VA Testimony of Thomas L. Garthwaite, MD before Congress on April 23, 1998

STATEMENT OF
THOMAS L. GARTHWAITE, M.D.
DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
HOUSE OF REPRESENTATIVES

We are pleased to be here to discuss a draft bill being considered by the Subcommittee. This bill would –

--authorize VA to furnish health care for illnesses that might be attributable to future combat service,

--grant a higher enrollment priority to veterans seeking care for disabilities possibly associated with exposure to Agent Orange, ionizing radiation, or with service in the Gulf War or a future war or combat,

--and establish a National Center for the Study of War-Related Illnesses. Our testimony addresses the draft bill provided to us by the Subcommittee staff. You also asked that we discuss issues associated with the Department’s research and treatment of war-related illnesses and VA’s sexual trauma counseling program.

As you are aware, the draft bill has four basic provisions. My testimony will review VA’s assessment of these elements. First, the proposed legislation would enhance the eligibility for care for two groups of veterans. It would authorize VA to provide health care to those veterans who serve on active duty in a theater of combat operations during a period of war after the Vietnam era and to veterans of future combat against a hostile force during a period of hostilities. Both groups would be provided health care for any illness that might be attributable to such service, for a period of up to five years after their discharge. The Secretary would be required to submit to Congress a report on VA’s experience under that authority. Second, the draft bill would grant a higher enrollment priority to veterans seeking care for disabilities possibly associated with exposure to Agent Orange, ionizing radiation, or with service in the Gulf War or a future war or combat. Third, the draft bill would extend until December 31, 2001, the authority for VA to furnish health care to Gulf War veterans with disabilities possibly associated with such service. Finally, the bill would direct VA to establish a National Center for the Study of War-Related Illnesses.

After periods of war or hostilities, veterans have experienced illnesses that current medical knowledge cannot fully link to a causative agent. Some of these health problems can become chronic. The draft bill would ensure that VA can provide health care for such illnesses to war zone veterans while research is conducted to determine the causes, mechanisms, and treatment of their illnesses.

In 1981, Congress authorized VA to provide care and services for any disability to Vietnam-era veterans who were exposed to Agent Orange and to those veterans exposed to radiation during weapons testing, or at the close of World War II. Congress authorized this special treatment authority notwithstanding the absence of a clear association between the disability and the exposure. In 1993, Congress provided a special treatment authority for Gulf War veterans who were exposed to a toxic substance or environmental hazard while serving on active duty. In each of these three situations, VA was specifically directed to provide care and services unless a VA physician affirmatively determined, in accordance with VA guidelines, that the veteran’s disability resulted from a cause other than such exposure. In 1997, the Congress broadened the special treatment authority for Gulf War veterans to allow care for any disability possibly related to their service in the theater of operations, rather than requiring evidence of particular exposures. The draft bill would establish a similar treatment authority for veterans of future armed conflicts.

VA would be authorized to provide health care to veterans who served on active duty in a theater of combat operations during a period of war after the Vietnam era or in future combat against a hostile force during a period of hostilities, for any illness that might be attributable to that service. This authority would extend for up to five years after their discharge from service. These veterans would be able to receive care for any illness unless a VA physician determines in accordance with VA guidelines that the condition resulted from a cause other than such service. This is consistent with the special eligibility for care of Gulf War veterans for medical conditions that are possibly related to their service in the theater of operations rather than requiring evidence of particular exposure(s). The draft bill would obviate the need for additional legislation to authorize VA action on behalf of veterans for each future military conflict. It also would eliminate possible delays in providing necessary medical care in VA facilities. It should be noted that this bill would measure eligibility based on discharge from service, which may be many years after a veteran has been in the combat theater. An alternative construction could be to extend medical care to veterans within five years of departure from combat theater.

In 1996, Congress directed VA to establish a system of annual patient enrollment for use in managing the provision of hospital care and medical services within the limits of appropriated funds. The Secretary was directed to manage the enrollment of patients in accordance with a list of seven priorities:

(1) Veterans with service-connected disabilities rated 50% or greater;

(2) Veterans with service-connected disabilities rated 30% or 40%;

(3) Former prisoners of war, veterans with service-connected disabilities rated 10% or 20%, veterans discharged or released from active military service for a disability that was incurred or aggravated in the line of duty, and veterans who are in receipt of section 1151 benefits;

(4) Veterans who are in receipt of increased pension based on a need of regular aid and attendance or by reason of being permanently housebound and other veterans who are catastrophically disabled;

(5) Veterans who have annual income and net worth below the so-called "means test" threshold;

(6) All other eligible veterans who are not required to pay a copayment for their care; and

(7) Veterans who must pay a copayment for their care.

The draft bill would grant a higher enrollment priority to veterans seeking care for disabilities possibly associated with exposure to Agent Orange or ionizing radiation, or with service in the Gulf War or a future war or conflict. These veterans, who are currently placed in enrollment priority six, would be elevated to priority four under the draft bill. We support this provision. It is entirely appropriate for war zone veterans to have a higher priority for care during the time it takes to assess the relationship between their illnesses and service.

The draft bill would extend until December 31, 2001, the authority for VA to furnish health care to Gulf War veterans with disabilities possibly associated with such service. Under existing law, the authority will expire on December 31, 1998. As you know, there is ongoing research into the health problems of Gulf War veterans. By extending their special eligibility for care, the draft bill would recognize our ongoing responsibility to Gulf War veterans during this continuing research effort. VA supports the three-year extension of the Gulf War treatment authority.

As a further matter, the draft bill calls for the establishment no later than October 1, 1999, of a National Center for the Study of War-Related Illnesses. The center would be a focal point for research, particularly into the development of treatments for war-related illnesses, education and training. This center would complement our current interagency efforts by helping to coordinate all research on war-related illnesses. In the past, when dealing with Gulf War-related illnesses, the Federal Government has demonstrated its ability to coordinate an extensive interagency research program. I will discuss this effort more fully later in my testimony.

Historically, ill-defined post-war health problems occur following every war. We should anticipate their occurrence after future conflicts, be prepared to provide health care and treatment, and develop methods to prevent post-war health problems in the future. For this reason, VA supports the concept of a National Center for the Study of War-Related Illnesses. We envision that the Center will provide a focal point for activity related to the development of investigations of risk factors, preventive measures, treatment, and basic research on wartime exposures, including physiological and psychological stressors. In previous congressional testimony, Veterans Health Administration’s (VHA) Under Secretary for Health has expressed his views that an interagency research effort should be considered to investigate the health effects of low-level chemical exposures, alone and in combination with other toxicants. These will be important public health issues for the 21^st century battlefield, as well as our civilian workplaces, homes and communities. Focused research in the area of war-related illnesses would be competitively awarded to investigators who apply to work at the Center. Such research could include the full range of research from basic to applied.

A National Center for the Study of War-Related Illnesses would enhance our ability to create a comprehensive VA program for post-war clinical care, medical education, health risk communication and research. Active DoD and HHS partnership and collaboration in the Center would be a key to optimal performance. The Center should be designated as a VA repository for transfer of DoD deployment health and environmental surveillance data. These databases would provide the basis for future research on preventive medicine, risk factor analysis, and epidemiologic studies. An education function at the Center would share best practices and lessons learned concerning clinical strategies and treatment for ill-defined war-related illnesses with the federal and non-federal medical community.

VA has significant experience with centers such as the one proposed. The Geriatric Research, Education, and Clinical Centers (GRECCs) and the National Center for Post Traumatic Stress Disorder (PTSD) have served similar functions with regard to developing our approach to care of aging veterans and veterans suffering with PTSD. We believe a Center such as the one proposed has the potential to significantly enhance the medical community’s ability to address the needs of future wartime veterans.

Mr. Chairman, VA testified before the full Committee on February 5,1998, and provided information on our Gulf War health care and research efforts. I would like to reference our previous testimony and provide an update on VHA's Gulf War veterans’ health care and research programs.

The Department of Veterans Affairs began planning to provide health care and benefits to the service members deployed to Operations Desert Shield and Desert Storm as soon as the first soldiers entered the theater of operations. VA's Gulf Registry Health Examination Program was the first component of VA's comprehensive Gulf War response. VA developed the Registry in 1991, and Congress passed authorizing legislation in 1992. The Gulf War Registry was established primarily to assist Gulf War veterans to gain entry into the continuum of VA health care services by providing them with a free, complete physical examination with basic laboratory studies; and to act as a health screening database. VA staff are instructed to encourage all Gulf War veterans, symptomatic or not, to get a Registry examination. The Registry's database, which in addition to allowing VA to communicate with Gulf War veterans via periodic newsletters, provides a mechanism to catalogue possible exposures and prominent symptoms and to report diagnoses present at the time of the examination. This record of symptoms, diagnoses and exposures makes the Registry valuable for health surveillance purposes; however, the voluntary, self-selected nature of the database means that the experiences, illnesses and health profiles of those in the Registry cannot be generalized to represent those of all Gulf War veterans. The Registry was neither designed nor intended to be a research tool. It was also not envisioned to be a "stand-alone" health care program, a mechanism to assess treatment effectiveness, or a mechanism to monitor the health outcomes of Gulf War veterans through longitudinal follow-up.

Since the Registry examination program was initiated, VHA's Gulf War programs have grown to encompass a comprehensive approach to health services, addressing relevant medical care, research, outreach and educational issues. In 1993, at the request of VA, Congress passed legislation later enacted as Public Law 103-210, giving Gulf War veterans special eligibility (priority) for VA health care. This law gave VA the authority it requested to treat Gulf War veterans who have health problems which may have resulted from exposure to a toxic substance or environmental hazard during Gulf War service. We are also pleased that Congress passed legislation subsequently enacted as P.L. 105-114, which expands a Gulf War veteran’s eligibility for health care for any condition that might be associated with the veteran’s service in the Gulf War. VA now provides Gulf War Registry health examinations and hospital and outpatient follow-up care at its medical facilities nationwide, specialized evaluations at four regional Referral Centers, and readjustment and sexual trauma counseling at Vet Centers and VA medical facilities nationwide to Gulf War veterans. To date, almost 67,000 Gulf War veterans have completed Registry examinations; more than 2.5 million ambulatory care visits have been provided to 221,225 veterans; more than 22,000 Gulf War veterans have been hospitalized at VA medical facilities; there have been almost 500 admissions to specialized Referral Centers; and more than 83,000 Gulf War veterans have been counseled at VA's Vet Centers. VA is committed to continue to provide, and improve, health care services available to Gulf veterans.

As was discussed during the February 5 hearing, VA has contracted with the National Academy of Sciences, Institute of Medicine (IOM), to provide advice on the optimal methods to assess the health status of Gulf War veterans and the effectiveness of treatments being delivered by the Department. The IOM has scheduled a workshop in Washington, DC, on May 7, and will produce an interim report following the workshop.

In response to Public Law 105-114, VA will initiate clinical demonstration projects for case management and multidisciplinary clinical care for Gulf War veterans.

Last year, the Under Secretary for Health implemented a new case management initiative aimed at improving services to veterans with complex medical problems. In its Special Report, the Presidential Advisory Committee on Gulf War Veterans Illnesses supported our efforts to implement case management. Significant progress has already been made. In addition, performance measures for the Network Directors have been established to ensure that the appropriate resources are devoted to these efforts at all facilities.

The demonstration projects are an important component of this effort. The projects will use objective outcome measures to assess whether health care for Gulf War veterans is improved by multidisciplinary clinics or case management approaches. A Request For Proposals for the demonstration projects was issued on April 14, 1998. Funding will be awarded for the demonstration projects in July 1998. These projects will be funded as two-year studies and VA looks forward to reviewing the results.

To maintain the quality of health care provided to Gulf War veterans and keep our health care providers informed about the latest developments related to Gulf War veterans’ health, VHA has utilized a wide array of communication methods, including periodic nationwide conference calls, mailings, satellite video-teleconferences and annual on-site continuing medical education (CME) conferences. On March 5, 1998, VBA and VHA broadcast a joint teleconference regarding enhanced guidelines for compensation examinations of Gulf War veterans with disability due to undiagnosed illnesses. On

March 25, 1998, VHA produced a satellite video teleconference on Depleted Uranium (DU) and the new DU protocol examination. The most recent national training program, Gulf War CME Conference, was held on June 3-4, 1997, in Long Beach, California. This year VHA will hold a joint conference to update clinical and research staff on the latest scientific developments in Gulf War veterans’ health.

VA's past internal educational efforts have been primarily aimed at developing a cadre of well-informed Registry physicians and staff, who in turn provide a source of education and consultation to other health care providers at their facilities. However, with the universal implementation of primary care and the growing recognition that the health problems of Gulf War veterans span all medical subspecialties, we are expanding our educational programs to encompass other medical personnel. Our goal is that all VA health care providers will have a working understanding of Gulf War exposures and health issues and will be able to discuss with their Gulf War patients how these issues could impact on their current or future health status. As a first step to meet this challenge, in March 1998 VHA published a self-study Gulf War CME program that has been distributed to every VA physician. We will make this educational tool available to all health care providers via the Internet. This can serve to improve the health care available to Gulf veterans in VA, DoD, and civilian settings nationwide.

In order to get the best assessment of the health status of Gulf War veterans, a carefully designed and well-executed research program is necessary. VA, as lead agent for Federally sponsored Gulf War research, has laid the foundation for such a program. Under the auspices of the Persian Gulf Veterans Coordinating Board Research Working Group, VA has developed a structured research portfolio to address the currently recognized, highest priority medical and scientific issues. Over 120 Federally sponsored research projects are pending, underway or have been completed. More than half of these projects are being carried out by non-Federal investigators. Thirty-nine of the 121 projects are completed. Seventy-eight are ongoing, and four have been awarded funds but are pending start-up. VA’s own research programs related to illnesses of Gulf War veterans include more than 40 research projects, amounting to a cumulative expenditure of research dollars projected from FY 1994 through FY 1998 of approximately $27 million. Federally funded researchers have, to date, published approximately 60 papers in the peer-reviewed literature, including nearly 40 from VA investigators alone. The research portfolio of VA encompasses a variety of research approaches, including epidemiology, basic research, clinical research, and applied research, applied to a vast array of potential exposures and health outcomes. In addition, VA research is embarking on some important steps toward the assessment of effective treatments for Gulf War veterans’ illnesses. Detailed information regarding the studies is provided in the Annual Report to Congress for Federally Sponsored Research on Gulf War Veterans’ Illnesses.

There has been significant progress on a number of key VA research studies. The Office of Research and Development has awarded funding for Phase III of the National Health Survey of Gulf War Veterans, and preliminary site selection has begun. It is expected that physical examinations will begin in the near future. As you may recall, the National Survey is designed to determine the prevalence of symptoms and illnesses among a random sampling of Gulf War veterans across the nation. The Survey is being conducted in three phases. Phase I was a population-based mail survey of the health of 30,000 randomly selected veterans from the Gulf War era (15,000 Gulf War veterans and 15,000 non-Gulf War veterans, males and females). The data collection phase is complete and analysis of the data continues. Phase II consisted of a telephone interview of 8,000 non-respondents from Phase I (4,000 deployed and 4,000 non-deployed veterans) to determine if there are any response differences between respondents and non-respondents to the mail survey. Additionally, 2,000 veterans from each of the deployed and non-deployed groups (1,500 mail respondents and 500 telephone interview respondents) will be selected to validate their health questionnaire responses (mail or telephone) against their medical records. Phase II is nearing completion. In Phase III, 2,000 veterans who responded to the postal survey or underwent a telephone interview will be invited, along with their family members, to participate in a comprehensive physical examination protocol. These examinations will be conducted at 18 VA medical centers nationwide and involve specialized examinations, including neurological, rheumatological, psychological, and pulmonary evaluations. Completion of data collection is anticipated around mid-1999. At that time, we should have a more complete picture of the prevalence of symptoms and illnesses among veterans who served in the Gulf War.

The VA Office of Research and Development has initiated the planning stages for a multi-site randomized clinical trial to assess the effectiveness of treatments for Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM) in Gulf War veterans. These conditions appear to significantly overlap with the types of symptoms and illnesses reported by many Gulf War veterans. Such a study is possible because these conditions have clearly defined case definitions along with proposed treatments that have undergone preliminary evaluation. This study will be carried out in collaboration with the Department of Defense and conducted at multiple VA and DoD health care facilities. VA and DoD are investing up to $5 million each to conduct this trial. Because of HHS’ experience and research on the characteristics of these diseases, we plan to consult with NIH and CDC in the development of these research protocols. In addition, the VA Office of Research and Development has issued a Program Announcement, or general invitation to VA clinicians/scientists, to propose additional multi-site trials to evaluate the effectiveness of different treatment strategies. The planned treatment trial, along with any trials proposed in response to the Program Announcement, will undergo rigorous scientific peer review by VA’s federally chartered Cooperative Studies Evaluation Committee. These treatment trials are in response to the mandate in P.L. 105-114 to establish demonstration projects to test new approaches to treating and improving satisfaction with treatment of Gulf War veterans who suffer from undiagnosed and ill-defined disabilities.

The Office of Research and Development has taken a number of steps to expand research on the neurobiological effects of stressors. First, VA and DoD have issued a request for intramural proposals valued at $5 million for research on the neurobiology of stress and stress-related disorders. Proposals will undergo scientific review by a joint VA/DoD appointed panel of experts, and programmatic review by the Research Working Group. Proposals will undergo peer review this spring, with the award and funding of projects expected by July 1, 1998. Second, in June 1997, VA funded a multi-center cooperative study examining the effectiveness of a computerized battery of neuropsychological tests that could improve the accuracy of the diagnosis of PTSD and enable clinicians to better assess the presence or absence of central nervous system dysfunction. Third, in July 1996, VA funded a new multi-center treatment trial investigating the efficacy of a highly structured and traumatic event focused approach to group therapy in the treatment of PTSD. In addition, VA issued a Program Announcement in August 1997 requesting proposals for additional multi-center trials of PTSD treatment. Studies will evaluate methodologies which include new, non-pharmacologic approaches to treatment.

VHA has undertaken several initiatives aimed at improving the patient satisfaction and quality of care for Gulf War veterans. VHA has conducted focus groups and developed a new customer satisfaction survey, which includes a statistically significant sample of Gulf War veterans. This national survey was sent to veterans in the fall of 1997. The analysis of the customer satisfaction survey results was completed in March 1998. A final report was provided to the Network Directors, Service Evaluation and Action Teams (SEATS), and Veterans Affairs Medical Centers (VAMCS) for their review. A copy has also been provided to the Committee.

I have just described VA's extensive treatment and research efforts on behalf of Gulf War veterans. Research related to the illnesses of Gulf War veterans is highly complex, and this is equally true of outcomes research. VA is committed to meeting these challenges and providing quality health care and the most effective treatments to Gulf War veterans. We will continue to solicit the advice of scientific experts, oversight groups and this Committee to improve our programs for veterans and will take steps to improve the program when weaknesses have been identified. VA health care providers are dedicated to providing compassionate care and answering important medical questions. We believe the approaches being pioneered for these veterans will benefit others in the future. President Clinton has made it clear that no effort should be spared in this regard.

The Veterans Health Care Act of 1992, P. L. 102-585, authorized VA to establish programs to improve health care services for women veterans, including the provision of priority counseling for the treatment of the psychological consequences of sexual trauma experienced by veterans while on active duty. In 1994, Public Law 103-452 amended this authority to allow VA to provide treatment for the physical consequences of sexual trauma experiences, and extended this care and counseling to male veterans. This authority expires December 31, 1998.

Over the last six years, VA has undertaken a focused effort to expand and improve sexual trauma counseling services at our health care facilities. Through a National Training Program initiated in 1992, approximately 2000 VA mental health professionals and other health care providers have developed expertise in the diagnosis, assessment, and treatment of the physical and mental health consequences of sexual trauma. They have also gained an appreciation of the unique aspects of sexual trauma that occurs in the context of military service and an understanding of the effect of these experiences on the health of the veteran.

To date, more than 18,000 women veterans and 200 male veterans have accessed sexual trauma counseling services. Last year (FY 1997), the number of new clients seeking counseling for such experiences increased 20% over FY1996 (Attachment). At least two published VA research studies have found that 15 to 20% of women veterans seeking VA services report having suffered a rape or other form of sexual assault while on active duty, while 35 to 50% report having suffered at least one sexual harassment experience during their military career. The 1995 DOD survey on sexual assault and harassment experiences of military personnel indicated that 14% of the men and 55% of the women surveyed reported having suffered one or more instances of sexual harassment during the prior year, while 6% of the women and fewer than 1% of the men reported having suffered an actual sexual assault experience. These findings indicate that sexual harassment/assault of women service members remains a serious problem for the active duty military.

In summary, the number of veterans accessing the sexual trauma counseling program has increased each year since its inception. VA research indicates sexual trauma is more prevalent among women veterans seeking services at VA health care facilities than we had previously thought, and the negative impact of sexual trauma experiences on the physical and mental health of affected veterans is significant. Therefore, VA is committed to continuing this program and has submitted a legislative request to extend VA’s authority to provide this care through December 31, 2003.

Mr. Chairman, that concludes my prepared statement. My colleagues and I will now be happy to respond to any questions Committee members may have.

The following tables reflect the number of veterans seen for sexual trauma counseling in each of these programs over the last 5 years.