mr. Shays. Thank you.
Dr. Roswell. Mr. Chairman, let me begin by thanking you for
your leadership over the last decade in moving our government
closer to a more full and complete understanding of causes of
illnesses following military service in combat. I think your
leadership has been instrumental in improving our understanding
and readiness and preparedness.
Like so many Americans, my thoughts and prayers today are
with the men and women in uniform in Iraq and in the theatre of
operations supporting that conflict, and I hope that some way
they understand and can know that when they return they will
face a vastly improved VA health care system that is responsive
to their needs, and they will understand that the very best
possible care we can provide will be available to them, and
we'll do everything we can to provide that for as long as it's
needed.
Mr. Shays. Thank you. Dr. Hyams.
Dr. Hyams. I come to this with my own perspective. I
deployed to the Persian Gulf in 1990 to help establish a
laboratory in the theatre of operation to survey for biological
agents. So I've been dealing with these problems for a long
time, and I think one of the points that is often missed is
that we have an obligation also to healthy war veterans. I came
back healthy. A lot of other veterans did, too. Nevertheless,
we had a lot of questions about what happened to us when we
were in the Gulf. I think as a Nation we owe it to even healthy
veterans to be able to answer those questions.
Mr. Shays. Thank you very much. Gentlemen, we appreciate
your contribution to the work of this committee, and thank you
for your service to your country.
Our second panel is Dr. John H. Moxley III, managing
director, North American Health Care Division, Korn/Ferry
International; Dr. Manning Feinleib, professor of epidemiology,
Bloomberg School of Public Health, John Hopkins University; and
Mr. Steven Robinson, executive director, National Gulf War
Resource Center, Inc.
You might want to remain standing, and I'll swear you in.
Moxley, Feinleib and Robinson. Thank you, gentlemen. Raise
your right hands, please. First off, is there anyone
accompanying you or responding? No. OK.
[Witnesses sworn.]
Mr. Shays. Note for the record that all three of our
witnesses have responded in the affirmative. Thank you,
gentlemen, for your patience. You have the opportunity to read
a statement or submit a statement and make some comments. You
have obviously heard the panel before you. So you might want to
respond in what you've heard, which would be helpful.
So we're going to start, just as you are there, and we'll
start with you, Dr. Moxley.
STATEMENTS OF DR. JOHN H. MOXLEY III, MANAGING DIRECTOR, NORTH
AMERICAN HEALTH CARE DIVISION, KORN/FERRY INTERNATIONAL; DR.
MANNING FEINLEIB, PROFESSOR OF EPIDEMIOLOGY, BLOOMBERG SCHOOL
OF PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY; AND STEVEN
ROBINSON, EXECUTIVE DIRECTOR, NATIONAL GULF WAR RESOURCE
CENTER, INC.
Dr. Moxley. Yes, sir. Thank you. Mr. Chairman, members of
the committee, as has been noted, I'm managing director of the
North American Health Care Division of Korn/Ferry
International. I'm here because I served as chair of the
Committee on Strategies to Protect the Health of Deployed U.S.
Forces of the Institute of Medicine. The Institute of Medicine
is part, as you well know, of the National Academies chartered
in 1863 to advise the government on matters of science and
technology.
We have submitted a written statement for your review and
for the record. I shall not repeat that statement. What I
intend to do in the next few minutes is to summarize the
history of the need for a report, highlight a few of our
findings and proposals and then close by attempting to convey
to the committee the intensity that our committee felt about
the need for progress in the protection of deployed forces.
The immediate history of the committee stems from the
concern of then Deputy Secretary of Defense John White that
there was a need to learn from lessons of the Gulf war and
develop a strategy to better protect the health of U.S. troops
in future deployments.
In consultations with the IOM, it was agreed that they
would undertake the study. The first step was the development
of four technical reports addressing, first, health risks
during deployments; second, detection and tracking of
exposures; third, physical protection and decontamination; and,
fourth, health consequences and treatment and the importance of
medical recordkeeping.
All four of those reports were detailed, were released at
the time of completion, and were excellent reports.
The committee that I chaired was charged with attempting to
synthesize the technical findings of the aforementioned reports
and other information to form a final overarching policy
report. Our report was completed over 2 years ago.
One of the first and most surprising findings was that we
were not alone. Between 1994 and 2000, the Department of
Defense sought assistance from seven expert panels who
generated 10 reports examining these issues. Although DOD had
agreed with the large majority of the findings, we found that
very few had been implemented at the field level. Many
recommendations remained totally unimplemented. Our committee
concluded that despite all the advice and apparent agreement
with it, progress had been unacceptable.
We also concluded that it was very difficult to improve
upon the recommendations made multiple times since 1994. Hence,
many of our recommendations are restatements of recommendations
that had been made before but remained unimplemented. We
continue to stand behind all of them.
I'd now like to briefly summarize three areas of particular
concern to the committee. First, it is vital that the location
of units and individuals, together with activity information,
be documented during deployments. The information is important
for real-time command decisionmaking and essential for
reconstructing deployments for epidemiological studies and the
provision of post-deployment health care.
Despite many previous painful lessons, adequate systems for
recording and archiving the locations of deployed individuals
are not in place. The technology exists. Troops can be tracked
in real-time, and it is time to do it.
Second, the Department of Defense must be candid and
trusted by service members, their families and the American
people. To achieve that end, they must be more proficient at
understanding and using contemporary principles of risk
assessment, risk management and risk communication.
The following vignette from the Somalia deployment vividly
makes the point. Problems arose when family members learned of
fire fights from news media instead of from official sources of
information in the chain of command.
Distraught family members in the United States were calling
deployed service members on cell phones, upsetting the service
members and causing decreases in force effectiveness. Rather
than trying to quash the situation with top-down orders, the
commanders worked with the troops and family members and
developed a system of phone trees to notify family members in
near real-time of the status of their deployed loved ones after
a conflict.
The point is that DOD cannot suppress the Information Age.
It must find effective means to embrace it.
Finally, medically unexplained symptoms are symptoms that
are not clinically explained by a medical etiology, but
necessitate the use of the health care system. They are
increasingly recognized as prevalent among civilian populations
and are associated with high levels of distress and functional
impairment. In the military, they have been observed following
deployments as far back as the Civil War.
Clinicians and other persons must recognize that medically
unexplained symptoms are just that. There are no current
explanations for them. Communicating the limits of modern
medicine, coupled with the compassionate approach, is essential
to management. There's also very good evidence that early
intervention leads to better results.
The committee's overriding concern was that everything
consistent with mission accomplishment was done to protect the
health and lives of U.S. service members who are knowingly
placed in harm's way. The committee understood that the changes
would be costly and inflict the pain of organizational change.
The Department of Defense, however, has in our opinion an
obligation to avoid unnecessary disease, injury, disability and
death as it pursues the accomplishment of its missions. Not to
fulfill that obligation would be simply unconscionable.
Thank you for the opportunity to testify, and I'll be
pleased to answer any questions the committee might have.
[The prepared statement of Dr. Moxley follows:]
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Mr. Shays. Thank you, Dr. Moxley. I understand it's Dr.
Feinleib and not Dr. Feinleib. I am noted, unfortunately, for
brutalizing names. I apologize, Dr. Feinleib.
Dr. Feinleib. No apology needed. Thank you, Mr. Chairman.
Mr. Shays. I'm going to have you bring the mic a little
closer to you.
Dr. Feinleib. I am Manning Feinleib, professor of
epidemiology at Johns Hopkins School of Public Health. I was
formerly director of the National Center for Health Statistics,
and I was a associate director for Epidemiology and Biometry at
the National Heart, Lung and Blood Institute.
Today I will discuss some aspects of the design of
surveillance systems needed to generate valid epidemiological
data on deployed forces. With your permission, I would like to
place my full written comments in the record and just give an
abridged version right now.
As we have just heard, DOD has established several programs
to track the health of veterans in accordance with some of the
recommendations which you have just heard. Recently analyses of
the data generated from these efforts have begun to appear.
It is my overall impression that implementation of the
surveillance programs have been fragmented and little
worthwhile data will be forthcoming from the forms currently
used for pre and postdeployment health assessment.
Several expert committees have been unanimous in
recommending that the type of surveillance most suitable for
studying emerging health problems in deployed forces is the
prospective cohort study. Congress has already mandated this
tracking system in the National Defense Authorization Act of
1998. More detailed descriptions of this tracking system were
made by several IOM committees. The committees all recognize
the great challenge this presented and that it would require
the collaboration and commitment of both the VA and DOD and
probably several other agencies.
The committees emphasize that this approach could eliminate
major problems encountered in trying to resolve many of the
veteran health issues that arose following the Vietnam and Gulf
wars. DOD and the VA have recently launched such a study called
the Millennium Cohort Study, which will follow 140,000 veterans
for 21 years. This is a start in the right direction, and I
vigorously endorse this study and urge that adequate direction
and resources be provided to implement it effectively.
From an epidemiological perspective, cohort surveillance in
a military setting offers formidable challenges but also unique
opportunities. I would like to go over some of these in the
next few minutes.
First of all, there should be a clear explanation of the
purposes of a surveillance system for deployed forces. There
are many parties concerned about the health of veterans. So
questions to be addressed by the surveillance of these deployed
personnel are many and varied. For some of these purposes it
may not be necessary to track all of the deployed personnel,
and appropriate samples of the population may provide desired
information in a more efficient and timely manner.
Two of the basic purposes are to ascertain health status
immediately before and after deployment and to provide an
opportunity for personnel to address concerns about their
health and receive early medical attention.
These, I understand, are the purposes of the currently used
pre and post discharge--postdeployment health assessment forms.
Three other major purposes have not been as well documented;
for example, to document the exposures to known or potential
hazards, especially to new substances and technologies that
were not seen in previous encounters, to ascertain the health
events after discharge, including physical, mental and
reproductive effects, and to compare the nature and frequency
of health events among groups with different exposures.
A second major point is that of obtaining accurate, timely
and complete information at baseline. Although the cohort of
deployed personnel is inherently well defined, obtaining
accurate, timely and complete information on all of the
participants has not been achieved despite strenuous efforts to
do so.
Recent reports from the Army medical surveillance activity
highlighted some of the deficiencies of the recent experience
using the postdeployment health assessment forms. Only about
one-third of the completed predeployment forms could be matched
with the relevant postdeployment forms. Much of the information
that was obtained was incomplete. The question on exposures in
particular seemed to be misunderstood by many, if not most of
the respondents.
All positive responses about health concerns should have
been followed up with more detailed interviews and medical
examinations, but apparently were not. Obviously, it would have
been desirable if all of the forms could have been linked to
records of sites of deployment and to specific exposure
information obtained during deployment.
A third point is that of assembling comparison groups, and,
except to say that these would be very useful, both in those
people who are actually deployed as well as those who are not
deployed, would be an advantage.
The issue of active and passive surveillance is paramount
after returning from deployment. This is a very difficult task
and would require a great deal of effort and resources. Passive
surveillance, the ascertainment of health outcomes from
routinely collected administrative data, might be possible for
veterans using the VA health system. It would be extremely
difficult for those using private sector health care providers.
A system of active surveillance, periodic contact with the
veterans would be more feasible and presents major challenges
also.
Contact by telephone or mail requires maintaining an up-to-
date roster of addresses and phone numbers. Obtaining the long-
term cooperation of the veterans, following up on all positive
responses and providing feedback to the participants would be
important components of such a tracking system.
A fifth point is that of disease definition. Most
epidemiologic studies have a relatively clear concept of the
outcomes they are concerned with and go to great lengths to
establish standards for defining these outcomes. One of the
lessons learned from previous deployments is that new symptoms
and diseases may occur following deployments that do not fit
into current classification systems. These may involve physical
manifestations, as well as psychological ones.
Concerns have also been voiced about possible effects on
the families and progeny of the veterans from possible residual
contamination after discharge or from genetic effects of
noxious exposures.
Finally, I'd like to discuss the keeping of good medical
records. Most of the expert committees stress the importance of
upgrading the medical recordkeeping capacity of these
surveillance systems. Methods must be created to obtain
information in real-time in the field to transfer to a
centrally maintained data repository and link the information
to individual level records. Quality control measures must be
in place to assure that all records are accounted for and that
individual items are completed and that editing and coding
procedures are adhered to. If systematic deficiencies are
uncovered, they should be corrected as soon as feasible.
Structural problems in the design of the instruments may be
uncovered that require major overhauls. As mentioned earlier,
the AMSA analyses revealed major problems for the question on
exposure and recommended major revisions of this question. But
even such items as the sex of the deployed person were not
completed for about 10 percent of the forms.
An expert group recommended that the pre and postdeployment
health assessment forms be dropped altogether. The health
enrollment assessment review questionnaire has been suggested
as a more useful form. I personally recommend that the
potential of computer-assisted interviews be explored as a
substitute for pencil and paper forms to obtain more accurate
and timely information.
Mr. Chairman, I will close my remarks at this point. I'll
be pleased to respond to any questions you may have.
[The prepared statement of Dr. Feinleib follows:]
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Mr. Shays. Thank you, Dr. Feinleib.
Mr. Robinson.
Mr. Robinson. Mr. Chairman, the National Gulf War Resource
Center thanks you for this hearing and all the hearings that
you've conducted to get to the bottom of what has been very
troublesome for people who served in the last Gulf war.
Why is this hearing important? It's important because I and
others in this room have family members within striking
distance of Saddam's chemical and biological weapons right at
this moment. It's important because it's been a personal
experience for Gulf war veterans. It's important because it
matters, and it's important because a lack of that has
prevented meaningful research and prevented scientists from
interpreting what really happened on the battlefield.
You don't walk up to your F-16 in the morning and ask it
how is it doing. You put your hands on it. You look at the
internal mechanisms that control its flight. You make sure it
has enough gas. You do what you have to do to ensure that that
system will perform.
Public laws that were specifically designed to protect
soldiers on the battlefield are currently being ignored,
thereby setting a stage for mystery illnesses to again present
themselves after a war. Unfortunately, the results of force
health protection, as described by the Department of Defense,
have been utterly disappointing. These shortfalls demonstrate a
lack of willingness to follow the intent of Congress and the
public law.
Understanding the lessons from medical mistakes made more
than 12 years ago, it's important for us to ensure that these
mistakes are not made on a new generation of veterans. Recently
the Institute of Medicine completed its review of pesticides
and solvents used in the first Gulf war, and one of the
conclusions the committee made was that lack of data prevented
them from linking exposures of the war to the illnesses that
veterans suffer from. And as the IOM began its next round
investigations into oil well fires and chemical compounds, they
are keenly aware that there's also a lack of data on these
types of exposures.
We can safely predict that they may reach the same
conclusion, because the baseline data was never considered and
the post-exposure data was never collected.
It's important also to note that the reports from the IOM
are used by the Department of Veterans Affairs to make
conclusions on whether or not illnesses are service-connected
to wartime-related exposures.
Briefly I'd like to talk about what we are aware of in
terms of what has been implemented and what is not being
implemented in terms of the public law. The Department has
standardized methods for identifying medical threats and
appropriate countermeasures prior to deployment. They've also
incorporated planning efforts into the early stages that
continue throughout the deployment. They also use surveillance
teams to monitor the environment and chemical-biological
weapons exposures. These things are lessons learned from the
first Gulf war.
What they're not doing and what is the meat of why we are
here today is that they are not conducting medical screening
and analysis, both pre and postdeployment. Congress passed
Public Law 105-85 in 1998 as part of the defense authorization
bill at a time when veterans were experiencing various
illnesses. The reason Congress passed this law was so that
physicians could monitor changes over time, particularly during
and after the deployment. This law also called for the drawing
of blood samples, significant medical recordkeeping, and an
examination of the soldiers's mental health before and after
the conflict.
Instead of following the letter of the law in a meaningful
way that will produce scientifically valuable evidence, the
Department of Defense and the people responsible for force
health protection are interpreting the law so that it creates a
deceptive compliance. This half-hearted evidence will produce
similar results that have prevented the Institute of Medicine
from reaching conclusions from the last Gulf war. The Director
of the Deployment Health Support Directorate is charged by this
law to implement the lessons learned, and DOD is not following
the law.
I will now describe what we understand is the current
status of affairs for force health protection. In the
predeployment phase, the Department is not conducting hands-on
physicals to determine the health status of the force before
deployment, as required by law. Instead, they give out a
questionnaire. A DOD quote from a recent congressional inquiry
described its own questionnaire as follows: These forms contain
a limited amount of information. They do provide a means to
document health status before and after deployment and afford
the deployed service member the opportunity to have deployment-
related health concerns addressed.
More significantly in the predeployment phase, the
Department is not drawing blood samples from the entire force
prior to the deployment, as required by law. Instead, the
Department relies on serum collection for HIV testing. This
serum could be anywhere from 1 to 3 years old and will not be a
snapshot of the soldier's current predeployment health
condition. Every scientist from the IOM agrees that
predeployment and postdeployment surveillance is the key to
understanding illnesses on the battlefield after wars.
More data is preferred over less data. The current
activities of DOD and health monitoring in the postdeployment
phase are that the Department is not conducting mental and
physical evaluations after deployment, as required by law.
Instead, the DOD hands the soldiers a questionnaire. The
survey, as demonstrated by the testimony of the gentleman to my
right, is inadequate and does nothing to satisfy the
requirements of the law or provide meaningful information.
Additionally, the lack of mental screening has been
demonstrated as problematic. Soldiers recently who served in
Afghanistan were sent directly home without any medical
assessments. Some of these soldiers committed horrible crimes
that may have been related to combat stresses. Had the public
law been followed, perhaps a terrible tragedy might have been
averted.
In the postdeployment phase, the Department is not drawing
blood samples from the force after the deployment as required
by law. Instead, they rely on the serum collection for HIV.
This serum collection can be old and will not be a snapshot of
what has recently occurred on the battlefield. Because the
Department is again failing to collect the baseline data,
veterans will not be able to meet the burden of proof required
by the Department of Veterans Affairs for treatment. This
mistake is precisely what created the controversy surrounding
Gulf war illnesses. Service members are being set up to face
another round of delays, denials and obstructions.
This prospect is unacceptable and must be corrected. The
current medical practices of DOD are all half-hearted, and they
are a public disaster waiting to happen. Since forces are
actively engaged in combat, we have missed the opportunity to
conduct baseline predeployment screening. Mr. Chairman, I
humbly request that we implore, demand and make the Department
collect the postdeployment data so that we will not face
another round of unanswered questions.
In the military that I served in, there were consequences
for failure to obey orders, and anything less than 100 percent
effort was unacceptable. We were not allowed to interpret the
intent of orders but rather to obey them implicitly. These core
values do not seem to work both ways. Veterans will be the ones
who will suffer the consequences of the poor implementation of
this law, and veterans will be the ones who face another fight
because of the lack of data.
I hope that those responsible for the implementation of
this law will understand that their failures are going to
impact the lives and well-being of soldiers returning from this
conflict.
Mr. Chairman, I would like to know who we may hold
accountable, and I humbly request that we find out immediately.
Thank you.
[The prepared statement of Mr. Robinson follows:]
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Mr. Shays. Thank the gentleman very much. We're going to
start with Mr. Janklow.
Mr. Janklow. Thank you very much, Mr. Chairman. I'm puzzled
as I sit here. I just listened to the previous panel, and now I
listen to you three gentlemen, and it's like two trains passing
in the night. They're on the same track, but they don't have a
chance of hitting each other. I should say they're along the
same route, but they are on different tracks.
You listened to the previous panel. This isn't quite fair
to the previous panel, but I don't quite know how to do this.
Dr. Moxley and Dr. Feinleib and you, Mr. Robinson--let me take
you two doctors first. You listened to the testimony of the
previous panel. Have you ever expressed to the current
leadership of the Department of Defense your concerns about
what I would call the unlearned lessons of the Gulf war?
Dr. Moxley. Not specifically, sir. I've not been asked to.
All I can say is at the time of our report, which is now 2
years ago, all of the criticisms that you have heard--I would
have to say--were valid. There was not very much being done.
What has been said--and I have no reason to doubt the
Secretary--is that there has been a lot of progress, but it has
to have been in the last 2 years because we didn't see it.
If indeed that progress has been made, it is nothing short
of miraculous, because there was a long way to go, but I have
no way of documenting where, if you will--the correct or--the
truth is, I don't mean to imply by that anybody is fabricating
it.
Mr. Janklow. What I'm puzzled with, sir, one of the things
is that your vitae indicates that the organization that you
worked for was one that's been around for 100 years.
Dr. Moxley. Yes.
Mr. Janklow. Amend that, it was mandated by Congress and
funded by the public. In the last--from the time you issued
your report, did anybody ever go to the Department of Defense
to say how you're coming on the list, or is there anything
further we can do to contribute, or was it just issuing a
report and then stepping back?
Dr. Moxley. Well, there is no mandate in any of the reports
that we--well, I guess there may be----
Mr. Janklow. I know there's no mandate but I'm just
wondering----
Dr. Moxley. No. We have not--No. 1, we wouldn't have
access. I don't think I could get into the Pentagon if I tried
at this point in time to talk to anyone, and I'm certain I
would have--this--far more difficulty than you would have, for
instance, in asking any of the questions. So it is not an
automatic part of the report, and we do not have access. I
mean, one of the things that could be done is--whether it be
the IOM or not, is--there seems to be a great difference in
story here as to the status of where things stand.
Mr. Janklow. Yes, sir.
Dr. Moxley. An outside group taking a quick look at that
and trying to determine--what needs to be done. It is fairly
clear, and it's printed time and time again in seven different
reports. Whether or not it's occurred is hard to determine at
this point in time, because there are differing opinions.
Mr. Janklow. Do you have a sense from listening to the
previous panel that they professionally differ from the--from
you gentlemen in the conclusions you have reached?
Dr. Moxley. No.
Mr. Janklow. Do you, Dr. Feinleib?
Dr. Feinleib. Yes, I think I do. One is I think they are
acting under very different circumstances than most
epidemiologists operate. They have real-time things that have
real needs which haven't been explicitly stated.
Mr. Janklow. Pardon me?
Dr. Feinleib. They have real needs for the data that
haven't been explicitly stated. So it's difficult to evaluate
it. On the predeployment health assessment they have a question
like, do you have a 90-day supply of your prescription
medication, yes or no? If it says yes, there doesn't seem to be
any followup question, what are you taking, what are you taking
it for?
Mr. Janklow. And if they say no, same thing?
Dr. Feinleib. Then fine, exactly. I don't know the purpose
of why they're asking that question. If you say no and you're
supposed to be taking medication, you go home or what?
Mr. Janklow. And you're probably the wrong gentleman to
ask, but what is so tough about all of this? I mean, what we're
talking about is looking for elemental data on how healthy
someone is. When I went into the Armed Forces a while ago, I
had a physical. Some people made it, some didn't. In my State
today, if they call up National Guard units, some go, some
don't, because some individuals flunk their physical exam.
What is it that's so mysterious about giving people a
physical exam before they deploy to war? That's not everybody
in the Armed Forces right now. It's those that are going off to
war, first of all. And second of all, coming up with the right
forms, how can we be 12 years after the war and still trying to
figure out what the right form is? That tells me we're never
going to get to the right form. I'm not blaming you, but whose
fault is all of this, who is doing all of this? Is it the
system that's broke or is it the people or both?
Dr. Moxley. I don't know what else to say, except it's
clear that the responsibility lies with the Department of
Defense. Now, you've had two or three changeovers in each of
the offices. So in terms of pinning it down below that, I don't
know how to help you, but they have the responsibility for
implementing the recommendations that have been made. And in
part, we're dealing with first and second order of questions
here, because 2 years ago--or 3 years ago we did not think
there was even an elemental sort of analysis pre and post. At
least now there's a document--it may not right document, but
there is a document that exists.
Mr. Janklow. We talk about the drawing of blood. It can't
be that difficult to draw blood on a couple hundred thousand
people and store it--several hundred thousand people and store
it. Is it?
Dr. Feinleib. It can be done.
Dr. Moxley. It certainly can be done.
Mr. Janklow. Is it an expense problem, as far as you know?
And I know you may not be the right people to ask, but I can't
believe you've done all this work and just think it's going to
get filed on a shelf.
Dr. Moxley. Well, is that specifically an expense problem?
My guess is the answer is no. Is the implementation of all of
the recommendations and of the public law that has been
referred to so many times today, is the full implementation of
that a significant expense? I would say yes, it is.
Mr. Janklow. Let me ask you two doctors again, both of you,
if I could. If you were in Congress, Republicans and Democrats,
what would you recommend we do?
Dr. Moxley. I would recommend----
Mr. Janklow. Nobody wants to revisit this Gulf war problem
again, and if everything we hear is accurate, we may have to
visit it again. So we have learned some lessons, but is there
anything we can do legislatively, or is it a matter of
implementing the existing law?
Dr. Moxley. Well, sir, it strikes me that it's a matter of
we don't know what has been implemented and what hasn't been
implemented, and there seems to be a lot of debate on that
issue.
Mr. Janklow. Let me interpret you if I can, please. Could
you give us a list of the questions that we ought to send to
the Defense Department as a congressional panel that we need
the answers to, the questions that you just referred to? Could
you do that, sir?
Dr. Moxley. I don't know whether I can do it off the top of
my head.
Mr. Janklow. No. No. Could you prepare them after today and
send them to us?
Questions we ought to ask the Department.
Dr. Moxley. To do it, I would need the help of some of the
staff members of the Institute of Medicine, and I don't know
whether that would be made available or not.
Mr. Janklow. Could you, Dr. Feinleib, prepare any questions
that we ought to ask the Defense Department?
Dr. Feinleib. That is a complex question, because I'd like
to say there are many epidemiologic studies going on, and all
of them spend a considerable amount of time designing their
forms, figuring out what the objectives are, making, pretesting
them, standardizing them. It is not an overnight operation, and
they find from experience for the purposes of their study which
types of forms work, which types of questions work, etc.
Mr. Shays. This may be a little more simple, because, in
other words, it costs money to design a questionnaire and do it
properly and so on, and you have your reputations on the line.
But would you at least be able to give this committee a
document, each of you, that just points out in more specific
terms the way the question was asked and the way it should be
asked?
For instance, I look at this question. It says during the
past year have you sought counseling or care for your mental
health? And I'm at a quandary as to know the value of that
question. If you said yes, maybe it's a good thing and maybe
more of us should be doing it. And if you said no, maybe you
should have, and so I don't really know what it tells you.
Dr. Feinleib. Yes. That is why I suggested that we ought to
be looking to computer-assisted interview. We could allow
secondary questions, branching questions, etc. If you answer
yes to that, it will say what was the nature of your complaint,
what was done, how do you feel now, whatever would be
appropriate, rather than just yes or no not knowing what
happened.
Mr. Shays. But my point is I don't know whether no or yes
is the wrong answer.
Dr. Feinleib. Neither do I. But that's where you have to
ask more questions if you want a face-to-face interview to find
out what it means.
Mr. Shays. So without asking you to do this whole
questionnaire, but maybe you could just take a few questions
and illustrate your concerns. I'm sorry. I didn't even ask the
gentleman if----
Mr. Janklow. No. That's OK. Go ahead, Mr. Chairman.
Mr. Shays. That's what happens when you get to the end of
the day. You have the floor and you're asking great questions.
I'm done.
Dr. Moxley. In our written statement, we----
Mr. Shays. Could I just thank--before--I'm interrupting.
I'm sorry. I just wanted to thank Dr. Winkenwerder for staying
here and having the courtesy of listening to their points. I'd
like to do a little connection between you and them and also to
point out Dr. Kilpatrick is here and also Dr. Hyams as well,
and thank all three of them for showing you the courtesy and
also learning from what you might say. That's very helpful of
you.
Thank you.
Dr. Winkenwerder. Thank you. We're glad to have more
interaction here.
Mr. Shays. We'll make sure that happens. Thank you.
I'm sorry to interrupt.
Dr. Moxley. Well, I was trying to come back to some sort of
answer to your question. I was going to say in our written
statement we recapitulate our recommendations. I mean, it would
be a fairly long list of inquiries, but one could ask whoever
is responsible has this been implemented. I don't know that
going over it I could improve upon it, and they are in the
written record.
Mr. Janklow. Sir, after this report was submitted to the
Defense Department, did you ever hear back anything?
Dr. Moxley. I did not personally, no.
Mr. Janklow. Do you know of anyone who did?
Dr. Moxley. No, I do not.
Mr. Janklow. Do you, Dr. Feinleib?
Dr. Feinleib. I'm a newcomer to this area, but what I say
is I haven't heard directly at all. I see evidence that they've
been thinking about these things. The Millennial Cohort Study,
for example, follows many of the ideas and recommendations made
by the IOM committees, but it's only on a hundred thousand of
the troops. There still are several hundred thousand more that
aren't covered by this survey.
Mr. Janklow. Mr. Robinson, as I read your resume, obviously
nobody can question in any way your service to this country or
your concern as I listen to you. What do you think is wrong? I
mean, understanding that, all right, we weren't prepared in the
Gulf war for what we ran into, maybe we didn't really
understand and we were destroying these kinds of stockpiles
without thinking enough of the safety of our people, I mean,
our collective ignorance. But what went wrong after that when
the problems started to arise, people were--Congress is holding
hearings, the media is making reports. I mean, you can see, you
know, this mushroom cloud of concern going up. What happened?
In your opinion, what happened?
Mr. Robinson. I think one of the first things that happened
is we didn't listen to our veteran. It's interesting that in
this area of force health protection when soldiers get ready to
deploy the Department's answer to finding out if they're
medically fit to deploy is to ask them if they feel like
they're fit to deploy, but yet when soldiers return from the
Gulf war and said we think we were exposed to some things that
made us ill, they did not listen and said that stress was the
reason why they were sick.
Mr. Janklow. That's a good point.
Mr. Robinson. And I say that I'm troubled, deeply troubled
by listening to someone of Dr. Winkenwerder's stature and his
responsibility for the Department of Defense and the care of
our servicemen and women to say that self-reporting is more
important than hands-on evaluation and serum collection. It was
the intent of Congress after passing this law from preventing
an event like Gulf war illnesses from ever happening again by
providing the Department a method for collecting exculpatory
evidence to determine whether illnesses were or were not
related to their exposures. By handing out a questionnaire and
relying on what potentially could be year-old serum, we are
setting ourselves up for the exact same event.
So you ask me--to get back to your question--why did it
happen? I think it happens because we tend to put more emphasis
on systems than we do soldiers, and I think it happened
because--it does boggle my mind first off, because I briefed
this issue working for the Secretary of Defense, working with
Dr. Kilpatrick while assigned to the Department of Defense for
3 years, and the first year that I began to brief it--and this
is a copy of the slide that I'll provide to the committee. One
of the things that we talked about was that it was important to
verify the DNA sample on file. You had to conduct a
predeployment serum sample. You had to verify the HIV tests,
both in the pre and postdeployment phase.
I briefed this to thousands of soldiers and commanders all
across the United States, and they would look at me with a
strange look and say, well, that's new. That is important. We
should do it. And I would tell them, no, it's more than just
important. It's required. And so to now at the 59th minute and
the 59th second as people are approaching Baghdad, to tell you
why it hasn't happened, I can't begin to imagine, but I can say
that since we have missed the opportunity to collect the
predeployment baseline data, we must not miss the
postdeployment collection of data. We must not just simply hand
out a questionnaire. We must do what the public law said.
Mr. Janklow. Can I ask one more question, Mr. Chairman?
Mr. Shays. The gentleman has as much time as he'd like. I'm
learning from his questions.
Mr. Janklow. Dr. Moxley, since the time you've written your
report, your issue of the report, is there anything new that
you've come across that you would have added to the report?
Dr. Moxley. No, sir, not----
Mr. Janklow. There's no addendums I guess is what I'm
asking.
Dr. Moxley. No. But realize that this was an intense
experience. We were very wrapped up in it for a period of a
year. It is not an area that I'm involved in every day in my
workaday world. So that the fact that I don't have any addenda
does not mean that someone who has spent more time thinking
about it in the last 2 years wouldn't. I do not.
Mr. Janklow. Dr. Feinleib, have you read the report?
Dr. Feinleib. Yes, several of the reports.
Mr. Janklow. Is there anything you would add as a
postscript or an addendum if we were to seek responses from the
Department of Defense?
Dr. Feinleib. Yes, in the following sense. I think the
military should start----
Mr. Janklow. Sir, I wear hearing aids. Could you speak up a
little too, please?
Dr. Feinleib. I think the military should start changing
its time horizon in relation to the veterans. They have the
immediate problem of processing probably hundreds of people a
day to get them ready for deployment or to get them discharged
afterwards. They don't worry what's going to happen to them 10,
15, 20 years later. They have the technologies. They have the
resources to call on people and say, how would you plan a
system that prevents such and such events 20 years from now
rather than just during the next 30 days or 2 years, whatever
the current laws are.
I would urge them to use some of the technology which we
have seen so much about, smart bombs and things like that. To
use pencil and paper forms in this day and age is making short
use of available technology. This could really help them. They
should be given the resources and the incentive to do this, get
the right people to either deal with it directly or contract
to. I think they could do a much better job.
Mr. Janklow. If I can ask you, Dr. Feinleib, again, what is
it--have you ever dealt with a problem of--let me back up, if I
can. I'm stumped by--not that it's important, but I'm stumped
by the fact that this doesn't seem complicated. I mean, we're
12 years later and we're still deciding whether or not a 2-page
form is or is not accurate. You know, somebody once said for
God so loved the world he didn't send a committee, but is it
that difficult to prepare a form that will give enough
information that someone can look at it--and I realize it's not
a form to decide whether or not I'm mentally ill now, whether
or not I'm sick now as opposed to establishing some kind of
baseline to compare me to later to see if something happened to
me when I was in a theatre of military operations that for
which I needed to be treated or taken care of. That's what I
assume is the inference of all of this.
So the three of you are all very bright people. What's----
Dr. Feinleib. I share your frustration, because I think
that at one level it's a quite doable task. You have to get the
agreement of a lot of people. To do a good form might take--
I'll take a guess--an hour to fill out. Not for everybody but
for the people who answer the questions. They want to followup
on it. They might figure we don't have the time to do that
during the predeployment procedures. We don't have the time to
do it during our postdeployment procedures. So they push it
aside, minimize the thing, and are more concerned with spending
no more than 5 minutes on it rather than doing the job
properly.
Mr. Janklow. And, sir, I realize you're not the one to ask
this. I understand if you're deploying very quickly, but they
started calling up National Guard units in my State while I was
still Governor. Last summer they started calling them to Active
Duty, and so there's been--I can't believe that the units of
the Active Armed Forces that they're calling, that they've sent
overseas, are people they made a decision on somehow in the
last 15 or 20 days. There may be some like that that have been
suddenly deployed, but my guess is the vast majority of them
have been preplanned. So I'm back to my question on the form,
and it's not you folks.
Mr. Chairman, I really don't have any more questions, and
thank you for the indulgence you gave me. I appreciate that.
Mr. Shays. I frankly enjoy the opportunity when there are
less Members to allow for a little more delving. So I'm going
to follow along some of the lines that my colleague has
questions. We passed a law, Public Law 105-85, November 18,
1997. I'm darn proud of this law. The law has improved the
medical tracking system for members deployed overseas in
contingency or combat operations.
And then under it is another heading, medical tracking
system for members deployed overseas, system required, elements
of system recordkeeping, quality assurance.
And now we have another report of plans to track location
of members in a theatre of operation. All of this was done
because lessons learned, and, you know, it's too bad in a way
we had to pass the law and it was 1997. It would have been
better if we had done it sooner, but now we are in this debate
of understanding whether the law--the letter of the law is
being implemented in the spirit of the law, and both need to be
implemented.
Now, one of the things that I would like to ask you, Dr.
Moxley and Dr. Feinleib, and you, Mr. Robinson. You answered
one of my questions, but first off, when we use the term, the
systems described in subsection (a) shall include the use of
predeployment medical examinations and postdeployment medical
examinations, did we just blow it if our intent was to have
physicals, or what most people have concluded, that it should
have been physicals?
Dr. Moxley. I think most people would have concluded that
when you use the term ``medical,'' you are referring to an
examination that includes a physical examination. You could
include a history also. If you use the term ``health,'' one
could more easily interpret it as being a series of questions
without a physical exam.
Mr. Shays. I mean, from our standpoint, we didn't want to
say physical examination and then exclude the other things that
might be involved. So we thought there was something that
included a little bit more than just a physical. Dr. Feinleib.
Dr. Feinleib. I agree with that, with a slight
modification. When you go into your doctor's office nowadays,
they give you a sheet to fill out, any allergies, any
medications, etc. And then the doctor usually uses that as----
Mr. Shays. I call that a questionnaire.
Dr. Feinleib. That's right. That's a questionnaire. But he
uses that as a starting point to start asking you questions,
and that leads to a whole new thing. Then when he gets you up
on the table, he'll know what to look for, what to feel for,
etc. That's the way this should be designed.
Mr. Shays. And still gives you a physical examination.
Mr. Robinson, you already asked the question, but since
we're going in order here, was it your interpretation based on
your testimony that this medical examination would include a
physical examination?
Mr. Robinson. Absolutely. In fact every scientist and
doctor that I have spoken with says that the only way to get to
the answers about what or whether or not exposures are related
to illnesses, you have to have a baseline data.
One of the things that was very interesting that was a
theory that came up after the Gulf war was they said perhaps
some of the people that deployed were ill before they deployed.
A lot of Gulf war veterans found that to be strange.
Let me give you a perspective that----
Mr. Shays. I'll tell you--interrupting the gentleman, the
benefit of doubt has to go to now the veteran.
Mr. Robinson. Absolutely.
Mr. Shays. But what it raises is the clear need to either
maybe pass a resolution quickly that requires that our veterans
be given in their medical examination a physical.
Mr. Robinson. Absolutely.
Mr. Shays. But you were going to say something.
Mr. Robinson. I was going to say that I want to give a
soldier's perspective of how this gets implemented. If you're a
soldier in the 82nd Airborne about to deploy with your unit to
Baghdad or to Kuwait and you're handed this questionnaire and
it says, do you have any current illnesses that will prevent
you from deployment? Do you got your glasses? Do you got--the
chances are the soldier is going to check every answer that is
appropriate to allow him to deploy. Soldiers want to go and be
with their fellow warriors.
The same is true when they return. When they return, they
don't want to sit down and aren't going to sit down--if you
hand them a piece of paper and say fill this out and mail it in
30 days later, they are not going to credibly report incidents
that are related to their exposures based on this sample
questionnaire, and from everyone I've talked to they have said
that this would not provide any evidence that could be used in
an epidemiological way to find any answers.
Although it may be well intended to have a questionnaire,
the intent of the law was to have a medical exam before and
after, to include the drawing of blood, and all of those things
in combination would be the keys to understanding whether an
illness was related to an exposure or whether--you know, we
have the capability to look at blood serum to the molecular
level, to look at cell changes as a result of exposures. It's
important that we get the data when the soldiers--before they
deploy and when they return.
I think the public law was written in a way that actually
provides a mechanism, if followed properly, to get to the root
of this answer, but because it has been interpreted rather than
implemented, this particular means by which they use to get
answers is not satisfactory.
Mr. Shays. I'm not going to dwell too long----
Mr. Janklow. Can I ask you a question, Mr. Chairman? I
wasn't----
Mr. Shays. You're going to ask me a question?
Mr. Janklow. If I could. I'm not familiar with that law
until you elaborated on it today. How do you conduct--is there
a way that you've ever heard of to conduct a medical--not
questionnaire but examination without a physical exam? I mean,
how would you do it?
Mr. Shays. You're asking the wrong guy. I don't know what
compelled you to want to ask me that question.
Mr. Janklow. Doctor, can you tell us? Can you do a medical
examination without physically examining a patient?
Dr. Moxley. Yes.
Mr. Janklow. You can.
Dr. Moxley. There are things called multiphasing screening
which a number of HMOs and so forth have set up where one goes
through and has a whole raft of laboratory studies and x-rays
and so forth but is not physically examined. There are some who
would argue that provides a very good index of state of health,
assuming the person is feeling well. I mean, if the person is
not feeling well, then it's a different story.
Mr. Shays. But if the gentleman would just yield a second,
are you saying that you actually are taking lab tests?
Dr. Moxley. Yes, sir, but it's a----
Mr. Shays. That strikes me as a----
Dr. Moxley. I haven't looked at it recently, and I am sure
it varies from medical group to medical group. My guess is it
does involve a questionnaire and then a series of laboratory
tests, and so forth and so on. It gives a check for people who
are feeling well at the time. It's also true--and I don't want
to complicate this any further, but it's also true that
repeated physical examinations on people between, say, the age
of 20 and 40 who are feeling well yield very little new data,
which is why a number of insurance companies----
Mr. Janklow. But we're looking for baseline on the----
Dr. Moxley. No. I'm saying this is a deployment situation,
so it's different. You were asking me a general question, and
I'm trying to answer it. So that those sorts of things do
exist, where you don't have an actual--but we're talking about
a specific predeployment and postdeployment here. That changes
it a whole lot.
Mr. Janklow. Can I ask one more question?
Mr. Shays. Sure.
Mr. Janklow. Have you ever in all your medical life, either
of you doctors, heard someone say that you could define medical
examination as filling out a two-page questionnaire and having
drawn blood for HIV purposes from today to 3 years prior to now
and heard that defined as a medical examination?
Dr. Feinleib. I think at a minimum you'd want to look down
his throat----
Mr. Janklow. You've got to say yes or no, if you would.
Dr. Feinleib. Not a----
Mr. Janklow. Would my facts ever have been described to you
or would you have ever concluded that's a medical examination,
to fill out a questionnaire and to have drawn blood for HIV
purposes and then storage for the rest of it?
Dr. Feinleib. No, I do not think that would be a medical
exam.
Dr. Moxley. No.
Mr. Janklow. OK. Thank you.
I have nothing further, sir.
Mr. Shays. OK. I am just struck, Dr. Moxley, if you are
doing lab work, it sounds pretty physical to me.
Dr. Moxley. Well, the physical examination, as it is taught
in medical school, is the actual laying on of hands, Mr.
Chairman.
Mr. Shays. Right.
Dr. Moxley. And that's the distinction I was making.
Mr. Shays. But the bottom line is, you are still drawing
blood, you are still taking pictures. You are doing a lot of
things.
Dr. Moxley. We are doing everything but the laying on of
hands, yes, sir.
Mr. Shays. OK. In this, there is the predeployment and the
postdeployment. It is two pages long. The first page is, you
know, name and today's date and Social Security and gender,
service branch component, pay grade, location of operation.
That's not unemployment.
Mr. Janklow. Does it have your mother's maiden name?
Mr. Shays. You know what, it doesn't ask that.
And then down here it has, for administrative use only. And
then the second page is eight questions, and then down here is,
referral indicated. And I gather this is for the person looking
at the form. So, basically in a two-page document, one-third of
one page has the questions.
I am going to say this though; I do think at least they are
listening. And we have been asking DOD and VA to listen.
So I like the idea of a questionnaire. But to have the
questionnaire, in a sense, take the place--and then these eight
questions. And I just--you know, I look at some of these
questions, but one in particular about the mental health. It's
like asking someone, are they crazy. And you know I don't know
what they are going to say. I hope they say, no.
But you get my gist. And I look at this and I am not
impressed; and you are not impressed.
Dr. Feinleib. I agree with you. In fact, one of the things
that upsets me most is that on that first page where they ask
very simple things like your gender, service branch, etc., so
many of them are unknown. They were left blank. They weren't
readable. That indicates very poor quality in filling them out,
looking at them when they come in; and then I wonder what kind
of use you can make of that.
Mr. Shays. In other words, really what should happen is
when these are filled out, they should be reviewed by someone
on the spot to make sure they understand them?
Dr. Feinleib. At least. I don't know why some of this
couldn't be just passing the dog tag through a card reader
essentially.
Mr. Shays. Yes. Well--and, you know, and one of the
questions is, are you pregnant, which--that leaves out one
question for some of us. And it's not an unimportant question.
But my point is that there aren't a lot of questions. And
with the postdeployment--there are six questions: Would you say
your health in general is excellent, very good? Do you have any
unresolved medical or dental problems? Are you currently on a
profile or light duty? During this deployment, have you sought
or intended to seek counseling or care for mental health? Do
you have concerns about possible exposure of events during this
deployment that you may feel affect your health? That's not an
unimportant question. Then, list your concerns. And the last
question is, do you currently have any questions or concerns
about your health? And please list your concerns. And they
leave you two lines to list your concerns.
So with this panel, at least, this questionnaire doesn't
measure up, correct? For the record note that----
Dr. Moxley. No.
Dr. Feinleib. No.
Mr. Robinson. No.
Mr. Shays. No. And what this tells me for this committee is
that we clearly want to back up Secretary Principi's request
that the questionnaire be more intensive, and we also, I think,
are going to pursue--I mean, if you had a choice of only giving
a physical once, it's too bad it's not done twice and drawing
blood once.
Would it be better pre or post? Dr. Moxley.
Dr. Moxley. Without the pre, the post would not be nearly
as helpful. What you do is, you measure back against what you
find pre to see what is new in the post.
Mr. Shays. This is a tragedy. It really is, isn't it?
Mr. Janklow. Mr. Chairman.
Mr. Shays. Just 1 second. If you will keep your thought,
just don't ask me the question.
Dr. Feinleib.
Dr. Feinleib. I was just going to make one comment. If you
impose a full physical examination, you are going to need
personnel to do that.
Mr. Shays. Right.
Dr. Feinleib. If they have to be physicians, you are going
to have to have a physician draft to be able to conduct all
those examinations. You have to find some other method, trained
medics, for example, to check for the specific factors that an
expert committee might recommend be checked, and an abbreviated
physical exam for what might usually be 95 percent of the time
relatively healthy young men and women.
Mr. Shays. I am going to come back to you.
Mr. Robinson.
Mr. Robinson. Mr. Chairman, when we want to know if our F-
16s are capable of flying, we don't ask them questions. We put
our hands on them and in them, and then those maintenance
records are maintained. And the next time the pilot walks out,
before he gets in the plane he himself walks around that
aircraft and puts his hands on that aircraft, even though he
has read the maintenance logs, to ensure that certain key
critical components have been addressed before he gets in the
seat and flies away.
We have trained people, medical professionals, that in the
process of getting people ready to deploy could conduct a serum
draw both pre and postdeployment, and could ensure that if we
are going to use a questionnaire, that it's filled out
properly. And we could also, at that same predeployment process
and postdeployment process, have medical professionals there to
put their hands on soldiers, look them in the eye and talk to
them and find out what their current conditions are.
It is not rocket science, and it can be done. And we need
to put the same amount of emphasis on looking at the soldier
that we do looking at the technology.
Mr. Shays. I want to ask both doctors if they agree with
that comment, but I would like to yield to my colleague.
Mr. Janklow. Mr. Chairman, one, I do believe that everyone
who goes into the Armed Forces has a current blood sample
drawn--has a blood sample drawn. I don't know if that is saved.
Assuming----
Mr. Shays. At least within 12 months.
Mr. Janklow. Yes. And so, you know, that will at least give
you some baseline for some of the people, one.
And, two, with the correct--with a good form, would it--
couldn't physicians' assistants and nurses also contribute to
doing some of these physicals, if I can call them that?
Dr. Feinleib. Absolutely. Yes.
Mr. Janklow. And it doesn't have to be a medical doctor.
Aren't there certain differential diagnoses that you kind of
look at and go from there?
Dr. Feinleib. Exactly. Yes.
Dr. Moxley. It probably should be under the overall
supervision.
Mr. Janklow. Sure.
Dr. Moxley. But you can have nurse practitioners or
physician assistants who are trained to do routine physicals
and do them very well.
Mr. Robinson. If there is the will to examine, you know, an
aircraft, we can find the will to examine people. We can do it.
Mr. Janklow. Sir, I am a pilot; I preflight my airplane
every flight.
Mr. Shays. Well, you know, I just want to make sure,
though, that, Dr. Feinleib and Dr. Moxley, you agree with Mr.
Robinson's comments or would qualify them. And then I want to--
yes, the first one. When he was, his--not his last response,
but the response before last.
Dr. Moxley. Which was? I'm sorry.
Mr. Shays. Which was, well, first the analogy of the
airplane to the person. But I guess what--since you didn't hear
it, and he spent more than just a sentence describing it, let
me ask you these questions.
I am going to share with you that I am concerned that maybe
we didn't see the physicals, not because we didn't need them,
but because we didn't think we could afford them or we didn't
have the people in place. And that makes me very concerned,
because we have just put on the record that nobody is going to
be denied anything based on cost. Our men and women are going
to get whatever they need. And it strikes me that if that is
the reason, that's pretty unfortunate.
So let me ask you, first, if you would agree with Dr.
Feinleib that we would need a whole host of people to have
given a physical to the 250,000 Americans who were sent to the
Gulf.
How long does a physical take nowadays?
Dr. Moxley. Excluding taking the history or filling out the
questionnaire, I would think one could be done every 15
minutes, probably.
Dr. Feinleib. I would concur with that. You would need
another station in the processing.
Mr. Shays. You would have to automate the system a bit, and
you'd need different people to do different things. And so I
guess we could figure out 15 minutes times 250,000 people does
sound like a lot of work, and so that is one issue.
But the other issue that--so, Dr. Feinleib, you made that
point. I am happy you made it, but I am unhappy to know it.
Dr. Moxley, you made another point which I'm happy to
know--I am happy you made, but unhappy to know--and that's what
you are saying, that we can't correct the damage done--if we
happen to think it's damage done, in other words, not giving
them the physicals before they left. Because what you're
telling me is, we need both ends in order to really get the
information, unless we assume they were all well before they
went. And then we would--it would seem to me then we would have
to assume that.
Dr. Moxley. Correct.
Mr. Shays. And then we would have to--we would then have
to, in this instance, when they came home sick, say--we could
not allow DOD or VA to say, you know what, they were sick
before because we don't know.
So we have to assume they weren't, in order to----
Dr. Moxley. Again, I don't know what data DOD has on the
troops that were deployed. But unless it's there, you would
have to assume that, yes, it was a result of the deployment. I
don't know what else you could do.
Mr. Shays. But now, assuming that, will we be able to help
them? Financially, we will be able to, but are you saying that
they may not get the kind of medical attention they need
because we didn't check before?
Dr. Moxley. I don't know that you can say that, no.
I think that in most of the veterans coming back, the
illnesses they develop will undoubtedly be illnesses that
people in the general population develop.
The question is, if there is a cohort that develop signs
and symptoms that we don't understand, as there apparently were
coming back from the Gulf war, then those will have to be just
treated with the state-of-the-art which, at the present time,
is to understand that we don't know the cause for them, and to
be honest with them about that and treat them prospectively and
just do the best we can.
Mr. Shays. Is there any final point you want to make?
Mr. Janklow. I have nothing. Thank you very much, Mr.
Chairman. It has really enlightened me.
Dr. Moxley. May I add something to an answer I gave to you,
Mr. Janklow?
Mr. Shays. Just a little louder, Dr. Moxley.
Dr. Moxley. You asked me if there was any addendum or
anything like that I would add--and I said no, and I meant
that.
But let me just say that I would be ecstatic if it could be
documented that the recommendations that we made in this
report, which were made by, in one form or another, seven other
groups in the decade in the 1990's.
Mr. Shays. State the report again, please, for the record.
Dr. Moxley. Pardon me? The name of the report is Protecting
Those Who Serve: Strategies to Protect the Health of Deployed
U.S. Forces.
If there was a positive answer from the DOD that these
recommendations had been implemented, I would be ecstatic and
think that they deserved enormous credit, because there is a
lot of work laid out here that had to be done.
Mr. Janklow. Can I ask one more question, sir?
Mr. Shays. Absolutely.
Mr. Janklow. Doctor, can you tell me, do you sense in any
way that this is a partisan, political thing? I mean, the
report was issued under a previous administration. We are in
another one. Do you sense anything like that? Or is that not
the issue?
Mr. Shays. Now, that's a question you could ask me.
Dr. Moxley. No, I really don't. I think that people who are
interested in these matters have a deep and abiding interest.
My interest in medical readiness goes back 20 years. And they
are interested in it as a concept, and they are not interested
because of the hat you wear.
Mr. Janklow. Good. I'm glad to know that, because we can
fix the other.
Mr. Shays. You think so?
Mr. Janklow. Yes, sir.
Mr. Shays. As we look at this, you know, my sense is
having--you know, the men and women who serve in DOD and the
Department of Veterans Affairs are very good people. They all
have restraints. And sometimes I get the view that someone is
told, you can't do it, so make the best you can; and so, then,
inventive minds are trying to make the best they can.
The problem is--and that's why you sometimes have a
Congress that says, are you doing what the law requires? Does
this makes sense?
Now, our committee is a committee that looks--we don't
write laws and we don't appropriate. We look at how laws are
implemented, and we look at waste, we look at abuse, we look at
mismanagement, and we look at fraud. What's troubling in this
hearing is that we've had 13 years to deal with this problem,
and we all know what we need to do and we passed a law that was
pretty sensible.
And if DOD didn't think it was sensible or the VA didn't
think it was sensible, then they needed to come back to tell us
to amend the law because there are restraints like, guess what,
it is impossible to give everybody a physical. And then we
would have a wonderful debate about that, and then we might
amend the law or we might not. Or we might say, well, if you
are Active Army you don't, but if you are Reserves and National
Guard you are going to. I mean, who knows what we would have
concluded? But we would have had an honest dialog back and
forth.
What I'm sensing and what the committee will continue to
try to look at is that there may have been a concern that we
just simply didn't have the capability or resources to do what
the Congress wanted and what the President signed into law, and
that we didn't pay attention to it back then, and my God, all
of a sudden we have 250,000 people sent off to fight a war. And
we can't undo that.
And, by the way, we've got the problem with protective gear
and that's a higher priority. And the JLA suits are all around
the freaking country and we don't know where they are, so let's
get that; and the committee's making noise about that, so
that's a higher priority.
I mean, I can just begin to imagine in my own mind why this
happened. But this I know: It would have been the right thing
to have given them physicals, and we could have found a way to
deal with it. And we might not have had a doctor at every
station, but we could have done that.
And this just makes me more convinced than ever that we had
better give them the physicals when they leave, and that we had
better have a better questionnaire. And, for that, I thank you
all.
I thank you for a lot of things, but I think we have our
work cut out for us. Do you agree? OK.
Is there any final word that any of you want to make?
Anything on the record that needs to be part of the record? Dr.
Moxley.
Dr. Moxley. No, sir.
Mr. Shays. Dr. Feinleib.
Dr. Feinleib. I want to thank you personally for inviting
me today and giving me a chance to contribute to your
deliberations. And thank you for playing this leadership role
again and trying to rectify this problem and preserve the
health of the fighting men and women who are helping us.
Mr. Shays. Thank you.
Mr. Robinson.
Mr. Robinson. I would like to echo the sentiments that we
are concerned about our fighting force and pray for them. And I
would like to also say that there was no Kosovo syndrome and
there was no Bosnia syndrome when soldiers returned. And the
reason there wasn't was because there were no mysterious
illnesses that came from there.
I look forward to the recommendations of the committee and
hope that we can implement them to protect the force. Thank you
very much.
Mr. Shays. Thank you all very much. And you all have made a
wonderful contribution, and I do thank you for that. It's been
a very interesting hearing.
I don't want to put anyone in an awkward situation from the
first panel. But if there is anything from the first panel that
needs to be made part of the record, we would put it on the
record publicly if that needs to be done.
If not, we are going to let the record stand as it exists
and we will continue this process. And I thank you all very
much.
This hearing is adjourned.
[Whereupon, at 5:16 p.m., the subcommittee was adjourned.]
[The prepared statement of Hon. Dan Burton and additional
information submitted for the hearing record follows:]
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