[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
       
       
       
       
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             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\
---------------------------------------------------------------------------
    \1\ https://www.nap.edu/catalog/12662/veterans-and-agent-orange-
update-2008.
---------------------------------------------------------------------------
     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 [email protected].
                                 ______
                                 
  Prepared Statement of Dr. Thomas Zampieri, President and Chairman, 
                      Blinded Veterans Association

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                              ______
                              
 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.

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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.

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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                            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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                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.

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    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
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    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⊂=cto&pag=dis&ItemID=124046
    \7\ https://www.ncbi.nlm.nih.gov/pubmed/30511179
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    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
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                               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.