    [Senate Hearing 116-332]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-332

      TOXIC EXPOSURE: EXAMINING THE VA'S PRESUMPTIVE DISABILITY DECISION-
                                 MAKING PROCESS

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 25, 2019

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

                               ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
    43-347 PDF            WASHINGTON : 2021

                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman
    Jerry Moran, Kansas                  Jon Tester, Montana, Ranking
    John Boozman, Arkansas                   Member
    Bill Cassidy, Louisiana              Patty Murray, Washington
    Mike Rounds, South Dakota            Bernard Sanders, (I) Vermont
    Thom Tillis, North Carolina          Sherrod Brown, Ohio
    Dan Sullivan, Alaska                 Richard Blumenthal, Connecticut
    Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
    Kevin Cramer, North Dakota           Joe Manchin III, West Virginia
                                         Kyrsten Sinema, Arizona
                           Adam Reece, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                               September 25, 2019
                                    SENATORS

                                                                       Page
    Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     2
    Boozman, Hon. John, U.S. Senator from Arkansas...................    11
    Rounds, Hon. Mike, U.S. Senator from South Dakota................    15
    Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    17
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    22
    Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    24
    Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    26
    Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    29
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    31
    Moran, Hon. Jerry, U.S. Senator from Kansas......................    34
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    35
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    37
    Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    65

                                   WITNESSES

    Hastings, Patricia R., M.D., Chief Consultant, Post Deployment
      Health, U.S. Department of Veterans Affairs; accompanied by
      Drew Helmer, M.D., Director, War Related Illness and Injury
      Study Center (WRIISC)..........................................     5
        Prepared statement...........................................     6
        Response to request arising during the hearing by:
          Hon. Johnny Isakson........................................ 12,13
          Hon. Mazie K. Hirono.......................................    17
          Hon. Dan Sullivan..........................................    30
          Hon. Richard Blumenthal....................................    37
        Response to posthearing questions submitted by:
          Hon. Jon Tester............................................    69
          Hon. Bernie Sanders........................................    97
          Hon. Sherrod Brown.........................................    98
          Hon. Richard Blumenthal....................................    99
          Hon. Mazie K. Hirono.......................................   101
          Hon. Joe Manchin III.......................................   102
    Rauch, Terry M., Ph.D., Acting Deputy Assistant Secretary of
      Defense (Health Affairs) Health Readiness Policy and Oversight,
      U.S. Department of Defense.....................................     8
        Prepared statement...........................................     9
        Response to request arising during the hearing by:
          Hon. Mazie K. Hirono.......................................    19
          Hon. Sherrod Brown.........................................    32
        Response to posthearing questions submitted by:
          Hon. Jon Tester............................................   111
          Hon. Bernie Sanders........................................   113
          Hon. Sherrod Brown.........................................   114
          Hon. Richard Blumenthal....................................   115
          Hon. Mazie K. Hirono.......................................   116
    Butler, David, Ph.D., Director, Office of Military and Veterans
      Health, Health and Medicine Division, The National Academies of
      Sciences.......................................................    40
        Prepared statement...........................................    41
    Liermann, Shane L., Deputy National Legislative Director for
      Benefits, Disabled American Veterans (DAV).....................    45
        Prepared statement...........................................    47
    Miller, Robert, M.D., Vanderbilt University Medical Center.......    57
        Prepared statement...........................................    59

                                    APPENDIX

    The American Legion; prepared statement..........................   119
    Zampieri, Dr. Thomas, President and Chairman, Blinded Veterans
      Association; letter............................................   123
    Burn Pits 360; prepared statement................................   125
        Appendix A...................................................   144
        Appendix B...................................................   145
        Appendix C...................................................   151
        Appendix D...................................................   151
        Appendix E...................................................   156
    Samet, Jonathan M., M.D., M.S., Dean and Professor, Colorado
      School of Public Health, Aurora, CO (CSPH); prepared statement.   165
        Attachments: Summaries from the report Improving the
          Presumptive Disability Decision-Making Process for Veterans
          (2008).....................................................   170
    Porter, Tom, Vice President, Government Affairs, Iraq and
      Afghanistan Veterans of America (IAVA); prepared statement.....   185
    Tragedy Assistance Program for Survivors (TAPS); prepared
      statement......................................................   188
    Weidman, Richard F., Executive Director for Policy and Government
      Affairs, Vietnam Veterans of America (VVA); prepared statement.   190
    Wounded Warrior Project; prepared statement......................   192
        Appendix.....................................................   198
    Zeier, Susan M., Veteran Advocate, Burn Pits 360-Ohio, and
      Mother-in-Law of a Burn Pit Veteran; prepared statement........   201
        Attachment 1.................................................   208
        Attachment 2.................................................   210
        Attachment 3.................................................   211

      TOXIC EXPOSURE: EXAMINING THE VA'S PRESUMPTIVE DISABILITY DECISION-
                                 MAKING PROCESS

                                  ----------

                         WEDNESDAY, SEPTEMBER 25, 2019

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

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

        Chairman Isakson. Good morning. We are glad to have you
    here at the Veterans' Affairs Committee for this hearing today,
    which is a very important hearing. It has been scheduled twice
    before and was postponed for other problems. One was the
    principal author could not be here for the hearing, on his
    bill, and we did not want to do that. The other cancellation
    was because of conflicts--problems with our whole calendar on
    the day and we had to pull it off the calendar because of other
    votes that preceded it.
        But, today we do not have any competition. We have
    competition but it is not any good competition, so we are going
    to have our hearing and hopefully we are going to have good
    attendance.
        This is a very important hearing issue that is bubbling up
    from time to time in our military, and it is an issue that is
    not covered greatly, because it is an issue of more modern
    warfare than some of the old stuff. I think it is important
    that we hear everything that is going on and what the
    Department of Veterans Affairs is doing, and what problems
    veterans who have been conflicted with, associated with toxic
    waste and toxic fire pits, have endured.
        We are in the process of beginning to gather facts, and I
    want to point out today something I have never said before. The
    high level of toxic exposure issues with claims and benefits
    never occurred to me until we started working on the Blue Water
    Navy legislation. As you know, we passed Blue Water Navy, what,
    a month ago, Jon?
        Senator Tester. Yes.
        Chairman Isakson. We have had been working on Blue Water
    Navy for, I guess, ever since you have been Ranking Member and
    I have been Chairman--four years anyway--to include Blue Water
    Navy benefits for those who did not serve on land, but served
    at sea in the Vietnam War. That expanded payments for presumed
    illness due to Agent Orange exposure. It might be from Agent
    Orange, while it could be from something else.
        We have to be very careful in the future when we start
    gathering facts to make certain we take into account facts, and
    clarify indirect cause and effect. We want to find out exactly
    what is causing illnesses and diseases, exactly where the
    problems may or may not be, and hear from the Department of
    Veterans Affairs about exactly what it would take for us to do
    the research and what to do with the findings. Then, if we did
    have a cause for action, how long it would take us and how far
    we would have to go in substantiating that cause of action for
    veterans.
        We have got a long way to go before we have any
    legislation, but it is time to start looking at this very
    important topic. In Iraq and Afghanistan, there have been lot
    of incidences of burn pits, which is only exacerbated by the
    terrain and atmosphere, and those countries are already
    classified as austere living conditions. So, you have the waste
    that comes from a burn pit affecting soldiers who are fighting
    today, and that is something that causes a big problem.
        We are going to gather all the facts we can. We will make
    sure our soldiers get what they are entitled to and what they
    have earned for representing our country. I want to see to it
    that we get all the facts on the table so we don't have a rush
    to judgment without something that isn't scientifically
    founded. The only thing we need to rush to do is what is right
    by veterans because we know it is, and that is what we plan on
    doing at this hearing today.
        Before I introduce our guests I want to introduce Ranking
    Member Jon Tester from Montana for his comments.

      OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S.
                          SENATOR FROM MONTANA

        Senator Tester. Well, thank you, Mr. Chairman.
        I want to thank the folks on both panels who are going to
    be testifying today. I appreciate you taking time out of your
    schedules to be here to testify before us on a very critically
    important issue.
        Before we get to business I also want to take a moment and
    recognize Bobby Daniels, a Blue Water Navy veteran from
    Missouri. Bobby, it is good to have you in the crowd. I know
    this is an issue that you have been working on for some time,
    and we appreciate your service, so thank you, sir. [Applause.]
        I also want to say a few things about the fellow to my
    left, who said he would be returning back home to Georgia at
    the end of this year. There are going to be a lot of things
    said about Johnny Isakson over the next 3 to 4 months, but the
    fact is that serving with Johnny on this Committee has been an
    honor of a lifetime for me. He is an example of what the U.S.
    Senate should be--civility, bipartisanship, and decency--and
    one that we should all try to emulate.
        Johnny is everything that you could ask for in a colleague,
    in a friend, and he has been the best damn advocate for
    veterans in this country that they could ever ask for. We have
    accomplished a lot under Johnny's chairmanship, from the
    MISSION Act to the Forever GI bill, to the Appeals
    Modernization, and, yes, to the Blue Water Navy Veterans Act.
        That is why we are here today, not just to talk about the
    process, but to talk about fulfilling this Nation's promises to
    our veterans.
        When folks sign up for the military, there are promises
    made, and the cost of fulfilling those promises are the costs
    of war. In terms of Agent Orange exposure we are talking about
    an aging Vietnam veterans' population, a population that often
    returned home to protests in angry and divided communities.
    They did not return home to parades or other appreciation from
    a grateful Nation. This population has suffered for far too
    long from health conditions caused by service to a government,
    and far too frequently that government refused to acknowledge
    the true extent of their sacrifice.
        So, now is the time. The time has passed to wait for those
    veterans' families to wait for three medical conditions--
    hypothyroidism, bladder cancer, Parkinson's-type syndromes or
    Parkinsonism. The National Academy suggests that those are
    associated with Agent Orange. In the case of the fourth
    condition, hypertension, their view of the studies have shown
    there is a positive association between that and Agent Orange.
        Yet, in all four of these cases, Vietnam veterans continue
    to wait for VA bureaucracy to unravel itself from the red tape
    and issue a decision on whether to extend presumptive exposure.
    There is absolutely nothing stopping the Secretary from making
    a decision on these four conditions right now.
        Meanwhile, those Vietnam veterans who served offshore,
    their wait continues. Despite the court ordering the Department
    to finally acknowledge Blue Water Navy veterans' exposure to
    Agent Orange and other herbicides, the VA continues to slow-
    walk processing claims for these veterans, and the VA must do
    right by these Blue Water Navy veterans; quite frankly, lift
    the stay and the wait, and begin processing their claims today,
    because the fact is the VA is outliving these veterans and that
    is simply not right.
        We are at a point where our newest generation of veterans
    is losing faith in this government because the VA bureaucracy
    has not prioritized or appropriately addressed the health
    outcomes of veterans exposed to harmful toxins while in
    service. For the Gulf War veterans, their health has worsened
    in comparison to their non-deployed counterparts, and the VA
    must work harder to figure out why this is.
        While I understand the National Academy is undertaking a
    comprehensive review of the health effects of airborne hazards
    from burn pits, veterans are understandably frustrated with the
    pace of progress in examining their exposures. Moving forward,
    we must develop a better process for recognizing health
    outcomes caused by toxic and environmental exposures. Veterans
    and their families cannot wait decades for determinations that
    their military exposures caused their illness. We need a
    simpler, quicker process.
        At Secretary Wilkie's confirmation, he said that a veteran
    should not have to employ a team of lawyers to get their
    benefits to the care that they are entitled, and I know he
    sincerely believes that. I agree with him. But, it is my
    opinion that the VA could make this progress much less
    adversarial if it stopped employing armies of lawyers to find
    ways to deny care or benefits to veterans and start hiring
    additional docs and claims processors to provide more timely
    care to their veterans.
        Yet, the VA is not the only government agency that bears
    fault here. The Department of Defense must do a better job
    mitigating the damage done by environmental hazards, by working
    to prevent them in the first place. It needs to more accurately
    record the exposure our troops come in contact with and make
    sure our troops' medical records document these exposures.
        I have worked closely with Senators Blackburn and
    Blumenthal on the OATH Act, which would require such
    documentation. It would help veterans establish that contact
    with toxic occurred so that they have more easily fileable
    claims for exposure, just as it helps the VA with diagnosis and
    treatment.
        The Joint Economic Council exists to improve coordination
    between the DOD and the VA and ultimately improve outcomes for
    servicemembers and veterans. Why is common-sense legislation
    like the OATH Act even necessary when the highest levels of the
    DOD and VA are supposed to be looking into these issues
    routinely?
        To that end, I would like to see the JEC take a harder look
    at how the DOD and VA can work collaboratively to ensure that
    the VA has the information that it needs to substantiate the
    claims so that veterans do not have to hire a team of lawyers,
    as referenced by the Secretary.
        Making a decision on science should not take more than 3
    years. Following a court decision should not take 9 months. And
    not learning from decades of mistakes and allowing our newest
    generation of veterans to experience the same hold-ups as the
    Vietnam veterans have is a failure in and of itself.
        Mr. Chairman, I cannot thank you enough for calling this
    hearing today. It is one of the most important hearings I think
    we are going to have this year in the VA Committee. Thank you.
        Chairman Isakson. Well, thank you, Jon, and thank you for
    your kind remarks about me, but I want to tell everybody, one
    fact to keep in mind. In the past 2 years, all the legislation
    we have passed, making changes, all of them that have been
    made--new GI bill, everything--there was one dissenting vote
    from a Committee Member on one vote. So, we have 100 percent
    votes for everything we did, except for one time we had one no
    vote yet we had 14 yes votes on that bill. So, we are a team,
    we are not individuals up here. We are ready to work on
    problems and get them solved. I appreciate your help along the
    way. We had a good Committee all the way through.
        Now for our panel today. Our first panel is Dr. Patricia
    Hastings, Chief Consultant, Post-Deployment Health, VA;
    accompanied by Dr. Drew Helmer, Director of War-Related Illness
    and Injury Study Center. Then, Dr. Terry Rauch, Acting Deputy
    Assistant Secretary of Defense for Health Readiness, Policy,
    and Oversight.
        Dr. Hastings, you are first.

     STATEMENT OF PATRICIA HASTINGS, M.D., CHIEF CONSULTANT, POST
        DEPLOYMENT HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS;
    ACCOMPANIED BY DREW HELMER, M.D., DIRECTOR, WAR RELATED ILLNESS
                    AND INJURY STUDY CENTER (WRIISC)

        Dr. Hastings. Thank you very much.
        Chairman Isakson. I will interrupt for 1 second. You have
    got up to 5 minutes.
        Dr. Hastings. OK. Chairman Isakson, Ranking Member Tester,
    and Members of the Committee, I really want to thank you for
    having this meeting. I want to thank you for allowing the VA to
    talk about what we do in regard to military environmental
    exposures and how we take care of veterans.
        I am a 30-year veteran at retirement. I decided that I
    would come to the VA to continue to serve veterans. I am joined
    today by Dr. Drew Helmer. He is the previous director of the
    War-Related Illness and Injury Study Center at East Orange, NJ,
    and last month he was selected to be the Deputy Director at the
    Center for Quality Innovations, Effectiveness, and Safety at
    the Houston Medical Center in Houston, TX.
        I am a board certified emergency medicine physician with a
    degree in public health, and I am very happy to continue
    serving.
        Post Deployment Health Services (PDHS) is the oversight for
    military environmental exposures, and we know how critical this
    is for veterans. Exposures are the reason that my office
    exists. We have four programs in Post Deployment Health
    Services. These are the Pre-9/11 programs, the Post-9/11 Era
    Programs, and here we have subject matter experts that look at
    how to develop policy that is effective and works for the
    veterans.
        Epidemiology looks at the science, does some original
    research, and informs policy for the VA. The War-Related
    Illness and Injury Study Center, that I just spoke about, does
    research, education, very extensive education, and also sees
    the most difficult cases in the VA, those veterans that are
    hard to diagnose and hard to make a treatment plan for.
        At the War Related Illness and Injury Study Center in New
    Jersey there is the Airborne Hazards Open Burn Pit Center of
    Excellence, and I think you know about that because you have
    supported it vigorously. Your support has accelerated research
    for veterans and care for veterans, and I would like to
    sincerely say thank you.
        VA does recognize that environmental exposures during
    deployment may be associated with immediate and delayed adverse
    outcomes, and the greatest challenge there is getting the work
    done. VA cares for 9.6 million veterans. A third of these
    veterans report that they may have had an exposure to an
    environmental hazard, and a quarter of those veterans are
    concerned that they may have an adverse health outcome.
        We have teams that are addressing this. We have
    epidemiologists. We have physiologists. We have internists. We
    have pulmonologists. We work with the other Federal agencies.
    We work very closely with the DOD. We work with the National
    Academy of Medicine. We work with CDC, VBA, all of these in
    support of veterans.
        When a disability is determined to be due to an in-service
    exposure, whether it is through a presumption or direct proof
    of exposure, VBA is there to help veterans with compensation.
        In certain circumstances, VA does presume that a disability
    was caused by military service, and presumption can take the
    place of some other forms of proof. They are established by
    Congress or by the Secretary after review of the science by the
    subject matter experts, and in the VA we use external agencies
    as well as the internal subject matter experts. One of the
    greatest challenges with the presumption process is that good
    science does take time, and we are working very hard to get
    things done.
        In the absence of a presumption, however, we do encourage
    the veteran to turn in a claim which can be looked at on an
    individual basis if they believe that their service has harmed
    their health.
        A central question that does remain unanswered, in many
    cases, is what aspect of the deployment is causing the ill
    health? We see that right now with airborne hazards. Is it the
    dust? Is it the burn pits? Is it an infectious process? Is it
    blast over pressure or a combination of all those things? VA is
    working with DOD and our other partners to find the answers.
        An exciting new opportunity to improve understanding is
    ILER. I think most of you know about the Individual
    Longitudinal Exposure Record. If you match ILER with the
    electronic health record, and we have the ability to do big
    data, we have a very powerful tool that can look at large or
    small cohorts very quickly and get you the answers that you
    seek for care of veterans. We hold scientific exchanges with
    the DOD. We have the airborne Hazards Symposium, toxic-embedded
    fragments studies, the July Environmental Health Conference.
    All of these have taken place in the last 6 months. We publish
    our research findings in peer-reviewed journals.
        In conclusion, sir, VA is committed to the health and well-
    being of veterans. My office is dedicated to that specifically.
    To this end, your continued support, as has been, is essential.
        Mr. Chairman, this concludes my testimony. My colleague and
    I are prepared to answer your questions.
        [The prepared statement of Dr. Hastings follows:]
    Prepared Statement of Dr. Patricia R. Hastings, Chief Consultant, Post
    Deployment Health Services, Veterans Health Administration, Department
                            of Veterans Affairs (VA)
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, Thank you for the opportunity to discuss the ongoing
    processes, research, and actions that VA uses to identify illnesses and
    care for Veterans who may have an illness associated with environmental
    health hazards during military service. I am joined by Dr. Drew Helmer,
    Deputy Director of the Center for Innovations in Quality,
    Effectiveness, and Safety at the VA Medical Center in Houston, Texas,
    and immediate past Director of the War Related Illness and Injury Study
    Center (WRIISC) at the VA New Jersey Health Care System in East Orange,
    New Jersey.
                        post deployment health services
        Post Deployment Health Services (PDHS) oversees health-related
    concerns of relevance to Veterans and their occupational and
    environmental exposure.
        PDHS consists of four programs: Pre-9/11 and Post-9/11 Era
    Environmental Health Programs--addressing military environmental
    concerns from conflicts as well as garrison exposures; Epidemiology--
    providing research and scientific review to inform policy; and WRIISC
    located at three sites. WRIISC provides research, education, and
    medical consultation for cases that are difficult to diagnose or treat.
    WRIISC NJ houses the congressionally-mandated Airborne Hazards and Burn
    Pits Center of Excellence. Your support has accelerated Airborne
    Hazards research and Veteran care. Thank you.
        VA recognizes that environmental exposures during deployment may be
    associated with both immediate and delayed adverse health consequences.
    There are over 18 million Veterans in the United States, and VA cares
    for approximately 9.6 million of them. Exposures are a major concern of
    Veterans and why PDHS exits. One in three Veterans report a possible
    exposure to environmental hazards and one in four report health
    concerns due to deployment exposures. PDHS oversees VA's efforts to
    mitigate health effects of exposures and to provide care for the
    associated adverse health outcomes when necessary. When a disability is
    determined to be due to an in-service exposure, whether through direct
    proof or because the disability is eligible for presumptive service
    connection, the Veterans Benefits Administration (VBA) provides
    disability compensation. The teams addressing exposure concerns are
    diverse: epidemiologists, physiologists, pulmonologists, internists,
    other medical specialties, bench researchers, VBA, Department of
    Defense (DOD), and academia.
                            the presumptive process
        In certain circumstances, VA presumes that certain disabilities
    were caused by military service and subsequently awards disability
    compensation to a veteran. The presumption of service connection takes
    the place of some of the proof elements that apply in an ordinary
    direct service connection claim, such as proof of exposure or a causal
    link between the in-service exposure and subsequent disability,
    otherwise known as the nexus requirement. The first presumptions were
    established in 1921, with more added through the decades.
        The way VA currently handles decisions on claims based on illness
    asserted to be due to in-service exposure is through presumption or a
    direct causation analysis. Both of these methods can be complicated by
    a lack of contemporaneous proof of what happened to a given person in
    service. I will discuss a better method of documenting exposure and
    health outcomes in a moment. It is called the Longitudinal Exposure
    Record (ILER).
        Presumptions are established by Congress or by the Secretary after
    review of the science by subject matter experts (SME). VA uses external
    agencies such as the National Academy of Science, Engineering, and
    Medicine, the National Institutes of Health, and the Agency for Toxic
    Substance Disease Registry, as well as its own experts for these
    reviews. The greatest challenge with the presumption policymaking
    process is that it usually takes time to conduct the research to link
    military service to an illness for presumptive service connection. In
    the absence of a presumption, however, the Veteran can submit a claim
    for a condition that they believe was caused or exacerbated by their
    military experience. Other challenges are: establishing a dividing line
    for exposure; addressing attributable risk; advances in medical
    science; the relationship to service; delayed diagnosis; and incomplete
    or unavailable records.
        Military exposures research is challenging. Exposure information
    can be difficult to obtain. Individual exposure levels can vary
    tremendously even for Veterans deployed to the same geography or
    conflict. Details, such as the timing of deployment, exact locality,
    occupation, and actual assigned duties, can affect the presence or
    absence and extent of an exposure.
        Most literature on chemical and toxin exposures comes from
    occupational health providing some objective data about health risk and
    outcomes through analogy. Occupational exposures in civilian settings
    are managed proactively and systematically with a host of controls to
    include elimination, substitution, administrative controls, and
    personal protective equipment. Military Servicemembers in high-tempo
    operations or high-pressure environments often do not have the luxury
    of such controls.
        Researchers use scientific methods to detect causal associations
    between exposures and disease. Theoretically, the best method is a
    randomized clinical trial, but this is generally unethical for exposure
    research. Therefore, other techniques must be used such as animal and
    in vitro toxicity studies, observational studies, and case control
    studies. A disadvantage of these studies is the inability to make firm
    conclusions based on one study.
        A central question that remains unanswered in many cases is: What
    aspect of the deployment experience is contributing to poor health
    outcomes? In the matter of airborne hazards, is it the particulate
    matter, burn pits themselves, blast overpressure, an infectious agent,
    or a combination of exposures? VA and DOD continue working alongside
    academia to find these answers.
        As mentioned above, an exciting opportunity to improve our
    understanding and management of exposure-related health concerns comes
    from the new Individual ILER. VA and DOD are working jointly to improve
    real-time exposure monitoring and to capture these data in ILER.
    Initial Operational Capability for the ILER is scheduled for release on
    October 1, 2019. The ILER identifies a Servicemember's deployments by
    date, location, and known toxic exposures. ILER will improve care,
    benefits, and research.
    a strategic vision on research to enhance collaboration between va and
                                      dod
        In the Deployment Health Working Group, VA and DOD SMEs meet
    monthly to discuss and plan joint actions regarding deployment-related
    exposures and their possible association with subsequent adverse health
    conditions. VA and DOD also hold scientific exchanges for a variety of
    different exposures: in March 2019, the Airborne Hazards Symposium; in
    April 2019, a review of chelation interventions regarding toxic
    embedded fragments; and, in July 2019, the Environmental Health
    Conference.
        In order to improve evaluation and care of Veterans, PDHS/WRIISC
    has a robust educational program aimed at improving VHA and private
    sector providers' knowledge about deployment-related health concerns.
    WRIISC delivers monthly continuing education accredited Webinars for
    VHA providers and has eLearning modules available online and on demand.
    SMEs present and lead workshops to discuss exposure issues at
    professional and scientific meetings. We publish our research findings
    in peer-reviewed journals to improve clinical practice. All these
    education and dissemination activities contribute to raising the
    standard of care to improve Veterans' health and function.
                                   conclusion
        VA is committed to the health and well-being of Veterans and is
    dedicated to working with our Interagency and academic partners to
    investigate potential adverse health effects associated with exposure
    during deployment.

        To this end, your continued support is essential. Mr. Chairman,
    this concludes my testimony. My colleague and I are prepared to answer
    any questions.

        Chairman Isakson. Thank you very much for your testimony.
        Our next witness is Dr. Helmer of Veterans Affairs. Dr.
    Helmer. Oh, you're the----
        Mr. Rauch. I am the second.
        Chairman Isakson. You are the second?
        Mr. Rauch. Dr. Rauch, for the DOD.
        Chairman Isakson. OK, Dr. Rauch. I am sorry. We will take
    your expert testimony, and then he can correct it after I
    introduce him.
        Mr. Rauch. My pleasure.

      STATEMENT OF TERRY M. RAUCH, Ph.D., ACTING DEPUTY ASSISTANT
    SECRETARY OF DEFENSE FOR HEALTH READINESS POLICY AND OVERSIGHT,
                       U.S. DEPARTMENT OF DEFENSE

        Mr. Rauch. Chairman Isakson, Ranking Member Tester, and
    Members of the Committee, thank you for the opportunity to
    discuss the Department's process for exposure monitoring,
    identifying illnesses that are potentially associated with
    exposures during military service, and our collaboration with
    the VA.
        I spent 27 years on active duty in the Army, some of that
    time working on this topic in the deployed and garrison
    environment. The Department has a longstanding collaborative
    relationship with the VA, focused on a continuum of care for
    servicemembers and veterans. We collaborate extensively on
    occupational and environmental exposures, including the
    exchange of individual exposure information, health effects
    research to determine possible linkage of exposures to
    illnesses, exposure-related registries, and outreach and
    education to our servicemembers, veterans, and their health
    care providers.
        The Department's current process for assessing garrison-
    and deployment-related health hazards informs our commanders of
    the health risk to their personnel, so that they, along with
    their public health and safety professionals, can make
    necessary operational decisions to mitigate the health risk and
    protect the health of the force.
        The health risk assessment process also informs health care
    provided to individuals and provides information to the VA to
    support the determination of claims for veterans. The
    Department and VA have several processes in place to share
    exposure-related information on servicemembers and veterans.
    These processes include, but are not limited to, the service
    treatment record, the newly developed electronic Individual
    Longitudinal Exposure Record, known as ILER, establishment of
    specific exposure registries, and collaborative meetings,
    sharing research findings on the health effects of
    environmental exposures in military environments.
        The DOD and VA have collaborated on the establishment of
    several exposure-related registries as a means to provide
    event-related exposure information to the servicemember and
    veteran, health care providers, researchers, claims
    adjudicators, and others. Existing exposure registries include
    Agent Orange, Gulf War Illness, Ionizing Radiation, Depleted
    Uranium, Toxic Embedded Fragments, Operation Tomodachi, and the
    Airborne Hazards and Open Burn Pit Registry.
        Moreover, past, current, and emerging exposures of concern
    are deliberated with the intent of developing recommendations
    to inform policy decisions, updating of exposure and health
    effects knowledge, supporting joint project development,
    critical information-sharing, and health risk communication.
        The Department has, and will continue to, collaborate with
    the VA and other Federal agencies, academia, and others on
    epidemiological and health-related research to gain a better
    understanding of the potential long-term health outcomes
    associated with exposures and to translate our research
    findings to improve the health care of our servicemembers and
    veterans.
        The Department is grateful for the unwavering congressional
    support that has enabled collaborative actions, focused on the
    health and readiness of servicemembers, the health of veterans,
    and the provision of high-quality care to servicemembers,
    veterans, and their families.
        Thank you again for the opportunity to be here with my VA
    colleagues. I look forward to your questions.
        [The prepared statement of Mr. Rauch follows:]
     Prepared Statement of Terry M. Rauch, Ph.D., Acting Deputy Assistant
       Secretary of Defense (Health Affairs) Health Readiness Policy and
                     Oversight, U.S. Department of Defense
        Chairman Isakson, Ranking Member Tester, and members of the Senate
    Committee on Veterans' Affairs, I am pleased to represent the Office of
    the Secretary of Defense and have the opportunity to discuss the
    current Department of Defense (DOD) process to identify illnesses that
    are associated with occupational and environmental health hazards
    during military service and possible modifications to the process to
    address future exposure linked illnesses.
        The Department's current process for assessing health hazards
    informs our commanders of the health risk to their personnel so that
    the commanders can make necessary operational decisions to manage that
    health risk, protect the health of the force, and preserve mission
    readiness. The health risk assessment process also informs: (1) the
    occupational medicine community of the need for medical surveillance
    examinations to monitor for adverse health effects and further risk
    management actions; (2) DOD clinicians providing health care to their
    patients of exposures that may be causing reported symptoms; and (3)
    Department of Veterans Affairs (VA) to assist in claims determinations
    and for health care to veterans.
        The Department applies these processes for exposures in routine
    operations and deployed military operations, for the Military Services
    and Defense Agencies, for exposures to chemicals used by the worker,
    physical hazards, and from the ambient environment (commonly called
    ``environmental health hazards''), and for military Servicemembers and
    civilian employees.
        These processes are established as DOD policies in DOD Instruction
    (DODI) 6055.01, ``Safety and Occupational Health (SOH) Program;'' DODI
    6055.05, ``Occupational and Environmental Health (OEH);'' DODI 6055.20,
    ``Assessment of Significant Long-Term Health Risks From Past
    Environmental Exposures on Military Installations;'' DODI 4715.19,
    ``Use of Open-Air Burn Pits in Contingency Operations;'' DODI 6490.03,
    ``Deployment Health;'' and DOD Manual 6055.05-M, ``Occupational Medical
    Examinations and Surveillance Manual.'' The Military Services, Defense
    Agencies, and Geographic Combatant Commands develop implementing
    instructions to carry out these policies.
        Current policies are based on knowledge of the current science for
    health effects and the exposures that would cause those health effects.
    The Department has policy and procedures to review and analyze health
    literature and regulatory actions to identify the need to update health
    risk assessment procedures (reference: DODI 4715.18, ``Emerging
    Chemicals (ECs) of Environmental Concern''). These procedures have led
    DOD to begin updating health risk assessment procedures for lead,
    tricholoroethylene, and chromium compounds. ``Most recently, the DOD
    exposure community of interest has begun reviewing and analyzing
    continuous exposure to blast overpressure by servicemembers in the
    operational and training environments to determine potential health
    effects on the brain, in accordance with Public Law 115-91.
        Using lead as an example, the Department policy has followed the
    Occupational Safety and Health Administration (OSHA) lead standard for
    exposure and medical surveillance of military and civilian employees. A
    growing body of knowledge--confirmed by an independent assessment by
    the National Academies of Science Committee on Toxicology--found that
    the OSHA lead standard may not sufficiently protect against the latest
    findings of significant health effects. The Department updated DOD
    Manual 6055.05-M for medical surveillance and for medical removal of
    individuals with elevated blood lead levels from environments that put
    the individual at risk, and plans to issue policy in DODI 6055.01 with
    new health standards for allowable levels for inhalation of lead dust
    and fumes. The health risk procedures in DODI 6055.05 will apply to the
    new health standards. The Department will collaborate with the VA for
    health risk assessments of additional exposures of concern using the
    current DOD procedures for emerging chemicals.
        The Department and VA have several processes in place to share
    exposure-related information on Servicemembers and veterans. These
    processes include, but are not limited to: (1) making the
    Servicemember's Service Treatment Record (STR) available within 30 days
    of separation from service, (2) the newly developed electronic DOD/VA
    Individual Longitudinal Exposure Record (ILER); (3) establishment of
    specific exposure registries; and (4) collaboration meetings.
        The STR includes the Separation History and Physical Examination
    and any clinical evaluation and/or treatment associated with exposures
    during military service. The STR is maintained for 100 years after the
    date of separation of the member from the Armed Forces. DOD makes
    electronic copies of the STR available to the Department of Veterans
    Affairs within 30 days of separation from service.
        The first-ever ILER project recognizes the Department's commitment
    to establishing a permanent record of exposures. The ILER is a
    composite record of an individual's potential and documented exposures
    from garrison or deployment activities, from initial entry to discharge
    or retirement from military service. The ILER will be made accessible
    to DOD and VA medical providers, epidemiologists, and researchers, as
    well as to VA claims and disability adjudicators. The ILER will enhance
    medical evaluation and treatment; support epidemiological
    investigations and research to better understand potential and actual
    health outcomes; inform health risk mitigation strategies; and provide
    easily accessible exposure information when needed to DOD and VA
    medical and administrative offices. Release of the Initial Operational
    Capability version of the ILER is set for 1 October 2019, followed by
    spiral development rollout to Full Operational Capability over the next
    four years. The ILER will serve as a data culling repository for
    existing DOD exposure systems and provide a single access point for
    exposure information.
        The DOD and VA have collaborated on the establishment of several
    exposure-related registries as a means to provide event-related
    exposure information to the Servicemember and veteran, healthcare
    providers, researchers, claims adjudicators, and others. Existing
    exposure registries include the following: Agent Orange, Gulf War
    Illness, Ionizing Radiation, Depleted Uranium Registry, Toxic Embedded
    Fragments, Operation Tomodachi, and the Airborne Hazards and Open Burn
    Pit Registry.
        The DOD and VA have a long-standing collaboration on these
    processes through Joint Airborne Hazards Symposia focused exposure
    health effects research, outreach and education and the DOD/VA
    Deployment Health WG formed to focus on occupational and environmental
    exposures affecting the health of servicemembers and veterans.
        Past, current and emerging exposures of concern are deliberated
    with the intent of developing recommendations to inform policy
    decisions, updating of exposure and health effects knowledge, and
    supporting joint project development (such as the ILER), critical
    information sharing, and health risk communication.
        The Department has and will continue to collaborate with the VA,
    other Federal agencies, academia and others on epidemiological and
    health-related research focused on full and better understanding of
    potential long-term health outcomes associated with garrison and
    deployment-related occupational and environmental exposures, and to
    translate this research into prevention, diagnosis and treatment to
    better care for our Servicemembers and veterans.

        The Department is grateful for the consistent Congressional support
    that has enabled collaborative actions focused on the health and
    readiness of Servicemembers, the health of veterans, and the provision
    of high-quality care to Servicemembers, veterans and their families.

        Chairman Isakson. Thank you very much, Doctor. We are glad
    to have you here today. I will ask the first questions and then
    go to Jon, and then we will go to Mr. Rounds and other Members
    as they come here today.
        On the identification of illnesses, the work that you have
    to finally determine whether there is a presumption of
    association or not, how long a process is that; or is that a
    process to which there is a discipline and a rule of order, or
    does it depend on what the accusation is or what the illness
    is?
        Dr. Rauch, do you have anything on that?
        Mr. Rauch. Well, our process starts from the ground up,
    where we have preventive medicine units in the deployed and
    garrison environment that routinely collect surveillance data,
    environmental health, occupational health data. That data is
    then captured into databases. It is evaluated. It is reported
    to the commander. The commander has the ultimate decision to
    mitigate risk, which he or she sees from those environmental
    and occupational health assessments.
        Those are done routinely, and as a matter of fact, in some
    environments they are done routinely daily.
        Chairman Isakson. More of the things that you investigate
    are things that you initiate in the Department itself rather
    than things that are brought to you by a veteran. Is that
    right? Would that be a correct assumption?
        Mr. Rauch. Yes, that would be correct.
        Chairman Isakson. Very good. Dr. Helmer, I had a call 2
    weeks ago from a veteran, whom I know very well, so I know his
    credibility. In fact, he was an elected official after his
    service in Vietnam and a very successful person in our
    community. He has terminal liver cancer, and he called me and
    said that it is a liver cancer that is not covered by--I do not
    remember what the name of the cancer is. This is just a what-if
    question. It is a liver cancer for which there is no benefit
    paid from the Veterans Administration. There is some caregiver
    money but there is not any direct benefit paid.
        Is every benefit that is paid for an illness or a condition
    or a situation like cancer, is that determined broadly or is
    that determined individually in the Department by the disease?
        Dr. Helmer. I think the answer is that it is a combination,
    and that for the presumed service-connected conditions they are
    defined more explicitly and often have limits, in terms of what
    is covered, depending on the language that is used, either in
    the Secretary's language or in the congressional language.
        As Dr. Hastings mentioned, every veteran can file a claim
    for service connection on an individual basis, and that
    determination is made on a case-by-case basis, weighing both
    the evidence of the actual connection, the nexus to the
    military service, as well as the evidence supporting the
    association between perhaps an exposure and that health
    condition.
        Chairman Isakson. Do you know if there is a process in the
    Veterans Administration whereby someone can bring a request for
    a benefit for something that is not covered and is handled on
    an individual basis?
        Dr. Helmer. And it is handled on an individual basis?
        Chairman Isakson. Is there a process for that? I am not
    looking for one. I just want to know if there was one.
        Dr. Helmer. I will refer to Dr. Hastings.
        Dr. Hastings. Sir, that would be the claims process, and if
    any veteran has a condition that has caused a disability which
    they believe is related to their military service, it will be
    evaluated on an individual basis. In fact, that is how most VA
    claims are handled. It does not require a presumption.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Johnny Isakson
       to Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment
                  Health, U.S. Department of Veterans Affairs
        Question. Do you know if there is a process in the Veterans
    Administration whereby someone can bring a request for a benefit for
    something that is not covered and is handled on an individual basis?
        Response. The Department of Veterans Affairs (VA) has an existing
    process where Veterans can claim conditions that are not presumptively
    associated with their military service. For any condition that a
    Veteran believes is related to their military service, the Veteran can
    submit a claim for disability benefits; this can be done by mail, in-
    person, or online. For conditions that are not considered presumptively
    associated with their military service, service connection may still be
    granted if there is evidence that the disability was due to or caused
    by disease, injury, or event in military service.

        Chairman Isakson. If a condition is determined for one
    individual veteran and the Department pays benefits, then
    another veteran comes in with the same condition, do they
    automatically get the benefit or do they have to go through the
    same process as the first one did?
        Dr. Hastings. They would be going through the same process.
        Chairman Isakson. Does that happen very often?
        Dr. Hastings. I can ask the VBA how often it happens, and I
    would be very happy to get the information for you and brief
    you back on it.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Johnny Isakson
       to Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment
                  Health, U.S. Department of Veterans Affairs
        Question. If a condition is determined for one individual veteran
    and the Department pays benefits, and another veteran comes in with the
    same condition, do they automatically get the benefit, or do they have
    to go through the same process as the first one did?
        Response. Entitlement to disability compensation benefits is not
    automatic, unless established through presumption. Veterans go through
    the same process and each claimed condition is adjudicated on an
    individual basis, (i.e., considering factors such exposure time and
    duration, medical history, manifestation period for symptoms, etc.).

        Chairman Isakson. I want you to be very careful when you
    answer this question. This is the last one I am going to ask.
    There is a process whereby you could get a piece of legislation
    passed in the Congress on citizenship or on legality or on
    immigration, and handle a single case with one bill, if
    somebody wants it done. Would that be the case--do you know of
    any case within the Veterans Administration where a Senator or
    a Representative has introduced a bill that directed the VA to
    cover one individual incident or disease?
        Dr. Hastings. I do not know of any, but I will go to VBA
    and ask if there have been any.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Johnny Isakson
       to Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment
                  Health, U.S. Department of Veterans Affairs
        Question. I want you to be very careful when you answer this
    question. This is the last one I am going to ask. There is a process
    whereby you could get a piece of legislation passed in the Congress on
    citizenship or on legality or on immigration, and handle a single case
    with one bill, if somebody wants it done. Would that be the case--do
    you know of any case within the Veterans Administration where a Senator
    or a Representative has introduced a bill that directed the VA to cover
    one individual incident or disease?
        Response. VBA is unaware of any legislation that provides benefits
    for an individual person (single case) based on toxic exposures.
    However, Congress has previously passed laws to address specific
    exposure incidents. For example, under title 38 United States Code
    (U.S.C.) section 1112, Veterans located in Hiroshima or Nagasaki,
    Japan, during August 6, 1945, and ending on July 1, 1946, are
    considered radiation-exposed Veterans. Radiation-exposed Veterans are
    entitled to the presumption of service connection for certain diseases
    listed in 38 U.S.C. Sec. 1112(c)(2). Similarly, the Camp Lejeune
    Families Act of 2012 dealt with specific exposure to environmental
    hazards for persons residing or working at the U.S. Marine Corps Base
    Camp Lejeune, North Carolina.

        Chairman Isakson. That was a good answer. Thank you. I
    appreciate it.
        Dr. Rauch? No, you have already--who is next? Dr. Helmer,
    right? I am trying to avoid you.
        Dr. Helmer. Well, if I can just tag onto what Dr. Rauch
    said about the VHA, and you were asking do we ever go to the
    DOD and ask about service-connected conditions, or conditions
    of concern. I would say we do. As a matter of fact, on a
    clinical level, at the War-Related Illness and Injury Study
    Center, we have very close collaborations with our counterparts
    over in the DOD. We will routinely ask them about an exposure
    that a veteran brings to us. So, on a one-on-one basis we
    certainly have that opportunity, as well as the more formal
    arrangements that were mentioned.
        Chairman Isakson. Thank you very much. OK, next is Senator
    Tester.
        Senator Tester. Thank you, Mr. Chairman.
        Dr. Hastings, thank you for being here. Thank you all for
    being here. As I said in my opening remarks, I think it is time
    to end the way veterans, Blue Water Navy veterans, wait and for
    the VA to start making sure these guys and gals get the
    benefits that they have earned. I recognized Bobby Daniels in
    my opening statement. Bobby Daniels has just applied for a--
    recently applied for a second mortgage on his house to pay for
    his medical bills. It is my belief that these medical bills
    would be paid for if the blanket stay was lifted.
        Do you believe that the VA will reverse course on its
    blanket stay? I think they say it is going to be stayed until
    January 2020. Do you think there is any potential that it could
    lift its blanket earlier than that, and start processing
    claims?
        Dr. Hastings. I know that right now VBA is getting ready
    for the increased claims, doing the training. I do not know
    that they would be able to do it any earlier. But, they have
    hired more people, they are training them, and veterans
    certainly can put in a claim at this time. T5he adjudication
    process will take place as quickly as possible.
        Senator Tester. So, it is not an issue of recognizing that
    things like hypertension or bladder cancer are now to be
    covered, but it is more an issue of infrastructure within the
    VA?
        Dr. Hastings. It is the preparation in the VBA to make sure
    that they can process all the claims that will be coming on.
        Senator Tester. OK. So I--and you just have to help me with
    this. This is just a straight-up, honest question that I do not
    get. Isn't it the VBA's business to allocate benefits? I mean,
    isn't that what they are set up for?
        Dr. Hastings. That is what VBA is set up for, to make sure
    that they take care of the veterans with regards to claims.
        Senator Tester. I got you. So, why--I understand it is more
    numbers, but it looks to me like the process is already set up,
    ready to go. You just add the four presumptives on and you are
    rocking and rolling.
        Dr. Hastings. The presumptives are a separate issue, and
    those are with leadership and in coordination, right now, for
    the decisions to be made.
        With regards to Blue Water Navy, one of the things that
    they also are doing, since it is within 12 miles, there is a
    process by which they are taking the ships' logs from the
    archives, they are having them scanned in and put into a
    computer program. Ships used to make sure where they were in
    the ocean three time a day.
        Senator Tester. I got you. So--and this may not be in your
    bailiwick, but it would appear to me that they know already
    where some of those ships were. Why not lift the stay on those,
    at least? I mean, I am not sure that you need to know 100
    percent to be able to start giving out benefits.
        Dr. Hastings. With regards to the ships, I would have to
    ask VBA if they have any ships that they have already
    delineated, but I know they are scanning in 65 million pages of
    the ships' logs, in order to----
        Senator Tester. Yeah. I got that. I question whether there
    are 65 million pages of ship logs in relation to the Vietnam
    War, but maybe there is. I just--I think they are making it
    more complicated than it needs to be.
        As far as these presumptives go, is the research done on
    these presumptives now done because of the court cases and
    because of our actions here in Congress, or is there still work
    being done on those presumptives as applied to Agent Orange
    exposure?
        Dr. Hastings. There is still work that is being done on the
    presumptives. We are still researching the issues that face the
    Vietnam veterans.
        Senator Tester. OK. Is that going to have any impact upon
    benefits, that research?
        Dr. Hastings. I believe that it may. We are still looking
    at the issues that face veterans. We are looking at
    intergenerational effects. We are looking at other disease
    processes, not simply the bladder cancer----
        Senator Tester. I got you. All right. So, over and beyond
    what the court decision said, you are looking at potential
    impact, generational impacts, and others.
        Dr. Hastings. We have veterans that have many concerns that
    they expressed to us, and we do look at those individually----
        Senator Tester. OK.
        Dr. Hastings [continuing]. And on a population basis.
        Senator Tester. Because it appears to me, with the court
    case and with the action that Congress has taken, that it is
    pretty much as soon as you get the infrastructure built, the
    benefits should go out. Am I misreading that?
        Dr. Hastings. I do not believe so, sir.
        Senator Tester. OK. Good. I am out of time but hopefully we
    will have another round of questions. Thank you, Mr. Chairman.
        Chairman Isakson. Senator Rounds.

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

        Senator Rounds. Thank you, Mr. Chairman. Let me begin by
    just adding my thoughts with regard to having the privilege of
    serving with you, Mr. Chairman. I think the Ranking Member, Mr.
    Tester, has done a very nice job of indicating how strongly we
    feel about your service to our country, your service within the
    U.S. Senate, and as Chairman of this Committee, the work that
    you have done for veterans. We have been honored to be a part
    of this process with you.
        It would seem to me that there is a concept here that
    perhaps the VA and this Committee has tried to put together,
    with regard to the issue of disability and the issue of whether
    or not there is a connection between service-related injuries,
    disabilities, and so forth, and a simplified process of taking
    care of those veterans. I can't count the number of times that
    I have stood in front of groups and said ``thank you for your
    service,'' or the number of times that we have said we want to
    make sure that everything which you are entitled to, as a
    member, or as a former member, that you receive.
        Yet, when we get down to the paperwork of it, the legalese
    of it, it seems like we continue to find these reasons why we
    cannot get it done on a timely basis, and in some cases, there
    are reasons why we do not get it done at all, whether it be
    making payments for emergency room visits to veterans, which
    clearly should have been taken care of. It all comes back down
    to money, and it comes back down to where the money is going to
    go, inside the VA or outside the VA.
        Right now we are talking about what the DOD does and what
    the VA does. Are they consistent and are they focused with a
    culture of finding a way to take care of an injured veteran
    long-term.
        It starts with whether or not--and this may seem unusual,
    but we put men and women in harm's way, and we should find a
    way to take care of their health, if possible, to do everything
    we can to protect them. That means more than simply issuing the
    appropriate equipment, whether it be jackets, whether it be the
    right type of clothing, whether it be the right type of
    armaments. It also means protecting them from environmental
    issues as well, wherever possible.
        Dr. Rauch, what alternatives has DOD taken to reduce the
    likelihood of servicemembers being exposed to toxic materials,
    and is this integrated into logistical planning or, if not, is
    there an initiative to do so?
        Mr. Rauch. Thank you for the question, Senator. We, in the
    Department, have initiated an aggressive research agenda to do
    just that, research and develop technologies for the
    servicemember in the deployed environment, to sense and
    characterize the environment and potential exposures that he or
    she will be subject to, to sense, record, document, and
    analyze. Now that is a vision. It is a research program to
    research technologies. We are putting money against it, and we
    have an initiative to pursue that.
        Senator Rounds. OK. But, have we deployed any qualified
    medical service officers, or have any of them been assigned to
    pre-deployment or post-deployment planning cells, perhaps with
    an eye toward citing infrastructure, to reduce exposure to
    toxic elements? It seems to me that we have known about these
    issues for more than 20 years now, and it would seem that there
    would be something in the works besides just the research.
        Is any action being taken today to try to--with regard to
    burn pits, or with regard to exposures to chemicals, to where
    there are actual medical personnel who have been assigned to
    any of these facilities or any locations around the world
    today?
        Mr. Rauch. Every deployed force has some organic medical
    element to support that deployed unit, and that medical element
    will consist of medical professionals, to include a preventive
    medicine team.
        Senator Rounds. Do they have the ability to make
    recommendations, to limit exposure to those areas where they
    feel there is a risk involved?
        Mr. Rauch. The preventive medicine unit or team will make
    recommendations to the commander on the group, to identify
    health hazards and recommend mitigation of those health
    hazards. At the end of the day, the commander on the group is
    going to make a decision based upon the mission he or she has
    to do.
        Senator Rounds. Thank you.
        Thank you, Mr. Chairman. My time has expired.
        Chairman Isakson. Thank you, Senator Rounds.
        Senator Hirono.

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

        Senator Hirono. Thank you, Mr. Chairman.
        Dr. Hastings, I think I heard you say that most of the
    veterans who file claims to have coverage for their medical
    conditions are decided on an individual basis. On this there is
    a presumption that applies for their medical condition. Is that
    correct?
        Dr. Hastings. Right.
        Senator Hirono. So, I want to know, since most of the
    veterans have to come to you on a case-by-case basis and there
    is no presumption, what is the burden of proof on them to show
    that there is a connection between service and illness?
        Dr. Hastings. It would vary by the illness, but I would be
    very happy to get the information from VBA or arrange for them
    to give you a briefing.
        Senator Hirono. Well, give me an example. What is--because
    I think that it is quite a high burden for the veteran to show
    the connection, is it not?
        Dr. Hastings. We would want medical records that could be
    reviewed. In many cases it will talk about their medical
    condition, and if it does have a relation to an exposure, that
    will be adjudicated. It is very easy to look at someone who has
    a back injury and say here is an x-ray. It is harder to look at
    these things with toxic exposures, but there is literature that
    we use. We----
        Senator Hirono. I am not talking about the existence of a
    symptom or the injury, but it is the connection that is a
    barrier that the veteran faces, isn't it, that it is service-
    related?
        Dr. Hastings. That is one of the things they would need to
    show that they were near--in the example of airborne hazards,
    that they were in a certain location that had burn pits.
        Senator Hirono. Yeah, but who--and what the burden of proof
    is is often very--it is an indicator of what the result will
    be. I am very concerned that there is requirement that the
    veterans produce a whole slew of evidence to support their
    claim, and that this makes it really hard for them. So, I would
    like to know, in this review process I realize all the claims
    are different, but, you know, what is the average length of
    time for a veteran to come and ask for a decision regarding
    their claim and their decision?
        Dr. Hastings. I do not know the length of time from VBA. I
    am very happy to take that back. But, I do agree with you.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Mazie K. Hirono
       to Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment
                  Health, U.S. Department of Veterans Affairs
        Question. I want to know, since most of the veterans have to come
    to you on a case-by-case basis and no presumption, what is the burden
    of proof on them to show that there is a connection between service and
    illness? So, I would like to know, this review process I realize all
    the claims are different, but, you know, what is the average length of
    time for a veteran to come and ask for a decision regarding their claim
    and their decision?
        Response. The requirements to establish disability compensation for
    these types of claims are the same as any other claim. The evidence
    must show the following:

        (1) A current disability
        (2) An event, injury, or disease in service, and
        (3) Link or nexus between disability and service.

        VA does not have data on the average length of time between in-
    service exposures to environmental hazards, and a subsequent filing of
    a claim. Please note that many Veterans continue to serve actively in
    the military for years following exposure to environmental hazards and
    some Veterans could be exposed to environmental hazards more than once
    in their career. However, as of December 8, 2019, the average number of
    days a claim is pending a decision on entitlement to disability
    compensation is approximately 81 days.

        Dr. Hastings. One of the things that is a game-changer, as
    we talked about, is ILER. It will take some of the burden of
    proof----
        Senator Hirono. What is that?
        Dr. Hastings. The Individual Longitudinal Exposure Record.
        Senator Hirono. Uh-huh.
        Dr. Hastings. This will take some of the burden of proof
    off the veteran, it will make research easier, it will make VBA
    and the claims process easier, and it will improve medical
    care.
        Senator Hirono. So, when was this process instituted?
        Dr. Hastings. Well, it actually is going to go live 1
    October. We have already had some of the physicians and the
    researchers look at it already and use it, what we have had. It
    has been very well accepted. It will be able to match a
    servicemember with a location, a time and date, and the
    monitoring that went on there. And as I was saying before, in
    my testimony, if you can link this to the electronic health
    record and we can manipulate big data, it will make a huge
    difference for research claims and care.
        Senator Hirono. Is this available for Vietnam veterans, for
    example, or is it a timeframe that goes back not so long?
        Dr. Hastings. No. The timeframe is really from when we had
    the computerized records, so it is 2000 forward. But even
    though it----
        Senator Hirono. 2000?
        Dr. Hastings [continuing]. Is going forward, it will help
    us inform some of our decisions from the past.
        Senator Hirono. So, my point is that we should do
    everything we can to enable the veteran to meet his or her
    burden without making that burden so hard that their claims are
    routinely denied. I think there are so many barriers to them
    having their claims sustained that I am glad you have something
    in place. I am sorry that it took this long.
        Regarding--he already asked about the four new illnesses or
    conditions connected to Agent Orange, and you said you are
    still reviewing it. I mean, what is the timeframe for the VA to
    say, OK, that is going to be a presumption for these four new
    illnesses?
        Dr. Hastings. The review of the National Academy report was
    given to the leadership in mid-summer. It is with the
    leadership right now and undergoing a coordination with the
    other Federal agencies.
        Senator Hirono. You are supposed to do it within--this is
    also supposed to happen within 60 days of the report from the
    National Academy of Medicine, isn't it?
        Dr. Hastings. We do have a directive, which is called 0215,
    which does describe how we will review the external reports
    from the National Academy, and we did follow that. If anyone
    would like a copy of that, I can certainly provide it.
        Senator Hirono. Well, we know that there are years-long
    delays in the VA attending to these situations.
        I have a question about PFAs as it relates to the testing
    that you are doing. So, it is a class of chemicals, as you
    know, used in firefighting, et cetera, very toxic. And my
    understanding is that the DOD has been testing drinking or
    ground water on or around hundreds of military sites for PFA
    contamination.
        Dr. Rauch, has the DOD tested the water at military sites
    in Hawaii for this chemical?
        Mr. Rauch. Senator, I know that we have tested numerous
    military installations. I will get back to you with regard to a
    specific installation in Hawaii.
        Senator Hirono. OK. And, if you did do such testing, of
    course you will tell me what locations and if any contamination
    was found, and if there was not any testing on any of the
    military sites in Hawaii, why not. OK. Because we have a lot of
    military sites in Hawaii.
        Mr. Rauch. I will provide a detailed answer.

        [Responses were not received within the Committee's
    timeframe for publication.]

        Senator Hirono. Thank you. Thank you, Mr. Chairman.
        Chairman Isakson. Senator Boozman.

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

        Senator Boozman. Thank you, Mr. Chairman. We certainly
    appreciate you. You are not going anywhere, though, for a
    while. We need you around here to keep Senator Tester under
    control. [Laughter.]
        That is a big job.
        But, thank you for holding the hearing, both of you all.
    This is an area that I believe that everybody on the Committee
    is working on some project or working in unison. As most of you
    know, Senator Tester and I sponsored a bill in the last two
    Congresses to provide a way for veterans who served in Thailand
    to get benefits and health care. I believe that they would be
    left behind by the current limitations on the presumption of
    toxic exposure to Agent Orange. It was an Arkansas veteran,
    Bill Rhodes, who first brought this policy inequity to my
    attention. Mr. Rhodes served in Thailand and was exposed to
    toxic chemicals, and now suffers from an Agent Orange-related
    illness and cannot get the VA to consider his claim for
    benefits.
        The VA currently limits service-connected benefits to
    veterans whose duties placed them on or near the perimeters of
    military bases. The VA says that only those veterans might have
    been exposed to the harmful effects of toxic chemicals.
        The current policy further limits the possibility of
    exposure to veterans who served in security-related military
    occupational specialties. This limitation arbitrarily, I
    believe, disqualifies veterans who may have otherwise been
    exposed to toxic chemicals during their service in Thailand by
    transiting through the perimeter or by the toxin moving through
    air or water to other parts of the base. With the Thailand
    Toxic Exposure bill, S. 1381, Senator Tester and I seek to
    eliminate the barrier for veterans.
        For my colleagues on the Committee, most of you probably
    received letters in the bright orange envelopes like these. Mr.
    Rhodes and his fellow Thailand veterans and their families have
    started a letter-writing campaign to make sure that we keep
    them at the top our minds as we make policy. I appreciate their
    support. I understand their urgencies and hope that we can fix
    this soon.
        So, Dr. Hastings, within the VA's Post-Deployment Health
    Services, the environmental health program makes policy
    recommendations for health outcomes related to military
    exposure for Agent Orange, among other things. Let me ask you
    two or three things, you know, altogether, and then you can
    think about it.
        How often do you all look at your current policy to
    recommend updates, like to those currently limiting benefits
    for Thailand service? Is there any process to review claims
    data from claims approved, denied, and pending, to identify
    trends that may warrant a review of presumption policy?
        For example, let's say there were a number of claims from
    veterans who had served in the interior of a Thailand-based
    location not covered by the VA's current presumption. If those
    claims contain medical diagnosis of something like amyloidosis,
    you know, one of these things that seems to be directly related
    to Agent Orange, are you aware of a process that would identify
    that trend and trigger a view policy?
        Then, finally, when you recommend policy changes, who in
    the Department ultimately determines whether to implement your
    recommendations?
        Dr. Hastings. Yes, sir. Thank you very much. I would like
    to just comment on the Agent Orange locations, if I might. GAO
    asked for a report to be done by DOD and VA. DOD went to the
    archives and to the original manifest, et cetera. We do have a
    new Agent Orange list that we have just received from the DOD
    and we are looking at it right now. It is with my office and
    with VBA, and we hope to post that soon.
        You asked about looking at current policy and benefits
    review. We review it every 2 years. It has been with the
    National Academy of Medicine reports. We have 11 reports that
    they have given us, so we have had a review every 2 years. My
    office also looks at trends in between times with the registry.
    We look at some of the health outcomes. Recently, we were
    concerned about cholangiocarcinoma. There have been questions
    about brain cancers before. We do look at it in the interim,
    also.
        With regards to claims pending, we do look at those, for
    example, with the Airborne Hazards Registry. We look at the top
    10 items that go in, and I routinely screen those to see if
    there are any things that we might be missing or that we need
    to look at further.
        Further, we do take our registry, the Airborne Hazards
    Registry, and if people want to go online to see what the top
    complaints are, what the issues are, we have datamined that
    registry and it is available for people to look at. We want to
    be as open and transparent as possible.
        With regards to policy changes, those are submitted to the
    leadership of VA. They do recognize that my office has the
    subject matter experts, and if they have further questions they
    will work with us. But, our policies have mainly been in the
    area of the exams for the veterans and how to document those
    for the VA, and some care.
        Senator Boozman. We appreciate it, appreciate your hard
    work, and look forward to working with you. But I would be
    interested in following up, and maybe we can get together, as
    to if there are trends that you have identified in regard to,
    you know, just the military police that worked in the area. It
    is very restrictive right now. So, this is not asking that we
    do everybody, but it is asking that those that can build a
    case, that have a disease directly related to, you know, to
    Agent Orange, that they are able to prosecute that.
        Thank you very much.
        Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Boozman.
        Before we go to Senator Sinema I want to interrupt to make
    a statement, if I can, for the record, and for all of you that
    are here. It is because Senator Manchin is here and he may
    leave before I get to him, which, if he does I wanted him to
    hear it.
        You know, we had a lot of problems at the Veterans
    Administration with the timeliness of their follow-through on
    problems. I mean, they were quick to tell us about things they
    were doing good but they weren't quick to tell us about where
    they had problems. Then, we all of a sudden read about them on
    the front page of the newspaper, which got a lot of us upset;
    so we started working on ways to get that information out. I
    want to commend the VA on how forthright they have been in
    almost all cases, about bringing the bad news as well as the
    good news to us in a timely fashion. It is important if we have
    a problem that we address the problem so it does not happen
    again.
        The reason I bring this up when Senator Manchin is in line
    to talk, Senator Manchin brought a problem in West Virginia to
    our attention, as well as the other Senator from West Virginia,
    which we jumped on when we got it, but when we got it was a lot
    later than we should have gotten it. I want to commend the
    Senators from West Virginia for their bringing it to our
    attention.
        Senator Manchin called me at home. I was almost in bed when
    he called me. I did not mind to get out of bed for Senator
    Manchin at all, but it is--at my age, that's tough. So, we got
    to respond to it, and we are responding now. This is a
    situation that is going to probably include criminal charges as
    well as other things. So, whatever it is, it is going to take a
    while, but it has already been too long as far as the people
    affected by the charge or concern.
        So, we jumped on that late. We are jumping on it with both
    feet now and we are going to get to it as quick as we can. I am
    working with the West Virginia Senators to see to it we do.
        At the same time, I made a statement 2 weeks ago, on the
    floor of the Senate, about how proud I was of the VA for
    sending us the good news and the bad news contemporaneously, so
    that we were not having problems anymore with people finding
    out things after the fact. Lo and behold, I got home to Atlanta
    the same day and there was a big story about ants on the body
    of a man who died in the VA's care, at a senior facility in
    Atlanta. I just felt like my statement would have been
    considered wrong to have made it, because it was the same day
    that it happened and was uncovered.
        So, I wanted to say we got the VA on that as well, and
    because of the accountability law that we passed in this
    Committee, people on the--not on the West Virginia case,
    because that is a potential criminal case, but on the Atlanta
    case, for violations of the care, the standard of care--we have
    eight people that are gone. We are going to see that that
    accountability takes places.
        I want to you to know it is not just the good things we
    talk about, but it is also when we have a problem we jump on
    it. The VA is jumping on it now. We are making sure people are
    held accountable, and I just wanted to make sure that got in
    before Joe had to leave, or something else. So, that is all I
    have. We are bragging about the good things but we are also
    bringing the bad things to attention, and we are going after
    them just as fast as the headlines for the good things.
        Now Senator Sinema. it is your turn.

             HON. KYRSTEN SINEMA, U.S. SENATOR FROM ARIZONA

        Senator Sinema. Well, first, Mr. Chairman, let me thank you
    for the work of this Committee and for your leadership. You
    know, as we all know, I live in Arizona. Before coming to the
    Senate I served in Congressional District 9, which is home to
    the Phoenix VA, where we know many of the previous scandals
    came to light, unfortunately well after many of the individuals
    did not receive the care that they deserved and that they
    needed.
        So, I want to thank you for your leadership on this
    Committee and ensuring that we are taking care of our veterans
    all around the country. Thanks.
        I want to thank our witnesses for being here today. You
    know, my team of military and veteran case workers support
    Arizona veterans every day on a range of needs, including
    support with disability compensation claims. I can tell you
    that based on those calls and their work, the issue of
    presumptive conditions and the frustration with how slow the
    process can be to recognize presumptive conditions impacts
    veterans and their families every day.
        And, while it is important to consider the process, I
    wanted to remind us about the people who depend on the process
    to work for them. Mr. Grau is a Vietnam veteran who served in
    the U.S. Navy from 1967 to 1971, and deployed to Vietnam. He
    came home from Vietnam 50 years ago, and to this day he still
    dreams about his experiences in Vietnam. For 40 years after
    returning home, he did not pursue his VA benefits because he
    felt that no one wanted to hear about his nightmares and the
    trauma that he brought back with him from his service in
    Vietnam.
        He now has an 80 percent disability rating, which includes
    PTSD and Parkinson's disease. He was recently diagnosed with
    precancerous cells in his prostate and will soon be applying
    again to recognize service-connected diabetes as a presumptive
    condition. He began the disability compensation process 10
    years ago, and it has taken 10 years, including the help of my
    office, for VA to recognize his service-connected disabilities.
    His work continues as VA adds additional presumptive conditions
    to recognize his already obvious illnesses.
        As new presumptive conditions arise, he goes through the
    formal process of telling VA what he has known for years, that
    many of his health problems are connected to his service and
    that the country owes him care and compensation for those
    injuries and illnesses.
        So, in sharing this story, Mr. Grau told my staff that he
    was willing to risk his life for this country, but he did not
    realize he would also have to fight for his right to treatment.
    He said when the U.S. called upon him and his compatriots to
    serve, they stepped up without pause. They did not wait 10
    years to serve, but he is still waiting for much of his
    benefits and care.
        The men and women who served and continue to serve this
    country do so with an understanding that we will take care of
    them in return, and we cannot forget all that they and their
    families have given in service to our country. So, our priority
    must be about fulfilling our promise to care for them.
        For Doctors Rauch and Hastings, throughout our military
    history, the U.S. servicemembers have been exposed to chemicals
    and hazards that have had a negative impact on their health,
    and they have faced unreasonable obstacles in receiving care
    for the injuries and illnesses that have resulted from those
    exposures.
        While I understand the need for research to inform the
    process, one cannot cast aside the suffering that
    servicemembers and veterans who are waiting for the U.S.
    Government to fulfill its promise to care for those who have
    borne the battle.
        What lessons have been learned in navigating Agent Orange
    and other exposures to inform the process moving forward for
    current and future generations of our servicemembers and
    veterans?
        Dr. Hastings. Thank you very much. I agree with you that
    many things have taken too long, and ILER--I go back to the
    Individual Longitudinal Exposure Record--is one of the lessons
    learned. We need to be able to match a person with a location,
    a time, and the exposure.
        We have also learned, from the Agent Orange experience,
    that we need to constantly, during conflict, look at what are
    those exposures people may have and start studying them right
    away, and we have done that with airborne hazards. We
    appreciate the support that this Committee has given us with
    the Airborne Hazards Open Burn Pit Center of Excellence, that
    will be able to look at research much more quickly. The
    electronic health record will make a huge difference because of
    the transmission of data between the two groups, but we do have
    the ability to transfer now. This will make it more seamless.
        One of the things we need to get good with, in the VA and
    in my office, in particular, is the manipulation of big data,
    so we can look at the groups, whether they be a small group,
    like the Sulphur fires at Al-Mishraq, or a much larger issue
    like the burn pits. We have learned a lot with the Vietnam
    experience. We are carrying it over into the burn pits
    experience.
        Mr. Rauch. I will just add to Dr. Hastings' comment. I
    agree with you also. We have a duty in the Department of
    Defense, when we put servicemembers in harm's way, and we do,
    in some pretty tough environments, we have an obligation to
    take care of them. We have an obligation to protect them. And,
    we have an obligation to sponsor research and technologies to
    put into our force that deploys to be able to protect them, and
    at least capture the environment and the exposures that they
    are deployed into, for a matter of record, and for a matter of
    care.
        Senator Sinema. In 2008, the National Academy of Sciences
    published a report that reviewed the presumptive disability
    decisionmaking process for veterans, and they offered 19
    recommendations on the topic, and 12 were specifically
    addressed to VA and DOD. A number of these recommendations are
    geared toward developing and executing improved surveillance
    strategies, exposure monitoring, medical treatment, tracking,
    all of which would allow for a more proactive monitoring of
    exposures and health status of veterans.
        How have the DOD and VA effectively addressed the need to
    keep better record and proactively monitor this data so that
    servicemembers and veterans who are showing health impacts from
    these exposures do not have to wait decades for the research to
    catch up?
        Dr. Hastings. Senator, I do have a copy of that book, and I
    agree with you. It had some excellent points in it. That was
    probably the nidus for a number of things in the DOD and the
    VA, but most notably the Individual Longitudinal Exposure
    Record. It also made it apparent that we needed to do
    coordination, so we meet with the deployment health working
    group every month, and, in fact, I meet with them tomorrow
    afternoon. We talk about research, we talk about trends.
        Two years ago we were at--actually, two and one-half years
    ago we were talking about the perfluorinated compounds and the
    importance of studying that, so we have been working with EPA
    since that time.
        I absolutely agree with you. The ability to share the data,
    the ability to manipulate the data, is going to be critical,
    and that is going to improve care, research, and the claims
    process for veterans.
        Senator Sinema. Thank you. Mr. Chairman, I have exceeded my
    time. Thank you.
        Chairman Isakson. Thank you.
        Senator Cassidy.

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

        Senator Cassidy. Thank you. Mr. Rauch, a lot of my
    questions were set up by Senator Sinema. But, if DOD is not
    collecting the data, nothing the VA does is going to be of
    scientific worth. It will be presumptions, and presumptions are
    based upon assumptions, and assumptions can be manipulated.
        So can you go into detail how, if somebody is in Iraq--I
    saw a picture in the New York Times once of them around
    something which was clearly chemical weapons; they were not
    known to be there but they found them. How would you then
    document something which was not a planned exposure, like a
    burn pit, but rather an incidental exposure, and how would that
    be filed in a way in which subsequent investigators would be
    able to use the information?
        Mr. Rauch. Thank you for the question, Senator. The
    documentation really begins with the assessment, occupational
    health, and environmental assessment that is really done by the
    preventive medicine units that are deployed with----
        Senator Cassidy. I am thinking of a forward--I have limited
    time so I do not mean to interrupt. I am on the front lines. I
    am ahead of the support personnel in pursuit of an enemy when
    we come upon something which could be a toxic exposure. The
    enlisted man may not know--or woman--may not know that it is,
    but nonetheless it is. And, later on it is discovered by people
    coming behind that, indeed it is.
        I guess I am not quite sure, in that dynamic situation, how
    this is being captured.
        Mr. Rauch. Well, it is being captured because even in the
    forward deployed units you still have organic medical
    preventive medicine detachments with those forward----
        Senator Cassidy. I do not mean to be incredulous, but we
    are going to have an MPH--and I do not mean to be rude, but I
    truly do find that we are going to have somebody with master's
    of public health adjoining somebody with--going after bad guys,
    who are moving forward very quickly. And we can imagine, in
    that situation, that they would come up on multiple situations
    which would require an assessment. So, you would have to have
    redundancy in terms of your ability to track and trace, if you
    will.
        Because that does not seem logistically feasible to me, but
    is that the current plan?
        Mr. Rauch. Well, our ability to capture exposure
    information to far forward forces is really dependent upon our
    preventive medicine units that are in support of those far
    forward forces, and they move right along with those far
    forward forces.
        Senator Cassidy. I do not see--in all fairness, I do not
    see how, in the battle zone, that is going to be practical,
    because you would have to have a fair number of folks,
    presuming that the squad may end up being dispersed--I keep on
    think of what if in Fallujah, in Fallujah a firefight every
    street, with snipers all around, but you stumble upon chemical
    weapons. Again, I do not mean to challenge you. I know this
    sounds rude, and I apologize for that. But, I do find this--I
    am not quite sure how it works.
        I think Dr. Hastings just gave you a note, so Dr. Hastings,
    if you have something, again, I am just trying to understand
    this.
        Dr. Hastings. Like passing notes in school, it is bad.
        Senator Cassidy. No, no, no. I am OK with that, because I
    just want answers.
        Dr. Hastings. Absolutely. Some of it is done after the
    fact, and I have two examples, if I might. One is Qarmat Ali,
    the water treatment plant outside Basra, that had the
    hexavalent chromium--if anyone remembers that was the chemical
    in the Erin Brockovich movie. There were about 800
    servicemembers that were exposed to that. It was noted during
    the time that they were there. We have their names. We are
    following up with them with letters and chest x-rays.
        Senator Cassidy. So, let me ask you, when the soldier is on
    the battlefield, is their GPS location tracked so that if, at a
    later point, you can see that there was exposure to something,
    such as that?
        Dr. Hastings. They do track the location of the units.
        Senator Cassidy. And of the--would you be confident that
    the members of the unit would stay sufficiently together that
    if the unit were in a location, all would be in that location?
        Dr. Hastings. Some individuals may leave--this is speaking
    from my time in the military, when I was deployed to Iraq. Some
    of it would be self-reporting. But, we also have chemical
    weapons agents. There were some servicemembers exposed to
    chemical weapons agents. We looked at their medical records,
    and, in fact, Dr. Helmer has put a note in all of their medical
    records in the VA, so that we can track them. And this was a
    combination between the DOD and the VA.
        Senator Cassidy. One more thing, because I am out of time.
    That would go to location but not to intensity of exposure.
    Correct?
        Dr. Hastings. The intensity of exposure was examined not
    only were they seen at the time of the occurrence but they were
    looked at later at Walter Reed Army Medical Center, actually,
    Walter Reed National Military Medical Center now, and did get a
    screening exam, an exam which was transmitted to the VA. We are
    now caring for those individuals.
        Senator Cassidy. No. I mean, there can be a threshold
    effect of exposure. A little bit of sunlight is not bad, but
    too much sunlight gives you melanoma. And so--but I am over
    time and I will stop there. Thank you very much.
        Chairman Isakson. Senator Manchin.

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

        Senator Manchin. Thank you, Mr. Chairman, and I am going to
    follow up on what you had mentioned. I want to thank you and
    Senator Tester for being so attentive to a horrible situation,
    and I can report what I know, that has been publicly made, and
    I think you all know a little bit about it, in Clarksburg, WV.
    We know that we had at least two of our veterans murdered, and
    maybe more. It is a horrible, horrible situation.
        Let me tell you something that is even more disturbing. The
    people in charge--the people in charge at that VA hospital--and
    the VA hospital has had a good record of doing great jobs and
    doing good work--they did not know--did not know; this is the
    head doctor in charge, and the head of nursing--so they didn't
    know. But, the inspector general was able to find, in an
    investigation that was done very quickly, that almost 9 months
    before they even said they knew, which the inspector general
    found very expediently that somebody knew something, that there
    were some concerns 9 months prior to that.
        Nothing adds up here. Nothing makes any sense. We are in
    a--it is a homicide, and it is going to be horrible when we
    find out the details. We do not know if it is one person of
    interest or more. We do not know.
        What I also did not know is how the VA controls its
    medication on the floors; I mean, who has control of that, who
    has access to it. Then, I also did not know this. I did not
    know that basically insulin--this is hypoglycemia, in all these
    cases--that insulin can be purchased in any pharmacy, without
    any prescription, and you can get a syringe to administer it.
    There are so many fallacies in all of this.
        We are going to need all hands on deck. Our veterans
    deserve better than this, and to have this horrible, horrible
    atrocity on these veterans is something that is unexplainable.
    You can imagine the fear that we have. Operations are being
    canceled. They are afraid of getting services, and things on
    and on and on.
        Hopefully--and I want to thank you again, both of you, for
    being attentive to this. We need to get to the bottom as quick
    as possible. The inspector general--it has been over a year
    now, this has been under investigation--I mean, the northern
    prosecuting attorney, U.S. attorney is on top of this, and I
    have all the confidence in him, because his father is a veteran
    and also uses the hospitals and clinics.
        I just want you all to be aware, and I hope you are looking
    through all your operations, all the operations, throughout the
    hospitals and clinics throughout this country.
        On another note here, I know we were talking; I know
    Senator Cassidy was talking about, as am I, about the veterans
    who served in Iraq and Afghanistan after 9/11. They were
    exposed to large-scale use of open-air pits to dispose of waste
    during combat operations. The burn pits exposed our
    servicemembers to toxic chemicals, like benzene, arsenic,
    freon, sulfuric acid, which have had all sorts of impact on
    otherwise healthy veterans. That is why many are calling burn
    pits this generation's Agent Orange.
        That is why I am working on a bill with Senator Sullivan to
    provide presumption of exposure, not presumption of benefits,
    for veterans who served in an area with burn pits. Our bill
    would make it easier for veterans to prove their exposure to
    toxic burn pits.
        My question would be, we cannot take as long on burn pits
    as we did on Agent Orange to take care of our veterans. What
    are the VA and DOD doing in accelerating research into the
    health impacts of these chemicals?
        Dr. Hastings. Sir, I will go ahead and start, then I am
    sure that Dr. Rauch would probably have something to add.
        We work with the DOD very closely on research. We also work
    with our academic institutions. We have Airborne Hazard
    Symposium that takes place each year. DOD ran it last year and
    we will be running it this year. We do invite the VSOs to that.
    We have over 50 research projects right now with the DOD in
    regard to the toxic substances. We have SME exchanges. We do
    conferences together. We publish our information in the peer-
    reviewed journals. And this is not only beneficial to the
    veterans and the active-duty servicemembers but also to the
    civilian community that are also affected by toxic hazards at
    other----
        Senator Manchin. Let me just, if I may, interrupt real
    quick.
        Dr. Hastings. Certainly.
        Senator Manchin. You know, we know about Agent Orange. We
    did not know until well after, many, many years after the
    exposure that Agent Orange even, had not a direct but
    incidental exposure. So, we know what effects it is having now.
    The burn pits we know because it has been reported and all the
    different types of toxic material that are being disposed of
    identified.
        Are we looking at other ways our servicemembers are being
    exposed to toxic chemicals that could have an effect? Are we
    doing that in a proactive way or are we just waiting until we
    have these devastating effects to their health?
        Dr. Hastings. We are looking very proactively. We learned a
    lot from Agent Orange. That is the unfortunate reality. We are
    looking at burn pits proactively. We are actually looking at
    the health effects right now with the National Academy. They
    are doing a report that we will have next October. We know that
    intergenerational effects are of concern to veterans also. We
    just had an intergenerational effects report that came to us
    from the National Academy.
        We want the answers to come more quickly. We are datamining
    the registry. We are actively pursuing the electronic health
    record and the Individual Longitudinal Exposure Record, because
    that really will make a difference with looking at exposures,
    and even in some cases of very small exposures.
        Dr. Helmer. Could I just add to that?
        Senator Manchin. Please.
        Dr. Helmer. I was the Director at the War-Related Illness
    and Injury Study Center and I would like to just say that the
    Burn Pit Center of Excellence that is based there is really
    doing exactly what Dr. Hastings said. We are taking advantage
    of some of the data that have already been gathered, and ILER
    is going to make that even better.
        But, as of right now we have 185,000 veterans and
    servicemembers who have participated in the Burn Pit Registry,
    and because it is the modern registry where the data are
    online, it is pretty instantaneous that we get access to the
    information, from the veteran themselves, which we can link to
    the electronic medical record and actually do this cross-match
    through the big data activities, to see what is going on.
        So, we generate reports on a quarterly basis and more
    often.
        Senator Manchin. I know about the reports. I am asking, are
    we being proactive in looking at other exposure, exposures that
    our servicemembers might have that we do not--we are not even
    looking at at this point in time? We have only seen, you know,
    post, if you will, what happened with Agent Orange, now what
    happens with burn pits. It there something else besides Agent
    Orange and burn pits we should be looking at, that we are
    exposing our servicemembers to?
        Dr. Helmer. On the VA side, certainly as a clinician I get
    that information, and as the War-Related Illness and Injury
    Study Center, people are referred to us, we take that
    information and we share it with our colleagues in Central
    Office, and it is shared with the DOD through the Defense
    Health Working Group. But, we are not able to do the
    assessments in real time, in terms of the exposures.
        Chairman Isakson. Thank you, Senator Manchin.
        Senator Sullivan.

              HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA

        Senator Sullivan. Thank you, Mr. Chairman, and I want to
    thank Senator Manchin. We have----
        Senator Brown. [Off microphone.]
        Senator Sullivan. Yeah, I think we go--thank you. So, I
    want to thank Senator Manchin for the work. His questions are
    going to be similar to mine, because what we are trying to do
    with our bill is get this right, get this right in terms of how
    we do it, but we are going to need your help. And there are
    lessons learned, right, from previous examples of toxic
    exposure.
        I also want to just thank the Chairman here. And, you know,
    in light of his announcement that he is going to retire at the
    end of year, I just want to thank him, in this Committee, on
    the great leadership that he has provided all of us for all of
    our veterans. A true champion of our veterans. I think when you
    see how much impactful legislation this Committee gets done, it
    is, in large measure, due to the distinguished Senator from
    Georgia. So, I am honored to serve with him. Thank you, Mr.
    Chairman.
        Let me follow up. Again, it is more process. We are always
    talking process, and I think it is important for legislation.
    But, we have got to remember that there are people at the end
    of the process chain, and I know you guys all know that.
        Let me just ask a couple of questions that are going to
    help us refine this kind of legislation and work with all of
    you to get it right. How does DOD assist a servicemember who is
    deployed at a site with a known burn pit but does not have it
    in their health records? So, that is kind of a big gap in how
    can we or the Department of Defense or VA try to address that
    gap?
        Mr. Rauch. Well, thank you, Senator, for the question. At
    the deployed site, as I explained in some previous remarks,
    there are preventative medicine assessment teams that do health
    hazard and occupational health assessments. If a servicemember
    presents a complaint to the medical unit while they are
    deployed, that is documented. It is in their medical record.
    And then as we explained a little while ago, now that medical
    record is going to be linked to ILER, which is a long-term
    environmental health exposure record.
        Senator Sullivan. But, if you have a soldier, a Marine who
    is like, ``Well, wait. I was in Bagram. I know there is--and my
    medical record does not indicate this.'' Is there a way to fix
    that?
        Mr. Rauch. Certainly. I mean, the servicemember can present
    to their provider, and the provider can so indicate those
    symptoms in the servicemember's record. Also, the provider, if
    it is primary care, can refer that servicemember in to
    occupational health.
        Senator Sullivan. OK. Let me ask Dr. Hastings, according to
    the VA, from 2007 through 2018, there were 11,500 burn pit
    claims lodged with the VA. Out of those, over 9,000, or 80
    percent, were denied. My staff has been working with your staff
    on trying to get a little granularity on why the majority of
    these claims were denied.
        Can you go into a little bit more detail from your
    perspective? I know they are individual cases, but that is a
    pretty high number. Maybe you could submit for the record, to
    the Committee here, in a little bit more detail than you have
    with a minute left in my questioning on why you think that
    pretty high majority of claims is denied, at least at this
    juncture.
        Dr. Hastings. Sir, I would be very happy to go ahead and
    get that information for you on the number of claims that are
    covered and not covered. If it would not be inappropriate, I
    would also like to just answer your other question just a
    little bit----
        Senator Sullivan. Sure.
        Dr. Hastings [continuing]. In regard to----
        Senator Sullivan. Do you have an answer to my first
    question?
        Dr. Hastings. Your first question----
        Senator Sullivan. Eighty percent----
        Dr. Hastings. I do not. I would have to look at what the
    reasons were. I know that in the top 10 reasons that people put
    in a burn pit claim, some of them do not seem like they would
    be related to burn pits----
        Senator Sullivan. OK.
        Dr. Hastings [continuing]. But, I do not have the medical
    records and review. Some are complaining of irritable bowel
    syndrome. Some people are complaining of migraines. The
    sinusitis and the breathing problems, those are pretty easy to
    connect. Some of the others that would be harder to connect
    would be things that were not associated with the respiratory
    system. I would be very happy to talk to VBA and get that
    information for you.
        Senator Sullivan. Good. That would be helpful.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Dan Sullivan to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
        Question. OK. Let me ask Dr. Hastings, according to the VA, from
    2007 through 2018, there were 11,500 burn pit claims lodged with the
    VA. Out of those, over 9,000, or 80 percent, were denied. My staff has
    been working with your staff on trying to get a little granularity on
    why the majority of these claims were denied. But can you go into a
    little bit more detail from your perspective? I know it is individual
    ones, but that is a pretty high number. And maybe you could submit, for
    the record, to the Committee here, in a little bit more detail than you
    have, with a minute left and my questioning on why you think that
    pretty high majority of claims is denied, at least at this juncture.
        Response. The most common reason for denying burn pit related
    claims is that the Veteran's record did not contain evidence that the
    claimed condition was incurred in or caused by military service. The
    second most common reason is that there was no evidence that the
    Veteran had a current diagnosis showing the presence of the condition
    they were claiming.

        Senator Sullivan. On the other one?
        Dr. Hastings. On the other one, everyone goes through a
    post-deployment health assessment when they come back. I have
    gone through several of those. I did them for my co-
    servicemembers as their physician, and I also had someone else
    do them for me. We also have the feed from the Defense Manpower
    Data Center, so we know where people were.
        Now, there are times that they would be sent out of area,
    but for the most part we know where people were. Frankly, in
    most cases, we do believe the servicemember or the veteran. In
    fact, I know of stories where there were no records of the
    person being in Vietnam because they flew from Korea. All we
    asked for was a picture of them in front of their aircraft at
    the Osan Air Base. So, in the majority of cases, we do believe
    the information that is given to us by the veteran.
        Senator Sullivan. Great. Thank you. Thank you, Mr.
    Chairman.
        Chairman Isakson. Thanks, Senator Sullivan. Before I go to
    Senator Brown I want to say that while he was a little bit
    late, there is something we need to take care of. Senator Brown
    is the reason this hearing is taking place today. He and
    Senator Tester and a few others have insisted on us dealing
    with toxic exposure and getting that information for us. So,
    even though he was a little bit late he did not need to
    apologize for that. He told me yesterday he would be. He is
    appropriately here now and I want to introduce him with the
    appropriate credit for what he did.

               HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

        Senator Brown. Thank you, Senator Isakson. Thanks to you
    and Senator Tester for this hearing, and your Staff--Pat,
    Leslie, Adam, Simon, J.C., and Tony, and my staff, Anne and
    Drew. This is such an important hearing and I appreciate all of
    you being here.
        Senator Tester, Senator Isakson, and I--Senator Moran came
    a little bit later--we have been on this Committee for 13 years
    now. I have known Johnny longer, but Jon and I are with him for
    13 years. And, the question is always, ``Why isn't the VA
    taking better care of these awful illnesses and diseases?'' The
    question never seems to be, ``Why do we pursue stupid wars in
    Vietnam and Iraq?'' So, now I worry, with Iran and the tough
    talk and the escalation on both sides, where this leads.
        Sitting on this Committee really makes you, I think,
    understand the cost of war, and what Senator Sinema said about
    this constituent of hers waking up and still thinking about
    Vietnam five decades later ought to be a lesson to our
    policymakers and President on making some of the decisions they
    have had on if we go to war with Iran--three big, stupid wars
    in a row.
        Dr. Hastings, on March 26, not you but VA officials told
    this Committee that within 90 days the Department would make a
    decision on expanding the list of Agent Orange presumptive
    diseases to include bladder cancer, hypothyroidism,
    Parkinson's-like symptoms, and hypertension. March 26th--April,
    May--June 26th was the 90 days. Now it has been 183 days. You
    just told the Committee the decision is within leadership. It
    might be a commentary on your leadership, but when is this
    going to be made?
        Dr. Hastings. It is in leadership and it is in coordination
    with other Federal agencies. So, I am as hopeful for a decision
    soon as you are.
        Senator Brown. Can you do anything about more than hope?
    Can you accelerate this? I mean, it has been twice the 90 days
    that your superiors came in here and promised. I assume they
    are your superiors.
        Dr. Hastings. Pretty much everybody is my superior.
        Senator Brown. I do not think so, but----
        Dr. Hastings. I can absolutely find out where it is in the
    process with the external coordination, and I would be very
    happy to get that information and give you that brief.
        Senator Brown. OK. I mean, every day we wait on presumptive
    eligibility is more people fighting with the VA, more of your
    resources, processing these, with less certitude, and probably
    more men and women dying from one of these illnesses.
        I will shift to burn pits. Since forces deployed to
    Afghanistan and Iraq, DOD has known that burn pits, similar to
    Dow Chemical and probably DOD knowing about Agent Orange, DOD
    has known that burn pits released toxic blooms into the air.
    There are memos, one dating back to 2006, near the beginning of
    the Iraq war or soon after, containing phrases like ``an acute
    health hazard for individuals,'' another phrase, ``possibility
    for chronic health hazards associated with smoke,'' another,
    ``the known carcinogens and respiratory sensitizers released
    from the atmosphere present both an acute and a chronic health
    hazard to our troops and our local population.''
        But, the burn pits continued, the size of football fields,
    is my understanding. Air quality testing in Bagram airfield
    found that air samples were considered, ``unhealthy by EPA
    standards.''
        Dr. Rauch, walk me through the Department's thinking here.
    If we have weekly air sample data from burn pits that routinely
    show particulate matter exceeding EPA health standards, DOD
    shared that raw data with VA or outside experts to build a
    comprehensive picture of what our servicemembers, civilians,
    contractors in the local populations were exposed to. So, walk
    me through this. What is the problem?
        Mr. Rauch. Well, the Department's position is in response,
    really, to, I believe it was on the House side that requested a
    report from the Department, which is due February, on
    alternatives to burn pit--technology alternatives to burn pits
    in the deployed environment.
        That report is still ongoing, in terms of the analysis and
    the proposed solutions, but the Department is moving away from
    open burn pits----
        Senator Brown. As they should have. But, let me boil it
    down. DOD shared that information with VA years and years ago.
    Am I correct?
        Mr. Rauch. Well, I--we share information with the VA all
    the time. I can't say it was years and years ago.
        Senator Brown. OK. I would really like to know some of
    those comments made, that I quoted, and other data from DOD, I
    would like to know when, in fact, that was shared with the VA,
    first point, and if you would get that to us----
        Mr. Rauch. I will.

        [Responses were not received within the Committee's
    timeframe for publication.]

        Senator Brown [continuing]. At some point. You know, I
    would like to know what local population were exposed to. That
    is really important. We go into these war zones. We leave
    behind lots of things, some toxic, sometimes a better life for
    people. But, sometimes--you get it.
        And last, Dr. Hastings, has VA established a presumption of
    eligibility of service connection and list of diseases
    associated with exposure? Senator Manchin asked about, you
    know, it took us a long time, but we learned something from
    Agent Orange. We were too slow. Elected officials were too
    slow. VA, we were all too slow. DOD knew more than they told
    us, all those things.
        But, we know that burn pits--exposure to burn pits is a
    very serious thing, resulting in illness and sometimes death.
    Are we going to do a presumption of service connection and list
    diseases on burn pits? If we are, when, and why not yet?
        Dr. Hastings. I do not know if we will be required to do a
    presumption for burn pits. We are getting a lot more
    information----
        Senator Brown. What do you mean, required?
        Dr. Hastings. I do not know if a presumption will be
    necessary. We may be able to do it on an individual basis. If
    we do have a presumption that comes out, I believe we would
    look at it after the National Academy Report that we will get
    in October of next year.
        I would like to ask my colleague, Dr. Helmer, who was
    previously at the War-Related Illness and Injury Study Center
    at the Airborne Hazard and Open Burn Pit Center of Excellence
    if he has any comments in regard to that.
        Dr. Helmer. I think you are seeing a real flourishing of
    information and scientific, high-quality research that is
    coming out about what might be associated with, let's start
    with the unexplained shortness of breath and decreased exercise
    tolerance that many of our veterans have reported since their
    deployment to Iraq or Afghanistan.
        I think at this point there are multiple potential causes,
    the burn pit smoke being one of them. The ambient air quality
    was actually highlighted by the National Academy's report in
    2011 as maybe the most likely source of the problem for those
    servicemembers. And our own work, more recently, has actually
    highlighted the possibility of blast over pressure as being a
    contributing factor, at least in some individuals experiencing
    shortness of breath.
        I think there is a lot of good science that is being done,
    and we are getting a better understanding of what the causal
    factors might be. So, I would just--you know, before a
    presumption is determined, perhaps, we should understand a
    little better about why.
        Senator Brown. Thank you. I see that. My time is way over,
    but I want to make three real quick comments.
        First of all, there seems to be a lack of urgency in all of
    this, as people get sick and die, in far too many cases, and
    every time we wait to add names to the presumption list, to the
    Agent Orange presumptive eligibility list, every time we talk
    about this with burn pits, another day goes by in people's
    lives. That is one point.
        Dr. Hastings, you used the word ``requirement.'' Well,
    there is no requirement. Congress should pass a requirement,
    but you can move on a requirement of beginning to compile which
    diseases should, in fact, be on this list.
        And third, that you made a statement--and you do not need
    to respond now. It is just that I am over time--but you made a
    statement that the VA--that we do not know if we need
    presumptive eligibility, that we can handle each one
    individually--and that is the whole point. If we handle each
    one it just slows everything down. That is what we tried to do
    with Agent Orange for, I don't know, two decades, or whatever,
    until Congress and the VA and the public and the DAV and the
    VFW and The American Legion and Polish American Vets had all
    figured this out, that we need presumptive eligibility.
        So, those are just my three assertions that I hope you take
    into account. Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Brown.
        Senator Moran.

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

        Senator Moran. Mr. Chairman, thank you. It is a pleasing
    thing to me that it is not Senator Tester who is departing the
    Committee but you, because I could not find anything nice to
    say about Senator Tester. [Laughter.]
        But, if you say that, I will believe it. I would take this
    moment to thank you for your leadership on this Committee and
    your love, care, and compassion for the U.S. Senate, for the
    citizens of Georgia, and, most particularly in this instance,
    for the veterans of America.
        I have been in a number of settings where you have received
    accolades, toasts, and cheers, pats on the back and cheers, a
    lot about who you are as a person, a man who was interested in
    bipartisanship, a person who cares about this institution for
    its well-being and the well-being of America, your willingness
    to, in addition to working across the aisle, trying to find
    right answers and treating people with respect. Those are
    things that ought to be able to be said about every person in
    public life, and, unfortunately, it is more rare than it should
    be.
        So, for you and the way you treat people and the role model
    that you provide for those of us who serve in public service, I
    thank you for that. I cannot imagine that one would want to be
    known more than being a good person, but I would add to that
    there is not a veteran in this country who has not benefited by
    what you have done on their behalf. So, I commend you for that
    and I respect you for that. Should Senator Tester retire or be
    defeated, I will work on something to say about him as well.
        I appreciate you having this hearing and the leadership
    that many around the table have led on toxic exposure. My
    particular interest was piqued in 2014, when I attended a
    conference in Wichita, KS, hosted by the Vietnam Veterans of
    American, on toxic exposure. I visited with veterans who
    certainly experienced the consequences of that exposure
    themselves.
        What captured my attention even more than that was the
    realization, the belief, the recognition that there are those
    who are the children and grandchildren of those veterans who,
    it is believed, are experiencing consequences from their
    mother, father, or their grandparents' exposure to toxic
    substances. We set out to try to do something to find out what
    the nature of the relationship is between toxic exposure for a
    veteran, for a military man or woman, and those who follow
    them, their children and grandchildren.
        My guess is that most every service man or woman recognizes
    that they are creating risks for themselves, but what a
    tremendous burden it must be to recognize that something you
    did, in service to your country, has a consequence to those in
    your family who are yet to be born.
        So, I will save my questions for the second panel. I am
    interested in the scientific nature of the study that has been
    completed.
        Senator Blumenthal and I teamed up on this issue. We
    introduced legislation that would require a scientific study,
    review and assessment conducted by the National Academy of
    Sciences, regarding the toxicological and epidemiological
    research on descendants of individuals with toxic exposure. I
    am interested in hearing more about what the results from the
    National Academy of Sciences is, so that we can set the stage
    to care for those who, through no actions of their own, now may
    be suffering from the actions of the patriotic service of their
    parents and grandparents.
        Senator Tester and I, we teamed up to try to get
    legislation passed, which we were successful, that declassifies
    records of veterans exposed to toxins, so they can better
    pursue their claims. One of the things I learned in those
    conversations with those veterans that day in Wichita was that
    we cannot often prove our case to the Department of Veterans
    Affairs because of the places that were served, the
    circumstances we served under, the records simply are not
    available.
        So, that bill is part of NDAA, which a year or so ago
    became law, and I needed to follow up and make certain that
    there is a consequence to the law changing and that veterans
    have greater access to those records.
        And, I would suggest to this panel that we are spending a
    lot of money on information services. The DOD, in my view,
    ought to be able to collect--it is a bit of what Senator
    Sullivan was talking about--ought to be able to collect
    information when that military man or woman returns and enters
    into the care of the VA. That is the moment--as you tell your
    personal history and your medical history, that is the point at
    which that service man and woman ought to be able to tell their
    story.
        But, I also would say that with the new electronic health
    records that we have underway, that could be the place to
    capture the exposure information and track conditions, not only
    of that military man or woman, and soon to be veteran, but also
    their family members, as well.
        I would recommend to the VA, if you are not specifically
    looking at electronic medical records, that ought to be an
    awfully good place to start as we presumably are on a path that
    puts the Department of Defense and the Department of Veterans
    Affairs in the same system.
        Mr. Chairman, thank you for the opportunity to make those
    remarks, and I will save my questions for Panel 2.
        Chairman Isakson. Thank you, Senator Moran.
        Senator Blumenthal.

                       HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Mr. Chairman. I want to
    thank both you and the Ranking member for holding this year. I
    apologize that I was at other hearings, so missed the first
    panel, but I just want to--I am sorry--I missed the beginning
    of the testimony from the first panel.
        I want to really second, as strongly as possible, the point
    made by Senator Tester, that the VA seems to be needless
    staying and delaying the Blue Water Navy veteran Vietnam
    claims. The date is now January 1, 2020. The VA had been
    issuing claims decision since April 2019.
        I do not need to go over the history of the Blue Water Navy
    veterans, but I am proud of the work that we have done, on a
    bipartisan basis, over the past several years, to pass the Blue
    Water Navy Act. And I am deeply disappointed--in fact, I am
    angry, like a number of my colleagues, that the VA chose to
    stay all these claims until the last possible minute, rather
    than work to grant them as soon as possible.
        So, I hope that the VA can address this issue and move
    forward without hiding behind their lawyers. I have nothing
    against lawyers. I am one myself. But, the VA has no excuse for
    failing to move forward on these claims.
        I am also concerned, and I have been very proud to team
    with my colleague, Senator Moran, on the issue of burn pits,
    airborne hazards, and other toxins and poisons on the
    battlefield. Many of us have a personal stake in this issue,
    having family members who have served there. I am concerned
    that the DOD continues to use open burn pits when we know there
    are serious medical consequences for our troops. We have got
    millions of servicemembers deployed to areas in which the DOD's
    own tests show the air is not safe to breathe, and we are, in
    effect, repeating mistakes that we made in the past with our
    Agent Orange veterans.
        I know Senator Sullivan asked you, Dr. Rauch, about this
    topic, but can you specify what DOD reporting requirements are
    for exposure to burn pits? Does the DOD keep records of
    detailed information, that would allow the VA and veterans to
    establish a claim for disability?
        Mr. Rauch. Thank you, Senator, for the question. First of
    all, the Department's position is to move away from burn pits
    and replace them with alternative technologies. The
    documentation of ambient air quality surrounding burn pits and
    the deployed environment is collected by area air monitoring,
    which is done daily by the preventive medicine that is organic
    to the unit attached to that area. So the ambient air quality
    is assessed 24/7, as well as other environmental hazards in
    that area.
        Senator Blumenthal. So, a veteran could establish the
    connection between the disability and that service connection?
        Mr. Rauch. Well, the veteran--so I am talking about air
    monitoring in an area. So, now we are talking about an
    individual in that area, and once again, determining what the
    rate or degree of exposure is difficult. I can just tell you
    that the Department is not there on----
        Senator Blumenthal. Could the DOD establish better
    measures?
        Mr. Rauch. Absolutely. Absolutely.
        Senator Blumenthal. Do you think that it will?
        Mr. Rauch. We will. We have a research effort to develop
    technologies--it is probably going to be wearable--for the
    individual, that would characterize and capture the exposures
    at a point in time to that individual servicemember. This is
    research, so it is not going to happen tomorrow, but it is an
    active research effort that we are spending money on.
        Senator Blumenthal. Dr. Hastings, can you explain why the
    VA has stayed every single claim under the Blue Water Navy Act?
        Dr. Hastings. I know that the VBA is getting ready for
    January, but I cannot tell you why there is a stay.
        Senator Blumenthal. You cannot tell us why?
        Dr. Hastings. I do not know.
        Senator Blumenthal. Well, I would like to ask you to
    respond in writing.
        Dr. Hastings. I absolutely will, sir.
        [The information requested during the hearing follows:]
        Response to Request Arising During the Hearing by Hon. Richard
       Blumenthal to Patricia R. Hastings, M.D., Chief Consultant, Post-
             Deployment Health, U.S. Department of Veterans Affairs
        Question. Dr. Hastings, can you explain why the VA has stayed every
    single claim under the Blue Water Navy Act?
        Response. VBA is working to ensure that the proper resources are in
    place to meet the needs of all claimants whose claims have been stayed,
    as authorized by the Blue Water Navy Vietnam Veterans Act of 2019. In
    addition to claims based on service in the offshore waters of the
    Republic of Vietnam, the claims affected by the stay include all claims
    based on service along the Korean DMZ between September 1, 1967, and
    August 31, 1971, as well as claims for spina bifida based on exposure
    in Thailand.
        Although some claimants with service along the Korean DMZ may have
    been eligible for benefits prior to the passage of the law, VA has
    elected to stay all claims specifically allowed by the Act. This has
    been necessary to ensure that VA processes and adjudicates all affected
    claims in an accurate and consistent fashion by carefully implementing
    the Act as Congress intended. VA is using this time until January 1,
    2020, to build tools and procedures for claims adjudication and to
    develop evidence for the claims to appropriately identify qualifying
    service. VA continues to process all claims which the Act did not
    expressly allow to be stayed.

        Senator Blumenthal. Thank you. My time has expired. Thank
    you, Mr. Chairman.
        Chairman Isakson. Thank you.
        Senator Tillis.

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

        Senator Tillis. Thank you, Mr. Chairman. I want to
    associate myself with the comments made by Senator Moran about
    you and your role-model behavior. I will only take one
    exception to something that Senator Moran said. ``Senator
    Tester, I like your hair.'' [Laughter.]
        That is a place to build on.
        Thank you all for being here. I want to go back. It was not
    a question I had intended to ask, but I think it is very
    important, since we have the DOD and the VA represented here.
    One thing that I am very interested in and excited about, is
    having more compatible electronic health records going forward.
        Dr. Rauch, as we move forward and we collect more
    information, I think we need to understand the situation that
    we find ourselves in sometimes when burn pits are used today.
    These are very dangerous situations where they are trying to do
    the best to get out of a dangerous situation. It is clearly not
    a preferred technique, and I know we are looking for other
    ones. So, while we still have these practices in place, we have
    to capture more information, have more insight into how
    individuals were exposed.
        I am particularly interested in making sure that once we
    capture that data it becomes a part of the lifetime record for
    that soldier when they move into veteran status, so that, over
    time, we may be able to predict a risk before any symptoms
    manifest themselves. So, that is the idea future state of
    fully-interactive, integrated electronic health records, and I
    think the research that you say that you are working on may be
    an indicator that we need to make sure ultimately finds itself
    into the man or woman who is serving at the time of exposure.
        Ms. Hastings, I had a question for you on the family member
    program, specifically around some of the toxic substances that
    you may know that we worked a fair amount on the toxic
    substances issue down at Camp Lejeune. And I believe the number
    is right, that we have about 300 family members who may have
    been exposed to toxic substances that seem to be linked in
    utero, but they are having a difficult time getting care.
        So, what do we need to do, if it is not within the VA's
    authorities, to step up that family member care? What should we
    be looking at, as a matter of policies that we should consider
    for congressional action?
        Dr. Hastings. Sir, I am very active in the Camp Lejeune
    Community Assistance panel meetings, and, in fact, they had one
    here in D.C. the 13th and 14th, which I did attend. They are
    run by the Agency for Toxic Substance Diseases Registry. If
    there was a child in utero, and had a specified relationship
    with the veteran on Camp Lejeune----
        Senator Tillis. In the time period in question?
        Dr. Hastings [continuing]. In the time period in question,
    they are covered for those 15 covered conditions. And the
    community program, the Community Care Program, run out of
    Denver, I routinely talk with them if there are problems.
    Whether they are financial or medical reviews, we help them
    with them. If you have a specific case, I am very happy to take
    that forward to the Community Care group, because I do also get
    individual requests from people. I had one yesterday. I am very
    willing to run the traps and help people.
        Senator Tillis. It may very well be that once they go
    through the traps they are in a good place. Some of it seems to
    be getting them to the point to where I guess they present a
    sufficient case. We will go back--I do not do casework in
    committee hearings, but we will go back to any specific cases.
    But, the main thing, much the same way that we went through
    some of the presumptions, you know, we got to, I think, a much
    better place in terms of the presumptions a couple of years
    ago. But, it is sort of giving them the benefit of the doubt,
    if a significant part of the information that they present
    looks like they should be qualified for support. So, we will
    deal with that outside of the Committee.
        The other question that I did have for you, though, was
    this idea--and I saw this when we were going through the Camp
    Lejeune discussion, about some of the additional presumptions.
    Do you think that there is a value in us having--as more
    information is available, more scientific data is available--
    that we have more frequent reviews of presumptions and update
    these? It took a lot of time and effort for us to get where we
    ultimately got, under the Ensminger Act and some of the other
    VA decisions. But, what more could we do to just make this a
    recurring, iterative process, not episodic?
        Dr. Hastings. I just agreed, at this last Community
    Assistance panel meeting, to talk with the Agency for Toxic
    Substance Disease Registry and have another meeting to review
    the new scientific literature. I did review much of the
    research that they have just completed. I have my
    epidemiologists working on that right now.
        Senator Tillis. Thank you very much. Thank you, Mr. Chair.
        Chairman Isakson. Thank you, Senator. Before I introduce
    Panel 2 I want to turn the gavel over to Senator Tester, who
    has agreed to finish the balance of the hearing, which I
    appreciate very much. I have a previous commitment that I have
    to finish with.
        I want to say, though, that this is the best participation
    for any meeting we have had. Almost every Member of the
    Committee, at one time or another, was in asking questions, and
    our panel did an excellent job and I want to thank both of you
    for your time.
        I will ask Panel 2 to move forward and Panel 1 may move
    out.
        Senator Tester. Can I just say one thing?
        Chairman Isakson. Before that, Senator Tester has a
    comment.
        Senator Tester. I appreciate you guys' testimony and I
    really appreciate your work, when you talk about the studies
    that you are doing. Ultimately, decisions have to be made.
        I think Senator Brown touched on this. I often think that
    there is an adversarial relationship between the VA and the
    veterans. I don't think that is you guys' intent, but the truth
    is we have got folks out there that are dying, that were put in
    positions that got them that way.
        I am a farmer. I could get hit by a tractor and get killed
    any time. That is my choice. These folks were put in
    positions--and you folks; you are probably all military, right,
    at one time or another--were put in positions that you had no
    control over. We have an obligation to deal with these folks in
    a timely manner.
        You do good work. We need to make sure that your work
    results in decisions, not just reports. Again, I just want to
    thank you for being here today.
        Dr. Hastings. Thank you, sir.
        Dr. Helmer. Thank you.
        Chairman Isakson. Panel number 2, please come forward.
        [Pause.]
        Senator Tester [presiding]. First of all, I want to welcome
    the second panel. This is going to be a very, very brief
    introduction, and forgive me for that. You all deserve a longer
    one.
        I want to first introduce Dr. David Butler, Director of the
    Office of Military and Veterans Health, the National Academies
    of Sciences, Engineering, and Medicine. Thank you for being
    here, David. We have got Mr. Shane L. Liermann, who is familiar
    to all of us. He is DAV Deputy National Legislative Director
    for Benefits. Thank you for being here, Shane. And, we have Dr.
    Robert Miller, from Vanderbilt University Medical Center. We
    appreciate you making the trek up, Robert. Thank you.
        We will let you start, Dr. Butler. You have got 5 minutes,
    and the remainder of your testimony will be put in the record.

    STATEMENT OF DAVID BUTLER, Ph.D., DIRECTOR, OFFICE OF MILITARY
    AND VETERANS HEALTH, HEALTH AND MEDICINE DIVISION, THE NATIONAL
            ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE

        Mr. Butler. Thank you, Ranking Member Tester, and Members
    of the Committee, for the opportunity to testify today. As you
    mentioned, my name is Dr. David Butler. I serve as a Scholar in
    the Health and Medicine Division of the National Academies of
    Sciences, Engineering, and Medicine, and director of its Office
    of Military and Veterans Health.
        The National Academies have a long history of advising the
    Federal Government on the health effects of military service in
    general, and on the effects of in-theater exposures resulting
    from military activities, in particular. We have also, when
    requested, offered perspectives on the decisionmaking processes
    used by the Department of Veterans Affairs in their
    determination of whether a particular health problem in a
    veteran may be associated with their military service.
        The most recent report addressing this issue as it relates
    to toxic exposures is entitled ``Improving the Presumptive
    Disability Decision-Making Process for Veterans,'' which was
    released in 2008. The study committee formed to research and
    write that report was charged with describing the process for
    how presumptive decisions are made for veterans who have health
    conditions arising from military service and proposing a
    scientific framework for making such presumptive decisions in
    the future.
        To address its charge, the study committee conducted a
    thorough review of relevant research and met with a full range
    of involved stakeholders, including Congress, the VA, veteran
    service organizations, and individual veterans. It attempted to
    capture how VA's presumptive disability determination approach
    works and completed a set of case studies to identify lessons
    learned that would be useful in proposing new approaches.
        The study committee also considered how information
    obtained on the health of veterans and how exposures during
    military service can be linked to health consequences via
    scientific investigation. Substantial attention was paid to how
    information can best be synthesized to determine if a
    particular exposure is associated with a risk to health.
        This assessment led the study committee to recommend an
    approach to assure that the presumptive disability
    decisionmaking process is based on the best possible scientific
    evidence.
        That approach comprised the following components: an open
    process for nominating exposures and health conditions for
    review, involving all stakeholders in the process; a revised
    process for evaluating scientific information on whether a
    given exposure causes a health condition in veterans, including
    a revised set of categories to assess the strength of evidence
    for an association, and estimate the number of exposed veterans
    whose health condition might be attributed to their military
    exposure; a consistent and transparent presumptive disability
    determination process by the VA; a system for tracking
    exposures of military personnel and for monitoring the health
    conditions of all military personnel while in service and after
    separation; and an organizational structure to support this
    process.
        To support the implementation of the study's
    recommendations, it suggested the creation of two panels. One
    was an advisory committee to the VA that would assemble,
    consider, and give priority to exposures and health conditions
    proposed for possible presumptive evaluation. Nominations for
    presumptions could come from veterans or other stakeholders, as
    well as from health tracking, surveillance, and research.
        The second panel was a scientific review board, an
    independent body that would evaluate the strength of evidence
    that links a health condition to a military exposure, and then
    estimates the fraction of exposed veterans whose health
    condition could be attributed to their military exposure. The
    scientific review board's reports and recommendations would
    then go to VA for its consideration.
        The VA would use explicit criteria to render a decision
    with regard to whether a presumption would be established. In
    addition, the scientific review board would monitor information
    on the health of veterans as it accumulates over time in DOD
    and VA tracking systems, and nominate new exposures for health
    conditions for evaluation, as appropriate.
        The report suggested that this framework be considered as a
    model to guide the evolution of the current process. It
    observed that the ability to implement changes would be
    improved by the provision of appropriate resources for all the
    participants in the presumptive disability decision-making
    process.
        The study committee recognized that action by Congress
    would be needed to implement all of the components of its
    proposed approach, but noted that some changes could be carried
    out without legislative action. They concluded that veterans
    deserve to have an improved system where decisions about
    disability compensation and related benefits are based on the
    best possible documentation and evidence.
        Thank you.
        [The prepared statement of Mr. Butler follows:]
       Prepared Statement of David A. Butler, Ph.D., Scholar | Director,
    Office of Military and Veterans Health, National Academies of Sciences,
                           Engineering, and Medicine
        Chairman Isakson, Ranking Member Tester and Members of the
    Committee, Thank you for the opportunity to testify today. My name is
    Dr. David Butler and I serve as a Scholar in the Health and Medicine
    Division of the National Academies of Sciences, Engineering, and
    Medicine and as Director of its Office of Military and Veterans Health.
        The National Academy of Sciences was created more than 150 years
    ago through a congressional charter signed by Abraham Lincoln in order
    to serve as an independent, authoritative body outside the government
    that could advise the Nation on matters pertaining to science and
    technology. Every year, approximately 6,000 Academies members and
    volunteers serve pro bono on our consensus study committees or
    convening activities. We do not advocate for specific policy positions.
    Rather, we enlist the best available expertise across disciplines to
    examine the evidence, reach consensus, and identify a path forward. Our
    reports, proceedings and other publications are available via the web
    in PDF form without charge.
        The National Academies have a long history of advising the Federal
    Government on the health effects of military service in general and on
    the effects of in-theater exposures resulting from military activities
    in particular. The Office of Military and Veterans Health that I direct
    includes the Medical Follow-up Agency, which was established after
    World War II and which maintains a collection of epidemiologic data on
    over 100 study populations of former military personnel. I have
    included a list of recent National Academies reports related to
    military and veterans health issues in the materials submitted for the
    Committee's attention.
        The National Academies have also, when requested, offered
    perspectives on the decisionmaking processes used by the Department of
    Veterans Affairs (VA) in their determination of whether a particular
    health problem in a veteran may be associated with their military
    service. The most recent report addressing this issue as it relates to
    toxic exposures--Improving the Presumptive Disability Decision-making
    Process for Veterans--was released in 2008. The study committee formed
    to research and write that report was a multidisciplinary group of 16
    people who covered the broad range of expertise needed to take on this
    important, but very challenging topic. A copy of the summary of the
    report and a list of the people who were involved in its writing is
    attached to my testimony.
        That study committee was charged with describing the current
    process for how presumptive decisions are made for veterans who have
    health conditions arising from military service and with proposing a
    scientific framework for making such presumptive decisions in the
    future. Presumptions are made in order to reach decisions in the face
    of unavailable or incomplete information. They address the gaps in
    evidence that introduce uncertainty in decisionmaking. Presumptions
    have been made with regard to exposure and the association between
    exposure and outcome. In trying to assess whether a particular health
    problem in veterans can be linked to their exposures in the military, a
    presumption might be needed because of missing information on exposures
    of the veterans to the agent of concern or because of uncertainty as to
    whether the exposure increases risk for the health condition. A
    presumption might also be made with regard to the link between an
    exposure and risk for a disease, while the evidence is still uncertain
    or accumulating as to whether the exposure causes the disease.
        Presumptions regarding service connections have long been made; in
    fact, the first were established in 1921. More recently, a number of
    presumptions have been made with regard to the consequences of
    herbicide (generically referred to as ``Agent Orange'') exposure during
    service in Vietnam and the health risks resulting from a series of
    exposures experienced by military personnel involved in the Persian
    Gulf conflicts.
        To address its charge, the 2008 National Academies committee met
    with the full range of involved stakeholders, including Congress, the
    VA, Veterans Service Organizations, and individual veterans. The
    Department of Defense (DOD) gave the study committee information about
    its current activities and its plans to track exposures and health
    conditions of personnel. The Committee attempted to formally capture
    how the current approach works and completed a series of case studies
    to identify ``lessons learned'' that would be useful in proposing a new
    approach. The Committee also considered how information is obtained on
    the health of veterans and how exposures during military service can be
    linked to any health consequences via scientific investigation. It gave
    substantial attention to how information can best be synthesized to
    determine if an exposure is associated with a risk to health and
    whether the association is causal.
        The present approach to presumptive disability decisionmaking
    largely flows from the Agent Orange Act of 1991, which started a model
    for decisionmaking that is still in place. In that law, Congress asked
    the VA to contract with an independent organization--the National
    Academies--to review the scientific evidence regarding wartime exposure
    to herbicides in Vietnam. Subsequently, we have produced reports
    evaluating the potential association between wartime exposure and
    health outcomes in Vietnam veterans (the Veterans and Agent Orange
    series) and a variety of exposures and health outcomes related to
    service in the Gulf conflicts (the Gulf War and Health series). The
    National Academies provides its reports to the VA, which then acts
    through its own internal decisionmaking process to determine if a
    presumption is to be made.
        The case studies conducted by the 2008 study committee probed
    deeply into this process. The case studies pointed to a number of
    difficulties that the Committee said needed to be addressed in any
    future approach:

         Lack of information on exposures received by military
    personnel and inadequate surveillance of veterans for service-related
    illnesses.
         Gaps in information because of secrecy.
         Varying approaches to synthesizing evidence on the health
    consequences of military service.
         In the instance of wartime exposures to herbicides in
    Vietnam, classification of evidence for association but not for
    causation.
         A failure to quantify the effect of the exposure during
    military service, particularly for diseases with other risk factors and
    causes.
         A general lack of transparency of the presumptive
    disability decisionmaking process.

        The study committee discussed in great depth the optimum approach
    to establishing a scientific foundation for presumptive disability
    decisionmaking, including the methods used to determine if exposure to
    some factor increases risk for disease. This assessment and the
    findings of the case studies led to a number of observations and
    recommendations to improve the process:

         Congress could provide a clearer and more consistent
    charge on how much evidence is needed to make a presumption. There
    should be clarity as to whether the finding of an association in one or
    more studies is sufficient or the evidence should support causation.
         Due to lack of clarity and consistency in congressional
    language and VA's charges to the Committees, National Academies
    committees have taken somewhat varying approaches since 1991 in
    reviewing the scientific evidence, and in forming their opinions on the
    possibility that exposures during military service contributed to
    causing a health condition. Future National Academies committees could
    improve their review and classification of scientific evidence if they
    were given clear and consistent charges and followed uniform evaluation
    procedures.
         The internal processes by which the VA makes it
    presumptive decisions following receipt of a National Academies report
    have been unclear. VA should adopt transparent and consistent
    approaches for making these decisions.
         Adequate exposure data and health condition information
    for military personnel (both individuals and groups) usually have not
    been available from DOD in the past. Such information is one of the
    most critical pieces of evidence for improving the determination of
    links between exposures and health conditions. Approaches are needed to
    assure that such information is systematically collected in an ongoing
    fashion.

        All of these improvements are feasible over the longer term and,
    the Committee said, are needed to ensure that the presumptive
    disability decisionmaking process for veterans is based on the best
    possible scientific evidence. Decisions about disability compensation
    and related benefits such as medical care for veterans should be based
    on the best possible documentation and evidence of their military
    exposures as well as on the best possible information. A fresh approach
    could do much to improve the current process. The study committee's
    recommended approach had several parts:

         an open process for nominating exposures and health
    conditions for review, involving all stakeholders in this process;
         a revised process for evaluating scientific information on
    whether a given exposure causes a health condition in veterans,
    including a revised set of categories to assess the strength of the
    evidence for association and an estimate of the numbers of exposed
    veterans whose health condition can be attributed to their military
    exposure;
         a consistent and transparent decisionmaking process by the
    VA;
         a system for tracking the exposures of military personnel
    (including chemical, biological, infectious, physical and psychological
    stressors), and for monitoring the health conditions of all military
    personnel while in service and after separation; and
         an organizational structure to support this process.

        To support the study committee's recommendations, it suggested the
    creation of two panels. One was an Advisory Committee (advisory to VA),
    that would assemble, consider and give priority to the exposures and
    health conditions proposed for possible presumptive evaluation.
    Nominations for presumptions could come from veterans and other
    stakeholders as well as from health tracking, surveillance and
    research. The second panel would be a Science Review Board, an
    independent body that would evaluate the strength of the evidence
    (based on causation) which links a health condition to a military
    exposure and then estimates the fraction of exposed veterans whose
    health condition could be attributed to their military exposure. The
    Science Review Board's report and recommendations would go to the VA
    for its consideration. The VA would use explicit criteria to render a
    decision by the VA Secretary with regard to whether a presumption would
    be established. In addition, the Science Review Board would monitor
    information on the health of veterans as it accumulates over time in
    the DOD and VA tracking systems, and nominate new exposures or health
    conditions for evaluation as appropriate.
        The study committee recommends that the following principles be
    adopted in establishing this new approach:

        1. Stakeholder inclusiveness
        2. Evidence-based decisions
        3. Transparent process
        4. Flexibility
        5. Consistency
        6. Causation, not just association, as the target for
    decisionmaking.

        The last principle needs further discussion, as it departs from the
    current approach. In proposing causation as the target, the study
    committee had concern that the approach of relying on association,
    particularly if based on findings of one study, could lead to ``false-
    positive'' presumptions. The Committee calls for a broad interpretation
    of evidence to judge whether a factor causes a disease in order to
    assure that relevant findings from laboratory studies are adequately
    considered. The report also recommends that benefits be considered when
    there is at least a 50% likelihood of a causal relationship, and does
    not call for full certainty on the part of the Science Review Board.
        The report suggested that this framework be considered as the model
    to guide the evolution of the current approach. While some aspects of
    the approach may appear challenging or infeasible at present,
    feasibility would be improved by the provision of appropriate resources
    to all of the participants in the presumptive disability decisionmaking
    process for veterans and future methodological developments. Veterans
    deserve to have these improvements accomplished as soon as possible.
        The study committee recognized that action by Congress would be
    needed to implement its proposed approach. The Committee's report notes
    that legislation to create the two panels would be needed and Congress
    would also need to act to ensure that needed resources were available
    to create and sustain exposure and health tracking for service
    personnel and veterans. Many of the changes proposed by the National
    Academies could be carried out even as steps were taken to move the DOD
    and VA toward implementing the full model recommended. They concluded
    that veterans deserve to have an improved system as soon as possible.

        Thank you for the opportunity to testify. I would be happy to
    address any questions that you might have.

    Recent Military and Veterans' Health Reports from the National Academies
                     of Sciences, Engineering, and Medicine
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Evaluation of the Disability Determination Process for           2019
     Traumatic Brain Injury in Veterans........................
    Gulf War and Health: Volume 11: Generational Health Effects      2018
     of Serving in the Gulf War................................
    Feasibility of Addressing Environmental Exposure Questions       2018
     Using Department of Defense Biorepositories: Proceedings
     of a Workshop--in Brief...................................
    Understanding and Overcoming the Challenge of Obesity and        2018
     Overweight in the Armed Forces: Proceedings of a Workshop.
    Veterans and Agent Orange: Update 11 (2018)................      2018
    Evaluation of the Department of Veterans Affairs Mental          2018
     Health Services...........................................
    An Evidence Framework for Genetic Testing..................      2017
    Assessment of the Department of Veterans Affairs Airborne        2017
     Hazards and Open Burn Pit Registry........................
    Evaluation of the Congressionally Directed Medical Research      2016
     Programs Review Process...................................
    A National Trauma Care System: Integrating Military and          2016
     Civilian Trauma Systems to Achieve Zero Preventable Deaths
     After Injury..............................................
    Gulf War and Health: Volume 10: Update of Health Effects of      2016
     Serving in the Gulf War...................................
    Veterans and Agent Orange: Update 2014.....................      2016
    Assessing Health Outcomes Among Veterans of Project SHAD...      2016
    The Air Force Health Study Assets Research Program.........      2016
    Review of VA Clinical Guidance for the Care of Health            2015
     Conditions Identified by the Camp Lejeune Legislation.....
    Post-Vietnam Dioxin Exposure in Agent Orange-Contaminated C-     2015
     123 Aircraft..............................................
    Chronic Multisymptom Illness in Gulf War Veterans: Case          2014
     Definitions Reexamined....................................
    Gulf War and Health, Volume 9: Long-Term Effects of Blast        2014
     Exposures.................................................
    Preventing Psychological Disorders in Service Members and        2014
     Their Families: An Assessment of Programs.................
    Research on Health Effects of Low-Level Ionizing Radiation       2014
     Exposure: Opportunities for the Armed Forces Radiobiology
     Research Institute........................................
    Treatment for Posttraumatic Stress Disorder in Military and      2014
     Veteran Populations: Final Assessment.....................
    Veterans and Agent Orange: Update 2012.....................      2014
    Cognitive Rehabilitation Therapy for Traumatic Brain             2013
     Injury: Model Study Protocols and Frameworks to Advance
     the State of the Science: Workshop Summary................
    Gulf War and Health: Treatment for Chronic Multisymptom          2013
     Illness...................................................
    Returning Home from Iraq and Afghanistan: Assessment of          2013
     Readjustment Needs of Veterans, Service Members, and Their
     Families..................................................
    Substance Use Disorders in the U.S. Armed Forces...........      2013
    Evaluation of the Lovell Federal Health Care Center Merger:      2012
     Findings, Conclusions, and Recommendations................
    Future Uses of the Department of Defense Joint Pathology         2012
     Center Biorepository......................................
    Treatment for Posttraumatic Stress Disorder in Military and      2012
     Veteran Populations: Initial Assessment...................
    Blue Water Navy Vietnam Veterans and Agent Orange Exposure.      2011
    Cognitive Rehabilitation Therapy for Traumatic Brain             2011
     Injury: Evaluating the Evidence...........................
    Long-Term Health Consequences of Exposure to Burn Pits in        2011
     Iraq and Afghanistan......................................
    Veterans and Agent Orange: Update 2010.....................      2011
    Gulf War and Health: Volume 8--Health Effects of Serving in      2010
     the Gulf War..............................................
    Returning Home from Iraq and Afghanistan: Preliminary            2010
     Assessment of Readjustment Needs of Veterans, Service
     Members, and Their Families...............................
    Provision of Mental Health Counseling Services Under             2010
     TRICARE...................................................
    ------------------------------------------------------------------------

                                     Current Military and Veterans' Health Projects
    ----------------------------------------------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
    Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military
     Operations

    Long-term Health Effects of Antimalarial Drugs

    Ensuring the Readiness of the Military Medical Workforce for Future Combat Operations

    Assessment of the Care and Use of Dogs in Biomedical Research Funded by or Conducted at the U.S.
     Department of Veterans Affairs
    ----------------------------------------------------------------------------------------------------------------
    Revised September 20, 2019

        Senator Tester. Thank you.
        Shane?

      STATEMENT OF SHANE L. LIERMANN, DEPUTY NATIONAL LEGISLATIVE
           DIRECTOR FOR BENEFITS, DISABLED AMERICAN VETERANS

        Mr. Liermann. Ranking Member Tester, Members of the
    Committee, thank you for inviting DAV to testify at today's
    hearing on toxic exposures and the presumptive decisionmaking
    process.
        At the outset, I want to thank Mr. Bobby Daniels, a Blue
    Water Navy veteran, and Mrs. Claudia Holt, wife of Frank Holt,
    a Blue Water Navy veteran who passed away this May. They
    proudly stood with us and others yesterday, in front of the
    Capitol, to call on the President to lift the stay and put an
    end to their wait.
        Bobby Daniels, who is with us today, has terminal prostate
    cancer. He is fearful and angry that his wife of 56 years,
    Judy, may not receive survivor benefits after he is gone.
    Claudia Holt, who has applied for survivor benefits, is worried
    about how she will pay her bills and whether or not she will
    lose her home. But, because of the blanket stay, both of them
    are forced to continue waiting.
        That is why today's hearing on the future of presumptive
    decisionmaking process is so important, so we can prevent these
    types of injustices from ever happening again.
        You have my full written testimony, but in my oral remarks
    I will highlight three of our key recommendations. First, we
    recommend to statutorily require future studies on all toxic
    exposures. Not all of the established presumptive processes
    have requirements for future studies for reviewing and
    potentially adding new diseases to each presumptive disease
    list. Only Persian Gulf water illnesses and Agent Orange
    exposures have required continued studies. Therefore, in order
    to ensure we utilize all scientific analysis and research for
    toxic exposures, we recommend that any new presumptive process
    have a requirement for new studies every 2 years.
        Second, we recommend to add time requirements for decisions
    and actions by the Secretary. The statutory provisions for
    Agent Orange and Persian Gulf illnesses that require timely
    decisions and actions by the Secretary, on the recommendations
    from the National Academies, have expired.
        The lack of statutory mandate unfortunately has resulted in
    no action by the VA, on the National Academies recommendations
    on three presumptive diseases from 2016--bladder cancer,
    hypothyroidism, and Parkinson's-like syndromes, as well as one
    from 2018, hypertension. All of these diseases are associated
    with Agent Orange exposure, and in our view all four should be
    added.
        Veterans with terminal diseases such as bladder cancer do
    not have the time to wait for the Secretary to decide.
    Regardless of whether the Secretary decides to add the diseases
    or not, veterans deserve timely action.
        Third, we recommend to establish a concession of exposure
    for burn pits. The common denominator for all presumptive
    processes is something called the concession of exposure to a
    specific toxin or environmental hazard. There are requirements
    that must be met to concede the toxic exposure prior to
    establishing if a presumptive process applies to that veteran.
        For example, the presumptive processes for mustard gas,
    radiation, Persian Gulf illnesses, Agent Orange, and Camp
    Lejeune contaminated water all have a concession of exposure
    built into the presumptions.
        We are proposing to concede the exposure without
    establishing a presumptive process for burn pits. A concession
    of exposure would still require a veteran to provide a
    diagnosis of a current illness. However, by conceding veterans
    who served in areas of active burn pits, were exposed to
    chemicals and toxins, to include those already recognized in
    VA's adjudication manual, the veteran would not have to provide
    proof of their personal evidence of that exposure.
        This would still require veterans to have a medical opinion
    linking the condition to the exposure. However, by conceding
    their exposure to the known toxins, a physician, VA or private,
    will now be able to provide a medical opinion, with the
    scientific rationale, as the toxins of exposure are now known.
    To be clear, this proposal would not create a list of diseases
    for burn pit exposures.
        We are currently working with Senator Sullivan and Senator
    Manchin to draft legislation that would address the need for a
    concession of exposure for burn pits. They are both committed
    to providing an avenue for burn pit veterans to establish
    entitlement to benefits and VA health care. We look forward to
    their introduction of the bill in the near future.
        This concludes my testimony. I would be pleased to answer
    any questions you or Members of the Committee may have.
        [The prepared statement of Mr. Liermann follows:]
     Prepared Statement of Shane L. Liermann, Deputy National Legislative
               Director for Benefits, Disabled American Veterans
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee: Thank you for inviting DAV (Disabled American Veterans) to
    testify at today's hearing on ``Toxic Exposures: Examining the
    Presumptive Disability Decision-Making Process.''
        DAV is a congressionally chartered national veterans' service
    organization of more than one million wartime veterans, all of whom
    were injured or made ill while serving on behalf of this Nation. To
    fulfill our service mission to America's injured and ill veterans and
    the families who care for them, DAV directly employs a corps of
    National Service Officers (NSOs), all of whom are themselves wartime
    service-connected disabled veterans, at VA regional offices (VARO) as
    well as other VA facilities throughout the Nation. Together with our
    chapter, department, transition and county veteran service officers,
    DAV has over 4,000 accredited representatives on the front lines
    providing free claims and appeals services to our Nation's veterans,
    their families and survivors. We represent over one million veterans
    and survivors, more than any other veterans' service organization
    (VSO). This provides us with an expert understanding and direct
    knowledge in navigating the VA claims and appeals process.
        Mr. Chairman, the men and women who serve are often placed in
    situations that have long-term health effects that will impact their
    individual functioning, provide industrial impairments and require
    physical rehabilitation and future health care. Combat wounds,
    illnesses, and invisible wounds will stay with them long after service.
    Our nation has a sacred obligation to care for those who bore the
    burden of battle. When these men and women are subjected to toxins and
    environmental hazards, our sense of duty to them must be heightened as
    many of the illnesses and diseases due to these toxic exposures may not
    be identifiable for years, even decades after they have completed their
    patriotic service.
        Although there has been some significant progress achieved over the
    past two decades for veterans who suffered illness due to toxic and
    environmental exposures, there are still too many who have yet to
    receive the full recognition, health care and benefits our Nation owes
    to them. Notwithstanding numerous laws and regulations governing how VA
    makes presumptive decisions, there are still gaps and breakdowns that
    have left some veterans, particularly Vietnam veterans, waiting.
    Throughout this testimony we will refer to the numerous studies and
    reports from the National Academy of Sciences, to include the National
    Academy of Medicine formerly known as the Institute of Medicine. From
    this point we will refer to them collectively as the National
    Academies.
        While reform of the presumptive decisionmaking process is critical,
    it cannot be done overnight. There are, however, two actions that the
    Administration can take immediately related to Agent Orange (AO)
    presumptions that would provide greater justice and support to Vietnam
    veterans.
        First, the Secretary can accept the recommendations of the National
    Academies to add four new conditions to the Agent Orange presumptive
    list. In 2016, the National Academies recommended that Bladder Cancer,
    Hypothyroidism and ``Parkinson-like symptoms'' be included. In
    December 2018, the National Academies found that there was ``sufficient
    evidence'' linking Agent Orange and Hypertension, strengthening their
    prior recommendation, and again calling for it to be included on the AO
    presumption list.
        As I will explain in greater detail below, although the landmark
    Agent Orange Act of 1991 required VA to make decisions on National
    Academies' recommendations within 60 days, that law was allowed to
    expire in 2015. As a result, despite clear scientific and medical
    evidence, veterans continue to wait for a decision on these four
    recommended presumptives.
        Second, the President can overrule Secretary Wilkie to end the
    blanket stay on Blue Water Navy claims, rather than waiting until
    January to begin processing them.
        Mr. Chairman, we do not believe that Congress intended, nor that
    the law requires, VA to stay every pending Blue Water Navy claim. But
    that is exactly what VA has done. Despite the U.S. Court of Appeals for
    the Federal Circuit decision in Procopio v. Wilkie in January, and
    subsequent passage of the Blue Water Navy Vietnam Veterans Act in June,
    there are thousands of sick and dying veterans, as well as surviving
    spouses, who must continue to wait and wonder if their claims for
    health care and benefits will be granted. Two of those people are here
    with us today.
                             bobby and judy daniels
        Robert ``Bobby'' Daniels, from Missouri, served in the Navy from
    1960 to 1964, including service onboard the USS Lexington, an Aircraft
    Carrier deployed to Vietnam. It was there, while serving as a
    Machinist's Mate that he was exposed to Agent Orange in the offshore
    waters. Bobby says that he has the ship logs to prove it.
        In 2011, Bobby was diagnosed with prostate cancer and diabetes,
    diseases that many of his former shipmates have also suffered from.
    Unfortunately, since 1997, VA has not provided the Agent Orange
    presumption of exposure for Blue Water Navy veterans like Bobby who
    served only in the waters offshore Vietnam without ever setting foot on
    the land. As he began this new battle, Bobby was blessed to have his
    wife of more than 50 years, Judy, a former school teacher, by his side.
    Over the years, Bobby and Judy have struggled through tough times
    together, including taking out a second mortgage to help pay for his
    medical expenses. Last year Bobby was told that his prostate cancer had
    reached a terminal stage with no cure possible. Although he had not
    previously sought benefits due to his prostate cancer or diabetes, he
    was now worried about how his wife would get by after he was gone, and
    filed new claims in January and February of this year so that his wife
    might be eligible for survivor benefits.
        When the Procopio decision was rendered in January ruling that the
    Agent Orange Act of 1991 was clearly intended to include all those who
    served in the waters offshore, Bobby had new hope that he might finally
    get long overdue recognition and support from VA. He had accepted that
    his journey is almost over; he is now focused on getting survivor
    benefits for his wife Judy after he is gone.
        When Congress passed, and the President signed the Blue Water Navy
    Vietnam Veterans Act on June 26, Bobby and Judy, like so many others,
    celebrated what they thought would finally bring them some measure of
    justice and support. But just five days later, the Secretary issued a
    blanket stay on all Blue Water claims until January 1, 2020. Bobby said
    this blow felt like getting hit in the mouth with a sledgehammer.
        Today, Bobby and Judy continue to wait for VA to review and decide
    his claims, not knowing if or when they might get a decision. And
    Bobby, who may not make it to the new year, remains fearful and angry
    that his wife, Judy, may not receive the survivor benefits she would be
    entitled to as a result of his Agent Orange-related conditions.
                             frank and claudia holt
        Frank Holt served in the Navy from November 1960 to November 1964,
    including service onboard the USS Prichett during the Vietnam War.
    While serving off the cost of Vietnam, he claimed he was exposed to
    Agent Orange and was never the same since. For the past two decades,
    Frank suffered from numerous illnesses, including lung cancer, a
    disease presumptively linked to Agent Orange. Frank was lucky to have
    his wife Claudia, a nurse by profession, at his side throughout his
    health struggles. But like Bobby Daniels and other Blue Water Navy
    veterans, Frank's claims for health care and benefits due to prostate
    cancer were denied.
        Sadly, on May 13 of this year, months after the Procopio decision
    was rendered, Frank Holt died. Following his death, Claudia applied for
    survivor benefits, based on the Procopio decision and the new law. But
    because of the blanket stay issued by the Secretary on July 1, Claudia
    must continue to wait until at least January before VA will even look
    at her claim.
        Claudia, who is 78 years old and in mourning, is worried about how
    she will pay her bills, whether or not she'll lose her home, and how
    she'll keep food on the table and the lights on overhead. Claudia drove
    almost three hours to be here so that she could represent for her
    husband who never got his justice, as well as other Blue Water Navy
    veterans and their spouses who continue to wait.
        My colleagues and I have heard from dozens of others who, like
    Bobby Daniels, Frank Holt and their spouses Judy and Claudia, continue
    waiting, wondering if they can hold on until January when VA plans to
    finally begin looking at their claims. It's time to end their wait.
        For this reason, DAV, together with other leading veterans
    organizations, including the Veterans of Foreign Wars (VFW), Vietnam
    Veterans of America (VVA), Paralyzed Veterans of America (PVA), AMVETS,
    Fleet Reserve Association (FRA), Military Officers of America (MOAA)
    and Blinded Veterans Association (BVA), joined with Senator Tester and
    House Chairman Takano yesterday, to call on President Trump to end the
    wait for Blue Water Navy Vietnam veterans by lifting the stay.
        That is also why we believe today's hearing on the future of
    presumptive decisionmaking is so important, to prevent these types of
    injustices from happening in the future. Our testimony will address the
    known toxic exposures with resultant presumptive service-connected
    process, how the current processes are inconsistent and present our
    recommendations to improve and reform the future of the presumptive
    decisionmaking process.
    Known Military Toxic Exposures and Presumptive Service Connection
        In discussing the future of the presumptive-decisionmaking process,
    we must examine the history and impact of chemical and toxic exposures
    thrust upon our military servicemembers. In all of the instances noted
    below, the U.S. Government or Department of Defense (DOD), exposed
    military servicemembers to toxins without being fully aware of the
    immediate or long-term health effects.
    Mustard Gas and Lewisite Exposure
        During World War II (WWII), both the Axis and Allies produced
    millions of tons of chemical weapons and had made massive preparations
    for their use. The U.S. established secret research programs to develop
    better chemical and toxic weapons and better methods of protecting
    against these poisons. At the end of WWII, over 60,000 U.S.
    servicemembers had been used as human test subjects. At least 4,000 of
    these active military servicemembers had participated in tests
    conducted with high concentrations of mustard agents or Lewisite in gas
    chambers or in field exercises over contaminated ground areas. The U.S.
    servicemembers were intentionally exposed to mustard agents or
    Lewisite, from mild (a drop of agent on the arm in ``patch'' tests) to
    quite severe (repeated gas chamber trials, sometimes without protective
    clothing).
        All servicemembers in the chamber and field tests, and some in the
    patch tests, were told at the time that they should never reveal the
    nature of the experiments. Attention was drawn to these experiments
    when some of the veterans began to seek benefits from VA for health
    problems they believed were caused by their exposures to mustard gas
    and lewisite. Two factors complicated these cases. First, there were
    often no records or documentation available of a veteran's individual
    participation in the testing programs. Second, there was a great deal
    of uncertainty about which health problems were in fact the result of
    mustard agent or Lewisite exposure.
        Not until 1991, over 70 years from the use in WWI and over 50 years
    from the secret testing in WWII, did the VA provide guidelines for
    establishing claims related to these exposures. That same year the VA
    requested a study from the National Institute of Medicine (IOM),
    currently the National Academy of Medicine. On July 31, 1992, VA
    published a final regulation, 38 CFR Sec. 3.316, authorizing service
    connection in claims from veterans who underwent full-body exposure to
    mustard gas during field or chamber experiments. The report, ``Veterans
    at Risk: The Health Effects of Mustard Gas and Lewisite'' was issued in
    1993 and prompted an updates to the regulatory provision in 1993 and
    1994. We would like to point out that this presumptive, when
    established in 1992, excluded WWI veterans exposed to mustard gas.
    Radiation Exposure
        Some of the first atomic veterans were servicemembers who were sent
    to Hiroshima and Nagasaki to assist in clean-up. Approximately 255,000
    troops were involved in the occupation of Hiroshima and Nagasaki. From
    1946 to 1962, the United States conducted about 200 atmospheric nuclear
    tests. Approximately 400,000 servicemembers were present during these
    atmospheric tests, whether as witnesses to the tests themselves or as
    post-test cleanup crews. Sworn to secrecy, many of these servicemembers
    never told anyone of what they witnessed. If they told anyone that they
    were involved in these nuclear tests, they could have been fined up to
    $10,000 and tried for treason.
        On October 24, 1984, the Veterans' Dioxin and Radiation Exposure
    Compensation Standards Act was enacted to ensure compensation to
    veterans and their survivors for disabilities or deaths related to
    exposure to ionizing radiation during atmospheric nuclear testing or
    the occupation of Hiroshima and Nagasaki. The law instructed VA to
    prescribe regulations setting forth specific guidelines, standards, and
    criteria for adjudicating compensation claims based on radiation
    exposure.
        On September 25, 1985, VA published 38 C.F.R. Sec. 3.311b (now
    designated Sec. 3.311) to implement the radiation provisions of Pub. L.
    No. 98-542. This regulation contains standards and criteria under which
    service connection is to be considered for diseases first appearing
    after service in radiation-exposed veterans.
        Effective May 1, 1988, 38 U.S.C. Sec. 1112(c) provided compensation
    on a presumptive basis for radiation-exposed veterans who developed one
    of 13 specified diseases to a degree of 10 percent or more within 40
    years following participation in a radiation risk activity. The
    presumptive period for one of the 13 diseases, leukemia, was set at 30
    years.
        In 1994, the Advisory Committee on Human Radiation Experiments was
    created to investigate the US government's role in radiation
    experiments on US servicemembers and American civilians from 1944 to
    1974. The Committee found the U.S. Government had conducted human
    experimentation that included injection of radioisotopes and
    intentional releases of radioactive gases into the environment. The
    Committee discovered that the government, scientists, and officials
    involved did not follow any procedures to obtain consent from the
    subjects in these experiments.
    Agent Orange Presumptive
        The U.S. program, code-named Operation Ranch Hand, sprayed more
    than 20 million gallons of various herbicides over Vietnam, Cambodia
    and Laos from 1961 to 1971. The purpose was to strip the thick jungle
    canopy that could conceal opposition forces, to destroy crops that
    those forces might depend on, and to clear tall grasses and bushes from
    the perimeters of US base camps and outlying fire-support bases. At the
    time of the spraying, 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), the
    most toxic form of dioxin, was an unintended contaminant generated
    during the production of 2,4,5-T and so was present in Agent Orange as
    well as some other formulations sprayed in Vietnam.
        After their service, many Vietnam veterans were developing multiple
    illnesses and fatal diseases. It was not until Veterans' Dioxin and
    Radiation Exposure Compensation Standards Act of 1984 that VA
    recognized presumptive service connection for an illness related to
    Agent Orange. As we will outline later in this testimony, it took many
    years of legislation, regulations and court battles to establish
    exposure to this deadly toxin. Because 20 million gallons were sprayed,
    VA has ultimately conceded exposure for those who served in Vietnam and
    the waters offshore.
    Persian Gulf War and Undiagnosed Illnesses
        In response to the invasion of Kuwait by Iraq in August 1990, the
    United States led a coalition of 34 countries in Operation Desert
    Shield in the Persian Gulf. This was followed by Operation Desert
    Storm, which began in January 1991 with an air offensive and a 4-day
    ground war; the war ended with a cease-fire in April 1991. Almost
    700,000 U.S. troops were deployed to the Persian Gulf region during the
    height of the buildup.
        The U.S. military engaged in further conflicts in the Middle East
    following the terrorist attacks of September 11, 2001. Operation
    Enduring Freedom began in October 2001 with troops stationed in and
    around Afghanistan. Operation Iraqi Freedom began in March 2003 with
    the invasion of Iraq, and it ended on August 31, 2010. Operation New
    Dawn, whose goal was to reduce the number of U.S. military personnel in
    Iraq, was initiated in September 2010 and ended in December 2011.
    However, there is still a U.S. military presence in Iraq.
        As noted by the National Academy of Medicine report, ``Gulf War and
    Health: Volume 11: Generational Health Effects of Serving in the Gulf
    War'' (2018), veterans who served in the 1990--1991 Gulf War and Post-
    9/11 were subjected to a variety of exposures during deployment that
    have been associated with health effects in veterans and other exposed
    populations. These exposures include burning oil fields, pesticides,
    nerve agents, depleted uranium, burn pits, particulate matter,
    vaccinations and many other environmental hazards.
        The Persian Gulf War Veterans Acts of 1998, codified at 38 U.S.C.
    Sec. 1118, was established to associate the numerous health effects
    known as Persian Gulf Illnesses. It also established a requirement for
    continual research and studies form the National Academies.
    Airborne Hazards and Open Burn Pits
        Veterans who served in Southwest Asia during the first Persian Gulf
    as well as those serving in those locations, including Afghanistan
    after 9/11, have been exposed to the large scale use of burn pits.
        DOD has acknowledged the vast use of burn pits to dispose of nearly
    all forms of waste. Several studies have indicated that veterans were
    exposed to burned waste products including, but not limited to:
    plastics, metal/aluminum cans, rubber, chemicals (such as paints,
    solvents), petroleum and lubricant products, munitions and other
    unexploded ordnance, wood waste, medical and human waste, and
    incomplete combustion by-products. The pits did not effectively burn
    the volume of waste generated, and smoke from the burn pit blew over
    bases and penetrated all living areas/quarters.
        DOD has performed air sampling at Joint Base Balad, Iraq and Camp
    Lemonier, Djibouti. Most of the air samples have not shown individual
    chemicals that exceed military exposure guidelines. The air sampling
    performed at Balad and discussed in an unclassified 2008 assessment
    tested and detected all of the following: (1) Particulate matter; (2)
    Polycyclic Aromatic Hydrocarbons (PAH); (3) Volatile Organic Compounds;
    and (4) Toxic Organic Halogenated Dioxins and Furans (dioxins).
        The VA launched the Airborne Hazards and Open Burn Pit Registry in
    June 2014 to allow eligible veterans and servicemembers to document
    their exposures and report health concerns through an online
    questionnaire. To date, the VA has not created any presumption
    associate with exposure to airborne hazards and open burn pits.
    Contaminated Water
        From the 1950s through the 1980s, people living or working at the
    U.S. Marine Corps Base Camp Lejeune, North Carolina, were exposed to
    drinking water contaminated with industrial solvents, benzene, and
    other chemicals. The Caring for Camp Lejeune Families Act of 2012,
    recognized exposure and treatment for veterans and families members for
    15 specific diseases.
        In 2017, by regulation, the Secretary established 8 presumptives
    diseases for active duty, reservists, and National Guard members who
    were stationed at Camp Lejeune for 30 aggregate days. However, this
    does not include any requirements for future studies to consider adding
    any potential new diseases in the future.
        As of August 2017, DOD has identified 401 military sites that could
    be contaminated with the toxic compounds known as per-and
    polyfluoroalkyl substances (PFAS). PFAS are found at high levels in a
    concentrate for a firefighting foam which has leaked into groundwater
    and contaminated drinking water. Currently, there are no presumptive
    illnesses, diseases or conditions established. Recently VA contracted
    with the National Academies to undertake a study on PFAS.
                  differences in current presumptive processes
        To best understand the current presumptive decisionmaking process,
    we must look at the overall presumptive processes for toxic exposures.
    The presumptive processes and the presumptive decisionmaking process
    are not consistent among all of the different types of exposures; it
    varies from exposure to exposure. Which means that not all presumptive
    processes are the same when it comes to establishing concession of
    exposure, or in adding new diseases linked to the exposure, or
    requirements for additional studies, or requirements from the Secretary
    to act on adding new diseases linked to exposure.
        Some of these inconsistencies or differences can be traced back to
    the ways each of the presumptive processes based on each specific
    exposure is established. There are two paths to establish new
    presumptive exposure processes; Congress by statute and the Secretary
    of Veterans Affairs by regulation via the formal rulemaking process.
    Differences with Presumptive Exposure by Regulation
        The presumptive exposures based on mustard gas and Camp Lejeune
    contaminated water were established by the Secretary via Federal
    rulemaking and not based on congressional action. Neither of these
    regulatory presumptive processes have requirements for additional
    studies to address potentially new diseases linked the toxic exposures.
    There is not a specific process in play, for these exposures, that
    regulates the addition of new diseases or any requirements on the
    Secretary to define their responses. However, new diseases for these
    exposures can be added by statute or Federal rulemaking, but again,
    there are no specific controls or requirements in doing so.
    Differences with Conceding Exposure
        The current presumptive process for exposure to radiation was
    established by Congress and further defined by VA regulation per formal
    rulemaking. There are inconsistencies with the concession of exposure
    for radiation exposure. The statute clearly states that a radiation-
    exposed veteran is one who participated in radiation-risk activities.
    It further provides a list of radiogenic diseases that will be service-
    connected if they become manifested in a radiation-exposed veteran.
        VA regulation 38 CFR Sec. 3.311 states that dose estimates for all
    radiation-exposed veterans, which is not required by the statute, must
    be conducted to estimate the dose of radiation. The dose estimates are
    provided by the Defense Threat Reduction Agency. Once they provide
    their estimate, it is given to a physician with subject matter
    expertise for an opinion if the estimated dose amount caused the
    radiation-exposed veteran's radiogenic diseases. This is the only
    presumptive process that requires estimation of dose of exposure and
    then a medical opinion if the known diseases are related to the
    exposure. This places a higher burden of proof on radiation exposed
    veterans for a presumptive disease than any other presumptive process
    within the VA. It is more akin to the direct service connection process
    than an actual presumptive process.
        In 2000, the Government Accountability Office (GAO) released a
    report on the DOD's dose reconstruction program, which established the
    estimated amount of radiation a veteran could have been exposed to. The
    report determined that there should be an independent review board that
    would examine the program, because many of the atomic veterans
    questioned the program's validity. As a result, Congress mandated an
    independent review.
        The Defense Threat Reduction Agency tasked the National Research
    Council to conduct the review. In 2003, The Board on Radiation Effects
    Research, under the auspices of the National Research Council, released
    its report. It found that while the estimated average dose was valid,
    estimated individual exposure was uncertain, because many veterans at
    the time of exposure were not wearing film badges that would collect
    radiation data. It was determined that methods to estimate ``inhaled
    radioactive materials involve many assumptions that are subject to
    error'' due to a lack of data.
        By contrast, the current Agent Orange presumptive process includes
    requirements for exposure based on the Agent Orange Act of 1991. The
    Secretary has conceded exposure to the toxin for those who served in
    the Air Force and a part of Operation Ranch Hand. This concession of
    exposure was added via 38 CFR Sec. 3.307. The VA has also conceded
    exposure to Agent Orange for those who served on eight specific Royal
    Thai Air Forces Bases during the Vietnam Era. However, this was not
    added by statue or formal rulemaking; it was added via VA's M21-1
    adjudication manual. It restricts exposure to Agent Orange to only
    those who served on the perimeter of the bases.
        Until the recent passage of the Blue Water Navy Vietnam Veterans
    Act, concession of exposure to Agent Orange for those who served on the
    Korean Demilitarized Zone was only available by the Secretary
    previously adding it via Federal rulemaking. The men and women who
    served in the waters offshore of Vietnam were conceded as being exposed
    to Agent Orange in 1991. However in 1997, a VA General Counsel Opinion
    determined only veterans who physically served in Vietnam were exposed
    to Agent Orange, excluding Blue Water Navy veterans. The Blue Water
    Navy Vietnam Veterans Act of 2019 has conceded their exposure.
    Differences with Future Studies Required
        Not all of the presumptives have requirements for future studies to
    be conducted for reviewing and potentially adding new diseases to the
    established presumptive diseases lists. There are no requirements for
    future studies of mustard gas; Camp Lejeune contaminated water, and
    radiogenic diseases. However, statutes require continued studies and
    the National Academies recommendations on diseases related to Agent
    Orange and exposures to toxins in the Persian Gulf. Both respective
    laws require studies to be conducted by the National Academies. We are
    concerned that those presumptive processes without required future
    studies will not provide current information on the toxic exposures and
    any advances or changes in science that can relate additional diseases
    or illness to that exposure. These are further evident of the overall
    differences in the presumptive decisionmaking process overall.
    Time-Required Actions by the VA Secretary on Recommendations
        When the Agent Orange Act of 1991 was passed into law, it contained
    requirements for action by the Secretary when a report and
    recommendations from the National Academies was received. It noted the
    Secretary not later than 60 days after the date on which the Secretary
    receives a report, shall determine whether a presumption of service
    connection is warranted for each disease covered by the report. If the
    Secretary determines that such a presumption is warranted, the
    Secretary, not later than 60 days after making the determination, shall
    issue proposed regulations setting forth the Secretary's determination.
    If the Secretary determined that a presumption of service connection is
    not warranted, the Secretary, not later than 60 days after making the
    determination, shall publish in the Federal Register a notice of that
    determination. The notice shall include an explanation of the
    scientific basis for that determination. It further added that not
    later than 90 days after the date on which the Secretary issues any
    proposed regulations under this subsection, the Secretary shall issue
    final regulations.
        This section of the statute included a date to discontinue this
    requirement. It was reauthorized several times; however, this part of
    the Agent Orange Act, 38 U.S.C. Sec. 1116, expired on October 1, 2015.
    This means, the Secretary no longer has a required timeframe for
    actions on recommended diseases to be added as a presumptive to Agent
    Orange. The lack of the time-required action is having a negative
    impact on veterans and their families.
        The National Academies ``Veterans and Agent Orange'' update was
    published in 2016. The Committee concluded that there was compelling
    evidence for adding bladder cancer and hypothyroid conditions as
    presumptive diseases. Further, the study clarified that Vietnam
    veterans with ``Parkinson-like symptoms,'' but without a formal
    diagnosis of Parkinson's disease, should be considered under the
    presumption that Parkinson's disease and the veterans' are service-
    connected. On November 1, 2017, the VA issued a press release noting
    they were exploring these new presumptive conditions related to Agent
    Orange.
        In December 2018, the National Academies issued a report noting
    there was sufficient evidence of a relationship between hypertension
    and Agent Orange and recommended for it to be added to the presumptive
    list. In March 2019, at a congressional hearing, Dr. Stone, Executive
    in Charge of the Veterans Health Administration (VHA) indicated that an
    answer on these presumptives could be released within 90 days. To date,
    there has been no action or responses from the VA in reference to a
    decision on adding these four presumptive diseases.
        The Persian Gulf War Veterans Act of 1998, codified at 38 U.S.C.
    Sec. 1118, originally had these same types of time-required actions by
    the Secretary. However, those requirements expired on October 1, 2011,
    as the date was not reauthorized for the future. All of this means
    there are no current time requirements on the Secretary to act on
    recommendations made by the National Academies in reference to
    additional diseases related to toxic exposures.
    Causation vs Association
        As noted in the many reports from the National Academies, there is
    a distinction between causation and association of a disease to the
    specific exposures. There is debate over which requirement should drive
    the presumptive decisionmaking process, or whether both should be
    included.
        Regardless of the outcomes from a report or study indicating
    causation or association, we would like to note, the ultimate decision
    for adding the presumptive disease lies with the Secretary, as well as
    Congress, which also has the authority to add diseases, as was the case
    with radiation-exposed veterans. As noted below, there are differences
    in the presumptive statutory language and the recommendations by
    veterans, the VA, and the National Academies.
        The Veterans' Dioxin and Radiation Exposure Compensation Standards
    Act of 1984 used language of both association and causation in
    describing the evidence required for presumptions. VA interpreted the
    law as requiring a certain threshold of evidence for causation, and as
    a result denied presumptions between Agent Orange and all diseases
    except Chloracne. Veterans filed a lawsuit against the VA and as
    determined by district court in Nehmer v US Veterans Administration,
    1989, the Act was ambiguous and interpreted congressional intent as
    establishing a threshold of evidence for an association.
        The Agent Orange Act of 1991, 38 U.S.C. Sec. 1116, originally
    stated that each additional disease that the Secretary determines in
    regulations warrants a presumption of service connection by reason of
    having positive association with exposure to a herbicide agent.
    Unfortunately, this requirement of association was not carried forward
    and ended on October 1, 2015. However, each subsequent report from the
    National Academies provides their assessments based on this original
    requirement of association.
        In ``Veterans at Risk: The Health Effects of Mustard Gas and
    Lewisite,'' issued in 1993, the study only focused on findings of a
    causal relationship and did not provide any comments or recommendations
    on diseases that may have an association vs causation. However, since
    this presumptive was established by regulation, there is no language or
    directions in reference to ongoing studies or any requirement of
    causation vs. association.
        The Persian Gulf War Veterans Act of 1998, 38 U.S.C. Sec. 1118,
    notes that the Secretary determines if illnesses or diseases warrant a
    presumption of service connection by reason of having a positive
    association with exposure to a biological, chemical, or other toxic
    agent, environmental or wartime hazard, or preventive medicine or
    vaccine. The plain text of the law notes association and not causation.
        In the National Academies report, ``Improving the Presumptive
    Disability Decision-Making Process,'' 2008, it made recommendations of
    causation over association. However, in the National Academies
    ``Veterans and Agent Orange'' update 2016; it discussed this question
    of whether the Committee should be considering statistical association
    rather than causality. The Committee believed that the categorization
    of strength of evidence on association is consistent with the previous
    court ruling.
    Classification Scheme used by the National Academies
        The National Academies ``Veterans and Agent Orange'' reports
    originally created and provided the four different classifications for
    associations of diseases to Agent Orange exposure as follows:

                Sufficient Evidence of an Association
              Epidemiologic evidence is sufficient to conclude that there
            is a positive association. That is, a positive association has
            been observed between exposure to herbicides and the outcome in
            studies in which chance, bias, and confounding could be ruled
            out with reasonable confidence. For example, if several small
            studies that are free of bias and confounding show an
            association that is consistent in magnitude and direction, then
            there could be sufficient evidence of an association.
                Limited or Suggestive Evidence of an Association
              Epidemiologic evidence suggests an association between
            exposure to herbicides and the outcome, but a firm conclusion
            is limited because chance, bias, and confounding could not be
            ruled out with confidence. For example, a well-conducted study
            with strong findings in accordance with less compelling results
            from studies of populations with similar exposures could
            constitute such evidence.
                Inadequate or Insufficient Evidence to Determine an
                        Association
              The available epidemiologic studies are of insufficient
            quality, consistency, or statistical power to permit a
            conclusion regarding the presence or absence of an association.
            For example, studies fail to control for confounding, have
            inadequate exposure assessment, or fail to address latency.
                Limited or Suggestive Evidence of No Association
              Several adequate studies, which cover the full range of human
            exposure, are consistent in not showing a positive association
            between any magnitude of exposure to a component of the
            herbicides of interest and the outcome. A conclusion of ``no
            association'' is inevitably limited to the conditions,
            exposures, and length of observation covered by the available
            studies.

        The Gulf War and Health reports issued by the National Academies
    have used five classifications of association that they noted, ``gained
    wide acceptance by Congress, government agencies (particularly VA),
    researchers, and veterans groups.'' They present a common message: the
    validity of an association is likely to vary to the extent to which
    common sources of spurious associations can be ruled out as the reason
    for the observed association. The one additional category provided by
    these reports is:

                Sufficient Evidence of a Causal Relationship
              Evidence is sufficient to conclude that a causal relationship
            exists between being deployed to the Gulf War and a health
            outcome. The evidence fulfills the criteria for sufficient
            evidence of a causal association in which chance, bias, and
            confounding can be ruled out with reasonable confidence. The
            association is supported by several of the other considerations
            such as strength of association, dose--response relationship,
            temporal relationship, and biologic plausibility.

        It is important to note, that of all the diseases that have ever
    been recommended to be added to any of the presumptives lists, no
    diseases classified as Inadequate or Insufficient Evidence to Determine
    an Association or Limited or Suggestive Evidence of No Association have
    been added as a presumptive disease.
                       recommendations for moving forward
        While considering the future of the presumptive-decisionmaking
    process, we must look at all aspects of the presumptive process as well
    as other ways for the men and women who served to establish entitlement
    to their earned benefits. Below are DAV's recommendations moving
    forward for strengthening and reforming the presumptive-decisionmaking
    process.
    1. Improve DOD Recordkeeping, Data Collection and Information Sharing
            with VA.
        In reference to the lack of information regarding exposures while
    on active duty, the National Academies noted, ``It is too late for
    Vietnam veterans and other more recently deployed veterans, but DOD
    should prepare the way for addressing the issue of delayed service
    related health conditions in a more coherent and better documented
    fashion for future veterans. The compilation of rosters of individuals
    sent on various deployments is a rudimentary starting point for any
    subsequent epidemiologic investigations. Documentation of medical
    procedures such as vaccinations should also be maintained for such
    cohorts.''
        As noted throughout our testimony and the many reports from the
    National Academies, there is a fundamental lack of exposure data for
    servicemembers to include troop locations, vaccinations, and other
    relevant information.
        DAV supports S. 1680, the ``Servicemember's Occupational and
    Environmental Transparency Health Act'' or the ``OATH Act,'' as this
    take steps to avoid the lack of medical data and exposure information
    for future generations of veterans. We also support the ongoing efforts
    to improve the data collection for the VA's Airborne Hazards and Burn
    Pit Registry as noted by S. 191, the Burn Pits Accountability Act, and
    S. 554, the Burn Pit Registry Enhancement Act, as well as the
    inclusions in the pending National Defense Authorization Act of 2020.
        As we look to create better record keeping and data of exposures
    for future veterans, we must reconcile the poor record keeping for past
    generations trying to establish their exposure to toxins. As noted,
    veterans exposed to mustard gas, radiation-risk veterans, veterans
    exposed to Agent Orange, Persian Gulf veterans, and those serving
    today, have difficulty establishing their exposures, due in part to
    poor DOD record keeping, especially during periods of war.
    2. Establish Concession of Exposure.
        One of the common denominators for all presumptive processes is the
    concession of exposure to a specific toxin or environmental hazard.
    There are requirements that must be met to concede the toxic exposure
    prior to establishing if the presumptive process applies and thus the
    granting of association for diseases, illnesses and conditions.
        When veterans have been exposed to toxins and current science and
    medical evidence fails to provide diseases or illnesses, they cannot
    use the presumptive process to establish service connection for their
    illnesses. So prior to the establishment of a presumptive process or
    disease list, the concession of exposure can provide an avenue to
    establish service connection for access to VA benefits and VA health
    care.
        For example, The Independent Budget Veterans Agenda for the 116th
    Congress notes that a Concession of Exposure can provide veterans
    exposed to open air burn pits a means to establish service connection
    as there is currently not a presumptive process for burn pit exposure.
    Without a presumptive process, veterans exposed to burn pits with
    associated diseases and illnesses must establish service connection by
    the means of direct service connection, which requires three
    components:

        1. A current diagnosis of a disease;
        2. Evidence of in-service injury, illness, treatment or exposure;
    and
        3. A medical opinion linking the current diagnosis to that in-
    service event.

        VA has reported that since 2007, 80 percent of claims for illnesses
    and diseases related to burn pits have been denied, mostly as the
    veteran does not have a medical opinion linking the illness to the
    claimed exposure. Again, there are few, if any, records to establish a
    veteran's exposure to and specific toxin from burn pits.
        A Concession of Exposure would still require a veteran to provide a
    diagnosis of a current condition, however, by conceding veterans who
    served in areas of active burn pits were exposed to certain chemicals
    and toxins, including those recognized in VA's M21-1, adjudication
    manual, the veteran would not have to provide personal evidence of
    exposure. This will still require veterans to have a medical opinion
    linking the condition to the exposure. By conceding their exposure to
    the known toxins, a physician will now have a better ability to provide
    a medical opinion as the toxins of exposure are known.
        A Concession of Exposure can provide benefits to veterans before a
    presumptive process is established or even if one is not created. For
    example, in April the National Academies started a 21-month study for
    VA on the long-term health effects of burn pits. If this report does
    not identify any diseases associated to burn pits, veterans will still
    have the ability to establish entitlement to service connection on a
    direct basis by Concession of Exposure and an independent medical exam.
        We are currently working with Senators Sullivan and Manchin to
    draft legislation that would address the need for a Concession of
    Exposure for veterans exposed to burn pits. They are both committed to
    providing an avenue for veterans exposed to burn pits to establish
    entitlement to benefits and VA health care. We look forward to their
    introduction of the bill in the near future.
    3. Approve Legislation or Regulations Requiring VA to Apply the Court's
            Holdings in Combee Whenever Applicable.
        Currently when the VA adjudicates a claim that associates a disease
    to a toxic exposure, but the disease is not one of the recognized
    presumptive diseases, it is usually denied. One of the most common
    reasons for this denial is that the disease is not listed as a
    presumptive. However, there is a means for this type of claim to be
    established based on direct service connection, as determined by the
    U.S. Court of Federal Appeals. In their decision of Combee v. Brown, 34
    F.3d 1039, 1042 (Fed. Cir. 1994); they held that notwithstanding the
    presumption provisions, a claimant is not precluded from establishing
    service connection with proof of direct causation.
        While this precedent has existed since 1994, most VA regional
    offices fail to apply this legal standard. When a veteran provides
    evidence of the disease, has a concession of the exposure, and even
    with an opinion with scientific and medical rationale linking the
    disease to the exposure, it is denied. These denials are then appealed
    to the Board of Veterans' Appeals and in many cases are granted by the
    Board based on the holdings of Combee.
        Many claims based on a toxic exposure for a disease not recognized
    as a presumptive can be resolved quickly based on Combee and would not
    add to the backlog of pending appeals.
    4. Statutorily Require Future Studies on Toxic Exposures.
        Not all of the presumptives have requirements for future studies to
    be conducted for reviewing and potentially adding new diseases to the
    established presumptive diseases lists. Only Persian Gulf War Illnesses
    and Agent Orange associated diseases have statutorily required
    continuing studies. As noted in the numerous studies and reports from
    the National Academies, additional scientific research and new medical
    processes continue to change. Therefore in order to ensure that
    diseases are properly associated with toxic exposures, any new
    presumptive processes should have a requirement for new studies every
    two years.
    5. Time Requirement for Action from the Secretary.
        As noted above, the statutory provisions that required the
    Secretary to respond and take actions on the recommendations from the
    National Academies have expired. While Congress has the ability to
    reauthorize the law, or directly add presumptions, no such action has
    been taken in recent years. This lack of statutory mandate,
    unfortunately, has resulted in no action by VA on the recommendations
    on three presumptive diseases from 2016 and one from 2018. Veterans
    with these diseases, such as bladder cancer, do not have the time to
    wait for the Secretary to decide on action. These veterans with
    terminal illnesses are left with no action from the Secretary. These
    situations need to be avoided in the future. Regardless of whether the
    Secretary decides to implement the diseases or not, veterans deserve
    action. A future presumptive decisionmaking process must include timely
    action.
        We recommend inclusion of the language previously found in 38
    U.S.C. Sec. Sec. 1116 and 1118. We recommend including, ``the Secretary
    not later than 60 days after the date on which the Secretary receives a
    report from the National Academies, shall determine whether a
    presumption of service connection is warranted for each disease covered
    by the report. If the Secretary determines that such a presumption is
    warranted, the Secretary, not later than 60 days after making the
    determination, shall issue proposed regulations setting forth the
    Secretary's determination. If the Secretary determined that a
    presumption of service connection is not warranted, the Secretary, not
    later than 60 days after making the determination, shall publish in the
    Federal Register a notice of that determination. The notice shall
    include an explanation of the scientific basis for that determination.
    It further added that not later than 90 days after the date on which
    the Secretary issues any proposed regulations under this subsection,
    the Secretary shall issue final regulations.''
    6. Association of Diseases to Exposure.
        As noted in the many reports from the National Academies, there is
    a distinction between causation and association of a disease to the
    specific exposures. The debate of which requirement should be included
    in the presumptive decisionmaking process is noted throughout.
        We recommend that the studies from the National Academies continue
    the use of statistical association between an exposure and a disease or
    illness. There is judicial precedent as noted by the Court in Nehmer v
    US Veterans Administration, 1989. The Court held, ``the legislative
    history, and prior VA and congressional practice, support our finding
    that Congress intended that the Administrator predicate service
    connection upon a finding of a significant statistical association
    between dioxin exposure and various diseases. We hold that the VA erred
    by requiring proof of a causal relationship. [712 F. Supp. 1404, 1989].
        The National Academies discussed this question of whether they
    should be considering statistical association rather than causality as
    has been debated. It is believed that the categorization of strength of
    evidence on association is consistent with that court ruling. However,
    we do realize that due consideration should be given to causation as in
    certain situations it can provide a path to adding a presumptive
    disease when the statistical analysis for association is not yet
    available.
        It is important to note that in each National Academies report they
    make their recommendations on adding diseases to the presumptive lists.
    This is based on their compiled research, studies, statistical analysis
    and most importantly, their professional expertise. Veterans rely on
    the scientific community to make these recommendations. As they have
    the expertise, we believe VA and Congress should follow their
    recommendations based on the merits, medical evaluations, and
    scientific value.
    7. Classifications of Scientific Association.
        We have discussed and explained the currently used classifications
    for scientific association between exposures and the identified
    diseases. We propose the below classification of associations to be
    used for future studies:

        Sufficient: The scientific analysis and evidence is sufficient to
    conclude that an association exists between the exposure and the
    disease.
        Equipoise and Above: The scientific analysis and evidence is
    sufficient to conclude that an association is at least as likely as
    not. 38 U.S.C. Sec. 5107 notes that if the evidence is in equipoise,
    the benefit of the doubt is resolved in the veteran's favor, thus the
    presumptive would be established. This would replace the ``limited but
    suggestive'' classification.
        Below Equipoise: The scientific analysis and evidence is not
    sufficient to conclude that an association is at least as likely as
    not.
        Against: The scientific analysis and evidence suggests a lack of an
    association.

        In discussion for future presumptive decisionmaking, we should
    consider adding a requirement on the Secretary when it comes to adding
    a disease to the presumptive list from our recommendations above. As
    there is no current time requirements on the Secretary to act on
    recommendations and much debate over these issues, requiring any
    disease as noted above being classified as sufficient association,
    would require the Secretary to add to the presumptive list unless there
    is clear and convincing scientific evidence to the contrary.
        In conclusion, we have discussed the known toxic exposures with
    resultant presumptive service-connected process, how the current
    processes are inconsistent and our recommendations to improve and
    influence the future of the presumptive decisionmaking process. Changes
    to the presumptive processes will have monumental impacts on the men
    and women exposed to toxins in their military service. We offer our
    assistance and want to participate in these ongoing conversations and
    debates to ensure that veterans and their families are able to access
    all of their VA benefits and VA health care, now and into the future.

        Mr. Chairman, this concludes my testimony on behalf of DAV. I would
    be happy to answer any questions you or other Members of the Committee
    may have.

        Senator Tester. Thank you, Shane.
        Robert?

    STATEMENT OF ROBERT MILLER, M.D., VANDERBILT UNIVERSITY MEDICAL
                                 CENTER

        Dr. Miller. Chairman Isakson, Ranking Member Tester, and
    Committee, thank you for allowing me to present today.
        I began seeing soldiers with unexplained shortness of
    breath in 2004, following their deployments in support of
    Operation Iraqi Freedom. All were physically fit at the time of
    deployment but were quite short of breath on return. They were
    incapable of completing their two-mile runs within regulation
    time, which meant that they no longer met Army physical fitness
    standards. Ft. Campbell referred dozens of similarly affected
    soldiers to Vanderbilt University Medical Center, and as a
    result we became leaders in evaluating and understanding this
    condition.
        The soldiers referred underwent standard testing, including
    chest radiographs, pulmonary function testing, and exercise
    studies, all of which were normal, and therefore failed to
    explain their exercise limitation. This led us to perform
    surgical lung biopsies, which consistently exhibited
    characteristics of toxic inhalation. Most of the biopsies
    demonstrated a condition known as constrictive bronchiolitis
    affecting the small airways, but there were multiple other
    pathologic features demonstrating toxic inhalation.
        You may wonder why the earlier studies failed to detect
    these changes, and the answer is that diseases affecting the
    small airways are frequently missed with non-invasive tests and
    are diagnosed only with biopsy, something that has been known
    for over 40 years.
        Performing surgical biopsies in patients with normal
    preexisting testing was unconventional, but the stories of
    these deployers were striking. All of them faced dismissal from
    the military with a label of ``unexplained shortness of
    breath,'' which does not qualify as a diagnosis and therefore
    does not meet the standard for disability. The biopsies
    established a connection between the exposers of deployment,
    and their symptoms, as a result. The results of our initial 80
    patients were published in the New England Journal of Medicine
    in August 2011.
        Vanderbilt University has now evaluated over 250 deployers
    with unexplained shortness of breath. Approximately 100 of them
    have had surgical lung biopsies, all of which are abnormal.
    Other major academic centers have reported similar biopsy
    results. The DOD STAMPEDE trial reported that standard clinical
    evaluations fail to explain respiratory complaints of over 40
    percent of patients presenting with shortness of breath. These
    patients were similar to the patients that we saw at
    Vanderbilt, but they did not under biopsy.
        A large number of deployers report respiratory symptoms
    associated with deployment. Some of them are easily assessed
    and meet criteria for straightforward diagnoses, such as
    asthma, sinusitis, allergic rhinitis. But, the patients
    referred to Vanderbilt were more complicated, and they had been
    dismissed by clinicians who had limited experience with this
    presentation, and who misinterpreted their normal preoperative
    evaluations. The absence of a diagnosis was unsettling to those
    veterans who were affected.
        This brings us to the two issues that I would like to raise
    related to unexplained respiratory symptoms following
    deployment. The first is how to best medically evaluate those
    with this presentation. While surgical biopsies may explain
    symptoms, performing them on a routine basis is not practical.
    They are invasive and expensive. They may, however, provide
    clarity for veterans whose symptoms are unrelenting and severe
    enough to end their military service and whose symptoms may
    have been dismissed by previous providers.
        The DOD and VA should consider designating Centers of
    Excellence to evaluate deployers with unexplained shortness of
    breath. These centers would establish standard protocols for
    evaluating these respiratory symptoms, and determine who may
    need surgical lung biopsy and who may be eligible for a
    presumptive diagnosis of deployment-related lung injury.
        The second issue relates to disability benefits for
    deployers who have been diagnosed with a deployment-related
    lung disease. As noted earlier, Vanderbilt has performed
    surgical lung biopsies in over 100 deployers. Those who were
    actively serving were medically boarded out of the military
    with inconsistent ratings. Those who applied for VA benefits
    were usually denied a rating, due to their normal pulmonary
    function tests. The current VA standard does not allow a
    disability rating for veterans with biopsies showing inhalation
    lung injury when pulmonary function tests are normal. This is
    inconsistent with the report from the U.S. Defense Health
    Board, which states that pulmonary function testing usually
    fails to detect small airways disease.
        Patients with deployment-related airways disease represent
    a unique group of veterans. While this injury may not be as
    noticeable as loss of limb, respiratory disorders are
    associated with lifetime limitation.
        It has been 10 years since I first presented our
    preliminary data to this Committee. I hope that it is evident
    that this issue is not a transient one for our veterans and
    that too many of them with this disorder feel that they are not
    receiving proper health care or appropriate disability
    benefits.
        Thank you, and I would be glad to answer any questions.
        [The prepared statement of Dr. Miller follows:]
     Prepared Statement of Robert F. Miller, M.D., Patricia and Rodes Hart
          Professor of Medicine, Vanderbilt University Medical Center
            ``disabling respiratory illnesses following deployment''
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, Thank you for the opportunity to testify today. My comments
    today relate to a cohort of United States servicemembers with permanent
    respiratory impairment following service in Iraq and Afghanistan. I am
    here to advocate for improved respiratory evaluations and disability
    benefits for those affected.
                                   background
        I began seeing soldiers with unexplained shortness of breath in
    2004 following their deployments in support of Operation Iraqi Freedom.
    All were physically fit at the time of deployment but were quite short
    of breath on return. They were incapable of completing their two-mile
    runs within regulation time which meant that they no longer met Army
    physical fitness standards. Ft. Campbell referred dozens of similarly
    affected soldiers to Vanderbilt University Medical Center and as a
    result we became leaders in evaluating and understanding this
    condition.
        The soldiers referred underwent standard testing, including chest
    radiographs, pulmonary function testing and exercise studies, all of
    which were normal or near normal and therefore failed to explain their
    exercise limitation. This led us to perform surgical lung biopsies,
    which consistently exhibited characteristics of toxic inhalation. Most
    of the biopsies demonstrated a condition known as constrictive
    bronchiolitis affecting the small airways, but there were multiple
    other pathologic features consistent with toxic inhalation. You may
    wonder why the earlier studies failed to detect these changes. The
    answer is that diseases affecting the small airways are frequently
    missed with non-invasive tests and are diagnosed only with biopsy.
        Performing surgical biopsies in patients with normal pre-operative
    testing was unconventional but the stories of these deployers were
    striking. All faced dismissal from the military with a label of
    ``unexplained shortness of breath,'' which does not qualify as a
    diagnosis and therefore does not meet a standard for disability. The
    biopsies established a connection between the symptoms of deployers and
    a shared history of exposures in Iraq and Afghanistan. The results of
    our initial eighty patients were published in the New England Journal
    of Medicine in August 2011.\1\
    ---------------------------------------------------------------------------
        \1\ King MS, Eisenberg R, Newman JH, Tolle JJ, Harrell FE Jr, Ninan
    M, Miller RF, et al. Constrictive bronchiolitis in soldiers returning
    from Iraq and Afghanistan. N Engl J Med. 2011;365:222-230.
    ---------------------------------------------------------------------------
        Vanderbilt University Medical Center has now evaluated over 250
    deployers with unexplained shortness of breath. Approximately 100 of
    them have had surgical lung biopsies, all of which were abnormal. Other
    major academic centers have reported similar biopsy results.\2\ The DOD
    STAMPEDE study reported that standard clinical evaluations fail to
    explain respiratory complaints over 40% of the time.\3\ The patients in
    this study were very similar to those studied at Vanderbilt, but none
    of them underwent biopsy.
    ---------------------------------------------------------------------------
        \2\ Garshick E, Miller R, et al. Respiratory Health after Military
    Service in Southwest Asia and Afghanistan: An Official American
    Thoracic Society Workshop Report. Ann Am Thoracic Soc. 2019 16(8):937-
    946.
        \3\ Morris MJ, Dodson DW, Lucero PF, Haislip GD, Gallup RA,
    Nicholson KL, et al. Study of Active Duty Military for Pulmonary
    Disease Related to Environmental Deployment Exposures (STAMPEDE). Am J
    Respir Crit Care Med. 2014;190:77-84.
    ---------------------------------------------------------------------------
        Almost three million servicemembers have been deployed to central
    and southwest Asia since 2001. Many of those deployed report frequent
    and complex hazardous inhalational exposures. The DOD surveyed multiple
    sites in Iraq and Afghanistan and consistently found airborne
    particulate matter levels (PM5/8x-03/16) well above safe
    standards as established by both DOD and EPA.\4\ Elevated particulate
    matter is considered a standard for assessing air quality and is
    associated with increased risk for pulmonary and cardiovascular
    diseases.\5\ The sources contributing to elevated particulate levels
    came from a combination of geologic dusts, and human sources such as
    burning waste, local industry, battle field smoke and vehicle exhaust.
    The National Academy of Sciences has emphasized the importance of
    considering the health effects associated with high particulate matter
    exposure in Iraq and Afghanistan.\6\
    ---------------------------------------------------------------------------
        \4\ National Research Council. Review of the Department of Defense
    enhanced particulate matter surveillance program report. Appendix D--
    Final report of the Department of Defense enhanced particulate matter
    surveillance program. Washington, DC: National Academies Press; 2010.
        \5\ Brook RD, Rajagopalan S, Pope CA 3rd, et al. Particulate matter
    air pollution and cardiovascular disease: an update to the scientific
    statement from the American Heart Association. Circulation.
    2010;121(21):2331-2378.
        \6\ Institute of Medicine, Board on the Health of Select
    Populations, Committee on the Long-Term Health Consequences of Exposure
    to Burn Pits in Iraq and Afghanistan. Long-term health consequences of
    exposure to burn pits in Iraq and Afghanistan. Washington, DC: National
    Academies Press; 2011.
    ---------------------------------------------------------------------------
        A large number of deployers report respiratory symptoms associated
    with deployment.\7\,\8\ Some of them are easily assessed and
    meet criteria for straight forward diagnoses such as allergic rhinitis,
    sinusitis and asthma.\9\ However, many of the patients referred to
    Vanderbilt had been dismissed by other clinicians who had limited
    experience with this presentation and misinterpreted initial normal
    testing results. The absence of a diagnosis was unsettling to those
    affected. They required sophisticated diagnostic evaluations by
    professionals with knowledge of their exposures and the spectrum of
    illnesses encountered with such exposures.
    ---------------------------------------------------------------------------
        \7\ Rivera AC, Powell TM, Boyko EJ, Lee RU, Faix DJ, Luxton DD, et
    al.; Millennium Cohort Study Team. New-onset asthma and combat
    deployment: findings from the Millennium Cohort Study. Am J Epidemiol.
    2018;187:2136-2144.
        \8\ Falvo MJ, Osinubi OY, Sotolongo AM, Helmer DA. Airborne hazards
    exposure and respiratory health of Iraq and Afghanistan veterans. Epid
    Rev. 2015;37:116-130.
        \9\ Krefft SD, Meehan R, Rose CS. Emerging spectrum of deployment-
    related respiratory diseases. Curr Opin Pulm Med. 2015;21(2):185-92.
    ---------------------------------------------------------------------------
                                 recommendation
        This brings us to the two issues that I would like to raise related
    to unexplained respiratory symptoms post-deployment. The first is how
    to best medically evaluate those with this presentation. While surgical
    biopsies may explain symptoms, performing biopsies on a routine basis
    is not practical; they are invasive and expensive. They may, however,
    provide clarity for Veterans whose symptoms are unrelenting and severe
    enough to end their military service and whose symptoms may have been
    dismissed by previous providers.
        The DOD and VA should consider designating Centers of Excellence to
    evaluate deployers with unexplained shortness of breath. These centers
    would establish standard protocols for evaluating disabling respiratory
    symptoms, determine who may need surgical lung biopsy and who may be
    eligible for a presumptive diagnosis of deployment related lung injury.
    Centers of Excellence would provide leadership in the area of research
    to identify and mitigate the causes of lung injury for this group of
    service members.
        The second issue relates to disability benefits for deployers who
    have been diagnosed with a deployment related lung disease. As noted
    earlier, Vanderbilt has performed surgical lung biopsies in over 100
    deployers. Those who were actively serving were medically boarded out
    of the military with inconsistent disability ratings (10%-100%). Those
    who applied for VA disability benefits were usually denied a rating due
    to their normal pulmonary function tests. The current VA standard does
    not allow a disability rating for Veterans with biopsies showing
    inhalation related lung injury when pulmonary function tests are
    normal. This is inconsistent with the report from the US Defense Health
    Board, which states that pulmonary function testing usually fails to
    detect small airways disease.\10\
    ---------------------------------------------------------------------------
        \10\ United States Defense Health Board Report: Deployment
    Pulmonary Health, Feb 11, 2015.
    ---------------------------------------------------------------------------
        I have seen several patients who received one rating from the DOD
    only to have it downgraded by the VA. I have seen patients who have
    received a rating for constrictive bronchiolitis only to have their
    rating reduced at a later date without explanation. This is despite
    that fact that this condition does not resolve spontaneously and has no
    known effective treatment. We need to re-define the disability criteria
    for our servicemembers and Veterans with deployment related respiratory
    disease.
        Patients with deployment related airways disease represent a unique
    group of Veterans. While this injury may not be as noticeable as loss
    of limb, respiratory disorders are associated with lifetime limitation.
    It has been 10 years since I first presented our preliminary data to
    this Committee. I hope that it is evident that this issue is not a
    transient one for our Veterans and that too many of them with this
    disorder feel that they are not receiving proper health care and
    appropriate disability benefits.

        Thank you for your attention and I would be glad to answer any
    questions.

        Senator Tester. Thank you, Dr. Miller.
        Senator Moran.
        Senator Moran. Mr. Chairman, or Mr. Ranking Member, thank
    you. Thank you for your service on this Committee.
        Dr. Butler, I have questions for you, but I thank all of
    you for being here, and I took seriously the testimony that you
    presented.
        Dr. Butler, in November of last year, the National Academy
    of Sciences published the Gulf War and Health, Volume 11,
    Generational Health Effects of Serving in the Gulf War. This
    report concluded that there is, ``a substantial dearth of
    information,'' on the generational effects of toxic exposure.
    Also within that report, the National Academy prioritized the
    collection, storage, and maintenance of a comprehensive
    baseline and longitudinal data, and biospecimens from veterans,
    their partners, and their descendants, in order to develop an
    effective, successful health monitoring and research program.
        The Department of Defense and the Department of Veterans
    Affairs continued to develop that, an Individual Longitudinal
    Exposure Record. My questions to you--well, first of all, I
    learned in our efforts to have research completed that would
    demonstrate whether or not there is a medical-scientific
    connection between generations, that before that was possible
    we had to demonstrate that there was not sufficient evidence in
    that regard existing. So, your study, Dr. Butler, at the
    National Academy of Sciences, was very important as a step in
    determining that connection.
        So, my question is, I just want you to expand upon that
    report, your findings, and if you have any sense of whether the
    cooperation between the Department of Defense and Veterans
    Affairs is on its path toward getting the necessary data about
    the necessary facts about the occurrences.
        Mr. Butler. Thank you for the question. The Gulf War and
    Health Update 11 Report not only looked at the existing
    evidence regarding possible reproductive effects of exposures,
    but also put together a comprehensive research plan that could
    be followed that would allow VA to make more informed decisions
    about this in the future. The report is still a relatively new
    one. As Dr. Hastings mentioned, and Dr. Rauch, the ILER system
    that is about to come on line is going to provide an important
    new source of information on exposures and getting a handle on
    exposure assessment, which is typically the poorest part of the
    information set that is available for making decisions like
    this. It is going to be really important in the future for
    getting a better handle on outcomes that might be related, not
    only to reproductive and generational effects, but all the
    other effects.
        Senator Moran. Do you have a sense--you know, I have heard
    and read the testimony of the Department--do you have a sense
    that that process is--which is soon to be completed and
    available, utilized--is it the right process? You are
    comfortable with the direction they are going, or have you not
    analyzed that?
        Mr. Butler. The National Academies has not yet analyzed it.
    The extensive research plan that was put forward as part of the
    Gulf War and Health Report does provide a roadmap in the future
    for getting information specific to reproductive and
    generational effects.
        Senator Moran. Do you have the sense your roadmap is being
    followed?
        Mr. Butler. We do not have specific information on what is
    being done at the moment.
        Senator Moran. Thank you, Doctor. Thank you.
        Senator Tester. Senator Brown.
        Senator Brown. Thank you, Senator Tester.
        Before I start I would like to acknowledge my constituents,
    Susan Zeier, who has joined us. She has been a driving force
    behind this hearing. Senator Isakson and Senator Tester
    commented earlier this hearing was done because of a push from
    people in Ohio and elsewhere. She has made countless visits
    with Burn Pits 360. We are also joined by Paul McMillan, who is
    an activist in Ohio. Thank you for joining us. They have made
    these visits to ensure that we acknowledge what has been done
    for our servicemembers in finding an approach that provides the
    kind of help that all of them have earned.
        I would like to submit a statement for the record that she
    prepared, with information we gathered from Ohio veterans.
        Senator Tester. Without objection.

        [The Zeier letter and attachments appear in the Appendix.]

        Senator Brown. Thank you. Also, Ms. Zeier is training a
    service dog for someone, so thank you for that.
        Dr. Miller--thank you for your testimony, all three of
    you--you have treated servicemembers exposed to sulfur mine
    fire burn pits, other environmental exposures. Walk me through
    examples of what you have seen while treating patients, and in
    your clinical opinion, do you think DOD and VA have the
    protocols in place to correctly diagnose these respiratory
    illnesses?
        Dr. Miller. There are probably two phases to what we have
    seen. Early on, in 2004, we saw a free flow of patients from
    Fort Campbell who returned from 1 year of service in Iraq with
    unexplained shortness of breath. There was good cooperation at
    that time. That is when we made our original find of
    constrictive bronchiolitis.
        Over time, these servicemembers have become more
    complicated. They are farther out from service. We are not
    seeing as many direct referrals from Fort Campbell as we used
    to. A lot of them have seen other providers who are not
    familiar with this, or----
        Senator Brown. They stopped referring veterans to
    specialists?
        Dr. Miller. They stopped referring to Vanderbilt and other
    academic institutions and chose to refer to DOD facilities.
        Senator Brown. Are they getting the care they should?
        Dr. Miller. I think that if you were to go to one of the
    centers that they were referring to you would get a different
    evaluation than you might get with us or with other academic
    medical centers. We felt like we were able to characterize
    those patients who were ultimately diagnosed with deployment-
    related lung disease. They had a consistent pattern of exercise
    limitation, and despite their pulmonary function tests and
    exercise studies being normal, we were willing to take this a
    step further and get them a diagnosis with lung biopsies. I
    would say that except in rare circumstances, the DOD facilities
    did not do that.
        Senator Brown. Thank you. Mr. Liermann, thank you for being
    in front of this Committee again. The first panel I asked a
    similar question, why do you think, given what we know about
    air quality tests and DOD recordkeeping, DOD and VA, have not
    been more forward-leaning to develop a process, a presumption
    or otherwise to provide health care and disability for
    servicemembers and veterans exposed to burn pits?
        You ended by suggesting that one step Congress should take
    to apply pressure would be to reinstate the timeline by which
    VA needs to act after receiving a National Academies report.
    Senator Hill and I introduced a bill last year, which obviously
    did not pass.
        Why is it important to reinstate that requirement?
        Mr. Liermann. Thank you, Senator. Without that requirement
    we are in the situation we are right now where we have three
    additional diseases that have not been added for almost 3
    years, yet were recommended. That requirement that there be
    some sort of action within the timeframe, good, better,
    indifferent is going to get a decision, and at the very least
    veterans need to have a decision. That way we know other
    avenues to proceed for service connection if it is not going to
    be as a presumptive disease.
        Senator Brown. OK. Thank you. Thank you, Mr. Chairman.
        Senator Tester. Thank you, Senator Brown.
        Senator Tillis.
        Senator Tillis. Thank you, Senator Tester, and thank you
    all for being here. You know, one question I wanted to ask Dr.
    Miller, you alluded to the idea of centers of excellence in
    your opening statement, and it really relates somewhat to the
    discussion you just had with Senator Brown on some of the
    referrals going to facilities that may or may not have the same
    level of expertise.
        So, in your mind, waving a wand, what would a good network
    of centers of excellence look like? And I would assume that
    that would be in and out of the DOD or VA.
        Dr. Miller. I think it could be in or out of DOD and VA,
    but I think that for patients with unexplained shortness of
    breath, which are the large number of patients with respiratory
    disorders, there is an unfamiliarity that you can be ill, that
    you can have toxic inhalation with a normal x-ray and pulmonary
    function test.
        There is also an unwillingness to take it to the next
    level, to either do a lung biopsy or to say, ``You have the
    characteristics of people who have been diagnosed with
    deployment-related lung disease, and we think that you meet
    those criteria.''
        So, you need the expertise, but you also need the
    willingness to take it to that level.
        Senator Tillis. Some of that may require us to do a better
    job of educating servicemembers who were in potential at-risk
    situations to understand what they may be going through and
    getting advice or engaging experts in the area. That is more a
    matter of increasing awareness and engagement on the part of
    the servicemember?
        Dr. Miller. It is more about increasing awareness among
    providers. The typical person that I am seeing now is somebody
    who has seen multiple providers, some of them in the private
    world, some of them through DOD, some of them through VA. The
    DOD and VA providers frequently are aware of what we have done
    at Vanderbilt or has been done at National Jewish Health in
    Colorado, but they do not take it to the level that we do.
    Then, the servicemembers leave with a diagnosis that, ``We are
    sorry that you are short of breath. Your x-rays and pulmonary
    function tests are normal.''
        Senator Tillis. You mentioned that the referrals reduced to
    Vanderbilt in favor of, I guess, DOD Health. Do you know why
    that happened? Is there any speculation on why that happened?
        Dr. Miller. I think you would have to ask them.
        Senator Tillis. We will.
        Dr. Miller. I think that they were uncomfortable with the
    idea that we would do lung biopsies on somebody who had normal
    x-rays and pulmonary function tests. I will tell you that that
    is a leap for me, as a clinician, to have made that diagnosis,
    and it is one that when I see patients I tell them that it is
    unconventional. But, in this group of patients, it has a very
    high yield.
        Senator Tillis. Thank you. Mr. Butler, I want to go back
    and follow up on a question I asked of Dr. Hastings on the
    first panel, and that has to do with what the National
    Academies specifically can do to review some of the other
    conditions affecting dependents and family members. I referred
    to some of the exposures in utero. What more do you think we
    can do there?
        Mr. Butler. Well, as I mentioned, the Gulf War and Health
    11 Report put forward a comprehensive research protocol that
    could be followed to get more information in this area. The
    National Academies is an institution and does not conduct
    primary research, which is to say we do not research data on
    individual veterans or groups of veterans directly, but we do
    review the literature. It is a challenging area to do research
    in, but it is one that is very important and that the Committee
    who wrote the Gulf War and Health 11 Report thought deserved
    greater attention.
        Senator Tillis. Mr. Liermann, it is good to see you back.
    Just a real quick question that also relates to a question I
    asked of the prior panel, which has to do with--I think you are
    familiar with the fact that Senator Burr co-introduced the
    Janey Ensminger Act, and we have worked hard to make sure the
    VA is changing some of their presumptions. We have made some
    progress over time.
        But, what do you think that we need to do, either what the
    VA can do or what more we need to do to make sure that we are
    constantly reassessing the data, constantly challenging the
    presumptions and making sure we are giving the care to as many
    people as we can?
        Mr. Liermann. Thank you, Senator. I believe one of the big
    things we can do is require additional studies, have additional
    research, because as things change and more information is
    gathered we are going to know more commonalities between
    different diseases and different disabilities.
        So, by providing that research every 2 years, and having
    that available for the scientific community to go through, to
    glean and find that key information, is really a key part of
    this. Because, if we do not continue to do those types of
    things--for example, for Agent Orange-exposed veterans--we
    would not continue to find these additional diseases that are
    associated with their exposure. So, studies and research, and I
    would say, at the minimum of 2 years, would go a long way.
        Senator Tillis. Thank you very much. Thank you, Senator
    Tester.
        Senator Tester. Yes.
        Senator Blackburn.

                  STATEMENT OF HON. MARSHA BLACKBURN,
                      U.S. SENATOR FROM TENNESSEE

        Senator Blackburn. Thank you.
        Dr. Miller, I appreciate so much that you are here, and, of
    course, representing our great State of Tennessee. I have heard
    a bit about your work at Vanderbilt, and the fact that I have
    two military retirees and veterans that are a part of our team
    and they had been deployed in the Gulf. I have heard many
    stories, as I have talked with those Fort Campbell families,
    about the crud that they bring back with them from those early
    days in Iraq and Afghanistan.
        We will be following up with you on some more specifics. I
    know the lung biopsies are painful. It is not a simple
    procedure. Yet, we want to make certain that the best treatment
    possible is available for our men and women in uniform. Indeed,
    we have heard so many stories about the shortness of breath
    issue, which seems to be unexplainable in an otherwise
    completely healthy individual. Mr. Liermann, you spoke to the
    toxins and the inhalation of them.
        So, it does concern us and as someone who in 2003--a group
    of women went in to visit the 101st. There were six female
    Members of the House that went in, and I was in that group. We
    saw firsthand some of the particulate that seemed to be
    floating through the air and ever-present. So, living in that
    and inhaling it is something that does leave that residual
    effect. We want to make certain that things are well cared for.
        We have just had votes called and we are going to need to
    scoot to the floor, but, Dr. Miller--and I think I am going to
    ask you to do this as a written response, just in the interest
    of time. So, what I would like to have from you is a little bit
    of a deeper dive, when you talk about the differences in the
    DOD testing and what Vanderbilt has done. It is also so curious
    to me when there is research work that is being done with the
    VA located on Vandy's campus. It seems as if more would be
    available for these veterans, and we appreciate that you have
    targeted this area.
        So, if you would talk a little bit about these exams, the
    center of excellence type of concept, what DOD does, and where
    they end the process and how that is not the fullness of what
    ought to be the process, to get to the bottom of this. I would
    appreciate that.
        With that, Mr. Chairman, I am going to yield back. I thank
    each of you for your attention to the issue. And, Dr. Miller, I
    especially thank you for your willingness to come and speak
    before us today.
        I yield back.
        Senator Tester. Yes, thank you, Senator Blackburn. I want
    to also thank Dr. Hastings and Dr. Helmer for sticking around
    here for the second panel. I appreciate you wanting to hear
    what these folks have to say. And, I don't know if Dr. Rauch--I
    did not pick him out in the crowd--if he is here I thank him
    also.
        I am going to start with you, Dr. Butler. As requested by
    the VA, the National Academies have convened a committee to
    review, evaluate, and summarize available scientific and
    medical literature regarding respiratory health effects and
    exposure to airborne hazards. Can you summarize the process for
    performing this study?
        Mr. Butler. Yes. This is a study that is ongoing. We have
    assembled an expert panel of----
        Senator Tester. When did it start?
        Mr. Butler. It started at the beginning of this year. We
    are going to be holding a meeting next Thursday and Friday, a
    workshop, where we will be gathering information for the
    committee's consideration. That is a public event and one that
    will be broadcast over the Web.
        We are also in the middle of a large-scale literature
    review of all of the information that has been published on
    this topic. We will be assembling that literature review, the
    additional information, including a presentation from one of
    Dr. Miller's colleagues from Vanderbilt. We will be preparing a
    report that will be completed in late spring of next year.
        Senator Tester. Late spring of next year? OK. That report
    will go to the VA, correct?
        Mr. Butler. It will, and it will also be made public and
    will be capable of being downloaded for free from the internet.
        Senator Tester. Yeah, and typically--and I do not know if
    you can answer this question, and if you cannot you do not have
    to--but typically, how long does it take the VA to make a
    decision after you have forwarded information to them?
        Mr. Butler. That would depend on the particular report that
    we are doing.
        Senator Tester. I am assuming these reports are pretty
    comprehensive?
        Mr. Butler. We try to make them as comprehensive as
    possible, yes.
        Senator Tester. OK. Are there any ongoing studies right now
    that have been requested of the National Academies over and
    above this?
        Mr. Butler. Aside from this study, we are completing a
    study on the effect of exposure to anti-malarial agents----
        Senator Tester. OK.
        Mr. Butler [continuing]. And that will also come out in
    2020.
        Senator Tester. OK. All right.
        Dr. Miller, you have seen a number of servicemen. There is
    a study you did--it may be a number of years ago now--where you
    conducted research on 100 veterans who had, I believe,
    shortness of breath, and you performed biopsies on those. Were
    all 100 percent abnormal?
        First of all, did all 100 veterans have shortness of
    breath?
        Dr. Miller. All of them did. Our original study was 80
    patients. We have now seen 250 with shortness of breath, and we
    have done biopsies on a little over 100. All of the biopsies
    are abnormal.
        Senator Tester. OK.
        Dr. Miller. All of them are patterns of toxic inhalation.
        Senator Tester. I got you. How do you choose the 100? Was
    it random or was it the worst-case scenarios?
        Dr. Miller. Some of them had other explanations for their
    shortness of breath. They might have asthma. Some of them had
    too many comorbid conditions to undergo biopsy, and some of
    them did not want biopsies.
        Senator Tester. OK. So, as I am sitting here listening to
    your testimony and you do a biopsy on the 100 veterans who have
    shortness of breath and it all comes back bad news, and then
    the VA does not use you anymore, it tends to put red flags up
    for me, because potentially it makes me think they do not want
    to hear the bad news. Do you look at it the same way?
        Dr. Miller. Between 2004 and 2009, we worked very closely
    with the DOD, and we had people come down and define the
    protocol that we used with Fort Campbell. I felt like that we
    were working well together.
        Senator Tester. Yeah, to supplant DOD. Yeah, keep going.
        Dr. Miller. Then, it changed. It changed when our data
    became more nationally known. There was a large consensus
    conference in Denver where we presented our data, which was the
    first time that a lot of them had seen our data. That is when
    things changed.
        Over time, many VA facilities have been willing to take the
    same approach that we do. For example, the VA in Nashville, the
    VA in Denver do a lot of biopsies.
        The big problem with the VA has been in the disability
    rating----
        Senator Tester. Oh yeah.
        Dr. Miller [continuing]. And that has been--I guess there
    were two issues. One is their willingness to say that someone's
    unexplained shortness of breath was deployment-related, or to
    do a biopsy, and the other is that for those that were
    diagnosed they would not give them a disability rating, despite
    significant exercise limitations.
        Senator Tester. OK. Really quick, going back to Dr. Butler,
    you are gleaning information from a lot of different sources,
    including places like Vanderbilt. Correct?
        Mr. Butler. That is correct. As I mentioned, one of Dr.
    Miller's colleagues will be giving us a presentation.
        Senator Tester. Right. And when is the last time you did
    any research that the DOD requested?
        Dr. Miller. The DOD has not requested any from us. We get a
    few patients----
        Senator Tester. In how many years--10?
        Dr. Miller. It has probably been 10.
        Senator Tester. OK. The information that you are gleaning,
    Dr. Butler, is it 10-year-old information, or are you getting
    all your information from the DOD over the last 5 years?
        Mr. Butler. We try to get the most recent information
    available from all sources.
        Senator Tester. I got you, but is that information only
    available from the DOD now?
        Mr. Butler. No. It is also available from academic
    researchers. We also ask the service organizations and
    veterans.
        Senator Tester. OK. Sounds good, and thank you.
        Shane, do you believe the VA is capable of rewarding claims
    of some Blue Water veterans right now?
        Mr. Liermann. Absolutely.
        Senator Tester. So, why is it important that at least they
    take a look at some of them? In your testimony that we heard
    yesterday you actually listed off some that they should be
    considering. Why is that important?
        Mr. Liermann. When you take a look at veterans like Bobby,
    who is here with us today, who is terminal and dying from his
    condition, yet they will not take any action on his care, that
    is one of the very important reasons why they should at least
    look at those cases now. And then--this was touched on earlier,
    Senator, and I just wanted to expand on it a little bit----
        Senator Tester. Yeah. Go ahead.
        Mr. Liermann [continuing]. There are certain pieces where
    the VA already knows where the ship was. They do not have to
    reconstruct hundreds of thousands of millions of pages of
    documents to prove it.
        Senator Tester. Bingo.
        Mr. Liermann. For example, Da Nang Harbor. For years, if a
    veteran served on a ship in Da Nang Harbor but never went
    ashore, they were not considered in country. They already have
    all of that information on those veterans. There is enough
    information for them right now to make decisions on cases. Will
    a lot of them have to be developed more? Absolutely. But, do
    they have enough now they can make decisions on? Yes.
        Senator Tester. Gotcha.
        I want to thank all three of you for your testimony and the
    work that you do. I very much appreciate it. Keep up the good
    work.
        I would just say that Members have 5 days to submit
    additional statements or questions for the record. With that we
    will adjourn this hearing. Thank you all.
        [Whereupon, at 12:32 p.m., the Committee was adjourned.]
                                    ------

       Response to Posthearing Questions Submitted by Hon. Jon Tester to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
                         presumptive service connection
        Question 1. The 2008 NAS report on ``Improving the Presumptive
    Disability Decision-Making Process for Veterans'' made 6
    recommendations specific to VA to improve the process. What is the
    status of implementing these recommendations?
        Response. Please see the following VA responses to the 2008
    National Academy of Sciences (NAS) Report on Improving the Presumptive
    Disability Decision-Making Process for Veterans Recommendations
    3,4,5,6,7, and 8:\1\
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         Recommendation 3: VA should develop and publish a formal
    process for consideration of disability presumptions that is uniform
    and transparent and clearly sets forth all evidence considered and the
    reasons for the decisions reached.
        Response. Following release of the Institute of Medicine (IOM)
    report, Veterans and Agent Orange, Update 2008, VA established the
    Agent Orange Update 2008 Task Force. In the past, similar VA Task
    Forces were established to consider previous IOM committee reports upon
    their completion. The 2008 Task Force, chaired by the VA Acting Under
    Secretary for Health and including the VA Under Secretary for Benefits,
    the VA General Counsel, and the VA Acting Assistant Secretary for
    Policy and Planning, was supported by a work group. The work group was
    chaired by the Director of Regulatory and Policy Management and
    consisted of representatives from the Office of Public Health and
    Environmental Hazards, Veterans Benefits Administration (VBA), Office
    of General Counsel, Patient Care Services, and Office of Policy and
    Planning. The work group included experts in disability compensation,
    health care, occupational and environmental medicine, neurology,
    cardiovascular disease, and hypertension, and on VA's legal
    requirements under the relevant statutes. The work group received a
    briefing by the NAS Committee Chair about the new report on July 21,
    2009, which provided an opportunity to hear about the report and to ask
    questions. The work group met three times (July 27, 2009, August 13,
    2009, and September 2, 2009) to discuss possible VA responses, and
    prepared a report for consideration by the VA Task Force, which then
    had responsibility for making relevant recommendations to the
    Secretary.
        Independent of recommendations based on reports from IOM, the
    Secretary has general authority under 38 United States Code (U.S.C.)
    Sec. 501(a)(1) to issue regulations governing ``the nature and extent
    of proof and evidence and the method of taking and furnishing them in
    order to establish the right to benefits'' under laws administered by
    VA. Pursuant to this authority, the Secretary may establish regulatory
    presumptions of service connection, if warranted by evidence, on
    grounds other than those specified in 38 U.S.C. Sec. 1116(b)(2).
        Currently, VA follows VA Directive 0215, Management of Institute of
    Medicine Reports (Attachment 1), when considering whether to establish
    new service connection presumptions for additional medical conditions.
    To make recommendations to the Secretary of Veterans Affairs, VA uses
    several levels of workgroups and a leadership governance process that
    spans from the technical (subject matter expert (SME)) level through VA
    leadership.
        These deliberative efforts require VA to collaborate, internally
    and externally, with stakeholders, medical experts, scientific
    researchers, and Federal agencies in order to study the debilitating
    effects of diseases and injuries on Veterans who have been exposed to
    or impacted by various toxins and chemicals during events in military
    service.
                                  attachment 1

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Recommendation 4: The Committee recommends that the goal
    of the presumptive disability decisionmaking process be to ensure
    compensation for veterans whose diseases are caused by military service
    and that this goal must serve as the foundation for the work of the
    Science Review Board. The Committee recommends that the Science Review
    Board implement its proposed two-step process.
        Response. Since 2008, VA has established a Secretary-level Advisory
    Committee for Disability Claims to advise and review VBA's overall
    disability claims process--including adding presumptive disabilities to
    the VA Schedule for Rating Disabilities (VASRD). This advisory
    committee is routinely kept apprised of the status of VASRD rulemaking
    and intermittently participates in the pre-decisional review of
    materials related to military exposures.
        VA already had an established organizational structure which
    collectively scrutinized the validity of presumptive service-related
    conditions and makes recommendations to the Secretary of Veterans
    Affairs, considering an evidence-based approach to creating new service
    connection presumptions. As part of VA's Office of Patient Care
    Services, the Office of Post Deployment Health is primarily responsible
    for administering programs related to environmental and occupational
    exposures of U.S. Veterans during military service, including Operation
    Enduring Freedom/Operation Iraqi Freedom (OEF/OIF), Gulf War, Vietnam,
    World War II, and atomic Veterans. The Office of Post Deployment Health
    also maintains several registries based on these exposures. Together,
    with VBA Compensation Service, these VA offices convene regularly to
    discuss military exposures and the pertinent new literature that may
    pertain to and may be associated with diseases and disabilities
    Veterans experience due to military exposure incidents.
         Recommendation 5: The Committee recommends that the
    Science Review Board use the proposed four-level classification scheme,
    as follows, in the first step of its evaluation. The Committee
    recommends that a standard be adopted for ``causal effect'' such that
    if there is at least as much evidence in favor of the exposure having a
    causal effect on the frequency or severity of disease as there is
    evidence against, then a service-connected presumption will be
    considered.
        Response. The Academies typically use the following four-level
    scheme employed in the Veterans and Agent Orange series: 1) Suf?cient
    Evidence of an Association; 2) Limited or Suggestive Evidence of an
    Association; 3) Inadequate or Insuf?cient Evidence to Determine an
    Association; and 4) Limited or Suggestive Evidence of No Association.
        VA formalized the process for scientific review of literature
    reviewed by NAS in VA Directive 0215. Consistent with the suggested
    two-step process underlying Recommendation 5 for the Committee's
    proposed Scientific Review Board, VA assembles a Technical Work Group
    (TWG) of SMEs to provide an objective critique and scientific review of
    the NAS recommendations for VA leadership.
        The Directive 0215 TWG is empaneled to review recommendations and
    considers the classification scheme used by the NAS Committee report.
    Causation is a higher standard that epidemiological studies are not
    often able to achieve. Where evidence of causation is presented, VA
    would consider it in support of establishing a presumption, regardless
    of the levels of evidence employed by NAS.
         Recommendation 6: The Committee recommends that a broad
    spectrum of evidence, including epidemiologic, animal, and mechanistic
    data, be considered when evaluating causation.
        Response. Epidemiologic, animal, and mechanistic studies all
    contribute to scientific understanding and VA decisionmaking. Well-
    designed human epidemiologic studies may be given greater weight
    because of the more direct demonstration of effect of exposure on human
    disease. VA carefully considers all available scientific evidence to
    examine the relationship between exposure and disease prior to
    recommending presumptions. National Academy Committees develop criteria
    for literature to be reviewed in response to the VA charge to the
    Committee. Either the charge to the Committee or deliberative Committee
    decisionmaking directs the scope of literature under NAS review.
         Recommendation 7: When the causal evidence is at Equipoise
    and Above or Sufficient, the Committee recommends that an estimate also
    be made of the size of the causal effect among those exposed.
        Response. There are limitations to causal inference from
    observational data commonly found in human studies. The scientific
    community, including VA in policymaking, relies on standard estimations
    of risk--relative risk, odds ratios, hazard ratios, standardized
    mortality rates, etc. Determining the magnitude of causal effect is
    often limited in human studies of exposure and disease because of the
    imprecise measures of exposure that are employed and ethical issues in
    research design. As science advances, techniques for exposure
    measurement and systematic collection of exposure data are developed,
    estimation of causal effect may become possible.
         Recommendation 8: The Committee recommends that, as the
    second part of the two-step evaluation, the relative risk and exposure
    prevalence be used to estimate an attributable fraction for the disease
    in the military setting (i.e., service-attributable fraction).
        Response. VA considers scientific literature that includes measures
    of attributable risk, when available. Unfortunately, estimates of the
    fraction of disease prevalence due to military service or magnitude of
    risk associated with military exposure are often not available. VA and
    the Department of Defense (DOD) have been developing the Individual
    Longitudinal Exposure Record (ILER). ILER may allow better estimates of
    exposure and more precise application of measures of attributable risk
    as related to specific military exposures or experiences.

        Question 1a. Would VA need any new statutory authorities from
    Congress to implement any of the remaining NAS recommendations?
        Response. No.

        Question 1b. As it pertains to providing presumptive benefits, what
    is the standard VA process for implementing recommendations from the
    National Academy of Sciences, including timelines for completion each
    step of the process?
        Response. When specified in statute, VA must follow certain
    procedures, as VA did with the now-expired provisions of the Agent
    Orange Act of 1991. Otherwise, VA generally relies on the guidance of
    VA Directive 0215 for reviewing the recommendations presented by the
    National Academies of Sciences, Engineering, and Medicine (NASEM)--
    formerly IOM. This policy provides the framework for developing
    guidance for decisionmaking by the Secretary of Veterans Affairs and
    any subordinate required actions.

        Question 1c. When VA decides makes a decision on NAS
    recommendations, where can Congress or the public go to get the
    rationale behind those decisions?
        Response. The final reports issued by NASEM remain the
    authoritative review of the literature used for decisionmaking. If VA
    makes official decisions based on NASEM's recommendations, the House,
    and Senate Committees on Veterans' Affairs (HVAC and SVAC) are formally
    notified by letter from the Secretary of Veterans Affairs explaining
    the decisions made. In some instances, such as where VA's decision
    involves rulemaking, notice of proposed or final action or regulation
    would be published in the Federal Register with an explanation for the
    decision.

        Question 1d. Does VA need any additional authorities to make the
    process for adding new presumptive conditions be more productive and
    transparent?
        Response. No.
                                   burn pits
        Question 2. The VA reported that 184,795 individuals have enrolled
    in the Airborne Hazards and Open Burn Pit Registry as of August 30,
    2019. How does the population of enrolled individuals compare to the
    number of individuals who have served at burn pit locations?
        Response. The eligible population is estimated to be 3 million. The
    number of participants in VA's Airborne Hazards and Open Burn Pits
    Registry (AHOBPR) continues to grow by at least 500 people a week. It
    is open to any Veteran or Servicemember who served in the Southwest
    Asia (SWA) theater of operations on or after August 2, 1990. Consistent
    with 38 CFR Sec. 3.317(e)(2), the SWA theater of operations refers to
    Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi
    Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of
    Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea,
    and the airspace above these locations. In addition, VA expanded
    participation in the Airborne Hazards and Burn Pits Center of
    Excellence (AHBPCE) to include individuals who served in Afghanistan or
    Djibouti on or after September 11, 2001.
        VA and DOD continue their respective and mutual efforts to increase
    participation numbers using targeted mailings, social media, videos,
    and the VA Public Health Web site. These efforts are coordinated
    through the monthly VA/DOD Deployment Health Working Group. In
    addition, DOD covers and highlights VA Environmental Health programs,
    to include AHOBPR, during its Transition Assistance Program (TAP),
    which is held for separating/discharged Servicemembers to inform them
    of both DOD and VA benefits available to them.

        Question 2a. Of the enrolled individuals, how many have opted to
    participate in a medical evaluation?
        Response. There are 159,566 Servicemembers and Veterans who are
    eligible for the AHOBPR examination. Approximately 60 percent of
    eligible Veteran-participants request a registry exam. Regarding
    Veterans, of those who have completed AHOBPR's online questionnaire and
    requested a VA AHOBPR health examination, 9,303 have been completed the
    health examination. DOD Active Duty participant numbers are 25,229. VA
    has implemented multiple education efforts to continue to improve exam
    completion numbers. This resulted in a 35 percent increase in exam
    numbers from Fiscal Year (FY) 2018 to FY 2019. These efforts will
    continue through FY 2020 and into the future.

        Question 2b. What actions has the VA taken to increase awareness of
    the availability of the registry and medical evaluations to eligible
    veterans and current servicemembers?
        Response. VA has contracted with DCG Communications to conduct
    focus-group interviews with over 100 Veterans and Servicemembers to
    better understand barriers to registering for the AHOBPR and for
    completing requested in-person registry examinations. The results of
    these focus groups, once analyzed, will help inform VA's enhanced
    outreach campaign targeted at individuals eligible to participate in
    the registry. It is projected that this outreach campaign will begin
    once all preparatory steps have been completed in the Fall of 2020.
        VA has produced fact sheets on the topic, including an overview of
    the registry, steps for completing the optional in-person registry (in
    English and Spanish), fact sheets for VA providers performing the
    registry examination, quarterly fact sheets displaying the number of
    participants by location, and biannual fact sheets summarizing registry
    findings. VA released newsletters with information about the registry,
    including articles in past issues of the annual Gulf War Newsletter and
    Post-9/11 Vet Newsletter (retired in 2019 and 2018, respectively) and
    the new biannual Military Exposures & Your Health newsletter for
    Veterans with service in 1990 through the present. The first Military
    Exposures & Your Health newsletter, released in September 2019,
    contains two articles about the registry. VA also has several blog
    posts on the registry, an article on MyHealtheVet, social media
    postings and email announcements, and a VHA Facebook chat on the
    registry.
        In addition, VA meets with Veterans Service Organizations (VSO)
    periodically to discuss AHOBPR operations to include outreach and
    barriers to participation. A meeting with the Veterans of Foreign Wars
    resulted in the organization sending out a message to its members to
    ensure the accuracy of their AHOBPR contact information. VSOs with a
    specific focus on Airborne Hazards are invited to the annual VA/DOD
    Airborne Hazards Symposium.
        VA has produced two videos on the AHOBPR registry that are
    available to Servicemembers and Veterans. One video provides an
    overview of the registry and the other focuses on steps to complete an
    in-person exam, if requested, and it explains how participating in the
    registry may contribute to VA research efforts aimed at studying
    possible relationships between long-term respiratory disease and/or
    other health conditions and possible in-service AHOBPR-related
    exposures.
        Find materials on the registry, including the videos, on VA's Web
    page https://www.publichealth.va.gov/exposures/burnpits/registry.asp.

        Question 2c. What efforts are underway at VA to improve the
    registry?
        Response. In 2017, NASEM (NAM or National Academy of Science
    Engineering and Medicine) published a report titled ``Assessment of the
    Department of Veterans Affairs Airborne Hazard and Open Burn Pit
    Registry.'' VA has completed 5 of the 9 recommendations. Two will be
    addressed with a future contract and two (research and improved
    clinical exams) are ongoing projects. As per the Congressional law
    regarding the AHOBP Registry, another review is due 5 years after the
    first review. It has been commissioned and is expected in
    February 2022.
        In addition, VA's contract with DCG Communications, discussed
    previously, should help VA better understand and address barriers to
    participation and help identify possible incentives VA can undertake to
    increase participation.
        Major improvements to the online questionnaire must be programmed
    in coordination with VA information technology contracting projects.
    Improvements requested for this contract cycle include allowing
    registry participants to add new deployment information during their
    military time. VA is also working to improve its software capability to
    better process and schedule requested in-person registry examinations.
        VA conducts yearly training at the Environmental Health
    Coordinators and Clinicians (EHCC) Conference for VA Medical Center
    (VAMC) EHCCs from across the Nation. VA has quarterly phone conferences
    with each Veterans Integrated Service Network (VISN) to update VA
    EHCCs.

        Question 2d. Does VA need new authorities to make any appropriate
    changes to the Burn Pit Registry to increase its usefulness?
        Response. No.

        Question 2e. What are the most recent policy guidance documents
    that VA released related to both the disability criteria and treatment
    of deployment related respiratory conditions?
        Response. VBA's Compensation Adjudication Procedures Manual
    contains guidance on processing claims for service connection for
    disabilities resulting from exposure to specific environmental hazards.
        For Veterans enrolled in VA's health care system, the treatment of
    respiratory conditions that may be related to Airborne Hazards, such as
    asthma, sinusitis, or other medical conditions, are the same regardless
    of the underlying cause. Hence, there is no need for a specific or
    separate VHA policy related to the treatment of the AHOBP-participant
    cohort. As to the registry, in August 2019, VA published a policy on
    administering AHOBPR, VA Directive 1307, AIRBORNE HAZARDS AND OPEN BURN
    PIT REGISTRY (AHOBPR). Please see Attachment 2.

                                  Attachment 2

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Question 2f. How often does VA review and update that guidance?
        Response. VHA policies are active for 5 years, although they remain
    in effect until rescinded, re-issued, or replaced. VA Directive 1307
    technically expires on August 31, 2024. Nevertheless, policy amendments
    may occur before a formal expiration date, if and as needed.

        Question 2g. What criteria does the VA consider in determining
    whether a regulatory presumptive service connection is warranted for
    airborne hazard and burn pit exposed veterans?
        Response. Currently, there are no presumptive service-connected
    diseases for Airborne Hazards exposures. Any Veteran who believes their
    illness or injury is the result of military service is encouraged to
    submit a claim. The NASEM report on Medical Effects of Airborne Hazards
    and Open Burn Pits is expected in May 2020.
        Presumptive determinations are based on scientific evidence of an
    association between a toxic exposure of adequate dose and duration to
    cause harm and a defined health condition.

        Question 2h. What is the position of the VA on the establishment of
    a regulatory presumptive service connection between exposures to open
    burn pit emissions during military service? And the subsequent
    development of certain diseases or illnesses?
        Response. Currently, there is insufficient scientific evidence to
    create presumptive service connection between exposure to Airborne
    Hazards associated with open burn pit emissions and disease.
        VA commissioned an updated NASEM review of health outcomes that may
    be related to Airborne Hazards. The report on this review is due in
    Spring 2020. The previous NASEM report was completed in 2011.
        VA also continues to work on original Airborne Hazards research
    with DOD and academia.
                                     ______

     Response to Posthearing Questions Submitted by Hon. Bernie Sanders to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
        Question 1. Dr. Hastings, what are some of the major roadblocks
    that our veterans keep facing when they file a claim for an illness
    that could be connected to toxic exposure, and how is VA mitigating
    these roadblocks?
        Response. Military environmental exposures and indeed in-depth
    environmental exposure training are not taught in medical school. There
    are about 150 EH Coordinators at VAMCs to assist Veterans. PDHS
    provides an annual conference covering environmental exposures. PDHS
    also provides Webinars, a robust Web site and monthly calls to EHCCs.
    Creation of more clinics with additional specialty training could
    better serve Veterans potentially exposed to environmental exposure
    with increased access and services.
        Additionally, VA has encountered a lack of documented exposure and
    verification of exposure. VA is continually coordinating with DOD to
    continue developing avenues to assist Veterans in verifying potential
    exposures to environmental hazards. In order to mitigate these risks,
    VA continues to obtain all military service records to substantiate the
    Veteran's claim, as well as other relevant evidence, to include lay
    evidence. VA is statutorily obligated to assist Veterans in obtaining
    evidence in support of their claims, which also includes medical
    examinations for purposes of completing their disability claims, when
    necessary.

        Question 2. Dr. Hastings, are all VA facilities equipped to help
    veterans who have been exposed to toxic chemicals?
        Response. VA health care providers are more than equipped to
    provide examinations and referrals for specialty care, as needed, for
    health problems which may be related to patients' self-reported or
    verified in-service exposure(s) to Airborne Hazards or toxic chemicals.
    Within each VISN there is a cadre of lead EH clinicians who have
    specialized knowledge and direct communication with a network of
    similarly trained colleagues to provide support for questions regarding
    environmental exposures or unique clinical presentations. Further, at
    each VAMC there is a designated EHCC; however, these staff may have
    other clinical non-EH assigned duties and responsibilities, as well.
        VA health care providers are provided training opportunities in
    environmental exposure assessment. This includes the annual EHCC
    Conference, monthly EH Webinars, bi-monthly VISN EH Lead phone
    conferences, quarterly VISN EHCC phone conferences, and on demand e-
    learning.

        Question 2a. If not, what percentage of VA facilities are so
    equipped? And if not, are there plans to ensure all VA facilities are
    so equipped?
        Response. See response to Question 2.

        Question 3. Dr. Hastings, what is the extent of the collaboration
    between the DOD and the VA that helps our Veterans receive the
    treatment that they need for exposure to toxic chemicals?
        Response. DOD and VA meet monthly at the PDHS Working Group.

        Question 3a: To be more specific, does the DOD provide in a timely
    and efficient manner, information of burn pits and other environmental
    hazards to the VA to speed up the claims process for our Veterans?
        Response. DOD provides the Periodic Occupational Environmental
    Monitoring System (POEMS) data, which is very helpful in evaluation of
    locations and any monitoring that may have been performed. The ILER
    will improve the sharing of available environmental exposure data
    between DOD and VA. A specifically identified end user of the ILER, and
    thus a driver for ILER functionality, is the VA claims adjudicator.

        Question 3b. If yes, has that been helpful in reducing waiting
    times for our Veterans in regard to their claims?
        Response. Generally, DOD provides most information in a timely
    manner, but of late there have been delays in the receipt of Defense
    Manpower Data base Center (DMDC) direct feed. This, in turn, delays our
    ability to enter eligible individuals in the AHOBPR because VA must
    manually enter their eligibility data. DOD and VA are working with the
    DMDC to more efficiently authenticate AHOBPR eligibility for veterans
    and Servicemembers.

        Question 4. Dr. Hastings, during your testimony you alluded to the
    fact the Veterans Benefit Administration faces a staffing
    infrastructure issue when processing the incoming claims related to
    toxic exposure. How many more permanent staff members does VBA need to
    process these claims in a timely manner, and how can Congress help you
    reach that goal?
        Response. The infrastructure that was being discussed was related
    to increasing the staffing and training needed for processing of Blue
    Water Navy claims.
        Beyond the additional resource request VBA has submitted regarding
    Public Law 116-23 (Blue Water Navy) that is effective January 1, 2020,
    VBA is sufficiently staffed to process all claims, including toxic
    exposure claims.

        Question 5. Dr. Hastings, during your testimony you mentioned the
    new ILER system for identifying veterans who may have been exposed to
    toxic chemicals during their service. How long until veterans can
    expect to hear from this new system if they were exposed?
        Response. ILER is at Initial Operating Capability (IOC) as of
    30 September 2019. Fully Operating Capability will be developed through
    FY 2023. ILER is at Initial Operating Capability (IOC) as of
    30 September 2019. Fully Operating Capability will be developed through
    FY 2023. It will be available for clinicians to use for evaluation of
    Veterans' exposure related concerns during FY 2020. VA is working with
    DOD to implement a plan for provider access and training. We anticipate
    that most clinicians will have ILER access in Winter 2020. ILER has
    direct deployment information from about 2000 on from the Defense
    Manpower Data Center (DMDC).
                                     ______

     Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
        Question 1. Dr. Hastings, prior to this hearing I asked Ohio
    veterans to detail any environmental or toxic exposure they experienced
    during service. The majority of veterans who wrote in said they had
    been exposed to Agent Orange. One of those veterans has bladder cancer.
    You said the decision to expand the list of Agent Orange presumptive
    diseases to include bladder cancer, hypothyroidism, Parkinson's-like
    symptoms, and hypertension is with leadership and the interagency. What
    recommendation did VA make to the interagency?
        Response. This is still in deliberation.

        Question 1a. What questions or concerns did OMB relay back to VA
    leadership?
        Response. This is still in deliberation.

        Question 1b. When can Congress expect the administration to move
    forward with a regulation?
        Response. This is still in deliberation.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
       to Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment
                  Health, U.S. Department of Veterans Affairs
                     va stay of all blue water navy claims
        Question 1. Why has VA stayed every single claim under the Blue
    Water Navy Act?
        Response. The Blue Water Navy Vietnam Veterans Act of 2019 (Act),
    Public Law 116-23 that was signed into law on June 25, 2019, and goes
    into effect on January 1, 2020, gave the Secretary of Veterans Affairs
    the discretionary authority to issue a stay of pending claims in order
    to prepare for implementation of the Act. This authority was exercised
    on July 1, 2019, based on reasoned judgment that it was in the best
    interest of Veterans and the VA adjudication system as a whole.
        As HVAC recognized, the Procopio v. Wilkie court decision did not
    define the term ``territorial sea.'' H.R. Rep. No. 116-58, at 11
    (May 10, 2019). Although some claimants may have been eligible for
    benefits under the Procopio ruling, the stay became necessary to ensure
    that VA will process and adjudicate all Blue Water Navy claims in an
    accurate and orderly fashion by carefully implementing the ``broad and
    comprehensive'' definition of service in the Republic of Vietnam that
    Congress intended. VA is also working to ensure that the proper
    resources are in place to meet the needs of the Blue Water Navy Veteran
    community and all Veterans filing for disability compensation and
    survivors claiming Dependency Indemnity and Compensation. In addition,
    VA is using this time, until January 1, 2020, to build tools for claims
    adjudication and to develop evidence for the claims to appropriately
    identify those who served offshore of Vietnam. Once these issues are
    addressed, VA will begin processing these claims based on the date that
    the law goes into full effect.
        Although VA stayed the issuance of decisions until the new law
    becomes effective on January 1, 2020, VA is authorized to effectuate
    Board of Veterans' Appeals decisions, issued before July 1, 2019,
    directing a grant of benefits; VA is currently effectuating those
    granted benefits. Also, VA continues to concede herbicide exposure and
    award service connection under existing rules and procedures. These
    include Veterans who are shown to have served in or visited the country
    of Vietnam (``boots on ground'') and those who served on vessels on the
    inland waterways of Vietnam.

        Question 1a. How will the Individual Longitudinal Exposure Record
    (ILER) allow VA to adjudicate claims such as these more quickly?
        Response. The ILER will not include records of exposure from the
    Vietnam era, thus will not be useful in adjudicating Blue Water Navy
    claims (see below). The ILER will include environmental exposure
    information that will assist VA in researching and describing military
    and deployment related exposures for those who have served after 2000.
    At Full Operating Capability, ILER is intended to provide information
    about location of service and known recognized exposure hazards. In
    addition to service location there may be environmental or personal
    sampling data about specific agents or toxic chemicals, as well as
    qualitative reports addressing specific situational and environmental
    conditions at a particular time or place of concern. Records in ILER
    will be available to claims adjudicators and health care providers in
    real-time as they work with Veterans to develop claims files or provide
    care.
        Because of the specific requirements of the law, VA will not rely
    upon ILER for purposes of adjudicating Blue Water Navy claims. In
    identifying vessels that traveled within 12 nautical miles seaward from
    the Vietnam water demarcation line as defined by the law, VA has
    collaborated with the National Archives Records Administration and the
    Naval History and Heritage to scan and transcribe deck logs for the
    eligible ships over a 10-year timeframe. The data will then be
    populated into an electronic repository, which will be utilized by
    claims processors to determine whether a ship operated in the offshore
    waters during the prescribed timeframe.
                         burn pits and airborne hazards
        Question 2. Will servicemembers have access to data from ILER and
    other DOD records when they are trying to show a disability caused by
    exposure to burn pits?
        Response. Yes, Veterans will be able to see and have copies of
    their respective individual summary ILER data. The amount of summary
    data available will improve over time as the ILER is developed from
    Initial Operating Capability to Full Operating Capability.
                                  agent orange
        Question 3. Why has the VA not added bladder cancer,
    hypothyroidism, hypertension, and Parkinson-like symptoms as
    presumptive disabilities, since the National Academy of Sciences
    recommended it in 2016?
        Response. This is still in deliberation.

        Question 3a. In a January 17th letter, Secretary Wilkie indicated a
    decision on these conditions could be expected summer 2019. During a
    March 26th hearing, Dr. Richard Stone of the Veterans Health
    Administration stated that a decision could be expected within the next
    90 days. Why have these decisions been delayed?
        Response. This is still in deliberation.
                              palomares radiation
        Question 4. Secretary Wilkie committed to using a scientifically
    valid dose estimate methodology to evaluate Palomares veterans'
    radiation exposure in June 2018. Over a year later, the VA continues to
    use the Air Force's flawed methodology. Why has the VA continued to use
    this faulty methodology, and when will it reform its methodology to
    provide the benefit of the doubt for Palomares veterans as required by
    law?
        Response. The Air Force Medical Service contracted out a ``re-
    look'' of exposure and biological monitoring data using the most up-to-
    date methods for estimation of plutonium intake and committed dose
    (total dose integrated over a 50-year period following intake). That
    effort, completed in 2001, confirmed the overall conclusions from 1968
    that adverse health effects would not be expected for responders to the
    accident, but offered three recommendations on actions that might be
    taken to improve the estimates of plutonium intake and committed doses,
    and provide further explanation of the discrepancy between the initial
    high bioassay (urinalysis) results and exposure estimates from
    environmental sampling.
        The methodology used is not flawed (VA and USAF). The question
    around the radiation doses comes from a number of contaminated samples
    that were excluded from the initial analyses. The original Labat-
    Anderson report and the USAF (most recently as 2014) have addressed the
    issue in detail. Most of the Veterans who participated had no dose or a
    dose that was barely above the lowest limit of detection. As a result
    of the most recent USAF communication to VBA, we have used the highest
    calculated doses for individual Veteran claims, which does indeed give
    benefit of doubt to the Veteran.

        Question 4a. Around 1,600 servicemembers participated in the
    Palomares clean-up, nearly all of them airmen from a nearby U.S. Air
    Force base. Some servicemembers have since passed away, many due to
    illnesses arising from radiation exposure at Palomares. How many
    Palomares veterans are still alive today?
        Response. VA received a Defense Threat Reduction Agency (DTRA) file
    of individuals who served at the Palomares location. There were 1465
    unique observations. After making attempts to fill in missing data for
    social security numbers (SSN), which is required to complete a search
    for causes of mortality, there remained 273 records with no SSN. [Many
    of these 273 had Spanish surnames and may have been Spanish citizens.]
    This leaves a list of 1192 persons with a valid SSN. Of the list of
    1192 with a valid SSN, 923 (60 percent) have been previously submitted
    to the National Centers of Disease Control, National Death Index (NDI).
    The most recent search of mortality records through 2016 shows that for
    the period captured by the National Death index (1979-2016) VA searched
    923 records and identified 450 deaths. As of the fourth quarter of FY
    2019 there remain 269 Palomares Veterans who have not yet been
    searched in the NDI.
        VA is developing the submission list for the NDI search for the
    2018 mortality file. This submission will include the entire list of
    1192 Palomares Veterans who have a valid SSN and should provide an
    accurate count of vital status through calendar year 2018.

        Question 4b. How many Palomares veterans have applied for benefits
    connected to their radiation exposure at Palomares?
        Response. VA does not track, at the corporate level, every specific
    exposure location, such as Palomares, for claims for service connection
    based on radiation exposure. Therefore, VA cannot accurately identify
    the number of Veterans who participated in the Palomares clean-up
    efforts and have applied for benefits.

        Question 5. If the Palomares Veterans Act of 2019 (S. 1896) were
    passed into law as it is currently written, what is the expected cost
    and maximum cost to the VA?
        Response. Without data on the number of living Palomares Veterans
    or data on previous claims, VA is unable to provide accurate benefits
    costs projections. Cost estimates would need to be developed by VHA
    Forecasting. PDHS has requested data on the Palomares Veterans in order
    to look at health outcomes. Any Veteran may submit a claim for any
    illness that they believe was caused by military service. Claims
    involving radiation are reviewed by a health physicist in VA's Post
    Deployment Health Services.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
                            blue water navy veterans
        Question 1. Earlier this year, Congress passed and the President
    signed legislation to establish presumptive eligibility for Blue Water
    Navy Veterans, a policy I have long supported. However, the VA has
    decided to implement a stay on all claims until January 1, 2020. I
    continue to hear from veterans in my state, asking when they will be
    able to access these benefits. These veterans have already waited a
    long time. How does the VA justify making them wait even longer to seek
    relief?
        Response. The Blue Water Navy Vietnam Veterans Act of 2019 (Act),
    Public Law 116-23 that was signed into law on June 25, 2019, and goes
    into effect on January 1, 2020, gave the Secretary of Veterans Affairs
    the discretionary authority to issue a stay of pending claims in order
    to prepare for implementation of the Act. This authority was exercised
    on July 1, 2019, based on reasoned judgment that it was in the best
    interest of Veterans and the VA adjudication system as a whole.
        As HVAC recognized, the Procopio v. Wilkie court decision did not
    define the term ``territorial sea.'' H.R. Rep. No. 116-58, at 11
    (May 10, 2019). Although some claimants may have been eligible for
    benefits under the Procopio ruling, the stay became necessary to ensure
    that VA will process and adjudicate all Blue Water Navy claims in an
    accurate and orderly fashion by carefully implementing the ``broad and
    comprehensive'' definition of service in the Republic of Vietnam that
    Congress intended. VA is also working to ensure that the proper
    resources are in place to meet the needs of the Blue Water Navy Veteran
    community and all Veterans filing for disability compensation and
    survivors claiming Dependency Indemnity and Compensation. In addition,
    VA is using this time, until January 1, 2020, to build tools for claims
    adjudication and to develop evidence for the claims to appropriately
    identify those who served offshore of Vietnam. Once these issues are
    addressed, VA will begin processing these claims based on the date that
    the law goes into full effect.
        Although VA stayed the issuance of decisions until the new law
    becomes effective on January 1, 2020, VA is authorized to effectuate
    Board of Veterans' Appeals decisions, issued before July 1, 2019,
    directing a grant of benefits; VA is currently effectuating those
    granted benefits. Also, VA continues to concede herbicide exposure and
    award service connection under existing rules and procedures. These
    include Veterans who are shown to have served in or visited the country
    of Vietnam (``boots on ground'') and those who served on vessels on the
    inland waterways of Vietnam.
                                   burn pits
        Question 2. In talking with veterans in my state, I hear warnings
    that burn pits will be this generation's Agent Orange. We have an
    obligation to our servicemembers and veterans to ensure this generation
    does not have to wait decades for care and benefits needed to address
    illnesses caused by their service. What action is the VA taking now to
    ensure veterans exposed to burn pits can be properly diagnosed,
    treated, and cared for?
        Response. For Veterans enrolled in VA's health care system,
    treatment of their conditions is the same regardless of etiology. For
    example, asthma treatment is the same for all causes of asthma.
    Generally stated, applicable standards of care dictate what is
    necessary and appropriate treatment, not possible disease etiologies.
        Veterans' primary care teams can, as part of their care, complete a
    clinical evaluation of symptoms and concerns related to Veterans' self-
    reported burn pit smoke exposure(s). As clinically indicated, Veterans
    are referred for necessary diagnostic testing and specialty care within
    the VHA system of care, or, if eligible, to needed specialty care in
    the community.
        For enrollees with difficult-to-diagnose or poorly controlled
    symptoms, a clinical referral can also be made to AHBPCE at the War-
    Related Illness and Injury Study Center (WRIISC-NJ). In addition,
    AHBPCE is reaching out to AHOBPR Veteran-participants who appear to
    have high priority conditions. AHBPCE is inviting these individuals to
    come to AHBPCE for a comprehensive in-person clinical evaluation to
    facilitate their diagnosis and management, and to learn more about the
    health conditions being experienced by this cohort of Veterans.
        As noted, for Veterans who are not enrolled in VA's health care
    system but who are eligible to participate in the AHOBPR, once they
    have completed the online AHOBPR questionnaire, they may request an
    optional in-person registry medical examination at no cost. This
    examination is not, however, for treatment purposes and does not serve
    as a basis for either enrollment in VA's health care system or service-
    connection for purposes of VBA-administered benefits. The VA clinician
    performing the registry examination uses a standardized medical note
    template to ensure complete assessment and capture of the registry-
    required clinical data. Necessary tests and specialty care can also be
    provided at no cost as part of the registry examination.

        Question 2a. What are the barriers facing the VA in meeting this
    mission?
        Response. There are about 300 EHCCs system-wide; they are typically
    aligned under Primary Care Services. VHA has considered, and will
    continue to consider, the merits of having large VAMCs operate
    independent EH programs and clinics with their own dedicated EH staff.
    For now, due to resources and other reasons, establishing independent
    EH programs and clinics at these facilities remains an individual VAMC
    decision.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
     Patricia R. Hastings, M.D., Chief Consultant, Post-Deployment Health,
                      U.S. Department of Veterans Affairs
        Question 1. As part of legislation created by Congress, the new
    Airborne Hazards and Burn Pits Center of Excellence was stood up in May
    at the VA's War-related Illness and Injury Center in East Orange, New
    Jersey. From what we know, respiratory issues will make up a large part
    of its research, since the most obvious immediate impact of burn pits
    is on the respiratory system. However, similar to what we say with
    Agent Orange it's likely that there are far more conditions that should
    be studied. What is the timeline for what conditions will be studied
    and when?
        Response. Please see Attachment 3 for a list of ongoing research
    projects.
     attachment 3: completed, ongoing, and planned post-deployment health
                               studies in humans

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Question 1a. When will the center study other health issues like
    cancer, autoimmune diseases, endocrine system issues, and cognitive
    dysfunction? What resources do you need to accelerate this research?
        Response. VA's Office of Research and Development (ORD) routinely
    solicits additional investigator proposals to conduct research related
    to toxic exposures and respiratory hazards. ORD and VA Post Deployment
    Health Services (PDHS) review disease trends to assess for new
    disease(s) which might be increasing in the affected community and
    suggest need for greater attention by clinicians and researchers.
        The initial focus of the AHOBPCE is on unexplained dyspnea and
    decreased exercise tolerance. In addition, the team has begun looking
    at the AHOBPR data in conjunction with the VHA electronic medical
    record data and diagnoses to detect other conditions. Two other
    conditions are currently being studied--pancreatic cancer and
    sarcoidosis. Other conditions will be added as we follow trends in the
    registry. Additional capacity and capabilities in analyzing large data
    sets more thoroughly and in real time would accelerate discovery and
    translation of findings into the public view. ILER will enhance these
    activities with additional information about deployment-related
    exposures.

        Question 2. Other than the Center of Excellence, what is the VA
    doing to study all relevant health issues due to open air burn pits?
        Response. NASEM is conducting a review of all the literature
    through an expert panel on AHOBP to answer this question and others
    related to burn pits. We anticipate the report to be released Spring
    2020.

        Question 2a. Can you share with us a master list of health issues
    being studied, by whom, and when?
        Response. VA and DOD work together and with academia on issues
    related to Airborne Hazards. Please see the attached list (Attachment
    3) and the following subset:

        1. The Study of Active Duty Military for Pulmonary Disease Related
    to Environmental Deployment Exposure (STAMPEDE) Michael J. Morris, MD
    (DOD)
        2. Service and Health Among Deployed Veterans study Eric Garshick,
    MD (VA)
        3. The Millennium Cohort Study by Rudolph P. Rull, Ph.D., MPH (DOD)
        4. National Health Study for a New Generation of U.S. Veterans (New
    Gen) and Comparative Health Assessment Interview (CHAI) studies Aaron
    Schneiderman, Ph.D., MPH, RN (VA)
        5. Effects of Deployment Exposures on Cardiopulmonary and Autonomic
    Function (AirHzds) study Michael J. Falvo, Ph.D. (VA)
        6. The Gulf War Era Cohort and Biorepository Wu, MD, R. Ryanne MHS
    (VA)

        Question 3. How many Veterans who have applied for benefits through
    BVA for Burn Pit related conditions have been approved/denied?
        Response. Veterans do not apply for benefits through the Board of
    Veterans' Appeals; Veterans can only appeal to the Board.
        VA is able to provide data for Veterans who applied for service-
    connected disability benefits through the Veterans Benefits
    Administration for Burn Pit related conditions. As of November 1, 2019,
    11,799 Veterans had their claims completed for disabilities based on
    exposure to burn pits. From that number, 2,629 Veterans have been
    awarded service connection for a medical condition related to burn pit
    exposure.

        Question 3a. What are the leading causes for being denied?
        Response. The Board is unable to readily track the specific Burn
    Pit related decision outcomes; however, these are tracked within VBA
    which shows the most common reason for denials of burn pit related
    claims is that the claimed condition was not incurred during or caused
    by military service.
        The second most common reason is that there was no current
    diagnosis associated with the claimed condition.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Jon Tester to Terry
       M. Rauch, Ph.D., Acting Deputy Assistant Secretary of Defense for
       Health Readiness Policy and Oversight, U.S. Department of Defense
                 individual longitudinal exposure record (iler)
        Question 1. What challenges or opportunities have been identified
    during the ILER pilot program?
        Response. One challenge in implementing the ILER program is the
    declassification of location data for deployed Servicemembers. To
    associate exposure assessments conducted in specific deployment
    locations, the date and location of each deployed Servicemember is
    needed. A large amount of location data was declassified to support
    development of the ILER Pilot and recent release of the ILER Initial
    Operational Capability. DOD is working with each Service classification
    authority to determine an automated process for routinely declassifying
    these data. The biggest opportunity for ILER is the ability to build
    occupational and environmental exposure profiles for each Servicemember
    to ensure proper, appropriate, and sufficient medical care is available
    to meet the Servicemember needs into the future, to support exposure
    epidemiological studies, and to assist the Veteran with adjudication of
    claims related to exposures and health outcomes.

        Question 2. How will those challenges or opportunities be used to
    inform the future deployment of the ILER?
        Response. The challenges identified will influence development by
    improving our planning and enhancing our ability to establish
    agreements and data sharing policies. It has also made us more able to
    develop a technology agnostic data exchange standard and improving
    processes that should drastically reduce the time required to bring in
    new data sets. As ILER capabilities are developed, more types and
    sources of exposure data will be integrated into the individual
    Servicemember exposure profiles, providing a more comprehensive
    assessment of military service-related exposures. This will provide a
    ready resource for assessing multiple chemical exposures that is not
    possible today.

        Question 3. How will the ILER be interoperable or integrated with
    Military Health System (MHS) Genesis and the VA's Electronic Health
    Record (EHR) modernization solution?
        Response. Requirements for this are being defined. The current
    requirements (which we are funded for) are for interoperability where
    ILER would have an interface to the EHR and correlate medical encounter
    and health data relevant to the exposure incidents. The EHR vendor and
    DOD/VA Interoperability Office are scheduled to include ILER
    integration into their development timeline. Current and short term
    efforts include providing read-only access, using Joint Legacy Viewer
    (JLV), for individual exposure summaries.

        Question 4. What is the current timeline to full deployment of the
    ILER? Do you anticipate further delays, or additional costs with
    deploying ILER?
        Response. Current timeline is to reach Full Operating Capability
    (FOC) deployment not later than September 30, 2023. There are some key
    efforts that allow us to progress toward FOC, including integrating
    thirty data sources identified as the most valuable, most relevant, and
    highest priority. Unanticipated data quality and availability
    challenges will determine delays to FOC or additional costs for
    complete deployment.

        Question 5. DOD continues to utilize several methods and
    recordkeeping systems to document certain environmental and
    occupational exposures to servicemembers. Before the ILER is fully
    deployed, are there any efforts to improve this process as an interim
    solution?
        Response. There are a variety of possible mechanisms that currently
    exist for informing Servicemembers when the results of an exposure
    assessment show an increased health risk. These are all
    contemporaneous, in that the personnel exposed at the time are most
    likely to get this information. The Armed Forces Health Surveillance
    Branch (AFHSB) is tasked to coordinate health surveillance activities
    with each Service's public health division so that information about
    increased threats to health are communicated to the Combatant
    Commanders. Each Service has their own mechanism for sharing that
    information with their respective Servicemembers. The AFHSB also has
    registries for known exposure events that allow for direct
    communication with participating Servicemembers if new medical or
    health information becomes available.

        Question 6. Will servicemembers and veterans have access to their
    ILER data?
        Response. Yes, when ILER is fully deployed and integrated with the
    new DOD electronic health record. Otherwise, Servicemembers can request
    their ILER data through their medical providers.

        Question 7. If I'm a servicemember or veteran that served on a base
    where it turns out that the air is full of contaminants that I didn't
    know about, how would I find out about that exposure, aside from the
    manifestation of a health condition?
        Response. Exposures that potentially increase their risk for
    illness or disease will be identified, much like a public health
    assessment, so that actions can be taken to reduce the risk. Currently,
    DOD implements outreach programs to Servicemembers and veterans, in
    coordination with the VA, when there is an established/known exposure.
    When ILER is fully implemented, Servicemembers will be informed of
    their exposures when they visit their military care provider or when
    they have access to their EHR.

        Question 8. Who is responsible for the outreach to servicemembers
    when we do identify dangerous exposures?
        Response. The primary persons responsible for outreach to
    Servicemembers regarding dangerous exposures include commanders,
    supervisors, medical staff and environmental health/industrial hygiene
    specialists at installation and unit level; healthcare providers,
    including primary care and specialty care providers via the Medical
    Treatment Facility network; and Service Public Health organizations.
                             exposure to burn pits

        Question 9. In June 2018, the Government Accountability Office
    (GAO) reported that the VA planned to work with DOD to update their
    Airborne Hazards Joint Action Plan by the third quarter of FY 2018.91.
    Could you please describe the process for working with the VA to update
    the Action Plan, including the selection of research priorities to
    better understand the potential health risks associated with exposures
    to burn pit emissions?
        Response. DOD and VA scientists work together on an interagency
    committee, called the DOD/VA Deployment Health Work Group (DHWG). This
    group wrote the initial Joint Action Plan on Airborne Hazards. DHWG
    scientists update the Plan periodically to incorporate new agency
    practices and new scientific information. For example, the Plan was
    updated when VA established the VA Open Burn Pits Registry. DHWG
    scientists periodically review the new research on the potential health
    risks associated with exposures to burn pit emissions. They consider
    published results from clinical studies and epidemiological studies.
    They identify research questions for which there are large gaps in
    understanding, based on the currently available results. The scientists
    make recommendations that those research gaps should be considered for
    future research priorities.

        Question 10. Has DOD established policies to assess the pulmonary
    health condition of servicemembers before they are deployed to
    locations with known airborne hazards?
        Response. Current DOD policies require annual periodic health
    assessments, and pre-/post-deployment health assessments that establish
    Servicemembers' general health status, which includes pulmonary health
    conditions. Follow on pre- and post-deployment health assessments do
    assess pulmonary type conditions. These individual health assessments
    include questionnaires, medical provider reviews, and specialty
    referrals (if indicated) addressing individual Servicemember concerns
    about deployment environmental exposures and potentially related health
    issues. These policies and assessments provide guidance on conducting
    periodic health risk assessments at deployment sites, including
    monitoring emissions from operational burn pits and other airborne
    hazards. These assessments are used to inform decisions that mitigate
    health risks, document potential exposures, inform medical care, and to
    compile publically-available Periodic Occupational and Environmental
    Monitoring Summary (POEMS) reports for geographically-associated
    forward operating bases in Iraq, Afghanistan and other operational
    areas. Furthermore, the policies direct pre- and post-deployment health
    assessments for deployed Servicemembers; an annual periodic health
    assessment for all Servicemembers; and upon separation or retirement
    from military service, a separation history and physical exam to
    facilitate the transfer of care from the DOD to the VA.

        Question 11. How many servicemembers has DOD had to medically
    retire for conditions related to Airborne Hazards and/or burn pit
    exposure?
        Response. Additional time is required to assess the available data
    necessary to provide an accurate answer.

        Question 12. How many servicemembers have been medically discharged
    since 2001 for pulmonary conditions or explained shortness of breath?
        Response. Additional time is required to assess the available data
    necessary to provide an accurate answer.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
    Terry M. Rauch, Ph.D., Acting Deputy Assistant Secretary of Defense for
       Health Readiness Policy and Oversight, U.S. Department of Defense
              best practices for mitigating environmental hazards
        Question 13. Dr. Rauch, what are some of the best practices that
    the DOD has discovered to be most effective to mitigate the damage done
    by environmental hazards such as burn pits? Does DOD have plans to
    expand these best practices to all burn pit sites? If not, why not?
        Response. DOD has implemented guidance, DOD Instruction 4715.19,
    Use of Open-Air Burn Pits in Contingency Operations, November 13, 2018,
    for the Military Departments and Combatant Commanders to determine the
    need for burning any trash, health risk assessments when trash burning
    is operationally required, procedures for safely operating the burn
    pit, and the proper collection and disposal of the ashes. The guidance
    also requires congressional notification if the burn pit must be
    operated for an extended period of time.
                            elimination of burn pits
        Question 14. Dr. Rauch, do you believe that the DOD should push out
    policies directed to specific units that will ultimately lead to the
    elimination of burn pit usage?
        Response. Current policy and guidance is adequate to meet our
    current operational requirements. As new waste disposal technology is
    developed, DOD will make adjustments that do not impact operational
    readiness and force security.
                            research and development
        Question 15. Dr. Rauch, has DOD allocated enough resources to
    research and development on this burn pit exposure? If so, what is the
    status on some of the conclusions drawn from these types of research?
    If not, what can this Committee do in order to guarantee the reduction
    or elimination of burn pits and other environmentally harmful
    practices?
        Response. DOD and VA have funded and continue to fund many studies
    on the potential health effects of exposure to airborne hazards during
    deployments, including burn pit emissions, sand storms, and other
    sources of air pollution. This includes personnel who were deployed
    during Operation Iraqi Freedom and Operation Enduring Freedom. Many
    human health studies have been published, and some long-term follow-up
    studies are continuing. These include in-depth clinical studies, as
    well as very large epidemiological studies. The National Academy of
    Sciences, Engineering and Medicine (NASEM), an independent scientific
    organization, published a long, comprehensive review of the health
    effects of airborne hazards in theater in 2011, titled: ``Long-term
    Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan.''
    While the NASEM report concluded there was insufficient evidence of
    long-term health risks associated with burn pit exposure, the report
    found that negative health effects (particularly respiratory) were
    plausible due to particulate matter, albeit burn pits were likely one
    of many factors. The reviewed literature provided limited but
    suggestive evidence of decreased pulmonary function associated with
    combustion products. However, there was insufficient evidence of an
    association between exposure to combustion products and cancer,
    respiratory disease, circulatory disease, neurologic disease, or
    adverse reproductive and developmental outcomes in the populations
    studied. The VA commissioned and updated NASEM review of health
    outcomes that may be related to airborne hazards. The report, ``Medical
    Effects of Airborne Hazards and Open Burn Pits'' is expected to be
    published in May 2020. On the basis of the available peer-reviewed
    published research, we do know that military personnel deployed to Iraq
    and Afghanistan appear to experience elevated rates of acute upper
    respiratory symptoms during deployment and may be at greater risk for
    post-deployment respiratory symptoms and respiratory illnesses. DOD has
    and will continue to collaborate with the VA, other Federal agencies,
    academia and others on epidemiological and health-related research
    focused on full understanding of potential long-term health outcomes
    associated with burn pit and other complex airborne exposures during
    deployments.
                                     ______

     Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
    Terry M. Rauch, Ph.D., Acting Deputy Assistant Secretary of Defense for
       Health Readiness Policy and Oversight, U.S. Department of Defense
                            burn pit air sample data
        Question 16. Dr. Rauch, if DOD has weekly air sample data from burn
    pits that routinely show particulate matter exceeding EPA health
    standards, has DOD shared that raw data with VA, or outside experts to
    build a comprehensive picture of what our servicemembers, civilians,
    contractors, and the local populations were exposed to? And if not, why
    not?
        Response. Military Department deployed preventive medicine teams
    conduct periodic exposure monitoring, including monitoring of airborne
    exposures, at contingency locations per DOD policy for deployment
    health and use of open-air burn pits. The exposure monitoring
    analytical results are used to construct health risk assessments,
    Occupational and Environmental Health Site Assessments (OEHSA),
    Periodic Occupational and Environmental Monitoring Summaries (POEMS),
    and Incident Reports, which are entered into the Defense Occupational
    and Environmental Health Readiness System (DOEHRS). DOEHRS data is
    available to VA. A significant improvement over the past year is the
    development and fielding of the Individual Longitudinal Exposure Record
    (ILER) which will now be a primary means to share individual exposure
    data between DOD and VA. DOD also provides health surveillance
    information to the VA upon request through sharing agreements. Sharing
    information requires specific conditions to be satisfied to protect
    sensitive health information from being released. When outside experts
    request DOD exposure information, the request may include an
    institutional review board-approved protocol that ensures that the any
    information covered under the Privacy Act is necessary and protected.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
    to Terry M. Rauch, Ph.D., Acting Deputy Assistant Secretary of Defense
     for Health Readiness Policy and Oversight, U.S. Department of Defense
                         burn pits and airborne hazards
        Question 17. What is DOD doing to mitigate the effects of burn pits
    and airborne hazards to our servicemembers? How often is air quality in
    deployed locations tested, and what equipment is used to test it?
        Response. DOD recognizes and is concerned about the potential acute
    and chronic health effects of burn pits and other airborne hazards to
    Servicemembers and Veterans. Achieving a reduction in the use of burn
    pits, improved exposure monitoring and documentation of ambient air
    conditions, and health risk mitigation are the primary focus areas at
    the operational level. Collaborative and targeted research to better
    understand potential health effects from exposures and better inform
    health care is also a primary focus area of the Department. Specific
    initiatives focused on protecting the health of our Servicemembers
    include: o Recently issued updated policies and procedures, including
    Deployment Health, that details extensive pre-, during, and post-
    deployment health activities, and Use of Open-Air Burn Pits that
    requires additional monitoring and health risk assessments. o Routine
    monitoring, health risk assessments, and mitigation of environmental
    exposures from all sources, including airborne exposures from burn pits
    and other pollution sources: completed and electronically logged over
    1,000 deployment-related Occupational and Environmental Health Site
    Assessments (OEHSA) of base camps, and 139 Periodic Occupational and
    Environmental Monitoring Summaries (POEMS). o Reduced use of burn pits
    to 14 sites (as of Oct 2019 reports) via use of landfills, contracted
    hauling of waste off the operating base, and incinerators. o Periodic
    health assessments (PHA), pre- and post-deployment health assessments,
    and mental health assessments: this comprehensive health assessment,
    coupled with other as needed specific medical evaluations, allows for
    multiple Servicemember and healthcare provider interactions to evaluate
    exposure concerns, and treat any resulting medical conditions. o
    Medical research to enhance our understanding of health effects from
    exposures to burn pits and other airborne hazards: the DOD and VA have
    funded and continue to fund studies on the potential health effects of
    exposure to airborne hazards during deployment. Many human health
    studies have been published and some long-term follow up studies are
    continuing. o Health risk communications to Servicemembers and their
    providers: an ongoing effort to continuously communicate known and
    potential health risks, including mitigation of hazards, in the
    garrison, training and deployed environments. DODI 9490.03, Deployment
    Health, requires a Periodic Occupational and Environmental Monitoring
    Summary (POEMS) to be conducted annually at the direction of the
    Combatant Commander. Any environmental sampling conducted as part of a
    POEMS is done using approved EPA methods. Occupational and
    Environmental Health Site Assessments (OEHSA) are conducted as needed
    to ``identify and provide recommendations to manage OEH threats and
    their sources at a particular deployment site (e.g., base camp,
    airbase, forward operating base (FOB)) with complete or potentially
    complete exposure pathways to a current or future deployed
    population.'' Any air quality sampling conducted as part of a POEMS is
    done using approved sampling and analytical methods that includes the
    equipment. Data collected to support a POEMS or OEHSA are entered into
    the Defense Occupational and Environmental Health Exposure Readiness
    System (DOEHRS), the DOD system of record for recording occupational
    and environmental health monitoring data.
        Question 18. Going forward, how will DOD ensure that ILER is
    actually used to document airborne exposures? Will servicemembers have
    access to data from ILER and other DOD records when they are trying to
    show a disability caused by exposure to burn pits? How would
    servicemembers access classified data and records from DOD to prove
    exposure?
        Response. The primary emphasis will be implementing installation
    and deployed occupational and environmental health policy that directs
    periodic and incident exposure monitoring. Monitoring includes entering
    exposure measurements and risk assessments into the into DOEHRS. DOEHRS
    is and will be the primary exposure data source extracted to populate
    the ILER and present the information to designated users. Yes, when
    ILER is fully deployed and integrated with the new DOD electronic
    health record. Otherwise Servicemembers can request their ILER data or
    their medical records from their medical providers or from their
    medical treatment facilities, respectively. Due to security and
    classification concerns and policies, access continues to be a
    challenge that DOD is addressing with the Military Departments and
    Combatant Commanders who control the classification of data for
    specified operations, and potential
                              palomares radiation
        Question 19. Will DOD commit to looking into the Palomares
    exposures, and establishing a more accurate scientific methodology for
    determining how much radiation these veterans were exposed to?
        Response. The Department is committed to looking into possible
    exposures of Servicemembers to radiation and airborn hazard exposures.
    DOD is also committed to medical research to enhance our understanding
    of health effects from exposures and continue to fund studies on the
    potential health effects of exposure.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
    Terry M. Rauch, Ph.D., Acting Deputy Assistant Secretary of Defense for
       Health Readiness Policy and Oversight, U.S. Department of Defense
                         testing for pfas contamination
        Question 20. PFAS, a class of chemicals used in firefighting foam
    and flame retardant clothing, are highly toxic and very persistent. I
    understand the Department of Defense (DOD) has tested drinking or
    groundwater on or around hundreds of military sites for PFAS
    contamination. Has DOD tested the water at military sites in Hawaii? If
    so, did you find contamination? If not, when do you expect that testing
    to occur?
        Response. In June 2016, DOD directed the Military Departments to
    test for PFOS/PFOA where DOD supplies drinking water to the
    installation. No installations in Hawaii tested above the Lifetime
    Health Advisory (LHA) established by the Environmental Protection
    Agency.
                              preventing exposures
        Question 21. What is DOD doing to prevent exposing our
    servicemembers to toxins? Are you taking proactive steps to ensure that
    our military understands the immediate and long-term health impacts of
    potential occupational and environmental exposures before we expose
    troops?
        Response. DOD Instruction 6490.03, ``Deployment Health'' requires
    Periodic Occupational and Environmental Monitoring Summary (POEMS) to
    be conducted annually at the direction of the Combatant Commander. Any
    environmental sampling conducted as part of a POEMS is done using
    approved EPA methods. Occupational and Environmental Health Site
    Assessments (OEHSA) are conducted as needed to ``identify and provide
    recommendations to manage OEH threats and their sources at a particular
    deployment site (e.g., base camp, airbase, forward operating base
    (FOB)) with complete or potentially complete exposure pathways to a
    current or future deployed population.'' Any air quality sampling
    conducted as part of a POEMS is done using approved sampling and
    analytical methods that includes the equipment. Data collected to
    support a POEMS or OEHSA are entered into the Defense Occupational and
    Environmental Health Readiness System (DOEHRS).
                                   burn pits
        Question 22. In talking with veterans in my state, I hear warnings
    that burn pits will be this generation's Agent Orange. We have an
    obligation to our servicemembers and veterans to ensure this generation
    does not have to wait decades for care and benefits needed to address
    illnesses caused by their service. What actions is the DOD taking now
    to ensure servicemembers exposed to burn pits can be properly
    diagnosed, treated, and cared for? What are the barriers facing the DOD
    in meeting this mission?
        Response. In 2016, DOD implemented a policy requiring every
    Servicemember to have an annual periodic health assessment that
    includes questions about exposures during deployments and any
    respiratory system health issues. The medical provider can use this
    assessment as a tool to arrange any follow-up medical tests or
    examinations to address any respiratory system health complaints or
    concerns. Servicemembers also complete post-deployment health
    assessments that provide several opportunities for the Servicemember to
    discuss their overall health and specific health concerns.

                                A P P E N D I X

                                  ----------

                   Prepared Statement of The American Legion
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Committee; On behalf of National Commander James W. ``Bill''
    Oxford, and the nearly 2 million members of The American Legion, thank
    you for inviting The American Legion to submit the following testimony
    on ``Toxic Exposure and Examining the Presumptive Disability Decision-
    Making Process.''
        The American Legion has long been at the forefront of advocacy for
    veterans who have been exposed to environmental hazards such as Agent
    Orange, Gulf War-related hazards, ionizing radiation, the various
    chemicals and agents used during Project Shipboard Hazard and Defense
    (SHAD), and contaminated groundwater at Camp Lejeune. The American
    Legion continues to urge the study of all environmental hazards and
    their long-term effects they have on our servicemembers, veterans, and
    their families.
        The effects of the often dangerous environments in which
    servicemembers operate is a top concern of The American Legion, as
    thousands of veterans who are or have been exposed to various toxins
    are often left behind when it comes to vital treatments and benefits.
    The American Legion remains committed to ensuring that all veterans who
    served in areas of exposure receive recognition and treatment for
    conditions linked to environmental exposures.
        To this end, The American Legion has been meeting with the newly
    formed veteran and military toxic exposure working group called the
    Toxic Exposure in the American Military (TEAM) coalition, which
    includes 15+ Veteran Service Organizations (VSO) and Military Service
    Organizations (MSO) all addressing toxic exposure issues. Currently,
    the members of TEAM include, Wounded Warrior Project, BurnPit360, Cease
    Fire Campaign, Hunter Seven, Iraq and Afghanistan Veterans of America,
    Military Officers Association of America, Tragedy Assistance Program
    for Survivors, Veteran Warriors, Vietnam Veterans of America, Enlisted
    Association of the National Guard of the United States, California
    Communities Against Toxics, National Veterans Legal Services Program,
    Vets First, and the Dixon Center.
        Our advocacy also includes the filing of an October 15, 2018 amicus
    brief in the case of Procopio v. Wilkie. On January 29, 2019, the U.S.
    Court of Appeals for the Federal Circuit handed a major victory for
    Blue Water Navy veterans in their long fight for Department of Veterans
    Affairs (VA) benefits to treat illnesses linked to exposure to Agent
    Orange during the Vietnam War.\1\
    ---------------------------------------------------------------------------
        \1\ Procopio v. Wilkie, 913 F.3d 1371, 1387 (Fed. Cir. 2019)
    ---------------------------------------------------------------------------
        Procopio presented two issues for the full Federal Circuit to
    consider:

        1. Does the definition of ``Vietnam'' in 38 U.S.C. Sec. 1116
    include the territorial waters? (i.e.,Should blue-water Navy veterans
    be presumed to have been exposed to Agent Orange and awarded benefits
    for conditions presumptively related to exposure?)
        2. What is the interaction between the Chevron canon that courts
    defer to agencies in interpreting statutes and the Gardner canon that
    veterans benefits statutes are to be liberally construed in favor of
    veterans? (i.e.--When a veterans benefits statute is unclear, do the
    courts generally have to accept VA's interpretation of what it says?)

        The Procopio decision rested on the plain meaning of Congress's
    words in the 1991 Agent Orange Act, specifically ``the Republic of
    Vietnam.'' According to international law, ``the Republic of Vietnam''
    includes the territorial waters within twelve nautical miles of the
    coast. This reasoning convinced most of the judges; however, our brief
    alternatively argued that the pro-claimant canon would result in
    granting the presumption of service connection.
        Because the court resolved the case without addressing our
    alternative argument, this testimony will rehearse some of the argument
    and considerations in our amicus brief on the second issue, which has
    bearing on the topic being considered by the Committee in this hearing.
    The American Legion encourages Congress to review the amicus brief
    recognizing that court decisions commonly interpret congressional
    language.\2\
    ---------------------------------------------------------------------------
        \2\ http://www.vetlawyers.com/wp-content/uploads/2019/09/
    Procopio_Legion_Amicus_Brief_2018-10-15-1.pdf
    ---------------------------------------------------------------------------
                        summary of amicus brief argument
        In our brief, The American Legion joined Navy veteran Alfred
    Procopio Jr. in urging the Court to reverse the judgment of the lower
    court. It supported his argument that the intent of Congress is clear
    in this matter. However, it believes that the simple application of the
    principle of veteran-friendly interpretation of step one of the
    traditional analysis from Chevron U.S.A., Inc. v. NRDC, 467 U.S. 837,
    842 (1984), misstates the long-established relationship between
    Congress and the VA on veterans issues and downplays the interpretive
    principle that the Supreme Court reaffirmed after Chevron in cases such
    as King v. St. Vincent's Hospital, 502 U.S. 215 (1991), and Brown v.
    Gardner, 513 U.S. 115 (1994).
        The American Legion agreed that the application of proper deference
    resolves any lingering doubt as to the interpretive issue here.
    However, this particular application of the Gardner principle to a
    question of the scope of substantive entitlement serves an important
    role in counterbalancing the null hypothesis of science that typically
    works against veterans whose disabilities are related to service in
    hidden and complex ways. These are often difficult to understand on the
    timescales that flesh-and-blood veterans experience the employment
    impairment and mortality that the system was intended to compensate.
        Belatedly awarding benefits to Americans who served in Vietnam is
    small consolation to those who have lived a lifetime without proper
    compensation. The practical application of resolving interpretive doubt
    in favor of veterans often means erring on the side of supporting
    disabled veterans in need while their lives can still be changed,
    instead of waiting for a scientific consensus that might arrive--if
    ever--only after those who have borne the battle are no longer around
    to be cared for.
                         the null hypothesis of science
        One of the hallmarks of modern veteran disabilities is that
    invisible injuries can occur unnoticed, and often take years or decades
    to manifest as observable conditions. The general problem of caring for
    those harmed by exposures is a perpetual issue that will require
    constant attention due to the lack of knowledge about the conditions at
    the time of exposure. Despite advances in medicine and the ability to
    leverage big data, answers to complex issues of causation are still
    difficult to generate.
        The null hypothesis in science often creates a gap in which
    veterans go uncompensated for decades while evidence is developed to
    prove an association between their conditions and harmful exposures in
    service. The most difficult foe for veterans is not uncaring government
    bureaucrats but the remorseless law of science known as the null
    hypothesis. This is the baseline assumption that two observed facts
    have no relationship to each other until a proper application of the
    scientific method provides reliable evidence of a relationship.
        The development of this baseline was critical to overcoming ancient
    superstitions and developing the scientific method as a reliable way to
    generate knowledge. Nonetheless, when applied to the problem of
    providing benefits to veterans who were exposed to harmful agents in
    service, the result is that the award of benefits often lags decades
    behind the experiences of veterans and survivors who are affected by
    service but cannot successfully prove causation.
        Inevitably, whenever a new type of exposure affects veterans, some
    are at the front edge and develop problems first. Based upon their
    experience in service, they might have an intuition about why they
    became sick. Typically, the first complaints are rejected based upon a
    ``lack of evidence'' to support their suspicions. For example, it was
    1977 when VA received the first claim asserting a condition was caused
    by Agent Orange. However, that was only the beginning of a decades-long
    struggle to obtain recognition of the harms caused by the use of
    herbicides. As of 1988, VA recognized only the skin condition chloracne
    as related to Agent Orange and--even though it had received 150,000
    claims for conditions related to Agent Orange exposure--it had not
    granted a single one.\3\ Many of those most severely poisoned never
    lived to see their claims vindicated. Many others have now suffered for
    years without compensation.
    ---------------------------------------------------------------------------
        \3\ See Gerald Nicosia, Home to War: A History of the Vietnam
    Veterans' Movement 475 (2001); see also Diseases Associated with
    Exposure to Contaminants in the Water Supply at Camp Lejeune, 82 Fed.
    Reg. 4,173 (Jan. 13, 2017) (recognizing service connection for
    conditions caused by exposure to contaminated water for the more than
    three decades between August 1, 1953, to December 31, 1987).
    ---------------------------------------------------------------------------
        Typically, benefits are not retroactive prior to the filing of a
    claim, but even when large retroactive awards occur they still do not
    allow veterans to relive the years when they struggled without
    compensation. For example, veterans cannot retroactively choose to send
    their children to college without compensation. Veterans make endless
    choices about employment, retirement, health care treatment, and living
    circumstances that cannot be reversed decades later. Even when lost
    income is fully replaced, a lost lifetime of opportunity cannot be.
        The application of Gardner to issues such as this one serves--at
    least in a small way--to mitigate the effects of the null hypothesis.
    Initially, it always operates to cause the system to err on the side of
    denying benefits. However, once evidence becomes sufficient to generate
    action by Congress, liberally interpreting benefits is an appropriate
    way of erring on the side of compensation when the system has a long
    history of going in the opposite direction.
        In fact, there is no guarantee that science will ever be able to
    fully resolve the uncertainties involved in any issue.\4\ Therefore,
    some approach is required to deal with scientific uncertainty,
    recognizing that any approach carries a risk that it might be someday
    be judged as wanting in retrospect. Consistent with Gardner and the
    history of interpreting veterans benefits statutes, the proper approach
    is to resolve lingering uncertainty in favor of veterans, within the
    bounds of the benefits authorized by Congress, rather than wait for
    certainty that might never come while veterans continue to suffer and
    die.
    ---------------------------------------------------------------------------
        \4\ See, e.g., INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES,
    GULF WAR AND HEALTH, TREATMENT FOR CHRONIC MULTISYMPTOM ILLNESS 1
    (2010). (``Despite considerable efforts by researchers in the United
    States and elsewhere, there is no consensus among physicians,
    researchers, and others as to the cause of C[hronic] M[ultisymptom]
    I[llness]. There is a growing belief that no specific causal factor or
    agent will be identified.'' (emphasis added)).
    ---------------------------------------------------------------------------
        Additionally, rare conditions present additional difficulties. As
    Judge Newman lamented in her dissent in Bastien v. Shinseki, 599 F.3d
    1301 (Fed. Cir. 2010), the system is ill-equipped to handle rare
    conditions for which it is unlikely that there will ever be enough data
    to determine causation with scientific certainty, id. at 1307-08
    (Newman, J., dissenting). Combining all these uncertainties into a
    single, binary determination under the benefit of the doubt is a
    problem has never been squarely addressed. The correlation between the
    rare lung disease obliterative or constrictive bronchiolitis and
    exposure to open air burn pits used in Iraq and Afghanistan is just one
    example of where causation may not have been determined as yet, but the
    volume of correlative evidence is fairly clear and mounting as veterans
    of the last 18 years of war are beginning to seek help.\5\ If VA would
    empirically study the sample of veterans who have self-identified as
    having exposure symptoms in its own Airborne Hazards and Burn Pit
    Registry (with 165,000 registered thus far), perhaps causation and
    trends could be identified from the collected data.
    ---------------------------------------------------------------------------
        \5\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296566/
    ---------------------------------------------------------------------------
        Fortunately, the veterans benefits system is not based upon the
    scientific gold standard of ninety-five-percent confidence that an
    observed effect is real and not simply a random variation within a
    small sample. The paternalistic system is willing to act in the face of
    more uncertainty than that with which scientists are comfortable.
    Courts cannot change the standards established by Congress, they can
    apply interpretive doubt liberally in favor of veterans, as a partial
    bridge over the gap between differences in how the legal and the
    scientific worlds handle uncertainty. This dynamic, specifically the
    way in which the laws it writes are interpreted, is something Congress
    must consider as the presumptive disability decisionmaking process is
    reviewed.
                                   conclusion
        In 2017, Secretary Shulkin was considering recommending ``bladder
    cancer, hypothyroidism and Parkinson-like symptoms'' to the list of
    presumptive conditions linked to Agent Orange exposure as a result of a
    recently released Institute of Medicine study.\6\ The consideration of
    adding these conditions, some of which have not yet been implemented,
    comes nearly 50 years after the initial exposure and has resulted in
    some veterans suffering with these conditions for decades without the
    proper compensation.
    ---------------------------------------------------------------------------
        \6\ https://www.stripes.com/news/veterans/shulkin-will-decide-
    whether-to-add-more-conditions-to-agent-orange-list-by-nov-1-1.481353
    ---------------------------------------------------------------------------
        The American Legion has been the leading advocate for veterans
    exposed to Agent Orange since the first file was claimed in 1977. When
    VA failed to conduct congressionally-mandated studies, The American
    Legion commissioned its own study, not once, but twice.\7\ For over 40
    years, Legionnaires have tirelessly advocated on behalf of those that
    were exposed to these herbicides, to include filing lawsuits in Federal
    District Court.\8\ We are proud to have contributed to the efforts to
    pass the long overdue Blue Water Navy Act this past summer, but it is
    imperative that we do not put the current generation of servicemembers
    and veterans through an equally painful process.
    ---------------------------------------------------------------------------
        \7\ This study was known as The American Legion-Columbia University
    Vietnam Veteran Health Study. Approximately 12,000 members were
    surveyed to better understand, among other things, the impacts of
    herbicides exposure.
        \8\ https://www.nytimes.com/1990/08/02/us/american-legion-to-sue-
    us-over-agent-orange.html
    ---------------------------------------------------------------------------
        We call on VA to empirically study the sample of 165,000
    registrants of the Airborne Hazards and Burn Pit Registry, all of whom
    served on or after 9/11, during operations Desert Shield and Desert
    Storm, or in the Southwest Asia theater of operations after August 2,
    1990, and were deployed to a base or station where open burn pits were
    used or where possible exposures to toxic substances occurred. It also
    makes sense to separate these eras of war in order to accurately assess
    causation and trends in hazardous exposures.
        As Congress considers implementing new procedures to deal with
    contemporary toxic exposure issues like burn pits, it is crucial that
    the lessons of previous generations are taken into consideration. Due
    to the retrospective and ambiguous nature of this process, it is
    imperative that the presumptive disability decisionmaking processes, no
    matter what form they take, err on the side of the veteran.
        The American Legion is thankful for the invitation to submit this
    statement for the record and stand ready to assist when needed on these
    issues and any others that may arise. For additional information
    regarding this testimony, please contact Senior Legislative Associate
    Mr. Jeffrey Steele at (202) 861-2700 or jsteele@legion.org.
                                     ______

      Prepared Statement of Dr. Thomas Zampieri, President and Chairman,
                          Blinded Veterans Association

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                  ______

     Prepared Statement of Jonathan M. Samet, MD, MS, Dean and Professor,
                  Colorado School of Public Health, Aurora, CO
                                   background
        I write to provide comments for the September 25, 2019 Senate
    Veterans' Affairs Committee Hearing titled, ``Toxic Exposure: Examining
    the VA's Presumptive Disability Decision-Making Process.'' I presently
    hold the position of Dean and Professor at the Colorado School of
    Public Health. These comments are written based on my perspective from
    serving as Chair of the Institute of Medicine's (IOM) 2008 report:
    ``Improving the Presumptive Disability Decision-Making Process for
    Veterans.'' I have included two summaries from that report with my
    testimony: a general summary written for the public and the report's
    Executive Summary and the full report can be found at the following
    link (https://doi.org/10.17226/11908).
        Presumptions are made to cover gaps in information; as documented
    in the IOM report, presumptions have long been necessary in providing
    benefits to veterans, e.g., presumed exposure to Agent Orange during
    the Vietnam conflict based on time period, activities, and location of
    service. In 2004, Congress established the Veterans' Disability
    Benefits Commission (the Commission), which was charged with ``studying
    the benefits provided to compensate and assist veterans for
    disabilities attributable to military service.'' The Commission
    identified the presumptive disability decisionmaking process (PDDM) as
    a topic needing assessment and asked the IOM to establish a committee
    for this purpose that would be funded by the Veterans Administration
    (VA). The resulting committee, the Committee on Evaluation of the
    Presumptive Disability Decision-Making Process for Veterans (the
    Committee), was given the charge below:

         Describe and evaluate the current model used to recognize
    diseases that are subject to service connection on a presumptive basis.
         If appropriate, propose a scientific framework that would
    justify recognizing or not recognizing conditions as presumptive.

        To meet this charge, the IOM assembled an appropriately
    multidisciplinary 14-member committee that included subject matter
    experts, statisticians, epidemiologists, toxicologists, clinicians,
    exposure scientists, and policy experts. Committee members also held
    knowledge of the Department of Defense (DOD) and VA's approach to
    disability compensation. The Committee's approach was multifaceted:
    collection of information through open meetings involving the VA, DOD,
    Veterans groups and others; the completion of 10 case-studies related
    to PDDM to gather ``lessons learned'' to guide the development of the
    Committee's recommendations; committee deliberations on evidence,
    causation, and decisionmaking; and the elaboration of the Committee's
    recommended approach. The resulting report was 372 pages in length with
    over 400 pages of supporting materials including the case studies.
                                    findings
        Here, I focus on some of the key findings that provided the basis
    for the Committee's recommended approach. With regard to the first
    element of the charge, the Committee characterized the current approach
    through its 10 case studies, input from the VA and particularly
    responses to questions from the Committee, and review of other
    materials. In spite of its efforts, the Committee could not fully
    assess all aspects of the extant approach, in part because VA would not
    reveal all aspects of its pre-decisional processes. This lack of
    transparency on the part of the VA clouded understanding of the current
    model.
        Nonetheless, the Committee did offer a diagram representing its
    understanding of the approach followed by VA (see Figure S-1). The
    diagram captures the key actors (Congress, VA, and the IOM through its
    role with Agent Orange and other exposures) and stakeholders. The paths
    for stakeholder input are not specifically defined and various channels
    are used. Most importantly, the Committee was unable to fully
    characterize the principles underlying decisionmaking by the VA with
    regard to presumptions (i.e., the right side of Figure S-1).
        In the Committee's proposed model, the ambiguities of Figure S-1,
    reflecting the current approach, are replaced by a fully specified and
    evidence-based process (captured in Figure S-2). Quoting the IOM
    report, ``The Committee's recommended approach for the future (Figure
    S-2) has multiple new elements: a process for proposing exposures and
    illnesses for review; a systematic evidence review process
    incorporating a new evidence classification scheme and quantification
    of the extent of disease attributable to an exposure; a transparent
    decisionmaking process by VA; and an organizational structure to
    support the process. The Committee also calls for comprehensive
    tracking of exposures of military personnel and monitoring of their
    health while in service and subsequently.''
        The Committee also offered six principles as foundational to its
    model: (1) stakeholder inclusiveness; (2) evidence-based decisions; (3)
    transparent process; (4) flexibility; (5) consistency; and (6) using
    causation, not just association, as the basis for decisionmaking. These
    principles addressed limitations of the existing approach and were seen
    as critical to remedying its lack of transparency. In particular, the
    Committee offered a schema for classifying the strength of evidence for
    causation that would provide a consistent basis for making causal
    judgments.
        The Committee also proposed two new and permanent entities: the
    Advisory Committee, serving in an advisory capacity to the VA and the
    Science Review Board, independent of VA. Quoting the report: ``The
    Advisory Committee would consider the exposures and illnesses that
    might be a basis for presumptions and recommend to the VA Secretary
    exposures and illnesses needing further consideration. It would also
    consider research needs and assist VA with strategic research planning.
    The Science Review Board would evaluate the evidence for causation and,
    if warranted, estimate the service-attributable fraction of disease in
    veterans. One critical element in the deliberations of the Science
    Review Board would be evidence from monitoring the exposures and health
    of the veterans.'' The Committee saw the potential for carrying out
    health surveillance of veterans in relation to their exposure history.
                       general committee recommendations
        Quoting the report: ``Based on its evaluation of the current
    process for establishing presumptive disability decisions and its
    consideration of alternatives, the Committee has specific
    recommendations for an approach that would build stronger scientific
    evidence into the decisionmaking process and, at the same time, be even
    more responsive and open to veterans. We propose a transformation of
    the current presumptive disability decisionmaking process. We recognize
    that considerable time would be needed to implement some of these
    recommendations as would additional investment to create systems needed
    to track exposures and health status of currently serving military
    service personnel and veterans. Progress depends on greater research
    capacity and improvements in the evaluation and utilization of
    scientific evidence in making compensation decisions. We find that
    there are elements of the current process that could be changed quickly
    and we recommend that VA consider prompt action as it moves toward
    implementation of a new approach.'' The specific recommendations are
    appended to this testimony, organized by the body to which they are
    directed.
                                 final comments
        Subsequent to its release, the report of the Committee on
    Evaluation of the Presumptive Disability Decision-Making Process for
    Veterans received little attention. While this lack of attention might
    reflect the institutional and political context of the time and an
    unwillingness to consider a needed overhaul of compensation for
    veterans, the conceptual flaws and inconsistencies of the extant system
    merited consideration and still do. In calling for an evidence-based
    and transparent replacement to the opaque and not well documented
    processes of the VA, the Committee did offer an alternative approach.
    The principles underlying that approach should be the starting point
    for a transition away from making presumptions to cover evidence gaps
    that can be filled.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

       FIGURE S-1 Roles of the participants involved in the presumptive
                disability decisionmaking process for veterans.

        (a) Stakeholders include (but are not limited to) veterans service
    organizations (VSOs), veterans, advisory groups, Federal agencies, and
    the general public; these stakeholders provide input into the
    presumptive process by communicating with Congress, VA, and independent
    organizations (e.g., the National Academies).
        (b) Congress has created many presumptions itself; in 1921,
    Congress also empowered the VA Secretary to create regulatory
    presumptions; on several occasions in the past, Congress has directed
    VA to contract with an independent organization (e.g., the National
    Academies) to conduct studies and then use the organization's report in
    its deliberations of granting or not granting regulatory presumptions.
        (c) VA can establish regulatory presumptions; VA sometimes
    contracts with the National Academies to conduct studies and uses the
    organization's report in its deliberations of granting or not granting
    regulatory presumptions.
        (d) The National Academies (Institute of Medicine and National
    Research Council) submit reports to VA based on requests and study
    charges from VA.

    Source: Institute of Medicine 2008. Improving the Presumptive
    Disability Decision-Making Process for Veterans. Washington, DC: The
    National Academies Press. https://doi.org/10.17226/11908.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        FIGURE S-2 Proposed framework for future presumptive disability
                      decisionmaking process for veterans.

        (a) Includes research for classified or secret activities,
    exposures, etc.
        (b) Includes veterans, Veterans Service Organizations, Federal
    agencies, scientists, general public, etc.
        (c) This Committee screens stakeholders' proposals and research in
    support of evaluating evidence for presumptions and makes
    recommendations to the VA Secretary when full evidence review or
    additional research is appropriate.
        (d) The board conducts a two-step evidence review process (see
    report text for further detail).
        (e) Final presumptive disability compensation decisions are made by
    the Secretary, Department of Veterans Affairs, unless legislated by
    Congress.

    Source: Institute of Medicine 2008. Improving the Presumptive
    Disability Decision-Making Process for Veterans. Washington, DC: The
    National Academies Press. https://doi.org/10.17226/11908.
                            specific recommendations
    Congress
        Recommendation 1. Congress should create a formal advisory
    committee (Advisory Committee) to VA to consider and advise the VA
    Secretary on disability-related questions requiring scientific research
    and review to assist in the consideration of possible presumptions.

        Recommendation 2. Congress should authorize a permanent independent
    review body (Science Review Board) operating with a well-defined
    process that will use evaluation criteria as outlined in this
    Committee's recommendations to evaluate scientific evidence for VA's
    use in considering future service-connected presumptions.
    Department of Veterans Affairs

        Recommendation 3. VA should develop and publish a formal process
    for consideration of disability presumptions that is uniform and
    transparent and clearly sets forth all evidence considered and the
    reasons for the decisions reached.
    Science Review Board
        The recommendations that follow are directed toward the proposed,
    future Science Review Board, the entity to be established in the
    Committee's proposed approach.

        Recommendation 4. The Committee recommends that the goal of the
    presumptive disability decisionmaking process be to ensure compensation
    for veterans whose diseases are caused by military service and that
    this goal must serve as the foundation for the work of the Science
    Review Board. The Committee recommends that the Science Review Board
    implement its proposed two-step process.

        Recommendation 5. The Committee recommends that the Science Review
    Board use the proposed four-level classification scheme, as follows, in
    the first step of its evaluation. The Committee recommends that a
    standard be adopted for ``causal effect'' such that if there is at
    least as much evidence in favor of the exposure having a causal effect
    on the frequency or severity of disease as there is evidence against,
    then a service-connected presumption will be considered.

        1. Sufficient: The evidence is sufficient to conclude that a causal
    relationship exists.
        2. Equipoise and Above: The evidence is sufficient to conclude that
    a causal relationship is at least as likely as not, but not sufficient
    to conclude that a causal relationship exists.
        3. Below Equipoise: The evidence is not sufficient to conclude that
    a causal relationship is at least as likely as not, or is not
    sufficient to make a scientifically informed judgment.
        4. Against: The evidence suggests the lack of a causal
    relationship.

        Recommendation 6. The Committee recommends that a broad spectrum of
    evidence, including epidemiologic, animal, and mechanistic data, be
    considered when evaluating causation.

        Recommendation 7. When the causal evidence is at Equipoise and
    Above or Sufficient, the Committee recommends that an estimate also be
    made of the size of the causal effect among those exposed.

        Recommendation 8. The Committee recommends that, as the second part
    of the two-step evaluation, the relative risk and exposure prevalence
    be used to estimate an attributable fraction for the disease in the
    military setting (i.e., service-attributable fraction).
    Department of Defense and Department of Veterans Affairs
        The following recommendations are intended to improve the evidence
    on exposures and health status of veterans:

        Recommendation 9. Inventory research related to the health of
    veterans, including research funded by DOD and VA, and research funded
    by the National Institutes of Health and other organizations.

        Recommendation 10. Develop a strategic plan for research on the
    health of veterans, particularly those returning from conflicts in the
    Gulf and Afghanistan.

        Recommendation 11. Develop a plan for augmenting research
    capability within DOD and VA to more systematically generate evidence
    on the health of veterans.

        Recommendation 12. Assess the potential for enhancing research
    through record linkage using DOD and VA administrative and health
    record databases.

        Recommendation 13. Conduct a critical evaluation of Gulf War troop
    tracking and environmental exposure monitoring data so that
    improvements can be made in this key DOD strategy for characterizing
    exposures during deployment.

        Recommendation 14. Establish registries of Servicemembers and
    veterans based on exposure, deployment, and disease histories.

        Recommendation 15. Develop a plan for an overall integrated
    surveillance strategy for the health of Servicemembers and veterans.

        Recommendation 16. Improve the data linkage between the electronic
    health record data systems used by DOD and VA--including capabilities
    for handling individual Servicemember exposure information that is
    included as part of the individual's health record.

        Recommendation 17. Ensure implementation of the DOD strategy for
    improved exposure assessment and exposure data collection.

        Recommendation 18. Develop a data interface that allows VA to
    access the electronic exposure data systems used by DOD.

        Recommendation 19. DOD and VA should establish and implement
    mechanisms to identify, monitor, track, and medically treat individuals
    involved in research and other activities that have been classified and
    are secret.
                                     ______

          Attachments: A General Summary (written for the public) and
                         the Report's Executive Summary

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                                general summary
        The United States has long recognized and honored the service and
    sacrifices of its military and veterans. Veterans who have been injured
    by their service (whether their injury appears during service or
    afterwards) are owed appropriate health care and disability
    compensation. For some medical conditions that develop after military
    service, the scientific information needed to connect the health
    conditions to the circumstances of service may be incomplete. When
    information is incomplete, Congress or the Department of Veterans
    Affairs (VA) may need to make a ``presumption'' of service connection
    so that a group of veterans can be appropriately compensated. The
    missing information may be about the specific exposures of the
    veterans, or there may be incomplete scientific evidence as to whether
    an exposure during service causes the health condition of concern. For
    example, when the exposures of military personnel in Vietnam to Agent
    Orange could not be clearly documented, a presumption was established
    that all those who set foot on Vietnam soil were exposed to Agent
    Orange.
        The Institute of Medicine (IOM) Committee was charged with
    reviewing and describing how presumptions have been made in the past
    and, if needed, to make recommendations for an improved scientific
    framework that could be used in the future for determining if a
    presumption should be made. The Committee was asked to consider and
    describe the processes of all participants in the current presumptive
    disability decisionmaking process for veterans. The Committee was not
    asked to offer an opinion about past presumptive decisions or to
    suggest specific future presumptions. The Committee heard from a range
    of groups that figure into this decisionmaking process, including past
    and present staffers from Congress, the VA, the IOM, veterans service
    organizations, and individual veterans. The Department of Defense (DOD)
    briefed the Committee about its current activities and plans to better
    track the exposures and health conditions of military personnel. The
    Committee further documented the current process by developing case
    studies around exposures and health conditions for which presumptions
    had been made. The Committee also reviewed general methods by which
    scientists, as well as government and other organizations, evaluate
    scientific evidence in order to determine if a specific exposure causes
    a health condition.
        The history of presumptions is a fascinating and complex story. In
    1921 Congress empowered the VA Administrator (now Secretary) to
    establish presumptions of service connection for veterans. Only
    Congress and VA have the authority to establish presumptions for
    veterans. Since 1921, nearly 150 health outcomes have been service-
    connected on a presumptive basis by Congress and VA. This process has
    evolved over the years. The current process for making presumptions can
    be traced to the Agent Orange Act of 1991 (Public Law 102-4. 102d
    Cong., 2d Sess.), an act that established a model for decisionmaking by
    VA that still stands today. In the 1991 Act, Congress asked VA to
    contract with an independent organization to review the scientific
    evidence on Agent Orange. VA turned to the IOM of the National Academy
    of Sciences to carry out these reviews. Subsequently, VA turned to IOM
    for issues arising from the 1990 Gulf War. Based on the work of a
    committee, IOM provides VA with reports that describe the strength of
    evidence that links agents of concern with specific health conditions.
    VA uses IOM reports and other information in an internal decision-
    making process to decide whether a presumption will be made.
        The Committee carefully studied the current approach to presumptive
    disability decisionmaking and examined a number of specific case
    examples. This assessment led to a number of recommendations to improve
    the process:

         As the case studies demonstrated, Congress could provide a
    clearer and more consistent charge on how much evidence is needed to
    make a presumption. There should be clarity as to whether the finding
    of an association in one or more studies is sufficient or the evidence
    should support causation.
         Due to lack of clarity and consistency in congressional
    language and VA's charges to the Committees, IOM committees have taken
    somewhat varying approaches since 1991 in reviewing the scientific
    evidence and in forming their opinions on the possibility that
    exposures during military service contributed to causing a health
    condition. Future committees could improve their review and
    classification of scientific evidence if they were given clear and
    consistent charges and followed uniform evaluation procedures.
         The internal processes by which the VA makes its
    presumptive decisions following receipt of an IOM report have been
    unclear. VA should adopt transparent and consistent approaches for
    making these decisions.
         Complete exposure data and health condition information
    for military personnel (both individuals and groups) usually have not
    been available from DOD in the past. Such information is one of the
    most critical pieces of evidence for improving the determination of
    links between exposures and health conditions.

        All of these improvements are feasible over the longer term and are
    needed to ensure that the presumptive disability decisionmaking process
    for veterans is based on the best possible scientific evidence.
    Decisions about disability compensation and related benefits (e.g.,
    medical care) for veterans should be based on the best possible
    documentation and evidence of their military exposures as well as on
    the best possible information on any health conditions caused by these
    exposures. While it is impossible to provide certainty in every case, a
    fresh approach could do much to improve the current process. The
    Committee's recommended approach (Figure GS-1) has several parts:

         An open process for nominating exposures and health
    conditions for review; involving all stakeholders in this process is
    critical
         A revised process for evaluating scientific information on
    whether a given exposure causes a health condition in veterans; this
    includes a new set of categories to assess the strength of the evidence
    for causation, and an estimate of the numbers of exposed veterans whose
    health condition can be attributed to their military exposure
         A consistent and transparent decisionmaking process by VA
         A system for tracking the exposures of military personnel
    (including chemical, biological, infectious, physical, and
    psychological stressors), and for monitoring the health conditions of
    all military personnel while in service and after separation
         An organizational structure to support this process

        To support the Committee's recommendations, we suggest the creation
    of two panels. One is an Advisory Committee (advisory to VA), that
    would assemble, consider, and give priority to the exposures and health
    conditions proposed for possible presumptive evaluation. Nominations
    for presumptions could come from veterans and other stakeholders as
    well as from health tracking, surveillance, and research. The second
    panel would be a Science Review Board, an independent body, which would
    evaluate the strength of the evidence (based on causation) that links a
    health condition to a military exposure and then estimates the fraction
    of exposed veterans whose health condition could be attributed to their
    military exposure. The Science Review Board's report and
    recommendations would go to VA for its consideration. VA would use
    explicit criteria to render a decision by the VA Secretary with regard
    to whether a presumption would be established. In addition, the Science
    Review Board would monitor information on the health of veterans as it
    accumulates over time in the DOD and VA tracking systems, and nominate
    new exposures or health conditions for evaluation as appropriate.

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       FIGURE GS-1 Proposed framework for future presumptive disability
                      decisionmaking process for veterans.

        (a) Includes research for classified or secret activities,
    exposures, etc.
        (b) Includes veterans, Veterans Service Organizations, Federal
    agencies, scientists, general public, etc.
        (c) This Committee screens stakeholders' proposals and research in
    support of evaluating evidence for presumptions and makes
    recommendations to the VA Secretary when full evidence review or
    additional research is appropriate.
        (d) The board conducts a two-step evidence review process (see
    report text for further detail).
        (e) Final presumptive disability compensation decisions are made by
    the Secretary, Department of Veterans Affairs, unless legislated by
    Congress.

        This Committee recommends that the following principles be adopted
    in establishing this new approach:

        1. Stakeholder inclusiveness
        2. Evidence-based decisions
        3. Transparent process
        4. Flexibility
        5. Consistency
        6. Causation, not just association, as the target for
    decisionmaking

        The Committee suggests that its framework be considered as the
    model to guide the evolution of the current approach. While some
    aspects of the approach may appear challenging or infeasible at
    present, feasibility would be improved with the full implementation of
    the Committee's recommendations, provision of appropriate resources to
    all of the participants in the presumptive disability decisionmaking
    process for veterans, and future methodological developments. DOD and
    VA have already been discussing various aspects of improving exposure
    and health tracking and how the two agencies can share data and
    information with each other. Veterans deserve to have these
    improvements accomplished as soon as possible.

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                                    Summary
                                  introduction
        The United States has long recognized and honored military
    veterans' service and sacrifices. Veterans injured by their service,
    becoming ill while in service, or having an illness after discharge as
    a long-term consequence of their service have been given healthcare
    coverage and disability compensation. As the complexity of exposures
    during combat has increased, the list of service-connected illnesses
    has grown. The Department of Veterans Affairs (VA) now provides
    disability compensation to approximately 2.6 million veterans for 7.7
    million disabilities annually, expending approximately $24 billion for
    this purpose (VBA, 2006, pp. 19, 24, 27).
        Disability compensation for military veterans requires that there
    be a service connection. A medical illness or injury that occurred
    while a member was in military service is considered service-connected
    whether caused by or aggravated by an exposure or event during service
    or simply occurring coincidentally with military service. However, if a
    medical condition appears after the period of military service and it
    is presumed to be caused by or aggravated by an exposure or an event
    that occurred during military service, then veterans may receive
    compensation based on that presumption (Pamperin, 2006).
        In making a decision to provide compensation, VA needs to determine
    whether the illness of concern can generally be caused by exposures
    received during service and whether the illness in a specific claimant
    was caused by the exposure. The answer to the general question of
    causality comes from a careful review of all available scientific
    information, while the answer to the question of causation in a
    specific person hinges on knowledge of the exposure received by that
    individual and of other factors that may be relevant. If the scientific
    evidence is incomplete, there may be uncertainty on the question of
    causation generally; if there is limited or no information on exposure
    of individual claimants or if other factors also contribute to disease
    causation, there may be uncertainty on the question of individual
    causation.
        To provide benefits to veterans in the face of these two broad
    types of uncertainty, Congress and VA make presumptive decisions that
    bridge gaps in the evidence related to causation and to exposure.
    Presumptions may relieve the veteran of persuading VA that the exposure
    produced the adverse health outcome and of proving that an exposure
    occurred during military service (Pamperin, 2006). Once a medical
    condition is service-connected through presumptions, and the veteran
    can document military service consistent with having received the given
    exposure, the veteran only has to show the basic fact that he or she
    suffers from the condition in order to receive a disability payment and
    eligibility for medical care (Zeglin, 2006).
        In 2004, Congress established the Veterans' Disability Benefits
    Commission (the Commission), which was charged with ``studying the
    benefits provided to compensate and assist veterans for disabilities
    attributable to military service'' (VDBC, 2006, p. 1; as found in
    Appendix A). The Commission identified the presumptive disability
    decisionmaking process as a topic needing assessment and asked the
    Institute of Medicine (IOM) to establish a committee for this purpose
    that would be funded by VA. The resulting committee, the Committee on
    Evaluation of the Presumptive Disability Decision-Making Process for
    Veterans (the Committee), was given the following charge by VA:

          Describe and evaluate the current model used to recognize
    diseases that are subject to service connection on a presumptive basis.
          If appropriate, propose a scientific framework that would
    justify recognizing or not recognizing conditions as presumptive.

        The Commission further elaborated the charge, asking the Committee
    to ``help ensure that future veterans are granted service connection
    under a presumptive basis based on the best scientific evidence
    available'' (VDBC, 2006, p. 4; as found in Appendix A). The Commission
    asked the Committee to ``evaluate the current model used to determine
    diseases that qualify for service connection on a presumptive basis,
    and if appropriate, propose improvements in the model'' (VDBC, 2006,
    p. 1; as found in Appendix A). The Commission emphasized that ``having
    a method of granting service connection quickly and fairly based on a
    presumption is of critical importance to our disabled veterans and
    their surviving spouses'' and that ``ensuring that future presumption
    processes reflect the then current medical knowledge about the causal
    relationship would benefit the entire veteran community'' (VDBC, 2006,
    p. 4; as found in Appendix A). The Commission's summary statement
    further commented that ``[t]o the extent possible, suggestions that
    will avoid the necessity for many future presumptions by ensuring that
    exposure of servicemembers is documented and scientific evidence is
    made available would be important'' (VDBC, 2006, p. 4; as found in
    Appendix A).
        IOM appointed a 14-member committee that covered the broad
    scientific and medical areas of general, occupational, and psychiatric
    medicine; biostatistics; epidemiology; toxicology; industrial hygiene;
    and exposure and risk assessment. The Committee's members also brought
    expertise in law, philosophy, causal decisionmaking, and policy as well
    as knowledge of the Department of Defense (DOD) and VA's approach to
    disability compensation.
                     the committee's approach to its charge
        In fulfilling its charge, the Committee first investigated and
    attempted to characterize Congress' and VA's recent approach to
    presumptive disability decisionmaking, and then developed a conceptual
    framework for a new, more evidence-based process. It then constructed a
    way to move forward that builds on the framework and addresses
    deficiencies of the current process.
        The Committee held three open meetings to gather information on the
    current presumptive disability decisionmaking process. The Committee
    heard from past and present congressional staff members,
    representatives of VA, DOD, IOM, various stakeholder groups (e.g.,
    veteran service organizations [VSOs]) and the general public. Committee
    members also participated in conference calls with DOD experts on
    medical surveillance and exposure data collection and exposure
    assessment systems.
        The Committee reviewed extensive background information including:
    documents provided by the Commission, public laws and supporting House
    and Senate reports, Federal Register notices, VA documents (e.g., cost
    estimates, a white paper on VA's decisionmaking processes [found in
    Appendix G], and responses by VA to written questions from the
    Committee), DOD documents, and past IOM reports commissioned by DOD and
    VA. The Committee conducted 10 case study reviews--Mental Disorders'
    Presumptions, Multiple Sclerosis Presumption, Prisoners of War
    Presumptions, Amputees and Cardiovascular Disease Presumption,
    Radiation Presumptions, Mustard Gas and Lewisite Presumptions, Gulf War
    Presumptions, Agent Orange and Prostate Cancer Presumption, Agent
    Orange and Type 2 Diabetes Presumption, and Spina Bifida Program (not a
    presumption but a VA program area)--that cover a wide variety of
    circumstances for which presumptions have been established by Congress
    and VA since 1921. The case studies were a foundation for the
    Committee's efforts in understanding past practices of all participants
    in the presumptive disability decisionmaking process (see Appendix I).
        The Committee also researched and considered capabilities and
    limitations of the exposure data and health outcome information
    available to DOD and VA for exposure assessment, surveillance, and
    research purposes. The Committee examined whether DOD and VA have a
    strategic research plan and vision for the necessary interface between
    the agencies, as well as with other, relevant research organizations.
        The Committee considered the use of scientific evidence in guiding
    the process for making presumptive decisions that affect the
    compensation of veterans. Drawing upon the Committee members' expertise
    in epidemiology, medicine, toxicology, biostatistics, and causal
    decisionmaking, the Committee covered the evaluation of evidence for
    inferring association and causation as well as methods for quantifying
    the contribution of an agent to disease causation in populations and
    extending this quantification to individuals. Using this framework, the
    Committee developed an evidence-based approach for making future
    decisions with regard to presumptions.
        the presumptive disability decision-making process for veterans
        In 1921 Congress empowered the VA Administrator (now Secretary) to
    establish presumptions of service connection for veterans. Only
    Congress and the VA Secretary have the authority to establish
    presumptions. Over time, presumptions have been made to relieve
    veterans of the burden to prove that disability or illness was caused
    by a specific exposure that occurred during military service (e.g.,
    Prisoners of War). Since 1921, nearly 150 health outcomes have been
    service-connected on a presumptive basis (see Appendix F). In
    February 2006, Congress codified all regulatory presumptions that VA
    had put in place to that time.
        The current presumptive disability decisionmaking process for
    veterans involves several steps and several organizations. The process
    involves input from many parties--Congress, VA, the National Academies,
    and stakeholders (e.g., VSOs, advisory committees, and individual
    veterans) (Figure S-1). Congress has made presumptions itself. In the
    current model, Congress or stakeholders acting through Congress may
    call on VA to assess whether a presumption is needed. The VA turns to
    IOM for completion of a review of the scientific evidence. The findings
    of that evaluation are considered by VA in its presumptive disability
    decisionmaking process. Decisions made in the courts have also
    influenced the current presumptive process.

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       FIGURE S-1 Roles of the participants involved in the presumptive
                disability decisionmaking process for veterans.

        (a) Stakeholders include (but are not limited to) veterans service
    organizations (VSOs), veterans, advisory groups, Federal agencies, and
    the general public; these stakeholders provide input into the
    presumptive process by communicating with Congress, VA, and independent
    organizations (e.g., the National Academies).
        (b) Congress has created many presumptions itself; in 1921,
    Congress also empowered the VA Secretary to create regulatory
    presumptions; on several occasions in the past, Congress has directed
    VA to contract with an independent organization (e.g., the National
    Academies) to conduct studies and then use the organization's report in
    its deliberations of granting or not granting regulatory presumptions.
        (c) VA can establish regulatory presumptions; VA sometimes
    contracts with the National Academies to conduct studies and uses the
    organization's report in its deliberations of granting or not granting
    regulatory presumptions.
        (d) The National Academies (Institute of Medicine and National
    Research Council) submit reports to VA based on requests and study
    charges from VA.

        Three major legislative actions by Congress have influenced the
    recent presumptive decisions--the Radiation Exposed Veterans
    Compensation Act of 1988 (Public Law 100-321. 100th Cong., 2d Sess.),
    the Agent Orange Act of 1991 (Public Law 102-4. 102d Cong., 1st Sess.),
    and the Persian Gulf War Acts of 1995 (Veterans' Benefits Improvement
    Act of 1994. Public Law 103-446. 103d Cong., 2d Sess.) and 1998 (Making
    Omnibus Consolidated and Emergency Appropriations for the Fiscal Year
    Ending September 30, 1999, and for Other Purposes. Public Law 105-277.
    105th Cong., 2d Sess.). The concept of ``at least as likely as not''
    with regard to exposure potential was introduced for radiation
    exposures and its use has since been continued. The Agent Orange Act
    (Public Law 102-4. 102d Cong., 1st Sess.) grew out of events following
    the Vietnam War, and its language expresses substantial and significant
    elements of the presumptive story. The presumptions put in place by
    Congress for Gulf War illnesses represent the first time that Congress
    produced a list of health outcomes that it defined as ``undiagnosed
    illnesses'' (Veterans Education and Benefits Expansion Act of 2001.
    Public Law 107-103. 107th Cong., 1st Sess.).
        When Congress enacted the Agent Orange Act of 1991 (Public Law 102-
    4. 102d Cong., 1st Sess.), it started a model for a decisionmaking
    process that is still in place. Congress asked VA to contract with an
    independent organization--VA contracted with IOM--to review the
    scientific evidence for Agent Orange. Since 1994, IOM has produced
    biennial reports on Agent Orange for VA to use as it considers making
    presumptive decisions (IOM, 1994, 1996, 1999, 2001, 2003b, 2005b). IOM
    has also delivered five volumes on the Gulf War (IOM, 2000a, 2003a,
    2005a, 2006, 2007). Congress requires VA to respond after receiving an
    IOM report with a determination as to whether VA will make a service
    connection for particular health outcomes on a presumptive basis. VA
    has described its internal decisionmaking processes to the Committee in
    a general fashion, and the Committee has reviewed VA's Federal Register
    notices and documents (see Chapter 3). However, it remains unclear to
    the Committee how VA makes particular determinations with regard to
    weighing strength of evidence for causation and exposure potential in
    making its presumptive decisions.
        Analysis of the Agent Orange and Gulf War case studies (see
    Appendix I) shows important similarities and differences relevant to
    the over-all presumptive process. One difference is that Agent Orange
    is a single product (actually a mixture of compounds that contains the
    contaminant dioxin), extensively researched for associated health
    outcomes, whereas the health consequences of the Gulf War are unlikely
    to be the result of any single agent. Military service men and women
    may have received a number of health-relevant exposures during service
    in the Persian Gulf, complicating the development of evidence reviews.
    For Agent Orange, there is one exposure of concern and a more
    constrained set of health indicators. There have been some differences
    in approaches of Agent Orange and Gulf War committees. The IOM Agent
    Orange reports (IOM, 1994, 1996, 1999, 2001, 2003b, 2005b) did not
    explicitly include a causal category in their evaluations whereas
    recent Gulf War reports (IOM, 2000a, 2003a, 2005a, 2006, 2007) did
    include a category for evidence sufficient to infer causation when
    characterizing the strength of evidence for agents evaluated. For
    neither set of reports does VA describe in its Federal Register notices
    how it accounted for exposure potential or magnitude in making its
    presumptive decisions.
                            findings of case studies
        The case studies offered a diverse set of lessons learned and
    indicated elements of the current process that need to be addressed. In
    carrying out the case studies, this Committee had the opportunity to
    retrospectively examine the work of IOM committees as they grappled
    with the challenge of using uncertain evidence and of VA staff as they
    used the findings of IOM committees to make decisions about
    presumptions. The case studies demonstrate that the process has acted
    to serve the interests of veterans in many instances. Congress and VA
    have repeatedly acted to maximize the sensitivity of presumptive
    decisions so as to assure that no veteran who might have been affected
    is denied compensation. On the other hand, in maximizing sensitivity of
    presumptive disability decisionmaking, substantial numbers of veterans
    whose illnesses may or may not have been actually service related are
    nonetheless compensated. There are both financial and nonfinancial
    costs to such decisions.
        The case studies illustrate the use of presumptions to cover gaps
    in evidence, gaps that exist in part because of lack of information on
    exposures received by military personnel and inadequate surveillance of
    veterans for service-related illnesses. Secrecy is a particularly
    troubling source of incomplete information, as illustrated by the
    veterans who participated in studies of mustard gas and lewisite.
    Research carried out directly on the health of veterans has proved
    useful in some instances, leading to a decision, for example, on
    granting disability compensation for cardiovascular disease in
    amputees. But the research has not been systematic, and in the example
    of cardiovascular disease in amputees no further evidence relevant to a
    presumption made in 1979 has been collected. Research on radiation
    risks in veterans has been severely constrained by a lack of dose
    information, and the studies on radiation-exposed veterans have not
    been highly informative.
        Across the case studies, the Committee found variable approaches to
    synthesizing evidence on the health consequences of military service.
    The inferential target of scientific evidence reviews has not been
    consistent and varied between causation (e.g., mustard gas and
    lewisite, Gulf War) and association alone (e.g., Agent Orange). The
    more recent IOM Agent Orange reports have emphasized findings of
    observational studies on association and interpretation that might have
    been enhanced by placing the findings within a biological framework
    strengthened by greater attention to other lines of evidence. In the
    Agent Orange case studies, the category ``limited/suggestive'' for
    classifying evidence for association has been used for a broad range of
    evidence from indicating the mere possibility of an association to
    showing that an association is possibly causal. The ``limited/
    suggestive'' evidence of association--on which the VA's presumptive
    decisions to compensate type 2 diabetes and prostate cancer were made--
    may be below the level of certainty needed to support causation absent
    strong mechanistic understanding or to meet the congressional language
    of ``if the credible evidence for the association is equal to or
    outweighs the credible evidence against the association,'' which the
    Committee refers to ``at least as likely as not.''
        Both prostate cancer and type 2 diabetes illustrate situations in
    which the contribution of military exposures should be assessed against
    a background of disease risk that has other strong determinants: age in
    the case of prostate cancer and family history and obesity in the case
    of type 2 diabetes, as indicated by the IOM committee in its report
    (IOM, 2000b). For both type 2 diabetes and prostate cancer, the
    magnitude of the relative risks observed for pesticide exposure implies
    that the contribution of military exposures is likely to be small in
    comparison to those of the other contributing factors. In such
    circumstances, an estimation of the proportion of cases attributable to
    military exposures could be helpful to the VA in considering whether or
    not to presumptively service-connect disabilities. The Committee
    recognizes that development of such estimations is a complicated
    process dependent on acquiring better exposure data, which may not be
    available for some period of time.
        In the case studies, the Committee's analyses were based on the
    very general information provided by VA about its internal
    decisionmaking processes. The case studies and VA's decision to
    withhold documents related to specific decisions from the Committee did
    make clear, however, that these processes are not fully transparent. VA
    believes that access to predecisional documents by outside sources
    could stifle candid staff discussions on issues. Once IOM carries out
    its reviews and provides VA with reports documenting the extent of
    evidence available on associations, the internal processes of VA that
    follow are not fully open to scrutiny. This closed process could reduce
    trust of veterans in the presumptive disability decisionmaking process
    and may hinder efforts to optimize the use of scientific evidence. The
    Committee also found inconsistency in the decisionmaking process.
                           scientific foundation for
                     presumptive disability decision making
        In developing a future approach for presumptive disability
    decisionmaking, the Committee first gave extensive consideration to
    causal inference and the processes used to make causal judgments. In
    other words, the Committee considered how scientific evidence is used
    to determine if exposure causes some disease. These determinations are
    generally made by expert committees that examine all relevant evidence
    for strengths and weaknesses and then synthesize the evidence to make a
    summary judgment. The Committee defines ``exposure'' in a broad manner
    to include chemical, biological, infectious, physical, and
    psychological stressors. The Committee recognizes that psychological
    stressors may be particularly difficult to describe, let alone measure
    and quantify.
        The Committee then considered the quantification of the
    contribution of a particular exposure to disease causation. This second
    issue addresses the question of how much of the observed disease in a
    group, in both absolute and relative terms, is caused by the exposure.
        Provision of compensation to veterans on a presumptive basis, or to
    any other group that has been injured, requires a general decision as
    to whether the agent or exposure of concern has the potential to cause
    the condition or disease for which compensation is to be provided in at
    least some individuals, and a specific decision as to whether the agent
    or exposure has caused the condition or disease in a particular
    individual. The determination of causation in general is based in a
    review and evaluation of all relevant evidence including (1) data on
    exposures of military personnel during service; (2) evidence on risks
    for disease coming from observational (epidemiologic) studies of
    military personnel; (3) other relevant epidemiologic evidence,
    including findings from studies of nonmilitary populations exposed to
    the agent of interest or similar agents; and (4) findings relevant to
    plausibility from experimental and laboratory research. The
    determination of causation in a particular case is based first on the
    general determination as to whether the exposure can cause disease,
    then on information about the exposures of the individual being
    evaluated for compensation, and on any other relevant information about
    the individual.
        The Committee considered the properties of a decisionmaking
    process, recognizing the possibility of two types of systematic errors:
    making a decision to compensate when the exposure has not caused the
    illness (false positive) and to not compensate when the exposure has
    actually caused the illness (false negative). The Committee recommends
    that any decision process consider the tradeoff between these two
    errors and attempt to optimize both the sensitivity (i.e., minimize the
    false negatives) and the specificity (i.e., minimize the false
    positives). Generally, higher sensitivity cannot be achieved without
    lower specificity. These errors have costs. False positive errors
    result in the expenditure of funds for cases of disease not caused by
    military service while false negative errors leave deserving veterans
    uncompensated. The appropriate balancing of these costs also needs
    consideration.
        The Committee considered ways to classify evidence, reaching the
    conclusion that a broader and more inclusive evidence review process is
    needed. It found that IOM reviews could be enhanced if a broader array
    of epidemiologic and other evidence (e.g., animal and mechanistic data)
    was considered. The Committee also found that the target of inference
    had varied from causation (e.g., mustard gas and lewisite, Gulf War) to
    association (e.g., Agent Orange). Consequently, the Committee
    recommends that categories of evidence for reviews be established to
    make clear those relationships that are at least as likely as not to be
    causal. The Committee has concluded that a categorization of evidence
    is needed that gives a scientifically coherent rendering of the
    language employed by Congress in calling for review of available
    scientific evidence. The Committee proposes a four-level hierarchy that
    classifies the strength of evidence for causation, not just
    association, and that incorporates the concept of equipoise: that is,
    whether the weight of scientific evidence makes causation at least as
    likely as not in the judgment of the reviewing group.
        The Committee also gave consideration to the quantification of the
    burden of disease attributable to an exposure. This quantification
    would be made to provide an evaluation of the numbers of veterans to be
    compensated, but it would not be a component of the evidence evaluation
    for causation. For the purpose of quantification, the attributable
    risk, termed the service-attributable fraction, can be calculated if
    the needed information is available on the relative risk of disease
    among exposed individuals. For those exposures meeting the necessary
    level of evidence for compensation, the Committee recommends that the
    service-attributable fraction should be estimated overall and for
    subgroups of veterans, perhaps grouped by level of exposure, if the
    requisite data are available. Until more complete exposure information
    becomes available in the future, such calculations may not be possible
    for all conditions for which presumptions are made.
                committee's recommended approach for the future
    Overview
        The Committee's recommended approach for the future (Figure S-2)
    has multiple new elements: a process for proposing exposures and
    illnesses for review; a systematic evidence review process
    incorporating a new evidence classification scheme and quantification
    of the extent of disease attributable to an exposure; a transparent
    decisionmaking process by VA; and an organizational structure to
    support the process. The Committee also calls for comprehensive
    tracking of exposures of military personnel and monitoring of their
    health while in service and subsequently.

     Inadequate training for both VBA adjudicators and
    Compensation and Pension (C&P) examiners.
         The failure of adjudicators to recognize that the examiner
    has provided an unnecessary medical opinion concerning service
    connection (nexus), thus wrongfully denying veterans' claims.
         The abysmal number of C&P examiners--only 10 percent of
    them--who had taken an optional online 90-minute training course.
         The failure of VBA decision letters that often do not
    communicate key information as to why a veteran's claim was denied.

        Since the 2016 GAO report, there has been no significant
    improvement in regard to the issues Gulf War veterans face in having
    claims properly adjudicated, despite years of advocacy efforts, two
    hearings in the House (March 15, 2016 and July 13, 2017), and numerous
    promises by the VA. Still today, according to data furnished by the
    VBA, Undiagnosed Illness claims (UDX) are denied at a 95 percent rate,
    and Medically Unexplained Chronic Multi-Symptom Illness (MUCMI) claims
    at a 73 percent rate.
        Another recent problem in Gulf War Illness-related disability
    claims is that the examiner, usually a nurse practitioner, will often:

         State that the veteran doesn't have a current diagnosed
    disability, when in fact the examiner failed to view non-VA medical
    records.
         Lump several illnesses into one condition, effectively
    denying the other conditions.
         Overrule and alter the diagnosis, or challenge the
    qualifications of the veteran's treating physician, resulting in a
    denial.

        To us, this is deja vu all over again. Today, 45 years after the
    last U.S. combat troops exited South Vietnam, we're still fighting to
    ensure that Vietnam veterans receive the benefits that we've earned for
    having served our country in a war halfway around the globe.
        What should the VA, the VBA, do to do right by the veterans it
    serves? What can Congress do to ensure that the VA uses the tools
    provided by statute, in regulations, and in the VA's own processes and
    procedures? Inasmuch as acronyms are coin of the realm here in the
    Nation's capital, let us offer TOAT:

        Training: The VBA must ensure that adjudicators and Compensation
    and Pension (C&P) examiners are adequately trained and updated with
    changes in the law, with scientific and epidemiological advances, with
    alterations in policy--and that they are in fact using the tools and
    references available to them. Also, for instance, the VA's ``optional''
    90-minute training module for Gulf War Illness claims should be
    required.
        Oversight: Congress must insist that the VA provide quarterly
    statistics on how its adjudicators handle particular conditions, the
    problems and issues they perceive, the complaints they receive.
        Accountability: Whenever and wherever possible, claims for a
    particular condition--PTSD or Military Sexual Trauma or Gulf War
    Illness, for example--ought to be steered to adjudicators who
    ``specialize'' in such claims in order to increase consistency in
    ratings throughout the system. Just as important, because it has been
    our experience that adjudicators routinely deny presumptive, service-
    connected maladies, to hold their supervisors accountable, which is not
    done at present.
        Transparency: The VA ought to hold quarterly briefings for
    Congress, the media, and the veterans' community based on their
    quarterly reports. Officials ought to unshackle themselves from a
    bunker mentality, defend what they do yet acknowledge their mistakes,
    and make public what they will transmit to Congress what they feel they
    need to improve their own processes and procedures. And this can't
    simply be, We need more money.

        Vietnam Veterans of America thanks you for this opportunity to
    submit our Statement for the Record, and will reply to any questions
    regarding this testimony that you may have.
                                     ______

                 Prepared Statement of Wounded Warrior Project
        Chairman Isakson, Ranking Member Tester and distinguished Members
    of the Senate Committee on Veterans' Affairs, Thank you for inviting
    Wounded Warrior Project (WWP) to submit the following testimony on
    ``Toxic Exposure: Examining the VA's Presumptive Disability Decision-
    Making Process.''
        Wounded Warrior Project is transforming the way America's injured
    veterans are empowered, employed, and engaged in our communities. Since
    our inception in 2003, we have grown from a small group of friends and
    volunteers to an organization of nearly 700 employees spread across the
    country and overseas delivering over a dozen direct-service programs to
    warriors and families in need.
        While we are primarily an organization that assists post-9/11
    wounded, ill, and injured servicemembers (and their families), the
    issue of toxic exposure is a cross-generational problem, and we are
    proud to advocate for all veterans affected. We understand that for
    thousands of men and women who served, environmental and chemical
    hazards have carried real and potential health risks. Accordingly, WWP
    has a strong interest in Congress' work on studying and addressing any
    harm to veterans that may have been caused by toxic exposure illnesses
    related to service.
        A significant number of post-9/11 servicemembers and veterans (like
    their Vietnam era counterparts), seem to be suffering from uncommon
    illnesses or unusually early onset of more familiar diseases like
    cancer. It appears that exposure to contaminants such as burn pits,
    toxic fragments, or other hazards typically seen on overseas
    deployments, are emerging as common threads among veterans who are
    sick, dying, or already deceased. We believe there is likely causation
    between deployments of the last 18 years and illnesses as noted above.
    While we are currently focused on deployment exposures, we are also
    aware of the challenges servicemembers face regarding possible
    exposures stateside. Debates in scientific and medical communities have
    not reached consensus on the relationships between certain toxic
    exposures and presumed health outcomes which is why the issue must be
    further researched.
        These concerns were the impetus behind recent WWP partnerships with
    the Tragedy Assistance Program for Survivors (TAPS), Burn Pits 360, and
    Vietnam Veterans of America (VVA) to bring forth public awareness and
    investigate the harmful effects of toxic exposures in the military. To
    date, WWP has invested $620,000 in these partnerships to address the
    needs associated with toxic exposure. These funds help drive the
    mission to bring awareness and advocacy to servicemembers, veterans,
    and survivors seeking access to the care they need and benefits they
    deserve.
        To further raise awareness and improve collaboration across the
    community, WWP has led the formation of a new veteran and military
    toxic exposure working group called the Toxic Exposure in the American
    Military (TEAM) coalition. The TEAM coalition includes 15 Veteran
    Service Organizations (VSO) and Military Service Organizations (MSO)
    all addressing toxic exposure issues. Members of TEAM include, WWP,
    Burn Pits 360, Cease Fire Campaign, Hunter Seven, Iraq and Afghanistan
    Veterans of America, Military Officers Association of America, The
    American Legion, Tragedy Assistance Program for Survivors, Veteran
    Warriors, Vietnam Veterans of America, Enlisted Association of the
    National Guard of the United States, California Communities Against
    Toxics, National Veterans Legal Services Program, Vets First, and the
    Dixon Center. Additional organizations attend the monthly coalition
    meetings for broader input.
        With the legacy of a decades-long struggle to deliver care and
    benefits to those who have or continue to suffer from the effects of
    Agent Orange, we strive to ensure that today's veterans struggling to
    receive health care are not fighting for treatment years from now. If
    we do not act, we may look back wondering if we should have done more
    sooner. Accordingly, our mission is focused on treating servicemembers
    and veterans before they become critically ill through early
    identification and better research, which can be utilized to develop
    new forms of treatment.
        Through our testimony, we hope to highlight a host of issues we
    have seen regarding toxic exposure, and while the issues are broad--and
    the challenges great--we will be focusing on five key topic areas for
    this testimony that WWP considers to be the appropriate first steps
    needed to address the needs of the community. Additionally, our
    recommendations are informed by daily interaction with the young
    veterans we serve, guided through the work from the TEAM coalition, and
    from data captured using our Annual Wounded Warrior Alumni Survey,
    which is the largest and longest longitudinal survey of the post-9/11
    veteran population with over 35,000 respondents and in its tenth
    iteration. The full results of this year's data will be released on
    October 29, in the Kennedy Caucus Room, but we are able to share data
    regarding toxic exposure for this testimony.
               2019 wwp warrior survey results on toxic exposure:
        A new question in the 2019 Annual Wounded Warrior Alumni Survey
    asked post-9/11 wounded, ill, and injured servicemembers about exposure
    to environmental hazards such as chemical warfare agents, ionizing
    radiation, burn pits, or other potentially toxic substances during
    their military service. A majority (70.4%) of Warriors reported certain
    exposure to hazardous chemicals or substances; however, only 9.3% said
    they had received treatment for their exposure at the VA. Slightly more
    than thirty percent (31.2%) are enrolled in VA's Airborne Hazards and
    Burn Pit Registry. Warriors who reported exposures were more likely to
    indicate poorer health. Additionally, 89.8 % of Warriors who reported
    their health as ``Poor'' or ``Fair'' indicated ``Probably Yes'' or
    Definitely Yes'' to exposure of an environmental hazard during military
    service versus 81.9 % of Warriors who rated their health as ``Very
    good'' or ``Excellent'' indicated ``Probably Yes'' or Definitely Yes''
    to exposure of an environmental hazard during military service.
        Of those that indicated that they were exposed to environmental
    hazards such as chemical warfare agents, ionizing radiation, burn pits,
    or other potentially toxic substances during service, 9.3% stated they
    sought treatment at VA, 12.4% said that they did not receive treatment
    at VA for toxic exposure illnesses but tried, and 31.2% indicated that
    they have not tried to receive treatment at VA but have enrolled in
    VA's Airborne Hazards and Burn Pit Registry. Although we do not clearly
    know why so few veterans seem to be receiving treatment at VA, our
    assumption is that access issues are driven by a lack of communication
    with veterans on this topic and the difficulty of establishing service
    connection for illnesses believed to be caused by toxic exposure.
    Whether successful in receiving VA treatment or not, it is noteworthy
    that nearly 22% of surveyed Warriors reported seeking such treatment.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        As the conversation regarding prevention and treatment moves
    forward, it is important to look at the populations that legislative
    changes affect the most. We recommend reaching out to organizations who
    have original data on these populations to better understand how
    veterans might be affected and where lapses in care currently exist.
    Please see the appendix for additional data on Toxic Exposure from our
    2019 Warrior Alumni Survey.
        Below are Wounded Warrior Project's recommendations for the
    Committee as it addresses the presumptive disability decisionmaking
    process.

    1.  Establish Entitlement to Care for Veterans Suffering from Toxic
        Exposure Illnesses
        While burn pit exposure numbers are alarming in their own right,
    these numbers pale in comparison to the population of servicemembers
    who were exposed to other toxins for which there is no registry. Health
    outcome studies such as those performed by the National Academy of
    Medicine and the Committee on the Assessment of VA's Airborne Hazards
    and Open Burn Pit Registry have shown that ``not only are the emissions
    released by burn pits a complex mixture of various chemicals and
    particulates that depend on factors such as the composition of the
    trash burned, accelerant used, temperature, ventilation, and the burn
    rate, but the composition and magnitude of air pollutants on military
    bases in theaters of operation are also affected by a variety of other
    anthropogenic and natural toxicants.''\1\
    ---------------------------------------------------------------------------
        \1\ https://www.ncbi.nlm.nih.gov/books/NBK436096/
    ---------------------------------------------------------------------------
        This is why we believe that post-service preventative health checks
    and treatment for those suffering from toxic exposure illnesses are a
    priority. As with any large scale health concern, prevention and
    treatment go hand in hand. While the Department of Defense (DOD) is
    best suited to develop prevention measures to stop exposures to toxic
    substances, VA is best equipped to identify illnesses and the
    development of treatments related to those exposures. WWP recommends VA
    work with DOD using the Individual Longitudinal Exposure Record (ILER),
    and other evidence, to develop a ``High Risk'' database. This database
    should allow identified ``High Risk'' veterans the ability to receive a
    presumptive zero percent disability rating for toxic exposure. This
    zero percent rating would allow veterans access to needed healthcare
    within the VA medical system. We ask that VA start with treatment in
    conjunction with a study and data collection on those who are receiving
    treatment for illnesses. This study and data collection, in conjunction
    with ILER and VA's Airborne Hazards and Burn Pit Registry, should
    provide researchers the data needed to develop a list of illnesses that
    could be presumed to be related to toxic exposures. In doing so, this
    addresses two of WWP's primary concerns regarding toxic exposure: (1)
    early identification of toxic exposure illnesses and (2) life-saving
    treatment for those affected.
        The difficulty in developing a ``High Risk'' database is defining
    those who could be considered ``High Risk.'' We recommend by starting
    with deployed servicemembers and veterans that have rare forms of
    cancer or other medical conditions that fall outside the norm for their
    age and background. The ILER system has the ability to pull clusters of
    individuals based off of common exposures and units. If a unit has an
    unusual amount of cancer rates, this would be an indication that the
    entire unit is at a higher than normal rate of risk. Once these
    clusters are identified, notification should be sent out by DOD and VA
    to inform the servicemembers and veterans that they are considered to
    be at ``High Risk.'' For those who receive treatment for illnesses
    through DOD and VA treatment centers, it is imperative that this data
    is fed back into the ILER system for tracking and research. By
    identifying ``High Risk'' cohorts, compiling data on their illnesses,
    and administering treatment, it may help compiling the data necessary
    to develop a list of presumptive illnesses.

    2.  Allow Veterans and VSOs Access the ILER System
        The Individual Longitudinal Exposure Record (ILER) is a web-based
    application developed over the past eight years between DOD and VA that
    can assist in determining the linkage between individuals and possible
    toxic exposures while serving in the military. DOD has been proactive
    in reaching out to the veteran and military communities to answer
    questions and identify concerns from VA and key stakeholders. The
    system is impressive and we sincerely appreciate the work that DOD has
    done to demonstrate the system to the community.
        ILER can create a comprehensive exposure record for individual
    veterans by cross-referencing available DOD data. The system links
    individuals with known exposure events and incidents to compile a
    servicemember's possible exposure history. This system will be
    accessible to DOD clinicians, VA clinicians, VA claims adjudicators,
    and researchers. In theory, anyone with access to the database will
    have the ability to download a pdf file that contains a servicemembers
    historical exposure, a possible connection between exposures and
    different medical complications, possible illnesses attributed to these
    exposures, high-risk indicators, and cross-reference other
    servicemembers from a unit that might also be exposed. This system is
    useful to researchers attempting to find and isolate specific control
    groups and to servicemembers and veterans undergoing treatment.
        While this system has the potential to be life-saving, it is
    currently unavailable for use by anyone outside the DOD or VA. Allowing
    servicemembers, veterans, and their health care providers the ability
    to identify possible exposure risk factors before or during treatment
    could mean the difference between life and death. We recommend that
    Congress consider directing DOD and VA develop an easy to use portal
    that allows individuals to download their ILER information. Currently,
    the process for a veteran to obtain his or her record is to file a
    Freedom of Information Act (FOIA) request with DOD. Alternatively, it
    is possible for a veteran to obtain permission from VA to release the
    information to a private health care provider, but not directly to the
    veteran. We find this unnecessary and counterproductive when this could
    be the difference between proving service connection or not receiving
    health care from VA. Additionally, while VA claims adjudicators have
    access to the system, Veteran Service Organization (VSO) claims
    representatives do not have access and are limited in their ability
    appropriately represent veterans.
        We are also concerned that this system will be available to VA
    claims adjudicators with little understanding of how information will
    be interpreted. When individuals access the ILER database, there is a
    small disclaimer that states that lack of information found in the
    system does not indicate that a veteran was not exposed. It is our
    understanding that each military branch collects toxic exposure
    information differently. We would not want differences in data
    collection to lead to denial of benefits and healthcare. We must be
    careful to ensure that VA claims adjudicators do not inadvertently use
    the ILER system to deny claims if sufficient information does not exist
    within ILER regarding the veterans possible exposure. We would
    recommend Congress set clear guidelines on how VA can use the ILER
    system when processing a VA claim for possible exposure. Additionally,
    we look forward to working with the Veteran Benefits Administration
    (VBA) on learning how claims adjudicators are being trained to access
    the system and interpret the information.
        Last, while DOD has done a great job reaching out to the community,
    it has been difficult to understand how VA will use the ILER system and
    whether VA has worked with VSOs regarding their implementation and
    usage plan. We encourage Congress to continue oversight of the ILER
    system and how VA is able to utilize this system.

    3.  Order Additional Research into Treatment and Causation
        While working collaboratively with the TEAM coalition, WWP was able
    to identify common trends in existing research and delineate paths for
    future studies. The need for research can be broken down into two
    separate issue areas: (1) research into treatments and (2) research
    into causation. It is important to note the difference between research
    for treatment versus research for connection between exposure and
    illnesses. Research into treatment should encourage greater focus on
    genomics studies in order to ascertain the best treatments and expand
    predictive medicine for veterans. Research into causation should be
    focused on how different exposures relate to different illnesses.
    Research for Treatment:
        We recommend that VA perform a study on how to develop better
    treatment options for those affected by toxic exposure. Specifically,
    we would like VA to implement a national screening, treatment and
    research program within a Center of Excellence, preferably VA's
    Airborne Hazards and Burn Center of Excellence (AHBPCE), under the
    direction of the Deputy Under Secretary of Health for Policy and
    Services. One area of focus we would recommend looking into would be
    lung cancer screening and how to expand VA's ability to identify lung
    cancers. The incidence rate of lung cancer among veterans (137 per
    100,000) is more than double that of civilian rates (54.9 per 100,000)
    \2\ due primarily to higher smoking rates and exposure to known and
    suspected carcinogens during service.
    ---------------------------------------------------------------------------
        \2\ https://seer.cancer.gov/csr/1975_2016/
    browse_csr.php?sectionSEL=15&pageSEL=sect_15_ table.05
    ---------------------------------------------------------------------------
        Lung cancer develops slowly and rarely exhibits obvious symptoms
    until the late stages when survival rates drop to 5%.\3\ Screening
    those at high risk with CT scans before symptoms appear can shift
    diagnosis to early stage. Since the National Cancer Institute's 50,000-
    person National Lung Screening Trial in 2010, multiple international
    screening randomized controlled trials--including the Belgian-Dutch
    NELSON trial,\4\ the MILD trial in Italy,\5\ decades of population
    screening in Japan,\6\ and the 20-year International Early Lung Cancer
    Action Program (I-ELCAP) \7\ study, all show that between 50% and 80%
    of those diagnosed at early stage by CT screening will have long-term,
    recurrence-free survival.
    ---------------------------------------------------------------------------
        \3\ https://seer.cancer.gov/statfacts/html/lungb.html
        \4\ https://www.ascopost.com/issues/october-25-2018/nelson-trial/
        \5\ https://doi.org/10.1093/annonc/mdz117
        \6\ https://www.auntminnie.com/
    index.aspx?sec=sup&sub=cto&pag=dis&ItemID=124046
        \7\ https://www.ncbi.nlm.nih.gov/pubmed/30511179
    ---------------------------------------------------------------------------
        Therefore, WWP recommends legislation authorizing the Deputy Under
    Secretary for Health for Policy and Services to develop and validate
    protocols and quality controls for simultaneous screening and
    management of other findings, including, specifically, baseline and
    follow up CT scans to document and validate cohort and case-controlled
    studies of those exposed to burn pit emissions and other known and
    suspected carcinogens.
    Research for connection between exposure and illnesses:
        Wounded Warrior Project realizes that a barrier to care at VA, for
    health issues believed to be from toxic exposures, is proving an
    illness is related to service and as a result of toxic exposure. In
    order to fill gaps in research about the relationships between burn
    pits and other toxic exposures and specific illnesses, WWP recommends
    establishing a study by the National Academy of Medicine on burn pits
    and other contaminants that might have affected servicemembers deployed
    Outside Continental United States (OCONUS). While the National Academy
    of Medicine has performed reports in the past, new conclusions can
    likely be drawn using the new ILER data. In the past, the National
    Academy of Medicine listed ``Limited statistical power--Small sample
    size in many of the studies prevents the detection of associations''
    \8\ as a reason for not being able to connect exposure and illness.
    Access to the ILER data should help address this problem. We recommend
    this report cover current ongoing research, identification of the
    negative effects of exposure from burn pits and other contaminants, an
    estimate of how many servicemembers might have been affected, possible
    ways to develop a ``High Risk'' list using the ILER system, and what
    Congress, the Federal Government, and the VSO/MSO community can do to
    assist these servicemembers and veterans.
    ---------------------------------------------------------------------------
        \8\ https://www.nap.edu/download/13209
    ---------------------------------------------------------------------------
        Additionally, new epidemiological data on the entire Post-9/11
    cohort should be collected to understand exposures and current short
    and long-term health problems related to their military service.
    Wounded Warrior Project would also like to see an in-depth report on
    the DOD Periodic Occupational and Environmental Monitoring Summary
    (POEMS). These reports have a vast amount of data regarding
    environmental exposures in Afghanistan and Iraq. Conducting a report
    that can capture this data in a way that promotes informed legislative
    action is critical for future progress on this issue.

    4.  Update the Airborne Hazards and Burn Pit Registry
        There are more than 165,000 veterans enrolled in VA's Airborne
    Hazards and Burn Pit Registry--all of whom served on or after 9/11,
    during operations Desert Shield and Desert Storm, or in the Southwest
    Asia theater of operations after August 2, 1990, and were deployed to a
    base or station where open burn pits were used or where possible
    exposures to toxic substances occurred. While VA's Airborne Hazards and
    Burn Pit Registry asks questions regarding exposures not related to
    burn pits, it can be unclear to veterans if exposure to other relevant
    containments is recorded in the registry due to the name. Our first
    recommendation would be to update the name to include or convey the
    idea that all forms of toxic exposures during deployments are captured.
        While VA's Airborne Hazards and Burn Pit Registry is important, we
    are unaware of any analysis of the information being performed other
    than the 2016 study titled Burn Pit Emissions Exposure and Respiratory
    and Cardiovascular Conditions Among Airborne Hazards and Open Burn Pit
    Registry Participants.\9\ We recommend VA's Airborne Hazards and Burn
    Pits Center of Excellence conduct a comprehensive report on information
    that is being captured and any trends that have been identified.
    ---------------------------------------------------------------------------
        \9\ https://www.ncbi.nlm.nih.gov/pubmed/27218278
    ---------------------------------------------------------------------------
        Last, WWP recommends Congress pass H.R. 1001, the Family Member
    Access to Burn Pit Registry Act, which will direct the Secretary of
    Veterans Affairs to provide a process by which a family member of a
    deceased individual who is eligible for the Department of Veterans
    Affairs burn pit registry may register for such registry on behalf of
    the deceased individual. While we support H.R. 1001, we understand that
    it is important to keep datasets clean; however, we feel that it is
    still important to track this information. Therefore, allowing family
    members to add information to a file while keeping the original data
    safe from alteration still allows researches to identify trends, and
    expands the data to include those who are deceased. We feel this
    additional language should be considered if H.R. 1001 were to be
    addressed in the Senate. We also feel that feeding this information
    back into the ILER system and developing ``High Risk'' cohorts could
    save lives in the long run. A proactive approach VA and DOD can take is
    to track which veterans have passed away, from what type of illness,
    identifying clusters, and reaching out to other members of that unit.

    5.  Provide Training for Clinicians
        Recently, WWP had a post-9/11 wounded warrior attend a medical
    examination for difficulty breathing, with the examination conducted by
    a VA contractor. During the medical assessment, the veteran reported
    that he was never asked about possible exposures to burn pits or other
    contaminants. Proper training and identification of possible ``High
    Risk'' veterans go hand in hand. WWP recommends VA develop a training
    module on questions VA providers and VA contractors should ask veterans
    at the beginning of an exam to help identify a possible ``High Risk''
    veteran. This would include adding questions to the exam questionnaire,
    training to probe for additional information regarding types of
    exposures, and training to inform veterans of resources available to
    them. For instance, research has shown that there is a possible
    connection between chemicals that were inhaled by servicemembers while
    deployed and a higher risk of chronic bronchitis or chronic obstructive
    pulmonary disease.\10\ If VA clinicians are not trained on the types of
    symptoms that may be common to different toxic exposures, then there is
    a risk of misdiagnosis. Sometimes it can be as simple as asking ``were
    you ever stationed near a burn pit?'' to get both patient and provider
    to think more critically about toxic exposures.
    ---------------------------------------------------------------------------
        \10\ https://www.ncbi.nlm.nih.gov/pubmed/27218278
    ---------------------------------------------------------------------------
                                   conclusion
        Wounded Warrior Project's mission is to honor and empower wounded,
    ill, and injured veterans, servicemembers, and their families. We have
    seen increased health complications for a young population that should
    be generally healthy. We cannot ignore obvious correlation between
    certain toxic exposures and illnesses with no reasonable explanation
    for onset. We do not have the resources to adequately answer these
    questions alone and rely on our partners, both in and out of Congress,
    to help understand why we have seen an increase in rare cancers and
    other illnesses. We believe it is in large part to toxic exposure. This
    is not only related to those deployed overseas but also encompass Per-
    and Polyfluoroalkyl Substances (PFAS) contaminants, Camp Lejeune water
    contamination, burn pits, and many other exposures. We will continue to
    advocate for all generations of Warriors who are dealing with medical
    complications due to toxic exposures and urge Congress to take action
    as each day that veterans are denied proper medical diagnosis and
    treatment is another day that could mean life or death.

        Wounded Warrior Project thanks the Senate Committee on Veterans'
    Affairs, its distinguished members, and all who have contributed to the
    discussions surrounding today's hearing. We share a sacred obligation
    to serve our Nation's veterans, and WWP appreciates the Committee's
    effort to identify and address the issues that challenge our ability to
    carry out that obligation as effectively as possible. We are grateful
    for the invitation to submit this statement for the record and stand
    ready to assist when needed on these issues and any others that may
    arise.
                                     ______

    Appendix:

                           2019 Annual Warrior Survey
              toxic exposure information by demographic variablesn
        A higher rate of male warriors indicated they had some exposure to
    environmental hazards such as chemical warfare agents, ionizing
    radiation, burn pits, or other potentially toxic substances during
    their military service, with 90% of male warriors reporting they were
    definitely or probably exposed versus 76% of female warriors.
        The treatment rates between male and female warriors were similar.
    Of those who indicated some exposure, 46% of male warriors had not
    received treatment or enrolled in the VA's Airborne Hazards and Burn
    Pit Registry, while 53% of female warriors had not received treatment
    or enrolled in the VA's Airborne Hazards and Burn Pit Registry.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        There was little variation among race or ethnicity for warriors
    reporting exposure to environmental hazards such as chemical warfare
    agents, ionizing radiation, burn pits, or other potentially toxic
    substances during their military service.
         The treatment rates among race or ethnicity were also
    similar.
         In the future, we will do significance testing to see if
    there are true differences.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Older Warriors report higher rates of exposure to environmental
    hazards such as chemical warfare agents, ionizing radiation, burn pits,
    or other potentially toxic substances during their military service,
    with 92 percent of Warriors age 41-45 indicating definitely or probably
    yes, and 91 percent of Warriors age 45 and older indicating the same.
    For comparison, 51 percent of warriors age 18-24 indicated definitely
    or probably yes, and 72 percent of Warriors age 25-30 indicated the
    same.
         The treatment rates among age groups followed a similar
    trend. Of those who indicated some exposure, Older warriors had higher
    rates reporting treatment or enrollment in the VA's Airborne Hazards
    and Burn Pit Registry.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Perhaps not surprisingly, Warriors who reported being deployed 3 or
    more times reported higher rates of exposure to environmental hazards
    such as chemical warfare agents, ionizing radiation, burn pits, or
    other potentially toxic substances during their military service, with
    93% of Warriors deployed three times indicating definitely or probably
    yes, and 94% of Warriors deployed more than three times indicating the
    same. For comparison, 85% of warriors deployed once indicated
    definitely or probably yes and 91% of Warriors deployed twice indicated
    the same.
         Despite the high rates of reported exposure among Warriors
    who deployed multiple times, these Warriors do not report high rates of
    treatment. A little over a third of Warriors within each deployment
    category have enrolled in the VA's Airborne Hazards and Burn Pit
    Registry (35% of Warriors deployed more than three times, 33% of
    Warriors deployed three times, 31% of Warriors deployed two times).

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                                   ______

     Prepared Statement of Susan M. Zeier, Veteran Advocate, Burn Pits 360-
                 Ohio, and Mother-in-Law of a Burn Pit Veteran
                               september 25, 2019
        Soldiers are the epitome of excellent health before being deployed
    to war zones like Iraq and Afghanistan yet thousands have returned home
    safely from war only to realize a battle for their lives are just
    beginning. These returning soldiers are dying at alarming rates and
    fighting for their lives now in their 20s, 30s, and 40s and it's a
    disgrace that our country is not helping many who need desperate tests,
    surgeries, biopsies, and treatment.
        As the mother-in-law, of an Iraq War Veteran, on March 21, 2017,
    the agony of realizing that thousands of our servicemembers returning
    from Iraq and Afghanistan and have experienced a constellation of
    debilitating chronic ailments including terminal diseases hit my family
    like a rock. Around noon on that fateful March day, my phone rang with
    the caller ID telling me it was my daughter. I knew she was with her
    active duty military husband and where they were, at a local cancer
    center meeting with an oncologist who was to deliver them news on the
    type of cancer my son-in-law had, having had test results show days
    earlier that he indeed was suffering from some form of cancer.
        Anxiously waiting for this phone call, I already knew that my son-
    in-law been diagnosed with a rare autoimmune disease called mucous
    membrane pemphigoid which is known mainly to strike elderly women and
    not 35 year old men. Diagnosing him took bouncing around to about 10
    different doctors after the first nine couldn't figure out the health
    condition causing his chronic daily nosebleeds and eventual bleeding
    from his ears but we were hopeful after being told the disease was
    manageable and possibly curable. But having cancer was another story,
    thus my anxiety awaiting his test and scan results, I answered the
    phone like I always do when I know it's her, ``Hi Sweetie.'' Before I
    could barely get ``Hi'' out, the most terrifying unintelligible
    hysterically distressed shrieks were blasting in my ear. Not one word
    could I understand but I knew it was bad . . . very, very bad. This was
    a distraught wail no mother ever wants to hear from their child and
    especially, as was soon substantiated that I'm not going to be able to
    do anything to take away hers or her husband's excruciating pain. I
    won't be able to fix this.
        Finally about 15 minutes later after calming my daughter down
    enough to speak coherently but still somewhat hysterically screaming at
    me. She was able express that the doctor walked into the room and the
    first words out of his mouth were, WHAT THE HELL HAVE YOU BEEN EXPOSED
    TO???? While he went on to explain that my grand-daughter's daddy has
    contracted an extremely rare form of cancer, non-small cell
    adenocarcinoma lung cancer with no primary turnor and the cancer is
    stage IV. 20 highly respected oncologists were consulted with to
    hopefully figure out the best treatment that would possibly extend his
    life past the life expectancy prognosis of two weeks to a few months if
    the aggressive cancer could not be brought under control. The
    oncologists agreed that his form of cancer could've only been caused by
    long term toxic exposure, but none of the 20 consults had answers other
    than experimenting with a variety of treatments and pray that one
    works. The physician's dilemma occurred because seeing patients with
    this rare form of lung cancer never happens so there just aren't any
    statistics on prognosis and treatments that work the best. The doctor
    told the young couple that people just aren't exposed to the type of
    toxins he apparently was. To complicate matters, not having a primary
    turnor there's nothing to direct chemotherapy or radiation to. He
    already had mets (metastases) to his bone and pericardium and if
    initial treatments didn't slow down the cancer's progression the
    oncologist told them he only has at most a couple months to live as his
    bronchioles and airway was being compromised.
        Cancer has taken over his membranes, his lungs, thoracic wall,
    heart, and all of the chest and neck lymph nodes. My kids were told on
    that day to get his affairs in order and complete any paperwork
    pertaining for the end of life. The doctor cried and had to excuse
    himself from the room while giving them time to fall apart. As my
    daughter described it to me, her husband aguishly pounded on the wall
    before leaning against it and started crying almost collapsing until
    she held him up to prevent him from falling.
        Our entire family was in total shock, walking around in a daze for
    a few days speculating where the toxic exposure took place and what
    were we going to do to help. How are we going to explain to his 3-1/2
    year old daughter that her daddy will be going away and never coming
    back? Our family was devastated and confused as we tried to grasp what
    was happening. My husband and I were asked by our son-in-law to make
    sure his girls are OK. Make sure his daughter uses his GI Bill and goes
    to college. Make sure we are with her for all of her milestones growing
    up: starting kindergarten, Sweet 16, homecomings, proms, father-
    daughter dances, boyfriends, learning to drive, graduating high school
    and college and getting married. He was so distressed telling me that
    he won't get too see his baby girl grow up and witness all those parts
    of her life.
        I sat with him the day his former Captain who is now a Sergeant
    Major stopped by to visit. The officer was about to be deployed to
    Kuwait for a year and was struggling to say ``good-bye.'' I listened as
    both men were in tears talking about their time together in the
    military and the close bond they developed. It was gut wrenching to
    hear my daughter's husband ask his former commander that if he passes
    away while the Sergeant Major is still in Kuwait , will he be able to
    come back for his funeral. He went on to say, wiping tears on his
    sleeve, that there is no other person that he wants to speak at his
    funeral than the man who was his first captain upon joining the
    military. With tears pouring from his eyes, Sergeant Major explained
    that he already made arrangements just in case.
        That was 2-1/2 years ago. With immunotherapy keeping my beloved
    son-in-law alive for now, those two have had more time together as
    well, but more on that later.
        I soon learned the horrifying meaning of two simple words: ``Burn
    Pits.'' The only thing, which even remotely explains his type of Cancer
    and his extremely rare autoimmune disorder is the burn pits he was near
    when he was in Iraq on guard duty near one of Saddam's palaces for a
    period of 3 months. He is an army medic and was stationed at a clinic
    on Camp Liberty, but at some point during his time there and he wrote
    me letters and emails explaining as much. He was pulled from medic
    duties and given orders to stand guard near one of Saddam's palaces
    located on Camp Victory and near military headquarters. While Camp
    Liberty was nicknamed ``Camp Trashcan'' in honor of their notorious
    burn pits, Camp Victory was also well known for huge infernos of
    burning trash. Most days for a period of 3 months, this soldier was
    forced to stand in an area very close to the edge of a burn pit. If the
    smoke blew his way, he couldn't leave. His duty was to watch out for
    and protect the defense contractors working the pits. Learning the hows
    and whys, he was exposed to a plethora of toxins every day for 3 months
    was mind boggling to me and quite frankly, pissed me off. It's
    unconscionable that our military commanders would turn a blind eye and
    ignore the fact that my family member was being poisoned. Believing
    that our country learned a tough lesson after the Agent Orange
    disgrace, man was I wrong. In the months moving forward I felt as if I
    was a zombie walking around in a science fiction movie where for some
    whacked out reason our government leader's unleashed chemical weapons
    on our own troops in Iraq. Watching this hypothetical movie, one would
    be relieved, thinking, ``This could never happen because it's so
    stupid.'' But it did happen and it's worse than stupid. It's horrifying
    and criminally negligent and there are no words enough to describe the
    anger, heartbreak and disgust at how our country could perpetrate
    actions so deadly onto our war heroes. And in turn, not do everything
    humanly possible to take care of them after they return home. I've
    never seen an ounce of shame or remorse from anyone associated with the
    military other than Lt. Col Dan Brewer, a military environmental
    engineer who was tasked with testing the air quality at just about
    every burn pit in the Middle East. Brewer's warnings were brushed
    aside. So they KNEW! They KNEW soldiers were being poisoned, the proof
    was there. Any intelligent individual would say, ``This is good! They
    know!! Now they will stop the practice of open burning all trash.'' But
    they DIDN'T!!! As a taxpayer who helped fund the poisoning of American
    soldiers I feel so much shame that America did this. A country I love
    and has so many things to be proud of, but not everything we do is
    good; and the bad things need desperately to be acknowledged before
    that shame can be fixed.
        Eventually, the oncologist was able to get the cancer under control
    with chemo and radiation before starting immunotherapy treatments that
    he still undergoes to this day. However, we know immunotherapy is not a
    cure, but if he continues responding to it, it does shrink the cancer
    and slows down the progression. It will not be gone though. It will buy
    him time and quality of life. And it surely has. There are good days
    and there are bad days. My son-in-law never has a completely
    comfortable day and I wish he could. He puts up with more than a person
    should have to, but he is blessed to have more time on this earth with
    his family and friends and most importantly, his 6 year old daughter,
    Brielle. The anger, the depression, the worry, the fear, having faith,
    praying, the roller coaster ride is like nothing I can imagine anyone
    having to experience. Surgeries, ER visits, countless treatments,
    countless imaging, countless meds, everyday nose bleeds, the hair loss,
    the throwing up, the shortness of breath, the fatigue, the extensive
    sleeping, the insomnia, the gaining weight, the heart racing, the
    headaches, the blisters, the skin reactions, the bad news, the good
    news, the lack of feeling like you are a person or even the lack of
    feeling you are in your body at all. This is the whirlwind of a
    nightmare my children have been living for the past 2-1/2 years. And
    this is not a person who was dealt a bad hand and got cancer. THIS WAS
    DONE TO HIM!!! He should be looking forward to taking his daughter to
    school and gymnastics classes and planning vacations with his wife and
    daughter, but instead, he must spend most of this time and energy
    fighting for his life.
        On top of that I learned that the VA and Dept. of Defense refuse to
    acknowledge that the toxic infernos in Iraq caused his and thousands of
    other veterans' diseases and that absolutely made my blood boil.
    Because my loved one was still active duty, his care has been
    phenomenal and first rate most of the time, however, once I heard of
    and met other veterans who have been denied benefits even though they
    are seriously ill was just mind boggling to me. Why on earth would we
    not take care of our soldiers and sailors who willingly volunteered to
    fight for all of us? It is all of our responsibility to take care of
    every single war hero suffering and dying from war wounds, be they
    physical, invisible or toxic wounds making them ``delayed'' casualties.
        Reading the stance on the Veterans' Administrations website over 2
    years ago infuriated me so much so it was making me sick: ``At this
    time, research does not show evidence of long-term health problems from
    exposure to burn pits. VA continues to study the health of deployed
    Veterans.'' I knew in an instant that this was a slap in the face to
    all Middle East war veterans who lived on bases with burn pits. You
    don't have to be a genius to KNOW that burning the vast array of toxic
    causing substances and waste such as: Asbestos, medical waste, human
    remains, animal remains, plastics, rubber, military vehicles,
    munitions, explosives, chemical weapons, pesticides, gasoline, lp
    tanks, batteries, Styrofoam, aerosol cans, expired medications, human
    waste, mattresses, 50 gallon metal drums, oil, adhesives and
    containers, paint cans, and coated electrical wire . . . that anyone
    exposed to and inhaled the smoke daily, for weeks, months and even
    years is highly likely to become seriously ill and die. This remains
    the VA's stance despite numerous other studies and information that
    prove burn pits, were in at least some cases positioned so all smoke
    traveled downwind toward soldiers' living areas, some being as close as
    one quarter of a mile. This remains the VA's stance even though there's
    evidence that burn pit emissions contain particulate matter, sulfur
    oxides, carbon monoxide, volatile organic compounds and various
    irritant gases, and according to the American Lung Association, even
    short exposures can kill for vulnerable persons and long term exposures
    are dangerous for everyone. Inhalation of particulate matter air
    pollution can lead to premature death from respiratory and
    cardiovascular causes, including strokes. Burning materials that the
    military disposed of in the burn pits produces chemicals associated
    with immune dysfunction, IQ deficit, reproductive abnormalities, nose
    and throat cancer liver and kidney disease and leukemia. This remains
    the VA's stance even though there's evidence of what kinds of trash was
    incinerated in open air toxic infernos including chemical weapons.
        What I would like to know is, ``Is there any evidence that
    definitively shows burn pit exposure DOES NOT cause long-term health
    problems?''
        My stomach hurt every day and the nausea wouldn't quit. For about a
    month the pain felt as if someone kicked me in the gut and then turned
    around and denied they did it until I found the only way to ease my
    pain was to become active in fighting for Burn Pits Veterans. My son-
    in-law and daughter have been reluctant and scared to speak out on
    their own behalf because he is active duty. The separation process has
    begun and fortunately his current Captain has been fighting for him to
    get the benefits he deserves even though the chain of command on the
    other side is trying to force him to accept retiring with the least
    amount of benefits . . . a regular military retirement with much less
    benefits than a medical and disabled due to combat injuries retirement.
    Fortunately, for the Sergeant Major mentioned earlier, he copied and
    saved all of my son-in-law's deployment records. It's outrageous that
    we just learned in this retirement battle that shortly after his lung
    cancer diagnosis, some of his deployment records disappeared. I had
    heard that from my Congresswoman's veteran affairs staff member as he
    told me early on to make sure we had copies of his records, but as far
    as we knew, his stayed intact when actually they hadn't.
        It's a disgrace that a dying active duty soldier can't even speak
    out on his own behalf because he fears retaliation and will be denied
    the compensation and benefits he's earned. Even though he has followed
    the letter of ``military law,'' they are still trying to screw him
    over. It's outrageous and my anger is such that I've become consumed by
    burn pits. My granddaughter's daddy will be officially retired very
    soon and he will at that time speak to anyone who is truly interested
    in hearing his story. In my opinion he is a cut and dried case with
    absolutely no doubt of proof that burn pits have given him a death
    sentence.
        The anger has caused me to become consumed with burn pits so two
    years ago I began searches to educate myself and learn everything I
    could about them. My research began on the obvious place, the internet,
    everything burn pits and here is what my research has showed and some
    of what I've learned along the way:

              Burn Pits 360 Veterans Organization is the only veterans
            group solely focused on burn pits issues and I am fortunate to
            have them be one of my first discoveries on my initial burn
            pits internet search, reaching out to them and joining their
            cause. I am now the Ohio Advocate for Burn Pits 360 and it was
            through them that I first learned that thousands of our
            servicemembers have come back from Iraq and Afghanistan and
            have experienced a constellation of debilitating, chronic
            ailments. Many of them served around open air burn pits where
            thousands of pounds of trash was burned daily. Much of this
            trash was known to be toxic such as: plastics, batteries,
            paints and solvents, and much more. Despite the connection we
            feel research does support between our servicemembers'
            illnesses and the burn pits, they are being denied specialized
            healthcare, disability claims and death benefits at an
            extraordinarily high rate.

        For these reasons Burn Pits 360 has for over a decade been lobbying
    Congress to pass legislation that would force the VA to acknowledge
    that there is a connection between burn pits and many serious, chronic
    and terminal diseases. The research is there. We don't need more
    research. In fact, Burn pits 360 was a force behind Congress forcing
    the VA to construct the Burn pits Registry, which does nothing, by the
    way, but list potential burn pit victims. The VA registry alone does
    not assist anyone and not all Iraq and Afghanistan Veterans can be on
    it, mainly because their deaths occurred before 2014.
        Burn pits 360 started their own registry and has over 6,000
    veterans signed on. Our data has been used several times for credible
    research and their results are astounding. What we need is for the DOD
    to acknowledge results from years of research from brilliant doctors
    and researchers like Dr. Anthony Szema and Dr. Robert Miller. Even air
    quality studies by military bioenvironmental engineers like Lt. Col
    Darrin Curtis and Lt. Col. Dan Brewer are being ignored by military and
    VA officials. THE RESEARCH IS THERE. NO MORE RESEARCH IS NECESSARY TO
    START HELPING THE VETERANS NOW.
        It is imperative that Congress moves to solve this problem so that
    servicemembers, veterans, and their family members get the support they
    need and are entitled to. Supporting and writing a Senate Companion
    Bill to proposed legislation proposed earlier this year is a first step
    toward making sure that happens. Let's end the policy of ``delay, deny
    and wait till they die.'' Those House Bills are:

        1. Family Member Access to Burn Pits Registry Act (H.R. 1001) This
    Act would allow family members of deceased Servicemembers who suspect
    the death was a result of a burn pit exposure caused illness to
    participate in the Airborne Hazards and Open Burn pit Registry on their
    behalf with new registry entries. Current rules don't allow family
    members access, therefore many soldiers who passed away prior to the
    2014 enactment of the registry are not included.
        2. Burn Pits Revision Act (H.R. 1005) This Act would require the
    Department of Veterans Affairs to establish a diagnostic code and
    evaluation criteria for Constrictive Bronchiolitis.
        There are a few doctors out there doing lung biopsies on sick
    soldiers and are finding titanium and copper elements in the soldiers
    lungs, which they have been able to tie it back to burn pits in Iraq
    and Afghanistan but military officials refuse to accept those studies.
        3. In 2006, Air Force Lt Col Darrin Curtis commissioned a study at
    a Balad burn pit which was done by the US Army Center for Health
    Promotion and Preventative Medicine showing results as being labeled by
    an assessment team member as ``the worst environmental site I have
    personally visited.'' Curtis wrote in his memo: ``It is amazing that
    the burn pit has been able to operate without restrictions over the
    past few years without significant engineering controls being put in
    place. I would hope in the future that issues such as burn pits are
    identified early on and engineering controls such as incinerators would
    be used to mitigate these hazards. It seems that money has been the
    issue of why engineering controls are not currently in place.'' And:
    ``In my professional opinion, there is an acute health hazard for
    individuals. There is also the possibility for chronic health hazards
    associated with the smoke. It is my recommendation that engineering
    controls, such as the anticipated incinerators, should be expedited to
    solve this problem. In my professional opinion, the known carcinogens
    and respiratory sensitizers released into the atmosphere by the burn
    pit present both an acute and a chronic health hazard to our troops and
    the local population.''
        While everything burn pits is horrifying and incredibly disturbing
    to me, this is one of the studies that really hurts because it was
    completed right before my son-in-law landed in Iraq. It is my
    understanding that this memo warning of health risks from inhaling burn
    pits smoke was immediately classified and no action was taken to
    protect soldiers and Iraqis from the danger.
        4. Thousands of our servicemembers have come back from Iraq and
    Afghanistan and have experienced a constellation of debilitating,
    chronic ailments and rare, terminal cancers. Many of them served around
    open air burn pits where thousands of pounds of trash was burned daily.
    Much of this trash was known to be toxic such as: plastics, batteries,
    paints and solvents. human remains and much more. Despite the
    connection between our servicemember's illnesses and the burn pits,
    they are being denied specialized healthcare, disability claims and
    death benefits at an extraordinarily high rate.
        I realize there has been toxic exposure legislation passed and also
    more pending but none of it is moving fast enough to help veterans
    being denied healthcare.
        5. From the Atlanta Journal Constitution, April 25. 2019
        This quote infuriates me because I know there's plenty of SCIENCE
    and research out there to give credence to a long list of burn pit
    presumptive illnesses--``We continually look at the research and follow
    trends since some diseases, such as a cancer, have a long latency
    period,'' VA spokesman Terrence Hayes said in an email. ``At this time,
    science does not support making burn pit exposure a presumptive
    condition for any illness.''
        Seriously, is this acceptable? 1/5th ??? And many veterans I've
    conversed with feel that the VA will grant one condition but give only
    a small percentage disability rating if any in efforts to pacify the
    veteran and make them give up appealing the decisions. Still, the
    agency has approved some disability compensation claims that had at
    least one condition related to burn pit exposure. From June 2007
    through March of this year, the VA processed 12,378 of them. Of those,
    2,425--or a fifth--had at least one burn pit condition granted,
    according to the VA.
        6. The VA is doing a serous injustice to war veterans by not
    facilitating benefits and services that they are entitled to and
    rightly deserve by keeping a burn pits registry that disallows changes
    and updates in health conditions. Once the veteran is registered even a
    death entry cannot be made if he or she dies.
        7. I couldn't believe and was stunned to learn that no
    environmental laws were being practiced overseas. It seemed like the
    manuals for disposing of waste whether they be EPA guidelines or from
    another entity evidently were just tossed in the burn pits unread.
        8. And even more unsettling was realizing there is that there is
    seems to be a repetitive expression of insensitivity and neglect by the
    government when it comes to caring for soldiers harmed by actions
    approved by top military commanders. This happened to Vietnam Veterans
    and now is continuing throughout the wars in Iraq and Afghanistan.
    Though the DOD does admit that soldiers were constantly exposed to
    heavy smoke and ash from the burn pits in those war zones, it continues
    to deny that this massive exposure in any way harmful to the men and
    women serving on those bases as stated in a pamphlet made available to
    military personnel back in July 2008. The brochure gave assurances that
    ``Under most conditions, breathing smoke from burning trash and human
    waste does not result in any significant risk to short--or long-term
    health issues.'' The pamphlet went on to say that ``smoke from burning
    trash or human waste'' was usually made up of relatively harmless
    ``heated gases including carbon monoxide and dioxide, water vapor, and
    fine particulate matter and hydrocarbons.''
        A year later, the U.S. Government Accountability Office (GAO)
    published it's burn pits report detailing what was burned at the Balad
    base burn pit in Iraq which pretty much was anything and everything
    imaginable that we know not to burn like, rubber, batteries, medical
    waste, human remains, plastics and so much more. The Balad pits burned
    about 147 tons of trash a day, seven days a week for seven straight
    years and no regulations at all. What's even more alarming about the
    Balad pits is that they were built on and around a mustard gas facility
    yet contamination in the soil was never tested after the U.S. bombed
    the site.
        9. The fact that the British military hired Iraqi's to install
    incinerators on their bases, but what I don't know is if anyone has
    ``researched'' the health on soldiers living on those bases. If the
    claims by the DOD that the sand/dust storms and other uncontrollable
    pollution is the cause of so many deaths and chronic diseases then why
    hasn't anyone suggested finding out about the health of soldiers who
    weren't exposed to toxic burn pits but were exposed to the other
    elements suggested by the U.S. DOD? If the Brit veterans aren't as
    sick, wouldn't that be another check in the box that burn pits are
    responsible for many of our soldiers' rare and terminal chronic
    diseases?
        That brings me to another outrage: How does the wealthiest,
    greatest, most powerful military in the world decide that installing
    incinerators would not be cost effective? What price do we put on
    keeping our men and women in uniform safe and healthy even AFTER they
    leave the other obvious dangers of a warzone?
        I'd like to add that the cost of installing incinerators should
    pale in comparison to what healthcare costs for thousands upon
    thousands of seriously and terminally ill veterans will be. But then
    again, maybe not because most of the war heroes aren't being taken care
    of by the VA.
        10. Several studies and leaked memos that the Pentagon has tried to
    hide have surfaced. Attached are a few of them.

              1: Leaked Memo: Afghan Burn Pit Could Wreck Troops' Hearts,
            Lungs
              2: Lt. Col. Darrin Curtis memo, i.e., Balad Air Base Iraq
              3: Dr. Anthony Szema's statement to the Senate Democratic
            Policy Committee Hearing, ``Are Burn Pits in Iraq and
            Afghanistan Making Our Soldiers Sick?'' on Friday, Nov. 6. 2009

        11. I know that there are over 3600 Ohio veterans registered on the
    VA's Burn Pit Registry and that there should be many more.
        12. It is terribly unjust and sad for the soldiers that they aren't
    awarded Purple Hearts for suffering from toxic wounds of war. It's sad
    to know that one day when the Iraq War Memorial is constructed in our
    Nation's Capital that my grand-daughter's daddy's name won't be on it.
    It's a disgrace that Burn Pits Veterans are not counted as the
    casualties of combat and war as they should be.

        In conclusion, I don't think anybody in Washington would be
    comfortable if there was a 10-acre pit in their backyard where they
    were burning blown-up Humvees, car paint cans, unused pharmaceuticals,
    human remains, pesticide containers, plastics, chemical weapons and
    rubber. I beg you to don't let open air burn pits continue on any
    overseas or homeland bases. Give our soldiers clean water. Follow all
    EPA/OSHA regulations just as civilians would! They aren't animals, this
    isn't a Third World country! Take care of our own!!! If you aren't
    going to expose yourselves to it than don't expose our loved ones to
    it!!! If I came and burned all of these things a few yards from your
    home every day I would be arrested. Don't do it to our military!!! Just
    STOP POISONING OUR SOLDIERS!!!
        The military is still utilizing burn pits overseas!!! Who is next
    to be stricken with a debilitating disease because of this toxic
    exposure? You grandchildren, your nieces, your nephews, a friend, a
    neighbor, or someone else you know who could have their life put in
    jeopardy for what reason? To save money? Veterans and we family members
    and caregivers need our voices heard. We need, you, our senators to
    step up and let our voices be heard, but not only do our voices need to
    be heard, but you have to have an open heart to feel what we are going
    through in order to not allow this to happen to our own any more. You
    need to take care of our soldiers who have fought so unselfishly for
    our lives and this includes all of you in Congress. You all need to
    hear our voices!
        Our military volunteer to go into war and enter in to a special
    Brotherhood/Sisterhood, so that civilians don't have to in order to
    continue our independence and freedoms. They know they may die from
    being shot or blown up, but they certainly don't sign up to be poisoned
    by their own commanders. They don't expect that when they come home
    from war they may battle a whole different monster and end up fighting
    for their lives on our own turf after the war is done!!!
        Now, take care of them and don't let open air burn pits continue on
    any overseas or homeland bases. Give them clean water. Follow all
    EPNOSHA regulations just as civilian would! They aren't animals, this
    isn't a Third World country! Take care of our own!!! If you aren't
    going to expose yourselves to it than don't expose our loved ones to
    it!!! If I came and burned all of these things a few yards from you
    every day I would be arrested. Don't do it to our military!!!
        And yes this is 2019!!! This should have been taken care of a long
    time ago!!! We know what cancer causing agents are and that it is
    unsafe to smoke cigarettes and be next to a fire with everything you
    can think of being burned in it! There is no excuse in the entire world
    for not installing incinerators and properly disposing of waste.
        There needs to be a bill for those affected by the burn pits, so
    that you can sue the DOD and contractors for negligence in exposure to
    burn pits.
        There needs to be a law not allowing a monopoly for contractors to
    be hired to complete jobs with the DOD resulting in politicians
    benefiting and profiting from their companies receiving the contracts.
        This problem is just beginning. The illnesses are just now starting
    to manifest themselves. We don't need any more damn research. The
    research that supports the dangers of inhaling toxins and its effects
    on the human body are already well documented and accepted science. We
    already have the Agent Orange debacle. We already know the rate of
    cancers among fire fighters is tremendous, and they wear PPE and suffer
    high exposures for limited amounts of time. Those who were exposed to
    the Burn Pits suffered heavy to moderate exposures for months,
    sometimes even years with multiple deployments. The items burned in the
    Burn Pits you would find in your home and then some. We don't burn
    waste here in the States because we already know breathing toxins
    produce long term negative health effects, cancers, respiratory
    ailments and so on. We require incinerators for that reason. This is
    simply outrageous what they are doing to all of them.
        American and other countries soldiers were knowingly, willingly and
    unnecessarily exposed to the toxins from the Burn pits. The evidence of
    this negligence is overwhelming with what we already knew, and with the
    air quality samples taken, the memos written since around 2003 warning
    of the long term health effects of this. This is a national disgrace to
    treat people who willingly signed up to serve and went down range like
    this.

    Pass This Bill:

          Any American Citizen who was exposed to the toxins from
    the Burn Pits and been diagnosed with an illness related to them will
    get any and all medical they need.
          Any American Citizen who was exposed to the toxins from
    the Burn Pits should receive immediate compensation for their injuries.
          Any American Citizen who was exposed to the Burn Pits
    should receive a monthly pension in addition to the compensation. The
    pension should be equal to or greater than the amount of the livelihood
    they had lost due to the illness inflicted on them.

        My husband and I were honored to receive an America flag that was
    flown in our honor over the military headquarters on Camp Victory in
    Iraq and was presented to us from our son-in-law as a thank you for the
    support we gave him while he was deployed to Iraq. Not wanting the flag
    to be weathered or tattered we decided we would fly it on our front
    porch on strictly military holidays, like Memorial Day, 4th of July,
    Veterans' Day, etc. As Memorial Day approached in 2017, my husband
    asked me, ``Should I get out the Iraq flag?'' and his words hit me like
    a ton of bricks.
        You see when our son-in-law explained to us his close proximity to
    the burn pits for those 3 months, he mentioned that it was something he
    emailed me about back then, because he wasn't happy to be pulled from
    medic duties. So, I asked him if Saddam's Palace was the military
    headquarters where our flag flew in our honor and he replied, ``Yes.''
        My heart sunk as I realized I was holding in my hand a now symbol
    and reminder of the EXACT LOCATION my son-in-law was severely poisoned
    and that symbol had flown there in my honor. I was devastated and we
    haven't flown that particular flag yet. It's been a war in my head as
    to what to do with it. Have it destroyed, put it in the attic and
    forget about it. I feel like my support while he served our country is
    tainted now so I tried to come up with ways that I could feel good
    about that flag again and do it in his honor: I would fight to get a
    congressional hearing where veterans impacted by burn pits could have
    their voices heard and if I accomplish that goal I will gladly fly that
    flag again in his and all other burn pit victims' honor.
        My heart is broken that my goal was not accomplished today and my
    flag will remain in a box and out of sight.
        Thank you for taking the time to read my statement and for hosting
    this very important hearing. What our veterans need now is action to
    get them help ASAP. They don't have years to wait on more research.
    They are dying now with many already dead. Please work on Senate bills
    to correspond with H.R. 100 I and H.R. 1005. Schedule more hearings and
    bring in veterans who are afflicted and affected by burn pits. These
    are the men and women who you should be listening to. You can't pass
    legislation that takes care of their needs without giving them a seat
    at the table to express those needs. Not one burn pit bill already in
    effect or pending does anything to get burn pits veterans the
    healthcare they need right now. You must act NOW!!! Not tomorrow!!!
    Now!!!!
                Sincerely,
                                        Susan M. Zeier,
                                                Sandusky, Ohio.
    Attachments (3)
                                     ______

                                 Attachment #1
                                    Department of the Air Force
                                    332D Air Expeditionary Wing
                                 Balad Airbase, Iraq, 20 December 2006.

    MEMORANDUM FOR 332 EAMDS/SGP FROM: 332 EAMDS/SGPB

    SUBJECT: Burn Pit Health Hazards

        1. The burn pit at Balad AB (Logistics Support Area Anaconda) has
    been identified as a health concern for several years in numerous after
    action reports, Standard Form 600s (Environmental/Occupational Health
    Workplace Exposure Data (EOHWED), attached) in addition to other
    Bioenviromnental Engineering continuity documentation. During the
    Environmental Health Site Assessments ducted January-April 2006 by the
    US Army Center for Health Promotion and Preventive Medicine (USACHPPM),
    open burning of solid waste was identified as the number two most
    common environmental health finding. Balad's burn pit was quoted as
    being ``the worst environmental site I have personally visited, and
    that includes 10 years working RCRA/CERCLA clean-up for the Anny and
    DLA,'' by one of the assessment team members.
        2. We have not yet been able to quantify contaminants that exceed
    the Military Exposure Guides (MEG) for most of the chemicals of
    concern. This data gap is a result of our inability to collect ``worst
    case'' data due to the dynamic nature of the burn pit's plume.
    Contributing to the difficulty of conducting a thorough scientific
    investigation are ongoing ground and air combat operations and the
    remoteness of the base. Army Technical Guide (TG) 230 specifically
    states that the guidance in TG 230 is not a ``substitute for having
    trained preventive medicine personnel onsite or in theater.''
        3. The Air Force documents exposure to the burn pit for those
    stationed at Balad AB as an environmental health hazard by placing
    detailed information in each Airman's medical record during their post-
    deployment medical outprocessing. This is a permanent part of their
    medical record and is a mandatory document that assists the Air Force
    in complying with Presidential Review Directive 5. It is amazing that
    the burn pit has been able to operate without restrictions over the
    past few years without significant engineering controls being put in
    place. I would hope in the future that issues such as burn pits are
    identified early on and engineering controls such as incinerators would
    be used to mitigate these hazards. It seems that money has been the
    issue of why engineering controls are not currently in place.
        4. The smoke hazards are associated with burning plastics,
    Styrofoam, paper, wood, rubber, POL products, non-medical waste, some
    metals, some chemicals (paints, solvents, etc.), and incomplete
    combustion by-products. A list of possible contaminants includes:
    acetaldehyde, acrolein, arsenic, benzene, carbon dioxide, carbon
    monoxide, dichlorofluoromethane, ethylbenzene, formaldehyde, hydrogen
    cyanide, hydrogen chloride, hydrogen fluoride, various metals, nitrogen
    dioxide, phosgene, sulfuric acid, sulfur dioxide, toluene,
    trichloroethane, trochloropropane, and xylene. Many of these chemical
    compounds have been found during past air sampling. Burn pits may have
    been an acceptable practice in the past, however today's solid waste
    contain materials that were not present in the past that can create
    hazardous compounds such as those listed above. Open pit burning may
    only be practical when it is the only available option and should only
    be used in the interim until other ways of disposal can be found. This
    interim fix should not be years, but more in the order of months.
        5. In my professional opinion, there is an acute health hazard for
    individuals. There is also the possibility for chronic health hazards
    associated with the smoke; thus the information is being made a
    permanent part of each Airman's medical record. I base this assessment
    on the data that I have reviewed and on-site smoke plume assessments
    (boots on the ground). My background includes a Doctor of Philosophy in
    Engineering (Environmental), registered and licensed as a Professional
    Engineer in Arkansas and Utah, respectively, and seventeen years of
    conducting health risk assessments.
        I am writing this memo to translate what I see is an operational
    health risk to those that have been, are now and will be deployed to
    Balad AB (LSAA). It is my recommendation that engineering controls,
    such as the anticipated incinerators, should be expedited to solve
    this.
                           Darrin L. Curtis, Lt Col, USAF, BSC,
                         Bioenvironmental Engineering Flight Commander.

    cc: 332 EAMDS/CC

                                     ______

                                                              20 Dec 06
    1st Ind., 332 EMDG/SGP

    MEMORANDUM FOR 332 EMDG/CC

        I concur with Lt Col Curtis' risk assessment. In my professional
    opinion, the known carcinogens and respiratory sensitizers released
    into the atmosphere by the burn pit present both an acute and a chronic
    health hazard to our troops and the local population.
                       James R. Elliott, Lt Col; USAF, MC, SFS,
                                           Chief, Aeromedical Services.

    cc: CENTAF(F)/SG Bioenvironmental Engineer

                                     ______

                                 Attachment #2
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

                                 Attachment #3

      Anthony Szema, M.D., Chief of the Allergy Section, Veterans Affairs
                      Medical Center, Northport, New York
                       senate democratic policy committee
      ``are burn pits in iraq and afghanistan making our soldiers sick?''
        Good morning. My name is Dr. Anthony Szema. Thank you, Senator
    Dorgan, for the opportunity to testify. I am the Head of the Allergy
    Diagnostic Unit at Stony Brook University Medical Center in New York. I
    also serve as an Assistant Professor of Medicine and Surgery at SUNY
    Stony Brook School of Medicine and the Chief of the Allergy Section at
    the Veterans Affairs Medical Center in Northport, New York. I received
    my undergraduate degree in Industrial and Management Engineering from
    Rensselaer Polytechnic Institute in Troy, NY, and my medical degree
    from Albany Medical College in Albany, New York. I completed three
    fellowships at Columbia University in pulmonary diseases, critical care
    medicine, and clinical and adult and pediatric allergy/immunology.
        I am testifying today in my personal capacity and do not in any way
    represent the interests, beliefs or opinions of my employers.
        It is common sense and widely known that smoke from any fire can
    affect health. There is an extensive body of research on the dangers of
    smoke inhalation. Trash should not be burned because it can cause
    harmful air pollution. The contents of smoke depend on the trash,
    temperature and oxygen available. There are short- and long-term health
    consequences associated with exposure to fire, smoke and fumes. The
    synergistic impact from the combination of burning chemicals is
    unknown. Soldiers acutely exposed near the burn pits may have burning
    eyes and nose, nausea, headaches and asthma-like symptoms.
        Incinerators may provide a healthier alternative to burn pits in
    Iraq and Afghanistan because they burn trash at higher temperatures,
    which create less harmful smoke than the burn pits. Ten pounds a day of
    trash from a household burn barrel may produce as much pollution as a
    modern, well-controlled incinerator burning 400,000 pounds of trash a
    day. Harmful smoke may also be reduced by recycling plastic, paper,
    metal, glass, ink cartridges and by installing EPA-compliant biohazard
    waste measures for medical waste.
        Burning anything leads to particulate matter (PM) which is inhaled
    and toxic to the lungs and heart. The size of particulate matter is
    important to consider because the particles act as a carrier of various
    harmful chemicals in the air. The smaller the particulate matter, the
    deeper the particles are able to travel into the lungs. PM 10 are
    larger particles which can be trapped in the nose, whereas PM 2.5 and
    ultrafine PM are able to enter the lung alveoli or air sacs. PM 2.5 and
    ultra-fine PM are particularly harmful to human health. Not only is
    there a risk of asthma, bronchitis, and emphysema with ultrafine PM,
    but there is also an association with respiratory and cardiovascular
    mortality--death--from inhalation of ultrafine particulate matter.
    Particulate matter levels are especially bad if they are high, but
    particulate matter may even be worrisome if levels are low. The
    toxicity depends on the composition of the particulate matter itself.
    For example, is the particulate matter acting as a carrier of black
    carbon or arsenic? Particulate matter levels should always be
    considered when performing air sampling to measure air quality.
        The US Army Center for Health Promotion and Preventive Medicine
    (CHPPM) did not include data about particulate matter PM 10, PM 2.5 or
    ultra-fine PM levels in their May 2008 analysis of the air quality at
    Balad Air Base in Iraq. PM 2.5 and ultra-fine PM should have been a
    large component of CHPPM's analysis. CHPPM also failed to conduct
    comprehensive testing at any other bases using burn pits in Iraq and
    Afghanistan, so we do not have information about air quality at those
    bases.
        When I think of air pollution, the first issue I think of is the
    level of PM 2.5 and the potential toxins these could be carrying.
    Inhalation of PM air pollution can lead to premature death from
    respiratory and cardiovascular causes, including strokes. Inflammation
    and reduced lung function may even be seen in lung tissue from healthy
    adults. Year-round exposure to PM has been associated with small airway
    disease and increased risk of dying from lung cancer and cardiovascular
    disease. Reduction in PM 2.5 by 10 mg/m3 is associated with reduced
    mortality risk.
        Individuals have reported uncontrolled burning of waste in the burn
    pits in Iraq. The chemicals generated from slow, low-heat burning
    present a variety of health risks. The type of plastic (PVC) used to
    make plastic bottles produces dioxin and hydrochloric acid when burned.
    These chemicals are associated with immune dysfunction, IQ deficit, and
    reproductive abnormalities. Polystyrene foam cups can be a source of
    carcinogens including dioxin, benzene, styrene and furans when burned.
    Chromated copper arsenate (CCA)-treated wood contains pro-carcinogenic
    arsenic. Bleached or colored paper contains harmful chemicals. Bleached
    paper contains halogenated hydrocarbons and furans associated with
    leukemia and liver disease. Colored paper contains heavy metals like
    lead and cadmium associated with blood, liver and kidney disease.
    Particle board and plywood release formaldehyde when burned; this is
    associated with nose and throat cancer, as well as liver and kidney
    disease and airway inflammation. Cardboard used for packaging of
    foodstuffs may contain fungicides which are associated with
    neurological disorders. The variety of materials burned at the burn
    pits in Iraq produces an enormous array of chemicals which may
    plausibly combine when burned to produce unknown dangers.
        The location and time during which air sampling occurs can largely
    impact the results and reliability of those tests. I think of this as
    garbage in, garbage out. If the sampling equipment, location of testing
    and timing are not performed properly, one will not gather accurate
    information and will not be able to provide a confident analysis of the
    results. The May 2008 CHPPM report included analyses based only on
    testing conducted from January to April 2007. This was partly conducted
    during Iraq's rainy season and did not include any measurements from
    the summer. The results could not reflect a year-long exposure to the
    smoke from the burn pit because of the changing weather conditions.
    This would be like testing for snow in Albany, NY, during the summer.
    Testing will not detect any snow, but this does not mean that it does
    not snow in Albany.
        With regard to location, if the wind typically blows the fumes away
    to the north, this does not mean that a lack of detection in monitors
    placed to the south means that the air is safe to breathe. The timing
    of the testing is also relevant because numerous materials were burned
    in the pits. If you tested during a time when medical trash was not
    burned, then you would not detect the toxins emitted from this type of
    burning, including le ad, mercury, and furans. The testing does not
    tell us anything about the air quality before or after the burning
    occurred. Individuals exposed to burn pit fumes in 2004 may have
    experienced worse conditions than those in 2007. It is also important
    to analyze the ashes and dust in a burn pit pile after materials have
    been burned. This dust may contain toxins which are not detectable by
    airborne collection methods.
        In my practice as an allergist and pulmonologist at the Veterans
    Affairs Medical Center in Northport, NY, the demographics of the
    patients I typically see have changed since 1997. Until 2004, I mostly
    saw 80-year-old veterans. However, from 2004 to the present, I have
    begun seeing young women and men who were previously healthy athletes
    capable of passing basic training and performing combat duty. Now these
    individuals suffer from a variety of respiratory illnesses, including
    asthma and difficulty breathing during exertion, and are not fit for
    continued military duty. This is an alarming trend.
        In 2008, I presented data at the American Thoracic Society
    International Conference showing high new-onset asthma diagnosis rates
    among soldiers deployed to Iraq. I performed a study of veterans who
    served in Iraq and were treated at the Veterans Affairs Medical Center
    in Northport, NY, from March 2004 to May 2007. Our study was prompted
    by the fact that 13 percent of U.S. Army Medic visits in Iraq are for
    new-onset acute respiratory illness. We compared veterans who served in
    Iraq with those who served in the United States. After studying more
    than 6,000 veterans, we found that deployment to Iraq is associated
    with new-onset asthma. Individuals who have asthma are not allowed to
    serve in the military, but our data of soldiers returning from Iraq
    indicates new-onset adult asthma is diagnosed at twice the rate (10%)
    compared to stateside-based troops (5%). Even when stratified by age
    groups, the higher risk for asthma still holds. Our findings are not
    surprising given that a survey of 15,000 military personnel deployed to
    Iraq and Afghanistan found that nearly 70 percent reported experiencing
    respiratory illness during their service. Of these, 17 percent required
    medical care.
        It is important to understand that occupational asthma from
    phthalates is subtle and is not detected with PM monitors. It may be
    assessed by known exposure, clinical symptoms, and physical examination
    of patients, physiology and skin testing. Also, many of the tests
    typically given to determine respiratory illness, such as spirometry, a
    pulmonary function test, are insensitive and may not detect the true
    nature of the illness. Dr. Robert Miller, a doctor at--Vanderbilt
    University, has performed a study of individuals exposed to a fire in
    Iraq in 2003. These individuals had normal CT scans and pulmonary
    function tests. Only by performing a lung biopsy was he able to
    properly diagnose most of his patients with constrictive bronchiolitis,
    likely from exposure to toxic smoke fumes.
        Additional funded research is needed to fully understand the health
    implications for soldiers breathing the fumes from burn pit smoke, such
    as: 1) a university-based health research network, utilizing more
    sophisticated tertiary-care testing; and 2) basic research institutes
    at these health research sites to study the mechanisms of these new
    diseases in animal models and develop novel drugs to treat new,
    deployment-related diseases. These efforts may lead to health benefits
    for not only our military personnel but also for the general
    population.
        In summary, you should not bum trash or inhale burning trash. There
    are short- and long-term health consequences associated with exposure
    to fire, smoke and fumes.