Research Advisory Committee on Gulf War Veterans’ Illnesses
May 29, 2013
Hon. Jose D. Riojas Interim Chief of Staff Department of Veterans Affairs Washington, DC 20420 Dear Mr. Riojas: Staff has convinced you to convert the Research Advisory Committee into a typical VA advisory committee, dependent on VA staff, and you have invited me to assist with this transition. I want you to understand the limits of what I practically can do, and the implications of what you are doing. You have not previously involved me in the discussions leading to these decisions. I respectfully request that you consider the following additional background. For each numbered item, the tab provides supporting documentation. I would welcome the opportunity for me and other members of the committee to discuss it with you in more detail. 1. The RAC is not the problem. Eighteen months ago, it was praising the progress made by this administration. The RAC’s annual report for 2011 concluded: "It appears likely that for the first time VA will soon have a comprehensive strategic plan to provide the foundation for an effective Gulf War research program." http://www.va.gov/RACGWVI/2011annualreport.pdf (p. 3) 2. The problem is that staff hardliners pushed back to reverse this progress, seeking to reestablish scientifically-discredited policies from the 1990’s, including the fiction that the illness is or may be psychiatric. The RAC documented these actions in its 48-page June 2012 findings and recommendations to the Secretary. In March 2013, two members of the RAC testified about these staff actions to a Congressional subcommittee, the ninth Congressional hearing where RAC members have testified since the establishment of the committee. In retaliation, staff has convinced you to turn the RAC into a typical VA advisory committee, eliminating its independence. http://www.va.gov/RACGWVI/docs/Committee_Documents/CommitteeDocJune2012.pdf 3. Congress, however, created the RAC precisely to provide this kind of independent advice, because of the demonstrated inability of VA and DoD staff to face this problem honestly and conduct an effective research program to solve it. The 1997 Congressional committee report that led to the legislation creating the RAC was entitled: “Gulf War Veterans Illnesses: VA, DOD Continue To Resist Strong Evidence Linking Toxic Causes To Chronic Health Effects". http://www.gpo.gov/fdsys/pkg/CRPT105hrpt388/pdf/CRPT-105hrpt388.pdf 4. The report concluded: “After 19 months of investigation, the subcommittee finds the status of efforts on Gulf War issues by the Department of Veterans Affairs, the Department of Defense, the Central Intelligence Agency, and the Food and Drug
Administration to be irreparably flawed... [W]e find current approaches to research, diagnosis and treatment unlikely to yield answers to veterans' life-or-death questions in the foreseeable, or even far distant, future." The individuals behind the recent staff pushback are some of the same people that Congress was concerned about in 1997, who have built their careers on minimizing the health consequences of toxic exposures. Dr. Michael Peterson, currently in charge of post-deployment health research at the VA Office of Public Health, was a principal investigator of the 1987 update to the Ranch Hand study that concluded Agent Orange had no adverse effect on the health of Vietnam veterans. Dr. Kelley Brix, currently DoD co-chair of the Deployment Health Working Group subcommittee that co-ordinates VA/DoD research policy, was a staff member of the 1995-1997 Presidential Advisory Committee that concluded the likely cause of Gulf War Illness was stress. http://www.gulflink.osd.mil/gwvi/toc-f.html (Executive Summary and Appendix D) and webapp1.dlib.indiana.edu/cgibin/virtcdlib/index.cgi/4886372/FID1/reports/Morbidity_Report/Summary_Resul ts.pdf (pp. 1, 43, 45). The worst of the old policies resurrected by staff in early 2012 was the manipulation of Institute of Medicine Gulf War studies, because it misdirects the entire scientific community. This practice had been halted by Secretary Shinseki’s intervention to ensure that the speakers invited to address the IOM 2010 report committee included members of the Research Advisory Committee. Early last year, however, six speakers invited to address the IOM 2013 Treatment report committee presented the view that the illness is or may be psychiatric, although science has long been settled to the contrary. The speakers included VA’s own representative, although he himself had served on a 2011 committee that re-wrote VA physician training guidelines to state that the illness is not psychiatric. http://www.va.gov/RACGWVI/docs/Committee_Documents/CommitteeDocJune2012.pdf (Appendix D) At a Congressional hearing in March, Dr. Stephen Coughlin, a former VA senior epidemiologist, testified that Dr. Peterson identified the speakers to invite, among other actions to misguide research related to the health effects of toxic exposures in Gulf War and Iraq/Afghanistan veterans. A second witness is prepared to testify that the chairman of the Treatment Committee informed him that Drs. Peterson and Brix told him which speakers to invite. http://veterans.house.gov/hearing/gulf-war-what-kind-of-care-areveterans-receiving-20-years-later The membership of Treatment Report Committee itself was stacked with experts in psychosomatic illness. The membership of IOM Board on the Health of Select Populations that oversees Gulf War reports includes three individuals who played active roles in minimizing the scope and nature of Gulf War Illness in the 1990’s, and no one who represents current scientific knowledge of the subject. Recently VA staff has contracted with the IOM to develop a case definition of chronic multisymptom illness in Gulf War veterans through a literature review, although this approach runs counter to the guidance provided in VA’s own Gulf War Strategic Research Plan released earlier this month. The choice of a case definition will shape all future Gulf War illness research for better or for worse (Appendix B to this letter). http://www.iom.edu/Activities/Veterans/GulfWarMultisymptom.aspx
It has been accepted science since 2004 that Gulf War illness is not a psychiatric problem, when Secretary Principi on the recommendation of the RAC forbade further research based on the
premise that it was caused by stress. It is extremely alarming to see hardline staff seeking to undermine this knowledge. The chairman of the 2010 IOM report committee emphasized in its preface that with the right research, “treatments, cures, and, it is hoped, preventions” can likely be found. The right research is the key to improving veterans’ health, to saving public money on health care and benefits, and to protecting U.S. military men and women on future battlefields. Steering Gulf War health research again down the wrong path, as was done for so many years, carries enormous human and financial costs. The Congressional committee that wrote the Congressional report cited above and created the RAC was the House Government Reform and Oversight Committee, now called Oversight and Government Reform. Some of the ill veterans who worked for years to get Congress to establish the RAC are still alive. Some committee staff are still there, and some Members are still in Congress. They all know that Congress intended the Research Advisory Committee to be far more than a typical VA advisory committee, and they will not buy a statutory construction argument to the contrary. They will object to the elimination of charter provisions that were put in the RAC’s charter at its inception precisely to enable it to perform the role Congress intended: to provide an independent source of advice on the conduct of federal Gulf War health research. Attached is a summary of these changes. Given the current state of affairs in Washington, the charter change will provide another issue for the Oversight and Government Reform Committee to discredit the Administration. Moreover, up to now the problems that have occurred in Gulf War health research have always been described as contrary to the policy of the Secretary. He does not own these problems. Even Dr. Coughlin testified that the Secretary was being lied to about the abuses he described. Having the Secretary sign the new charter will place him in the line of fire. It makes no sense for him to take ownership of dishonorable actions that are diametrically opposed to his own policy and leave him on the wrong side of science and history. He cannot want the man who hid the truth about Agent Orange running his environmental health research and determining his legacy. If you pursue your current course, I can do nothing to alter these outcomes, and would not want to mislead you into thinking I can. If you wish to consider other approaches for transitioning the RAC to a less confrontational role and VA staff to a more productive role, I look forward to assisting.
Appendix A. Changes to RAC Charter: a. The role of the committee to “assess the overall effectiveness of government research to answer central questions on the nature, causes, and treatments for health consequences of military service . . . during the 1990-1991 Gulf War” has been eliminated. (Section 3, former para. 2) b. Provision for the committee to have its own staff has been eliminated. (Sections 6, 7) The new language will permit staffing to be provided in the future by VA staff. As with other changes, this may not necessarily happen immediately. c. The budget has been reduced from $400,000 to “not to exceed $400,000”, and under the new language the committee likely exercises no control over these funds in any case. (Section 7) d. The committee may meet as infrequently as once a year. (Section 9) e. The committee’s review of Gulf War research activities by other departments will be limited to “publicly available” materials. (Section 3) The practice of VA departments (ORD and OPH) has also increasingly been to show the committee only publicly available VA materials, not “proposed research studies, research plans, or research strategies,” as required by Public Law 105-368. f. The committee’s direct connection to the Secretary’s Office appears to have been eliminated or greatly reduced. While the charter still refers pro forma to providing advice to the Secretary, and reporting to the Secretary, the administration of the Committee (determination of budget, size of committee staff), formerly in the Secretary’s Office, is no longer mentioned. (Section 6). g. The “guiding principle for the work of the Committee . . . that the fundamental goal of Gulf War health-related government research . . . is to ultimately improve the health of ill Gulf War veterans, and that the choice and success of research efforts shall be judged accordingly” has been eliminated. (Section 3, former para. 2) h. While not a charter subject, the termination of half the current membership of the committee, in connection with these other changes, raises concerns that the RAC, like the IOM panels, will soon be populated with associates of the same people it was intended to oversee.
Appendix B: Membership of the IOM Gulf War Treatment Committee The Treatment Committee had fifteen members. http://www.iom.edu/Activities/Veterans/GulfWarMultisymptom.aspx Of the fifteen, four are particularly identified with somatic and psychosomatic illness: Dr. Francesca Dwamena is an internal medicine specialist and assistant professor of medicine and adjunct assistant professor of psychiatry at Michigan State. She has a Certificate in Psychosocial Medicine, is the director of Psychosocial Rounds, and has spoken on such subjects as "Treatment of Somatization in Primary Care" and "Medically Unexplained Symptoms and Physician Frustration." She has co-authored two papers with Dr. Joel Kupersmith, VA's chief research and development officer. http://www.healthteam.msu.edu/medicine/curriculum%20vitaes/Dwamena.pdf Dr. Frank de Gruy is a family physician and chairman of the department of family medicine at the University of Colorado, Anschutz Campus. He lists his research interests as "mental disorders in the primary care setting" and "unexplained physical symptoms." He has co-authored eight papers with Dr. Kurt Kroenke, the VA doctor who was one of the five psychiatric-oriented speakers at the 2/29/12 IOM treatment committee meeting, e.g, "Multisomatoform disorder: an alternative to undifferentiated somatoform disorder in primary care." http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/ab out/faculty/Pages/FrankdeGruy.aspx Dr. Douglas Drossman is adjunct professor of gastroenterology and psychiatry at the University of North Carolina. He is a past president of the American Psychosomatic Society, and has published on such topics as "Psychosocial Aspects of Inflammatory Bowel Disease" and "Teaching Psychosomatic (Biopsychosocial) Medicine in United States Medical Schools". http://www.med.unc.edu/ibs/files/cvs/DougDrossmanCV%2004-30-2010.pdf Dr. Javier I. Escobar is professor of psychiatry at the Robert Wood Johnson Medical School. With Dr. Kroenke, he was a member of the "Conceptual Issues in Somatoform and Similar Disorders" project that laid the groundwork for the controversial expansion of the definition of somatoform disorders in the recently revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association. He was a member of the task force that wrote DSM-5. http://www.dsm5.org/MeetUs/Documents/Task%20Force%202012/Escobar-Disclosure2012.pdf http://dxrevisionwatch.com/dsm-5-proposals/dsm-5-ssd-work-group/ In addition, Dr. Kasisomayajula Viswanath, is a Ph.D. at the Harvard School of Public Health who specializes in health risk communication. "Risk communication" is a phrase often applied by government officials to the care of ill Gulf War veterans, suggesting, in effect, that doctors communicate to ill veterans that their health problems are not related to environmental exposures. http://www.viswanathlab.org/index.php/people/drviswanath
Two other committee members are Ph.D. psychologists. Dr. Lori Zoeller directs the Center for Anxiety and Traumatic Stress at the University of Washington. http://faculty.washington.edu/zoellner/people/zoellner.html Dr. Wayne Gordon is an associate professor of is a professor of rehabilitation medicine and associate professor of psychiatry at Mt. Sinai Hospital and specializes in traumatic brain injury research. http://www.mountsinai.org/profiles/wayne-a-gordon The remaining eight members have a range of backgrounds. Dr. Bernard Rosof, the committee chairman, heads a consulting firm on medical quality http://www.qhcag.com/4.html Dr. Karen A. Robinson, epidemiologist, Johns Hopkins University; specializes in evidence-based medicine, health informatics. http://www.hopkinsmedicine.org/gim/faculty/robinson.html Dr. Isabel V. Hoverman, internal medicine specialist, private practice http://www.healthgrades.com/physician/dr-isabel-hoverman-y323w http://www.pwrnewmedia.com/2009/jointcommission91202/assets/Hoverman_bio.pdf Dr. Elaine L. Larson, epidemiologist, Columbia University, infection control and prevention http://www.mailman.columbia.edu/our-faculty/profile?uni=ell23 Dr. Wayne Jonas, professor of family medicine, Georgetown University, alternative medicine http://www.samueliinstitute.org/about-us/wayne-b-jonas-md Dr. Diana Cardenas, professor and chairman, Department of Rehabilitation Medicine, University of Miami, spinal chord injuries, management of chronic pain http://www.miamiproject.miami.edu/page.aspx?pid=329 Dr. Joanne Kutzman is a neurologist with experience in treating fibromyalgia. http://hospitals.unm.edu/pain/clinicians/katzman_joanna.html Dr. Stephen Mitchell, rheumatologist, Georgetown University http://www.georgetownuniversityhospital.org/body_fw.cfm?id=8&action=detail&ref=2930 No one appears to have any expertise in treating or researching Gulf War illness, and only the last two members and Dr. Drossman appear to have direct experience with other multisymptom illnesses. Thus the only group with similar backgrounds with major representation on the committee was the four psychosomatic specialists, the risk communication expert, and the anxiety/traumatic stress psychologist. This emphasis on psychiatric views is striking giving the conclusion of the 2010 IOM report that this illness is not a psychiatric problem. The other background affiliation that stands out is that four of the treatment committee members had previously served on Gulf War health committees. Three served on previous IOM committees (Dr. Rosof, two; Dr. Drossman, three; Dr. Hoverman, four), and Dr. Larson served on the Clinton-era Presidential Advisory Committee on Gulf War Veterans Illnesses, which concluded that stress was the likely cause of GWI. Again, none of them have treated or studied ill Gulf War veterans. What they know about the problem comes from service on previous committees, and we have seen how IOM committees generally have been educated. Dr. Drossman, the past president of the American Psychosomatic Society, has been appointed to the last four IOM Gulf War committees. http://www.iom.edu/Global/Directory/Detail.aspx?id=0020010777
Appendix B: Membership of the Board on the Health of Select Populations The IOM board that handles military and veterans projects is the Board on the Health of Select Populations. Three members of the board were leading proponents of the government theory of Gulf War health issues in the 1990’s: - Kurt Kroenke Dr. Kroenke, one of the five psychiatric-oriented speakers who addressed the IOM treatment committee on Feb. 29, 2012, a close associate of two members of that committee, and a recognized figure in somatic medicine, was an Army doctor and active Gulf War psychiatric-oriented researcher in the 1990's. - Francis Murphy During the mid-to-late '90's, Dr. Murphy held the position at VA of "chief consultant" on occupational and environmental health, the position that Dr. Michael Peterson holds today. She was a leading spokesperson for the position that there is no Gulf War syndrome. - Greg Gray As a Navy doctor, Dr. Gray published 10+ papers between 1996-2001 that generally dismissed the idea that Gulf War veterans have any special health problems. They often appeared together as part of what Ross Perot called the “stress team.” For example, Murphy and Gray both addressed a 1998 IOM Committee formed to review Gulf War veterans' health care and research in response to a 1997 GAO report: http://www.gulflink.osd.mil/news/na_iomstudies_072398.html There is no one on the board of the Health of Select Populations who represents current scientific understanding of Gulf War illness.