Donald Mattison, M.D.
National Academy of Sciences
Institute of Medicine
Committee on Veterans’ Affairs
U.S. House of Representatives
February 5, 1998
Mr. Chairman, members of the committee, I am accompanied today by Dr. Dan Blazer and we appreciate the opportunity to provide testimony to you regarding a new IOM study. This study will evaluate the available scientific and medical literature in regarding an association between exposures during the Gulf War and potential health effects as experienced by Persian Gulf veterans. As requested, I will also briefly review the recommendations of the recent IOM study, chaired by Dr. Blazer, regarding the adequacy of the Department of Defense’s (DoD) Comprehensive Clinical Evaluation Program (CCEP), and how those findings relate to similar programs administered by the Department of Veterans’ Affairs (DVA). Dr. Kenneth Shine, President of the IOM, regrets that he is unable to attend this hearing, however, he will make himself, members of the Institute, and staff available to provide information and testimony to the committee as necessary.
The DVA has requested that IOM conduct a comprehensive review of the available scientific and medical literature regarding the association between exposures during the Persian Gulf War and adverse health effects experienced by Persian Gulf War Veterans. This study will be conducted by a committee of experts drawn from a broad range of public health, scientific, and medical fields. Based on its review and findings, the committee will also make recommendations for additional scientific studies to resolve areas of continued scientific uncertainty related to health consequences.
The IOM plans to conduct the study in three phases. During the first phase, the committee will develop criteria by which specific exposures and adverse health outcomes are to be chosen for study. The committee will review different types of research findings in the scientific and medical literature, for example, data from animal studies, occupational exposures, and epidemiologic studies. They will conduct a review of the literature regarding prototypic exposures in order to develop methods for analysis and synthesis of findings. Scientific evidence concerning association of exposures and health effects will be examined. The committee will consider the strength of the scientific evidence and the appropriateness of the methods used to identify associations; the exposure levels of the study populations in comparison to the Gulf War exposures; and whether there exists a plausible biological mechanism for a causal relationship between the exposure and the manifestation of a health effect.
During the second phase of the study, the remaining exposures will be subject to review and analysis. The final phase, to be conducted every two to three years, will update the literature reviews and the associations that have been identified between exposures and adverse health outcomes. It is assumed that the IOM will begin this project in the Spring of 1998 and complete the first phase by Spring of 2000.
I would like to focus now on the findings of the recently released IOM report evaluating the adequacy of the Comprehensive Clinical Evaluation Program (the CCEP) administered by the Department of Defense, and how the report findings relate to similar programs administered by the DVA. The charge to the IOM committee conducting the evaluation was to examine the adequacy of the CCEP diagnostic protocol as it relates to ill-defined and difficult-to-diagnose conditions, and to stress and psychiatric disorders.
The committee chose, based upon an examination of the conditions described as difficult-to-diagnose or ill-defined, to refer to this spectrum of illnesses as medically unexplained symptom syndromes. Medically unexplained symptom syndromes are often associated with depression and anxiety, yet this does not imply that the syndromes are psychiatric disorders. In addition, stress is a major issue in the lives of patients within this spectrum of illness. Stress need not, however, be looked at so much as a causative agent, but rather as a part of the condition of the patient that can not be ignored. With medically unexplained symptom syndromes, the potential for stress proliferation is great among both the person deployed to the Persian Gulf and the family members.
Research has shown that stressors have been associated with major depression, substance abuse, and various physical health problems. Those deployed to the Gulf were exposed to a vast array of different stressors that carry with them their own potential health consequences. It was the conclusion of the committee that, “in cases where a diagnosis cannot be identified, treatment should be targeted to specific symptoms or syndromes (e.g., fatigue, pain, depression).” The committee also recommended that “providers acknowledge stressors as a legitimate but not necessarily the sole cause of physical symptoms and conditions” and that providers should be educated to the fact that “conditions related to stress are not necessarily psychiatric conditions.”
There is another committee of the IOM that is currently completing its evaluation of the DVA Persian Gulf Registry and Uniform Case Assessment Protocol for Persian Gulf veterans. The charge to that committee is much broader than the charge to the CCEP committee because it includes an examination of the adequacy of (1) the protocol, (2) its implementation and administration, (3) outreach efforts to inform veterans of available services, and (4) education of providers. The final report is due to be released in March of this year. We would be pleased to share copies of the report with you as soon as it is available.
Thank you for this opportunity to address the committee. Dr. Blazer and I would be pleased to answer any questions you may have.