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News from the National Academies

Date: Oct. 9, 1996
Contacts: Dan Quinn, Media Relations Associate
Darice Griggs, Media Relations Assistant
(202) 334-2138; Internet <news@nas.edu>

EMBARGOED: NOT FOR PUBLIC RELEASE BEFORE 5 P.M. EDT WEDNESDAY,
OCT. 9

Seamless Medical Record System Needed
To Fully Research Gulf Veterans' Ailments

WASHINGTON -- Studies on the health of soldiers who served in the Persian Gulf War are hampered by a system of medical record-keeping that is poorly suited for research on veterans' ailments, according to a new report* by an Institute of Medicine committee. It calls for development of a uniform electronic medical record system and other improvements to allow the Department of Defense (DOD), the armed services, and the Department of Veterans Affairs (VA) to better investigate health complaints of those who served in the war.

The congressionally requested report says that while the departments of Defense and Veterans Affairs have improved their research programs over the past two years, more is needed to ensure a full investigation and to prepare for health questions that will arise from future military conflicts. The committee recommended completion of several important data sets -- including one on environmental exposures during the war -- as well as prompt submission of research for publication in peer-reviewed journals. The capability of the armed forces to conduct medical and population-based research needs to be strengthened, and all projects selected for funding should be evaluated first by a team of scientists, the report says.

"Six years after almost 700,000 American troops were sent to the Gulf, major questions remain about whether some of their health problems resulted from their military service," said committee chair John Bailar, chair of the department of health studies, University of Chicago. "The recent confirmation that at least some American troops were exposed to chemical weapons heightens our obligation to soldiers and their families to provide investigators with an atmosphere most conducive to proper research."

The IOM committee is one of several organizations directed by Congress and the White House to evaluate the health of Persian Gulf veterans. The committee's three-part charge from Congress was to assess the effectiveness of the Defense Department and the VA in collecting and maintaining information on the health consequences of Persian Gulf service; to make recommendations on ways to improve the information; and to advise on the scientific bases and possible nature of a future epidemiologic study or studies of health effects. The committee said that there is a strong likelihood that no single hypothesis could account for all of the abnormalities reported by veterans, whether or not their illnesses are linked to service in the war.

Recent Defense Department confirmation that as many as 15,000 U.S. troops may have been exposed to chemical weapons during the war came too late for full consideration by the committee. The disclosure "continue[s] to raise questions about the completeness of exposure information provided by DOD to date," Bailar says in the preface of the report. "We encourage disclosure of all information that may inform the public understanding about the health effects of Persian Gulf service."

Anticipating Future Needs

The major problem in investigating veterans' health complaints is the very nature of war, where preparation for future medical or epidemiologic evaluation is not the primary mission. But even within the constraints of a wartime setting, it is possible to anticipate the information needed for research by drawing on prior experience. In the years following Vietnam and the Gulf War, researchers trying to reconstruct possible environmental exposures have been stymied by a lack of uniform, complete, high-quality information.

To prepare for future military conflicts, the Defense Department should make plans in advance to monitor natural and man-made environmental exposures, and prepare for rapid response, early investigation, and accurate data collection on all such exposures in ways that do not compromise the military mission. The committee also urged the Defense Department to complete and ensure the quality of its troop exposure assessment model for the Persian Gulf, which aims to establish the geographic location of each unit from Jan. 15, 1991, until the unit left the Gulf. Such a system potentially could pinpoint unit locations and document local environmental conditions, the report says.

The Defense Department, the branches of the armed services, and the VA should cooperate to develop a new uniform medical record that includes all relevant health information for each service person, such as personal health risk factors as well as all medical contacts and interventions. The single, continuous, and retrievable record should be kept in a format that allows linkage to other data sets -- for example to those now being compiled on troop environmental exposures during the war. Presently, medical records are kept by each organization separately, making it difficult to follow the medical history of each individual service person. The committee stressed that safeguards would need to be in place to ensure the confidentiality of medical records under the proposed system.

Bringing Information into the Open

To help improve the flow of information among researchers and the public and to ensure at least minimal scientific quality, the committee recommended that all reports funded by the Defense Department and VA be published in open, peer-reviewed journals. Presently, while many reports are available to researchers who know they exist and ask for them, they are not generally indexed and accessible where they can be located and evaluated by independent researchers. In some instances, members of the IOM committee had difficulty identifying and tracking down these reports.

Some studies suffer from obvious flaws in the questions being posed, in the population being studied, or in the study design. The IOM report recommends that Congress and the federal agencies require that all federally funded research related to unexplained illnesses or other health matters be generally announced and open to the scientific community. These proposals should be reviewed by qualified experts, and funding decisions should be made on the basis of their recommendations.

Basis of Future Studies

Although recent reports have focused primarily on possible exposures to chemical weapons in the war, there remain other important research questions related to the health of Gulf veterans. The committee recommended rapid completion of several large studies currently under way, and said that while there is basis for several epidemiologic studies to answer many remaining questions, an additional comprehensive nationwide study would be of limited scientific value at this time.

The report recommends research in the following areas:
> excess mortality from unintentional injury among veterans;
> the high incidence of psychiatric disorders among those who served -- an occurrence common to every major military engagement since the Civil War -- to identify factors that may indicate increased risk for stress-related psychiatric disorders among personnel;
> possible differences between the experiences of reserves, National Guard troops, and regular troops; and
> health consequences of assigning men and women to serve together in combat.

The committee also recommended that some federally funded studies be continued for up to 30 years to compare the health of those who saw action during the Persian Gulf War with veterans assigned elsewhere.

The report was funded by the Department of Defense and the Department of Veterans Affairs. A committee roster follows. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences.

Read the full text of <Health Consequences of Service During the Persian Gulf War: Recommendations for Research and Information Services> for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).
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INSTITUTE OF MEDICINE
Medical Follow-up Agency

COMMITTEE TO REVIEW THE HEALTH CONSEQUENCES OF SERVICE
DURING THE PERSIAN GULF WAR

JOHN C. BAILAR III *(CHAIR)
Professor and Chair, Department of Health Studies
University of Chicago

CHRISTOPHER C. GREEN
Executive Director, Research and Development
General Motors Corp.
Warren, Mich.

RICHARD B. HORNICK
Vice President of Medical Education
Regional Healthcare System
Medical Education Administration
Orlando, Fla.

KARL T. KELSEY
Associate Professor of Occupational Medicine and Radiobiology
Harvard School of Public Health
Boston

WAYNE M. LEDNAR
Corporate Medical Director
Eastman Kodak Co.
Rochester, N.Y.

THOMAS A. LOUIS
Professor and Head, Division of Biostatistics
University of Minnesota School of Public Health
Minneapolis

GARY M. MARSH
Professor, Department of Biostatistics
Graduate School of Public Health
University of Pittsburgh

DAVID P. RALL *
Foreign Secretary, Institute of Medicine, and
Director Emeritus, National Institute of Environmental Health Services
National Institutes of Health
Bethesda, Md.

PHILIP K. RUSSELL
Professor, Department of International Health
School of Hygiene and Public Health
Johns Hopkins University
Baltimore

DAVID A. SAVITZ
Professor and Chairman, Department of Epidemiology
School of Public Health
University of North Carolina
Chapel Hill

G. MARIE SWANSON
Director, Cancer Center, and
Professor, Department of Family Practice and Medicine
Michigan State University
East Lansing

GUTHRIE L. TURNER JR.
Chief Medical Consultant, Department of Social and Health Services
Division of Disability Determination Services
Washington State University
Olympia

MARK J. UTELL
Professor, Department of Medicine and Environmental Medicine, and
Director, Pulmonary/Critical Care and Occupational Medicine Divisions
University of Rochester School of Medicine
Rochester, N.Y.

JAMES H. WARE
Dean for Academic Affairs
Harvard School of Public Health
Boston

DAVID H. WEGMAN
Professor and Chair, Department of Work Environment
University of Massachusetts
Lowell

LOUIS JOLYON WEST
Professor, Department of Psychiatry and Biobehavioral Sciences
University of California, and
School of Medicine
Neuropsychiatric Institute
Los Angeles

ELIZABETH A. WILLIAMS
Associate Professor, Department of Internal Medicine
James Quillen College of Medicine
East Tennessee State University
Johnson City

NANCY FUGATE WOODS *
Director
Center for Women's Health Research, and
Professor, Family and Child Nursing
University of Washington
Seattle

INSTITUTE OF MEDICINE STAFF

DIANE J. MUNDT
Study Director

(*) MEMBER, INSTITUTE OF MEDICINE