[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


  AN ASSESSMENT OF THE POTENTIAL HEALTH EFFECTS OF BURN PIT EXPOSURE 
                             AMONG VETERANS

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH


                                OF THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         THURSDAY, JUNE 7, 2018

                               __________

                           Serial No. 115-65

                               __________

       Printed for the use of the Committee on Veterans' Affairs


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Available via the World Wide Web: http://www.govinfo.gov                     
                     
                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-728                      WASHINGTON : 2019                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                      NEAL DUNN, Florida, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
BILL FLORES, Texas                       Ranking Member
AMATA RADEWAGEN, American Samoa      MARK TAKANO, California
CLAY HIGGINS, Louisiana              ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto      BETO O'ROURKE, Texas
    Rico                             LUIS CORREA, California
BRIAN MAST, Florida

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            
                            
                            C O N T E N T S

                              ----------                              

                         Thursday, June 7, 2018

                                                                   Page

An Assessment Of The Potential Health Effects Of Burn Pit 
  Exposure Among Veterans........................................     1

                           OPENING STATEMENTS

Honorable Neal Dunn, Chairman....................................     1
Honorable Julia Brownley, Ranking Member.........................     3
Honorable Phil Roe, Chairman, House Veterans Affairs Full 
  Committee......................................................     4

                               WITNESSES

Tom Porter, Legislative Director, Iraq and Afghanistan Veterans 
  of America.....................................................     5
    Prepared Statement...........................................    35
Kenneth Wiseman, Associate Legislative Director, Veterans of 
  Foreign Wars of the United States..............................     7
    Prepared Statement...........................................    36
Ralph L. Erickson, M.D., Dr.PH , Chief Consultant, Post-
  Deployment Health, Office of Patient Care Services, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....     9
    Prepared Statement...........................................    38

  Accompanied by:

    Drew A. Helmer M.D., M.S., Director, War Related Illness and 
        Injury Study Center and Airborne Hazards Center of 
        Excellence, VA New Jersey Health Care System, Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

                        STATEMENT FOR THE RECORD

Burn Pits 360 (Tom Porter).......................................    42
Government Accountability Office (GAO)...........................    63
Victor J. Dzau, MD, President, National Academy of Medicine, on 
  behalf of The National Academies of Sciences, Engineering, and 
  Medicine.......................................................    68
Veterans Warriors................................................    69
Whistleblowers of America........................................    71
Tragedy Assistance Program for Survivors, Wounded Warrior 
  Project, Vietnam Veterans of America...........................    74

 
  AN ASSESSMENT OF THE POTENTIAL HEALTH EFFECTS OF BURN PIT EXPOSURE 
                             AMONG VETERANS

                              ----------                              


                         Thursday, June 7, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                     Subcommittee on Health
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 3:01 p.m., in 
Room 334, Cannon House Office Building, Hon. Brad Wenstrup 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Dunn, Bilirakis, Radewagen, 
Higgins, Mast, Roe, Brownley, Takano, Kuster, O'Rourke, and 
Correa.
    Also Present: Representatives Esty, Wenstrup, Ruiz, and 
Gabbard.

            OPENING STATEMENT OF NEAL DUNN, CHAIRMAN

    Mr. Dunn. All right. Good afternoon, and thank you all for 
joining us today. The subject of today's meeting is an 
assessment of the potential health effects of burn pit exposure 
among veterans.
    And I would like to ask unanimous consent for the following 
non-Subcommittee Members to sit on the dais and participate in 
today's hearings: Congresswoman Esty from Connecticut, 
Congressman Wenstrup from Ohio, Congressman Ruiz from 
California, and Congresswoman Gabbard from Hawaii. Without 
objection, that is so ordered.
    Before we begin, I want to take a moment to say what an 
honor it is to have been selected to serve as the Chairman of 
this Subcommittee. I am the son of a multigeneration Army 
family. I also had the privilege of serving as an Army surgeon. 
I am also the father of a combat veteran.
    I have treated many thousands of soldiers, sailors, airmen, 
and veterans in my career. And I have treated them in VA 
hospitals and clinics, DoD facilities, civilian facilities, and 
intense and MASH units in a combat zone, so--I have worked in 
most of the American territories, from Puerto Rico and the USVI 
to the Trust Territories of Oceania. I feel personally familiar 
with the health needs of our Nation's veterans, and I am 
committed to meeting those needs.
    We have great veterans, deserving veterans, in all of the 
places that I mentioned. And as a Nation, I feel that we are 
failing most of them to one degree or another.
    I look forward to work with all of my colleagues on this 
Committee, and I do mean all of my colleagues on this 
Committee. And I thank you for your commitment to our veterans.
    With that, I think we can also agree that this is a 
critical time for the Department of Veterans Affairs health 
care system, particularly with the signing of the MISSION Act 
just this week. I am grateful to Chairman Roe and former 
Subcommittee Chairman Wenstrup for their leadership and 
support. I am very much looking forward to continuing this 
Subcommittee's long history of rigorous oversight to ensure 
that our veterans have the timely quality care that they 
deserve.
    Today's hearing concerns regarding the potential long-term 
health effects of burn pit exposure. This is a critical issue 
facing today's servicemembers and veterans, and should be an 
equally critical issue for VA's clinical and research programs.
    The testimony provided for today's hearings by the veteran 
service organizations and other advocacy groups and the 
anecdotal reports of serious issues following exposure to burn 
pits in Iraq and Afghanistan are worrisome to say the least. 
They also make it clear that, despite a high level of 
attention, far more questions remain than answers on the exact 
nature and impact of burn pit exposure.
    The Airborne Hazards and Open Burn Pit Registry, which 
Congress mandated in 2013, is an important tool for the VA to 
use to track and monitor those who are exposed to burn pits 
during their service. I have concerns that the Registry is not 
being used to its greatest potential to communicate with 
veterans exposed to burn pits who are worried about their 
current and long-term health and well-being. This registry 
should be used to guide the VA's research into toxic exposures.
    Just 3 weeks ago, we held a joint hearing with the 
Subcommittee on Oversight and Investigations that exposed fears 
that the VA research program was not properly prioritizing 
proposed research regarding veteran-specific conditions and 
concerns. I have a hard time thinking of a topic that is more 
relevant, important, or deserving of the attention and support 
of the VA researchers than this one.
    Moving forward, I would like to see the VA prioritize 
supporting and conducting the epidemiological research that 
will enable us to understand the relationship between burn pit 
exposure and the pulmonary and respiratory issues that veterans 
returning from deployment report experiencing.
    That said, I fear that the narrow focus on burn pit 
exposure could be blinding us to other potential in-theater 
exposures, like particulate matter and unknown or unrecognized 
infectious pathogens that could have an even greater risk to 
those who have been deployed in the Middle East. And I believe 
these subjects need to be carefully monitored and researched as 
well.
    I am grateful to our witnesses from the VA and from our 
veteran service organizations partners for being here this 
afternoon. I would also like to thank all of you who provided 
statements for the record, as your input is extremely 
beneficial and serves as an important part of the record as 
well.
    I will say that I am disappointed that the representatives 
of DoD chose not to participate today. This is currently the 
only planned panel on this subject. Their statement is 
available for the record. However, as a potential key 
contributor in what needs to be an ongoing research into this 
problem, their presence today would have been valuable.
    I will now yield to Ranking Member Brownley for any opening 
statement that she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman.
    Every era of veterans has experienced some type of 
environmental, radiological, chemical, biological hazard while 
on the battlefield. Most recently, Operation Iraqi Freedom and 
Operation Enduring Freedom era servicemembers were exposed to 
airborne toxins, many of which we have yet to identify.
    We send our servicemembers to fight abroad, and now DoD and 
VA have a responsibility to properly address their health care 
needs when they come home. The DoD and VA must work together 
with clinicians and investigators to identify all veterans who 
may have been exposed to airborne hazards.
    This need to know has resulted in numerous VA-maintained 
registries. While today's hearing is centered around only one 
of these registries, I urge today's witnesses to consider 
whether the value of these registries would be vastly improved 
by consolidating them into one. One master registry would 
likely be easier for both veterans, physicians, and 
investigators to navigate.
    With that said, today's hearing is focused in part on the 
Airborne Hazards and Open Air Burn Pit Registry. The exposure 
of post-9/11 veterans stationed in Iraq and Afghanistan to 
airborne hazards because of the military's use of open air burn 
pits has affected an untold number of servicemembers and 
veterans.
    For this reason, in 2012, Congress required VA to establish 
the open burn pit registry. The open burn pit registry is an 
effort to identify and monitor the health effects of toxic 
airborne chemical and fumes on veterans exposed to those open 
air burn pits. While in the current state it cannot be the 
basis of scientific research, it can help the VA to define 
research questions and allow the VA to update and track 
participants.
    However, it does have its limitations, as outlined by the 
National Academy of Sciences. As this registry is voluntary and 
based on self-reported information, investigators cannot link 
airborne hazards and long-term health efforts. This is 
disappointing because our veterans need our help now.
    One way the VA has attempted to advance research is through 
its war-related injury and illness center, Airborne Hazards 
Center of Excellence, by flagging veterans with particularly 
complex or unique symptoms or diagnosis that were exposed to 
airborne hazards for more complete evaluations. But also, not 
only is VA capturing much needed data, but also ensuring they 
receive advanced clinical care through expertly prepared 
treatment plans.
    However, VA's ability to advance this type of research is 
limited by DoD's cooperation and efforts to identify the 
servicemembers exposed to burn pits. That is why it is both 
unfortunate and disappointing, as the Chairman said, that the 
agency who will need to be a true partner is unwilling to 
participate in today's discussion.
    Furthermore, until a fully interoperable electric health 
record system is set up between two agencies, VA will continue 
to be beholden to DoD's willingness to cooperate. For this 
reason, it is of utmost importance that VA's Electronic Health 
Record Modernization team is in direct communication with both 
VA clinicians and VA investigators. And I look forward to 
hearing more from the VA on this issue.
    Mr. Chairman, thank you for holding today's hearing. It is 
an important one. And I thank you to each of the witnesses for 
the work you have done to ensure these veterans are neither 
forgotten or overlooked. And I yield back.
    Mr. Dunn. Thank you very much, Ranking Member Brownley.
    I now yield 5 minutes to the overall Committee Chairman, 
Dr. Phil Roe.

OPENING STATEMENT OF PHIL ROE, CHAIRMAN, HOUSE VETERANS AFFAIRS 
                         FULL COMMITTEE

    Mr. Roe. Thank you, Mr. Chairman and Ranking Member 
Brownley. And I thank everyone for being in attendance today.
    As a scientist in training in medical school, epidemiology 
always tweaked my interest. And as a Member of this Committee 
for the past several Congresses, I have been following the 
issue of DoD toxic exposures with great interest. In fact, 
Ranking Member Walz and I have been the lead sponsors 
supporting appropriations for DoD's congressionally directed 
medical research program on Gulf War illness the past several 
years. However, I have shared my thoughts on toxic exposure 
medical research methodology in past hearings. I maintain that 
using data from self-reported registries creates a selection 
bias and is an inherently flawed way to conduct research.
    That being said, I see tremendous room for improvement in 
this arena, especially with the ongoing development of a joint 
electronic health record between DoD and VA. With this new EHR, 
we have an incredible opportunity to ensure data integrity for 
future environmental and toxic exposure epidemiological 
studies. Granted, that joint health record will likely not be 
deployed 10 years down road. But if DoD, VA, and Cerner can't 
develop ways to use it to capture and mine deployment and 
related health data during its development, we lose an 
incredible opportunity to identify data to help us understand 
whether a veteran's service to this country contributed to 
their or caused their unexplained health conditions. I believe 
we can and must use this opportunity to ensure that capability 
is part of the design.
    I also believe we should be taking a look, to the extent 
possible, at the local populations of where these exposures are 
believed to have originated. For example, we should be looking 
to study local and native people of Kuwait and Iraq to see if 
the conditions attributed to Gulf War illnesses are present 
within the local population. If you actually have a whole two 
sets of populations, you could study and compare. If we can 
broaden the sample size of those infected beyond servicemembers 
and veterans who self-report, we might have a better 
opportunity to identify the causality of military practices and 
related health conditions. Just some food for thought.
    As I mentioned before, this is an incredibly important 
subject to me, and I am disheartened that DoD declined to 
participate today. Current and future servicemembers deserve to 
know what steps DoD is taking to protect the health of the men 
and women who sign up to serve. Veterans deserve to know what 
steps VA is taking to advance research to identify and address 
health hazards that may be related to exposure.
    I will just harken back 40 to 50 years ago now to Vietnam 
when we, you know, sprayed everything, and Korea also, where I 
served, Thailand, other places where Agent Orange was sprayed. 
The people who transported this, we didn't keep adequate 
records. And we are going to vote on a bill hopefully on the 
House floor in the next couple of weeks, the Blue Water Navy 
bill, which every Member of this Committee--we have been trying 
for 20 years to get it done. This Committee got it done.
    We didn't keep adequate records. There is really no way to 
determine the science behind that. That is just impossible. So 
I finally said, look, let's just make this determination and do 
it on the basis of what is right for the veteran to do, since 
we cannot prove it one way or the other.
    Again, I would like to thank Dr. Dunn for allowing me to 
join the hearing today, as well as the panelists for sharing 
your time with us.
    And, Mr. Chairman, I yield back.
    Mr. Dunn. Thank you very much to Chairman Roe.
    Joining us this afternoon for our first and only panel is 
Tom Porter, the Legislative Director for the Iraq and 
Afghanistan Veterans of America. And also, Mr. Kenneth Wiseman, 
the Associate Legislative Director for the Veterans of Foreign 
Wars of the United States. And Dr. Ralph Erickson, the Chief 
Consultant for Post-Deployment Health for the Office of Patient 
Care Services for the Veterans Health Administration of the 
Department of Veterans Affairs. Dr. Erickson is accompanied by 
Dr. Drew Helmer, the Director of the War Related Illness and 
Injury Study Center and Airborne Hazard Center of Excellence 
for the VHA New Jersey Health Care System.
    Thank you all for taking the time to participate in this 
important hearing today.
    And, Mr. Porter, I believe we will begin with you. You are 
now recognized for 5 minutes.

                    STATEMENT OF TOM PORTER

    Mr. Porter. Thank you, Mr. Chairman.
    Before I get started, I would like to call your attention 
to the many IAVA members that are here in town, many from 
California and Tennessee and Texas. So I just wanted to ask you 
to note that we have got folks in town storming the Hill on 
burn pits issue.
    On behalf of IAVA, thank you for allowing me to share our 
views on what may now be the Agent Orange of our generation. I 
am here not only for IAVA, but as an OEF veteran exposed to 
airborne toxins from burn pits and other sources at many 
locations I was deployed to in Afghanistan and Kuwait between 
2010 and 2011.
    Before I went down range, I had healthy lungs. Shortly 
after I arrived in Kabul, where the air is particularly bad, my 
lungs had a severe reaction and became infected. It was 
controlled with medication over the next year. However, after 
redeploying home, I stopped the medications and symptoms came 
back. And I was diagnosed with asthma as a result of my 
deployment.
    Exposure to burn pits used by the military to destroy 
medical and human waste, ordnance, plastics, and other waste 
has been widespread. It is not just those working at burn pits. 
Search for the Poo Pond song on YouTube and you will hear one 
soldier's humorous take on the enormous lake of human waste 
that tens of thousands of servicemembers lived, worked, and ate 
around at Kandahar Airfield in Afghanistan.
    You could also learn from many who have served in Kabul, an 
enormous city with open sewers and whose population routinely 
burns dry animal dung to keep warm in the winter. Our military 
serving there are suffering the impacts from breathing airborne 
feces and other toxins for extended period of time. There have 
been burn pits there as well.
    Our VSO friends, especially those who served in Vietnam, 
know the depth of this problem. Dr. Tom Berger at Vietnam 
Veterans of America will tell you they know too well the 
hazards of these battlefield exposures saying, quote, that is 
one of the reasons VVA is so involved in this issue. We don't 
want to see the newest generation of vets go through the same 
health care challenges we are still facing with toxic 
exposures, especially with our children and grandchildren.
    Army veteran Christina Thundathil, a member of ours, told 
us recently of her deployment to Iraq. Although her specialty 
was food prep, her job was to drag the full bins of Porta-John 
refuse daily, douse it with jet fuel, and light it on fire, 
stir it with her e-tool, then repeat it until she had a brick 
that she could bury in the sand. She has got serious injuries 
and she needs a cure now.
    The examples are many. However, little is understood about 
the long-term effects. We see an upward trend in the number of 
members reporting symptoms associated with burn pits, with 80 
percent of IAVA members reporting being exposed to burn pits on 
deployment and over 60 percent of those suffering symptoms.
    This year, IAVA will educate Americans about burn pits and 
airborne toxic exposures and the devastating impact it could be 
having on the health and welfare of millions of post-9/11 vets. 
To see the enormous extent of interest in this issue by 
veterans, you need to only look at the comments section on any 
related article online or see our viral burn pits hash tag on 
social media.
    The VA has an airborne hazards and burn pit registry which 
helps them collect and analyze data on health conditions 
related to deployment exposures. Unfortunately, only 141,000 
have completed the registry out of 3.5 million the VA says are 
eligible. Only 1.7 percent of the post-9/11 veterans eligible 
have completed it, and only 35 percent of IAVA members exposed 
have.
    A definitive link between exposure and specific illnesses 
has not yet been made, and the registry is not well-known and 
is underused. The result is that the data is not being 
collected at the levels desired to inform the next steps. It is 
for this reason that IAVA helped to develop new legislation.
    On May 17, IAVA stood with Iraq war veteran Congresswoman 
Tulsi Gabbard and Afghanistan veteran Congressman Brian Mast. 
Thank you, Congressman. We also stood with the support of 23 
other VSOs in support of the introduction of the Burn Pits Act.
    The bill directly directs DoD to include periodic health 
assessments done by the military and, at separation, an 
evaluation of whether a servicemember has been exposed to burn 
pits or toxic airborne chemicals. If they have, they will be 
enrolled in the burn pit registry, unless they opt out.
    The bill simply does what should have been done long ago. 
It compels DoD to record exposures before the servicemember 
leaves the military. Retired general and IAVA board member 
David Petraeus, who once commanded all forces in Iraq and 
Afghanistan, recently expressed his support for the bill 
saying, quote: Veterans are currently experiencing illnesses 
that are like--that likely are related to exposure to toxins in 
the war zones and swift action is needed to understand the 
impact on health from exposure to smoke from burn pits and 
other sources.
    We ask the Committee to hear the calls of the many exposed 
veterans and enact the Burn Pits Accountability Act this year.
    Again, I thank the Committee for inviting me to express our 
views, and I stand by for any questions.

    [The prepared statement of Tom Porter appears in the 
Appendix]

    Mr. Dunn. Thank you, Mr. Porter.
    Mr. Wiseman, you are now recognized for 5 minutes.

                  STATEMENT OF KENNETH WISEMAN

    Mr. Wiseman. Chairman Dunn, Chairman Roe, and Ranking 
Member Brownley, and Members of the Subcommittee, on behalf of 
the Veterans of Foreign Wars of the United States and its 
auxiliary, thank you for the opportunity to testify on the 
important issue of burn pits.
    The use of open air burn pits in combat zones has caused 
grave health complications for many servicemembers, past and 
present. Harmful materials are present in burn pits creating 
clouds of hazardous chemical compounds that are unavoidable to 
those in close proximity.
    While the VFW is glad to see more than 140,000 veterans 
have enrolled in the VA's Airborne Hazards and Open Burn Pit 
Registry, we are concerned that the results of the National 
Academy study on the registry have not been fully implemented. 
The VFW urges VA and Congress to act swiftly on these important 
recommendations.
    For example, a similar study operated by Burn Pits 360 
allows the spouse or next of kin of registered veterans to 
report the cause of death for the veteran. VA must add a 
similar feature to its registry to ensure VA is able to track 
trends.
    The VFW hears from veterans about the lack of outreach from 
the registry. The low rate of completion for the medical exam 
associated with joining the registry is one of many reasons VA 
must improve its outreach efforts.
    As VA moves to implement the electronic health record, EHR, 
special attention must be given to ensuring the record can 
interact with the registry. This will ensure that data follows 
the veteran from the time of the exposure through discharge and 
life after the military. It will also allow doctors to provide 
proper care knowing the full history of the veteran.
    Much of the veterans' long-term health is dependent on what 
happened to them while in the military. While ensuring the EHR 
communicates with the registry is important, there is also a 
need for other information from DoD. The VFW has long advocated 
for better sharing of all relevant data on burn pits, to 
include environmental studies and medical records of veterans 
with related health issues. Congress must require DoD to share 
all data related to burn pits.
    The VFW supports passage of H.R. 5671, the Burn Pits 
Accountability Act, and H.R. 5920, the Airborne Hazards and 
Open Burn Pit Registry Improvement Act, which would improve the 
Registry and the overall body of knowledge on burn pits.
    The VFW is happy to learn that a joint project between DoD 
and VA to create a database of exposure information is 
underway. The individual longitudinal exposure record will 
create a centralized database for records related to exposure, 
feed data into needed research, allow doctors to know what the 
veteran has faced, and will allow greater access to evidence 
for a veteran's disability claim. The VFW knows that research 
is being funded and performed by the VA. The VFW supports VA's 
inclusion of oversight ensuring proper scientific methods are 
used in the studies being funded.
    We also support VA's efforts to hire more researchers and 
to fund employee-led research like that conducted at the VA 
medical center in Northport, New York, which found a connection 
between deployments to Iraq and Afghanistan and adult onset 
asthma among 6,200 veterans in the local area of the facility. 
Several other studies are underway, and this will require 
dedicated funding.
    The VFW is pleased that VA will ask the National Academies 
to review existing research to determine whether the evidence 
supports a connection between exposure to burn pits and deadly 
respiratory conditions. Veterans deserve to know what is making 
them sick. The VFW urges this Subcommittee to ensure the 
important study is commissioned and properly conducted.
    Incorporating proper oversight and dedicated funding for 
burn pit related research is why the VFW also supports 
establishing a Congressionally Directed Medical Research 
Program, or CDMRP, specific for burn pits. The Gulf War Illness 
CDMRP has shown progress in identifying causes and effective of 
treatments for Gulf War Illness, and a similar program for burn 
pits will help exposed veterans.
    The VFW also wants to highlight the impact of burn pits on 
women veterans with particular regard to reproductive issues. 
Medical research on the Gulf War has historically failed to 
properly include women veterans. A VFW member who was exposed 
to burn pits called me, and she told me how her children were 
born with birth defects, including seizures, how they were born 
with high levels of heavy metals in their blood, and how she 
had to get a hysterectomy in her late 20s. This is not normal, 
and this must be answered.
    Women veterans deserve to understand how their military 
service may or may not have long-term impacts on their health. 
As such, the VFW calls on VA to improve research related to the 
impact of burn pits as they relate to reproductive health 
issues and birth defects.
    In closing, the VFW sees that there are more miles in front 
of us than behind us on the issue of burn pits.
    Mr. Chairman, this concludes my testimony, and I am ready 
for any questions you or the Subcommittee may have. Thank you.

    [The prepared statement of Kenneth Wiseman appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Mr. Wiseman.
    Dr. Erickson, I now yield 5 minutes to you.

          STATEMENT OF RALPH L. ERICKSON, M.D., DR.PH

    Dr. Erickson. Good afternoon, Chairman Dunn, Ranking Member 
Brownley, and Members of the Subcommittee. I appreciate the 
opportunity to discuss the ongoing research and actions of the 
Department of Veterans Affairs is taking to identify and care 
for veterans who are exposed to burn pits during service in the 
Armed Forces.
    I am accompanied today by Dr. Drew Helmer, director of both 
the War Related Illness and Injury Study Center, New Jersey, 
and VA's Airborne Hazard Center of Excellence.
    Veterans are appropriately concerned about burn pits and 
airborne hazards during deployments, and so are we. These and 
other exposures may be associated with the reported symptoms of 
shortness in breath and diminished exercise capacity that we 
hear from our veterans. The collaborative and ongoing efforts 
of VA, DoD, and our partners in academia are being fully 
employed to identify veterans who may be at risk and to better 
understand potential short-term and long-term adverse health 
effects that may be associated with their exposure. Our 
combined aim is to limit future exposure to deployed forces and 
to prevent the development of disease and disability.
    Open burn pits were used as a common waste disposal method 
at military bases in Iraq, Afghanistan, and other countries in 
the region. The smoke and fumes created by these burn pits 
added to the already existing complex burden of dust, 
particulate matter, and general air pollution commonly present 
in the Southwest Asia environment.
    In 2013, Congress enacted legislation requiring VA to 
establish and maintain an open burn pit registry for eligible 
individuals who may have been exposed to toxic airborne 
chemicals and fumes caused by open burn pits. In 2014, VA 
established the Airborne Hazards Open Burn Pit Registry. This 
is VA's fastest growing environmental health registry and 
includes more than 144,000 participants as of today.
    VA and DoD subject matter experts meet monthly to discuss 
and plan joint actions for the study of deployment-related 
exposures and their possible association with subsequent 
adverse health conditions. In May of 2017, VA and DoD gathered 
50 subject matter experts and held a symposium to address the 
health effects of airborne hazards exposure during deployment. 
This allowed VA and DoD to review and develop innovative 
approaches to research and clinical care. VA investigators 
recently convened a similar group of experts for a workshop at 
the American Thoracic Society meeting in San Diego.
    One specific early innovation by VA was the establishment 
of the Airborne Hazards Center of Excellence in 2013 at the New 
Jersey War Related Illness and Injury Study Center. The Center 
of Excellence houses VA's only comprehensive clinical 
assessment program dedicated to studying the adverse effects of 
airborne hazards in veterans. Of special note, select registry 
participants with high priority conditions and exposures will 
be invited in for a comprehensive in-person clinical evaluation 
with the option to volunteer for related research projects.
    As part of our written testimony, we highlighted six major 
VA and DoD studies which are addressing the potential adverse 
health effects associated with burn pits and airborne hazards. 
We also included a bibliography of recently published VA work 
and provided two extensive lists of ongoing VA research 
projects in this area.
    VA is committed to the health and well-being of our 
veterans and is dedicated to working with our interagency and 
academic partners to determine the best possible care for our 
veterans. VA hopes to ease the suffering of veterans, while 
building on the momentum and gains made thus far. To this end, 
your continued support is essential and greatly appreciated.
    Mr. Chairman, this concludes my testimony. My colleague and 
I are prepared to answer any questions. Thank you.

    [The prepared statement of Dr. Ralph L. Erickson appears in 
the Appendix]

    Mr. Dunn. Thank you very much, Dr. Erickson.
    I now yield myself 5 minutes for questions. And I will 
start with you, Dr. Erickson.
    One of the critiques we have heard regarding the assessment 
of pulmonary health of returning servicemembers is the use of 
PFTs. Specifically, we have heard that studies on post-
deployment servicemembers are simply read as normal or 
abnormal, and the studies are not compared to any potential 
test numbers prior to deployment because no pulmonary studies 
are often performed before deployment. I am looking 
specifically at the diagnosis of constrictive bronchiolitis.
    Unless you have an abnormal PFT value, you really don't 
have an indication of progress in your workup, yet the patient 
says they don't--he or she doesn't feel as well as they--are as 
fit as they used to be. And given that most of these servicemen 
and -women are at the peak of health, would you agree that it 
is possible that there is a significant decrease in pulmonary 
function that can occur and yet the studies might still be read 
as normal? And do you plan on performing a study that would 
look at the differences in PFTs pre- and post-deployment?
    Dr. Erickson. Absolutely, Chairman. Your question hits to 
the heart of the limitation of pulmonary function tests. One of 
our DoD collaborators in San Antonio, in fact, is trying to 
look at pre- and post-deployment PFTs.
    But one of the innovations that I was alluding to earlier 
at the Airborne Hazard Center of Excellence, in fact, involves 
actually looking at the molecular level, looking at the 
diffusion of oxygen and CO2 across the alveolar membrane, 
because we think, in fact, that PFTs are, in fact, inadequate 
as a screening mechanism.
    Mr. Dunn. Thank you very much.
    Doctor, I think the next question is in the wheelhouse of 
Dr. Helmer.
    One of the major problems impacting the ability to find a 
causative etiology from the burn pits for these illnesses is 
the difficulty in separating local environmental factors, such 
as the burning of dung for fuel, particulate matter, and local 
microscopic flora.
    Has any research been done or are you planning on doing any 
research to look at the pathologic conditions endemic to the 
local population? Do we have any indication that the local 
population has been affected by the burn pits? If not, why do 
you think this is so, and should we be looking into that? And 
also, is it possible, because our servicemembers are not native 
to the area, that they are having an inflammatory action to the 
local environment which the native population may be--to which 
the native population may be immune?
    Dr. Helmer. That is a great question, because I think we 
don't know a lot of those answers right now. And people are 
looking at those issues, both the geologic dust and its effect 
on our servicemembers and the local population. We are also 
looking at the possibility of a genetic environment interaction 
in our servicemembers that may be responsible for the symptoms 
that develop and the various health conditions that we can 
diagnose in servicemembers.
    It is an ongoing question that we are looking at, and we 
are actually partnering with the DoD to try to do some of that 
work.
    Mr. Dunn. Do you have any speculation on infectious 
conditions that--and I am thinking, you know, because of my 
deployments, honestly, of San Joaquin valley fever, 
coccidiomycosis, or unknown or unrecognized other infectious 
agents that behave like those in terms of respiratory 
conditions?
    Dr. Helmer. That is not my particular area of expertise, 
but I know we are looking at that. And certainly, in terms of 
some of the identifiable infectious agents, we have not found 
them when we have gone looking for the underlying mechanism of 
disease in the patients who are symptomatic. But we will need 
to continue to look at that.
    Mr. Dunn. Thank you.
    So I suspect I speak for the entire Committee when I say we 
will be interested in seeing some of the research that you are 
doing to identify any of the many, many potential complicating 
agents here, some of which are every bit as concerning as toxic 
exposure.
    With that, I am going to yield back my time, and we will 
recognize Ranking Member Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    You know, I personally feel like the very best strategy to 
address this issue altogether is just to eliminate the use of 
burn pits. It seems to me that--I have a large Navy base in my 
district. They are using biofuels to fly their airplanes. I 
think that if we put our heads together, we could figure out a 
better way in which to address these issues in the battlefield. 
So I just wanted to say that for the record.
    Dr. Erickson, I wanted to talk to you a little bit about--
you stated in your testimony that the DoD is making a concerted 
effort to encourage servicemembers to enroll in the Registry. 
Can you tell me a little bit about, you know, how they are 
stepping up their efforts and what is really happening?
    Dr. Erickson. Yes. Absolutely, Ranking Member. We very much 
cherish the relationship with DoD because we need to be linked 
at the hip. As we have had our monthly deployment health 
workgroup meetings to deal with these issues, it has become 
very clear that there needs to be no separation from when 
someone takes the uniform off and then enters VA care. And to 
that end, we have partnered with them.
    DoD has, on their own, then, taken steps to actually 
promote participation in the Registry, either after a 
deployment or at the point of transition, which we think is 
just exactly the teachable moment. It is just exactly the right 
place.
    At the present time, I mentioned we have 144,000 people who 
are participating. About 30 percent of that 144,000 are 
individuals who are currently on Active Duty, in the Guard, or 
the Reserve. And we expect that percentage to actually 
increase.
    Ms. Brownley. And are you monitoring that increase? I mean, 
it seems as though 144 is--you are stating that is a lot of 
progress. But based on the entire population, it seems like a 
drop in the bucket to me.
    Dr. Erickson. We certainly are monitoring it. And yet I 
will be the first to tell you that we can do better, and we 
want to do better. This involves outreach through many 
modalities right now, not just in partnering with DoD, but 
through our newsletters, through our participation with VSOs, 
our Web sites. We do a lot of education, townhalls. The list 
goes on, because we want to get the word out. My hope would be 
that, in fact, a hearing such as this would bring additional 
attention to the need for more to participate.
    Ms. Brownley. And I was disturbed to hear Mr. Wiseman's 
testimony with regards to women and women really being 
underrepresented. And I think it is--I think we know that many 
times, not always, but many times, women, once they leave the 
military, they sometimes don't see themselves and identify 
themselves as veterans. So it seems to me we need to make a 
special effort to make sure that we have a large enough 
population of women to be able to ultimately get to the 
research we need to find the treatments that we need. I mean, 
to hear the testimony of a woman who is bearing children with 
defections and so forth, it is very, very disturbing.
    Can you speak to that?
    Dr. Erickson. Yes. Absolutely. I am a third-generation 
career Army officer. My daughter right now is a lieutenant 
colonel in the Army. And she, in fact, is deployed right now to 
that region.
    This issue is very important to us. Our large epidemiologic 
studies, six of which we mentioned, purposely oversample for 
women, so an adequate number of women participating in those 
studies. Because you are exactly right; women may, in fact, 
have different adverse health effects. They may respond 
differently.
    As it relates to these intergenerational effects, the next 
generation, we currently have two ongoing studies that we have 
commissioned with the National Academy. One of them is the Gulf 
War and Health, Volume 12, in which we have asked the National 
Academy, in fact, to give us a roadmap, to give us a template 
for how should we launch with other interagency partners to do 
the proper study to actually look at those effects that might 
be heritable, that might be passed to the next generation.
    Ms. Brownley. Thank you.
    I only have 30 seconds left. But do the VSOs have any 
suggestions or ideas in terms of outreach to improve the 
circumstances?
    Mr. Wiseman. Every year, Madam Ranking Member, the VA sends 
numerous employees to the VFW national convention. We would be 
happy to continue that effort. We would also be happy to go to 
our State level conventions and regional conventions. Outreach 
is something that already happens. And so we can add this as 
one more thing that we are working on through that outreach 
process. And I think that would be easy, and it is a great 
idea.
    Ms. Brownley. Mr. Porter?
    Mr. Porter. Congresswoman, thanks. Well, I think they need 
to understand how veterans communicate and how they would like 
to be communicated to. Whereas one generation might want a 
newsletter, I can tell you the post-9/11 generation, they don't 
read newsletters. I was walking through the Rayburn building 
the other day outside the VA's office, and there was a 
newsletter that said for post-9/11 veterans. I had never seen 
that before. And that was the only time I have ever seen any 
kind of outreach on burn pits. I thought, wow, this would be 
great if it was on social media.
    I mean, it would be great if they asked veterans how they 
would like to be communicated to, and they would probably be 
surprised. So they are going to have to get used to using 
Twitter and Instagram and Facebook and Snapchat and all those 
kind of things to be able to reach those folks.
    Ms. Brownley. Thank you, Mr. Porter.
    My time is up, and I yield back.
    Mr. Dunn. Thank you very much, Ranking Member Brownley and 
Mr. Porter.
    I now turn to the Full Committee Chairman, Dr. Phil Roe. I 
yield 5 minutes for questions.
    Mr. Roe. Thank you. And welcome Dr. Ruiz back to the 
Committee. We are glad to have you here.
    And my generation likes to be communicated with smoke 
signals, so we are all different.
    And I hope--and I don't know what kind of physical exam 
that people get when they go in the military now. But when I 
went in, this is the truth, my physical examination to go into 
the 2nd United States Infantry Division was, ``If I examined 
you, would I find anything wrong?'' So nobody ever laid a glove 
on me getting in the Army. I hope they do a little better now 
than they were then.
    I don't know whether PFTs are actually done or not, but 
this is so intriguing to me. I would love to be involved in 
this clinical study, because you have a population, Dr. 
Erickson and Dr. Helmer, that were deployed. You also have a 
group of people who never enlisted--never volunteered I mean. 
They are the same cohort age. You also have a population that 
were deployed, if you can identify them. And you also have the 
Navy population. So it is really an amazing group of people 
that you have. And I think it is important to try to 
differentiate whether the burn pit had anything to do with it 
or whether just being deployed.
    I have been to Afghanistan many times. And I know 40, 50 
years ago when--40-plus years ago when I was in Korea, it was 
very different than it is today. And hopefully, Afghanistan and 
Southeast Asia, Iraq will be different going forward. But it 
looks to me like we could find that out. Is it just being there 
in that environment where they said they are burning dung, or 
whatever toxins may be just in the air, or whether it actually 
had to do with how the military dispensed with its waste?
    So is that being done? Because the Registry is--it is good 
to sign the people up. You know who they are. But I think that 
is very limited, what you can do. But are you doing that 
population study? Because it is laid right out there for us to 
do. And what do you need to do it? Because I would support that 
in a heartbeat.
    Dr. Erickson. Yes, sir. I am picking up exactly what you 
are saying as it relates to epidemiology because, of course, we 
would always want to have a comparison group. And the perfect 
built-in comparison group are those who did not deploy.
    Some of the studies, though, actually we might include a 
second comparison group which involves the civilian population. 
Of course, we would need to do some types of adjustments. You 
can do matching, as you know, or post hoc analysis that 
controls for those differences. But absolutely.
    Mr. Roe. Are we doing that?
    Dr. Erickson. So the large survey studies that were 
mentioned in the written testimony actually are able to do 
those comparisons.
    Mr. Roe. And what did you find?
    Dr. Erickson. Most of those are ongoing right now, so it is 
too early to share all those results. But they are built into 
the study design to--and it is intended to have those 
comparison groups.
    Mr. Roe. Well, it is the reason I want to go ahead is I got 
tired of talking about cannabis, medical cannabis. And I said, 
well, why don't we study it? And it makes sense to me to do 
that. It has for 10 years. I don't know why we hadn't done it.
    But the same thing here. So that study, when will we have 
that data? Because that will help us a lot up here at the dais 
to be able to make some decisions about these young people 
sitting out here in the audience.
    Dr. Erickson. Chairman Roe, I will get that for you, and 
for each of those major studies, I will get you the expected 
completion date. And, of course, the goal is for them to be 
published in the peer-reviewed literature.
    Mr. Roe. Well, I would hope that it would be.
    Dr. Erickson. Yes.
    Mr. Roe. And I think that will be incredibly helpful to us 
as a Committee going forward to making the decisions we need to 
make when we get that science-based study out there.
    The other thing, and I will bring it up and only just to 
mention, and I will yield my time back, is that we have a 
phenomenal opportunity in the next few years when we roll out 
this combined DoD EHR. If it can do what we need for it to do, 
maybe not right now--and certainly, you know, my electronic 
health record was this. I just carry it around. This is the 
same as Thomas Jefferson's. But I think we have an opportunity 
to be able to watch a population throughout their entire life 
from when they are young adults until they pass on. So I hope 
we do it right and can set that up, because the amount of data 
we are going to have with this--millions of our American 
citizens is going to be a treasure trove of information.
    So I hope you all can help us with that so, when we are 
guiding through that, we can use that information.
    Dr. Erickson. Just if I can quickly say, the individual 
longitudinal exposure record, which is piloted this fall, will 
be the initial step in that direction. And through the 
development of the EHR through Cerner, we are looking to have 
that same capability carried into the record itself, so it will 
be permanently available.
    Mr. Roe. Well, please help us--any way we can help make 
that happen, please let us know.
    I yield back.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    And we now recognize Representative Takano from California.
    Mr. Takano. Thank you, Mr. Chairman.
    Dr. Erickson, last month, as you know, the VA entered into 
a contract with Cerner to support its efforts to modernize its 
electronic health record system. With the development of a 
system where VA and DoD may share electronic--or while the 
development of a system where VA and DoD may share electronic 
health records, it will directly increase the quality of and 
access to health care for veterans. It will also significantly 
improve the development of health care solutions as it will 
allow for the mining and analysis of data on a much larger 
scale, so big data. The impact of this type of data collection 
is likely to have on the VA's research arm will be incredible.
    What interactions have either post-deployment health 
services or Airborne Hazards Center for Excellence had with the 
EHRM team to ensure that the resulting EHR system is conducive 
to the collection of data surrounding a servicemember's 
encounter with hazardous environmental conditions such as open 
air burn pits?
    Dr. Erickson. Thank you for the question. Sir, we have a 
member of our team, in fact, embedded with one of the subgroups 
that is helping develop the EHR for exactly the purpose that 
you express.
    Mr. Takano. Well, my interest is, of course, that we have a 
more proactive approach to anticipating these sorts of 
symptoms. And I think if we can trace where somebody's been on 
Google Maps and navigation systems, we should be able to know 
where every servicemember has also been and correlate that to 
place specific kinds of ailments. Am I correct in that?
    Dr. Erickson. Absolutely. In fact, our goal, the end state, 
would be that from induction to the point of discharge or 
retirement from the military, we would then have captured 
through the lifespan, the military lifespan of that individual, 
all of those exposures, all of those deployments, all of the 
medical encounters, both inpatient and outpatient.
    Mr. Takano. So who would be responsible? Whose 
responsibility would that be to try and track--to try to 
correlate a servicemember's service record and any kind of 
diseases, ailments, or symptoms that there may be a pattern--
recognized in that pattern? Is it DoD? Is it the VA research 
function?
    Dr. Erickson. This, in fact, is a shared responsibility 
between DoD and VA. And, hence, the workgroup that I have 
mentioned to you actively looks to find a common solution. And 
sometimes, in fact, our studies will track someone from a given 
unit when they were in uniform to when they entered the VA 
medical system and points thereafter. So it is actually a 
responsibility that we share.
    Mr. Takano. Now, do we know for a fact that the data that I 
am talking about, the geographic data of where that 
servicemember's unit was involved, is that integrated into the 
health record at the DoD?
    Dr. Erickson. At the present time it is not.
    Mr. Takano. Do we know if that is part of a future plan?
    Dr. Erickson. You know, this is something, Representative 
Takano, that it is under development, and so I can't speak to 
that in a definitive way. I think this would be certainly a 
good thing to have. However, I can't confirm that the exact geo 
coordinates, for instance, would be included.
    Mr. Takano. Because part of what we have experienced with 
Agent Orange is, you know, where were these servicemembers? 
Were they on ships and were they in waters or were they--how 
far from--and do we know when we use certain kinds of 
defoliants? It seems to me that when we deploy soldiers, that 
we have an assessment of the environmental hazards that 
preexist their deployment but also these burn pits, which also 
add to the environmental hazards. So it seems to me that we 
need to have, not only an integrated medical health record that 
is interoperable between the DoD and the VA, but we need to be 
able to integrate the data, the geographic data.
    Do we need to kind of have a different kind of dog tag to 
know where these servicemembers actually have been? So I think 
the technology makes that available--makes it possible. Am I 
correct?
    Dr. Erickson. Absolutely. One of the related issues would 
be classification of certain missions may make that not 
possible.
    Mr. Takano. I get that, yes.
    Dr. Erickson. And, of course, operational security.
    Mr. Takano. Okay.
    Well, I yield back, Mr. Chairman.
    Mr. Dunn. Thank you very much, Representative Takano.
    Representative Bilirakis, you are recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much. Congratulations on your chairmanship. I know you 
will do an outstanding job. It is great to see a fellow 
Floridian in the chair.
    Folks, I would like to invite our veterans who were exposed 
to the burn pits to my office, maybe after the hearing, if 
they'd like to come and share their personal stories, those who 
are here in the audience. I have seen documentaries and also I 
have constituents who have gone through this. But I would love 
to hear from you as well, so please don't hesitate. My office 
is at 2112 Rayburn.
    My first question is for Dr. Erickson. In his statement for 
the record, Captain Torres recommends establishing a scientific 
advisory committee to comprehensively review the full spectrum 
of research on burn pit exposure, independently examining the 
medical evidence both inside and outside of the VA. Other 
testimonies mention this similar, they have the similar ideas.
    Do you support this idea?
    Dr. Erickson. Thank you for the question. At the present 
time, we have a joint action plan with DoD that actually helps 
us set priorities for this type of research, and so that is a 
collaborative effort between DoD and VA which, no, it does not 
include an outside independent body.
    Mr. Bilirakis. And why not? Why not?
    Dr. Erickson. I don't know.
    Mr. Bilirakis. Well--
    Dr. Erickson. I can tell you this, that we have relied, for 
the most part, on the National Academy of Medicine to review 
much of our work. In fact, right now, we are under negotiation 
with the National Academy to do a new airborne hazards 
consensus review of our work.
    Mr. Bilirakis. I just don't understand why we can't have 
some outside research. I mean, we have got to get in front of 
this issue, sir. I don't want to see--I don't want to see what 
happened with our Vietnam vets and the Agent Orange. This is 
really tragic.
    So what I would like to do now is ask Mr. Wiseman and Mr. 
Porter. I am currently working on legislation that would 
explore this idea of a separate independent Federal scientific 
body solely charged with evaluating all the research in this 
area.
    Can you provide any additional insight and will you both 
work with me on developing this further? And do you agree with 
me that this should be both an outside and inside medical 
evidence, obviously the VA but also outside the VA, so we can 
tackle this issue for our heroes?
    Mr. Wiseman. Well, we would agree with you, Mr. Bilirakis. 
And your leadership on toxic exposure issues says that you 
would be a great partner for the VFW.
    Transparency is key. For too many years, we were told that 
there were no servicemembers on the Korean DMZ exposed to Agent 
Orange prior to April 1, 1968. And documentation has then been 
declassified and that is why H.R. 299 now includes that section 
for the Korea DMZ presumptive to start September 1, 1967. It is 
that type of continued research and transparency that must be 
had.
    I mentioned in my testimony, both written and oral, the 
need for DoD to be required to share everything. The oversight 
mechanisms that Congress has in place will help with that. And 
I will also point to Camp Lejeune where contaminated water was 
found. It was reviews that found a spike in male breast cancer 
that led us down that road.
    And so absolutely more research. Absolutely more 
transparency. And absolutely the VFW would be willing to work 
with Congress because every day is Veterans Day.
    Mr. Bilirakis. Sir, Mr. Porter.
    Mr. Porter. We would support additional research 
definitely. The higher quality of the research and data that we 
can get produced, whether it is private or public, but we need 
somebody like the VA to be able to pull all that together and 
corral it so that it can reviewed and have it all in one spot.
    The transparency is big to have DoD to be able to share all 
that information with the VA and the public so that we can know 
all the facts. So, yeah, we look forward to working with you on 
that.
    Mr. Bilirakis. All right. Very good. As far as I am 
concerned, it is a no-brainer. So I look forward to working 
with you all and other Members of the Committee.
    Dr. Erickson--I know I don't have much time--it seems from 
the witnesses' testimonies today and from colleagues on the 
Committee that many of us have concerns about the scientific 
validity, again, of the open burn registry. In fact, 
stakeholders in my district have told me it is so poorly 
designed that it results in data that is virtually useless.
    You mentioned the National Academy study, but it is unclear 
to me how far the VA has gone to implement the recommendations 
from the study. Based on these concerns, what value do you 
think the Registry has? And what concrete examples can you give 
us of how the Registry has been used to advance clinical care 
for veterans who may have been exposed to burn pits? And I know 
you have addressed this, but can you address it one more time 
for us, because this is vital. It is very--
    Dr. Erickson. Yes. I will try and be very quick and, of 
course, get back to you with additional information as 
necessary.
    The Registry, I think, excels in allowing members of the 
service, veterans, to participate in a very difficult issue. So 
by volunteering, they are participating, they are giving us a 
lot of information about their experiences, their exposures, 
their health. Though it is not an epidemiologic study that 
would have the validity of a well-constructed prospective 
study, et cetera, it still can generate hypotheses. It can give 
us leads. It can give us ideas of things that we need to be 
looking at.
    And so as we look at trends, as we cross-reference what is 
in the Registry with what is, for instance, in the electronic 
health record for those who are enrolled at VHA, again, that 
gives us additional ideas of what we need to be looking at, 
where we need to prioritize our work.
    Mr. Bilirakis. All right. Thank you very much.
    I yield back, Mr. Chairman.
    Mr. Dunn. Thank you very much, Representative Bilirakis, 
for your questions and your comments.
    Mr. O'Rourke, you are recognized for 5 minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    And Mr. Porter and Mr. Wiseman, thank you for your 
testimony and for the advocacy of the members of your 
organizations.
    I am just constantly reminded that any progress we make in 
Congress or on this Committee is thanks to the pressure that 
you bring to bear. And I feel that today. And the urgency, just 
at a personal level, and I think for the Committee, has been 
raised. And I want to make sure that we are not having yet 
another meeting on this issue trying to describe why it is 
taking so long for us to do what is necessary for those who 
have served this country, and also to the Ranking Member's 
point, to stop this from continuing to happen. I feel like 
those are the two basic charges: to make sure that we cared for 
those who have been exposed and who are suffering and to stop 
this from happening going forward.
    And I know the Chairman of the Full Committee has left, but 
I love that he reminded us of the example that we have with 
Agent Orange, and that it took this country more than 40 years 
to acknowledge our responsibility and our accountability and to 
pony up and begin to take care of people who we should have 
decades earlier been there for. Belatedly, but we got it done. 
And we are about to do that with blue water veterans as well, 
thanks to those veterans who have shown up at our townhall 
meetings and forced the issue. So I know that when something 
happens, it is going to be thanks to your advocacy. And I just 
want to tell you I am grateful for that.
    And to Dr. Erickson, I am really--this is not on you. I am 
just really disappointed, and the Chairman of the Subcommittee 
already said this, but I join him in just saying how 
disappointed I am that the Department of Defense ducked this 
meeting. They have every reason in the world to be here. Deeply 
disappointing that they are not. But what I want to know from 
you is how have they been as a partner?
    Your title is chief consultant, Post-Deployment Health, 
Office of Patient Care Services, Veterans Health 
Administration, U.S. Department of Veterans Affairs. So your 
post-deployment, how are you doing in working with the 
deployment side of the equation? As to the point as you can be.
    Dr. Erickson. Again, we have a deployment health workgroup 
which we, on a regular basis, work to discuss these issues.
    Mr. O'Rourke. So let me get to this. You have 144,000 on 
the voluntary registry out of 3.5 million eligible. Is DoD 
doing everything within their power to identify those 3.5 
million and connect you with them?
    Dr. Erickson. Representative O'Rourke, I cannot speak for 
DoD in that regard.
    Mr. O'Rourke. I am asking you.
    Dr. Erickson. My sense is that they have taken very strong 
steps to that end, especially as it relates to the point of 
transition.
    Mr. O'Rourke. Is there something more that they could do?
    Dr. Erickson. You know, I think all of us could partner to 
do more. My sense is that, with having a much greater 
enrollment in the Registry, we will be able to take this much 
further than we have to date.
    Mr. O'Rourke. Let me ask you this question. So the 
Chairman, Chairman Roe, referred to his desire to study medical 
cannabis. And while I support that effort, I also just support 
allowing doctors at the VA to prescribe it today, because there 
are doctors who would like to prescribe it today. There are 
veterans who would like to receive it. And if those two agree, 
then let's move forward. I don't need to study it anymore.
    Are we at a point now where doctors can begin treating this 
without more studies and where we can--we have enough 
information, even if it is not, you know, studied, you know, to 
the 10th degree. But there are veterans who are saying ``I am 
experiencing this, and I need this help,'' and there are enough 
doctors who are saying ``I can do the following to help those 
veterans, and here are the kind of unique conditions that we 
can respond to.''
    Dr. Erickson. To the degree that a servicemember or a 
veteran has a defined condition, bronchitis, a type of cancer, 
et cetera, we certainly will aggressively pursue the normal 
methods of treatment to the state of the art. As it relates to 
answering all the questions that are surrounding this from 
exposure, there is a lot we still need to learn. And we are in 
that phase right now. We know there is an issue, but we don't 
have all the answers for causation.
    Mr. O'Rourke. Can we get to like a presumptive status akin 
to Agent Orange where you just say, look, I was here in Iraq or 
in Afghanistan at this time, and I can't tell you how many 
kilometers away from a burn pit I was or the date or exactly 
what was burned, but I am experiencing this, help me, and the 
VA is going to help you?
    Dr. Erickson. With Agent Orange, presumptions came into 
effect both through legislation, which specified which diseases 
would be presumptions. Also--
    Mr. O'Rourke. Are you waiting on us to do that?
    Dr. Erickson. No.
    Mr. O'Rourke. Do you need that statutorily or can you 
deliver that care?
    Dr. Erickson. Or that the Secretary would have the 
authority, through the authority that Congress has provided the 
Secretary, to say that the level of evidence is sufficient for 
us to make a presumption. At the present time, we don't have 
sufficient evidence.
    Mr. O'Rourke. Even if the veteran says, I was here, I 
experienced this, and there were at least 150,000 other people 
who have taken the time to register that same complaint, we 
just don't have enough?
    Dr. Erickson. We need those answers. We need those six 
studies that I mentioned. We need those to go to completion. We 
need to be able to work on a population.
    Mr. O'Rourke. Last question because I am out of time. What 
is the timeline to have those studies done?
    Dr. Erickson. Again, I will provide that to you. That will 
be one of my takeaways.
    Mr. O'Rourke. Give me the ballpark.
    Dr. Erickson. These can take several years.
    Mr. O'Rourke. So at the earliest, 3 years from today?
    Dr. Erickson. That is a possibility, but it will vary study 
to study.
    Mr. O'Rourke. Okay. Thank you, Mr. Chairman.
    Mr. Dunn. Thank you, Mr. O'Rourke.
    I now recognize the representative from Louisiana, Captain 
Clay Higgins.
    Mr. Higgins. Thank you, Mr. Chairman.
    I would like to state for all present that it is quite 
disturbing that DoD is not present. I interviewed a veteran 
that was exposed to burn pit, a young man from my district, 
yesterday. He described that the burn pit was run every day and 
it was about 700 yards from their encampment, their permanent 
encampment. He stated that the smoke would envelop at times the 
camp and come into their tents, the large tents, their 
barracks. What was most disturbing is that he described the 
smoke as frequently being sort of sticky and was heavy, stayed 
together.
    And this reminded me of my own personal understanding of 
chemical and biological weapons devised--the gas thereof to be 
cohesive, and to be heavier than air whereby a large invisible 
cloud of biological or chemical agent would be deployed.
    So, Mr. Chairman, I am quite disturbed that DoD is not 
here, because I would like to ask them who the genius was that 
came up with this idea to create--we have essentially--we have 
essentially as a Nation deployed chemical and biological 
weapons upon our own troops. Wow.
    Dr. Erickson, so as you know, the National Academy of 
Medicine has found significant limitations to the burn pit 
registry. It relies on self-reported information. Is that 
correct?
    Dr. Erickson. That is correct.
    Mr. Higgins. Is there any sort of an organized outreach 
program nationwide through social media, through VSOs, through 
CBOCs, through VHA facilities? Is there any sort of an 
organized effort to reach into the veteran population by the VA 
or DoD?
    Dr. Erickson. Yes. In fact, all of the above. Within VA, we 
have environmental health coordinators and clinicians at each 
of the medical centers which, in fact, for their catchment area 
try to put the word out. We have educational opportunities 
through webinars, one of which will be next week and will 
involve hundreds of providers. We have an e-learning module 
that is available to civilian providers to instruct them about 
airborne hazards and about treatment. We have a training 
conference which is coming up for hundreds of folks who work at 
our medical centers to that end. I had mentioned Web sites, 
townhalls, newsletters.
    I take to heart your comment about social media. We will do 
a better job beyond the blogs that we are doing--
    Mr. Higgins. So there is an understanding that there must 
be an organized outreach into the veteran communities through 
existing avenues and pathways?
    Dr. Erickson. There is.
    Mr. Higgins. Thank you.
    It is also my understanding that the Registry takes a 
significant amount of time, and that we have nearly 40 percent 
of the questionnaires are left incomplete, that submissions 
cannot be made by family posthumously, and that very few 
veterans choose to follow through with the free medical exam. 
Is that correct?
    Dr. Erickson. That is all correct.
    Mr. Higgins. I ask you, good doctor, how can we properly 
assess veteran's health and the effects of burn pits on exposed 
veterans if the quantitative data is lacking?
    Dr. Erickson. My answer would be that the Registry will not 
give us the definitive answers. The other six studies which I 
mentioned, in fact, are the place to go for those answers.
    Mr. Higgins. Thank you for your answers, sir.
    My final suggestion, Mr. Chairman, and to the panel and to 
the VSOs present, is that the DoD should hear, as the noise of 
thunder from all of us, that they were not present today. These 
veterans have been subjected to a great deal of carnage from 
enemy fire and from occasional friendly fire, as tragic as that 
may be, in the form of munitions. But to think that we have 
purposefully deployed burn pits and created chemical and 
biological fumes and smokes to deploy upon our own troops is 
very disturbing.
    Mr. Chairman, I yield back.
    Mr. Dunn. Thank you, Captain Higgins.
    I do want to take as a point of privilege on the chair to 
point out from the testimony that has been submitted that--the 
DoD testimony, that GAO has estimated 273 burn pits in 2010 in 
Afghanistan and Iraq combined. In 2016, they found a single 
burn pit that was operated by the military. However, the 
disposal of this refuse has been contracted to civilians, 
presumably local civilians. I know not exactly what they are 
doing, but some progress has been made. I don't want everybody 
to think that this is still an active practice. But I share 
your concern.
    And I want to recognize Mr. Correa for 5 minutes for 
questions.
    Mr. Correa. Thank you, Mr. Chair.
    First of all, let me thank Mr. Porter, Mr. Wiseman, and the 
veterans that are here today for your service to our country. 
And also, of course, for bringing these most important issues 
to our attention. And I want to start out by saying that I 
concur with Mr. Higgins and his comments about the DoD not 
being here.
    But, Dr. Erickson, is the DoD--do you work, coordinate 
together on these issues? I presume you talk on what has been 
going on, communication?
    Dr. Erickson. Yes, Congressman. We talk on sometimes a 
daily basis, but certainly a weekly basis about these airborne 
hazards and burn pit issues.
    Mr. Correa. So, you know, at every, you know, conflict that 
we have had, every war, we seem to have these issues that pop 
up. Agent Orange, Blue Water Navy, World War II, other issues.
    Looking forward, are these registries open to veterans that 
are now serving, let's say, for example, begin to complain of 
certain issues? You begin to get these data points, you begin 
to create information there that maybe indicate that something 
is going on right now that we are not aware of. Do you keep 
that data? Is this registry open to everybody or just to the 
burn pit folks?
    Dr. Erickson. Congressman, we have seven registries total. 
The eligibility requirements for the airborne hazards' 
registry, an individual would have had to have served in OIF, 
OEF, OND, Desert Storm, Desert Shield, stationed in Djibouti, 
Southwest Asia theater of operations after August of 1990.
    Mr. Correa. So my question is more of a, kind of a--do you 
have a situation, a process where if you have a person in the 
service right now and believes that there is something 
seriously wrong, where they can report this information so we 
begin to discover what is going on right now as it develops? Or 
do we have to wait years and years to figure out, ah, something 
was going on in 2018, we should have done something then at the 
early stages of this development?
    Dr. Erickson. Congressman, that is a good question, and 
that would be the responsibility of the DoD to answer that for 
you. I am sorry.
    Mr. Correa. Do you work with the DoD on--
    Dr. Erickson. I certainly do.
    Mr. Correa [continued].--on these kinds of processes?
    Dr. Erickson. But I can't speak authoritatively or directly 
as to what steps they do take.
    Mr. Correa. I don't want you to answer for them. I am just 
trying to figure out, if you work with them, if there is a 
process like that so we can continue or begin to anticipate 
these issues before they are actually on top of us. And we have 
so many of our men and women in uniform that have to go through 
this.
    Dr. Erickson. Absolutely. In fact, that is our joint aim, 
is that we could, as a team, actually prevent these exposures, 
but in lieu of that, be able to detect early the development of 
disease and disability, to take care of those individuals who 
so proudly served our country.
    Mr. Correa. I am a little slow here, so can you repeat that 
to me again? Is that your aim or are we actually taking steps 
in that direction?
    I am not trying to put you on the spot. I am just trying to 
ask, are you and the DoD working in something that could give 
us an early indicator of these issues that are kind of before 
us or is there no process there so that maybe this Committee 
can begin to address that issue? It is a very simple yes-or-no 
question.
    Dr. Erickson. Yes.
    Mr. Correa. Yes, you are working?
    Dr. Erickson. Yes.
    Mr. Correa. Thank you very much, sir. I have no questions--
further questions, sir.
    Mr. Dunn. Thank you very much, Mr. Correa.
    I now recognize Mr. Mast of Florida for 5 minutes for 
questions.
    Mr. Mast. Thank you, Chairman.
    I do want to thank both the IAVA and Representative Gabbard 
for their work on this issue. I know it has been vigilant, to 
say the least, and so I do greatly appreciate that.
    When I look back on my service, I think one of my least 
favorite parts of training was when one of my sergeants would 
yield out, gas, gas, gas. And we would have to do everything we 
could to get on our MOPP gear and our masks within seconds or 
whatever timeframe they set in front of us. And what is 
absolutely disturbing to me is that the chemical attacks that 
we really needed to fear were those that were coming from 
within our own camps.
    And it is in that that I want to start with asking you a 
few questions, Mr. Porter. Of all of those veterans that you 
know of within your ranks, do you know of veterans that were 
exposed to burning vehicle parts?
    Mr. Porter. That and a whole lot of other things.
    Mr. Mast. How about burning tires?
    Mr. Porter. Yes.
    Mr. Mast. How about burning bottles?
    Mr. Porter. Certainly. I think, though, that people don't 
even know what they are exposed to because it is everything 
burnt all together, so--
    Mr. Mast. How about those square green batteries that the 
military uses in basically everything that is electronic? They 
burned some of those?
    Mr. Porter. A good chance, yes. Everything from human waste 
to medical waste to fuel to tires to excess clothing, and all 
those bottles that 100,000 people in theater, in each theater. 
They would drink 10 bottles of water a day. That has all got to 
go somewhere. It is not going to the recycling center in 
Jalalabad.
    Mr. Mast. MRE wrappings?
    Mr. Porter. Sure.
    Mr. Mast. Mattresses?
    Mr. Porter. Sure.
    Mr. Mast. ChemLights?
    Mr. Porter. Yep.
    Mr. Mast. Chemical drums?
    Mr. Porter. Yep.
    Mr. Mast. Tarps.
    Mr. Porter. Everything.
    Mr. Mast. Movies? Magazines?
    Mr. Porter. Everything.
    Mr. Mast. You already mentioned human waste.
    Mr. Porter. Right.
    Mr. Mast. I think we could probably sit here all day and 
list the things that anybody that spent time in uniform has 
seen burned overseas and the stuff that they had to breathe in 
constantly, the stuff they had to taste in their food on a 
daily basis.
    These airborne hazards, they do go well beyond just what is 
burned. I can look back and I can think about those smoke 
grenade holders that are right next to the driver's hatch on so 
many of our fighting vehicles. You were expected to put those 
smoke grenades directly next to where it was that you were 
driving. The motor pools, lined with vehicle after vehicle that 
were just running during PMCS, running JPA. Sandstorms, the 
internal exhaust that you get while you are on a Black Hawk, 
the CS chambers that you would go into, DU rounds from close 
air support. All those folks that were working on flight decks, 
breathing in that exhaust from aircraft. Bases, even here at 
home, bases that we are tearing down old buildings filled with 
asbestos and things like that. My fellow bomb technicians who 
would detonate thousands of pounds of explosives at one time 
and would be expected to go check out those shot holes 
afterwards to make sure there was nothing additional laying in 
there. Airborne hazards there. Of course, the burning oil 
fields from the times of the Gulf War.
    Is there any other experiences that you would wish to share 
from your membership of those exposures to burn pits?
    Mr. Porter. Well, I don't know very many servicemembers and 
veterans that are complaining about having to go to these 
places. You know, from the experience yourself, you put on the 
uniform and you go where they tell you to go. And you even know 
that there is bad stuff in the air and hazards, and a lot worse 
than that, in the places that we are deployed to.
    It is just that the expectation is, by servicemembers and 
veterans, is that they get taken care of when they come home. 
And so that is the key, is they are going to go places, they 
are not going to complain about going those places, but they 
want to be treated when they return back.
    Mr. Mast. I think you are exactly right, Mr. Porter. We do 
our job and we do it joyfully, even though there is not often 
joyous things that we are doing. And the veteran should be 
taken care of joyfully as well.
    Mr. Porter. Yes, sir.
    Mr. Mast. I do want to move to you, Mr. Erickson, while I 
still have a minute here. How many burn pit exposure disability 
claims have been filed?
    Dr. Erickson. I actually have that number. My understanding 
is a little over 9,000.
    Mr. Mast. What percentage of the claims are approved for 
disability compensation?
    Dr. Erickson. That number, Congressman, I will have to get 
for you.
    Mr. Mast. Okay. What is the most common reason that 
veterans who have been exposed to these burn pits are being 
rejected for their disability claims?
    Dr. Erickson. I will also have to take that for report 
afterwards.
    Mr. Mast. Perfect. I will look forward to hearing your 
answers on those questions.
    Dr. Erickson. Certainly.
    Mr. Mast. With that, Chairman, I yield back. Thank you.
    Mr. Dunn. Thank you very much, Representative Mast, for 
that very vivid description of the environmental hazards of 
combat theater. One might almost think you had been there.
    And by the way, I think the entire Committee would be very, 
very interested in seeing the numbers of adjudicated claims and 
how that played out.
    Representative Kuster, you are recognized for 5 minutes.
    Ms. Kuster. Thank you very much, and congratulations. We 
are pleased to have you on board as our chair.
    So I think you can tell by the bipartisan response today 
how concerned we are. And thank you to the VSOs and to every 
one present for bringing this issue once again to the 
forefront.
    Just a brief point of personal privilege. In March of 2009, 
I was in Alaska for a ski race, of all things, during a 
volcano, Mount Redoubt. And I came home to New Hampshire, 
having been in the ash for several days, and ended up with 
several years of pulmonary difficulties: breathing, asthma, et 
cetera. And it took me a while to piece this all together. It 
certainly took my doctors at home a while to piece it together. 
I continue to have asthma-related symptoms because it was 
crushed glass, is my understanding, coming from--
    So this is obviously very different than the experience you 
all have had, the folks in the room. But my point being, I 
think there is difficulty in just trying to piece together 
these kinds of symptoms. And you pointed out, I think, that the 
pulmonary function test is inadequate.
    So I guess I want to hone in on two things. One is this 
electronic health record and how we can make sure that there 
are questions asked that specifically tease out what we know to 
be the constellation of symptoms from illness related to burn 
pits. Is that part of what this Committee is looking at that is 
working with the electronic health record?
    Dr. Erickson. Congresswoman, I think that would certainly 
be the desired end state. Again, we are just at the front end 
of the development of that new electronic health record, but I 
can tell you that these environmental exposure equities are 
going to be included.
    Ms. Kuster. And I think for us, and what you are hearing 
from us, and it may take bipartisan legislation that we would 
draft to put together to say we should have a presumption 
because I don't see why there is any reason to wait. Obviously, 
we have got people in the audience today that have complex 
symptoms, and they should be served. They should be treated.
    So the other thing that I am interested in, though, is this 
epidemiological studies that are going on. And I understand 
from your testimony that you have requested the National 
Academy of Science to be involved with this. They have a series 
called Gulf War and Health. And you have asked that we have a 
long-term study of health effects of airborne hazards. Can you 
tell me the status of that particular study and what the 
conclusions are to date?
    Dr. Erickson. Yes, ma'am. We are at the front end of that 
study in that, literally, we are working to draw up that 
contract right now. We have the authority to work with the 
National Academy because of legislation that enables us to do 
that.
    We are looking for what is called a consensus study, which 
involves them putting together an ad hoc committee of blue 
ribbon subject matter experts from around the United States, 
and they will review all of the existing literature published, 
unpublished, they will have public meetings, and they are going 
to draw this together in the form of a report that we can work 
with.
    Ms. Kuster. So I guess, let me understand. There are two 
parts of this, it seems to me. Looking for this direct causal 
link, which would then, obviously, help us with the presumption 
and we could move forward. Is there also a medical purpose? In 
other words, then, pulmonologists will know what they are 
looking for, for symptoms and they can come to consensus on 
treatment. Is it two part?
    Dr. Erickson. There certainly could be. Those of that 
practice medicine use a term called index of suspicion, and we 
also use a word called the differential diagnosis.
    If, in fact, we know that a given patient has had certain 
exposures, that cues us to be looking for certain types of 
things, certain types of disease outcomes. So, in fact, that 
could enhance treatment.
    Ms. Kuster. So I guess--and I want to share the Ranking 
Member's concern about the testimony about women veterans, 
birth defects. You know, look, everybody is suffering, but 
let's try not to go to a whole other generation here.
    How do we convey our urgency for both, for both the causal 
link, so that we can get to the presumption and make sure 
people are served and treated, and as to helping to move 
forward on the medical treatment?
    Dr. Erickson. I certainly think that the urgency is 
underscored by this hearing, and I thank the chair, the Ranking 
Member, and all the Committee Members for bringing this to the 
attention of the Nation.
    Ms. Kuster. Well, I want to thank the chair, certainly for 
your knowledge, and the Ranking Member. And my Subcommittee is 
the Oversight Subcommittee, but we will continue to work with 
the Health Subcommittee. And I think this is something that we 
have got consensus on. We want to move forward. Thank you.
    I yield back.
    Mr. Dunn. Thank you very much, Representative Kuster.
    And now we turn to the Representative from American Samoa, 
Amata Radewagen, for 5 minutes.
    Mrs. Radewagen. Thank you, Chairman Dunn and Ranking Member 
Brownley for holding this hearing today. And thank you to the 
panel for your testimony. Thank you all for your service.
    Ensuring the long-term health of our veterans is a top 
priority, and any potential hazards to our Armed Forces need to 
be addressed swiftly and thoroughly. To that end, I am proud to 
cosponsor Congresswoman Gabbard's H.R. 5671 and Congresswoman 
Esty's H.R. 1279. I believe these pieces of bipartisan 
legislation are good first steps towards addressing this issue, 
and I hope this hearing will help flesh out other potential 
steps we can take and address some of the concerns surrounding 
this problem.
    Research and data collection are paramount to understanding 
a health risk with potential long-term effects, whether it be 
burn pits or other environmental factors. And I would like to 
focus my question on the burn pit registry and how it may serve 
as an informational resource.
    So, Dr. Erickson, just so I can better understand, from an 
epidemiological perspective, what challenges arise when working 
with data points collected via voluntary health survey and 
registry such as that used in the burn pit registry? And as 
time passes, since the initial point of exposure, does research 
become more difficult? And if so, why?
    Dr. Erickson. Those are excellent questions. From an epi 
standpoint, there are two major biases that we are concerned 
about. One bias is who is volunteering to participate. There is 
the potential that the most sick individuals, in fact, will 
participate, and, therefore, then give a nonrepresentative view 
of who is being affected and who is not.
    The second bias involves self-report, in that it is an 
individual who is reporting their exposures, reporting what 
they have been told by a doctor they have. And this is not to 
impugn the character of anybody, but through time, it is true 
that sometimes, you know, my recollection, perhaps all of us, 
starts to wane. And so there can be a bias in that regard.
    The second part of your question was--oh, with time. 
Absolutely. We want to get out in front of this. In fact, I 
hope that the written testimony that we submitted shows that, 
in fact, VA desires and is getting out in front of this as best 
we can. There are so many questions to be answered. We have got 
the studies underway. We are doing a lot of really good things. 
Can we do better? Yes, we can do better. We hope to do better. 
We are looking to do better. But I think what we are doing is, 
in fact, on the right track. And we need to get to it now. We 
need to start these studies now. Because you are right, if we 
waited 10 years, 20 years to start those studies, then that 
would be Agent Orange all over again.
    Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
    Mr. Dunn. Thank you very much, Mrs. Radewagen.
    I now recognize Congressman Ruiz from California for 5 
minutes for questions.
    Mr. Ruiz. Thank you, Mr. Chairman. It is great to be back 
in my alma mater committee.
    I am going to be very quick and to the point. My point is 
this: If you have a high enough suspicion for a severe enough 
consequence, then you need to act, and you need to act now.
    So, Dr. Erickson, in your testimony, you say, quote, ``The 
evidence for an association between the development of specific 
respiratory diseases and exposures to combustion products was 
found to be inadequate or insufficient.''
    Oftentimes, the VA says that there is no scientific proof 
between a link of burn pits and long-term health effects. That 
statement is misleading and very intellectually dishonest, that 
the VA makes. And I will explain why.
    The 2011 Institute of Medicine report is the report that 
you are telling us that you are commissioning the National 
Academy of Science to do. I mean, it is not the report. I am 
saying that they took a blue ribbon group to look at all the 
other studies and to give us an update of what they thought. 
And they state, quote: Information that would have assisted the 
Committee in determining the composition of the smoke from the 
burn pit and, therefore, the potential health effects that 
might result from exposure to possible hazardous air pollutants 
was not available. Specifics on the volume and content of the 
waste burned at Balad Base as well as air monitoring data 
collected during smoke episodes were not available.
    In addition, the report states that, quote: The available 
epidemiological studies are inconsistent in quality, were 
conducted with various degrees of methodologic rigor, and had 
considerable variations in design and sample size.
    So, Dr. Erickson, if this critical data was not available 
or the studies' methodologies were flawed, is it just as 
accurate to say that studies fail to prove or disprove a causal 
link between burn pits and adverse health outcomes?
    I don't have much time. I need you to answer.
    Dr. Erickson. No, it was the complex wording of the 
question, sir.
    Mr. Ruiz. So let me be very clear. There are no studies 
right now that can prove and there are no studies that can 
disprove that there is a link between the exposure to burn pits 
and long-term health effects, correct?
    Dr. Erickson. I think we need to look at the totality of--
    Mr. Ruiz. I am looking at the totality. There is no studies 
right now. I am a scientist. I am an emergency medicine doctor. 
I am a public health expert. You know the literature. I know 
the literature. Are there studies that can disprove that there 
is no link?
    Dr. Erickson. I don't think the point, sir, is a matter of 
disproving, because as you--
    Mr. Ruiz. That is the point exactly, because if we cannot 
disprove, then it is very possible that there is a link between 
the burn pits and the health effects that our veterans are 
facing. And if we don't have that information, then we have to 
go by how we practice in emergency medicine and public health. 
Meaning, if you have a high enough suspicion, a severe enough 
consequence, you have got to act. You have got to start taking 
care of your veterans right now.
    So do we have a high enough suspicion? So we have 
independent research that raise suspicion of a causal link that 
veterans exposed to burn pits are developing serious 
respiratory issues, cancers, and autoimmune illnesses.
    The same report found dioxins, dioxin-like compounds to be 
of concerns because of their association to burn pits and 
because some of the concentrations exceeded U.S. Air Quality 
standards. We know that dioxin was present in Agent Orange.
    The New England Journal of Medicine, a study by Robert 
Miller from Vanderbilt University, performed lung biopsies in 
49 soldiers exposed to burn pits in Iraq and Afghanistan who 
were healthy before being deployed. 38 of the 49 were diagnosed 
with constrictive bronchiolitis, a very rare disease.
    In another study in Seton Hall University Law School, 
Center for Policy and Research analyzed 500 veterans who were 
exposed to burn pits while serving in Iraq and Afghanistan. 
Seventy-four percent reported respiratory issues, including 
severe shortness of breath. Twenty-six percent of them had more 
severe illnesses such as brain cancer, lung cancer, hardened 
bronchial tubes, and acute leukemia. We have found carcinogens 
in the smoke, carcinogens in the soil, metals found in lung 
biopsies in these patients.
    There are case studies, like Jennifer Kepner, my 
constituent, 39 years old, who died of pancreatic cancer. Her 
oncologist did all the studies, genetic tests, all the other 
history, exposure history. The only plausible source was 
exposure to these burn pits.
    So, Dr. Erickson, in your testimony, the evidence for an 
association between the development of specific respiratory 
diseases and exposure to combustion products was found to be 
inadequate or insufficient. So would you say these studies and 
other case examples of veterans like Jen Kepner show a high 
suspicious enough for an association between burn pits and the 
long-term consequences?
    Dr. Erickson. The concern that you are voicing, sir, is in 
fact the reason that we are asking the National Academy to--
    Mr. Ruiz. Great. So you agree with me, there is high enough 
suspicion for you to pursue these studies.
    So now let's ask the question. Is there severe enough 
consequences? Ask the family of Jennifer Kepner who died from 
pancreatic cancer; Amanda Downing, who died to adrenal cancer 
at the age of 24; Brandon Maddick, who died of esophageal 
cancer at 26. If the outcome is severe enough. Ask the patients 
sitting in this room if their dyspnea on exertion, their 
autoimmune disease, their pulmonary fibrosis, their chronic 
bronchiolitis, and others who are permanently disabled, oxygen-
dependent, with broken families, depression, exacerbated PTSD, 
and possible suicidal ideations.
    Do you think that the consequences of this exposure are 
severe enough?
    Dr. Erickson. I very much believe that their suffering is 
real. I very much believe that--
    Mr. Ruiz. Great.
    Dr. Erickson [continued].--the exposures are real.
    Mr. Ruiz. So if there is a high enough suspicion with 
severe enough consequences, we must act. And let's keep in 
mind, I know we are talking about registries, but registries 
aren't going to remove cancer in a body. Registries aren't 
going to provide the health care that the patients need or the 
benefits that they need. We need to make sure that we give the 
veterans their treatment, their benefits, and educate doctors 
and veterans about this right now.
    Mr. Dunn. Dr. Ruiz, your comments are well taken. We 
appreciate that.
    Mr. Ruiz. Thank you.
    Mr. Dunn. Representative Tulsi Gabbard from Hawaii, you are 
recognized for 5 minutes for questions.
    Ms. Gabbard. Thank you very much, Chairman Dunn, Ranking 
Member Brownley. I appreciate the opportunity to come and join 
your Committee on this critical issue.
    There obviously are some important pieces of legislation 
that we are seeking to push through to begin to address some of 
these issues. It is unfortunate that this remains an obscure 
issue for too many Members of Congress and too many people who 
either have not served themselves or have not been directly 
impacted, to be friends with or related to someone who has.
    The fear I know that we hear from fellow veterans is that 
this will continue to drag on and on. And as soon as you talk 
about a government study, this is something that can drag on. 
Meanwhile, people here are suffering from illnesses, and they 
wonder if they will be alive when these studies are complete.
    It is a testament to the importance of this issue that we 
see VSOs who are here, who have united from across generations 
to help bring attention to this issue and to make it so it is 
no longer obscure. It is not only impacting our veterans, but 
it is impacting their family members.
    I want to recognize a military spouse who is in the room, 
Tori Seal. She has been a strong advocate on this issue. Her 
husband, Jay, tended burn pits during his deployments and is 
now suffering from stage IV cancer. Because this issue is not 
resolved, she is not eligible for any caregiver benefits 
because her husband was not diagnosed with PTSD or TBI, and his 
illness is not being recognized as service-connected, even as 
his specific job, his duty while deployed was to tend to these 
burn pits directly.
    What can be done for people like Tori at this point whose 
full-time job is caring for her husband who has stage IV 
cancer?
    Dr. Erickson. Congresswoman, I am not a benefits expert, 
and so I will have to get back to you with a more detailed 
answer. Because there are things to be done, but I don't want 
to misspeak and misrepresent. I know there are things that are 
available for surviving spouses.
    Ms. Gabbard. Something similar that I heard from another 
veteran, who is working with Burn Pit 360, this morning was the 
comparison between the types of exposure that our veterans have 
had deployed throughout the Middle East, Iraq, Afghanistan, 
Kuwait, elsewhere, both those who were working directly with 
burn pits and those who were working within the area, as many 
of us did, living and working and breathing the toxic fumes 
that came from these burn pits every day, and how similar that 
exposure is to the multitude of toxins that first responders 
were exposed to after 9/11.
    Congress passed the James Zadroga 9/11 Health and 
Compensation Act of 2010 to address the very type of thing we 
are talking about here, where first responders were getting 
very sick with all kinds of illnesses and cancers and dying at 
a very early age. And yet they were not receiving the benefits 
or care or recognition that this is a result of their service.
    We shouldn't be re-creating the wheel here, so I am 
wondering what the VA has done in looking at what has already 
happened with James Zadroga Act to help with the 9/11 first 
responders so that we are not starting from scratch and 
studying something for years that has already been studied in a 
similar situation and applied and fixed.
    Dr. Erickson. One area that we could collaborate in, and 
this would be with all the Members of the Committee, would be 
that if you have candidate diseases or health care outcomes 
that you think are tied to exposure to burn pits and airborne 
hazards, that we would be able to then work with you on that 
list to see where the evidence is, where it is not. Because I 
don't think you are looking for any and all health care 
outcomes and proposed legislation that might match the World 
Trade Center-type legislation, but I think you would want a 
defined list.
    Ms. Gabbard. So what has the VA done in this respect so 
that we are not starting from scratch?
    Dr. Erickson. As I mentioned, we have in our written 
testimony a number of major studies, six major studies that are 
underway with DoD. Also, there were attachments in the written 
testimony which, in fact, provided examples of our published 
studies. The bibliography that I provided. Also, two lists of 
additional studies that are currently funded by VA.
    Ms. Gabbard. Okay. That doesn't really answer the question 
as far as an action. You listed a whole bunch of different 
studies, but as far as what action steps are being taken to 
make it so that we are recognizing the service-connected 
illnesses.
    Dr. Erickson. So specific actions--I apologize for not 
understanding the question. The specific actions, currently, 
those who serve in the military and are honorably discharged 
receive 5 years of health care eligibility, I understand. So 
that's an open door.
    The registry which exists, which we are trying to now 
encourage additional participation in, provides an entry point 
where the individual who is participating can ask for a medical 
exam. So this provides a clinical encounter which is then--
    Ms. Gabbard. Excuse me, Dr. Erickson. I appreciate that you 
are kind of starting from ground zero here. Everyone in this 
room is aware of kind of the basic benefits that servicemembers 
are eligible for, but it is not addressing the fact that we 
have a lot of people in this room and a lot of people who can't 
be here today who have tried over and over and over and over 
again to get that care, and they have been denied. And they 
have specifically attributed their illness to their exposure to 
burn pits.
    Dr. Erickson. As it relates to claims, again, this is not 
my wheelhouse to discuss claims and how those are processed, 
but I can put you in touch with those who will be able to 
answer those questions.
    Ms. Gabbard. Okay. Thank you, Mr. Chairman. I think that 
the attention that you are placing on this issue is so, so, so 
important. And the only way that we are going to get anything 
done on this, whether we do it as a body in Congress or whether 
we work with the VA to be able to help these veterans, either 
way, I appreciate the urgency and attention that you are 
placing on this as people's lives hang in the balance.
    Mr. Dunn. Thank you, Representative Gabbard.
    I will say, I don't want the veterans in the crowds to 
think that they can't get treated for these illnesses. I think, 
as I understand it, you can get treatment for these 
disabilities. What we are having trouble with, the thing that 
is in limbo is the disability recognition and the rights. I 
will allow Dr. Ruiz to answer that.
    Mr. Ruiz. And, Dr. Dunn, one of the things that we found in 
the case study of Jennifer Kepner was that they need to report 
this illness within 5 years.
    Many of the presentation of pulmonary fibrosis, autoimmune 
diseases, cancers, including even PTSD, our veterans don't even 
understand or develop symptoms beyond 5 years. And so when they 
get ill, they can't get care from the VA.
    Mr. Dunn. Okay. Thank you for that clarification.
    And I want to recognize Representative Esty from 
Connecticut for 5 minutes for questions.
    Ms. Esty. Thank you, Mr. Chairman. And I want to thank all 
of you for joining us here today.
    Mr. Wiseman, it is your second appearance before this 
Committee today.
    Mr. Wiseman. We are going strong, ma'am.
    Ms. Esty. And again, I want to thank you. As people on the 
Committee may or may not know, he will be leaving us, his 
position to go to Virginia and help head things up over there. 
But I want you to know, I know we would not be here today if it 
were not for your personal fierce persistent advocacy on this 
issue.
    Mr. Wiseman. Thank you. And it is going to likely take 
legislative action by this body. That is how we got Blue Water 
Navy. That is how we got Agent Orange. That is how we have got 
so many other things. Congress needs to act.
    VA's hands, in their defense, are tied because of 
Congress's previously passed laws. I am accredited to do VA 
claims. I will still be doing those. I will still be inside the 
VFW as a state commander, and I will be happy to come back any 
time. I thank you.
    Ms. Esty. Well, thank you very much. I am actually the 
Ranking Member of the disability appeals Subcommittee, so we 
are very much looking at this. And I think, you know, my 
colleague, Ms. Gabbard, is right, this is going to require 
congressional action. And it is completely unacceptable to 
think that we are going to wait having just now really been 
wrestling through the Agent Orange issues, that we would be 
doing that to the present generation of veterans. It is wrong. 
We should know better by now. And I know people here know that, 
but we have to find the will to make that happen.
    Shortly after I was elected in 2012, a decorated Iraq 
veteran in my district came to me, Mike Zacchea. He has written 
a book called The Ragged Edge. And he experienced the burn pits 
and saw his colleagues, his men experience them too. And he 
educated me as soon as I got elected. I wasn't on the 
Committee. He said, you need to do something about this. You 
need to understand how important that is.
    And since his educating of me over 5 years ago, as everyone 
on this Committee has seen, you begin to open the door on that 
and you hear, you hear from people all over your district about 
it. And I had a niece who served in Afghanistan. This is a real 
problem.
    So a couple of things I wanted to flag. The issue about 
women's exposure is real and serious, and especially when the 
consequences, again, may be outside this time period, the 
exposure and then refusal to cover is unacceptable. And we 
should do better. Congress needs to do better on that issue.
    I have often wondered, if the Defense Department were 
responsible for paying the bill after the fact, if they 
wouldn't think a lot more about it before exposing people? Have 
the payment for those come out of the DoD budget rather than 
coming out of Veterans' budget and we might be in a different 
place.
    I don't know how we do that, but I will tell you, I think 
that we need to seriously engage. And again, I will add my 
voice to the chorus of my colleagues to express our extreme 
disappointment that DoD did not come today. The fact that they 
aren't here does not absolve them of responsibility. And they 
have the opportunity to mitigate this at the time. And we need 
to get them back to the table, because those serving deserve to 
have them, their awareness of this at the time that it is 
happening. It is not their only mission, but it is part of 
their mission to take care of those who are serving while they 
are serving. It is the VA's mission to take care of them when 
they come home or don't come home.
    So, again, I know we are looking forward to working with 
you, but epidemiological studies take a really long time, and 
people have direct needs right now. So this Committee is 
committed to moving forward, taking care of the people who are 
suffering right now, and do what we can to mitigate in the 
future and reduce the exposures. Try to understand that, but 
not wait till we have all the answers. I serve on the Science 
Committee. We will never have all the answers. That should not 
get in the way of our doing right by the people who wear the 
uniform.
    So again, I thank you for allowing me to join the Committee 
today for this hearing. I have legislation, as I think you 
know, on this topic, and have since early on in Congress. And I 
am really grateful to the Chairman and Ranking Member and the 
Full Committee's Chairman commitment for us to do whatever we 
can to address this issue head on and not stick our heads in 
the sand. Thank you.
    Mr. Dunn. Thank you very much, Representative Esty.
    With that, we have--all Members of the Committee have asked 
questions.
    I want to extend my gratitude as Chairman to all the panel 
Members. I think you have all showed a great deal of work and 
dedication to this. We appreciate you taking your time and 
sharing your expertise and your personal stories. With the 
Committee, clearly this is a subject that touches a wide 
variety, a large number of people. You saw a great interest on 
the part of the Committee, and I think that you will see that 
continue. So please keep us in your thoughts. Please keep us 
informed. And I will tell the panel, you are now excused. And 
thank you for your service very much.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material. And without objection, that is so ordered. And this 
hearing is now adjourned.

    [Whereupon, at 4:45 p.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

                    Prepared Statement of Tom Porter
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee:

    On behalf of Iraq and Afghanistan Veterans of America (IAVA) and 
our more than 425,000 members worldwide, thank you for the opportunity 
to share our views, data, and experiences on the matter of burn pits 
and airborne toxins, what may indeed now be the ``Agent Orange'' of our 
generation.
    I am here not only as IAVA Legislative Director, but as a veteran 
of Operation Enduring Freedom who was exposed to a variety of airborne 
toxins from burn pits and other sources at many locations I was 
deployed to in Afghanistan and Kuwait between 2010 and 2011. Before I 
went downrange during that period, I had zero breathing problems and 
completely healthy lungs. In the first couple of weeks after I arrived 
in Kabul, where the air is particularly bad, my lungs had a severe 
reaction and became infected. It was controlled with medication over 
the next year. However, after re-deploying home, I stopped the 
medications and symptoms came back and I was diagnosed with asthma as a 
result of my deployment.
    Exposure to burn pits used by the military to destroy medical and 
human waste, chemicals, paint, metal/aluminum cans, unexploded 
ordnance, petroleum and lubricant products, plastics, rubber, wood, and 
other waste has been widespread.
    And it is not just those working at burn pits. Search for the ``Poo 
Pond Song'' on YouTube and you will hear one Soldier's humorous take on 
the enormous lake of human waste that tens of thousands of 
international servicemembers lived, worked, and ate around at our 
formerly large base at Kandahar, Afghanistan.
    You could also learn from the many who have served in Kabul--an 
enormous city with open sewers and whose population routinely burns dry 
animal dung to keep warm. Our military serving there get a healthy 
dose--and are suffering the impacts from breathing airborne feces for 
extended periods of time. There have been burn pits there as well.
    This is to say nothing of the other toxic chemicals and fine 
particulates our men and women in uniform were exposed to everyday. Our 
friends around the veteran space, especially those who served in 
Vietnam, know all too well how detrimental toxic exposures and 
environmental hazards can be. As Dr. Tom Berger, Executive Director at 
Vietnam Veterans of America's Veterans Health Council explains, 
``Vietnam veterans know only too well the health hazards of exposure to 
toxic chemicals on the battlefield. That's one of the reasons VVA is so 
involved in this issue--we don't want to see the newest generation of 
vets go through the same health care challenges we're (still) facing 
with toxic exposures, especially with our children and grandchildren.''
    One of our members, Christina Thundathil, a U.S. Army veteran, told 
us recently of her deployment to Balad, Iraq. Although her specialty 
was in food preparation, her job in Balad was to drag the full bins 
from port-o-johns daily, douse the contents with jet fuel, light on it 
on fire, stir it with her e-tool, then repeat until she had a brick she 
could then bury in the desert. She's severely injured because of these 
exposures, and she desperately needs a cure for her ills.
    The examples are many. However, little is understood about the 
long-term effects of exposure to these burn pits and other airborne 
hazards. With our presence in Iraq and Afghanistan no longer in the 
headlines, the country must continue investing in the system of care 
for veterans and their families.
    Year after year, we have seen an upward trend in the number of 
members reporting symptoms associated with burn pit exposure. Eighty 
percent of IAVA members who responded to our latest survey report being 
exposed to burn pits during their deployment; over 60% of those exposed 
report associated symptoms.
    Our members have made it clear: 2018 is the year IAVA will educate 
Americans about burn pits and airborne toxic exposures and the 
devastating potential impact they could be having on the health and 
welfare of millions of Post-9/11 veterans and their families.
    To see the enormous extent of interest in this issue by veterans, 
you only need to look at the comments section of any related article, 
or see our #BurnPits hashtag that has gone viral. These veterans need 
help now.
    The Department of Veterans Affairs has a ``Airborne Hazards and 
Open Burn Pit Registry,'' which helps VA ``collect, analyze, and report 
on health conditions that may be related to environmental exposures 
experienced during deployment.'' Although established in 2014, only 
141,000 have completed the registry questionnaire out of the 3.5 
million veterans the VA says are eligible to register. Only 1.7% of the 
post-9/11 veterans eligible to register have done so, and only 35% of 
IAVA members exposed have.
    A definitive scientific link between exposure and specific 
illnesses has not yet been made, and the Burn Pit Registry is not well-
known and is underutilized. The result is that the data on these 
exposures is not being collected at the levels desired to inform next 
steps. Until this point, the Department of Defense (DoD) has not taken 
formal accountability of toxic exposures by theater locations for 
deployed servicemembers. It is for this reason that IAVA helped to 
develop new legislation to tackle this problem.
    On May 17, the IAVA team stood alongside Iraq War veteran, 
Congresswoman Tulsi Gabbard, and Afghanistan veteran, Congressman Brian 
Mast, with the support of 23 other veteran service organizations to 
announce the introduction of the Burn Pits Accountability Act. The 
legislation directs DoD to include in periodic health assessments and 
during military separations an evaluation of whether a servicemember 
has been exposed to open burn pits or toxic airborne chemicals. If they 
report being exposed, they will be enrolled in the Burn Pit Registry 
unless they opt out.
    This legislation is bipartisan, commonsense, and simple. It simply 
does what should have been done long ago--compels DoD to record 
exposures before the servicemember leaves the military.
    IAVA Board Member and retired General David H. Petraeus, who once 
commanded all forces in Iraq and Afghanistan, in recently expressing 
his support for this bill, said ``Veterans are currently experiencing 
illnesses that likely are related to exposure to toxins in the war 
zones and swift action is needed to understand the impact on health of 
exposure to smoke from burn pits and other sources.
    IAVA has supported and does support other VA-focused toxic exposure 
legislation, and will continue to, but this is a new solution to 
tackling this enormous problem.
    We ask the Committee to hear the calls of the many exposed veterans 
and get our arms around the problem now so VA can do the necessary 
research and better support and inform treatment. Congress should enact 
the Burn Pits Accountability Act THIS YEAR.
    Again, I thank the Chairman and Members of the Committee for 
inviting me to express our members' views on this critical issue. I am 
happy to answer any questions.

                                 
                   Prepared Statement of Ken Wiseman
    Chairman Dunn, Ranking Member Brownley and members of the 
Subcommittee, on behalf of the Veterans of Foreign Wars of the United 
States (VFW) and its Auxiliary, thank you for the opportunity to 
testify on the important topic of burn pits.
    The use of open air burn pits in combat zones has caused invisible, 
but grave health complications for many service members, past and 
present. Particulate matter, polycyclic aromatic hydrocarbons, volatile 
organic compounds and dioxins--the destructive compound found in Agent 
Orange--and other harmful materials are all present in burn pits, 
creating clouds of hazardous chemical compounds that are unavoidable to 
those in close proximity.
    While the VFW is glad to see that more than 140,000 veterans have 
enrolled in VA's Airborne Hazards and Open Burn Pit Registry, we are 
concerned that the results of the National Academies of Science's study 
on the burn pit registry have not been fully implemented. The findings 
must be included in forging a path forward for research on conditions 
caused by exposure to the toxins associated with burn pits. The VFW 
urges the Department of Veterans Affairs (VA) and Congress to act 
swiftly on recommendations from this important study.
    For example, a similar registry operated by Burn Pit 360 allows the 
spouse or next-of-kin of registered veterans to report the cause of 
death for veterans. VA must add a similar feature to its registry to 
ensure VA is able to track trends. Other improvements include 
streamlining the registration process, updating duty locations based on 
records provided by the Department of Defense (DoD), and eliminating 
technical glitches to ensure veterans are able to register. Another 
concern the VFW hears from veterans is the lack of outreach from the 
registry. Veterans expect to receive notifications or updates from VA 
on current research and VA's progress to identify and treat conditions 
associated with exposure to burn pits.
    As VA moves to implement the Electronic Health Record (EHR), 
special attention must be given to ensuring this record can interact 
with the Airborne Hazards and Open Burn Pits Registry. This will ensure 
that data follows the veteran from the time of the exposure through 
discharge and life after the military. It will also allow doctors to 
provide proper care knowing the full history of the veteran.
    Much of a veteran's long-term health is dependent on what happened 
to them while in the military. Burn pit exposure can cause problems 
while in service and this information must be shared with VA to ensure 
proper care is given. While ensuring the EHR communicates with the 
registry is important, there is also a need for other information to 
come from DoD. The VFW has long advocated for better sharing of 
information to include the location of burn pits used, types of 
materials burned in the pits, data collected by industrial hygienists 
regarding exposures, data collected from post-deployment health 
assessments, and all information associated with a medical retirement 
caused by health conditions related to burn pit exposures.
    Such information from DoD will go a long way in ensuring veterans 
receive the care and benefits they deserve. It would provide for data 
needed to conduct longitudinal studies which contribute to the existing 
body of research on health conditions. The VFW continues to hear from 
members who suffer from debilitating respiratory conditions believed to 
be caused by exposure to toxic burn pits. The VFW sees the publication 
from The National Academies of Science, Engineering, and Medicine, 
Assessment of the Department of Veterans Affairs Airborne Hazards and 
Open Burn Pit Registry, as further proof that a connection between the 
EHR and the VA's burn pit registry must be made.
    The 2017 report noted that there was a connection between burn pit 
exposure and numerous health conditions including emphysema, chronic 
obstructive pulmonary disease (COPD), and asthma. However, the report 
stated that the evidence for this connection was self-reporting by 
veterans, that further research would be needed to make a more 
definitive connection, and that medical records would be the best 
source of the needed information about proper diagnoses of these 
conditions. The VFW supports this call for further research and 
inclusion of the veteran's VA medical records in this research.
    There are three major areas where the VFW sees a need for action. 
The VFW has always agreed that science must connect the medical 
conditions of veterans to their military service. However, ensuring 
research is properly funded and conducted in an academic manner remains 
a concern.
    The VFW is confident that research conducted with proper scientific 
methods exists. One such study, New-onset Asthma Among Soldiers Serving 
in Iraq and Afghanistan, published in the Allergy & Asthma Proceeding 
and conducted by staff at the VA Medical Center in Northport, New York, 
found a connection between deployment to Iraq and Afghanistan and 
asthma among the 6,200 veterans reviewed. Other studies have shown 
similar evidence of association between pulmonary conditions and 
exposure to toxic burn pits. That is why the VFW urges VA and Congress 
to commission a review of the existing body of research on burn pits to 
determine what conclusions can be made and what research needs to be 
conducted to find more answers.
    While the VFW is glad to see VA has commissioned independent 
research on the burn pit registry, more independent research is 
necessary. That is why the VFW supports establishing a Congressionally 
Directed Medical Research Program (CDMRP) specifically for burn pits. 
The CDMRP has shown progress in identifying causes, effective 
treatments, and biomarkers for Gulf War Illness, and the VFW is 
confident a similar program for burn pits will help exposed veterans 
finally determine whether their exposure to burn pits while deployed is 
associated with their negative health outcomes.
    An important finding in the Assessment of the Department of 
Veterans Affairs Airborne Hazards and Open Burn Pit Registry is the 
need for new research methods to be developed. The VFW is concerned 
about the impact of sampling error on the results of some studies. 
Specifically, several VA and DoD-sponsored epidemiologic studies 
compare the difference in pulmonary health conditions between veterans 
who deployed to Iraq and Afghanistan and those who did not deploy. 
However, such studies do not control for the realities of deploying to 
combat zones. Often, the deployed veteran's sample included veterans 
who were deployed, but whose duties did not require them to work in or 
near burn pits. Additionally, non-deployed samples include veterans who 
may have deployed in support of previous operations such as the Gulf 
War, during which they may have been exposed to other toxins.
    Historically speaking, medical research has never exceeded at 
including women. Another barrier also faced by VA is the need for women 
veterans to be over-represented in medical research in order to produce 
accurate and usable results. With this in mind, as well as budgetary 
restrictions, the data on reproductive outcomes of women veterans who 
have served is lacking. While there are plenty of anecdotal stories and 
seeming trends surrounding infertility issues for women who served--be 
it in combat, surrounded by toxic exposures, or in a training command--
there is minimal scientific data.
    VA found some preliminary data showcasing that women who have 
deployed may have higher rates of pregnancy loss and infertility, but 
the researchers acknowledged that the study did not include enough 
participants to confidently deem that data as valid. Women veterans 
deserve to understand how their military service may or may not have 
long-term effects on their health. As such, the VFW calls on VA to 
improve research related to the impact of burn pits as they relate to 
reproductive health issues.
    An additional area of concern where research is needed is how burn 
pit exposure impacts future generations. The biological children of 
those veterans exposed may face health issues just like the children of 
Vietnam veterans. There are two significant sections of the law that 
cover spina bifida and other birth defects, and it was research that 
connected these conditions. The Toxic Exposure Research Act was 
designed to provide the type of research needed for connecting 
conditions affecting children because of their parents' exposure, and 
the VFW supports funding such research so that care can be provided to 
those affected.
    In closing, the VFW sees that there are more miles in front of us 
than behind us on the issue of burn pits. We call on VA to take actions 
under current regulations with regard to the processing of disability 
claims and research so that veterans and their loved ones get the 
answers they deserve. We also support additional funding and oversight 
being provided by Congress to ensure that the research can be conducted 
in a way that provides these needed answers. Considering the use of 
open air burn pits is unique to the military, there is no escaping the 
fact that veterans are sick and dying because of their military 
service. This is an area where action must be taken.
    Mr. Chairman, this concludes my testimony. I am prepared to take 
any questions you or the Subcommittee members may have.

                                 
              Prepared Statement of Dr. Ralph L. Erickson
    Good afternoon Chairman Dunn, Ranking Member Brownley, and Members 
of the Subcommittee. I appreciate the opportunity to discuss the 
ongoing research and actions the Department of Veterans Affairs (VA) is 
taking to identify and care for Veterans who were exposed to burn pits 
during service in the Armed Forces. I am accompanied today by Dr. Drew 
Helmer, Director, War-Related Illness and Injury Study Center, New 
Jersey (WRIISC--NJ) and VA's Airborne Hazards Center of Excellence 
(AHCE).

Introduction

    Exposure to open-air burn pits and airborne hazards during 
deployment may be associated with adverse health consequences. The 
collaborative and ongoing efforts of VA, the Department of Defense 
(DoD), and our partners in academia in the areas of clinical care, 
research, education, and communications are being fully employed to 
identify Veterans who may be at risk and to investigate and quantify 
potential short-term or long-term adverse health effects that may be 
associated with their exposure to contaminants or toxic substances from 
open-air burn pits and other airborne hazards. Information obtained 
through these collective efforts helps inform study designs and, in 
time, helps advance clinical practice and standards, as medical 
practice continually evolves based on new knowledge. Simply put, the 
ultimate aim of these combined efforts is to place us in a position to 
know how to better limit future deployed units' exposure to potentially 
harmful contaminants and toxic substances and to prevent the clinical 
manifestation of any associated diseases, or at least enable us to 
clinically manage and control progression of any confirmed associated 
adverse health outcomes in affected individuals.
    Open burn pits were used as a common waste disposal method at 
military sites in Iraq and Afghanistan. They have historically been 
used in other parts of the world by the military, but the contents of 
what was burned in these conflict areas, as well as the Southwest Asia 
environment itself with dust, particulate matter, burning oil wells, 
and general air pollution make these recent exposures more complex.
    On January 10, 2013, Section 201 of Public Law 112-260 was enacted, 
requiring VA to establish and maintain an open burn pit registry for 
certain eligible individuals who may have been exposed to toxic 
airborne chemicals and fumes caused by open burn pits. As implemented 
and enhanced by VA, the registry was designed to include Servicemembers 
who deployed to the Southwest Asia theater of operations (as that term 
is defined in 38 Code of Federal Regulations Sec.  3.317(e) (2)) on or 
after August 2, 1990, or on or after September 11, 2001, to include 
Afghanistan and Djibouti. On June 16, 2014, in response to this 
mandate, Veterans Health Administration's (VHA) Office of Public Health 
(now managed by the Office of Post Deployment Health Services) 
established the Airborne Hazards Open Burn Pit Registry (AHOBPR) for 
eligible Servicemembers and Veterans. At present, this is VA's fastest 
growing registry and has over 143,000 participants as of June 2018.
    Smoke from open-air burn pits contained substances that may have 
adverse health effects. Separate and distinct from potential open-air 
burn pit hazards, ambient particulate matter (PM) was identified as a 
potential threat to respiratory health early in Operation Iraqi Freedom 
(OIF). Sampling conducted by preventive medicine personnel deployed to 
the United States Central Command area of operation typically 
demonstrated levels of PM (sometimes referred to as particle pollution 
in public communications) above those the U.S. Environmental Protection 
Agency's National Ambient Air Quality Standards, which are designed to 
protect sensitive populations with an adequate margin of safety. A 
major contributor to ambient PM in Southwest Asia was re-suspension of 
dust and soil from the desert floor. During Desert Shield/Desert Storm, 
Operation Enduring Freedom (OEF), Operation New Dawn (OND), and OIF, 
open-air burn pits were used with high frequency. Burn pit emissions 
contributed to the total burden of air pollutants, including gases and 
PM, to which deployed personnel were exposed.

Potential Long-Term Health Effects of Exposure to Open Burn Pits and 
    Airborne Hazards

    A 2011 Institute of Medicine Report on ``Long-term Health 
Consequences of Exposure to Burn Pits in Iraq and Afghanistan'' 
determined that there is ``limited/suggestive evidence of an 
association between exposure to combustion products and reduced 
pulmonary function'' in the subject populations. The evidence for an 
association between the development of specific respiratory diseases 
and exposure to combustion products was found to be inadequate or 
insufficient. Currently, it is unknown if reduced pulmonary function is 
a consequence of exposure to PM during deployment or if combustion 
products exposure during deployment is a risk factor for the 
development of clinical disease later in life.
    VA's Post Deployment Health Services (PDHS) is currently working to 
match the health records of participants in AHOBPR. This will be a 
long-term review as many disease processes, such as cancer or chronic 
obstructive pulmonary disease, may have a long latency period. As 
mentioned, this is the VA's fastest growing registry, and it was 
recently critically evaluated by the National Academy of Medicine 
(NAM). NAM noted that a limitation of this registry is that it is self-
reported information and therefore subject to inaccuracies. DoD is 
making a concerted effort to encourage all eligible Servicemembers who 
are separating from the service to enroll in the registry during their 
transition period. Also, the optional Airborne Hazards registry 
physical examination allows an objective recording of physical 
manifestations of a condition/illness and current health status. PDHS 
sends out approximately 5,000 emails and letters a month to encourage 
completion of the medical exam. An estimated 3.7 million Veterans and 
Servicemembers are eligible to join the registry.
    PDHS continues to review and conduct original research with AHCE 
located at WRIISC--NJ. Additionally, PDHS has requested that the next 
consensus report from NAM in the series ``Gulf War and Health,'' 
(Volume 12) review what is known about the long-term health effects of 
airborne hazards. We anticipate that these efforts will lead to better 
understanding of these exposures.
    VA and DoD continue to research possible relationships between 
exposure to open-air burn pits and cardiopulmonary symptoms, such as 
shortness of breath or decreased exercise tolerance. An illness of 
particular interest and concern is constrictive bronchiolitis. 
Constrictive bronchiolitis is a chronic debilitating lung condition and 
can have many causes including chemical and other environmental 
exposures, organ transplant rejection, medications, infection, and 
smoking. Due to an early report of a case series of possible 
constrictive bronchiolitis, there has been great interest in this 
condition as a potential explanation for the cardiopulmonary symptoms 
of Servicemembers after deployment. At this time, there is little 
evidence that the diagnosis of constrictive bronchiolitis accounts for 
more than a tiny portion of the Veterans with symptoms after 
deployment. There is a growing consensus that the cardiopulmonary 
symptoms experienced by some Veterans after deployment to Iraq and 
Afghanistan are due to a heterogeneous collection of conditions that 
may be either triggered or exacerbated by a variety of contributing 
factors. VA is committed to continued research to identify any 
statistically significant associations between this type of exposure 
and the onset of constrictive bronchiolitis, including the mechanism of 
injury and dysfunction, ultimately leading us to the identification of 
more targeted effective treatments for Veterans with associated 
cardiopulmonary symptoms (beyond what is now available to treat them 
symptomatically).

Current and Anticipated Future VA Actions

    VA and DoD Subject Matter Experts (SME) meet monthly to discuss and 
plan joint actions for the study of deployment-related exposures and 
their possible association with subsequent adverse health conditions. 
Though many deployment-related topics are discussed, airborne hazards 
and open-air burn pit-related issues are a frequent agenda item. In 
particular, the VA/DoD Health Working Group Airborne Hazards Joint 
Action Plan, in support of the VA/DoD Joint Executive Council Strategic 
Plan, is updated annually by this group.
    VA and DoD are also working jointly to improve real-time exposure 
monitoring of deployed forces and to fully capture of these data in the 
Individual Longitudinal Exposure Record (ILER) currently under 
development. Once fully fielded, ILER will match a Servicemember's 
deployments by date and location with the exposures they have 
experienced.
    In May 2017, VA and DoD gathered 50 SMEs and held the 4th Airborne 
Hazards Symposium to address the health effects of airborne hazards 
exposure during deployment to Iraq and other countries in the Southwest 
Asia Theater of Operations. VA and DoD speakers provided updates on the 
current status of the environmental exposure assessment, clinical care, 
surveillance, education, outreach, and research on airborne hazards. 
Representatives from Veterans Service Organizations provided insight on 
the needs of Veterans and made recommendations on VA/DoD efforts. 
Experts actively worked in breakout sessions to identify the 
challenges, priorities, and gaps in each of these areas. These SMEs 
also reviewed recommendations from NAM report, ``Assessment of the 
Department of Veterans Affairs Airborne Hazards and Open Burn Pit 
Registry, 2017.'' This Symposium has allowed VA to develop a cogent 
direction regarding innovative approaches to research and clinical 
care.
    AHCE at WRIISC--NJ is located at the East Orange Campus of the VA 
New Jersey Health Care System. AHCE was established in 2013 to provide 
an objective and comprehensive evaluation of Veterans' cardiopulmonary 
function, military and non-military exposures, and health-related 
symptoms for those with airborne hazard concerns. As planned, AHCE has 
expanded to become the VA's only comprehensive clinical assessment 
program for airborne hazards concerns of deployed Veterans. However, 
AHCE reach extends well beyond innovative clinical evaluations, as AHCE 
has leveraged its experience to educate providers (e.g., national 
webinars, symposia, fact sheets) and engage the research community 
(e.g., conference presentations, invited research discussions, 
publications, and grants).
    Regarding clinical care, AHCE at WRIISC--NJ will link the self-
reported responses from the AHOBPR online questionnaire to VHA clinical 
data. Building on this information, the AHCE team will screen targeted 
participants and gather additional non-VHA medical records. AHOBPR 
participants with high-priority conditions and exposures will be 
invited in for a comprehensive in-person clinical evaluation with the 
option to volunteer for related research projects.

Scientific Research Regarding Open-Air Burn Pit Exposure

    The Cooperative Studies Program within the VA Office of Research 
and Development (ORD) approved funding in 2016 for a large cohort study 
to examine the potential effects of PM exposure on lung function. The 
aim of the proposed study is to assess the association of previous 
land-based deployments to Iraq, Afghanistan, and neighboring regions 
with current measures of pulmonary health among a study cohort of 4,500 
Veterans. The cohort will include a representative sample of U.S. Army, 
Marine Corps, and Air Force military personnel who served during the 
OEF/OIF/OND era, between October 2001 and December 2014, and who have 
separated from the active military.
    VA and DoD are working together and in partnership with various 
private institutions on studies regarding possible adverse health 
effects related to exposure to open-air burn pits as well as on the use 
and effectiveness of AHOBPR. A few of these studies include:

      The National Health Study for a New Generation of U.S. 
Veterans: This population-based epidemiologic study of 22,000 Veterans 
will determine if the Veterans of OIF and OEF have reported an 
increased prevalence of health problems and behavioral risks following 
deployment in combat theaters relative to non-deployed Veterans.
      The Comparative Health Assessment Interview: This study 
is currently surveying Veterans who served in Iraq and Afghanistan, 
Veterans who served elsewhere, and a comparison group of civilians to 
assess environmental and deployment related exposures and health 
outcomes. Data analysis will begin in early 2019 with preliminary 
results in late 2019 or 2020.
      The Pulmonary Health and Deployment to Iraq and 
Afghanistan Objective: This study is intended to assess the association 
of deployment and potential exposure to airborne hazards during 
deployment with current measures of respiratory health. The project is 
funded for May 2016 through September 2022.
      The Effects of Deployment Exposures on Cardiopulmonary 
and Autonomic Function: The study evaluated cardiopulmonary function in 
deployed OEF/OIF Veterans versus those deployed elsewhere to determine 
whether deployment related exposures alter cardiovascular autonomic 
control.
      The Millennium Cohort Study: Led by DoD, this is the 
largest prospective study in U.S. military history. It is designed to 
assess the long-term health effects of military service both during and 
after service time; 70 percent of the enrollees are now Veterans.
      The Million Veterans Program: This is a VA ORD-funded 
project that is collecting demographic, medical, and genetic data on 1 
million Veterans who receive their care through VA. This study will be 
invaluable in evaluating the genetic components of respiratory disease 
risk.

    As noted above, more than 143,000 Veterans are enrolled in AHOBPR 
and an estimated 3.7 million Veterans and Servicemembers are eligible 
to join. With continued outreach, VA hopes the number enrolling will 
climb and more individuals will opt to have the Airborne Hazards 
medical examination, which will allow us to obtain more data. These 
data will inform current and future study designs and ultimately 
translate into the clinical sphere, helping us to more fully address 
the health-related concerns of potentially affected Veterans. Their 
concerns are, of course, shared by VA, DoD, and Congress.
    Investigators at VA ORD PDHS and AHCE have authored or co-authored 
important peer-reviewed published manuscripts related to the 
respiratory health of Iraq and Afghanistan Veterans, including 
comprehensive literature reviews, evaluations of health and exposure 
concerns, relationships between pulmonary function and deployment-
exposure, association of respiratory and cardiovascular conditions with 
burn pit emissions, and a unique pattern of pulmonary function 
abnormalities. AHCE researchers collaborate frequently with research 
entities, such as Northwell Health Systems and National Jewish Health, 
on joint projects, including presentations at national medical 
professional meetings.
    A bibliography of these scientific articles and other research is 
submitted to the Committee as an appendix to this testimony.

Conclusion

    VA is committed to the health and well-being of our Veterans and is 
dedicated to working with our Interagency and academic partners 
determine the best care possible for our Veterans. VA acknowledges the 
many sacrifices Veterans make in service our country and remains 
committed to outreach and research on potential adverse health effects 
associated with exposure during deployment to open-air burn pits and 
airborne hazards. This information is needed to improve therapeutic 
approaches to care. VA also remains committed to conduct aggressive 
outreach about AHOBPR to eligible populations to ensure that these 
individuals are aware of the benefits of participating in AHOBPR and 
are informed about the Departments' efforts, both joint and separate, 
to determine if such exposures are associated with any specific adverse 
health effects.
    It is critical that we continue to move forward with the current 
momentum and preserve the gains made thus far. To this end, your 
continued support is essential. Mr. Chairman, this concludes my 
testimony. My colleagues and I are prepared to answer any questions.

                                 
                       Statements For The Record

                     BURN PITS 360 (LE ROY TORRES)
    Thank you, Chairman Dunn, Ranking Member Brownley, and Members of 
the Subcommittee for today's hearing and for this opportunity to submit 
a statement for the record.

Introduction

    My name is Le Roy Torres, Captain, U.S. Army Reserve (Retired). I 
am a 2007 Iraq War veteran, and Founder of the Burn Pits 360 veterans 
organization. My wife Rosie Torres, co-founder and Executive Director 
of Burn Pits 360 has provided a statement for the record on a previous 
occasion, but today is especially notable. After a decade of advocacy 
following my service in Iraq, we are grateful that the Committee today 
is conducting a hearing on the health consequences of burn pits 
exposure and investigating how the government is treating veterans 
suffering from these toxic wounds of war. Today we ask each of you to 
stand in solidarity with us to honor with substantive measures the 
lives of thousands of my fellow comrades who lost their lives to the 
``war that followed us home.''
    I served a dual role as a Texas State Trooper for 14 years after 
being discharged from state service and as a Soldier for 23 years 
before being medically retired. I earned my graduate degree from the 
University of the Incarnate Word with the hopes of becoming an Army 
Chaplain. I deployed to Balad, Iraq from 2007 to 2008 where I was 
exposed to the largest burn pit within the Operation Iraqi Freedom 
(OIF) theatre of operations. As a husband, a father and a first 
responder, I have been deprived of my dignity, honor and health. I 
returned home from war to face a health care system that failed me and 
an employer too afraid to understand an uncommon war injury resulting 
in termination of my law enforcement career; subsequently facing 
foreclosure, while at the same time receiving VA denial letters for 
compensation for illnesses still not recognized by VA.
    Since returning from Iraq, I have had over 250 medical visits and 
was hospitalized immediately upon returning from the war. In November 
2010, I was diagnosed with a debilitating lung condition (constrictive 
bronchiolitis) following a lung biopsy at Vanderbilt University. My 
medical doctors determined last month that I have toxic brain injury 
due to exposure to toxins, likely resulting from my burn pits exposures 
in Iraq.
    For the past decade, Burn Pits 360, which Rosie and I co-founded, 
has been at the forefront of this issue, advocating for the families of 
the forgotten and those battling life-threatening illnesses. They stand 
with us here today and will be standing with us later on the steps of 
Congress, and many of their personal stories are included in Appendix 
A, which we encourage you to review with the care that they deserve.
    Burn Pits 360 is a 501(c)(3) non-profit veterans organization 
located in Robstown, Texas.
    Our mission is to advocate for veterans, service members, and 
families of the fallen affected by deployment-related toxic exposures. 
Burn Pits 360 created and maintains a burn pits exposure registry, 
which we will discuss in more detail below.
    Our organization's impact has included helping to provide impetus 
to legislation creating the Airborne Hazards and Open Burn Pit Registry 
(AHOBPR) signed into law in 2013, P.L. 112-260, which also directed a 
longitudinal burn pits exposure study to be jointly conducted by the 
U.S. Departments of Defense (DoD) and Veterans Affairs (VA).
    We participated in the open comment period for registry revisions 
submitted to the VA Office of Public Health (OPH), resulting in the 
addition of constrictive bronchiolitis (CB) to the registry. We 
presented our registry data to the National Academy of Sciences, 
Engineering, and Medicine (NASEM) committee created under the 2013 
legislation, which resulted in an insightful scientific publication 
online in 2015 and in a peer reviewed medical journal in 2017. \1\ We 
have presented key statements to the Defense Health Board and have 
actively participated in every VA/DoD AHOBPR Burn Pit Symposium.
---------------------------------------------------------------------------
    \1\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung 
Injury (IAW-LI) Clinical Practice Recommendations: National Academy of 
Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6): 
1653-1663. https://  dx.doi.org/10.1177%2F1557988315619005

---------------------------------------------------------------------------
Burn Pits and Health Consequences

    Numerous military bases in the Operations Iraqi Freedom (OIF) and 
Enduring Freedom (OEF) theatres of operation produced several tons to 
several hundred tons of solid waste per day. Open-air burn pits were 
the primary waste disposal method during the majority of the duration 
of these wars in Iraq and Afghanistan. This involved the burning of 
plastics, medical waste including human body parts, expired 
pharmaceutical drugs, chemicals including paint and solvents, petroleum 
products, and unexploded ordinance, which according to some reports may 
have also included Iraqi chemical warfare agents.
    Additionally, some of the burn pits were reportedly built on top of 
soil contaminated by chemical warfare agents. \2\ Due to the 
unacceptable risk posed by these burn pits to our service members, 
their use was eventually mostly banned, except under narrow 
circumstances, in 2010. Tens of thousands of service members have been 
exposed to toxic chemicals and microfine, highly respirable and 
dangerous particulates from burns pits and they continue to suffer 
serious, disabling health consequences upon their return.
---------------------------------------------------------------------------
    \2\ Walker, Lauren, ``US military burn pits built on chemical 
weapons facilities tied to soldiers' illness,'' The Guardian (UK), 
February 16, 2016. https://www.theguardian.com/  us-news/2016/feb/16/  
us-military-burn-pits-chemical  -weapons-cancer-illness-  iraq-
afghanistan-veterans
---------------------------------------------------------------------------
    A defense contractor stationed at Al-Taqaddum in Iraq from 2006 to 
2007--roughly the same time as I was also stationed in Iraq--described 
the impact of burn pits and their health effects in a published news 
story: ``Burn pit smoke would encircle the entire military base in an 
enormous dark ring that settled to the ground after darkfall.. A lot of 
people got rare cancers and died. Any exposed skin and mucous 
membranes, as experienced by many of us, felt on fire, and burning. 
Many of us developed shortness of breath.'' \3\
---------------------------------------------------------------------------
    \3\ Elizabeth Hilpert, quoted by Dan Sagalyn, ``Photo essay: The 
burn pits of Iraq and Afghanistan,'' November 17, 2014, PBS News Hour. 
https://www.pbs.org/  newshour/world/  photo-essay-burn-pits-iraq-
afghanistan
---------------------------------------------------------------------------
    The wars in Iraq and Afghanistan exposed U.S. service women and men 
to an unprecedented array of airborne health hazards including from 
open-air burning in vast burn pits; shock waves and toxic particulates 
from improvised explosive devices (IEDs), including vehicle-borne 
improvised explosive devices (VBIED) and those containing chemical 
warfare agents; and hazardous microfine sand particles. \4\ Service 
members with new-onset, post-deployment respiratory symptoms from these 
hazards have been labeled as having Iraq/Afghanistan War-Lung Injury 
(IAW-LI), \5\ a term we will also use throughout this document.
---------------------------------------------------------------------------
    \4\ Szema, Anthony et al, ``Iraq dust is respirable, sharp, and 
metal-laden and induces lung inflammation with fibrosis in mice via IL-
2 upregulation and depletion of regulatory T cells,'' J Occup Environ 
Med. 2014 Mar;56(3):243-51. https://dx.doi.org/  10.1097/
JOM.0000000000000119
    \5\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung 
Injury (IAW-LI) Clinical Practice Recommendations: National Academy of 
Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6): 
1653-1663. https://  dx.doi.org/  10.1177%2F1557988315619005

Burn Pits Health Consequences Led to Creation of Burn Pits 360's 
---------------------------------------------------------------------------
    National Registry

    In 2010, Burn Pits 360 created a national burn pits exposure 
registry, joining forces with other affected families who were united 
by the need to prove the correlation between the veterans' toxic 
exposures during their deployments and the post-deployment illnesses 
(that in some cases were resulting in death) that had since plagued 
them. It appeared to be the only way to convince the federal government 
that its denials--of the reality of our exposures and resulting health 
issues, of granting us necessary health care, of approving our claims 
for needed disability compensation, and, ``bottom line,'' of allowing 
us the continued right to live--must stop.
    Burn Pits 360 continues to manage this registry, which has since 
grown to about 6,000 participants. This registry also allows 
registrants the ability to later report a decline in health function, 
and their survivors to record mortality information including the cause 
of death.

    Here is some of what we now know:

      Air sampling data indicate that smoke from these burn 
pits contained chemicals associated with cancers, lung diseases, 
cardiovascular disease, kidney disease, neurological disorders, and 
more.
      The Burn Pits 360 national registry confirms that the 
array of devastating health conditions being suffered by exposed 
veterans include rare forms of cancer, pulmonary diseases, neurological 
disorders, and many other otherwise-unexplained diseases and symptoms.
      There are over 100 death entry submissions in the Burn 
Pits 360 registry, including from rare cancers--and from suicide.
      Burn Pits 360's registry data demonstrates the national 
failure to adequately prevent, diagnose, treat, and compensate burn 
pit-exposed service members and veterans.

Proposed Agenda

    There are a number of crucial issues related to burn pit exposure 
and IAW-LI that we strongly believe the House Veterans' Affairs 
Committee should investigate and which require the focused attention of 
the VA. The current lack of clear understanding of the health impacts 
of these exposures should not circumvent our national obligation to 
assist every affected military service member and veteran. In 
particular, we highlight the following important focus areas:

    1) Improving the VA's burn pit registry so that it is can be an 
effective research tool for monitoring and identifying the health 
consequences of burn pit exposure;

    2) Conducting more and better research into the health consequences 
of burn pit exposures and to develop effective treatments;

    3) Establishing evidence-based clinical practice guidelines and a 
specialized care program for IAW-LI and comorbid conditions;

    4) Creating a scientific advisory committee related to burn pit 
exposures and IAW-LI;

    5) Improving VA disability compensation claims for burn pit 
veterans, including establishing presumption of service-connection for 
debilitating symptoms and diseases that have been linked to burn pit 
exposure.

1) Improving the VA's Burn Pit Registry

    As noted earlier, in 2013, DoD and VA were directed by Congress to 
set up a registry to collect information from service members who may 
have been exposed to toxic chemicals and fumes caused by open air burn 
pits and other airborne hazards. The resulting Airborne Hazards and 
Open Burn Pit Registry (AHOBPR) to date has 141,246 registrants who 
completed and submitted the registry questionnaire. \6\
---------------------------------------------------------------------------
    \6\ U.S. Department of Veterans affairs Web site, retrieved June 5, 
2018, https://www.publichealth.va.gov/  exposures/  burnpits/
registry.asp Registrants completed and submitted the registry 
questionnaire between April 25, 2014 and May 1, 2018, including from 
OIF, OEF, Operation New Dawn, Djibouti since 9/11, and Southwest Asia 
since August 1990.
---------------------------------------------------------------------------
    And, on February 28, 2017, the NASEM committee mandated in P.L. 
112-220 (the Committee on the Assessment of the Department of Veterans 
Affairs Airborne Hazards and Open Burn Pit Registry) released its final 
report, entitled, ``Assessment of the Department of Veterans Affairs 
Airborne Hazards and Open Burn Pit Registry.'' Several key points 
emerged that we will mention shortly.
    First, with a total of over 3.5 million eligible personnel, 
participation in the VA's registry is far below expectations and there 
is not yet a clear understanding why. Without a drastic increase in 
registration, it is difficult to see how the VA's registry can provide 
an accurate assessment of the health effects of open-air burn pits on 
our service members and veterans.
    Further, our constituents on the Burn Pits 360 registry have raised 
concerns as to how the VA's registry functions. Currently, there is no 
way for a service member or veteran to report a decline in health like 
we allow in our registry. If registrants initially register as having 
no ill effects from the burn pits but are subsequently diagnosed with a 
disease or illness, they cannot later add that information to the A 
registry. This limits the long-term effectiveness of using the VA 
registry to assess the impact of toxic burn pits on our service 
members' health over an extended period of their lives and to conduct 
longitudinal studies regarding the health effects associated with burn 
pit exposures.
    We are also concerned with the participation rate in the VA 
registry's initial in-person medical evaluation. As we understand it, 
the evaluation's intent is to have a VA practitioner systematically 
assess a service member or veteran for symptoms related to their toxic 
exposures. This would allow for the creation of a fuller picture of the 
patient's health than can be obtained through the self-reported survey 
alone. However, according to a presentation given by Stephanie Eber and 
Susan Santos of the VA, as of April 2017, only 2.8 percent of registry 
participants have undergone this exam. We have also received reports of 
inconsistent examinations, diagnoses, and treatments afforded to 
service members seeking care associated with their toxic exposures.
    Another serious shortfall of the VA registry is that it does not 
allow family members to register the death of registry participants, 
especially important when there is reason to believe the death was a 
result of toxic exposure from burn pits (ours does). Without tracking 
the mortality rate through methods such as allowing surviving family 
members to report deaths and the cause of death, the registry's ability 
to establish mortality rates related to conditions and diseases 
associated with toxic exposure is precluded.
    Most significantly, the NASEM committee on the assessment of VA's 
registry stated in its final report: ``On the basis of its evaluation 
of the data, the committee concluded that the exposure data are of 
insufficient quality or reliability to make them useful in anything 
other than the most general assessments of exposure potential.'' \7\
---------------------------------------------------------------------------
    \7\ National Academy of Science, Engineering, and Medicine (NASEM), 
Committee on the Assessment of the Department of Veterans Affairs 
Airborne Hazards and Open Burn Pit Registry, ``Report Highlights,'' 
February 28, 2017. http://www.nationalacademies.org/  hmd/reports/2017/  
assessment-of-the-va-airborne-hazards-  and-open-burn-pit-registry.aspx

---------------------------------------------------------------------------
The Committee concluded:

    Attributes inherent to registries that rely on voluntary 
participation and self-reported information make them fundamentally 
unsuitable for addressing the question of whether burn pit exposures 
have caused health problems. Addressing the issues identified by the 
committee would, though, improve the AH&OBP Registry's utility as a 
means of generating a roster of concerned individuals and creating a 
record of self-reported exposures and health concerns.
    All parties-service members, veterans, and their families; VA; 
Congress; and other concerned people-would benefit from having a 
realistic understanding of the strengths and limitations of registry 
data so that they can make best use of them and, if desired, conduct 
the kind of investigations that might yield salient health information 
and improve health care for those affected. \8\
---------------------------------------------------------------------------
    \8\ NASEM 2017
---------------------------------------------------------------------------
    Finally, as of June 4, 2018, the VA's Web site currently states 
that ``VA is working to improve the registry based on recommendations 
in the report'' \9\ that was issued more than 15 months earlier. It 
appears that this sentence of the Web site was recently changed. 
Previously, the Web site stated, ``A workgroup of VA subject matter 
experts is reviewing the report's nine recommendations to determine 
ways to improve the health status and medical care of veterans.'' To 
date, we are not yet aware of improvements to the VA's registry 
recommended either by the NASEM report last year or the researchers' 
recommendations published online in 2015 and in a medical journal last 
year. \10\
---------------------------------------------------------------------------
    \9\ ibid.
    \10\ Szema et al, 2017

    Recommendation. We encourage the Committee to seek answers from the 
VA for the following important questions, and legislating or otherwise 
---------------------------------------------------------------------------
ensuring changes as may be appropriate based on VA's responses:

    1. Thousands of veterans who were exposed to toxic smoke from burn 
pits in Afghanistan and Iraq are coming home and developing serious 
illnesses like constrictive bronchiolitis, other respiratory 
conditions, and cancers. Is it VA's position that prolonged exposure to 
smoke from open burn pits burning of toxic waste can have lasting 
negative health consequences?

    2. The VA has not seriously researched the consequences of burn pit 
exposure. Congress mandated that VA implement the Registry to monitor 
health conditions affecting veterans and service members who were 
exposed to toxic smoke from burn pits and other hazards. But, according 
to a 2017 report from the National Academy of Sciences, the registry is 
fatally flawed and ineffective as a way to investigate the true health 
consequences of burn pits. Will VA commit to reforming the burn pits 
registry to make it a genuinely useful tool for documenting the true 
health consequences of burn pits?

    3. Who is on the ``workgroup of VA subject matter experts'' that 
was reviewing the nine recommendations? What records reflect their work 
in response to the 2017 National Academy of Sciences report, including 
their recommendations or determinations?

    4. What records reflect the improvements that the VA is considering 
to the Registry based on the recommendations of the 2017 report?

    5. What records exist regarding complaints about the burn pit 
registry, including complaints from individual veterans regarding the 
registry?

    6. What outreach methods are in place to ensure that service 
members deployed to Iraq and Afghanistan post-9/11 are aware of the 
registry and are encouraged to register if they believe they have been 
exposed to toxic matter through open air burn pits?

    7. What factors explain the discrepancy between the numbers of 
service members potentially exposed, versus the number of registrants 
to the burn pits registry?

    8. What is the VA's strategy to increase participation in the 
registry?

    9. Does the VA regularly communicate with registrants?

    10. How is the VA gathering data, if at all, to assess change or 
decline in health among service members, to support a longitudinal 
assessment? Why would the VA not support including an option for 
updated reporting in the registry?

    11. How is the VA gathering mortality data, if at all, associated 
with toxic exposures through burn pits? Why would the VA not support 
including an option for reporting deaths in the registry?

    12. What factors explain the low participation rate of registrants 
with the associated exam?

    13. Has the VA adopted a strategy to increase the participation 
rate in the initial exam?

    14. Is there a uniform protocol in place that practitioners who 
administer the exam are following? If yes, what is the protocol and has 
it proven effective in recognizing common warning signs and symptoms 
indicating toxic exposure?

    15. What protocol does the VA have in place to ensure that its 
practitioners are equipped to detect and treat medical issues 
associated with toxic exposure among registry participants VA examines?

    Recommendation. To encourage full Registry participation, Congress 
should direct VA to conduct a national outreach campaign to include:

      Newsletters to registry participants
      Social media campaigns
      Development of VA registry outreach written materials for 
distribution in VA and veterans service organization (VSO) facilities, 
at events, and on all social media sites operated by DoD and VA.

2) Conducting More and Better Research

    The VA was directed under P.L. 112-260 to contract for an 
independent scientific report that would contain the following: \11\
---------------------------------------------------------------------------
    \11\ PUBLIC LAW 112-260-JAN. 10, 2013 126 STAT. 2423--SEC. 201. 
ESTABLISHMENT OF OPEN BURN PIT REGISTRY.
    (b) REPORT TO CONGRESS.-
    (1) REPORTS BY INDEPENDENT SCIENTIFIC ORGANIZATION.- The Secretary 
of Veterans Affairs shall enter into an agreement with an independent 
scientific organization to prepare reports as follows:
    (A) Not later than two years after the date on which the registry 
under subsection (a) is established, an initial report containing the 
following:
    (i) An assessment of the effectiveness of actions taken by the 
Secretaries to collect and maintain information on the health effects 
of exposure to toxic airborne chemicals and fumes caused by open burn 
pits.
    (ii) Recommendations to improve the collection and maintenance of 
such information.
    (iii) Using established and previously published epidemiological 
studies, recommendations regarding the most effective and prudent means 
of addressing the medical needs of eligible individuals with respect to 
conditions that are likely to result from exposure to open burn pits.
    (B) Not later than five years after completing the initial report 
described in subparagraph (A), a follow-up report containing the 
following:
    (i) An update to the initial report described in subparagraph (A).
    (ii) An assessment of whether and to what degree the content of the 
registry established under subsection (a) is current and scientifically 
up-to-date.
    (2) SUBMITTAL TO CONGRESS.-
    (A) INITIAL REPORT.-Not later than two years after the date on 
which the registry under subsection (a) is established, the Secretary 
of Veterans Affairs shall submit to Congress the initial report 
prepared under paragraph (1)(A).
    (B) FOLLOW-UP REPORT.-Not later than five years after submitting 
the report under subparagraph (A), the Secretary of Veterans Affairs 
shall submit to Congress the follow-up report prepared under paragraph 
(1)(B).
    https://www.gpo.gov/  fdsys/pkg/PLAW-112publ260/pdf/PLAW-
112publ260.pdf

      An assessment of the effectiveness of actions taken by 
the Secretaries to collect and maintain information on the health 
effects of exposure to toxic airborne chemicals and fumes caused by 
open burn pits.
      Recommendations to improve the collection and maintenance 
of such information.
      Using established and previously published 
epidemiological studies, recommendations regarding the most effective 
and prudent means of addressing the medical needs of eligible 
individuals with respect to conditions that are likely to result from 
exposure to open burn pits.

    To date, it is unclear to us whether this has happened. Certainly 
VA has not yet determined the ``most effective and prudent means of 
addressing the medical needs of eligible individuals with respect to 
conditions that are likely to result from exposure to open burn pits.''

    Recommendation. We encourage the Committee to provide continued 
oversight with regards to the status of this report and the 
implementation of its recommendations.

    According to VA's Web site, NASEM's 2011 report, Long-Term Health 
Consequences of Exposure to Burn Pits in Iraq and Afghanistan, ``found 
limited but suggestive evidence of a link between exposure to 
combustion products and reduced lung function in various cohorts 
similar to deployed Service members, such as firefighters and 
incinerator workers. This finding focused on pulmonary (lung) function, 
not respiratory disease, and noted that further studies are required. 
There is little current scientific evidence on long-term health 
consequences of reduced lung function.'' \12\
---------------------------------------------------------------------------
    \12\ U.S. Department of Veterans Affairs Web site, retrieved June 
4, 2018: https://www.publichealth.va.gov/  exposures/burnpits/health-
effects-studies.asp
---------------------------------------------------------------------------
    VA goes on to say, ``VA and the Department of Defense will conduct 
a long-term study that will follow Veterans for decades looking at 
their exposures and health issues to determine the impact of deployment 
to Iraq and Afghanistan. Read the February 4, 2013 notice in the 
Federal Register to learn more.''
    It has been more than five years since VA announced it planned to 
conduct this long-term study. VA has had ample opportunity to conduct 
it.

    Recommendation. We encourage Congress to mandate an independent 
epidemiologic research study--outside of VA, which has already had 
ample opportunity to do so--that will help to more formally identify 
the association our Burn Pits 360 Registry has already shown between 
burn pit exposure and resultant health conditions and deaths.

    Such research should include determining the incidence and 
prevalence of IAW-LI and other potentially related health conditions 
in: (1) military service members and veterans currently in treatment 
for post-burn pit exposure health complaints; (2) Iraqi local 
populations similarly exposed to U.S. burn pits; (3) healthy control 
populations of Iraq and Afghanistan War deployed and non-deployed era 
service members/veterans.

    Recommendation. We encourage the Committee to seek answers from the 
VA for the following important questions, and legislating or otherwise 
ensuring changes as may be appropriate based on VA's responses:

    1. Which specific office(s), working group(s) or people are 
assessing the adequacy and effectiveness of data gathering and 
surveillance of the health consequences of burn pits?

    2. Does VA have any unpublished studies, reports, or similar 
documents regarding health effects of burn pits?

    3. How does VA review, assess, and assimilate studies into (i) its 
assessment of the long-term health consequences of burn pits and (ii) 
its screening for potential burn-pit related disease and (iii) its 
treatment for burn-pit related disease?

    4. What records exist that would reflect VA's assessment of such 
studies (including, potentially, internal correspondence, memos, etc.)

    5. What internal assessments, memos, or other documents underlie 
the VA's determination that ``At this time, research does not show 
evidence of long-term health problems from exposure to burn pits.''

    6. Which specific office (or which officials) are involved in 
internal reassessment or reevaluation of VA's determination that there 
is currently no evidence of long-term health problems? What records 
exist that would reflect any such ongoing assessment or evaluation?

    7. The VA's ``fact sheet'' on burn pits, which describes ongoing 
research into the health effects of burn pits and the inconclusive 
nature of prior research. The last time we reviewed it, that fact sheet 
was last updated in November 2013 and only referred to studies from 
2009 and 2011. Which specific office (or which officials) are involved 
in reassessing the statements in that fact sheet in light of more 
recent research? What records exist that would reflect potential 
reassessments or updates of the fact sheet?

DoD-CDMRP Burn Pit Exposure Medical Research

    As many of the members of this Committee know from past hearings on 
another toxic exposure issue, Gulf War Illness, many ill Gulf War 
veterans are encouraged by ongoing treatment research directed by 
Congress, including by many of you and other leaders and Members of the 
House Veterans' Affairs Committee. Specifically, that treatment 
research is being done by the Gulf War Illness Research Program 
(GWIRP), part of the Congressionally Directed Medical Research Program 
(CDMRP) that is funded under the Department of Defense (DoD) health 
budget.
    Like the GWIRP, many of the health research programs within the 
CDMRP are standalone programs. However, others are congressionally 
designated topic areas within broader programs like the CDMRP's Peer 
Reviewed Medical Research Program (PRMRP). The specific topic areas to 
be pursued are determined by Congress each year through annual Defense 
appropriations.
    For Fiscal Year 2018, there are several medical research topic 
areas in the CDMRP-PRMRP that remain of strong interest to veterans 
affected by burn pit exposure, including: Acute Lung Injury; Burn Pit 
Exposure; Constrictive Bronchiolitis; Lung Injury; Metals Toxicology; 
Mitochondrial Disease; Pulmonary Fibrosis; and Respiratory Health. We 
are grateful to Congress for including all of these research topic 
areas, particularly the restoration of the Burn Pits Exposure topic 
area.
    CDMRP is important for this treatment-focused research for several 
reasons. First, CDMRP has the ability to fund any qualified research 
team, not just those employed by the funding agency. By contrast, VA's 
medical research program is solely intramural and open only to VA-
employed researchers. Much of the valuable medical research related to 
burn pits exposure has been led by researchers at independent, academic 
medical centers including Vanderbilt University, Stony Brook 
University, the Deployment-Related Lung Disease Center at National 
Jewish Health, and others.
    Second, CDMRP includes in all levels of planning, proposal review, 
and funding decisions the active participation of consumer reviewers--
patients (or their caregivers) who are actually affected by the 
disease. This is of critical importance. VA offers no opportunity for 
similar involvement in research decision-making by the patients who are 
ultimately affected by such decisions.
    Finally, CDMRP has already shown its effectiveness with regards to 
other complex post-deployment, toxic exposure health conditions 
including traumatic brain injury (TBI) and Gulf War Illness (GWI), 
including through its emphasis on collaboration, treatment focus, and 
effective two-tiered peer review.

    Recommendation. We encourage Members of the Committee work to 
create a Congressionally directed standalone Burn Pits Exposure 
Research Program (BPERP) within the Congressionally Directed Medical 
Research Program (CDMRP), modeled after the successes of other CDMRPs 
including the treatment-focused Gulf War Illness Research Program, as 
follows:

    A standalone burn pits exposure CDMRP would ideally be laser-
focused on improving the health and lives of veterans suffering the 
negative health effects of burn pit exposures and on learning all that 
is possible from their health experiences to help future veterans 
similarly exposed. Like the existing standalone CDMRPs, the proposed 
Burn Pits Exposure Research Program would have its own dedicated staff, 
focused exclusively on advancing the Congressional directives related 
to this burn pit exposure medical research program. Ideally, it would 
be focused on several major areas to more rapidly improve the health 
and lives of veterans affected by burn pits exposure:

      Accelerating the development of treatments and their 
clinical translation for Iraq/Afghanistan War Lung Injury (IAW-LI) and 
comorbid associated conditions
      Improving scientific understanding of the pathobiology 
resulting from burn pit exposures, including in both affected veterans 
and in animal models of burn pit exposures, and including research 
priorities to identify biomarkers of exposure, biomarkers of exposure 
effect, and biomarkers of illness--all critical in improving the 
definition and diagnosis, disease monitoring, and monitoring of the 
effectiveness of tested treatments of veterans affected by burn pit 
exposure
      Assessing comorbidities, including the incidence, 
prevalence, early detection and diagnosis, treatments for, and any 
unique factors related to burn pits exposed veterans': constrictive 
bronchiolitis (CB/OB), pulmonary fibrosis, sarcoidosis, chronic 
obstructive pulmonary disease (COPD), post-exertional asthmas, and 
other respiratory diseases; cancers including lung cancer, leukemia, 
glioblastoma and other brain cancers, renal cancer, and other cancers
      Identifying force health protection prevention measures 
to prevent future burn pit exposures, and to provide early assistance 
to future military service members exposed to burn pits?
      Using other CDMRP successes as a model, investing 
appropriated medical research funding to develop a collaborative, 
inter-institutional, interdisciplinary burn pits exposure research 
consortium, while investing other appropriated medical research funding 
to support focused medical research in the areas described above

    We understand the process for fiscal year 2019 Defense 
appropriations has already moved forward. However, we have seen there 
is great value in having a project like this led by Members of the 
House Veterans' Affairs Committee. We would be pleased to work early 
next year with any Members interested in creating, on a bipartisan, 
bicameral basis, a cosigned request for fiscal year 2020 funding to 
create such a Burn Pits Exposure Research Program.

3) Establishing Evidence-Based Clinical Practice Guidelines and 
    Specialized Treatment

    According to a recent search of VA's Web site that appears to list 
and link to all of the existing VA/DoD Clinical Practice Guidelines, VA 
and DoD have not yet developed evidence-based Clinical Practice 
Guidelines (CPG's) for health care providers to know how to identify, 
evaluate, treat, and refer patients with IAW-LI or other conditions 
that may be associated with exposure to burn pits. \13\ At least one 
other VA/DoD CPG has come under harsh fire in a 2013 hearing before 
this Committee for not being evidence-based, and worse. \14\
---------------------------------------------------------------------------
    \13\ U.S. Department of Veterans Affairs Web site, retrieved June 
5, 2018: https://  www.healthquality.va.gov
    \14\ U.S. House Committee on Veterans' Affairs, ``Persian Gulf War: 
An Assessment of Health Outcomes on the 25th Anniversary,'' https://
veterans.house.gov/  calendar/  eventsingle.aspx?EventID=1104
---------------------------------------------------------------------------
    There remains an unmet need of adequately educating primary care 
clinicians in the evaluation and treatment of burn pit related physical 
illness, including in DoD, VA, and civilian health care environments. 
There also remains an unmet need of describing evidence-based treatment 
recommendations for IAW-LI (including post-exertional shortness of 
breath and diagnosed respiratory conditions), toxic brain injury, and 
all disease and illnesses associated with deployment toxic exposures 
including from burn pits.
    IAW-LI is debilitating to the affected veterans. This war-induced 
disease impacts multiple dimensions of everyday life, such as the 
ability to perform one's job and the ability to exercise. Research has 
shown that service members and veterans suffering from this war-related 
lung injury have new-onset asthma or fixed obstructed airways. Research 
has also reported titanium bound to iron in fixed mathematical ratios 
of 1:7, which is extremely rare in nature, in the lungs of soldiers, 
suggestive of an anthropogenic, man-made source. In more severe cases, 
these service members developed severe respiratory disability that 
required a lung transplant. IAW-LI has been shown to be long-term and 
does not improve, even though some of these veterans were exposed in 
2003--fifteen years ago. Yet almost counter intuitively, symptoms as 
severe as these are not detectable by routine testing and require 
sophisticated specialty care.
    Currently, there are no evidence-based treatments available for 
this disease process, but researchers are investigating several 
candidate medications in development, which have been found to reverse 
IAW-LI injuries in mice exposure models. ??Because of the VA's 
dereliction of duty to this matter for the last fifteen years; it is 
our generation's Agent Orange.
    IAW-LI sometimes is not easily diagnosed by physicians, because 
many are still unaware of this injury. Also, it is difficult for 
suffering patients to realize what their symptoms are because this is 
an unconventional disease. Many believe the symptoms are attributed to 
Post-Traumatic Stress Disorder (PTSD), not IAW-LI. Sophisticated tests 
such as impulse oscillometry and analysis of lung tissue for metals are 
only available at Quaternary Care Medical Centers. Quaternary care is 
very specialized and highly unusual and not offered at most medical 
facilities.

    Recommendation. Congress should mandate that VA create evidence-
based clinical practice guidelines for IAW-LI that are appropriate for 
DoD, VA, and non-VA health care providers to be able to identify, 
evaluate, treat, and refer patients with conditions that may be 
associated with exposure to burn pits including IAW-LI and comorbid 
cancers, respiratory, and other diagnosed diseases.

VA Clinical Care: Establishing a Specialized Health Care Program

    Develop deployment related toxic exposure specialty clinic within 
the VA health care systems. Currently veterans are being misdiagnosed 
and symptoms are being dismissed as psychosomatic and not for the true 
illnesses they are suffering from.

    Recommendations. We ask that Congress query VA leadership: Will VA 
commit to establishing a dedicated research center to study and develop 
treatments for health conditions resulting from burn pit exposure?

4) Develop a Burn Pits Exposure Scientific Advisory Committee

    Currently, no federal advisory committee exists that is specific to 
burn pits exposures. And, there are few opportunities within current 
DoD and VA activities that allow for burn pit exposed service members 
and veterans to actively participate in making recommendations related 
to research or policymaking that directly affects their well-being.

    Recommendation. Congress should mandate the establishment of a 
federal scientific advisory committee to provide a comprehensive review 
and recommendations on the full spectrum of burn pits exposure 
research. It should include several VA, DoD, and independent scientific 
researchers and clinicians who actively work on burn pits exposure 
research or clinical care, and should include several clearly 
representative, affected service members, veterans, and their 
survivors. Its activities should include review the experiences of 
affected service members and veterans, and scientific and medical 
evidence in order to make recommendations to DoD, VA, and possibly also 
the Department of Health and Human Services (HHS).

5) Improving VA Burn Pits Exposure Claims

    VA's Compensation and Pension Manual, M21-1MR, provides guidance 
for adjudicating claims resulting from various toxic exposures. The 
relevant section, entitled, ``Service Connection for Disabilities 
Resulting from Exposure to Other Specific Environmental Hazards,'' \15\ 
at least partially governs VA's burn pits exposure-related compensation 
claims. Relevant identified hazards include ``large pit burns 
throughout Iraq, Afghanistan, and Djibouti on the Horn of Africa'' and 
``particulate matter in Iraq and Afghanistan.''
---------------------------------------------------------------------------
    \15\ U.S. Department of Veterans Affairs, Veterans Benefits 
Administration, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, 
Topic 12, ``Service Connection for Disabilities Resulting from Exposure 
to Other Specific Environmental Hazards.'' https://www.benefits.va.gov/  
WARMS/docs/admin21/m21--1/  mr/part3/subptiii/  ch05/pt03--sp03--ch05--
secj.doc
---------------------------------------------------------------------------
    VA Training Letter 10-03, identified in the manual, provides more 
specific policy guidance on processing burn pit claims.
    Additionally, after the 1991 Gulf War, Congress enacted statutory 
directives at 38 U.S.C.Sec.  1117, which addressed a range of 
disabilities in veterans who served in Southwest Asia. VA then 
promulgated its regulations at 38 C.F.R. Sec.  3.317. Although rarely 
applied correctly by VA, the law provides for presumptive service 
connection for a ``qualifying chronic disability.'' A qualifying 
chronic disability means a chronic disability resulting from ``an 
undiagnosed illness'' (UDX) or ``a medically unexplained chronic multi-
symptom illness [CMI] that is defined by a cluster of signs or 
symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) 
functional gastrointestinal disorders'' [including irritable bowel 
syndrome (IBS)]. If a veteran's disability pattern is either one of 
these, then VA must grant service connection based on Sec.  3.317. 
Veterans with burn pit exposure who served in the Southwest Asia 
theatre of operations (which does not include Afghanistan or Djibouti) 
anytime from August 1991 the present may also qualify to have their 
claims adjudicated under these provisions.
    VA should have little problem establishing exposure in burn pit 
cases because nearly every forward operating base (FOB) in Iraq, 
Afghanistan, and Djibouti had a burn pit. Given the widespread nature 
of the burn pits, and the inability of military personnel records to 
identify all duty locations, VA adjudicators are generally supposed to 
accept the veteran's lay statement of burn pit exposure as sufficient 
to establish the occurrence of such exposure if the Veteran served in 
Iraq or Afghanistan.

VA Claims: Medical Diagnosis and Adjudication Practices

    At times, VBA staff have exhibited confusion about relevant 
diagnosis for veterans with burn pits exposures. Confounding burn pit 
claims with Gulf War Illness claims, they have returned documentation 
explaining that service-connection could not be granted because the 
veteran did not have an undiagnosed illness (UDX) or a medically 
unexplained chronic multi symptom illness (CMI). These are complex 
regulations that VA has systemically failed in correctly applying to 
the appropriate cases.
    Burn Pit related claims are not the same claims as under the 
Persian Gulf War regulations. Claims based on the Gulf War regulations 
are granted, if at all, on a legal presumption that the disability is 
related to service in Southwest Asia. Whereas, claims based on OIF/OEF 
exposures, such as burn pits, are granted, if at all on a direct basis 
(i.e., event or exposure during service; diagnosed disability; and, a 
medical nexus between the two.)
    There are times, however, when VA claims staff appropriately apply 
both sets of rules. A good example is when a veteran who served in Iraq 
after September 11, 2001 files a service connection claim for a 
disability that could satisfy the ``qualifying chronic disability'' 
requirements of 38 C.F.R. Sec.  3.317 but is also a disability that may 
be directly related to exposures in Iraq after September 11, 2001, such 
as burn pits. In such a case, VA should consider both sets of rules 
separately and then grant the veteran's claim under whichever is of 
greatest benefit to the veteran.

    Recommendation. The Committee should request detailed information 
from VA on the gaps and overlaps between the application of these two 
types of claims adjudication processes for veterans with burn pits 
exposure and resultant disability.

VA Claims: Adjudication Issues

    Most disability claims require a medical examination from a VA 
practitioner or contracted VA examiner. In burn pit claims, these so-
called Compensation and Pension (C&P) exams are very important because 
VA has not yet acknowledged a medical nexus between burn pit exposure 
and the disabilities burn pit veterans are experiencing. Often, the 
veteran's only chance to show a medical link between their symptoms and 
contact with burn pit emission is a medical opinion issued by one of 
these C&P examiners.
    This makes it all the more troubling that VBA staff so routinely 
fail to follow VA guidance on requesting C&P exams for burn pit 
exposure claims. When they do follow the guidance, the only training 
C&P examiners receive on burn pit emissions is a one-page ``fact 
sheet'' produced by VBA when it issued Training Letter 10-03.
    VBA staff also frequently neglect to send the minimalist fact sheet 
required for all C&P exam requests pursuant to VBA's M-21 procedural 
manual. This leaves examiners with little to no information about which 
chemicals have been detected in burn pits emissions, how burn pits were 
operated, and other potentially critical medical information.
    Most examination reports serve little more purpose than to reveal 
the person conducting the examination has no experience in burn-pit 
related claims or are simply not aware they even exist. The status quo 
answer in response to requests for VA medical opinions is quickly 
becoming that VA has not found the particular veteran's disease process 
is caused by service in Southwest Asia. Such opinions rarely 
acknowledge the claim is even burn pit related, much less provide any 
analysis on the chemicals produced by the burn pits in relation to the 
veteran's disability.
    If a veteran files a disability claim within a year of their 
separation from service, a C&P exam is generally ordered for all 
claims. A year or more after a Veteran's separation, C&P exams are 
ordered if the claim meets a certain threshold of evidence. VBA usually 
manages to verify exposure and thus request an exam in burn pit cases. 
But confusion about burn pit claims has led to mistakes that could 
prevent or delay the ordering of a C&P exam. Or, if the wrong type of 
exam is ordered, a second exam may need to be requested. Veterans often 
have to wait months to get an exam due to the longstanding backlog of 
disability claims.
    In developing for a medical nexus between burn pit exposure and the 
veteran's diagnosis, VBA staff have ordered medical examinations for 
the wrong condition (often Gulf War Illness related). Or, when claims 
staff ordered the correct exam, they have requested medical opinions 
from examiners who, by VA's own standards, are unqualified to give 
them-for example, physicians assistants (PAs).
    Inadequacy of training on burn pits exposure and Gulf War claims 
appears to be a deciding factor in the negative outcomes veterans are 
experiencing with these claims. This inadequate training appears to 
extend from VHA and contractor medical examiners to VBA claims 
adjudication staff.
    These errors and confusion in the development process have led to 
unnecessarily long wait times for veterans suffering from often 
debilitating, and sometimes life-threatening, disabilities resulting 
from their burn pits exposures.

    Recommendation. Congress should make necessary statutory changes to 
ensure appropriate outcomes for burn pits exposure claims, including 
mandating training (and ensuring the appropriateness of that training) 
for VHA and contractor medical examiners and VBA claims adjudication 
staff.

VA Claims: Tracking Burn Pit Claims

    Despite establishing the Airborne Hazards and Open Burn Pit 
Registry where veterans can self-report burn pit exposure and related 
symptoms, VA does not adequately identify or track VA compensation 
claims related to burn pit exposure. VBA frequently uses ``Special 
Issue Identifiers'' to track certain types of claims. Claims related to 
military sexual assault, for example, would be marked so that VBA staff 
or VHA researchers could see claim-specific trends in wait times, 
approval rates, etc.
    In VA Training Letter 10-03, VBA staff are instructed to use the 
only identifier pertaining to exposure claims: ``Environmental Hazard 
in Gulf War.'' This identifier covers a range of exposures too diverse 
to draw any statistical conclusions about burn pit claims.
    Without a tracking system, veterans' advocates are left in the 
dark. We don't know how many burn pit-related claims have been 
submitted, how many have been denied, which medical issues are being 
reported, or how long veterans are waiting to get an answer. 
Importantly, we cannot confirm that burn pit claims are being 
incorrectly processed in a systemic way, as it often appears.

    Recommendation. Congress should mandate that VA track and report on 
a quarterly basis all relevant data for VA compensation claims related 
to burn pit exposure, including numbers of claims submitted, approved, 
denied, reasons for denial, and numbers of claims denied per reason for 
denial.

VA Claims: Establishing presumptions of service-connection

    Among the serious diagnosed medical conditions identified in 
service members with IAW-LI is an extremely rare, irreversible, and 
often fatal respiratory disease called constrictive bronchiolitis (CB) 
and sometimes also called bronchiolitis obliterans (OB). The medical 
literature reveals CB/OB to be caused by occupational exposure to 
diacetyl (``popcorn lung''), in Iranian survivors of Iraqi sulfur 
mustard (mustard gas) attacks during the 1981-88 Iran-Iraq war, and in 
OIF/OEF veterans.
    Currently, CB/OB can only be can only be identified by a highly 
invasive lung biopsy conducted under general anesthesia, though medical 
research is currently underway in the Congressionally Directed Medical 
Research Program (CDMRP) that if successful would allow for non-
invasive diagnostic methods.
    Biopsies have been performed on numerous OEF/OIF Veterans whose 
worsening breathing problems including shortness of breath, especially 
following even limited exertion, could not be diagnosed by traditional 
tests, such as x-rays, CT scans, MRIs, or pulmonary function testing. 
Lung biopsies have returned a positive diagnosis for CB/OB in 
approximately 90 percent of these cases.
    There are several issues of concern here. First, we are hearing 
from veterans that VA is not currently service-connecting their CB/OB 
without a confirmatory biopsy.
    And, even with such confirmation, VA often denies service-
connection on the basis of lack of proof of in-service causation. For 
veterans without a confirmatory biopsy of CB/OB, it is nearly 
impossible for them to get VA (or DoD) to provide one.
    And, veterans returning without a formal CB diagnosis but with 
debilitating post-deployment respiratory and other chronic symptoms, 
which for many veterans developed while they were still deployed, far 
too often are denied by VA for service-connection.
    In short, VA's requirements for these debilitating post-deployment 
respiratory conditions are nearly impossible for most veterans to meet, 
despite their serious disability. By contrast, the U.S. Social Security 
Administration (SSA) has added CB as a Compassionate Allowance after 
medical research identified the disease as causally related to 
environmental toxins, including burn pits, in Iraq and Afghanistan. Not 
so with VA.
    Additionally, many of Burn Pits 360's members and constituents have 
been diagnosed with unexplained cancers, including an array of 
leukemias, brain cancers, and other cancers. Many of these veterans are 
young. Many have died, without compensation or appropriate VA 
assistance for themselves or their survivors.

Recommendations. We ask that Congress amend Title 38, United States 
    Code, to:

    A.) Provide a presumption of service-connection for VA compensation 
for symptom-based respiratory disability in veterans exposed with 
presumed exposure to these airborne hazards;

    B.) Provide a presumption of service-connection in cases where the 
veteran has been given a diagnosis of CB/OB or other debilitating 
respiratory diseases, including chronic obstructive pulmonary disease 
(COPD), post-exertional asthma, pulmonary fibrosis, and other diagnosed 
respiratory conditions;

    C.) Provide a presumption of service-connection in cases where the 
veteran has developed any of the array of post-deployment cancers that 
we have identified in these veterans.

6) Legislation

    We urge Congress to introduce a health care and compensation act.

                               APPENDICES
Appendix A: Burn Pits 360 Registry Testimonies

Appendix B: Medical Opinions

Appendix C: Burn Pits 360 Staff Biographies

Appendix D: Burn Pits Photos (Upon Request)

             APPENDIX A: Burn Pits 360 Registry Testimonies
    The following are testimonies of service members, veterans, and 
Gold Star families affected by this generation's Agent Orange. They are 
written in their own words.

Greg (Caro, Michigan)

    Mrs. Torres, I talked to you a couple of years ago when my health 
really started getting bad. Well, here I am and my health is more than 
bad. I am standing at deaths door, my lungs are shutting down and the 
VA will do nothing. I would just appreciate if you would help my wife 
Theresa and my son Travis after I am gone...help them to go after the 
VA, and get something for the hassle of it all and for having to watch 
me slowly die. I would appreciate it, Thanks Greg

Jay Seals (Nashville, Tennessee)

    In March 2008 my husband joined the Army. He went to Basic training 
at Ft. Jackson, AIT at Ft Gordon, and then was stationed at Ft. 
Campbell to be assigned the 101st airborne division 2-502 HHC from 
November 2008 to August 2012. While serving with the 2-502 HHC he was 
deployed to Howz-e Madad Afghanistan from June 2010 to April 2011. In 
August of 2012 he was assigned to SHAPE in Belgium until November 2013. 
While serving in Belgium he received surgery for a hernia. Shortly 
before the surgery, according to documentation, a scan was done and a 
small mass was found. This information was added to his Military 
Medical records but no follow up was done and he was not informed of 
the mass. In December 2013 Jay returned to Ft.Campbell and was assigned 
to 101st airborne division 5-101 CAB HHC. During this time he had many 
appointments with various medical staff about this stomach and 
abdominal pain. He was given OTC pain meds and told to hydrate. Jay was 
Honorably discharged from the Army April 19, 2016. He was then 
hospitalized for a bowel blockage from April 27th to April 30th 2016 at 
Blanchfield Army Community Hospital. He reported for duty with the 
Tennessee National Guard in May of 2016. He filled out all of the 
paperwork with the VA and was seen by VA doctors. He was experiencing 
weight loss and esophageal spasms. On September 12, 2016 he was 
diagnosed with stage 2 gastric cancer. On October 3, 2016 surgeons 
installed a port for chemo and performed an exploratory laparoscopy. 
During the laparoscopic procedure they found that the cancer had broken 
through the stomach wall and ``spots'' of cancer was found throughout 
the peritoneal cavity. This changed the diagnosis to Stage 4 gastric/
stomach (terminal) cancer and was placed on a palliative care plan. 
After finding the document stating that a mass was found in 2012 was 
reviled by the Tennessee National Guard, it was requested that Jay 
receive Line of Duty status and be placed as Activated National Guard 
assigned to the Warrior transition Battalion. He has been in this 
position since November 29, 2016. Jay is currently being treated by the 
VA and Vanderbilt Oncology teams in Nashville. I was told at the 
beginning of this that Jay might have 6-9 months to live but he has 
exceeded the expectations. Jay knows he will pass in the next year or 
two and he hopes to still be with the WTB to make sure that I will have 
a support base to fall back on when he is gone.

    *A brief bio for me *

    Cheryl ``Tori'' Seals is a mother, wife, advocate and palliative 
caregiver. She is the mother of 2 children that have now ventured out 
on adventures of their own. Tori is a full-time caregiver for her 
husband, Jay, who is fighting terminal stage 4 stomach cancer. Care 
giving for Jay includes everything from getting him to all his medical 
appointments and chemo sessions to assisting him in all his daily 
routines including but not limited to making sure he eats, personal 
grooming, making him as comfortable and happy as possible and taking 
medication. Since his cancer is terminal, we know we must prepare for 
his end of life needs as well. When late night insomnia strikes she is 
preparing for her future by working on becoming an advocate and 
lobbyist for soldiers and their families by taking online training on 
political science and advocacy. Prior to being a full-time caregiver, 
she has had a variety of careers, Including but not limited to 
Information Technology Specialist for a Defense Contractor; Designer, 
Production Manager and Sales Representative for a Promotions Company; 
Federal Compliance Officer for a Home Loan Company; Artist and Creative 
designer/sales for a couple of Renaissance Festivals; Personal 
Assistant to an Executive Sales Representative; and Talent/Celebrity 
Handler, Physical Security, Logistics and Operations Specialist for 
many Conventions and Festivals across many genres and locations 
throughout the US.

Megan Kingston (Virginia)

    My story begins in 2007, when I was deployed to Iraq for Operation 
Iraqi Freedom. We were stationed at Camp Liberty, pad 12. We literally 
ate, slept, and lived right next to one of the largest burn pits in the 
country. Every morning we would wake up to go to work and be rained 
upon by large pieces of black soot and debris from the pit. We would 
walk through this to get to the chow hall, and we would be in it all 
day long. On some nights, we were even able to see the flames change 
different colors based on what they were burning. (Different colors 
mean different types of heavy metals.) I can recall on many occasions, 
I would have upper respiratory infections and I also treated many 
people in my unit for the same. I was the medic. It was like this day 
in and day out.
    On some occasions, I even lit burn pits on fire using jet fuel and 
a flare to get it going, so we could dispose of our trash while out in 
the field. To paint the best picture, this is every day life in Iraq, 
for over 365 days.
    After returning home from the War, I remember coughing up so much 
black stuff in the first six months. I though nothing of it other than 
we are finally in clean air and it was my body getting rid of the 
toxins of war. To my surprise, that was just the beginning of my 
medical issues to come later. The year was 2014 and I was training for 
a triathlon and remaining fit for work, as I was a plain-clothes 
officer for the US Government. I went for a run one day, and couldn't 
breathe the next. Over the course of two years, I finally underwent an 
open lung biopsy to diagnosis Obliterative Bronchiolitis. This disease 
is more commonly known as Constrictive Bronchiolitis and, it is 
terminal. I continue to progress to the point where I am on oxygen 24/7 
and can no longer do my job. I was medically retired and now I focus my 
energy on school and remaining as healthy as possible. If it were not 
for these Pits, I would still be able to have my career and my health. 
I thank you for your time and understanding in this matter and I hope 
that you have a pleasant rest of the day. I look forward to meeting 
with you all on the 7th of June.

Staff Sgt. David L. Thomas (Colorado)

    Noncommissioned officer in charge, S-2, 1st Space Battalion, was 
diagnosed with Stage IV lung cancer that metastasized to the brain in 
April 2013, but has chosen to continue his service. ??''I was given a 
prognosis of six to 18 months survival rate,'' Thomas said. ``What I 
was most disappointed about at that moment was the fact that I was 
selling Bethe (his wife) and our children short. Second was the fact 
that I would no longer be here serving in the U.S. Army doing what was 
the most important thing: overseeing the safety of my family and our 
great country via my service. Upon enlisting, he intended to be a 
career service member. ??''Joining the Army was something that was 
always on my mind since I was a child,'' Thomas said. ``The attacks 
made up my mind for me. Defending my family and America itself was no 
longer an option, but rather a duty.
    Thomas deployed to Iraq for the first time. After 13 months in 
Baghdad and a few months at home, he deployed again in September 2005, 
back to Baghdad. He returned home in January 2007, reclassed his job 
specialty, and in December 2008 deployed to Northern Iraq, first to 
Kirkuk and then to Mosul. He returned home in September 2009 and began 
preparing for his next deployment, this time to Kandahar, Afghanistan, 
in May 2011. It was during this fourth deployment that he began to 
notice a prevalent and chronic cough. He returned from this deployment 
in May 2012, and in October 2012, Thomas transferred to the 1st Space 
Battalion headquarters in Colorado Springs, Colo.??''I saw a doctor in 
January 2013, and was told I had an upper respiratory infection or the 
flu,'' Thomas said. ``I did not receive any diagnostic testing such as 
a chest X-ray or lung function test. I was given an antibiotic and sent 
on my way.''??Elizabeth had begun insisting that he go to the doctor 
because of the chronic cough, and finally on April 19, Thomas decided 
to seek medical advice. ??''My wife and I were in bed watching TV when 
I had an episode of chest pain. I thought I had a mild heart attack,'' 
Thomas said. ``The next morning I went to the emergency room since sick 
call could not see me for chest pain.''??After diagnostic testing, 
Thomas was informed that he had a nodule in his medial left lobe, and 
additional doctor visits and testing were conducted. ??''It was the day 
after my 46th birthday that I was diagnosed,'' Thomas said. ``I also 
learned that I had actually had lung cancer for more than two years, 
including during my last deployment to Afghanistan.''??Elizabeth said 
her initial reaction was shock. ??''I remember thinking, 'I can't 
believe I'm hearing these words,'' she said. ``I felt cheated. This was 
the first time in a while we were going to have uninterrupted family 
time free from deployment. I thought we were going to have all of this 
time together.''??Thomas began treatment in May 2013. ??''I determined 
to fight cancer and have been undergoing chemotherapy,'' Thomas said. 
``I have also undergone two cyber knife procedures to my brain for 
tumors and a week of radiation to my chest.''??. Through David's fight 
both internally and externally without complaint, we are witness to his 
courage and commitment to complete the mission. ??Thomas, however, does 
not feel like he is doing anything extraordinary. ??''Never did 
quitting my career in the U.S. Army cross my mind,'' Thomas said. ``Nor 
will I allow this illness to prematurely cause me to leave the Army. If 
it is up to me, I will be a member of the armed forces until the day I 
do leave this world to be with my father in heaven. ??''I have made a 
decision that I will not let cancer change my duty to my country, 
family or friends,'' he said. ``I will fight cancer and continue to 
work as long as I am able. I will continue to place the mission first 
while acting with professionalism and continuing to mentor my NCOs and 
Soldiers.''??Upon learning of his cancer, Thomas began to research what 
could have caused it. ??''I began to uncover the research and studies 
on Iraq Afghanistan War Lung disease, and the devastating effects of 
the 'burn pits' on service members and civilians who have served 
overseas,'' Thomas said. ``Through my research I learned that IAWL is a 
chronic pulmonary condition that will affect one in seven service 
members who have served overseas. While Veterans Affairs and the 
services have not officially recognized IAWL or the effects of the burn 
pits, there are a lot of people suffering and awareness of IAWL needs 
to be brought to the public's attention.''??Thomas established the 
David Thomas IAWL Foundation to promote awareness of the disease. 
??''Eventually, through fundraising, we hope that the foundation has 
enough funds to provide basic testing for veterans or active duty 
service members who might need to determine if they have IAWL,'' Thomas 
said. ``In many ways, through my foundation, my last mission is to 
bring awareness to IAWL and those who are suffering.''??Elizabeth said 
that her husband is her hero, and not just because of his current 
fight. ??''David kept saying, 'I'm never going to deploy again. I need 
to be able to. It's my job,''' she said. ``He loves what he does. He's 
always saying he wished he could do more; that what he's done isn't 
enough. He's a hero to me. Not just that he's kept going, but his whole 
Army career. Even with all of this, he doesn't take the praise. But 
just by getting up every day and going to work, he shows everyone that 
he doesn't quit. He always replies with, 'Where else would I be?'"

CSM James Hubbard (Kansas)

    My name is Katie Hubbard, and I am the widow of Command Sergeant 
Major James W. Hubbard, Jr. CSM Hubbard. He was a great husband, 
father, grandfather, and soldier. CSM Hubbard served eight years on 
active duty before becoming a soldier in the United States Army 
Reserve.
    CSM Hubbard's unit was called to Active Duty orders and sent to 
Iraq as part of Operation Enduring Freedom and Operation Iraqi Freedom 
1. During those campaigns, CSM Hubbard served as the Command Sergeant 
Major for the 450th Movement Control Battalion, Talil Air Base in Iraq 
and Camp Arifjan in Kuwait. CSM Hubbard stated that he had to climb 
into check the remnants of tanks that were blown up by depleted uranium 
as well as living and working around burn pits throughout the country. 
CSM Hubbard noted the smells and smoke that he observed from the burn 
pits and even noted on his post-deployment medical check that he was 
concerned about the chemicals in the air at Talil, as well as smoke 
from oil fires, pollution, other fuels, solvents, paints, radiation, 
lasers, and other environmental exposure concerns.
    Upon his return from Iraq, the medical doctors noted his blood was 
``wonky'' and referred him to his civilian provider. He was followed 
for six months after before being initially cleared. In 2007, CSM 
Hubbard was deployed as the CSM for the 139th Med Group, Task Force 
Falcon IX to Camp Bond steel in Kosovo. While there, he complained of 
getting more tired easily and that his run was not as good as he was 
used to. He would also often reflect on his service in Iraq, what he 
saw, and the concerns he had about all the things that were released 
into the air from all the stuff that they burnt in the burn pits.
    When he returned in late summer of 2008, he was sent to the VA 
hospital in Topeka, KS for a post-deployment check-up and is cleared to 
return to his civilian job. The VA was concerned with his blood work 
and called him to immediately return, stating he may have to be 
hospitalized. CSM Hubbard and I were in shock and were not told what 
may be going on. He went back to the VA for a follow-up after taking a 
military trip to Washington State, where it was noted that his 
hemoglobin levels were very concerning, and he was referred to the 
oncology department. His first appointment the VA oncology doctor 
stated to us that he did not think it was cancer that it was possibly 
just a bug from his deployment, but if it were cancer it would not be 
the ``bad'' kind. He ordered a bone marrow biopsy on October 24, 2008. 
We were to return on November 14, 2008, where the VA oncologist told 
him that he had cancer. Specifically, he was diagnosed with Acute 
Lymphocytic Leukemia, or ALL, which is common in young children not 
50+yr old men!
    We were then sent to the VFW service office where we met with the 
officer and the social worker for the VA. When meeting with the service 
officer and social worker, we were told they had seen an increase in 
the number of service members coming back from Iraq and Afghanistan 
with leukemia and other cancers. Our doctor also stated he believed the 
cancer was due to the burn pits and depleted uranium. CSM Hubbard was 
given a 100% service connected disability rating from his leukemia 
diagnosis. CSM Hubbard went to MD Anderson in Houston, TX for 
treatment, where they stated that 85% of his blasts in his blood were 
cancerous when he began treatment.
    Unfortunately, during cycle four of treatment, he died suddenly on 
May 21, 2009. He was serving as the interim brigade CSM for the 330th 
Med Brigade in Fort Sheridan, IL and the CSM for the 139th Med Group in 
Independence, MO, at the time of his death. After his death, I wanted 
to learn more about the areas he served and what he may have been 
exposed to that contributed to his death, which the Topeka VA had told 
us that his leukemia was a result of the burn pits and depleted uranium 
he was exposed to in Iraq. We were one of the lucky few that had his 
cancer acknowledged and rated as service-connected.
    I found many reports during my research that substantiated CSM 
Hubbard's concerns about the toxins in the air from the burn pits, 
including government documents listing chemicals found in the air in 
Iraq. CSM Hubbard had also expressed difficulty running and tiredness, 
which were the result of his leukemia. The VA also had told us that 
they had noticed that it was taking five to ten years after deployment 
for some of the cancers to be found, which fit in the timeline of 
James' exposure and subsequent diagnosis. His cancer was also not 
common at all for people his age, further connecting the effects of 
deployment to his cancer. CSM Hubbard is greatly missed, and it is my 
hope that his death will help shine a light on the toxic effects of the 
burn pits and help to create the necessary steps to protect service 
members, take care of the ones effected, and honor the ones that have 
died as casualties of war.

Alyssa Holschbach

    I appreciate all the great work Burn Pits 360 has been doing for 
years. I first learned of your excellent organization in September of 
2012, when I was stationed at Bagram and being sickened by a burn pit 
that was moved very close to my camp (Sabalu-Harrison).
    Over the course of about three weeks after that pit was moved close 
to my camp, I got very ill. The smoke was so thick, you could taste it. 
It engulfed our whole camp, including our living spaces. I guarded the 
prison and was up in the towers most days. It would get so thick; you 
couldn't see the next tower over. We all were suffering. They gave us 
respirators you would maybe use for painting. They didn't do anything 
to block the smoke and fumes. The cartridges were also only good for 
eight hours and we never received replacements. We worked twelve-hour 
shifts. They probably only gave them to us in an attempt to shut us up. 
I developed symptoms similar to a severe allergic reaction. My face 
swelled up with hives (which it hurt to put that useless respirator on 
over). My skin, tongue, and lips tingled. I had sharp pains in my chest 
while I breathed and it was very hard to breathe. I was so miserable; I 
maybe could get one to hours of sleep a night because I felt like I was 
suffocating. I was finally Medevaced to Germany on October 1, 2012.
    In the years since, I've struggled with respiratory and skin 
issues. I'm very worried about health consequences down the line, but 
VA doctors blow off my concerns. Some don't even know what a burn pit 
is.
    Congress needs to take action to ensure that all service members 
exposed are taken care of properly and receive appropriate screenings 
given our risk for rare cancers and other diseases.
    The ``Burn Pits Accountability Act'' is a great start, but it 
doesn't impact veterans already out of the service from my 
understanding. More needs to be done for all of us.
    Thank you for your time and for letting me share my story,

    P.S. I've attached pictures of the burn pit I was exposed to. One 
is a picture of it engulfing our living area.

SFC Heath Robinson (Ohio)

    The oncologist's first words were, ``WHAT THE HELL HAVE YOU BEEN 
EXPOSED TO?'' before continuing on with my husband's diagnosis of Stage 
IV terminal lung cancer with no primary tumor. He explained that this 
type of cancer is ONLY caused by toxic exposure and in tears told us 
that if the cancer can't be controlled the prognosis was 6 to 8 weeks 
for Heath to live. With no primary tumor to target, we learned that any 
treatment would be experimental. After consulting with 20 fellow 
oncologists to determine the best course of treatment, no one had an 
answer. The cancer is so rare that there aren't enough statistics 
regarding life expectancy or which treatments have the best results. A 
month prior to the cancer diagnosis, Heath was suffering from chronic 
nose bleeds and eventually bleeding from his ears which was determined 
to be manifestations of a rare autoimmune disorder, Mucous Membrane 
Pemphigoid
    The cancer had metastasized to Heath's mucous membranes, scapula, 
pericardium, lymph nodes and his entire thoracic cavity. The 
immunotherapy, Keytruda has extended his life and improved his quality 
of life, however, we are unable to attend your hearing on June 7 due to 
his scheduled treatment day and his condition right now isn't very good 
for him to travel.
    SFC Heath Robinson served as an army combat medic being deployed to 
Kosovo and eventually Iraq for Operation Iraqi Freedom. He was exposed 
to burn pits during both deployments and more so in Iraq. He lived on 
Camp Liberty in late 2006 and worked a lot of the time on Camp Victory. 
Both bases had notorious burn pits, however, one job he held for 3 
months placed him within 75 yards of a burn pit for hours on end each 
day.
    Our family is devastated, as we have been living this nightmare 
with him battling to stay alive for just over a year. Even more 
devastating for us is worrying about what's going to happen to our 4 
year old daughter and me if he doesn't survive this. It's even more 
mortifying to hear the V.A. continuing to deny a connection between 
toxic emissions from burn pits and illnesses while they claim research 
and data supports their conclusion. This is ridiculous as other 
credible studies have already proven and warned of the dangers of 
serious health issues those in close proximity to those burn pits could 
contract. These studies have been totally ignored by the V.A. and 
that's shameful.
    I am asking you today, as the wife of a terminally ill wounded 
soldier and now his caregiver, counselor and the one making sure every 
day he has left on this earth is a good one.to please stop this 
nonsense of the V.A. commissioning burn pits research. An outside 
entity not controlling the outcomes to favor the V.A. should be in 
charge. Robert F. Miller, M.D. Pulmonary Medicine; Vanderbilt 
University and Dr. Anthony Szema, 2500 Nesconset Highway, Suite 17A, 
Stony Brook, New York 11790 have both done tireless studies and 
research on why thousands of Iraq and Afghanistan War veterans have 
succumbed or are battling serious, rare and unheard of diseases. It's 
an injustice to all potential burn pit victims that these two 
physicians were not invited to testify at your Subcommittee on 
veterans' health hearing on June 7, 2018.
    Thank you for reading my letter. My veteran husband is truly 
discouraged and disappointed that he won't have an opportunity to 
testify before a congressional committee. He's proud to have served his 
country with honor and dignity and wouldn't hesitate to do it again, 
however, he is deeply disturbed that his country refuses to acknowledge 
his toxic wounds as combat related and that hurts.

Heath's wife, Danielle Robinson June 2, 2018

SFC Fred Slape (Texas)

    My name is Diane Slape, I am the widow of SFC Frederick T Slape, 
Retired US Army. When we retired in 2012, I was certain War Zone 
dangers were behind us. In late August 2015, days after we'd sent our 
daughter to her first year of college and started building our Forever 
Home, Fred went to his routine VA Drs appointment. Just to be told 
again ``your White Blood Cell count is elevated, you need to stop 
smoking.'' But this time was different, The VA called to tell Fred, 
they were concerned about the results, to call for a lab appointment, 
one he couldn't get until October. Despite my 43yr old husband's 
overall good health, according to his Oncologist Team, Fred died 9 
weeks after he was diagnosed with Stage 4 Adenocarcinoma of the Brain & 
Lung lymph nodes, a disease that usually strikes 70-80yr old people. 
Most Veterans exposed to the Toxic Burn Pits, who are diagnosed with 
cancer, aren't living past 18-24 months, due to the aggressive nature.
    His exposure to the Toxic Burn Pits occurred during his 2 
deployments, 2009 in Southern Afghanistan and 2011 in North Eastern 
Afghanistan. Fred & his troops had their living & working quarters 
combined in the same building, less than 25ft from the burn pits, that 
burned 24 hours a day, 7 days a week; unless a General or the SECDEF 
was coming. These burn pits were shoveled/raked by my husband's 
soldiers, with little to no protective clothing on. The soldiers 
breathed this black acrid smoke morning, noon and night, even in their 
sleep. My husband had mentioned to his commanders that the Burn Pits 
were causing difficulty breathing and that they were going to kill 
somebody, to which they replied Stop being so dramatic, SFC Slape. My 
husband told me that they burned items, such as vehicle fluids, aerosol 
cans, computers, Styrofoam, human waste, plastic water bottles, medical 
waste, amputated body parts, uniforms, dead animals--many things that 
shouldn't be burned, much less burned together.
    In August 2015, Fred still showed no symptoms, then 2 days of 
sporadic headaches along with seriously impaired vision, an MRI 
discovered the mass in Fred's brain. As if we had expected it, when the 
Dr told us of the brain mass--Fred & I looked at each other and said 
``Burn Pits''. After 5 days in the hospital, every infectious disease 
test known to man, and a CAT scan, they discovered the mass in his 
chest. Many asked Why didn't we go to the VA? My husband said chuckling 
``What? And Die there?'' After reviewing 3 years of lab results, the VA 
Drs should have been concerned about Fred's blood work since 2012. 
Being Retirees, we had Tricare coverage too, as well as VA access. Most 
non-retired veterans do not have the Tricare option, leading to 
possibly better care.
    In the remaining 5 weeks of Fred's life, he would have 1 round of 
the most intense 3 day chemo treatment, his first and only seizure, 
brain surgery to remove an aggressively growing brain tumor, during the 
2 wk recovery from surgery, He had chest radiation & a stomach tube 
inserted, just in case the radiation closed off his esophagus. During 
this recovery period, 4 new inoperable tumors were growing quite 
rapidly inside Fred's brain. 1 very large one in the Temporal lobe 
where the initial one was removed, 1 in the Frontal lobe that tripled 
in size and 2 in the cerebellum, never seen before in all the CAT Scans 
previously. 3 days later Fred had started brain radiation, which 
hospitalized him the next day. Oncologists informed us the chest/brain 
radiation, as well as the 1 round of Chemo had no effect on the cancer 
in his chest or brain. We opted for 1 more round of brain radiation, 
which rapidly led to Fred's death 2 days later. Please help so that 
Fred's young soldiers, who are 20 & 30 yrs old and currently healthy, 
do not struggle or suffer as Fred did, but without Healthcare that is 
specific to their exposures & services for their families.

Colonel Mc Cracken (Georgia)

    Dear Mr. Vice President,

    I am so very sorry for the loss of your son, Beau. My husband, USA 
Colonel David A. McCracken served an active duty tour at Victory Base 
Complex (VBC), Baghdad, Iraq in 2007. My husband also died of 
glioblastoma multiform on September 2, 2011 after an 11-month battle. A 
year after his death, it was brought to my attention that exposure to 
toxic chemicals from the open-air burn pits were an attributing factor 
to his cancer.
    My husband was also mentioned in the book, ``The Burn Pits, the 
Poisoning of America's Soldiers'' by Joseph Hickman, page 126. As you 
know, grief is a powerful emotion and I make a choice everyday to 
ensure that my journey is one of healing and hope. I can't imagine the 
pain associated with the loss of a child. I can only see and experience 
this loss from my own perspective and that of my children.
    I have researched, spoken of and supported efforts regarding the 
effects of these burn pit toxins. I do this so that my children will 
see that this effort is a worthy one. It can be exhausting, frustrating 
straight through to my soul. I've spent more restless nights than I 
like relentlessly learning and researching this issue with limited 
return on this particular `investment'.
    It is a special breed of people who take up the calling to serve. I 
will continue the fight with my small voice to keep my husband's memory 
alive and to show my children that where there is a passion to make 
things right, change can be affected.
    My husband, a 45-year-old in perfect health returned coughing and 
complaining of headaches. I watched his health decline rapidly as I'm 
sure you have witnessed as well. If anything, I want my husband's death 
to mean something. Some small thing. Not an `agent of change' but an 
`angel of change'.
    Sir, my spirit was renewed with your words during your recent 
interview with PBS. It is my greatest hope that you are able to 
embrace--with similar passion--an outlook of support that brings 
awareness to the effects of burn pits on our loved ones. I have long 
felt that I didn't want David's death to be simply a memory, but a 
catalyst for change and action. I have every hope that you feel the 
same.
    Please continue this fight. Continue to engage and bring awareness 
to this issue.

    Signed with hope and renewed spirit,
    Tammy J. McCracken
    Proud Wife of deceased USA Colonel David A. McCracken

Timothy Johnson

    Dear Vice President,

    First off I was so very saddened to hear of your sons diagnosis and 
eventual passing. I too am a parent whose son has died because of brain 
cancer.
    I am writing in regards to the burn pits in Iraq and their link to 
cancers. My son Sgt. Timothy Lee Johnson of the USMC died of 
glioblastoma multiform at the age of 35. He was a bomb dog handler 
deployed to Iraq. Upon his diagnosis he was deemed 100% disabled 
service connected with the VA. He had a wonderful doctor who believed 
the exposure to these toxins were the contributing factor in his 
cancer.
    My hope is more investigation and subsequent help to victims will 
take place.
    I am glad to hear more safety and equipment is now in place.
    I have attached the memorial from His funeral. The photo is him 
with his dog in Iraq. I believe there are thousands of other veterans 
who have suffered many illnesses and cancers because of the exposure to 
the burn pit toxins. I believe many have not come forward not realizing 
they are sick because of their exposure.
    May the word continue to be declared so they too can get the 
medical care they need. Sincerely, A hurting mom, Donna Johnson

    P.S. If this letter can be added to many more of those whose lives 
and loves were lost.

Major Kevin Wilkins ( Eustis, Florida)

    Dear Vice President

    I do not want to take up much of your time, so this letter to you 
will be short and to the point.
    My husband, USAF Major Kevin E. Wilkins, RN., served an active duty 
tour at the Balad Air Force Base, Balad, Iraq in 2006 where your son 
Beau was also stationed. My husband died of a glioblastoma brain tumor 
in 2008 after exposure to the toxic chemicals from the open-air burn 
pit at that base. (He was also mentioned in the book, ``Burn Pits'' by 
Joseph Hickman on page 32). I won't go into the effect his death had on 
my 2 children and me because you already know the pain.
    VP Biden, you can help by talking about the effects these burn pits 
have had on you, Beau's wife and the entire family. I know you promised 
Beau that you would run for President, but I believe that standing up 
for Beau in the light of what has happened to him and many other 
soldier's and their families, is so much greater than being President 
of the United States. Everything happens for a reason, and I believe it 
is your calling to help the many other soldiers who are still alive but 
fighting to live.
    If you would like to see the work I have been doing to try to help 
other families whose soldiers have been exposed to the toxic chemicals, 
please Google ``Jill Wilkins Burn Pits'' and you will see the media 
coverage I have been involved in including CNN.

    Very Sincerely,

    Jill R. Wilkins

    Proud Wife of deceased USAF Major Kevin E. Wilkins, RN

Robert Elesky

    I served four years active duty 1981-85 US Army. During that time, 
I served in the 172nd, Fort Hood 2nd Armor Division, and in the Sinai 
Desert Egypt on the MFO Peace Keeping Force.
    When the war started in Afghanistan they needed Veterans to fill 
crucial support roles for our military and I needed a job, so I signed 
on with KBR. I ended up on Kandahar Airfield on January 2, 2004. I for 
sure will never forget the stench of the five-acre sewage pond on the 
west end of the base. When units would leave, anything they didn't take 
with them went into a pile on the southwest end of the base. We would 
go to that pile daily to salvage things we needed for repair of 
vehicles and whatever else we might need. Then a big armored bulldozer 
showed up, dug a big hole, and push the pile into it and it was set 
afire, exactly when I can't recall, but not too long after the pile was 
pushed into the pit. After they started burning the stuff my sinuses 
were a disaster. The burn pit was set on fire every evening around 
dark. I could see the burn pit from my tent is how close it was to us. 
We slept in the fumes, worked in the fumes, and ate in the fumes.
    In 2012 I developed difficulties in breathing out of my right 
nostril and started developing nose bleeds. I then went to the Dr. and 
they diagnosed me after scans a nasal biopsy with a solitary sphenoid 
sinus plasmacytoma, very very rare, with most cases in the Middle East 
to my understanding. When I was diagnosed I immediately wanted to know 
what I had, and how I got it. All my research led me back to ``Toxic 
Exposure'' The only place I was ever exposed to toxins that would cause 
something like this was Kandahar Airbase in 2004-2005 and Balad, Iraq 
2005.
    During my research I discovered I could file a DBA claim which is 
workers compensation for civilians who work oversea in support of our 
military. I did that right away. My case drug on for years and KBR 
eventually settled with me for an amount that was nowhere near what was 
needed for such a situation, but we had no choice because of the 
financial situation this illness had put us in.
    After my diagnoses they immediately started radiation therapy on me 
and was able to kill the plasmacytoma in my nasal cavity. However 
subsequent PET scans revealed a bone lesion on my sternum which they 
again radiated but it didn't work, so I ended up on sixteen weeks of 
chemo therapy.
    After recovery I went back to work in Medical sales. I then 
developed other lesions on my right cheek bone about the size of a golf 
ball. Again, I was put back into radiation treatment. Having to take 
more time off work to go to Portland for radiation treatments again. 
Devastating to our income. Again, the radiation was successful, but by 
now my employer could see I couldn't do my job like I used to with my 
illness and I was terminated in the hospital while undergoing 
treatment. They didn't say my illness was the reason, I'm just if, but 
based on my past performance and the current performance the conclusion 
is a logical one.
    So, after being terminated I found odd jobs to do to keep busy as 
my wife was working at the time and I just needed some time to recoup.
    I was sent for another PET scan that revealed multiple bone lesions 
on my head, arm, knee, and femur. What has everyone a bit baffled is my 
blood work is always unremarkable and my bone marrow biopsies always 
come back clean. So currently I have been on chemo therapy since 
January unable to work due to my treatments and on my way to Seattle 
for a bone marrow transplant. My wife no longer works at the post 
office to support us as her position there was seasonal, my youngest 
son who is a firefighter and EMT is having to take leave of his work to 
be my care provider in Seattle, so my wife can continue to work the 
only job she can find to try and pay our mortgage and bills.
    This has been devastating to us emotionally, financially, anyway 
that you can't think of something like this can negatively affect your 
life. The anxiety of the cancer, the anxiety of wondering if you'll 
have a home to come home to is overwhelming. I'm not the only one in 
this position. There are literally thousands of us who went down range 
in defense of our nation who are being discarded as if we were garbage 
with little to no compensation.
    All we hear is that there's no direct link between the Burn Pits 
and our illnesses. I find that insulting. If that's true, why don't we 
just burn trash in our neighborhoods? Why do we have an EPA? The data 
already exists. That's why we don't burn trash in our neighborhoods. We 
already know breathing toxins make people sick, don't we?
    I'm outraged that memos were sent to the pentagon as far back as 
2000 with air quality reports saying that we should stop burning this 
trash next to the bases. Those memos were ignored and shoved in 
someone's desk drawer. Why? Who did that? I'd like to know.
    So, for now we are just barely making it. I rarely see my wife, 
children and grandchildren because of their work schedules and I fear 
of getting a sickness from one of the grandkids. One of them always has 
a runny nose or something. I live in constant pain and isolation 
wondering how it's all going to end and I'm not alone. There are 
``Thousands'' if not ``Tens of Thousands of us, and we'd like to know 
what you're going to do for us after sending us down range in defense 
of freedom, and knowingly poisoning us. Can you answer that question? 
We willingly accepted the risk of war.
                      APPENDIX B: Medical Opinions
    (see below)

              APPENDIX C: Burn Pits 360 Staff Biographies
                 CPT (Army Ret.) Le Roy Torres, Founder
    Le Roy Torres is the co-founder of Burn Pits 360 Veterans non-
profit organization. Torres was medically retired from the Army after 
23 years with the rank of Captain following his diagnosis from a lung 
biopsy to include other secondary medical diagnosis. He served 7 years 
Active and 16 years Reserve. Torres also worked as a State Trooper for 
the Texas Highway Patrol after he was forced to accept a medical 
discharge following his 14 years of state service. Torres earned his 
B.A. and M.A. in Administration--Organizational Development at the 
University of the Incarnate Word. Torres also enrolled in Seminary and 
completed several courses through Liberty University during his 
application process for the Army Chaplaincy Program. Subsequently 
Torres was medically boarded from the Army Reserve due to his medical 
conditions associated with burn pit exposure forcing him to discontinue 
the Army chaplaincy process.
    Torres is an ardent advocate alongside his wife Rosie for the 
military families and warriors battling illnesses associated with 
deployment related environmental toxic exposures during the OEF/OIF War 
Campaigns. Torres alongside his wife founded the first Burn Pits 360 
Warrior Support Center in Robstown, Texas. Torres is also passionate 
about assisting the first responder community that serve a dual role to 
their state and country that are battling not only medical conditions 
from exposure; but also those facing battles with invisible wounds, job 
loss, and other challenges that arise from such hardships that have 
taken a toll on so many Veterans and their families.
                    Rosie Torres, Executive Director
    Rosie Lopez Torres is the co-founder of Burn Pits 360 Veterans 
Organization. Rosie held a civil service position at the Department of 
Veteran Affairs Health Care System for 23 years. Rosie advocates full 
time for Veterans, Service members and families suffering from 
deployment related illnesses. She co-founded Burn Pits 360 alongside 
her husband Le Roy Torres. Rosie also co-founded the Warrior Support 
Center, which is the organization's headquarters but also a center 
where local Veterans and their families can seek access to training, a 
computer room, recreation room, and peer support services. Rosie is 
currently attending Liberty University where she is studying law.
                       Tammy McCracken, Secretary
    Professionally, Tammy McCracken works full time as a Senior 
Technical Architect with GISinc., a location analytics company. She has 
managed over $250M in technical projects over the course of her career. 
She is responsible for client relations and designing solutions that 
meet the unique needs of her clients. She is a Certified Information 
Systems Auditor and is currently pursuing her Master's in Data 
Analytics at Georgia Tech.
    In addition to her technical career, she is a military widow 
serving on several non-profit boards promoting healing and health to 
Veterans and Widows. Her passion is to ensure that her husband, Colonel 
David A McCracken's memory and legacy live on and that no other widows 
face the trials and challenges she has painfully navigated subsequent 
to his untimely and unnecessary death.
                    Cindy Aman, Legislative Liaison
    In her professional life, Cynthia Aman works full time for the 
Delaware State Public Defender's office as a Mitigation Specialist. She 
has her Master's in Forensic Psychology and continues to pursue 
continued education in this field.
    Cynthia is also a Veteran who was assigned to the 1138th Military 
Police Company with the Missouri Army National Guard. She developed an 
irreversible, progressive lung disease called Constrictive 
Bronchiolitis, from her deployment to the Middle East. Since her 
diagnosis she has worked as an advocate on Burn Pits and Toxic 
Exposure. She is currently the Legislative Liaison with Burn Pits 360 
and spends her free time working hard to represent and speak for those 
who have been silenced.
                 Stacy Pennington, Legislative Liaison
    Stacy Pennington has been an advocate for veterans fighting for 
rights of those affected by toxic exposure caused from burn pits in 
Iraq and Afghanistan. This deep commitment to fight for those affected 
by toxic exposure occurred a decade ago after the onset of her 
brother's sudden illness and death.
    Stacy is the Community Outreach Director for AARP. She is dedicated 
to the field of Gerontology. She is active in educating, providing 
services and advocating for those 50 plus. Stacy has worked for the 
AARP for thirty years.
    In addition, Stacy is a part of several non-profit organizations 
including Burn Pits 360, Leadership Cheatham County and Leadership 
Middle Tennessee.
          Diane Slape, Director of Gold Star Families Program
    Diane Slape's professional career is currently the Project 
Administrator for NNAC, Inc., a Commercial Construction firm with the 
majority of their projects in the Military Sector, all over the 
Northwest and Texas. Diane always knew she wanted to help Vietnam 
Veterans with PTSD, but financial aid and family contribution couldn't 
handle the requirement. So she volunteered for many non-profit Military 
organizations, to give back as much of her free time in appreciation of 
their sacrifices. She volunteered to be her husband's unit Family 
Readiness Group leader. She developed a working relationship with the 
unit's Chain of Command in garrison and downrange, as well as a loving, 
supportive relationship with the soldiers and their families. She made 
it her mission to support the soldiers and their missions and helps 
guide their families through their military experience, to include 
consecutive deployments and Duty Station moves, even after her husband 
retired from Military Service.
    Her career involvement with the Military didn't stop, after 
becoming a military widow. She still had soldiers and Veterans to 
support, as well as their families. She serves on several non-profit 
organizations assisting Veterans reintegrating into Civilian life after 
the Military, as well as promoting their mental & physical health, 
despite their exposures. Her life's mission is to carry on her husband, 
SFC Frederick T Slape's caring and compassion for his fellow soldiers 
in need and to do whatever possible so that soldiers or widows do not 
have to endure the same struggles and tragedies that she found herself 
involved in, so abruptly and unprepared for.
                      Will Wisner, Program Manager
    William is a Senior Director at CCS Fundraising, a strategic 
fundraising firm that partners with nonprofits for transformational 
change. Prior to joining CCS, William served as the Veteran Fellow for 
Mission Leadership at the Sergeant Thomas Joseph Sullivan Center, a 
nonprofit organization dedicated to the issue of toxic exposure 
illnesses in Iraq and Afghanistan veterans. William holds a M.A. in 
Nonprofit Management from Washington University in Saint Louis.
    William was a Staff Sergeant in the United States Army and is a 
veteran of Operation Iraqi Freedom having served as Cavalry Scout in 
the 3rd Squadron of the 1st Cavalry Regiment, 3rd Heavy Combat Brigade, 
3rd Infantry Division.
           Daniella Molina, Director of Community Development
    Daniella Molina currently serves as the volunteer Director of 
Community Development with Burn Pits360 Veterans Organization. Outside 
of her volunteer services Daniella is a full-time caregiver, mother of 
two, and student. She is currently pursuing a degree in Psychology: 
Military Resilience through Liberty University. Upon graduation, she 
plans to assist active/veteran service members and their families 
through the challenges associated with life after war. Daniella is the 
wife of retired Army veteran, Jonathan Ray Molina.

Advisory Board Members

Former Congressman Solomon Ortiz
Solomon Ortiz Jr.
Ret. Colonel David Sutherland
Ret. Lt. Col Gregg Deeb
Ret. Lt. Col. Brian Lawler
Dr. Robert Miller
Dr. Steven Coughlin
Kerry Baker
              APPENDIX D: Burn Pits photos (upon request)
    (Ret. CPT. Le Roy Torres & his sons Kenneth and Christopher)
    (Brian Alvarado & his daughter Rihanna)
    (Ret. SSG Will Thompson, double lung transplant recipient)
    Fallen Heroes
    Major Kevin Wilkins

                                 
          United States Government Accountability Office (GAO)
                            WASTE MANAGEMENT
        DoD Needs to Fully Assess the Health Risks of Burn Pits
Statement for the Record by Cary Russell, Director, Defense 
    Capabilities and Management

    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee,

    I am pleased to submit this statement on our September 2016 report 
covering the Department of Defense's use of burn pits. \1\ Since the 
initiation of military operations in Afghanistan in 2001 and Iraq in 
2003, the Department of Defense (DoD) has employed several methods to 
dispose of the waste that U.S. forces have generated in both countries. 
In general, the methods employed have been left to the discretion of 
base commanders and include the use of incinerators, landfills, and 
open-air burn pits on or near military bases. According to DoD 
officials, when making these decisions base commanders may take into 
consideration a number of factors, including the local security 
situation, the number of personnel on the installation, and the amount 
and type of waste generated by those personnel. As one of the options 
available, burn pits help base commanders manage waste, but they also 
produce smoke and harmful emissions that military and other health 
professionals believe may result in acute and chronic health effects 
for those exposed to the emissions.
---------------------------------------------------------------------------
    \1\ GAO, Waste Management: DoD Has Generally Addressed Legislative 
Requirements on the Use of Burn Pits but Needs to Fully Assess Health 
Effects, GAO-16-781 (Washington, D.C.: Sept. 26, 2016).
---------------------------------------------------------------------------
    My statement today focuses on the extent to which DoD has assessed 
any health risks of burn pit use. This statement is based on our 
September 2016 report. That work was conducted in response to section 
313 of the Carl Levin and Howard P. ``Buck'' McKeon National Defense 
Authorization Act for Fiscal Year 2015 (NDAA for Fiscal Year 2015). \2\ 
Specifically, we assessed the methodology DoD used in conducting a 
review of the compliance of the military departments and combatant 
commands with DoD Instruction 4715.19, Use of Open-Air Burn Pits in 
Contingency Operations, \3\ and the adequacy of the subsequent report 
DoD sent to the defense committees containing the results of its 
review. \4\
---------------------------------------------------------------------------
    \2\ Pub. L. No. 113-291, Sec.  313 (2014).
    \3\ DoD Instruction 4715.19, Use of Open-Air Burn Pits in 
Contingency Operations (Feb. 15, 2011) (incorporating change 3, July 3, 
2014). The instruction was updated on Oct. 6, 2017.
    \4\ Department of Defense, Report on Prohibition of the Disposal of 
Covered Waste in Open-Air Burn Pits (March 2016).
---------------------------------------------------------------------------
    To evaluate the extent to which DoD has assessed any health effects 
of burn pit use, we reviewed relevant health assessments on the effects 
of burn pits, including a 2011 report by the Institute of Medicine that 
was contracted by the Department of Veterans Affairs, as well as prior 
related reports by GAO and the Special Inspector General for 
Afghanistan Reconstruction. We also interviewed officials from U.S. 
Central Command (CENTCOM), U.S. Army Central Command, U.S. Air Force 
Central Command, Department of Veterans Affairs, and Institute of 
Medicine to discuss any effects of exposures to burn pit emissions, 
among other things. Additionally, we obtained an update from DoD in May 
2018 on actions taken regarding our findings and recommendations from 
our September 2016 report.
    We conducted the work on which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

Background

    Burn pits-shallow excavations or surface features with berms used 
to conduct open-air burning-were often chosen as a method of waste 
disposal during recent contingency operations in the CENTCOM area of 
responsibility, which extends from the Middle East to Central Asia and 
includes Iraq and Afghanistan. In 2010, we reported that there were 251 
active burns pits in Afghanistan and 22 in Iraq. \5\ However, in 2016, 
we reported that the use of burn pits in the CENTCOM area of 
responsibility had declined since that time. As of June 2016, DoD 
officials told us that there were no military-operated burn pits in 
Afghanistan and only one in Iraq. According to DoD officials, the 
decline in the number of burn pits from 2010 to 2016 could be 
attributed to such factors as (1) using contractors for waste disposal 
and (2) increased use of waste management alternatives such as 
landfills and incinerators. However, DoD officials acknowledged that 
burn pits were being used to dispose of waste in other locations that 
are not military-operated. Specifically, these officials noted 
instances in which local contractors had been contracted to haul away 
waste and subsequently disposed of the waste in a burn pit located in 
close proximity to the installation. In such instances, officials 
stated that they requested that the contractors relocate the burn pit. 
According to a DoD official, as of May 2018 there are two active burn 
pits in the CENTCOM area of responsibility.
---------------------------------------------------------------------------
    \5\ GAO, Afghanistan and Iraq: DoD Should Improve Adherence to Its 
Guidance to Open Pit Burning and Solid Waste Management, GAO-11-63 
(Washington, D.C.: Oct. 15, 2010).
---------------------------------------------------------------------------
    Although burn pits help base commanders to manage waste, they also 
produce smoke and emissions that military and other health 
professionals believe may result in acute and chronic health effects 
for those exposed. We previously reported that some veterans returning 
from the Iraq and Afghanistan conflicts have reported pulmonary and 
respiratory ailments, among other health concerns, that they attributed 
to burn pit emissions. \6\ Numerous veterans have also filed lawsuits 
against a DoD contractor alleging that the contractor mismanaged burn 
pit operations at several installations in both Iraq and Afghanistan, 
resulting in exposure to harmful smoke that caused these adverse health 
effects. We also previously reported on the difficulty of establishing 
a correlation between occupational and environmental exposures and 
health issues. \7\ For example, in 2012 we reported that establishing 
causation between an exposure and an adverse health condition can be 
difficult for several reasons, including that for many environmental 
exposures, there is a latency period-the time period between initial 
exposure to a contaminant and the date on which an adverse health 
condition is diagnosed. \8\ When there is a long latency period between 
an environmental exposure and an adverse health condition, choosing 
between multiple causes of exposure may be difficult. In addition, in 
2015 we reported that the Army had recently published a study that 
evaluated associations between deployment to Iraq and Kuwait and the 
development of respiratory conditions post-deployment. \9\ However, the 
study was unable to identify a causal link between exposures to burn 
pits and respiratory conditions.
---------------------------------------------------------------------------
    \6\ GAO-11-63.
    \7\ GAO, Defense Health Care: DoD Needs to Clarify Policies Related 
to Occupational and Environmental Health Surveillance and Monitor Risk 
Mitigation Activities, GAO-15-487 (Washington, D.C.: May 22, 2015).
    \8\ GAO, Defense Infrastructure: DoD Can Improve Its Response to 
Environmental Exposures on Military Installations, GAO-12-412 
(Washington, D.C.: May 1, 2012).
    \9\ GAO-15-487 and Abraham et al., ``A Retrospective Cohort Study 
of Military Deployment and Postdeployment Medical Encounters for 
Respiratory Conditions,'' Military Medicine, vol. 179 (2014): 540-546.

---------------------------------------------------------------------------
DoD Had Not Fully Assessed the Health Risks of Burn Pits

    In our 2016 report, we found that the effects from exposing 
individuals to burn pit emissions were not well understood, and DoD had 
not fully assessed these health risks. Under DoD Instruction 6055.01, 
DoD Safety and Occupational Health (SOH) Program, it is DoD policy to 
apply risk-management strategies to eliminate occupational injury or 
illness and loss of mission capability or resources. DoD Instruction 
6055.01 also instructs all DoD components to establish procedures to 
ensure that risk-acceptance decisions were documented, archived, and 
reevaluated on a recurring basis. \10\ Furthermore, DoD Instruction 
6055.05, Occupational and Environmental Health (OEH), requires that 
hazards be identified and risk evaluated as early as possible, 
including the consideration of exposure patterns, duration, and rates. 
\11\ Notwithstanding this guidance, which applies to burn pit emissions 
among other health hazards, DoD had not fully assessed the health risks 
of use of burn pits according to DoD officials.
---------------------------------------------------------------------------
    \10\ DoD Instruction 6055.01, DoD Safety and Occupational Health 
(SOH) Program (Oct. 14, 2014).
    \11\ DoD Instruction 6055.05, Occupational and Environmental Health 
(OEH) (Nov. 11, 2008). This instruction was updated on November 21, 
2017.
---------------------------------------------------------------------------
    According to DoD officials, DoD's ability to assess these risks was 
limited by a lack of adequate information on (1) the levels of exposure 
to burn pit emissions and (2) the health impacts these exposures had on 
individuals. With respect to information on exposure levels, DoD had 
not collected data from emissions or monitored exposures from burn pits 
as required by its own guidance. DoD Instruction 4715.19 requires that 
plans for the use of open-air burn pits include ensuring the area was 
monitored by qualified force health protection personnel for 
unacceptable exposures, and CENTCOM Regulation 200-2, CENTCOM 
Contingency Environmental Standards, requires steps to be taken to 
sample or monitor burn pit emissions. \12\ However, DoD officials 
stated that there were no processes in place to specifically monitor 
burn pit emissions for the purposes of correlating potential exposures. 
They attributed this to a lack of singular exposure to the burn pit 
emissions, or emissions from any other individual item; instead, 
monitoring was done for the totality of air pollutants from all sources 
at the point of population exposure. As we reported in September 2016, 
given the potential use of burn pits near installations and their 
potential use in future contingency operations, establishing processes 
to monitor burn pit emissions for unacceptable exposures would better 
position DoD and combatant commanders to collect data that could help 
assess exposure to risks.
---------------------------------------------------------------------------
    \12\ CENTCOM Regulation 200-2, CENTCOM Contingency Environmental 
Standards (Sept. 15, 2014).
---------------------------------------------------------------------------
    In the absence of the collection of data to examine the effects of 
burn pit exposure on servicemembers, the Department of Veterans Affairs 
in 2014 created the airborne hazards and open-air burn pit registry, 
\13\ which allows eligible individuals to self-report exposures to 
airborne hazards (such as smoke from burn pits, oil-well fires, or 
pollution during deployment), as well as other exposures and health 
concerns. \14\ The registry helps to monitor health conditions 
affecting veterans and servicemembers, and to collect data that would 
assist in improving programs to help those with deployment exposure 
concerns.
---------------------------------------------------------------------------
    \13\ This registry was created in response to the Dignified Burial 
and Other Veterans' Benefits Improvement Act of 2012, Pub. L. No. 112-
260, Sec.  201 (2013).
    \14\ Eligible individuals include servicemembers or veterans who 
served in Iraq, Afghanistan, or Djibouti on or after September 11, 
2001, or the Southwest Asia theater of operations on or after August 2, 
1990 (e.g., the Persian Gulf War).
---------------------------------------------------------------------------
    With respect to the information on the health effects from exposure 
to burn pit emissions, DoD officials stated that there were short-term 
effects from being exposed to toxins from the burning of waste, such as 
eye irritation and burning, coughing and throat irritation, breathing 
difficulties, and skin itching and rashes. However, the officials also 
stated that DoD did not have enough data to confirm whether direct 
exposure to burn pits caused long-term health issues. Although DoD and 
the Department of Veterans Affairs had commissioned studies to enhance 
their understanding of airborne hazards, including burn pit emissions, 
the then-current lack of data on emissions specific to burn pits 
limited DoD's ability to fully assess potential health impacts on 
servicemembers and other base personnel, such as contractors.
    For example, in a 2011 study that was contracted by the Department 
of Veterans Affairs, the Institute of Medicine stated that it was 
unable to determine whether long-term health effects are likely to 
result from burn pit exposure due to inadequate evidence of an 
association. \15\ While the study did not determine a linkage to long-
term health effects, because of the lack of data, it did not discredit 
the relationship either. Rather, it outlined a methodology of how to 
collect the necessary data to determine the effects of the exposure. 
Specifically, the 2011 study outlined the feasibility and design issues 
for an epidemiologic study-that is, a study of the distribution and 
determinants of diseases and injuries in human populations-of veterans 
exposed to burn pit emissions. Further, the 2011 study reported that 
there were a variety of methods for collecting exposure information, 
but the most desirable was to measure exposures quantitatively at the 
individual level. Individual exposure measurements could be obtained 
through personal monitoring data or biomonitoring. \16\ However, if 
individual monitoring data were not available, and they rarely are, 
individual exposure data might also be estimated from modeling of 
exposures, self-reported surveys, interviews, job exposure matrixes, 
and environmental monitoring. Further, to determine the incidence of 
chronic disease, the study stated that servicemembers must be tracked 
from their time of deployment, over many years.
---------------------------------------------------------------------------
    \15\ Institute of Medicine for the Department of Veterans Affairs, 
Long-Term Health Consequences of Exposure to Burn Pits in Iraq and 
Afghanistan (Washington, D.C.: The National Academies Press, 2011).
    \16\ Biomonitoring assesses an individual's exposure to 
environmental agents by measuring the concentrations of the agents in 
biological samples, usually blood or urine but possibly adipose tissue, 
hair, or nails. The biomarker can be the external substance itself (for 
example, lead) or a metabolite of the external substance processed by 
the body (for example, cotinine, a metabolite of nicotine) and it 
indicates the absorbed dose or allows an estimate of the target-tissue 
dose for the time of exposure.
---------------------------------------------------------------------------
    While the Institute of Medicine outlined a methodology of how to 
conduct an epidemiologic study, DoD had not taken steps to conduct this 
type of research study, specifically one that focused on the direct, 
individual exposure to burn pit emissions and the possible long-term 
health effects of such exposure. Instead, some officials commented that 
there were no long-term health effects linked to the exposures of burn 
pits because the 2011 study did not acknowledge any. Conversely, 
Veterans Affairs officials stated that a study aimed at establishing 
health effect linkages could be enabled by the data in its airborne 
hazards and open-air burn pit registry, which collects self-reported 
information on servicemembers' deployment location and exposure.
    In response to a mandate contained in section 201 of Public Law 
112-260, the Department of Veterans Affairs entered into an agreement 
with the National Academies of Sciences, Engineering, and Medicine to 
convene a committee to provide recommendations on collecting, 
maintaining, and monitoring information through the registry. The 
committee assessed the effectiveness of the Department of Veterans 
Affairs' information gathering efforts and provided recommendations for 
addressing the future medical needs of the affected groups. The study 
was conducted in two phases. Phase 1 was a review of the data 
collection methods and outcomes, as well as an analysis of the self-
reported veteran experience data gathered in the registry. Phase 2 was 
focused on the assessment of the effectiveness of the actions taken by 
the Department of Veterans Affairs and DoD and provided recommendations 
for improving the methods enacted. The committee released its final 
report in February 2017. \17\ As we reported in September 2016, 
considering the results of this review as well as the methodology of 
the 2011 Institute of Medicine study as part of an examination of the 
relationship between direct, individual exposure to burn pit emissions 
and long-term health effects could better position DoD to fully assess 
those health risks.
---------------------------------------------------------------------------
    \17\ Since the committee's report was released after the release of 
our September 2016 report we did not evaluate it. See National 
Academies of Sciences, Engineering and Medicine, Assessment of the 
Department of Veterans Affairs Airborne Hazards and Open Burn Pit 
Registry (Washington, D.C.: The National Academies Press, 2017).
---------------------------------------------------------------------------
    In our September 2016 report we recommended that the Secretary of 
Defense direct the Under Secretary of Defense for Acquisition, 
Technology, and Logistics \18\ to:
---------------------------------------------------------------------------
    \18\ Effective February 1, 2018, the National Defense Authorization 
Act for Fiscal Year 2017 provided for the restructuring of the Under 
Secretary of Defense for Acquisition, Technology, and Logistics. Pub. 
L. No. 114-328, Sec.  901 (2016) (codified at 10 U.S.C. Sec. Sec.  133a 
and 133b). The position has been divided into the Under Secretary of 
Defense for Research and Engineering and the Under Secretary of Defense 
for Acquisition and Sustainment.

      take steps to ensure CENTCOM and other geographic 
combatant commands, as appropriate, establish processes to consistently 
monitor burn pit emissions for unacceptable exposures; and
      in coordination with the Secretary of Veterans Affairs, 
specifically examine the relationship between direct, individual, burn 
pit exposure and potential long-term health-related issues. As part of 
that examination, consider the results of the National Academies of 
Sciences, Engineering, and Medicine's report on the Department of 
Veteran Affairs registry and the methodology outlined in the 2011 
Institute of Medicine study that suggests the need to evaluate the 
health status of service members from their time of deployment over 
many years to determine their incidence of chronic disease, with 
particular attention to the collection of data at the individual level, 
including the means by which that data is obtained.

    DoD concurred with the first recommendation, stating that the 
department will ensure that geographic combatant commands establish and 
employ processes to consistently monitor burn pit emissions for 
unacceptable exposures at the point of exposure and if necessary at 
individual sources. In a May 2018 status update regarding this 
recommendation, DoD stated that it will be updating applicable 
department policy and procedures, its tactics techniques and procedures 
manual, and guidance for sampling and analysis plans to improve 
monitoring of burn pit emissions and other airborne hazard emissions. 
Specifically, DoD stated it will update DoD Instruction 6490.03, 
Deployment Health; that the update will provide revised procedures on 
deployment health activities required before, during, and after 
deployments, including Occupational and Environmental Health Site 
Assessments; and that it estimates this will be completed by the 4th 
quarter of fiscal year 2018. In addition, the department stated it will 
update its Occupational and Environmental Health Site Assessments 
tactics, techniques, and procedures manual and update guidance for 
sampling and analysis plans and that the updates will provide revised 
tactics, techniques, and procedures that will improve the quality of 
health risk assessment. The department expects this to be completed by 
the 1st quarter of fiscal year 2019. GAO believes that upon completion 
of these actions, DoD will have met the intent of this recommendation.
    With respect to our recommendation to sponsor research, in 
coordination with the Secretary of Veterans Affairs, to specifically 
examine the relationship between burn pit exposure and potential 
health-related issues, DoD partially concurred, stating that a 
considerable volume of research studies had already been completed, 
were ongoing, or were planned in collaboration with the Department of 
Veterans Affairs and other research entities to improve the 
understanding of burn pit and other ambient exposures to potential 
long-term health outcomes and that the studies, where applicable, 
consider and incorporate the methodology outlined in the 2011 Institute 
of Medicine study. In a May 2018 status update regarding this 
recommendation, the department stated that DoD and the Department of 
Veterans Affairs continue to collaborate with each other and other 
entities on research activities that address burn pit and other 
airborne exposures, and potential long-term health outcomes. 
Specifically, the department cited a DoD/Veterans Affairs Airborne 
Hazards Symposium held in May 2017; an update to the Veterans Affairs/
DoD Deployment Health Working Group ``Airborne Hazards Joint Action 
Plan'' to be completed by the 3rd quarter of fiscal year 2018; and the 
completion of research to examine airborne hazard exposures and 
potential health-related issues. GAO believes that to the extent that 
continued studies consider and incorporate the methodology outlined the 
2011 Institute of Medicine study, where appropriate, DoD will have met 
the intent of this recommendation.
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee, this concludes my statement for the record.

GAO Contact and Staff Acknowledgments

    If you or your staff have any questions about this statement, 
please contact Cary Russell, Director, Defense Capabilities and 
Management, at 202-512-5431 or [email protected]. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. GAO staff who made key contributions 
to this statement include Guy LoFaro (Assistant Director), Lorraine 
Ettaro, Shahrzad Nikoo, Jennifer Spence, and Matthew Young.

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                           Victor J. Dzau, MD
President, National Academy of Medicine, on behalf of The National 
    Academies of Sciences, Engineering, and Medicine

    Dear Chairman Roe:

    Thank you for your invitation to submit a statement for the record 
on scientific research regarding the potential long-term health effects 
of burn pit exposure among veterans and, in particular, the use and 
effectiveness of the Airborne Hazards and Open Burn Pit (AH&OBP) 
registry that Congress mandated that VA create in 2013.
    As you know, The National Academies of Sciences, Engineering, and 
Medicine released the report Assessment of the Department of Veterans 
Affairs Airborne Hazards and Open Burn Pit Registry on February 28, 
2017. The report was written by a committee of experts assembled by the 
National Academies in response to a request by the US Department of 
Veterans Affairs (VA), who were fulfilling a provision of Public Law 
112-260, Section 201 mandating a study. VA sponsored the effort but, 
other than defining its statement of task at the beginning of the 
study, had no influence on the content of the report.
    The report offered several observations concerning how the AH&OBP 
Registry questionnaire collects information and recommended changes 
intended to improve and streamline it. It noted, though, that 
registries like the AH&OBP that rely on voluntary involvement and self-
reported information on exposures and health outcomes are not suitable 
for assessing the health effects of exposure due to respondents' 
selective participation, inaccurate recall, or inadvertent or 
intentional under- or overestimation. Such registries are thus an 
intrinsically poor source of information on exposures, health outcomes, 
and possible associations among these events. The report also concluded 
that, given these inherent weaknesses, the best use of the AH&OBP 
Registry is as a means for the eligible population to document their 
concerns of health problems that may have resulted from their service, 
bring those concerns to the attention of VA and their health care 
providers, and supply VA with a roster of people who are interested in 
burn pit exposure issues.
    I have attached a summary of the report for your reference. The 
entire document may be downloaded in PDF format without cost by anyone 
via links available at the following URL: https://www.nap.edu/catalog/
23677/assessment-of-the-department-of-veterans-affairs-airborne-
hazards-and-open-burn-pit-registry
    The National Academies would be pleased to answer questions the 
Subcommittee may have concerning this work and assist in any other ways 
requested.

    Victor J. Dzau, M.D.

    President, National Academy of Medicine


                                 
                            VETERAN WARRIORS
    Chairman Dunn, Ranking Member Brownley, and members of this Panel, 
Veteran Warriors expresses their gratitude for the opportunity to offer 
our views on the potential health effects of exposure to burn pits 
(operated in combat areas of operation).
    There is currently legislation pending that would provide the 
Department of Veterans Affairs (VA) with the impetus and budget to 
institute a ``Center of Excellence''; in order to research what, if any 
harm is done to those service members who are exposed to toxic 
chemicals that are emitted from open-air burning of trash.
    That particular legislation will only succeed in solidifying what 
the ``burn pits'' have already been deemed; that being ``this war's 
Agent Orange''. The term is not used lightly; rather it is in reference 
to the over thirty years it took the Department to lawfully acknowledge 
the effects of ``Agent Orange'' had on service members.
    What many legislators, veterans and citizens are not aware of is 
that the Department of Veterans Affairs already has a substantial and 
specific policy in place regarding providing medical care and rating 
claims; for those veterans who have been exposed to burn pits. That 
policy; ``Training Letter 10-03'' (Environmental Hazards in Iraq, 
Afghanistan, and Other Military Installations); was issued throughout 
the VA on April 26, 2010. The only part of that policy that most do 
recognize is the ``Camp Lejeune Water Contamination'' section; (which 
is AFTER the burn pit policy section).
    Since that policy was issued; thousands of veterans have succumbed 
to burn pit related diseases. Just as many if not more, are dying. Yet, 
the VA continues to deny benefits and medical care for the predominance 
of those veterans who report illnesses associated with burn pit 
exposure. As of May 1, 2018; there are 141,246 veterans registered on 
the Burn Pit Registry.
    The VA established the Burn Pit Registry on April 25, 2014. 
Unfortunately, the Registry questions were so poorly designed as to 
leave the resulting data useless. Veterans who succumbed to their 
injuries before the Registry was initiated; are banned from being 
registered. Most VA providers have no knowledge of it or its use. None 
of the providers can ``see'' the veteran's answers. VA rating examiners 
cannot see them either; leaving the veteran with no recourse to be 
properly rated for their burn pit exposures.
    In February 2017, The National Academies of Sciences, Engineering, 
and Medicine, published their congressionally mandated study of the 
VA's Burn Pit Registry. While the study results are lengthy and offer 
other-use possibilities for the data collected; the most notable of the 
comments are as follows:

    ``While registries that rely on voluntary participation and self-
reported information are a common means of collecting data on large 
populations, they are an intrinsically poor source of information on 
exposures, health outcomes, and possible associations among these 
events. Even under the best of circumstances, there are substantial 
limits to the accuracy of the data and-when the respondents constitute 
only a small, unrepresentative fraction of the eligible population-the 
generalizability of analyses made with them as well.
    These weaknesses are apparent in the Airborne Hazards and Open Burn 
Pit (AH&OBP) Registry questionnaire and in the data collected in the 
registry's first 13 months. The weaknesses have been exacerbated by a 
series of flaws in the structure and operation of the questionnaire and 
in the questions that are asked and the way they are asked. The AH&OBP 
Registry questionnaire is flawed in that it;

      inappropriately uses questions that were validated for 
and meant to be administered by other survey means such as a face-to-
face or computer-assisted phone interview;
      asks questions that may be confusing for respondents 
because they are ambiguous or otherwise poorly written;
      elicits information on topics such as hobbies and places 
of childhood residence that do not yield information that could be 
productively used in any analysis that would be appropriate to 
undertake using registry data;
      fails to ask questions (regarding non-burn-pit trash 
burning, for example) that could yield information related to relevant 
exposures;
      does not take full advantage of its Web-based format to 
streamline and focus questions based on previous responses;
      does not permit answers to be supplemented or updated 
later in time; and
      requires respondents to complete a sometimes lengthy set 
of repetitive questions regarding deployments before addressing core 
issues such as health, increasing the possibility of response 
fatigue.''

    For over a decade, both the Department of Defense (DoD) and 
Department of Veterans Affairs (VA); have relied on their own internal 
research facilities and staff; who at the direction of their respective 
leadership; have denied that there is any correlation between service 
members and contractors contracting rare and inexplicable (through 
genetics or by other know impetus) diseases and the use of open-air 
burn pits as a method of waste disposal in combat zones.
    Both entities continue to deny the existence of any ``valid'' 
research which proves the direct causal links between open-air burning 
and over 141,000* (This number is taken from the VA's ``Burn Pit 
Registry''. It is not inclusive of all exposed and does not account for 
those who have succumbed to their diseases; as they are banned from 
being registered) service-members who are sick and in many cases dying. 
These agencies' refusal to publically acknowledge these causal links 
has had a direct impact on the service members receiving medical care 
and specific benefits that they would otherwise be entitled to under 
U.S. laws and regulations.
    For decades, the United States government (USG) has created and 
enforced specific laws to protect human life and the environment; with 
regard to burning of household trash, chemical, medical, manufacturing 
and even military waste. There has been literally hundreds of thousands 
of man-hours spent researching the effects on humans, animals and the 
environment when trash is burned in open-air pits.
    Inside the U.S. borders, it is illegal (under numerous federal and 
state statutes) to burn a wide variety of items in open-air burn pits. 
Yet, as the conflicts in the Middle East have worn on; the use of open-
air burn pits not only was permitted, but it was openly sanctioned as 
``necessary''.
    Each and every item burned in these pits emits a chemical or group 
of chemicals. Each of these chemicals has been studied by thousands of 
researchers around the world. The consistency in the results of that 
research is what the USG has used repeatedly to create and enforce laws 
about open-air burning of trash, inside our borders; yet the DoD and VA 
still refuse care and benefits to tens of thousands of service members 
on the basis of their myopic and pigeon-hole research base.
    The irony and insult to each service member is obvious and overt. 
The DoD has lengthy and specific regulations regarding burning such 
items as any piece of military equipment painted with CARC paint. As 
all military equipment is painted with CARC paint, it is a logical 
conclusion that no military equipment or part of such equipment be 
burned in an open-air pit. Yet the DoD has sanctioned the burning of 
all manner of military equipment painted with CARC paint for the entire 
duration of the Middle East conflict.

    1. https://phc.amedd.army.mil/PHC%20Resource%20Library/CARC--
Paint--37-011-0313.pdf
    2. https://phc.amedd.army.mil/PHC%20Resource%20Library/TG144--
NOV2012.pdf

    The VA also has a public policy about veterans who have been 
exposed to burning CARC paint and acknowledges that this paint contains 
toxic chemicals that can be harmful to humans.

    1. https://www.publichealth.va.gov/exposures/carc-paint/index.asp

    ``Health problems associated with CARC paint:

    Paint fumes present the most potential risk to users especially 
when CARC is spray painted, rather than applied with a brush or roller.
    CARC paint contains several chemical compounds that can be 
hazardous when inhaled or exposed to the skin:

      Isocyanyte (HDI)--Highly irritating to skin and 
respiratory system. High concentrations can cause: itching and 
reddening of skin; burning sensation in throat and nose and watering of 
the eyes; and cough, shortness of breath, pain during respiration, 
increased sputum production, and chest tightness.
      Solvents--Inhaling high concentrations can cause 
coughing, shortness of breath, watery eyes, and respiratory problems, 
including asthma
      Toluene diisocyanate (TDI)--High levels released during 
the drying process can cause kidney damage.''
    CARC paint is only one specific known chemical compound that has 
been routinely burned in open-air pits. There are literally thousands 
more.
    On April 26, 2010; the VA issued the ``Environmental Training 
Letter'' to all VA facilities nationwide. It is a policy document which 
clearly directs all rating examiners and clinical providers on specific 
chemicals known to be found in the open-air burn pits and how to rate 
and treat veterans who claim exposures.

    http://archive.sgtsullivancenter.org/wp-content/uploads/2014/11/
Training-Letter-10-03-OIF--OEF-Exposures.pdf

    Most are familiar with parts of this document; as it has supported 
the legislation surrounding the Camp Lejeune Water Contamination 
presumption of exposure that the VA has granted to those who served on 
that base.
    The existence of this ``Training Letter'' provides yet another 
layer of evidence that the VA is aware of the toxins veterans' who 
served near open-air burn pits were exposed to and continues to defy 
even its own edicts. Under this policy, the VA has granted 
``Presumptive Status'' to those exposed to contaminated water at Camp 
Lejeune (only); even though this very policy encompasses the burn pits 
in Iraq, Afghanistan and Djibouti; as well as water contamination at 
Camp Lejeune and Atsugi, Japan.
    As nearly all trash burned releases toxic chemicals and the USG has 
regulated this for decades; there is no excuse why it should even be an 
option, let alone continue.
    Those doing so are subject to fines and criminal sanctions inside 
the U.S. borders. Those service members exposed to these chemicals 
should not be denied access to any medical care or benefits when the 
hazards are well known to the USG.
    The Center for Disease Control (CDC) lists all of the chemicals 
found in the Middle East conflict areas, in their top three-hundred (in 
ranking of most dangerous); https://www.atsdr.cdc.gov/spl/previous/
07list.html
    As a nation, forcing our service members to fight or die waiting 
for rightfully earned benefits and services; solely based on two 
agencies refusal to acknowledge peer accepted science; should be a 
source of shame. To continue to behave as if these veterans are 
fabricating their injuries is tantamount to denying their service.
    Veteran Warriors has drafted legislation that will actually provide 
relief to the tens of thousands of veterans who are contracted 
illnesses associated with exposure to toxic chemicals in combat zones. 
The draft of the text follows this statement.

                                 
                    Whistleblowers of America (WoA)
Statement of Ms. Jacqueline Garrick, LCSW-C

    Dear Chairman Dunn and Ranking Member Brownley;

    Whistleblowers of America (WoA) is submitting this statement 
because we are concerned about the Department of Veterans Affairs (VA) 
lack of a consistent process to handle the toxic exposures, illnesses, 
and presumptions related to burn bits as the Gulf War continues. We 
have heard from numerous veterans--Vietnam to Gulf War to Iraq and 
Afghanistan (OIF/OEF) who feel that their concerns have been too long 
ignored while they get sick and their claims are denied. Furthermore, 
WoA also sees the fraud, waste and abuse of ignoring the Veterans 
Disability Benefits Commission (VDBC) recommendations \1\ made over a 
decade ago and VA ineffectiveness in implementing research because of 
it. The VA has had the authority to create presumptions since 1921 and 
has done so only 150 times. However, this piecemeal approach to 
disability presumption decision-making has been laborious and 
insufficient for almost a century. Too many veterans have died while 
waiting. Congress should end this dysfunction before 2021.
---------------------------------------------------------------------------
    \1\ VDBC. (2007) Honoring the call to duty: veterans' disability 
benefits in the 21st century. Department of Veterans Affairs, 
Washington, DC. Chapter 5.
---------------------------------------------------------------------------
    The VA has confirmed that burn pits have been in existence since 
1990, but we must do more than simply store veterans in a registry 
while they get sick and die. In the documentary Delay, Deny, Hope You 
Die: How America Poisoned its Soldiers, \2\ veterans describe the 
expansive environmental contaminations that they endured while the 
government neglected its responsibility to protect them. Among those 
who the film follows is former Marine, Brian Alvarado, who at 70 pounds 
is unable to speak because of his Squamous Cell Carcinoma that he and 
his family attribute to his burn pit exposures yet unrecognized by VA 
as related to his exposures. In 2016, Ben Krause \3\ wrote about the 
death of a 36 year-old Minnesota Air National Guard mother who died of 
Pancreatic Cancer after serving next to the 10 acre/100-200 tons a day 
burn pit on the base in Balad, Iraq. In January 2013, I visited the 
Bagram Air Force Base in Afghanistan on behalf of the Department of 
Defense (DoD) and saw the defunct burn bit operation and was truly 
taken aback by its enormity. Sadly, these stories are not new. In June 
2018, The American Legion featured in its magazine, a feature story on 
Exposed in Service \4\ related to Atomic Veterans from 1962 who were 
dosed with ionizing radiation but are also unable to obtain VA benefits 
because of the lack of evidence.
---------------------------------------------------------------------------
    \2\ Lovett, G. (2017) Morningstar Media.
    \3\ Krause, B. 36-year old mother possibly the newest burn pit 
victim. DisabledVeterans.org, June 21, 2016
    \4\ Olsen, K. Exposure wars: the long, connected and continuing 
fight for accountability. June 2018. Pgs. 34-40
---------------------------------------------------------------------------
    It its imperative that Congress fund VA research, plus research 
done by independent laboratories that can validate VA data on the 
impact of burn bit exposures as well as comorbid conditions more 
prevalent among those who have deployed to toxic environments where 
there is a likelihood of hazardous exposures. VA must have a research 
strategy that fences these priorities and MUST have a focus to support 
presumption decisions that can inform Veterans Benefits Administration 
(VBA) policies. It must also provide the proper management of research 
funds and oversight of execution.
    In prior testimony, WoA, highlight its concerns with previous 
generations of veterans who have been suffered toxic exposures and 
environmental hazards. We outlined:

    Agent Orange: A primary source of concern for veterans that have 
contacted WoA has been related to toxic exposures and environmental 
hazards. There are still so many Vietnam-era Veterans with Agent Orange 
related issues that have not been appropriately recognized because of 
the shortfalls in the research. For example, eye cancers are a 
continuous issue that lack research support. VA continues to deny 
claims for disability benefits, which in turn blocks veteran from 
accessing care. As the Vietnam generation ages and has more complex 
needs for care, the arguments over probable correlations need to be 
resolved before there is no one left for the science to help.

    Gulf War Illness: Although it has been more than 25 years since the 
US invaded Iraq, the mysteries of Gulf War Illnesses haunt veterans 
while perplexing VA. A July 2017 GAO report concluded that VA is still 
inappropriately denying veterans claims. It found an 80 percent denial 
rate, which is three times greater than any other type of claim 
denials. Plus, it also took VA longer to adjudicate these benefits. 
This delay means that sick veterans are not fully eligible for VA 
health care. VA has promised better training and to develop a new plan 
for research.

    Fort McClellan: The VDBC included these predominately female 
service members in its recommendations. Over 10 years later, the 
American Legion is still reporting on the ``unknown toxic legacy'' of 
Anniston and has a resolution that requires a toxic substance national 
research center, comprehensive examinations for environmental 
exposures, and improvement in these rules. \5\ (This is consistent with 
the VDBC findings.)
---------------------------------------------------------------------------
    \5\ Olsen, K. The long shadow of Ft. McClellan. The American Legion 
Magazine. March 2018. Pgs. 22-28

    Camp LeJeune: Due to the water contamination at the Marine Corps 
Base, Camp LeJeune, NC, increased reports of cancers in veterans and 
their families have been document over the last several decades related 
---------------------------------------------------------------------------
to the cleaning solvents in the water.

    Burn Pit Exposures: Similar to previous generations of veterans, 
those who have served in Afghanistan and Iraq since 9/11 were exposed 
to a concoction of burning substances on military installations that 
has caused them to raise health concerns from cancers to respiratory 
and gastrointestinal disorders. Although VA denies conclusive research 
for these conditions and does not have a presumption for burn pits, it 
has established a registry. However, this is an area yet again that the 
VDBC recommendation could be informative and assistive to veterans' 
wellness if implemented. A registry alone assists no one.

VDBC Recommendations for Reconsideration:

    The VDBC conducted its work over a three-year period and reported 
its findings and 113 recommendations in October 2007. It was a Federal 
Advisory Committee established by President George W. Bush and its 13 
commissioners were selected on a bipartisan basis. Presumption was a 
major issue that it tackled. The VDBC enlisted the subject matter 
assistance of the then Institute of Medicine (IOM) for its reliable and 
valid scientific approach. To meet the requirements outlined by VDBC, 
IOM established a committee that held meetings, reviewed research and 
other literature, and rendered its own report. \6\ The IOM 
recommendations were incorporated into the VDBC Final Report after a 
full period of vetting and commentary by the community. In sum, the 
VDBC recommended:
---------------------------------------------------------------------------
    \6\ IOM. (2008) Improving the presumptive disability decision-
making process for veterans. National Academies Press. Washington, DC.

    1. Congress should create a formal advisory committee on disability 
---------------------------------------------------------------------------
related questions requiring scientific review

    2. Congress should authorize a permanent independent Scientific 
Review Board (SRB) with a well-defined process using evaluation 
criteria

    3. VA should develop and publish a formal process for disabling 
presumptions that is uniform, transparent, and sets forth all 
considered evidence.

    4. The goal of presumptive disability should be to ensure 
compensation for veterans whose diseases are caused by military service 
(this goal is foundational for any related action)

    5. The SRB should adapt a standard for ``causal effect'' based on a 
more likely than not broad spectrum of evidence that is either 
Sufficient, Equipoise and above, Equipoise and below, Against.

    6. This calculation should include relative risk assessment, 
epidemiology, animal studies, registries, mechanistic data, predictive 
algorithms, and interfaces with DoD.

    7. When evidence is at Equipoise or Above, an estimate of exposure 
should be included.

    8. The relative risk and exposure prevalence should be used to 
estimate a service -attributable fraction.

    9. Inventory all research related to veteran's health (VA, DoD or 
the funded)

    10. Develop a strategic plan for OIF/OEF veterans research

    11. Develop a plan for augmenting research capabilities within VA 
and DoD to more systematically generate health related evidence.

    12. Assess enhancing research by linking VA and DoD health related 
databases

    13. Conduct a critical evaluation of Gulf War (this includes OIF/
OEF) tracking and environmental exposure monitoring data to categorize 
exposures during deployments (with DoD)

    14. Establish Registries based on exposures, deployments, and 
disease

    15. Develop an overall integrated (VA/DoD) surveillance plan

    16. Include exposure monitoring in an VA/DoD Electronic Health 
Record

    17. Implement a strategy for immediate and proximate exposure 
assessment and data collection

    18. Interface VA and DoD exposure data systems

    19. Mechanism to identify, monitor, track and treat individuals 
involved in research and other activities that are classified and 
secret

    20. VA should consider environmental issues in a new presumption 
framework

    Given that a decade has passed since the VDBC made these 
recommendations, Congress should ask the VA to relook at this 
systematic approach and design a comprehensive way forward for 
researching presumption related disabling conditions related to 
environmental hazards and toxic exposures. It should consider the 
comorbidity of chemical sensitivities and biological agents, especially 
in relation to neurological and psychological concomitant factors that 
may take years before onset.
    Thank you for this opportunity to express our views on this 
significant issue impacting thousands of disabled veterans, Service 
members, and their families. We hope that this Committee will compel VA 
to act on researching the presumptive conditions related to 
environmental hazards and toxic exposures.

    Jacqueline Garrick is a former Army social work officer who has 
worked in the Departments of Veterans Affairs and Defense as well as 
for the House Veterans Affairs Committee. She is a subject matter 
expert in mental health and program evaluation. She is an advocate for 
disabled veterans and the use of peer support to improve resilience in 
traumatized populations. She founded Whistleblowers of America in 2017 
based on her experience reporting attempted fraud with DoD Suicide 
prevention funds.
    Whistleblowers of America is a 501C3, EIN 82-3989539. Its mission 
is to provide peer support to employees and veterans who have reported 
wrongdoing and experienced retaliation.

Contact:
Jacqueline Garrick
[email protected]
202-309-1870

                                 
            TRAGEDY ASSISTANCE PROGRAM FOR SURVIVORS (TAPS)
                   VIETNAM VETERANS OF AMERICA (VVA)
                     WOUNDED WARRIOR PROJECT (WWP)

    Thank you, Chairman Dunn, Ranking Member Brownley, and 
distinguished members of the Health Subcommittee, for allowing us to 
present this statement for the record on behalf of the service members, 
veterans, family members, and survivors who have been affected by 
exposure to burn pits and other war related toxins.
    For decades, veterans of overseas conflicts and families of our 
nation's wounded, ill, injured, and fallen heroes have been advocating 
to investigate and bring public awareness to the harmful effects of 
toxic exposures in the military. Wounded Warrior Project (WWP), the 
Tragedy Assistance Program for Survivors (TAPS), and Vietnam Veterans 
of America (VVA) have partnered to give momentum to these causes and 
deliver change. While not the only form of toxic exposure that we or 
others wish to address, burn pits have become synonymous with our 
community's interest in acknowledging the harm these exposures have 
caused and ultimately delivering public policy changes that will ensure 
longer, healthier lives for the men and women who serve our country.
    As individual organizations, VVA, TAPS, and WWP have shared 
concerns for several years about the emergence of toxic exposure as a 
common thread among former service members who are sick, dying, or 
already deceased from uncommon illnesses or unusually early onset of 
more familiar maladies like cancer. In the past, we have advocated for 
initiatives such as the creation of the Airborne Hazards and Open Burn 
Pit Registry in June 2014 and the more recent passage of the Toxic 
Exposure Research Act of 2016 (P.L. 114-315, Sec. Sec.  631-34). Given 
our collective interest in prevention, treatment, and awareness, 
Wounded Warrior Project decided in October 2017 to coordinate efforts 
with TAPS and VVA and invested $200,000 in a needs assessment to guide 
our future advocacy. Wounded Warrior Project remains committed to 
continued investments of resources and expanding its partnerships to 
include others passionate about this important issue.
    Since joining together in partnership, we have concentrated our 
efforts to raise awareness of toxic exposures among and on behalf of 
Post-9/11 veterans. Our current undertaking is focused on gathering 
research and data that will help us all better understand the risks and 
effects of toxic exposure so that we may work to ensure service 
members, veterans, families, and survivors have access to the care and 
benefits they need. Thus far, we have built and maintain a database of 
empirical research on toxic exposures, and with the help of the U.S. 
Army, enlisted the help of the ``Soldier for Life Program'' to share 
toxic exposure information with their network of over a million 
veterans. We have created a flyer to be distributed nationally to help 
veterans take the next steps in identifying and being screened for 
symptoms of toxic exposures; recorded a podcast on toxic exposures 
among Post-9/11 veterans, and are networking with other toxic exposure 
awareness groups such as Burn Pits 360 to further share our message. We 
have lent our support to the work of others, including the effort 
behind the Burn Pits Accountability Act (H.R. 5671) introduced by Reps. 
Tulsi Gabbard (HI-02) and Brian Mast (FL-18), and we are working 
towards delivering an information paper to the Health Subcommittee that 
provides a full landscape of what our partnership has been able to 
bring to light over the past several months. More work needs to be done 
however, and we hope to build upon our momentum in the months ahead.

Burn Pits

    In the Post-9/11 era, it is estimated that as many as 3 million 
American service members may have been exposed to dangerous toxins 
during their deployments overseas. Potential sources of these exposures 
include, but are not limited to, depleted uranium used in military 
armor and munitions, toxins from burning oil refineries/destroyed 
weapons plants, and more than 260 open-air burn pits used for the 
disposal of all forms of waste on forward coalition bases around the 
world.
    In its 2011 study on Long-Term Health Consequences of Exposure to 
Burn Pits in Iraq and Afghanistan, the Institute of Medicine stated 
that it was unable to determine whether long-term health effects are 
likely to result from burn pit exposure due to inadequate evidence of 
an association. Although the study did not find a causal relationship 
between burn pits and long-term health issues, it similarly did not 
conclude that there is no relationship. That said, each of our 
organizations continue to see anecdotal evidence to the contrary. 
Accordingly, our organizations collectively agree that public policy 
moving forward should aspire to:

      Support research on the impact of service members exposed 
to environmental toxins or hazardous substances, and/or deployment 
illnesses that may have resulted from their military service (e.g., 
burn pit exposure in Iraq and Afghanistan and Camp Lejeune contaminated 
water).
      Ensure health care and benefits are established to 
appropriately compensate and support service members and veterans, 
family members, and survivors, particularly those experiencing 
catastrophic and devastating cancers, diseases, other health 
conditions, or death as a result of their service.
      Implement the Government Accountability Office's 
September 2016 Report (GAO-16-781) recommendation for the Department of 
Defense (DoD) and the Department of Veterans Affairs (VA) to examine 
the relationship between direct, individual, burn pit exposure and 
potential long-term health-related issues as well as the Institute of 
Medicine's 2011 report suggestion to evaluate the health status of 
service members from their time of deployment over many years.

Beyond Burn Pits

    As noted above, burn pits are just one of many ways that veterans 
were exposed to harmful toxins in service. While any progress to bring 
redress for the wounded, ill, and injured veterans, their families, and 
the families of the fallen who were exposed to burn pits would be 
meaningful, the most lasting impact will be made when we investigate 
other potential causes of death and disease for which there is already 
conspicuous correlation. In this context, our organizations are also 
committed to developing public policies that:

      Seek additional research by DoD and VA on the link 
between cancers that may be caused by toxic exposures in combat zones.
      Expand the current Burn Pit Registry so that it becomes a 
Toxic Exposure Registry, and includes exposures to depleted uranium, 
experimental medications, vaccinations, and aircraft fuels.
      Create an education program for distribution in both DoD 
and VA for veterans and family members that includes the known symptoms 
associated with toxic exposures in order to initiate earlier 
intervention.
      Allow surviving family members who believe that their 
service member/veteran may have died from a toxic exposure to add their 
names to the Toxic Exposure Registry.
      Encourage the VA to work with the Army Public Health 
Center to summarize and identify common risks using their Periodic 
Occupational and Environmental Monitoring Summary (POEMS).

    Additionally, while we know this committee only has jurisdiction 
over VA, we realize there is much to do by DoD. We would like Congress 
to require DoD to assess and research the diseases and illnesses 
resulting from toxic exposures by our Post-9/11 veterans in order to 
help ensure longer, healthier lives for the men and women who serve our 
country. Eventually, we would like to make sure that all exposures 
would be delineated so that none are overlooked or fall through 
loopholes. We would also like to see the list expanded to include 
depleted uranium, radiation exposures, infectious diseases, and 
occupational materials. We would hope that identifying each exposure is 
a step in the right direction.
    Lastly, we would like to see an evaluation of all duty locations in 
which a member served, not just those with open air burn pits, to 
ascertain the full measure of a service member's toxic exposures. The 
recently released DoD report from March 2018, Addressing 
Perfluorooctane Sulfonate (PFOS) and Perfluorooctanoic Acid (PFOA), 
outlines the full magnitude of the presence of PFOS and PFOA in 
drinking water and groundwater on our military bases and identifies 401 
active and Base Closure and Realignment installations in the United 
States with at least one area where there was a known or suspected 
release of perfluorinated compounds. This exposure should not be 
overlooked.

Final Remarks

    In conclusion, we sincerely appreciate the Health Subcommittee's 
commitment to assessing the potential health effects of burn pits. 
While our organizations have found compelling evidence in the anecdotal 
stories of death, early onset of disease, and lingering health ailments 
that are difficult to attribute to other potential causes, we 
understand that progress takes time. We are grateful that today's 
hearing will contribute to a greater understanding and increased 
information sharing related to burn pit exposure and the potential 
effects of such exposures on America's heroes and their families.
    In the future, we are eager to see the Health Subcommittee expand 
the aperture further to include other toxic exposures including 
depleted uranium, radiation exposures, infectious diseases, and 
occupational materials. We are confident that the TAPS, VVA, and WWP 
partnership--along with any others who may join or who share our 
interest in raising awareness and driving change in this area--can 
provide thoughtful, constructive, and informative assistance in 
Congress' future efforts, and we look forward to continued engagement 
with the Health Subcommittee on burn pits and other toxic exposures as 
we seek to support service members, veterans, family members, and 
survivors whose lives have been touched by exposure to burn pits.
                           Our Organizations
    The Tragedy Assistance Program for Survivors (TAPS) is the national 
organization providing compassionate care for the families of America's 
fallen military heroes. TAPS provides peer-based emotional support, 
grief and trauma resources, grief seminars and retreats for adults, 
Good Grief Camps for children, case work assistance, connections to 
community-based care, and a 24/7 resource and information helpline for 
all who have been affected by a death in the Armed Forces. Services are 
provided to families at no cost to them. We do all of this without 
financial support from the Department of Defense; TAPS is funded by the 
generosity of the American people.
    TAPS was founded in 1994 by Bonnie Carroll following the death of 
her husband in a military plane crash in Alaska in 1992. Since then, 
TAPS has offered comfort and care to more than 75,000 bereaved 
surviving family members. TAPS currently receives no government grants 
or funding.
    The national organization Vietnam Veterans of America (VVA) is a 
Congressionally chartered non-profit veterans' service organization 
whose founding principle is: ``Never again will one generation of 
veterans abandon another.'' VVA promotes and supports the full range of 
issues important to Vietnam veterans, to create a new identity for this 
generation of veterans, and to change public perception of Vietnam 
veterans. VVA knows what returning veterans face as we have been 
through it before. We know that, despite all the rhetoric, returning 
veterans will face major health problems and as such, VVA has a well-
known history of dealing with the health effects of toxic exposures 
during military service.
    In the 1970's, established veterans groups had failed to prioritize 
issues of concern to Vietnam veterans. Thus VVA came into existence at 
that time out of a clear necessity to advocate for and provide support 
to veterans in need. VVA will be here for as long as it takes to make 
sure that those who serve our country receive the care and respect they 
have earned.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives). This 
is also true of the previous two fiscal years.
    Wounded Warrior Project (WWP) is transforming the way America's 
injured veterans are empowered, employed, and engaged in our 
communities. Since 2003 we've been tireless advocates for our Nation's 
finest, improving the lives of over half a million warriors and their 
families.
    Warriors never pay a penny for our programs-because they paid their 
dues on the battlefield. Our free services in mental health, career 
counseling, and long-term rehabilitative care change lives. WWP is 
committed to helping injured veterans achieve their highest ambition. 
When they're ready to start their next mission, we stand ready to 
serve.
    WWP is humbled to be recognized as a charity with great impact, 
operating with efficiency, transparency, and accountability. We are an 
accredited charity with the Better Business Bureau (BBB), top rated by 
Charity Navigator, and hold a GuideStar Platinum rating. WWP has not 
received any federal grants or funding.

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