Wnited States Senate WASHINGTON, DC 20510 March 16, 2016 ‘The Honorable Thad Cochran The Honorable Richard J. Durbin Chairman Vice Chairman Subcommittee on Defense Subcommittee on Defense Committee on Appropriations Committee on Appropriations Washington, DC 20510 Washington, DC 20510 Dear Chairman Cochran and Vice Chairman Durbin: ‘Thank you for your continued support for the Gulf War Illness Research Program (GWIRP) within the Department of Defense (DOD) Congressionally Directed Medical Research Programs (CDMRP), including the $20 million provided to the program by Congress for Fiscal Year (FY) 2016. As your ‘Committee begins work on the FY 2017 DOD Appropriations Bill, we are writing to provide a program update and to request that you include the funding necessary to continue the GWIRP’s successful work on behalf of Gulf War veterans. We have made strides in the fight against Gulf War Illness, but many challenges remain. Since the 2008 report of the congressionally-mandated Research Advisory Committee on Gulf War Veterans’ Iinesses (RAC) and the 2010 report of the Institute of Medicine (IOM), science has shown that Gulf War Illness is a physical condition—likely caused by toxic exposures—affecting between one-quarter and one-third of the nearly 700,000 veterans who served. The most recent RAC update in 2014 affirmed these conclusions, and a 2016 IOM update “found little evidence to warrant changes to the conclusions made by the [2010 IOM] committee . . ”' Common symptoms include “some combination, of widespread pain, headache, persistent problems with memory and thinking, fatigue, breathing problems, stomach and intestinal symptoms, and skin abnormalities.” Studies also have found an elevated incidence of Lou Gehrig’s disease (ALS) among Gulf War veterans as well as significantly elevated rates of death due to brain cancer among those who were most exposed to the release of nerve gas by the destruction of the Khamisiyah Iraqi arms depot. The positive news is that treatment research has increased significantly since 2008, particularly reflecting the work of the GWIRP at CDMRP, and that early results represent encouraging steps toward achieving the 2010 IOM treatment goals “to speed the development of effective treatments, cures, and, it is hoped, preventions.”® Indeed, the GWIRP has served as a model of how to conduct treatment-oriented research to address a challenging illness and is succeeding where earlier programs failed. By Congressional design, the program is narrowly focused on identifying treatments and diagnostic markers. Its highly competitive, peer-reviewed process is open to all researchers, whereas Institute of Medicine, “Update of Health Effects of Serving in the Gulf War, 2016,” Gulf War and Health, no. 10 (2016): 6 *Research Advisory Committee on Gulf War Veterans Illnesses, “Research Update and Recommendations, 2009-2013,” Gulf War Illnesses and the Health of Gulf War Veterans, (2014): 5 > Institute of Medicine, “Update of Health Effects of Serving in the Gulf War,” Gulf War and Health, no, 8 (2010): ix.U.S. Department of Veterans Affairs (VA) research is restricted to VA staff, few of whom have expertise in this rapidly-evolving, cutting-edge area. GWIRP-funded studies have found treatments—like CoQ10, acupuncture, carnosine, and xylitol/saline nasal irrigation—that help alleviate some GWI symptoms, and ongoing evaluations of treatments include off-the-shelf medications and alternative therapies for which there is a rationale for GWI symptom relief. Other studies by multisite, multidisciplinary teams are focused on identifying treatments to attack the underlying disease and are showing great promise, finding that even low-dose chemical warfare agent and/or pesticide exposure leads to the following findings, among others: persistent brain changes associated with GWI; evidence of a GWI chronic central nervous system inflammatory state; a potential explanation of GWI immunological dysfunction; inflammation and immune dysfunetion in GWI after exercise challenge; evidence suggesting small fiber peripheral neuropathy in a subset of GWI veterans; lipid dysfunction following GWI exposures; and persistent changes in axonal transport in the brain. Some of the new pilot studies of treatments approved in 2015 include: vagus nerve stimulation; D-Cycloserine; anatabine; liposomal glutathione and curcumin; and a “mitochondrial cocktail” extending the benefits of CoQ10. New research to identify underlying disease mechanisms and biomarkers includes: studies of novel autoantibody serum and cerebrospinal fluid biomarkers; microtubule abnormalities; neurovascular and autonomic dysfunction; brain autoimmune dysfunction; muscle mitochondrial assessment; and an objective blood test from stimulated gene expression, In addition to improving the health of Gulf War veterans, these important discoveries also will help protect current and future American servicemembers who could be at risk of toxic exposures. Recognizing the program’s progress, the most recent RAC report recommends that “Congress should ‘maintain its funding to support the effective treatment-oriented [GWIRP].™ We agree and respectfully request that you provide the necessary resources to continue this vital and effective program in the FY17 DOD Appropriations Bill. Furthermore, it is critical to the program’s success and accountability that it remains a stand-alone program within CDMRP, rather than combined with other diseases. Thank you for your consideration of our request, which is supported by the American Legion, Veterans of Foreign Wars, Disabled American Veterans, Paralyzed Veterans of American, AMVETS, Vietnam Veterans of America, National Vietnam and Gulf War Veterans Coalition, the National Gulf War Resource Center, and Veterans for Common Sense. Sincerely, Tdémmy Bfldwin Elizabeth Warren United States Senator United States Senator * Research Advisory Committee on Gulf War Veterans Ilinesses, “Research Update and Recommendations, 2009- 2013," Gulf War Ilinesses and the Health of Gulf War Veterans, (2014): 14.~— 2h fle A Madly rian Schatz Jeff Merkley, United States Senator United States Senator United States Senator United States Senator Kirsten Gillibrand Ron Wyden United States Senator United States Senator bie St Sherrod Brown United States Senator United States Senator rary CAP eters Charles E. Schumer United States Senator United States Senator