[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




 
                  HEALTH EFFECTS OF THE VIETNAM WAR--
                             THE AFTERMATH

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 5, 2010

                               __________

                           Serial No. 111-75

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director


Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                              May 5, 2010

                                                                   Page
Health Effects of the Vietnam War--The Aftermath.................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    49
Hon. Cliff Stearns...............................................     3
Hon. John J. Hall................................................    11
    Prepared statement of Congressman Hall.......................    50
Hon. Harry E. Mitchell, prepared statement of....................    51
Hon. John H. Adler, prepared statement of........................    52

                               WITNESSES

U.S. Government Accountability Office, Randall B. Williamson, 
  Director, Health Care..........................................    10
    Prepared statement of Mr. Williamson.........................    61
U.S. Department of Veterans Affairs, Joel Kupersmith, M.D., Chief 
  Research and Development Officer, Veterans Health 
  Administration.................................................    39
    Prepared statement of Dr. Kupersmith.........................    86

                                 ______

American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission..........................    27
    Prepared statement of Mr. Wilson.............................    68
Blue Water Navy Vietnam Veterans Association, John Paul Rossie, 
  Executive Director.............................................    31
    Prepared statement of Mr. Rossie.............................    79
Fenske, Richard A., Ph.D., M.P.H., Professor and Acting Chair, 
  Environmental and Occupational Health Sciences, School of 
  Public Health and Community Medicine, University of Washington, 
  Seattle, and Chair, Committee on the Review of the Health 
  Effects in Vietnam Veterans of Exposure to Herbicides, (Seventh 
  Bienniel Update) Board on the Health of Select Populations, 
  Institute of Medicine, The National Academies..................     6
    Prepared statement of Dr. Fenske.............................    52
Gold Star Wives of America, Inc., Vivianne Cisneros Wersel, 
  Au.D., Chair, Government Relations Committee...................    32
    Prepared statement of Dr. Wersel.............................    85
Marmar, Charles R., M.D., Chair, Department of Psychiatry, New 
  York University Langone School of Medicine, New York, NY.......     8
    Prepared statement of Dr. Marmar.............................    55
Veterans Association of Sailors of the Vietnam War, Commander 
  John B. Wells, USN (Ret.), Cofounder and Trustee...............    29
    Prepared statement of Commander Wells........................    72
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs.....................    25
    Prepared statement of Mr. Weidman............................    65

                       SUBMISSION FOR THE RECORD

Reserve Officers Association of the United States, and Reserve 
  Enlisted Association, joint statement..........................    90

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to 
  Henry V. Fineberg, M.D., Ph.D., President, Institute of 
  Medicine of the National Academies, letter dated May 10, 2010, 
  and response letter dated June 17, 2010........................    95
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to 
  Charles R. Marmar, M.D., Chair, Department of Psychiatry, New 
  York University Langone School of Medicine, letter dated May 
  10, 2010, and response letter dated June 18, 2010..............   100
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to Gene 
  L. Dodaro, Acting Comptroller General, U.S. Government 
  Accountability Office, letter dated May 10, 2010, and GAO 
  responses......................................................   101
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to 
  Richard F. Weidman, Executive Director for Policy and 
  Government Affairs, Vietnam Veterans of America, letter dated 
  May 10, 2010, and VVA responses................................   103
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to 
  Steve Robertson, Director, National Legislative Commission, 
  American Legion, letter dated May 10, 2010, and response from 
  Joseph Wilson, Deputy Director, Veterans Affairs and 
  Rehabilitation Commission, American Legion, letter dated June 
  21, 2010.......................................................   105
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to Hon. 
  Eric K. Shinseki, Secretary, U.S. Department of Veterans 
  Affairs, letter dated May 10, 2010, and VA responses...........   106
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to Hon. 
  Eric K. Shinseki, Secretary, U.S. Department of Veterans 
  Affairs, letter dated May 18, 2010, transmitting questions from 
  Hon. Deborah L. Halvorson, and VA responses....................   113


            HEALTH EFFECTS OF THE VIETNAM WAR--THE AFTERMATH

                              ----------                              


                         WEDNESDAY, MAY 5, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.
    Present: Representatives Filner, Michaud, Herseth Sandlin, 
Hall, Perriello, Teague, Rodriguez, Donnelly, Walz, Adler, 
Stearns, Boozman, Bilbray, and Roe.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. Good morning. The Committee on Veterans' 
Affairs will come to order.
    I ask unanimous consent that all Members may have 5 
legislative days in which to revise and extend their remarks. 
Hearing no objection, so ordered.
    I believe it is appropriate that as we talk about the 
Vietnam War today, that we mention the Vietnam veteran tee-
shirt vendor who first alerted us to the car that had bomb 
material in it in New York City. He is the President of the 
Vietnam Veterans of America (VVA) Chapter 817. We want to add 
our thanks, the Nation's thanks to this Vietnam veteran who may 
have saved thousands of lives.
    Thank you all for being here this morning. The purpose of 
today's hearing is to examine the health effects that our 
veterans sustained during the Vietnam war as a result of being 
exposed to the toxic dioxin-based concoctions that we now 
generally refer to as Agent Orange.
    As such, we will follow-up on the U.S. Department of 
Veterans Affairs' (VA's) long outstanding promise to conduct a 
National Vietnam Veterans Longitudinal Study, the NVVLS. We 
ought to stop the stovepiping in VA and look at how all of 
these issues relate to providing benefits for presumptive 
conditions under current law for Agent Orange combat veterans.
    I want to ensure that we do not leave any of our veterans 
who were exposed to Agent Orange while fighting overseas 
uncompensated for their injuries and left behind due to VA 
technicalities.
    It has been 10 long years since Congress mandated that the 
VA study the long-term, lifetime psychological and physical 
health impact of the Vietnam War on the veterans of that era.
    In 2000, Congress required that the VA conduct this 
longitudinal study by building on the findings of the National 
Vietnam Veterans Readjustment Study in 1984. That study was a 
landmark report, which provided a snapshot of the psychological 
and physical health of Vietnam veterans.
    A follow-up longitudinal study, of course, is needed to 
understand the life course of health outcomes and comorbid 
events that have resulted from the traumas our men and women 
endured during the Vietnam War.
    Initially the VA adhered to the letter of the law, but 
halted the NVVLS study in 2003 by not renewing a 3-year, 
noncompetitive, sole-source contract that they awarded in 2001. 
The VA cited cost reasons, noting that the original estimate 
for completing the study had ballooned from $5 million to $17 
million.
    The VA took no further steps and ignored the law until this 
Committee received a proposal from former Secretary Peake in 
January of 2009. The Secretary recommended substituting the 
NVVLS with a study of twins who served in the Vietnam War and a 
study of women Vietnam War veterans, which would cost around 
$10 million.
    Given the cost of the alternative option, it seemed to me 
that the VA could have completed the original study on time had 
the Department chosen to allocate the $10 million to the 
original contract award back in 2003.
    This Committee and others do not see the merit of the 
alternative proposal and has continued to advocate for the 
completion of the original study that was mandated.
    In September 2009, Secretary Shinseki committed to carrying 
out this study. And, while I applaud the Secretary for his 
commitment, I remain very vigilant about the issue.
    In today's hearing, I would like to better understand the 
progress that VA has made in conducting the study. I also hope 
to learn about the potential barriers that we can proactively 
address so that the VA remains on track to complete the study.
    Also, Congress passed several measures to address 
disability compensation issues for Vietnam veterans. The 
Veterans Dioxin Radiation Exposure Compensation Standards Act 
of 1984 required the VA to develop regulations for disability 
compensation to Vietnam veterans exposed to Agent Orange.
    In 1991, the Agent Orange Act established, for the first 
time, a presumption of service-connection for diseases 
associated with herbicide exposure. The Agent Orange Act 
authorized the VA to contract with the Institute of Medicine 
(IOM) to conduct a scientific review of the evidence linking 
certain medical conditions to herbicide exposure.
    Under this law, the VA is required to review the biennial 
reports of the Institute of Medicine and to reissue regulations 
to establish a presumption of service-connection for any 
disease for which there is scientific evidence of a positive 
association with herbicide exposure.
    However, apparently VA illogically backtracked on the Agent 
Orange Act regulations by reversing its own policy to move to 
require a foot on land occurrence by Vietnam veterans in order 
to prove service-connection. This means that the Vietnam 
Service Medals and other such awards would no longer be 
accepted as proof of combat.
    This change excluded nearly one million Vietnam veterans 
who had served in our Navy, Air Force, and in nearby border 
combat areas. This is an unfair and unjust result that has been 
litigated endlessly and ultimately against the veterans.
    I am trying to undo this injustice in a bill that I have 
introduced called the Agent Orange Equity Act of 2009, H.R. 
2254. More than a majority of the Congress has in fact, been 
added as co-sponsors to this bill and I urge everyone to become 
a co-sponsor.
    Today, I hope to hear from the VA as to why it reversed its 
policy that now excludes our Blue Water servicemembers from 
presumptive consideration for service-connection and treatment.
    I also want to know why it is ignoring the latest 2009 IOM 
recommendation that members of the Blue Water Navy should not 
be excluded from the set of Vietnam era veterans with presumed 
herbicide exposure. I know the VA has asked the IOM to issue a 
report on Blue Water veterans in 18 months, but that is 18 
months too long.
    The foot on land requirement is especially unreasonable 
when you consider that these servicemembers were previously 
treated equally to other Vietnam veterans for benefit purposes.
    Moreover, several Australian Agent Orange studies long ago 
concluded that their Blue Water veterans who served side by 
side with our Blue Water veterans were exposed to Agent Orange 
and because of the water distillation process on the ships 
ingested it even more directly.
    While I applaud the VA for recently adding three new 
presumptions for Parkinson's disease, ischemic heart disease, 
and B-cell leukemias for Agent Orange exposed veterans, those 
are three new presumptions for which Blue Water veterans may 
suffer and will not be treated or compensated.
    I urge the VA to start compensating these veterans 
immediately. Just like it reversed the decision in 2002, I 
strongly urge VA to reverse back and compensate these deserving 
veterans.
    Finally, I want to know for sure that VA plans to make the 
Blue Water veterans included in the NVVLS so that they and 
their families and survivors have a chance to get the benefits 
they deserve on equal footing with other Vietnam veterans.
    I look forward to hearing from all of our witnesses today 
and thank you for being here to examine these long-standing 
issues.
    I now recognize Mr. Stearns for an opening statement.
    [The prepared statement of Chairman Filner appears on p. 
49.]

            OPENING STATEMENT OF HON. CLIFF STEARNS

    Mr. Stearns. Good morning, everybody.
    And thank you, Mr. Chairman.
    I would like to welcome everyone here this morning for 
obviously a very important hearing on the health effects from 
the Vietnam War. The focus of this discussion is to further 
examine the negative health impact the war has had on our 
veterans.
    Like many in the audience, I served during the Vietnam era 
and many of my colleagues were killed or suffered injuries.
    We want to ensure that our government is taking every 
possible measure to alleviate the physical and mental health 
afflictions these men and women have faced since the Vietnam 
War ended 35 years ago.
    Some veterans struggle today with post-traumatic stress 
disorder (PTSD), cancer, neurological disorders, and a number 
of other diseases that are associated with Vietnam and now they 
are suffering quite considerably. These veterans, so many years 
after the war ended, still fight their own battles every day. 
For some, the battle is with the intrusive memories of horrific 
events. For others, it is simply with the debilitating effects 
of diseases and their treatment.
    Regardless of what they face, they should not also have to 
battle the VA for their benefits. Our government was far too 
slow in recognizing the effects of the Vietnam War on veterans. 
But from this lesson, we have improved diagnoses, treatments, 
and compensation for our veterans.
    Congress passed the Agent Orange Act of 1991 as part of 
this effort. The legislation directed the National Academy of 
Sciences to conduct a comprehensive review and evaluation of 
the health effects of herbicide exposure.
    The Institute of Medicine completed the initial study in 
1994 and conducted subsequent periodic reviews of evidence as 
it became available.
    In these reviews, IOM evaluates scientific data to 
determine if there is a statistical association between various 
pathologies and exposure to herbicide agents.
    If it is shown that there is an increased risk for 
particular disease among those veterans who were exposed and 
that there is a plausible connection between exposure and the 
disease, then VA has the authority to establish a presumptive 
service-connection.
    We applaud Secretary Shinseki for recently utilizing this 
authority to add three new diseases to the VA's list of 
illnesses associated with exposure to herbicide agents. I 
understand the rule-making process is underway but that a 
number of steps remain before the final rule can take effect.
    So I look forward to hearing from our VA panel today and 
getting an update on what needs to be accomplished and how soon 
veterans can begin receiving compensation.
    Moreover, I am deeply concerned about VA's ability to 
handle the brunt of the hundreds of thousands of new claims it 
will potentially receive and the impact it will have on the 
unacceptable backlog that exists today for disability claims.
    Besides cancers and other debilitating conditions 
associated with Agent Orange, many Vietnam veterans are haunted 
by lingering memories of their involvement in the war. And 
tragically upon returning home from Vietnam, many veterans were 
personally attacked by those who opposed the war. Such 
disrespect magnified the stress associated with their combat 
experiences and not surprisingly left many of our war heroes 
bitter and emotionally scarred.
    Homelessness, substance abuse, and suicide are all too 
tragic problems that in many cases can be attributed directly 
to post-traumatic stress disorder. Unfortunately, so many of 
our veterans, including Vietnam veterans suffering from PTSD, 
have shunned any involvement with the government including 
tragically, the VA.
    A few years back, the VA along with several representatives 
from the VA, the veterans community, and community organizers 
visited a large veterans' encampment in my hometown of Ocala, 
Florida. This was part of a homeless veterans outreach program. 
It was discovered that some of the residents there were 
recipients of Purple Hearts and other combat awards who had 
never even sought VA benefits or care because of their mistrust 
of the United States Government.
    Fortunately, these veterans agreed to receive the 
assistance they had earned through their service. Sadly, there 
are still many more who remain isolated from VA and the care 
that is available to them.
    Over the past several years, VA has expanded its outreach 
efforts and the number of veterans receiving compensation for 
PTSD has grown dramatically.
    VA has also recently provided a regulatory change that more 
closely reflects the intent of Congress to provide due 
consideration to the time, place, and circumstance of a 
veteran's service. This change will facilitate the timely 
resolution of PTSD claims and provide compensation to those who 
suffer as a result of their service to our country.
    So I applaud the VA for this and the other steps it has 
taken on behalf of Vietnam veterans, but I am sure we all 
recognize that much remains to be accomplished and that is the 
purpose of our hearing today.
    I look forward to the testimony of our panels today, for 
this very important discussion.
    And I thank you, Mr. Chairman, for this hearing.
    The Chairman. Thank you, Mr. Stearns.
    I now call our first panel. We have watched for at least 40 
years, the bureaucratic ``movement'' on this issue. It took 
more than a decade to even recognize the effects of Agent 
Orange and when it was recognized, the VA set up incredible 
bureaucratic hurdles for the veteran to get disability 
compensation. We have waited years and years for this 
longitudinal study.
    It seems to me that our veterans have suffered enough. I 
think sometimes that veterans suffer more from fighting the VA 
than they probably do from their original injury or disease. 
Many people who have gone through this think VA means veterans' 
adversary instead of veterans' advocate. It seems to me that we 
ought to end this suffering.
    As I mentioned, I have a bill, that honors all the Agent 
Orange claims as of today. People have suffered enough. All 
this bureaucracy about what is presumptive, what qualifies, and 
the requirement of boots on the ground just puts people through 
more suffering.
    Not only should we honor those claims, but it would also 
help with the claims backlog that Mr. Stearns mentioned. I 
suspect there are a couple hundred thousand Agent Orange claims 
in the process. Let us just get those off the books.
    It is not too late to say thank you for those veterans that 
we did not honor, as Mr. Stearns again pointed out, when they 
came home. Let us not only say we are sorry as a Nation, but 
let us actually do something on their behalf.
    I hope people will respond to my modest proposal.
    If the first panel would please join us? Dr. Richard Fenske 
is the Professor and Acting Chair of the Environmental and 
Occupational Health Sciences at the School of Public Health and 
Community Medicine and he is here on behalf of the Institute of 
Medicine.
    Dr. Charles Marmar is the Chair of the Department of 
Psychiatry at New York University Langone School of Medicine, 
and Mr. Randall Williamson is a Director of Health Care at the 
U.S. Government Accountability Office (GAO).
    We thank you all for being here. Each one of you will be 
recognized for 5 minutes for an oral presentation and your 
complete written statement will be included in the hearing 
record.
    We will start with Dr. Fenske. Thank you again for being 
here.

 STATEMENTS OF RICHARD A. FENSKE, PH.D., M.P.H., PROFESSOR AND 
 ACTING CHAIR, ENVIRONMENTAL AND OCCUPATIONAL HEALTH SCIENCES, 
 SCHOOL OF PUBLIC HEALTH AND COMMUNITY MEDICINE, UNIVERSITY OF 
WASHINGTON, SEATTLE, AND CHAIR, COMMITTEE ON THE REVIEW OF THE 
 HEALTH EFFECTS IN VIETNAM VETERANS OF EXPOSURE TO HERBICIDES, 
    (SEVENTH BIENNIEL UPDATE) BOARD ON THE HEALTH OF SELECT 
  POPULATIONS, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES; 
 CHARLES R. MARMAR, M.D., CHAIR, DEPARTMENT OF PSYCHIATRY, NEW 
 YORK UNIVERSITY LANGONE SCHOOL OF MEDICINE, NEW YORK, NY; AND 
 RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE, U.S. GOVERNMENT 
                     ACCOUNTABILITY OFFICE

         STATEMENT OF RICHARD A. FENSKE, PH.D., M.P.H.

    Dr. Fenske. Thank you very much, Chairman Filner, and good 
morning to Members of the Committee.
    My name is Richard Fenske. I am at the School of Public 
Health at the University of Washington. I served as a member of 
the Veterans and Agent Orange (VAO) Committee established by 
the Institute of Medicine for updates 2002, 2004, and 2006 and 
then I became the Chair for update 2008. So I am here on behalf 
of the Institute of Medicine to briefly describe the process 
that we have used in those reports.
    The National Academy of Sciences was chartered by Congress 
in 1863 to advise the government on matters of science and 
technology and the Institute of Medicine was established in 
1970 by the National Academy to enlist the services of 
appropriate professionals to examine science and policy matters 
pertaining to the health of the public.
    As has been said, Congress established a mandate for a 
series of veterans and Agent Orange reports in the Agent Orange 
Act of 1991 and the legislation directed the Secretary of 
Veterans Affairs to have the National Academy of Sciences 
perform a comprehensive evaluation of scientific and medical 
information regarding the health effects of exposure to the 
herbicides used in Vietnam and it called for an update every 2 
years.
    Agent Orange was only one of several herbicide mixtures 
used in Vietnam. The name refers to the color band on the 
herbicide barrels. Agent Orange was a mixture of the phenoxy 
herbicides 2,4-D and 2,4,5-T.
    In addition to other herbicides, picloram and cacodylic 
acid were applied in Vietnam and a dioxin compound known as 
TCDD was an unwanted contaminant in the 2,4,5-T herbicide, so 
dioxin-like chemicals have also been considered in our 
Committee reviews.
    The legislation from 1991 directs VAO Committees to 
evaluate the evidence of statistical associations between 
specific health outcomes and exposure to the herbicides used by 
the military in Vietnam. The legislation does not ask the 
Committees to establish causality, which generally requires a 
more stringent standard of evidence. This charge is in keeping 
with judicial history related to Agent Orange exposure.
    In reaching consensus about an association between exposure 
and health effects, the Committee considers only peer-reviewed, 
published scientific literature. VAO Committees have viewed 
epidemiologic studies of Vietnam veterans to be central to 
their decision-making, working on the assumption that service 
in Vietnam was a proxy for exposure at levels in excess of what 
would have been experienced by nondeployed individuals.
    The Committees have also drawn upon relevant epidemiologic 
studies of other exposed populations and much useful 
information has come from these nonveteran studies.
    The original VAO Committee established a set of categories 
of association for adverse health outcomes. A chart with these 
categories has been provided in my written testimony.
    The starting point or default category is inadequate or 
insufficient evidence of an association. Any health outcome 
that is not explicitly listed falls into this category.
    Health outcomes that appear to be associated with exposure 
are placed in one of two categories, either of sufficient 
evidence or limited or suggestive evidence. There is not a 
discrete dividing point between these categories, so the choice 
depends on the number, the strength, and the consistency of the 
studies that indicate increased risk as well as consideration 
of factors like bias and confounding.
    Since Committee decisions focus on statistical 
associations, the placement of the health outcome in the 
sufficient category does not necessarily imply that a causal 
relationship has been established between exposure and disease.
    The original VAO Committee also established a category of 
suggestive evidence of no association. But over time, 
Committees have decided to move all but one health outcome from 
this category into the default category of inadequate or 
insufficient evidence since it is very difficult to determine 
that there is really no association.
    The summary chart details those health outcomes that have 
been placed in the sufficient or the limited or suggestive 
evidence categories and it also indicates the year of the VAO 
finding and any subsequent adjustment.
    The most recent VAO Committee update 2008 reviewed the 
scientific literature published from October 2006 through 
September 2008. We moved two conditions, Parkinson's disease 
and ischemic heart disease, to the limited or suggestive 
evidence category. We also concluded that hairy cell leukemia 
and chronic neoplasms belong with chronic lymphocytic leukemia 
in the sufficient evidence category.
    That concludes my testimony. Thank you. And I will be happy 
to answer questions.
    [The prepared statement of Dr. Fenske appears on p. 52.]
    The Chairman. Thank you.
    Dr. Marmar.

              STATEMENT OF CHARLES R. MARMAR, M.D.

    Dr. Marmar. Good morning, Chairman Filner, Congressman 
Stearns, and Members of the Committee.
    Nearly 25 years ago, Congress enacted Public Law 98-160 
directing the Veterans Administration to arrange for an 
independent scientific study of the adjustment of Vietnam 
veterans. The purpose of that study was to provide an empirical 
basis to formulate policy related to veterans' psychosocial 
health.
    In response to this mandate, the National Vietnam Veterans 
Readjustment Study or NVVRS was conducted. I was fortunate to 
have served as a member of the NVVRS research team. The survey 
component of the study was conducted in 1986 and 1987 with a 
nationally representative sample of all who served in Army, 
Navy, Air Force, and Marines during the years of the war.
    Findings from the NVVRS were an important ingredient in the 
mix of social and political forces that brought about major 
changes in VA policy towards post-war readjustment problems of 
Vietnam veterans and other veterans and in the public's 
understanding and acceptance of the concept of PTSD.
    For the past 13 years, I have been Chief of Psychiatry at 
the San Francisco VA where I have had a chance to implement 
many of those important findings into clinical care policy.
    Briefly what were the major findings from the NVVRS? At the 
time study was conducted in the late 1980s, the majority of 
Vietnam theater veterans had made a successful reentry into 
civilian life speaking to their resilience.
    However, an important minority, nearly one in three, met 
criteria for PTSD related to their war-zone deployment at some 
time following their service and strikingly half of the men and 
one-third of the women who ever developed war-zone PTSD 
continued to suffer with the disorder a decade or more 
following the conclusion of the war.
    Those with PTSD had higher rates of depression, alcohol and 
drug abuse, problems affecting work, family relations, and 
physical health. Families of veterans with PTSD have been 
affected with problems in marital adjustment, parenting skills, 
interpersonal violence, and children were affected with more 
adjustment behavioral problems.
    Finally and importantly, at the time the survey was 
conducted in the late 1980s, most Vietnam veterans had never 
used the VA for mental health services. There has been 
controversy about this study.
    In 2006, there was an important re-analysis done based on 
the use of military records to validate combat exposure. The 
major findings from that re-analysis were that there was, one, 
little, if any, falsification or dramatization of combat 
exposure. Overall, rates were found to be slightly lower at one 
in five rather than one in three veterans being affected. But I 
think it is important to also note that the study excluded as 
current combat PTSD cases anyone with a pre-military diagnosis 
of PTSD and we know that pre-military PTSD is a risk factor for 
developing war-zone PTSD.
    I would like to speak briefly to the imperative need to 
conduct a long-term follow-up to the NVVRS, that is the NVVLS. 
Because of the high rates of PTSD, the strong evidence for the 
persistence of this syndrome, its strength of association with 
war-zone stress exposure, it is imperative that VA have 
information about the current functioning of the participants 
in the original study in order to make projections about how 
the entire Vietnam generation is functioning today because of 
the representative nature of the sample.
    What would the NVVLS accomplish? As has been noted by the 
Chairman, there was a law in 2000 requiring the study to be 
conducted, but what would be the major benefits?
    One, provide important information about the current 
functioning of veterans of the Vietnam War 20 years downstream 
from their Vietnam experience. Of great interest would be an 
understanding of how new cases form, how some people have 
recovered, and what the course has been over time as well as 
the possible impact of VA programs on effecting the recovery of 
Vietnam veterans with PTSD.
    I want to emphasize that the NVVLS provides an unparalleled 
opportunity to determine if and how war-zone related PTSD is a 
risk factor for physical health problems. There are very great 
reasons to be concerned, that chronic post-traumatic stress 
increases the risk for high blood pressure, diabetes, heart 
attacks, stroke, and even possibly dementia. This study would 
answer those questions.
    Determine the long-term impact of war-zone deployment on 
spouses and families and determine what has happened with 
respect to mental health care utilization, barriers to care, 
and satisfaction with VA health services, as well as to plan 
for future services for aging veterans.
    Finally, the importance of the NVVLS must be placed in the 
context of the current readjustment of Iraq and Afghanistan 
veterans. To date, an estimated 1.9 million American men and 
women have served in Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) and they are at risk for 
similar problems suffered by the Vietnam generation.
    There is an urgent need to plan for their long-term adverse 
health consequences of OEF and OIF and these are underscored by 
recent studies showing a substantial minority of veterans from 
this new conflict are suffering from the same problems, PTSD, 
depression, alcohol and drug abuse, and risk of heart disease.
    The NVVLS will generate critical knowledge about risk and 
resilience, course and complications of war-zone related PTSD 
on veterans and their families. This knowledge will serve as a 
blueprint for better preparing for the readjustment needs of 
those serving in Operation Enduring Freedom and Iraqi Freedom 
as well as for our aging Vietnam veterans.
    Thank you.
    [The prepared statement of Dr. Marmar appears on p. 55.]
    The Chairman. Thank you, sir.
    Mr. Williamson.

               STATEMENT OF RANDALL B. WILLIAMSON

    Mr. Williamson. Good morning, Mr. Chairman and Members of 
the Committee. I am pleased to be here today as you discuss the 
VA's National Vietnam Veterans Longitudinal Study, which I 
shall refer to as the NVVLS.
    This study, which the Congress mandated VA to conduct in 
2000, is intended to be a follow-on study to an earlier 
comprehensive study that VA completed in 1988 on post-traumatic 
stress disorder and related post-war psychological problems 
among Vietnam veterans.
    Experts estimate that as many as 30 percent of Vietnam 
veterans may have experienced PTSD and currently Vietnam era 
veterans constitute the largest group receiving VA care for 
PTSD.
    In my testimony today, which is based on our report 
released this morning for the Committee, I will discuss VA's 
recent progress in conducting the NVVLS and the challenges it 
faces in this regard.
    VA's early progress on the NVVLS was slow. After the 
Congress mandated that VA conduct the NVVLS in 2000, VA awarded 
a contract in 2001 to an outside contractor for this follow-on 
study.
    However, in 2003, before data collection for the study 
began, the study contract was terminated and VA's Office of 
Inspector General (OIG) later found that VA did not properly 
plan or administer the contract.
    Thereafter, efforts to restart the study in earnest 
languished until September 2009 when the Secretary of Veterans 
Affairs announced that the Agency planned to award a new 
contract to an outside entity to conduct the NVVLS.
    Since September 2009, VA has taken or plans to take a 
number of important steps towards conducting the NVVLS. VA 
convened a project team for the NVVLS consisting of VA 
officials and PTSD experts within VA and outside of VA. 
According to VA officials, the NVVLS project team developed a 
draft performance work statement, which outlines VA's 
requirements for the contractor.
    VA expects to issue a request for proposals soon and select 
a contractor for this study this summer. VA officials say the 
study will be completed in 2014.
    Conducting the NVVLS study is not without challenges, 
however. In conducting the NVVLS follow-on study, VA is 
required to use the same database and sample as the original 
study and address specific areas such as the long-term course 
and medical consequences of PTSD and whether particular veteran 
subgroups are at risk of chronic or more severe problems with 
PTSD.
    One challenge pertains to locating prospective study 
participants and VA officials are unsure about how many 
veterans that participated in the first study will participate 
in the NVVLS.
    The majority of researchers and methodologists we 
contacted----
    The Chairman. I am sorry. I just cannot contain myself. You 
are reporting that the VA says it has problems finding these 
people?
    Mr. Williamson. Well----
    The Chairman. Any one of us can get you all the people you 
want. I do not understand. Well, you are not responsible, but, 
I can find as many veterans as you need. Ask the Vietnam 
Veterans of America. They will give you their list of members 
and you can start the study, right?
    How many members do you have, Rick?
    Mr. Weidman. Sixty-two thousand.
    The Chairman. I can find them in 5 minutes so I do not know 
why the VA has so much trouble. This idea that the study can't 
start until 2014 is because they are having a study of how to 
do the study. This is just ridiculous. I think we should end it 
all and just give everybody their benefits.
    Mr. Williamson. And I am just reporting what VA told us.
    Well, the majority of researchers and methodologists that 
we contacted within and outside of VA said that while locating 
participants from the first study is a formidable challenge, it 
is doable. They offered a number of suggestions such as data 
sources and methods that could be used.
    Another challenge involves gaining consent from prospective 
participants. Virtually all researchers and methodologists we 
contacted thought it was important that NVVLS participants 
receive assurances of confidentiality as a condition of 
participating.
    However, VA has not yet given such assurances and plans to 
take possession of all data including data identifying 
participants at the conclusion of the study.
    VA officials said that participation in the study will not 
affect participants' VA benefits or VA health care.
    The bottom line is that VA officials told us that they do 
not know whether the NVVLS can be completed given the 
challenges they face.
    During the initial phase of the study, VA expects the 
contractor ultimately selected to assess the feasibility of the 
NVVLS. In doing so, we believe it is critical that the 
contractor and VA thoughtfully address the challenges that VA 
has told us about and thoroughly assess potential ways to 
mitigate them.
    What is clear is this. Virtually all the experts with whom 
we had detailed discussions agreed that starting and completing 
the NVVLS soon is important not only because potential 
participants are aging but also it provides insights for 
treating PTSD not only for Vietnam veterans but for future 
generations of veterans as well.
    Mr. Chairman, that concludes my remarks.
    [The prepared statement of Mr. Williamson appears on p. 
61.]
    The Chairman. Mr. Stearns just pointed out that all my 
anger management sessions have been destroyed by your 
testimony.
    Mr. Hall.

             OPENING STATEMENT OF HON. JOHN J. HALL

    Mr. Hall. Thank you, Mr. Chairman and Ranking Member 
Stearns.
    And thank you to our panelists for your testimony.
    I would like to join the Chairman in praising the efforts 
of two Vietnam veterans whose brave actions this weekend saved 
many lives in Times Square. Today Duane Jackson and Lance 
Horton are once again heroes and true examples of the 
remarkable character of the men and women who wear the uniform 
of our country.
    I have the honor of representing Mr. Jackson in Congress 
and I am sure that I join everyone here today in extending our 
thanks to him and Mr. Horton for choosing action over inaction. 
And that is what our soldiers and veterans have been trained to 
do and their quick thinking as well.
    The subject before us today is vitally important. The war 
in Vietnam may have ended 35 years ago, but Vietnam veterans 
have not stopped suffering at that point. They continue to this 
day. And the fact that we need to have this hearing speaks to 
the inaction, the decades of inaction, dishonesty, and willful 
ignorance regarding the devastating impacts of both Agent 
Orange and PTSD.
    It is clear that we need more research on the long-term 
health effects that were suffered by Vietnam veterans. I 
commend the work of the Institute of Medicine, especially their 
recommendations last year that found three new diseases that 
are associated with Agent Orange. This will help thousands of 
sick veterans access the health care and benefits that they 
deserve.
    Unfortunately, I also find these reports to be limited 
because they only consider existing research. VA bills itself 
as a world-class health research institution. Why is VA not 
directing more of its resources or sponsoring independent 
research to study the full impact of the health crisis the U.S. 
Armed Forces created for its own servicemembers, our fellow 
citizens?
    In 1991, Congress established guidelines for the VA to 
determine scientifically if a particular illness or disorder is 
associated with Agent Orange. In a claims system that is 
supposed to be nonadversarial, Congress tilted the standard of 
proof even further in favor of veterans. However, Congress was 
not able to slay the one enemy that still plagues our vets and 
that is inertia.
    By not mandating new research focused on the health impacts 
of Agent Orange, Congress gave the VA the means to stall 
benefits for thousands of veterans. I think it is time for 
Congress to revisit that decision and also to acknowledge and 
for the VA to acknowledge that Agent Orange exposure goes far 
beyond those who set foot on Vietnamese soil, which is why I 
support the Chairman's Blue Water Bill, H.R. 2254, an important 
step in the right direction.
    Veterans who served in Guam, Thailand, and even air bases 
in the U.S. may have been exposed to toxic herbicides. 
Establishing their exposure might be difficult, but we owe it 
to them to raise this issue.
    I strongly support restarting the National Vietnam Veterans 
Longitudinal Study 8 years after Congress mandated it. I am 
interested in learning the VA's response to the GAO findings.
    And this weekend, I was reminded of the hurdles still 
facing veterans with PTSD. There was an Associated Press story 
that took a tiny sample of fraud cases and blew them out of 
proportion in my opinion to imply that it is too easy for 
veterans to obtain their benefits for PTSD. I suspect that many 
in this room would find that laughable. And, of course, the 
opposite is true.
    Just this week, I sat down in my district and spoke with a 
Vietnam veteran, sat at his kitchen table and talked about his 
case which dragged on for years until my office got involved, 
at which point we were quickly able to get him 100 percent 
disability rating for PTSD from his service in Vietnam four 
decades ago.
    While I am proud to help him, Mr. Berkowitz had earned 
those benefits and it is unacceptable that he had to wait so 
long and also that he had to come to his Congressman to get 
that help.
    The VA should automatically have a system for granting 
reasonable claims without having to have a Congressional office 
get involved because there is not enough of us to do that work. 
Congressmen are not going to solve the claims backlog 
personally by taking on every one of these hundreds of 
thousands of cases. It has to be done by the VA.
    So the topics covered here are extremely important. And I 
have used most of my time in a statement, which I will end and 
just ask a question perhaps for each of our panelists and 
submit more questions in writing if that is acceptable.
    [The prepared statement of Congressman Hall appears on p. 
50.]
    Mr. Hall. I would like to ask your opinion on the VA's 
proposed rule change to create a presumption of service-
connected disability for veterans diagnosed with PTSD, which I 
have a bill, H.R. 952, which just passed this Committee 
unanimously and is waiting for floor action. And the VA has 
proposed to do a rule change that would accomplish much of the 
same thing.
    Do you believe that these changes are supported by the 
statistical evidence and the NVVRS and other studies? Dr. 
Fenske?
    Dr. Fenske. Well, I am afraid I have not really studied 
that area of the mental health aspects, so I would defer to Dr. 
Marmar.
    Dr. Marmar. It is a difficult area. I would say in 
overview, the available evidence suggests that the large 
majority of Vietnam veterans when asked about either their 
symptoms of psychiatric distress related to PTSD, nightmares, 
flashbacks, startle reactions, or their actual details of their 
war-zone experience, where they served and what they were 
exposed to in combat in the theater, that the vast majority are 
truthful in their reports.
    Second, I think it should be emphasized that while 
occasionally there may be individuals for whatever reasons who 
dramatize their suffering following combat exposure, there is 
also a large number of men and women who serve in the military 
and in other important roles in our society who are reluctant 
to disclose their psychiatric problems because of reasons for 
stigma.
    So, in fact, the dangers of under-reporting of psychiatric 
distress may well be greater than the dangers of over-
reporting. So in general, I would say the majority of people 
seeking compensation do so for truthful reasons.
    Mr. Hall. Mr. Chairman, if Mr. Williamson could answer, 
then I would yield back.
    Mr. Williamson. I cannot address that. I am not up on that 
issue.
    Mr. Hall. Thank you.
    The Chairman. Thank you, Mr. Hall.
    Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman.
    Dr. Fenske, when we start talking about threshold of 
benefits, the criteria that is used involves a couple of 
statistical associations. And I just think the Committee needs 
to understand those thresholds and this goes to a little larger 
question when the Chairman says he would like to get everybody 
who is suffering have the benefits, but I think there should be 
some threshold level at which we understand whether a veteran 
is qualified.
    Can you explain the difference between a ``significant 
statistical association'' and a ``positive association'' and a 
``sufficient association?'' These evidently are statistical 
terms that are used to determine the threshold. And I would 
like you to explain that briefly, I only have a small amount of 
time, as it relates to the presumption of service-connection 
for herbicide exposure. Does that question make sense to you?
    Dr. Fenske. Yeah.
    Mr. Stearns. Can you pull the microphone a little closer to 
you too?
    Dr. Fenske. Yes. I should turn it on too.
    Mr. Stearns. Yeah. Turn it on. That is the problem, yes.
    Dr. Fenske. Threshold, well, yes. So in terms of the 
categories that we use, these were, it is on here, but--well, I 
will just speak up--established by the first Committee back in 
1992. And we have used them. I think they have held up very 
well. They are very similar to the categories that are used by 
the International Agency for Research on Cancer, which has to 
classify chemicals.
    Mr. Stearns. Can you just hold and find out what the 
problem is.
    The Chairman. We are going to try to fix the microphones.
    Mr. Stearns. Mr. Chairman, perhaps I can put this into a 
way that you can answer yes or no.
    Should these three statistical things be continued to be 
used as thresholds or are they obsolete? In other words, when 
you talk about a significant statistical association, are these 
sufficient now to determine a threshold or should they be 
sufficient, some additional statistical--I guess I am trying to 
understand. Do we have in place the right thresholds? That is 
the question. Yes or no?
    Dr. Fenske. Well, I think the categories we are using are 
the right categories, yes. As far as determining whether or not 
there should be benefits associated with a disease that is put 
in one of those categories, that is up to the VA. That is not 
part of the Institute of Medicine's charge.
    Mr. Stearns. So you say these thresholds are the problem? 
Are they working?
    Dr. Fenske. Yes.
    Mr. Stearns. Does someone have to make a subjective 
interpretation or is it very quantitative that comes from the 
statistical? Is it something that when I see it, I know it and 
it means something or is it very subjective?
    Maybe the other panelists would like to help us out. It is 
a rather technical question. What I am trying to understand is 
if it is subject to luck?
    Dr. Fenske. In a particular study, we review many, many 
studies, and in any particular study, it is very quantitative. 
We talk usually about relative risk and confidence intervals 
and this provides us with evidence essentially yes or no as to 
whether a study demonstrates an association.
    When we do our evaluation, we look at many studies and so 
we look at combinations of studies and we look at weaknesses in 
studies. So those judgments can be qualitative. So there is a 
mixture of quantitative and qualitative.
    Mr. Stearns. Okay. Thank you.
    Mr. Chairman, I would probably just request additional time 
just because the speaker went out if you do not mind.
    Dr. Marmar, how satisfied are you with the VA's recently 
announced plans to complete the longitudinal study after sort 
of the failure there as required by law and do you believe that 
they will meet the established timeline?
    Dr. Marmar. Well, it is difficult for me to answer that 
question on behalf of VA. Perhaps that is a better question for 
Dr. Kupersmith to address in his role in directing research at 
VA.
    But as someone who has spent the last 13 years as the Chief 
of Psychiatry at the San Francisco VA and now is outside of VA, 
but following this with great interest, I would say that moving 
forward at this point along the lines that has been suggested 
by yourself and the Chairman is the right thing to do. It is 
realistic. The contracting can be accomplished.
    And none of the obstacles that have been raised at this 
morning's discussion, whether locating subjects, guaranteeing 
confidentiality, or other aspects, none of those are obstacles 
that would prevent the timely conduct of the study.
    So the short answer is it is feasible to do the study. It 
is urgent to do the study and the time frame for doing the open 
contract and accomplishing the goal by 2014 appears reasonable 
to me.
    Mr. Stearns. Dr. Marmar, I am just looking from the 
outside. It looks like 2014 is too long. I mean, they started 
the study. They stopped it. They knew what the objectives were. 
They know what the problem is.
    Why would it take 4 years to do a study in your opinion? I 
guess a larger question is, could we do it in a shorter amount 
of time than 4 years?
    Dr. Marmar. It is possible to fast track it. I would say--
--
    Mr. Stearns. Not fast track it. I mean, it seems like 4 
years is 4 years and they have all the data. And they also have 
been through one race on this and they did not accomplish it.
    Dr. Marmar. Some work was accomplished during that time.
    Mr. Stearns. Yes. So they can build on whatever they had.
    Dr. Marmar. Yes. I would say to implement this study, to 
complete all of the human subjects' requirements for this 
study, to locate and evaluate all the subjects, to make the 
important----
    Mr. Stearns. So the bottom line is you think they need 4 
years?
    Dr. Marmar. I think if the study is to be comprehensive 
with regard to both the psychological and most importantly 
adverse physical health effects of serving in Vietnam, it will 
take 2 to 4 years.
    Mr. Stearns. Okay. Okay. Mr. Chairman, I think the 
Committee should get a report in less than 4 years, that we 
find out what they are doing, a draft form of some report. I do 
not think we should wait 4 years to see what happens. Just my 
suggestion.
    I would like to ask Mr. Williamson my last question.
    Mr. Williamson, you know, you are with the U.S. Government 
Accountability Office. What is your opinion? Do you think the 
VA can meet the challenges they face with this longitudinal 
study and can it be accomplished in 4 years or give me your 
feeling on some of what Dr. Marmar----
    Mr. Williamson. Well, we contacted 10 researchers and three 
methodologists who are experts in PTSD and experts in doing 
studies of this nature. And, yes, they think that all the 
challenges that the VA told us about are not insurmountable. 
There are ways to do the study.
    It takes a can-do attitude. And, quite frankly, until 
recently I do not think VA has had the will to do it.
    Mr. Stearns. So you are saying that VA did not have a 
``can-do'' attitude? Is that what you are saying?
    Mr. Williamson. Well, I mean, it has been 10 years since 
the law passed.
    Mr. Stearns. That is your perspective. I mean, somebody has 
got to say something here.
    Mr. Williamson. Yes.
    Mr. Stearns. And do you think that has changed?
    Mr. Williamson. I think under----
    Mr. Stearns. What has happened that made a change?
    Mr. Williamson. I think under the new Secretary, it appears 
that it has.
    Mr. Stearns. And what has happened to make a change in your 
opinion?
    Mr. Williamson. I think coming to the Committee for one and 
getting Chairman Filner to----
    Mr. Stearns. Okay. Yeah.
    Mr. Williamson. Yes.
    Mr. Stearns. I would just urge that the Committee ask for 
an interim report so that we do not sit here dumbfounded in 
2014.
    The Chairman. I am sick of the reports since they are 
rarely ever completed on time. The question really is, how many 
people will die between the interim and the report? This has 
gone on forever.
    Mr. Rodriguez.
    Mr. Rodriguez. Thank you, Mr. Chairman.
    I want to also congratulate you on staying on this subject 
and for moving forward. This just brings to light the need to 
do additional areas of study.
    I know one of the things that has concerned me is the 
numbers, and I have some friends included in this, that when 
they came back from Vietnam, they got involved with drugs and 
part of it, I assume, was, due to self-medication because of 
what they were dealing with, and I would hope that maybe we can 
also look at additional studies and assessments as to how deal 
with this.
    Additionally, I really believe we might have a case here, 
and although I do not have any proof of this, I would like to 
know if in the future, Mr. Chairman, we could look at how many 
of our veterans may have gone into our prison system, because 
of the use of drugs.
    Second, and I do not know if any of you might want to 
comment; however, I know we have some new veterans coming home 
with the onset of PTSD now, as compared to those that have had 
it for 20 or 30 years. As said I would like to see if there are 
any different approaches to treatment that we could come up 
with that respond to this immediate onset in PTSD that might be 
helpful versus the approaches used for those individuals that 
have been suffering from PTSD for 20 or 30 years, for example.
    And if there are any of these studies doing this and, if 
not, I would like to see how we might approach this and be able 
to reach out more veterans and even put more resources in this 
area and get independent groups to do it and maybe not the VA, 
but other groups to do these studies separate from the VA. I 
believe this is, something that might make sense from a 
research perspective.
    I was wondering if any of you would make any comments.
    Dr. Marmar. Yes, briefly. The NVVLS would not be primarily 
directed at the development of new treatments. It would make an 
assessment of which treatments may have been helpful or not 
over the course of Vietnam veterans' lives with PTSD.
    Congressman, to answer your question briefly about there 
are major advances in the understanding and treatment of 
combat-related PTSD which need to be and are being delivered to 
Iraq and Afghanistan veterans, as well as those from other eras 
suffering from the more chronic form.
    And in particular, there is research supported by VA, U.S. 
Department of Defense (DoD), and the National Institute of 
Mental Health to try to develop new treatments to help people 
at the time of battlefield exposure, to help them more quickly 
calm down so as they do not develop the chronic stress 
condition.
    And, second, we now have safe and effective medications and 
behavioral treatments for treating PTSD in the first months 
after it occurs. To the extent that those are provided, we can 
prevent a lifetime of mental health disabilities.
    Mr. Rodriguez. Now, because you are not directly treating 
those soldiers that are out there, because you do not get to 
them until after they leave the military, what do we need to do 
to get to them since you indicated the research indicates the 
quicker we get to them, the better? Is that what you said?
    Dr. Marmar. Yes. That is what I am saying. And this 
involves----
    Mr. Rodriguez. How do we get to them since they are not 
with the VA at that point?
    Dr. Marmar. Right. Well, the DoD and the VA are in a 
partnership to answer that question. There has been a recent 
DoD Blue Ribbon Panel to try to answer that question and to 
develop best practices for how to manage combat stress and 
other problems in theater before the war fighters even become 
veterans.
    Mr. Rodriguez. I really would want for you to offer with 
the recommendations on this because serving 8 years on the 
Armed Services Committee, I know how a military leader or 
military person thinks and to them this might be secondary in 
terms of providing this support--their main goal is the mission 
and sometimes providing this access to the need of those 
soldiers might not necessarily be there.
    This is very important for us to get as it points to what 
we might need to do from a Congressional perspective in this 
specific area. So I would, ask you to please get this to us.
    And especially there is a need to do some, I hate to say 
this, additional studies here, but if that is the case or 
taking that soldier out for a certain period of time to help 
them. I know that we have had studies on this and we just have 
not done the right thing in the military. We have not taken 
them out when we should to give the soldiers help.
    Dr. Marmar. Well, just to briefly reassure you on this 
point, Congressman, this recent high-level Blue Ribbon Panel 
has made direct recommendations for improved war-zone treatment 
for combat stress and for traumatic brain injury (TBI). And 
these recommendations have been provided to General Amos from 
the Marines and General Corelli from the Army. They have the 
operational responsibility for their implementation.
    Mr. Rodriguez. And do you have any idea if they have been 
implemented?
    Dr. Marmar. I do not.
    Mr. Rodriguez. Okay. And we will never know unless you help 
us get these reports to us, so we can see what might need to 
occur. I think it is important for us to be on top of this 
situation.
    The other thing is, Mr. Chairman, just to kind of look at 
other areas of the study and I will go back to those projects 
that we did in the 1960s and 1970s where we found 54 studies 
from--was supposed to have been 100, and make some assessments 
of those that also the military denied for 20 years until 
Congressman Thompson and the others uncovered them to see what 
we might be able to do to help out in those areas.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Mr. Rodriguez.
    Mr. Roe.
    Mr. Roe. Thank you, Mr. Chairman. Just a couple of comments 
and a couple of brief questions.
    One, if this were not important, it would almost be 
laughable that you could go on a clinical trial, a clinical 
study for 11 years to get the results. Having been involved in 
clinical trials, if you have a will to do it, you get a matrix 
out there and you do the trial. And it looks to me like the VA 
was either--who was in charge of it or whatever just dropped 
the ball. I mean, there is no way in the world this should have 
ever happened.
    And, Dr. Marmar, I totally agree with you and getting the 
information is critical because what happened at the end, and I 
am a Vietnam era veteran, what happened at the end of Vietnam 
was it was basically 20 years before anybody really--a lot of 
these men and women's lives were ruined because they were not 
treated.
    And if we were studying cancer, this would be ridiculous 
when you are trying to get research and trial on that. And 
remember that last year, more veterans died of suicide than 
died of combat wounds and more. So it is a lethal problem. And 
to get this information you are talking about, it is exciting 
because if you can apply those treatments in theater or when 
they come back obviously, the warriors do, then you can change 
maybe the next 30 to 40 years of their lives.
    So this longitudinal study ought to be done and it may not 
be able to be done in less than 4 years. A good clinical trial 
takes a while, as you know, to get accurate data and then 
evaluate that data. So I agree with you. It should be done.
    The excuse that it is hard to do is ridiculous. Of course 
good clinical trials are hard to do. If they were easy, this 
would have already been done. So just a couple of comments.
    And I think your point you just made a minute ago has been 
the most important one here about effective treatment. If we 
get this information and maybe it is useful, I think we should 
follow these veterans the rest of their lives.
    And that is exciting news right there that maybe the OEF 
and OIF veterans will not have the same outcomes that the 
Vietnam era veterans had because they will have early 
intervention.
    A comment?
    Dr. Marmar. I just strongly agree. With regard to any 
health care problem, but specifically for the problems of PTSD 
and TBI which are of great importance in the current conflict, 
the critical thing is early intervention, access, and 
destigmatizing the problem so that the veterans have access to 
the treatment and they are willing to take them because the 
problem is if you take the sort of like PTSD in its early form, 
it is treatable and usually not disabling in its early form.
    In its chronic forms, the dominos start to fall, alcohol, 
drugs, depression, marital problems, occupational instability, 
loss of income, homelessness. Those are a predictable set of 
dominos that fall if the disorder is allowed to progress into 
its end stage severe condition. So intervening early, 
aggressively, and in a way which does not undermine the 
confidence of the war fighter or the veteran is critical.
    Mr. Roe. Thank you.
    And Mr. Hall made a comment that somewhere he had read that 
they thought PTSD was overstated or whatever. I recommend you 
get shot at. We will see then if it is an issue. I think most 
veterans that have been out there and have been shot at realize 
it is real. I think it is real. Well, it is real. And certainly 
I appreciate your comments.
    I yield back.
    The Chairman. Thank you, Mr. Roe.
    Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Dr. Marmar, my question is, since it has been quite some 
time since it was requested for the study, would you say that 
anything should be changed in the study or we should keep going 
the way it is or should we make some changes?
    Dr. Marmar. Well, I am very familiar with the study as it 
was originally designed in the early 2000s. I would say the 
study is fundamentally the correct design.
    For the Committee, I would add only one important point. I 
think if we learned one thing dramatically new about the long-
term adverse health effects of PTSD in the past 20 years it is 
that PTSD is not only extremely detrimental to a veteran's 
psychological functioning and family functioning, there is very 
considerable risk of adverse chronic health effects of living 
with PTSD over years to decades.
    And specifically recent research from our group and others 
suggest that the risks of cardiovascular disease and the risks 
of diabetes and the risks even of earlier and more severe onset 
dementia because of the chronic effects of stress hormones and 
other factors, stress is a killer. We have known for years that 
stress is bad on the heart, but we have not known until 
recently that PTSD could be dramatically associated with 
increased risk for heart disease, stroke, and even dementia.
    And I would say it is of paramount importance that the 
NVVLS not change Vietnam veterans on a careful, in-depth 
assessment of the long-term adverse physical health 
consequences of their combat stress reactions.
    Mr. Michaud. Okay. Thank you.
    There are a number of Maine veterans who served in the 
National Guard and Reserves during the Vietnam time frame who 
were forced to conduct tactical herbicide training at the 
Canadian base, Gagetown.
    Have the Canadians done any study on Agent Orange or Agent 
Purple and, if so, what is wrong with using what they have done 
for their studies?
    Dr. Fenske. Did you say----
    Mr. Michaud. Anyone on the panel.
    Dr. Fenske. Did you say Canadian?
    Mr. Michaud. Yes.
    Dr. Fenske. Canadian?
    Mr. Michaud. Yes.
    Dr. Fenske. Well, one of the limitations of the work that 
we do for the Institute of Medicine is that we do not do any 
original research as has been pointed out. So we only review 
what is out there. And we have reviewed studies of Korean 
Vietnam veterans, Australian Vietnam veterans. I have not seen 
a study of Canadian Vietnam veterans.
    Mr. Michaud. Because I believe the Canadian government 
actually are giving benefits to their soldiers who served in 
Vietnam because of Agent Orange. And so I know they had done 
some work at Gagetown. So I think it might be helpful if they 
have already done it, we might want to follow up on it.
    Dr. Fenske. Definitely.
    Mr. Michaud. My other question is actually for the GAO. You 
mentioned the VA was reluctant and made excuses.
    Has the GAO done any studies similar with Agent Orange with 
DoD or the U.S. Department of Health and Human Services because 
my concern is the same as Mr. Chairman and the Ranking Member? 
Four years is quite some time.
    And if the study gets delayed and it is longer than 4 
years, that will put us past the 2014 election or during the 
interim, you made a comment that the reason why this is good 
because Chairman Filner is moving forward. We have a Secretary 
who is willing to do it.
    We do not know how long Secretary Shinseki is going to be 
there and if the new Secretary might decide to put it on hold 
again. So I think it is very important for us to move this 
forward not knowing what the outcome is going to come in 2012 
or 2014.
    Is there any way that the study can be moved up? Do we 
contract part of it out or do you find any way that it might be 
able to move forward thinking outside the box? For Mr. 
Williamson or Dr. Marmar.
    Mr. Williamson. Well, I would tend to agree with Dr. Marmar 
about part in terms of the clinical studies, but I am not 
really qualified to address that. I think he has addressed that 
already.
    As much as we want to move this forward, I would take with 
a grain of salt the 2014 date. If you look at the twin study 
and the women's study, which were offered as substitutes for 
the NVVLS completion, those studies both have slipped 2 years 
from their original dates.
    So I think that we have to be careful. And while we all 
want the 2014 date or sooner to materialize, there is certainly 
no guarantee of that.
    Mr. Michaud. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Boozman.
    Mr. Boozman. Mr. Williamson, in your testimony, you state 
the VA officials stated that they plan for the NVVLS to meet 
all the requirements of the law where scientifically feasible.
    Can you expand on the statement? And let me just ask some 
things in regard to that.
    Mr. Williamson. Okay.
    Mr. Boozman. Do you mean to imply that the VA may knowingly 
choose not to comply with some aspects of the law?
    Mr. Williamson. No, it is not that. It is just that there 
are a number of challenges which I talked about in my opening 
remarks.
    Again, locating the veterans is one. Now, regarding the 
failed NVVLS attempt in 2003, actually, we have talked to the 
co-principals that were involved in the NVVLS then and they 
actually did locate a large percentage of the veterans that 
participated in the original study.
    Our discussions with the methodologists and researchers 
indicate they are very positive about data sources that can be 
used to locate veterans for this study. Gaining their consent 
is a big factor as well.
    VA has talked to us about the measures to diagnose PTSD 
that were used during the original study and how those are very 
complex. Again, while they were very complex, and Dr. Marmar 
might be able to speak to this as well, certainly some of those 
same tools are used today. And I think VA plans to use a number 
of those tools again to the extent feasible.
    But regarding feasibility, you know, one of the things that 
VA officials could have done and is typical for a lot of 
studies of this nature is to have maintained that database by 
updating addresses and sending newsletters and things that 
would have kept the database much more current. They chose not 
to do that over the last decade or more. And so that is going 
to make it more difficult--not insurmountable, but more 
difficult.
    Mr. Boozman. Do you, and the rest of your guys can chime 
in, do you see anything that we need to modify to the law to 
address any of the concerns that you have?
    Mr. Williamson, again, you talked about some of these 
challenges. Do we need to modify the law in any way to help 
with any of the scientifically feasible challenges?
    Mr. Williamson. In discussions with our methodologists and 
researchers--who are prominent PTSD experts across the country 
and within VA--there were no show stoppers that said we should 
modify the law. There may be possible refinements that could be 
made.
    I think during the initial phase, after VA selects a 
contractor, they will assess the feasibility. And I think it is 
important that the Committee and all of us check in at that 
point in time to see what VA has concluded about the 
feasibility of the study.
    Dr. Marmar. The only thing I would add just to remind 
Members of the Committee since I was part of the original team 
that conducted the NVVRS in the mid 1980s, you can imagine at 
the time it was very challenging to locate the 3,016 
participants in the study. The political climate was not as 
favorable as it is now. The public's understanding of PTSD was 
very immature compared to what it is now.
    And the study was very successful using the tools that were 
then available to both identify and also to recruit and bring 
into the study the vast majority of those that were deemed 
eligible for the study. And now 20 plus years later, there are 
new tools available for identifying people, locating them, you 
know, the Internet, Google, other tools that were not available 
at the time.
    And I think also Vietnam veterans as a group have 
galvanized and understand the importance of serving the country 
by re-upping or reenlisting, if you like, in this study. I 
believe the question of finding people, the participants and 
getting their commitment is not the major thing. The most 
important thing is to move quickly now with the law in its 
present form.
    Mr. Boozman. Okay. Very good.
    Dr. Fenske. May I make one comment?
    Mr. Boozman. Yes, sir. Sure.
    Dr. Fenske. I am not familiar with maybe some of the 
complexities of this particular study, but it is hard for me to 
understand why this is so complicated. I mean, at the 
University of Washington, we have dozens of studies that are 
following people. We have studies, you know, following people 
who were exposed to chemicals in the 1940s. And it does require 
keeping up with the records. And so if that has not been done, 
then that is an extra chore. But I cannot see why you would 
need to do a feasibility study to determine if you could do 
this study. I think you could just do the study.
    Mr. Boozman. Do the study.
    Thank you, Mr. Chairman. That is a good point.
    The Chairman. Mr. Donnelly.
    Mr. Donnelly. Thank you, Mr. Chairman.
    Dr. Fenske, could you give us a brief summary of your 
recommendations regarding Blue Water veterans, particularly in 
regard to definition of service in Vietnam?
    Dr. Fenske. Yes, I can. This was not a major point of our 
Committee's deliberations, but from the outset when these 
committees started in the early 1990s, the Blue Water veterans 
were considered to be part of the exposed population.
    And so when we reviewed studies, we have always included 
studies of those kinds. When we looked at this issue the last 
time around, given the information, particularly from 
Australia, there did not seem to be any good reason to be 
excluding them from a scientific point of view.
    Mr. Donnelly. Following up on that, what further study do 
you think is needed in regards to the Blue Water veterans and 
the question of Agent Orange?
    Dr. Fenske. Well, there is a new Committee at the IOM that 
is looking specifically at the question of the exposure of Blue 
Water Navy. And I think that they will be able to address that 
as well as anyone can. You know, there were not samples taken 
at the time, so it is always hard to reconstruct these things. 
But I think that that is going to provide the information that 
will be needed to answer that question.
    Mr. Donnelly. Do you know what kind of time frame we are 
looking at on that?
    Dr. Fenske. That Committee just started and I believe it 
has an 18 month time frame.
    Mr. Donnelly. Okay. And then, Dr. Marmar, based on what you 
have seen, is there anything else the VA can be doing right now 
to complete the NVVLS in a timely manner?
    Dr. Marmar. Well, again, I am not directly involved with 
the internal operations of VA research. So that is a question 
perhaps best for Dr. Kupersmith to address.
    But just to come back to a point that was raised earlier 
about is there anything that we should be concerned about in 
terms of the scope of the study, the one thing again I would 
like to emphasize is that in the partnership between Congress 
and the VA and the study, that adequate resources be allocated 
for this study to ensure a high-level assessment of physical 
health consequences of long-term PTSD because at the end of the 
day, if that is not accomplished, a very large, very expensive 
study will have been conducted and one of the primary aims will 
not be fulfilled.
    Mr. Donnelly. Mr. Williamson, is there anything else you 
can think of that the VA can do to help complete this study in 
a timely manner?
    Mr. Williamson. Well, I think one of the things we have not 
talked about, as I mentioned in my short statement, is that 
there were, as the Office of Inspector General for the VA 
noted, some very serious contract planning and administrative 
problems that existed, and VA has to avoid those in the future.
    The OIG basically concluded in their report in 2005 that 
$4.7 million, all of it or a substantial part of it, was wasted 
in that failed attempt. So VA, in addition to all the other 
things we talked about, has to administer this contract in a 
very responsible way.
    Mr. Donnelly. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you all.
    I have had many panels that I have been either upset with 
or angered at. You are the messengers and I am not angry at 
you. But talk about analysis paralysis--this is ridiculous.
    We are talking about human lives here. We are sitting here 
talking about 4 more years when people are suffering. We ought 
to help the veterans first and then worry about all the 
studies.
    Mr. Williamson, you said at one point in your testimony, 
that the VA said the study could be completed in 2013 and 
later, you said they are not even sure it can be completed. I 
do not know which is the right statement.
    As Dr. Fenske pointed out, the first thing they are going 
to do is hire somebody to assess the feasibility of whether or 
not they are going to do it. I mean, this is ridiculous.
    A few years ago, I was in Illinois and I was handed a list 
of several hundred Vietnam veterans, who got Parkinson's about 
10 years earlier than you would expect them to get the disease. 
They were all around 50 years old. I do not need anything 
else--Parkinson's is related to Agent Orange. I am a layman, 
but I know that. It took how many years to say that it is 
presumptive?
    I am sure Mr. Weidman has and could do a focus group of 
Vietnam veterans around the country. We could come up with all 
of the health problems that affect our veterans. I am confident 
that the anecdotal problems based on human suffering is more 
relevant right now than all these studies. You can do all these 
studies--I do not care how long they take--but let us end the 
suffering of all these people and grant their claims now.
    I am sure that when Mr. Weidman gets to the witness table, 
he could tell us what could be presumptive because he has dealt 
with hundreds of people who have these ailments.
    It is ridiculous that we are putting our veterans through 
this. It is depressing that we are going to have to go through 
these studies over numerous years. Let us get them their 
benefits and then we can worry about these studies.
    Mr. Stearns said there is a true suffering here. If they 
have been applying for benefits and appealing their claim for 
30 years, I do not care what they have, we should grant their 
claim. If there is a small percent of fraud, to reach the 98 
percent who are actually suffering, I think we have to do it 
anyway.
    I am just amazed that we have allowed this kind of 
procrastination for 30 years. We should take this away from the 
VA because it took them decades to even say that Agent Orange 
could cause adverse health effects. It took them decades to 
figure out some of the presumptions. Now we still have study 
after study.
    What more proof do we have that they are incapable of doing 
it? Mr. Hall used the word willful ignorance. I think that is 
what is going on here. If they wait long enough, everybody will 
die and they will not have to spend any money trying to help 
them.
    I think there is this institutional--what is the equivalent 
of institutional racism--institutional death-ism. Somehow the 
institution is operating on such a level that people are all 
going to die and then we do not have to worry about it. Then we 
can forget the studies anyway.
    I appreciate you giving us this information. It is very, 
very disheartening. It reinforces my sense that we should just 
grant all these claims right now because they will never finish 
the study.
    If they cannot find addresses, what more data do we need 
that they are incapable of doing this? It is ridiculous--these 
are human beings. It is people. We are talking about people, 
who are suffering, and we cannot find addresses?
    I thank you for your testimony. You taught us a lot. I 
think you showed us that there is a deeper problem than 
traditional committees and bureaucracies can deal with.
    We will start with panel two. Rick Weidman is the Executive 
Director for Policy and Government Affairs of the Vietnam 
Veterans of America. Joseph Wilson is the Deputy Director of 
the Veterans Affairs and Rehabilitation Commission of the 
American Legion. Commander John Wells is the Cofounder and 
Trustee of the Veterans Association of Sailors of the Vietnam 
War. John Paul Rossie is the Executive Director of the Blue 
Water Navy Vietnam Veterans Association, and Dr. Vivianne 
Wersel is the Chair of the Government Relations Committee of 
the Gold Star Wives of America.
    We thank you all for being here. We will recognize you for 
a 5-minute oral summary and your written testimony will be a 
part of the record.
    Mr. Weidman, I have used your name a lot today, but welcome 
and thank you for all you do for our Vietnam veterans.

STATEMENTS OF RICHARD F. WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY 
AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA; JOSEPH L. 
 WILSON, DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION 
   COMMISSION, AMERICAN LEGION; COMMANDER JOHN B. WELLS, USN 
(RET.), COFOUNDER AND TRUSTEE, VETERANS ASSOCIATION OF SAILORS 
OF THE VIETNAM WAR; JOHN PAUL ROSSIE, EXECUTIVE DIRECTOR, BLUE 
WATER NAVY VIETNAM VETERANS ASSOCIATION; AND VIVIANNE CISNEROS 
WERSEL, AU.D., CHAIR, GOVERNMENT RELATIONS COMMITTEE, GOLD STAR 
                     WIVES OF AMERICA, INC.

                STATEMENT OF RICHARD F. WEIDMAN

    Mr. Weidman. Thank you very much, Mr. Chairman, for holding 
this hearing and continuing to exercise leadership on this 
issue.
    The law actually was not passed as mentioned earlier this 
morning in 2002. It was passed in the year 2000 as one of the 
last acts in that Congress that passed. It was originally due 
to the Congress on September 30th, 2004 and it was later 
amended and extended to September 30th, 2005.
    There is a book that is still a very good book, although 
somewhat outdated now, by a fellow by the name of Fred Wilcox 
published by Cornell University Press. That was published in 
1980. And the title of the book was, ``Waiting For An Army To 
Die.'' And I said to Fred, Fred, this is a great book, but this 
is a little histrionic, the title of the book.
    He had it right, he had it right 30 years ago that indeed 
you can argue that this is what the actuarial folks are doing 
at the Office of Management and Budget, which is waiting for an 
army to die. If you delay, delay, delay long enough, that will 
happen.
    And one can almost come to no other conclusion. There is, 
of course, a saying in Washington that never attribute to 
malice that which can be explained by rank, gross incompetence.
    But we do not think that the Office of Research and 
Development are incompetent. We think it is willful ignorance, 
that Mr. Hall had it right. They have refused to do Agent 
Orange research and they have refused to obey the law and meet 
the Congress' guideline that said they wanted the replication 
of the National Vietnam Veterans Readjustment Study in order to 
make it a longitudinal study and essentially serve as a robust 
morbidity and mortality study of Vietnam in-country vets versus 
Vietnam era vets versus nonveteran peers.
    There is no other way to explain why they have delayed. It 
is the only group that we have, that is a statistically valid 
random sample where we have a beginning point 20 years ago, 
actually, more than 20 years ago now, and it should not take an 
additional 4 years in order to get this study done.
    Much of the preliminary work was already done by Research 
Triangle Institute (RTI). VA continues to try and demonize RTI. 
And, in fact, if you read the Inspector General report, they do 
not demonize RTI, although they said they bought laptop 
computers out of sequence, but, in fact, it was VA who screwed 
up the contract. They did not write it properly. They did not 
write it with deliverables and due dates and timelines and 
milestones according to the Federal Acquisition Regulations 
that affect VA contracting.
    So it was really VA messed it up and then tried to blame 
somebody else and then still did not want the information. And 
for a long time, we were puzzled. Why in the world would you 
not want this information when we know it is so important and 
everybody who is an expert in post-traumatic stress disorder 
and in the clinical field from National Center for PTSD to both 
APAs to all of the medical schools say this is vital 
information to know what is the chronicity of PTSD and how does 
it impact on us both in terms of neuropsychiatric health and 
how does it affect psychosocial readjustment and how does it 
affect physiological health.
    And the only conclusion that we could come to is they did 
not want a robust mortality and morbidity study, which every 
single IOM panel since 1998 has said that is the only thing 
they lacked in order to do their work properly when it comes 
under the Agent Orange Act of 1991 is that they did not have a 
robust mortality and morbidity study of Vietnam veterans and 
recommended that VA do it and twice in the past decade have 
recommended specifically that they complete the National 
Vietnam Veterans Longitudinal Study and VA continues to not do 
it. At that point, it becomes willful flouting of the law.
    In the private sector, if the Board of Directors instructed 
somebody to take on a project and get it done and they do not 
do it properly after 9 years and then they finally say, okay, 
we are going to do it and give it back to exactly the same 
people in charge of that part of the corporation, they would 
not do it. That person would be down the road and they would 
bring in somebody who wanted to do the job.
    The purpose of the VA is not generalized health care. It is 
veterans' health care designed to meet the wounds, maladies and 
injuries, illness and conditions that stem from military 
service is the primary purpose. And it serves other purposes, 
too, but that is the primary purpose. That is what the American 
taxpayer pays for and we are not getting it as long as you do 
not have the proper research.
    So the first is obey the law, heed the will of the 
Congress, get the NVVLS done. We believe you can do it in 3 
years, possibly even less, but I would certainly not challenge 
Dr. Marmar's clinical credentials on that.
    But a lot of it is you could have conceived a baby. When 
the Secretary first instructed the Veterans Health 
Administration (VHA) to move ahead, it was August of last year. 
That is 9 months ago. That is 9 months ago and publicly 
announced it 8 months ago. A child could have been born in that 
period of time and they still have not put out a source that is 
sought.
    This is just outrageous. You know they are bright people, 
so what do you attribute it to? Got me. I think it is a failure 
on many fronts.
    And if I could just--I know I am over time, Mr. Chairman, 
but hopefully you will come back to the issue of Agent Orange 
because I did want to address that despite the colleagues here 
next to me.
    I thank you very much for the opportunity, and I thank this 
Committee for the incredible leadership that you have exercised 
in helping us convince Secretary Shinseki to finally move ahead 
and get this study done. Thank you.
    [The prepared statement of Mr. Weidman appears on p. 65.]
    The Chairman. Thank you.
    Please, Mr. Wilson?

                 STATEMENT OF JOSEPH L. WILSON

    Mr. Wilson. Mr. Chairman and Members of the Committee, 
thank you for this opportunity to present the American Legion's 
views on the National Vietnam Veterans Longitudinal Study and 
illnesses associated with exposure to Agent Orange.
    And due to time constraints, I will limit my testimony to a 
brief chronological synopsis of the subject matter, which is 
discussed in its entirety and already on record. If I see that 
I am reaching that time, I will jump down to the American 
Legion and what the American Legion urges Congress to do.
    In September 2009, VA announced plans to restart the 
follow-up to the 1984 National Vietnam Veterans Readjustment 
Study known as the NVVLS.
    In addition, the new study will supplement research already 
in progress at the VA to include studies on post-traumatic 
stress disorder and the health of women Vietnam veterans.
    One of the top priorities of the American Legion is to 
continue to assure that long overdue major epidemiological 
studies of Vietnam veterans who were exposed to the herbicide 
Agent Orange are carried out effectively.
    Shortly after the end of the Vietnam War, Congress held 
hearings on the need for such epidemiological studies. The 
Veterans Health Program Extension and Improvement Act of 1979, 
Public Law 96-151, directed VA to conduct a study of long-term 
adverse health effects in veterans who served in Vietnam as a 
result of exposure to herbicides. The American Legion supported 
Public Law 96-151.
    The Institute of Medicine or IOM has a report titled, 
``Characterizing the Exposure of Veterans to Agent Orange and 
Other Herbicides Used in Vietnam,'' which is based on research 
conducted by a Columbia University team and directed by 
principal investigator, Dr. Jeanne Stellman. The team had 
developed a contemporary method for characterizing exposure to 
herbicides in Vietnam. The American Legion is proud to have 
collaborated in this effort and endorses this IOM report.
    There is a matter of children of Vietnam veterans and 
illness like type 2 diabetes. In 2001, VA added type 2 diabetes 
to the list of presumptive diseases associated with exposure to 
herbicides in Vietnam. It is the American Legion's contention 
that more conclusive research be conducted to determine if the 
effects of exposure to herbicides in Vietnam affected the 
offspring of those who served.
    In 2003, the American Legion supported and endorsed the 
expansion of spina bifida benefits and set forth in H.R. 533 to 
a person suffering from spina bifida who is a natural child 
regardless of age or marital status of a parent who performed 
qualifying herbicide risk service provided that the individual 
was conceived after such service.
    According to VA, spina bifida is the most frequently 
occurring, permanently disabling birth defect affecting 
approximately one of every 1,000 newborns in the U.S. The 
American Legion urges Congress to amend title 38, chapter 18, 
to provide entitlement to spina bifida benefits for the child 
or children of any veteran exposed to a Vietnam era herbicide 
agent such as Agent Orange in any location including those 
outside of Vietnam where herbicides were tested, sprayed, or 
stored.
    Children of women Vietnam veterans. Under Public Law 106-
419, the Veterans Benefits and Health care Improvement Act of 
2000, VA also identified birth defects of children of women 
Vietnam veterans. The American Legion supported the above piece 
of legislation and urges Congress to include research involving 
women veterans who served in Vietnam to include in country and 
other locations and were exposed to herbicides, children of 
both men and women veterans who served in Vietnam to include in 
country and other locations and were exposed to herbicides.
    The Institute of Medicine in update 2008 specified, well, 
stated that the evidence it reviewed makes the current 
definition of Vietnam service for the purpose of presumption of 
exposure to Agent Orange, which limits it to those who actually 
set foot on land in Vietnam seem inappropriate. The American 
Legion submits that not only does the most recent IOM report 
fully support the extension of presumption of Agent Orange 
exposure to Blue Water Navy veterans, it provides scientific 
justification to current pending legislation in Congress that 
seeks to correct this grave injustice faced by Blue Water Navy 
veterans.
    In December 2009, IOM created a VA sponsored committee to 
further explore the Blue Water Navy exposure issue. The 
duration of this project is to last 18 months. The American 
Legion looks forward to the completion of this project.
    The American Legion urges Congressional oversight to assure 
that additional information identifying involved personnel or 
units for the locations already known by VA as released by DoD 
as well as all relevant information pertaining to other 
locations that have yet to be identified. Locating this 
information and providing it to VA must be a national priority.
    The American Legion believes the new study facilitators 
should take heed of the circumstances prompting the abrupt halt 
of the 2001 NVVLS study. The American Legion urges Congress to 
insist on the assessment and review with all pertinent parties 
of all VA sponsored and IOM studies to fulfill the most recent 
charge by VA to ensure no evidence and information is lacking. 
To prevent that which occurred with the incomplete 2001 NVVLS 
study, the American Legion encourages proper Congressional 
oversight as well as continuous inclusion of stakeholders such 
as veteran service organizations.
    Since 1990, when the American Legion brought a suit against 
the U.S. Government for failure to carry out its 
Congressionally mandated Agent Orange study, the American 
Legion remains steadfast in its belief that such studies are 
needed.
    The American Legion firmly believes Congress should 
exercise Congressional oversight to make sure these studies it 
has mandated are carried out.
    We also urge timely disclosure of ongoing studies by IOM 
through veterans and Agent Orange update publications promptly 
every 2 years as directed by Public Law 107-103, Veterans 
Education and Benefits Expansion Act of 2001.
    Mr. Chairman and Members of the Committee, this concludes 
my testimony. Thank you.
    [The prepared statement of Mr. Wilson appears on p. 68.]
    The Chairman. Thank you.
    Commander Wells.

        STATEMENT OF COMMANDER JOHN B. WELLS, USN (RET.)

    Commander Wells. Thank you.
    I learned how to work the microphone there. My name is John 
Wells. I am a retired Navy Commander. I am also representing 
the Veterans Association of Sailors of the Vietnam War.
    I am an old steam engineer. I have been on a lot of the 
types of ships that served during the Vietnam War, although I 
did not personally serve. I am also an attorney. I think that 
makes me a dangerous combination. I know the VA seems to think 
so. My actual qualifications are in the written testimony, so I 
am not going to reiterate them here.
    What I do want to do is talk about why we need to cover the 
Blue Water veterans, why H.R. 2254 needs to go forward. And, 
you know, I think it is hard for us to go now and test the 
waters. The Agent Orange dioxin is gone. It is no longer there. 
So we cannot come up with any kind of direct evidence, but we 
can certainly come up with circumstantial evidence. As an 
attorney, I can tell you there are a lot of folks in prison 
right now and rightfully so based on circumstantial evidence.
    What can we show, what can we prove? One of the things that 
we can show, as the Chairman said, we do not need any more 
studies. I went and testified before the Institute of 
Medicine's new committee on Monday. Bright, intelligent folks, 
wonderful people, really interested, but the studies have 
already been done not by the United States Department of 
Veterans Affairs but by the Australian Department of Veterans 
Affairs.
    The University of Queensland back in the late 1990s got 
together with the Australian Department of Veterans Affairs who 
were saying, hey, we have more Navy veterans dying of Agent 
Orange cancers than we do land veterans. Why? Well, they went 
out, contracted with the Queensland folks. They went out and 
found out why. Because as the Agent Orange rolled out to sea--
now, somebody I am sure from the VA will tell you it never 
rolls out to sea. Folks, it is oil based. I live in Louisiana. 
Come down to where I live. You will see what happens to oil 
going on the water. Okay?
    As it goes out to sea or it is blown out to sea, people 
will say, hey, that is heavier than air, it is going to fall. 
Well, so is dust. And my wife tells me my office is very dusty 
and it blows around all the time. Okay? If you have ever 
sprayed fly spray, you know what happens if you spray it into 
the wind. The stuff does get blown out to sea and we have 
plenty of anecdotal evidence to prove that. And common sense 
will tell you that. It went into the ocean. It went into the 
South China Sea.
    It was then brought in by the ships' distiller plants as 
they converted their water from saltwater to potable drinking 
water and unknown to anybody at the time, it went straight 
through the water distribution system and people drank that 
water. That is the methodology and a very important part of 
circumstantial evidence.
    But we also know from the Australian study, and the 
Australians track all their veterans. I mean, I heard somebody 
say, oh, we do not know where our veterans are. I am like come 
on, you could have put that on the Census. I mean, come on, VA, 
this is not hard. They track them all. They track them 
individually. They know where they live. They know what kind of 
diseases they have. That is how this whole thing got started.
    And we know that there is a 19 percent mortality rate due 
to cancer, 19 percent above the average based on the Australian 
mortality studies, which we should have been doing all along.
    Based on their cancer instance studies, we also found out, 
and this is the smoking gun or the corpus delicti, what type of 
cancers are being caused by Navy veterans and guess what? There 
are all types of things caused by our oral ingestion, by head, 
neck, throat, larynx, esophagus, stomach, colon, 
gastrointestinal system. That is the type of cancers that are 
being developed by the Australians.
    Now, I can tell you. Australians are built just like 
Americans. I know. I am married to one. Okay? And there is no 
difference. Why do we need another study? Why do we study this 
to death? Why can't we use what the Australians have done?
    Nobody at the Department of Veterans Affairs has ever 
called Dr. Keith Horsley at the Australian Department of 
Veterans Affairs. He said he has never gotten a call. The 
University of Queensland folks, they have never gotten a call. 
I have their phone numbers. If anybody wants them, I will be 
more than happy to give them to them. I gave them to the IOM. 
Hopefully they will call.
    Folks, this is not hard. The studies exist. We cannot keep 
studying this to death.
    Everybody talked about, you know, the fine job the Vietnam 
vet, Duane Johnson did, you know, on the Times Square incident. 
He saw something and he took action. What would have happened 
if the VA had observed that SUV sitting there? People would 
have died. That is what would have happened. And guess what? 
People are dying now. People are dying now because the VA is 
not taking the action. They are not going out with a bang or a 
blast of a bomb. They are going out with a torturous cancer in 
a painful way as their bodies are being eaten away while we 
study, study, study.
    You know, I dealt with the Australians. I am over time. I 
am sorry, or almost over time. I am sorry. But I have dealt 
with the Australians. They are a pleasure to talk to. They 
answer the mail. They answer the e-mail. They answer the phone 
call. They will give you their home phone. They really care.
    If you talk to the Australian vets, they talk about their 
Australian VA with respect, with gratitude. Our folks say, hey, 
they just give you a second chance to die for your country and 
often refer to them by names such as the Department of Veterans 
Abuse.
    I am proud of my country. I served 22 years as a Navy 
officer. I am proud of being a Navy officer. I am proud of 
being a military person. I am proud of our government. I am 
proud of our President. I am proud of our Congress. I am proud 
of our Supreme Court. I wish I could say I was proud of my VA, 
but I cannot.
    I am over time. I thank you for the opportunity to talk to 
you today.
    [The prepared statement of Commander Wells appears on p. 
72.]
    The Chairman. Thank you, sir.
    Mr. Rossie.

                 STATEMENT OF JOHN PAUL ROSSIE

    Mr. Rossie. Thank you.
    My name is John Paul Rossie. I am a Navy veteran of the 
Vietnam War. I am currently the Founder and Executive Director 
of the Blue Water Navy Vietnam Veterans Association. That is 
based in Littleton, Colorado.
    For the record, I would like to state that Blue Water Navy 
refers to Coast Guard, Navy, Fleet Marines, and other 
servicemen that were offshore Vietnam and their widows and 
their children.
    I submitted my written testimony for the public record. It 
deals specifically with the veterans who did not have their 
boots on the ground and who are addressed by H.R. 2254. I 
respectfully request that each of you personally review this 
document. It contains facts and it offers solutions.
    It discusses how the Department of Veterans Affairs has 
been presenting this Committee with contrived numbers relative 
to H.R. 2254. It very clearly shows you that you have been 
misled about the head count of the Vietnam veterans and about 
the cost of treating the veterans who are victims of chemical 
warfare. And this is truth. We need to call it like it is. It 
was designed to kill jungle foliage. It inadvertently killed 
human beings.
    As I find myself seated here surrounded by all of you, 
because I was invited here today, I have mixed emotions. I am 
honored to be associated with the group, the Blue Water Navy 
Association, that has earned a seat at this table.
    I am mortified to have to sit before a Committee and plead 
for the health benefits of American veterans of the Vietnam War 
that are desperately needed. We should have never gotten to 
this point.
    Mostly I am stunned to realize that I am pleading before 
individuals who have already promised to help America's Vietnam 
veterans. If your promises had not been so convincing, you 
would not be seated on your side of the table because the 
promises you make are why we elect you to fill those seats.
    I am proud to say I am here because I want to help 
restructure a Department of Veterans Assistance, but apparently 
that cannot be done without the help of a strong legislative 
body such as a Committees like this which I hope would be 
renamed the Committee for Veterans Assistance.
    Before I roll up my sleeves and get to work, I would like 
to clear up some heavier issues. I am not at all comfortable 
when prominent individuals and august bodies such as this make 
promises that they do not keep and that people actually die 
because of it.
    I am appalled when I have to witness the warriors of the 
greatest generation, our parents, having to bury their children 
who did not die of natural causes. They are dying because 
companies like Dow and Monsanto are being protected and 
insulated by my government.
    Our parents are burying their own children who have been 
deprived of a long, prosperous life, cut short by an average of 
13 years and racked by many years of pain and physical 
disability. And I am disheartened to see that this trend 
continues with our own children serving in the Middle East.
    Many things have to change and I am here to offer my help. 
This coming year, we will see the highest death toll of Vietnam 
veterans to date. Every day the Congress delays in getting the 
veterans their basic medical benefits, another 300 or more 
veterans from the Vietnam War will die because of that. You 
cannot stop them from dying, but you can ensure that their 
final years, months, weeks provide them and their families 
basic human dignity.
    We also suspect there may be a high suicide rate among 
Vietnam veterans who more likely than not are going to see H.R. 
2254 and S. 1939 delayed by this Congress. And they will be 
facing their greatest adversary, the Department of Veterans 
Affairs, as is a phrase used by Congressman Filner.
    So I end with a question. What can I do to help you make 
H.R. 2254 and S. 1939 law of the land? Thank you.
    [The prepared statement of Mr. Rossie appears on p. 79.]
    The Chairman. Thank you, sir.
    Dr. Wersel.

          STATEMENT OF VIVIANNE CISNEROS WERSEL, AU.D.

    Dr. Wersel. Mr. Chairman and Members of the Committee, I am 
pleased to be here today on behalf of Gold Star Wives. I am 
Vivianne Wersel, the widow of Lieutenant Colonel Rich Wersel, 
United States Marine Corps, who died suddenly a week after 
returning from the second tour of duty in Iraq. I am also the 
daughter of Colonel Phil Cisneros, United States Marine Corps 
retired, served three tours in Vietnam.
    We are heartened by the restarting of the National Vietnam 
Veterans Longitudinal Study as it is very clear that our 
knowledge is not yet complete on the long-term health 
consequences of those who served in Vietnam.
    However, we cannot forget the importance of communication 
to the impacted community including surviving spouses and their 
children.
    Therefore, it is important to further investigate the 
results of the effects of the deadly toxins used in Vietnam as 
well as to identify the servicemembers, their spouses, and 
surviving spouses. Not everyone has a connection with the 
military and the VA.
    We have concerns for the veterans and their survivors who 
were never in the VA system but became ill and died. Many 
veterans may have died years ago under conditions caused by 
Agent Orange. The VA must take a lead in outreach to these 
servicemembers and survivors.
    A common theme that our members encounter is a lack of 
information, the lack of the government reaching out to them to 
alert them of changes in benefits and compensation that they 
may be eligible to receive. Many were never informed of 
benefits initially and many still are not aware of their 
benefits.
    So while it is wonderful for the scientific community to 
gain these valuable insights, the next crucial step is to 
assure that those who have been harmed as a result of the 
chemicals will be identified. Therefore, the VA outreach to 
survivors must be drastically improved.
    My uncle served and died of amyotrophic lateral sclerosis 
(ALS). He served his country in the Marine Corps. My aunt was 
not married to him during his military service and was unaware 
of the changes of the VA policy to include ALS as a presumptive 
illness. This benefit made a difference to her quality of life, 
yet she never would have known it if I had not made a point to 
share the information with her. She was grateful of the VA 
Respite Program during his final months and is concerned that 
other families are unaware of the significant benefit.
    We are certain that there are many other surviving spouses 
who have yet to be identified as beneficiaries as was my Aunt 
Sandy. We, as a grateful Nation, have the ethical role to reach 
out to better identify those veterans and survivors who qualify 
for compensation.
    A widow in Florida has an adult son with spina bifida. Her 
son is relatively independent and, yet, still needs care. Since 
the loss of her husband, the widow now bears the full burden of 
caring for her adult son.
    For many years, caregivers provided for their spouses who 
were less than 100-percent disabled and these widows were not 
eligible for Dependency and Indemnity Compensation when their 
spouses died. The caregiver's quality of life was compromised 
as well as their own health. Many spent their life savings on 
medical expenses. Spouses were forced to give up careers 
because their disabled husbands needed ongoing care.
    We do not want new members in our organization because the 
requirement for entry is loss of a loved one, but we are 
protective of those who eventually will join us as well as for 
those surviving spouses who suffered right along with the 
veteran. They need to be given some peace of mind about why 
life was so radically different for so long after their spouse 
returned from Vietnam, whether it was from PTSD or burying a 
child with a neural tube defect or sadder yet, left barren.
    Results of the present longitudinal study may reveal new 
presumptive illnesses that not only affect the servicemember 
but many generations thereafter. Service to this Nation 
deserves life-long respect and care, certainly to the veteran, 
but to the veteran's family as well even when the veteran is no 
longer alive.
    Simply stated by one of our members, I just pray that no 
one else has to go through what Les went through, a very 
tortured, painful, long, anguished death. After his death, I 
was burdened with medical bills, exhaustion, and ruined career 
that I am still trying to repair.
    The Vietnam veteran did battle for our country and now has 
to battle with the VA and the VA bureaucracy rules to obtain 
the benefits he deserves and has more than earned. In many 
instances, the surviving spouse must continue to fight for the 
benefits the veteran earned.
    It is our responsibility as a Nation to honor these 
veterans and their survivors. We hope that the restart of the 
study will continue to reveal data and information crucial to 
the optimal well-being of our servicemembers and their 
families. It is imperative that a more aggressive outreach is 
implemented to identify veterans, spouses, and survivors 
concerning any new presumptive illnesses developed as a result 
of the study.
    Thank you for the opportunity to testify and I will answer 
any questions you may have. Thank you.
    [The prepared statement of Dr. Wersel appears on p. 85.]
    The Chairman. Thank you, Dr. Wersel.
    And thank all of you.
    Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    I guess, Commander Wells or Mr. Weidman, I appreciate well 
the whole panel first of all for coming here this morning. This 
has definitely been very informative.
    And you mentioned the Australian study and I do know that 
the Canadians actually have given benefits for the soldiers in 
Canada that served, you know, had time at Gagetown.
    I guess my question is, you mentioned the Australian study, 
did the Canadians do a study as well or is it just Australia 
that had a comprehensive study?
    Commander Wells. I do not know, sir, if the Canadians did a 
study. I think they may have relied on the Australian studies, 
which were pretty comprehensive.
    And by the way, I failed to mention the Australians have 
been granting benefits to their Blue Water Navy veterans for 
several years now. So, you know, the Australians and the New 
Zealanders, as well as the Canadians, have been giving the 
benefits that we are asking you to provide by H.R. 2254.
    Mr. Weidman. There were a couple of small studies of the 
veterans in Gagetown done by the Ministry of Health in Canada, 
but they also relied on the international science, which is 
incidentally what we have had to do since we do not fund any 
Agent Orange related research.
    Currently VA lists three things. You go to the VA Web site 
and punch in on the research Agent Orange research funded by 
VA. They bring up three things.
    One is the women's study as if it is ongoing. And, in fact, 
they have not completed the Institutional Review Board (IRB) 
process on that after 9 months. Once again, these ladies could 
have all had a baby in that time.
    And, number two, they list a study by Dr. Han Kahn who 
works 2 days a week, he is semi-retired from VA, not funded by 
the Office of Research and Development, by the way, but funded 
by Public Health and Environmental Hazards. And Dr. Kahn is 
doing two studies.
    One is that one, this one which is looking at the Agent 
Orange registry to discover how many of those people have PTSD. 
We have a hard time coming to the conclusion or agreeing with 
the conclusion that it is Agent Orange research. And the second 
one is a meta-analysis of some earlier work and looking at 
death rates.
    We have a lot of respect for Dr. Kahn, but this is a paltry 
effort given the amount of energy and the number of veterans 
affected and the energy that you as Chair and your colleagues 
on the Subcommittee on Health and the full Committee on both 
sides of the aisle have put into this issue of trying to 
discern the truth. This is the best that VA can come up with 
given the fact that they have a research budget of $540 million 
a year. We have a hard time with that.
    So for the second year in a row, VVA did not support VA 
research and development week, which was last week. It is not 
because we do not support medical research. We are the only 
veteran service organization that is a member of Research 
America, which is a broad coalition of folks who support 
increased medical research by funds through the National 
Institutes of Health, through the Center for Disease Control 
and Prevention, through the Agency for Health care Research and 
Quality, et cetera.
    So it is not that. It is that they are not doing their 
segment of the job, which is to research into the wounds, 
maladies, injuries, illnesses, and conditions that emanate from 
military service.
    Dow Chemical is not going to fund it. VA should be funding 
it.
    Mr. Michaud. My second question is, as you heard, Secretary 
Shinseki is moving forward on this and it is good to see that 
he is moving forward, but a lot of times, even if a Secretary 
does say something and it is directed down below, they could 
delay it for those who might not want the study to go forward.
    Clearly there is a change in the top Administration. The 
people who are supposed to be dealing with this longitudinal 
study within the bows of the VA, are they pretty much the same 
ones that have been there before and do you feel that that is 
where the problem is going to come even if they have a lot of 
push from the Secretary himself?
    Mr. Weidman. Congressman, I came dangerously close to being 
ad hominem today and I do not mean to be. It is not 
appropriate. It is not who does it. It is what gets done by an 
agency.
    The Secretary is ultimately responsible, but our view on 
him is he is extraordinary. And he has really been a breath of 
fresh air. He made the decision to move ahead and instructed 
VHA last August and publicly announced it on September 15th. 
And we kept asking what is happening, what is happening, what 
is happening by e-mail, not by formal exchange of 
correspondence.
    And in January, we pushed hard enough, said, okay, you keep 
saying that you are working on it, who is working on it. In 
which case, they turned to the General Counsel and the Deputy 
General Counsel, I get a message or a missive from him saying 
you are trying to interfere with a procurement process. No, I 
am not. I am not going to bid on the damn contract. What the 
hell is wrong with you? We just want to make sure it is done 
right.
    We shared all of that e-mail correspondence with the staff 
of the Subcommittee on Health on both sides of the aisle, and 
so it is documented, and had conversations with the Chief of 
Staff and with the Secretary as recently as breakfast this 
morning. And he was somewhat surprised to find out that they 
were not funding anything having to do with Agent Orange and 
that the NVVLS still there was no publicly visible action on 
it. Maybe there is some behind the scenes that they refused to 
share with us.
    But from our point of view, there are certain things on 
procurements that you have to keep confidential until it is 
listed in the Federal Register. But the general strategy, you 
do not have to go silent on. You do not have to put up a Wall 
of Omerta, if you will, towards either the constituents and 
representatives or certainly not towards the Congress.
    The Chairman. Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman.
    Let me just ask each of you yes or no. I mentioned earlier 
that I like the idea of an interim report from the VA on the 
longitudinal study.
    Do you agree? Just go across.
    Mr. Weidman. Yes, sir.
    Mr. Wilson. Yes.
    Commander Wells. Yes, sir.
    Mr. Rossie. I think the answer is yes, but I think they 
have enough to move on right now.
    Dr. Wersel. Yes.
    Mr. Stearns. Okay. Mr. Weidman, do you think the 
experiences of servicemembers in Iraq and Afghanistan are 
similar enough to benefit the findings of the longitudinal 
study?
    Mr. Weidman. It is going to inform us a lot about the 
course of the disease over or the medical condition over a 
lifetime, Mr. Chairman, and that is going to for planning 
purposes for this Committee and for the Appropriations 
Committee as well as for VA should inform what kinds of things 
you are doing now.
    Example is the Capital Asset Realignment for Enhanced 
Services formula. If you know that people are going to have X, 
Y, and Z conditions, you need to be planning for that and the 
facilities that you are building today that will still be in 
use 20 years from now. So the answer is, yes, it will be 
valuable.
    Mr. Stearns. So you are saying you feel very strongly that 
the experiences in both Iraq and Afghanistan are similar?
    Mr. Weidman. In terms of combat? Combat is combat.
    Mr. Stearns. No. But I mean in terms of environment and the 
effects on this longitudinal study, dealing with a longitudinal 
study. I am not talking about combat, but I am just saying the 
environment.
    I mean, I guess maybe the question could be re-phrased. Are 
there differences between the two that would have to be nuanced 
in the study so that we would be aware of what the benefits 
would be for the veterans?
    Mr. Weidman. Well, the answer to that question is this, is 
that we should be doing epidemiological studies of a robust 
size on every generation of veterans. The Australians have 
completed three complete epidemiological studies on their 
Vietnam veterans and are running epidemiological studies on 
their soldiers who have served in Iraq and are today serving in 
Afghanistan. That is what we need to be doing and track people 
over the course of a lifetime.
    Why do you do that? You do that so that the anomalies start 
to show up which in and of themselves would be enough in many 
cases for the Secretary to move to service-connect and make 
sure that they are getting medical treatment and benefits where 
deserved and but also should inform where you invest your 
research dollars.
    If your primary purpose is the wounds, maladies, injuries, 
and conditions that stem from military service and it is, it is 
not a generalized medical system, then that should be informed 
by those epidemiological studies.
    There is finally some movement, at least at the top level 
of VA, to start to address the need for an overall 
epidemiological study.
    Mr. Stearns. I assume there is no other study besides the 
Australian study? I mean, the Canadians. There is no other----
    Commander Wells. The only studies that we know of as far as 
the Blue Water Agent Orange are the Australian studies. The 
United States VA has not done. I am not aware of any Canadian.
    I can tell you the Australian study has been peer reviewed. 
It was presented several places, Korea and a few other places, 
although VA put in the Federal Register it was not peer 
reviewed, but, in fact, it was and that information is in the 
prepared text.
    The doctor, Steven Hawthorne, was asked by the Institute of 
Medicine, he is from the University of North Dakota, to review 
the Australian study and he came back and validated its 
results. So as far as I know, that is the extent of the 
research.
    Mr. Weidman. The key question perhaps, Mr. Stearns, was 
asked at the IOM Committee meeting on Monday afternoon when one 
of the scientists, after going back and forth on this, whether 
VA had the standing, said that they had severe doubts about the 
methodology and validity of the Australian study.
    She asked the key question which is have you funded an 
effort to replicate this study to see if you have the same 
results. That is what makes science science is if you replicate 
it and you do not get those results, then you have got a real 
problem.
    VA has the money, but they have never in all this period of 
time, I think it is 8 years since the Australian study came 
out, 9 years, have not tried to replicate that study. They 
shoot it down, discount it, but do not try and replicate it.
    Mr. Stearns. I am just going to conclude, Mr. Chairman, and 
ask each of them a question.
    This question is a little subjective. You do not even have 
to answer it. But based upon the history here, how satisfied 
are you with the VA's recently announced plan to complete the 
study as required by law? Do you believe they will meet the 
established timeline of 2014?
    Do you feel confident that will happen, Mr. Weidman?
    Mr. Weidman. I believe that Secretary Shinseki is serious 
as a heartbeat about it.
    Mr. Stearns. So under his leadership, you think it will 
occur?
    Mr. Weidman. Under his leadership, it will occur despite 
road blocks that may be thrown in the way.
    Mr. Stearns. Mr. Wilson.
    Mr. Wilson. Well, while excited about the 2009 
announcement, we are still a little puzzled about----
    Mr. Stearns. So your answer would be no? I am just looking 
for yes or no here. Maybe?
    Mr. Wilson. Yes.
    Mr. Stearns. Okay. Mr. Wells.
    Commander Wells. Based on history, I would have to say I 
would be very surprised if they did.
    Mr. Stearns. There is a no. Okay.
    Mr. Rossie.
    Mr. Rossie. Historically I would suspect that it would be 
late.
    Mr. Stearns. No. Okay.
    Dr. Wersel. I agree. I think it would late. I think they 
might just hope we forget about it.
    Mr. Stearns. Okay. Mr. Chairman, we have the veterans 
coming up in the next panel and so they have their work cut out 
for them because they have the group here, almost the majority 
of them, more than the majority think that they will not meet 
the deadline.
    Thank you.
    The Chairman. Thank you, Mr. Stearns.
    Again, we thank all of you for testifying and making us all 
aware, or reminding us, that with all the words about studies, 
there are people here and we have to take care of them. I thank 
you all.
    Mr. Weidman, I think it is within the gift laws limitation 
if you can get me Wilcox's book, that would be great. All 
right? Thank you very much.
    Thank you all.
    The third panel joining us this afternoon is Dr. Joel 
Kupersmith, the Chief Research and Development Officer of the 
Veterans Health Administration, accompanied by Dr. Victoria 
Cassano, Director of Radiation and Physical Exposures and the 
Acting Director of the Environmental Agents Service of the 
Veterans Health Administration.
    Thank you for being here. Dr. Kupersmith, you may proceed.

    STATEMENT OF JOEL KUPERSMITH, M.D., CHIEF RESEARCH AND 
   DEVELOPMENT OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY VICTORIA ANNE 
CASSANO, M.D., MPH, DIRECTOR, RADIATION AND PHYSICAL EXPOSURES, 
  AND ACTING DIRECTOR, ENVIRONMENTAL AGENTS SERVICE, VETERANS 
   HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Kupersmith. Thank you.
    Mr. Chairman, Ranking Member, and Members of the Committee, 
thank you for the opportunity to appear today to discuss our 
progress in conducting the National Vietnam Veterans 
Longitudinal Study and the illnesses associated with exposure 
to Agent Orange.
    I am accompanied today by Dr. Victoria Cassano from our 
Office of Public Health and Environmental Hazards.
    In 1983, the Congress mandated that VA conduct a study on 
post-war psychological problems among Vietnam veterans. VA 
contracted with an external entity, the Research Triangle 
Institute, to conduct the National Vietnam Veterans 
Readjustment Study.
    The study completed in 1988 provided an extensive report of 
disabilities including post-traumatic stress disorder in 
Vietnam era veterans and is considered to be a landmark study 
of post-traumatic stress disorder and its consequence in 
Vietnam veterans.
    In 2000, Congress passed and the President signed the 
Veterans Benefit and Health care Improvement Act, which became 
Public Law 106-419. Section 212 of this legislation directed VA 
to contract for a follow-up study of Vietnam veterans in the 
original 1988 NVVRS.
    In 2001, individuals then at the VA entered into a contract 
with the same contractor for NVVLS. However, delays, escalating 
costs, and concerns about contracting practices prompted 
suspension of the study and cancellation of the contract before 
data collection began.
    An Office of the Inspector General audit report confirmed 
these concerns.
    Following these events, VA initiated a broad portfolio of 
scientifically rigorous studies dedicated to addressing the 
needs of the Vietnam veteran population and offered two of 
these as alternatives to restarting the NVVLS.
    In September 2009, the Secretary of Veterans Affairs 
announced that the Agency planned to award a contract to an 
external entity to conduct NVVLS. VA has reinstituted the 
process to contract for completion of NVVLS paying close 
attention to prior OIG recommendation and the intent of Public 
Law 106-419.
    In September 2009, the Office of Research and Development 
took over the study. We convened a scientific panel and other 
experts as part of an integrated project team to develop 
requirements for NVVLS. The scientific panel consisted of 
subject matter experts from within and outside the Department, 
a number of whom were involved in the original NVVRS study.
    This panel identified several challenges to reopening 
NVVLS, which are detailed in my written statement.
    As part of reopening NVVLS, the integrated project team 
developed a performance work statement and acquisition package 
during 2009.
    In early March 2010, this group forwarded the package to 
the VA Contract Review Board. Once the acquisition package has 
been approved, VA will solicit bids and evaluate proposals.
    We expect this will be completed this summer. VA will then 
award the contract and begin the study in early fall. The 
integrated project team has determined milestones for the study 
and the contracting officer will use performance metrics to 
monitor progress to avoid previous problems.
    Between 2011 and 2013, the awarded contractor will obtain 
Institutional Review Board, which is part of every study done 
by everyone inside and outside the VA, and Office of Management 
and Budget approvals for the project and initiate the study 
under VA monitoring.
    By 2014, the data should be available for analysis and we 
anticipate the results will be available shortly thereafter for 
publication in the Scientific Journal.
    VA is committed to the success of the NVVLS and will 
continue to keep Congress apprised of any significant 
developments. I believe it has already made progress reports on 
it.
    In addition to its research portfolio for Vietnam veterans, 
VA has a number of health care programs specifically designed 
for this population. VA established the Agent Orange Registry 
to track the special health concerns of veterans who may have 
been exposed to Agent Orange during their military service.
    VA also operates three War-Related Illness and Injury 
Centers that provide clinical expertise for veterans with 
deployment health concerns or difficult to diagnose illnesses.
    VA is also in the process of updating the Veterans and 
Agent Orange Veterans Health Initiative, which will cover a 
range of issues including Agent Orange, infectious diseases, 
PTSD, other psychological outcomes and reproductive outcomes 
specific to the Vietnam War.
    Earlier this year, the VA published a regulation to 
establish presumptions of service-connection between exposure 
to herbicides in Vietnam and Parkinson's disease, ischemic 
heart disease, and all B-cell leukemias. The new rule will 
bring the number of categories of illness presumed to be 
associated with herbicide exposure to 14 and significantly 
expand the current leukemia definition to include a much 
broader range of chronic B-cell leukemias beyond chronic 
lymphocytic leukemia previously recognized by VA.
    VA has previously recognized a number of other illnesses as 
presumptively service-connected for exposure to herbicides 
during the Vietnam War.
    Mr. Chairman, Vietnam veterans represent the largest 
proportion of veterans in terms of service area and VA will 
continue to deliver them the quality of health care and 
benefits they deserve.
    I thank you again for your support for our work in this 
area and for the opportunity to appear for you today. I am now 
prepared to answers your questions. Thank you.
    [The prepared statement of Dr. Kupersmith appears on p. 
86.]
    The Chairman. Dr. Kupersmith, we put the VA on the third 
panel so they could listen to the first two and then respond.
    Dr. Kupersmith. Yes.
    The Chairman. You have not said a word about the earlier 
testimony. You read your prepared statement----
    Dr. Kupersmith. Well, I----
    The Chairman [continuing]. Which basically said what I 
said.
    All you do is confirm the fact that all you care about is 
process and not about people. Why don't you respond to some of 
the issues that were raised?
    Dr. Kupersmith. Okay.
    The Chairman. Why is this taking so long? In fact, tell me 
who should be fired because it has been taking this long and 
why are you not responding to the substance of the situation?
    Dr. Kupersmith. Okay. Well, I am happy to answer the 
questions. And first of all, let us talk about the feasibility 
of the study. I think it was said that the reason that we had 
some questions about the feasibility was the ability to find 
the veterans. That is not true.
    The feasibility and the numbers that we have depend on how 
many veterans are still alive, how many will consider----
    The Chairman. Why do we need this? Are people not suffering 
from Agent Orange problems? Why don't you just treat them and 
give them the disability payments?
    Dr. Kupersmith. Well, I----
    The Chairman. Why are you going through all this stuff?
    Dr. Kupersmith. Okay.
    The Chairman. It is ridiculous to ask questions if you are 
going to give me the same explanation about the process.
    Dr. Kupersmith. I do not think it is process, if I may say 
that. We will determine the number of veterans who can answer 
these questions. That is part of the study.
    The Chairman. I could have told you Parkinson's was 
presumptive 20 years ago. Why did it take you this long to 
compensate the disease?
    Dr. Kupersmith. Well, if you would like----
    The Chairman. Or any of the other 13 or 20 diseases?
    Dr. Kupersmith [continuing]. I represent research. If you 
would like, we have a representative from Veterans Benefits 
Administration (VBA) here, Mr. Sampsel, and if you wish, he can 
answer questions directed at those.
    The Chairman. Okay, Mr. Sampsel, please come to the witness 
table. He does not look too happy about coming forward. What 
was the question that you referred for him to answer?
    Dr. Kupersmith. Well, you have questions apparently about 
benefits. If you wish to ask them----
    The Chairman. I am saying why are we not giving these 
veterans any benefits? Why are we putting them through this 
incredible bureaucratic maze where people die while fighting 
for benefits?
    Mr. Sampsel. Mr. Chairman, my name is James Sampsel. I work 
for Compensation and Pension Service. I think it is----
    The Chairman. You work for who? I am sorry.
    Mr. Sampsel. Compensation and Pension Service, VA, VBA. We 
provide compensation. I have sympathy for Vietnam veterans 
also. I happen to be a Vietnam veteran.
    The Chairman. Well, that is very nice of you. I appreciate 
that.
    Mr. Sampsel. And I think it is easy to----
    The Chairman. Sympathy is not what they are looking for. 
They are looking for treatment and compensation.
    Mr. Sampsel. Well, I do not know that I can answer your 
questions.
    The Chairman. That is what I thought.
    Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Doctor, you mentioned that the VA is committed to the 
success of this longitudinal study.
    Dr. Kupersmith. I am sorry. I could not understand what you 
said.
    Mr. Michaud. You had mentioned that the VA is committed to 
the success of this study----
    Dr. Kupersmith. Yes.
    Mr. Michaud [continuing]. The longitudinal study. I guess 
my concern is we required that a long time ago. And the big 
concern that I have just only being on this Committee for a 
short 8 years, the Committee actually passed legislation that 
required the VA to pay the full cost of veterans' nursing home 
care for State Veterans Homes. The VA decided, through their 
rule-making process, to narrow what full cost meant.
    Also in 2009, and I will get to my question, in 2008, we 
passed Mr. Moran's legislation that said the VA will establish 
five pilot programs within each Veterans Integrated Service 
Network (VISN), the total VISN. The VA was ready. They did not 
report back until March. They said they cannot implement that 
legislation. They needed changes.
    We changed the law. Then VA was actually looking at 
narrowing the full VISN pilot program to certain regions within 
the VISN, which is contrary to what the law stated. Thank God 
that the VA is going to now do the full VISN.
    My concern is that even when Congress and the President 
might pass legislation, those who are supposed to implement it 
is doing everything they can to implement it the way that they 
want it. And the fact that it has taken this study so long and 
we are still not getting anywhere is really concerning.
    And according to the GAO report, VA confirmed that it would 
release the request for proposal in the spring of 2010 and it 
is already May 5th and the request for proposal has not yet 
been released.
    You know, what is the cause of the delay and is the VA 
really moving forward and interested in getting the study done 
is my first question?
    My second question is, why can you not use what Australia 
did? We heard a lot in the previous panels about Australia. Why 
can you not utilize that study? Is there something wrong with 
that that we cannot utilize it? And I would like you to answer 
those two questions.
    Dr. Kupersmith. Okay. Thank you.
    Yes. We are committed to do this study. We took this study 
over when the Secretary directed us to do it. The first part of 
it has been discussing all the aspects with a scientific panel. 
And as I said before, the scientific panel consists mainly of 
people who were involved in the NVVRS study, so they are very 
knowledgeable in this area. And I believe the advice they have 
given us is of the highest, highest quality.
    The other part of the initial process has been to be 
meticulous about contracting. I mean, looking back to the first 
attempt at this, we read very carefully the Inspector General's 
report. There is a number of items of recommendation that they 
made about contracting and we are following every one of them.
    We expect that the contract will be let, if that is the 
right term, very soon, this month, and it is in the very last 
phases. Contracting is, as you know in government, a difficult 
process, but it is being done.
    Once that is done, you know, there will be bids and when 
the contract is awarded, we have assured this time around 
unlike last time that the contractor will have to have a plan, 
a research plan for this and will have to abide by performance 
measures and a number of other factors that were not done 
before following the OIG report.
    The time we take now, I mean, certainly this has been 
delayed many years, the time we take now to assure 
meticulousness about contracting will be less time in the 
future if it is done incorrectly. So that has been our 
approach.
    Now, as far as your other question, I think perhaps one of 
the other members can answer, address those.
    Dr. Cassano. Sir, could you please repeat the second 
question for me?
    Mr. Michaud. You heard about the Australian study that went 
on. Why can we not use that? Is there something dramatically 
wrong with that study that we cannot utilize that?
    Dr. Cassano. Sir, I am well aware of the Australian study 
as are other individuals in my office. To go back a little bit, 
we were already in discussion with Institute of Medicine on 
doing a Blue Water Navy study before this last panel reported 
out. The small segment of that entire report that was given to 
the Blue Water Navy issue did not seem to us to be robust 
enough for the Secretary to be able to--for us to be able to 
make any recommendation to the Secretary.
    We think the Australian study needs to be looked at. We 
also want to look at any other relevant information. Blue Water 
Navy means a lot of different things.
    And just to reiterate boots on the ground, as you know, 
sir, it is not just boots on the ground. It is boots on the 
ground and those serving as riverines and in the inland 
waterways and the coastal ships.
    We have very many Blue Water ships that are already and 
continue to be included in the Brown Water Navy cohort of 
ships, over 20, and we add more every week, every month almost. 
That is continually being updated.
    The question becomes do you make this entire issue one that 
goes all the way out to Yankee Station, which is 100 miles 
offshore or similar to where the Australian ships were 
operating, which was slightly different than where all of our 
Blue Navy ships were operating.
    So I think it is in the best interest of all of us, of all 
Vietnam Veterans. And believe me, sir, I was in college at the 
time and if I were male, I probably would have been a Vietnam 
vet. I am a veteran. I am retired Navy. These were my friends 
and my colleagues that were over there. So it is not a matter 
of not being interested. It is a matter of trying to actually 
align the science with what we may empirically know and what we 
may anecdotally know.
    But based on the laws that we are required to work with 
under the IOM process, we need scientifically significant----
    The Chairman. Why did you reverse the policy toward the 
Blue Water Navy veterans? There was no new law. You have the 
authority to change it. Why don't you change it back?
    Dr. Cassano. Sir, I cannot speak to that. I can certainly 
find that for you.
    The Chairman. Who can?
    Dr. Cassano. I will get that answer.
    The Chairman. Can anybody? Apparently the Blue Water Navy 
was considered to be part of the cohort and then it changed. 
You are talking all about aligning the science with anecdotal 
and empirical knowledge. I want to know why this policy was 
changed and why you don't just change it back? You have the 
authority to do if you changed it from one to the other.
    Dr. Kupersmith. I do not have the authority. I mean, so we 
will take that question and respond to it.
    [The VA subsequently provided the information in the answer 
to Question #14 in the Post-Hearing Questions and Responses for 
the Record, which appears on p. 110.]
    The Chairman. Thanks. Appreciate it.
    Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman.
    Dr. Kupersmith, were you involved with the original 
longitudinal study back in 2003, 2004?
    Dr. Kupersmith. No.
    Mr. Stearns. Were you involved with it subsequent to 2004? 
I mean, were you involved in 2005, 2006? Did you ever have any 
contact, any relationship with the program?
    Dr. Kupersmith. Not with the study itself, but it was 
discussed while I was there, yes.
    Mr. Stearns. It was discussed?
    Dr. Kupersmith. Yes.
    Mr. Stearns. So you were familiar with it; is that correct?
    Dr. Kupersmith. Yes.
    Mr. Stearns. And were you familiar with the fact that they 
were not fulfilling the contract, that they----
    Dr. Kupersmith. The contract?
    Mr. Stearns [continuing]. Had put out a contract? They 
found that the contract had malfeasance. And were you aware of 
the whole problem that occurred?
    Dr. Kupersmith. Yes. I was made aware of the----
    Mr. Stearns. So you cannot----
    Dr. Kupersmith [continuing]. Inspector General report, yes.
    Mr. Stearns. Okay. So my point is since you knew about it 
and were aware of it, then you want to make sure it does not 
happen again.
    Dr. Kupersmith. Correct.
    Mr. Stearns. Okay. Do you agree with me that we should have 
an interim report on this----
    Dr. Kupersmith. Yes.
    Mr. Stearns [continuing]. Before 2014?
    Dr. Kupersmith. Yes. We have agreed to make those reports, 
yes.
    Mr. Stearns. Those reports plural or a report to Congress, 
this Committee, the full Committee?
    Dr. Kupersmith. Well, I am sorry. My apologies. We have 
agreed to make interim reports, but obviously will make any 
report that you wish, certainly.
    Mr. Stearns. So you think you have no objection to doing an 
interim report to this Committee on how you are doing on the 
longitudinal study; is that correct?
    Dr. Kupersmith. Yes.
    Mr. Stearns. Okay. I have a White Paper from your office 
that we received in March 2010, and it is entitled National 
Vietnam Veterans Longitudinal Study Narrative Summary of 
Activity October, December 2009, in which you outline your 
timeline.
    Dr. Kupersmith. Yes.
    Mr. Stearns. It said here that you plan to submit the 
acquisition plan to the Office of Procurement and Logistics at 
the end of March 2010. Did you do that? Yes or no?
    Dr. Kupersmith. Yes.
    Mr. Stearns. You go further on in this report, it says due 
to the longer than expected preparation of the scientific 
requirements and a potential change in contract support 
structure, the acquisition package is now expected to be 
released in April 2010.
    So this paper disputes that you met the March 2010. In 
fact, it slipped to April 2010.
    Dr. Kupersmith. Yes.
    Mr. Stearns. Are you incorrect?
    Dr. Kupersmith. I am sorry. I----
    Mr. Stearns. When I initially asked you if the acquisition 
submission plan would be done by March 2010, you said yes. Then 
the next paragraph of your own White Paper says that you missed 
that deadline and the package is now expected to be released--
--
    Dr. Kupersmith. Okay.
    Mr. Stearns [continuing]. April 2010.
    Dr. Kupersmith. I am sorry. The dates I have are the 
acquisition package was forwarded to the contract office on 
March 23rd. A contract officer in VISN 6 was assigned on March 
29th and that is where the package is now. We anticipate that 
the contract will be let out, as I said, imminently this month.
    Mr. Stearns. So was it let out in April 2010?
    Dr. Kupersmith. No.
    Mr. Stearns. Okay. So you missed your deadline there.
    Dr. Kupersmith. Okay.
    Mr. Stearns. Okay. That is my point.
    Dr. Kupersmith. Okay. I am sorry.
    Mr. Stearns. My point is it appears from the get-go you as 
a person who knew about the problem have already recognized 
that you are not meeting your own timeline. Is that a correct 
statement?
    Dr. Kupersmith. Well, yes. I mean----
    Mr. Stearns. Okay. Okay. Yes or no. That is all I am 
asking.
    Dr. Kupersmith. Okay.
    Mr. Stearns. Okay. So the panel two before you almost in 
the majority said, no, the longitudinal study will not be met 
on time. So you can see why they are a little pessimistic 
because I just illustrated that you cannot even meet your own 
deadlines. And this here is your White Paper.
    So I guess when can you tell us today that the acquisition 
package will be approved and will be sent to contractors for 
their solicitation?
    Dr. Kupersmith. Imminently, you know, contracting 
determines----
    Mr. Stearns. No. Imminently is not the word.
    Dr. Kupersmith. I cannot----
    Mr. Stearns. What is the date?
    Dr. Kupersmith. The----
    Mr. Stearns. Imminently sounds good, but I think that is 
what we are asking here based upon past experience----
    Dr. Kupersmith. This month----
    Mr. Stearns [continuing]. We want a date.
    Dr. Kupersmith [continuing]. I mean, the contracting office 
is working on this and is about to release it. I cannot----
    Mr. Stearns. About to release it. I think you----
    Dr. Kupersmith. I think you can see, sir, that I cannot 
give you the exact date----
    Mr. Stearns. Okay.
    Dr. Kupersmith [continuing]. Because it is up to 
contracting. And it is true that there was--that is a month or 
less slippage and that there were improvements made in the 
contracting office during that time to assure that these things 
are done as properly as possible. And that may have been the 
reason for the 1-month slippage.
    Mr. Stearns. Do you set the timeline or does someone else?
    Dr. Kupersmith. Well, we----
    Mr. Stearns. No. I mean you personally.
    Dr. Kupersmith. I do not personally.
    Mr. Stearns. Yeah. Okay. So----
    Dr. Kupersmith. We set it in agreement with others. And, of 
course, the Office of Management and Budget is part of the 
timeline. The Institutional Review Board reviews a part of the 
timeline. So, you know, we need to do patient protections. They 
are very important.
    Mr. Stearns. Oh, I do not discount that, but we have had a 
history here of slippage and malfeasance and you are aware of 
it. So now out of the box I see slippage again and sort of 
words that are not giving me assurance that this is going to be 
moving on a strict timeline in which somebody is going to be 
pushing it. So my concern is this is going to slip more and you 
will keep saying it is imminently going to occur and it is not. 
So----
    Dr. Kupersmith. Well----
    Mr. Stearns [continuing]. Can you tell me to the best of 
your knowledge when the acquisition package will be released? 
Give me a date.
    Dr. Kupersmith. I do not want to give you something that 
just comes from my head in response to your question. I mean, 
it will come imminently. It is not up to me to decide the date. 
I have been expecting it every day. And, you know, it will come 
very soon.
    I think you can see that I cannot give you the date and I 
answered the question, but, I mean, it will come and we will be 
notifying you immediately when it comes. I think that, yes, 
there was a slippage of a month due to improvements in the 
contracting process.
    Mr. Stearns. Well, not to beat up on you too much, but the 
point is that 1 month, okay. But if it is going to be 2 months, 
could be 3 months, and I think that is what we are concerned 
about.
    Dr. Kupersmith. It will not be.
    Mr. Stearns. And, you know----
    Dr. Kupersmith. May I say that--I am sorry to interrupt 
you, sir.
    Mr. Stearns. That is all right.
    Dr. Kupersmith. May I just say that it will not be 2 or 3 
months.
    Mr. Stearns. Okay.
    Dr. Kupersmith. My inability to give you an exact date 
tomorrow or the next day or May 12th----
    The Chairman. Would you like to make a bet on what day?
    Dr. Kupersmith. No.
    The Chairman. I bet you will be too early whatever you bet 
on.
    Dr. Kupersmith. Gambling is not legal, so I do not think--
--
    The Chairman. Okay. Let us see how sure you are. Let us 
make a bet--your job versus my job.
    Mr. Stearns. Well, let me just conclude, Chairman, on my 
time that----
    Dr. Kupersmith. No. I----
    Mr. Stearns. Dr. Kupersmith, I think when we leave this 
hearing, all of us want to have assurance that this is going to 
be pushed on time. And so----
    Dr. Kupersmith. I understand that.
    Mr. Stearns [continuing]. You have heard----
    Dr. Kupersmith. I am sorry.
    Mr. Stearns [continuing]. Have heard our concerns. And so 
my point is, just to try and reiterate, your job as knowing 
what the problem with malfeasance and all the things that 
occurred in the past that you will give us assurance this 
morning that you are going to be on top of the situation----
    Dr. Kupersmith. Yes.
    Mr. Stearns [continuing]. And you are going to make sure we 
meet timelines. And hopefully we will get, Mr. Chairman, an 
interim report that we can use and help----
    The Chairman. I hope we are still alive.
    Mr. Stearns. Yeah. Thank you.
    Dr. Kupersmith. Yeah. What is not reflected in any of those 
timelines is the work that we have done to do just what you 
said.
    Mr. Stearns. Yeah.
    Dr. Kupersmith. We have been working on this, members of 
our office and myself have been working on this very hard 
during that entire time, you know, to keep the process moving. 
And, yes, you are correct it was a 1-month slippage.
    Mr. Stearns. Okay. Thank you.
    The Chairman. We do not know it was 1 month. It could be 12 
months by the time we come around to this again.
    This last exchange just proved everything I have been 
saying. All this talk about contracts, acquisitions, and 
packages, etcetera and what do you have?
    You said, it is patient protection. Well, I have news for 
you--the ultimate patient protection is to take care of these 
heroes. You are not taking care of them. You are involved in 
this bureaucratic process that is interminable. It just 
restrengthens, or reinforces, my conviction that we should pass 
legislation that grants all of these Agent Orange claims now.
    I do not care when that report is going to come back. It 
will slip by a month or a year. Then you will find out it is 
not even feasible to do the study. We will just go on and on.
    You said there were people currently on the advisory panel 
who were on the panel from the last study. Well, I am glad they 
are alive because there are a lot of Vietnam veterans who are 
not. That is the problem and we have to cut through the 
bureaucracy right now.
    The fact is that people are suffering and people are dying. 
We better take care of them now and you are not doing it.
    This Committee is adjourned.
    [Whereupon, at 12:35 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

            Prepared Statement of Hon. Bob Filner, Chairman,
                  Full Committee on Veterans' Affairs

    I would like to thank everyone for attending today's hearing 
entitled, ``Health Effects of the Vietnam War--the Aftermath.'' The 
stated purpose of today's hearing is to examine the health effects that 
our veterans sustained during the War in Vietnam as a result of being 
exposed to the toxic dioxin-based concoctions that we now generally 
refer to as Agent Orange.
    As such, we will follow-up on VA's outstanding promise to finally 
conduct the National Vietnam Veterans Longitudinal Study (NVVLS). In 
this vein, we will try to stop the stovepiping in VA by also looking at 
how all of these issues relate to providing benefits for all Agent 
Orange combat veterans for presumptive conditions under current law.
    I want to ensure that we do not leave any of our veterans exposed 
to Agent Orange while fighting overseas uncompensated for their 
injuries and left behind due to VA technicalities. It has been 10 long 
years since Congress mandated that the VA study the long-term lifetime 
psychological and physical health impact of the Vietnam war on the 
veteran of that era. In 2000, Congress required that the VA conduct a 
longitudinal study by building on the findings of the National Vietnam 
Veterans Readjustment Study of 1984.
    The 1984 study was a landmark study, which provided a snapshot of 
the psychological and physical health of Vietnam veterans. A follow-up 
longitudinal study is needed to understand the life course of health 
outcomes and co-morbid events that have resulted from the traumas our 
men and women endured during the Vietnam war.
    Initially the VA adhered to the letter of the law, but halted the 
NVVLS study in 2003 by not renewing a 3-year non-competitive sole 
source contract that they awarded back in 2001. The VA cited cost 
reasons, noting that the original estimate for completing the NVVLS had 
ballooned from $5 million to $17 million.
    The VA took no further steps and ignored the law until this 
Committee received a proposal from former Secretary Peake in January of 
2009. Former Secretary Peake recommended substituting the NVVLS with a 
study of twins who served in the Vietnam War and a study of women 
Vietnam war veterans, which would cost about $10 million.
    Given the cost of the alternative option, it seems to me that the 
VA could have completed the NVVLS on time had the Department chosen to 
allocate the $10 million to the original contract award back in 2003.
    This Committee did not see the merit of the alternative proposal 
and has continued to advocate for the completion of the NVVLS. In 
September 2009, Secretary Shinseki committed to carrying out the NVVLS 
study and while I applaud the Secretary for his commitment, I remain 
cautious and vigilant about this issue.
    Through today's hearing, I would like to better understand the 
progress that the VA has made in conducting the NVVLS study. I also 
hope to learn about the potential barriers that we can proactively 
address so that VA remains on track to complete the study. Also, 
Congress passed several measures to address disability compensation 
issues of Vietnam veterans.
    The Veterans' Dioxin and Radiation Exposure Compensation Standards 
Act of 1984 (P.L. 98-542) required the VA to develop regulations for 
disability compensation to Vietnam veterans exposed to Agent Orange.
    In 1991, the Agent Orange Act (P.L. 102-4) established for the 
first time a presumption of service-connection for diseases associated 
with herbicide exposure. The Agent Orange Act authorized the VA to 
contract with the IOM to conduct a scientific review of the evidence 
linking certain medical conditions to herbicide exposure.
    Under this law, the VA is required to review the biennial reports 
of the IOM and to issue regulations to establish a presumption of 
service-connection for any disease for which there is scientific 
evidence of a positive association with herbicide exposure. However, VA 
illogically back-tracked on the Agent Orange Act regulations by 
reversing its own policy to move to require a ``foot on land 
occurrence'' by Vietnam veterans in order to prove service-connection. 
This means that the Vietnam Service Medals, etc. would no longer be 
accepted as proof of combat.
    This change excluded nearly 1 million Vietnam veterans who had 
served in our Navy, Air Force, and in nearby border combat areas. This 
is an unfair and unjust result that has been litigated endlessly--and 
ultimately against these veterans. I am trying to undo this injustice 
in my bill, the Agent Orange Equity Act of 2009, H.R. 2254. I thank all 
of my fellow colleagues for their support of my bill and urge all 
Committee Members to become a co-sponsor.
    Today, I hope to hear from VA why it reversed its policy that now 
excludes our Blue Water servicemembers from presumptive consideration 
for service-connection and treatment. I also want to know why it is 
ignoring the latest 2009 IOM recommendation that members of the Blue 
Water Navy should not be excluded from the set of Vietnam-era veterans 
with presumed herbicide exposure. I know that VA has asked the IOM to 
issue a report on Blue Water veterans in 18 months, but that's 18 
months too long.
    The ``foot on land'' requirement is especially unreasonable when 
you consider that these servicemembers were previously treated equally 
to other Vietnam Veterans for benefits purposes. Moreover, several 
Australian Agent Orange studies long ago concluded that their Blue 
Water veterans who served side-by-side with our Blue Water veterans 
were exposed to Agent Orange and because of the water distillation 
process on the ships ingested it more directly.
    While I applaud VA for recently adding the three new presumptions 
for Parkinson's Disease, ischemic heart disease and B-cell leukemias 
for Agent Orange exposed veterans, those are three new presumptions for 
which Blue Water veterans may suffer and will not be treated for or 
compensated. I urge VA to start compensating these veterans now. Just 
like it reversed itself in 2002, I strongly urge VA to reverse itself 
now and compensate these deserving veterans.
    Finally, I want to know for sure that VA plans to make sure Blue 
Water veterans are also included in the NVVLS so that they and their 
families and survivors have a chance to get the benefits they deserve 
on equal footing with other Vietnam veterans. I look forward to hearing 
from all of our witnesses today and thank you for being here to examine 
these long-standing issues.

                                 
                Prepared Statement of Hon. John J. Hall

    Thank you Mr. Chairman.
    I'd like to single out the efforts of two other Vietnam veterans 
who brave actions this weekend saved many lives in Times Square. Today, 
Duane Jackson and Lance Orton are heroes all over again, and true 
examples of the remarkable character of the men and women who wear the 
uniform of our country. I have the great honor of representing Mr. 
Jackson in Congress, and I am sure that I join everyone here today in 
extending our thanks to him and Mr. Orton for their vigilance and quick 
thinking.
    The subject before the Committee today is vitally important. The 
Vietnam War ended 35 years ago, but Vietnam veterans haven't stopped 
suffering. The fact that we need to have this hearing now speaks to 
decades of inaction, dishonesty and willful ignorance regarding the 
devastating impacts of Agent Orange and PTSD.
    However unfortunate the current state of affairs, it is clear that 
we need more research on the long term health effects suffered by 
Vietnam veterans. I commend the work of the IOM, especially the 
recommendations last year that found three new diseases are associated 
with Agent Orange. This will help thousands of sick veterans access VA 
health care and benefits.
    Unfortunately, I find these reports to be limited because they only 
consider existing research. VA bills itself as a world-class health 
research institution. Why is VA not directing some of its resources, or 
sponsoring independent research, to study the full impact of a health 
crisis U.S. Armed Forces created for our own servicemembers?
    In 1991 Congress established guidelines for the VA to determine 
scientifically if a particular illness or disorder is associated with 
Agent Orange. In a claims system that is supposed to be non-
adversarial, Congress tilted the standard of proof even further in 
favor of veterans.
    However, Congress was not able to slay one enemy that still plagues 
Vietnam veterans--inertia. By not mandating new research focused on the 
health impacts of Agent Orange, Congress gave the VA means to stall 
benefits to thousands of veterans. I think the time has come for 
Congress to revisit that decision.
    The time has also come for the VA to acknowledge that dangerous 
Agent Orange exposure goes far beyond veterans who set foot on 
Vietnamese soil. Passing Chairman Filner's Blue Water bill, H.R. 2254 
would be an important step in this direction, but veterans who served 
in Guam, Thailand, and even airbases on U.S. soil may have been exposed 
to toxic herbicides. Establishing their exposure may be difficult, but 
we owe it to these brave men and women to raise this issue.
    I strongly support restarting the National Vietnam Veterans 
Longitudinal Study, 8 years after Congress mandated it. I am interested 
in learning the VA's response to the GAO findings, given that GAO's 
report seems to question a number of the VA's rationales for delaying 
the study.
    This weekend I was reminded of the hurdles still facing veterans 
with PTSD. An AP article took a tiny sample of fraud cases and blew 
them out of proportion to imply that it is too easy for veterans to 
receive benefits for PTSD. I think everyone in this room knows how 
laughable that assertion is.
    Of course, the exact opposite is true. That's why I introduced the 
COMBAT PTSD Act and why the VA drafted a rule granting service 
connected disability to veterans who served in a theater of combat if 
they are diagnosed with PTSD.
    Just this week I sat down and talked with a Vietnam veteran from my 
district in New York, Howard Berkowitz. Mr. Berkowitz just received a 
100 percent disability rating from the VA for PTSD which he had 
originally applied for in 2006. Despite having a clear diagnosis of 
PTSD, his claim went nowhere with the VA for more than 3 years until he 
sought help from his Congressman.
    While I was proud to help Mr. Berkowitz receive the benefits he 
earned, it is unacceptable that he had to wait 3 years. Veterans should 
not need to take the extraordinary step of involving their elected 
officials for help with the VA. That is a sign of a system that is 
broken.
    The veterans covered by the topic of this hearing are the last 
generation to include draftees in addition to volunteers. When they 
returned from Vietnam, they were not welcomed home by the public, and 
they have been fighting their own government ever since to receive the 
benefits and health care they earned through service. It is long past 
time to remove these final barriers for Vietnam Veterans and let them 
finally be at peace.
    Thank you Mr. Chairman.

                                 
              Prepared Statement of Hon. Harry E. Mitchell

    Thank you Mr. Chairman.
    As you know, many veterans were exposed to the harmful toxins Agent 
Orange during their service in Vietnam.
    Exposure to herbicides was not considered a health hazard when 
spraying took place.
    As a result, many Vietnam veterans who were exposed to these 
herbicides during the War began to experience serious illnesses upon 
return as well as birth defects in their children.
    While it has been several decades since these soldiers returned 
home from Vietnam, I find it unacceptable that some Vietnam veterans 
are still fighting the VA to get the benefits they deserve.
    I believe that all Vietnam veterans who served whether in the 
inland waterways, the waters offshore, or the airspace above deserve 
benefits they have earned.
    I support Chairman Filner's efforts to extend presumption of 
service-connection for diseases associated with herbicide exposure to 
those that have been previously excluded by the Department of Veterans' 
Affairs' narrow definition of service-connection--mostly Navy veterans.
    Specifically, this bill helps to clarify Congress' intent to 
include all veterans who served in Vietnam as being entitled to 
presumptive service-connection for exposure to Agent Orange. Passing 
this bill honors their service to our Nation and ensures Vietnam 
veterans get the benefits they have earned.
    Ensuring veterans get these services must remain a clear and 
unmistakable priority.
    I look forward to hearing from today's witnesses about how we can 
ensure Vietnam veterans receive the benefits they have earned.
    I yield back.

                                 
                Prepared Statement of Hon. John H. Adler

    I would like to thank Chairman Filner and Ranking Member Buyer for 
holding today's hearing on the Health Effects of the Vietnam War. I 
would also like to thank our witnesses for agreeing to testify.
    We are here today for several important reasons. First, we are here 
to examine the health effects that Vietnam veterans sustained during 
that war, especially concerning their exposure to herbicides we 
generally refer to as Agent Orange. Second, we are here to discuss VA's 
exclusion of Blue Water veterans from presumption of service connection 
for certain illnesses. Lastly, we are here to determine why it has 
taken the VA nearly 10 years to conduct the congressionally-mandated 
National Vietnam Veterans Longitudinal Study.
    Our first President, George Washington, once said, ``The 
willingness with which our young people are likely to serve in any war, 
no matter how justified, shall be directly proportional as to how they 
perceive the Veterans of earlier wars were treated and appreciated by 
their country.''
    Our brave men and women sacrificed their lives and well-being to 
fight on behalf of our country in Vietnam. Since they have returned 
home, this country has been nothing short of ungrateful. We must do 
more for these veterans, starting with ensuring passage of Chairman 
Filner's Agent Orange Equity Act. We must honor their service to our 
country by extending the presumption of service-connection for diseases 
associated with herbicide exposure to all veterans who served in 
Vietnam, whether they had a ``foot on land'' experience or not. These 
veterans deserve the best medical care this grateful nation can 
provide. I look forward to hearing from the VA today that they are 
ready to justly compensate these deserving veterans.
    I also look forward to getting some answers today from the VA about 
why they have been so resistant to conducting a study of the long-term 
lifetime psychological and physical health impacts of the Vietnam War 
on the veterans of that era. Too often, we see the VA acting against 
the best interests of our veterans. As members of this esteemed 
committee, we must remain vigilant in ensuring that the VA is acting as 
our veterans' advocate, not our veterans' adversary.
    I look forward to hearing from our witnesses.
    Thank you, Mr. Chairman.

                                 
 Prepared Statement of Richard A. Fenske, Ph.D., M.P.H., Professor and
     Acting Chair, Environmental and Occupational Health Sciences,
     School of Public Health and Community Medicine, University of
     Washington, Seattle, and Chair, Committee on the Review of the
     Health Effects in Vietnam Veterans of Exposure to Herbicides,
  (Seventh Bienniel Update) Board on the Health of Select Populations,
             Institute of Medicine, The National Academies

                 VETERANS AND AGENT ORANGE: UPDATE 2008

    Good morning, Chairman Filner and Members of the Committee. My name 
is Richard Fenske. I am Professor and Acting Chair of the Department of 
Environmental and Occupational Health Sciences at the University of 
Washington's School of Public Health and Community Medicine. I have 
served on several of the Institute of Medicine's Committees to Review 
the Health Effects in Vietnam Veterans of Exposure to Herbicides--as a 
member on the Committees that prepared Updates 2002, 2004, and 2006 and 
as Chair of the most recent Veterans and Agent Orange (VAO) committee, 
which authored Update 2008.
    The National Academy of Sciences was chartered by Congress in 1863 
to advise the government on matters of science and technology. The 
Institute of Medicine was established in 1970 by the National Academy 
of Sciences to secure the services of appropriate professionals to 
examine policy matters pertaining to the health of the public.
    I will give you a brief overview of the charge to the VAO 
committees and a synopsis of how these committees have approached their 
task. Congress established the mandate for the series of ``Veterans and 
Agent Orange'' reports in the Agent Orange Act of 1991. That 
legislation directed the Secretary of Veterans Affairs to have the 
National Academy of Sciences perform a comprehensive evaluation of 
scientific and medical information regarding the health effects of 
exposure to the herbicides used in Vietnam and then conduct updates 
every 2 years. The Veterans Education and Benefits Expansion Act of 
2001 extended the mandate for biennial updates through 2014. Upon 
receiving a report from IOM, it is up to the VA Secretary to 
``determine whether a presumption of service connection is merited.''
    The legislation indicated that, in making judgments concerning 
compensation of Vietnam veterans for health problems, a somewhat less 
stringent standard of evidence must be used than what would establish 
causality, as was expressed in the 1989 ruling in Nehmer v.  U.S. 
Veterans' Administration: ``The legislative history, and prior VA and 
congressional practice, support our finding that Congress intended that 
the Administrator predicate service connection upon a finding of a 
significant statistical association between dioxin exposure and various 
diseases. We hold that the VA erred by requiring proof of a causal 
relationship.''
    The resulting legislation directed the IOM committees to: 
``determine (to the extent that available scientific data permit 
meaningful determinations)'' the following regarding associations 
between specific health outcomes and exposure to TCDD and other 
chemicals in the herbicides used by the military in Vietnam:

    A.  Whether a statistical association with herbicide exposure 
exists, taking into account the strength of the scientific evidence and 
the appropriateness of the statistical and epidemiological methods used 
to detect the association;
    B.  The increased risk of disease among those exposed to herbicides 
during service in the Republic of Vietnam during the Vietnam era; and
    C.  Whether there exists a plausible biological mechanism or other 
evidence of a causal relationship between herbicide exposure and the 
disease.''

    In reaching consensus about association for health effects, the 
Committees consider only the available scientific evidence; policy 
considerations definitely are not part of their deliberations.
    In 1992, IOM convened a committee that conducted a comprehensive 
evaluation of the peer-reviewed published literature addressing 
association between adverse health outcomes in humans and exposure to 
the herbicides used by the U.S. military in Vietnam. This group 
established the approach that has been followed in large part by the 
following eight committees conducting the biennial updates.
    Agent Orange was only one of several herbicide mixtures or 
``Agents'' used in Vietnam and referred to by the color of the band on 
the barrels they came in. Agent Orange was a 50:50 mixture of two 
phenoxy herbicides, 2,4-D and 2,4,5-T, then in wide use in the United 
States. In addition to various combinations of the phenoxy herbicides 
use in other Agents, two other herbicides, picloram and cacodylic acid, 
were also applied in the deforestation effort. The dioxin, or TCDD, 
contaminating the 2,4,5-T is the component of the herbicides of most 
concern as a toxic chemical, but the VAO committees have also 
thoroughly reviewed all peer-reviewed epidemiological studies 
addressing these four herbicides.
    Of course, the VAO committees have considered epidemiological 
results from studies of the Vietnam veterans themselves to be central 
to their decision-making. The most informative studies evaluate health 
outcomes in terms of serum TCDD levels as a quantitative measure of 
exposure, but until recently such measurements were costly, but 
relatively insensitive, and consequently, uncommon. As the measurement 
technology has improved over time, ever more half-lives for elimination 
have accrued and the residual levels of TCDD in potentially exposed 
veterans will merge with the background levels of the general public. 
For this reason of very scarce accurate exposure information and in 
accord with VA's presumption of exposure to Agent Orange for all 
Vietnam veterans, the original VAO committee adopted the assumption 
that service in Vietnam was a proxy for potential exposure to dioxin 
and herbicides at levels in excess of what would have been experienced 
by non-deployed individuals.
    Over successive updates, VAO committees have become increasingly 
convinced that generating estimates of risks to Vietnam veterans 
(overall, to particular subgroups, or individually) of developing 
particular health problems given as directed in Item B of their charge 
was intractable. Making an estimate of risk entails combining estimates 
of potency (per unit of exposure) for producing a given health outcome 
with corresponding estimates of exposure, but both these aspects of 
risk estimation continued to be unavailable. With the prospect of 
improved exposure estimates in the future being very remote, the 
Committee for Update 2006 made a general statement to this effect and 
stopped reiterating this problem for every health outcome addressed.
    In an effort to anticipate what herbicide-related health effects 
might arise in Vietnam veterans, however, the VAO committees have also 
factored in all relevant epidemiological information on other 
populations exposed to any of the five chemicals of interest. As a 
result, much of the most useful information has come from cohorts that 
were exposed before the Vietnam era, such as herbicide production 
workers, or from study populations whose exposures are better defined 
on an individual basis, such people residing around Seveso, Italy, 
during or after the industrial accident in 1976.
    The original VAO committee also established a set of categories of 
association into which any adverse health outcome could be placed on 
the basis of the epidemiological results found in the published peer-
reviewed literature. The starting point or default category is 
``inadequate or insufficient evidence of an association.'' VAO 
committees list in the inadequate category on the summary table all 
those health problems addressed in the text (because some 
epidemiological information was found) that did not present an 
indication of association. Any health outcome that is not a subtype of 
one of the illnesses mentioned and is not explicitly listed falls in 
the inadequate category. (Being placed in this category does not mean 
that a given health outcome is ``as likely as not'' to be associated 
with herbicide exposure, as some have interpreted the reassignment of 
GI cancers in Update 2006).
    Health problems having evidence of being associated with exposure 
to at least one of the chemicals of interest are placed in either the 
``sufficient evidence'' category or the ``limited or suggestive 
evidence'' category. There is not a discrete dividing point between 
these classifications, so the choice depends on the number, strength, 
and consistency of the statistics for increased risk and how well 
factors like bias and confounding have been accounted for in the 
various studies. Because of the Committee's directive to assess 
statistical association (in keeping with the underlying principle of 
``giving the veteran the benefit of the doubt''), being placed in the 
``sufficient'' category does not necessarily imply that a causal 
relationship has been established for a disease and herbicide exposure. 
Even the criteria for causality applied by scientific review groups do 
not constitute an absolute check list, and those for association are 
still less well defined. As to the role of Item C of the VAO 
committees' charge, evidence of an association is strengthened by 
experimental data supporting biologic plausibility, but there is no 
requirement for biological plausibility for the epidemiological 
evidence of an association to be found either ``limited/suggestive'' or 
``sufficient.''
    The original VAO committee also established a category of 
``suggestive evidence of NO association'' and placed several health 
outcomes in it on the basis of generally negative findings for exposure 
to dioxin. Asserting that a negative has been established is always 
problematic, but for the VAO task placement in this category implies 
that there is negative evidence for each of the five chemicals of 
concern. With more information becoming available on the phenoxy 
herbicides and still virtually none on picloram or cacodylic acid, the 
pattern has become less clear and the Committees for successive updates 
have moved all but one dioxin-specific outcome back into the 
indeterminate ``inadequate or insufficient evidence'' category.
    The summary chart (below) of the health effects for which the VAO 
committees have found the evidence for an association with herbicide 
exposure to be at least suggestive indicates the year of the VAO 
finding and any subsequent adjustment, followed by whether and when VA 
adopted the health condition as being presumptively associated with 
herbicide exposure for Vietnam veterans.
    The Committee for the first comprehensive report, published in 
1994, confirmed that the epidemiological evidence for association with 
herbicide exposure was indeed ``sufficient'' for the conditions that VA 
had previously recognized as being presumptively service-related 
(chloracne, soft tissue sarcoma, and non-Hodgkin's lymphoma). In 
addition to finding that the evidence for statistical association was 
also ``sufficient'' for Hodgkin's disease and porphyria cutanea tarda, 
the first committee reported that there was ``limited or suggestive'' 
evidence of an association with herbicide exposure for respiratory 
cancers, prostate cancer, and multiple myeloma. Over the course of the 
next seven VAO updates, with the exception of hypertension, VA has 
adopted as presumptively service-related all conditions listed has 
having either ``sufficient'' or ``limited/suggestive'' evidence of an 
association with herbicide exposure.
    Following its review of the literature published from October 2006 
through September 2008, the Committee for Update 2008 specified two 
additional conditions (Parkinson's disease and ischemic heart disease) 
as having ``suggestive'' evidence of association with herbicide 
exposure and concluded that hairy cell leukemia and other B-cell 
chronic leukemias belong with chronic lymphocytic leukemia in the 
``sufficient'' evidence category. On March 25, VA posted a Federal 
Register notice of its intention to classify all three as presumptive.
    This concludes my testimony. Thank you for the opportunity to 
testify. I welcome any questions the Committee may have.
   Cumulative findings of IOM's Veterans and Agent Orange Committees
     through Update 2008 (year of IOM finding; year of VA service 
                              connection)

    Sufficient evidence of an association:

      Soft tissue sarcoma (1994; 1990)
      Chloracne (1994; 1985)
      Non-Hodgkin's lymphoma (1994; 1990)
      Hodgkin's disease (1994; 1995)
      Chronic lymphocytic leukemia (2003; 2004) (including 
hairy cell leukemia and other chronic B-cell leukemias) (2009; 2009)

    Limited/Suggestive evidence of an association:

      Respiratory cancers--lung, larynx, trachea (1994; 1995)
      Prostate cancer (1994; 1997)
      Multiple myeloma (1994; 1995)
      Porphyria cutanea tarda (1994-suf, 1996-lim/sug; 1995)
      Early-onset transient peripheral neuropathy (1996; 1997)
      Spina bifida in the children of veterans (1996; 1996 by 
Congress)
      Type 2 diabetes (2000; 2001)
      [Some birth defects in the children of female veterans 
(--; 2000 by Congress)]
      Acute myeloid leukemia in the children of veterans (2001, 
retracted 2002)
      AL amyloidosis (2007; 2009)
      Hypertension (2007; --)
      Ischemic heart disease (2009; 2009)
      Parkinson's disease (2009; 2009)

    Limited/Suggestive Evidence of NO Association:

      Skin cancer, gastrointestinal tumors, bladder cancer, 
brain tumors (1994, retracted 2007)
      Spontaneous abortion following paternal exposure to TCDD 
(2002)

    Inadequate or Insufficient Evidence to Determine Association:

      Most health outcomes reviewed fall in this category 
because there are not enough high quality data available on the 
chemicals of interest to determine whether or not an association exists
      Health outcomes for which no data are available fall into 
this category by default

                                 
         Prepared Statement of Charles R. Marmar, M.D., Chair,
         Department of Psychiatry, New York University Langone
                    School of Medicine, New York, NY

Overview of Post-Traumatic Stress Disorder
    War-zone related post-traumatic stress disorder (PTSD) is a 
psychiatric disorder that includes specific distressing symptoms 
resulting from traumatic exposure to a life threat and/or other highly 
distressing events during deployment, and results in impairments in 
work and relationship functioning. To meet diagnostic criteria for PTSD 
the following seven conditions must be met:

      Exposure to one or more traumatic events during which a 
person experiences, witnesses or is confronted with actual or 
threatened death or serious injury, or threat to the physical integrity 
of self and others.
      At the time of traumatic exposure the person experiences 
intense levels of terror, horror, or helplessness.
      The traumatic event is persistently reexperienced in one 
or more of the following ways: recurrent unwanted memories of the event 
including images, thoughts and perceptions; recurrent distressing 
dreams of the event; acting or feeling as if the traumatic event were 
recurring again; intense psychological distress provoked by reminders 
of the traumatic event; physical reactions when reminded of the event 
including heart racing, sweating, and rapid breathing.
      Persistent avoidance of reminders of the event and 
emotional numbing as indicated by three or more of the following: 
efforts to avoid thoughts, feelings or conversations associated with 
the trauma; efforts to avoid activities, places or people that bring 
back memories of the trauma; difficulty recalling important aspects of 
the traumatic event; loss of interest or participation in previously 
significant and enjoyable activities; feeling distant or cut off from 
other people; trouble experiencing feelings such as love or happiness; 
and feeling that your future will be cut short.
      Persistent symptoms of increased arousal not present 
before the traumatic event as indicated by two or more of the 
following: difficultly falling or staying asleep; irritability or 
outbursts of anger; difficulty concentrating; being alert or watchful 
when there's no real need to be; and strong startle reactions.
      These symptoms persist for more than 1 month.
      These symptoms result in significant emotional distress, 
or impairment in social and occupational functioning.

    In addition to these seven conditions, individuals with post-
traumatic stress disorder may also describe painful feelings of guilt 
for surviving when others died or were more seriously injured; have 
difficulty regulating their emotions; may be troubled by feelings of 
shame and hopelessness; see the world as a dangerous, uncontrollable 
and unpredictable place fraught with future risks; withdraw from 
important family and social relationships; may experience a variety of 
stress related physical problems; and over time if symptoms persist, 
experience negative changes in personality.
    Post-traumatic stress disorder may occur at any age, including 
during childhood and later life. The lifetime risk for PTSD in the 
general American population has been estimated to be 7.8 percent, with 
5 percent for men and 10 percent for women. Risk factors for adult 
onset PTSD include exposure to traumatic events during childhood and 
adolescence, family history of anxiety and depression, family history 
of alcohol and drug abuse, female gender, lower IQ, poorer social 
supports before and after traumatic exposure, higher levels of 
stressful life events in the year before and after traumatic exposure, 
higher levels of terror, horror and helplessness at the time of 
traumatic exposure, and higher levels of dissociation at the time of 
traumatic exposure, including feelings that what was happening was not 
real (as though one were in a movie, dream or a play), feeling distant 
or detached from the traumatic events as they were occurring, 
experiencing time moving in slow motion, muffled sounds, and tunnel 
vision.
    In the general American population, the time course for symptom 
duration is highly variable, with most people developing symptoms in 
the first month, although delayed onset 6 months or longer occurs in a 
minority of cases. Approximately 50 percent of individuals with 
civilian PTSD will recover in the first 3 months. However, recovery 
after 1 year is limited, with half of those with PTSD at 1 year 
remaining symptomatic three to 5 years or longer.

PTSD in Vietnam Veterans
    Nearly 25 years ago, in response to unanswered questions concerning 
Vietnam Veterans' postwar adjustment, the United States Congress 
enacted Public Law 98-160, which directed the Veterans Administration 
to arrange for an independent, scientific study of the adjustment of 
Vietnam Veterans. The purpose of this study was to provide an empirical 
basis for the formulation of policy related to Veterans' psychosocial 
health. In response to congressional mandate, the National Vietnam 
Veterans Readjustment Study (NVVRS; Kulka, Schlenger, Fairbank, Hough, 
Jordan, Marmar & Weiss, 1990, Jordan and colleagues, 1991) was 
conducted. The survey component of the NVVRS was conducted in 1986-87 
with a national probability sample of Veterans who had served in the 
U.S. Army, Navy, Air Force or Marines between August 5, 1964 and May 7, 
1975. The findings of the survey were presented to Congress in 1988. 
Because of its important scientific strengths, including a 
representative sampling of all who had served in the Vietnam War, and 
its comprehensive assessment using reliable and valid measures, NVVRS 
findings have been an important part of the foundation of a federal 
policy related to war veterans for more than two decades.
Highlights of the Findings of the NVVRS
      As of the time the study was conducted in 1986 and 1987, 
the majority of Vietnam theater veterans had made a successful reentry 
into civilian life and were experiencing few symptoms of PTSD or other 
readjustment problems.
      15.2 percent of male Vietnam theater veterans met the 
criteria for current cases of PTSD, representing approximately 479,000 
of the estimated 3.14 million men who served in the Vietnam theater. 
This compared with rates of 2.5 percent for male Vietnam-era veterans 
who did not serve in the Vietnam theater.
      Among Vietnam theater veteran women, current PTSD 
prevalence was estimated to be 8.5 percent of the approximately 7,200 
women who served. This compares with rates of 1.1 percent for female 
Vietnam era veterans who did not serve in the Vietnam theater.
      Comparisons of current and lifetime prevalence indicated 
that 49.2 percent of male and 31.6 percent of female theater veterans 
who had developed PTSD since returning from their war-zone service 
still had it at the time of their 1986-87 survey interview.
      An additional 11.1 percent of male theater veterans and 
7.8 percent of female theater veterans, approximately 350,000 
additional men and women, suffered from partial PTSD.
      30.6 percent of male Vietnam theater veterans and 26.9 
percent of female veterans serving in the Vietnam theater met criteria 
for full PTSD at some time during their lives. Thus, about half of the 
men and one third of the women who ever developed war-zone related PTSD 
had PTSD at the time of the study, a decade or more after the 
conclusion of the war.
      Vietnam veterans with PTSD have higher rates of other 
specific psychiatric disorders including depression and alcohol and 
drug abuse, and a wide variety of other postwar readjustment problems 
affecting work, family functions and physical health.
      Substantial difference in PTSD prevalence rates were 
found by minority status. Prevalence of PTSD was estimated to be 27.9 
percent among Hispanics, 20.6 percent among African-Americans, and 13.7 
percent among Whites/Others. The African-American and White/Others 
differential rates were attributable in part to greater levels of 
warzone stress exposure for African-Americans. The differences between 
Hispanics and the other two groups could not be explained by level of 
warzone stress exposure.
      Interviews conducted with spouses and partners of Vietnam 
theater veterans with and without PTSD indicated that PTSD has a 
substantial negative impact not only on the veterans own lives, but 
also on the lives of spouses, children, and others living with Vietnam 
veterans with PTSD.
      At the time the survey was conducted in 1986 and 1987, 
very substantial proportions of Vietnam veterans with readjustment 
problems had never used the VA or any other source for their mental 
health problems, particularly during the 12 months prior to their 
assessment.

NVVRS Findings on the Impact of PTSD on Military Families
    Post-traumatic stress disorder in those who serve in combat may 
have a profound effect on their relations with their spouses, partners, 
and children. As part of the NVVRS, spouses and partners of 376 Vietnam 
combat veterans were interviewed. These interviews assessed the 
spouses'/partners' views of family and marital adjustment, parenting 
problems, and interpersonal violence, as well as the spouses'/partners' 
view of their own mental health, drug and alcohol problems. It 
additionally assessed behavioral problems of school-age children living 
at home. Compared with families of male veterans without current PTSD, 
the families of male veterans with current PTSD showed markedly 
elevated levels of severe and diffuse problems in marital and family 
adjustment, parenting skills, and violent behavior.
    The spouses/partners of Vietnam theater veterans with PTSD were 
significantly more likely to report lower levels of happiness and life 
satisfaction, higher demoralization scores, and higher numbers of 
alcohol problems. This is true despite the fact that 75 percent to 80 
percent of the spouses/partners were currently working, and the 
majority had worked for most of their relationship with the veteran. 
The spouses/partners had about 13 years of education and, overall, the 
prestige of the spouses'/partners' occupation did not differ 
significantly between the PTSD and non-PTSD groups.
    In addition, the children of male Vietnam veterans with PTSD had 
higher levels of behavioral problems than children of male Vietnam 
veterans without PTSD. The NVVRS findings are consistent with other 
published studies of the impact of combat related PTSD on family 
functioning. Across studies, veterans with PTSD are much more likely to 
report marital, parental, and family adjustment problems than veterans 
without PTSD. Children of veterans with PTSD are much more likely to 
have behavioral problems than children of veterans without PTSD, with 
more than one-third of all male veterans with PTSD having a child with 
problems in the clinically significant range.
    A primary conclusion of the NVVRS findings of the impact of combat 
related PTSD in male Vietnam theater veterans on their families is that 
early treatment for those suffering the effects of combat related PTSD, 
including family therapy, is essential in preventing symptoms of PTSD 
and related psychiatric disorders from wreaking havoc on marital and 
family relationships.

Military Record Validation of War-zone Exposure and PTSD Rates in the 
        NVVRS
    Dohrenwend and colleagues (2006) reanalyzed the prevalence rates of 
PTSD in the NVVRS. They used military records to construct a new combat 
exposure measure that was independent of the veterans' self-report of 
their combat exposure and to crosscheck exposure reports and diagnoses 
of 260 NVVRS veterans. They found little evidence of falsification of 
combat exposure, and a very strong relationship between records-based 
severity of warzone stressor exposure and risk for PTSD. They did find 
adjusted PTSD rates lower than the original NVVRS results, with 18.7 
percent of the veterans developing war related PTSD at some time after 
their return from Vietnam and 9.1 percent currently suffering from PTSD 
11 to 12 years after the war. Current PTSD was associated with moderate 
levels of impairment.
    The PTSD rates reported by Dohrenwend and colleagues can be 
considered a conservative, lower bound estimate of the true prevalence 
rates in the Vietnam theater groups. In particular, they excluded as 
PTSD cases those veterans with a pre-military diagnosis of PTSD. This 
represents a conservative bias given the extensive literature 
demonstrating that childhood trauma exposure is one of the best 
established risk factors for adult onset PTSD in both civilian and 
military studies (Brewin, Andrews and Valentine, 2000). The decision to 
exclude those with pre-combat PTSD accounts for about half of the 
reported prevalence differences from the original NVVRS findings. By 
comparison, adjustment for impairment and exposure documentation 
together account for only 3.8 percentage points of the reduction in 
lifetime prevalence and 3.1 percentage points of the current prevalence 
difference. In other words, half or more of the ``reduction'' in PTSD 
prevalence rates is attributable to not counting as cases those 
veterans who came to Vietnam with one of the most potent risk factors 
for PTSD.

Imperative Need to Conduct a Long-term Follow-up Study to the NVVRS
    The Department of Veterans Affairs (VA) is recognized as an 
international leader in the study and treatment of PTSD. The NVVRS was 
a landmark investigation, providing definitive information about the 
prevalence and etiology of PTSD and other mental health and 
readjustment problems. Findings from the NVVRS were an important 
ingredient in the mix of social and political forces that brought about 
substantial changes in VA policy towards the postwar readjustment 
problems of Vietnam veterans and in the public's understanding and 
acceptance of the concept of PTSD. Because of the high rates of PTSD, 
the strong evidence for the persistence of this syndrome, and the 
strength of its association with war-zone stress exposure, it is 
imperative that the VA have information about the current functioning 
of the participants in the original study. This imperative is 
heightened by the need to understand the long-term mental and physical 
health consequences of war-zone related PTSD to inform strategies for 
preserving resilience and mitigating complications in those serving in 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).
    The November 2000 Public Law 106-419 specified that a follow-up 
study be conducted utilizing the database and sample of the NVVRS 
study. The law specified that the study be designed to yield 
information on the following:

    1.  the long-term course of post-traumatic stress disorder in 
Vietnam Veteran
    2.  any long-term medical consequences of post-traumatic stress 
disorder
    3.  whether particular subgroups of veterans are at greater risk of 
chronic or more severe problems with such disorder
    4.  the services used by veterans who have post-traumatic stress 
disorder and the effect of those services on the course of the 
disorder.

    The proposed follow-up, referred to as the National Vietnam 
Veterans Longitudinal Study (NVVLS) will address the aims mandated by 
P.L. 106-419. Specifically it will accomplish the following:

      Provide important information about the current 
functioning of veterans of the Vietnam War, who will be more than 20 
years further downstream from their Vietnam experiences than they were 
at the time of the NVVRS.
      Systematically document long-term course of PTSD and 
other postwar adjustment problems based on the experiences of a cohort 
with internal and external validity unmatched in the field. Of 
particular interest would be new cases of PTSD, recovery or chronicity 
among prior cases, and the possible impact of VA programs on the course 
and outcome of PTSD
      The NVVLS provides an unparalleled opportunity to 
determine if war zone related PTSD is a risk factor for physical health 
problems. This concern is highlighted by recent findings: a study of 
Iraq and Afghanistan Veterans (Cohen and colleagues, 2009) provided 
preliminary evidence for an increased risk of cardiovascular disease in 
those with PTSD, depression and the combination; and a VA database 
study of middle aged Veterans (Yaffe and colleagues, in press) reported 
a twofold increase in the 10 year risk for dementia in those with PTSD. 
The NVVLS will explore the potential association of PTSD with 
hypertension, adult onset diabetes, increase blood lipids, premature 
morbidity and death due to cardiovascular complications and the risk 
for early onset dementia. The power to detect these associations is 
greatest in veterans in their 50s, 60s and early 70s, the current age 
range of those originally enrolled in the NVVRS.
      Determine the long-term impact of war zone deployment on 
the spouses, partners and children of Vietnam veterans with and without 
PTSD.
      Advance the field's understanding of the etiology of PTSD 
in ways that cross-sectional assessments cannot.
      Determine the patterns of mental health care utilization, 
identify long term barriers to care, determine satisfaction with VA and 
other mental health services, and identify needs for future health and 
mental health services for aging Vietnam Veterans.

Combined Mild Traumatic Brain Injuries and PTSD
    It has been proposed that the signature wound in the global war on 
terror is traumatic brain injury. There are multiple causes of head 
trauma including blast exposure, gunshot wounds, motor vehicle injury, 
and other accidents causing concussive injury. These are the same 
events that are likely to trigger terror, horror and helplessness 
associated with life threat exposure, creating a double jeopardy in 
which veterans are simultaneously exposed to the risk for PTSD and 
concussive head injury. As noted by Ritchie, the severely wounded are 
routinely screened for head trauma, however, others who may have been 
simply knocked unconscious for short periods of time may not present 
for treatment.
    OEF and OIF veterans who have suffered repeated mild traumatic 
brain injuries (TBI), including concussions, may have gone undiagnosed 
in the theater. The symptoms may only surface later, after the veterans 
return home. Given that certain of the symptoms of mild repeated 
concussive head injury and post-traumatic stress disorder are similar, 
including concentration difficulties, sleep disruption, and 
irritability, and given that concussive head injuries are likely to 
occur in settings of a high war-zone traumatic stress exposure, 
veterans with dual diagnosis PTSD and TBI will present unique 
diagnostic and treatment challenges. As one example: cognitive 
behavioral treatment, the best evidence-based psychosocial treatment 
for PTSD, depends upon intact cognitive functioning which may be 
compromised following repeated closed head injuries. Repeated closed 
head injuries, particularly in those who are genetically vulnerable, 
also constitute risk factors for early cognitive decline and dementia.
    The VA's recent institution of mandatory training in traumatic 
brain injury for health care professionals is an important step in 
preparing to better manage the long-term consequences of concussive 
injuries in the war zone.
    Assessment of TBI was not a focus in the NVVRS. It will be of great 
interest to determine the incidence of mild TBI in the NVVLS and how 
closed head injuries have influenced the course of Vietnam combat 
related PTSD.

Importance of Conducting the NVVLS for the Readjustment of Iraq and 
        Afghanistan Veterans
    An estimated 1.9 million American men and women have served in 
these conflicts and are at risk for psychiatric problems. The NVVLS 
will generate critical knowledge about risk and resilience, course and 
complications of war-zone related PTSD on veterans and their families 
over a more than a four decade time frame. This knowledge has the 
potential to serve as a blueprint for better preparing for the 
readjustment needs of those serving in Operation Enduring Freedom (OEF) 
and Operation Iraqi Freedom (OIF). The urgent need to plan for long-
term mental health consequences of OEF and OIF is underscored by the 
following research findings:

PTSD in OEF and OIF Personnel
    Hoge and colleagues (2004, 2006, 2007) have published studies 
reporting on PTSD and associated psychological problems related to 
combat duty in Iraq and Afghanistan. Highlights from those research 
findings are as follows:

      Exposure to combat was significantly greater among those 
deployed to Iraq than Afghanistan.
      Three to 4 months after their return from combat duty, 
15.6 to 17.1 percent of those who were deployed to Iraq met screening 
criteria for major depression, generalized anxiety disorder, or PTSD.
      In their initial report published in 2004, only 23 to 40 
percent of those who screened positive for mental health problems 
sought mental health care.
      Those screening positive for mental disorders were twice 
as likely as those screening negative for mental disorders to report 
concerns about possible stigmatization and other barriers to seeking 
mental health care.
      One year after deployment, or at the time of separation 
from military service if earlier than 1 year, 19.1 percent of 
servicemembers returning from Iraq screened positive for mental health 
problems compared with 11.3 percent returning from Afghanistan. Mental 
health problems were significantly associated with combat experiences, 
mental health care referral and utilization, and attrition from 
military service.
      35 percent of the Iraq war veterans accessed mental 
health services in the year after returning home.
      Combat experienced soldiers serving in Iraq reported 
greater physical health complaints relative to soldiers with no prior 
combat experience.
      Among battle injured soldiers who served in OEF and OIF, 
4.2 percent had probable PTSD at 1 month, compared with 12.0 percent at 
7 months post-deployment. Among battle injured soldiers who served in 
OEF and OIF, 4.4 percent had probable depression at 1 month, compared 
with 9.3 percent at 7 months.
      Among battle injured soldiers who served in OEF and OIF, 
early severity of physical injuries was strongly associated with later 
PTSD or depression, with an important delay in the onset for symptoms 
in a majority of cases.
      In a sample of 2863 soldiers 1 year after their return 
from combat duty in Iraq, 16.6 percent met screening criteria for PTSD. 
PTSD was significantly associated with lower ratings of general health, 
more sick call visits, more missed workdays, more physical symptoms, 
and higher somatic symptom severity. These results remained significant 
after controlling for being wounded or injured.
      High prevalence rates of physical health problems among 
Iraq veterans with PTSD 1 year after deployment have important 
implications for delivery of medical services, including the importance 
of DoD primary care screening of those who present with physical 
symptoms for combat related PTSD.

    Recently Seal and colleagues (in press) investigated longitudinal 
trends and risk factors for mental health diagnoses among Iraq and 
Afghanistan veterans. Among 289,328 Iraq and Afghanistan veterans 
entering Veterans Affairs (VA) health care from 2002 to 2008 using 
national VA data, 106,726 (36.9 percent) received mental health 
diagnoses; 62,929 (21.8 percent) were diagnosed with post-traumatic 
stress disorder (PTSD) and 50,432 (17.4 percent) with depression. 
Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after 
the invasion of Iraq. Active duty veterans younger than 25 years had 
higher rates of PTSD and alcohol and drug use disorder diagnoses 
compared with active duty veterans older than 40 years (adjusted 
relative risk = 2.0 and 4.9, respectively). Women were at a higher risk 
for depression than were men, but men had over twice the risk for drug 
use disorders. Greater combat exposure was associated with higher risk 
for PTSD.

Limitations of Current Studies of Readjustment of OEF and OIF Veterans; 
        Relevance for Conducting the NVVLS
    A recent Institute of Medicine (IOM) report notes that the majority 
of studies of OEF and OIF Veterans have relied on samples of 
convenience, limiting their external validity, and limiting 
generalizability to all men and women who have served in active duty, 
guard and reserve components. The studies to date have for the most 
part relied on brief screening instruments to identify key outcomes and 
to estimate prevalence, which limits internal validity. The use of 
cross-sectional designs limits the ability to support causal inference 
and to elucidate the course of disorders. The NVVRS, if complimented 
with the NVVLS, will provide critical lessons learned for anticipating 
the long-term readjustment needs of OEF and OIF veterans and will 
inform resource allocation in planning for health care services. Of 
note, because the NVVLS will be a longitudinal study of a true 
probability sample of all who served in Vietnam, it is the only design 
option which will address all of the internal and external validity 
concerns raised by the IOM report.
References:
    1990--Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, 
Marmar CR, Weiss, DS. Trauma and the Vietnam War Generation. New York: 
Brunner/Mazel.
    1990--Jordan BK, Schlenger WE, Hough RL, Kulka RA, Weiss DS, 
Fairbank JA, Marmar, CM. Lifetime and current prevalence of specific 
psychiatric disorders among Vietnam veterans and controls. Archives of 
General Psychiatry. 48:207-215
    2006--Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, 
Marshall R. The psychological risks of Vietnam for U.S. Veterans: a 
revisit with new data and methods. Science. 313:979-82.
    2000--Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk 
factors for post-traumatic stress disorder in trauma-exposed adults. J 
Consult Clin Psychol. 68:748-66.
    2009--Cohen BE, Marmar C, Ren L, Bertenthal D, Seal KH. Association 
of cardiovascular risk factors with mental health diagnoses in Iraq and 
Afghanistan war veterans using VA health care. JAMA. 302:489-92.
    2010--Yaffe K, Vittinghoff E, Lindquist K, Barnes D, Covinsky K, 
Neylan T, Kluse M, Marmar, C. (in press). Post-Traumatic Stress 
Disorder and Risk of Dementia among U.S. Veterans. Archives of General 
Psychiatry.
    2004--Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman 
RL. Combat duty in Iraq and Afghanistan, mental health problems, and 
barriers to care. N. Engl J Med. 2004 Jul 1;351(1):13-22.
    2006--Hoge CW, Auchterlonie JL, Milliken CS. Mental health 
problems, use of mental health services, and attrition from military 
service after returning from deployment to Iraq or Afghanistan. JAMA. 
295:1023-32.
    2007--Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC.
    Association of post-traumatic stress disorder with somatic 
symptoms, health care visits, and absenteeism among Iraq war veterans. 
Am J Psychiatry. 164:150-3.
    2010--Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar 
CR. (in press). Trends and risk factors for mental health diagnoses 
among Iraq and Afghanistan veterans using Department of Veterans 
Affairs health care, 2002-2008. Am J Public Health.

                                 
  Prepared Statement of Randall B. Williamson, Director, Health Care,
                 U.S. Government Accountability Office
  VA HEALTH CARE: Progress and Challenges in Conducting the National 
                  Vietnam Veterans Longitudinal Study

    Mr. Chairman and Members of the Committee:
    I am pleased to be here today as you discuss the National Vietnam 
Veterans Longitudinal Study (NVVLS). According to the Department of 
Veterans Affairs (VA), experts estimate that up to 30 percent of 
Vietnam veterans have experienced post-traumatic stress disorder 
(PTSD), an anxiety disorder that can occur after a person is exposed to 
a life-threatening event.\1\ Veterans suffering from PTSD may 
experience problems sleeping, maintaining relationships, and returning 
to their previous civilian lives.\2\ Additionally, studies have shown 
that many veterans suffering from PTSD are more likely to be diagnosed 
with cardiovascular disease and other diseases.
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    \1\ Unless otherwise noted, Vietnam veterans refers to those who 
served in Vietnam during the Vietnam era, from February 28, 1961, 
through May 7, 1975. See 38 U.S.C. Sec. 101(29). Estimates for Vietnam 
veterans who have experienced PTSD vary. For example, according to the 
Centers for Disease Control and Prevention's 1989 Vietnam Experience 
Study, about 15 percent of Vietnam veterans have experienced PTSD. 
American Psychiatric Association, Diagnostic and Statistical Manual of 
Mental Disorders, Fourth Edition, Text Revision (Washington, D.C., 
2000).
    \2\ Those diagnosed with PTSD may also suffer from other ailments, 
such as depression and substance abuse.
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    After the Vietnam War, Congress wanted information about the 
psychological effects of the war on Vietnam veterans to inform the need 
for PTSD services at VA. Consequently, in 1983, Congress mandated that 
VA provide for the conduct of a study on PTSD and related postwar 
psychological problems among Vietnam veterans.\3\ VA contracted with an 
external entity, the Research Triangle Institute, to conduct the 
National Vietnam Veterans Readjustment Study (NVVRS).\4\ According to 
VA, the NVVRS was a landmark study and is the only nationally 
representative study of PTSD in Vietnam veterans. PTSD is an ongoing 
concern for Vietnam veterans, and today, Vietnam-era veterans still 
constitute the largest group of veterans receiving VA care for PTSD.\5\ 
Congress and others have been concerned about the continued prevalence 
of PTSD and VA's capacity to meet the needs of Vietnam veterans. In 
section 212 of the Veterans Benefits and Health Care Improvement Act of 
2000, Congress required that VA contract with an appropriate entity to 
conduct a follow-up study to the NVVRS.\6\ The law specifies certain 
requirements that the follow-up study must meet, including that the 
study must use the database and sample of the NVVRS and be designed to 
yield information on the long-term effects of PTSD and whether 
particular subgroups were at greater risk of chronic or more severe 
problems with PTSD. In 2001, VA awarded another contract to the 
Research Triangle Institute to plan and conduct a follow-up study, the 
NVVLS.\7\ However, in 2003, before data collection for the study began, 
VA terminated the contract and the study was not completed.\8\ In 
September 2009, the Secretary of Veterans Affairs announced that the 
agency planned to award a new contract to an external entity to conduct 
the NVVLS.
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    \3\ Veterans' Health Care Amendments of 1983, Pub. L. No. 98-160, 
Sec. 102, 97 Stat. 993, 994-95. This law defined Vietnam veterans as 
those who served in Vietnam or elsewhere in the Vietnam theater of 
operations from August 5, 1964, through May 7, 1975, the Vietnam era. 
See 38 U.S.C. Sec. 101(29) (1982).
    \4\ Other collaborators, such as Louis Harris and Associates, Inc., 
and The Graduate Center of the City University of New York, were also 
involved in conducting the NVVRS.
    \5\ When we use ``Vietnam-era veteran'' in this testimony, we are 
using the current governing definition: from February 28, 1961, through 
May 7, 1975, for veterans who served in Vietnam, and from August 5, 
1964, through May 7, 1975, for veterans who served in any other 
location. See 38 U.S.C. Sec. 101(29).
    \6\ Pub. L. No. 106-419, Sec. 212, 114 Stat. 1822, 1843-44. 
Throughout this testimony, we refer to section 212 as the law.
    \7\ A longitudinal study approach involves the repeated examination 
of a set of study participants over time.
    \8\ In this testimony, we use ``2001 NVVLS attempt'' to refer to 
the efforts that began in 2001 to complete the NVVLS. After the 
contract was terminated, VA's Office of Inspector General investigated 
the 2001 NVVLS attempt. The resulting 2005 report found that VA did not 
properly plan or administer the study contract. It recommended that VA 
use appropriate contracting processes to complete the mandated follow-
up study. See Department of Veterans Affairs, Office of Inspector 
General, Audit of VA Acquisition Practices for the National Vietnam 
Veterans Longitudinal Study (2005).
---------------------------------------------------------------------------
    My testimony is based on our May 2010 report,\9\ which is being 
released today, and discusses two issues related to VA's current 
efforts to address the law: (1) the recent progress VA has made in 
conducting the NVVLS and (2) the challenges VA faces in its plans to 
conduct the NVVLS.
---------------------------------------------------------------------------
    \9\ GAO, VA Health Care: Status of VA's Approach in Conducting the 
National Vietnam Veterans Longitudinal Study, GAO-10-578R (Washington, 
D.C.: May 5, 2010).
---------------------------------------------------------------------------
    To obtain information about VA's progress in conducting the NVVLS 
and its challenges, we interviewed VA officials responsible for 
managing VA's PTSD research, including officials on the project team 
responsible for restarting the NVVLS.\10\ We also interviewed VA 
officials who are conducting VA's studies of PTSD in male twin Vietnam-
era veterans and female Vietnam-era veterans. In addition, we obtained 
and reviewed relevant documents regarding VA's PTSD research studies, 
including a draft performance work statement \11\ and progress report 
for the NVVLS, study protocols for the studies on male twin Vietnam-era 
veterans and female Vietnam-era veterans,\12\ and other documents 
related to the study methodologies. In order to understand how the 
NVVLS will be conducted, we also obtained and reviewed information 
about the NVVRS and the 2001 NVVLS attempt.
---------------------------------------------------------------------------
    \10\ The NVVLS project team is composed of 14 individuals, 
including 7 VA officials who are handling various aspects of the study, 
3 VA representatives who are subject matter experts, 2 non-VA 
representatives who are subject matter experts, and 2 facilitators.
    \11\ A performance work statement, also known as a statement of 
work, is a description of the work the government expects the 
contractor to perform.
    \12\ A study protocol is a document that describes the formal 
design of a research study.
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    To provide context for the information we obtained from VA, 
particularly about VA's reported challenges in conducting the NVVLS, we 
interviewed 10 researchers who are currently involved in or have 
previously been involved in managing or conducting PTSD research.\13\ 
The criteria we used to select the researchers we interviewed included 
expertise in PTSD, as indicated, for example, by service on national 
committees focused on veterans and PTSD, and knowledge of or 
involvement with the NVVRS, the 2001 NVVLS attempt, or the NVVLS. We 
chose these researchers to represent a range of perspectives on the 
studies we examined: for example, we interviewed both researchers who 
are currently employed by VA and researchers who are not employed by 
VA. To obtain additional perspectives on study design techniques and 
feasibility issues, we also interviewed three Department of Health and 
Human Services methodologists: two from its Agency for Healthcare 
Research and Quality and one from its Centers for Disease Control and 
Prevention.\14\
---------------------------------------------------------------------------
    \13\ We contacted a total of 13 researchers, but 3 researchers 
declined to speak with us. Two of them felt unable to provide specific 
comments on our issues, and the third stated that he did not have time 
to speak with us.
    \14\ In addition, we interviewed representatives of two veteran 
service organizations, the Vietnam Veterans of America and Disabled 
American Veterans, in order to obtain their perspectives on the 
concerns and needs of veterans with PTSD. We also contacted 
representatives from the American Legion.
---------------------------------------------------------------------------
    We conducted this performance audit from October 2009 through April 
2010 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives.
    In summary, we found that since September 2009, VA has taken a 
number of steps toward conducting the NVVLS. VA convened a project team 
for the NVVLS consisting of VA officials and PTSD experts both within 
VA and outside of VA. According to VA officials, the NVVLS project team 
developed a performance work statement, which outlines VA's 
requirements for the contractor selected to conduct the NVVLS.\15\ VA 
expects to select a contractor for the NVVLS in the summer of 2010 and 
for the NVVLS to be completed in 2013. VA officials stated that they 
plan for the NVVLS to meet all of the requirements of the law where 
scientifically feasible. In addition, VA is conducting studies of PTSD 
in male twin Vietnam-era veterans\16\ and female Vietnam-era 
veterans,\17\ and VA officials maintain that these studies will also 
provide useful information in response to the law.
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    \15\ We reviewed a draft version of this performance work 
statement.
    \16\ This study, officially titled ``A Twin Study of the Course and 
Consequences of PTSD in Vietnam Era Veterans,'' began in 2006 and is 
projected to finish in 2013. The objectives of the study are (1) to 
estimate the longitudinal course and current prevalence of PTSD; (2) to 
identify the relationships between the longitudinal course of PTSD and 
veterans' current mental and physical health conditions, such as 
cardiovascular disease, diabetes, depression, and substance use 
disorders; and (3) to identify the relationships between PTSD and 
veterans' current functional status and disability. VA estimates that 
5,306 men will participate in the study. This study defines the Vietnam 
era as 1965 through 1975.
    \17\ This study, officially titled ``Long Term Health Outcomes of 
Women's Service During the Vietnam Era,'' began in 2008 and is 
projected to conclude in 2014. The study will examine the following 
issues in Vietnam-era female veterans: (1) the prevalence of lifetime 
and current psychiatric conditions, including PTSD; (2) physical 
health; and (3) the level of current disability. According to VA, 
approximately 7,000 women will participate in the study. This study 
defines the Vietnam era as July 4, 1965, through March 28, 1973.
---------------------------------------------------------------------------
    VA reported that it faces several challenges in restarting the 
NVVLS. However, in several instances, the researchers and 
methodologists we interviewed offered suggestions for how these 
challenges could be addressed. The challenges reported by VA included 
the following:

      Locating and gaining consent from NVVLS participants. VA 
officials stated that they did not know how many of the NVVRS 
participants can be located and would agree to participate in the 
NVVLS, which could impact the feasibility of the study. While 6 of the 
10 researchers and the 3 methodologists we interviewed agreed that it 
could be challenging to locate the original participants, 9 of the 
researchers offered suggestions for overcoming this challenge, such as 
using the data sources and methods from previous successful efforts to 
reconnect with study participants and taking advantage of current 
technology.\18\ All 10 researchers and 3 methodologists stated that to 
encourage participation, it was important for NVVLS participants to 
receive assurances of confidentiality--that is, assurances regarding 
use of their identifying information, as was done with the NVVRS 
participants.\19\ According to VA's draft performance work statement 
for the NVVLS, the NVVLS consent form will not contain these assurances 
of confidentiality but it will state that study participation will not 
affect participants' VA benefits or VA health care. However, the draft 
performance work statement also states that the agency plans to take 
possession of study participants' identifying data at the conclusion of 
the NVVLS. While nine of the researchers commented that this 
requirement could impact whether veterans would agree to participate in 
the NVVLS, VA stated that it conducts many internal research studies 
and has no material issues recruiting study participants due to 
mistrust of VA.
---------------------------------------------------------------------------
    \18\ The one researcher who did not offer a suggestion stated that 
VA may not be able to overcome the challenge.
    \19\ The NVVRS provided participants with assurances of 
confidentiality via the NVVRS consent form, which stated that their 
identifying information would not be disclosed in any government 
proceedings.
---------------------------------------------------------------------------
      Mitigating possible bias in a follow-up study. VA 
officials said that there could be bias in the NVVLS because the NVVRS 
was not designed to accommodate a follow-up study. The three 
methodologists we interviewed stated that this challenge was closely 
related to the challenges of locating the original participants and 
obtaining their agreement to participate in the study--that is, bias 
will be present in the NVVLS if representative participation across the 
subgroups included in the NVVRS is not achieved.\20\ The methodologists 
stated that if bias in the NVVLS is a concern, VA could survey 
additional individuals from the general Vietnam-era population to 
supplement the original NVVRS cohort or develop a new sample of 
participants from the general Vietnam-era population for the NVVLS. 
VA's draft NVVLS performance work statement states that the contractor 
can choose to examine all or some of the NVVRS participants, but does 
not address the question of whether the contractor could propose to 
survey other Vietnam-era veterans.
---------------------------------------------------------------------------
    \20\ The NVVRS was required by law to provide information on 
certain subgroups, specifically veterans with service-connected 
disabilities, female veterans, and minorities.
---------------------------------------------------------------------------
      Assessing PTSD in the NVVLS. VA officials were concerned 
about appropriately assessing PTSD in the NVVLS. Because there was no 
widely accepted PTSD screening method at the time the NVVRS was 
conducted, the study's estimates of PTSD prevalence were based on a 
multimeasure approach involving the use of 10 PTSD assessment 
instruments administered to a subset of NVVRS participants by doctoral-
level mental health professionals. VA officials stated that this 
complex approach has not been used in other PTSD studies and would not 
be desirable to replicate. Nine of the 10 researchers we interviewed 
stated that the multimeasure method used to identify PTSD in the 
original study was not of concern.\21\ In order to provide comparable 
longitudinal data, 9 of the researchers and 2 of the methodologists we 
interviewed recommended that the NVVLS contractor use PTSD assessment 
instruments similar or identical to those used in the NVVRS in addition 
to more current approaches.\22\ According to the NVVLS draft 
performance work statement, the PTSD instruments used in the NVVRS 
should be used in the NVVLS, when appropriate, to enhance consistency 
and facilitate long-term analyses. The draft performance work statement 
also recommends that newer measures should be included when possible.
---------------------------------------------------------------------------
    \21\ One researcher thought the method used to identify PTSD in the 
NVVRS was of concern because the PTSD assessment instruments used in 
the method lacked validity. However, this researcher acknowledged that 
these instruments may have been the best available at the time.
    \22\ One researcher said that this approach would not necessarily 
be recommended because it may burden the participants and reduce 
participation rates.

    Overall, VA officials do not know whether, given the challenges 
they face, the NVVLS can be completed. VA's NVVLS draft performance 
work statement includes an initial phase during which VA expects the 
contractor to assess the feasibility of the study. All 10 researchers 
we interviewed said that restarting the study soon is important because 
as the study participants continue to age, an increasing number will be 
lost for follow-up because of illness or death.\23\ Nine of the 
researchers told us that they believe it is important for VA to 
complete the NVVLS because it will potentially provide important, 
nationally representative information on PTSD and related issues in 
Vietnam-era veterans.
---------------------------------------------------------------------------
    \23\ The youngest Vietnam-era veterans still living today would be 
approximately in their early 50s. During the 2001 NVVLS attempt, the 
researchers estimated that 8.5 percent of the Vietnam-era veterans who 
originally participated had died.
---------------------------------------------------------------------------
    In responding to a draft of the report from which this testimony is 
based, VA explained its position on the ownership of the NVVRS and 
NVVLS study data. VA stated that the NVVRS contract provided that the 
study data was the property of the agency and did not provide that the 
identifying information be kept from VA. The agency also stated that 
the NVVRS consent documents did not restrict VA from possessing the 
identifying information of participants. VA confirmed that the agency 
intends to receive all the NVVLS study data, including participants' 
identifying information, upon completion of the study, and stated that 
the NVVLS consent form will explain to participants that VA does not 
intend to use the data to determine eligibility for VA benefits.
    Mr. Chairman, this concludes my statement. I would be pleased to 
respond to any questions you or other Members of the Committee may 
have.
Contacts and Acknowledgments
    For further information about this testimony, please contact 
Randall B. Williamson at (202) 512-7114 or [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this testimony. Individuals who made 
key contributions to this testimony include Mary Ann Curran, Assistant 
Director; Susannah Bloch; Stella Chiang; Martha R. W. Kelly; Lisa 
Motley; Rebecca Rust; and Suzanne Worth.

                                 
Prepared Statement of Richard F. Weidman, Executive Director for Policy 
          and Government Affairs, Vietnam Veterans of America

    Chairman Filner, Ranking Member Buyer, and distinguished Members of 
this committee, on behalf of our officers, Board of Directors, and 
members, thank you for allowing Vietnam Veterans of America (VVA) the 
opportunity to present our testimony today regarding the implementation 
of the health effects of the Vietnam War and the efforts to discern 
those effects, including the National Vietnam Veterans Longitudinal 
Study.
National Vietnam Veterans Longitudinal Study
    No one really knows how many of our troops in Iraq and Afghanistan 
have been or will be affected by their wartime experiences, despite the 
early intervention by psychological personnel. No one really knows how 
serious their emotional and mental problems will become, nor how 
chronic the neuro-psychiatric wounds (particularly PTSD) and the 
resulting impact that this will have on their physiological health. 
However, reports from researchers at Walter Reed have suggested that 
troops returning from service in Afghanistan and Iraq are suffering 
mental health problems at rates at least comparable to or higher than 
the levels seen in Vietnam War veterans, if indeed not higher rates.
    There is no reason to believe that the rate of veterans of this war 
having their lives significantly disrupted at some point in their 
lifetime by PTSD will be any less than those estimated for Vietnam 
veterans by the National Vietnam Veterans Readjustment Study. There is 
mounting peer reviewed evidence that the incidence of PTSD will be even 
greater than in the Vietnam generation, largely because of ever longer 
exposure to hostile action.
    Results from the original NVVLS which was conducted more than 20 
years ago demonstrated that some 15.2 percent of all male and 8.5 
percent of all female Vietnam theater veterans were current PTSD cases, 
e.g., at some time during 6 months prior to interview. Rates for those 
exposed to war zone stress were dramatically higher--a four-fold 
difference for men and seven-fold difference for women--than rates for 
those with low or moderate stress exposure. Rates of lifetime 
prevalence of PTSD were 30.9 percent among male and 26.9 among female 
Vietnam theater veterans. Comparisons of current and lifetime 
prevalence rates indicate that 49.2 percent of male and 31.6 percent of 
female theater veterans, who ever had PTSD, still had it at the time of 
their interview. Thus the NVVLS was a landmark investigation in which a 
national random sample of all Vietnam theater and era veterans, who 
served between August 1964 and May 1975, provided definitive 
information about the prevalence and etiology of PTSD and other mental 
health readjustment problems. The study over-sampled African-Americans, 
Latinos, and Native Americans, as well as women, enabling conclusions 
to be drawn about each subset of the veterans' population.
    The NVVLS enabled the American public and medical community to 
become aware of the documented high rates of current and lifetime PTSD, 
and of the long-term consequences of high stress combat exposure. 
Because of its scope, the NVVLS has had a singular effect on VA 
policies, health care delivery, and service planning. In addition, 
because the study clearly demonstrated high rates of PTSD and strong 
evidence for the persistence of this disease, it was generally accepted 
that the VA would pursue a follow-up, or longitudinal, study of the 
original participants in this seminal research project.
    Thus in 2000, Congress, by means of Public Law 106-419, mandated 
the VA to contract for a subsequent report, using the same 
participants, to assess their psychosocial, psychiatric, physical, and 
general well-being. Such research would become a longitudinal study of 
the mortality and morbidity of the participants, and draw conclusions 
as to the long-term effects of service in the military as well as about 
service in the Vietnam combat zone in particular. The law requires that 
the VA use the previous report, and the same sample population, as the 
basis for the longitudinal study.
    In early 2001, the VA solicited proposals for non-VA contractual 
assistance to conduct a longitudinal study of the physical and mental 
health status of a population of Vietnam era veterans originally 
assessed in the NVVLS. It is apparent that a follow-up to the NVVLS is 
necessary to meet the requirements of the law, and to do what just 
makes sense in both policy and scientific terms. However, not only has 
the VA failed to meet the letter of the law, there has been no effort 
to build upon the resources accumulated from this unique and 
comprehensive study of Vietnam veterans in a highly cost-efficient and 
scientifically compelling manner.
    A longitudinal study would provide clues about which VA health care 
services are effective and about ways to reach veterans who receive 
inadequate services or do not seek them at all. This has important 
consequences for America's current veterans, and for future veterans 
not to mention the casualties returning today from the wars in Iraq and 
Afghanistan.
    At that same hearing on Research & Development on June 7, 2006, the 
VA also said that it could not conduct the study because staffers could 
only find 300 of the original more than 2,500 persons in the 
statistically valid random sample chosen by the Gallup Organization at 
a public cost of more than $1 million in 1984 dollars. If that were 
true (which strains credulity at best), then that would mean that 85 
percent of that valid national sample have died in the past 25 years. 
VVA would suggest that, if true, this should be front-page news. The VA 
has claimed in the past that they would be better off using the widely 
discredited and failed ``Twins'' study data base from the Centers for 
Disease Control and Prevention (CDC) that has no women at all and not 
nearly enough African-Americans, Hispanics, or Asian-Americans to make 
valid conclusions. Furthermore, the twins ``sample of convenience'' 
database is so small that it is not a statistically valid random sample 
for anybody. One can speculate that the VA has refused to obey the law 
because officials do not want a longitudinal study, or perhaps they do 
so because they do not want validation of the results of what the NVVLS 
may demonstrate in regard to high mortality and morbidity of Vietnam 
veterans, especially those most exposed to combat.
    It is now clear that the VA has been ignoring the law and the 
Congress and just plain refusing to undertake the study, until 
recently. It also seems clear that some in the VHA hierarchy intend to 
continue delaying the study and/or doing everything they can to stop 
the study from being done correctly, despite the orders from Secretary 
Shinseki last September 15. Clearly the senior officials in the Office 
of Research & Development (ORD) think they can act this way with 
impunity, and so far there has been no action or repercussions from 
this ``slow rolling'' dilatory behavior to disabuse them of their 
hubris.
    The VA has said in past Congressional testimony that ``the 
Inspector General stopped the study,'' when in fact the Inspector 
General (IG) has no line authority to do any such thing. The then 
Undersecretary and Secretary halted the study. The only real criticism 
by the IG was for VHA failing to follow proper contract procedures or 
exercise proper oversight. The VA convinces no one that this decision 
is anything by the so-called permanent bureaucracy to try and minimize 
possible future costs to the VA by underestimating the needs of combat 
veterans.
    It has now come to our attention that the VA, though their contract 
officer is apparently still demanding of the Research Triangle 
Institute (RTI) to know the names and social security numbers of the 
participants in the original study, who had been assured anonymity. 
Previous as well as current VHA leaders not only have tried to besmirch 
the reputation of this respected research institution by citing things 
in a report by the VA IG that the report did not contain, but now they 
are threatening RTI with legal and or other punitive actions, through 
the VA contract officer, if they don't violate privacy rights of the 
participants in this study. This unconscionable effort to compromise 
the study population, to violate basic scientific principle of 
protection of human subjects, as well as an effort to again violate the 
privacy rights of the individuals concerned, must be stopped by 
Congress before the VA totally mucks things up and precludes a proper 
follow-up study ever being done on this population.
    Secretary Shinseki ordered VHA and ORD to move forward to complete 
the replication of the National Vietnam Veterans Readjustment study, 
thereby making it a robust longitudinal mortality and morbidity study 
of Vietnam veterans (NVVLS), has resulted in inaction since he 
announced the order to proceed on September 15 of last year. There has 
not even been a ``Sources Sought'' notice put out to discover which 
private research institutions might be interested in this contract, 
much less any concrete action in the almost 7 months since the 
announcement. We are somewhat baffled as to why this clear thwarting of 
a direct order of the Secretary is allowed to continue.
    With your strong support, we are hopeful that the VA will finally 
do the right thing and finish this study and intended by the Congress, 
and observe scientific ethics in doing so. The results of this study 
are vitally important to this Committee and to all stakeholders and 
policy makers as plans for the future of VA services are being made 
now.

Agent Orange
    VVA reiterates our strong support for early passage of H.R. 2254, 
the Agent Orange Equity Act. We must do whatever needs to be done, in 
this 35th year since the end of the Vietnam war, to ensure that these 
veterans receive some measure of justice as soon as possible.
    Vietnam Veterans of America is the only veterans service 
organization who is a member of the Research!America, which is the 
Nation's premier consortia of groups that strongly favor and advocate 
for increased medical research in America. Our commitment to this 
effort is unflagging.
    Mr. Chairman, there may well be much that is excellent and 
deserving of great respect in the VA Research program. However, most of 
it has little or nothing to do with the wounds, maladies, injuries, 
illnesses, and conditions that stem from military service.
    VA is currently funding no research into the long term effects of 
Agent Orange, nor are they funding any research into the long term 
effects of exposure to environmental toxins in Gulf War I that may be 
causing Gulf War illness.
    VA celebrated Research week in the latter part of April, spending a 
good deal of money and effort to run this self-congratulatory in regard 
to all the wonderful research they are doing that benefits veterans. It 
is, however, not much more than ``spin.'' VVA has inquired as to how 
much money all of this ``hoopla'' costs, including staff time, but has 
yet to receive an answer.
    For the second year in a row VVA did not participate nor support 
this effort, because VA ORD leadership continues to act in an 
irresponsible manner toward Vietnam veterans, as well as other 
generations of veterans, by willfully ignoring the adverse health 
conditions of veterans and our families resulting from exposure to 
toxins during military service. Therefore our decision to not support 
VA's effort was not taken lightly, but only after numerous years of 
unresponsiveness on the part of the current head of ORD.
    We have brought this lack of proper focus in research to the 
attention of the current Secretary of Veterans Affairs, as well his 
last four predecessors, but the pattern does not seem to fundamentally 
change.
    The position of the VA and of the Federal Government is untenable, 
and just not honest on the face of it. First the Federal Government 
does not fund any research into the long term adverse health effects of 
Agent Orange on Vietnam veterans (or our progeny), and then claims that 
there is no scientific proof of any adverse health effects on Vietnam 
veterans, nor our children and grandchildren. Clearly Dow Chemical is 
not going to fund this research. Any reasonable and honest person knows 
this. Therefore this position amounts to ``willful ignorance.'' We 
would suggest that the only unpardonable sin is willful ignorance in 
the face of gross injustice.
    After much thought and discussion within VVA it is clear that while 
pressing for enactment of the pending legislation we must forge a 
contingency plan that will achieve the same purpose. The analogy would 
be that while many of us still believe that health care funding for 
veterans should be mandatory, we supported Advance Appropriations in 
the meantime.
    As the Members of this Committee no doubt know, all of the National 
Institutes of Health (NIH) have two basic sections of their budget: one 
is for intramural research performed with full time scientists employed 
by that institute as the principal investigator; and, two, extramural 
research whereby they put out grants to universities and other private 
and public research entities. VA only has an intramural research 
program at present. Much of the money in this program goes to the 
``stars'' at medical schools that are affiliated with a VA Medical 
Center, whether it has anything in particular to do with the wounds, 
maladies, injuries, illnesses, and adverse health conditions that may 
be attributable to military service or not.
    Clearly what is needed is the creation of an office of extramural 
research at VA that has totally separate leadership that the current 
leadership of ORD. Said office should be structured in such a way that 
there is strong input from the veterans' community and from the 
elements of the scientific community outside of government that have a 
good track record in regard to this kind of research that is focused on 
the wounds, maladies, injuries, illnesses, and adverse medical 
conditions that result from military service, depending on when and 
where one served as well as one's job (MOS) in such service. Further, 
said office should be contracting for epidemiological studies of 
various groupings of veterans, and use that information to inform the 
priorities for further research to be funded.
    Additionally, the need is for full disclosure of all use of any 
form of Agent Orange, other herbicides, or pesticides, or other toxins, 
wherever they were used in the world on military bases. There is 
absolutely no national security reason that would legitimately prevent 
such full disclosure. During the Vietnam war, there is reported use of 
herbicides in Thailand, Okinawa, the Philippines, Guam, and many other 
locations on the Pacific rim. There is also evidence that in addition 
to Eglin AFB there was extensive use of said herbicides on other 
military bases in CONUS during the same time period. This evidence from 
DoD records must be made available to VA, as well as to the public, 
prompting action by the Secretary to extend service connected 
presumption to veterans who served in those locations.
    It is also clear that there is strong evidence, reinforced by the 
latest Institute of Medicine (IOM) report that the so-called ``blue 
water'' Navy veterans should be included in the group of those who are 
included in the presumptive group of those who are considered to be 
``in-country'' Vietnam veterans for purposes of service connection, 
along with their brethren in the Army and Marines. The evidence from 
the desalinization units on board ships resulting in even higher 
exposure to dioxin than many on land is clear.
    Mr. Chairman, again all of us at VVA thank you for this opportunity 
to present our testimony before you today. I will be pleased to answer 
any questions that you or your distinguished colleagues may have.

                                 
   Prepared Statement of Joseph L. Wilson, Deputy Director, Veterans 
         Affairs and Rehabilitation Commission, American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present the American Legion's 
views on the National Vietnam Veterans Longitudinal Study and illnesses 
associated with exposure to Agent Orange.
    The American Legion supported Public Law (P.L.) 96-151, which 
mandated that the Department of Veterans Affairs (VA) to conduct a 
major epidemiological study of Vietnam veterans who were exposed to 
dioxin, an impurity in the herbicides sprayed by the United States 
(U.S.) military stationed in Vietnam.
    One of the top priorities of the American Legion continues to 
assure that long-overdue, major epidemiological studies of Vietnam 
veterans, who were exposed to the herbicide Agent Orange, are carried 
out. Shortly after the end of the Vietnam War, Congress held hearings 
on the need for such epidemiological studies. The Veterans' Health 
Programs Extension and Improvement Act of 1979, P.L. 96-151, directed 
VA to conduct a study of long-term adverse health effects in veterans, 
who served in Vietnam, as a result of exposure to herbicides. When VA 
was unable to do the job, the responsibility was passed to the Centers 
for Disease Control (CDC). In 1986, CDC also abandoned the project, 
asserting that a study could not be conducted based on available 
records. The American Legion did not give up though. Three separate 
panels of the National Academy of Sciences have agreed with the 
American Legion and concluded that CDC was wrong and that 
epidemiological studies based on Department of Defense (DoD) records 
are possible.
    The Institute of Medicine (IOM) report entitled Characterizing 
Exposure of Veterans to Agent Orange and Other Herbicides Used in 
Vietnam (2003) is based on the research conducted by a Columbia 
University team. Headed by principal investigator Dr. Jeanne Mager 
Stellman, the team has developed a powerful method for characterizing 
exposure to herbicides in Vietnam. The American Legion is proud to have 
collaborated in this research effort. In its final report on the study, 
the IOM urgently recommends that epidemiological studies be undertaken 
now that an accepted exposure methodology is available. The American 
Legion strongly endorses this IOM report.
    Meanwhile, VA estimates 2.6 million Vietnam veterans were exposed 
to Agent Orange. Currently, approximately 900,000 Vietnam veterans are 
alive and eligible for treatment of exposure to Agent Orange-related 
illnesses. To date, the study has not been completed.
    From 1962 to 1971, the United States military used various blends 
of herbicides to remove foliage from trees that provided cover for the 
enemy. One of these herbicides was labeled as Agent Orange. These 
herbicides have been associated with various illnesses affecting 
veterans who served in the Vietnam. The following illnesses are 
currently recognized by VA as being associated with exposure to 
herbicides used in Vietnam:

      Acute and Subacute Peripheral Neuropathy
      AL Amyloidosis
      Chloracne (or Similar Acneform Disease)
      Chronic Lymphocytic Leukemia
      Diabetes Mellitus (Type 2)
      Hodgkin's Disease
      B Cell Leukemias (Pending Final Regulation)
      Ischemic Heart Disease (Pending Final Regulation)
      Multiple Myeloma
      Non-Hodgkin's Lymphoma
      Parkinson's Disease (Pending Final Regulation)
      Peripheral Neuropathy (acute or subacute)
      Porphyria Cutanea Tarda
      Prostate Cancer
      Respiratory Cancers
      Soft Tissue Sarcoma (other than Osteosarcoma, 

Chondrosarcoma, Kaposi's sarcoma, or Mesothelioma)
      Spina Bifida in children of veterans (not including spina 
bifida occulta)
             Children of Vietnam Veterans and Spina Bifida
    In 2003, the American Legion supported and endorsed the expansion 
of spina bifida benefits, as set forth in H.R. 533, the Agent Orange 
Veteran's Disabled Children's Benefits Act of 2003, to a person 
suffering from spina bifida who is a natural child, regardless of age 
or marital status, of a parent who performed ``qualifying herbicide-
risk service,'' provided the individual was conceived after such 
service. A parent would be considered to have performed ``qualifying 
herbicide-risk service'' if, while performing active military, naval, 
or air service, the parent ``served in an area in which a Vietnam-era 
herbicide agent was used during a period during which such agent was 
used in that area; or . . . otherwise was exposed to a Vietnam-era 
herbicide agent.'' Spina bifida is a neural tube birth defect that 
results from the failure of the bony portion of the spine to close 
properly in the developing fetus during early pregnancy.
    According to VA, it is the most frequently occurring permanently 
disabling birth defect; affecting approximately one of every 1,000 
newborns in the US. Although Vietnam veterans are almost out of the age 
category for having children, VA reports that some future births will 
occur and some of these children may have birth defects, to include 
spina bifida. The American Legion urges Congress to amend title 38, 
Chapter 18, to provide entitlement to spina bifida benefits for the 
child or children of any veteran exposed to a Vietnam-era herbicide 
agent, such as Agent Orange, in any location, including those outside 
of Vietnam, where herbicides were tested, sprayed, or stored.
           Children of Vietnam Veterans and Type II Diabetes
    In 2001, VA added type II diabetes to the list of ``presumptive 
diseases associated with exposure to herbicides in Vietnam.'' This 
action was in response to a report by the IOM that found ``limited/
suggestive'' evidence of an association between the chemicals used in 
herbicides during the Vietnam War, such as Agent Orange, and Type II 
diabetes. Type II Diabetes occurs mainly in adults, however, a CDC 
report revealed it is becoming more common among youth and adolescents.
    It is the American Legion's contention that more conclusive 
research be conducted to determine if the effects of exposure to 
herbicides in Vietnam affected the offspring of those who served.

                   Children of Women Vietnam Veterans

    Under P.L. 106-419, the Veterans Benefits and Health Care 
Improvement Act of 2000, VA also identified birth defects of children 
of women Vietnam veterans that:

      Are associated with service in Vietnam.
      Result in permanent physical or mental disability.

    The American Legion supported the above piece of legislation and 
urges Congress to include research involving:

      Women veterans who served in Vietnam to include, in 
country and other locations, and were exposed to herbicides.
      Children of both men and women veterans who served in 
Vietnam, to include, in country and other locations, and were exposed 
to herbicides.
                            Blue Water Navy

    IOM, in Update 2008, specifically stated that the evidence it 
reviewed makes the current definition of Vietnam service for the 
purpose of presumption of exposure to Agent Orange, which limits it to 
those who actually set foot on land in Vietnam, ``seem inappropriate.'' 
Citing an Australian study on the fate of the contaminant TCDD when sea 
water is distilled to produce drinking water, an IOM committee stated 
that it was convinced that such a process would produce a feasible 
route of exposure for Blue Water veterans, ``which might have been 
supplemented by drift from herbicide spraying.'' (See IOM, Veterans and 
Agent Orange, Update 2008, p. 564; July 24, 2009.) IOM also noted that 
a Centers for Disease Control and Prevention study in 1990, found that 
non-Hodgkin's lymphoma, a classic Agent Orange cancer, was more 
prevalent and significant among Blue Water Navy veterans. IOM 
subsequently recommended that, given all of the available evidence, 
Blue Water Navy veterans should not be excluded from the group of 
Vietnam-era veterans presumed to have been exposed to Agent Orange/
herbicides. The American Legion submits that not only does this latest 
IOM report fully support the extension of presumption of Agent Orange 
exposure to Blue Water Navy veterans, it provides scientific 
justification to the legislation currently pending in Congress that 
seeks to correct this grave injustice faced by Blue Water Navy 
veterans.
    In December 2009, IOM created a VA sponsored committee to further 
explore the Blue Water Navy exposure issue. The duration of this 
project is to last 18 months. According to IOM, their report will 
include the following:

      Historical background on the Vietnam War, Combat troops, 
Brown Water Navy, Blue Water Navy.
      Discussions on comparison of herbicides exposure to Blue 
and Brown Water Navy veterans; examination of the range of exposure 
mechanisms for exposures, to include toxics in drinking water and air 
exposure from drifts from spraying; food; soil, and skin.
      Conclusion on the comparative risks for long-term health 
outcomes comparing Vietnam veteran ground troops; Blue Water Navy 
veterans; and other ``Era'' veterans serving during the war in Vietnam 
at other locations.
      A complete review of studies of Blue Water Navy veterans 
for health results.

    The American Legion looks forward to the completion of this 
project.

                   Herbicides Used Outside of Vietnam

    The American Legion is also extremely concerned about the timely 
disclosure and release of all information by DoD on the use and testing 
of herbicides in locations other than Vietnam during the war. Over the 
years, the American Legion has represented veterans who claim to have 
been exposed to herbicides in places other than Vietnam. Without 
official acknowledgement by the Federal Government of the use of 
herbicides, proving such exposure is virtually impossible. Information 
has come to light in the last few years leaving no doubt that Agent 
Orange, and other herbicides contaminated with dioxin, were released in 
locations other than Vietnam. This information is slowly being 
disclosed by DoD and provided to VA.
    In April 2001, officials from DoD briefed VA on the use of Agent 
Orange along the Korean Demilitarized Zone (DMZ) from April 1968 
through July 1969. It was applied through hand spraying and by hand 
distribution of pelletized herbicides to defoliate the fields of fire 
between the front line defensive positions and the south barrier fence. 
The size of the treated area was a strip 151 miles long and up to 350 
yards from the fence to north of the civilian control line.
    According to available records, the effects of the spraying were 
sometimes observed as far as 200 meters downwind. DoD identified units 
that were stationed along the DMZ during the period in which the 
spraying took place. This information was given to VA's Compensation 
and Pension Service, which provided it to all of their Regional 
Offices. VA Central Office has instructed its Regional Offices to 
concede exposure for veterans who served in the identified units during 
the period when the spraying took place.
    In January 2003, DoD provided VA with an inventory of documents 
containing brief descriptions of records of herbicides used at specific 
times and locations outside of Vietnam. The information, unlike the 
information on the Korean DMZ, does not contain a list of units 
involved or individual identifying information. Also, according to VA, 
this information is incomplete, reflecting only 70 to 85 percent of 
herbicide use, testing and disposal locations outside of Vietnam. VA 
requested that DoD provide it with information regarding units involved 
with herbicide operations or other information that may be useful to 
place veterans at sites where herbicide operations or testing was 
conducted. Unfortunately, as of this date, additional information has 
not been provided by DoD.
    Obtaining the most accurate information available concerning 
possible exposure is extremely important for the adjudication of 
herbicide-related VA disability claims of veterans claiming exposure 
outside of Vietnam. For herbicide-related disability claims, veterans 
who served in Vietnam during the period of January 9, 1962 to May 7, 
1975 are presumed, by law, to have been exposed to Agent Orange. 
Veterans claiming exposure to herbicides outside of Vietnam are 
required to submit proof of exposure. This is why it is crucial that 
all available information relative to herbicide use, testing, and 
disposal in locations other than Vietnam be released to VA in a timely 
manner. The American Legion urges congressional oversight to assure 
that additional information identifying involved personnel or units for 
the locations already known by VA is released by DoD, as well as all 
relevant information pertaining to other locations that have yet to be 
identified. Locating this information and providing it to VA must be a 
national priority.

         Department of Veterans Affairs (Readjustment Studies)

    In September 2009, VA announced plans to restart the follow-up to 
the 1984 National Vietnam Veterans Readjustment Study, known as the 
National Vietnam Veterans Longitudinal Study (NVVLS). In its 
announcement, VA stated NVVLS will study the Vietnam generation's 
physical and psychological health. In addition, the new study will 
supplement research already in progress at VA, to include studies on 
post-traumatic stress disorder (PTSD) and the health of women Vietnam 
veterans.
    The Veterans Administration (now known as VA) initiated the 
National Vietnam Veterans Readjustment Study in 1984 as a result of a 
congressional mandate. Until the NVVLS completion in 1988, this study 
included utilization of a nationally representative sample of male and 
female veterans. Following the 1984-1988 study P.L. 106-419 required VA 
to contract with a non-VA entity to conduct a new approach. In 
addition, P.L. 106-419 required the new study to employ the database 
and sample population from the original Readjustment Study.
    In January 2001, the Veterans Health Administration (VHA) assigned 
the project to the Mental Health Strategic Healthcare Group (MHSHG) to 
plan and manage the study. The MHSHG, then, created a management 
structure to oversee the study, to include:

      An Executive Committee comprised of the Readjustment 
Counseling Director (Vet Center), three mental health professionals 
from different VA medical facilities, and a veterans' service 
organization (VSO) representative.
      A Project Coordinator and Project Officer; both having 
served in the same capacities during the original Readjustment Study.
      A Scientific Advisory Board of 10 expert consultants in 
various disciplines, to include cardiology-epidemiology, psychiatry, 
and biomedical statistics (A similar advisory board had also been used 
for the original Readjustment Study).

    Later in 2001, VHA allotted $4.9 million and awarded a 
noncompetitive contract to the Research Triangle Institute (RTI) to 
conduct the study, to include $460,000 for Fiscal Year (FY) 2001. 
However, in 2003, after the RTI had worked for more than 2 years, VA 
chose not to exercise the third-year of the contract. This was due to 
concerns of lack of competition in the contract award, as well as 
estimated costs of completing the study, which had increased from the 
original estimate of $4.9 million to $17 million. VA ultimately ruled 
that the study was not properly planned, procured or managed, and 
ordered that it be completed; in the interim they were making 
provisions to avoid these same problems.
    The American Legion, as before and at the onset of all Agent 
Orange-related illnesses, will continue to closely monitor the 
development of all ongoing research on the long-term effects of Agent 
Orange exposure and disclose all findings to Congress regarding any 
perceived deficiencies or discrepancies; and to ensure that Federal 
Government committees charged with review of such research are composed 
of impartial members of the medical and scientific community.

             The American Legion/Columbia University Study

    In 1983, the American Legion initiated a joint study with Columbia 
University to ascertain the effects of exposure to service in Vietnam 
on veterans of the Vietnam War. The joint study facilitators were 
Columbia University Drs. Jeanne Stellman and Steven Stellman. The 
study, a cross-sectional survey of then current and past health status 
among members of the American Legion, compared veterans who served in 
Southeast Asia with those who served in locations outside of Southeast 
Asia. The results of the study revealed serious combat-related mental, 
physical and social problems. Veterans, who served in heavily-spread 
areas, had poorer general health. The studies also showed that veterans 
were not satisfied with the services provided by VA. A follow-up study 
conducted in 1998 showed that many of the health effects had endured 
over the decades.

                               Conclusion

    The American Legion believes the new study facilitators should take 
heed of the circumstances prompting the abrupt halt of the 2001 NVVLS 
study. When studies, such as those involving Agent Orange and of the 
more than 900,000 Vietnam veterans, are proposed and/or conducted, we 
must keep in mind that other circumstantial processes, to include 
funding and contracting, should be properly planned, executed, and 
maintained. Otherwise, opportunities for inclusion of new illnesses are 
missed, resulting in thousands of affected veterans going without 
treatment.
    Other additional consideration placed on the new study includes the 
fact that the previous NVVLS was concluded in 1988. The American Legion 
urges Congress to insist on the assessment and review, with all 
pertinent parties, of all VA-sponsored and IOM studies, to fulfill the 
most recent charge by VA to ensure no evidence and information is 
lacking.
    To prevent that which occurred with the incomplete 2001 NVVLS 
Study, the American Legion encourages proper congressional oversight, 
as well as continuous inclusion of stakeholders, such as veterans' 
service organizations. Since 1990, when the American Legion brought 
suit against the U.S. government for failure to carry out its 
congressionally-mandated Agent Orange study, the American Legion 
remains steadfast in its belief that such studies are needed. The 
American Legion firmly believes Congress should exercise congressional 
oversight to make sure these studies, it has mandated, are carried out. 
We also urge timely disclosure of ongoing studies by IOM, through 
Veterans and Agent Orange (VAO) update publications; promptly every 2 
years, as directed by P.L. 107-103, Veterans Education and Benefits 
Expansion Act of 2001.
    Mr. Chairman and Members of the Committee, the American Legion 
sincerely appreciates the opportunity to submit testimony and looks 
forward to working with you and your colleagues on the abovementioned 
matters and issues of similarity. Thank you.

                                 
 Prepared Statement of Commander John B. Wells, USN (Ret.), Cofounder 
    and Trustee, Veterans Association of Sailors of the Vietnam War

    Good Morning Mr. Chairman and Members of the Committee. I 
appreciate this opportunity to speak with you on behalf of the Veterans 
Association of Sailors of the Vietnam War concerning the ``Health 
Effects of the Vietnam War--The Aftermath.'' I intend to address my 
remarks in support of those who have been left behind. We continue to 
stand with all veterans Blue Water Navy, Blue Sky Air Force, Thailand, 
Laos and Cambodia veterans in seeking the enactment of H.R. 2254 so 
that benefits to all groups may be quickly restored. Our friends and 
allies, the Australians, who fought beside us on land and at sea in 
Vietnam and every conflict subsequent to Vietnam, have taken the lead 
in granting Agent Orange benefits to those who served outside of the 
land mass of Vietnam. They have also taken the lead in the scientific 
research in this field, which has recently been validated by our own 
Institute of Medicine.
    By way of introduction, my name is John B, Wells and I am a retired 
Navy Commander as well as an attorney. I entered the Navy in February 
of 1972 and was commissioned an Ensign in June of 1973. In June of 1974 
I completed the Main Propulsion Assistant course and was assigned to 
the USS Holder (DD-819) as Main Propulsion Assistant. Ships of that 
class served frequently on the gun line off the coast of Vietnam in its 
territorial waters. The ship's distilling plant/evaporators 
(hereinafter distillers) were part of the equipment under my purview. 
In October of 1976 I transferred to the USS Coronado, (LPD 11) also as 
Main Propulsion Assistant. In the fall of 1977 I was reassigned as 
Chief Engineer after that Engineer was detached for cause. I guided the 
ship through a successful Operational Propulsion Plant Examination. 
Again, the ship's distillers were part of the equipment under my 
purview. Later I was asked to oversee the preparation of the ship's 
repair plan for the upcoming shipyard overhaul. While I was onboard, 
the ship deployed to the Caribbean and to the Mediterranean.
    After a 2 year shore assignment, I was assigned to the Surface 
Warfare Officers School Department Head Course. That course included 
several months of engineering training as well as combat systems and 
fundamentals. I was assigned to the USS Badger (FF-1071) as Operations 
Officer. I was also in charge of the ship's shipyard overhaul. When the 
Badger's Chief Engineer was fired, I was assigned to that position. 
Again, the ship's distillers were part of the equipment under my 
purview. I guided the ship through a successful Light Off Examination 
and Operational Propulsion Plant Examination. In 1982, I was assigned 
to the USS Worden, (CG-18) as Chief Engineer. I was responsible for the 
ship's distillers. Worden made deployments to the Western Pacific, 
Indian Ocean and the North Arabian Sea.
    In late 1984, I was reassigned to the staff of the Commander Naval 
Surface Reserve Force. My responsibilities included the operation and 
scheduling for nineteen ships of the Naval Reserve Force. In 1987, I 
was assigned to the pre-commissioning unit of Battleship Wisconsin (BB-
64) as Main Propulsion Assistant. I served as Acting Chief Engineer for 
a number of months until the Engineer reported. Again, the ship's 
distillers were part of the equipment under my purview. I was later 
reassigned as Executive Officer (second in command) of the USS Puget 
Sound (AD-38). Puget Sound's mission was the repair of other ships. The 
ship deployed to the North Atlantic and Indian Ocean-Persian Gulf while 
I was on board.
    In 1989 I was reassigned as Commanding Officer, Naval Reserve 
Readiness Center Pittsburgh, PA. At this time I began attending law 
school during the evening. Part of my responsibilities was the training 
of over 1000 reservists. We developed many training courses including 
engineering courses to include ship's distillers. I retired from the 
Navy, as a Commander on 1 August, 1994. I graduated from Duquense Law 
School with a Juris Doctor approximately 6 weeks prior to my 
retirement.
    In the Navy I was qualified as a Surface Warfare Officer, Officer 
of the Deck (underway), Combat Information Center Watch Officer, 
Command Duty Officer, Tactical Action Officer, Navigator, and 
Engineering Officer of the Watch. I was also qualified for command at 
sea. I received a mechanical engineering subspecialty based on 
significant experience. My ships operated with units of the Royal Navy 
and the Royal Australian Navy. This included NATO exercises, RIMPAC 
exercises and other multi-national exercises and global operations.
    The history of the blue water Navy tragedy begins in Australia. In 
the late 1990s, the Australian Department of Veterans Affairs noticed a 
significant number of Agent Orange related cancers in Royal Australian 
Navy veterans who had never set foot on land in Vietnam. Dr. Keith 
Horsley of the Australian Department of Veterans Affairs met Dr. Jochen 
Muller of the National Research Centre for Environmental Toxicology and 
the Queensland Health Services (hereinafter NRCET) at a conference in 
Stockholm. Dr. Horsley addressed the phenomena with Dr. Mueller who 
agreed to conduct a study to explore the reasons for this apparent 
dichotomy. Dr. Horsley arranged for funding from the Australian 
Department of Veterans Affairs and commissioned NRCET to explore the 
mystery. Their report, entitled the Examination of The Potential 
Exposure of Royal Australian Navy (RAN) Personnel to Polychlorinated 
Dibenzodioxins And Polychlorinated Dibenzofurans Via Drinking Water, 
(NRCET study) was published in 2002. I have talked with the authors of 
that report via telephone and e-mail. My wife, who is a Louisiana 
notary and paralegal, and also an Australian native, traveled to 
Brisbane to interview the authors of the report.
    At about the same time the NRCET report was published, the American 
Department of Veterans Affairs issued a change to their Adjudication 
Procedures Manual (M21-1 Manual) that deleted those soldiers, sailors 
and airmen who did not set foot on land in Vietnam from the presumption 
of herbicide exposure. This decision later led to the litigation 
discussed below.
    As a threshold matter, the vessels of both Australian and American 
origin operated side by side in the waters adjacent to Vietnam. The 
missions were driven by the ship capabilities and not by nationality. 
There was no tactical differences between the operations conducted by 
ships of the United States and Royal Australian Navy.
    The NRCET study noted that ships in the near shore marine waters 
collected waters that were contaminated with the runoff from areas 
sprayed with Agent Orange. NRCET Study at 10. The authors later 
reported to this office that estuary containing the dioxins extended 
more than three nautical miles from shore. This means that the 
contamination would have extended well past the gun line which was 
normally located 2000 to 5000 yards from shore. The distilling plants 
aboard the ship, which converted the salt water into potable drinking 
water, actually enhanced the effect of the Agent Orange. NRCET Study at 
42. The study found that there was an elevation in cancer in veterans 
of the Royal Australian Navy which was higher than that of the 
Australian Army and Royal Australian Air Force. NRCET Study at 13. This 
was confirmed by the ``The Third Australian Vietnam Veterans Mortality 
Study'' (hereinafter 2005 Mortality Study). The NRCET Study at page 35 
noted significant concentrations at Vung Tau, an area visited by 
Australian and American ships. Theories that the Agent Orange stopped 
at the water's edge are simply preposterous. Congress in enacting the 
Clean Water Act recognized that pollutants discharged from shore will 
contaminate the navigable waters, waters of the contiguous zone, and 
the oceans. Anecdotal evidence reports Agent Orange in the waters of 
the rivers which then empty out into harbors and eventfully the 
estuaranine waters. Sailors aboard the HMAS Sydney noted that brown 
water runoff would go many kilometers out to sea. 2005 Mortality Study 
at 196. Da Nang harbor was identified as a serious Agent Orange ``hot 
spot.'' Anecdotal evidence noted that clouds of Agent Orange were blown 
out to sea. Approximately 10-12 percent of the land area was sprayed 
with Agent Orange. In contrast everyone aboard a ship that distilled 
contaminated water from estuarine sources was exposed.
    The distillers all work on similar principles to produce water 
(feed water) for the boilers and potable water for the ship's crew. 
Water is introduced from the sea and is passed through the distilling 
condenser and air ejector condenser where it acts as a coolant for the 
condensers. It is then sent through the vapor feed heater into the 
first effect chamber and into the second effect chamber where it is 
changed to water vapor. Vapor then is passed through a drain regulator 
into a flash chamber and passes through baffles and separators into the 
distilling condenser where it is condensed into water and pumped to the 
ship's water distribution system. Sea water not vaporized is pumped 
over the side by the brine pump. Id. This is the same process discussed 
in the NRCET Study. It was used by American, British and Australian 
ships. In fact many Royal Australian Navy ships were retired United 
States Navy ships or ships of the same class as the American ships. 
Those that were not of American design were often constructed by the 
British. They all used the same system. This system was used well into 
the 1990s. More recently a new system, reverse osmosis, is being 
adopted, but that did not see service during the Vietnam War.
    Potable water was manufactured continuously along with ``feed'' 
water for the ship's boilers. It was a constant headache and as a Chief 
Engineer there were many times that I was given round the clock hourly 
briefings on the status of water. This was especially true in southern 
latitudes such as Vietnam since the higher ambient sea water 
temperatures reduced the efficiency of the distilling process.
    As discussed in the NRCET Study the distilling process enhanced the 
effect of the dioxin. Additionally the dioxin was ingested orally 
through drinking water, food, oral hygiene etc. On land, the dioxin, 
once sprayed, would become embedded in the soil. Since the water 
systems of the ships would have been thoroughly contaminated, the 
dioxin would have adhered to piping and continued to contaminate in an 
ever increasing amount. The authors confirmed this in their discussions 
with my office. The cumulative effect of the contamination would have 
resulted in a very high concentration. It would have taken weeks and 
perhaps months to completely flush the system once the ship moved away 
from contaminated waters. The Australian study confirmed the enhancing 
effects of the shipboard distilling plants. NRCET Study at 42. In other 
words, the effect was even more pronounced than if the veteran had 
merely ingested Agent Orange by breathing it or by drinking water from 
a contaminated stream.
    In their publication in the Federal Register, Vol. 73, No. 73, of 
April 15, 2008, the Department of Veterans Affairs complained that the 
NRCET study was not peer reviewed. Actually it was peer-reviewed and 
published. The report was presented to the 21st International Symposium 
on Halogenated Environmental Organic Pollutants and POPs in Gueongu 
Korea on 9-14 September 2001. It was them published in Volume 52 of 
Organohalogen Compounds (ISBN 0-9703315-7-6) which is published by Dr. 
Jae Ho Yang, Catholic University of Daegu, Korea. Please see http://
espace.library.uq.edu.au/view/UQ:95837 (last visited June 13, 2008). 
More importantly, the study was prepared at the request of and for the 
Australian Department of Veterans Affairs who accepted the study. The 
study was cited in ``The Third Australian Vietnam Veterans Mortality 
Study'' (hereinafter 2005 Mortality Study) published in 2005 by the 
Department of Veterans' Affairs and Australian Institute of Health and 
Welfare and resulted in the Department's consideration of Royal 
Australian Navy Vietnam Veterans as potentially exposed Vietnam 
Veterans. The study was further reviewed at the request of the 
Institute of Medicine's Agent Orange Committee, by Dr. Steven Hawthorne 
of the University of North Dakota. He certified that the NRCET study 
was scientifically viable and that the conclusions, based on Henry's 
Law were correct.
    In their Federal Register article, the DVA asserted that:

        ``VA's scientific experts have noted many problems with this 
        study that caution against placing significant reliance on the 
        study. In particular, the authors of the Australian study 
        themselves noted that there was substantial uncertainty in 
        their assumptions regarding the concentration of dioxin that 
        may have been present in estuarine waters during the Vietnam 
        War.''

    This is a blatant misrepresentation of the author's position. When 
Dr. Caroline Gaus, one of the report's author was questioned on this 
point, she replied as follows:

        ''The problem referred to in this comment is associated with 
        estimating the exposure level of Vietnam Veterans, not with the 
        study's primary finding that exposure to dioxins was likely if 
        (i) drinking water was sourced via distillation and (ii) the 
        source water was contaminated. As highlighted by the authors, 
        the exact level of exposure via this pathway is uncertain due 
        to the lack of data on contaminant levels in the source water 
        during the Vietnam War. The attempt made by the study to 
        estimate the level of exposure serves only as an indication 
        that exposure may have been considerable (and depends on the 
        concentrations in the source water). Hence, the problem lies in 
        the lack of exposure information, not with the study. The study 
        clearly demonstrates that if source water is contaminated, 
        dioxins are expected to co-distill with drinking water.

        This issue is also not related to the study's quality, but 
        rather highlights one of its findings out of context. The study 
        noted that, while increasing suspended sediment loads in the 
        source water decreases the co-distillation of dioxins, dioxins 
        still co-distill with water at the highest level of suspended 
        sediment in the water tested (i.e. at 1.44 g/L 38 percent of 
        2,3,7,8-TCDD co-distilled in the first 10 percent of source 
        water). If 10 percent of the source water is distilled, TCDD 
        would enrich in the drinking water by a factor of almost 4 
        compared to the source water. This was confirmed by using water 
        from a tropical estuary with naturally high suspended sediment 
        loading, where 48-60 percent of TCDD co-distilled with the 
        first 10 percent of source water.

        As noted above and in the study itself, estimating the level of 
        exposure via this pathway is difficult due to the lack of data 
        on the concentrations of dioxins in the source water. The level 
        of exposure would depend strongly on the dioxin concentrations 
        in the source water (which would have varied from location to 
        location) as well as on the amount and duration of water 
        consumed for drinking and/or cooking.

        The study attempted to provide an estimate on the 
        concentrations of dioxins in source water (0.043-0.69 ng/L). 
        While the uncertainty around this value is large (approximately 
        in the order of a factor of 10 or more), it cannot be 
        determined whether it represents an over- or underestimate 
        (which would also depend on location). Hence, it would be 
        difficult to determine whether the level of exposure was 
        similar, higher or lower compared to veterans who served on 
        land. However, the study demonstrates that exposure is likely 
        to have occurred if source water was contaminated and suggests 
        that exposure may have been considerable.

    Notably the study Identification of New Agent Orange/Dioxin 
Contamination Hot Spots in Southern Viet Nam Final Report conducted by 
Hatfield Consultants in 2006 noted significant hot spots in the land 
and waters internal to Vietnam, including Da Nang harbor. Concentration 
levels were still significant, over 30 years after the end of the war.
    The DVA Federal Register comment contained the curious remark that 
one had to assume that the sailors drank only the contaminated water 
and only for an extended period of time. That is a safe assumption. All 
Navy ships manufacture potable drinking water from sea water. This 
water is replenished almost daily. These ships did not have the 
capacity to carry potable water throughout the voyage without 
replenishment via their distillers. These ships patrolled the entire 
coast of Vietnam and often anchored in harbors to provide gunfire 
support. To infer that these ships never steamed through contaminated 
waters is naive. Additionally, there was no means to transport large 
quantities of water outside of the reserve potable water tanks. Nor was 
there a long water hose connecting the ship with Hawaii.
    As previously discussed the NRCET study was cited in the 2005 
Mortality Study. That study was conducted by the Australian Institute 
of Health and Welfare for the Australian Department of Veterans 
Affairs. It found a 19 percent increase in mortality for Navy veterans 
over the Australian population. This is despite the fact that mortality 
among Vietnam veterans as a whole was lower than the general Australian 
community. In another study, Cancer Incidence in Vietnam Veterans 2005 
(hereinafter the 2005 Cancer Study), the Australian Department of 
Veterans Affairs again cited the NRCET study. The 2005 Cancer Study 
found that Royal Australian Navy veterans had the highest rate of 
cancer, higher than expected by 22-26 percent, followed by Army 
veterans, higher than expected by 11-13 percent and Air Force veterans 
with a 6-8 percent higher than the expected rate of cancer. Navy and 
Army veterans showed a higher than the expected incidence of cancers of 
the colon, oral cavity, pharynx and larynx and cancers of the head and 
neck and gastrointestinal. Whereas Navy veterans demonstrated a higher 
than the expected incidence of gastrointestinal cancer, Army and Air 
Force veterans showed higher than the expected incidence of Hodgkin's 
disease and prostate cancer. The cancers unique to the Navy would 
appear to support the ingestion of the dioxin orally rather than 
nasally.
    Notably, cancer in Navy veterans could not be attributed to the 
ship on which they served or the time spent in Vietnamese waters. This 
would indicate, I believe, that the contamination of the waters was 
extensive and the contamination of the water storage and distribution 
system long lasting. Although the passage of time has made it 
impossible to produce direct proof, the circumstantial evidence is 
certainly compelling.
    The Australians have stepped forward and began granting benefits to 
those who had served (i) on land in Vietnam, (ii) at sea in Vietnamese 
waters, or (iii) on board a vessel and consuming potable water supplied 
on that vessel, when the water supply had been produced by evaporative 
distillation of estuarine Vietnamese waters, for a cumulative period of 
at least 30 days. They have defined Vietnamese waters as an area within 
185.2 kilometers from land (roughly 100 nautical miles). In reliance 
upon the NRCET Study, they began promulgating Statements of Principles, 
which are similar to our Code of Federal Regulations, covering various 
cancers. For several years now, Australian Navy veterans have been 
receiving benefits denied to their American counterparts.
    In the summer of 2008, I presented to the Institute of Medicine's 
(IOM) Committee to Review the Health Effects in Vietnam Veterans of 
Exposure to Herbicides (Seventh Biennial Update) in San Antonio, Texas. 
We provided them with copies of the NRCET study, the VA's Federal 
Register notice and reclamas, by myself and Dr. Gaus. The IOM Committee 
conducted an exhaustive review of the NRCET study and requested an 
independent review by Dr. Steve Hawthorne who is the Senior Research 
Manager of the Energy & Environmental Research Center (EERC), 
University of North Dakota. Dr. Hawthorne's principal areas of interest 
and expertise include environmental chemistry and analysis, and 
supercritical and subcritical (superheated) fluid extraction. After 
reviewing the NRCET study, Dr. Hawthorne reported:
    . . . that leaves two questions to be answered:

    1.  Is there a physiochemical basis to expect that non-polars (like 
the dioxins) would distill, while polars (like dimethylarsenic acid) do 
not distill?
    2.  Do their experiments confirm expectations based on 
physiochemical parameters that dioxins distill and DMA does not?

          The answers to both questions are definitely yes. An 
        explanation of these results can be based on Henry's law--i.e., 
        the tendency of a solute to evaporate from water. This tendency 
        is enhanced by high vapor pressure (obviously), but also by low 
        water solubility. Thus, even molecules like 2,3,7,8-TCDD that 
        have high boiling points will evaporate from water because 
        their solubility is so low. Conversely, molecules like DMA that 
        are very soluble in water do not evaporate from water. The fact 
        that non-polar molecules (even those with high boiling points) 
        evaporate from water is well-known in environmental science, 
        and has been demonstrated to occur with a broad range of 
        pollutants such as PCBs, PAHs, organochlorine pesticides, as 
        well as dioxins. For example, the EPA estimates that the half-
        life for evaporation of 2,3,7,8-TCDD from a pond is 46 days. 
        The distillation process greatly enhances this process by 
        adding heat and reducing the pressure. The experiments 
        described confirm expectations based on Henry's law that 
        dioxins would be concentrated in the distillate, while DMA 
        would not. (The formation experiment was inconclusive, but I 
        don't believe it is important to their conclusions.) Assuming 
        that their apparatus mimics ship-board units (and that seems 
        reasonable), the increased concentration of dioxins in 
        distillate water should be accepted to a reasonable scientific 
        certainty.

    The IOM report accepted the proposition that Navy veterans off the 
coast were exposed and recommended that they be given the presumption 
of exposure. In their recommendation, the IOM committee stated: ``Given 
the available evidence, the Committee recommends that members of the 
Blue Water Navy should not be excluded from the set of Vietnam-era 
veterans with presumed herbicide exposure.''
    Although the DVA accepted other recommendations from this IOM 
report, including the extension of benefits for ischemic heart disease, 
Parkinson's disease and B cell leukemia such as hairy cell leukemia. 
Inexplicably the Department of Veterans Affairs refused to accept the 
IOM report, instead ordering another study by a different committee of 
the IOM to review areas previously addressed by the Agent Orange 
Committee and the Australians. The study was commissioned in February 
of this year and is expected to take 18 months. Meanwhile, our Navy 
veterans are dying of Agent Orange-related diseases.
    The Department of Veterans Affairs has undertaken a project to 
cover some blue water Navy veterans. If a ship entered inland waters, 
such as a river, the presumption is granted. This is a classic case of 
doing the right thing for the wrong reason. It is doubtful that the 
distillers, designed to convert salt water to fresh, would have been 
operating in the rivers. More importantly, Navy regulations at the time 
stated potable water should not be distilled in rivers, streams etc. 
This project, while covering a few more veterans, is a mere extension 
of the DVA's irrational ``boots on the ground'' requirement.
    This project is complicated by the difficulty in proving ships' 
locations. Logs are not always available and are handwritten. Specific 
locations are not always identifiable. Locations are often specified by 
directional bearings and/or ranges to navigational points that may no 
longer exist or may be called by a different name. Personnel going 
ashore are never documented unless they are permanently reporting to or 
transferring from the command. The project has resulted in a massive 
expenditure of time with little reward.
    I would be remiss if I did not address the case of Haas v.  Peake, 
525 F.3d 1168 (Fed. Cir. 2008). I filed an amicus brief in Haas which 
centered on international law and the NRCET study. The presumption 
issue in Haas was a secondary issue. Actually Commander Haas was 
directly exposed from an airborne cloud.
    The Haas case was primarily decided on administrative law 
principles dealing with rulemaking. In revising their M21-1 Manual, the 
DVA failed to follow the rulemaking provisions of the Administrative 
Procedures Act (APA). The Court of Appeals for Veterans Claims found 
that the provision was irrational and not promulgated pursuant to law. 
The Court of Appeals for Veterans Claims had also ruled that the 
Department of Veterans Affairs' interpretation of the enabling statute, 
38 U.S.C. Sec. 1116, which excluded the Navy veterans, was unreasonable 
and inconsistent.
    The Federal Circuit excused the VA's compliance with the rulemaking 
provisions of the APA. Acting on administrative law principles, it also 
reversed the Veterans Court holding that the DVA was not given 
sufficient deference in the way they interpreted the statute. The 
Federal Circuit relied upon the ``Chevron doctrine,'' that states 
``when an agency invokes its authority to issue regulations, which then 
interpret ambiguous statutory terms, the courts defer to its reasonable 
interpretations.'' In a split (2-1) decision, the Federal Circuit held 
that the DVA was entitled to Chevron deference because they found that 
the phrase ``served in the Republic of Vietnam in section 1116 is 
ambiguous.'' It was this curious finding which caused the predecessor 
of H.R. 2254 to be introduced in the last session, and H.R. 2254 in 
this session, to clarify the ``ambiguous'' language.
    In my amicus brief I raised the argument that the statutory 
language incorporated the territorial seas. U.S. Navy ships, like their 
Australian counterparts, steamed within the territorial waters of 
Vietnam. Territorial waters were historically defined as (1) the water 
area comprising both inland waters (rivers, lakes and true bays, etc.) 
and (2) the waters extending seaward three nautical miles from the 
coast line, i.e., the line of ordinary low water, (ofttime called the 
`territorial sea'). Seaward of that three-mile territorial sea lie the 
high seas. C. A. B. v.  Island Airlines, Inc. 235 F.Supp. 990, 1007 
(D.C. Hawaii 1964). A wider area, the contiguous zone, reaches out to 
12 miles from the coast. United States v.  Louisiana 394 U.S. 11, 23 n. 
26. (1969). Vietnam claimed a 12-mile territorial sea limit, which 
defines its sovereignty. That is consistent with the limitations of the 
United Nations Convention on the Law of the Sea Article 3. Three 
nautical miles is within the outermost range of the 5"38 gun mounts of 
Destroyer type ships used in the Vietnam war. Twelve nautical miles 
(24,000 yards) is beyond the maximum range of the most commonly used 
shipboard batteries, the 5"38 or the 5"54 naval gun. The same holds 
true for the 6" and 8" guns. Only the Battleship could provide support 
beyond 12 miles.
    The enabling statute, 38 U.S.C. Sec. 1116(a)(1)(A) recognizes a 
presumption of service connection when the veteran manifests an 
enumerated disease, if the person was ``a veteran who, during active 
military, naval, or air service, served in the Republic of Vietnam 
during the period beginning on January 9, 1962, and ending on May 7, 
1975.'' The threshold factors are the existence of a prescribed disease 
and service in Vietnam.
    In Louisiana v.  Mississippi, 202 U.S. 1, 52 (1906), the Supreme 
Court held that the Mississippi Sound, and by extension the waters 
surrounding all harbors as inland waters, were under the category of 
``bays wholly within [the Nation's] territory not exceeding two marine 
leagues in width at the mouth.'' Inland, or internal waters are subject 
to the complete sovereignty of the Nation, as much as if they were a 
part of its land territory. United States v.  Louisiana, supra. Thus 
the presumption should apply to any harbor as well as inland waters. 
The territorial waters to include the contiguous zone are also under 
the control of the sovereign nation, although innocent passage may not 
be denied. Id. Subject to the right of innocent passage, the coastal 
state, in this case Vietnam, has the same sovereignty over its 
territorial sea as it has with respect to its land territory. See, 1958 
Territorial Sea Convention Article 1-2; Law of the Seas Convention, 
Article 2.
    Thus any time a Navy ship was firing its guns ashore, it would have 
had to have been within the territorial waters of Vietnam. When at 
anchor in a harbor, it was within the inland waters of Vietnam. At all 
relevant times, the ship was within the sovereignty of Vietnam and 
therefore its crew ``served in the Republic of Vietnam.'' The distance 
to shore directly corresponds to the maximum range of the support of 
forces ashore. Consequently, most naval units operated close to shore. 
Gunfire missions were often shot from two to three thousand yards of 
the shore, well within the three nautical mile limit. Many were 
anchored in Da Nang Harbor. The closer a ship was to the coast, the 
higher the possibility that they steamed through waters contaminated 
with Agent Orange. In the case of the harbor anchorages, the ships were 
not only within the sovereign territory of Vietnam, they were within 
the inland waters. Under both national and international law, most 
ships served in the Republic of Vietnam. The Federal Circuit, in ruling 
on a petition for rehearing, refused to address the international law 
arguments, stating that Mr. Haas had waived the argument by not 
presenting it at the Veterans Court.
    After the submission of all briefs and a few days before the May 8, 
2008 decision was rendered, the Department of Justice, acting on behalf 
of the DVA, submitted a supplemental brief based on the erroneous April 
15, 2008 Federal Register notice. Although the information in that 
article has since been refuted, there was not sufficient time to 
respond to the supplemental brief. This left the Court under the 
impression that the NRCET study had not been peer reviewed, that the 
Australians used different ships and distilling systems, that American 
ships did not make water and that the authors doubted their own study. 
Those impressions were blatantly false, but this was not brought before 
the Court. Although not a holding of the Court, the DVA 
misrepresentations were discussed in dicta and obviously had some 
impact on the decision.
    While this adversarial ploy was a brilliant tactical move, it was a 
reprehensible act by an agency who claims to stand as a non adversary 
to care for the veteran, his widow and orphan. I am reminded of Justice 
Black's dissent in St. Regis Paper Co. v.  United States, 368 U.S. 208, 
229 (1961). ``Our Government should not by picayunish haggling over the 
scope of its promise, permit one of its arms to do that which, by any 
fair construction, the Government has given its word that no arm will 
do. It is no less good morals and good law that the Government should 
turn square corners in dealing with the people than that the people 
should turn square corners in dealing with their government.''
    These men left their homes to go to war. It was an unpopular war, 
but they went. There were teach-ins telling them how to dodge the draft 
or flee to Canada. But they went. When they returned they were spat 
upon and called the most terrible of names. But they went. These men 
were and are casualties of war. Many have died and others are dying. 
Their names will never go on the Wall, but they are casualties who have 
had or will have their lives cut short. In the midst of recession they 
are left without medical care. Their families are left without support 
as they pass. These men are heroes and we owe them medical care and a 
pension.
    Currently Australia recognizes a presumption of exposure for all of 
those who served within the 185.2-kilometer radius of Vietnam for 30 
days or more. That is roughly the same area as the Vietnam Service 
Medal area. While I am certainly happy that our Allies have taken the 
step of compensating and treating their Navy veterans, as an American, 
I am somewhat chagrined that we did not immediately follow suit. As the 
leader of the Free World, we should take the lead in taking care of our 
veterans.
    It is impossible to provide direct evidence as to the dioxin 
content of the South China Sea and the waters off Vietnam in the 1960s 
and 1970s. Too much time has passed to be able to make that 
determination. The circumstantial case, however, is compelling. The 
2005 Mortality Study and Cancer Incidence Study identified an exposure 
problem unique to the Navy. The NRCET study shows how exposure most 
probably occurred. The type of cancers developed by Australian Navy 
veterans confirm that exposure did occur.
    H.R. 2254 is designed to correct years of neglect and degradation. 
It will restore earned benefits to these heroes and ensure that their 
families will receive a pension upon their premature death. It will 
also implement the recommendations of the IOM's Agent Orange committee. 
This is not a gift. It is not welfare. It is an earned benefit bought 
and paid for with their health and their lives. I urge this Committee 
to favorably report H.R. 2254 with a strong recommendation that it be 
sent to the full House for expedited passage. Again thank you for the 
opportunity to speak with you today. It is a great personal honor both 
to appear before you and to represent the Navy heroes of the Vietnam 
War. God bless our veterans and God bless the United States of America.

                                 
      Prepared Statement of John Paul Rossie, Executive Director,
              Blue Water Navy Vietnam Veterans Association

The Problem of H.R. 2254
    H.R. 2254 is being held in Committee, even though it has 256 
cosponsors within the House. That means it has a pretty good chance of 
passing the House by a substantial margin. And yet, it sits.
    This situation makes me question this government's willingness to 
keep its promises to all its veterans. The commitment of a nation to 
provide care to its veterans was clearly expressed by Abraham Lincoln 
when he prayed for people to do the right thing, ``. . . to care for 
him who shall have borne the battle and for his widow and his orphan . 
. . .'' More recently, we have heard pledges by members of this 
legislature to support Vietnam veterans. The last time I saw its 
language, H.R. 2254 would recognize certain individuals who show 
symptoms of contamination by herbicides used in Vietnam if they served 
offshore of Vietnam or were in the vicinity of Vietnam. There was 
conjecture that it ought to cover military personnel not in the local 
area of Vietnam, but who handled the herbicide containers and show 
symptoms of contamination.

The Need for Proof
    We hear rumors that one thing delaying passage of H.R. 2254 is a 
need for proof that these individuals were contaminated by herbicides. 
In the requirement of demanding that proof, Congress is holding these 
individuals to a much higher standard than some other military 
personnel. If a member of the Armed Forces can show that they actually 
stood on the soil of the Vietnam homeland, they are granted their 
medical and compensation benefits under a concept of ``presumptive 
exposure.'' Presumption of exposure does not require proof of any sort, 
short of documentation verifying a physical presence, for even the 
shortest amount of time, on the land mass of Vietnam. They are not 
questioned on the possible mode of transport that caused their 
exposure, nor are they required to prove their physical location while 
on Vietnamese soil. They are not asked about or tested for dosage of 
exposure. They need only present with symptoms as specified by the 
Department of Veterans Affairs (DVA). Yet their symptoms are identical 
to the symptoms of personnel who did not have a physical presence upon 
the land mass of Vietnam. Here we see a very clear instance of 
comparing elements that both walk like a duck and quack like a duck, 
but are denied a rational conclusion that they both are ducks. Denial 
of this commonality is the first hint that something is terribly wrong.

The Statistical Analysis
    In a classic manner of rationalizing, there comes the fatal slide 
to the analysis of numbers. There are those who want to see perfect 
columns of numbers showing several enumerable facts:

      How many people are we talking about that will be 
impacted by the passage of H.R. 2254?
      How many dollars are associated with compensating each 
individual?
      How long a time will these payments be made?
      What are the exact parameters to qualify for H.R. 2254 
benefits?

    But actually, we are not really talking about numbers. We are 
talking about human beings and the quality life and death of those 
people. We are talking about providing a basic dignity in dying. We are 
talking about how we can provide comfort in the final days of human 
beings who are dying of unnatural causes directly related to their 
duties in the Armed Forces during the Vietnam War.
    Do I mean to say that these numerical values are not needed for a 
decision to be made? Yes, categorically. The issue of H.R. 2254 is 
about humanitarian principles. Does it matter if we are talking about 
0.01 percent of the total U.S. population or 1 percent of the total 
U.S. population? Absolutely not. Regardless of the number of people 
involved, we are still talking about the death of human beings; human 
beings who just happened to swear an oath to fight for this country so 
that our principles of free speech and peaceful assembly, exactly like 
what we are doing with this Committee Hearing, can go forward without 
fear of ``black-booted thugs'' bursting in to shoot, arrest or even 
just harass us.
    The willingness to give one's life for one's country is not the 
same as volunteering to be a guinea pig for Chemical Warfare. The 
symptoms we are talking about are the result of Chemical Warfare. The 
herbicides were developed to kill plant life, but their additional 
consequence was that they contaminated our own soldiers and sailors. 
Please call it like it is. We are acknowledging that this government 
may have been completely ignorant of the impact on our own soldiers. 
But those consequences are taking the lives of our veterans, and 
something needs to be done about it right now. This legislative body 
needs to take ownership of this problem and fix it.

The Inevitable
    All of us are going to die at some point in time. But we generally 
assume it will be by natural causes. Or it could be by accident, but we 
still picture that as a fairly quick process. Our military personnel 
contaminated by chemical agents are dying of unnatural causes with slow 
and painful deaths. The average life span of a non-veteran male in the 
United States is something near 79 years. The average life span of a 
Vietnam veteran is about 66 years. So in addition to having defended 
this country and dying a painful, gruesome death because of it, we are 
giving up, on average, about 13 years of our lives.
    We have set ourselves up to be the policemen of the world. We 
occasionally come across situations where a foreign government uses 
Chemical Weapons on its own people, and we howl and are the first to 
shout and point a finger at an atrocious violation of human rights. We 
get righteously indignant. Even though we did not intend it, the 
veterans of Vietnam are dying horrible, prolonged deaths like all other 
victims of manmade Chemical Weapons. What our soldiers and sailors are 
dying of looks very similar to what other people go through when dying 
of chemical poisoning. Both of these situations look like ducks, quack 
like ducks, smell like ducks. How much more evidence do we need to 
conclude that, by golly, we've got two ducks here?
    Pointing fingers and assigning blame is not what this is about. It 
is about recognizing a problem and fixing it. This Committee can do 
something right now to address the current problems that still exist 
for some Vietnam veterans. That is all we are asking you to do. Act 
now, before we are all dead.
    In putting our estimates of how many veterans will likely be 
impacted and what the potential cost of this bill could be for new 
claims of livings veterans, we did work through the numbers, very 
carefully. And those numbers are presented here in the Appendix. In A-
1, we have an analysis of the number of troops most likely involved in 
various elements of the Vietnam War. The data attempts to count the 
number of military personnel in the ``off shore'' regions and those 
assigned to Thailand, Cambodia and Laos. The two organizations that 
jointly authored that paper are clearly identified. The analysis might 
contain refutable numbers, or someone might argue that it is totally 
wrong whether it is or not. However, all sources were traced as far 
back to the original sources as possible.
    Appendix A-2 provides a screen capture simulation of a lengthy and 
complicated spreadsheet that shows the associated costs of H.R. 2254 as 
regards new claims for presumptive exposure. The screen shot shows the 
total project cost, which occurs in the year 2020, 10 years from now. 
After that date, we postulate that no significant number of this class 
of veterans will be alive. The full spreadsheet is large and needs to 
be reviewed in full on the Internet at http://bluewaternavy.org/
spreadsheet%202254.htm. Since several factors in a complete cost 
analysis are variable, that Internet location includes an MS Excel 
spreadsheet that can be downloaded to a viewer's computer. The user can 
change very key data points to see the effects on cost. Parameters 
available to change include:

      Total number of Blue Water Navy (BWN) veterans who served
      Percent still alive
      Percent who will seek/not seek benefits
      Percent who will receive 100 percent disability rating
      Percent who will receive 40 percent disability rating
      Monthly & Annual Cost of BWN veterans receiving 100 
percent disability
      Monthly & Annual Cost of BWN veterans receiving 40 
percent disability

    I provided this tool so everyone could put in their own range of 
numbers for several components that make up the final cost. You should 
download this spreadsheet and manipulate it because it is very 
educational and instructive and hopefully provides a new perspective on 
estimating these costs.
Uncertainty
    But I have already stated we are not playing the numbers game. No 
matter what number is chosen, another number can be given to challenge 
the first. And do you realize who you are playing number games with? 
Certainly not the American public. Certainly not the veterans who are 
asking for your help. In this case, it is with an agency that 
absolutely cannot provide ``the real and exact number'' of any basic 
head count related to the Vietnam War. Every number they have to work 
with started as an after-the-fact estimate by the Department of 
Defense. ``The real numbers'' do not exist. What you are getting from 
the DVA are estimates and extrapolations that have appeared to solidify 
over the years and tend to be taken as concrete and true. In some 
cases, those estimates are probably very close to reality. In other 
cases, not so much. The basic numbers of participants in our Vietnam 
War were estimated quite some time ago, and over the years they have 
become accepted Urban Myth. But they are no more solid or certain than 
that.
    Where is my source for such an outlandish statement? Well, beyond 
common sense, and a knowledge of history, and the experience of being 
there and noting how records were kept, it is a bit of wisdom passed on 
to me by the Department of Veterans Affairs, Office of Policy & 
Planning some time ago. It has also been reported to me by the National 
Archives Electronic Records Division and the Library of Congress. I 
will not release personal information on the sources involved in my 
conversation. But if you get through all the parts of my presentation 
and still have doubts about my honesty, I have to suspect you have not 
read this with an open mind.
    I will not be guilty of placing a dollar value on the men and women 
that I speak for. I will let that be your job. My main concern is to 
help you realize that this is a very clear situation with a very simple 
solution. These men are sick. They are disabled by illness on the list 
of presumptive diseases for dioxin poisoning. If you took a soldier who 
served on land that is dioxin-sick, and a sailor who served offshore 
that is dioxin-sick and set them in a room together, no doctor would 
see the difference. They both look like ducks. They both quack like 
ducks. They both smell and waddle like ducks. My guess is that they are 
both ducks.
    But I would like to take the pressure off. I am not even asking you 
to declare them as ducks. That can come later; history can sort that 
out. If you are so obviously uncomfortable with identifying and 
labeling the parts of these ducks, then do not worry about that. Let 
someone else worry about putting their neck in that imaginary noose. 
But these poor ducks have spent the past 40 years paying for their own 
medical care, and now they are in desperate need. They can not afford 
more medical care. They can not afford to eat well or even pay their 
rent. Many have been forced to give up their homes for much smaller 
accommodations. They can not provide for their families. And they are 
just damned tired of trying to deal with the DVA. They are tired of 
that illusive false hope that sometimes dangles in their faces.
    No one can tell you that our diseases were absolutely not caused by 
dioxin. We were often no further than a couple hundred yards from the 
men who served on land. Isn't that a strange coincidence that we both 
have the identical problems? No one can tell you that the amount of 
Agent Orange dumped into, sprayed onto, blown by the wind or washed 
into the South China Sea by run-off water was not enough to transit 80 
to 100 miles from the shoreline of Vietnam to the constantly moving 
location of Yankee Station--possibly via the microlayers that can 
travel below the surface for extreme distances. It is medically and 
scientifically impossible for anyone to make a definitive statement 
that the diseases of offshore veterans, or veterans from other areas, 
were not caused by the dioxin content within Agent Orange.
    We believe that the Department of Veterans Affairs, by their own 
admission, is using numbers inappropriately. They are using what we 
believe to be inflated estimates as a scare tactic, and we fear you 
have bought into it. They have over-inflated the number of veterans one 
can rationally project to have been in Vietnam, or offshore Vietnam, or 
in the vicinity of Vietnam. They have over-inflated the number of 
veterans who are probably alive today. And they have projected their 
response to compensation claims to a level that far exceeds their past 
trends. America can find hundreds of millions, and even trillions, of 
dollars for far less worthy enterprises. And yet we cannot afford to 
care for damages of war to our own military. We are watching this 
happen to us, the Vietnam veterans. We are watching this happen to our 
children, who fought the Gulf War and served in EOF/IOF and 
Afghanistan. We have watched both the DVA and our legislators use 
number games to save trivial dollars at the expense of making this 
country morally bankrupt. Where is the value, in that scenario?

The End Game
    Will our government provide a small percentage of the population 
with the pittance it takes to live out the next six to 10 years? With 
that, we can die in less miserable conditions and can leave this world 
knowing the country we served afforded this dignity in our death. They 
had already promised to soothe us and our families in our final hours. 
Can we be comfortable leaving our families strapped with our medical 
bill, or in poverty housing? No one is asking for this assistance 
except those who can prove an Agent Orange-based disability and we are 
asking for no more than other veterans of the Vietnam War are given.
    Can we expect H.R. 2254 to become law before we die? If not, then 
please just tell us. We are mature enough to take a negative answer--
after all, we were ready to die for you and this government 40 years 
ago. And we have been living and dying with false promises since then. 
Just tell us so we can have absolute certainty of how this country and 
its leaders really value us. But we also ask that you stop delaying and 
lying to us while you comfortably sit back and wait for us to die. In a 
very few years, we will not be alive, and you will never have to step 
forward and honestly deal with this problem. It will be thrown onto the 
bone pile the way many other problems are currently being handled. And 
you wonder why the approval rating of your jobs and of this 
administration's actions have fallen to new low points!
    We are asking you to do something that will allow us to die with 
dignity. Do not keep playing this game of delay, deny, until we die. 
And do not keep dishing out false hope.
    Please, if you have already decided you will never fund H.R. 2254 
and S. 1939, just tell us to go away. We will stop wasting your time 
and our energy, and we will find some alternative to living and dying 
with our illnesses and our frustration.

                               __________
                               [GRAPHIC] [TIFF OMITTED] T7019A.001
                               
                              Appendix A-2
            Spreadsheet of Cost (Screen capture simulation)
         Estimates for H.R.-2254: With User-Defined Parameters

----------------------------------------------------------------------------------------------------------------
       TOTAL ANNUAL AND AGGREGATE COST OF THE AGENT ORANGE ACT OF 2009                        Year       2020
----------------------------------------------------------------------------------------------------------------
Total number of Blue Water Navy (BWN) Veterans who served (1*)                   514,300
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Total number of personnel who served in Thailand, Cambodia, and Laos (1*)        294,800
----------------------------------------------------------------------------------------------------------------
Number of BWN and TLC veterans who served during Vietnam War                     809,100
----------------------------------------------------------------------------------------------------------------
% still alive                                                                      33.0%
----------------------------------------------------------------------------------------------------------------
Total living veterans eligible for benefits under AO Act of 2009 at year's       267,003       2009        6,898
 end (3*)
----------------------------------------------------------------------------------------------------------------
% who will not seek benefits (4*)                                                  70.0%
----------------------------------------------------------------------------------------------------------------
% who will seek benefits                                                           30.0%
----------------------------------------------------------------------------------------------------------------
BWN veterans forecasted to file for benefits                                                               2,069
----------------------------------------------------------------------------------------------------------------
% of claims denied by the VA (5*)                                                  60.0%                   1,242
----------------------------------------------------------------------------------------------------------------
Number of processed claims                                                         40.0%                     828
----------------------------------------------------------------------------------------------------------------
% who will receive 100% disability rating (6*)                                     12.0%
----------------------------------------------------------------------------------------------------------------
Veterans who will receive 100% disability rating                                                              99
----------------------------------------------------------------------------------------------------------------
% who will receive 40% disability rating                                           88.0%
----------------------------------------------------------------------------------------------------------------
Veterans who will receive 40% disability rating                                                              728
----------------------------------------------------------------------------------------------------------------
Monthly & Annual Cost of BWN veterans receiving 100% disability (7*)              $2,823    $33,876   $3,364,894
----------------------------------------------------------------------------------------------------------------
Monthly & Annual Cost of BWN veterans receiving 40% disability                      $601     $7,212   $5,253,350
----------------------------------------------------------------------------------------------------------------
ANNUAL COST OF AGENT ORANGE ACT OF 2009                                                               $8,616,244
----------------------------------------------------------------------------------------------------------------
CUMULATIVE COST OF AGENT ORANGE ACT OF 2009                                                          $2,124,765,
                                                                                                             333
----------------------------------------------------------------------------------------------------------------
Average cost for 1 year per BWN veteran (8*)                                                             $10,412
----------------------------------------------------------------------------------------------------------------
Daily BWN Vietnam Veteran deaths (9*)                                                 39     14,235       22,381
----------------------------------------------------------------------------------------------------------------
Total Cumulative BWN Vietnam Veterans                                                                    268,251
----------------------------------------------------------------------------------------------------------------
Annual Mortality Rate for BWN Vietnam Veterans (10*)                                                       49.0%
----------------------------------------------------------------------------------------------------------------
Annual Increase in Mortality Rate                                                                           2.5%
----------------------------------------------------------------------------------------------------------------
Average Age at Death for Vietnam Veterans                                             66
----------------------------------------------------------------------------------------------------------------

                                 
     Prepared Statement of Vivianne Cisneros Wersel, Au.D., Chair,
    Government Relations Committee, Gold Star Wives of America, Inc.

    Mr. Chairmen and Members of the House Committee on Veterans' 
Affairs, I am pleased to be here today to testify on behalf of Gold 
Star Wives on the health effects of the Vietnam War and its aftermath 
for our Nation's surviving spouses. My name is Vivianne Wersel, Chair 
of the Gold Star Wives' Government Relations Committee. I am the widow 
of Lt. Col. Richard Wersel, Jr., USMC, who died suddenly on February 4, 
2005, one week after returning from his second tour of duty in Iraq. I 
am also the daughter of Colonel Philip C. Cisneros, USMC (Retired) who 
fought in the Chosin Reservoir in Korea and served three tours of duty 
in Vietnam.
    Gold Star Wives of America, Incorporated (GSW), founded in 1945, is 
a Congressionally Chartered organization of spouses of military members 
who died while serving on active duty or as a result of a service-
connected disability. GSW is an all-volunteer organization. We could 
begin with no better advocate than Mrs. Eleanor Roosevelt, at the time 
newly widowed, who helped make Gold Star Wives a truly ``national'' 
organization. Mrs. Roosevelt was an original signer of our Certificate 
of Incorporation as a member of our Board of Directors. Our current 
members are widows and widowers of military members who served during 
World War II, the Korean War, the Vietnam War, the Gulf War, the 
conflicts in both Iraq and Afghanistan and every period in between
    I will start with our primary message to you today--nearly 40 years 
since the last American servicemembers left Vietnam we are still 
dealing with the repercussions. We cannot forget the importance of 
communication to the impacted community, including the surviving 
spouses of that era.
    There is no question of the magnitude of the problem that this 
Nation must continue to face. For nearly 20 years, the Department of 
Veterans Affairs (VA) has provided disability benefits to Vietnam 
veterans who suffer from certain illnesses causally linked to Agent 
Orange exposure. With the addition of two new and one expanded Agent 
Orange presumptive diseases, the VA will be automatically awarding 
disabilities for 14 different conditions. We are heartened by the 
restarting of the National Vietnam Veterans Longitudinal Study as it is 
very clear that our knowledge is not yet complete on the long-term 
health consequences of those who served in the Vietnam War. For over 
2.1 million current Vietnam veterans, this has been a long and often 
arduous road. I can't help but think that what we learn here will lead 
us to better care for all of America's veterans, their families and 
survivors, including those engaged in the current wars/conflicts.
    A common theme that the membership of Gold Star Wives encounters, 
whether from the new, young surviving spouses of the current wars or 
those survivors from earlier conflicts, is the lack of information--the 
lack of the government reaching out to them to alert them to changes in 
benefits and compensation that they may be eligible to receive. Many 
were never informed of their benefits initially and many still are not 
aware of their benefits. So while it is wonderful for the scientific 
community to gain these valuable insights, the next crucial step is to 
assure that those who have been harmed as a result of exposure to harsh 
chemicals, can adequately understand what they must do to improve the 
quality of their health and lives to the extent that that can occur. VA 
outreach to survivors must be drastically improved.
    A widow in Florida has an adult son with spina bifida. Her son is 
relatively independent yet he still needs care. Since the loss of her 
husband, the widow now bears the full burden of caring for her adult 
son.
    For many years caregivers provided for their spouses who were less 
than 100% disabled and these widows were not eligible for DIC when 
their spouses died. The caregiver's quality of life was compromised as 
well as their own health. The many spouses who cared for these 
dedicated servicemembers were forgotten. Many spent their life savings 
for medical expenses. Spouses were forced to give up careers because 
their disabled husbands needed ongoing care. These families have 
survived after their husband's death however the pain of their 
experience is still vivid. Therefore it is important to further 
investigate the results of the affects of the deadly toxins used in 
Vietnam as well as to identify the servicemembers, their spouses or 
surviving spouses. Not everyone has a connection with the military or 
the VA.
    My uncle served his country and died of ALS in January 2005. My 
aunt was not married to him during his military service and was unaware 
of the change in the VA policy to include ALS as a presumptive 
disability. This benefit made a difference to her quality of life yet 
she never would have known if I had not made a point of sharing this 
information. We are certain that there are many other surviving spouses 
who have yet to be identified as beneficiaries. We as a grateful nation 
have an ethical role to reach out to better identify those veterans and 
survivors who qualify for compensation.
    We do not want new members in our organization because of the 
requirement for entry--the loss of a loved one--but we are protective 
of those who eventually will join us, as well as for those surviving 
spouses who suffered right along with the veteran during these last 40 
years. They need to be given some peace of mind about why life was so 
radically different for so long after their spouse returned from 
Vietnam whether it was PTSD or bearing a child with a neural tube 
defect or sadder yet left barren.
    We don't yet know how many generations will be affected by Agent 
Orange. The children and grandchildren of Vietnam veterans are 
suffering the after-effects. The results of the longitudinal study 
should reveal the adverse effects for future generations. We have 
concerns for the veterans and their survivors who were never in the VA 
system, but became ill and died. Many veterans may have died years ago 
of conditions just now being recognized as caused by Agent Orange. How 
are we going to locate and notify those survivors? Who takes this lead? 
The VA must take the lead in outreach to these servicemembers and 
survivors. In concert with Veterans, Military and survivor 
organizations, many more deserving and qualified beneficiaries must be 
found.
    Service to this Nation deserves life-long respect and care, 
certainly to the veteran, but to the veteran's family as well, even 
when that veteran is no longer alive. Not only did returning Vietnam 
veterans experience adverse encounters with an ungrateful nation, but 
they also had to return to an uncaring government that sent them to 
war, perhaps even against their will because of the draft. The Vietnam 
veteran did battle for our country and now has to do battle with VA 
bureaucracy and rules to obtain the benefits he deserves and has more 
than earned. In many instances, the surviving spouse must continue to 
fight for the benefits the veteran earned. It is our responsibility as 
a nation to honor those veterans and their survivors.
    Please continue with the longitudinal study, look at all 
independent variables, including interviewing the deceased spouses. 
Simply stated by one of our members, ``I just pray that no one else has 
to go through what Les went through, a very tortured, painful, long, 
anguished death. After his death I was burdened with medical bills, 
exhaustion, and a ruined career that I am still trying to repair.'' 
Results of the present longitudinal study may reveal new presumptive 
illnesses that not only affect the servicemembers but many generations 
thereafter.
    In 1862 during the battle of Antietam, 23,000 men were killed in 
one day, which was the bloodiest single-day battle in our country's 
military history. In retrospect, the Vietnam War was the war whose 
casualties lingered over the longest period of time; it's the war that 
keeps on ticking. The VA needs to identify these late onset casualties 
to help minimize the suffering these families endure financially, 
emotionally and physically. Look deep in the histories of those who 
have died as well as their families.
    We hope that the restart of the National Vietnam Veterans 
Longitudinal Study will continue to reveal data and information crucial 
to the optimal well being of our servicemembers and their families. It 
is imperative that a more aggressive outreach is implemented to 
identify veterans, spouses and survivors concerning any new presumptive 
illnesses developed as a result of this study.
    No one said it more eloquently than President Lincoln in his second 
inaugural address:

        ``With malice toward none; with charity for all; with firmness 
        in the right, as God gives us to see right, let us strive to 
        finish the work we are in; to bind up the Nation's wounds, to 
        care for him who has borne the battle, his widow and his 
        orphan.''

    Thank you for this opportunity to testify. I will be elated to 
answer any questions you have.

                                 
    Prepared Statement of Joel Kupersmith, M.D., Chief Research and
          Development Officer, Veterans Health Administration,
                  U.S. Department of Veterans Affairs

    Mr. Chairman, Mr. Ranking Member, and Members of the Committee: 
Thank you for the opportunity to appear today to discuss the Department 
of Veterans Affairs' (VA) progress in conducting the National Vietnam 
Veterans Longitudinal Study (NVVLS) and the illnesses associated with 
exposure to Agent Orange. I am accompanied by Victoria Anne Cassano, 
MD, MPH, Director, Radiation and Physical Exposures; and Acting 
Director, Environmental Agents Service, VHA. My testimony today will 
discuss the history of the NVVLS, VA's current plans for a 
comprehensive, longitudinal study of Vietnam Veterans, other research 
relevant to Vietnam Veterans, and our health care programs specifically 
tailored to the needs of Vietnam Veterans.

History of the National Vietnam Veterans Longitudinal Study
    In 1983, Congress mandated that VA conduct a study on post-war 
psychological problems among Vietnam Veterans. VA contracted with an 
external entity, the Research Triangle Institute, to conduct the 
National Vietnam Veterans Readjustment Study (NVVRS). The study, 
completed in 1988, provided an extensive report of disabilities, 
including post-traumatic stress disorder (PTSD), in Vietnam-era 
Veterans, and is considered to be a landmark study of PTSD and its 
consequences in Vietnam Veterans. Based on the diagnostic approach used 
in the study, it was determined that 15 percent of male Vietnam 
Veterans experienced PTSD within the previous 6 months and an estimated 
31 percent would experience PTSD during their lifetime. Prevalence 
rates for PTSD in female Vietnam Veterans were similar but somewhat 
lower. Subsequent reanalysis of the original NVVRS data by other 
scientists has estimated a somewhat lower prevalence of PTSD that is 
more in line with other studies of PTSD in Vietnam Veterans.
    In 2000, Congress passed and the President signed the Veterans 
Benefits and Health Care Improvement Act of 2000, which became Public 
Law (P.L.) 106-419. Section 212 of this legislation directed VA to 
contract for a follow-up study of Vietnam Veterans in the original 1988 
NVVRS. In 2001, VA entered into a contract with the same contractor for 
a follow-up called the National Vietnam Veterans Longitudinal Study 
(NVVLS). However, delays, escalating costs, and concerns about 
contracting practices prompted suspension of the study and cancellation 
of the contract before data collection began. A VA Office of Inspector 
General (OIG) audit report, released September 30, 2005, confirmed 
ineffective planning, contracting, and project management.
    In 2008, the Senate Appropriations Committee included a requirement 
in Senate Report 110-428 directing VA to fulfill the requirements of 
section 212 of P.L. 106-419. In January 2009, VA informed the Chairs 
and Ranking Members of the House and Senate Veterans' Affairs and 
Appropriations Committees of concerns that the NVVLS approach would not 
adequately or substantively address questions about the mental or 
physical health status of the Vietnam Veteran population or about the 
course and consequence of PTSD. VA had, in the interim, initiated a 
broad portfolio of scientifically rigorous studies dedicated to 
addressing the needs of the Vietnam Veteran population and offered two 
of these as alternatives to restarting the NVVLS. Specifically the 
Department has funded several major research efforts, including a 
longitudinal follow-up study entitled, ``A Twin Study of the Course and 
Consequences of Post Traumatic Stress Disorder (PTSD) in the Vietnam 
Era Veterans,'' based upon the well-studied Vietnam Era Twins Registry 
(VET-R), together with a second study, ``Determining the Physical and 
Mental Health Status of Women Vietnam Veterans.''
    The House Committee on Veterans' Affairs concluded in June 2009 
that these two studies did not adequately address the law and directed 
that NVVLS be completed. In September 2009, the Secretary of Veterans 
Affairs announced that the agency planned to award a contract to an 
external entity to conduct the NVVLS.

Current Plans for NVVLS
    VA understands that Veterans and Congress are still concerned about 
the long-term effects of military service in Vietnam; VA shares that 
concern as well. This is why VA continues to support programs and 
efforts addressing the needs of the Vietnam Veteran population. VA also 
has reinstituted the process to contract for the completion of NVVLS, 
paying close attention to prior OIG recommendations and the intent of 
P.L. 106-419. VA's Office of Research and Development (ORD) is managing 
the project and has completed a number of necessary steps.
    Specifically, in September 2009, VA convened a scientific panel and 
other experts (legal, administrative and contracting) as part of an 
Integrated Project Team (IPT) to develop requirements for the NVVLS. 
The Scientific Panel consisted of subject matter experts from within 
and outside of VA. This Panel was asked to establish the scientific 
requirements and propose a valid approach to serve as the basis for the 
contract. They identified several challenges to reopening the NVVLS:

      The data from the initial contractor regarding NVVRS must 
be transferred safely and securely to the new contractor for NVVLS.
      There may be difficulties in getting the original cohort 
of Veterans to participate in the new NVVLS. Of those not already 
enrolled in the VA system, it is not known how many would be located 
and agree to participate in a new study, or even how many are still 
alive. Thus it is unclear if the sample size will be large enough to 
yield statistically significant findings, particularly for questions 
involving subgroups.
      Methods for diagnosing PTSD have evolved over the 25 
years since the NVVRS. The design of the NVVLS will need to strike a 
balance between repeating methodologies using in NVVRS, for the sake of 
longitudinal consistency, and incorporation of new diagnostic 
strategies for contemporary validity.
      The NVVRS was not designed to accommodate a follow-up 
study and there is a potential for statistical bias that the contractor 
will need to consider.

    As part of re-opening the NVVLS, the IPT also developed a 
Performance Work Statement and Acquisition Package during 2009. In 
early March 2010, the IPT forwarded the Package to the VA Contract 
Review Board. This Package contains:

      A Performance Work Statement, which describes the 
background of NVVLS, public law mandates, the study objectives, the 
specific mandatory tasks (organized by study phase) and associated 
deliverables, and VA security and data use and ownership requirements;
      An Acquisition Plan, which describes the statement of 
need, schedule constraints, current estimated cost, desired capability 
of offers, risks, plan of action, and milestones. The plan of action 
also describes the evaluation factors for source selection;
      An Independent Government Cost Estimate, which describes 
the methodology and assumptions in calculating the best estimate of the 
cost of the contract;
      A Market Research Report, which describes the outcome of 
market analysis, including a request for information along with online 
searches for capabilities of potential offers under social-economic 
considerations; and
      A certificate of a potential Contract Officer Technical 
Representative (COTR).

    Once the Acquisition Package has been approved, VA will solicit 
bids and evaluate proposals; we expect this will be completed this 
summer. VA will then award the contract and begin the study in the 
early fall. VA has established a project management structure to 
ensure: the project reaches its objectives; a COTR in ORD will monitor 
the contractor's performance and ensure that the contractor adheres to 
study performance requirements, cost, reporting schedule, and 
timeliness; and reports any unexpected events in the course of the 
study. The IPT has determined milestones for the study and the COTR 
will use performance metrics to monitor progress.
    Between 2011 and 2013, the awarded contractor will obtain 
Institutional Review Board (IRB) and Office of Management and Budget 
(OMB) approvals for the project and initiate the study under VA 
monitoring. By 2014, the data should be available for analysis and we 
anticipate the results will be available shortly thereafter for 
publication in a scientific journal.
    The new NVVLS will consist of the following four phases:

      Feasibility Phase: Establish how many individuals from 
the original National Vietnam Veterans Readjustment Study (NVVRS) 
cohort are available and potentially willing to participate in the 
NVVLS;
      Start-Up Phase: Prepare the assessment and data 
collection materials, finalize protocol and obtain IRB and OMB 
approval.
      Implementation Phase: Recruit and enroll participants, 
conduct assessments on all participants.
      Close-Out Phase: Analyze data, prepare final reports, and 
deliver data to VA.

    VA is committed to the success of the NVVLS and will continue to 
keep Congress apprised of any significant developments.

Other Research on Vietnam Veterans
    The U.S. Air Force made a commitment to Congress and the White 
House in 1979 to conduct an epidemiologic study of the military 
personnel that were likely to have been the most highly exposed U.S. 
Servicemembers to Agent Orange herbicide in Vietnam, in Operation Ranch 
Hand missions. The ``Ranch Hand'' study's assets include an electronic 
database and biospecimens such as serum, urine, adipose tissue and 
semen. These have been maintained and managed by the Medical Follow-Up 
Agency of the Institute of Medicine of the National Academies (IOM) as 
directed by P.L. 110-389, the Veterans' Benefits Improvement Act of 
2008. This act authorizes IOM during fiscal years 2009 through 2012 to 
conduct additional research on the assets to develop a better 
understanding of the health determinants and wellness promotion among 
Veterans. The law also requires an IOM report to Congress assessing the 
feasibility and advisability of conducting additional research on such 
assets after the end of fiscal year 2012. To accomplish this goal, VA 
is contracting with IOM; to date, VA has met with IOM and has enlisted 
the assistance of VA's Office of General Counsel and a contracting 
specialist. Ultimately, funds will be transferred from VA to the U.S. 
Air Force for the maintenance of the biospecimens using a Military 
Interdepartmental Purchase Request.

VA's Health Care and Benefits Programs for Vietnam Veterans
    In addition to its research portfolio for Vietnam Veterans, VA has 
a number of health care programs specifically designed for this 
population. The most notable example of health effects related to 
military service from Vietnam are the health effects associated with 
exposure to herbicides such as ``Agent Orange.'' During the Vietnam 
War, the U.S. military used more than 19 million gallons of various 
herbicides for defoliation and crop destruction in the Republic of 
Vietnam. Veterans who served in Vietnam anytime during the period 
beginning January 9, 1962, and ending on May 7, 1975, are presumed to 
have been exposed to herbicides.
    VA established the Agent Orange Registry to track the special 
health concerns of Veterans who may have been exposed to Agent Orange 
during their military service. This program includes a medical exam 
that is comprehensive (including exposure and medical histories, 
laboratory tests, and a physical exam). A VA health professional 
discusses the results with the Veteran in a face-to-face consultation 
and a follow-up letter. The exam is cost-free for Veterans and does not 
require enrollment in VA health care or VA's benefits programs. 
Veterans who served in Vietnam or other areas where the herbicide Agent 
Orange was sprayed are eligible for the Agent Orange Registry 
examination. Veterans should ask to speak to their Environmental Health 
Coordinator or Patient Care Advocate at their local VA medical center 
for information about participating in an Agent Orange Registry health 
exam. VA also offers an array of resources to providers to inform them 
of health care concerns and treatment approaches related to Agent 
Orange exposure. We are currently in the process of updating the 
Veterans and Agent Orange Veterans Health Initiative (VHI). Now called 
``Caring for Vietnam Veterans,'' this program will cover a range of 
issues including Agent Orange, infectious diseases, post-traumatic 
stress disorder (PTSD) and other psychological outcomes, as well as 
reproductive outcomes specifically related to the Vietnam War.
    On March 25, 2010, VA published a proposed regulation to establish 
presumptions of service connection between exposure to herbicides in 
Vietnam anytime during the period beginning January 9, 1962, and ending 
on May 7, 1975, and Parkinson's disease, ischemic heart disease (IHD), 
and all B-Cell leukemias (which include Chronic Lymphocytic Leukemia, 
previously service connected, and hairy cell leukemia). This decision 
was based on an analysis of the findings from the Institute of 
Medicine's seventh biennial update, ``Veterans and Agent Orange: Update 
2008.'' As a result of this decision, an estimated 86,069 disability 
claimants who were previously denied benefits for one of those 
conditions will be eligible to receive retroactive payments for the new 
presumptive conditions in 2010. An estimated 32,606 Veterans who 
currently receive compensation for other service-connected conditions 
will become eligible for prospective benefits based on the new 
presumptions in 2010, which may increase their disability payments. An 
estimated 28,934 and 10,416 potential accessions are also expected in 
the same year for Veterans and survivors, respectively. VA estimates 
that the total impact on health care costs for this new determination 
will be $236 million in fiscal year (FY) 2010, $165 million in FY 2011, 
and $171 million in FY 2012. VA is requesting a supplemental 2010 
appropriation of $13.4 billion to provide for the increased disability 
compensation and survivor benefits.
    The new rule will bring the number of categories of illness 
presumed to be associated with herbicide exposure to 14 and 
significantly expand the current leukemia definition to include a much 
broader range of chronic B-cell leukemias beyond Chronic Lymphocytic 
Leukemia previously recognized by VA. VA has previously recognized a 
number of other illnesses as presumptively service connected for 
exposure to herbicides during the Vietnam War, including: AL 
Amyloidosis, Acute and Subacute Transient Peripheral Neuropathy, 
Chloracne or other Acneform Diseases consistent with Chloracne, Chronic 
Lymphocytic Leukemia, Diabetes Mellitus (Type 2), Non-Hodgkin's 
Lymphoma, Porphyria Cutanea Tarda, Prostate Cancer, Respiratory 
Cancers, Soft Tissue Sarcoma (other than Osteosarcoma, Chondrosarcoma, 
Kaposi's sarcoma, or Mesothelioma), and spina bifida in the children of 
exposed veterans. Veterans whose service in Vietnam qualifies them for 
presumptive service connection of a medical condition do not have to 
prove they were exposed to Agent Orange to receive VA health care 
benefits related to Agent Orange exposure. VA operates three War-
Related Illness and Injury Study Centers (WRIISC) that provide clinical 
expertise for Veterans with deployment health concerns or difficult to 
diagnose illnesses. Any Veteran concerned about their exposure can seek 
a referral to a WRIISC from their primary care provider.

Conclusion
    Mr. Chairman, Vietnam Veterans represent the largest portion of 
Veterans in terms of service era, and VA will continue to deliver them 
the quality health care and benefits they deserve. I thank you again 
for your support of our work in this area, and for the opportunity to 
appear before you today. I am now prepared to answer your questions.

                                 
  Statement of Reserve Officers Association of the United States, and 
                      Reserve Enlisted Association
Introduction
    Mr Chairman and Members of the Committee, ROA thanks Chairman 
Filner for the introduction of H.R. 2254, Agent Orange Equity Act of 
2009, that includes blue-water sailors, and blue-sky airman for 
treatment of ailments relating to exposure to toxic herbicides, and the 
256 House members who have cosponsored it. H.R. 2254 is intended to 
clarify the law so that every servicemember awarded the Vietnam Service 
medal, or who otherwise deployed to land, sea or air, in the Republic 
of Vietnam is fully covered by the comprehensive Agent Orange laws 
Congress passed in 1991.

A Personal Testimony
    I am Captain Marshall Hanson, U.S. Naval Reserve (retired). I did 
two tours in the waters off Vietnam as a blue-water sailor. One tour in 
1971 was under training orders as a college student, and the next just 
following my commissioning in 1972.

[GRAPHIC] [TIFF OMITTED] T7019A.002

                  Marshall Hanson and daughter Sydney

    Normally, I would be submitting written testimony strictly on 
behalf of the Reserve Officers Association and the Reserve Enlisted 
Association. ROA does have a resolution #11 that was passed in 2008 
which talks to ``Preserving Veteran Status and Benefits for Those Who 
Have Served in Theaters of Operations'' that is based on the lack of 
available treatment for certain Vietnam Veterans, but for this one time 
I think I need to reflect on my personal experience.
    In 1998, my youngest daughter was born with a cleft soft and hard 
palate, a condition that surprised my wife and me as we couldn't 
identify a reason for it at the time. Cleft palate is a condition in 
which the two plates of the skull that form the hard palate (roof of 
the mouth) are not completely joined, leaving a hole in the top of the 
mouth into the nasal passages. This condition has been found in 
offspring of veterans exposed to Agent Orange. From the characteristics 
of the cleft, the doctors assured us it was not genetic in the sense of 
family history. Luckily the correction to this condition was covered by 
private health insurance and personal copayments, and access to one of 
the world's best craniofacial surgery teams at Seattle Children's 
Hospital. Today, she is a healthy smart-mouthed between, and dentists 
have to be informed that she ever had surgery.
    With only 6 days in Da Nang, Vietnam, while awaiting transit to and 
from ships, I had always felt that I was lucky, figuring that I had 
little to no exposure to herbicides. Since moving to Washington, D.C. 
11 years ago, I have had the chance to work with other Vietnam veterans 
who were not so lucky and had suffered from the cancers associated with 
Agent Orange. One, John Morrison, prematurely passed away with in the 
last few years, after decades of suffering from crippling ailments 
related to his exposure.
    Then, I learned at age 57 that I have a heart condition that will 
require heart surgery in the fall of 2010. Was I exposed, and are 
herbicides the cause? Does my condition qualify as ischemic heart 
disease? These are questions yet to be asked and answered by my 
cardiologist. But this is yet another condition, without a family 
history correlation. Recent facts that I learned have caused me to 
wonder about a possible connection.
    As the Committee is aware, American forces sprayed millions of 
gallons of Agent Orange and other defoliants over parts of Vietnam from 
1961 to 1971. During ``Operation Ranch Hand,'' U.S. forces sprayed 
about 20 million gallons of Agent Orange and other herbicides on 
southern and central Vietnam to deprive enemies of jungle cover. The 
ship that I was assigned to on my second tour was USS Niagara Falls 
(AFS-3), which was included on a short presumption of Agent Orange 
exposure list of offshore ``blue water'' naval vessels conducted 
operations on the inland ``brown water'' rivers and delta areas of 
Vietnam that was issued by the Department of Veteran Affairs.
    I reported aboard the Niagara Falls in 1972, but the period of 
presumptive exposure is 1968. The Niagara Falls did similar types of 
assignments with cargo pickups anchored in the brown waters of Da Nang 
Harbor and replenishments off of Cam Ranh Bay and the mouth of the 
Mekong Delta. The Niagara Falls also steamed along the Vietnam coast 
resupplying Navy destroyers along the inshore gunline, and the aircraft 
carriers and support ships on Yankee Station to the North.
    In addition to similar littoral water duty, the Niagara Falls like 
many blue water ships was exposed to herbicide runoff from Vietnam 
river basins. With 13 large river systems, Vietnam is considered to 
have a complex and dense river network with most of the large river 
systems linked. The Mekong River, alone, splits into nine arms, with 
all flowing down and emptying into the sea. Agent Orange is insoluble. 
It was carried whole into the swamps, down creeks into the rivers and 
down the rivers into the South China Sea.
    It can also be noted in Figure One (see page 6) that herbicides 
were heavily sprayed along the coast. The Navy ships stationed of the 
coast were adrift in an herbicide soup, with runoff continuing to occur 
even after spraying ended in 1971.
    Aboard Navy ships, potable water is produced by evaporative 
distillation of seawater. In distillation plants on ships seawater was 
usually fed into an evaporator where the water was boiled by a 
combination of heating and reduced pressure (vacuum). The vapor was 
condensed in the condenser from where it was pumped into the feed 
tanks.
    As a result insoluble agents remained in the water. An Australian 
study focused on the evaporative distillation process that was used to 
produce potable water by Navy ships from surrounding estuarine waters. 
It was entitled Co-Distillation of Agent Orange and other Persistent 
Organic Pollutants in Evaporative Water Distillation, and found that 
``the main contaminant in Agent Orange was found at about 85 percent of 
the quantity observed in the control samples and co-distilled to a 
greater extent than any other PCDD/F investigated here.'' Sailors were 
being exposed to herbicides through their drinking water. The 
Australian study also was motivated by an Australian Veterans 
Administration report noted that veterans of the Royal Australian Navy 
(RAN) experienced higher mortality than other Australian Vietnam 
Veterans. Australia's largest naval commitment to the Vietnam War was 
the provision of destroyers, on rotation, to serve on the gunline--
delivering naval gunfire support for allied ground forces.
    Navy destroyers provided mobile battery support for troop actions 
in Vietnam. Located between one to two miles off the coast, they 
accurately fire 5 inch shells at a rate of 40 rounds per minute on 
targets at ranges beyond 14 nautical miles inland. This bombardment 
would go 24 hours a day, with ships firing thousands of rounds. These 
ships were close enough ashore that during the war, 29 gunline ships 
were hit by enemy shore artillery.
    A question should be asked as to what happened to the remaining 15 
percent? As kitchen chemistry demonstrates to anyone who cooks, an 
agent in the water when it is boiled migrates to the sides of a 
container. Boil an insoluble salt in a coffeepot, soon that insoluble 
salt coats the inside of the coffeepot. Through the distilling process, 
Agent Orange continued to percolate within the evaporators even after 
external exposure ceased because it coated the system. Every additional 
load of seawater taken into a Navy ship and then boiled added to the 
concentration of Agent Orange on the inside of the evaporators and 
condensers--continuing to contaminate potable water used on the ship.
    Evaporators and condensers are not cleaned, unless the whole system 
is disassembled and re-installed. When undergoing Regular Overhaul (a 
3-year cycle on destroyers) new evaporators and condensers are 
installed.
    During the third year I was aboard USS Niagara Falls, the 
evaporator distillation had to be overhauled during the ship's cycle 
overhaul. Contaminant scale had built up requiring the system to be 
cleaned and parts to be replaced, finally removing any potential Agent 
Orange contaminate from the ship's drinking water system. If exposed, I 
not only was subject to particulates in 1971 and 1972, but may have 
also been exposed by contaminated ship's distilling systems until 1975, 
from sources earlier than 1971
    Unfortunately without the law being changed, the burden of proof is 
on me to convince the Veterans Administration that through my Vietnam 
service, I have been adversely affected by herbicides. There is an 
element of timing, and despite six days ``feet on land'' in Vietnam, 
there is no official documentation that I was there, although with luck 
I might get some confirmation from some classmates that I haven't seen 
for 38 years. My case is further complicated because of the nature of 
the statistical analysis used to determine a basis for presumption. And 
I am just one of hundreds of Reserve Officers Association and Reserve 
Enlisted Association members facing these challenges.
    Health-wise I am told that I am not in a position to wait for the 
VA to process a delayed claim. With luck prior to required surgery, I 
will qualify for TRICARE as I am a retired Reservist who will turn 60 
in September. While I have military health care to fall back on, most 
Vietnam Veterans don't have access to that as an option.

Conclusion
    Thousands of Sailors served providing gunfire support aboard 
destroyers along the coast and on Yankee Station aircraft carriers 
providing air cover and bomb support over Vietnam. Navy veterans who 
were awarded the Vietnam Service Medal as a result of service in the 
waters offshore Vietnam (blue water vets) should be entitled to the 
same presumption of exposure to Agent Orange as veterans who set ``foot 
on land'' in Vietnam or did duty in brown water missions. As a result, 
many Navy veterans who served offshore and their survivors were granted 
disability or DIC benefits based on an Agent Orange-related disease.
    Also overlooked are Air Force Airmen who were exposed to herbicides 
stored at staging airbases, and storage sites outside of Vietnam and in 
the airspace above. Many are suffering the same diseases as a result of 
exposure to the herbicide Agent Orange, and deserve Veteran health 
care, and disability benefits for their ailments, or care for 
survivors.
    The Reserve Officer Association (ROA) and the Reserve Enlisted 
Association representing over 65 thousand members support expanding the 
presumptive coverage by the Department of Veterans Affairs.
    But in addition ROA recognizes with Resolution 08-11 (see page 
seven) that exposures to chemicals, toxins and heavy metals can occur 
in any war and that these can be spread more widely by airborne drift 
or water-borne runoff than calculated computer models. It remains 
vitally important in any theater of contingency operations that 
individuals are recognized for their service and remain eligible for 
health benefits regardless of manner of exposure whether on land, sea, 
or in the air. Medical treatment of serving members as well as veterans 
needs to take precedence over determining statistical correlations.
Figure One follows: Spray Patterns of Herbicides in Vietnam.
[GRAPHIC] [TIFF OMITTED] T7019A.003


                                 
                      Reserve Officers Association
       Preserving Veteran Status and Benefits for Those Who Have
           Served in Theaters of Operations. Resolution 08-11

    WHEREAS, the Department of Veterans Affairs (VA) has proposed to 
amend its adjudication regulations regarding the definition of service 
in the Republic of Vietnam in regard to exposure to Agent Orange;
    WHEREAS, the current definition of service in Vietnam includes 
service in the waters offshore and service in other locations if 
``conditions of service involved duty or visitation in the Republic of 
Vietnam''; and
    WHEREAS, the VA wishes the definition ``to include only service on 
land and on inland waterways'' of the Republic of Vietnam; and
    WHEREAS, thousands of Sailors served providing gunfire support 
aboard destroyers along the coast and on Yankee Station aircraft 
carriers providing air cover and bomb support over Vietnam; and
    WHEREAS, thousands of Airmen stationed in Thailand, prepared 
aircraft and flew missions over Vietnam; and
    WHEREAS, Marines and Soldiers fought in Laos and crossed into 
Cambodia; and
    WHEREAS, distinguishing types of service in an theater of 
operations is a bad precedent, when ``boots-on-the-ground'' veterans 
are differentiated from all other Armed Forces participants, especially 
when this Nation is currently at war; and
    WHEREAS, exposures to chemicals, toxins and heavy metals can be 
spread more widely by airborne drift or water-borne runoff than 
calculated patterns;
    NOW THEREFORE BE IT RESOLVED, that the Reserve Officers Association 
of the United States, chartered by the Congress, urge the Congress, the 
Department of Defense and the Department of Veterans Affairs, to retain 
current definitions of service in any theater of operations ensuring 
that individuals are recognized for their service and remain eligible 
for health benefits regardless of manner of exposure whether on land, 
sea, or in the air.

Time Sensitive--submitted by ROA Headquarters Staff
Adopted by the ROA National Convention, June 28, 2008
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Harvey V. Fineberg, M.D., Ph.D.
President
Institute of Medicine of the National Academies
500 Street, NW
Washington, DC 20001

Dear Harvey:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         BOB FILNER
                                                           Chairman

CW:ds

                               __________
                    Institute of Medicine of the National Academies
                                                    Washington, DC.
                                                       17 June 2010
The Honorable Bob Filner
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515

Via fax: 202-225-2034/Attn: Debbie Smith

Dear Representative Filner:

    Thank you for sending the follow-up hearing questions to the full 
Committee hearing entitled ``National Vietnam Veterans Longitudinal 
Study: Where are we?'' held on 5 May 2010. Attached please find the 
answers to those questions. If we can be of further assistance, please 
contact Mary Paxton at 202-334-1731 or [email protected].

            Sincerely,

                                    Harvey V. Fineberg, M.D., Ph.D.
                                                          President

                               __________
                   Responses to Questions Posed after
          Hearing of the House Committee on Veterans' Affairs
                          Held on May 5, 2020
    Question 1: What will be your process in carrying out the Blue/
Brown Water Navy study?

    Response: In conducting the ongoing IOM study, Blue Water Navy 
Vietnam Veterans and Agent Orange Exposure, the IOM has followed its 
standard committee processes and procedures. After approval of the 
study by the National Research Council Governing Board, the study is 
assigned to a division (in this case the Institute of Medicine), a 
board (the Board on the Health of Select Populations), and a study 
director. The study director is responsible for working with the 
Committee to develop a consensus report that addresses the Committee's 
charge. Specifically, the consensus committee was formed according to 
our standard practice as follows:

      Prospective members were suggested by individuals 
knowledgeable in the fields in which nominees are sought, including 
IOM, National Academy of Sciences, and National Academy of Engineering 
members, IOM Board Directors, members of the Board on the Health of 
Select Populations, and committee members from previous Veterans and 
Agent Orange committees. Over 80 people were screened as potential 
committee members. This committee was organized to reflect a range of 
technical expertise related to dioxin exposure and assessment. In 
addition to toxicologists, epidemiologists, and exposure assessors and 
modelers (both atmospheric and water), the Committee nominees included 
experts in desalination of water. None of the nominees had served on 
previous IOM Agent Orange studies.
      The Committee members were appointed by the Institute of 
Medicine with the approval of the President of the National Academy of 
Sciences.
      Before the appointments were finalized, the provisional 
committee members' names, affiliations, and short biographies were 
posted for public comment on the Academies' Web site for 20 days. All 
the Committee members participated in a bias and conflict of interest 
discussion at the first committee meeting to ascertain any potential 
conflicts of interest and to ensure that the Committee was properly 
balanced with regard to any biases.

    The Committee has held the first of five meetings. At this first 
meeting, the Committee held an ``information gathering'' session that 
was open to the public. At the meeting, the Committee heard from three 
representatives of the Department of Veterans Affairs who provided the 
Committee with information on the need for the study, the charge to the 
Committee, an overview of the Haas v.  Peake court case that eventually 
upheld the VA's determination that the presumption of herbicide 
exposure applies to veterans who served on land or inland waterways in 
Vietnam, but not to veterans who served only in offshore waters, and a 
discussion of the current process for reviewing Agent Orange claims by 
the VA Compensation and Pension Service. The Committee also heard from 
several veterans who had served in the blue or brown water Navy. The 
Committee also received numerous materials from Vietnam veterans, and 
all such materials have been included in the Committee's public access 
files. Following the open session, the Committee deliberated in closed 
session.
    It is expected that a second information-gathering session will be 
held at the second committee meeting. That meeting, like the first one, 
will be announced on the Committee's Current Projects Web site and a 
notice will be sent to a list of interested veteran organizations and 
individual veterans. During its future meetings, the Committee will 
deliberate in closed session and prepare a draft report. The report 
will be based on what the Committee has learned at its open meetings, 
published literature and other resources, as deemed appropriate by the 
Committee members.
    The draft report, once approved by the Committee, will undergo the 
National Academy of Sciences' report review process. This process 
entails the following:

      Prior to release, report is reviewed by individuals who 
are not involved in authoring the report and whose names are not 
revealed to the Committee or the study director during review.
      Reviewers are selected by the major unit responsible for 
the project, in consultation with the National Academy of Sciences' 
Report Review Committee.
      The review is overseen by a review monitor and/or 
coordinator.
      Each committee must respond to, but need not agree with, 
reviewer comments in a detailed ``response to review'' that is examined 
by the monitor and/or coordinator, who ensure that the report review 
criteria have been satisfied.
      The report may not be released to sponsor or the public 
until the chair of the Report Review Committee (or designee) signifies 
that the review process has been satisfactorily completed.
      The Department of Veterans Affairs will not be given an 
opportunity to suggest changes in the report.
      The names and affiliations of the report reviewers will 
be made public when the report is released.

    Once the report is finalized and approved for public release, 
briefings and embargoed copies of report will be provided to the 
Department of Veterans Affairs and Congress just prior to public 
release of the report, which is planned for June, 2011.

    Question 2: Please briefly summarize your recommendations regarding 
Blue Water Veterans as outlined in your Veterans and Agent Orange 
Update 2008, particularly regarding the definition of ``service in 
Vietnam'' and the pertinent findings of the 2002 Australian report (p. 
564-566) [sic].

    Response: The Committee for Update 2008 was aware of the ``boots on 
the ground'' controversy associated with the Haas case. The definition 
of ``service in Vietnam'' has been a component of the deliberations of 
all Veterans and Agent Orange (VAO) committees. The Committee 
responsible for the first VAO report (1994) considered epidemiologic 
studies of both blue and brown water Navy personnel in their analysis 
of research on the health of Vietnam veterans. This approach to 
classifying Vietnam veteran status had been followed by all subsequent 
VAO committees for the biennial updates.
    As detailed on pages 54-55 and 655-656 of Update 2008, the 
Committee explained that it was not aware of scientific information to 
merit changing its operational definition of ``Vietnam service.'' After 
obtaining an explanation of the physicochemical principles applicable 
to the 2002 Australian distillation study from Steven Hawthorne of the 
University of North Dakota's Energy and Environmental Research Center, 
the Committee was satisfied that concentration of dioxin by shipboard 
preparation of drinking water constituted a possible route of exposure. 
The Committee noted that observed health outcomes in blue water Navy 
veterans (particularly non-Hodgkin's lymphoma) are concordant with 
possible dioxin exposure. The Committee also remarked that admittedly 
limited measurements of serum TCDD levels indicate considerable overlap 
in the distributions for veterans who had been on Vietnamese soil and 
for those who had served elsewhere in Southeast Asia.
    From the perspective of the VAO committee for Update 2008, adoption 
of a definition of ``Vietnam service'' in accord with the February 27, 
2002 directive in VA's M21-1 manual concerning BWN veterans for use in 
the Committee's deliberations would represent a change from its 
established procedures without compelling supporting evidence and would 
not be consistent with the premise of giving the veterans the benefit 
of the doubt.

    Question 2(a): Given your recommendation in your 2008 Update, do 
you think further study is needed on establishing the exposure of Blue 
Water veterans to Agent Orange?

    Response: The Committee that prepared Veterans and Agent Orange: 
Update 2008, with its pre-existing familiarity with the general paucity 
of information concerning the exposure of individual veterans to the 
herbicides sprayed by the U.S. military in Vietnam, did not engage in 
exhaustive searches for any and all possible information specifically 
related to the BWN veterans. After seeking outside expertise, the 
Committee was satisfied that concentration of dioxin during shipboard 
preparation of drinking water was a possibility. In the absence of new 
evidence demonstrating that BWN veterans were definitively less exposed 
than all veterans with ``boots on the ground'' experience in Vietnam, 
who VA now regards as presumptively exposed to Agent Orange, the 
Committee for Update 2008 did not see a rationale for altering the 
operational definition of ``Vietnam service'' used in the Veterans and 
Agent Orange series since release of the first report in 1994.
    The study now being conducted at VA's request by the new IOM 
committee on Blue Water Navy Vietnam Veterans and Agent Orange Exposure 
has as its sole purpose conducting a comprehensive search for all 
relevant information that might support or refute VA's current manner 
of classifying veterans as ``Vietnam veterans'' with presumed possible 
exposure to Agent Orange.

    Question 3(a): In accordance with a provision outlined in P.L. 110-
389, what is being done to ensure the preservation of the Air Force 
Health Study (Ranch Hand) samples by the IOM's Medical Follow-up 
Agency?

    Response: Section 803 of P.L. 110-389--the Veterans' Benefits 
Improvement Act of 2008--is entitled ``Maintenance, Management, and 
Availability for Research of Assets of Air Force Health Study.'' The 
law states that ``[t]he purpose of this section is to ensure that the 
assets transferred to the Medical Follow-Up Agency from the Air Force 
Health Study are maintained, managed, and made available as a resource 
for future research for the benefit of veterans and their families, and 
for other humanitarian purposes.'' It transfers the data and biologic 
samples collected during the course of the Air Force Health Study 
(AFHS) to the Medical Follow-up Agency (MFUA), and requests that MFUA

      maintain and manage these assets;
      conduct ``such additional research on the assets . . . as 
the Agency considers appropriate toward the goal of understanding the 
determinants of health, and promoting wellness, in veterans'';
      make grants for pilot studies in connection with this 
research; and
      ``submit to Congress a report assessing the feasibility 
and advisability of conducting [further] research on the assets'' at 
the end of trial period specified in the legislation.

    The Department of Veterans Affairs was directed to supply funding 
for these activities in subsection (f) of the law.
    Since the law went into effect, MFUA has:

      accepted custody of an electronic database containing the 
information collected from those AFHS participants who consented for 
their data be transferred to MFUA, and placed that database in secure 
storage;
      arranged with the U.S. Air Force's 711th Human 
Performance Wing, Human Effectiveness Directorate, Biosciences and 
Protection Division, Applied Biotechnology Branch, located at Wright-
Patterson AFB to hold and maintain the AFHS biologic samples in secure 
storage; and
      been negotiating with the Department of Veterans Affairs 
to provide the funding for the assets maintenance and research 
activities specified in subsections (d) and (e).

    The negotiations with VA were still in progress as of 15 May 2010. 
In his 5 May testimony before the Committee, Joel Kupersmith, MD--Chief 
Research and Development Officer for VA's Veterans Health 
Administration--stated:

        To accomplish [the goals of P.L. 110-389], VA is contracting 
        with IOM; to date, VA has met with IOM and has enlisted the 
        assistance of VA's Office of General Counsel and a contracting 
        specialist. Ultimately, funds will be transferred from VA to 
        the U.S. Air Force for the maintenance of the biospecimens 
        using a Military Interdepartmental Purchase Request.

    MFUA hopes to conclude negotiations with DVA in the near future, 
receive the funding that will it allow it to carry out the provisions 
of Section 803 in a timely manner, and then implement those provisions.

    Question 3(b): Does the Medical Follow-up Agency need anything 
further from VA or Congress to preserve these specimens?

    Response: MFUA believes that, once the funding for its activities 
is in place, it will be able to carry out the Congress' intent to 
preserve the AFHS assets and promote research regarding them. It notes 
that the Congress anticipated that this funding would be made available 
at the beginning of FY 2009, stating in Section 803, subsection (d)(1):

        The Medical Follow-Up Agency may, during the period beginning 
        on October 1, 2008, and ending on September 30, 2012, conduct 
        such additional research on the assets transferred to the 
        Agency from the Air Force Health Study as the Agency considers 
        appropriate toward the goal of understanding the determinants 
        of health, and promoting wellness, in veterans. [emphasis 
        added]

    More than a year and a half has elapsed since then. It is not 
possible for MFUA to fulfill the mandates of the section in fewer than 
the 4 years the Congress specified in the subsection because time is 
required to determine whether the additional research called for is 
yielding information relevant to the determinants of health and 
promotion of wellness in veterans. If MFUA is to fulfill the mandates 
of section 803 it will be necessary to adjust both the funding years 
for the research and the due date for the report requested in 
subsection (e)(1).

    Question 4: What is being done to further study the possible birth 
defects or developmental disease in the offspring of herbicide exposed 
veterans or even their children's offspring (epigenerational [sic] 
effect of exposure)?

    Response: Although VAO committees have repeatedly noted the great 
concern of Vietnam veterans about the possibility that their deployment 
(presumably because of possible herbicide exposure) may be responsible 
for health problems in their children (and now their grandchildren) and 
recommended that additional epidemiologic investigation be conducted, 
we are not aware that any such study of Vietnam veterans and their 
offspring is underway.
    The Committee for Update 2008 noted that recently explored 
epigenetic mechanisms might provide a previously overlooked means by 
which paternal transmission of transgenerational effects could arise 
from exposure to components of the herbicides sprayed in Vietnam. 
Epigenetic modifications are chemical changes to DNA that do not 
involve base-pair alterations, but that are transmissible through cell 
division. The currently understood consequences of such modifications 
arising from gestational or postnatal exposure (i.e., not paternal 
transmission) involve transmission from an altered cell to an 
individual's own somatic tissues resulting in impacts on gene 
expression with potentially adverse effects in later life such as 
cancer, obesity, behavioral problems, etc. There is preliminary 
evidence that epigenetic modifications induced by some chemicals may 
persist through gametogenesis to produce transgenerational effects. As 
of Update 2008, toxicologic studies had not been published on the 
potential of any of VAO's chemicals of interest to produce epigenetic 
effects. The nature of dioxin's pattern of toxic activity through 
signaling pathways impacting gene expression, however, suggested to the 
Committee that it would be an appropriate target for such toxicologic 
investigation.
    Epidemiologic studies of transgenerational effects, particularly by 
paternal transmission, are logistically extremely challenging, but 
protocols would not necessarily be altered by whether the underlying 
mechanism of action is hypothesized to be genetic or epigenetic.

    Question 5(a): What is your charge as you begin to collect data and 
ramp up for your next Update in 2010?

    Response: In accordance with P.L. 102-4, the Committee preparing 
Update 2010 will ``determine (to the extent that available scientific 
data permit meaningful determinations)'' the following regarding 
associations between specific health outcomes and exposure to TCDD and 
other chemicals in the herbicides used by the military in Vietnam:

      whether a statistical association with herbicide exposure 
exists, taking into account the strength of the scientiﬁc 
evidence and the appropriateness of the statistical and epidemiological 
methods used to detect the association;
      the increased risk of the disease among those exposed to 
herbicides during service in the Republic of Vietnam during the Vietnam 
era; and
      whether there exists a plausible biological mechanism or 
other evidence of a causal relationship between herbicide exposure and 
the disease.

    Question 5(b): Are there any conditions to which you are paying 
special attention?

    Response: As is the standard VAO procedure, the Committee for 
Update 2010 will focus its deliberative efforts on health effects for 
which the peer-reviewed literature published in the last 2 years has 
provided new data related to exposure to the components of the 
herbicides sprayed in Vietnam that might result in a change in the 
health effect's category of association.

    It is our understanding that VA is again requesting special 
attention to the possibility of adverse transgenerational effects 
occurring in the offspring of male Vietnam veterans.

    Question 5(c): Is there any thing else you need from Congress to 
carry out your charge?

    Response: VAO committees have recommended that additional 
epidemiologic studies of Vietnam veterans be facilitated since the 
original report was published in 1994. Data from such studies would 
greatly help future committees to draw conclusions on the three 
elements of the charge listed above. Because the publication period for 
Update 2010 ends on September 30, however, newly initiated research 
will not have generated results for consideration in this biennial 
update.

                                 
                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Charles Marmar, M.D.
Chair, Department of Psychiatry
New York University Langone School of Medicine
550 First Avenue
OBV Building A, Rm. A645
New York, NY 10016

Dear Charles:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         BOB FILNER
                                                           Chairman

CW:ds

                               __________

                         New York University Langone Medical Center
                                                      New York, NY.
                                                      June 18, 2010
Chairman Bob Filner
Committee on Veterans' Affairs
U.S. House of Representatives
One Hundred Eleventh Congress
335 Cannon House Office Building
Washington, DC 20515

Dear Chairman Filner:

    Below please find my responses to the Post-Hearing Questions 
following the May 5, 2010, full Committee Hearing entitled, ``National 
Vietnam Veterans Longitudinal Study: Where Are We?''
    Question 1: How important is it that the NVVLS be conducted:

      It is of exceptionally high importance in order to 
determine the longitudinal course, mental health consequences, family 
impact, and medical consequences of war zone related PTSD.
      The NVVLS is the only nationally representative sample of 
Vietnam veterans' comprehensive readjustment findings at baseline 
during 1986 and 1987, permitting a careful analysis of risk and 
resilience for long-term adverse health consequences.
      The findings from the NVVLS will inform policy for the 
mental health and family adjustment of Iraq and Afghanistan veterans.
      Determining the long-term adverse mental health and 
physical health consequences of Vietnam war service will allow the DoD 
and the VA to develop prevention strategies to preserve the resilience 
of Iraq and Afghanistan veterans and their families.

    Question 2: Would you like to comment on the VA's contention that 
the NVVLS will not adequately address questions about, ``the mental or 
physical health status of the Vietnam veteran population?''
      The majority of participants will be locatable, 
interviews will be conducted by telephone, and mental and physical 
health status will be accurately determined in a nationally 
representative sample of Vietnam veterans.
      Studies currently in progress supported by VA, including 
the twin study and women veterans study, are important, but they will 
not address the fundamental question of the rates of mental health and 
physical health problems in a representative sample of Vietnam 
veterans.

    Question 3: I found interesting your comments that the NVVRS, if 
complemented with the NVVLS, will provide critical lessons learned for 
the long-term readjustment needs of OEF and OIF veterans. Please 
elaborate on that point:

      The NVVLS will provide a roadmap defining resilience and 
vulnerability of those exposed to war zone stressors.
      This information will inform novel strategies for 
mitigating the effects of PTSD, depression, alcohol and substance 
abuse, and family stress, as well as adverse physical health problems, 
including cardiovascular disease and risk for early onset dementia, for 
OEF and OIF veterans.

    If you have any additional questions, or need further clarification 
on these responses, please feel free to contact me at 212-263-6214 or 
via email to my assistants: [email protected] or 
[email protected].

            Sincerely,

                                            Charles R. Marmar, M.D.
                                                Professor and Chair
                                           Department of Psychiatry

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Gene L. Dodaro
Acting Comptroller General
U.S. Government Accountability Office
441 G Street, NW
Washington, DC 20548

Dear Gene:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         Bob Filner
                                                           Chairman

CW:ds

                               __________
                       Testimony on May 5, 2010:
          ``Health Effects of the Vietnam War--The Aftermath''
       VA Health Care: Progress and Challenges in Conducting the
       National Vietnam Veterans Longitudinal Study (GAO-10-658T)

    Question 1: When a Federally-funded study is conducted solely by a 
contractor, is it typical for Federal agencies to require that the 
contractor give the agency the identifying information of the 
participants in the study?

    Answer: Not for studies like the NVVLS.

      Methodologists we talked with said that it is typical for 
the contractor to ensure confidentiality to participants, especially 
for studies funded by Federal Government agencies, because many people 
distrust government agencies. Identifying information is not usually 
provided in these cases.
      The methodologists and researchers we spoke to did not 
know why VA would want that information.

    Question 2: Is it important for agencies such as VA to contract out 
research studies on sensitive issues such as PTSD?

    Answer: For studies like the NVVLS, Yes.

      Again, because of distrust that many people have for 
Federal Government agencies, such as VA and DoD, independent third 
parties--who can assure confidentiality among participants--may be in a 
better position to elicit more open and accurate answers on sensitive 
issues.

    Question 3: What type of information could the NVVLS provide?

    Answer: A number of things:

      It would provide information on the long-term-course and 
medical consequences of PTSD;
      It would provide information on the services used by 
veterans with PTSD and the effect of those services in treating PTSD;
      And, it would provide information on particular 
subgroups, such as Hispanic and black males, women, and veterans with 
service-connected disabilities to help discern whether those veterans 
are at greater risk of chronic or more severe problems with PTSD.

    Question 4: Could the NVVLS provide information related to Agent 
Orange exposure and other health effects from the Vietnam War?

    Answer: The NVVLS could provide long-term health information for 
those Vietnam-era veterans that may have been exposed to Agent Orange.

      The contractor for the NVVLS could include questions 
related to Agent Orange as part of the analysis, according to 
researchers and methodologists we talked with.

    Question 5: Based on the work you have done, is VA doing everything 
they can to complete the NVVLS in a timely manner?

    Answer: That's hard to say, since we don't have access to internal 
VA discussions on this matter.

      If the past is any indication, the answer is no. It has 
been 7 years since the failed NVVLS attempt, and as recently as last 
year, VA has asked this committee to accept the Twin and Women Veteran 
studies as substitutes for the NVVLS. These facts speak volumes about 
VA willingness to get the NVVLS moving.
      Looking forward, a couple of things are important to do 
expeditiously:

        1.  First, VA has not yet selected a contractor.
        2.  Second, after a contractor is selected, VA expects the 
        contractor to assess the feasibility of the NVVLS, given the 
        challenges VA has identified. It is very important that this 
        phase of the study is done thoughtfully and thoroughly.

    Question 6: Do the twin and the women's studies meet all the 
requirements of the Veterans Benefits and Health Care Improvement Act 
of 2000?

    Answer: Not entirely.

    The law clearly states that VA must contract with an appropriate 
entity to conduct a follow-up study to the NVVRS using the same data 
base and sample.

      Neither the twin nor women's study will use the complete 
NVVRS data base and sample.
          The twin study sample is limited to male twins and 
        the women's study sample is comprised of only women.
      The women's study will not provide information on the 
long-term course of PTSD.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Richard F. Weidman
Executive Director for Policy and Government Affairs
Vietnam Veterans of America
8719 Colesville Road
Silver Spring, MD 20910

Dear Rick:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         Bob Filner
                                                           Chairman

CW:ds

                               __________
                   Vietnam Veterans of America (VVA)
           Questions and Answers from the May 5, 2010 Hearing
                     From the Honorable Bob Filner
    Question 1: Mr. Weidman, you lay out a strong case for the 
importance of the NVVLS to providing quality health care to veterans of 
both the Vietnam War and current and future conflicts. What do you view 
as the most important benefits that this study would provide?

    Response: Properly completing the NVVLS will prove to be valuable 
in many ways. First, it will give us a good picture of the arc of 
psychosocial readjustment and mental health of the last large cohort of 
combat veterans prior to the current wars. This is important not only 
to be able to plan for the medical needs of the Vietnam cohort, but to 
do long range planning for the needs of the newest combat theater 
veterans are likely to be.

    Secondly, there has always been a need for a robust epidemiological 
study of the overall health of the Vietnam generation of veterans, 
particularly how the combat theater veterans are doing in comparison to 
those who did not serve in a combat theater and how they compare to 
their non-veteran peers. This kind of epidemiological work is just 
basic good scientific practice, particularly in a democracy where you 
have citizen soldiers. The Australians have done three complete 
universe epidemiological studies on all branches of their Armed 
Services who served in the Vietnam Era, and are working on their fourth 
such study. That is how you pick up on anomalies that then should be 
pursued by specific scientific studies to discover why there is a 
higher incidence of a disease, malady, or condition that is higher than 
would be expected in this population.
    Third, the Institute of Medicine (IOM) of the National Academies of 
Science (NAS) has noted as they released their biennial reviews of 
Agent Orange pursuant to the requirements of Public Law 102-4, the 
Agent Orange Act of 1991, that the one major thing they were lacking to 
do their job correctly was a robust epidemiological study or Vietnam 
veterans and their families. While the NVVLS does not address the 
families (progeny), it is probably as close as we in America are going 
to get to a complete epidemiological study of Vietnam veterans.
    Fourth, all of the above should guide the military in taking steps 
in the future to better protect our servicemembers from harm while they 
still accomplish the mission.

    Question 2: Mr. Weidman, both your testimony and that of GAO notes 
that VA's requirement that the agency or organization contracted with 
to conduct the NVVLS disclose the identifying information of 
participants is not in keeping with standard scientific protocol. Do 
you believe that this requirement could dissuade some original 
participants from the NVVRS from participating in the NVVLS?

    Response: We believe that this requirement for disclosing the 
participant identifiers will doom the effort to complete the NVVLS 
project. The Research & Development (R&D) personnel know this, which is 
why they inserted it. They used the same sneaky and dishonest method to 
kill the Congressionally mandated brain study of Gulf War I veterans 
being done by Dr. Robert Haley in Texas.

    Frankly, given the VA's terrible track record of using such 
confidential information in an improper manner, VVA does not think that 
any objective person should be surprised that veterans would balk at 
``writing the VA a blank check'' to use this info. Such disclosure as 
they are asking of these participants is not only giving permission to 
have access to information shared in this round with whoever at VA has 
a whim to do so, but to have the same wide open access to all 
information shared 25 years ago in the original study. This flies in 
the face of commonly accepted scientific practice for human subject 
research guarantees of confidentiality that are routinely approved. 
Individual identifiers are not needed for any valid scientific reason. 
Frankly, why would they want this info? For I can assure you that if 
they have it, somebody at VA will sooner or later decide to use this 
info for some improper usage, probably against the individual veteran, 
without regard to the fact that the veteran may have acted in good 
faith in every facet of his/her behavior.
    What is puzzling to us is why the Secretary of Veterans Affairs 
listens to these people. These people have no business leading any 
organization because of their lack of integrity and veracity, much less 
the R&D section of VA that should be devoted to helping improve the 
care and the health of those who have served our Nation well in the 
Armed Services of the United States.
    We have repeatedly explained to the Secretary and his team (and The 
White House) that at VVA we usually do not get involved with 
personalities or personnel decisions. However, in this case the lies 
and other dishonest acts are just plain unacceptable behavior, and that 
whole leadership team at R&D within VA needs to be replaced with people 
of integrity. Fortunately there are many people who are much more 
talented and qualified for these positions than the current incumbents 
who could be attracted to come to VA. There are many that would step up 
to the challenge who are able to do what all good scientists do: seek 
the truth wherever it may lead, and then speak the truth about it to 
all in an open and transparent way. Dishonesty and lying by public 
officials is intolerable. In medical scientists it is both outrageous 
and immoral. We need new leadership at VA R&D.

    Question 3: You have stated that the ``Twins Study'' and other 
proposed alternatives to the NVVLS are not adequate replacements. What 
additional benefits does the NVVLS provide, in comparison to these 
alternative studies?

    Response: The so-called ``Twins Study'' that was done by the 
Centers for Disease Control (CDC) is not a statistically valid random 
sample that would allow one to form conclusions that would apply to all 
Vietnam veterans in the country. Rather, the ``Twins Study'' is based 
on a sample of convenience, meaning that it consists of sets of 
identical twins, who opted to volunteer to participate in the study, 
where one twin served in the U.S. military in Vietnam, and the other 
twin served in the U.S. military but did NOT serve in Southeast Asia. 
This sample is virtually all Caucasian, with fewer than a dozen black 
or Hispanic veterans combined, and no women whatsoever. All of the 
money spent using this sample would not lead to answering the questions 
at hand about all Vietnam veterans, much less very important subsets of 
the population (e.g., women veterans or Hispanic veterans). Neither the 
``Twins Study'' nor any other ``alternative'' studies that VA said 
would suffice are statistically valid random samples of men and women 
who served Vietnam, nor are these other studies ``oversampled'' in a 
way that is necessary in order to be able to draw valid conclusions 
about the subsets to the overall population.

    ONLY the NVVLS existing pool of human subjects can be used for the 
purpose of being able to draw conclusions about the overall population 
of Vietnam veterans as compared to to others their age, and the only 
one where you can reach valid conclusions as to the health of subsets 
of the population. Further, The NVVLS is the only study population 
where the beginning point dates back 25 years, and the only one that 
has both a control group of military personnel who served in the era 
but not in Vietnam, as well as a second control group of those the same 
age who did not serve in the military at all. For all of these reasons, 
it is imperative that VA move forward with getting the NVVLS done, and 
done properly.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Steve Robertson
Director, National Legislative Commission
The American Legion
1608 K Street, NW
Washington, DC 20006

Dear Steve:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith at by fax at 202-225-2034. If you have any questions, 
please call 202-225-9756.

            Sincerely,

                                                         Bob Filner
                                                           Chairman

CW:ds

                               __________
                                                    American Legion
                                                    Washington, DC.
                                                      June 21, 2010
Honorable Bob Filner, Chairman
U.S. House of Representatives
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515

Dear Chairman Filner:

    Thank you for allowing The American Legion to participate in the 
Committee hearing on Health Effects of the Vietnam War--The Aftermath 
on May 5, 2010. I respectfully submit the following in response to your 
additional questions:

    1.  VA has expressed concerns about the feasibility of mustering a 
statistically significant sample size of participants in the NVVRS; not 
just due to difficulties in locating all of the participants, but also 
to concerns that some of the original participants may be reluctant to 
participate. Do you share their concern that reluctance on the part of 
participants in the NVVRS may be problematic?

    Mr. Chairman, The American Legion does share a concern if there are 
no original participants to take part in the study. However, we do feel 
that VA should conduct the study, and as long as a representative 
sample is found the results would be valid. During the 2001 NVVLS 
study, the researchers estimated that 8.5 percent of the Vietnam-era 
veterans who originally participated in the first NVVRS, had died. 
Therefore we can anticipate a significantly reduced number of 
participants. We recommend that VA provide the number of remaining 
original participants and request their participation in the upcoming 
study.
    In conclusion, The American Legion again applauds the addition of a 
consent form and VA's promise that study participation will not affect 
the participants' VA benefits or VA health care; however, we also have 
further concerns over other language in the form or lack thereof. Left 
out of the consent form was the lack of assurance of confidentiality of 
the veterans identifying information. This could make potential veteran 
participants, to include original participants, reluctant to 
participate in the upcoming study; which may in turn invalidate the 
study.

    2.  Do you share GAO's concerns about VA's requirements that the 
NVVLS contractor provide them with the identifying information of 
participants in the study?

    It is The American Legion's belief that the identifying information 
should be used for conducting the NVVLS study only. According to 
researchers and methodologists, to encourage participation for previous 
NVVRS participants, veterans were assured confidentiality of their 
identifying information. This confidentiality served as a factor to 
motivate veteran participation in the past and should be included on 
the upcoming NVVLS consent form.
    VA's NVVLS consent form will lack assurances of confidentiality, 
because it states VA will in fact take possession of study 
participants' indentifying information. We also share concerns that 
this may minimize veteran participation in the study.
    Thank you for your continued commitment to America's veterans and 
their families

            Sincerely,

                                     Joseph Wilson, Deputy Director
                     Veterans Affairs and Rehabilitation Commission

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 10, 2010

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our full Committee hearing entitled ``National 
Vietnam Veterans Longitudinal Study: Where are we?'' on May 5, 2010, I 
would appreciate it if you could answer the enclosed hearing questions 
by the close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith at by fax at 202-225-2034. If you have any questions, 
please call 202-225-9756.

            Sincerely,

                                                         Bob Filner
                                                           Chairman

CW:ds

                               __________
                        Questions for the Record
                   The Honorable Bob Filner, Chairman
                  House Committee on Veterans' Affairs
            Health Effects of the Vietnam War--The Aftermath
                              May 5, 2010

    Question 1: What is the current state of the NVVLS?

    Question 1(a): Specifically, it seems that the study is not 
progressing as originally planed. According to the GAO report, VA 
confirmed that it would release the request for proposals in spring 
2010, and it is already May 5 and a request for proposals has not been 
released. What are the causes of these delays and what is VA's plan to 
move forward with the NVVLS in a timely manner?

    Response: The solicitation for the National Vietnam Veterans 
Longitudinal Study (NVVLS) contract was released on May 26, 2010. 
Review of proposals will take place in July 2010, and the award 
recommendation should be completed in August 2010. All of these 
components meet the projected timeline.

    Question 2: Your testimony states that the NVVLS would not 
adequately address questions about ``the mental or physical health 
status of the Vietnam Veteran population.''

    Question 2(a): Specifically, which components of mental and 
physical health do the parameters of the NVVLS fail to sufficiently 
address? Please explain why VA believes that the proposed alternative 
studies would better address these questions.

    Response: We believe that as the NVVLS, is one single study of an 
observational nature, it would not be sufficient to fully understand 
the mental and physical health of the Vietnam era population. VA has 
sponsored many studies of the Vietnam Veteran population, including two 
large studies currently being conducted: Cooperative Studies Program 
(CSP) #569, A Twin Study of the Course and Consequences of Post 
Traumatic Stress Disorder in Vietnam Era Veterans, and CSP #579, Health 
of Vietnam Era Veteran Women's Study. In addition, other studies are 
focused on improving the understanding of exposures and treatment 
trials. Together with NVVLS, the body of research supported by VA will 
provide a great deal of information about the status of the Vietnam 
Veteran population's mental and physical health.

    Question 3: You note that the Scientific Panel of the Integrated 
Project Team has found that the NVVRS was not designed to accommodate a 
follow-up study and that the potential for statistical bias must be 
addressed. Please elaborate on this concern.

    Response: The National Vietnam Veterans Readjustment Study (NVVRS) 
population has not been maintained as a cohort for long-term follow up. 
At the initiation of a long-term study, there are plans to follow the 
individual participants from the initiation of the longitudinal study 
and over the ensuing years. Participants are contacted regularly, 
contact information is kept up to date, and information about 
activities regarding the cohort is provided using a variety of 
communications such as newsletters. For example, the Vietnam Era Twins 
Registry (established in the 1980s) sends out newsletters, and the 
twins are contacted on an ongoing basis for participation in studies 
sponsored by the Registry, making it a very well studied cohort. This 
did not occur with the NVVRS, which was conducted at a single point in 
time as a cross-sectional study.

    Question 4: The Integrated Project Team has also noted the need to 
transfer data from the NVVRS to the NVVLS. Given that this data was 
initially gathered in 1988, has it been digitized?

    Question 4(a): If not, what challenges will VA face in doing so?

    Response: VA, through the Office of General Counsel, has recently 
received confirmation that the NVVRS data will be transferred smoothly 
to the awarded contractor.

    Question 5: A third challenge identified by the Integrated Project 
Team is the potential difficulty in getting the original cohort of 
Veterans to participate in the NVVLS.

    Question 5(a): Was this a challenge during the NVVRS?

    Question 5(b): If so, how did VA address it then?

    Question 5(c): If not, why does VA believe it may be a challenge 
now?

    Response: While we do not know whether the participation rate was a 
challenge in the NVVRS, it is a challenge now because the NVVRS is a 
``closed cohort,'' meaning the intent of the NVVLS is to re-assess the 
exact same participants in the NVVRS. After locating the individuals, 
if living, the NVVLS contractor will then determine their willingness 
and ability to participate in NVVLS.

    Question 6: What is your plan for completing the NVVLS if the 
chosen contractor can not get enough NVVRS participants to participate 
in the study?

    Response: One part of the contract will include a feasibility phase 
to determine the estimated response rate for the NVVRS participants and 
pursue as much of the study as possible based upon information from 
this phase. If insufficient participation rates are estimated, it will 
adversely impact the scientific questions being asked and the 
information gathered may not be sufficient to draw meaningful 
conclusions for all of the components mandated in Public Law (P.L.) 
106-419. The study plan will be to first assess feasibility, and then 
determine what scientific goals can be met based on the response rate. 
Planned subgroup analyses could be affected. For example, if the 
response rate is lower in the subgroup of NVVRS women, the findings in 
NVVLS might not be meaningful as the NVVRS initially included a lower 
number of women than men. In comparison to the NVVLS, the VA women's 
Vietnam Veterans study (CSP #579) may provide more meaningful data from 
which to draw conclusions given that the women's study will attempt to 
survey thousands of women.

    Question 7: Why does VA want the identifying information of the 
NVVRS participants?

    Response: VA plans to establish the NVVLS cohort under the auspices 
of research, specifically for the purpose of additional study. 
Ultimately, the security of these data is VA's responsibility, not that 
of any contractor as stipulated in 44 U.S.C. Sec. 3101--Records 
management by agency heads; general duties, which states: ``The head of 
each Federal agency shall make and preserve records containing adequate 
and proper documentation of the organization, functions, policies, 
decisions, procedures, and essential transactions of the agency and 
designed to furnish the information necessary to protect the legal and 
financial rights of the Government and of persons directly affected by 
the agency's activities.'' Since these data are owned by the Federal 
Government, it needs to be legally under our control for the NVVLS and 
for future purposes as consented to by the participants.

    Question 7(a): Is VA concerned that asking for this information 
from participants may dramatically impact the participation rate of the 
study?

    Response: VA does not have any information suggesting this would 
have a dramatic impact on the participation rate.

    Question 7(b): How would obtaining this information be perceived by 
contractors proposing to conduct the NVVLS, or by the previous 
contractor, the Research Triangle Institute, who currently holds the 
data?

    Response: VA's contracting officer and attorneys will work with RTI 
for the transfer of data, which is necessary for the new contractor. 
The new contractor needs the information in order to contact the exact 
same participants. RTI has stated that it will provide the information 
to the new contractor once the contract is awarded by VA.

    Question 8: In 2005, the Health and Human Services Office of 
Inspector General found that the Research Triangle Institute provided 
VA with deliverables from the 2001 NVVLS attempt that provided detailed 
information on an approach for a follow-up study to the NVVRS. Has VA 
been using these deliverables to help plan the NVVLS?

    Response: No, the 2001 deliverables have not been used. The 
solicitation was developed in conjunction with scientific expert 
consultation; many of these scientists were involved in NVVRS.

    Question 9: Why does VA plan to fund the NVVLS from the medical 
care appropriation instead of from the medical and prosthetic research 
appropriation?

    Response: ORD will be funding this program from the Medical and 
Prosthetic Research appropriation.

    Question 10: After the 2001 NVVLS attempt was terminated in 2003, 
why did it take ORD so long to restart the study?

    Response: NVVLS was stopped at the direction of the Secretary in 
2003 due to contracting and study management irregularities and only 
restarted in September 2009, by the Secretary. Since September 2009, VA 
ORD has been working with our attorneys and contracting office to 
carefully develop the Statement of Work and the solicitation, which was 
released on May 26, 2010 and which will be awarded by the end of August 
2010.

    Question 11: Please elaborate on the specific problems that VA 
encountered in 2001, when the contract stipulating that the Research 
Triangle Institute conduct the NVVLS was terminated.

    Question 11(a): How will VA learn from the lessons of this failed 
attempt to conduct the NVVLS and adapt to ensure that similar issues do 
not arise again?

    Response: The contracting procedures and policies for VA have 
changed since 2001 and VA has set in place requirements for proper 
contracting to avoid the issues encountered with the prior attempt to 
conduct NVVLS. We, therefore, believe that the considered development 
of the current NVVLS solicitation and statement of work will result in 
successful implementation of the study. The NVVLS contract will have 
performance measures in place that will be followed throughout the 
contract performance period to ensure that similar issues do not arise 
again.

    Question 12: Do you think the PTSD prevalence rates in Vietnam 
Veterans have improved over time?

    Response: Numerous studies have examined post-traumatic stress 
disorder (PTSD) prevalence in Vietnam Veterans, with other studies 
reporting lower PTSD prevalence estimates for Vietnam Veterans than 
NVVRS reported. Vietnam Veterans still have health care needs related 
to PTSD that may be influenced by factors such as better case 
recognition (improved diagnostic methods over time), or a greater 
understanding, willingness, and interest among Veterans with symptoms 
to come forward for care or compensation. Studies underway at this time 
should result in a better understanding of the natural history of PTSD.

    Question 12(a): How has VA helped Vietnam Veterans, particularly 
those with issues such as PTSD?

    Response: The treatment of PTSD and other war-related disorders is 
the highest priority for VA health care. VA has the responsibility for 
providing clinical care and benefits for our Nation's veterans. VA 
operates an internationally recognized network of more than 200 
specialized programs for the treatment of PTSD through its medical 
centers and clinics. Every VA Medical Center (VAMC) has outpatient PTSD 
specialty capability and, to address cases where PTSD might be 
complicated by a substance use disorder, each team has an Addictive 
Disorders Specialist associated with it.

    PTSD programs provide a comprehensive continuum of care from 
outpatient PTSD Clinical Teams (PCT) through specialized inpatient 
units, brief-treatment units, and residential rehabilitation treatment 
programs. In addition, there are increasing numbers of specialized 
resources within PTSD programs to meet special needs such as Veterans 
who are survivors of Military Sexual Trauma.
    VA has increased mental health staff by 5,075 over the last 3 years 
through Mental Health Expansion Initiative (MHEI) funds. This includes 
340 new FTE for PTSD programs.
    VA has always had a commitment to provide the most effective, 
evidence-based care for PTSD. VA has implemented significant training 
initiatives to ensure that VA clinicians receive training in state-of-
the-art treatments for PTSD. VA has trained more than 2,800 VA 
clinicians in the use of Cognitive Processing Therapy (CPT) and 
Prolonged Exposure (PE). CPT and PE are evidence-based therapies cited 
by the Institute of Medicine Committee on Treatment of PTSD, proven to 
be effective treatments for PTSD. VA's treatment approaches for PTSD 
are described in the Joint VA/DoD PTSD Clinical Practice Guideline, 
originally published in 2004 and currently being updated.
    With regard to the treatment of mental disorders, including PTSD, 
VA's orientation towards care is based on the concepts of 
Rehabilitation and Recovery. Rehabilitation means that in addressing 
mental health problems one looks at strengths as well as symptoms and 
deficits in functioning, just as one does in rehabilitation from 
physical injuries or medical/surgical health problems. Recovery 
involves including the patient and their significant others in active 
planning and implementation of their care.
    The number of Vietnam Veterans treated for mental disorders has 
increased from 162,127 unique Veterans in FY 2002 to 464,900 unique 
Veterans in fiscal year (FY) 2008, the last complete year for which 
these data are currently available. The number of Vietnam Veterans 
treated in specialty mental health services has increased from 90,000 
in FY 1997 to 210,000 in FY 2007. In FY 2007, Vietnam Veterans 
represented 67 percent (210,000 of 310,000) of Veterans receiving 
specialty mental health services for PTSD.

    Question 13: How does VA perform outreach to advise Vietnam era 
Veterans that they are eligible for a free Agent Orange Registry 
examination?

    Response: VA has several mechanisms to conduct outreach to Agent 
Orange Veterans. Most importantly every VAMC has a designated 
Environmental Health Coordinator who is the point of contact for combat 
Veterans with concerns regarding environmental exposures. This person 
is knowledgeable about all of the Registry programs and can schedule 
appointments for Registry examinations with designated Environmental 
Health Clinicians. The Registries are also promoted through print media 
such as program specific posters, pamphlets, the Agent Orange Review 
newsletter, and Internet resources including a social marketing plan 
and a dedicated Agent Orange Web site located at: http://
www.publichealth.va.gov/exposures/agentorange/index.asp.

    We also routinely present to VA's VSOs monthly meeting regarding 
updates to the registry program.

    Question 13(a): You noted that VA offers ``an array of resources to 
providers'' regarding concerns and treatments related to Agent Orange. 
Please discuss in greater detail how VA works with these providers and 
how this fits into the broader outreach plan for Vietnam Veterans.

    Response: VA has developed a series of educational modules, titled 
``The Veterans Health Initiative,'' which includes a volume dedicated 
to Veterans and Agent Orange. This compendium provides background 
information on the laws, science and related practice concerns relative 
to the clinical treatment of Vietnam Veterans. Also, Environmental 
Health Coordinators and Clinicians are present in VAMCs to assist 
providers who may have questions while caring for Vietnam Veterans. The 
Office of Public Health and Environmental Hazards (OPHEH), 
Environmental Health Strategic Health care Group, maintains a 
relationship with the Environmental Health personnel in the field 
through quarterly teleconferences which provide updates on issues 
relevant to delivering health care to the combat Veterans under VA's 
care. OPHEH staff members with significant experience in occupational 
and environmental medicine are available to answer queries from 
frontline providers. Non-VA clinicians will be able to obtain the 
content of this training through a PDF document, posted on OPHEH Web 
site. In addition, we have established a VHA charter review committee 
which includes Employee Health Specialists, subject matter experts from 
OPHEH and Patient Care Services. Further, there is coordination with 
the Office of Academic Affiliations to ensure these very important 
training tools are available for all clinicians (VA, non-VA, residents 
and Fellows) who care for Veterans regardless of the era in which they 
served.

    Question 14: Why did VA change its regulations in 2002 to require a 
``foot on land'' occurrence, thereby excluding Blue Water Veterans from 
the presumption of service-connection for herbicide exposure recognized 
conditions?

    Response: Under the Agent Orange Act of 1991 (codified in pertinent 
part at 38 U.S.C. Sec. 1116(f)), the statutory presumption of herbicide 
exposure applies to Veterans who served ``in the Republic of Vietnam.'' 
Since 1993, VA's regulation implementing the Agent Orange Act has 
consistently provided that ```Service in the Republic of Vietnam 
includes service in the waters offshore and service in other locations 
if the conditions of service involved duty or visitation in the 
Republic of Vietnam.'' 38 CFR Sec. 3.307(a)(6)(iii). That regulation 
reflects VA's view that Congress intended the presumption of exposure 
to apply to Veterans who were present on land or on the inland 
waterways of Vietnam, where herbicides were applied.

    In Haas v.  Peake, 525 F.3d 1168 (Fed. Cir. 2008), the United 
States Court of Appeals for the Federal Circuit noted that, although 
there was some ambiguity in the language of VA's regulation, VA had 
consistently explained its view that the governing statute required 
service on land or on the inland waterways of Vietnam, and the court 
concluded that VA's position was a reasonable interpretation of the 
statute. As the court noted, VA's interpretation of the statute was 
explained in General Counsel opinions and Federal Register notices in 
1997 and 2001.
    In 2002, the Veterans Benefits Administration (VBA) revised the 
language in its ``Adjudication Procedures Manual M21-1,'' an internal 
manual providing instructions to VA adjudicators, to more clearly 
explain its interpretation of the governing statute as requiring 
service on the land or inland waterways of Vietnam. As the Federal 
Circuit found in Haas, this 2002 revision of the manual was not a 
change in VA's regulations, nor was it a change in VA's longstanding 
interpretation of the governing statute.
    It should be noted that VA interprets the governing statute to mean 
only that Veterans who served solely in offshore waters, where 
herbicides were not applied, are not presumed to have been exposed to 
herbicides. However, if such a Veteran alleges exposure to herbicides, 
VA will develop the evidence to determine if herbicide exposure may be 
established. If VA finds that the Veteran was exposed to herbicides, 
the Veteran is then entitled to the presumptions of service-connection 
for any conditions VA recognizes as being associated with herbicide 
exposure.

    Question 15: Is VA aware of the findings in the studies conducted 
by the Australian government whereby it was determined that Blue Water 
Veterans in the Australian Royal Navy were Agent Orange exposed from 
use of contaminated sea water and it was likely exacerbated through the 
ship's water distillation process? If so, why does VA continue to 
require a ``physical foot on land occurrence'' in Vietnam to prove 
herbicide exposure for our combat Veterans who served in identical 
situations?

    Response: VA is concerned about Blue Water Navy Veterans. Prior to 
the release of Update 2008, VA had entered into discussions with 
National Academy of Science to undertake a comprehensive evaluation of 
the potential for herbicide exposure among U.S. blue-water Veterans, 
taking into account the Australian study and all other relevant 
information. VA entered into a contract with the Institute of Medicine 
(IOM) to provide a careful assessment of the exposure potential for 
U.S. Veterans aboard naval vessels in the coastal estuaries and waters 
off the coast of Vietnam. The IOM unexpectedly addressed that issue in 
Update 2008, without the benefit of a charge from VA and, therefore, 
did not address significant questions that VA has determined are 
central to a determination on this important issue. Accordingly, VA 
intends to proceed with its ongoing contract to obtain a sufficient 
analysis of the scientific issues based on a thorough review of the 
scientific and medical literature relevant to the matter. VA has 
specifically asked IOM to provide an assessment of the relevance and 
significance of the findings of Australian studies of exposure of naval 
personnel to the exposure experience of Blue Water Navy personnel who 
served in the waters off the coast including, but not limited to, 
ingestion of distilled sea water. VA has asked IOM to specifically 
address in its review comparisons of those who served in the Blue Water 
Navy with those who served in the Brown Water Navy, and those who 
served ``boots on the ground.'' VA has also asked the IOM Committee to 
evaluate a wide range of exposure mechanisms including the potential 
for concentrating toxins in drinking water, airborne exposure from 
drift of spray paths, contamination of food, and contaminated soil.

    Question 16: In light of the IOM's recommendations in Update 2008 
in which it concluded that Blue Water Navy personnel should not be 
excluded from the set of Vietnam-era Veterans with presumed herbicide 
exposure and that ``service in Vietnam'' should be more broadly defined 
to include Blue Water Veterans to comport with the epidemiologic 
evidence, does VA plan to continue to deny presumptive service-
connection for these Veterans?

    Response: VA has contracted with IOM to better understand the 
exposure scenarios of those in the Blue Water Navy when compared to 
Veterans who served in other settings. The IOM review will help to 
clarify the relevance and significance of the Australian Royal Navy 
study findings to the experience of U.S. Navy personnel. The Australian 
Royal Navy study findings must be considered in the context of all 
other evidence regarding exposure potential for U.S. military personnel 
in order to assess the body of scientific findings before a judgment 
regarding presumption can be made.

    Question 17: Blue Water Veterans have been included in all of the 
IOM Agent Orange Updates. Will VA include Blue Water Veterans in the 
NVVLS study and any future Vietnam veteran studies it conducts?

    Response: Blue Water Veterans may be included in the NVVLS if they 
were participants in NVVRS; approximately 350 Navy participants 
completed NVVRS. It is not known how many would have been Blue Water 
Veterans.

    Question 18: In light of the recommendations made by the IOM in its 
2008 Update concerning Blue Water Veterans, does VA's request for an 
additional Blue Navy study by the IOM (due in 2011) contravene or at 
the very least frustrate congressional intent outlined in P.L. 102-4 
for these Veterans? What is VA's intent for requesting this separate 
study?

    Response: VA has contracted with IOM to better understand the 
exposure scenarios of those in the Blue Water Navy when compared to 
Veterans who served in other settings. The IOM unexpectedly addressed 
that issue in Update 2008, without the benefit of a charge from VA, and 
therefore, did not address significant questions that VA has determined 
are central to a determination on this important issue. Accordingly, VA 
intends to proceed with its ongoing contract to obtain a sufficient 
analysis of the scientific issues based on a thorough review of the 
scientific and medical literature relevant to the matter. The IOM 
review will help to clarify the relevance and significance of the 
Australian Royal Navy study findings to the experience of U.S. Navy 
personnel. The Australian Royal Navy study findings must be considered 
in the context of all other evidence regarding exposure potential for 
U.S. military personnel in order to assess the body of scientific 
findings before a judgment regarding presumption can be made.

    Question 19: As recommended by the IOM in Update 2008, does VA plan 
to evaluate the possibilities for studying health outcomes among 
Vietnam-era Veterans by identifying and linking Vietnam service in the 
computerized index of records within DoD and VA to assemble 
epidemiologic information.

    Response: The IOM's Committee to Review the Health Effects in 
Vietnam Veterans of Exposure to Herbicides--``Veterans and Agent Orange 
Update 2008''--has recommended that VA undertake studies that utilize 
existing data resources. To satisfy this recommendation, VA will 
undertake an evaluation of health care utilization at VAMCs by 
beneficiaries identified on our roster of deployed Vietnam Veterans. 
This will provide a snapshot of the diagnoses assigned and procedures 
used by those Veterans who obtain care at VA facilities. The 
methodology for such a study might include a comparison with non-
deployed Vietnam-era Veterans who have used our facilities to determine 
the potential contribution of deployment on the health and illness 
experience of Veterans seen by VA. VA will conduct a mortality study of 
deployed Vietnam Veterans to determine cause of death. This will allow 
for comparison with other population samples of Veterans and non-
Veterans to assess differences that may be attributed to service in 
Vietnam.

    Question 20: What is being done to further study the possible birth 
defects or developmental disease in the offspring of herbicide exposed 
Veterans or even their children's offspring (epigenerational effect of 
exposure)?

    Response: The IOM Committee to Review the Health Effects in Vietnam 
Veterans of Exposure to Herbicides--``Veterans and Agent Orange Update 
2008''--concluded ``that it is considerably more plausible than 
previously believed that exposure to herbicides sprayed in Vietnam 
might have caused transgenerational effects.'' The Committee 
recommended ``that toxicologic research be conducted to address and 
characterize TCDD's potential for epigenetic modifications'' and stated 
that it ``is more convinced that additional epidemiologic study would 
be a worthwhile investment of resources.'' The Committee suggested that 
epidemiologic studies of adult off-spring would require ``the 
development of innovative techniques and protocols,'' but provided no 
guidance regarding methodology. Also, the Committee did not suggest 
what specific health endpoints might be observed in subsequent 
generations.

    Additional challenges of such a study include: tracking and 
locating subjects across multiple generations as there is no existing 
list of offspring of herbicide exposed Veterans; securing informed 
consent for a project of this nature; assessment of exposures to 
herbicides during each individual's life; and, accounting for diverse 
health outcomes. Even with a successful effort to contact and enroll 
individuals into a study, there would not likely be a sufficient number 
to allow for scientifically valid estimates of the trans-generational 
effect of paternal exposure.
    Recognizing these significant challenges, VA will review this issue 
over the next 6 months and consider various research strategies 
regarding the potential for paternally mediated trans-generational 
epigenetic effects in the offspring of herbicide exposed Vietnam 
Veterans that is consistent with available resources and priorities.

    Question 21: What other plans does VA have to ensure the collection 
of longitudinal information of Vietnam-era Veterans?

    Response: The Office of Research and Development is continuing to 
follow a cohort of Vietnam era male twins who participate in the 
Vietnam Era Twins Registry. Multiple studies have been conducted on 
these twins over the past 25 years, with over 130 scientific 
publications to date. Many of these have focused on PTSD--examining 
environmental and genetic factors, as well as pre-disposing risk 
factors such as early trauma exposure. More recently, samples from the 
cohort have participated in studies focused on genetic relationships 
between heart rate variability and depression.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                       May 18, 2010

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our full Committee hearing entitled ``Health 
Effects of the Vietnam War--The Aftermath'' on May 5, 2010, I would 
appreciate it if you could answer the enclosed hearing questions by the 
close of business on June 21, 2010.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         Bob Filner
                                                           Chairman

CW:ds

                               __________
                        Questions for the Record
                   The Honorable Deborah L. Halvorson
                  House Committee on Veterans' Affairs
            Health Effects of the Vietnam War--The Aftermath
                              May 5, 2010

    Question 1: What are we doing to make sure that veterans are aware 
of the illnesses that are listed as presumptive?

    Response: The Veterans Benefits Administration (VBA) continually 
provides outreach to Veterans with presumptive disabilities or to those 
with military service that tends to lead to presumptive illnesses. In 
addition to traditional methods of delivery, such as mailings, 
pamphlets, Federal Benefits book, and fact sheets, VBA is also 
employing newer communication venues to include Web and social media 
outlets, such as Facebook and Twitter.

    VBA has taken a proactive approach in targeting these Veterans. In 
October 2008, VBA identified more than 28,000 Vietnam Veterans through 
the Veterans Health Care system that had been diagnosed with 
disabilities presumed related to Agent Orange exposure. These Veterans 
were sent special outreach letters informing them of the benefits for 
which they may be entitled.
    In partnership with VHA and Office of Public Health and 
Environmental Hazards, VBA provides content for newsletters related to 
Agent Orange, Gulf War service, radiation exposure, and service in the 
current conflicts in Afghanistan and Iraq. These newsletters, which may 
be received via mail, email, or reviewed online are published two to 
three times annually and keep interested Veterans updated on new 
medical studies, changes in benefits, and other related information.

    Question 2: Why isn't compensation retroactive to the date the 
Veteran is diagnosed with a presumptive illness, instead of the date 
the claim is filed?

    Response: Effective dates for beginning distribution of Department 
of Veterans Affairs (VA) compensation payments based on service-
connected disabilities are governed by 38 U.S.C. Sec. 5110. This 
statute requires that: ``Unless specifically provided otherwise . . . 
the effective date of an award based on . . . [a disability claim] . . 
. shall not be earlier than the date of receipt of application 
therefore.'' This is a Congressional mandate that VA must follow. It 
applies to claims for presumptive conditions as well as all other 
claimed disabilities. There are exceptions, as for example, when a 
claim is filed within 1 year of separation from service for certain 
presumptive conditions, the effective date may go back to the day 
following separation. However, it is clear that Congress did not intend 
compensation payments to be retroactive to the date the Veteran was 
diagnosed with a presumptive illness.

                                 
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