Finding 4: Pyridostigmine bromide [PB] can have serious side effects and interactions when taken in combination with other drugs, vaccines, chemical exposures, heat and/or physical exercise.

Pyridostigmine bromide [PB] pills were distributed to and ingested by U.S. personnel under the threat of court-martial,⁽²⁸³⁾ as a means of protecting them against the nerve agent soman.
According to Dr. Stephanie Padilla, who works at the Neurotoxicology Division of the U.S. Environmental Protection Agency [EPA], PB produces some of the same reactions as the very nerve agent it is intended to protect against, making it difficult to determine its effectiveness:

It is my understanding that pyridostigmine, the idea is to mask the effects of the nerve agent, but also they would produce some of the same effects that the nerve agent would produce and so you either have an extremely high baseline or it would mask the effect of the nerve agent.⁽²⁸⁴⁾

Dr. Robert Haley of the University of Texas Southwestern Medical Center points out another danger. When introduced to the human body after exposure to a neurotoxin such as soman has taken place, PB can trigger a side effect from an otherwise safe agent:

Research published since the war has shown that giving a protective drug after the exposure can paradoxically promote brain damage from even a low dose of a neurotoxic chemical that might not have caused a problem otherwise.⁽²⁸⁵⁾

According to Dr. Thomas Tiedt, PB inhibits a critical enzyme, acetylcholinesterase [AchE] which can result in nerve and muscle degeneration within moments of a single dose, which may intensify with further doses.⁽²⁸⁶⁾ What's more, Tiedt says the onset of stress makes the blood/brain barrier susceptible to PB leakage, increasing its ability to cause damage to the central nervous system. Tiedt cites two examples to support his assertion: the advent of behavioral changes in veterans within weeks of ending PB treatment, and the objective signs of nerve damage in veterans who took the drug.
Dr. Satu Somani expands Tiedt's conclusion about the mental or psychological rigors of war to incorporate the physical aspects of the Gulf, such as heat and exercise, saying:

The adverse effects [of PB] were amplified by physical stress. ⁽²⁸⁷⁾

Perhaps most disturbing is the revelation that the risks were well-known before the drug was issued. Dr. Tiedt says the DOD was aware that the pills were dangerous because the Department's own research had documented the risks at the time of the war.

The scientific evidence shows that Gulf War Syndrome was easily predictable ... DOD established by the early 1980's that PB causes persisting `counterproductive consequences ...' DOD research also found that at sublethal dosage PB is more dangerous and more toxic than Sarin nerve gas. ⁽²⁸⁸⁾

Dr. Myra Shayevitz, an environmental physician at the Veterans Administration Medical Center [VAMC] in Northhampton, MA, agrees that risks had already been established, and points to one of the DOD's own documents as proof. According to her testimony,

The Army Institute of Chemical Defense in their Doctrine of Use recognized the potential toxicity of this compound, stating that `If a dose is missed, under no circumstances should one take two tablets as a make-up dose.'⁽²⁸⁹⁾

Nevertheless, U.S. troops were still ordered to take the pills, and many experts say DOD should have expected a number of servicemen and women to fall ill. Some scientists have tried to attribute the sickness to a reaction to the stresses of war, ignoring the intake of PB, but Dr. Miller says some veterans started feeling ill in August - before the advent of the war, but after taking PB.⁽²⁹⁰⁾
Furthermore, veterans didn't even have to make it into the Gulf region to feel the effects. As noted in the Background section, James B. Green became sick without ever setting foot in the theater. Green was given shots and a series of PB pills while he was stationed in Germany, in preparation for going to the Gulf, but another group was assigned to that post instead and he was sent home. Before going into the service, Mr. Green was in excellent health - but that changed when he started taking PB pills and his life has never been the same.

After receiving the shots and the PB pills, I suffered many symptoms ... I am scared to go to the VA hospital for treatment. The government thought it was okay to give us poison once. Why wouldn't they do it again? I am referring to the shots and the PB pills. That is what I believe is making me sick with this illness ... This disease is obviously not stress related, as they would like us to believe. I am a perfect example. My jobs weren't stress related, and I am experiencing the same symptoms as others. My theory rests on the inoculations and the PB pills. As everybody knows, the French troops were not given the experimental pills, and not many of them are sick. ⁽²⁹¹⁾

Unfortunately the uncontrolled manner in which the drug was distributed, and poor records thereof, make it extremely difficult to draw any conclusions about PB and undiagnosed illnesses. Veterans have testified DOD did nothing to protect against over-medication. Rather, they were simply ordered to take the pills with little or no supervision other than to make sure the pills were swallowed. Dr. Myra Shayevitz says some veterans ingested more than 30 tablets. ⁽²⁹²⁾ This reported lack of oversight is consistent with Staff Sgt. Wood's experience.

The full dosage was given_enough for 2 weeks, I do believe. Each soldier had their own in a blister pack ... It's highly possible that someone that was scared could have taken more ... They did not check on it.⁽²⁹³⁾

Testimony from scientists indicated the military had funded and conducted research which concluded that PB, combined with other similar compounds and/or physical stress, could produce long term health consequences, including nerve damage. The idea that DOD would proceed to administer PB in light of this research is disturbing, made more so by the fact that DOD administered the drug without providing the written information on PB the FDA required be provided to the troops. In light of these facts, the subcommittee believes DOD and VA should consider potential health effects of PB far more seriously.

Finding 5: VA and DOD health registry diagnosis protocols rely on the unfounded conclusion there were no chemical, biological or other toxic exposures to U.S. troops in the Gulf War theater.

For years, the DOD and CIA falsely or mistakenly maintained U.S. troops were not subject to any chemical, biological or other toxic exposures during their tour in the Gulf War theater. Rather than starting with a blank slate and an open mind, health officials at VA and DOD then used this misinformation to shape health registry diagnosis protocols, perpetuating the myth.
While military and intelligence officials would eventually concede there was a potential for toxic exposures from the detonations at Khamisiyah, they spent several years denying the existence of such a possibility. According to DOD's Bernard Rostker, the CIA made that argument as late as September 1996.

The CIA reports said that the analysis and computer models indicate chemical agents released by aerial bombing of chemical warfare facilities did not reach United States troops in Saudi Arabia. ⁽²⁹⁴⁾

Trained to look for irrefutable proof as opposed to the mere possibility of exposures, field commanders had apparently not given any credence to the sounding of 14,000 M8A1 alarms. According to the December 3, 1996 edition of the New York Times:

General Powell, the Chairman of the Joint Chiefs of Staff at the time in 1991, said in an interview that while chemical detection alarms had sounded repeatedly during the war, American commanders in the Gulf had been unable to confirm the detections and had believed them to be false alarms. ⁽²⁹⁵⁾

Despite mounting testimonials and other evidence suggesting the alarms were not false but indicative of actual toxic exposures, VA and DOD health registry officials did not include specific questions about chemical warfare and toxic exposures in its Persian Gulf Registry Code Sheet until late 1995. ⁽²⁹⁶⁾ Even after DOD and the CIA conceded exposures were likely during the detonation at Khamisiyah, VA Secretary Jesse Brown saw no reason to change protocols, saying the VA had "always accepted the possibility" of exposures and therefore had no need to change its diagnosis, treatment or compensation policies in the absence of a definitive diagnostic test and specific treatments. ⁽²⁹⁷⁾
However, passively accepting a possibility is not the same as actively pursuing it. Nowhere is this distinction more evident than in the testimony of Dr. Susan Mather. As noted in the Background section, in December 1996, Dr. Mather testified that questions about veterans' interaction with the physical environment of the Gulf were not revised until "this past year," ⁽²⁹⁸⁾ 5 years after the war had ended.
Faced with conflicting evidence, VA and DOD health registry officials chose to put more faith and stock in military and intelligence officials, who assured them there was no toxic exposure, than in numerous veterans who expressed concerns that they had been poisoned as a result of their service. Had VA and DOD health registry officials listened to the 93 percent of veterans who reported exposure to toxic contaminants⁽²⁹⁹⁾ and aggressively pursued it as a legitimate hypothesis back in 1992, science - and many veterans - would be 5 years ahead of where they are now.

Finding 6: VA and DOD health registry diagnosis protocols rely on the unwarranted conclusion that, unless there is an immediate and acute reaction, exposures to chemical weapons and other toxins do not cause delayed or chronic symptoms.

VA and DOD health registry diagnosis protocols wrongly assumed that in the absence of an immediate and acute reaction to a toxic exposure, such an exposure will not cause delayed or chronic symptoms. Given the notable lack of data on the subject, there is no way to know that this is true. Nevertheless, officials in charge of the diagnosis protocols refused to give veterans the benefit of the doubt, saying they required incontrovertible proof that toxins can cause delayed or chronic symptoms without an immediate and acute reaction, while lifting the burden of proof on researchers who were unable to demonstrate the opposite.
VA Secretary Jesse Brown planted his feet squarely in the camp of officials who made this choice. While conventional wisdom says absence of proof is not proof of absence, Secretary Brown would not yield to subcommittee requests to consider the opposing position. In fact, in a December 10 letter to the subcommittee, Brown displayed an active reluctance to open the subject up for discussion again:

In VA's view, the published literature, while limited, does not demonstrate the development of readily identifiable, long-term adverse health effects due to nerve agent exposures in human subjects who have not shown signs of acute toxicity or poisoning ... Because there are so few studies on this question, we believe that additional research is needed to determine whether exposure to low-levels of chemical warfare nerve agents can cause long-term health effects, including chronic or delayed onset of a characteristic set of symptoms, signs or medical conditions.⁽³⁰⁰⁾

Secretary Brown and others who share his opinion have asked veterans and veterans' advocates to establish something which, by virtue of its terms, is inherently vague and therefore difficult to prove. Scientists do not seem to have agreed upon what comprises an "immediate and acute" reaction. Many veterans have reported a variety of symptoms that, under normal conditions, would probably qualify as immediate and acute but were dismissed as a circumstantial by-product of the harsh Gulf environment. These include but are not limited to: chest and joint pains, chronic coughing, memory loss, rashes, the appearance of pustules, muscle atrophy, nausea, diarrhea, vomiting and bloody stools, among others.
As has already been noted, PB is capable of masking the symptoms of chemical nerve agent intoxication.⁽³⁰¹⁾ As a result, veterans may have experienced immediate and acute reactions and not known it.
Another reason military officials may have been blind to the possibility that toxic exposures, which do not produce an immediate and acute reaction, may still engender delayed or chronic illness is that it makes their work easier. According to the former senior policy analyst on the staff of the Presidential Advisory Commission, Dr. Jonathan Tucker, the pressures of war and the need for maximum mobility encourage military personnel to underestimate the threat of toxicity as a way of avoiding having to wear the constricting and bulky MOPP 4 protective gear.

The goal of chemical defense doctrine has been to minimize the impact of an enemy's use of chemical weapons on the tempo and effectiveness of U.S. military operations, and they have done this by setting up the so-called MOPP scale - mission oriented protective posture ... The idea is to calibrate the level of protection to the assessed chemical threat, because when people are in MOPP-4, the full ensemble, they are almost incapacitated ... To deal with this problem, the Army has sought to minimize the level of protection that troops wear in combat and calibrate it to the assessed level of threat. As a result of this, there has been a kind of all-or-nothing mindset that has viewed chemical weapons exposures as either severe, if they produce acute effects if they're sub-acute, they're just discounted, they're viewed as harmless ... I believe that, later on, after the war, when large numbers of troops began getting sick, the same commanders who wished to avoid accountability for serious errors of judgment, such as blowing up many bunkers that may have contained chemical weapons, just refused to acknowledge the problem, hoping it would simply go away.⁽³⁰²⁾

Health registry diagnosis protocols wrongly assumed that toxic exposures which did not produce immediate and acute reactions would not generate delayed and chronic symptoms. However, there is no logical reason to believe this should be the case, only explanations for why registry officials believed it to be true. While scientists have yet to prove that these exposures could incite delayed and chronic effects, no one has proved they could not. Moreover, that assumption is refuted by the experiences of many people with common environmental toxins such as asbestos and lead. Consistent exposure in small quantities may not be enough to spark a sharp reaction in the average person, but exposure over time may damage internal organs. Had health registry diagnosis protocols been more prone to explore new theories and hypotheses, the medical community might not have accepted the Pentagon's unfounded assurances quite so easily. Nonetheless Secretary Brown and others chose to give the military and medical establishments the benefit of the doubt over the numerous veterans who complained of delayed and chronic effects, again perpetuating a myth with growing implications for future research and treatment procedures.

Finding 7: Prematurely ruling out toxic exposures as causative, VA and DOD doctors relied on diagnoses of somatoform disorder and Post Traumatic Stress Disorder [PTSD] to explain Gulf War veterans' illnesses.

DOD assumed, in the absence of definitive medical evidence in support of this position or to the contrary, that many PGW illnesses were attributable to PTSD and stress, and they did not consider toxic exposures. The predominant diagnosis of patients in the DOD Comprehensive Clinical Evaluation Program [CCEP] was psychological disorders, 18 percent, followed by: signs, symptoms, ill-defined conditions, 18 percent; musculoskeletal disorders, 18 percent; healthy, 10 percent; respiratory, 7 percent; GI, 6 percent; skin, 6 percent; nervous system, 6 percent; and other, 11 percent. ⁽³⁰³⁾
Veterans have described their painful experiences with the VA medical system, which has disregarded their symptoms and labeled their ailments as "stress." Kimo Hollingsworth described experiences many Persian Gulf War veterans have had with the VA medical system. "The VA Hospital in Washington, DC performed a complete physical and concluded that I was in excellent health. The VA doctor informed me that the dark green chunks of sputum and pain in the center chest were normal in some people. I was then directed to a social worker who discussed the issue of Post Traumatic Stress Disorder. The VA also provided me a brochure outlining psychological counseling services to Persian Gulf veterans."⁽³⁰⁴⁾
Private Stacy testified about VA arbitrarily denying his claim for Persian Gulf illnesses. "I have a claim pending for chronic fatigue. It has been pending for 2 years. My records are being shuffled back and forth from Nashville, TN to Muskogie. They believe that all of my complaints are due to stress ... The doctor says in my records, `I believe the patient is exaggerating symptoms, I believe the patient has been coached, and I believe he is here to try to get increased disability.'" ⁽³⁰⁵⁾
Mr. Stacy told the subcommittee, "I am 40 percent disabled. I receive $467 a month. I left the Post Office after 3 years. My house payment is $500 a month. I do not even have money to drive or put gas in my car. We are literally starving to death. We receive no help from nobody." ⁽³⁰⁶⁾

Finding 8: There is no credible evidence that stress or PTSD causes the illnesses reported by many Gulf War veterans.

Although physicians at VA and DOD are more likely to diagnose veterans as having PTSD, the medical community has been unable to establish a causal link between stress or PTSD and most veterans' illnesses. There is simply no irrefutable evidence that such a link exists. As a result, any conclusion that so-called "Gulf War Illnesses" are rooted in stress or PTSD involves an unwarranted leap of faith.
After reviewing the Government's research strategy, the GAO did not concur with DOD's and VA's attribution of PGW illnesses to somatoform disorders and PTSD. In its June 1997 report, "Gulf War Illnesses: Improved Monitoring of Clinical Progress and Reexamination of Research Emphasis are Needed," the GAO concluded that:

While stress can induce physical illness, the link between stress and these veterans' physical symptoms has not been firmly
established.⁽³⁰⁷⁾

Dr. Daniel Clauw, a rheumatologist, testified:

My personal experience is that in some cases the VA Medical Centers are not well-versed in the treatment of these conditions,⁽³⁰⁸⁾ perhaps in part because these illnesses occur more frequently in females (and so few women are seen within the VA system), and perhaps because there is a cultural bias within the VA system to quickly refer these patients to psychiatrists. If a physician or other health care provider does not believe that these individuals are suffering from a real disease, they will likely be ineffective in treating this group of patients.⁽³⁰⁹⁾

He added:

Most of the experts on these types of illnesses in this country are not in the VA or military systems.⁽³¹⁰⁾

The sole evidence physicians have offered as proof that stress or PTSD is the source of most Gulf War sicknesses is the assumption that most veterans must have suffered from stress by virtue of the stressful environment in which they found themselves during the war. According to an article from the Annals of Internal Medicine:

Poorly understood war syndromes have been associated with armed conflicts at least since the U.S. Civil War. Although these syndromes have been characterized by similar symptoms ... no single recurring illness that is unrelated to psychological stress is apparent ... but one unifying factor stands out: A unique population was intensely scrutinized after experiencing an exceptional, life-threatening set of exposures. As a result, research efforts to date have been unable to conclusively show causality.⁽³¹¹⁾

As the article notes, while it is difficult if not impossible to say sick veterans do not suffer from any stress or PTSD at all, it is also unwarranted to say stress or PTSD is the driving force that actually triggered the onset of so-called "Gulf War Illnesses." All of the evidence that has been presented up until now suggests while they may have contributed to veterans' being sick, stress and PTSD alone are an insufficient explanation. According to VA Under Secretary for Health Dr. Kenneth Kizer:

VA and DOD studies demonstrate that although PTSD rates among Persian Gulf veterans who were exposed to violence and carnage are elevated, post-traumatic stress disorder does not explain the majority of health problems in Persian Gulf veterans.⁽³¹²⁾

Dr. Haley agrees and uses his own research to support his point.

We found no evidence that the veterans had post-traumatic stress disorder, none, zero. We found no evidence that combat stress, the ones that had high levels of combat stress had the same risk of the syndrome as those with low levels of stress.⁽³¹³⁾

Dr. Garth Nicolson, Chief Scientific Officer with the Institute for Molecular Medicine, concurs. He believes the symptoms are indicative of something else - not stress or PTSD, but exposure to a combination of chemical or biological agents.

We do not feel that Post-Traumatic Stress Disorder is a major cause of the Gulf War illnesses. We think, again, that it is combinations of chemical and biological agents that produce these very complex signs and symptoms. We do not see how it could be produced any other way. ⁽³¹⁴⁾

Unfortunately, too few tests and studies have been completed to establish Dr. Nicolson's or anyone else's theory as fact. It is a similar problem Dr. Murphy acknowledges with regard to low-level exposures to nerve agents.

We recognize there is a gap in the scientific knowledge. It is very hard to prove a negative. The evidence does not exist in the scientific literature at this time that clearly says asymptomatic exposures to low-level nerve agents cause this recognized group of signs and symptoms, physical findings."⁽³¹⁵⁾

And yet despite any scientific proof that stress or PTSD has caused, triggered, or amplified veterans' undiagnosed illnesses, many VA and DOD physicians continue to diagnose veterans as having PTSD - by default. While the VA and DOD have opted to accept a lapse of evidence in this regard, they refuse to give veterans' contentions that toxic exposures are to blame the same courtesy. This attitude places the burden of proof squarely on the shoulders of the veterans, a grossly unfair and impossible task, especially given the magnitude of the job, their ailing health, and the little power they exert over the scope and focus of scientific research.

Finding 9: Accurate diagnosis of veterans' illnesses remains difficult due to inadequate or missing personal medical records, missing toxic detection logs, and unreleased classified documents.

While our military may be the most powerful, efficient, and best equipped armed forces in the world, its management and bookkeeping in the Gulf War were deplorable. Just a few years after the war, personal medical records and scientific toxic detection logs are missing, and many documents are still classified as secret. Unfortunately, many of these records, logs, and documents may be critical in diagnosing veterans' illnesses.
For example, with regard to the role of PB in illnesses, Dr. Heivilin of GAO says the records were so poorly maintained that the government does not even know who took the pills - an oversight DOD readily admits.

DOD has acknowledged that the records of the use of PB and vaccinations to protect against chemical and biological warfare exposures were inadequate. There is research going on right now to try to find the majority of the records, which seem to be missing.⁽³¹⁶⁾

Furthermore, even if DOD could determine which veterans took the pills, the distribution of the drug was so poorly planned that there is no guarantee the doses and frequency of doses would be comparable and of any scientific value. According to Dr. Rostker:

There was poor quality control in terms of the regimen of PB. In some units it was careful. In other units it was not careful. We don't have records that would definitively establish who had PB. It was not done the way any of us would have liked to have seen it done. There's no question about that. ⁽³¹⁷⁾

According to Major Randy Hebert, the poor management did not stop at the border, or with the end of the Persian Gulf conflict. He says he knows of hospitals that have lost records of veterans' tests, even records documenting the fact of their visits.

I have spoken to a Marine who was evaluated with several other Marines from his squad upon their return from the war. They were told they were being studied for adverse effects from the desert sun. They were told this by someone whom he believes was a civilian doctor. They all were observed for 1 week. The following week the Marines went back to the hospital to find the results. They were told that they were never there. Also, there is not an indication in their records they were ever there. ⁽³¹⁸⁾

Mr. Tuite says health reports are not the only kinds of records that were lost. Chemical and biological warfare logs also seem to have been misplaced or else never maintained. Mr. Tuite told the subcommittee that Senate Banking Committee Chairman Donald Riegle (D-Michigan) had requested logs of chemical and biological warfare activity from the Secretary of Defense, only to be notified by the General Counsel's office that the command element during the Gulf War (CENTCOM) could not locate any such document.⁽³¹⁹⁾
Still more disturbing is the alleged falsification of toxic detection logs and the secret classification of medical records for the entire 330th Ordinance Company. According to former CIA analyst Patrick Eddington, they were allegedly made secret to conceal the fact that DOD sent troops to the Gulf knowing there were risks associated with low-level chemical exposure and did so without alerting the soldiers to the dangers. Eddington says Sergeant First Class Michael Morrissey's unit was charged with removing more than 170,000 chemical weapons and nerve agent munitions from an American depot in Germany. Sgt. Morrissey apparently saved the relevant unit logs, despite orders to destroy them. When he noticed that reports that went up the chain of command noted an absence of chemical incidents, he concluded they had been deliberately altered.

In my presence, Morrissey pulled out a log entry for July 10, 1990 showing that an M-8 alarm had gone off at one of the chemical storage bunkers. There were no other contaminants in the area and the device was fully functional and working normally. Additional detection equipment was dispatched to the bunker and, according to the log extract, the air sample readings appeared to indicate a slight trace of nerve agent in the air. `I was told to overlook' such incidents, Morrissey noted. The 10 weeks of logs that Morrissey retained appear to have several such incidents to include some personnel who displayed pin-point pupils and other telltale signs of nerve agent exposure ... . What upset Morrissey the most was that his chain of command clearly understood the potential risks. ⁽³²⁰⁾

Eddington then noted a startling declassified document entitled General Information: Nerve Agent Intoxication and Treatment. The document is basically a disclaimer. It explicitly states serious cognitive problems may result from low-dose exposure even though there is no scientific proof that this may be so, alludes to the possibility of birth defects from organophosphate pesticides, and includes an acknowledgment that the reader (soldier) understands the risks. It is then signed by the soldier (in this case, Sgt. Morrissey) and a medic.

Signs and symptoms of chronic, low dose exposure: memory loss, decreased alertness, decreased problem solving ability, and language problems are suspected but have not been proven by scientific study ... Teratogenicity (ability to cause birth defects): although some organophosphate pesticides have been shown to be teratogenic in animals, these effects have not been shown in carefully controlled experiments using nerve agents ... I have read and understood the above information. All questions have been explained to my understanding and satisfaction. Soldier/Employee (Michael Morrissey's signature), Medical Personnel (Richard W. Kramp, M.D.-initials), Date January 19, 1990. ⁽³²¹⁾

Eddington concluded DOD had reason to suspect chronic low level nerve agent exposure could produce serious chronic health problems in exposed personnel a full year before the detonation at Khamisiyah. Every member of Sgt. Morrissey's unit was reportedly required to sign an identical document. Eddington concludes that DOD's classifying this information sheet and the entire Company's medical records as secret is "irrefutable evidence" that DOD knowingly placed U.S. troops at risk and did not want to be found out.

In my opinion they lied. I spent 11 years in the Army Reserve and National Guard. I have never seen a document like this. You classify something like this and you classify medical records secret, when clearly you are telling people that they could suffer long-term effects, serious long-term effects, from chronic low-level exposures? ... This document makes it very clear that they understood the risks these people were facing.⁽³²²⁾

While Mr. Eddington's suspicions may or may not be accurate, DOD's tendency to classify information that scientists and other investigators believe ought to be released is not new, as Dr. Tucker, director of the chemical and biological weapons nonproliferation project the Monterey Institute of International Studies, pointed out to the subcommittee.

A crucial untapped source of information about possible toxic exposures during the Gulf War is the large volume of environmental and biomedical samples that U.S. technical intelligence teams collected throughout the war zone during and after Desert Storm ... It was coordinated by a unit called - a rather shadowy unit - called the JCMEC, based in Dhahran. Despite requests under the Freedom of Information Act, the results of these analyses have never been made public.⁽³²³⁾

Finding 10: Accurate diagnosis of veterans illnesses was also hampered by the VA's lack of medical expertise in toxicology and environmental medicine.

One of the reasons the VA has been unable to determine potential role of toxins in causing veterans' ailments is the lack of toxicological and environmental medicine expertise among the staff. While the VA initially refuted the argument, it has since acknowledged its deficiencies and has taken steps to buttress its expertise in areas where it was lacking.
Asked point-blank how many toxicologists work for the Department full-time, Dr. Murphy was only able to come up with the name of one physician out of a total full-time staff of 8,000. When asked why that was, Dr. Murphy simply said:

In general, toxicologists don't work in health care organizations. They're often in research laboratories or in organizations like the EPA.⁽³²⁴⁾

Dr. Haley believes regular physicians are poor substitutes for toxicologists because they may not explore diagnoses like organophosphate-induced delayed polyneuropathy [OPIDP] that would come naturally to an expert focused on toxicology:

Since these cases are usually treated by toxicologists, few regular physicians are familiar with OPIDP. This probably explains why no one explored this diagnosis earlier. ⁽³²⁵⁾

Dr. Haley says the medical toxicologist on staff in his department, Dr. Tom Kurt, is such a leader on the issue that he proposed the OPIDP mechanism for the Gulf War syndrome as early as 1994.
Following the hearing on December 11, 1996, Dr. Kizer wrote to Subcommittee Chairman Shays, saying the discussion prompted him to find out how the VA's personnel office obtains and tracks information about the specialty certifications of VA physicians. Dr. Kizer concluded the VA's database needed improvement, and efforts are reportedly being made to ensure this comes to pass.
In addition, Dr. Kizer directed the Office of Academic Affiliations to improve the VA's toxicology and occupational medicine expertise by initiating efforts to support 12 new medical toxicology fellowships and 25 residency positions for occupational medicine. While Dr. Kizer noted the response was somewhat disappointing, the VA will fund three additional medical toxicology fellowships and five new occupational medicine residency positions in the 1997-1998 school year, with more expected in the years ahead.
Finally, Dr. Kizer said he plans to establish occupational and environmental health as a VHA strategic healthcare group [SHG]. According to Kizer:

The SHG is a multidisciplinary group organized to support the delivery of a continuum of care to a defined population or care in a particular setting. The SHG functions by integrating data, skills nd best practices into a systemwide policy, planning and service delivery through the development of clinical care strategies ... and decision support mechanisms.⁽³²⁶⁾

Accurate diagnosis of veterans' illnesses was hindered by the lack of relevant expertise at the VA. Rather than challenge either the lack of expertise or the impact it has on diagnosis, as well as research and treatment, the VA decided to firm up its toxicological and environmental medicine resources by expanding its fellowship and residency staff.

Finding 11: Exposures to low levels of chemical warfare agents and other toxins can cause delayed, chronic health effects.

Dr. Claudia Miller, a University of Texas Southwest Health Sciences Center at San Antonio scientist, whose research focuses on low-level chemical exposures, told the subcommittee at a September 19, 1996 hearing, "There are now several studies, in addition to our own, linking chronic, multi-system symptoms to [low level] organophosphate/carbamate exposure." ⁽³²⁷⁾
It is apparent that DOD and FDA did not evaluate and recognize the importance of the existing body of scientific literature on chronic health effects resulting from chemical warfare exposure and resulting delayed neurotoxicity. Dr. Satu Somani told the subcommittee that, "The literature suggests that Sarin can be responsible for delayed neurotoxic effects which may not appear until years after a low level of exposure. Although pyridostigmine is not normally taken up by the brain, it crosses blood brain barrier under conditions of physical stress and causes central nervous system effects. Insecticides, inspect repellants and other chemicals can also contribute to neurotoxic effects of nerve agents as Sarin, soman, tabun and Vx and they are important weapons of chemical warfare. ... Although we have a treatment for a single dose toxicity, there is no treatment, however, for the delayed neurotoxicity. Delayed neurotoxicity was first reported in the 1950's."⁽³²⁸⁾
Dr. Myra Shayevitz, an environmental physician, in material inserted in the hearing record by Representative Bernard Sanders, described the relationship between chemical warfare agents and toxic health effects. "One clinically useful theoretical model of MCS holds that each individual has a total tolerable load of chemical, physical and emotional stress, which, when exceeded, may lead to MCS in susceptible individuals."⁽³²⁹⁾
Multiple low-level chemical exposures could result in a synergistic effect. The symptoms of low level exposure may not appear for several years. Dr. Thomas Tiedt described the genetic basis of variations in response to chemical exposure in testimony before the subcommittee's April 24, 1997 hearing. "Due to the principle of biological variation, different cells and different individuals will experience different degrees of acute and chronic effects."⁽³³⁰⁾
Dr. Satu Somani testified "based on the recent experimental evidence and the similarities of the symptoms of the delayed neurotoxicity reported by workers in the organophosphate industry and also by Desert Storm veterans, I'm inclined to suggest that the Gulf War syndrome may be due to low-level exposure to Sarin. ... The symptoms are due to low-level exposure to Sarin. Pyridostigmine in combination with physical exercise can contribute to neurotoxic effects. Finally, the simultaneous exposure to insecticides and other chemicals under physical stress may have initiated the neurotoxicity."⁽³³¹⁾
The effects of low level chemical warfare agent exposure is a legitimate line of inquiry for DOD and VA to have pursued. The Federal agencies possessed a research bias against the possibility of chemical warfare exposure and did not initiate any research into this area until 1997. Results will not be available until the year 2000 or beyond, fully 9 years after the Gulf War.

TREATMENT

[NOTES]

283. Testimony of Steven Wood, Human Resources Subcommittee hearings, No. 2, p. 55.
284. Testimony of Stephanie Padilla, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 1-4, p. 528.
285. Statement of Robert Haley, Human Resources Subcommittee hearings, No. 1, p. 252.
286. See supra note 130.
287. See supra note 136.
288. Testimony of Thomas Tiedt, Human Resources Subcommittee hearings, No. 2, p. 298.
289. Report submitted for the record, "A Biopsychosocial Therapeutic Approach for the Treatment of Multiple Chemical Sensitivity Syndrome in Veterans of Desert Storm: Treatment Protocol," Dr. Myra Shayevitz, May 5, 1995, Human Resources Subcommittee hearings, No. 1, p. 16.
290. Testimony of Stephanie Miller, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 1-4, p. 531.
291. Testimony of James Green, Human Resources Subcommittee hearings, No. 1, p. 303-304.
292. See supra note 289.
293. See supra note 283, p. 76.
294. See supra note 272, p. 182.
295. Statement of Representative Bernard Sanders (I-VT) quoting the New York Times of December 3, 1996, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 135.
296. See supra note 227.
297. See supra text of Secretary Brown's letter in Background section entitled, "Exposures and VA Medical Protocols for Gulf Veterans."
298. See supra note 170, p. 246.
299. See supra note 227.
300. Attachment to chairman's opening statement, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 11.
301. See supra note 284.
302. Testimony of Jonathan Tucker, Human Resources Subcommittee hearings, No. 2, p. 349.
303. Statement of Stephen Joseph, Human Resources and Intergovernmental Relations Subcommittee hearings, No. 1-4, p. 223.
304. Statement of Kimo Hollingsworth, Human Resources and Intergovernmental Relations Subcommittee hearing, No. 1-4, p. 29.
305. See supra 266, p. 93.
306. Ibid., p. 50.
307. U.S. General Accounting Office, Gulf War Illnesses: Improved Monitoring of Clinical Progress and Reexamination of Research Emphasis Are Needed, GAO/SNIAD-97-163, June 1997, p. 8.
308. Neuro-immunological disorders such as fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity.
309. Statement of Daniel Clauw, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 1-4, pp. 188-189.
310. Ibid., p. 189.
311. Hyams, et al., "War Syndromes and Their Evaluation: From the U.S. Civil War to the Persian Gulf War," Annals of Internal Medicine, September 1, 1996, Vol. 125, No. 5, p. 398.
312. Statement of Kenneth Kizer, Human Resources Subcommittee hearings, No. 1, p. 138.
313. Testimony of Robert Haley, Human Resources Subcommittee hearings, No. 1, pp. 241-242.
314. Testimony of Garth Nicolson, Human Resources Subcommittee hearing of June 26, 1997, original transcript, pp. 117-119, in subcommittee files.
315. Testimony of Frances Murphy, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 255.
316. Testimony of Donna Heivilin, Human Resources Subcommittee hearings, No. 3, p. 38.
317. Testimony of Bernard Rostker, Human Resources Subcommittee hearings, No. 2, p. 249.
318. Testimony of Randy Hebert, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 107.
319. Testimony of James Tuite, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 1-4, p. 438.
320. Testimony of Patrick Eddington, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 143-144.
321. Document submitted for the record, "General Information, Nerve Agent Intoxication and Treatment," Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, pp. 163-164.
322. Testimony of Patrick Eddington, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, p. 177.
323. Testimony of Jonathan Tucker, Human Resources Subcommittee hearings, No. 2, p. 350.
324. Testimony of Frances Murphy, Human Resources and Intergovernmental Relations Subcommittee hearings, Nos. 5-6, pp. 259-260.
325. Statement of Robert Haley, Human Resources Subcommittee hearings, No. 1, p. 251.
326. Letter from Kenneth Kizer to Chairman Shays, June 6, 1997, p. 2 (in subcommittee files).
327. Statement of Claudia Miller, Human Resources and Intergovernmental Relations Subcommittee hearings, No. 1-4, p. 271.
328. Statement of Satu Somani, Human Resources Subcommittee hearings, No. 2, p. 317.
329. See supra note 289, p. 15.
330. Statement of Thomas Tiedt, Human Resources Subcommittee hearings, No. 2, p. 303.
331. See supra note 328, pp. 318-319.