Correcting Flaws in Force Health Protection


It took much longer than it ever should have taken, but the Department of Veteran Affairs has finally recognized that something out of the 1991 Gulf War is affecting a significant number of veterans.

 

Thanks in large part to the concerted efforts of numerous groups organized to promote the welfare of Gulf War veterans, it is now possible for those suffering from mysterious symptoms to get help from the government. This has been no mean accomplishment, although it was a long time in coming.

 

An outgrowth of these efforts is Sec. 765 of Public Law 105-85, titled: Improved medical tracking system for members deployed overseas in contingency or combat operations. Dr. Sue Bailey, who was the Assistant Secretary of Defense for Health Affairs when this law was passed, wrote a Department of Defense (DoD) memorandum on Oct. 6, 1998 , implementing a Policy for Pre- and Post-Deployment Health Assessments and Blood Sample. This memorandum ordered the immediate implementation of its directives, and contained two attachments: Pre-Deployment Health Assessment (DD2795), and Post-Deployment Health Assessment (DD2796), basically forms to be filled out by members pre- and post-deployment.

 

The DoD should have implemented this system for safeguarding the health of personnel deployed to high-risk areas shortly thereafter. In fact, perhaps as an “inspired cost-saving measure,” all the DoD actually did was to collect questionnaires from deploying and returning troops, and tag blood samples specifically taken to identify possible HIV infection. Blood sample collection designated for this specific purpose did not start until April 29, 2003 , four years and seven months after Dr. Bailey penned her implementing memo.

 

Since Dr. Bailey’s memo was addressed directly to the Surgeons General of the Army, Air Force and Navy, and also to the Deputy Director for Medical Readiness of the Joint Chiefs of Staff, this delay is an outrageous abuse of executive privilege by those responsible for its implementation.

 

The irony is that even with its implementation, our troops are not really receiving the protection envisioned by the law’s framers. Although it is not apparent to the casual reader, Public Law 105-85 has some serious limiting flaws. The Rhode Island Gulf War Commission appointed by R.I. Governor Donald Carcieri examined these flaws and came up with a complementary program under the sponsorship of George Washington University and the Boston VA Healthcare System.

 

The following comparison of the DoD program and the Rhode Island Plan was compiled by the National Gulf War Resource Center (NGWRC) and is presented courtesy of NGWRC.

 

The current DoD program consists of:

 

(1) Blood sampling: Pre- and post-deployment blood sampling (per DoD instruction 6490.3) is accomplished by routine participation in service programs for HIV screening. These blood collections are conducted every 12 months. The serum fraction of blood is extracted and archived at the DoD Serum Repository in Silver Spring Md. , maintained by the Army Medical Surveillance Activity.

 

(2) Pre- and post-deployment health assessment: This is accomplished by completion of a health assessment form by each service member, which is subsequently reviewed by a health care provider (who may be a military medic or corpsman). This information is then relayed to a DoD database.

 

(3) DoD Facility description: The DoD serum repository in Silver Spring contains samples from 7.5 million military personnel divided into more than 30 million aliquots. This archive was created in 1989 using the blood remaining after AIDS testing. Currently each deployed service member must have a sample taken 12 months or less prior to deployment, the serum fraction of which is sent to the repository. Serum from many blood specimens taken during annual physical exams from active-duty personnel is routinely archived in the DoD facility, creating a resource which should prove to be enormously valuable in longitudinal studies.

 

(4) Limitations of DoD Facility: Samples in the Silver Spring repository may be used for comparative evaluation of disease biomarkers before and following tours of duty. However the current approach to collection of the samples introduces confounding factors which would make interpretation of such data very difficult. These are listed below:

 

(a) Samples are not uniformly collected at the time of deployment and upon return from overseas service. Hence health-impacting occupational and/or environmental influences occurring before or after combat tours would also affect lab analyses of serum samples. It would thus be impossible to determine with reasonable certainty whether expression in the blood of some disease associated biomarker occurred due to events during combat tours or not. This distinction is particularly important for cohorts of active duty personnel. These individuals are routinely exposed to potentially health-affecting influences as part of their military duties (such as CARC paint, insecticides and exposure to toxic munitions).

 

(b) The sampling strategy is not structured so as to collect blood post-baseline and then following pre-deployment (or other) vaccinations. This makes it impossible to use the DoD facility to specifically assess the impact of vaccines on blood biomarkers of disease.

 

(c) The repository archives only serum. This is the most useful fraction of blood to analyze for indicators of disease. However other fractions of blood would also be useful. As an example, if white blood cells are collected and dissolved while still alive in a solution called “tri-reagent”, it is possible to store this “lysate” for years and analyze it for messenger RNA as desired. This allows risk for certain latent diseases to be predicted, allowing very effective preventive medicine approaches to be developed.

 

(d) There is no public domain program for ongoing analyses of these samples for blood biomarkers of any kind. This in itself is puzzling since using this resource, the DoD might have been able to significantly characterize biological elements of illness associated with service in the Gulf region.

 

(e) The health assessment questionnaires given by DoD to personnel deploying for overseas duty are not tightly linked to the pre- and post-tour blood draws. Thus it is difficult to cleanly correlate questionnaire responses with lab data from serum analysis. Likewise, vaccination record data are not linked with blood samples.

 

(f) Access to this repository is highly restricted. It is essentially impossible to obtain permission from DoD for analysis of these samples.

 

The features of the Rhode Island plan are:

 

(1) The R.I. Gulf War Commission, George Washington University and Boston VA Healthcare System have developed a program whereby a representative cross-section of Reservists deployed for the current military activities will enter a program of medical monitoring consistent with Public Law 105-85. Outcome of this effort is creation of a body of data and a blood products repository which will serve as a resource during the next decade by which health crises emerging among veterans of the current conflict may be addressed more definitively than was possible for veterans of previous conflicts.

 

(2) The major attributes are as follows:

 

(a) Blood sampling uniformly brackets deployment, vaccinations and demobilization.

 

(b) Reserve military personnel constitute the sample population. The first blood sample is taken as service members make a clean transition from civilian to military life. Hence any disease–associated changes detected in blood between the first and final blood draw may be linked to either events during the tour or vaccines (or both) with much greater definition than would be possible using samples in DoD’s Silver Spring facility.

 

(c) The repository generated under the R.I. effort archives serum, plasma and white blood cell lysate. It thus offers future investigators the ability to perform analyses for a much greater range of health-related variables than does the DoD facility.

 

(d) The R.I. investigators have developed a structured program of analysis for the samples and information collected. This is based on a well-defined hypothesis, specific aims, methodology, budget and timetable. The work is focused so as to generate well-defined results with direct clinical use to both troops and vets. Participants will be followed for a period of four years to determine how their health and profiles of blood biomarkers change with time.

 

(e) Lab data under this program is tightly linked with both vaccination records and questionnaires. Each category of data is entered into a single comprehensive database at University of Connecticut Health Center’s Office of Biostatistical Analysis.

 

(f) Access to the resulting biospecimen repository is subject only to restrictions on sample availability. Improvements in analytical technology will make it possible for an enormous number of studies to be conducted using these samples. All data will be public domain.

 

The major advantage offered by the Rhode Island Plan is the accuracy with which major deployment events can be linked to changes in blood biomarkers. Because the current DoD sampling interval between pre- and post-deployment blood draws for almost everyone whose serum is stored in the Silver Spring facility does not match deployment and demobilization dates, there is an enormous amount of exposure time which occurred outside the period of deployment.

 

Furthermore, the DoD program does not include serum drawn immediately following pre-deployment vaccinations. On the other hand, the Rhode Island Plan protocol addresses these issues definitively. Under the Rhode Island Plan, it is possible to distinguish between disease-associated biomarkers arising as a result of events occurring during active-duty tours versus garrison time. It is also possible to distinguish between biomarkers arising as a result of vaccinations versus environmental exposure.

 

It doesn’t take an advance medical degree to see that the Rhode Island Plan medical monitoring system complements the existing DoD approach, and offers enormous potential for reducing the extent of emerging health crises following deployments.

 

Despite this, the DoD has rejected all attempts thus far to include the Rhode Island Plan in the Force Protection Procedures it currently implements. Taking such action is not a partisan matter, and it carries no political overtones. It is simply a matter of intelligent implementation of a public law passed by Congress nearly five years ago.

 

It is not possible to go back and correct past mistakes, but the Rhode Island Plan can be implemented immediately. If this is not done, we should ask a loud public “Why?” And while we are at it, I want to know who has stonewalled its implementation all these years, and what is the reason.

 

The bottom line is the safeguarding of our most precious military resource: the grunt on the line. To the men and women risking their lives on our behalf, we owe nothing less than the greatest possible level of protection. By today’s best measure, that includes the immediate, full implementation of the Rhode Island Plan.