STATEMENT OF
JOHN LOONEY, MSW
TEAM LEADER
WHEELING, WV VET CENTER
BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS (FIELD HEARING)

April 3, 1997

Senator Rockefeller: it is an honor to be able to address you and the Senate Veterans' Affairs Committee during this field hearing. I am particularly pleased that you have included the Northern Panhandle to inquire about the Persian Gulf veterans.

The Wheeling Vet Center is a three-person team: An office manager, a therapist, and myself as team leader. We serve 12 counties of West Virginia, Pennsylvania, and Ohio. There is a total of 68,010 veterans in our catchment area. We have seven auxiliary staff to include a senior aide, work studies, and clinical volunteers that enable us to present a program of readjustment counseling. This includes three combat veteran groups, one POW group, one spouse's group and individual and family therapy. We also work with homeless veterans.

One particular project I am pleased to focus on today is service to Persian Gulf veterans. The Wheeling Vet Center, over the past six years, outreached Persian gulf veterans through television, radio, and with personal visits to the four area National Guard and Reserve units that were activated. We have outreach during Health Fairs for veterans and at Veteran Service Organizations.

We encourage Persian Gulf veterans to get on the Persian Gulf Registry, a health surveillance program, even if they are not experiencing health issues at this time in their life. The function of Vet Centers is to provide individual and family treatment. We educate the veteran about illness or symptoms they and their families may be experiencing. We assist veterans to get on the registry by helping them fill out the forms before their appointment at the VA Medical Center. Our staff calls the medical center while the veteran is in the office to secure an appointment for lab tests. While at the VA Medical Center, the veteran is to schedule another appointment to review lab results with a physician. We follow up with the veteran to assist with future medical appointments.

To date, this Vet Center has opened 187 cases of Persian Gulf veterans. These Persian Gulf veterans' medical complaints span the entire range of reported symptoms. Also, individuals and families are anxious about the future effects on themselves and their families. State employment services for Ohio and West Virginia is provided at our office. We refer veterans for benefit counseling to West Virginia Veterans Affairs, the DAV, and Regional Office in Pittsburgh. We work as liaison with the veterans and the VA Medical Center.

There are two concerns that veterans have:

1. The VA Medical Center in Pittsburgh is 70 miles away. Employed and unemployed veterans do not always have transportation. A locally operated volunteer van service coordinated at this Vet Center is available to provide transportation to the VA Medical Center five days a week.

2. The second concern regards the stress, frustration, and anxiety of waiting for reliable information regarding their current health conditions and possible future health concerns for the veterans and his/her family members. The Vet Center addresses these issues by clarifying the role of the Persian Gulf Registry versus actual treatment and by encouraging Persian Gulf veterans to pursue follow up medical care.

This Valley is proud of all its sons and daughters that served to liberate Kuwait, and particularly with the citizen soldiers from the 152nd MP National Guard and the 660th and 630th Army Reserve Transportation Units from Ohio and Pennsylvania. We also recognize citizen soldiers activated from the 463rd Engineer Company. Along with feelings of pride there is a feeling of concern for these soldier's' health. We appreciate your efforts and support your endeavors.

Good morning, Mr. Chairman, my name is David Macpherson. I am a physician working at the VA Pittsburgh healthcare system with responsibilities as the Associate Chief of Staff for Ambulatory Care and the Chief of the Section of General Internal medicine. These duties involve oversight of the clinical care delivered through our primary care providers and the medical examinations performed as part of the Persian Gulf Registry at our facility. In addition, I continue to be active in the clinical care of both outpatients and inpatients at our medical center and continue to care for veterans from the Persian Gulf war.

I appreciate the opportunity to speak with you briefly this morning. I wish to describe our current approach to outpatient delivery of medical care to veterans including those veterans who have symptoms after their return from the Persian Gulf conflict. Over the past 4 years, our facility has embarked on an extensive effort to enhance the delivery of primary care to veterans. Our main goal is to have each veteran who is cared for in a primary care setting feel that he or she has a single primary provider who is the "quarterback" for their healthcare needs. The primary provider may choose to use other specialists for healthcare concerns. Each primary provider and their patients is associated with a specific primary care team. Primary care teams consist of several healthcare professionals from a wide variety of disciplines, such as nurses, social workers, dietitians known to be necessary for the delivery of primary care services. Veterans who are suffering symptoms after return from the Persian Gulf conflict who have an interest in receiving outpatient primary care at our facility are scheduled with a primary provider. It is our intent that any veterans, whether he or she be a Persian Gulf veterans or from another era who is interested in longitudinal primary care, will establish a trusting relationship with a primary care provider. We have received many informal and formal compliments from veterans in our area about our primary care initiative and have documented significant improvement in patient satisfaction compared to a period before our initiative was begun. We hope that in the primary care setting Persian Gulf veterans who wish longitudinal primary care will feel they have a caring provider whose main interest is the patient's healthcare needs. We have seen 212 patients at our facility who have completed the Persian Gulf registry exam. Of these, 138 have received some sort of follow-up care and 67 are seeing a primary care provider within one of our primary care teams. We are happy to see other veterans from our area who have not yet registered or who desire primary care services. Interested veterans can call of VIP (Veterans Information Phoneline) and once eligibility is established by phone, be scheduled to see a primary care provider in the near future.

Persian Gulf veterans have a high frequency of multiple symptoms. In this hearing, I would like to remind you of the natural. frustration that patients and physicians would feel under the current circumstances. While most Persian Gulf veterans have diagnosable, conventional medical conditions, some Gulf veterans have difficult to diagnose or unexplained symptoms. The scientific understanding of the unexplained illnesses in Persian Gulf veterans is still at its infancy. There is much uncertainty of the cause of the symptoms and no clear data as yet about the prognosis nor proven treatment. This uncertainty can lead to a frustrated patient who is anxious to learn what the long-term health consequences are likely to be and to learn of treatments that are beneficial. Currently, the physician can offer little solid answers to questions about unexplained illnesses asked by these patients. However, uncertainty in medicine is not unusual. Most physicians are able to offer some comfort in these situations if mutual trust exists. We hope that the improved structure of how we deliver primary care at our hospital does lead to improved trust between patient and physician.

I would like now to introduce Dr. C. B. Good who cares for several veterans who served in the Persian Gulf war and serves as our hospital's Persian Gulf Registry physician. After Dr. Good has completed his testimony, Dr. John Houri, who works both as a primary care physician and a rheumatologist at our facility will speak. Once again, I thank you for hearing my testimony.

Good morning, Senator Rockefeller. My name is Bernie Good. I am a staff physician in the Section of General Internal medicine in the VA Pittsburgh Healthcare System; I oversee the clinical programs for Persian Gulf veterans, as well as serve as a primary care provider for some of these patients. In addition, I am Associate Professor of Medicine, Pharmacy and Therapeutics at the University of Pittsburgh. I thank you for your interest in the health concerns of veterans who served in the Persian Gulf arena. I would like to address briefly some of the medical problems we have seen in these patients, what our approach has been with these patients, and finally to comment on the illness itself.

We have seen over 200 Persian Gulf veterans in our registry examination program, and many of them continue to receive their care at our facility. Their complaints are similar to those of other Persian Gulf veterans nationally; common complaints include joint aches, fatigue, headaches, respiratory symptoms, heart bum, sleep disturbances, and memory difficulties. Some of our patients have no medical complaints. Several of our patients have been diagnosed with serious medical problems; one patient died of heart problems at a relatively young age, and another died from a relatively rare tumor. This is the challenge of caring for this patient population; although many of the patients have medical problems that are readily diagnosed and are common in patients of this age group, some of our patients have diffuse and relatively nonspecific medical complaints that do not fit any recognizable medical diagnosis, and a few patients have unusual or rare medical problems. Thus, some of the lay press refer to the constellation of multisystem symptoms as "Persian Gulf Syndrome;" however, several non- governmental expert panels have been unable to establish criteria for such a syndrome, including panels commenced by the National Institutes of Health (1994) and the Institute of Medicine (1995).

Further confusing the picture for both practicing physicians and patients has been the intense media interest in the medical problems of Persian Gulf veterans. In addition to some useful information that has come from these reports, there has also been significant misinformation, including a recent report that health professionals have become ill caring for our Persian Gulf veterans.

There have been several scientific reports concerning unexplained illnesses in Persian Gulf veterans. Unfortunately, these reports do not offer any new treatment strategies for the physician caring for these patients. Thus, our approach to Persian Gulf veterans with health concerns has been somewhat pragmatic. We believe that until medical science provides new direction for treatments, the best care is to provide symptomatic treatments and follow-up by a primary care team. We encourage all Persian Gulf veterans to participate in the Persian Gulf registry, regardless of whether they have any current health problems. Based on the patient's symptoms, we do a thoughtful and thorough medical evaluation, with referral to medical specialists as indicated. We identify and treat common, ordinary medical diagnoses that are seen in patients of this age group, such as heartburn and headaches. We understand that post-traumatic stress disorder (PTSD) is common in this group, and that this is a legitimate, real medical condition that can be associated with many of the symptoms seen in Persian Gulf veterans, for which good treatments are available. When no disease is found, we try to give reassurance while acknowledging that there is much to be learned in this area, and we continue to follow them in our medical clinic. In Persian Gulf veterans with unexplained illnesses, we treat symptoms in the absence of a specific diagnosis, and this approach is useful and provides relief to many of the patients.

Several of our more perplexing patients have been referred to our Persian Gulf Referral Center at the Washington, D.C. Veterans Affairs Medical Center, and our administration has been very supportive in facilitating this. In addition, we have sent blood and tissue specimens to the Centers for Disease Control (CDC), and the Air Force Institute of Pathology which have not revealed any unusual infections in these patients.

We have made an effort locally to disseminate useful information to physicians in the VA as well as elsewhere who care for our Persian Gulf veterans. We have broadcast several educational seminars provided by VA on the care of Persian Gulf patients; in addition, we have sent several physicians to continuing medical education programs by VA addressing Persian Gulf issues. I have taken a personal interest in this medical condition, and I have regularly spoken with experts both within and out of VA, locally and nationally. We have tried to be cooperative with the local media, to provide accurate, useful information to their audiences. We have made an effort to speak with the specialists at our institution about problems they are seeing in Persian Gulf veterans, to find out what we are doing to address the problems, I have given medical grand rounds at the University of Pittsburgh on Persian Gulf medical concerns, and this talk was also taped and distributed to other hospitals in our region for continuing medical education. I have also been invited to speak about this topic at other medical institutions. Lastly the most important communication, is the informal conversation that occurs between practicing physicians who care for Persian Gulf veterans.

In closing, I am encouraged by hearings such as this which indicate a commitment to the care of our Persian Gulf veterans. As veterans who served their country honorably, they should expect quality care for their medical problems, as well as receive compensation for legitimate disabilities. Thank you.

My name is John Houri. I am a physician at the VA Pittsburgh Healthcare System and a member of the divisions of general internal medicine and Rheumatology. In my capacity as a primary care physician and a consultant rheumatologist, I have had the opportunity to examine a number of veterans of the Persian Gulf War.

The patients referred to the Rheumatology clinic present with a variety of symptoms including, muscle and joint pain, fatigue, and sleep disturbances. We have attempted to link the similarity of these symptoms to other rheumatologic conditions. Most rheumatologic conditions are diagnosed by, in addition to history and physician examination, laboratory studies and x-rays. Extensive laboratory evaluation has generally included muscle enzymes (CPK), and autoantibody studies for screening for specific inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus, and inflammatory muscle disease. X-rays have been generally obtained in patients with joint pain. Unfortunately, despite these studies, the illness of Persian Gulf War veterans have uncommonly been linked a specific rheumatological condition. Treatment, therefore has focused on improving the underlying symptoms. Additionally attempts are made to obtain an extensive history. Particularly the focus has been on possible environmental and infectious exposures. It has been theorized that many of the diseases typically seen in Rheumatology may be secondary to an environmental or an infectious trigger in a genetically predisposed individual. An example is reactive arthritis, which is triggered by an infection.

In addition to diffuse muscle and joint pain, fatigue and difficulty sleeping; headaches and difficulty concentrating are common. These symptoms are sometimes associated with a condition called fibromyalgia. Fibromyalgia is a syndrome of widespread pain with a duration of 3 months or longer. To meet the diagnostic criteria, pain must be present in 11 or more out of 18 specified tender point sites on digital palpation. Sleep disturbance and fatigue are very common with this syndrome. As has been recognized by myself and also by several expert panels, a number of Persian Gulf veterans examined meet the criteria for fibromyalgia. It must be emphasized that fibromyalgia can be a primary condition, or secondary to another disease or condition. Although universally effective treatment and a precise cause have yet to be identified, we continue to work diligently towards this goal.