STATEMENT OF
JASBIR S. MAVI, M.D.
PERSIAN GULF REGISTRY PHYSICIAN
VA MEDICAL CENTER, HUNTINGTON, WV
BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS (FIELD HEARING)
HUNTINGTON, WV

April 2, 1997

Mr. Chairman and Members of the Committee,

I thank you for the opportunity to appear before this committee today. My name is Jasbir Mavi. I am the Persian Gulf Registry (PGR) Physician at the VA Medical Center, Huntington, West Virginia.

The Committee is well aware of VA national programs and initiatives regarding Persian Gulf veterans' health issues. After a quick overview of Persian Gulf Registry program, I will primarily focus on the Persian Gulf Registry program at the VA Medical Center, Huntington, West Virginia.

Persian Gulf Registry (PGR) Program

The Persian Gulf Registry (PGR) program was initiated in 1992 following reports of various symptoms in veterans returning from deployment in Persian Gulf. In 1994, Department of Veterans Affairs adopted "Uniform Case Assessment Protocol" (UCAP) in order to systematically evaluate veterans' symptoms. (This protocol is comparable to DoD's Comprehensive Clinical Evaluation Protocol [CCEP]). The UCAP is a two phase process. Phase I comprises detailed medical and exposure history, a complete physical examination and certain lab tests. If a veteran is found to have symptoms for which no clear diagnosis can be made, Phase II is initiated. Phase II of UCAP includes more detailed clinical tests and consultation with specialist(s) appropriate for the veteran's symptoms. This information is entered into the veteran's Consolidated Health Record.

On completion of each clinical evaluation, relevant data such as symptoms and diagnoses (if any) are entered on a code sheet. The code sheet is sent to Austin Automation center where it becomes part of the national registry database.

The Persian Gulf Registry examinations serve at least two important purposes. One, they allow the individual veterans to be medically evaluated in a systematic manner and properly treated. Second, they generate the clinical data that are necessary for ongoing health surveillance and eventually may help us generate research hypotheses concerning veterans' symptoms. As of January 1997, over 65,000 PRG examinations were completed nationwide.

VA encourages all Persian Gulf veterans to get a medical examination under this registry program whether or not they have any symptoms.

It is important for the Persian Gulf registry physicians and coordinators to stay abreast of the current health and policy issues. There are three important channels that help accomplish this goal.

• The VA Environmental Agents Service holds quarterly conference calls which allow two way discussion between headquarter staff and PG physicians and coordinators in the field.
• Periodic (quarterly) mailings from VA Environmental Agent Services.
• Annual meetings on Persian Gulf health issues. The last such national conference was held in August of 1996. The PGR physician and a Vet Center staff member attended that conference from Huntington. The next conference is planned for June 1997 which will be attended by the PGR physician.

PGR Program at VAMC, Huntington

Huntington VA Medical Center serves veterans living in West Virginia, Ohio and Kentucky. In our database, we have over 2600 veterans listed as Persian Gulf Era veterans. (Please note that this is not the number of Persian Gulf war veterans in this area).

VAMC Huntington has actively participated in the PGR program since its inception. To date, we have completed about 290 examinations under this program. This represents about 11 percent participation and is consistent with the national participation rate of about 10 percent.

When a PG veteran requests an examination and sends in requisite forms, an appointment is scheduled. Presently, we are able to schedule such examination within two weeks.

A PGR examination consists of a detailed history which includes, among other things, history of harmful exposures, birth defects in children, and details of each symptom the veteran has. This is followed by a complete physical examination. The findings of history and physical examination are explained to the veteran and plans for further evaluation are discussed. A typical initial PGR examination takes one to one and a half-hour.

An important aspect of PG examinations is involvement of families. Many veterans come for examination with their significant other who shares the veteran's health concerns. On completion of the examination, if a significant other is present, he or she is invited to discuss any health concerns. Many young couples are concerned about possibility of birth defects in children. A calm, fact based discussion that presently there is no scientific evidence of increased risk of birth defects in children of PG veterans helps reduce such anxieties.

Many veterans have symptoms that cannot be fully explained on completion of an initial examination. Such veterans are requested to undergo additional clinical tests and examination by appropriate specialists. Most of the specialty consultations are available within Huntington VAMC. When a consultation from an outside specialist is needed, it is arranged by the VA medical center at no cost to the veteran. These consultations provide both diagnostic work-up and treatment. Further, follow-up visits are scheduled both in the Persian Gulf clinic and in the specialty clinics as indicated by individual's health problems.

We ensure continuity of care by enrolling PG veterans in our Primary Care Clinics (PCC) where they periodically see the same medical care provider for their ongoing health care needs. Our female veterans are encouraged to enroll in women's health clinic which provides regular medical care as well as preventive health services.

We are sensitive to numerous stressful factors that PG veteran endured during PG deployment. Though the actual war lasted only a short period, many veterans stayed in a foreign, potentially hostile environment for months. They faced various combat related risks including exposure to chemical and biological warfare. On returning home, many face unemployment or underemployment, family problems or suffer from substance abuse. In addition, many veterans suffer from unexplained health problems.

All these stresses can create health problems of their own. Our Mental Health Clinic (MHC) provides diagnostic and therapeutic services for these veterans. Such services include psychiatric evaluation and treatment as well as individual and group therapy. The therapy sessions involve family/spouse when appropriate. As an example, MHC offers individual and group therapy for PTSD, anxiety, anger management, family/marriage counseling and substance abuse.

Conclusion

Even six years after the Persian Gulf War, many PG veterans' health concerns remain unanswered. Numerous research projects are in progress to look into these issues. As of now, no single disease or chemical exposure has been identified which can explain PG veterans' health problems.

We know that given our present state of medical knowledge and our current understanding of Persian Gulf veterans' illnesses, we do not have answers to many questions. We also know that numerous scientists, both in public and private sectors, are working hard to solve the mystery of the so-called "Persian Gulf Syndrome."

At VAMC Huntington, we strive to provide medical care with understanding and compassion. In the majority of veterans we find known medical conditions and offer them the best medical care we can. In any case, we do our best to provide as much relief as medically possible.

Mr. Chairman, in my personal experience, the vast majority of PG veterans are satisfied with the PGR examinations. During these examinations, many of their questions and concerns are addressed and anxieties relieved. They may not get all the answers but they know we truly care about their health problems.

Again, I thank you for the opportunity to appear before this committee. This concludes my prepared statement.

Senator Rockefeller and members of the Committee,

My name is Johnny Bragg. I am the Acting Team Leader at the Morgantown Vet Center. I have worked in the Vet Center Program for 2½ years. During this period I have had contact with Persian Gulf veterans both as a counselor and on outreach activities. The Morgantown Vet Center has the largest catchment area in West Virginia. Our area includes 16 counties in Northern Central West Virginia, 2 counties in Pennsylvania and 1 county in Maryland. This catchment is mostly rural with a widely dispersed population. In this catchment area we provide services to 11 reserve and national guard units that served in the Persian Gulf War. In addition, we provide outreach to other reserve and national guard units that were not deployed in the Gulf that now include members that are Persian Gulf veterans. In the Morgantown Vet Center catchment area, there are 2,040 Persian Gulf veterans.

Immediately after the Persian Gulf War, Readjustment Counseling Service was allotted additional temporary staff to outreach to our returning veterans and their families to make them aware of VA services. Since the Persian Gulf War, the Morgantown Vet Center has seen 505 Persian Gulf veterans. Two hundred and seven of these Persian Gulf veteran have been seen for multiple overlapping issues to include post-Traumatic Stress Disorder, alcohol/drug abuse counseling, marital and family counseling, and psychological counseling. Employment counseling assistance was provided to 127 vets. Medical counseling for referrals for Persian Gulf veterans illnesses and medical issues has been provided to 150 Persian Gulf veterans. Also, benefits counseling including assisting with obtaining Vocational Rehabilitation, G.I. Bill, compensation and pension exams for service-connection, Persian Gulf registry and other VA benefits was provided to 245 of our Persian Gulf clientele.

The Morgantown Vet Center provides on-going counseling for Persian Gulf veterans. Counseling services are provided for Post-Traumatic Stress Disorder and Sub Diagnostic Post-Traumatic Stress Disorder, martial/family counseling, psychological counseling, and substance abuse counseling. The Morgantown Vet Center has at different times conducted group therapy for Persian Gulf vets as well as individual sessions. Our center is now in the process of beginning a new group composed strictly of Persian gulf vets to address the problems that are surfacing due to the recent flurry of media coverage relating to the illnesses of Persian Gulf veterans.

Mental health treatment for Persian Gulf veterans is provided at the Morgantown Vet Center in much the same manner as for any other veteran. The process begins with an initial intake assessment by a clinician to determine the most pressing problems are severe enough to require referral to the Mental Hygiene Clinic at the VA Medical Center.

Persian Gulf veterans who present with medical issues are referred to their nearest VA Medical Center. All Persian Gulf veterans are encouraged to obtain a baseline Persian Gulf Registry examination. Veterans with physical problems are also encouraged to follow-up with counseling to deal with any psychological problems that may result from their illness, or frustrations they may develop while seeking treatment. The significant others of Persian Gulf veterans may be seen individually with the veteran's consent, or may join the significant others' group at the center. Marital and family counseling is also available to deal with the problems arising from the way itself, or from any illness that may be associated with the veterans tour in the Gulf.

Currently the Morgantown Vet Center performs regular outreach to all military, reserve, and national guard units in our catchment area. In addition, outreach is performed through veterans service organizations such as American Legions, VFWs, and Disabled American Veterans. The Vet Center also works closely with its support facility, the Louis A. Johnson Medical Center, at Clarksburg, West Virginia, to insure a continuity of care for clients obtaining services at both facilities. Efforts are also directed at other community service providers to increase their awareness of VA services available to their veteran clients.

Senator Rockefeller, it is my honor and pleasure to testify at this committee hearing on medical and health services provided, to Persian Gulf War veterans and the Beckley Vet Center's role in serving Persian Gulf veterans.

The mission of the Vet Center is to serve veterans and their families by providing ongoing quality care that adds value for veterans, families, and communities. I represent a community-based arm of the Department of Veterans Affairs (VA) Readjustment Counseling Service. Our staff provides professional readjustment counseling, community education, outreach to special populations, the brokering of service with community agencies, and provides a key access link between the veteran and other services in the Department of Veterans Affairs. We are currently providing Readjustment Counseling to Vietnam Era Veterans, war zone veterans from all eras, and Sexual Trauma and/or Harassment assessment and referral for any veteran who experienced sexual assault and/or harassment in the military.

The Beckley Vet Center covers a geographical area in southeastern West Virginia encompassing 5,096 square miles and eight rural counties. The center is staffed by 3 full-time FTEE which are responsible for serving a target veteran population of 20,915. Initially, it was estimated that 165 Persian Gulf male veterans were contained within this target population, however, we found the population to be much larger. Since August 2., 1990, our staff has counseled 317 Persian Gulf veterans. The veterans were categorized as follows: (1) Males: 301, (2) Females: 16, (3) Regular Military: 292, (4) Activated Reserve/National Guard: 25, and (5) Non-West Virginia Residents: 11.

An analysis of the expressed problem codes indicated (65.6%) of the veterans were requesting employment and benefits assistance. These requests included job placement, career planning, establishing eligibility for VA Educational Benefits/Work-study Benefits, VA Home Guaranty Entitlement, VA Vocational Rehabilitation services, Medical Benefits, Military Discharge Upgrades and obtaining the West Virginia Veterans Bonus.

After an intake assessment, the veteran may be referred to appropriate individuals and agencies for specialized assistance. Currently the Vet Center is providing employment assistance and career planning/educational assistance through working agreements with WV Job Service and Bluefield State College.

We have counseled Persian Gulf veterans on 44 separate occasions (6.39%) regarding their expressed concerns over health-care issues. Our counseling sessions centered around establishing VA service-connected claims for injuries received in the military, their expressed anxiety over having possible symptoms of the Persian Gulf undiagnosed illnesses, treatment available to them, and establishing their expressed health problems on the VA Persian Gulf Health Registry.

Some veterans also received mental health counseling for anxiety and anger associated with their perception of being exposed to chemical weapons in the Persian Gulf, being given untested drugs, having children born with genetic defects, and the veterans' feelings of a possible government cover-up.

Other prevalent problems expressed at the Vet Center include Post Traumatic Stress Disorder, Psychological issues, and Sexual Trauma. During the past 6 years, (38) Persian Gulf veterans were counseled for Post Traumatic Stress Disorder, (11) for Drug/Alcohol, (16) for Marital/Family conflict, (40) for Psychological problems, (3) assessment and referrals for Sexual Trauma, and (6) for high-risk behavior. The six high-risk veterans were referred to the VA Medical Center Mental Hygiene Clinic, Beckley, West Virginia for psychiatric intervention and management. The Beckley Vet Center does not have a Sexual Trauma counselor; therefore, all sexually traumatized veterans are referred to the Beckley VA Medical Center for treatment and management.

In addition, some Persian Gulf veterans were counseled for anxiety and frustration over their perception of not being able to receive psychiatric treatment for nonservice-connected conditions, differences in eligibility requirements at the Vet Center v/s VA Medical Center, and problems with verifying war stressors for VA compensation claims.

In conclusion, the Vet Center staff provides a full-range of services for eligible combat veterans including psychosocial assessments for war traumas, high-risk behavior, expressed healthcare issues, and social problems. We use a multi-disciplinary treatment and holistic approach when treating veterans. Our services include, but are not limited to: clinical counseling for Post Traumatic Stress Disorder, Employment/Career Counseling, Benefits Referral Assistance, Community Education, post-hospital follow-up for veterans suffering from war traumas, and referral assistance to multiple community and federal agencies.

Senator Rockefeller, I am honored to appear before you and testify about health care concerns relating to Persian Gulf War veterans. I will also take this opportunity to commend you and your devoted persistence to insure quality care to the Persian Gulf veterans.

It is with great pride that as a Readjustment Counseling Service employee in West Virginia that we have accomplished many successful efforts to outreach Persian Gulf veterans which have been coordinated with Federal, state and local agencies. Vet Center staff have contacted and personally briefed area Reserve units that were activated to the Desert Storm operation, as well as, attending and speaking at Veterans Service Organization's meetings and conferences. These briefings highlighted Vet Center services for war trauma, sexual trauma and general medical and benefits information. We have also collaborated with local healthcare providers and VAMCs for several one-day health fairs targeting female and Persian Gulf veterans which have benefited veterans living in remote rural areas. These efforts to outreach Persian Gulf veterans providing well needed services.

As community-based mental health providers, we refer all Persian Gulf veterans to the Huntington VA Medical Center for the Persian Gulf Registry examination and all other medical issues. We have established key referral contacts and open dialogue with various hospital departments, depending upon the service requested. At this time. most Persian Gulf veterans who seek Vet Center assistance in the Charleston, WV area, are reporting somatic illnesses and associated emotional issues. Our office also serves as the central location for transportation to and from the VA Medical Center. This transportation is provided four days per week.

In the area of treatment, the Vet Center assesses and provides treatment for Post Traumatic Stress Disorder (PTSD), depression, substance abuse and related family issues. We also counsel veterans who express frustration about the lack of available medical knowledge to treat their physical complaints. This frustration causes anxiety, anger, mistrust, authority issues and has exacerbated PTSD symptoms.

The Huntington VA Medical Center is presently conducting a successful health risk assessment clinic at the Charleston Vet Center. This collaborative effort has been praised by the veterans utilizing the clinic and is gaining support throughout veteran organizations. Many veterans including Persian Gulf veterans have visited the clinic and are being introduced to Vet Center and VA medical services. This proven strategy to outreach veterans with a hands on service approach tremendously benefits many veterans living in the surrounding remote areas.

This simple outreach service approach breaks from traditional methods of serving only those veterans who can travel to VAMCs, to include those veterans who can not conveniently do so. All veterans benefit from this service, and this approach can assist VAMCs with outreaching Persian Gulf veterans providing healthcare and accumulation of scientific evidence that can be used for treatment purposes. This is a good example of Putting the Veteran First! Again I am honored to testify concerning Persian Gulf healthcare issues and thank you for your continued support for all veterans.

Introduction

Good morning Senator Rockefeller. My name is Dr. Desty A. Manzo-Chua, a fifteen year VA physician, currently assigned since 1994, to perform the Persian Gulf Registry health examinations, at the Louis A. Johnson VAMC, Clarksburg, WV. In addition to that duty, l am Registry Physician for the Agent Orange examinations. In addition I perform Compensation and Pension, Fee Basis and annual employee health examinations.

Persian Gulf Registry health examinations were initiated in our facility in August 1992. The examinations were initially performed by Physician-Assistants. Since 1994, the responsibility was assumed by a physician, myself. I have tried to improve the program by providing a more comprehensive evaluation and follow up of the veteran's medical complaints and compliance to prescribed guidelines.

To date, the total number of Persian Gulf Registry health examinations completed at our facility, is 154. Another 29 veterans scheduled an exam, but failed to keep their appointments. Primary Care and Mental Health and Behavioral Science Services have combined a comprehensive evaluation of the multitude of complaints received from the Persian Gulf veterans included in the Registry.

In my experience, veterans have reported a diverse array of symptoms. The most commonly reported symptoms are; fatigue, headache, muscle and joint pain, memory problems, shortness of breath, sleep disturbances, nausea, diarrhea, and other gastro-intestinal complaints, rashes, and chest pain.

At our facility, a comprehensive family, occupational, social, psycho social, and history of possible civilian exposure to toxic agents is obtained, including initial lab tests and chest x-ray, symptom checklist and a complete physical examination. Neurologic examination is part of the phase II protocol, with referral to specialties and consultants as needed. The labor intensive requirement of this examination has prompted me to request an increase of the time allotted for each evaluation from 40 minutes to one hour since August 1996. The additional time gives the veteran the opportunity to express his concern, ask questions, perform patient education, and for me, to give reassurance the government cares for them and discuss the wide array of research projects which are on-going.

All follow up care is done by the Primary Care Physician for which each veteran is assigned permanently for their medical care. A referral center is available for all undiagnosed illnesses. For Clarksburg, it the Washington, D.C., VAMC. Out of the 154 patients registered at our facility, three have been referred. All recommendations from the referral center are instituted by their Primary Care Physicians.

The Post Traumatic Stress Disorder Team (PTSD) has coordinated with me to meet and interview every veteran seen in my clinic daily. A war stress interview is completed with other screening procedures. From the interview process, referral to mental health services are done, if warranted. This includes smoking cessation and alcohol and drug use treatment. If symptoms are evident of traumatic stress, a psychiatric evaluation is conducted.

The PTSD Team offers both inpatient, and outpatient treatment programs to veterans diagnosed for Post Traumatic Stress Disorder.

Other referral centers for clinical care include:

1) Houston VAMC, Texas

2) West Los Angeles VAMC, California

3) Birmingham VAMC, Alabama

4) Women's Health Care Center, Washington, D.C. (Gynecological Referrals)

5) Cincinnati VAMC, Ohio (Sexual Dysfunction and Spouses Sensitivity)

6) Baltimore VAMC, Maryland (Embedded fragments of depleted uranium)

Health examinations for certain eligible spouses and children of Persian Gulf Registry participants are conducted under contract by non-VA physicians in non-VA medical facilities and the results are included in the VA Registry. To be available for participation, an individual must be the spouse of a veteran who is listed in the VA's Persian Gulf Registry and questions about this should be directed to 1-800-PGW-VETS. West Virginia coordinating sites for the Spouse and Children Examination Program are at Philadelphia, Cleveland, and Washington, D.C. To date, none of my patient's family members have participated in the VA Spouses/Children Program.

This concludes my testimony. I would be happy to answer any questions.

Mr. Chairman,

Thank you very much for the opportunity to appear before this committee today. My name is Faustino A. Reniva, Jr. I am a staff physician and the Persian Gulf Registry physician coordinator at the VA Medical Center, Beckley, West Virginia.

I would like to start by saying that I am honored to have the opportunity to address this distinguished panel. The Persian Gulf Registry Program at the Beckley VAMC operates as follows. Steps are initiated when a Persian Gulf veteran calls or comes in inquiring about the program. Eligibility is verified, and if eligible, the veteran is scheduled for a Persian Gulf examination within 25 days. This process is handled by the Veterans Registry Coordinator. On the day of examination, the veteran is asked to come in early for required blood work, chest X-ray and electrocardiogram. An established protocol dictates the examination process and a complete medical history is obtained including family history, occupational history, social history, civilian exposure history to possible toxic agents, psychosocial history, and a review of systems. In gathering the data, the following is important, namely, the time of onset of symptoms, the intensity of the symptoms, the degree of physical incapacitation, and the details of any treatment received. Following the examination, the veteran is briefed about the findings and the results of the tests. Depending upon the patient's symptoms, the physical findings, and the laboratory findings, additional diagnostic studies might be performed and specialist consultations obtained. If the patient is not already enrolled in the primary care clinic, he/she is assigned a primary care physician who will provide primary care and be involved in the follow up. Phase II Level Evaluation Protocol is activated if symptoms and/or disability are unexplained and no clearly defined diagnosis can be made. This protocol involves several supplemental laboratory tests, consultations, and symptom-specific examinations. Hard to diagnose patients are referred to one of four VA Persian Gulf Referral Centers, namely, Birmingham, Alabama; Houston, Texas; Washington, D.C.; and West Los Angeles, California.

VA provides health examinations for certain spouses and children of Persian Gulf Registry participants. These examinations are conducted under contract by non-VA physicians in non-VA medical facilities and are included in the VA registry. Eligible family members may register for the examination through the VA Persian Gulf Help Line at 1-800-PGW-VETS.

VA headquarters periodically forwards information about the Persian Gulf Registry Program to the field program coordinators in the form of memoranda, protocols, or practice guidelines. In addition, an audio-conference about the Persian Gulf Registry Program is held almost every month. A telephone line at headquarters is available to Persian Gulf Coordinators and all VA physicians who have questions about the Persian Gulf Program.