[Senate Hearing 117-093]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 117-093
 
        MILITARY TOXIC EXPOSURES: THE HUMAN CONSEQUENCES OF WAR

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 10, 2021

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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             U.S. GOVERNMENT PUBLISHING OFFICE 
 46-012 PDF           WASHINGTON : 2022        
        
        
        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran,Kansas, Ranking Member
Bernard Sanders, Vermont             John Boozman, Arkansas
Sherrod Brown, Ohio                  Bill Cassidy, Louisiana
Richard Blumenthal, Connecticut      Mike Rounds, South Dakota
Mazie K. Hirono, Hawaii              Thom Tillis, North Carolina
Joe Manchin III, West Virginia       Dan Sullivan, Alaska
Kyrsten Sinema, Arizona              Marsha Blackburn, Tennessee
Margaret Wood Hassan New Hampshire   Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
                 Jon Towers, Republican Staff Director
                 
                 
                            C O N T E N T S

                              ----------                              

                       Wednesday, March 10, 2021

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    14
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    18
Brown, Sherrod, U.S. Senator from Ohio...........................    19
Blackburn Hon. Marsha, U.S. Senator from Tennessee...............    21
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    22
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........    24
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    26
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    27

                               WITNESSES

Anthony Szema, MD, Director, International Center of Excellence 
  in Deployment Health and Medical Geosciences; Clinical 
  Associate Professor of Occupational Medicine, Epidemiology and 
  Prevention, Donald and Barbara Zucker School of Medicine at 
  Hofstra/Northwell..............................................     3
William Thompson, SSG, U.S. Army (Ret.), testifying in regard to 
  burn pit exposure..............................................     5
Karl Kelsey, MD, MOH, Professor of Epidemiology, Pathology and 
  Laboratory Medicine, Brown University School of Public Health..     7
Jeffrey O'Malley, Veteran, United States Army, testifying in 
  regard to Agent Orange and hypertension........................     8
Shane Liermann, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    10
Aleks Morosky, Government Affairs Specialist, Wounded Warrior 
  Project........................................................    12

                                APPENDIX
                     Witnesses Prepared Statements

Anthony Szema, MD, Director, International Center of Excellence 
  in Deployment Health and Medical Geosciences; Clinical 
  Associate Professor of Occupational Medicine, Epidemiology and 
  Prevention, Donald and Barbara Zucker School of Medicine at 
  Hofstra/Northwell..............................................    32
William Thompson, SSG, U.S. Army (Ret.)..........................    33
Karl Kelsey, MD, MOH, Professor of Epidemiology, Pathology and 
  Laboratory Medicine, Brown University School of Public Health..    37
   Reports from the National Academies of Sciences, Engineering, 
    and Medicine that Assess Exposure to Herbicides or Health 
    Outcomes Among Vietnam Veterans..............................    44
   (Table 42) Results of Epidemiologic Studies of Circulatory 
    Disorders Reviewed in Veterans and Agent Orange Series.pdf...    47
   (Table S-1) Summary of Outcomes Included in Veterans and Agent 
    Orange 11.pdf................................................    68
   Veterans and Agent Orange Update 11, Consensus Study Report 
    highlights.pdf...............................................    74
Jeffrey O'Malley, United States Army.............................    78
Shane Liermann, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    82
Aleks Morosky, Government Affairs Specialist, Wounded Warrior 
  Project........................................................    96

                        Statement for the Record

Tragedy Assistance Program for Survivors (TAPS)..................   106


        MILITARY TOXIC EXPOSURES: THE HUMAN CONSEQUENCES OF WAR

                              ----------                              


                       WEDNESDAY, MARCH 10, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:08 p.m., in 
room SD-G50, Dirksen Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Brown, Blumenthal, Manchin, 
Sinema, Hassan, Moran, Boozman, Rounds, Tillis, Blackburn, and 
Tuberville

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this meeting of the Senate 
Veterans' Affairs Committee to order. Good afternoon and thank 
you for joining us today, to hear from veterans, medical 
experts, and veteran services organizations about the long-term 
health consequences of war.
    When we promise to train and equip our servicemembers so 
that they are ready for war we also promised to care for them 
as veterans after they return home. We now know that not all 
injuries are visible, not all reveal themselves immediately, 
and not all are due entirely to enemy action. Some conditions 
can take years to manifest, and too often they are the results 
of our own government's actions, whether it is spraying the 
battlefield with Agent Orange to remove hiding spots from an 
enemy, or using burn pits to dispose of waste. No matter the 
cause, our promise remains the same--fight for us and we will 
fight for you.
    In the last Congress we made tremendous strides in keeping 
that promise. We are bringing relief to Vietnam-era veterans 
dealing with hypothyroidism, bladder cancer, and Parkinsonism. 
But this fight is not over. Current science shows even greater 
evidence of an association between Agent Orange and other 
conditions like hypertension and MGUS.
    So here we are again. Relief for these conditions is long 
overdue. We have wasted literally decades deliberating over 
science and wrestling with bureaucratic red tape. We should not 
delay any longer.
    Even as Vietnam-era veterans struggled with the decades-
long effects of Agent Orange, the next generation of brave men 
and women were fighting new wars in Iraq, Afghanistan, and 
Syria. There, many servicemembers were exposed to open burn 
pits to dispose of waste. Many returned with obviously damaged 
lungs while others continue to fall ill today, in some 
instances, a decade or more after coming home.
    As a government, we did not learn our lesson after Vietnam. 
Our veterans are still fighting red tape to get health care and 
benefits that they have earned and are needed. Because of the 
VA's inaction on behalf of Agent Orange-exposed veterans, 
Congress has acted to provide benefits for Blue Water Navy 
Vietnam veterans and Korean War veterans who served on the DMZ. 
And most recently, we worked to add three presumptive 
conditions in keeping with the scientific evidence provided by 
the National Academies.
    But that is not an ideal solution. We must develop a 
comprehensive system that is able to quickly deliver care and 
benefits to veterans as science develops around currently known 
and newly discovered exposures, without congressional action.
    This system must prioritize serving veterans' urgent needs 
and delivering life-saving care. Only then will we begin to 
fulfill the promises we have made to care for those who have 
sacrificed so much on our behalf. Otherwise, we will continue 
to hear from vets like Jeff O'Malley, a Vietnam War veteran, 
and William Thompson, Iraq War veteran, about how their 
government is failing to address the cost of war associated 
with their services to this Nation. And I ask my colleagues, 
listen closely today to their testimony.
    I also want to thank our other witnesses for joining us 
today to help us better grasp the scientific evidence that 
should inform our decisionmaking, and the impact of these 
exposures on the veteran community at large.
    With that I turn it over to you, Senator Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Chairman, thank you. Thank you for the 
things you said in your opening Statement and thank you for 
organizing this hearing.
    Good afternoon, everyone. Thank you to all of our witnesses 
for joining us today. I certainly appreciate what Senator 
Tester had to say and I look forward to learning more from this 
hearing about how we can do our jobs, as a committee, better.
    In modern history, we have tragically seen that exposure to 
toxic substances have become an increasingly common component 
of armed conflicts and warfare. Such exposure is not always 
known or considered at the time, and too often the long-term 
health effects are not understood. For too long, veterans have 
been exposed to toxic substances during the course of their 
military service, and they have faced overwhelming barriers to 
get the VA care and services that they deserve. The burden of 
proof is a challenge for veterans, and we must find ways to 
bridge that gap.
    I was encouraged by bipartisan legislation passed by this 
Committee last Congress to address these issues. As a result of 
our work, we have seen several new laws on the books directing 
research and covering more of our veterans from Vietnam and 
Korean War, but our work, of course, is far from done.
    Over the years, Congress has responded to multiple cohorts 
of veterans affected by exposure to mustard gas, lewisite 
during the 1940's, iodizing radiation from nuclear test sites 
during the cold war, Agent Orange during the Vietnam War, Gulf 
War illnesses during Desert Storm, and now burn pits and other 
toxins during the global war on terror. The varied approaches 
to addressing these different exposures in the past 
demonstrates the need to establish a fair, transparent, and 
sustainable process going forward. Decades of patchwork fixes 
show a clear need for significant improvement.
    As we consider ways to improve how our country cares for 
those who became ill through exposure to these substances 
during their military service, we must and should listen to 
those who have suffered the negative health outcomes. I think 
all of my Committee colleagues would agree when I say that the 
voices of veterans are always those we want to hear, the ones 
we listen to most. Theirs are the voices we hold in highest 
regard in helping us do our jobs.
    It is also crucial that we hear from the scientific and 
medical communities. Care works best when there is a reliable 
system in place for the VA to first be provided with necessary 
scientific research on which to inform timely decision on 
whether to establish presumptions of service connection for 
certain conditions. Veterans deserve an enduring framework to 
identify, research, and address cases of toxic exposure in a 
timely manner. The need for reform has existed far too long, 
and veterans cannot be forced to wait decades for care any 
longer.
    In our last hearing, I remember hearing one of the VSO 
representatives indicate that he had been working on his case, 
his own case, really for his lifetime, since he departed from 
the service, with still no satisfaction.
    I am interested to hear from our witnesses today on how 
best we, on this Committee, can achieve the outcomes that we 
all want for veterans. I look forward to hearing from each of 
you today and to continue to work to make certain that all 
veterans suffering negative health consequences from their 
service receive the care they deserve.
    And I yield back to the Chairman.
    Chairman Tester. Thank you, Senator Moran. Thank you for 
your comments. I certainly appreciate them very much.
    We are going to have six witnesses today. The first four 
are going to give their testimony virtually. And so we will 
start out with Anthony Szema, who is an MD, a Clinical 
Associate Professor of Medicine in Pulmonary and Critical Care, 
Zucker School of Medicine at Hofstra/Northwell. You have the 
floor, Dr. Szema.

                   STATEMENT OF ANTHONY SZEMA

    Dr. Szema. Can you hear me?
    Chairman Tester. We can.
    Dr. Szema. The 2003 invasion of Iraq, and resulting 
conflicts in the Middle East, have led to the longest, 
prolonged military deployment in U.S. history. One million 
troops have served in Iraq and Afghanistan during the eighteen-
year conflict. Now, 26 percent of the 150,000 military 
personnel in the U.S. VA Burn Pits Registry self-report new 
onset respiratory symptoms, beginning in military theater. We 
noted 14.5 percent of New York-based soldiers developed new 
onset asthma post deployment.
    Airborne hazards may account for new onset lung diseases. 
Soldiers inhale dust storms, pollen, mold, and improvised 
explosive devices leading to shock waves in the lung with metal 
deposition. Blast overpressure from shock waves induces 
traumatic brain injury and post-traumatic stress disorder, 
PTSD, which, by itself, is linked to asthma.
    Most importantly, these troops are also exposed to burning 
trash in open air ``burn pits.'' Uniformly, trash was lit on 
fire with jet fuel, JP-8, which contains benzene, a carcinogen. 
Burn pits are in open air without an incinerator, and burn at 
low heat. This generates more particles than incinerators. More 
particles are associated with increased risk of all-cause 
mortality, or death, cardiovascular diseases such as heart 
attacks and strokes, and lung diseases, including asthma, COPD, 
and among these soldiers we have seen, as you will hear from 
Will today, constrictive bronchiolitis and lung scarring, or 
fibrosis. In fact, we can detect burned particles in the lungs 
of these troops.
    Military personnel often do not have pre-deployment lung 
testing other than a two-mile run time. If a soldier returns 
with a cardiopulmonary exercise test that is 80 percent 
predicted post-deployment, which would be considered otherwise 
within normal limits, if in fact pre-deployment that soldier 
was 120 percent predicted, then this is a significant decrease.
    We propose NIH-or NIOSH-funded monitoring centers of 
excellence for affected patients, analogous to World Trade 
Center Monitoring Programs, since in the greater New York area, 
for instance, most veterans are not seen in the VA since they 
exceed income limits, are young with full-time civilian jobs, 
and have commercial health insurance. We envision centers 
studying basic animal models, investigating therapeutic agents, 
clinically monitoring patients longitudinally, like the World 
Trade Center Monitoring Programs, and conducting clinical 
trials.
    The consultative National VA War-Related Illness injury 
centers are few and excellent, but neither monitor patients nor 
perform biopsies. We conceptually agree with 2020 bipartisan 
bill H.R.8261 in the House and S. 4572 in the Senate which 
proposed to grant presumption of medical claims for all troops 
who were deployed to Iraq and Afghanistan since 2003. We agree 
with the concept that President Biden should propose for 
consideration in his first 100 days, presumption of care for 
war fighters with subsets of lung diseases post-deployment.
    Even in 2020, 77 percent of veterans requesting 
compensation and pension medical exams for maladies beginning 
in Iraq and Afghanistan are denied benefits. The American 
Thoracic Society, in 2019, argued for more research. The 
National Academy of Medicine, in addition, argued for 
investigation of biomarkers and pre-deployment pulmonary 
diagnostic monitoring. So we urge further research on returning 
soldiers.
    Not only should we honor the dead who have made the 
ultimate sacrifice in war, but we also should provide care for 
the living: brave women and men who sacrificed their health for 
freedom.
    Senator Moran. [Presiding.] Doctor, thank you very much. I 
am now going to recognize one of your patients, William 
Thompson, who is an Iraq War veteran, who served in the Army, 
who has had both lungs transplanted twice due to his exposure 
in Iraq. Mr. Thompson?

                 STATEMENT OF WILLIAM THOMPSON

    Mr. Thompson. Yes, sir. Can you hear me?
    Chairman Tester. Yes, sir.
    Mr. Thompson. Thank you for hearing us today and thank you 
for having us. My name is retired Staff Sergeant William 
Thompson. I served 23 years, 3 months and 11 days in the United 
States Army and the West Virginia Army National Guard. I have 
deployed twice with the West Virginia Army National Guard to 
Iraq. During my last deployment, I was stationed at Camp 
Stryker at the Victory complex.
    My symptoms of frequent coughing started around September 
2009, while in Iraq, in which my doctors and physician 
assistants treated me for what they thought were allergies. I 
returned to Fort Stewart, Georgia, and after I mentioned to the 
doctors I was having frequent cough, they did a chest x-ray 
that revealed bilateral pneumonia. They treated me with 
antibiotics and sent me home to West Virginia to followup with 
my PCP in 1 week.
    After a week, I followed up with my doctor, Dr. Remines, 
and he discovered, after more testing, that I had pulmonary 
fibrosis with nodules, and Stated that my lungs looked like an 
``80-year-old coal miner's lungs.'' He referred me to Walter 
Reed Army Medical Center pulmonary department where I was 
treated by Dr. Jacob Collins for 6 months. He admitted me to 
the Warrior Transition Unit at Walter Reed and after 6 months 
of testing, which included an open lung biopsy, I was informed 
that I had titanium, magnesium, and iron, in addition to 
silica, in my lungs. They diagnosed me with hypersensitivity 
pneumonitis and pulmonary fibrosis.
    I gained 60 pounds from the high amounts of steroids I was 
on daily. Because my lung disease was chronic, I was referred 
to Inova Fairfax Hospital by Walter Reed and was told I would 
most likely need a lung transplant in the future. I have been 
seen by Inova Fairfax Hospital Lung Transplant Clinic from 
February 2011 to the present time. During that time, I have 
been on oxygen levels as high as 10 liters continuously. On 
June 6, 2012, I received a double lung transplant. After 2 
months of followups, I was able to return home and start 
pulmonary rehab.
    The first year was a good year. I took all precautions and 
followed all the orders that were instructed by my doctors. 
Despite this, over the next 3 years, I went through periods of 
lung rejection and infections and decreased oxygen levels. I 
was back on oxygen again, and on March 9, 2016, I underwent 
another double lung transplant. Unfortunately, they are more 
susceptible to complications than other organ transplants since 
the lungs are exposed to everything from the environment.
    My life and my family's life have changed since I returned 
home in 2010. I have to wear a mask in highly populated areas. 
I know wearing a mask is typical these days, but I have been 
wearing one since 2012. It is hard to hang out with my kids 
only to tell them ``I cannot do that.''
    ``Daddy, let's go skiing.'' Sorry, kids, I cannot do that.
    ``Daddy, let's go swimming.'' Sorry, kids, I cannot do 
that.
    ``Daddy, can you give me a piggyback ride?'' Sorry, Ava, I 
cannot do that.
    ``Daddy, let's go fishing.'' Sorry, Ethan, I cannot do that 
because of the bacteria on the fish.
    ``Dad let's go to the beach.'' Sorry, kids, I cannot do 
that because of the bacteria in the water and the sun with my 
transplant medications makes me more prone to skin cancers.
    Speaking of skin cancers, I am currently battling 
trigeminal neuralgia after having a skin cancer removed from my 
left cheek that aggravated my trigeminal nerve. This is a very 
painful and debilitating condition that is also known as the 
``suicide disease'' and is known to be one of the most painful 
disorders known to medicine. It causes sudden shock-like pain 
in my face that lasts from minutes to hours at a time. Because 
of this disorder, I have added numerous medications to my 
previously very large daily pill regimen.
    I do not feel like a man anymore because my wife has had to 
take many roles from me. There are so many things that I can no 
longer do.
    I am a warrior of the United States of America. I gave my 
lungs for my country. The toxins in the air from the burn pits 
and the dust in Iraq has changed my life. I am glad to be alive 
and home when so many did not make it home. My illness and 
injuries are different. I have heard so many times from the VA 
``We do not know how to treat you,'' or ``You do not qualify or 
fit the parameters for benefits.'' I have been denied TSGLI 
because the Army does not think having a lung transplant is a 
``traumatic event.'' Burn pits should be recognized and 
acknowledged as an incident of war.
    Luckily, we found the group, Semper Fi of America Fund, who 
works with veterans and provided the funds to make my bathroom 
ADA accessible. Since then, the VA has helped me with one 
housing HISA grant, but only after being denied several times.
    My injuries and illnesses are different from other more 
common injuries from Iraq and because of that it took the VA 3 
years to provide me with an air purifier in my home to keep my 
home free of allergens and dust. They also denied help in 
removing carpet from my home that was instructed by my doctors, 
so we had to pay for this ourselves. We have also taken out a 
loan to build a workout area in my home where I can work out 
and continue my pulmonary rehab during times of my illness or 
times when cold or flu season is at its peak. Although I was 
100 percent service connected through the Army and VA, I do not 
qualify to receive my retirement until age 60 because my 
injuries were not ``combat related.'' I may not live to be age 
60--I turn 50 this year.
    Every day for me is a battle I continue to fight. I still 
have to battle infections and try to keep my body healthy from 
lung rejection. I still have to fight secondary problems 
related to my transplant. Hopefully, after hearing my story, it 
will bring awareness for not only me but others who are 
battling the same or similar injuries related to burn pit 
exposures from Iraq or Afghanistan.
    Thank you allowing me to share my story.
    Senator Moran. Mr. Thompson, thank you for your compelling 
story, your testimony. Senator Tester, Chairman Tester, has 
turned and I now turn the gavel back to him.
    Chairman Tester. [Presiding.] Thank you, Ranking Member 
Moran. Next up, virtually again, is Karl Kelsey, who is an MD, 
Professor of Epidemiology, Pathology and Laboratory Medicine at 
Brown University. Dr. Kelsey, you have the floor.

                    STATEMENT OF KARL KELSEY

    Dr. Kelsey. Good afternoon, Chairman Tester, Ranking Member 
Moran, members of the Committee. My name is Karl Kelsey. I am a 
professor at Brown University and a physician. I am here today 
in my capacity as a member of a committee formed by the 
National Academy of Sciences, Engineering, and Medicine to 
assess the evidence of an association between exposure to Agent 
Orange and other herbicides used in the Vietnam War and adverse 
health effects.
    As many of you know, the National Academies have a long 
history of advising the Federal Government on the health 
effects of military services. I have served on committees that 
produced 4 of the 12 reports in the Veterans and Agent Orange 
series. Today I will discuss Update 11, which was released in 
2018, and I will focus my testimony on the epidemiologic 
evidence of an association between exposure to herbicides and 
hypertension.
    From 1962 to 1971, the U.S. military sprayed herbicides 
over Vietnam for tactical purposes. The most used chemical 
mixture sprayed was Agent Orange, which, as you know, is 
contaminated with TCDD, which is the most toxic form of dioxin.
    The National Academies committees classified a strength of 
evidence regarding the association between exposure to the 
chemicals of interest and health outcomes into four categories: 
sufficient, limited or suggested, inadequate or insufficient, 
and no association. As mandated by the Agent Orange Act, the 
distinction among the categories are based on statistical 
association, not strictly on causality.
    Our Update 11 committee concluded that the available 
medical and scientific information constitutes significantly 
sufficient evidence of an association between exposure to at 
least one of the chemicals of interest and hypertension. The 
strongest conclusion regarding a potential increase in the 
incidence of hypertension came from studies that controlled for 
many risk factors associated with hypertension.
    Our committee reviewed six new studies of exposure to 
chemicals of interest and hypertension that have been published 
since the previous update. Five of these had one or more 
significant study design deficiencies that would not be 
considered adequate to change the level of association 
individually.
    Our decision to change the classification from ``limited or 
suggested'' to ``sufficient evidence'' of an association was 
really motivated by a 2016 paper, authored by VA researchers, 
Yasmin Cypel and colleagues. These investigators conducted a 
study of Vietnam veterans in the Army Chemical Corps, the ACC. 
The study was characterized by a large sample size, appropriate 
controls, and validated health endpoints. The statistical 
analysis was robust, they used State-of-the-art methods, they 
adjusted for relevant confounders, and included several levels 
of exposure, herbicide sprayers and non-sprayers, and Vietnam-
deployed and non-deployed veterans.
    The study clearly showed that self-reported hypertension 
rates were the highest among the military personnel with the 
greatest opportunity for exposure to the chemicals of interest. 
Among the Vietnam-deployed veterans, there was a statistically 
significant elevated association between the odds of 
hypertension through sprayers versus non-sprayers, and this 
remained after adjusting for potential confounders.
    Similarly, for the veterans who did not deploy to Vietnam, 
self-reported hypertension was significantly elevated among the 
sprayers compared with the non-sprayers.
    Among those with serum TCCD levels available, self-reported 
herbicide spray status had high agreement with the measured 
levels. The highest mean TCCD level was observed among the 
sprayers deployed to Vietnam, and the lowest level was found 
for the non-Vietnam non-sprayers. This would be expected with a 
significant dose response association.
    Likewise, there was high agreement between self-reported 
hypertension and in-person blood pressure measurements in 
medical records review that was done for a subsample of the 
participants. As I said, the analysis controlled for the 
important risk factors for hypertension.
    So a major strength of this analysis was also using non-
Vietnam-deployed ACC veterans as a comparison group, because 
they are really quite similar to the members of the study 
group. Although it is important to note the exact types and 
quantities of the various chemicals that these ACC veterans 
were possibly exposed to during the Vietnam War are unknown, 
and may include chemicals other than herbicides, there is a 
statistically significant support for an association between 
herbicide exposure and self-reported, physician-diagnosed 
hypertension.
    I should also mention recent biological mechanistic 
research was reviewed by the committee and it also showed 
evidence for dioxin's impact on hypertension via effects on 
gene expression, vascular function, lipid glucose metabolism, 
and so on. When the totality of evidence was considered, our 
committee found that this body of literature constituted 
sufficient evidence of an association.
    I thank you for the opportunity to testify, and I am happy 
to answer any questions that you may have.
    Chairman Tester. Thank you, Dr. Kelsey. I appreciate your 
testimony also, and there will be questions here as soon as we 
hear from all the witnesses.
    Next we have Jeffrey O'Malley. Jeffrey is a Vietnam veteran 
who served in the Army, currently living with drug-resistant 
hypertension and kidney cancer. Jeff, the floor is yours.

                 STATEMENT OF JEFFREY O'MALLEY

    Mr. O'Malley. Chairman Tester, Ranking Member Moran, 
honorable members of the Committee, my name is Jeff O'Malley, 
and I am honored to be asked to participate in today's hearing 
of the Committee. I would like to note the date as having 
special significance for me, as it is exactly 50 years from the 
date that I boarded the plane for Vietnam, March 10, 1971. The 
experiences I had during my tour, and those of all my comrades, 
have stayed with us for all these years.
    I signed a 4-year enlistment in June 1969, committing to 
assignment with the Army Security Agency, and with the 
expectation that I would probably be sent to language school. I 
completed basic and was sent to the Defense Language Institute, 
Southwest at Biggs Field, Ft. Bliss for the 47-week Vietnamese 
language course. After graduation, we were sent to an 
electronics courses and then Vietnam. During language school 
and the electronics course, our top secret security clearances 
were completed.
    I served from March 1971 to late February 1972, as a voice 
intercept linguist for the Army Security Agency. Except for a 
few day trips, I worked at the 8th Radio Research Field Station 
south of Hue. The work was important, and, at times, stressful, 
but the unit was well run and efficient, earning two unit 
citations during my tour.
    I returned to the United States in late 1972, pending my 
discharge, and received my discharge and I returned to Houston, 
and re-entered civilian life.
    Over the years, I used the GI Bill to go to college, and 
worked in various positions in retail, including a career of 
about 15 years as a loss prevention executive in Texas and 
Louisiana. After that career, I had various jobs, and many of 
them were of a contract nature and did not have benefits, 
including health insurance, but I was in generally good health.
    In the summer of 2008, I was offered a permanent position 
with an alternative school in the area, with a raise and full 
benefits. It was due to begin on September 1, 2008, and I 
accepted. As is fairly common in southeast Texas in late 
summer, a hurricane arose in the Gulf, knocking out power for a 
2-week period, and I was not able to start at the beginning of 
the school year. I took the time, during my downtime, to try to 
find a primary care physician with my new Blue Cross Blue 
Shield insurance, and I found one that was open and had power, 
and went to meet the doctor.
    Since the nurse had not been scheduled to be there that 
day, the doctor did the normal nurse things for me--height, 
weight, and took my blood pressure and history. When she took 
my blood pressure she got very quiet, and then she said, ``I 
think I am going to take it again,'' and she did, and she said, 
``Mr. O'Malley, I am your primary care physician now. I am 
going to give you a pill and you are going to sit in the lobby 
for an hour, and we are going to see if we can get it to come 
down, because it is really high.''
    I went and sat in the lobby. I think I had a Klonopin pill. 
And in an hour she took it again and she said, ``I am going to 
give you another pill and we are going to wait another hour.'' 
During that time she scheduled me for blood work and a chest x-
ray, and various other tests, and it was determined that my 
blood pressure, at that point, when she first read it, was 210/
140. She had indicated that she had never seen blood pressure 
that high in the office. She had seen it in the emergency room 
when someone was having a stroke.
    She needed to find out why I had that high blood pressure, 
but she gave me a prescription and I started work. The 
prescription did not work for me. I regularly had my blood 
pressure taken and was sent home because it was too high. 
Eventually I went to a cardiologist who got my prescription 
right, but he still needed to find out why, so he was going to 
send me for a CT scan. Sometimes the kidney arteries can cause 
high blood pressure.
    After the CT scan it was determined that I also had kidney 
cancer. It was stage I, because I had no symptoms of anything 
when I went to the doctor. I did lose my kidney at that point, 
but I have not ever had radiation or chemo.
    After about 6 months I tried to figure out why was it, 
since I lost my kidney, why was I still taking blood pressure 
medicine? And the doctor had to tell me, ``Mr. O'Malley, we 
found your kidney cancer but we still do not know why you have 
high blood pressure.''
    So I take four medications for my high blood pressure, and 
it is under control when I take my medication but it causes me 
a great deal of fatigue. It took me a while to recover, and in 
the long run I lost the job that I had, I lost the Blue Cross 
insurance that I had, and that is when I came to the VA.
    A fellow veteran of mine, who trained and served with me, 
Dan Ferguson, from Toledo, Ohio, asked me, on a trip to Toledo, 
what kind of cancer I had and whether it was an Agent Orange 
presumptive disease. It was not. We went to his VSO to try to 
determine if there was anything that could be done, and he 
indicated to me that I should start watching the research on 
hypertension, and I did so.
    When Dr. Shulkin, in 2017, in November, announced that he 
had made a decision about the pending presumptives, I tried to 
figure out what that decision actually was, and I could not. I 
did everything that the VA asked me to do. I called the White 
House Veterans Hotline; they could not give me an answer. Four 
times I called them and they never did anything, were able to 
tell me.
    Eventually, I filed a FOIA and was denied, and then 
appealed, and then I won, and then I started getting documents 
from the VA. I, over a period of time, grew frustrated with the 
process, and provided those documents to the press and to 
Congress, which indicated some of the flaws in the way 
presumptives are decided.
    My health, when my blood pressure is controlled, has been 
pretty good, but my stamina has meant that I, at my age, I was 
not able to find meaningful employment after that.
    The opportunity to testify about this before the Committee 
and to support the effort to understand the ongoing problems 
resulting from the use of Agent Orange is greatly appreciated, 
and I look forward to any questions you may have.
    Chairman Tester. Thank you, Mr. O'Malley, and I want to 
thank Mr. Thompson and Drs. Kelsey and Szema for their 
testimony. Now we will hear from Shane Liermann, Deputy 
National Legislative Director for the DAV. Shane, you are up.

                  STATEMENT OF SHANE LIERMANN

    Mr. Liermann. Thank you. Chairman Tester, Ranking Member 
Moran, and members of the Committee, on behalf of DAV's more 
than 1 million members who have wartime service-related wounds, 
injuries, diseases, and illnesses, we thank you for the 
opportunity to appear before you today to discuss the human 
costs of toxic exposure.
    When our service men and women are subjected to toxins and 
environmental hazard, our sense of duty to them must be 
heightened, as many of the illnesses and diseases due to these 
exposures may not be identified for years, even decades, after 
they have completed their service. As noted in our written 
testimony, this is compounded by the time it takes for VA to 
concede these exposures and to scientifically associate 
presumptive diseases. In many instances, it has taken decades 
to provide these veterans access to benefits and health care 
they have earned.
    Although Congress established a presumptive process and 
diseases for Vietnam veterans exposed to Agent Orange in 1991, 
it is now over 40 years--excuse me, over 50 years since the end 
of that conflict and they are still fighting for inclusion of 
presumptive diseases. We thank you, Chairman Tester and Ranking 
Member Moran, and the whole committee for getting bladder 
cancer, hypothyroidism, and Parkinsonism added to the 
presumptive list.
    However, Vietnam veterans are still facing obstacles. For 
example, Theodore Kalagian, my wife's uncle, honorably served 
the United States Army in Vietnam and is still fighting VA for 
his benefits. He was diagnosed with bladder cancer in 2005, and 
was denied VA benefits in 2007. Subsequently, he developed 
ischemic heart disease, diabetes, and prostate cancer, all 
presumptive to his Agent Orange exposure. Last, he also has 
hypertension, which VA died and has refused to add as a 
presumptive disease, despite, as noted, the National Academies 
determined there is a significant, positive, scientific 
association to Agent Orange exposure.
    There are millions of other veterans exposed to toxins that 
VA has not conceded or established presumptions for, such as 
burn pits. Ms. Ashley McNorrill was deployed to Iraq as an Army 
JAG officer stationed at Camp Victory in Baghdad in 2005. She 
was exposed to toxins emitted from burn pits that she noted 
were only a few feet from their chow hall. After service, Ms. 
McNorrill and her husband tried to start a family but were 
unable to conceive due to what they were told was 
endometriosis, which required a hysterectomy. After they 
adopted two small twin boys, she decided to have the 
hysterectomy, and during the surgery was discovered that she 
had stage IV appendiceal cancer, a rare form of the disease 
occurring only in one or two cases out of a million.
    After years of VA claims and appeals, with the assistance 
of a DAV service officer in South Carolina, she was awarded 
total and permanent VA disability benefits. The grant of 
benefits was based on her private medical opinion, linking her 
burn pit exposure to the development of her rare disease. 
Shortly after this victory, she succumbed to her burn pit-
related cancer and left her husband and two young sons behind.
    This is why S.437, the Veterans Burn Pit Exposure 
Recognition Act, is so important. The bill would concede 
exposure to burn pits for anyone who served in a recognized 
country and concede their exposure to the specific list of 
toxins already accepted by VA. It would also guarantee a VA 
exam and medical opinion, if required, to grant the claim. This 
bill would not provide presumptive diseases. Instead, it will 
remove barriers for direct service connection.
    We thank Senator Sullivan and Senator Manchin for 
introducing this legislation, and it could have granted Ms. 
McNorrill benefits much sooner and allowed her to enjoy more 
time with her family in her final years, instead of fighting 
the VA.
    Mr. Chairman, we are at a critical crossroads of the 
horrific cost of toxic exposures and a presumptive process that 
is wildly inconsistent and lacking flexibility moving forward. 
It is clear that veterans need a way of establishing service 
connection for diseases related to toxins now, and not wait for 
the scientific community or VA's bureaucratic processes. We 
recommend reforms and a new framework which should include 
access to VA health care, a concession of exposure, and time-
required actions by the VA.
    This concludes my testimony, and I am pleased to answer any 
questions you may have.
    Chairman Tester. Thank you, Mr. Liermann. I appreciate your 
testimony. Next up we have Aleks Morosky, Government Affairs 
Specialist for the Wounded Warrior Project. Aleks?

                   STATEMENT OF ALEKS MOROSKY

    Mr. Morosky. Chairman Tester, Ranking Member Moran, and 
members of the Committee, thank you for the opportunity to 
testify on Wounded Warrior Project's efforts to assist veterans 
who have been exposed to toxic substances during their military 
service.
    For nearly 20 years, a significant number of post-9/11 
veterans have been exposed to contaminants such as burn pits, 
toxic fragments, radiation, and other hazardous materials found 
on deployments to countries like Iraq, Afghanistan, and 
elsewhere. As an organization dedicated to connect, serve, and 
empower our Nation's post-9/11 wounded ill and injured 
veterans, we are firmly committed to addressing their toxic 
wounds with the same urgency that we address the physical and 
invisible wounds of war.
    Results from our 2020 Annual Warrior Survey confirm the 
scope of the issue, but the warrior story cannot be told with 
data alone. To better illustrate the challenges that exposed 
warriors face, both with their illnesses and with access to VA 
health care and benefits, I would like to tell you about a 
warrior named Scott Evans.
    Scott was a Marine. He deployed twice to Afghanistan as a 
combat engineer and as a dog handler. He served at the Battle 
of Marjah, and like so many, he also suffered exposure to open-
air burn pits during his deployments. He says burn pits were 
sometimes even used as a training area where they taught 
military dogs to sniff out munitions among burning waste.
    In 2012, Scott was honorably discharged and immediately 
began working a full-time civilian job. Like many hard-charging 
veterans, since he felt he suffered no significant disabilities 
from his service, he never filed a claim or enrolled in VA 
medical care.
    Then suddenly, in the spring of 2020, at the age of 32, 
Scott started experiencing severe abdominal pain and rapid 
weight loss. At that point, he attempted to enroll for care at 
his local VA, but learned that he was not eligible since he 
never filed a disability claim and was beyond the 5-year 
enhanced eligibility period for combat veterans.
    In July 2020, a friend who had served with Scott reached 
out to Wounded Warrior Project to see if we could help, and by 
this time Scott had incurred about $20,000 in medical bills, 
seeking a diagnosis and treatment for his condition. It was 
obvious at that time that Scott was critically ill.
    Our Wounded Warrior Project teammate convinced Scott to 
return with him to the VA hospital. When he got there, the 
emergency room doctors immediately recognized the seriousness 
of the situation but needed Scott to visit Eligibility before 
they could provide further care. Eligibility told him once 
again that he was ineligible to until he was service connected.
    After Scott and his wife left the room a teammate told the 
clerk that Scott was an uninsured, terminal cancer patient with 
multiple combat tours and an honorable discharge. After looking 
again at Scott's combat service record, the clerk relented and 
Scott was enrolled at VA.
    Since then, Scott has received compassionate, life-
prolonging care for his illness, eventually diagnosed as 
terminal pancreatic cancer. Scott has since been granted 
service connection, but we are immensely grateful that our 
teammate was able to obtain care for him when he did. Sadly, a 
veteran without such an advocate may have been turned away 
indefinitely.
    I spoke to Scott and his wife on the phone yesterday. They 
told me that while the care has been good at VA since he has 
been enrolled, it is a terrible feeling to wonder whether the 
mass on his pancreas may have been operable if it was caught a 
few months sooner, when he first tried to seek care. They also 
told me that they know that there are other veterans who are in 
the same situation as them, and they only hope that sharing 
their story will lead to improvements in the system for others, 
even though Scott does not know how much time he has left.
    Wounded Warrior Project thinks that no veteran should have 
to go through what Scott went through. This is why we believe 
that access to care for all veterans who suffered toxic 
exposures is an urgent priority, and we think that any veteran 
who has served in an area of known exposure should be eligible 
for permanent enrollment in Priority Group 6, regardless of the 
location or timeframe in which they served, now and in the 
future.
    And while we see health care as an urgent need, we also 
recognize that benefits, including disability compensation and 
DIC eligibility, are critically important. That is why we 
support the establishment of a permanent framework that 
requires VA to respond to scientific data and create 
presumptive service connection whenever there is a positive 
association between an illness and an exposure, in a timely and 
transparent manner. Once again, we feel this should apply to 
all toxic exposures, regardless of era or location of service.
    Finally, we believe there are several ways to improve the 
process for direct service connection, and these include 
concession of exposure to burn pits and other toxic substances 
for all current-era veterans who served in areas of known 
exposure.
    Senators, the Wounded Warrior Project believes that we owe 
it to veterans like Scott to get this right, and we look 
forward to continuing to work with the Committee to address 
this urgent issue in the 117th Congress.
    Chairman Tester, Ranking Member Moran, this concludes my 
Statement and I look forward to your questions.
    Chairman Tester. Thank you for your testimony, Aleks. We 
are going to start with questions. These will be 5-minute 
rounds. I would ask the Senators to try to stay as close to 
that as you possibly can.
    I will yield my time to Senator Hassan from New Hampshire, 
because she has a conflict at the top of the hour. Senator 
Hassan.

                  SENATOR MAGARET WOOD HASSAN

    Senator Hassan. Thank you so much, Mr. Chairman, and thank 
you for your courtesy in yielding the time. To Ranking Member 
Moran, thank you as well for holding this hearing. To all of 
the witnesses, thank you for your testimony today. To the 
veterans, thank you so much for your service and sacrifices, 
and I particularly want to thank Mr. Thompson and Mr. O'Malley 
for your testimony. It is not easy to talk about these things 
in front of an audience but it makes such a difference for your 
fellow veterans and your fellow Americans to hear what you have 
to say, so thank you.
    I am going to, I think, just stick to one question, because 
I have to go preside at the top of the hour, which the Chairman 
referenced, and I want to talk to Mr. Liermann and Mr. Morosky, 
because as we examine these issue we have to recognize that 
unfortunately servicemembers, veterans, and their families may 
have been exposed to toxic environments not only while serving 
overseas but also while they are right here at home.
    In my State of New Hampshire, members of the military who 
serve at the Pease Air Force Base, their families, and people 
living in the surrounding community, were exposed to drinking 
water contaminated by high levels of PFAS, pollutants that are 
known as, quote, ``forever chemicals.'' I know that the Biden 
administration is currently considering implementing better 
PFAS safeguards, and I strongly support these efforts.
    Unfortunately, toxic exposure at domestic sites is not 
unique to New Hampshire. For example, decades ago, Camp Lejeune 
in North Carolina experienced dangerous water contamination, 
and the VA has since appropriately created a presumption of 
service connection for certain diseases for veterans and their 
families who were exposed at Camp Lejeune.
    So, Mr. Liermann and Mr. Morosky, can you speak to some of 
the issues facing veterans and their families who were exposed 
to toxic environments within the United States, and any lessons 
learned from Camp Lejeune that can be applied to other 
situations such as the PFAS one?
    Mr. Liermann. Thank you, Senator. I believe if you take a 
look at the types of toxic exposures, just domestically, within 
the U.S., outside of Camp Lejeune and the PFAS there then is 
also Ft. McClellen, Alabama. So there is a history of toxic 
exposures throughout the country, even domestically. So finding 
a way to establish something, as you mentioned, like Camp 
Lejeune, is what we are all striving for, especially the PFAS 
issue. They are now indicating over 600 military installations 
have been known to have high levels of PFAS.
    So there are several different things that can be done, 
like setting up a presumptive like Camp Lejeune, or like the 
idea of the concession of exposure as noted in S.437. If we 
could conceded their exposure to those chemicals now, instead 
of waiting for studies and science, we can provide a quicker, 
direct path for service connection for diseases related 
thereto.
    Senator Hassan. Great. Thank you. Mr. Liermann?
    Mr. Morosky. Senator, I will just add that in the past we 
have often dealt with toxic exposures on sort of a conflict-by-
conflict basis. What we envision would be offering access to 
health care and benefits for all eras on the same basis, and 
toxic exposures now and in the future, and that would also 
include domestic as well as overseas. We think that those who 
were exposed on a domestic basis should be offered care and 
benefits on the same basis as those overseas.
    Senator Hassan. Thank you very much. I look forward to 
working with you all on that. To all the witnesses, thank you, 
and to those advocating and researching on these issues we are 
really grateful for your work too.
    Thank you, Mr. Chair. I yield back.
    Chairman Tester. Senator Moran.
    Senator Moran. Chairman Tester, thank you.
    Chairman Tester. Sherrod, you have got to mute.
    Senator Moran. Thank you very much, Mr. Chairman. I was 
waiting to see if Senator Brown had any other comments before I 
began my remarks. Let me start with Mr. Morosky. Can you opine 
on what you believe to be Congress' role in adding additional 
presumptions to the list versus the Executive branch, the 
Department, and others exercising its authority? And can you 
comment on any concerns that the precedent being set, if it 
continues to be left to Congress to add to that presumptive 
list.
    Mr. Morosky. Thank you, Senator Moran. You know, in the 
past we have seen presumptive service connections that are 
established by Congress, with bills in Congress, and we have 
seen cases where the VA acted based on scientific evidence. We 
believe it is ideal when the VA acts based on scientific 
evidence, which is why we support a framework that would 
require them to respond to the scientific data in a timely and 
transparent manner. We believe that veterans deserve that. 
While we will continue to support bills introduced in Congress 
that establish presumptive service connection by statute in 
that way, we also think that it should not always take an act 
of Congress for veterans to have their claims granted, and it 
should ideally be the VA that is responding to the scientific 
data and giving that.
    Senator Moran. I guess that is a good point, because often 
the expression is it will take an act of Congress, as if that 
is something nearly impossible, but we generally respond when 
something is not being done, less than we are able to do. So 
thank you for that analysis.
    Mr. Liermann, in your testimony you noted the barriers to 
veterans' claims for benefits related to burn pit exposure. 
Noting the history of toxic exposures that have face multiple 
subsequent generations of veterans and future uncertain combat 
environments, what actions can Congress take to most 
immediately--most immediately--make an impact for veterans 
suffering from toxic exposure today? In other words, I think my 
question is, what can we do now that would make a difference 
now?
    Mr. Liermann. Thank you, Senator. Two things. I believe, 
one, if we take this idea of the concession of exposure and 
implement it now--it does not require science, it does not 
require anything additional--it is a quicker path for direct 
service connection for veterans. Two, we need to establish a 
framework, as Aleks has mentioned and several other people 
mentioned, that has a lot of these built in so we are not 
spending time squabbling over the science each and every time 
there is a new presumptive or a new exposure. We have something 
in place so immediate action can be taken, so veterans do not 
have to continue to wait decades for access to health care and 
benefits.
    Senator Moran. Thank you for that answer. Let me turn again 
to Mr. Morosky and ask, any comments that you have about 
expedited health care for veterans for toxic exposure? I think 
your testimony indicates how important it is for a quick 
answer. Is there something specific that we should know why 
that is important, or is that just self-evident?
    Mr. Morosky. We think it is self-evident, and we think it 
is an urgent need that is not being met for veterans like 
Scott, that I spoke about in my opening Statement, Mr. Ranking 
Member. Access to care is something that is provided to Vietnam 
veterans on a priority group 6 basis, without the need to 
establish a presumptive service connection. It is provided to 
post-9/11 combat veterans but only for a period of 5 years. 
Once that 5-year window runs out, veterans like Scott, who have 
serious illnesses seven or 8 years later, are turned away, 
unfortunately.
    Senator Moran. So it may be true, if I had time to ask the 
medical doctors that are our witnesses today, and maybe I will 
have that chance later, that there may be specific nature of 
these conditions that so much better result can occur if 
treatment begins quickly. I would guess that is true in most 
instances, but maybe there is something unique about these 
circumstances that our service men and women face.
    I would conclude, Mr. Chairman, by saying that a number of 
years ago, certainly during my time in the Senate, a group of 
veterans met in Wichita, Kansas, and it was family members, and 
I would highlight what has stuck with me since then, probably 
for a decade now. And that is that these veterans and their 
family members were there because they were concerned about 
their own children and grandchildren. And the consequences that 
occur from these exposures, those consequences are appearing 
their children and grandchildren. It has always stayed with me 
that I know service men and women are willing to accept risks 
for their service, but I cannot imagine one of them thought 
they were doing anything that might harm a family member, or 
somebody who may not even be born yet.
    And so we will continue. Senator Blumenthal and I have 
worked to try to make certain that we get the scientific and 
medical evidence necessary to determine what role the 
Department of Veterans Affairs, what we as Congress should do 
for another generation of service men and women's family 
members.
    Mr. Chairman, thank you.
    Chairman Tester. Thank you, Senator Moran. Mr. Thompson, I 
am going to start with you. First of all, thank you for your 
testimony. Thank you for your service.
    Your health problems started to manifest toward the end of 
your second deployment in Iraq in 2009. Could you tell me, how 
long from when you started to experience symptoms did it take 
before a doctor concluded that burn pits played a role?
    Mr. Thompson. Yes, sir. It was September 2009 is when I 
started feeling the effects, and I would say it was the summer 
of 2010 that the doctor from Walter Reed had listed that the 
burn pits and environmental agents caused the effect.
    Chairman Tester. I appreciate that. Has either the DoD or 
the VA conceded that your health conditions were caused 
directly by your exposures in Iraq?
    Mr. Thompson. No, sir. Not to my knowledge.
    Chairman Tester. And what has that meant for you on a day-
by-day basis? What has that meant?
    Mr. Thompson. Well, I was denied my Army retirement because 
if it was not a combat action then I do not receive that 
retirement.
    I am sorry for being slow. I am going on 3 days without any 
sleep.
    Chairman Tester. Well, you are doing just fine. Do not 
apologize for that. We appreciate your testimony.
    Dr. Szema, you have done some pretty amazing research on 
lung injury in Iraq and Afghanistan veterans. I want you to 
walk us through some of the conditions that your research has 
found to be associated with burn pit exposures.
    Dr. Szema. So the most common ones would be asthma, 
bronchitis, and COPD, chronic obstructive pulmonary disease, 
even in the absence of smoking. But we see a rare form of lung 
disease called constrictive bronchiolitis, which have been 
duplicated by Dr. Robert Miller of Vanderbilt. And the most 
severe patients are like Will, who have had lung scarring with 
the constrictive bronchiolitis, and actually Will was gracious 
enough to give his native lungs to us. We actually determined 
that there were burned particles in his lungs. They were 
polycyclic aromatic hydrocarbons, which are products of 
incomplete combustion. So he has got burn pit stuff in his 
lungs.
    And we can duplicate it. He was at Camp Victory. We, at the 
surface, grabbed samples from Camp Victory, Iraq, taken in that 
timeframe, and we found those same particles as well, burn 
particles in the actual dust, that the U.S. Geological Survey 
connected for us.
    Chairman Tester. I appreciate that. Mr. O'Malley, by the 
way, you have the same name as my elementary principal so I 
feel like I am talking to him. But I want to thank you for your 
service. I want to thank you for your testimony. You talked 
about not having health insurance until you learned you were 
eligible for VA health care, from a fellow Vietnam veteran. Can 
you tell us about your experience with VA health care?
    Mr. O'Malley. Thank you, Chairman. For those of you not 
familiar with Houston area, I get my primary care and my 
special care at the Michael DeBakey Veterans Affairs Medical 
Center in Houston. It is located in basically the heart of the 
Texas Medical Center, which is one of the finest research areas 
for medicine in the United States and in the world. Many of the 
doctors who do specialty care for me when I need it are wearing 
also Baylor College of Medicine tags and are receiving their 
training under the supervision of Baylor and the VA.
    I have had, in my 11 or so years of treatment at the VA, 
exemplary care, and it is by far the longest relationship with 
a primary care physician I have had in my life. I recently, for 
the first time, experienced a new primary care physician after 
mine retired. The hearing aids I am wearing, the treatments I 
have received for conditions that have arisen have been top 
notch. And in my experience talking to other veterans that I 
know, they may be frustrated with bureaucratic things with the 
VA, but I do not know anybody in the Houston area that is upset 
with their medical care.
    Chairman Tester. That is good news and that is news we 
always like to hear on this Committee.
    Senator Tillis, you are up.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman, and thank you to 
the witnesses for testifying. Mr. Chairman, I want to thank 
you, in the time that we have worked together, since I have 
been on this Committee and particularly with your vocal support 
for trying to move forward with the TEAM Act. I want to thank 
former Chair and Ranking Member Moran for having a vote where 
the TEAM Act was passed unanimously out of the Committee.
    I know that one of the witnesses referred to the process 
that they go through with the VA, when dealing with exposures 
and presumptions as--Shane, I think it was you, actually, that 
said it was complex and uncaring, exposure and presumptive 
process. I think it is. And that is why I think the TEAM Act, 
and actually the Burn Pit Exposure Act that was co-sponsored by 
Senators Sullivan and Manchin, are so important for us to get 
before this Committee.
    We have a coalition of some 30 veteran service 
organizations. I think every one that is not even on the 
coalition supports the bill. And I believe that it moves 
forward with getting rid of some of that frustration and not 
putting the weight on veteran, but having an independent 
review, and maybe let the tie go to the veteran. And I look 
forward to working with you and the other members to get that 
to the floor and ultimately to the President's desk.
    I am sorry for not being here earlier. We have got another 
committee that I have to speak at shortly. But the other thing 
that I hope we start thinking, I think we are going to make 
progress on the TEAM Act. I think that we can figure out a way 
to resolve some minor differences with some of our colleagues 
on the House side and move forward with the bill in this 
Congress, and hopefully the first half of this Congress.
    But also, as I was looking at some of the provisions in the 
TEAM Act, something as simple as an exposure questionnaire when 
a veteran comes into a VA facility, I think we have got to 
start looking further upstream. And I think I have made note 
for my staff that I would like to have that exposure 
questionnaire as a part of a TAP program, before they ever 
transition into veteran status.
    And I would even like to go further. I would like to be 
able to provide information in the electronic health record for 
a servicemember to where we are capturing information that we 
can predict--it may have been an event that they can no longer 
remember, but with increased situational awareness on the 
ground there should be some way to be able to capture that 
information over the life of a servicemember so that we could 
even predict someone who may fill out that form and just blow 
through it because, you know, when you go through TAP what you 
are really wanting to do is make the transition.
    I want to get to a TAP program of one. I want to know 
everything that we need to know about that servicemember, up to 
and including potential health risk exposures, so that we can 
actually vector them immediately, before they ever have any 
sign or a symptom, and then have the weight of their service 
history, the medical and exposure dimensions of their service 
history, as being the weight that they carry to that process, 
along with a fairer process with respect to outside 
consultation on exposures.
    So, Mr. Chairman, this is a group of people that my office 
has spent a lot of time with, and we are going to spend a lot 
more time because we are going to do everything we can to get 
the TEAM Act and some great ideas from other members embodied 
in the same bill, and we are going to need your support to make 
sure that in this Congress we can all have a celebration, 
hopefully without masks and not virtually, of what I think is a 
major step forward. We have made great progress.
    I got exposed to this when I first came to the Senate 6 
years ago, with the Camp Lejeune situation. We fought and I 
dealt with administrations, Democrat and Republican 
administrations, where the presumptions were almost maddening, 
and, you know, as a U.S. Senator I found it maddening. I cannot 
imagine what it would be like for a veteran who has encountered 
an illness, that is going through this process.
    So, Mr. Chairman, I am not going to ask any other questions 
except to say, in my remaining minute, I really do hope that 
you all will not only think about those veterans but think 
about that servicemember, that active servicemember, and what 
more we can do to better integrate and better identify these 
problems before that servicemember or that veteran may ever 
know that they have an exposure or a problem.
    Chairman Tester. Thank you, Senator Tillis, and it is fair 
to say that you and your predecessor, Senator Burr, on this 
Committee have been on this issue for a long, long time now, so 
we appreciate your leadership.
    Next we have Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman, and I apologize for 
my talking when I was not muted before. I was just asking if 
Mr. Hamilton was actually here, because I could not see on the 
screen, so thank you. I know he is remote, so thank you. And I 
appreciate the comments of Senator Tillis a moment ago.
    Thanks for the hearing, first. Thanks for the witnesses' 
testimonies. I really am heartened the way that all of your 
talking about toxic exposures. I appreciate Senator Tester's 
leadership on Agent Orange. We have still got to work on 
hypertension, but the success of last year of presumptive 
eligibility were really important to so many veterans who I 
have met in Ohio and I know across the country.
    I want to talk about burn pits a little bit. I appreciate 
comments earlier. Mr. Hamilton, I will start with you--Mr. 
Thompson, I am sorry. Mr. Thompson, let me start with you. 
Thanks for your testimony today. I heard part of it and then I 
heard your answer to a couple other questions. I am sorry, I 
was on another meeting. Nobody should have to go through what 
you have gone through, still, what your family has been 
through.
    Mr. Thompson, what should servicemembers who are currently 
overseas and exposed to burn pits do? What steps do you think 
the Army and DoD should take? So answer that, and then what 
steps the Army and DoD should take to prevent this exposure in 
the first place, to burn pits.
    Mr. Thompson. Well, first and foremost, they have already 
improved incinerators back when--I think back when I was still 
in country. And the only thing they need to do is just 
implement it and get them up, get them running.
    And then, it comes back to my memory. When I was there, 
there were some of the foreign workers that we had at Camp 
Stryker, every day I saw them wearing masks, and now I wish I 
had took their lead and wore one every day. I do not know if it 
would have helped but at least it would have been something.
    Senator Brown. Yes, Okay. Thank you, Mr. Thompson, and 
thanks again for serving, and I hope you are seeking out 
results and getting better support from others and from the VA, 
especially.
    Dr. Szema, Dr. Miller was before our Committee a year, 18 
months ago maybe, and I will ask similar questions to what I 
asked him. You have treated servicemembers exposed to burn 
pits. You have treated other environmental exposures. Do DoD 
and VA have the protocols in place to correctly diagnose these 
respiratory illnesses, and I think you mentioned constrictive 
bronchiolitis? Are we doing that right? Do we have the 
protocols in place?
    Dr. Szema. The problem with diagnosing constrictive 
bronchiolitis is that it is going to require a lung biopsy. Now 
what we are working on at my hospitals, Norwell Health, with my 
colleague, Dr. Agarwal, is transbronchial cryobiopsy. So that 
is a way of getting a piece of lung without taking patients to 
the operating room. So that is in the formative stages, but we 
have a robust interventional pulmonary program. So that will be 
a game-changer in terms of diagnosing without going for a 
surgical biopsy, which was one of the criticisms in the past of 
taking everybody to the operating room.
    The other problem is there is noninvasive testing that I 
use that is not widely available in the VA, and among the 
things we do are something called impulse oscillometry, and it 
is a $15,000 machine, and it takes 2 minutes. You put your 
mouth on it and it determines if your distal areas are 
narrowed. And if you do not reverse with an inhaler, it 
suggests that your distal airways are narrowed and fixed, 
consistent with constrictive bronchiolitis, in the absence of 
other disease. So some of the tools are not available widely in 
the VA.
    Senator Brown. Thank you. My last question, Mr. Chairman, 
Senator Portman and I have introduced a bill named after Heath 
Robinson, an Ohioan who served in Iraq who was exposed to burn 
pits and later died, far too young, of cancer. I hope that our 
bill will help connect the dots between veterans' health 
outcomes and burn pit exposure so that veterans get the 
benefits that they have surely earned.
    This is for Mr. Liermann, or maybe anybody else. Do you 
happen to know at what rate burn pit victims' disability claims 
are approved?
    Mr. Liermann. Thank you, Senator. I believe the report the 
VA put out last year was roughly 78 percent of the claims are 
being denied when they are specific to burn pits, so roughly 22 
to 24 percent are being granted, or 30 percent. I am a Marine; 
math is not my strong suit.
    Senator Brown. Why do you think, representing veterans, why 
do you think that is the case, that that many are denied?
    Mr. Liermann. Well, I think part of the problem is VA is 
not recognizing that exposure as being toxic exposures, plus 
there are no presumptive diseases. Fifty percent, or over 50 
percent of those cases being denied are because they do not 
have a medical link or a nexus between that exposure and that 
disease, and that is why S. 437 would definitely remove some of 
those barriers and make it easier to get direct service 
connection in those cases.
    Senator Brown. Mr. Chairman, if I could do one more real 
quick question. Mr. Liermann, do you see a time when we have 
presumptive eligibility for burn pits like we did, many years 
too late, for Agent Orange?
    Mr. Liermann. I would love to see that. Yes, absolutely, 
and I hope we get to that point. The problem is, it has already 
been, since the first Persian Gulf we are talking 30 years 
since burn pits were again active, since 2001. We are way 
behind the curve here. So I hope we do get to that point. I 
just hope we find a way, in the intermediate, to establish a 
way to get them health care, as Aleks was referring to, and 
service-connected benefits now, so they do not keep suffering 
and waiting another 10, 20, or 30 years.
    Senator Brown. Thank you. Thank you, Mr. Chairman.
    Chairman Tester. Yes, make no mistake about it, Senator 
Brown. We hold these hearings for two reasons: to gather 
information for the Committee members and to help educate the 
VA that they might take action before Congress does.
    Senator Blackburn, you are up.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
to each of you for being with us today.
    Just a couple of quick questions. I have done a good bit of 
work on the K2 veterans issue. We have folks in Tennessee that 
were part of the 5th Special Forces Group, the 160th SOAR, and, 
of course, they spent time there at K2. And we have worked 
diligently. The NDAA has a study, a 180-day study, that we are 
going to look at some of these veterans and getting to them 
what they need.
    It is of concern to us that we have the number of denied 
veterans that we have, and the hope there is that the TEAM Act 
would help with removing some of those barriers, by getting the 
K2 veterans included in the Burn Pit Registry, getting that 
exposure there. That is something that we think is going to be 
vital.
    Dr. Szema, I do have a question I wanted to ask you, 
because we have got the MISSION Act that allows veterans to go 
now outside of the VA system and seek care when they need it. 
So what I would like to hear from you is what ways could DoD 
proactively, or the VA proactively, pursue measures that would 
adequately capture a servicemember's long-term respiratory 
health, and then for issues like those that are suffered by our 
K2 veterans, seek that care there in their communities?
    Dr. Szema. So as I mentioned earlier, we are advocating for 
centers of excellence, sponsored by the NIH or NIOSH, analogous 
to the World Trade Center Monitoring Programs, because in order 
to capture the veterans, you really need a center of excellence 
that is impartial and academically based, and has the resources 
and the specialized diagnostic testing available that is 
largely not available at community veteran hospitals.
    Senator Blackburn. And I would add to that, timely, because 
that is part of the problem. They do not have that timely 
access.
    Dr. Szema. Right. I agree. And for example, I am in New 
York State. As part of Northwell Health, you know, we are the 
largest employer in New York State and we have 22 hospitals. So 
we were able to respond to the COVID pandemic very rapidly in 
New York, and it is one of those things where, you know, 
resources and expertise do matter. And I think, yes, you have 
to share with the VA, but you also have to rely on where the 
expertise is.
    For example, 4DMedical is a company that just got FDA 
approval last year to do a noninvasive test and use software to 
stack all the CT scans and fluoroscopy to do a 3D image and 
make a movie and tell me where the ventilation is abnormal, and 
it is color coded. So that is brand new. You have to be able to 
respond and be agile, and I think the problem with bureaucracy 
is, you know, these soldiers are not getting the care because 
of the existing framework of the benefit system.
    Senator Blackburn. Thank you. I appreciate that. Mr. 
Chairman, I yield back.
    Chairman Tester. Thank you, Senator Blackburn. Senator 
Manchin.
    [No response.]
    Chairman Tester. Senator Manchin? Senator Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman. Thank you for 
testifying today. This is kind of alarming, a little bit. You 
know, I grew up in Vietnam era. I lost a lot of my buddies, 
older buddies, to Agent Orange. It seems like it takes us 
forever, you know, to come up with any kind of answer to 
something like this, and now we have the burn pits. And, you 
know, sooner or later the type of country we have, you would 
think we would come up with some kind of idea of what affects 
people. We knew smoke affects people, and we have all these 
burn pits.
    But, Chairman Tester, I want to thank you. One of your top 
priorities is adding hypertension to, you know, this list, 
Agent Orange. My dad was in the military. He landed at Normandy 
at age 18, and fought all the way across Europe, and 30 years 
later died of a heart attack, of hypertension. And it is there. 
It is proven. Stress is a huge part of it, and you cannot 
imagine the stress that you have going through some kind of 
battle or war in the theater, especially in the type of areas 
that we fight in. You know, now we are in the mountains and the 
hills and deserts, a few years before that, and then the 
jungles back in my era. It is just amazing. But we have got to 
come up with advances in equipment.
    That is one thing I want to ask the doctors is, you know, 
once we go into an area, is there any way that we--preventive 
medicine is the best, you know, for all of us. I mean, if you 
go get a physical you tend to be able to find out things a lot 
quicker than just sitting around. And we could do the same 
thing when we are going to go to the theater, and we are going 
to fight these wars. We ought to be able to understand what we 
are getting into.
    And I want to ask the doctors about, you know, equipment 
and preventive measures. You know, for instance, this toxic 
exposure in the theater, do we have anything now that we give 
our troops that are out in the field, that are around--even if 
we have got these containers that we are burning it in, you are 
still going to have some exposure. Any doctor.
    Chairman Tester. Either Dr. Szema or Dr. Kelsey, you get 
that question.
    Senator Tuberville. Yes.
    Dr. Kelsey. Senator, I am not military personnel but my 
expertise is really in the area of the effects of exposures. I 
would say that I agree with you, prevention is the primary way 
to go here, and I would echo what Senator Tillis said, in the 
sense that we have got trouble trying to figure out what is 
exposure related if you do not measure it. And I think his 
comment was really quite insightful in the sense that I think 
the military does not do a great job of assessing exposure, and 
certainly they do not keep track of it.
    So in terms of going forward, one of the best things in the 
prevention world, that I can think of, is to act on Senator 
Tillis' observation that they can do a better job assessing and 
storing information on what active service encounters in terms 
of exposures.
    Senator Tuberville. Exactly. Thank you. You know, we send 
these young men and women to war. We pay them $38,000, and I 
get more calls on veterans than anything, and I have been doing 
this for 2 months. And it is amazing that they cannot get an 
appointment, they cannot get in. I know I have got something 
wrong with me because of the toxic I have got in my lungs. They 
tell me I have got to have more proof. We have got to do a 
better job of taking care of our young people. If we are going 
to go to war, we have got to understand, we have got to pay the 
price for it, on both ends.
    And so I want to thank you guys for your help, the Wounded 
Warriors and Disabled Veterans. It is so important, because 
what have we been fighting now, 20 years? Twenty years in these 
two wars we have been fighting, and we have got a lot of young 
people coming back, they have got bad problems, and PTSD--I am 
waiting every day. I will get a call from my best friend, 
wondering whether his wife is going to tell me whether he has 
committed suicide, because he cannot sleep. And he gets very 
little help at the VA, because it takes him a while to get in 
there.
    So thank you for your help. I know we have got huge 
problems. We look forward to working with you and I look 
forward to working hard on this Committee. Thanks for your 
help, and Doctors, thank you for your help, and you veterans, 
thanks for your service. Thanks for everything that you have 
done for our country, and hopefully we can do a lot better job 
taking care of you.
    Thank you, Mr. Chairman.
    Chairman Tester. I understand that Senator Manchin is on 
the phone? Speak to me, Senator Manchin.

                      SENATOR JOE MANCHIN

    Senator Manchin. I am on video for you, Mr. Chairman, just 
for you. I found a video that worked, and I came to make sure I 
could see you in person.
    Thank you, Mr. Chairman. I appreciate it very much. Mr. 
Thompson, I wanted to take a moment to thank you for your over 
23 years of service in the United States Army and the West 
Virginia National Guard. I am honored to have the opportunity 
to meet you, and I am proud to be a West Virginia because of 
veterans like you who have made unimaginable sacrifices for our 
country.
    Your testimony sheds light on so many problems veterans are 
facing when it comes to toxic exposure. But one in particular 
grabbed my attention. You wrote that you do not qualify to 
receive your retirement until age 60 because your injuries were 
not combat related. To me, this is just one part of a larger 
issue when it comes to toxic exposure. We are not providing 
parity between active-duty and reserve component service.
    So my question would be, what can Congress and VA do to 
ensure that veteran families are taken care of and receiving 
the benefits they are entitled to after our veterans are gone? 
Mr. Thompson?
    Mr. Thompson. Yes, sir. I want to say just make sure that 
the benefits that are there are the same across the board, 
because the way I felt after I was told that is that it is 
cheaper to send a National Guard soldier over to get injured or 
killed than it is an active duty soldier.
    Senator Manchin. Oh, my God. That is hard to believe.
    Mr. Thompson. That is exactly how I felt. I am not asking 
for, you know, anything special. None of us are. It is just, 
you know, if we do this, when I put on that uniform I gave 150 
percent. And when I take off that uniform I expect 150 percent.
    Senator Manchin. Right. Mr. Thompson, let me just tell you 
this. There is not a member on the Veterans Committee, Democrat 
and Republican, and sure not our Chairman or our Ranking 
Member, that does not believe that the fairness should be 
across the board, and we have all the respect, because all of 
us have National Guards that we basically love and support. So 
you making this testimony, hopefully it will make the changes 
that need to be made.
    My followup question to you would be, I would like to say 
to you, and all West Virginians who are servicemembers or 
veterans, that I am going to keep fighting for your access to 
health care and benefits in both my role on the Senate 
Veterans' Affairs Committee and the Armed Services Committee. 
So I just thank you for your service. I will say that I am 
proud to represent one of the most patriotic States in the 
Nation. As you know, we have a lot of veterans, on a per capita 
basis, one of the highest in the country.
    So, Mr. Thompson, thank you so much, sir. I just cannot 
thank you enough, and your testimony, I think, is going to make 
a big difference in what we are going to do and how we can make 
the changes. Thank you, sir.
    Mr. Thompson. Thank you very much.
    Senator Manchin. You are welcome, sir.
    I would like to address this to Mr. Shane Liermann. Mr. 
Liermann, first I want to thank you personally for all you have 
done and been doing to help us with the Veterans Burn Pits 
Exposure Recognition Act. I know you have been working 
tirelessly behind the scenes with my staff and Senator 
Sullivan's. I know you agree that we need to pass this 
legislation as soon as possible to ensure our veterans have the 
access to care that they desperately need.
    So my question would be, can you outline some of the 
consequences in the short and long term if we do not pass this 
bill and VA does not concede veterans' exposure to the specific 
toxins of burn pits?
    Mr. Liermann. Thank you, Senator. Unfortunately, if we do 
not pass this we are going to continue on the path we have been 
on for 20 years, and that means numerous veterans exposed to 
burn pits will continue to suffer from those illnesses, they 
will still continue to be denied health care, and we will not 
get any closer to establishing presumptive diseases.
    So if we do not do anything right now, while we wait for 
presumptives or find other science that we need to establish, 
millions of veterans exposed to burn pits will continue to 
suffer, without VA health care, without the peace of mind for 
benefits for their families, when they pass, due to those 
diseases.
    Senator Manchin. Let me just thank you, and, Mr. Chairman, 
let me just finish up by saying to you and Ranking Member 
Moran, that part of the reason I have enjoyed working in the 
Senate Veterans' Affairs Committee is because regardless of our 
party we always find a way to come together to support our 
veterans, in the most bipartisan way.
    I am proud that has been the case with the Veterans Burn 
Pits Exposure Recognition Act that Senator Sullivan and I re-
introduced. We have 18 co-sponsors and almost half of the 
Committee signed on. However, of those 18, only 6 are 
Democrats. We must do better. I am calling on my Democratic 
colleagues on the Committee to make joining the important piece 
of legislation a priority. And I know you can lead the charge, 
Mr. Chairman, as you always do for the right cause. Thank you.
    Chairman Tester. Thank you, Senator Manchin. Senator 
Sinema, I understand you are on.

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. That is right. Thank you so much, Mr. 
Chairman. I appreciate it. I want to start by thanking everyone 
for appearing today, and thank you for sharing your personal 
experiences and helping the Committee consider this important 
topic.
    As some of you have already alluded to, toxic exposure is 
an issue that requires this committee to take a retrospective 
and prospective view. We need to look back on our military 
operations and make amends where our veterans have been harmed 
by toxic exposures. And we also need to look at the current 
practices, the way the military uses these chemicals in burn 
pots and then do better to protect future generations of 
veterans from the terrible health impacts of these toxic 
exposures.
    In Arizona, we were recently notified of PFAS contamination 
outside of Luke Air Force Base. Mr. Liermann, you highlighted 
that DoD found evidence of over 600 installations with 
contaminated ground or drinking water. The Department of 
Defense has established a task force to address PFAS 
contamination. Do you feel that is enough, and what other steps 
need to be taken to ensure a national strategy to address PFAS 
use and the health risks associated with that use?
    Mr. Liermann. Thank you, Senator. I do not think it is 
enough. I think what we need to do is we need to start looking 
at are these exposures causing long-term diseases within those 
exposed to that PFAS-contaminated water. That is one. Two, we 
need to get established a presumptive process to make sure the 
men and women exposed have that access.
    So we need to be doing more, quicker, and I think that is 
the thing we are all talking about, is we are not moving fast 
enough in reference to how quickly we are learning of how 
severe some of these exposures really are.
    Senator Sinema. Thank you. My next question is for Mr. 
Morosky. You highlighted in your written testimony that the 
Wounded Warrior Project has been using DoD Individual 
Longitudinal Exposure Record, ILER, to help identify a link 
between a person's service and their exposures. I have 
repeatedly asked DoD and VA officials why is it that 
servicemembers or veterans are left to prove that they were 
exposed to toxic substances during their service, and DoD has 
answered that the ISER will enable DoD and VA to proactively 
identify exposures, taking the burden off of the servicemember 
or veteran.
    Is the ILER being used by the VA and DoD to proactively 
identify exposures?
    Mr. Morosky. Senator, we do not find that VA is using the 
ILER consistently. It is a relatively new tool. Our service 
officers request ILER reports and submit them as evidence for 
veterans' claims, and we have seen some success with that. 
However, we think that there should be better standards for 
when VBA claims personnel look into the ILER themselves in 
order to better develop the claim and help the veteran 
establish concession of exposure.
    Senator Sinema. So do you think the ILER could be developed 
to the point where it could be useful to help proactively 
address these claims and remove the burden from the veteran or 
servicemember, him or herself?
    Mr. Morosky. We think it is effective now. It will never be 
100 percent effective because there are gaps in it, and the 
further back it goes, the more gaps that there are. So we think 
that the improvement that really needs to be made is for VA 
claims personnel to be instructed how to use it, for there to 
be standards on that, but also for them to understand that a 
lack of evidence in ILER should never be grounds alone for a 
denial of claim.
    Senator Sinema. That is an important point. So ILER could 
be used to supplement or help prove, but the lack of 
information in ILER should not be used as dispositive to say 
that there is no injury or no exposure. Thank you. I appreciate 
that.
    My next question is for Drs. Szema and Kelsey. I hear from 
researchers and those gathering data on toxic exposure that 
though the VA and DoD are collecting information on toxic 
exposure through the various environmental health registries, 
this information is not available to researchers outside of DoD 
and the VA. If that is true, what would the advantages be to 
opening up the data to researchers outside DoD and VA if done 
in a way that protects the privacy rights of individuals?
    Dr. Szema. I think it is important to open up the data, but 
it depends on what is in the data base, otherwise it is garbage 
in, garbage out. For example, you know, one of my premed 
students is now graduating from medical school, Guadalupe 
Jimenez. When she was in the Marines she burned her trash on 
the side of the road in Iraq. She did not dig a pit. So in the 
questionnaire for the open-air burn pits registry she was not 
exposed to a burn pit, even though she definitely did it for a 
year.
    If you shoot a gun and you are lying on your stomach you 
are going to be exposed to the dust in the sandstorms that are 
there, and we know that the dust and the particulate matter in 
the sandstorms are frequent, they can rise as high as a mile or 
two up in the air, and they contain particles that include 
burning trash.
    So the questionnaire is key, and, you know, locations of 
military bases are often top secret. They are not on the map. 
So often the soldiers would say, ``I served here, here, and 
here,'' but that is not indicated in their record, as well. So 
I think there are some gaps that are going to be there, just on 
the basis of the current questionnaire.
    Chairman Tester. Thank you, Senator Sinema.
    Senator Sinema. Thank you.
    Chairman Tester. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks, Mr. Chairman. Thank you so much 
for holding this hearing, which is so vitally important to all 
of our veterans, and to all of the witnesses for being here 
today. And I want to thank Mr. O'Malley and Mr. Thompson, 
particularly, for sharing your stories.
    I was proud to support efforts led by Chairman Tester to 
grant a presumption of service connected for Parkinson's 
disease, bladder cancer, hypertension, and hyperthyroidism for 
veterans exposed to certain herbicide agents while serving in 
Vietnam, and I was proud, as well, to see the presumption for 
three of those conditions included in the recent National 
Defense Authorization Act, and we are going to continue to 
fight to have hypertension included on this presumption list as 
well.
    I am really concerned that we are repeating our past 
mistakes with more recently discovered toxic exposures like the 
ones associated with the burn pits at Karshi-Khanabad, also 
known as K2, the air base there. We must ensure that justice 
for these veterans is achieved now, and no longer delayed, the 
way it was for Blue Water Navy veterans exposed to Agent 
Orange.
    I appreciate your organizations, Mr. Liermann and Mr. 
Morosky, supporting my K2 Veterans Care Act. I understand that 
the DAV and the WWP assist veterans in pursuing veterans' 
benefits claims, and I am grateful for all of your work, and I 
am hopeful that Congress will act urgently to make it easier 
for veterans to receive the benefits they need and deserve.
    As Mr. Liermann noted in his testimony on a related topic, 
it has been decades since Congress or the VA has recognized 
additional radiation risk activities. Without this recognition, 
veterans face insurmountable barriers in having their radiation 
diseases recognized, and therefore in receiving the care and 
benefits they need. I want to thank the Yale Veterans Clinic 
for pursuing claims relating to the Palomares disaster.
    I have introduced, and I have led the Palomares Veterans 
Act in prior sessions of Congress, and I will introduce it 
again in the 117th Congress. The Palomares nuclear accident 
caused untold suffering and pain to men and women in uniform 
sent to the clean-up without proper protection and guidance, 
and the VA's unwillingness to review shoddy data from the 
Department of Defense has led to unconscionable delays for 
these veterans. They are aging. They cannot wait any longer.
    I have been encouraged by what Secretary McDonough has told 
me about his pursuing greater disclosure in the future from the 
Department of Defense in incidents like this one. The 
Department of Defense has a critical role to play in these 
toxic exposure incidents, both in providing information that 
makes it possible for veterans to pursue their claims, and with 
the VA in mitigating toxic exposures in the first place. They 
can prevent a lot of these harms. They need to take action. The 
DoD has a moral imperative as well as a military one.
    So my question is to Mr. Liermann. Could you outline for 
the Committee the unique barriers facing radiation-exposed 
veterans, including the veterans at Palomares?
    Mr. Liermann. Yes. Thank you, Senator. When we start 
talking about presumptive diseases related to ionized radiation 
exposure, there are several conditions that have to be met. One 
of those is veterans must have participated in a recognized 
radiation risk activity in order for them to be considered 
presumptive to assign one of the diseases. Once they determine 
it is a radiation risk activity, then they send it out to 
guesstimate on the amount of radiation they were exposed to, or 
the rems, to determine if that was enough. Then they send it to 
a medical specialist expert within VA who then will make a 
determination if that amount of radiation they were exposed to 
could have caused their disease.
    The problem is this does not sound like a presumptive 
process. Making them jump through every one of these hoops no 
longer sounds presumptive. It sounds like a direct service 
connected requiring all these things. But without that 
radiation risk designation, they cannot be considered a part of 
the presumptive radiation disease process.
    Senator Blumenthal. Excellent answer, and unfortunately my 
time has expired. I have more questions, and I may send them to 
you in writing. This panel is an excellent one, and again, my 
thanks, Mr. Chairman.
    Chairman Tester. Thank you. Thanks to all the folks who 
asked questions today, and I want to especially thank the 
witnesses who, quite frankly, did a marvelous job adding some 
meat to the bone on this issue.
    We have a lot more work to do. I think this Committee is 
committed to doing it, and we are going to need all your help 
to get it done. But the bottom line is this is a big issue, and 
it costs a lot of money, but the fact is that taking care of 
our veterans is a cost of war. We should not send them if we 
are not willing to take care of them when they get back.
    Thank you all, and we will continue the conversation. This 
hearing is adjourned.
    [Whereupon, at 11:46 a.m., the Committee was adjourned.]

                                APPENDIX

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