GULF WAR VETERANS TO VA SECRETARY ON VA OPENING VETERANS’ CLAIMS, ‘WE’RE HIGHLY SKEPTICAL’
March 4, 2010 posted by Denise Nichols · 25 Comments
Gulf War Veterans question how well the VA’s plan will work at reopening Gulf War Veterans’ claims on Gulf War Illness.Gulf War Veterans are concerned about how today’s headline, “VA to reopen Gulf War vets’ files”, will impact the VA’s procedures in determining their current and future benefits from the VA.
Jim Bunker, president for the National Gulf War Resource Center (NGWRC), is worried that having the same raters looking over claims they previously denied will be a waste of time and money. The VA’s first priority should be fixing the system.
In a letter he sent, on behalf of the NGWRC, to VA Secretary Eric Shinseki and Chief of Staff John R. Gingrich, Bunker has asked that there be better training on the entire rating system.
The Secretary of Veterans Affairs needs to set strong and clear policy and directives, that reflect the findings of the Research Advisory Committee (RAC), that will govern how the VA will update its clinician guides and training manuals on Gulf War Illness; and require all persons who treat, or do benefit rating of Gulf War Veterans to take the updated course (mandatory).
This training module dedicated to Gulf War Illness should be updated on an ongoing basis and should be made a requirement for all attending VA staff that treat Gulf War Veterans. All references to Gulf War Illness as “psychological” in nature should be eliminated from VA materials and replaced with real data and facts from the latest research and approved by the committee as true research into gulf war illness.
The next step is to add Gastroesophageal Reflux Disease (GERD) and sinus problems to the list of illnesses. The illnesses of Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFS) should all be treated and rated as CFS. They both have the same symptoms and it is only a doctor’s opinion that will assign them CFS or FM. The rating for FM is 40% and the rating for CFS is 100%. The tendency is to assign FM to the veteran; however, by law the VA is supposed to give the veterans the higher of the two, but is not.
The Computer system, at check in, also needs to change. Right now a veteran is only allowed to have one medical complaint entered even if he has many. This impacts the rating by showing on the records he did not have any other complaints, thus causing the claim to be denied.
The VA also needs to do a survey of all raters, caregivers, and directors about Gulf War illness to better understand where the problems are. The NGWRC knows from its many years of working this issue that some VA’s are better than others.
Veterans far and wide are offering their feedback to VA Directive Letter on Gulf War Veterans Claims below is a sampling of those offerring feedback comments:
- This “training letter” for C and P examiners is not needed. Software is provided for the C and P examiner which inserts the following paragraph in the C and P exam report of every Veteran tested:
“There is no record of any evidence that the Veterans illness was caused by military service. VA mailroom employees are hereby directed to shred any evidence to the contrary, including this exam, after the denial is made.” - Looks like another long winded way of delaying a claim again. This is just another spin on spin letter more of a cover your own ass, than a help to vets.
- I have kept up with everything I could find in the past the VA put out about Gulf war problems and also carefully read the instructions to the ROs about guidelines and I see nothing basically new but I would hope they check all records that Gulf veterans have with the VA and check everyone that has been turned down for medical problems related in the above info the veteran has. I hope this is a turn around but I have my reservations about how they, at the ROs are going to handle it. I still recall the MD at the Milwaukee VAMC, after a long Gulfwar veteran exam, telling me at the conclusion of the exam that she didn ‘t believe any of the stuff about problems with Gulfwar veterans. I brought this up to the Chief of Staff and he told me several days later she denied saying that.
- Yeah. My first doctor in Altus, OK..said I needed Spinal surgery but just in case, I needed a second opinion too. So i took my military health records and the MRIs to the RO in OKC. I still remember his quote, “I can’t find the problem. You’re going to have to live with the pain”. Then I went to another surgeon and got Spinal surgery six weeks later. Can’t remember how many times I have put that incident aside and went there trying to get treated. Maybe it’ll change but in the meantime I get my care somewhere else.
When I go to VA to treat my symptoms from CFS(which the VA has assigned me as my disability) due to my service in the Gulf(Desert Storm 1) the docs won’t even talk openly about CFS or GWI. They will treat/talk about my symptoms only.
It is also very interesting that when I volunteered for a study done at the Miami VA for GWI that the findings were classified(for their eyes only). Only the basic blood test results were revealed to me.
Matt, you have a right to those test results, tell them so and demand a copy of them. When I did the GW study in DC I got a copy of all the test results, which was several pages, and the doctor doing the study called me and explained it all to me.
This is another of the VA’s lies, you need to call them on it.
There are things you can do to treat your CFS naturally, not just the symptoms; I have and my symptoms are not as bad, most times, as they once were. Although they are still in the “extreme” category, they are improving slowly.
Tanya
Just a note to let my brother and sister Gulf veterans that you cannot get C&P exams like one used to. I found that out just this week. You must now go to the primary care coord and privacy problems, put in writing very exact that you would like the results of your C&P and use exact dates and that you are requesting this under thhe Freedom of Information Act. In my opinion, this is just another way to temporary deny what the veteran, in my opinion, is entitled too. I spoke to a retired JAG officer and he thought this was totally not helping the veteran with his/her claim.
Incidentally, the BVA, after two remands granted me 10% for respiratory problems of asthma and allergy caused by patroling in the smoke flume. My pulmonologist and allergist told them in no uncertain terms that regardless if I had hayfever as a child, I never smoked and had damage to my respiratory tract. In checking with 4.97 (respiratory) they should have granted me 30% as I have to take pulmacort and albuteral and nasacort off and on all day. They, the RO granted ten percent which I feel is wrong. However, it appears you have to keep trying,….this took over six years……don’t give up!
When I came back I have had skin problems. Eight different MDs have examined it and have used 12 different medications over the last 17 years and have all the containers. The RO turned me down and the BVA turned me down twice just recently after 7 plus years. I still have the strange patches that come and go and nothing works. I sure hope they check into this for me and a reliable person with common sense can see the skin problems I do indeed have.
SGT Majo and all welcome…interesting you brought up skin. Again this might be another of the symptoms that they will soon look at to rerate with the new directive letter they have sent from VA HDQTS to the raters..Worth a try! Also any of you that do it would be nice if you all let us know if you tried and what happened now. Also on my Facebook page last night I found one dermatological study and research article from the past re GW illness. I will try to bring it over here and post for you….must have had premonition a skin rash question would be coming up….Hope comments help.
Be aware all these directive letters from Headquarters were just sent out in last week or so time period, I will post them here…but they are posted on several sites…and I think I will recheck on the VA’s own website.
Q J Med 2002; 95: 671-676
© 2002 Association of Physicians
Skin disease in Gulf war veterans
E.M. HIGGINS, K. ISMAIL1, K. KANT1, K. HARMAN, J. MELLERIO, A.W.P. DU VIVIER and S. WESSELY1
From the Dermatology Department, King’s College Hospital, London, and 1 Gulf War Illness Research Unit, Guy’s, King’s & St Thomas’ Medical School, London, UK
Received 27 February 2002 and in revised form 13 June 2002
Summary
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Summary
Introduction
Methods
Results
Discussion
Appendix 1
References
Background: Gulf war veterans report more symptomatic ill-health than other military controls, and skin disease is one of the most frequent reasons for military personnel to seek medical care.
Aim: To compare the nature and prevalence of skin disease in UK Gulf veterans with non-Gulf veterans, and to assess whether skin disease is associated with disability.
Design: Prospective case comparison study.
Methods: Disabled (n=111) and non-disabled (n=98) Gulf veterans and disabled non-Gulf veterans (n=133) were randomly selected from representative cohorts of those who served in the Gulf conflict 1990–1991, UN Bosnia Peacekeeping Force 1992–1997, or veterans in active service between 1990–91, but not deployed to the Gulf. Disability was defined as reduced physical functioning as measured by the Short Form 36 [score <72.2]. All subjects recruited were examined by a dermatologist, blind to the military and health status of the veteran.
Results: The prevalences of skin disease in disabled Gulf, non-disabled Gulf and disabled non-Gulf veterans were 47.7, 36.7, and 42.8% respectively. Seborrhoeic dermatitis was twice as common as expected in the Gulf veterans (both disabled and non-disabled).
Discussion: Skin disease does not appear to be contributing to ill health in Gulf war veterans, with the exception of an unexplained two-fold increase in seborrhoeic dermatitis.
Introduction
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Summary
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Methods
Results
Discussion
Appendix 1
References
Gulf war veterans report more symptomatic ill health than other military controls.1–3 Symptoms reported are multi-system and non-specific, and as yet no medical explanation or cause(s) has been identified. Previous studies have also shown that skin disease is one of the most frequent reasons for military personnel to seek medical care.4,5 Rash was one of the most common symptoms reported by United States (US) registries of Gulf veterans6,7 and in studies comparing Gulf veterans with non-Gulf veterans.8 Dermatitis was the third most common health condition (21%) reported by Gulf veterans and reported twice as often than in Bosnia (13.7%) and Era veterans (12%).1 The limitation of these studies was that they used self-reported measures. To date, there has not been a study that has used clinician diagnosis of dermatological conditions. In this study, we investigated first, whether ill health in Gulf veterans was associated with skin disease and second, whether there was a difference in skin disease between Gulf veterans and non-Gulf veterans who reported ill health.
Methods
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Summary
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Methods
Results
Discussion
Appendix 1
References
Design
The study population was a sample from Stage 2 of a two-stage cohort study of three UK military populations,9 the study design being shown schematically in Appendix 1. Stage 1 was a random sample of veterans of the Gulf conflict (1990–1991) (n=5046), veterans of the Bosnia Peace-Keeping mission (1992–1997) (n=3450) and veterans in active service 1990–1991 who were not deployed to the Gulf (‘Era’ veterans) (n=4248). These veterans were sent postal questionnaires, and the details of recruitment, tracing, response rates and baseline levels of ill-health in Stage 1 have been reported elsewhere.1 In stage 2, four samples were randomly selected based on health status measured at Stage 1. Ill-health was defined as impaired physical functioning using the Short Form 36 Physical functioning measure (SF-36PF)10 at a cut-off of 30%.6
While skin disease is common in the general population,19 our study has confirmed that cutaneous disease is rather more prevalent in military veterans, but for the most part there appears to be no marked difference between the different cohorts studied. However, it is interesting that there was a trend for more skin problems to be seen in disabled Gulf than in the non-disabled Gulf, but not more than the disabled non-Gulf veterans. When all the miscellaneous benign conditions are grouped together, they are significantly more frequent in the disabled Gulf cohort. This cohort tended to be older and less likely still to be serving in the Armed Forces, and this may in part explain the increased skin disease in this group.
The most striking finding was the increase in seborrhoeic dermatitis in Gulf veterans. Seborrhoeic dermatitis was more common amongst veterans who served in the Gulf (17/209 (8.1%) vs. 3/133 (2.3%) in the non-Gulf cohort), irrespective of disability status. The prevalence of seborrhoeic dermatitis in the general population is estimated to be around 3%,20 so the prevalence of this condition in the Gulf sample is twice as high as expected. Although we do not have adjusted prevalences for a non-Gulf military group, this suggests that there may have been an effect of serving in the Gulf itself, rather than an effect associated with disability within the Gulf cohort. This ‘Gulf effect’ has not been reported previously. The explanation for the apparent increase in seborrhoeic dermatitis is not clear, and could be due to chance. However, it is noteworthy that seborrhoeic dermatitis is more common in patients with immune dysfunction20and there is some evidence that patients who served in the Gulf have identifiable immunological abnormalities.21 Further studies to measure immune dysfunction in Gulf veterans, with and without seborrhoeic dermatitis, will be needed to investigate the plausibility of this hypothesis more fully.
In conclusion, although a significant number of Gulf war veterans report on-going ill-health, including skin symptoms,2,5 there is little evidence from this study that dermatological disease is contributory to their perception of ill-health.
Appendix 1
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Summary
Introduction
Methods
Results
Discussion
Appendix 1
References
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Study design9
Notes
Address correspondence to Dr E.M. Higgins, Dermatology Department, King’s College Hospital, Denmark Hill, London SE5 9RS. e-mail: elisabeth.higgins@kcl.ac.uk
References
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Summary
Introduction
Methods
Results
Discussion
Appendix 1
References
1. Unwin C, Blatchley N, Coker W, et al. Health of UK servicemen who served in the Persian Gulf war. Lancet1999; 353:169–78.[Web of Science][Medline]
2. Coker WJ, Bhatt BM, Blatchley NF, Graham JT. Clinical findings for the first 1000 Gulf war veterans in the Ministry of Defence’s medical assessment programme. Br Med J1999; 318:290–4.[Abstract/Free Full Text]
3. Ismail K, Everitt B, Blatchley N, Hull L, et al. Is there a Gulf war syndrome? Lancet1999; 3453:179–82.
4. Selvaag E. Skin disease in military personnel. Mil Med2000; 165:193–4.[Web of Science][Medline]
5. Murphy FM, Kamg H, Dalager NA, Lee KY, et al. The health status of Gulf war veterans: lessons learned from the Department of Veterans Affairs Health Registry. Mil Med1999; 164:327–31.[Web of Science][Medline]
6. Joseph SC. A comprehensive clinical evaluation of 20 000 Persian Gulf war veterans. Mil Med1997; 162:149–55.[Web of Science][Medline]
7. Roy MJ, Koslowe PA, Kroenke K, Magruder C. Signs, symptoms and ill-defined conditions in Persian Gulf war veterans: findings from the Comprehensive Clinical Evaluation Programme. Psychosom Med1998; 60:669–70.[Free Full Text]
8. Gray G, Smith T, Knoke J, Heller J. The post war hospitalization experience of Gulf war veterans possibly exposed to chemical munitions destruction at Khamisiyah, Iraq. Am J Epidemiol1999; 150:532–40.[Abstract/Free Full Text]
9. Ismail K, Davies K, Brugha T, David A, et al. The mental health of United Kingdom Gulf war veterans: a two phase cohort study. Br Med J2002; in press.
10. Ware JJ, Sherbourne C. The MOS 36-item short-form survey (SF-36); conceptual framework and item selection. Med Care1992; 30:473–83.[Web of Science][Medline]
11. Higgins EM. Alcohol, smoking and psoriasis. Clin Exp Dermatol2000; 25:107–10.[Web of Science][Medline]
12. Dunn G. Statistics in Psychiatry. London, Arnold, 2000.
13. Gee MR. Dermatologic disease: twenty-two year experience at the USAF Aeromedical Consultation Service and review of other military and civilian experiences. Aviation Space Environ Med2000; 71:230–7.[Medline]
14. Sulzberger MB. Impact of skin diseases on military operations. Arch Dermatol1969; 100:702.[Abstract/Free Full Text]
15. Croft AM, Hoad NA, Dale RF. Hospitalization of British troops during Operation Joint endeavor (Bosnia). Mil Med1999; 164:460–5.[Web of Science][Medline]
16. Hepburn NC. Dermatological problems in British troops during the Gulf war. Br J Dermatol1992; 126:200–1.[Web of Science][Medline]
17. Winfield DA. Dermatological conditions in winter in Primary Health Care on Operation Resolute (Bosnia). J Roy Army Med Corps1997; 143:31–4.
18. Gray GC, Smith TC, Kang HK, Knoke JD. Are Gulf war veterans suffering war-related illnesses? Federal and civilian hospitalizations examined, June 1991 to December 1994. Am J Epidemiol1994; 151:63–71.[Abstract/Free Full Text]
19. Rea JN, Newhouse ML, Halil T. Skin disease in Lambeth. Br J Prev Soc Med1976; 30:107–14.[Web of Science][Medline]
20. Schechtman RC, Midgeley G, Hay RJ. HIV disease and malassezia yeasts: a quantitative study of patients presenting with seborrhoeic dermatitis. Br J Dermatol1997; 136:138–9.[Web of Science][Medline]
21. Zhang Q, Zhou XD, Denny T, Ottenweller JE, et al. Changes in immune parameters seen in Gulf war veterans but not civilians with chronic fatigue syndrome. Clin Diagnost Lab Immunol1999; 6:6–13.[Abstract/Free Full Text]
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This article has been cited by other articles:
M. Hotopf and S. Wessely
Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War
Int. J. Epidemiol., August 1, 2005; 34(4): 791 – 800.
[Abstract] [Full Text] [PDF]
You can ask your VA doctor for referral to one of the VA WRIIS New Jersey, DC, Palo Alto. I will post info on that since they presented at the last RAC meeting on March 2.
Again with the “new culture change” and new directive letters to the raters on GWI it might be beneficial to read and see if you want to contact your service officer or a service officer or go it alone and ask for your claim to be reevaluated….The VA is ding pretty good on their site posting news on what they are doing after all the PR and AP release this past end of Feb!
Let’s hope it helps!
the information on the WRIISC is in chapter 3 of the new NGWRC Self-Help Guide.
This article was written by me except the last part where the things numbered 1-4 was added.
Jim, the link for the WRIISC-DV is no longer active; this is the main link for WRIISC. http://www.warrelatedillness.va.gov/index.asp
There are some other links in the NGWRC Self Help Guide that are no longer active also. Can this guide be updated? Maybe just have it in PDF file only to defray cost of printing a bonded version.
It took me 11 years to go from an initial 10% to 30% for Chronic Bronchitis with Asthma, that start while I was still in Saudi, mysteriously within a few hours of receiving the first Anthrax vaccine. That last rating was 2002 and it has not went any higher yet. I did finally get the equivalent of 100% via 70% SC with IU P&T in 2006 because of my fibro getting as worse as it can get and getting the top out for that at 40% added to my other 2 SC conditions.
So you have to keep fighting, as soon as you get your denial or too low a % turn right around and file an appeal, and keep appealing until you feel you have been granted all you deserve.
Don’t ever give up.
When you are entered into the study, they usually tell you if it is research you will get all the normal extra test results but the items they are doing research on do not get to you until after the Research study is published!!!! I am in Miami study as is jagmedic re note below.
That is just standard for RESEARCH STUDIES BE patient.
Hmmm About that GERD. Never had it until a year after I got back from the Gulf. Don’t know how many different med.s I took for it (plus a few of my own) until finally six years after I got out, it was finally granted, though not backdated. As for the CFS what I listed as “sore joints” on my 21-526, well I’m not holding my breath on that. My god, it took so long to get surgery that was so obvious even a reta, I mean Moron could see if he looked at the way I walked that something that required common sense would be more than they could handle…either that or they didn’t care. I vote the first, with reservations to the second.
Alton be aware of the changes coming out of the VA now….you may be smart to ask them to relook at your claim since they are starting that process because IBS and joints may net you a gain in rating. Did you already have a service officer?
Alton and others, organic apple cider vinegar cured my GERD which was very bad and meds were only making it worse. The vinegar has helped others as well that I have recommended it to. It has to be organic to work.
I have been on other natural supplements for over a year now which are really helping me, I will be happy to tell anyone about these that is interested, just email me at tanya.boozer@veterans-for-change.com
We don’t have to continue suffering and can have a better quality of life and help each other out, that is what this is all about.
Alton and others, if you get an actual diagnoses of Fibromyalgia they have to grant your claim for service connection as it is presumptive for us, I think CFS is also, not sure on that one. I was diagnosed with Fibro in 2005, finally, but was turned down for the claim then. It became presumptive about a year later, don’t remember when exactly, and the VA itself reopened my file and granted me 20% SC which was later increased to 40% which is as high as Fibromyalgia goes.
So get you doctor to the the Fibro testing and get that in your records to submit with a claim or an appeal to the one you have in now.
We need to get Multiple Chemical Sensitivity as a presumptive as well. What do ya’ll think? Denise?
I will post the new directive letter. I think it will help you all see that they are trying to tell the ROs to be less constrictive. MCS, fibro, CFS all components….System is not perfect that is for sure…
I wish they would do something, I’m tired of being tired
There are some natural supplements you can try to see if they help. One I am trying currently is Liquid life availabe on the internet or at Sams. It seems to be helping. Plus the COQ10. Are you interested in being in any of the research studies for gulf war veterans? Also you might check in local community for a CFS support group there are tons of them out there and alot of civilians in those groups can help you with ideas and they are welcoming gulf war veterans. I will post some sites to visit on CFS, MCS, etc shortly…for information and to help.
VIBRATION SYNDROME is a progressive, nervous system disorder that affects ? people. See
http://www.cdc.gov/niosh/83110_38.html#Evidence of Health Effects
and.
http://safetycenter.navy.mil/acquisition/vibration/index.asp
Could this be one of the causes of Gulf War Illness?
The Gulf War was the largest troop build up in History. The vibration expouser to the troops was uncalculable.
Two United States Navy Seabee Units Nmcb 40 and Nmcb 133 are the most symptomatic troops. See
http://aje.oxfordjournals.org/cgi/content/full/155/11/1033
Could this be that they were Constuction Battalions?
Could this accout for the Seabees being the most symptomatic troops?
Would not the Seebeas occupation alone expose them to more dangrous vibration from equipment and tools?
Would this not be a plausible enough senario to warrant some research?
Wouldn’t knowing the cause of this Gulf War Illness help move us forward to start studing for a soultion to the problem and bring resolve to many?
Further Reading.
Human Response to Vibration
Neil J. Mansfield, Loughborough University, Leicestershire, UK ISBN: 9780415282390
Griffin, M.J. (1990, 1996) Handbook of human vibration. Published: Academic Press,
London, ISBN: 0-12-303040-4.
William, this makes a lot of sense really. I wonder if there are any clinical trials for VIBRATION SYNDROME? My unit was exposed to a lot of like activity and I have most of the symptoms of this condition. I will have to do some checking into this.
Thanks.
Hello Tanya,
It is the only thing that has ever made any sense for me. I never was into mysterious unknown things. There is alaways a reaction for every action. I like to see the world with my simple colored glasses on. I was a member of NMCB 40 and have stuggled with all the symptoms of GWI which are idenitical to Vibration Syndrome. Whole body Vibration syndrome is the worst of the bunch. Females are at greater risk. It has took me 17+ years of research to connect these dots. The VA has been nothing but outstanding. I commend the VA for there outstanding professionalism. But we all have room to improve.
W
As I listen to VA-RAC on GWI, they spoke about the VA-Advisory Committee on GW Veterans just as the OTHER committee and this lastest VA-Taskforce on GW illness is
internal and under the radar and NO input from Vets. Well are waiting for publish on the Federal Register serveral months away …last on Friday night with little notice. Hearings » “Gulf War Illness: The Future for Dissatisfied Veterans” at the HOUSE VA full committee (DC) is another sneak action maybe in end of April. no Doubt is this will be NOT be on TV.
I spoke to committee staff last week and again ask them to have it on the committee website as a webnar live and archived and asked that they also get C-Spann I have followed up with a letter re the same. They were not as evasive this time…and alluded to the fact that it probably will be but I for one will keep on them to do so.
WE dont trust but verify and keep checking and keeping them aware that we all gulf war veterans have our eyes on them NOW
There was some veterans input on the report.
See my comments this Memorial Day on the outrageous criminal activities of the fbi/cia,et al against veterans, even as Gary Sinise parades about in pretentious concern for our suffering vets.
—————————————–
This Memorial Day is day of National Disgrace for the corrupt USA’s treatment of its own war veterans and for this nation’s phony wars on the people of the world.The so-called “GOP Savior” Gary Sinise should stop insulting the veterans with his pretense of concern for them, especially as many suffer from unlawful assaults & mistreatment by the thugs of the government of the United States of America (i.e.: the fbi/cia assassins). See my reports on this subject as follows:
The intel services (fbi/cia) force suicide on some veterans with the full knowledge of VA. Other veterans prefer death to a padded cell or jail. In any event , Gary Sinise, stop the charade that USA cares for and has patience with its veterans. You are an actor, Gary, now playing politician on the backs of injured and killed veterans. Your silly ads are sadly laughable to all knowledgeable vets.
http://www.sosbeevfbi….com/geralsosbeearmyf.html
http://sosbeevfbi.ning.com/forum/topics/psychoelectronic-weapon
[QUESTIONS! geral sosbee (956)371-5210]
Actor Gary Sinise floated as possible GOP savior
politicalticker.blogs.cnn.com
[cnn-photo-caption image= http://i2.cdn.turner.com/cnn/2009/SHOWBIZ/Movies/03/21/sinise.military/art.gary.sinise.jpg caption="GOP strategist Nicole Wallace names Sinise and others as possible GOP saviors."] WASHINGTON (CNN) — Nicolle Wallace, a top adviser to George W.
http://www.opednews.com/articles/University-of-Texas–fbi-by-GERAL-SOSBEE-091112-100.html
http://www.opednews.com/articles/US-Army-Lies-To-Our-Young-by-GERAL-SOSBEE-080929-134.html
http://www.opednews.com/articles/USA-Military-Universal-Su-by-GERAL-SOSBEE-080915-75.html
http://www.sosbeevfbi.com/part4-worldinabo.html