[Senate Hearing 114-371]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 114-371
 
EXAMINING THE IMPACT OF EXPOSURE TO TOXIC CHEMICALS ON VETERANS AND THE 
                             VA'S RESPONSE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 29, 2015

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                            C O N T E N T S

                              ----------                              

                           September 29, 2015
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from 
  Connecticut....................................................     2
Rounds, Hon. Mike, U.S. Senator from South Dakota................    15
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    18
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    20
Tester, Hon. Jon, U.S. Senator from Montana......................    22
Heller, Hon. Dean, U.S. Senator from Nevada......................    24
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    26
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    33
Moran, Hon. Jerry, U.S. Senator from Kansas......................    36
Boozman, Hon. John, U.S. Senator from Arkansas...................    38

                               WITNESSES

Burr, Hon. Richard, U.S. Senator from North Carolina.............     4
Gillibrand, Hon. Kirsten, U.S. Senator from New York.............     7
Daines, Hon. Steve, U.S. Senator from Montana....................     8
McLenachen, David R., Acting Deputy Under Secretary for 
  Disability Assistance, Veterans Benefits Administration, U.S. 
  Department of Veterans Affairs; accompanied by Ralph L. 
  Erickson, M.D., M.P.H., Dr.P.H., Director, Post-Deployment 
  Health, Veterans Health Administration.........................     9
    Prepared statement...........................................    11
    Response to request arising during the hearing by:
      Hon. Jon Tester............................................    22
      Hon. Mazie K. Hirono.......................................    28
    Response to posthearing questions submitted by:
      Hon. Richard Blumenthal....................................    41
      Hon. Jerry Moral...........................................    43
      Hon. Thom Tillis...........................................    44
Ramos, Kenneth S., M.D., Ph.D., Associate Vice President for 
  Precision Health Sciences, Arizona Health Sciences Center, 
  University of Arizona and Chair, Institute of Medicine 
  Committee on Veterans and Agent Orange, Update 2014, the 
  National Academies of Sciences, Engineering, and Medicine; 
  accompanied by: Roberta Wedge, M.S., Senior Program Officer, 
  Institute of Medicine, the National Academies of Sciences, 
  Engineering, and Medicine......................................    44
    Prepared statement...........................................    47
Wells, John, Commander U.S. Navy (ret.), Executive Director, 
  Military-Veterans Advocacy, Inc................................    50
    Prepared statement...........................................    52
Rowan, John, National President, Vietnam Veterans of America.....    61
    Prepared statement...........................................    63
    Submission, Faces of Agent Orange............................    74
Ensminger, Jerome, Master Sergeant, U.S. Marine Corps (Ret.).....    65
    Prepared statement...........................................    68

                                APPENDIX

Blinded Veterans Association; letter.............................   127
Blue Water Navy Vietnam Veterans Association; letter.............   128
Children of Vietnam Veterans Health Alliance, Inc.; letter.......   129


EXAMINING THE IMPACT OF EXPOSURE TO TOXIC CHEMICALS ON VETERANS AND THE 
                             VA'S RESPONSE

                              ----------                              


                      TUESDAY, SEPTEMBER 29, 2015

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 
Rounds, Tillis, Blumenthal, Brown, Tester, Hirono, and Manchin.

           OPENING STATEMENT OF HON. JOHNNY ISAKSON, 
              CHAIRMAN, U.S. SENATOR FROM GEORGIA

    Chairman Isakson. I am going to call this hearing of the 
Veterans' Affairs Committee of the U.S. Senate to order. We 
have three members who will testify first today. One of them is 
here, punctual and on time, former Ranking Member Richard Burr. 
We welcome him. And hopefully by the time the two opening 
statements by myself and the Ranking Member have been made, 
Senator Daines and Senator Gillibrand will be here. But we want 
to start promptly so people will know we mean to start promptly 
around here on the Committee. I think that is important.
    This is an important hearing today for a lot of reasons, 
most importantly because we want to determine the presumptive 
nature of certain exposures to our veterans that could cause 
debilitating and deadly diseases. We want to hear testimony 
from the Veterans Administration. We are going to hear 
testimony from toxic experts and we are going to hear testimony 
from three members of the U.S. Senate.
    For me, it is very important that we have a thorough 
examination of what it takes to get to a presumptive conclusion 
that a disease or a disability has been caused by an exposure, 
that it be as scientific as it can be so it is absolutely, 
unequivocally clear. I am not an expert at that type of thing. 
I am a salesman. I am not an expert in science or technology or 
anything else, but I am here to learn, as I know the Ranking 
Member is, as well.
    I want to particularly thank Senator Burr and Senator 
Tillis for what they have done at Camp LeJeune to bring this 
issue forward over the last several years. I look forward to 
moving toward a successful conclusion in terms of presumption 
on that particular issue.
    With that said, today we will have three panels. First, the 
three Senate members that are here to testify, then the VA, 
then we will have a final panel to testify on the nature of 
toxic exposure and causation.
    With that said, I will turn to Senator Blumenthal, the 
Ranking Member.

         OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 
         RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman. I want to 
express my appreciation to you for holding this hearing to 
examine the multi-faceted harmful impacts of toxic exposures 
and the need for additional legislation, including the 
extension of the Secretary's authority to grant that 
presumptive coverage for service-connected disabilities based 
on exposure to herbicides.
    I very much regret that this authority, which Congress has 
provided the Secretary for the last 15 years, was not included 
in the extenders package that the Senate passed last week. I 
understand that this omission was based in part over the 
Chairman and other members' concerns regarding its possible 
scoring implications for the larger package that has bipartisan 
support to move before these vital authorities expired.
    Given our very mutual concern for veterans exposed to toxic 
chemicals in conflicts today and in prior years, I am hoping 
that the Chairman will assure me, as he has done privately, 
that he will give full and favorable consideration to 
legislation that I have introduced to ensure that the Secretary 
will regain this specific authority and, in the interim, work 
with me to encourage the Secretary to use his general rule to 
make authority as needed for all veterans who may have been 
impacted by these exposures. I am hoping that those assurances 
will be forthcoming at some point today or in the near future.
    To this end, I have introduced S. 2081, which would extend 
the Secretary's authority for an additional 15 years. It also 
ensures that there are no impediments in extending compensation 
to veterans exposed to herbicides, as medical evidence, 
research, and studies support. I have a letter from the Blinded 
Veterans Association expressing support for this measure and I 
ask that it be included in the record for this hearing.
    Chairman Isakson. Without objection.

    [The information referred to is in the Appendix.]

    Senator Blumenthal. Thank you. I look forward to hearing 
from all of our witnesses about this measure, along with other 
important issues including helping Blue Water veterans and all 
those returning from Iraq and Afghanistan with toxic exposures.
    Potential exposure to toxic chemicals during military 
service raises serious and complicated questions. While the 
impact is undeniable, establishing and qualifying a clear link 
between the exposures and health effects has become an 
intolerably long and complex process.
    As a result, I am hopeful that the Committee will continue 
to drill down and dig down and monitor the recommendations made 
by the Institute of Medicine's biennial updates on the health 
effects of Agent Orange exposure to ensure that the VA responds 
appropriately.
    In its report, Veterans and Agent Orange, 2012 Update, IOM 
stated, ``The amount of research providing reliable information 
on the consequences of paternal exposure is extremely sparse 
not only for Agent Orange, but for the full array of 
environmental agents that may pose threats to the health of 
future generations.''
    Here is what we know about the modern battlefield. There 
are all sorts of toxic substances out there, many more than are 
imaginable to the layperson, whether it is depleted uranium, 
pollutants from burn pits, or nerve gas in unexploded 
ordinances. We know that the modern battlefield includes perils 
even for the veteran who has not been engaged in combat.
    When a veteran signs up for duty, he or she has not signed 
up their children or grandchildren. Risking their own lives 
does not mean volunteering the next generation for neurological 
conditions, cancer, or other life-threatening conditions.
    So, earlier this year I introduced legislation with Senator 
Moran that is one step only, one step in the right direction. 
It says that we need to know a lot more because we know so 
little about the effects of these toxic substances on veterans 
and their families. We need to know more through a research 
center that can do the kind of fact-finding and fact-gathering 
and other kinds of medical and scientific research that will 
show us the way to better diagnose and treat the effects of 
toxic exposure.
    We need an advisory board of experts that can tell the 
secretaries of VA and HHS and other responsible government 
agencies they can do better. The IOM's 2011 report entitled, 
Blue Water Navy Veterans and Agent Orange Exposure, failed to 
find sufficient evidence to connect Blue Water Navy service 
with exposure to Agent Orange sufficient to merit a 
presumption, and led the Secretary of VA to issue a 
determination of no presumption in 2012. But this issue 
warrants and demands further investigation.
    In particular, the VA needs to follow up on an Australian 
Government study that established the possibility that so-
called Blue Water Navy ships off the coast of Vietnam ingested 
water contaminated by Agent Orange through their distillation 
systems that produced drinking water for their crews.
    Finally, I was deeply troubled and perplexed by Secretary 
Mabus's recent remarks dismissing links between Camp Lejeune 
water and the higher incidence of a number of illnesses of 
veterans who served in that area. We cannot be cavalier about 
the risks that our servicemen and women have taken.
    I know that Navy Secretary Mabus is also deeply concerned 
about this issue and I thank him for his concern. But many 
others in positions of authority have failed to demonstrate 
those kinds of concerns. My hope is that we will hear more from 
our witnesses that will bolster and substantiate the ongoing 
and increasing efforts to do more and do better in dealing with 
toxic exposure to dangerous chemicals on our battlefield and 
elsewhere in our military. I look forward to the opportunity 
for this important conversation. Thank you to our witnesses for 
being here today. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Ranking Member. In reference 
to his opening statement, I commit to him, as I have privately, 
then we are going to see to it that we explore thoroughly the 
causation of various diseases that take place, and when we find 
conclusive scientific evidence, we will move accordingly. I 
look forward to working with him on that effort as we improve 
the lives of our veterans.
    Senator Blumenthal. Thank you, Mr. Chairman.
    Chairman Isakson. I would like to welcome our three guest 
Senators. As is the tradition on the Committee, we will not ask 
questions of them, but we will ask for their testimony. I would 
ask that each of them try to keep their remarks within 5 
minutes, if possible. We welcome our first alumni, Richard 
Burr, the former Ranking Member of the Committee. Senator Burr, 
the floor is yours.

                STATEMENT OF HON. RICHARD BURR, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Mr. Chairman, Ranking Member, thank you for 
the opportunity to give the Committee my perspective on the 
effects of toxic exposure on our Nation's veterans and the 
Department of Veterans Affairs' often inadequate and 
frustrating response.
    Mr. Chairman, this has been a long road and I ask for the 
Committee's indulgence because I am not sure that I can give 
you this very long history in 5 minutes; it may take 6 minutes.
    Chairman Isakson. We will be easy.
    Senator Burr. To my colleague, Senator Blumenthal, I wish I 
could hold Secretary Mabus in the same regard that you do, but 
if there has been an epiphany that has happened lately as it 
relates to his concern over whether the appropriate documents 
were available, and many cases they have made it as difficult 
as it possibly can be.
    Before I begin, Mr. Chairman, I would like to recognize 
Master Sergeant Jerry Ensminger, U.S. Marine Corps, retired, 
from White Lake, NC, who is here today and who has been a 
relentless advocate for Camp Lejeune, for its veterans for over 
15 years. Let me just say, Jerry, we would not be here today if 
it was not for your fidelity, your courage, and your 
commitment.
    Mr. Chairman, during my time on the Committee, one toxic 
exposure issue continued to garner our attention because of its 
scope, its severity, and the intense public interest. That is 
the contamination of the water supply at Camp Lejeune, NC.
    From 1953 to 1987, we know Camp Lejeune residents were 
exposed to poisoned water from industrial dumping on the base 
and contamination from a dry cleaner off base. This 34-year 
event has been called the worst incident of environmental 
exposure in our Nation's history. Hundreds of thousands of 
servicemembers, their families, civilian workers, drank and 
bathed in water that had been exposed to mixed cancer-causing 
chemicals that, in one case, took the life of a 9-year-old 
girl, Janey Ensminger, who was born on base.
    Once metabolized, the chemical in the water could cause 
birth defects and increased risk of multiple cancers. The 
Government scientific investigation into Camp Lejeune began in 
1989, but we have only seen significant progress in the last 5 
years spurred by the uncovering of critical Navy and Marine 
Corps records and the completion of a long overdue study on the 
effects of the contamination.
    Along the way, I went to great lengths to reveal the truth 
about Camp Lejeune and hold the military and the VA 
accountable. To this day, I remain appalled at how the U.S. 
Government has treated these servicemembers and their families. 
Our Government rewarded the sacrifices of these patriotic men 
and women by negligently poisoning them and their families and 
by engaging in a decades long cover-up.
    It was not until 2011, after significant Congressional 
pressure, that the VA began consolidating all disability claims 
at one VA regional office in coding and tracking them. During 
the time I introduced the Janey Ensminger Act, named in honor 
of Master Sergeant Ensminger's late daughter. The law was 
passed and signed into law in 2012. It has provided the much 
needed and overdue medical relief to veterans and eligible 
family members seeking health care for cancers and conditions 
associated with toxic exposure at Camp Lejeune.
    Janey's Law was based on scientific findings required by 
Congressionally mandated review, because within the VA, there 
was neither the expertise nor the resources to explore the 
science of toxic exposure. The Government studies on Camp 
Lejeune conducted by the CDC's Agency for Toxic Substances and 
Disease Registry, or ATSDR, are based on test results from 
water samples taken at Camp Lejeune over successive years.
    The study shows some of the highest levels of recorded 
toxins in any U.S. water system and it reached the taps in 
houses, barracks and offices. ATSDR has found that Camp Lejeune 
residents experienced higher rates of mortality at a younger 
age than those from an unaffected Marine Corps base, higher 
incidence of birth defects in children born on the base, and a 
statistically high number of male breast cancer survivors.
    In fact, several chemicals found in Camp Lejeune water are 
now classified as known human carcinogens by the EPA and the 
International Agency for Research on Cancer.
    Mr. Chairman, the resistance inside the VA to the 
scientific data and the fact that Camp Lejeune demonstrates how 
VA has dealt with the scientific facts of toxic exposure 
overall. In the case of LeJeune, their approach ranged from 
scare tactics like issuing over-inflated estimates on long-term 
cost of care to this Committee for benefits, and suggesting the 
Department of Defense should take care of Camp Lejeune families 
instead of VA.
    They produced passive aggressive rebuttals of the 
scientific findings, have sought additional scientific studies, 
and created a bizarre procedural hurdle for Camp Lejeune 
veterans to overcome in the disability claims process.
    To this day, Lejeune veterans from across the country 
contact my office and relate demoralizing accounts of ignorant 
VA doctors in the claims process that is frequently deaf and 
blind to scientific evidence and medical opinion. This summer, 
Secretary McDonald indicated he wants his people to back away 
from this adversarial approach, work with veterans with a 
history of toxic exposure, and begin by engaging Congress and 
Government scientists to develop sound policies for Camp 
Lejeune veterans.
    In July, Senator Tillis and I sat down with the Chairman 
and Secretary McDonald to raise some questions that were very 
serious about a VA team of clinicians reviewing Lejeune 
veterans' disability claims before final decisions were made on 
service connection.
    These VA doctors were, in various cases, cherry picking the 
science, misrepresenting or misinterpreting scientific studies, 
using questionable sources, and overruling the opinions of 
veteran oncologists.
    In the glaring case of one Marine, Norman Mcilhenny, 
suffering from kidney cancer, a VA clinician stated that there 
was no evidence of the chemicals at Camp Lejeune water, the 
carcinogen TCE, which was known to cause kidney cancer. VBA 
later denied the claim. When VA was later shown evidence that 
the exposure to TCE is widely accepted as a cause of kidney 
cancer, VA removed the citation and the denial notice, then 
reissued it, then denied the claim again.
    Mr. Chairman, this is unbelievable, but sadly true. There 
are many other Camp Lejeune veterans with similar stories. Mr. 
Chairman, at our July meeting, Secretary McDonald, to his 
credit, openly and fully recognized the fact that the science 
on Camp Lejeune was undeniable and he agreed to work with ATSDR 
to compile data for a presumptive disability policy soon 
afterwards.
    Soon afterwards, VA publicly announced support for three 
cancers that would be covered. Last week, ATSDR submitted its 
70-page report to VA detailing at least six cancers where 
sufficient evidence of causation from toxic exposure at Lejeune 
exists and several other conditions where moderate evidence of 
causation exists.
    Secretary McDonald has taken the first step to acknowledge 
ATSDR, and other key agencies must play an integral role in 
helping VA confirm and understand toxic exposure. But I am not 
convinced the olive branch from the Secretary will result in 
good policy beyond Lejeune if VA ultimately decides on 
polishing its image more than the scientific merit.
    When it comes to confirming toxic exposure like those at 
Camp Lejeune, make certain that VA heeds the best science, will 
be required strong and engaged leadership from Secretary 
McDonald, and, Mr. Chairman, rigorous oversight from this 
Committee. Congress must ensure VA health and benefits policy 
is based on fact, not conjecture or emotion, so those veterans 
who have been harmed by toxic exposures are properly cared for 
and compensated for their suffering.
    Mr. Chairman, I thank you for this opportunity. I thank you 
for the indulgence of the Committee and I trust the Committee 
will continue its very important responsibilities.
    Chairman Isakson. Thank you, Senator Burr. Thank you for 
your focus on Camp Lejeune, as we continue to work with you 
until we get a solution on all those problems. Thank you for 
your testimony.
    Senator Gillibrand.

             STATEMENT OF HON. KIRSTEN GILLIBRAND, 
                   U.S. SENATOR FROM NEW YORK

    Senator Gillibrand. Thank you, Mr. Chairman. Thank you, 
Ranking Member Blumenthal. I am grateful for this hearing and 
for the bill that you recently introduced. I want to thank 
Senator Daines for joining me today. He has been a tremendous 
partner in this push to give our Blue Water veterans the 
coverage that they have earned and deserve.
    During the Vietnam War, thousands of American 
servicemembers were exposed to Agent Orange, servicemembers 
like Keith Martel from upstate New York. Keith was a sailor in 
Vietnam for 3 years, from 1967 to 1970. A few years after he 
got out, he joined the New York Army National Guard and stayed 
with them for decades. On September 11 he answered the call of 
duty and went to Ground Zero. Then 2 years later in his 50s, 
Keith was sent to Iraq.
    Keith was exposed to Agent Orange when he was in Vietnam 
and now he has prostate cancer, which has been linked to Agent 
Orange. So, what do you think the Department of Veterans 
Affairs did when Keith first went to them for coverage? They 
said, sorry, your boat was here, not here, so we cannot help 
you. Sorry, you did not have boots on the ground.
    All those Blue Water Navy veterans like Keith, we are 
letting them down. The U.S. Government has recognized the 
dangers of Agent Orange since 1960. Congress passed the Agent 
Orange Act in 1991, which allowed all Vietnam veterans to 
receive presumptive coverage if they had Vietnam service medals 
and could prove symptoms related to Agent Orange exposure.
    But in 2002, the VA decided to change the intent of 
Congress and halted its coverage to an estimated 174,000 
veterans, including those who had served in the Blue Water just 
off Vietnam's coast. Since then, instead of treating every 
Vietnam veteran who suffers from a disease caused by Agent 
Orange, the VA is only treating those veterans who stepped foot 
on Vietnamese soil or his boots--or whose boats were patrolling 
Vietnamese rivers.
    This distinction, which excludes the veterans who served on 
boats in Vietnam's bays and harbors, was recently ruled by the 
Court of Appeals for Veterans Claims as arbitrary and 
capricious. We are seeing veterans who did serve, who were 
exposed to Agent Orange and are now sick being denied coverage 
because of this arbitrary bureaucratic decision by the VA.
    The science does not support the policy. The Australian 
Department of Veterans Affairs recently commissioned a study 
specifically about the Navy's water distillation process. In 
the study, ships in near-shore marine waters collected water 
that was contaminated with the runoff from areas sprayed with 
Agent Orange, and they found that the distillation methods used 
on their ships, the same methods used on the American Navy 
ships, actually concentrated Agent Orange in the drinking 
water.
    Mr. Chairman, the evidence is clear. We have to pass the 
Blue Water Navy Vietnam Veterans Act of 2015, and because of 
the urgency of this issue, I request that your Committee mark 
up our legislation and expeditiously report it favorably to the 
floor for consideration by the full Senate. Thank you.
    Chairman Isakson. Thank you, Senator Gillibrand.
    Senator Daines.

                STATEMENT OF HON. STEVE DAINES, 
                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Chairman Isakson, Ranking Member 
Blumenthal, and my colleagues on the Veterans' Affairs 
Committee for allowing me to testify in this very important 
hearing on examining the impact of exposure to toxic chemicals 
on veterans and the VA's response.
    Montana veterans have strongly voiced concerns about the 
VA, that they have not acted in the best interests of our 
Vietnam veterans exposed to dangerous toxins, especially those 
who served in the Navy. While I continue to call for the 
Department of Veterans Affairs to clean up its poor record, the 
VA has not made substantive changes to the care of the men and 
women who defended this great nation when they were asked. 
Instead, the VA has chosen to exclude specific groups of 
veterans from receiving their medical benefits directly leading 
to deaths caused by Agent Orange-related cancers. I hope that 
today, in this Committee, we can convince the Department of 
Veterans Affairs that avoiding the care of those who have 
protected us is not how our Government should treat those who 
have given so much to defend our Nation and our fellow 
citizens. To address this unfair disparity, I have introduced 
Senate Bill 681, the Blue Water Navy Vietnam Veterans Act of 
2015 with Senator Gillibrand. I want to thank Senator 
Gillibrand for her leadership and her excellent testimony here 
today.
    In 2001, the Veterans Administration abruptly cutoff 
funding for benefits of these fully deserving Navy veterans. It 
has been called arbitrary and capricious. I urge the Committee 
to dig into why this decision was made and what was the basis 
of the decision in 2001 when these benefits were so abruptly 
cutoff.
    During the Vietnam War, the U.S. had sprayed more than 19 
million gallons of herbicides to defoliate the dense forests of 
Vietnam, with Agent Orange being the most commonly used 
herbicide. Dioxin is the most harmful chemical found in Agent 
Orange and has been proven to cause a variety of cancers, 
Parkinson's disease, coronary issues, and many more deadly 
diseases for those that come into contact with it.
    I am disturbed that those tasked with the ultimate 
responsibility of taking care of our veterans will be so 
callous as to remove their benefits. To this day, I have not 
been persuaded that the VA had a legitimate reason to do so.
    Within the last year, two Montanans living in the northwest 
part of my State, and using the Kalispell Veterans Service 
Office, applied for medical benefits. Both of these men are 
Blue Water Navy veterans, one of them having served on a patrol 
boat, the other on a destroyer. Both of these veterans have 
been diagnosed with cancers and diseases that the VA has 
readily admitted result from coming into contact with Agent 
Orange.
    Unless we pass legislation to include Blue Water Navy 
veterans like these two Montanans, they will be denied 
critically important VA care for diseases that our own military 
exposed them to. As the son of a Marine, I understand the 
importance of keeping the promises made to our veterans. Our 
bill would simply reinstate medical benefits for Blue Water 
veterans who served on ships within the territorial waters of 
Vietnam.
    These Blue Water Navy veterans should have access to the 
best medical care and not be ignored by the VA. This sort of 
indifference to our veterans is unacceptable, especially when 
combined with the constant failure by the VA to do its job. Our 
nation should not hesitate to invest in the care of these 
veterans and correct this wrong.
    So, I ask you to join us in cosponsoring this legislation 
and quickly pass it out of the Committee and the Senate so we 
can restore the medical benefits our veterans rightly deserve. 
Thank you.
    Chairman Isakson. Well, Senator Daines, thank you for your 
testimony. Senator Gillibrand, thank you for your testimony. 
Senator Burr, thank you for being here. As I said, we have a 
tradition on the Committee of not questioning our Members. We 
do not question their testimony, nor do we try and trip them up 
with questions, but we appreciate your testimony.
    We are committed as a Committee to see to it that causation 
and presumption is an issue that we solve. We understand what 
you have testified to, each of you, and we will work very hard 
to do it expeditiously before the end of this year. Thank you 
very much for your testimony.
    Senator Blumenthal. I wanted to do cross-examination, but 
the Chairman forbade me to.
    Chairman Isakson. He is just a reformed lawyer.
    Senator Blumenthal. Thank you all. It was excellent.
    Chairman Isakson. Our next panel will be made up of Dr. 
McLenachen--not Doctor, I am sorry--David R. McLenachen, Acting 
Deputy Director for Disability Assistance, Veterans Benefits 
Administration, accompanied by Ralph L. Erickson, who is a 
doctor and Director of Pre-9/11 Era Post-Deployment Health, 
Veterans Health Administration. So, if you will take your 
seats. Mr. McLenachen, you are recognized for your testimony.

STATEMENT OF DAVID R. McLENACHEN, ACTING DEPUTY UNDER SECRETARY 
 FOR DISABILITY ASSISTANCE, VETERANS BENEFITS ADMINISTRATION, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY RALPH L. 
  ERICKSON, M.D., M.P.H., Dr.P.H., DIRECTOR, POST-DEPLOYMENT 
             HEALTH, VETERANS HEALTH ADMINISTRATION

    Mr. McLenachen. Chairman Isakson, Ranking Member 
Blumenthal, and Members of the Committee. Thank you for the 
opportunity to discuss the Department of Veterans Affairs 
process for establishing service connection presumptions. I am 
accompanied by Dr. Ralph Erickson, Director of Post-Deployment 
Health at the Veterans Health Administration. He is a doctor 
and I am not.
    VA's authority to establish presumptions derives from 
statute. Many statutes relate to a particular event or location 
or set of circumstances. The VA can also craft presumptions 
under its broad regulatory authority also established by 
statute.
    These statutes and the regulations that implement them 
allow VA to deliver disability compensation to veterans when 
evidence of service connection might otherwise be incomplete. 
When considering circumstances unique to the experiences of 
Vietnam and Gulf War veterans, VA relies on reports from the 
National Academy of Sciences (NAS) and other sound medical and 
scientific information to establish presumptions.
    At VA's request, NAS reviews existing scientific and 
medical studies and summarizes the strength of evidence 
supporting association and causation. VA does not solicit and 
NAS does not make recommendations concerning the establishment 
of presumptions. Dr. Erickson can provide more insight on how 
this NAS review process works.
    Upon receipt of the finished NAS reports, VA staff review 
the findings and other available evidence, then make 
recommendations to the Secretary regarding the determinations 
of presumptions. The Secretary reviews staff recommendations 
and decides to create or not create presumptions. If the 
Secretary determines that a positive association between some 
circumstance of service and subsequent disability, VA issues a 
proposed regulation for public comment.
    The proposed regulation outlines the eligibility criteria 
to qualify for the presumption and the scientific evidence 
supporting the presumption. Once VA has received and reviewed 
the public comments, VA publishes a final regulation 
establishing the presumption, if appropriate.
    Through the Agent Orange Act of 1991 and subsequent 
amendments, Congress created a presumption that veterans who 
served in the Republic of Vietnam during the period January 9, 
1962, to May 7, 1975, were exposed to Agent Orange and other 
herbicides that are now associated with 14 diseases.
    VA's current policy, established through notice and comment 
rulemaking in 1994, extends this presumption of exposure to 
veterans with duty or visitation in the Republic of Vietnam, 
including its inland waterways, but not off Vietnam's coast 
during that period. The U.S. Court of Appeals for the Federal 
Circuit reviewed and upheld this policy in its 2008 Haas vs. 
Peake decision.
    However, in response to the Court of Appeals for Veterans 
Claims' recent decision in Gray vs. McDonald, VA has begun the 
process of thoroughly evaluating and clarifying its policies 
regarding this distinction between inland waterways and 
offshore service.
    Similarly, VA recently announced that it will amend its 
regulations to establish presumptions of service connection for 
certain conditions resulting from exposure to contaminated 
water at Camp Lejeune. We intend to establish a presumption for 
three diseases that are known to be related to chemicals that 
were in the water at Camp Lejeune from 1953 through 1987.
    We are working with the Center for Disease Control's Agency 
for Toxic Substances and Disease Registry, and possibly other 
scientific experts, to identify additional diseases that may 
have an association with exposure to chemicals in the water at 
Camp Lejeune during this period.
    This is in addition to the health care that VA already 
provides qualified Camp Lejeune veterans and the health care 
reimbursement it provides to their family members as a result 
of the Honoring America's Veterans and Caring for Camp Lejeune 
Families Act of 2012.
    Regarding S. 901, the Toxic Exposure Research Act, VA 
continues to oppose the bill for the reasons stated in our 
written and oral testimony earlier this year. Mr. Chairman, VA 
takes very seriously its obligation to care for disabled 
veterans, their families, and their survivors. We look forward 
to resolving these complicated legal and scientific matters 
through coordination with Congress and other concerned 
stakeholders.
    In particular, whether they are created by statute or 
regulation, new presumptions can significantly impact VA's 
workload and delay the processing of claims for all veterans. 
For this reason, the consideration of a presumption must 
include a careful analysis of the additional resources that VA 
will require to timely deliver benefits to exposed veterans.
    This concludes my testimony, Mr. Chairman. We would be 
pleased to address any questions that you or the other Members 
of the Committee might have. Thank you.
    [The prepared statement of Mr. McLenachen follows:]
    Prepared Statement of David R. McLenachen, Acting Deputy Under 
Secretary for Disability Assistance, Veterans Benefits Administration, 
                  U.S. Department of Veterans Affairs
                            opening remarks
    Chairman Isakson, Ranking Member Blumenthal, and Members of the 
Committee, thank you for the opportunity to discuss the Department of 
Veterans Affairs' (VA) process for establishing service connection 
presumptions. My testimony will provide an overview of presumptive 
service connection and explain the types of presumptions, the 
legislative authority for establishing presumptive service connection, 
regulatory implementation of presumptive service connection, and the 
science and rationale behind presumptive service connection. I am 
accompanied by Doctor Ralph Erickson, Director, Pre-9/11 Era, Post 
Deployment Health.
               overview of presumptive service connection
    Service connection requires medical evidence of a current 
disability; lay or medical evidence establishing the occurrence of an 
injury, disease, or event during active military, naval, or air 
service; and, medical or scientific evidence establishing a link or 
nexus between the two. A presumption of service connection relieves the 
Veteran of the burden of producing evidence that directly establishes 
one or more of these elements. These presumptions fill an evidentiary 
gap in cases where VA knows that necessary facts may not be documented 
in the Veteran's individual records. They are generally only rebuttable 
by clear and convincing evidence to the contrary. This is a high bar, 
and they are rarely rebutted.
                  statutory authority for presumptions
    VA's authority to establish presumptions derives from statute. 
There are statutes specific to a particular event, or location, or set 
of circumstances, such as those addressing status as a former prisoner 
of war or participation in radiation risk activities (38 U.S.C. 
Sec. 1112), exposure to herbicides in the Republic of Vietnam (38 
U.S.C. Sec. 1116), and service in the Southwest Asia theater of 
operations during the Persian Gulf War (38 U.S.C. Sec. 1118). These 
statutes establish presumptions that allow VA to deliver disability 
compensation where otherwise-necessary evidence of exposure or 
incurrence of injury or disease might be incomplete.
    Section 1112 establishes several presumptions, each applicable to a 
different cohort of Veterans. Paragraph (a) establishes entitlement to 
service connection for chronic or other listed disease if manifest to a 
compensable degree within a specified number of years following 
separation from service. This presumption is available to every Veteran 
with 90 or more days continuous active service during a period of war 
or after December 31, 1946. Paragraph (b) establishes former prisoner 
of war entitlement to service connection for listed disabilities if 
manifest to a compensable degree at any time following separation from 
service. Paragraph (c) establishes entitlement to service connection 
for listed radiation-related disabilities if manifest at any time 
following participation in a radiation risk activity, which is also 
defined in that section. Under this statute, once the Veteran 
establishes qualifying service, the law provides a presumed nexus to 
that service for any listed disability.
    Section 1116 codifies the Agent Orange Act of 1991 and subsequent 
amendments. This section establishes a presumption of herbicide 
exposure for Veterans who served in the Republic of Vietnam from 
January 9, 1962, through May 7, 1975, and charges the Secretary of 
Veterans Affairs with prescribing regulations which provide a 
presumption of service connection for diseases related to those 
herbicides. It covers both the in-service incurrence and the nexus 
elements necessary to substantiate a claim for service connection.
    Section 1118 charged the Secretary with prescribing regulations 
that provide a presumption of service connection for diseases related 
to exposure to biological, chemical, or other toxic agents, 
environmental or wartime hazards, or preventive medicine or vaccine 
associated with service in the Southwest Asia theater of operations 
during the Persian Gulf War.
    Based on the mandates set forth in sections 1116 and 1118, VA 
relies on reports from the National Academy of Sciences (NAS) and other 
sound medical and scientific information, where available, to establish 
presumptions of service connection. Upon review of such information, if 
the Secretary determines that a positive association exists between 
service in a given location and exposure to a particular agent, hazard, 
or other foreign substance, VA issues, to the public for notice and 
comment, a proposed regulation regarding the presumption. The proposed 
regulation outlines the scientific and/or medical basis for the 
presumption, as well as the eligibility criteria to qualify for the 
presumption. Once VA has received and reviewed the public comments, VA 
publishes a final regulation establishing the presumption.
                            scientific basis
    In preparing its reports for both Agent Orange and Gulf War health 
issues, NAS committees conduct comprehensive searches of all medical 
and scientific studies on the health effects of the environmental 
exposure being reviewed. In the course of this literature search and 
review, it is not uncommon for these committees to cover thousands of 
abstracts of scientific and medical articles, eventually narrowing 
their review to the hundreds of peer-reviewed journal articles which 
are the most relevant and informative to the question at hand. At this 
stage, the NAS committee scores the strength of the total medical and 
scientific evidence available by utilizing broad categories of 
association such as ``inadequate or insufficient evidence of an 
association'' or ``limited or suggestive evidence of an association'' 
or ``sufficient evidence of an association.'' Of note is that the NAS 
committees do not make direct recommendations for new presumptions.
    Upon receipt of the finished NAS reports, VA establishes task-
organized technical work groups comprised of experts in medicine, 
disability compensation, health care, occupational and environmental 
health, toxicology, epidemiology, and law. These technical work groups, 
along with senior VA leaders who comprise a standing task force for 
this purpose, review in detail the NAS reports and all available 
scientific and medical information before making recommendations to the 
Secretary regarding the determination of presumptions. These 
recommendations to the Secretary are based on the strength and 
preponderance of the medical and scientific evidence.
                       regulatory implementation
    VA, like other Federal agencies, must draft regulations to 
implement the authority granted by Congress. VA's regulations 
describing the requirements for service connection are generally 
located in sections 3.303 through 3.318 of title 38, Code of Federal 
Regulations. Regulations implementing presumptions are generally found 
here as well.
    The Secretary also has at his disposal a general rulemaking 
authority, prescribed in section 501, title 38, United States Code. 
Section 501 authorizes the Secretary to prescribe any rules and 
regulations necessary or appropriate to carry out the laws administered 
by the Department. Under this broad authority, VA has used the 
rulemaking process to craft numerous presumptions necessary to 
streamline its delivery of benefits to certain Veterans, including:

     former Reservists with regular and repeated contact with 
contaminated C-123 aircraft used to spray Agent Orange in Vietnam who 
are presumed to have been exposed to herbicides and are entitled to 
benefits as Veterans (38 CFR Sec. 3.307(a)(6)(v) (published June 19, 
2015));
     Veterans serving on the Korean demilitarized zone who are 
presumed to have been exposed to Agent Orange and other tactical 
herbicides between April 1, 1968, and August 31, 1971 and are thus 
entitled to service connection for Agent Orange disabilities on a 
presumptive basis (38 CFR Sec. 3.307(a)(6)(iv)); and
     Veterans with full body exposure to mustard gas who are 
entitled to a presumption of service connection for certain respiratory 
and other disorders (38 CFR Sec. 3.316).

    VA also uses regulations to prescribe the rules that are necessary 
to fully implement broad statutory authority, such as the determination 
under section 1116 that Veterans who served in the Republic of Vietnam 
are entitled to a presumption of exposure to Agent Orange.
                              agent orange
    VA's current policy, established through notice and comment 
rulemaking, extends the presumption of Agent Orange exposure to 
Veterans with ``duty or visitation'' within the Republic of Vietnam, or 
on its inland waterways, between January 9, 1962 and May 7, 1975. The 
``duty or visitation'' requirement was incorporated in VA regulations 
issued in 1994 to implement the Agent Orange Act of 1991. Prior to 
2002, internal VA policies allowed receipt of the Vietnam Service Medal 
(VSM) to be accepted as proof of Vietnam service. That medal, however, 
was awarded for ``support'' of the Vietnam War in various geographic 
locations rather than for service in Vietnam itself. In 2002, VA 
revised its internal policy to clarify that ``duty or visitation'' in 
Vietnam refers to presence within the Republic of Vietnam, on land or 
inland waterways.
    This rationale and interpretation of Vietnam service was upheld by 
the United States Court of Appeals for the Federal Circuit in Haas v. 
Peake, 525 F.3d 1168 (2008), cert. denied, 555 U.S. 1149 (2009). VA's 
position on various legislative proposals that would extend the 
presumption of exposure to Veterans whose only service was on Vietnam's 
offshore waters, such as S. 681, 114th Cong., has been consistent with 
VA's current policy.
    Under the general policy described above, VA necessarily has 
distinguished ``inland waterways'' from ``offshore waters.'' In 
April 2015, the U.S. Court of Appeals for Veterans Claims issued its 
decision in Gray v. McDonald, 27 Vet. App. 313 (2015), which required 
VA to review and clarify its policies for determining whether coastal 
bodies of water, such as Da Nang Harbor, constituted ``inland 
waterways'' or ``offshore waters'' for purposes of applying the 
presumption of herbicide exposure. Shortly after the court's decision, 
VA began the very deliberate process of thoroughly evaluating and 
clarifying its policies regarding such determinations.
                              camp lejeune
    Similarly, VA recently announced that it will start the process of 
amending its regulations to establish presumptions of service 
connection for certain conditions resulting from exposure to 
contaminated drinking water at the U.S. Marine Corps Base Camp Lejeune 
in North Carolina. This process is in addition to the healthcare VA 
already provides for 15 conditions to eligible Veterans who were 
stationed at Camp Lejeune for at least 30 days between August 1, 1953, 
and December 31, 1987, as a result of the Honoring America's Veterans 
and Caring for Camp Lejeune Families Act of 2012. VA also provides 
reimbursement of healthcare expenses for those 15 conditions to 
eligible family members who resided at Camp Lejeune during that time 
period.
    The diseases that are currently being reviewed for potential 
presumptive service connection include kidney cancer, angiosarcoma of 
the liver, and acute myelogenous leukemia, which are known to be 
related to long-term exposure to the chemicals that were in the water 
at Lejeune from the 1950s through 1987. The chemicals are Benzene, 
Vinyl Chloride, Trichloroethylene and Perchloroethylene, which are 
known as volatile organic compounds, used in industrial solvents and 
components of fuels.
    VA is working with the Agency for Toxic Substances and Disease 
Registry, and potentially will work with NAS, to evaluate the body of 
scientific knowledge and research concerning exposure to these 
chemicals and potentially related diseases.
    VA will carefully consider all public comments received when 
determining the final scope of any presumptions. Because there is no 
specific statutory authority for this undertaking, VA will draft 
necessary and appropriate rules under the general rulemaking authority 
prescribed in section 501.
    The Department has previously provided its views on S. 901 to this 
Committee on June 24, 2015.
                            closing remarks
    VA takes very seriously its obligation to care for disabled 
Veterans, their families, and their survivors. Some of the tools we use 
are the laws authorizing presumptive service connection. These laws 
fill a critical evidentiary gap when suspected exposures to toxic 
substances cannot be specifically documented in a Veteran's service 
records or by other contemporaneous evidence. We look forward to 
resolving these complicated legal and scientific matters through 
continued partnership with Congress, NAS, and other concerned 
stakeholders.

    This concludes my testimony, Mr. Chairman. I would be pleased to 
address any questions you or other Members of the Committee may have.

    Chairman Isakson. Thank you for your testimony. Let me 
begin the questioning by asking you, why are you acting in your 
title?
    Mr. McLenachen. Sir, the position was vacated by a senior 
executive that retired. I have been acting in this position, as 
well as the Director of VBA's Pension and Fiduciary Service. I 
permanently fill the position as of next Monday.
    Chairman Isakson. As of next Monday? You will be permanent 
next Monday?
    Mr. McLenachen. Yes, sir.
    Chairman Isakson. How long have you been Acting Deputy?
    Mr. McLenachen. Fourteen months.
    Chairman Isakson. Why has it taken 14 months for you to go 
from acting to permanent?
    Mr. McLenachen. I do not have that information, sir.
    Chairman Isakson. It is not a trick question, but for the 
Members of the Committee, I have gotten on Secretary McDonald a 
lot about this, there are far too many responsible positions in 
the VA where the title is acting. That does not send the right 
signal to our veterans nor the people they work for, so I am 
glad that you are going to become permanent next week. I hope 
we will have a more expeditious permanent determination by the 
VA in their appointments in the future.
    Mr. McLenachen. Yes, sir. Thank you.
    Chairman Isakson. Now, in your objection to S. 901, the 
Toxic Exposure Research Act, as I understand it from your 
testimony, you call it duplicative. Is that correct?
    Mr. McLenachen. Well, Mr. Chairman, because I am not the 
medical professional here and do not have that expertise, I am 
going to defer to Dr. Erickson to take the question.
    Chairman Isakson. Fair enough. Dr. Erickson.
    Dr. Erickson. Mr. Chairman, thank you for the question. Our 
concern--the primary concern is not one of duplication of 
effort, but rather that perhaps there are other Federal 
agencies that are better postured, equipped, resourced, and 
staffed to actually answer some of the more difficult questions 
that are in the legislation. Being able to look at multi-
generational effects suggests looking at pediatric populations; 
likewise, doing fairly complex genetic studies.
    Now, it is certainly true that VA is involved in doing 
genetic research, and at times asking questions concerning the 
health of children of veterans. However, we recognize that 
there are other parts of the Federal Government that actually 
have greater capability than we have in this regard. To that 
end, we would rather collaborate with them than be the primary 
lead.
    Chairman Isakson. Well, I understand the duplicative 
statement that was made, but, you know, when we have the 
National Institute of Health, we have the CDC, we have a lot of 
other organizations, and it seems to me like--I am just an 
observer, this is Senator Blumenthal's bill, not mine--but 
there does not seem to be a catalyst to bring people together.
    I mean, you can have all the great research institutions in 
the world, but if they are not communicating, they are not 
coordinating, if there is not a unified mission, then you never 
get a result. You get a lot of separate research that are in 
desperate need of coordination.
    The reason I ask the question is, it seems to me like one 
of the things I have heard, particularly for Camp Lejeune--I 
think Senator Tillis would agree with me--we get competing 
information. We get maybe this is a causation, maybe this is an 
association, maybe it is not, and if we had a central 
clearinghouse that was a catalyst, we would all be better off. 
That is my only reason for asking that question.
    On the Camp Lejeune question, I will ask, the CDC, as I 
understand it, has said there are six health conditions that 
should be presumptions now?
    Mr. McLenachen. Actually, as of the last meeting on 
September 22, they provided us information as, I believe, 
Senator Burr mentioned, about a number of conditions. The 
Secretary has already decided that he is going to create a 
presumption regarding three of those. That was before we had 
this additional information from ATSDR. Now that we have it, he 
has directed us--we work very closely with the VHA, Dr. 
Erickson's staff and others in VHA, to review this information.
    But, just for your information, there were 17 conditions 
that were listed in the information that ATSDR provided to us. 
We are not talking about three conditions or six conditions. We 
have got all of that information. We are going to look at it 
and make the right decision about which conditions are covered.
    Chairman Isakson. Collectively?
    Mr. McLenachen. Yes, sir.
    Chairman Isakson. Well, that would be my recommendation. I 
would like the record to reflect that while the Ranking Member 
was gone, I spoke favorably about his legislation.
    Senator Blumenthal.
    Senator Blumenthal. I am going to pass on questions right 
now.
    Chairman Isakson. Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman. I am just curious. 
I think you make a point, sir, when you suggest that perhaps 
the VA is not the appropriate entity to be doing the research 
and, in fact, I suspect that if I was one of the individuals 
suffering with this, I would have a lot more confidence in 
getting something done if we had a different agency doing the 
research, but with a clear understanding that the response and 
that the entity responsible for responding to and providing 
services afterwards would be the VA.
    Would you have an objection to Senator Moran's proposal? I 
think that is S. 901, if I am not mistaken, that we are 
speaking of. Would you have an objection to that bill if the 
appropriate agencies who do that type of research were the 
responsible entities for actually getting it done, completing 
it, and then delivering the results to the VA?
    Dr. Erickson. Yes, Senator Rounds, thank you for the 
question. This is as a quick statement and background. I served 
in the U.S. Army for 32 years on active duty, went to war a 
number of times. The last assignment I had on active duty, I 
was fortunate to be the commander of the DOD's largest 
biomedical laboratory, that being the Walter Reed Army 
Institute of Research, which is not too far from this location.
    I certainly have experience in being able to run a very 
large, what I would say, well-funded research laboratory that 
deals with soldier/veteran issues. I understand that we need to 
work across the interagency frequently. A recent experience 
with ATSDR has underscored for me that, in fact, they have 
significant experience and expertise that we simply do not 
have.
    I understand, certainly, your point that you need a single 
bellybutton. You need someone who will be responsive, who will 
manage this. The point I was trying to make is, there are 
others who can do some of the cutting edge research that is 
necessary in a more efficient way than we can.
    The epigenetic research that is called for is very new. The 
existing background and evidence for that is such that if there 
is going to be a significant amount of laboratory and benchwork 
that will be necessary, that this is not something that we 
necessarily have the expertise within VA to be able to manage.
    Senator Rounds. Thank you. I agree and, in fact, I think 
the cleaner we get the processes within the VA the better off 
we are going to be. We have got a bureaucracy which is as big 
as anything in the Federal Government today.
    With regard to the issues surrounding the Blue Water 
soldiers and sailors that we are talking about in Vietnam and 
thereabouts, do we have a disagreement with what has been found 
with the scientific studies that were reported just a minute 
ago on terms we discussed, in terms of what the country of 
Australia was able to determine?
    Can you share with us the thought processes with regard to 
the analysis that was done there versus the analysis, or if 
there has been an analysis done in terms of researchers within 
our own country on the same issue?
    Mr. McLenachen. Let me just address initially consideration 
of the policy issue there. What the IOM study did do is 
validate the lab study that was done regarding the Australian 
Navy exposure. In other words----
    Senator Rounds. You say it validated it?
    Mr. McLenachen. Yes. They concluded that if there was water 
taken in that was contaminated, they validated that was a way 
that there could be exposure. Our policy was based on Navy 
directives instructing that ships take on water far offshore. 
So, there is a lot more that goes into the policy rather than 
just the fact that yes, U.S. Navy used desalination processes 
similar to Australia, but they did take on water far offshore, 
and the IOM had no evidence to suggest that that water was 
contaminated. As far as the specific science behind that 
process, I will defer to Dr. Erickson.
    Dr. Erickson. Senator, I think you will be hearing more 
about this in great detail from the following panel, from our 
IOM colleagues. We, of course, commissioned the study of Blue 
Water Navy in asking the IOM to deal with the questions that 
you and others have proposed concerning the exposure, potential 
exposure of these individuals. As I think you are aware, the 
IOM conclusion was that they had neither sufficient evidence in 
favor or against being able to rule, being able to advise us.
    To that end, and with additional information that has 
become available to our Secretary, that is now being considered 
at the VA. That is something that both Mr. McLenachen and 
myself have participated in a small workgroup with the 
Secretary to discuss and it is presently at a deliberative 
point.
    Senator Rounds. Thank you. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you very much, Senator. Senator 
Blumenthal wants to reclaim his time after which I will go to 
Senator Tester to restore our order, then we will go to Senator 
Tillis, then we will go to Senator Manchin.
    Senator Blumenthal. I have just two quick questions. First 
of all, I take it from your testimony that Secretary McDonald 
has sent to Congress a request for legislation to reauthorize 
the extension of the Secretary's authority to determine 
presumptions for service connection of diseases.
    Would you, therefore, think it is important and necessary 
to approve Senate Bill 2081, which, in effect, extends this 
authority for an additional 15 years?
    Mr. McLenachen. It is the Department's position that we 
would support that bill.
    Senator Blumenthal. Thank you.
    Mr. McLenachen. We have seen the draft bill and would 
support it. One point I want to make, though, Senator, if I 
may, is the bill would reauthorize a specific process or 
procedure for getting information from the National Academy of 
Sciences and it has specific time limits for the rulemaking 
process. In our view, those rulemaking time limits are 
unreasonably short given the current Federal agency rulemaking 
process, so I just ask that the Committee consider whether 
those are appropriate.
    Senator Blumenthal. I am sure we will take that point under 
consideration.
    Mr. McLenachen. Thank you.
    Senator Blumenthal. Second question. In preparing for this 
hearing, I heard from the Blinded Veterans Association, the 
BVA, regarding an eye cancer called choroidal melanoma. I 
understand from the BVA that this type of cancer is rare in the 
civilian population, but it is ten times more common among 
Vietnam era veterans and currently is not being considered for 
an epidemiological study.
    I would like you to commit that you will consider it and 
tell the Committee the process by which the VHA decides to 
subject a particular issue to such a study.
    Mr. McLenachen. Senator, I am not familiar with that 
particular cancer, but we will certainly take that for the 
record and get back to the Committee, unless Dr. Erickson has 
anything he would like to add.
    Dr. Erickson. Senator, certainly we have epidemiologists 
that work in my shop, so following this meeting I will take 
that up with them right away, and we will get back to you.
    Senator Blumenthal. What is the process by which you 
consider whether to do an epidemiological study?
    Mr. McLenachen. If it is a large study, certainly funding 
is always an issue. If it is a study that we can accomplish in-
house using existing data from our health care system, in that 
case the funding issue is less of a major consideration. 
Initially, the consideration is going to basically be 
feasibility. Can we get to the data? Will there be enough cases 
for us then to be able to study to be able to answer some of 
those questions?
    Senator Blumenthal. Thank you.
    Chairman Isakson. Is Senator Tester coming back? I messed 
up the order a minute ago when I got a pass over here and I 
should have gone to Senator Tester then, which I apologize for. 
I think I will go to Senator Tillis and then Senator Manchin, 
then when Senator Tester gets back, I will go to him. How about 
that?
    Senator Tillis. You need to put that in a spreadsheet, Mr. 
Chair.
    Chairman Isakson. I will tell him our decision.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Mr. Chair, I appreciate you calling this 
Committee. I want to start by something I am going to do in 
every Committee meeting until we get closure on it. Your point 
about too many acting positions in the VA is spot on. First 
among them is the Inspector General. It is unacceptable and 
irresponsible not to have that position filled by somebody and 
I call on the Administration to do their job.
    Now, I want to talk about you all doing your job. I think 
you all know that, for the most part, I come into these 
Committee meetings highly supportive of the VA. I have gone out 
to the VA facilities and made sure that those folks know that I 
am there to help them. But, we have got a big issue here. It 
came from a conference call that I just had on Friday and I 
think we are conflating issues at the expense of taking ground 
where we can take ground.
    When I hear a comment like, well, we have got the Agent 
Orange and Blue Water issues solved before we can really move 
forward on a holistic basis with the Camp Lejeune exposure, 
that is unacceptable. There is not a single veteran that has 
ever served in the armed services who will say, we will not 
fight one battle until we can win them all. We have six of 
these diseases confirmed by the CDC that say that there is 
sufficient evidence of causation, period. We should look at the 
others and figure out whether we should do more.
    We should figure out a methodology and when everything is 
equal, the tie goes to the veteran. We need to get the Lejeune 
issue solved quickly. I was told 2 months ago that any claims 
for the diseases related, the three at least, would be delayed 
and not denied until we came up with a policy.
    The reason that we needed to do that is if you get a claim 
denied, then the veteran has to go through the process again. 
Whereas, if we just delay the decision until after we have the 
policy, they can move through the process in the order that 
they should. Conflating--look, my wife's uncle's name is 
inscribed on the Vietnam Veterans Memorial. He died from Agent 
Orange exposure.
    I have great sympathy for what Senator Blumenthal and 
everybody else is doing. I want this Lejeune problem solved. I 
think Secretary Mabus should be ashamed of the statement he 
made this week because he has taken the eye off the ball of 
solving this problem.
    So, I would like to get an assurance, first and foremost--I 
have not cited you two personally. I thank you for your service 
and I appreciate the work that you are doing. This is a process 
that is broken. We have got to solve the problem, not only with 
the three diseases, because I continue to hear about the three, 
but the CDC says six. So, let me start there. What has the CDC 
presented on the six conditions that they say there is 
sufficient evidence of causation that the experts in the VA 
think are wrong?
    Mr. McLenachen. I will defer to Dr. Erickson about that.
    Dr. Erickson. Senator Tillis, thank you for the question. I 
was fortunate to be a member of the VA team that has met with 
ATSDR professionals. We met on August 19 and September 22. We 
think we will be at the final meeting sometime prior to October 
13. Our ATSDR colleagues provided us with a 67-page document 
that was very well received. It involved a tremendous amount of 
work summarizing, aggregating the body of information that is 
available--not just ATSDR studies, but all of the occupational 
environmental studies within the scientific literature.
    Again, not wanting to usurp the authority of my big boss, 
Secretary McDonald, I can really tell you that we are moving 
from that work, that smaller work group that has been meeting 
with ATSDR, to a deliberative process that will, I think, move 
relatively quickly in bringing recommendations to the 
Secretary. I was able to listen in on that phone call that you 
had with the Secretary, Senator, and I very much appreciate the 
urgency to get this settled. As a veteran, I very much feel 
that as well.
    Senator Tillis. Let me--because my time is about to 
expire--I would like to get an assurance from you all. I 
thought that I had that assurance in July, according to my 
staff, which I may be wrong and if I am I will come to the next 
Committee and say that I am. But, I have been told that there 
have been claims denied since I was given an assurance that 
they would not be for at least the three types of diseases.
    What I would like is an assurance for at least the six 
conditions, where we have sufficient evidence of causation, 
that there is not going to be another denial, and if there is, 
you know--I know that I have ratcheted up my temperature in 
this meeting which will not compare to the next one if that 
happens because we owe it to these veterans.
    I will just finish my statement, Chairman. I will try to go 
quickly because I meet with you all on a regular basis, there 
are a lot of things you are doing that is good work. This is 
just not one that I am pleased with the progress.
    I want to make sure, but there is another piece here that 
we need to talk about. The disability benefits are mandatory 
spending. We will spend whatever we have to when we find out we 
have an obligation. I have heard on a couple of occasions about 
the operational impact and I get that. If we have to serve more 
veterans, we have to serve more veterans.
    Somebody is saying, well, we need to be careful because we 
do not want to hold up the backlog because that will create bad 
optics. I do not care. If we need a backlog to be created 
because we have people who may have legitimate claims, create 
the backlog and then we will figure out how to fund the 
operation to draw down the backlog. But let us not have policy 
being driven by optics that politicians just need to deal with.
    I will be honest with you all and I will stand up for you 
all. If you start putting processes in place where we are 
serving more veterans and it requires more people, I will be 
one of the first ones to do whatever I have to do to provide 
you all with the resources to do it. Thank you, Mr. Chair.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Manchin.

       HON. JOE MANCHIN, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman. As you can tell, 
it is very emotional for all of us because we have had people 
that served that we have lost--people who were very dear and 
near to us.
    History has shown our actions in combat, and we are finding 
even on our installations, no matter how necessary or well-
meaning, have often carried unintended consequences. I think we 
just heard Senator Tillis talk about Lejeune, burn pits, all 
the issues decades-old.
    The thing that we seem to be fighting over is or the delay 
is based on what we call presumption. I would like to know how 
you all intend or what have you learned from past experiences 
and what you are doing now because we know with all the 
conflicts we have been involved with in the last ten or more 
years, this is going to come to roost in 10, 20, 30 years from 
now.
    What have you done that we have learned from the past that 
we did not do which we are calling presumptive and not taking 
care of anybody to make sure this does not repeat itself?
    Mr. McLenachen. First, let me just address the point of 
developing policy. As science develops, so must our policy, 
which I think is really the issue that you are raising. As the 
science develops to the point where we can create a 
presumption, we should be creating a presumption. What we have 
learned is it is often a lengthy process to create the 
presumption. We have to go through rulemaking. We need to find 
ways to streamline that as much as possible.
    Senator Manchin. No, I think what I am saying is, that we 
have been engaged for almost two decades in the Middle East and 
our soldiers have been exposed. We know that. We know there has 
been chemical and a host of other exposures. You all have to be 
aware of that or they have to be, I would say, communicating 
with you all that you are preparing and building a case now.
    When they come to you 10, 20, 30 years from now, we have 
already set the stage. We do not have to go through this 
process we are going through, this timely process now. I think 
that is why you are seeing the compassion that Senator Tillis 
has and all of us have. How can we keep from repeating this?
    Mr. McLenachen. We get regular information from, for 
example, the National Academy of Sciences. In addition to that, 
I am sure that Dr. Erickson can give you more detailed 
information about what his staff does as far as----
    Senator Manchin. Are you all connected with Department of 
Defense right now knowing what soldiers that are basically--I 
mean, my goodness, we have had four and five deployments just 
in West Virginia from our National Guard.
    Dr. Erickson. Senator, we work very closely with the 
Department of Defense. We share a lot of staff in directing 
research that goes directly to those very issues you have 
talked about. I sit and co-chair with the DOD partner, the 
Deployment Health Work Group, that helps to guide much of this.
    But even more so, I will tell you, we are trying to be 
proactive so that we are not 10 and 20 years from now caught in 
this situation. In particular, we are working with Department 
of Defense to create what is called the Individual Longitudinal 
Exposure Record, the ILER. This, in fact, will be a database 
which will collect all of the exposures for every servicemember 
through the course of their entire career, and basically then 
be available to VA so that when an individual comes to us years 
later after faithful service and they say, I have this disease, 
I have this condition, we will be able to reach into the ILER 
to be able to say, yes, you were exposed here, you were exposed 
there, we have got great evidence, we have got background to 
work with, we are going to take care of you.
    Senator Manchin. If we were able to come to an agreement 
with you all, all of us agree to give presumptiveness to some 
or all of the claims being brought forward, how would that 
affect your claims process; and does a presumptive finding 
speed up your workload or does it increase in numbers so 
greatly that it slows it down?
    Mr. McLenachen. It generally increases the workload 
significantly. It depends on the presumption. The best example 
is the 2010 addition of three presumptive conditions for Agent 
Orange exposure which was, to a large extent, part of the cause 
of our backlog that we have been dealing with, which is, you 
know, down to about 75,000 claims, whereas at one point it was 
611,000 claims.
    Those are the kind of problems that we have, and what the 
Secretary is suggesting, he is not suggesting that policies 
should be based on that. He is saying, if we know that that is 
going to happen, he wants to work with the Congress to make 
sure that we have the resources we need to timely process all 
claims regardless of whether it is one of the presumptive 
conditions or one of the more than one million claims we 
receive every year. So, it does have a large impact on our 
workload and it depends on the presumption.
    Senator Manchin. OK. Thank you, Mr. Chairman. I would 
concede my time to Senator Tester since he has been waiting so 
long.
    Chairman Isakson. We will take in order the following: 
Senator Tester, followed by Senator Heller, followed by Senator 
Hirono, followed by Senator Cassidy, followed by Senator Moran.
    Senator Tester.

           HON. JON TESTER, U.S. SENATOR FROM MONTANA

    Senator Tester. Well, thank you, Mr. Chairman. You are way 
kind and I would tell you it is always dangerous to agree with 
the good Senator from West Virginia.
    I have got some questions. How many Blue Water vets are out 
there still living?
    Mr. McLenachen. Our estimate, Senator Tester, is about 
174,000. That is the population that we started with.
    Senator Tester. How many do you think have symptoms?
    Mr. McLenachen. We track this information. Of those 
174,000, about 40,000, we believe, are already covered by our 
current policy; that is the policy where if a ship sent 
personnel ashore, we have a presumption.
    Senator Tester. There were boots on the ground. How many 
left?
    Mr. McLenachen. About 80,000.
    Senator Tester. 80,000 that maybe would have symptoms.
    Mr. McLenachen. Well, those are 80,000 that are still 
alive. Of those we tracked a little over 20,000 that were 
denied benefits based on Blue Water service.
    Senator Tester. OK. Have you guys developed a cost for 
this?
    Mr. McLenachen. We are working on that.
    Senator Tester. Can you give me a ballpark?
    Mr. McLenachen. I can get that to you, Senator. Let me take 
that for the record.
 Response to Request Arising During the Hearing by Hon. Jon Tester to 
        David R. McLenachen, U.S. Department of Veterans Affairs
    Response:

     General Operating Expenses Costs:

         - 2016--729 FTE
         - By 2025--Reduced to 200 FTE
         - 2016--$77.7 million
         - 5 years--$208.3 million
         - 10 years--$357.7 million

     Mandatory Costs:

         - 2016--$1.3 billion
         - 5 years--$3.0 billion
         - 10 years--$5.3 billion

    Senator Tester. It is important and I will tell you why it 
is important. I would like to know what happened in 2001, too. 
I would also like to know what happened to the Priority 8 vets. 
It took them out. My guess is it was not a bureaucrat sitting 
in a room with no windows in it. It was probably somebody, 
maybe on this Committee or maybe in the Administration, that 
said, you guys have got to figure out ways to save some money.
    Mr. McLenachen. I could answer that question for you, 
Senator.
    Senator Tester. Yes, please.
    Mr. McLenachen. This has been our policy since 1994. Prior 
to 2002, the policy was based on receipt of the Vietnam service 
medal.
    Senator Tester. Yes.
    Mr. McLenachen. The Vietnam service medal was awarded to 
individuals who provided support in places other than Vietnam.
    Senator Tester. OK.
    Mr. McLenachen. For that reason, we changed the policy at 
that time to ensure that the presumption actually relates to 
the risk of exposure, and that is why the policy was changed. 
It was changed by regulation, by VA.
    Senator Tester. So, it was VA that directed that?
    Mr. McLenachen. Yes.
    Senator Tester. The Secretary?
    Mr. McLenachen. It was. It was a regulation issued by VA.
    Senator Tester. OK. All right. So, getting back to it, do 
you believe these Blue Water vets had an exposure to Agent 
Orange? Do you believe that a certain percentage of them 
present suffered some health problems?
    Mr. McLenachen. Yes. We already cover 40,000 of them, 
according to our estimates.
    Senator Tester. OK. So, you agree that this bill should go 
forward?
    Mr. McLenachen. If you are referring to S. 681, the 
Department does not support that bill, did not support it.
    Senator Tester. Why?
    Mr. McLenachen. Because the Air Force did not spray 
herbicides over offshore--off the shores of Vietnam. Now, that 
is not the end of the policy issue.
    Senator Tester. OK.
    Mr. McLenachen. As the Secretary has instructed us, based 
on the Gray decision that we received from the Court of Appeals 
for Veterans Claims, he has directed us to take another look at 
all of our policies.
    Senator Tester. Well, I would just say, look, this is heavy 
duty stuff.
    Mr. McLenachen. Absolutely is.
    Senator Tester. Let me tell you about stuff we spray on 
``ag'' land. Agent Orange blows this out of the water. I can 
tell you that when they spray, especially from an airplane, two 
or three miles away from my house, I can smell it, and those 
are ag chemicals. That is not Agent Orange.
    So, I think direct application to a human being is not 
necessarily what needs to be the standard. This is a farmer 
talking, not an M.D., not a researcher. I will just tell you, 
just because they did not get it--and look, I want people to 
get benefits who deserve benefits. If you do not deserve the 
benefit, you should not get it. OK?
    Mr. McLenachen. That is our mission.
    Senator Tester. Yes, that is exactly right. So, when we are 
talking about this, it is really important that we talk about 
reality. I am not being critical of the VA, by the way. I tend 
to be more on your side than others. Tell me about the guys who 
ran the airplanes. Are they covered, the C-123 folks?
    Mr. McLenachen. Yes, they are. We issued a regulation 
recently establishing a presumption of exposure and service 
connection for that.
    Senator Tester. That is good. Let me talk a little bit 
about genetic research. Dr. Erickson, I think you said that you 
did not have the capacity to deal with it. I am not speaking 
for Senator Moran here, but I do think the Chairman is right. 
There needs to be a lead dog. Do you have the capacity to 
contract out?
    Dr. Erickson. The short answer is yes, sir.
    Senator Tester. OK. So, you could really be the overseeing 
agency and contract the research out so you make sure you get 
the information back if we were to do this?
    Dr. Erickson. We could.
    Senator Tester. OK. I think, you know, we are talking about 
veterans and we are talking about generational things which is 
pretty complex. I get it that you do not have the capacity. I 
think we had this discussion on the building in Denver, as a 
matter of fact, and I think that there are certain areas where 
it is good for you guys to contract stuff out.
    Do not be opposed to it because you do not have the 
capacity when you can contract out and get that capacity. Are 
you guys opposed to this bill, the presumptive care one--not 
the presumptive care one, but what we talked about, the 
generational impact.
    Dr. Erickson. It is VA's position that we are opposed to 
it.
    Senator Tester. Is VA opposed to it because you do not have 
the capacity? Is that why?
    Dr. Erickson. That was the primary point. Again, we do not 
have the capacity; we are not postured as well as other Federal 
agencies. There is concern that it could be a distractor 
because language within the legislation, as I read it, talks 
about us assigning one of our medical centers as being the hub 
for this.
    Now, there is also language within the bill, if I read it 
correctly, that talks about provision of care to descendants, 
which is a little bit of a move away from our traditional role 
at VA of taking care primarily of veterans.
    Senator Tester. I got you. But if the research shows that 
this is a problem, do you not think it is right? Not to put you 
on the spot.
    Dr. Erickson. It would always be right to do the correct 
thing for veterans and their families.
    Senator Tester. All right. You guys do what you want, but 
if I were you guys, I would work with the bill's sponsors to 
figure out how you can make this bill work from a VA 
perspective. Then, if the sponsors agree and this Committee 
agrees, we are probably off and running. Thank you, Mr. 
Chairman.
    Chairman Isakson. Senator Heller.

           HON. DEAN HELLER, U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thanks for holding this 
hearing. I know that there are a lot of veterans watching this 
hearing closely, and I would like to share with the witnesses 
some of the questions that they have. I am no different than 
any other Senator in this Committee or any Senator regarding 
the number of phone calls that we receive from our veterans and 
their concerns for these issues. But I want to thank you both 
for being here. And congratulations on your new status, by the 
way.
    Mr. McLenachen. Thank you.
    Senator Heller. I guess what strikes me most about this 
hearing is not only exposures to toxins and how they can be 
linked to certain diseases for our veterans, but as important 
is the birth defects and other problems that affect the 
children and grandchildren of these veterans.
    Mr. Chairman, I am a son of a disabled Navy veteran, 
brother of a retired Navy veteran. Fortunately for our family, 
neither of them are Blue Water Navy veterans and we are 
grateful for that. But I share the concerns with veterans back 
home and their concerns about having been exposed to some of 
these toxins. They deserve more from us. And as a father and 
grandfather, watching what they are dealing with, I can truly 
sympathize with the issues that they have and their concerns.
    I want to share with you an issue just last month of a 
Vietnam veteran from Las Vegas. He wrote to me about his battle 
with bladder cancer. He pointed out that many other veterans 
who served in Vietnam also are suffering from bladder cancer 
and that may be due to toxic exposure.
    I just want to raise the same questions to you that he 
raised to us and hopefully, he and they can get some answers 
because I know they are watching intently on this hearing. Is 
there a venue for veterans to tell the VA that certain diseases 
are more common and see if theirs may be related to toxic 
exposure?
    Mr. McLenachen. Well, as far as a venue for them 
specifically to do it? We get the same communications all the 
time and raise issues and discuss them with VHA and the experts 
over on Dr. Erickson's staff. In addition to that, you will 
hear from the Institute of Medicine about the very detailed 
work that they do in this area as far as what does the science 
show about the association between exposure and specific 
conditions, and as the science develops, we get information 
about it.
    Senator Heller. Doctor.
    Dr. Erickson. Senator Heller, we have regular meetings with 
VSOs and with veteran advocates. That is certainly a great 
avenue to approach us. Over 30 percent of veterans have 
expressed, in a recent survey, that they are very concerned 
about environmental issues, so we want to hear from them.
    We have had veterans groups assist us in updating our web 
pages such that the information we are posting is the most 
current, the most useful both to veterans and to providers. We 
recently created an environmental exposure app for the iPhone 
which veterans can use and which providers can use. It is free 
on the Apple Web site, free for download.
    We have a number of newsletters that we send out. We have 
registries which help us to link-in veterans so we can, on a 
regular basis, reach out to them. Likewise, at the local level, 
we have environmental health clinicians and coordinators who 
help to make sure that all the providers at those facilities 
are kept abreast of the latest information made as policy 
decisions. We look to have a multilayered approach to reach 
veterans such as the one you have mentioned.
    Senator Heller. And that is great and I appreciate the 
answer to that. Doctor, let me ask you one other question. When 
these veterans do raise these concerns, and all these 
opportunities that you claim are available to them, how do you 
ensure that the VA talks to the Institute of Medicine to look 
into these specific claims?
    How can they be guaranteed this? You go through this whole 
process. How can you assure them that their concerns are going 
directly to where they need to go; IOM, as an example?
    Mr. McLenachen. If we understand the question correctly, 
you are asking, once we get that information, essentially what 
do we do with it?
    Senator Heller. Right, sure. They go to VA hospitals. This 
is not the same question. This is not a repeat of the same 
question. What they are saying is they come and talk to you and 
you hold all these clinics and you have all these hearings and 
then they want to know where the information goes. That is what 
they want. They want to be assured, they want to be assured 
that you are taking this information, their concerns and their 
problems, and making sure that there is a follow-up on it.
    Dr. Erickson. Right. Senator, maybe I can give you two 
examples, and this is by no means a promise that 100 percent 
satisfaction will be reached. However, for instance, the 
National Gulf War Resource Center President, Mr. Ron Brown, has 
worked with us very closely for Gulf War veteran issues. He 
collects those issues, brings them to us.
    He worked very closely with us to make sure that the 
newsletters we published this year addressed the very issues 
that those Gulf War veterans he represents were, in fact, 
included in the newsletter; that we, in fact, found SMEs to 
write the articles to answer those questions. Likewise, he 
worked with us to update our Web site.
    Concerning Fort McClellan, which is an emerging issue, we 
have had a lead advocate from Fort McClellan meet with us on a 
regular basis so that we are regularly fed information. To the 
degree that we can, we want to be responsive. We owe this to 
the veterans.
    Senator Heller. OK. Mr. Chairman, my time has run out.
    Chairman Isakson. Thank you.
    Senator Hirono.

         HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you, Mr. Chairman. I realize that it 
is very challenging to determine the causal effect of exposure 
to a substance and subsequent health of concerns. In the 
meantime, though, veterans who argue that their medical 
condition is service-related by exposure to some kind of a 
chemical or a substance, what is the burden that they bear, 
assuming that there is no presumption of connectedness? What is 
their burden? Do they have to show by clear and convincing 
evidence?
    Mr. McLenachen. No, we do not apply that high of a 
standard, but in situations where there is not a presumption, 
we determine service-connected conditions based on the 
information that we receive. So, on a case-by-case basis, the 
veteran can establish, whether it is providing us information 
or it is us obtaining information through our duty to assist, 
that the veteran was actually exposed to a harmful herbicide, 
for example, and actually developed a condition, we will 
service-connect that condition.
    The presumption makes it easier for us because then neither 
the veteran nor VA has to go out and find evidence that there 
was--this exposure actually occurred in service or that their 
disability developed in service.
    Senator Hirono. It seems as though if there is no 
presumption, then it is a pretty high burden for the individual 
veteran to make the connection claim. I have heard concerns 
from the Hawaii VFW about veterans who were exposed to 
radiation during the atomic debris cleanup of the Marshall 
Islands in the 1970s and 1980s, and several thousand of our 
troops were exposed as they were doing this cleanup.
    I think we already have evidence as to what kinds of 
medical conditions are connected to exposure to radiation, so 
when a veteran or, let us say, a number of veterans present 
with similar kinds of medical conditions, and we already know 
through other research, particularly after Hiroshima and 
Nagasaki, what would happen. Does that help to create a 
presumption?
    Mr. McLenachen. Yes. Actually, the Congress has a very long 
history of creating presumptions. They date back to chronic 
disabilities that develop after service. We can trace it all 
the way back to the 1920s. Radiation exposure is one of the 
presumptions that Congress has created for veterans and we do 
grant benefits on that basis.
    Senator Hirono. On the other hand, for these service people 
who were engaged in the cleanup, they are not categorized as--I 
think you have a presumption category called ``atomic 
veterans'' and they are not included. Why is that?
    Mr. McLenachen. I think that----
    Senator Hirono. Because we know that exposure to the 
environment, especially after 9/11 and what happened to the 9/
11 first responders, all kinds of health issues that arose. I 
think we were convinced that that was as a result of their 
efforts after 9/11. So, here is another group that were exposed 
to radiation as a result of cleanup.
    Mr. McLenachen. I believe Dr. Erickson can address it.
    Dr. Erickson. Senator, some of the more recent radiation 
exposure events, Tomadochi, Marshall Islands cleanup, et 
cetera, there were actual measurements taken of what radiation 
was present at the time.
    Individuals that are actually filing claims are reviewed on 
a case-by-case basis, and based on where they were, how many 
days, et cetera, there is actually a risk profile that is 
developed following established standards to then determine, 
you know, whether or not now the disease that they are filing 
the claim for is more likely than not to have been caused by 
the radiation. So, there actually is a rigorous process that is 
followed in the absence of there being a presumption.
    Senator Hirono. Have some of these service people who have 
made these claims who were involved in the cleanup of Marshall 
Islands, have they been provided the health care services as 
service-connected?
    Dr. Erickson. I would--we would have to get back to you to 
give you the exact numbers.
    Senator Hirono. Well, is it some, is it zero?
    Mr. McLenachen. It is not zero; it is some. As Dr. Erickson 
said, we go out and we get actual information which we use to 
rate the claim based on the dose exposure to adjudicate those 
claims.
    Senator Hirono. Considering that this is another group that 
is seeking a certain kind of status as atomic veterans, then I 
would be interested to know how many people you have already 
assessed as having shown that connection. If there is a 
significant number of them, then I would think that would raise 
an issue for you all as to whether they ought to be categorized 
as atomic veterans.
    Mr. McLenachen. We will take that for the record and get 
that information to you.
    Senator Hirono. Thank you.
Response to Request Arising During the Hearing by Hon. Mazie K. Hirono 
                 to U.S. Department of Veterans Affairs
    Response. VA is unable to provide the requested data because we do 
not have a method for identifying claims related to Marshall Islands 
cleanup during the 1970s and 1980s. Statutory and regulatory provisions 
do not include these Veterans as participants in a ``radiation risk 
activity'' and thus presumptively ``radiation exposed.'' Veterans who 
participated in the cleanup of Enewetak Atoll, part of the Marshall 
Islands, are not considered radiation-exposed for the presumption of 
service connection for disabilities because the cleanup project was a 
tightly controlled radiological work environment. Personnel that 
entered radiologically contaminated areas were monitored for both 
external and internal exposure. Of over 12,000 individual dosimetry 
records, only four exceeded 0.050 rem, and the highest of these was 
0.070 rem. Throughout the cleanup project, over 760,000 cubic meters of 
air were sampled on the controlled islands. Nearly 5,200 air samplers' 
filters were analyzed by the lab. No significant airborne radioactivity 
of any type (including beta) was detected. Extensive recording of all 
radiation safety data was accomplished. In addition to recording 
personal doses in each individual's military records, a permanent 
computerized database of all radiation safety information has been 
established at Defense Nuclear Agency's (DNA) Field Command in 
Albuquerque. The exhaustive data accumulated over the 3 years of the 
project do not indicate any area or instance of concern over 
radiological safety. All doses, internal and external, were minimal. 
(Taken from chapter 4 of DNA 1981--``The Radiological Cleanup of 
Enewetak Atoll.'' http://www.dtra.mil/Home/NuclearTestPersonnelReview/
EnewetakAtoll CleanupDocuments.aspx)
    However, VA takes seriously its obligation to care for Veterans 
exposed to ionizing radiation and has special processes to both verify 
exposure and establish service connection for Marshall Islands cleanup. 
These processes are described in 38 CFR 3.311, which is attached. For 
such claims, the Veterans Health Administration (VHA) Office of Public 
Health provides the Veterans Benefits Administration with a medical 
opinion concerning the likelihood of causation. VHA considers data from 
several publicly available reports on the cleanup from DOD's Defense 
Threat Reduction Agency (DTRA)/Nuclear Test Personnel Review (NTPR). 
DOD DTRA/NTPR has requested funding from Congress to further 
investigate radiation doses due to Veterans' participation in the 
cleanup.
                        Attachment--38 CFR 3.311

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




    Chairman Isakson. Senator Cassidy, followed by Senator 
Moran.

         HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA

    Senator Cassidy. So, I have got a bunch of questions. I 
think, Dr. Erickson, you mentioned that the Australian data was 
perhaps not directly--somehow it did not relate necessarily to 
the American data because they may have taken their water on 
board to distill at different locations.
    I have read that in Australia, the drinking water was taken 
in relatively small estuaries closer to the shore and that for 
the boilers was even further out. What were the policies for 
the U.S. Navy in terms of where they would take on water to 
distill?
    Mr. McLenachen. I can answer the question, Senator. It is 
our information that the Navy had a directive that that water 
was to be taken on offshore and I believe it was 11 or 12 miles 
offshore.
    Senator Cassidy. Now, if you are 11 or 12 miles off of the 
Mekong Delta, that would still be an estuary type situation, so 
do we know that they had requirements to be--and I presume they 
would often be off that estuary. In that situation, did they 
need to be further out?
    Mr. McLenachen. I do not have any information on that, 
Senator.
    Senator Cassidy. Do we know the amount of particulate 
matter, organic matter which is normally suspended in the 
waters off of the Mekong Delta? Do we know that? Relatively 
easy to find out. That is why I am asking.
    Mr. McLenachen. I will defer to Dr. Erickson, but I believe 
the IOM study did address that to a certain extent.
    Dr. Erickson. I would defer to the next panel because I 
would have to look that up, Senator. I just do not have that 
available.
    Senator Cassidy. Now, I read from the Australian data that 
if there is organic material, that they tend to retain--you 
have a greater distillation effect, as much as 70 percent 
distillation within the first process. Now, again, this seems 
relatively easy to ascertain. Maybe we have to wait for the 
IOM. Do you know if that has been ascertained again; what is 
the organic material, et cetera?
    Mr. McLenachen. No. I believe my non-scientific reading of 
the IOM report indicated exactly what you are saying, which is 
if that process was used, would it enhance essentially the 
strength or the degree of the----
    Senator Cassidy. But we are not sure about that? Do we have 
any banked tissue samples or serum samples from veterans, men 
and women who served at the time? Do we have any tissue banks 
or serum banks from their service?
    Dr. Erickson. Senator, we certainly have for the Air Force 
members who were participating in the spraying of Agent Orange. 
The Institute of Medicine, in fact, is working with us to make 
those specimens available for study. But I am not aware of any 
specimens that would have covered anyone who was serving in the 
Navy.
    Senator Cassidy. OK. I noticed in the eligibility for 
current benefits, basically, somebody could have been in Saigon 
at a desk job, but they would be eligible for Agent Orange 
benefits even if they plausibly never had an exposure, correct?
    Mr. McLenachen. That is correct.
    Senator Cassidy. Now, the Blue Water folks are saying, 
listen, there was transport, there were vessels going on and 
off from the mainland to these vessels, and plausibly there 
could have been cross-contamination. I do not know.
    How was the chemical transported? Was it in boats or was it 
flown over? I do not know that.
    Mr. McLenachen. It was flown, is my understanding. I do not 
have any additional information on that.
    Senator Cassidy. I am seeing people in the back shake their 
heads. It makes sense to me that if you are transporting tons, 
you would be more likely to do it by boat than by air, because 
it is not like you needed it acutely. You are going to use it, 
you know, a planned use.
    So, if the guy on the desk job in Saigon is eligible, but 
there is transport in boats and there is loading in boats and 
there is X, Y, Z in boats, plausibly it seems as if there 
should be--I can see why the Blue Water guys are a little 
upset.
    Mr. McLenachen. Senator, if we have information on ships 
that were hauling it and veterans had access based on serving 
on those ships, they would be on the ship list and that we 
would be recognizing as having the potential for exposure.
    Senator Cassidy. Got you. Now, last, in the VA system, 
clearly you all have large epidemiological databases 
potentially, and have you been able to look back at the 
incidence of dioxin-related conditions in the Blue Water vets 
relative to the Air Force or relative to those who were boots 
on the ground?
    Dr. Erickson. Senator, the answer is that there has not 
been a study of the Blue Water Navy by VA. The high-risk groups 
that we studied and have been studied for decades now were the 
Army Chemical Corps.
    Senator Cassidy. I get that.
    Dr. Erickson. And----
    Senator Cassidy. Now, the Australians did that and they 
actually found an increase incidence of certain tumors within 
the Blue Water group. Granted, we do not know where they got 
their water, vis-a-vis, us, but I guess it kind of begs the 
issue of why have you not? If this is out there and we have got 
all this data, it seems--if the Australians can do it--you see 
where I am going with this?
    Dr. Erickson. In the case of Blue Water Navy, Senator, we 
would have to go get the data. We would have to launch a rather 
large survey which would reach out to those individuals.
    Senator Cassidy. You cannot just take your subset of Naval 
veterans who have sought their care in the VA and compared them 
to a cohort of Army and Marine and Air Force veterans?
    Dr. Erickson. If we felt that particular group was 
representative of the entire Navy experience, then that would 
be a good study design, sir.
    Senator Cassidy. I can tell you there is a statistician 
that knows how to correct the variables, you know, some sort of 
regression analysis. It just seems like if we have all these 
unanswered questions, that study should have already been done. 
Maybe the IOM has done it.
    Dr. Erickson. Part of the challenge, Senator, if I may, is 
there is a lot of mixing of these populations. There would have 
been people who--
    Senator Cassidy. I accept that it is dirty data, but the 
Australians did it.
    Dr. Erickson. What I mean by this, sir, is that individuals 
who, during one tour, might have been way off shore. The next 
tour they may have come into port. Once they came into port, 
then they, under the presumption rules, you know, they are 
covered, so now they are enrolled in VA. Some challenges--and 
your point is well taken.
    Senator Cassidy. I am way over time. Thank you for your 
indulgence. I yield back.
    Chairman Isakson. Senator Moran.

           HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you for conducting this 
hearing. Secretary, thank you very much for being here. Let me, 
first of all, express my support for a bill I am a cosponsor of 
and that is the Blue Water Navy Vietnam Veterans Act of 2015. I 
will generally confine my remarks and questions to the bill 
that Senator Blumenthal and I introduced related to toxic 
exposure.
    First of all, let me express my concern for family members 
of those veterans and for the veteran who encountered that 
toxic exposure. It seems to me that those who served our 
country in the military, who were drafted, who volunteered, 
they have an expectation of taking certain risks associated 
with their military service.
    But I cannot imagine that any one of those men or women 
expected that their service would result in health care 
concerns for their children or their grandchildren. What a 
terrible burden that must be if you now believe that something 
that you voluntarily did has a consequence for people who were 
yet to be born, your children and grandchildren.
    I think this is an issue that is so deserving of the VA's 
attention and certainly of Congress's attention. My 
understanding is that--I am not certain, Mr. Secretary. You on 
behalf of the VA oppose that bill, is that true? That is your 
testimony today?
    Mr. McLenachen. Yes. VA opposed that bill, yes.
    Senator Moran. And you do that by referring to testimony 
that was given previously. Your testimony indicates the 
Department has previously provided its views on S. 901 to this 
Committee on June 24, 2015. When I read the testimony of that 
date, everything that is said about the VA's opposition is 
related to what it believes is a duplication of efforts 
previously and currently underway at the VA or at other 
agencies.
    My impression, I think probably this comes from what Dr. 
Erickson said this morning, is that is no longer your position. 
So, I mean, you denied, discounted the duplication and now, as 
I understand it, oppose the bill because the focus needs to be 
headquartered someplace other than the VA. True?
    Dr. Erickson. If I may, Senator Moran, for me the 
overriding concern--and yes, the VA position--is that there are 
other agencies that are better positioned to do this. But the 
duplicative effort--let me speak to that. There are some things 
at VA we do very well. We do large surveys, large epidemiologic 
studies of veteran cohorts.
    We have been in consultation with Vietnam Veterans of 
America to put together a Vietnam morbidity study, which is 
getting ready to be launched. As part of that study, we will be 
looking at the health of their children, but not the epigenetic 
piece. That is a little beyond the scope of the morbidity 
study. Likewise, there is an upcoming OEF/OIF veterans health 
study which will also be including questions of children, of 
veterans' children.
    I think the issue here is, again, perhaps this new 
recognition that VA and veterans in particular benefit 
considerably when we partner with the right Federal agency. 
Again, I use the ATSDR collaboration to which we have alluded 
as it relates to Camp Lejeune, as being a very strong example 
of how that can benefit veterans.
    Senator Moran. Well, I cannot imagine that is anything but 
true. We ought to be encouraging collaboration. There are 
agencies and departments who have expertise. There are outside 
experts who we ought to rely on. So, I do not think you are 
saying anything contrary to what common sense, perhaps, would 
suggest to be true.
    What Dr. Jain stated in that reference, the day of that 
testimony, the current VA activities include collaboration, et 
cetera, work being done by the National Institute of Health, 
Environmental Health and Sciences. It talks about studies and 
yet, I mean, the VA believes, as I understand, that there is 
insufficient evidence for benefits to accrue.
    Let me say it differently. There is insufficient evidence 
to tie the conditions that we find in children or grandchildren 
of veterans to the exposure of their mothers, fathers, 
grandmothers, or grandfathers. So, if that is a true statement, 
that the VA cannot find the connection, the scientific 
evidence, then it seems to me that the VA ought to be terribly 
interested in making that determination.
    It ought to be insufficient for the VA to say there is 
insufficient evidence. You ought to be determining whether 
there is evidence or not, scientifically, medically, for that 
condition. Is that true?
    Mr. McLenachen. Senator, if I might, one of the issues here 
is the extent of our current authority. Congress has given us 
authority, in limited situations, for example, spina bifida, to 
pay benefits to, say, a descendent of somebody who was been 
exposed. Other than that, our authority is very limited. We pay 
benefits to survivors based on the veterans' exposure. We allow 
survivors to substitute in a veterans' claim and we pay accrued 
benefits.
    Senator Moran. So, would you support--would the VA support 
the authority to do exactly that? I mean, what this bill does 
is to set the parameters by which that conclusion can be 
reached. Then I assume that you would endorse the idea that 
those benefits should be paid if that scientific evidence, 
medical evidence is prevalent?
    Mr. McLenachen. If Congress determines that that is what 
the Government should be doing and asks VA for its views on 
that, Senator, I feel very confident we would provide our 
views, let you know what they are.
    Senator Moran. Even though you provide the legislation 
designed to accomplish that?
    Mr. McLenachen. Well, if it is a bill that is introduced 
into the Congress and not one of our own legislative proposals, 
we would provide our views on it on that basis. If it is 
something that we would propose, yes, we would definitely 
propose something that we support, which this may happen to be 
what it is.
    Senator Moran. My point is, you oppose the bill that is 
designed to give us the standing in which we have the 
credibility to give you the authority; yet, you oppose the bill 
that creates that opportunity for us?
    Mr. McLenachen. I understand what you are saying. It would 
be helpful to have the research before you decide whether that 
is a benefit that should be provided.
    Senator Moran. My time has expired. I have just a couple of 
summations. Certainly everything that I have read by other 
agencies indicate that there is a need for additional evidence, 
scientific/medical research and that any suggestion that the VA 
or anybody else has reached the necessary conclusions, 
necessary evidence to draw a conclusion, is inadequate, is 
inaccurate.
    So, when the VA talks about duplication, there is plenty of 
room for scientific and medical evidence to be determined that 
has not been researched or studied previously.
    At then second, I would appreciate an answer to Senator 
Rounds' question which, I believe the question was, if the 
focus was elsewhere--somebody else is in charge of this 
program--would the VA then support the legislation, the concept 
contained in this legislation? I do not think that Senator 
Rounds' question was answered.
    Dr. Erickson. The answer is yes, Senator.
    Senator Moran. Thank you. I would highlight what Senator 
Tester had to say which was--and I cannot speak for Senator 
Blumenthal, but I have no doubt that what I, and I would guess 
Senator Blumenthal would be very interested in is finding the 
right place to house this effort. I would think we would start 
with the premises that we want to be housed by somebody who 
wants to do it so that the right attitude and approach is 
taken.
    Again, if we find the right place to do this, I then assume 
that the VA would be supportive of this effort. Is that 
accurate?
    Dr. Erickson. Yes, sir.
    Senator Moran. Thank you both.
    Chairman Isakson. Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Senator Isakson, and again, 
thank you so much for having this so important hearing. I 
apologize for being late. I am going to have to run out and 
then come back in the middle of the next panel in working with 
the budget issues that we are facing now, trying to help get 
some of those things sorted out. Mr. McLenachen?
    Mr. McLenachen. Yes, sir.
    Senator Boozman. Did I get that right?
    Mr. McLenachen. Yes, you did.
    Senator Boozman. Good, very good. I am proud of myself. On 
a separate issue of alleged toxic exposure, in Arkansas, we 
have a significant number of Gulf War 1 veterans who allege 
chronic illness due to toxic exposures. The Arkansas National 
Guard's 39th Infantry Brigade deployed in the Gulf in 1990, 
1991.
    Some of these folks have some real health issues now. Many 
of these veterans claim that they were exposed to toxic 
substances like benzene due to the oil fires that the Iraqi 
military set, and have issues like Agent Orange exposure and 
the Camp Lejeune water contamination situation. It takes a 
significant amount of time and research to fully grasp the 
effects and causal connection of such exposure.
    Can you give me an update? Can you give all of us an update 
on what efforts the VA is continuing to pursue to help these 
Gulf War veterans?
    Mr. McLenachen. Since that is a medical science research 
issue, I will defer to Dr. Erickson on that.
    Dr. Erickson. Certainly. Thank you for the question, 
Senator. We continue to partner with Gulf War veterans, 
veterans service organizations in particular, the National Gulf 
War Resource Center which is headed up by Mr. Ron Brown. He has 
worked very closely with us to make sure that our Web sites are 
accurate and our newsletters are actually useful by topic.
    He and his partner, Jim Bunker, have actually recommended 
to us research that they think is necessary for us to be able 
to answer some of these questions. And literally, while we sit 
in this room, the Gulf War Research Advisory Committee, which 
is, in fact, a Federal advisory committee, is meeting at VA 
headquarters. As you probably know, that committee, in fact, 
provides advice concerning the research to fill the gaps in a 
Gulf War illness.
    Senator Boozman. Very good. Thank you. Mr. McLenachen, with 
the Camp Lejeune water situation, it is my understanding that 
the VA representatives went down to North Carolina and 
explained how the disability claims process worked and the 
steps that people needed to take in order to file a claim and 
receive compensation. However, VA added another layer of 
bureaucracy to the process by adding subject matter experts 
into the adjudication process.
    I guess, you know, I would like to know if that was correct 
and if it is correct. Adding these SMEs into the adjudication 
process is unique to the Camp Lejeune situation. Is that 
correct? Then, the other question I have is, why was this done?
    Mr. McLenachen. Senator, I would not say it is unique 
because in every compensation claim that we adjudicate, we are 
required to obtain current, through our duty to assist, an 
examination or a medical opinion as required to properly 
adjudicate the claim. Sometimes we will get private evidence 
that does not require us to do that through VHA, but if we need 
an opinion, we often go to VHA and ask for an opinion.
    Our adjudicators are not the medical experts. They are the 
adjudicators who weigh the evidence that they are given. So, I 
would not say that it is unique that we have individuals 
providing us those kinds of opinions. However, in this case, 
recognizing that this is a special issue, we consolidated all 
those claims down to our Louisville Regional Office and we did 
collaborate very closely with the Veterans Health 
Administration to make sure that we were achieving a level of 
consistency that these veterans deserve.
    The way we did that was consolidate in Louisville and then 
working with VHA to set up a system with the special SMEs, 
subject matter experts, to help us with getting those opinions. 
I think Dr. Erickson could probably talk a little bit more 
about the SMEs themselves and what their qualifications are.
    Dr. Erickson. Senator, I am going to divide this into two 
pieces. One is the health care law that Senator Burr gave 
testimony to, the other would be the SMEs as it relates to 
presumptions. As Senator Burr appropriately said, he pushed 
legislation that was passed in 2012, and when that was enacted 
on the 6th of August, 2012, VA immediately started providing 
health care for 15 different conditions to Camp Lejeune 
veterans.
    I am proud to say that to date, we have provided health 
care to 21,154 veterans who had served at Camp Lejeune. Of 
these, 7,506 veterans have been treated specifically for a Camp 
Lejeune condition that is included in that law. Likewise, on 
the family member side of that, we have had 997 family members 
who have applied for the program.
    Again, this program is a little newer. 176 family members 
are both administratively and clinically eligible. To date, 
there have been 906 family members whose medical claims have 
been paid for, 65 unique family members for a total payout of 
$176,000.
    On the health care side, we have moved out smartly on the 
bill through the legislation that Senator Burr gave testimony 
to.
    On the presumption side, yes, there was a need for us to 
move beyond the cadre of compensation and pension examiners 
such that we would have a group that was more specially 
trained. We selected about 20 of these individuals, also in the 
fall of 2012, made sure that they were residency trained in 
occupational medicine, environmental, toxicology.
    They received, as Mr. McLenachen said, additional training 
at the VBA facility in Louisville to make sure they understood 
the complexity of the issues. Currently they have regular 
telephone conferences to discuss cases, especially the more 
difficult cases, so as to provide a certain level of peer 
review for those cases. They also continue to build and work 
with a comprehensive bibliography, the goal being to reduce 
variability in the decisions that are made.
    Senator Boozman. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Hirono has a follow-up question.
    Senator Hirono. Yes. I realized that the VA, in seeking to 
conclude that there is a service connection, relies on 
information from the Department of Defense. I do have a concern 
that with regard to Vietnam, that maybe not all of the 
information that you have is accurate in terms of things such 
as where Agent Orange was sprayed, where the water may have 
been contaminated. So, there is that issue.
    Dr. Ramos, who is on the second panel, notes in his 
testimony that veterans of the Blue Water Navy received a 
presumptive service connection as recently as 2002 before VA 
implemented a policy change. I assume that policy change meant 
that they no longer enjoy this presumption. Can you tell me if 
that is accurate, where you actually did--
    Mr. McLenachen. Yes. I believe that relates to my 
conversation with Senator Tester earlier. Our policy, dating 
back to 1994, was essentially consistent with what it is now, 
except to the extent that we used the Vietnam service medal for 
purposes of determining eligible Vietnam service. What we 
discovered was that medal was not a good way to do that because 
it is provided more broadly.
    It is provided to individuals who provided support during 
the Vietnam era, rather than actual duty in the Republic of 
Vietnam. The statute requires being in the Republic of Vietnam 
and that was the issue. So, that point is when we changed our 
regulation to clarify that issue.
    Senator Hirono. So, basically, it was a pretty fundamental 
thing, whether they were even in Vietnam serving at that time?
    Mr. McLenachen. Yes. You might have had, for example, 
veterans in the Philippines who were providing support.
    Senator Hirono. Thank you. Thank you, Mr. Chairman, for 
that clarification.
    Chairman Isakson. Thank you, Senator Hirono. I want to 
thank our two panelists for their extensive testimony and thank 
the Committee for their participation.
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
                 to U.S. Department of Veterans Affairs
    Question 1. Blue Water Navy Veterans Disability Claims--While VA 
does not allow the presumption of service connection to veterans who 
served in the territorial seas (12-miles) of the Republic of Vietnam, 
the Committee received a response to a pre-hearing question that 
indicated claims can be considered on a case-by-case basis. VA 
considers claims from Blue Water Navy veterans on a case-by-case basis. 
Has the Department granted any of these claims, and if so how many?
    Response. While the statute creating the presumption of Agent 
Orange exposure for Veterans who served ``in'' the Republic of Vietnam 
(38 United States Code (U.S.C.)Sec. 1116(f)) and the Department of 
Veterans Affairs (VA) regulation addressing the same (38 Code of 
Federal Regulations (CFR) Sec. 3.307(a)(6)(iii)) do not extend a 
presumption of Agent Orange exposure to ``Blue Water Navy'' Veterans, 
as these Veterans are not considered to have served ``in'' Vietnam, VA 
does recognize a presumption of exposure for Navy Veterans whose ships 
served on inland waterways while they were aboard, and for Navy 
Veterans who went ashore in Vietnam even for a brief stay. Those 
circumstances are among the ``case-by-case'' bases previously 
described. VA does not track, and has no method for tracking, grant 
rates for these claims. Additionally, a claimant who does not qualify 
for a presumption of exposure must seek to show that they were actually 
exposed to Agent Orange in service to establish service connection for 
a current disability. VA also is unable to track grant rates for cases 
of that nature.

    Question 2. Camp Lejeune Water--In his written testimony Mr. 
McLenachen stated that VA is in the process of amending its regulations 
to allow presumptions for conditions related to water contamination at 
Camp Lejeune to include kidney cancer, angiosarcoma of the liver, and 
acute myelogenous leukemia. Provide a status report, to include a 
timeline, on VA's progress to date in amending its regulations.
    Response. A draft recommendation for the Secretary, which is based 
on additional information provided by the Agency for Toxic Substances 
and Disease Registry, is currently under review within VA. The Veterans 
Benefits Administration (VBA) will begin the process of amending 
regulations as appropriate after the Secretary considers the 
recommendation and makes his final policy decision. Although this 
policy analysis is a high priority for VA, there is no timeline for 
final VA action on the matter.

    Question 3. Camp Lejeune Claims Processing--The Committee received 
testimony that in 2013 the Department consolidated Camp Lejeune claims 
processing at the Louisville, Kentucky Regional Office. What was the 
denial rate for Camp Lejeune claims before the consolidation and what 
has it been since? What qualifications are required and what special 
training do these ``subject matter expert'' claims processors receive 
who adjudicate Camp Lejeune water decisions?
    Response. VA consolidated the processing of claims based on 
exposure to contaminated water at Camp Lejeune to VBA's Louisville 
Regional Office in December 2010. At that time, VBA attempted to 
identify any claims previously decided with service at Camp Lejeune 
being implicated as the cause of disability. We were able to identify 
195 claims that VA decided between 1997 and 2010, with an 83 percent 
denial rate.
    Following a 2012 review of completed decisions, VA determined 
medical professionals with expertise in occupational and environmental 
health are required to obtain the best possible medical opinion 
evidence for adjudication of claims by Veterans exposed to the 
contaminated water at Camp Lejeune. VA identified these experts and 
provided them with three days of training on Veterans' exposure to the 
water at Camp Lejeune. To date, the grant rate for primary disease 
categories associated with exposure to water at Camp Lejeune (renal 
cancer, leukemia, breast cancer, etc.) is 11 percent.

    Question 4. Agent Orange Presumptive Authority--The Secretary's 
specific authority to grant presumption of service-connected 
disabilities based on exposure to herbicides in the Republic of Vietnam 
(38 U.S.C. Sec. 1116) lapsed as of September 30, 2015 after having been 
in effect for 15 years. Provide a summary of the presumptions the 
Secretary granted under this specific authority during that 15-year 
span.
    Response. Although VA's authority under section 1116 expired on 
September 30, 2015, the Secretary has general rulemaking authority 
under 38 U.S.C. Sec. 501, which will allow him to establish appropriate 
presumptions of service connection should it become necessary in the 
future.
    The Agent Orange Act itself established an association between 
Agent Orange exposure and:

    (1) Non-Hodgkin's lymphoma;
    (2) Soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, 
Kaposi's sarcoma, or mesothelioma); and
    (3) Chloracne or another acneform disease consistent with 
chloracne.

    Subsequent associations and dates established by VA regulations 
include:

    (4) Porphyria cutanea tarda [February 3, 1994];
    (5) Hodgkin's disease [February 3, 1994];
    (6) Respiratory cancers of the lung, bronchus, larynx, or trachea 
[June 9, 1994];
    (7) Multiple myeloma [June 9, 1994];
    (8) Prostate cancer [November 7, 1996];
    (9) Acute and subacute peripheral neuropathy (later replaced by 
(16)) [November 7, 1996];
    (10) Type 2 diabetes mellitus [May 8, 2001];
    (11) Chronic lymphocytic leukemia [October 16, 2003];
    (12) AL amyloidosis [May 7, 2009];
    (13) Ischemic heart disease [August 31, 2010];
    (14) Chronic B-cell leukemia [August 31, 2010];
    (15) Parkinson's disease [August 31, 2010]; and
    (16) Early-onset peripheral neuropathy [replaced (9)] [September 6, 
2013].

    Question 5. Exposure Research--Throughout the testimony at the 
hearing, VA witnesses frequently stated other Federal agencies would be 
better suited to conduct research about indirect exposure. Please 
elaborate on that point and also provide details about the specific 
agencies that would be better positioned to conduct this research.
    Response. The National Institute of Environmental Health Sciences 
(NIEHS), one of the National Institutes of Health (NIH) in the U.S. 
Department of Health and Human Services (HHS), has capacity, expertise, 
and a strong record of accomplishment in understanding environmental 
effects on epigenetics and epigenetic regulation of biological and 
developmental processes. Understanding both low-dose effects and the 
developmental windows of susceptibility will be critically important 
for determining the level of risk posed by indirect and 
transgenerational exposure. In addition, the National Toxicology 
Program, headquartered at NIEHS, is well placed to coordinate 
toxicological research from across agencies.
    The Eunice Kennedy Shriver National Institute of Child Health and 
Human Development (NICHD) is another NIH entity that has a specific and 
focused interest in the development of molecular level tools and multi-
institutional collaborations to support analyses of gene expression and 
genetic pathways to explain multigenerational effects that may result 
from myriad environmental factors. (NICHD--http://www.nichd.nih.gov/
health/topics/epigenetics/researchinfo/pages/goals.aspx)
    VA does not have the capacity and expertise in place to perform 
multigenerational studies, including research such as highly 
specialized epigenetic analyses.

    Question 6. Epidemilogical Studies--Does VA have plans to conduct 
an epidemiological study on Chorodial Melanoma? If yes, please provide 
details regarding a timeline for such research and if no, please 
provide detail regarding why this issue is not being considered.
    Response. There are 200 cases of choroidal melanoma in the VA 
Central Cancer Registry from 1995 to 2013, about 11 cases per year. 
There are an additional 113 melanoma cases located in the eye for a 
total of 313 ocular melanoma cases over this same time interval. This 
represents less than 0.05 percent of all cancers in the registry. The 
rarity of the cancer makes an epidemiological study infeasible without 
a very large risk.
    VA's National Program Director for Oncology found nothing in the 
literature or reference materials to support a claim of association 
between Veterans, military service, or Agent Orange and choroidal 
melanoma. Known risk factors for uveal melanomas (which are mostly 
choroidal) are host pigmentation factors, cutaneous and iris nevi, and 
ultraviolet light exposure.
    VA research does not currently have a study focused on the 
epidemiology of Chorodial Melanoma; primarily because we support 
investigator initiated research, and we have not reviewed an 
application on the topic that would be currently funded. However 
researchers from the Tampa VA recently published a paper as a case 
report, http://www.ncbi.nlm.nih.gov/pubmed/26066556
    Further, VA maintains a comprehensive database of cancer incidence 
in the VA Healthcare System in the VA Central Cancer Registry: http://
catalog.data.gov/dataset/veterans-administration-central-cancer-
registry-vaccr
    There is a non-VA citation, in the U.S. National Library of 
Medicine to a 2012 update from the Committee to Review the Health 
Effects in Vietnam Veterans of Exposure to Herbicides (see chapter 8, 
subchapter Skin Cancer) that includes this:

        This is the first update in which any information on ocular 
        melanoma has been identified. The case-control study of Behrens 
        et al. (2012) found some increases in the incidence of uveal 
        melanoma in association with unspecified herbicides; this is 
        not the degree of herbicide specificity required for results to 
        be considered fully relevant. A Vietnam veteran submitted 
        information (Data from Rutz [2012] available in the National 
        Academies Public Access Records Office [http://
        www8.nationalacademies.org/cp/Manage 
        Request.aspx?key=49448]) received in response to a Freedom of 
        Information Act request to VA about the frequency with which 
        choroidal melanoma (a specific type of uveal melanoma) was 
        diagnosed in VA facilities; the document indicated that a large 
        number of such cases had been seen, but the lack of 
        documentation explaining how the VA had gathered the data and 
        exactly what they represented prevented the Committee from 
        being able to assess their import. Because literature searches 
        did not identify any epidemiology studies of ocular melanoma in 
        association with the COIs, the Committee submitted an inquiry 
        to Carol and Mark Shields, who responded (Data from Shields 
        [2012] available in the National Academies Public Access 
        Records Office [http://www8.nationalacademies.org/cp/Manage 
        Request.aspx? key=49448]) that their analyses of more than 
        2,000 cases of uveal melanoma had not revealed any association 
        with the COIs.

    Question 7. Gray v. McDonald--During the hearing, the Committee 
received testimony that cited a recent Court of Appeals for Veterans 
Claims decision in Gray v. McDonald that found VA's demarcation between 
inland waterways and offshore waters to be ``arbitrary and 
capricious.'' Provide a status report, to include a timeline, on VA's 
progress to date in complying with the instruction of the Court to the 
Department to review and clarify its definition of inland waterways and 
offshore waters.
    Response. In April 2015, the U.S. Court of Appeals for Veterans 
Claims issued its decision in Gray v. McDonald, 27 Vet. App. 313 
(2015), which required VA to review and clarify its policies for 
determining whether coastal bodies of water, such as Da Nang Harbor, 
constituted ``inland waterways'' or ``offshore waters'' for purposes of 
applying the presumption of herbicide exposure. Shortly after that 
April 2015 decision, VA began the process of reviewing and clarifying 
its policies regarding such determinations. Secretary McDonald has 
directed that this important issue merits very deliberate and thorough 
evaluation by VA, which is ongoing. Although this policy analysis is a 
high priority for VA, there is no timeline for final VA action on the 
matter.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Jerry Moran on 
            S. 901, the Toxic Exposure Research Act of 2015
    Question 8. Please provide the VA's rationale for opposing further 
research into the effects of toxic exposure on a servicemember's 
progeny, when the VA has acknowledged that the science behind this 
topic is insufficient.
    Response. VA fully agrees that the science behind the effects of 
toxic exposures on a servicemember's progeny is presently insufficient 
to guide evidence-based policy. VA does not oppose further research 
into this important issue, but rather suggests that other Federal 
agencies are better equipped and postured to conduct this complex work.

    Question 9. The VA has stated they should not be the institution to 
oversee and carryout this research. Please provide specific changes and 
recommendations for S. 901 that would place the research and 
responsibilities in the appropriate agencies.
    Response. This important research mission should be fully-funded by 
Congress and assigned to the National Institute of Environmental Health 
Sciences (NIEHS) VA and the Department of Defense (DOD) should be 
directed to provide full cooperation and collaboration in the conduct 
of NIEHS multigenerational/epigenetic studies of the toxic 
environmental exposures experienced by Veterans (and in some cases 
their families) and their progeny. VA and DOD would be able to provide 
historical documents, medical records, and personnel lists (when 
available) as the needed foundation for these studies.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Thom Tillis to 
                  U.S. Department of Veterans Affairs
    Question 10. By what date will the VA announce presumptive 
disability coverage for veterans with conditions for which ATSDR has 
determined that there is ``sufficient evidence for causation'' by 
exposure to contaminated water at Camp Lejeune? By what date will the 
VA announce which of the diseases designated by the ATSDR as showing 
``modest evidence for causation'' will be included in the presumptive 
disability program?
    Response. Although the complex policy analysis associated with 
creating presumptions of service connection for diseases associated 
with exposure to Camp Lejeune drinking water is a high priority for VA, 
there is no timeline for a VA announcement regarding this complex 
matter.

    Chairman Isakson. I now invite our second panel to come 
forward. We are fortunate to have--I see five people, but I 
have only got four names. What am I missing? Ms. Wedge is 
accompanying Dr. Ramos. Now I understand.
    Welcome to our second panel. Doctor Kenneth Ramos, Chair of 
the Institute of Medicine Committee on Veterans and Agent 
Orange; Commander John Wells, Executive Director of the 
Military Veterans Advocacy, Inc.; John Rowan, National 
President of the Vietnam Veterans of America; and Jerry 
Ensminger, Master Sergeant, U.S. Marine Corps, Retired. I want 
to thank all of you for being here today and we will start with 
Dr. Ramos.

  STATEMENT OF KENNETH S. RAMOS, M.D., PH.D., ASSOCIATE VICE 
    PRESIDENT FOR PRECISION HEALTH SCIENCES, ARIZONA HEALTH 
SCIENCES CENTER, UNIVERSITY OF ARIZONA, AND CHAIR, INSTITUTE OF 
 MEDICINE COMMITTEE ON VETERANS AND AGENT ORANGE, UPDATE 2014, 
THE NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE; 
  ACCOMPANIED BY ROBERTO WAGE, M.S., SENIOR PROGRAM OFFICER, 
                     INSTITUTE OF MEDICINE

    Dr. Ramos. Thank you, Mr. Chairman, Members of the 
Committee. I am Ken Ramos, as was stated. I am a professor of 
medicine at the University of Arizona Health Sciences Center, 
and I also serve as Associate Vice President for Precision 
Health Sciences at that institution. The reason that I am here 
is because I also serve as Chair of the last Update for the 
Veterans and Agent Orange Committee, which is currently 
finalizing its report. It is the last report following 
completion of a 20-plus year series, as most of you know.
    I am here to speak, to represent the voices, I think, on 
the recommendations of multiple IOM committees and, of course, 
in some instances, I will also provide some comments which 
reflect my own thoughts and impressions regarding the issues at 
hand. My initial remarks will focus on IOM efforts to assess 
exposures to Agent Orange among Blue Water Navy veterans and 
the degree to which its exposures and long-term health outcomes 
are comparable to those of Brown Water Navy veterans and troops 
on the ground, which I think is one of the issues that has been 
debated this morning.
    As indicated in the 2011 report that the IOM committee 
provided from the IOM, the conclusion was made that given the 
lack of environmental monitoring that took place during and 
shortly after the war, and the variability and uncertainty in 
the fate and transport information for dioxin, and it is not 
possible to estimate the likely concentrations of dioxin in 
marine waters and air and at the time of the deployment for 
these veterans; therefore, quantitative measures of comparisons 
across three military populations of interest could not be 
made.
    I think this is an issue that certainly has posed a lot of 
problems with regards to decisionmaking because the science 
itself does not really actually support any specific 
conclusions in that sense. This said, the committee did 
identify possible pathways of exposure, which of course, 
included the distillation efforts on board ships which has been 
discussed, I think, a number of times in the course of 
testimony provided.
    I think that particular route of exposure is certainly 
important given efforts by the Australian Royal Navy looking at 
reconstruction experiments in which distillation experiments 
were completed establishing that, in fact, if dioxin was 
present in those waters, it would be concentrated through the 
process, and in so doing, making it available for exposure.
    On the basis of those findings, which were actually 
ratified by the 2008 Veterans Agent Orange committee, the 
conclusion has been made that we do not have any evidence 
either for inclusion or exclusion of Blue Water Navy veterans 
from coverage under the Agent Orange Act; therefore, this 
conclusion needs to be considered in further policy 
decisionmaking.
    Over the 20-plus years which have taken place since the 
veterans and Agent Orange series has been initiated, only a 
single epidemiological study has been completed that actually 
reported specific findings for Blue Water Navy veterans, 
showing, in fact, a higher incidence of non-Hodgkin's lymphoma 
in Blue Water Navy veterans and the highest and most 
significant risk across all branches of service for this 
adverse health outcome. This, I think, directly addresses one 
of the points that was raised in the previous discussion 
regarding findings for Blue Water Navy veterans in particular.
    Although this particular finding for epidemiological 
correlation does not directly address questions related to 
exposure, especially in light of the quantitative deficits 
which I described before, this is, in fact, considered a 
hallmark of disease for dioxin exposure, one of the signature 
cancers for dioxin, and therefore, health outcomes alone 
presumed by the VA to be service-related to the Blue Water Navy 
veterans.
    In reference to Senate Bill 681, which has been discussed 
here, it should be noted that in the judgment of all IOM 
committees which have taken on studies related to this, it is 
highly unlikely that any future scientific research will 
provide any additional information that would resolve questions 
related to exposures given the limitations which I described 
before, including those which were connected to service in the 
territorial waters of Vietnam.
    Whether or not the claims of Blue Water Navy veterans are 
to be processed like those of other Vietnam veterans, that is 
ultimately a policy decision and not one that can be answered 
on the basis of science.
    Given the lack of exposure information collected during or 
immediately after deployment for many of the conflicts that we 
have to deal with, I do not expect that new data will become 
available, you know, from past conflicts given that the 
collection of exposure information was not completed during 
that particular episode, and oftentimes what we find ourselves 
doing is trying to reconstruct exposures on the basis of 
statistical models that, as good as they might be, certainly 
will never provide complete answers, either at the population 
or the individual level.
    In my opinion, plans to extend the Agent Orange Act under 
House Resolution 3423, cited as the Agent Orange Extension Act 
of 2015, to complete an additional cycle is an excellent 
proposition that would not only ensure continuity in the 
monitoring of the health status of Vietnam veterans, but 
perhaps more importantly, provide all of us an opportunity to 
set a path forward on how to establish that area of evaluation 
processes that would be coherent across multiple military 
situations.
    I think we should learn from the experiences of the--you 
know, the mistakes that have been made in the past, certainly 
put in place, I think, resolutions that will enable us to move 
forward in a way that is going to be informed by actual data.
    I think it is also important to note that renewing the 
biennial updates as has been completed up until now probably is 
not going to be advisable given the fact that the needs that we 
have right now are needs for data rather than continued updates 
that probably sort of slow the process.
    Last, in reference to Senate Bill 901, Toxic Exposure 
Research of 2015, I think it is important to know that plans to 
establish a National Center for Research on the diagnosis and 
treatment of health conditions of the descendants of veterans 
exposed to toxic chemicals during service in the Armed Forces, 
although very important and highly significant and laudable, I 
believe it is actually premature at this point in time in light 
of the scarcity of scientific and medical data to support the 
contention that toxic exposures to veterans, particularly male 
veterans, can be transmitted to descendants across one or 
multiple generations.
    I think the danger in moving forward perhaps prematurely 
could certainly add confusion to an already very crowded 
environment. That said, I think efforts to create an advisory 
committee charged with overseeing the assessment and handling 
of possible health effects from all military exposures would be 
highly desirable in order to increase continuity and coherence 
of efforts across various situations.
    I thank you for inviting me to be here and I look forward 
to a dialog with you on this and issues that you may want to 
discuss. Thank you.
    [The prepared statement of Dr. Ramos follows:]
  Prepared Statement of Kenneth S. Ramos, M.D., Ph.D., Associate Vice 
   President for Precision Health Sciences, Arizona Health Sciences 
    Center, University of Arizona and Chair, Institute of Medicine 
Committee on Veterans and Agent Orange, National Academies of Sciences, 
                       Engineering, and Medicine
    Good morning, Mr. Chairman, Senator Blumenthal, and Members of the 
Committee. My name is Dr. Kenneth Ramos. I am Associate Vice President 
for Precision Health Sciences at the University of Arizona and a 
Professor of Medicine in the Division of Pulmonary, Allergy, Critical 
Care and Sleep Medicine at the Arizona Health Sciences Center. I also 
act as Director of the Center for Applied Genetics and Genomic Medicine 
and am Director of the College of Medicine M.D.-Ph.D. Program. 
Previously, I held faculty positions at the University of the Sciences 
in Philadelphia, at Texas Tech University Health Sciences Center, Texas 
A&M University, and at the University of Louisville School of Medicine. 
I am currently serving as chair of the Committee that is preparing the 
last update in the Veterans and Agent Orange (VAO) series of Institute 
of Medicine (IOM) reports mandated by the Agent Orange Act of 1991 (PL 
102-4) and renewed in the Veterans Education and Benefits Expansion Act 
of 2001 (PL 107-103). Today I will be talking about the VAO series of 
reports, but I will begin by discussing another IOM report that 
attempted to assess the exposure of Blue Water Navy (BWN) Vietnam 
veterans to Agent Orange.
    In 2010, an IOM committee completely separate from the VAO 
committees was tasked to study whether the Vietnam veterans in the BWN 
experienced exposures to herbicides and their contaminants that were 
comparable with those of the Brown Water Navy Vietnam veterans and 
troops on the ground in Vietnam, with a focus on Agent Orange and 
dioxin exposures. The Committee was asked to compare the possible 
routes of exposure of BWN veterans on ships and of ground troops in 
Vietnam, and the potential mechanisms of herbicide exposures (such as 
water exposure from contamination of potable water, air exposure from 
spray drift, and food and soil contamination). It was also asked to 
compare the risks of long-term adverse health effects in ground troop 
veterans, BWN veterans, and other ``era'' veterans, and to review any 
studies that addressed adverse health effects specifically in BWN 
veterans. I will focus on the exposure aspects of the resulting 2011 
report Blue Water Navy Vietnam Veterans and Agent Orange Exposure, but 
first I should note that, just prior to the initiation of this 
Committee's work, the VAO committee for Update 2008 had made a 
statement about the BWN controversy (based on a less extensive review 
of details of exposure estimation and its understanding that the BWN 
Vietnam veterans had previously been included) to the effect that 
available scientific information did not support making a decision to 
exclude them from coverage under the Agent Orange Act.
    The BWN committee gathered information on how Agent Orange had been 
used in Vietnam and the quantity and geographic range of its 
application. The Committee also considered data on the magnitude of 
dioxin contamination of Agent Orange. After reviewing information on 
releases of Agent Orange to the environment, the Committee explored its 
fate and transport in air, fresh and marine water, sediment, soil, and 
food to assess the plausibility of Agent Orange and dioxin exposure of 
military personnel who did not actually handle the herbicide 
themselves. The Committee attempted to identify any monitoring data on 
dioxin had been gathered during or shortly after the Vietnam War. The 
Committee also considered fate and transport models that could be used 
in conjunction with the limited available data to examine the 
plausibility of exposure of ground troops and BWN veterans to the 
chemicals. The Committee attempted to determine where BWN ships were 
during the war, their missions, how close they came to the Vietnamese 
coast, and the activities conducted aboard the ships by the sailors.
    Many data sources and methods were identified and pursued by the 
Committee, including published peer-reviewed literature, models for 
assessing the environmental concentrations of Agent Orange and dioxin, 
anecdotal information from veterans and other interested parties on 
veteran experiences during the war and afterwards, and such other 
information sources as written and published accounts of the war 
(including memoirs), government documents, and ships' deck logs.
    To determine whether BWN personnel had exposures to dioxin 
comparable with those of ground troops and Brown Water Navy personnel, 
the Committee sought to determine whether there were plausible exposure 
pathways between releases of Agent Orange (specifically, the spraying 
of Agent Orange during the Operation Ranch Hand missions) and the three 
populations.
    The Committee considered using a mathematical model to estimate 
likely dioxin concentrations based on Agent Orange inputs to the 
environment, but it found that input data and, importantly, data with 
which to evaluate model performance, were not available. The Committee 
did make the assumption that Agent and dioxin would have entered 
waterways from riverbank spraying or as runoff from soil, particularly 
in the Mekong delta area that was heavily sprayed and that experienced 
frequent flooding. The amount entering the rivers would be highly 
diluted by river flows.
    The concentration of dioxin in marine waters would be reduced to a 
great extent by dilution in river water and by dispersion in air, as 
well as by further dilution in the coastal waters. Given the total lack 
of monitoring information conducted during or shortly after the war and 
the variability and uncertainty in the fate and transport information 
on dioxin as it pertains to Vietnam, the Committee concluded that it is 
not possible to estimate the likely concentrations of dioxin in marine 
waters and air at the time of BWN deployment.
    The Committee was also tasked with comparing exposures among three 
military populations that served in Vietnam: troops on the ground, 
Brown Water Navy personnel, and BWN personnel. Since the 1970s, IOM 
committees and other groups have attempted to reconstruct Vietnam 
veterans' potential exposure to Agent Orange and dioxin. Given the lack 
of exposure data on ground troops, the uncertainty of exposure models, 
and the limited knowledge about exposure among BWN veterans, the 
Committee concluded that it was not possible to make quantitative 
exposure comparisons among the three military populations of interest 
to the VA. Therefore, the Committee evaluated the plausibility of 
exposure of the three populations to Agent Orange and dioxin via 
various mechanisms and routes. Several plausible exposure pathways and 
routes of exposure to Agent Orange--associated dioxin in the three 
populations were identified. Plausible pathways and routes of exposure 
of BWN personnel include inhalation and dermal contact with aerosols 
from spraying operations that occurred at or near the coast when BWN 
ships were nearby, contact with marine water, and uses of potable water 
prepared from distilled marine water.
    Large US Navy ships--such as aircraft carriers, cruisers, and 
destroyers--had their own distillation systems to produce potable-water 
and distribution systems that included water-treatment processes. The 
issue of distillation of marine water is important because the VAO 
committee for Update 2008 found that BWN veterans could have been 
exposed to dioxin via contaminated potable water. This conclusion was 
based on an Australian Department of Veterans Affairs report that 
determined that Royal Australian Navy personnel who served offshore in 
Vietnam were exposed to Agent Orange--associated dioxin because the 
distillation systems aboard the ships were thought to be able to 
concentrate the dioxin in marine water into the potable water during 
the evaporative process. If Agent Orange--associated dioxin was present 
in the marine water, distilled potable water would be a plausible 
pathway of exposure for BWN veterans.
    The 2011 committee concluded that, qualitatively, ground troops and 
Brown Water Navy veterans had more plausible pathways of exposure to 
Agent Orange--associated dioxin than did BWN veterans. But one exposure 
mechanism was specific to BWN ships: possible dioxin contamination of 
potable water from onboard distillation plants. However, without 
information on the dioxin concentrations in the marine feed water, it 
is impossible to determine whether BWN personnel were exposed to Agent 
Orange--associated dioxin via ingestion, dermal contact, or inhalation 
of potable water.
    In the course of their work over 20 years, VAO committees have only 
found a single epidemiological finding specific to BWN veterans. Non-
Hodgkin lymphoma was among the selected cancers addressed in CDC's 1990 
case-control study assessing the role of Vietnam service as a risk 
factor. As shown in the table below from VAO Update 2012, BWN veterans 
have been found to have a higher incidence of non-Hodgkin lymphoma than 
other naval Vietnam veterans and had the highest, most significant risk 
across all branches of service for this adverse health outcome.

 
------------------------------------------------------------------------
                                                        Odds Ratio  (95%
                                              Deployed     Confidence
                                              Veterans      Interval)
------------------------------------------------------------------------
US CDC Selected Cancers Study--case-control        99     1.5 (1.1-2.0)
 study of incidence of non-Hodgkin lymphoma
 (Dec 1, 1984-Nov 30, 1989) among US males
 born 1929-1953............................
  Army Vietnam veterans....................        45     1.2 (0.8-1.8)
  Marine Vietnam veterans..................        10     1.8 (0.8-4.3)
  Air Force Vietnam veterans...............        12     1.0 (0.5-2.2)
  Navy Vietnam veterans....................        32     1.9 (1.1-3.2)
  Blue Water Navy Vietnam veterans.........        28     2.2 (1.2-3.9)
------------------------------------------------------------------------

    Although this does not address the question of dioxin exposure 
directly, this disease is considered a signature cancer of dioxin 
exposure, and so this health outcome alone is presumed by VA to be 
service-related for BWN veterans.
    Ultimately, the BWN committee, like the VAO committee for Update 
2008, was unable to state with certainty that BWN personnel were or 
were not exposed to Agent Orange and its associated dioxin. Owing to a 
lack of data on environmental concentrations of Agent Orange and Agent 
Orange--associated dioxin and an inability to reconstruct likely 
concentrations, as well as the dearth of information about relative 
exposures among the ground troops and Brown Water Navy personnel and 
BWN personnel, it is impossible to compare actual exposures across 
these three populations. Thus, the judgment of both these IOM 
committees was that exposure of BWN Vietnam veterans to Agent Orange--
associated dioxin cannot reasonably be determined and no future 
scientific research is likely to provide additional information that 
would resolve the issue. Whether or not the claims of BWN veterans are 
to be processed like those of other Vietnam veterans is ultimately a 
policy decision.
    In fact, the paucity of reliable information on toxic exposures 
that military personnel may experience has been a problem not just with 
respect to the BWN situation. One of the three tasks assigned by the 
Agent Orange Act for each health effect evaluated by a VAO committee 
was to determine ``the increased risk of disease among those exposed to 
the herbicides during service in the Republic of Vietnam during the 
Vietnam era.'' After several updates that remarked individually for 
each of the dozens of health outcomes reviewed that such risks could 
not be calculated due to the lack of exposure information, VAO 
committees eliminated the individual sections in favor of a generic 
statement at the beginning of their reports. (This is an example of a 
legislative requirement that remained inconsistent with reality, even 
after two more decades of scientific progress.) IOM committees 
assessing the possibility of health consequences in other veteran 
cohorts (e.g., Gulf War, Operation Iraqi Freedom, etc.) have lamented 
the lack of information collected during or immediately after a 
deployment that might shed light on the frequency, duration, and 
intensity of the exposures that veterans experienced. In the case of 
Agent Orange, great efforts have been made to gather exposure estimates 
retrospectively, such as gathering blood sample from Air Force veterans 
who served in Operation Ranch Hand and modeling an exposure opportunity 
index for individual veterans based on melding information abstracted 
from records of spray missions and troop movements. The results of 
these exposure estimation efforts have largely proven to be 
frustrating; at best they have provided a very rough estimate of 
potential exposure for a particular group of services members. In 
response to repeated recommendations from VAO and other IOM committees, 
DOD has been attempting to develop ways to avoid repetition of this 
situation going forward, but anticipating what should be collected in 
various circumstances is exceedingly challenging. For example, 
collection of biologic samples from each servicemember before and after 
deployment might be ideal for some exposures such as depleted uranium, 
but useless for those that leave no detectable marker in a person. 
Unfortunately, I do not expect data will become available from past 
conflicts that will permit more accurate reconstructions of those 
exposures nor that the actual exposure of individual servicemembers is 
ever likely to be known.
    In addition to highlighting the difficulty of obtaining useful 
exposure data on veterans, the production of the series of VAO reports 
has been a constructive learning experience in other respects. 
Theoretically, the procedure set out in the Agent Orange Act and 
adopted in other instances when troops have possibly experienced toxic 
exposures might be expected to anticipate health problems that might 
ultimately prove to be more prevalent in a particular set of veterans. 
In practice, however, the approach of culling results from existing 
epidemiologic studies for adverse effects characteristic of the 
``suspect'' toxic agent in a given situation and then periodically 
iterating the procedure for more recent findings has been fraught with 
challenges and conveyed a sense of delayed response to the veterans. 
The process is contentious and time-consuming, and the underlying 
rationale is somewhat circular. Although answers prior to the 
manifestation of harm in veterans would be desirable, a shift in 
emphasis toward monitoring the veterans themselves more closely might 
ultimately be more definitive. Unfortunately, an improved approach is 
not readily apparent, especially not one that would smoothly transition 
from established procedures.
    Renewing the biennial AO updates may not be the optimal way to move 
forward, but extending it temporarily would at least ensure continuity 
to the monitoring of the health status of Vietnam veterans as they 
continue to age and a guaranty of periodic consideration of their 
situation. Production of one more VAO update after the one currently 
nearing release would provide time to re-evaluate the current process 
of identifying and assessing possible service-associated health 
problems in veterans and their families for compensation. Before 
legislating changes for which the scientific basis may be premature, 
this could be an opportunity to define a process that would be more 
coherent across various military situations.

    Thank you for asking me to join you today. If you would like 
additional clarification of any of the points I raised, I would be 
happy to answer your questions.
                               References
CDC (Centers for Disease Control and Prevention). 1990. The association 
            of selected cancers with service in the US military in 
            Vietnam. I. Non-Hodgkin's lymphoma. Archives of Internal 
            Medicine 150:2473-2483.
IOM (Institute of Medicine). 2009. Veterans and Agent Orange: Update 
            2008. Washington, DC: The National Academies Press.
IOM. 2011. Blue Water Navy Vietnam Veterans and Agent Orange Exposure. 
            Washington DC: The National Academies Press.
IOM. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The 
            National Academies Press.

    Chairman Isakson. Thank you for your testimony.
    Commander Wells.

    STATEMENT OF JOHN WELLS, COMMANDER, U.S. NAVY, RETIRED, 
      EXECUTIVE DIRECTOR, MILITARY VETERANS ADVOCACY, INC.

    Commander Wells. Thank you, Mr. Chairman, Ranking Member 
Blumenthal. Thank you for the opportunity to come talk to you 
today on the theme of examining the impact of exposure to toxic 
chemicals on veterans and the VA's response. That gives rise to 
two questions; both deserve a straightforward answer.
    First off is the impact of toxic research. Toxic exposure 
has been horrendous and the VA response has been disappointing, 
to say the least. Why do we need Senator Moran's bill and 
Senator Blumenthal's bill?
    Because--and this whole Blue Water Navy situation is a good 
reason why, because this started not with the United States, 
not with the Navy, but with the Government of Australia who has 
toxic exposure research, does toxic exposure research, 
outreached, and found there was a 22 to 26 percent increase 
above the norm in cancer research among Navy veterans compared 
to the 11 to 13 percent above the norm for Army veterans, and I 
think it was 7 to 9 percent for Air Force veterans.
    They discovered that. They are the ones who initiated the 
University of Queensland study that you have heard so much 
about on water distillation that actually showed that the 
distillation process did not remove the Agent Orange dioxin; it 
enriched it.
    Mr. Chairman, Senators, I was a Navy engineer. I was chief 
engineer on three different ships. I spent 22 years in the 
Navy. Water was my business. We made it, we distilled it, we 
used it for the boilers, we used it for drinking, and the first 
thing I would like to mention is, the VA is sending you out on 
a wild goose chase with this policy that says you cannot make 
water close to shore.
    What the policy actually said was that you should not make 
potable water close to shore unless it was necessary. That is 
the exact wording out of the water bill. It became necessary 
quite often in dealing with the tropics because people drank a 
lot of water, showered a lot, and used the water.
    But more importantly, it does not matter because there was 
no restriction on making water for the boilers. They called it 
feed water, which was the same distillation system all the way 
down to the final distribution manifold.
    So, if they sat in Da Nong Harbor and made water for the 
boilers, that entire system was contaminated; and if they went 
12 miles, 20 miles, 100 miles out to sea, that system was still 
contaminated. The VA knows that, and yet, they continue to 
bring that excuse to you and it is--I cannot think of a nice 
polite word to say it, so I will not. OK?
    Like the same thing, oh, we never sprayed over the harbors. 
Guys, we did spray over the harbors. There were defective spray 
nozzles. Senators, when I say guys I am talking generically. It 
is just a habit of mine. There were defective spray nozzles and 
sometimes they were dumping it making a landing. But again, it 
does not matter.
    Now, it is a tough concept for the VA to understand. It was 
mixed with petroleum. Petroleum floats. It would wash into the 
rivers, plus we sprayed the river banks and would go out to 
sea. Again, another tough concept for the VA. Rivers run out to 
sea and it would get out into the harbors, out into the South 
China Sea.
    How do we know this? The IOM, bless their hearts, did a 
good--some good work for us. They missed one thing. There was a 
report done by the Russians on Nha Trang Harbor, where they 
actually took bottom sediment samples in the Cau River 
downstream from where it was sprayed--your Committee staff has 
this report. They actually found that there was Agent Orange in 
the bottom sediment. All right?
    Then they went out and they took transepts coming out from 
the river and found more Agent Orange throughout the coral, 
which killed the coral, by the way. That is why they went in, 
to figure out what was going on, and they found it still in the 
bottom sediment. So, it kind of proves the point that rivers 
run out to sea.
    I have this, by the way, 5-minute temporally prepared 
statement which I have kind of thrown aside, so let us talk 
about one other thing, the original decision. They said, Well, 
it was not in the Republic of Vietnam, so therefore, we could 
not include the sea. Well, guess what? In 1954 in the Geneva 
Accords, the United States recognized Vietnamese sovereignty 
over the territorial seas.
    They did the same thing in the 1973 peace agreement. The 
Joint Chiefs of Staff recognize the 12-mile limit. And that, by 
the way, is not off the mainland; that is off the outermost 
islands. You will see it on the chart on the written testimony.
    So that whole opinion was in violation and we are flaunting 
international law. What is the problem with the VA? Well, you 
know, I met with Deputy Secretary Gibson twice. Good guy, you 
know, I like him a lot. But I basically said to him, Mr. 
Secretary, the people that you have studying this issue do not 
have any surface ship experience, do they? He admitted that was 
the case.
    That is the problem. That is why we need the Toxic Research 
bill, to get people, along with their subject matter experts, 
and yes, it should be the VA. You do not take jobs away from 
them for bad behavior, and quite frankly, DOT and HHS is not 
much better. They just have not hit the headlines yet.
    We need this bill. We need S. 901. We need S. 681. We need 
to restore the benefits to these people who earned them.
    I am sorry, Mr. Chairman, I ran over time. Thank you again 
for allowing me to come here.
    [The prepared statement of Commander Wells follows:]
Prepared Statement of Commander John B. Wells, USN (Retired), Executive 
               Director, Military-Veterans Advocacy Inc.
                              introduction
    Distinguished Committee Chairman Johnny Isakson, Ranking Member 
Richard Blumenthal and other Members of the Committee; thank you for 
the opportunity to respond to the Department of Veterans' Affairs on 
the Blue Water Navy Vietnam Veterans Act (S. 681).
                  agent orange and the blue water navy
    In the 1960's and the first part of the 1970's the United States 
sprayed over 12,000,000 gallons of a chemical laced with 2,3,7,8-
Tetrachlorodibenzodioxin (TCDD) and nicknamed Agent Orange over 
southern Vietnam. This program, code named Operation Ranch Hand, was 
designed to defoliate areas providing cover to enemy forces. Spraying 
included coastal areas and the areas around rivers and streams that 
emptied into the South China Sea. By 1967, studies initiated by the 
United States government proved that Agent Orange caused cancer and 
birth defects. Similar incidence of cancer development and birth 
defects have been documented in members of the United States and Allied 
Armed Forces who served in and near Vietnam.
    Throughout the war, the United States Navy provided support for 
combat operations ashore. This included air strikes and close air 
support, naval gunfire support, electronic intelligence, interdiction 
of enemy vessels and the insertion of supplies and troops ashore. 
Almost every such operation was conducted within the territorial seas.
    The South China Sea is a fairly shallow body of water and the 
thirty fathom curve (a fathom is six feet) extends through much of the 
territorial seas. The gun ships would operate as close to shore as 
possible. The maximum effective range of the guns required most 
operations to occur within the territorial seas as documented in the 
attachment.\1\ Often ships would operate in harbors or within the ten 
fathom curve to maximize their field of fire. The maximum range on 
shipboard guns (except the Battleship 16 inch turrets) required the 
ship to operate within the territorial seas in order to support forces 
ashore.
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    \1\ The red line on the chart is known as the base line. Vietnam 
uses the straight baseline method which intersects the outermost 
coastal islands. The dashed line is twelve nautical miles from the 
baseline and represents the territorial seas. The bold line marks the 
demarcation line for eligibility for the Vietnam Service Medal. Prior 
to 2002, the VA granted the presumption of exposure to any ship that 
crossed the bold line. S. 681 will restore the presumption only to a 
ship that crosses the dashed line.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    It was common practice for the ships to anchor while providing 
gunfire support. Digital computers were not yet in use and the fire 
control systems used analog computers. By anchoring, the ship's crew 
was able to achieve a more stable fire control solution, since there 
was no need to factor in their own ship's course and speed. It was also 
common for ships to steam up and down the coast at high speeds to 
respond to call for fire missions, interdict enemy sampans and other 
operational requirements.
    Small boat transfers were conducted quite close to land. Many 
replenishments via helicopter took place within the territorial seas. 
Small boat or assault craft landings of Marine forces always took place 
within the territorial seas. Many of these Marines re-embarked, 
bringing Agent Orange back aboard on themselves and their equipment. 
Additionally mail, equipment, and supplies staged in harbor areas were 
often sprayed before being transferred to the outlying ships. Embarking 
personnel would take boats or helicopters to ships operating in the 
outlying ships. Embarking personnel would take boats or helicopters to 
ships operating in the territorial seas. The Agent Orange would adhere 
to their shoes and clothing as well as to mail bags and other 
containers. It would then be tracked throughout the ship on the shoes 
of embarking personnel and the clothing of those handling mail and 
other supplies brought aboard. Their clothing was washed in a common 
laundry, contaminating the laundry equipment and the clothing of other 
sailors.
    Flight operations from aircraft carriers often occurred outside of 
the territorial seas. As an example, Yankee station was outside of the 
territorial seas of the Republic of Vietnam. Dixie Station, however, 
was on the border of the territorial seas. Some carriers, especially in 
the South, entered the territorial seas while launching or recovering 
aircraft, conducting search and rescue operations and racing to meet 
disabled planes returning from combat. Aircraft carriers also entered 
the territorial seas for other operational reasons. Many times these 
planes flew through clouds of Agent Orange while conducting close air 
support missions. These planes were then washed down on the flight 
deck, exposing the flight deck crew to Agent Orange.
    Mail for the ships positioned throughout the combat area was staged 
at air fields and docking facilities throughout South Vietnam. Mailbags 
were often in sprayed area and the Agent Orange not only contaminated 
the bag, but leeched through to some of the mail. This mail was 
transported to the ships by carrier onboard delivery (COD) aircraft or 
helicopters. The boat or helicopter crews were exposed to the Agent 
Orange and carried it throughout the ship. Additionally, the mail 
itself was distributed to divisional mail petty officers and passed on 
to individual sailors.
                        agent orange act of 1991
    In 1991, the Congress passed and President George H.W. Bush signed, 
the Agent Orange Act of 1991, Pub.L. 102-4, Feb. 6, 1991, 105 Stat. 11. 
This Federal law required VA to award benefits to a veteran who 
manifests a specified disease and 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.''
    In 1997 the VA General Counsel issued a precedential opinion 
excluding servicemembers who served offshore but not within the land 
borders of Vietnam. The opinion construed the phrase ``served in the 
Republic of Vietnam'' as defined in 38 U.S.C. Sec. 101(29)(A) not to 
apply to servicemembers whose service was on ships and who did not 
serve within the borders of the Republic of Vietnam during a portion of 
the ``Vietnam era.'' The opinion stated that the definition of the 
phrase ``service in the Republic of Vietnam'' in the Agent Orange 
regulation, 38 CFR Sec. 3.307(a)(6)(iii), ``requires that an individual 
actually have been present within the boundaries of the Republic to be 
considered to have served there,'' and that for purposes of both the 
Agent Orange regulation and section 101(29)(A), service ``in the 
Republic of Vietnam'' does not include service on ships that traversed 
the waters offshore of Vietnam absent the servicemember's presence at 
some point on the landmass of Vietnam.'' \2\
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    \2\ VA Op. Gen. Counsel Prec. 27-97 (1997).
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    After lying dormant for a few years, this General Counsel opinion 
was incorporated into a policy change that was published in the Federal 
Register during the last days of the Clinton Administration.\3\ The 
final rule was adopted in Federal Register in May of that year.\4\ 
Comments by the VA concerning the exposure presumption recognized it 
for the ``inland'' waterways but not for offshore waters or other 
locations only if the conditions of service involved duty or visitation 
within the Republic of Vietnam.
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    \3\ 66 Fed.Reg. 2376 (January 11, 2001).
    \4\ 66 Fed. Reg. 23166.
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    Historically the VA's Adjudication Manual, the M21-1 Manual, 
allowed the presumption to be extended to all veterans who had received 
the Vietnam service medal, in the absence of ``contradictory 
evidence.'' In a February 2002 revision to the M21-1 Manual, the VA 
incorporated the VA General Counsel Opinion and the May 2001 final rule 
and required a showing that the veteran has set foot on the land or 
entered an internal river or stream. This ``boots on the ground'' 
requirement is in effect today.
                          hydrological effect
    The Agent Orange that was sprayed over South Vietnam was mixed with 
petroleum. The mixture washed into the rivers and streams and 
discharged into the South China Sea. In addition, the riverbanks were 
sprayed continuously resulting in direct contamination of the rivers. 
The dirt and silt that washed into the river can be clearly seen 
exiting the rivers and entering the sea. This is called a discharge 
``plume'' and in the Mekong River it is considerable. Although the 
Mekong has a smaller drainage area than other large rivers, it has 
approximately 85% of the sediment load of the Mississippi. In two 
weeks, the fresh water of the Mekong will travel several hundred 
kilometers.\5\ Notably, the Agent Orange dioxin dumped off the east 
coast of the United States was found in fish over one hundred nautical 
miles from shore.\6\
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    \5\ Chen, Liu et. al, Signature of the Mekong River plume in the 
western South China, Sea revealed by radium isotopes, Journal of 
Geophysical Research, Vol. 115, (Dec. 2010).
    \6\ Belton, et. al, 2,3,7,8-Tetrachlorodibenzo-p-Dioxin (TCDD) and 
2,3,7,8-Tetrachlorodibenzo-p-Furan (TCDF), In Blue Crabs and American 
Lobsters from the New York Bight, New Jersey Department of 
Environmental Protection (November 12, 1988).
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    By coincidence, the baseline and territorial seas extend further 
from the mainland off the Mekong River. At its widest point off of the 
Mekong, the territorial seas extend to 90 nautical miles from the 
mainland. This was due to the location of the barrier islands owned by 
Vietnam. Given the more pronounced effect of the Mekong plume, however, 
the broader area off the Mekong Delta is appropriate. The force of the 
water in this area is greater than the river discharge in other parts 
of the country.
    Eventually, the Agent Orange/petroleum mixture would emulsify and 
fall to the seabed. Evidence of Agent Orange impingement was found in 
the sea bed and coral of Nha Trang Harbor.\7\ During the Vietnam War, 
the coastline, especially in the harbors and within the thirty fathom 
curve was a busy place with military and civilian shipping constantly 
entering and leaving the area in support of the war effort. Whenever 
ships anchored, the anchoring evolution would disturb the shallow 
seabed and churn up the bottom. Weighing anchor actually pulled up a 
small portion of the bottom. The propeller cavitation from military 
ships traveling at high speeds, especially within the ten fathom curve, 
impinged on the sea bottom. This caused the Agent Orange to constantly 
rise to the surface. The contaminated water was ingested into the 
ship's evaporation distillation system which was used to produce water 
for the boilers and potable drinking water. Navy ships within the South 
China Sea were constantly steaming through a sea of Agent Orange 
molecules.
---------------------------------------------------------------------------
    \7\ Pavlov, et, al, Present-Day State of Coral Reefs of Nha Trang 
Bay (Southern Vietnam) and Possible Reasons for the Disturbance of 
Habitats of Scleractinian Corals, Russian Journal of Marine Biology, 
Vol. 30, No. 1 (2004).
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           the australian factor and the distillation process
    In August 1998 Dr. Keith Horsley of the Australian Department of 
Veterans Affairs met Dr. Jochen Mueller of the University of 
Queensland's National Research Centre for Environmental Toxicology 
(hereinafter NRCET) in Stockholm at the ``Dioxin 1998'' conference. 
Horsley shared a disturbing trend with Mueller. Australian VA studies 
showed a significant increase in Agent Orange related cancer incidence 
for sailors serving offshore over those who fought ashore. Based on 
that meeting, the Australian Department of Veterans Affairs 
commissioned NRCET to determine the cause of the elevated cancer 
incidence in Navy veterans.
    In 2002, as the American Department of Veterans Affairs (VA) was 
beginning to deny the presumption of exposure to the United States Navy 
veterans, NRCET published the result of their study.\8\ Their report 
noted that ships in the near shore marine waters collected water that 
was contaminated with the runoff from areas sprayed with Agent Orange. 
The evaporation distillation plants aboard the ships co-distilled the 
dioxin and actually enriched its effects. As a result of this study, 
the Australian government began granting benefits to those who had 
served in an area within 185.2 kilometers (roughly 100 nautical miles) 
from the mainland of Vietnam.
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    \8\ Mueller, J; Gaus, C, et. al. Examination of The Potential 
Exposure of Royal Australian Navy (RAN) Personnel to Polychlorinated 
Dibenzodioxins and Polychlorinated Dibenzofurans Via Drinking Water 
(2002).
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                  institute of medicine (iom) reports
    In June 2008, Blue Water Navy representatives presented to the 
IOM's Committee to Review the Health Effects in Vietnam Veterans of 
Exposure to Herbicides (Seventh Biennial Update) in San Antonio, Texas. 
That Committee report \9\ accepted the proposition that veterans who 
served on ships off the coast of the Republic of Vietnam were exposed 
to Agent Orange and recommended that they not be excluded from the 
presumption of exposure. The Committee reviewed the Australian 
distillation report and confirmed its findings based on Henry's Law. 
The VA did not accept these recommendations. Instead then Secretary 
Shinseki ordered another IOM study. On May 3, 2010, Blue Water Navy 
representatives testified before the Institute of Medicine's Board on 
the Health of Special Populations in relation to the project ``Blue 
Water Navy Vietnam Veterans and Agent Orange Exposure.'' \10\ They 
concluded:

    \9\ IOM (Institute of Medicine). 2009. Veterans and Agent Orange: 
Update 2008. Washington, DC: The National Academies Press.
    \10\ IOM (Institute of Medicine). 2011. Blue Water Navy Vietnam 
Veterans and Agent Orange Exposure. Washington, DC: The National 
Academies Press.
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    (1) There was a plausible pathway for some amount of Agent Orange 
to have reached the South China Sea through drainage from the rivers 
and streams of South Vietnam as well as wind drift,
    (2) The distillation plants aboard ships at the time which 
converted salt water to potable water did not remove the Agent Orange 
dioxin in the distillation process and enriched it by a factor of ten,
    (3) Based on the lack of firm scientific data and the four decade 
passage of time, they could not specifically state that Agent Orange 
was present in the South China sea in the 1960's and 1970's,
    (4) There was no more or less evidence to support its presence off 
the coast than there was to support its presence on land or in the 
internal waterways, and
    (5) Regarding the decision to extend the presumption of exposure 
``given the lack of measurements taken during the war and the almost 40 
years since the war, this will never be a matter of science but instead 
a matter of policy.''

Notably this report did not contradict the findings of the Seventh 
Biennial report that the Blue Water Navy personnel should not be 
excluded from the presumption of exposure.
    The IOM's Eighth Biennial Update recognized that ``it is generally 
acknowledged that estuarine waters became contaminated with herbicides 
and dioxin as a result of shoreline spraying and runoff from spraying 
on land.''\11\ The Ninth Biennial Update stated that ``it is generally 
acknowledged that estuarine waters became contaminated with herbicides 
and dioxin as a result of shoreline spraying and runoff from spraying 
on land, particularly in heavily sprayed areas that experienced 
frequent flooding.'' \12\
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    \11\ IOM (Institute of Medicine). 2012. Veterans and Agent Orange: 
Update 2010. Washington, DC: The National Academies Press.
    \12\ IOM (Institute of Medicine). 2014. Veterans and Agent Orange: 
Update 2012. Washington, DC: The National Academies Press.
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                             law of the sea
    The Agent Orange Act of 1991 provides that:

         * * * [A] veteran who, during active military, naval, or air 
        service in the Republic of Vietnam during the period beginning 
        on January 9, 1962, and ending on May 7, 1975, and has * * * 
        [Diabetes Mellitus (Type 2)] shall be presumed to have been 
        exposed during such service to an herbicide agent containing 
        dioxin * * * unless there is affirmative evidence to establish 
        that the veteran was not exposed to any such agent during 
        service.

38 U.S.C. Sec. 1116(a)(3). (Emphasis added).
    Vietnam claims a 12 mile territorial sea. The United States has 
consistently recognized Vietnamese sovereignty over the territorial 
seas of Vietnam. This recognition was expressly incorporated into the 
1954 Geneva Accords Art. 4 which established the Republic of Vietnam. 
https://www.mtholyoke.edu/acad/intrel/genevacc.htm (last visited 
June 6, 2014). It was confirmed again in Art. 1 of the 1973 Paris Peace 
Treaty which ended the Vietnam War. http://www.upa.pdx.edu/IMS/
currentprojects/TAHv3/Content/PDFs/Paris_Peace_Accord_1973.pdf (last 
visited June 6, 2014). During the war, the United States recognized a 
12 rather than a 3 mile limit. See, The Joint Chiefs of Staff and the 
War in Vietnam 1960-1968, Part II which can be found at dtic.mil/
doctrine/ * * * /jcsvietnam_pt2.pdf at 358.
    Vietnam claims as internal or inland waters the landward side of 
the baseline.\13\ Additionally, bays such as Da Nang Harbor are 
considered part of inland waters and under international law are the 
sovereign territory of the Nation.\14\
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    \13\ United States Department of State Bureau of Intelligence and 
Research, Limits in the Seas No. 99 Straight Baselines: Vietnam, 
(1983).
    \14\ Convention on the Territorial Sea and Contiguous Zone, [1958] 
15 U.S.T. 1607, T.I.A.S. No. 5639.
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    The Secretary has recognized the presumption of exposure for those 
who served onboard ships who were in ``inland'' waters. The VA 
definition only includes inland rivers and does not cover the bays and 
harbors. Recently the Court of Appeals for Veterans Claims has rejected 
the VA's exclusion of Da Nang Harbor from the definition of inland 
waters as irrational and not entitled to deference.\15\ In this case, 
the Court reviewed the case of a veteran whose ship was anchored in Da 
Nang Harbor but who did not set foot on land. Da Nang Harbor is 
surrounded on three sides by land and is considered inland waters under 
international law. The VA is now required to rationally specify what 
they consider to be inland waters.
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    \15\ Gray v. McDonald, No. 13-3339, 2015 WL 1843053 (Vet. App. Apr. 
23, 2015).
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                             cost of s. 681
    In October 2012, the Congressional Budget Office provided a 
preliminary estimate that the Blue Water Navy Vietnam Veterans Act 
would cost $2.74 billion over ten years. The estimate is currently 
being recomputed based on information provided in a meeting between CBO 
and MVA. CBO originally used a gross exposure population of 229,000 
people. This estimate was based on the number of veterans serving 
within the Vietnam Service Medal area. The Navy Historical and Heritage 
Command and the Congressional Research Service estimated that the 
number of sea service veterans serving inside the territorial seas was 
174,000. Of the 713 ships deployed to Vietnam, however, there is 
documentation that 330 have entered the inland rivers. An MVA analysis 
provided to CBO estimates 83,000 sea service veterans are already 
covered under the existing inland waters provision. Of the remaining 
91,000 veterans, 1100 are covered under a different provision of the 
law for Non-Hodgkins Lymphoma. MVA estimates another 10% of the crews 
actually set foot in Vietnam. This includes crew members who went 
ashore for conferences, to pick up supplies, equipment or mail and 
those who piloted and crewed the boats and/or the helicopters that 
operated between the ships and shore. Additionally, some personnel went 
ashore to see the doctor, the dentist, the chaplain or the lawyer. They 
called home. Shopped at the PX and departed on emergency leave or 
permanent change of station orders. Additionally, men reporting to the 
ship would often transit though Vietnam. Finally, a number of ships 
that were at anchorage would send a portion of the crew ashore for 
beach parties or liberty.
    Although the official CBO report has not yet been issued, informal 
liaison indicates that the cost will be $1 billion or less. The VA has 
estimated a ten year cost of $4.4 billion but has not provided any data 
to support the conclusion. In a meeting between MVA officials and 
Deputy Secretary Sloan Gibson held on September 1, 2015, the VA 
estimate was discussed. MVA provided the Deputy Secretary several 
considerations which might affect the score. CBO remains confident that 
their $1 billion or less estimate is correct.
    Irrespective of what the cost is, MVA understands the need for a 
``pay for.'' There will be some automatic offsets in both discretionary 
and mandatory spending. There will be a dollar for dollar offset for 
Navy veterans currently receiving a non-service-connected pension as 
well as those receiving non-service-connected medical treatment at 
Veterans Health Administration (VHA) facilities. Additionally, under 
concurrent receipt laws, some veterans who are also military retirees 
will have a dollar for dollar offset due to waiver of their Title 10 
pension (less Federal tax liability).
    As most Blue Water Navy veterans are in their 60's they are 
Medicare eligible or will become Medicare eligible during the ten year 
cost cycle. In a previous report, the CBO has compared the cost of 
Medicare treatment with treatment at a VHA facility.\16\ One of the key 
findings of this report was that private sector Medicare services would 
have cost about 21 percent more than services at a VHA facility. When 
dealing with retirees, the cost would be greater since Medicare only 
provides coverage for 80% of the cost. TRICARE for Life provides an 
additional 20% coverage for military retirees.
---------------------------------------------------------------------------
    \16\ Congressional Budget Office, Comparing the Costs of the 
Veterans' Health Care System With Private-Sector Costs (December 2014).
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    Should the cost of the bill approach $1 billion, enactment of round 
downs would generate the required $1 billion. Round downs were in use 
for two decades through 2013 until they were discontinued by then 
Chairman Bernie Sanders. Round downs require disability payments to be 
``rounded down'' to the nearest dollar. This would result in a maximum 
loss of $11.88 per veteran per year. The average loss per veteran would 
be $.49 per month or $5.88 per year. In a poll of almost 500 veterans, 
authorized by Military-Veterans Advocacy via the Blue Water Navy 
Awareness Facebook site, 90% of respondents supported the use of round 
downs. In a separate poll conducted by the Fleet Reserve Association of 
1148 veterans revealed that 73.52% supported the use of round downs. 
Informal liaison with several veterans organizations found that these 
organizations will not oppose round downs if that is the only means 
available of funding S. 681.
    While Military-Veterans Advocacy understands and appreciates the 
reluctance of some Senators to enact round downs, it is a small price 
to pay to restore earned benefits to tens of thousands of veterans. If 
the VA will not extend coverage to the bays and harbors and the 
territorial seas, Military-Veterans Advocacy urges the Committee to 
incorporate ``round downs'' as an offset.
                impact of the gray v. mcdonald decision.
    In April of this year the Court of Appeals for Veterans Claims 
decided Gray v. McDonald, 27 Vet. App. 313 (2015). In Gray, the Court 
found that the VA's exclusion of bays and harbors was irrational and 
that their stated reasoning was arbitrary and capricious.
    The time period for appealing the Gray decision has passed and the 
VA must now re-write their regulation. A draft regulation continued to 
exclude the bays and harbors and was used to deny at least two claims 
at the Board of Veterans Appeals. That regulation should not have been 
released and when called to the attention of the Deputy Secretary was 
quickly rescinded. The Board of Veterans Appeals has since been 
cautioned to not rely on that draft. Military-Veterans Advocacy 
estimates that if the bays and harbors, as defined by the 1958 
Convention on the Territorial Seas and the Contiguous Zone, are 
included under current law, the actual cost of S. 681 will be reduced 
to $100 million over ten years. If the VA extends the presumption to 
the territorial sea and beyond, the cost of the bill will be reduced to 
zero.
    MVA officials met with VA Deputy Secretary Sloan Gibson on July 6, 
2015 and September 18, 2015. Both meetings were productive and the 
Deputy Secretary seemed to be responsive to the presentations. Although 
no decision has been reached, MVA is heartened by the willingness of 
the Deputy Secretary to meet and listen to our position and we look 
forward to further consultations.
                          litigation post gray
    The Blue Water Navy Vietnam Veterans Association had previously 
brought suit against the Secretary under the Administrative Procedures 
Act in the United States District Court for the District of Columba. 
The court dismissed that case for lack of jurisdiction, after 
recognizing that the plight of the Blue Water Navy veterans was of 
concern. An appeal of that jurisdictional ruling is pending before the 
United State Court of Appeals for the District of Columbia.
    The case of Trumbauer v. MacDonald, concerning Da Nang Harbor is 
now pending before the United States Court of Veterans Appeals. The 
Secretary's brief is due October 5, 2015. Military-Veterans Advocacy 
has file an amicus brief in this case.
    Another appeal, Johnson v. MacDonald, concerning Nha Trang Harbor 
is pending before the United States Court of Veterans Appeals. The 
initial brief is due October 19, 2015. Military-Veterans Advocacy is 
representing the veteran.
    The case of Crisp v. McDonald, involving Da Nang Harbor, will be 
filed by Military-Veterans Advocacy on behalf of the veteran. This is 
one of the two cases where benefits were denied using the prematurely 
released draft regulation. That appeal must be filed before 
Thanksgiving. As a sign of good faith, MVA has not yet filed the appeal 
to give the VA an opportunity to resolve this issue amicably.
                   additional toxic exposure concerns
    Unfortunately, exposure to toxic substances is part of life in the 
military. Some of these exposures are not preventable, while some could 
be prevented. Irrespective of whether there is any fault or negligence, 
the important issue is how we take care of our veterans who are victims 
of this exposure.
    The Agent Orange problem will not end with the Blue Water Navy and 
S. 681. Other ships that remained outside of the territorial seas were 
exposed through aircraft embarkation, contaminated personnel, 
equipment, mail etc. Veterans were exposed in Guam, Johnston Island, 
Thailand, Laos, Cambodia, Korea, Okinawa and even sites in the United 
States such as Gulfport Mississippi and Fort McClellan, Alabama.
    Additionally, Agent Orange is not the only toxic exposure that 
requires the attention of the Congress. Asbestos contamination, 
radiation, the Camp Lejeune water tragedy, depleted uranium, petroleum 
fumes and open air burn pits have exposed hundreds of thousands of 
veterans to toxic materials just as dangerous as chemical weapons.
    The Toxic Exposure Research Act, S. 901, is an important step to 
become proactive in the worked of toxic exposure. S. 901 will establish 
a center at an existing VA facility to research the diagnosis and 
treatment of health conditions of the biological children, 
grandchildren, or great-grandchildren of individuals exposed to toxic 
substances while serving as members of the Armed Forces that are 
related to such exposure. It further directs the VA to conduct a 
national outreach and education campaign directed toward members of the 
Armed Forces, veterans, and their family members to communicate 
information on incidents of exposure of members of the Armed Forces to 
toxic substances, health conditions resulting from such exposure, and 
the potential long-term effects. It also requires DOD and the 
Department of Health and Human Services to assist the VA in 
implementing such campaign.
    Congressman Tim Walz has also introduced H.R. 3423 to extend the 
Institute of Medicine's Biennial Agent Orange Committee for two years. 
It is expected to pass the House. Military-Veterans Advocacy recommends 
making this Committee a permanent entity and expanding its charter to 
include all toxic exposures. Working closely with the research facility 
envisioned by S. 901, the United States can take a proactive approach 
to quickly identify and treat veterans who have been exposed to toxic 
substances.
                               conclusion
    MVA continues to urge the adoption of S. 681. It will restore the 
earned benefits to tens of thousands of Navy veterans that were taken 
from them over a decade ago. This bill is supported by virtually all 
veterans organizations including the American Legion, Veterans of 
Foreign Wars, Vietnam Veterans of America, Reserve Officers 
Association, Fleet Reserve Association, Military Officers Association 
of America, Association of the U.S. Navy and other groups. We have 
always enjoyed the support of the Military Coalition. Enactment of this 
legislation is overdue and Military-Veterans Advocacy most strongly 
supports its passage.

    MVA further supports the enactment of S. 901 and H.R. 3423 to 
require research into toxic exposure treatment for veterans and their 
descendants.
                                 ______
                                 
    Supplemental Written Testimony of John B. Wells, Commander, USN 
       (Retired), Executive Director, Military-Veterans Advocacy
    Distinguished Committee Chairman Johnny Isakson, Ranking Member 
Richard Blumenthal and other Members of the Committee, thank you for 
the opportunity to supplement out testimony on the question of: 
``Examining the impact of exposure to toxic chemicals on veterans and 
the VA's response.''
    A response to the two questions is fairly straightforward. The 
impact of toxic exposure has been horrendous and the VA response has 
been disappointing to say the least.
    Military-Veterans Advocacy has taken the lead in petitioning 
Congress for relief for the Blue Water Navy veterans who were exposed 
to Agent Orange through their potable water supply. Our Australian 
allies discovered that the evaporation distillation systems did not 
remove the Agent Orange dioxin during the distillation process--it 
actually enriched it. Instead of embracing the findings of our Allies, 
the VA attacked the study until its science was confirmed by two 
separate committees of the Institute of Medicine.
    The Blue Water Navy situation was especially tragic since they were 
granted the presumption of exposure to Agent Orange prior to 2002. The 
VA General Counsel, in an opinion that flaunted international law and 
domestic policy interpreted the provisions of the Agent Orange Act 
requiring service ``in the Republic of Vietnam'' as meaning the land 
mass. Although the General Counsel used the terminology ``inside the 
borders of Vietnam,'' the VA rejected the inclusion of bays harbors and 
the territorial seas. This is despite the fact that the United States 
recognized Vietnamese sovereignty over these waters in the 1954 Geneva 
Accords and the 1973 Paris Peace Treaty. It was an irrational decision 
and was partially invalidated by the Court of Appeals for Veterans 
Claims in the landmark case Gray v. McDonald. Military-Veterans 
Advocacy proudly filed an amicus brief in that case. The court 
listened. That appeal period has expired and the VA is re-writing their 
regulation. Due to other pending court decisions we expect and hope for 
a positive decision this Fall.
    I do want to take a moment to thank the VA for finally agreeing to 
cover our brothers in arms who flew the C-123 aircraft after the war. 
Although not entirely satisfied with the effective date of the new 
regulation, I do believe it is a step I the right direction. I also 
want to mention to the Committee that I have met twice with VA Deputy 
Secretary Sloan Gibson and General Counsel Leigh Bradley on the Blue 
Water Navy issue. We have shown them how the Agent Orange, mixed with 
peritoneum, floated out to the bays barbers and territorial seas. They 
reviewed the report showing the presence of Agent Orange in Nha Trang 
Harbor. Hopefully, we have finally put to the rest the old VA 
misrepresentation that the Agent Orange never left the landmass. 
Petroleum floats and rivers run out to sea. A tough concept maybe, but 
a truism none the less. Both Secretary Gibson and General Counsel 
Bradley were interested in this matter and I thank hem for their 
courtesy.
    Currently pending before this body is S. 681 which will restore the 
presumption of exposure to the territorial seas. Military Veterans 
Advocacy urges its enactment. In doing so, we are not unaware of the 
offset requirements of the Pay as You Go Act. We have identified 
sufficient funds to pay for the bill through round downs. This would 
require the disability checks for all veterans to be rounded down to 
the nearest dollar. The most it would cost a veteran is $11.88 per 
year. The average cost is $5.88 per veteran per year.
    We understand and appreciate the resistance to round downs but the 
bottom line is that we need to ensure that these sick and disabled 
veterans are covered. Many are dying. Many had to leave the work force 
early. Some will leave their families destitute when the die. These 
veterans earned their benefits and we ask that you provide to provide 
them. While it is possible that the VA will grant the Blue Water Navy 
veterans partial or complete relief, we must be prepared to act if they 
do not. Accordingly, Military-Veteran Advocacy asks that you markup 
S. 681 and if the VA does not grant relief, send it to the floor using 
round downs as a pay for.
    This will not resolve the toxic exposure problem. The Blue Water 
Navy is a large part of the problem but not the entire problem. Agent 
Orange was also used on Guam, Johnston Island and in Thailand Laos and 
Cambodia. In the United States Agent Orange was used in the Canal Zone, 
Fort McClellan and Gulfport MS. Other veterans have been exposed to 
PCBs, depleted uranium, petroleum and other toxic fumes, asbestos and 
the latest killer, open air bum pits.
    Toxic exposure is a personal battle to me. My step-daughter Joanne 
has suffered birth defects due to Agent Orange. Her natural father was 
an Australian soldier fighting beside the United States in South 
Vietnam. She lives in Australia where she receives better services than 
she could get in the United States.
    Personally, I have been exposed to asbestos after working for years 
in shipboard engineering spaces. Through the grace of God I have not 
developed symptoms. Many others have.
    Open air burn pits have been called the Agent Orange of the 21st 
Century. Troops berthed downwind of these hellish pits were exposed to 
all types of toxic fumes. Worse, the Special Inspector General for 
Afghanistan Reconstruction found, even when incinerators were available 
at places like Camp Leatherneck in Afghanistan, open air burn pits were 
used. Military-Veterans Advocacy is currently representing a Lieutenant 
Commander who was sexually assaulted and then forced out of the Navy 
just shy of her retirement availability for raising the issue of open 
air bum pits at Camp Leatherneck. LCDR Celeste Santana is fighting with 
MVA to gain the retirement she lost for trying to do the right thing.
    And of course, Sen Burr's comments on Camp LeJeune hit home. Like 
the Blue Water Navy the Marines and their dependents were poisoned via 
their drinking water.
    The problem is that no one knows the extent of the damage caused by 
toxic exposure and whether or not it is generational. A central toxic 
exposure research facility, located at a state-of-the-art VA medical 
facility will allow the United States to assess the harm caused by 
these exposures and to reach out to those harmed. This will allow the 
VA to become proactive rather than reactive and stop this senseless 
adjudication on a case by case basis. As this program gains traction it 
will eliminate much of the backlog and ensure that those who truly need 
the benefits receive them. Military-Veterans Advocacy also recommends 
that the IOM Agent Orange Biennial Committee to be expanded to include 
all toxic exposures and to be made permanent.
    As you know we are currently standing up a state-of-the-art 
facility in New Orleans. This new facility would be a fantastic site 
for the new facility S. 901 will authorized. Southeastern Louisiana has 
significant toxic exposure experience most recently with the BP Oil 
spill but also through our familiarity with ``cancer alley.'' 
Universities such as Tulane and LSU will stand ready to work with the 
Federal Government to pursue the needed scientific research and 
evaluation. Our local industries would step forward to engage in 
private-public partnerships.
    Perhaps the location of the site is a bit premature, but the 
identification of the problem is needed. This bill is needed to address 
he many toxic exposures that have placed our veterans in jeopardy. It 
is a form of chemical warfare that is even more egregious than Saddam 
Hussein, because most of the chemicals come from out own side.
    Military-Veterans Advocacy appreciate the issues surrounding costs 
and are the first to admit that the Pay as You Go Act has been of 
tremendous assistance in arresting th trillion dollar deficits that 
were common place not that long ago. But today the Congress is funding 
several trillion dollars worth of expenditures. Taking care of veterans 
is part of the responsibility of raising a military force, That is 
Constitutionally mandated. Many of the things we spend Federal dollars 
on are not Constitutionally mandated. I do not want to get into 
specifics because, again, I do not want to give rise to partisan 
disputes. But, we believe, as citizens, that Congress should fund their 
constitutional mandates first.
    Military-Veterans Advocacy is a grass roots organization. We are 
all volunteers. No one gets paid. We come to you not to address a 
political agenda but to ask you to keep faith with the veterans. I have 
met many of you and I respect all of you. We recognize that you are 
good people trying to do the best job that you can. In the long run, 
S. 901 will help us to take care of our veterans and streamline the 
bloated and inefficient adjudication system. Accordingly, we urge you 
to adopt S. 681 and S. 901. If this requires a modification of the Pay 
As You Go Act, or an exception thereto, we ask you to take that action.
    One final thought--the exposure to toxic substances does not just 
affect veterans. Agent Orange dumped off the coast of New Jersey was 
found in seafood several years later 150 miles off the New York bight. 
Agent Orange that is being rededicated today near Da Nang airport, with 
U.S. Taxpayers dollars I might add, is finding its way back into the 
areas where fish farms are located. And by the way, FDA does not test 
Vietnamese seafood for the dioxin. Next time you go out to eat, you 
might want to check where the seafood comes from. Just a thought.
    Again thank you for allowing us to present our written and oral 
testimony and may God bless you, God bless the United Sates of America 
and God bless the military and veterans who have kept us safe.

    Chairman Isakson. You did just fine.
    Mr. Rowan.

 STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, VIETNAM VETERANS 
                           OF AMERICA

    Mr. Rowan. Good morning still, Mr. Chairman.
    Chairman Isakson. Barely.
    Mr. Rowan. Senator Blumenthal, Senator Moran, Senator 
Hirono, nice to meet you all. We have prepared testimony which 
we have submitted for the record. It is long and I am not going 
to get into all that. Let me just get to the heart of this.
    First of all, I wish we had an Individual Longitudinal 
Exposure Record when I was going through Vietnam. It would have 
been very interesting. I was interested about the Senator 
talking about the folks sitting in Saigon.
    Amazingly, how many of those people who sat in Saigon got 
exposed in all kinds of strange ways, not the least of which 
was the food they were eating every day or the water they were 
drinking every day. That stuff was pretty pervasive all over 
the place. Actually, I would guarantee you there were probably 
more Agent Orange exposure in the base camps and in the air 
bases than there was out in the bush.
    We did not go out in the bush and try to defoliate the 
entire jungle, but we certainly defoliated everything that grew 
around the air bases and around the base camps. And I would 
contend that my exposure to Agent Orange came from the three 
showers I took a day in the 130 degree heat in June and July 
1967.
    I cannot believe it has been 48 years since I tromped 
through Vietnam. In the 48 years since I came home, they have 
done nothing in the VA to study anything related to Agent 
Orange exposure. Everything we do is we are always relying on 
somebody else's testing and somebody else's, you know, 
research, which is ridiculous.
    The key to the 901 bill is the national center. That is the 
key. I contend that before they set the National Center for 
Post Traumatic Stress Disorder up, they did not know a whole 
hell of a lot about that either.
    Yet, somehow that is now the quintessential place to go to 
get information on PTSD. I would like to see this new national 
center be the place to go for research on toxic exposure for 
everyone going down to the children and grandchildren, maybe 
even great-grandchildren.
    Unfortunately, Vietnam veterans are now old enough to have 
great-grandchildren and we see the causes. We have held town 
hall meetings in 42 States all over the country, about 200 or 
more. Over 2000-plus families have come to us telling us about 
all kinds of horrific situations with their progeny.
    This research must be done, it just has to be done. Doctor, 
it is far from premature when it has been 50 years since we had 
been exposed and we do not have a clue about what is going on 
relating to anything that ever happened to us 50-plus years ago 
or 48 years ago.
    VVA obviously supports the Blue Water issue. By the way, 
the Air Force did spray the ships. I had--one of the people who 
is very involved in our organization was an Air Force crew 
member on the Ranch Hand cruise. He said, if they had a lot of 
excess stuff in the plane when they were coming in for a 
landing and they had to dump it out to sea, they dumped it out 
to sea. If there was a Navy ship there, they believed it would 
be more fun to dump it on them. You know, a little inter-
service rivalry there. So, God knows how many times that was 
done.
    S. 2081, the new bill that Senator Blumenthal has brought 
up, is also important. Again, because of this lack of research 
over all of these years--I am now 70--it has taken so many 
years now to get information about what has happened to me and 
my colleagues who were Vietnam veterans 50 years ago. We are 
still finding out every day more and more and more as more and 
more research gets done.
    So, it is very important that the process of the ILER, the 
1991 bill continue and that this extender go on. You are 
optimistic going to 2030. I have no idea how many of my 
colleagues will still be around in 2030, but hopefully some of 
us will be. It is important. It is also important that 901 does 
not talk just about us, but it talks about the vets who came 
after us, the Persian Gulf War and the new wars.
    Unfortunately, the more we learn about the new wars and 
with the exposures we have over there, I think the horrors are 
starting to show up already. And God knows what is going to 
happen 20 or 30 years from now. So, it is important that these 
bills get done.
    We are also looking to do a new bill which will take the 
Agent Orange Act of 1991 and expand it to include the other 
wars, frankly, so that they will be coming along like us and 
get the same research done. Research is the key. It needs to be 
done, it has never been done, we need it done, and that is the 
bottom line.
    You know, the other thing that concerns me is the CBO. I 
know Congress is having fun yelling at the VA bureaucracy, but 
the Congress has so little bureaucracy with the Congressional 
Budget Office which is giving us such a hard time about scoring 
which should be a simple bill. It is a research bill.
    It is not determining what comes out of that research; it 
is a research bill. We need them to tell us how much it is 
going to cost to do the research, which we do not think is 
astronomical and is within the VA's existing budget. Thank you.
    [The prepared statement of Mr. Rowan follows:]
       Prepared Statement of John Rowan, National President/CEO, 
                      Vietnam Veterans of America
    Good morning, Chairman Isakson, Ranking Member Blumenthal, and 
other Senators on this distinguished and important committee. Vietnam 
Veterans of America (VVA) very much appreciates the opportunity to 
offer our comments concerning several bills affecting veterans that are 
up for your consideration. Please know that VVA appreciates the efforts 
of this Committee for the fine work you are doing on behalf of our 
Nation's veterans and our families.
    I ask that you enter our full statement in the record, and I will 
briefly summarize the many of the important points of our statement.

    S. 901, Toxic Exposure Research Act of 2015, introduced by Senator 
Jerry Moran (KS), and cosponsored by Richard Blumenthal (CT), would 
establish in the Department of Veterans Affairs a national center for 
research on the diagnosis and treatment of health conditions of the 
descendants of veterans exposed to toxic substances during service in 
the Armed Forces that are related to that exposure, to establish an 
advisory board on such health conditions, and for other purposes.
    Among the invisible wounds of war are those brought home by troops, 
some of which may not manifest for years or even decades after the 
toxic exposure(s) while in military service to America. Most 
tragically, they may also pass on the effects of these toxic wounds to 
their progeny. No one can argue that our children and grandchildren 
should have these burdens visited on them. S. 901is a multi-
generational, multi-exposure bill. It provides a common vehicle for 
evaluating potential transgenerational effects of toxic exposures, from 
Camp Lejeune and Fort McClellan to Agent Orange in multiple locations, 
to the toxic plumes that sickened thousands of Gulf War veterans.
    Toxins, such as TCDD and 2,4D dioxin, are believed to cause birth 
defects in children of military personnel who came into contact with 
these toxins--in-country troops during the Vietnam War, as well as the 
several thousand Reservists who rode in and maintained aircraft that 
had been used to transport the toxins. Because the various herbicides 
used in Vietnam were generally mixed with kerosene or JP-4 or an 
admixture of these two petroleum products so that they would cling to 
leaves better, the toxins became suspended at or near the surface as 
run-off in streams then into rivers and ultimately the South China Sea. 
For this reason, these chemicals were taken in by the desalination 
units on Navy ships to make potable water for the ship's boilers and 
other purposes. The desalinization units had the perverse effect of 
concentrating the dioxin up to 30 times over. Navy personnel who served 
off the coast of Vietnam were exposed in this manner to even greater 
concentrations of these toxins than some of the ground personnel.
    For Gulf War veterans, the exposure was to chemical weapons in 
Iraqi ammo dumps containing chemical and biological agents that were 
blown up by U.S. Forces at the end of the Gulf War; pesticides and burn 
pit smoke and possibly tainted vaccines and medicines ingested by 
troops in Afghanistan and Iraq may also have proved toxic.
    This is a simple and straightforward proposal that will begin to 
address the needs of the progeny of every generation of veterans, 
because the health conditions seen in some are so heartbreaking to so 
many families who wonder, ``Did my service cause my children 
(grandchildren) to suffer?'' (Please see ``Faces of Agent Orange'' at 
https://www.facebook.com/pages/Faces-of-Agent-Orange/187669911280144)
    VVA unequivocally supports S. 901.
    Vietnam Veterans of America applauds the leadership of Senator 
Jerry Moran (KS), working with his colleague Senator Dick Blumenthal 
(CT), to construct and introduce this bipartisan bill to begin to 
properly address the situations outlined above.
    Let me address a few important issues within this legislation:

    First, the National Center envisioned in this bill belongs in the 
Department of Veterans Affairs. Doctrine, law, and precedent all 
dictate that, since the time of Abraham Lincoln, the concerns of 
veterans and their progeny are vested in this department. This Center 
for Excellence is a small entity that will functionally manage the 
activities to assist the Advisory Board in overseeing research.
    Second, we agree with VA testimony earlier this year that the VA 
lacks the internal capability, capacity, and experience in the 
intergenerational research that will be required. The Advisory Board 
provides the VA Secretary with knowledge and scientific expertise to 
obtain research required by the legislation.
    Third, we believe that the VA does have the capability, capacity, 
and experience to contract with any number of governmental, quasi-
governmental, academic, scientific, or non-profit research 
organizations skilled in the research and administration outlined in 
the legislation; and further, such organizations would be able to 
achieve the intent of the legislation in a timely and cost-efficient 
way.
    Fourth, the legislation gives the VA Secretary a strong, 
independent Advisory Board--of unpaid professionals--to provide diverse 
perspectives and technical expertise, assuring that the VA is provided 
with research-based outcomes that are respected and acknowledged by the 
military, our veterans and their descendants, and the scientific 
communities.

    While VVA's exploration into the health complications of veterans 
exposed to toxic substances during their service has centered on the 
families of Vietnam veterans, the veterans of more recent wars also 
report health issues in their children. For this reason, VVA is calling 
for more research on the generational legacy of toxic exposures for all 
veterans who have been exposed while serving in the Armed Forces.
    The Toxic Exposure Research Act of 2015, embodied in S. 901 and 
H.R. 1769, does just that. This Act directs the Secretary of the VA to 
select one VA Medical Center to serve as the National Center for the 
research and diagnosis into health conditions of descendants of 
individuals exposed to toxic substances while serving in the Armed 
Forces.
    The Toxic Exposure Research Act now has 18 bi-partisan co-sponsors 
in the Senate and 97 bi-partisan cosponsors in the House. The Act also 
has significant support in the community. The support from the military 
and veterans community has been overwhelming. Both the Military 
Coalition (representing 31 military and veterans groups) and the 
National Military and Veterans Alliance (representing 32 military and 
veterans groups) have publicly endorsed the Act. The National 
Association of Counties passed a Resolution supporting the Act, as did 
the National Association of County Executives. The National Federation 
of Republican Women also recently passed a Resolution supporting this 
Act. (Please see the appendices to this statement.)
    VVA agrees with VA testimony before the House Veterans' Affairs 
Subcommittee on Health on April 23, 2015, that this bill will be funded 
from the Research & Development line item of funding already accorded 
to VA. Frankly, the VA and the Department of Defense should have been 
funding good research in this area for the last forty years, so it is 
only fitting that part of this appropriation go to the Center of 
Excellence and to promising research proposals from within or without 
of the VA that will move us toward better understanding of the effects 
of these toxins or combinations of same.
    It is time that the Congress takes this meaningful step toward 
justice for every generation's progeny. It is our hope that this 
legislation will be passed in 2015 so that the research can begin, and 
science can provide the answers so desperately needed by our veterans 
and their families.

    S. 681--Blue Water Navy Vietnam Veterans Act of 2015, introduced by 
Senator Kirsten Gillibrand (NY)--This legislation would restore 
presumptive coverage for service-connected ills that afflict thousands 
of naval personnel who served in the Vietnam theatre of operations--
coverage that the Department of Veterans Affairs abruptly ended in 
March 2002.
    As noted on page 2 of this statement there is now no longer doubt 
of how the Navy personnel were exposed. Those who claim the toxin in 
the waters could not get out as far as the aircraft carriers should 
take a look at all of the highly radioactive debris from the Nuclear 
plant disaster in Japan that is now washing up on the western shores of 
the United States, having been carried more than 3,000 miles by the 
ocean currents.
    During the Vietnam War, some 20 million gallons of ``Agent Orange'' 
and other toxic substances was sprayed to remove jungle foliage around 
fire bases and to deny the enemy the ability to grow or harvest crops. 
Toxic chemicals in these herbicides have been linked to several 
afflictions, including non-Hodgkin's Lymphoma, various cancers, Type II 
diabetes, and Parkinson's disease. The Agent Orange Act of 1991 
empowered the VA Secretary to declare certain illnesses presumptive to 
exposure to Agent Orange, enabling veterans who served in Southeast 
Asia to receive health care and disability compensation for such health 
conditions.
    In March 2002, however, the VA ceased awarding benefits to any of 
the 534,300 so-called blue water veterans, limiting those eligible 
under provisions of the Agent Orange Act only to ``boots on the 
ground'' Vietnam veterans.
    Blue water veterans afflicted with any of the presumptive service-
connected maladies that the VA acknowledges to be associated with 
exposure to Agent Orange ought not be excluded from receiving 
healthcare services and disability compensation for which their boots-
on-the-ground brother and sister veterans are eligible. They, too, 
served honorably and well, and S. 681 introduced by Senator Gillibrand, 
will accord them benefits that they have earned.
    VVA fully supports S. 681.
                              camp lejeune
    When President Obama signed into law in early August a bill 2012 
enabling the Department of Veterans Affairs to provide health benefits 
to veterans and families diagnosed with diseases related to water 
contamination at Camp Lejeune, North Carolina, thanks in no small part 
to the energy and passion of Senator Richard Burr (NC), it culminated a 
more than fifteen-year struggle by families who believed something 
toxic at Lejeune had been behind the maladies that had taken the 
health--and the lives--of their loved ones.
    ``I think all Americans feel we have a moral, sacred duty toward 
our men and women in uniform,'' President Obama said before signing the 
Honoring America's Veterans and Caring for Camp Lejeune Families Act of 
2012 in the Oval Office. The law covers those with conditions linked to 
water contamination that occurred at Camp Lejeune between 1957 and 
1987.
    The military is a collection of very dangerous occupations beyond 
the obvious of hostile fire from our Nation's enemies. Therefore VA 
should operate as an occupational health care system that researches 
and diagnoses and treats maladies, illnesses, and conditions that may 
result from events or exposures that may have occurred during the 
veteran's military service.

    VVA thanks you for the opportunity to share our views on the 
vitally needed legislation that you are considering today. I will be 
pleased to answer any questions you might have.

    Chairman Isakson. Thank you, Mr. Rowan.
    Master Sergeant Ensminger.

  STATEMENT OF JEROME ENSMINGER, MASTER SERGEANT, U.S. MARINE 
                         CORPS, RETIRED

    MSgt. Ensminger. Yes. Thank you and good afternoon, Mr. 
Chairman. My name is Jerry Ensminger. I served faithfully in 
the U.S. Marine Corps for nearly a quarter of a century. Of my 
four children who all were born during my military career, my 
daughter, Janey, was the only one to have been conceived, 
carried, or born while we lived aboard Marine Corps Base Camp 
Lejeune, NC, during the years of the water contamination.
    When Janey was 6 years old, she was diagnosed with 
leukemia. She fought a valiant battle against her disease, but 
she eventually lost the war. She passed away on 24 September 
1985 at the age of nine. That is correct. The 30th anniversary 
of her death was just five short painful days ago.
    Janey is but one example of the multitude of tragedies 
suffered by former Camp Lejeune families who were exposed by 
this negligence. It was not until August 1997 that I became 
aware of the contaminated tap water within Camp Lejeune. The 
Department of the Navy and the U.S. Marine Corps did their very 
best to conceal the truth, but eventually that genie escaped 
its bottle.
    At first, the Department of the Navy and Marine Corps 
reported that the contamination had reached only a few of the 
base's water supply wells and they had immediately taken those 
wells off-line. There was absolutely no mention that the 
contaminants had reached our taps. When that fact was finally 
revealed, authorities with the Department of the Navy and 
Marine Corps publicly described the levels of contaminants that 
we were exposed to as minute, trace, small, or minuscule.
    Many years later when the truth was finally revealed, Camp 
Lejeune's contaminated tap water is now known as the worst and 
largest tap water contamination incident of a major water 
system in the history of our Nation. I would say that is a far 
cry from our leaders' description of the contaminant levels as 
minute, trace, small, or minuscule. Would you not agree?
    Mr. Chairman, I will now address my years of experiences 
with the Veterans Administration concerning the Camp Lejeune 
contamination issue. I would like to preface my detailed 
comments with this one statement which I feel encapsulates the 
VA/Camp Lejeune saga. Agents within the VA system have expended 
more effort, time, and money devising methods to deny Camp 
Lejeune victims their rightful benefits rather than providing 
them.
    During our April 2010 Camp Lejeune community assistance 
panel meeting, Mr. Brad Flohr of the VBA, described in great 
detail the VA claims process which Camp Lejeune veterans needed 
to follow when submitting a claim for service-connected 
benefits. A court-recorded transcript is available on ATSDR's 
Web site of that meeting.
    In 2013, the VA changed the rules and the requirements for 
Camp Lejeune claims. They had created an entire new step in the 
adjudication process for Camp Lejeune claims only. This step 
was called subject matter experts, or SMEs, who were selected 
from existing VA medical staff.
    These so-called SMEs were neither scientifically or 
medically qualified to make the judgments or evaluations that 
their VA handlers were tasking them to make. The fact that the 
VA has veered out of their lane of providing health care and 
benefits and into areas of expertise for which they have no 
business venturing, raises some very troubling questions for 
me.
    First and foremost, what is the motivation for VA staff in 
their incessant pursuit in denying veterans their benefits? 
Most of the VA staff involved in this VA/Lejeune debacle are or 
were retired military medical officers and their actions 
exhibit an almost maniacal desire to deny their fellow veterans 
their benefits.
    Second, we need to determine if a Congressionally-approved 
standardized VA claims process exists which veterans can 
confidently follow when making a claim. Apparently, the current 
policy allows the VA to modify the claims process at their whim 
without Congressional oversight. This allows the VA to create 
insurmountable obstacles in the claims process for which most 
veterans do not have the knowledge or the finances to overcome.
    In layman's terms, this amounts to authorizing a sports 
team to change the rules at any time they desire even during a 
game. How could anyone be successful in such a scenario? They 
cannot. For example, I have witnessed many Camp Lejeune 
veterans claims where these so-called VA SMEs completely 
ignored and even challenged the veterans' attending oncologists 
and other medical specialists.
    Third, Mr. Chairman, in light of the VA's Camp Lejeune/SME 
fiasco, with their demonstrated desire to rely on outdated 
science and their refusal to recognize and utilize the most up-
to-date scientific studies available, I must personally oppose 
Bill S. 901 in its current form.
    S. 901 would not only be dangerous to the welfare of our 
veterans and their families, it would create a conflict of 
interest and a duplication of efforts which other existing 
Governmental agencies are tasked, staffed, and equipped to 
perform. I would be in favor of a modified S. 901 which would 
mandate one or a combination of these existing agencies to 
perform the tasks outlined in this bill.
    In closing, Mr. Chairman, no other military toxic exposure 
incident in our history has been documented or studied as 
thoroughly as Camp Lejeune. Much of the science is already in 
and more is coming in future study reports. Many Camp Lejeune 
veterans and their families have waited, suffered, and yes, 
some even died waiting for this scientific evidence.
    They should not need to wait any longer for the help that 
they deserve. We were all at Camp Lejeune to serve and protect 
our Nation. None of us ever expected nor deserved to be 
poisoned, especially here on our own shores.
    Now, the VA representative you heard earlier brought up 
this VA app, exposure app that they have got. One of my 
colleagues just went to that app. The information on the Camp 
Lejeune page is incorrect. It is outdated science. It says TCE 
may cause kidney cancer. That app is like a computer; it is 
only good as what you put in it. Thank you.
    [The prepared statement of Master Sergeant Ensminger 
follows:]
              Prepared Statement of Jerome M. Ensiminger, 
                     Msgt U.S. Marine Corps (Ret.)

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Chairman Isakson. Without objection, we will include your 
comments about the VA app so they are part of the hearing 
record. I appreciate you bringing it forward and appreciate all 
of your testimony.
    Mr. Ensminger, our hearts go out to you in the loss of your 
daughter. Our admiration goes to you for taking the time to 
come here and testify today in a very forthright and powerful 
way. I am pleased to tell you that Senator Burr, Senator 
Tillis, and this Committee are working hard on the Camp Lejeune 
situation.
    I think progress is being made with what CDC has now come 
back with and hopefully we are finally going to bring a 
resolution, far too late, but a resolution nonetheless, on that 
case. I thank you very much for your testimony.
    MSgt. Ensminger. Yes, sir.
    Chairman Isakson. Dr. Ramos, I am going to say something 
and this is one of those yes or no things. You have got to tell 
me I have got it right or I have got it wrong.
    Dr. Ramos. Sure.
    Chairman Isakson. I was taking notes fast, though I do not 
write well. You said the lack of monitoring--talking about the 
Blue Water Navy off of Vietnam, there is no quantitative 
science to support and it would be unlikely in the future that 
enough data could be gathered to determine whether or not 
exposure to Blue Water Navy would or would not have been a 
cause of cancer. Is that correct?
    Dr. Ramos. That is correct, quantitatively.
    Chairman Isakson. Quantitatively. Dr. Ramos, you said it is 
strictly a question not of science, but of policy. Is that 
correct?
    Dr. Ramos. I did say that, correct.
    Chairman Isakson. In other words, the Congress of the 
United States has to make the decision, are we going to award 
those benefits or not. Is that correct?
    Dr. Ramos. That is correct.
    Chairman Isakson. There is not a scientific accumulation 
that could be anticipated because of the lack of collection 
that could certify it otherwise?
    Dr. Ramos. That is correct, sir.
    Chairman Isakson. OK. Make a note of that back there. (I am 
talking to my staff.)
    Senator Blumenthal. I will make a note of it, too.
    Chairman Isakson. Commander Wells, you were actually in the 
business of purifying water on a ship, is that right?
    Commander Wells. Yes, Senator. As an engineer on the ship, 
we had responsibility for the water distillation storage and 
distribution systems.
    Chairman Isakson. This is a wild question but just out of 
curiosity, because I know this was 40 or 50 years ago, but just 
out of curiosity, when you were in the process of doing that, 
did it ever occur to you that you might be processing water 
that could be a problem for soldiers to ingest?
    Commander Wells. Not at all, sir. I mean, we had several 
criteria tests for purity, but that was based on what could 
possibly damage the boilers. As far as potable water, there was 
actually a lot less testing. The only thing we had to do was 
add chlorination to it and do cultures sometimes to make sure 
there was no bacteriological contamination. As far as anything 
dealing with Agent Orange, nobody ever even thought of it, to 
be honest with you.
    Chairman Isakson. I think, Dr. Ramos, a fair statement to 
say is at the time that he was processing that water, he said 
the science would not have been there to have told us that 
would have been a problem anyway. Is that correct?
    Dr. Ramos. No. Actually if the question had been asked, 
that experiment could have been done back then, but it just was 
not asked.
    Chairman Isakson. So, that is your testimony, it was not 
asked and the experiments were not done?
    Dr. Ramos. That is correct. The experiments were actually 
completed post in reconstruction studies.
    Chairman Isakson. Ms. Wedge, you have been sitting there 
patiently for a long time. Did you have anything you wanted to 
contribute to this conversation?
    Ms. Wedge. Only that I concur with everything Dr. Ramos 
said. I was a study director for the Blue Water Navy study and 
we looked very, very hard for any kind of sampling data that 
had been collected during or shortly after the war. We found 
none of it.
    Chairman Isakson. It was nonexistent?
    Ms. Wedge. Nonexistent.
    Chairman Isakson. So, you corroborate your boss's 
testimony?
    Ms. Wedge. I do.
    Chairman Isakson. That is a smart employee. Thank you.
    Senator Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman, and I want to 
thank all of you for being here today. I recognize that each of 
you has invested a substantial part of your personal and 
professional lives in this cause, and I particularly appreciate 
the passion and urgency that you bring to this debate. This 
nation needs to understand, with passion and urgency, the 
importance of this issue. It affects veterans of every era.
    There may be new toxic substances and chemicals on the 
battlefield, but the principle is the same, that anybody in the 
vicinity of combat and many who may only be near it can be 
exposed to this type of insidious and pernicious chemical harm. 
And future generations bear the burden.
    The passion and urgency of this issue has to be understood 
by our Nation. The research that would be authorized by the 
bill I have introduced is long overdue, and I say that almost 
as a completely inadequate characterization that is so often 
used around here in these halls, long overdue.
    In this instance, it is almost criminally overdue because 
Congress and the country have simply chosen to look the other 
way. Whether it is Agent Orange or the chemicals in the water 
that you processed or the depleted uranium, pollutants from 
burn pits or nerve gas in unexploded ordnance found on the 
battlefields in Iraq and Afghanistan, our men and women in 
uniform have suffered, they continue to suffer, and their 
children and grandchildren will suffer.
    So, I am grateful for your advocacy and for the personal 
pain that you have brought to this forum. As a parent and a 
citizen, I want to thank each and every one of you; as a parent 
of two sons who have served and one now serving. I believe this 
Nation has an obligation that it has shirked unwisely and 
unforgivably, and I am determined that we will move more 
quickly with the measures that have been proposed to remedy 
this issue and with others that I intend to introduce.
    I think the stories you have brought here are the most 
powerful part of your testimony. So, I would like to ask Mr. 
Rowan and the Vietnam Veterans of America, first thanking you 
for your support for this measure and your advocacy.
    I understand that you have stories from families available 
that could be submitted for the record and that they would help 
to bolster support for S. 901 and some of the other measures we 
are considering. I would like to ask that those stories be 
submitted for the record.
    Chairman Isakson. Without objection.
    Mr. Rowan. We will be happy to do so. It is called ``Faces 
of Agent Orange.'' We have a whole compilation of all the--
distillations of the hearings we have been holding over the 
years.
    [VVA's Faces of Agent Orange stories follow:]
    
    
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(Please also see ``Faces of Agent Orange'' at https://
www.facebook .com/pages/Faces-of-Agent-Orange/187669911280144)

    Senator Blumenthal. Commander Wells, I understand that you 
have been involved in litigation or you know of litigation, 
Gray v. McDonald. Perhaps you could summarize for us the result 
of that litigation, because I think it shows how the VA 
bureaucracy--and I mean no disrespect to anybody who works at 
the VA. There are some hardworking, dedicated people there. 
Unfortunately, you made the point, I agree, that very often 
bureaucracies devote more time and effort and ingenuity to 
denying claims than enabling them.
    Commander Wells. Yes, sir.
    Senator Blumenthal. When you know in our gut they should be 
granted.
    Commander Wells. Thank you, Senator. We filed an amicus 
brief and worked very closely with the folks on Gray vs. 
McDonald. What the Court of Appeals for Veterans Claims said 
was that the exclusion of bays and harbors from inland waters--
and actually that would include from the sovereign territory of 
Vietnam--was completely irrational and that they felt that the 
regulation was arbitrary and capricious.
    They then ordered the VA to rewrite that regulation. The 
time for appeal has expired, and in an effort to provide 
assistance, I have met twice with Deputy Secretary Gibson and 
the general counsel, Lee Bradley, on this issue and have 
provided them some suggestions.
    In the pipeline, we have a couple of other cases dealing 
with Da Nang Harbor, including one with Nha Trang Harbor as 
well where there is documented proof of Agent Orange exposure.
    I think the VA is sensitive to this. While I cannot speak 
for the Deputy Secretary, I do believe that in sitting down and 
going through the briefings, the lightbulb came on and he was 
aware of what the situation is. So, we are at least cautiously 
optimistic that a new regulation will come out before these 
other court decisions come out and that we will not be 
dissatisfied, let me put it that way, with what they come up 
with. We are certainly hoping to get partial or complete 
relief, you know, as a result of their study.
    Senator Blumenthal. Thank you for that answer. Thank you 
for your work on this issue. The lightbulb needs to come on for 
the Nation on this issue.
    Commander Wells. Yes, sir. That is why we really think that 
your bill, S. 901, is great because it will help turn the light 
bulbs on. If the Australians had not turned the lightbulb on, 
there would be no Blue Water Navy movement.
    Senator Blumenthal. Let me just close by saying that term 
``arbitrary and capricious'' is not likely used by a court to 
describe administrative action. People should understand it is 
a term of art that is used to describe the most unacceptable 
and unjustifiable action by an administrative bureaucracy. It 
is the equivalent, in layman's terms, of dumb and unjustified.
    So, I say that as a lawyer--forgive me, Mr. Chairman, I am 
a recovering lawyer--that the conclusion of the Court is a 
pretty dramatic one here. So, I think it gives us an example of 
how we need to push the VA and our entire Federal executive 
branch to do more and do better. Thank you.
    Chairman Isakson. Senator Boozman.
    Senator Boozman. Thank you, Chairman Isakson. Again, thank 
you and Senator Blumenthal for having this very important 
hearing. Mr. Rowan, we certainly know that Agent Orange 
exposure has impacted the children of Vietnam veterans and 
caused serious health problems. As the Vietnam veterans 
population ages, what affects are we seeing in the 
grandchildren of these veterans?
    Mr. Rowan. Yeah, that is the really sad point that has been 
coming out at the hearings we have been holding. You know, it 
is one thing to talk to the 45-year-old daughter or son of a 
Vietnam veteran, but to look at the 12-year-old grandson or 
granddaughter or great-grandchild, believe it or not, who is 
suffering from learning disabilities or possible other cancer 
issues and/or other kinds of strange things, to be honest.
    Look, we have held these hearings all around the country 
the last several years. We have held over a couple hundred of 
them. There are thousands of people who have testified, so we 
are all over the map about what people are telling us. Yet, 
there are certain things that have kind of popped up to the 
fore that we think will probably be the highlight focus when 
they get this research moving to either say yea or nay. But it 
has really run the gamut.
    Senator Boozman. Who is conducting the research?
    Mr. Rowan. Nobody. That is it. We need this bill. We need 
this work done. That is the whole issue.
    Senator Boozman. Is VA showing any interest at all?
    Mr. Rowan. No. Very clearly they said no. They said, well, 
there are other agencies that could do this kind of work, which 
is true, but I will go back to my earlier analogy. I still 
remember when they called it post-Vietnam syndrome. OK? When we 
came home and we had our issues with the Vietnam vets. People 
would say, oh, it is post-Vietnam syndrome, like it was 
something bizarre just to us.
    Until they finally understood what Post Traumatic Stress 
Disorder was, and that was facilitated by the VA itself when 
they created their Center of Excellence, to focus on mental 
health and Post Traumatic Stress Disorder issues. They need to 
do the same for this issue.
    I understand the sergeant's reticence to give it to the VA, 
believe me--and you would not because the reality is they are 
right, the VA is right. They do not have the wherewithal inside 
their own organization today. But, by creating a Center for 
Excellence assigned to a university somewhere in this country, 
one of the many wonderful universities that work with the VA 
hospital systems, I guarantee you there would be several that 
would vie for the right to do this.
    I guarantee you that would give them the wonderful 
brainpower that we get this work done and it would all be 
outside contractors. Who are we kidding here? It is all going 
to be people we can bring up in the field of expertise.
    Frankly, one of our Vietnam veteran colleagues is the guy 
who invented the genome stuff, so what the hell. They are out 
there. We can find them.
    Senator Boozman. So, you have had your hearings and things, 
and yet, the reality is without S. 901----
    Mr. Rowan. We are going nowhere.
    Senator Boozman. We are not going any place.
    Mr. Rowan. No, no.
    Senator Boozman. Very good.
    Mr. Rowan. No. And as I say, it is not just for us. It was 
Persian Gulf veterans who were mentioned earlier. It was 25 
years ago. I hate to say it, stuff is bubbling to the top 
already for them and their kids. Even with some of the new vets 
coming home, I am getting some really sad stories coming to my 
attention from dealing with--many of whom are the sons and 
daughters of the Vietnam veterans that are in my organization.
    Senator Boozman. Dr. Ramos, in your written testimony, you 
mention the distillation process on board ships and how this 
process may concentrate Agent Orange in the distilled water. 
Can you expand on that? Is there evidence that suggests the 
distillation process did concentrate Agent Orange at levels 
significantly higher than that found in seawater?
    Dr. Ramos. The mechanics of that particular distillation 
process is really no different from any other purification 
process that takes place when you try to purify water. So, 
essentially, all that you are trying to do is heat up the 
water, vaporize it, condense it at the end, which leaves 
impurities behind.
    When that type of experiment is carried out, sort of in the 
laboratory setting, not really in the field, the demonstration 
that was made by both the Australians and then replicated here 
in the U.S. following that report is that, in fact, if dioxin 
is present in that water it would be concentrated because 
dioxin, of course, is not going to be water-soluble, it is not 
going to vaporize at the same rate that the water does, it is 
retained concentrated, and then leaches into the water that 
sort of comes on the next cycle.
    The challenge in interpreting that finding relative to the 
actual exposure scenario in Vietnam is, of course, that no 
evidence of that water being contaminated was available because 
it was carried out after the fact. That said, if, in fact, 
dioxin was there, and there are some individuals like Mr. Wells 
indicated before, then the possibility does exist for 
concentration to have taken place.
    Senator Boozman. Thank you, Mr. Chairman.
    Chairman Isakson. Senator Moran.
    Senator Moran. Mr. Chairman, again, thank you very much for 
holding this hearing. Let me ask first unanimous consent to 
have included in the record a number of Institute of Medicine 
reviews and I want to quote a couple of times from those 
reports.
    Chairman Isakson. Without objection.
    [The information referred to follows:]

    The entire 837-page 2010 Update PDF is available from The 
National Academies Press at http://www.nap.edu/catalog.php? 
record_id=13166

    The entire 1007-page 2012 Update PDF is available from The 
National Academies Press at http://www.nap.edu/catalog.php? 
record_id=18395

    Senator Moran. Thank you, Mr. Chairman. The 2010 Institute 
of Medicine review on the impact of future generations 
regarding Vietnam veterans' exposure says this, possible health 
effects in offspring following paternal exposure merit further 
investigation because, ``Most of the available epidemiology 
studies are not relevant to the primary exposure group of 
concern, male Vietnam veterans.''
    Then, in 2013, the same institute reached the conclusion, 
``A connection between toxin exposure and effects on offspring, 
including developmental disruption, and disease onset in later 
life is biologically plausible.'' Then, in 2012, ``The 
hypothesis that paternal preconception exposure to toxic agents 
may result in harm to their children remains unresolved, in 
part, because of the sparseness of research on the subject.''
    Mr. Chairman, I thank you for allowing that to be admitted 
to the record, in part, to make certain that the suggestion 
that anything is redundant and unnecessary is at least, 
according to this Institute, overcome. Let me just ask the 
witnesses, in particular, if they have anything that would like 
to respond that they have not been asked related to the 
testimony of the representatives from the Department of 
Veterans Affairs.
    My impression as I watched the audience, there was some 
disagreement in statements that were made and I wanted to give 
you the opportunity to explain why heads might have been 
shaking during their testimony.
    Mr. Wells.
    Commander Wells. Senator, one of the issues that I did not 
have an opportunity to respond to was the estimate of 40-some 
thousand people that would be covered under existing law, which 
I think this is important because the VA has used that, in 
part, to justify a $4.4 billion cost for S. 681 when our 
liaison, as confirmed by the Committee, with CBO indicates that 
it will be $1 billion or less. Part of that--and again, I think 
it is because they do not have people who know what they are 
doing as far as Navy ships go doing this process.
    We ran a manpower analysis ourselves using the Navy manning 
plan and we checked our analysis, double-checked it, we 
provided it to CBO, they agreed with our approach and showed 
that actually 83,000 people now are covered under existing law 
with another 1,100 people covered under non-Hodgkin's lymphoma.
    This, I think, is one of the reasons why the VA cost or 
projected cost of the bill is just way over the top. Now, I 
gave our figures--and we have also looked at other potential 
offsets that the VA has not and we gave all that information to 
the Deputy Secretary and I think he is working that with the VA 
bean counters now to see if we can respond to that.
    Other than that, I would say that the VA has come up with a 
number of reasons why this bill should not be adopted or why 
the Navy vets were not exposed and some of them we have 
addressed here today. If you all have any questions about any 
of those things, I would be happy to answer them. In our 
prepared testimony at the legislative hearing on S. 681, we did 
go through a number of those. Thank you, sir.
    Senator Moran. Master Sergeant Ensminger.
    MSgt. Ensminger. Yes, Senator. The VA's description of 
their process for Camp Lejeune claims that Dr. Erickson gave 
while the VA was testifying and how detailed they were, nothing 
could be further from the truth. I am serious. We have cases 
where their so-called subject matter experts have used 
citations from Wikipedia in their decisions.
    Some of them had conflicts of interest. While they are 
working for the VA as full-time staff, were also working for 
law firms in opposing Family Leave Act claims and workmen comp 
claims and toxic tort cases.
    We had one subject matter expert in the case that Senator 
Burr brought up during his testimony, the subject matter expert 
said that this veteran who had kidney cancer, they had done a 
comprehensive review of two decades worth of studies, and in a 
meta-analysis, and could find no documented evidence where TCE 
causes any kind of cancer.
    That was dated January of this year when no less than the 
EPA in 2011, IARC in 2013, and our national toxicological 
program this the summer have classified TCE as a known human 
carcinogen, mainly based on the evidence that it causes kidney 
cancer. So, you know, I do not know what they have been 
reading, or what they have been looking at, but their process 
is far from successful.
    Senator Moran. Thank you very much.
    Mr. Rowan.
    Mr. Rowan. Yeah, I would just like to add that one of the 
studies that was done was the Ranch Hand study where they 
followed these folks every 5 years for 20-plus years. The 
things that came out of there were horrifying, quite frankly; 
but it never seemed to penetrate into the VA structure. For 
example, I can give you something very simple. One of the 
things that came out very early in the Ranch Hand study was the 
fact of how many of them were diabetic.
    They were not even looking for that. It was an accident 
that one of the researchers finally said, whoa, wait a minute, 
half of these guys are diabetic. I knew that when I was 
diagnosed as a diabetic in 1994, but the VA did not get around 
to granting me any benefit until 2003 when the Secretary 
finally added diabetes to the list. There are all kinds of 
information in that data.
    By the way, those samples, those serum samples and all the 
rest of it, the biological stuff, was almost going to get 
thrown out. We had to fight like hell to get it saved, which 
had nothing to do with any Government agencies saving it, by 
the way. This stuff is still around. The researchers can still 
go back and access it.
    I would highly encourage anybody who wants to do that kind 
of research to do so. But those people are still here. And one 
of the things that came around--I remember talking to one of my 
colleagues who is going through that study, and he said that 
after they got finished and he had talked to one of the 
researchers he found out that his sterility was such an off-
the-chart rare issue. Later, he sat around with 12 guys at a 
bar when the study was done and six of them had the same issue. 
I mean, it is just crazy.
    Senator Moran. Mr. Rowan, thank you. Thank you for 
conducting the town hall meetings that the VBA has, especially 
the seven in Kansas. We are grateful for that.
    Mr. Chairman, thank you.
    Chairman Isakson. I want to thank all our panelists, and in 
light of the last comments, remind everybody that we will leave 
the record open for 7 days for any additional information you 
would like to submit. We appreciate your service to the country 
and appreciate your being here today.
    Senator Blumenthal.
    Senator Blumenthal. I would like to thank each of our 
witnesses as well. It has been very illuminating and profoundly 
important.
    MSgt. Ensminger, I was struck by your comments about the 
conflicts of interest and I would ask respectfully that you 
perhaps speak with our staff confidentially so that we can 
follow up on some of the information that you may have.
    I want to encourage each of you also to supplement the 
record, as I indicated earlier, with stories, personal stories, 
because many of these conditions do not manifest for years 
after exposure. This is not like the normal battlefield wound 
where it is visible, it is dramatic. It may be invisible at the 
time it occurs and manifests only years afterward and sometimes 
maybe a generation later. Yes, sir.
    MSgt. Ensminger. You just said something that brought an 
issue up for me and many other veterans that I have talked to. 
Why does the VA always say in their denials that the veteran 
did not demonstrate any signs of kidney cancer while he was on 
active duty? I mean, it is the most stupid phrase I have ever 
seen. I mean, of course they did not. It took 20 years for them 
to develop kidney cancer.
    Senator Blumenthal. It sounds arbitrary and capricious.
    MSgt. Ensminger. Yes, sir.
    Mr. Rowan. If I could add one thing?
    Senator Blumenthal. But I want to--I am not the Chairman so 
I cannot call on you, but I want to make one last point and 
that is the bill that Senator Moran and I have--and again, I 
want to thank him while he is here for his work on this bill--
provides for research. One of the points of today's testimony 
is the best research in the world has to be used to be 
effective.
    If the VA or any other agency looks away or turns a blind 
eye to it or ignores it or disregards it, it will have no 
effect. So, we need to work on the mindset and the attitude as 
well as the investigative authority. So, thank you very much to 
each of you.
    Chairman Isakson. Mr. Rowan.
    Mr. Rowan. Thank you, Mr. Chairman. Just one quick thing. 
Senator Hirono--I am mispronouncing her name probably--but she 
came on something earlier and one of the other people mentioned 
Fort McClellan. The DOD does not have clean hands here. They 
also fight like hell every time we try to ask for information.
    I mean, at the VVA, we like to sue people if we do not get 
what we want and we have had more suits than I care to think 
about against the Department of Defense to get them to cough up 
information. And exposure stuff, we have gone into this, the 
Camp Lejeune thing was water, Fort McClellan was experiments. I 
mean, it is just one thing after another. So, Congress must 
take a look at what the DOD is not providing but should.
    Senator Blumenthal. That is why I have been referring to 
the Federal executive branch, not just the VA. You are 
absolutely right, Mr. Rowan.
    Chairman Isakson. Thank you all for your testimony. We 
stand adjourned.
    [Whereupon, at 12:38 p.m., the hearing was adjourned.]

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