    [Senate Hearing 117-947]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-947

                    THE HEALTH EFFECTS OF EXPOSURE TO AIR-
                     BORNE HAZARDS, INCLUDING TOXIC FUMES
                     FROM BURN PITS

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

                                    HEARING

                                   BEFORE THE

                                SUBCOMMITTEE ON
                                   PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 16, 2022

                                   __________

             Printed for the use of the Committee on Armed Services

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                     Available via: http://www.govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    59-663 PDF                  WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                          COMMITTEE ON ARMED SERVICES

     JACK REED, Rhode Island, Chairman	JAMES M. INHOFE, Oklahoma

    JEANNE SHAHEEN, New Hampshire		ROGER F. WICKER, Mississippi
    KIRSTEN E. GILLIBRAND, New York		DEB FISCHER, Nebraska
    RICHARD BLUMENTHAL, Connecticut		TOM COTTON, Arkansas
    MAZIE K. HIRONO, Hawaii			MIKE ROUNDS, South Dakota
    TIM KAINE, Virginia			JONI ERNST, Iowa
    ANGUS S. KING, Jr., Maine		THOM TILLIS, North Carolina
    ELIZABETH WARREN, Massachusetts		DAN SULLIVAN, Alaska
    GARY C. PETERS, Michigan		KEVIN CRAMER, North Dakota
    JOE MANCHIN III, West Virginia		RICK SCOTT, Florida
    TAMMY DUCKWORTH, Illinois		MARSHA BLACKBURN, Tennessee
    JACKY ROSEN, Nevada			JOSH HAWLEY, Missouri
    MARK KELLY, Arizona                  	TOMMY TUBERVILLE, Alabama

    		 Elizabeth L. King, Staff Director
    		  John D. Wason, Minority Staff director

    _________________________________________________________________

                           Subcommittee on Personnel

     KIRSTEN E. GILLIBRAND, New York,
                   Chair			THOM TILLIS, North Carolina
    MAZIE K. HIRONO, Hawaii			JOSH HAWLEY, Missouri
    ELIZABETH WARREN, Massachusetts      	TOMMY TUBERVILLE, Alabama

                                      (ii)

                             C O N T E N T S

    _________________________________________________________________

                                 march 16, 2022

                                                                       Page

    The Health Effects of Exposure to Airborne Hazards, Including         1
      Toxic Fumes From Burn Pits.

                               Member Statements

    Statement of Senator Kirsten Gillibrand..........................     1

    Statement of Senator Thom Tillis.................................     2

                               Witness Statements

    Rauch, Terry, PhD, Acting Deputy Assistant Secretary of Defense       3
      for Health Readiness Policy and Oversight.

    Szema, Anthony, Medicare, Director, International Center of          16
      Excellence in Deployment Health and Geosciences, Northwell
      Health Foundation.

    Porter, Tom, Executive Vice President, Government Affairs, Iraq      19
      and Afghanistan Veterans of America.

    Torres, Rosie, Executive Director, Burn Pits 360.................    23

    Patterson, Steven, Former Environmental Science Officer, Combined    30
      Joint Task Force 101 Headquarters, Afghanistan, 2008-2009.

    Questions for the Record.........................................    40

                                    Appendix

    Supporting documents for Colonel Adam J. Newell question #10.....    51

    Supporting documents for Dr. Terry Rauch question #27............    61

                                     (iii)

      THE HEALTH EFFECTS OF EXPOSURE TO AIRBORNE HAZARDS, INCLUDING TOXIC
                              FUMES FROM BURN PITS

                                  ----------

                           WEDNESDAY, MARCH 16, 2022

                          United States Senate,
                                Subcommittee Personnel,
                                   Committee on Armed Services,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:30 p.m. in room
    SR-232A, Russell Senate Office Building, Senator Kirsten
    Gillibrand (Chairman of the Subcommittee) presiding.
        Committee Members present: Gillibrand, Warren, Hirono,
    Tillis, Hawley, and Tuberville.

            OPENING STATEMENT OF SENATOR KIRSTEN GILLIBRAND

        Senator Gillibrand. Good afternoon, everybody. The
    Personnel Subcommittee meets today to receive testimony on the
    health effects of exposure to airborne hazards, including toxic
    fumes from burn pits. Let me start by welcoming Ranking Member
    Tillis, who will be here very shortly, who has been an
    excellent partner on this subcommittee over the last several
    years. Senator Tillis and I have shared a commitment to
    supporting our servicemembers and providing them with the
    services, resources, and care that they need.
        That commitment extends to our shared drive to address the
    debilitating and extensive medical issues and disabilities
    caused by the use of burn pits in recent combat operations.
    When our servicemembers deploy they expect to face risks, but
    those risks should not come from the operations of our own
    bases, and when they do, we must take responsibility. I look
    forward to continuing to work together on this issue.
        I was also glad to hear that President Biden prioritized
    addressing this cost of war in the State of the Union, and
    again in Texas last week. He described the clear cause and
    effect of this crisis saying, ``The burn pits that incinerate
    the waste of war, medical and hazardous material, jet fuel, and
    so much more were just dug in big pits, not far from where our
    veterans were sleeping, and when our troops came home, the
    fittest among them, the greatest fighting force in the history
    of the world, too many of them were not the same--headaches,
    numbness, dizziness, cancer.'' That tells the whole story. Men
    and women who deployed at the peak of physical fitness are now
    fighting to survive.
        This is a health crisis among our armed services. Most
    public attention on this issue has been focused on the
    treatment of veterans at the Veterans Administration, but these
    health issues stem from time on Active Duty and can begin
    presenting while our troops are still serving. The DOD
    [Department of Defense] has a critical role to play in
    protecting the health of our current and transitioning
    servicemembers. That is why today's hearing is so critical. We
    need to have a better understanding of how toxic exposure has
    been and is being tracked and documented, and the barriers that
    have presented that documentation from being done effectively.
        Congress has already recognized DOD's responsibility and
    has passed legislation to require DOD to take appropriate
    measures, including requiring inclusion of exposure to open
    burn pits in post-deployment health assessments of
    servicemembers returning from deployment, recording burn pit
    registration in electronic health records, and mandatory
    training for military health care providers on the effects of
    burn pit exposure.
        But we need to go further. We need to build an
    understanding of the health impacts of toxic exposure and our
    knowledge of when such exposure is occurring, and we must make
    that information available to servicemembers, their families,
    and the medical professionals they rely on in order to properly
    and adequately care for our troops who have been exposed.
        As President Biden said, quote, ``We need to know more
    about which of our veterans may have been exposed to burn pits
    in the first place or other environmental toxins during their
    service, and record possible exposure before servicemembers
    separate from the military,'' end quote.
        Today's witnesses will help provide clarity in both of
    those areas. Our first panel consists of DOD witnesses who will
    testify about the health effects of toxic exposure, assessment
    of health impacts, documentation of potential exposure, and
    monitoring of exposure. Witnesses on our second panel will
    share what they have seen or experienced firsthand on this
    issue and will provide recommendations for ensuring the health
    and safety of our servicemembers.
        Witnesses for our first panel include Dr. Terry M. Rauch,
    Acting Deputy Assistant Secretary of Defense for Health
    Readiness Policy and Oversight; Dr. Raul Mirza, Division Chief
    of Occupational and Environmental Medicine, Clinical Public
    Health, and Epidemiology, U.S. Army Public Health Center;
    Colonel Adam J. Newell, Chief of Medical Readiness, Air Force
    Medical Readiness Agency; and Captain Brian L. Feldman,
    Commander, Navy and Marine Corps Public Health Center.
        I will introduce the second panel after we receive the
    testimony of the first panel. Again, thank you for being here
    today, and just for Senator Tillis' benefit, I told him how
    wonderful you are at the opening of my remarks.

                    STATEMENT OF SENATOR THOM TILLIS

        Senator Tillis. Could you please repeat that? I am sorry I
    am running late. I went ahead and voted so I figured we could
    tag team and not disrupt the hearing. But thank you all for
    being here. Senator Gillibrand, thank you for holding the
    hearing and your advocacy of the work that I am well of in
    veterans' affairs, that we need to continue to work on.
        I have worked on this subject for a long time when I first
    came to the Senate. I was involved with trying to get the
    presumptions in place for Camp Lejeune, toxic exposures down
    there. Fortunately, after a lot of back and forth with the
    Veterans Affairs (VA) we were successful, but we have more work
    to do.
        I am happy that the Veterans Affairs Committee has
    unanimously reported out a bill on toxic substances. We are
    going to continue to work in the VA Committee to do right by
    those who were exposed and who are now in veteran status.
        The objective of today's hearing, though--and it is
    something that I have said on a number of fronts, whether it is
    traumatic brain injury, low-level concussive events, things
    that men and women, while they are on Active status, experience
    that could ultimately result in problems in the long term--I
    think we have an opportunity here to get ahead of it. Instead
    of waiting for the next burn pit, or waiting for the next Agent
    Orange, what more can we do downrange? What more can we do in
    our military installations to understand the potential risk
    that we are putting our men and women, potentially putting them
    in a position to where they too are going to have negative
    health consequences, either while they are serving or after
    they transition to veteran status.
        So today I look forward to talking with you all about how
    we can get ahead of the curve, how we can do a better job of
    tracking potential exposures so that it makes it very easy
    later on, if we get into a situation. We cannot always, when we
    are downrange, know what we are going to get exposed to, but
    once we know it then we should make sure that every single
    electronic health record of any man or woman who is exposed to
    it is updated, and maybe we can even anticipate that they are
    at risk before they ever exhibit the first symptom. That is the
    end goal, and I am sure that you all, the witnesses, agree that
    that should be an end goal of everybody.
        So I look forward to this testimony today. I look forward
    to moving up in the cycle, talking with the DOD to figure out
    what more we can do to actually begin to bend the curve on some
    of the consequences that we have to deal with, with our men and
    women in uniform, and with the men and women who have served
    before.
        So thank you all. I look forward to your testimony.
        Senator Gillibrand. Colonel Newell? Dr. Rauch?

        STATEMENT OF TERRY RAUCH, PhD, ACTING DEPUTY ASSISTANT
     SECRETARY OF DEFENSE FOR HEALTH READINESS POLICY AND OVERSIGHT

        Dr. Rauch. Chairwoman Gillibrand, Ranking Member Tillis,
    and members of the subcommittee, thank you for inviting the
    Department to testify for the Senate Armed Services Committee
    hearing on military exposures of concern, including airborne
    hazards and open burn pits. I am pleased to represent the
    Office of the Secretary of Defense and have the opportunity to
    discuss the Department's actions in addressing airborne
    contaminants and open burn pits in military options, and the
    potential health effects to our servicemembers and veterans.
        Joining me today and representing their military
    departments are Colonel Newell from the Air Force, Dr. Mirza
    from the Army, and Captain Feldman from the Navy.
        The Department recognizes the concerns about the potential
    health impact of burn pits and other airborne exposures. The
    relationship between burn pit exposure and illness is a topic
    of active research by the Department, the Veterans Affairs,
    National Academies of Science, Engineering, and Medicine, and
    other research institutions. The Department and VA continue to
    support and fund these research efforts to better understand
    any health effects that will better inform the health care
    provided to our servicemembers and veterans.
        Health care providers play a critical role in understanding
    health-related exposures and becoming proficient in assessing
    patients' exposure concerns. This month, the Department will
    launch an updated version of its Airborne Hazards and Open Burn
    Pit Registry Overview course for health care providers. In
    addition to the training course, an Airborne Exposure Clinical
    Toolbox is available to our health care providers.
        The Department and the VA continue to share education,
    training, and outreach products to improve exposure-related
    clinical care. Airborne hazards pose potential acute and
    chronic health effects during deployment and post-deployment.
    As such, the Department has enhanced its pre- and post-
    deployment-related health assessments and the Separation Health
    Assessment to include more specific occupational and
    environmental exposure questions, including questions on burn
    pits and other airborne hazards.
        The Department and VA are currently collaborating on
    multiple efforts, including the development of the first-ever
    Individual Longitudinal Exposure Record--we call it the ILER--
    providing exposure summaries by leveraging personnel location,
    environmental monitoring and health assessment data. The
    Department is also conducting a comprehensive exposure
    monitoring capabilities-based assessment aimed at improving
    individual and area exposure monitoring and record-keeping
    across the installation, training, and deployed environments.
        In closing, the Department remains committed to continually
    improving our understanding of exposures of concern and
    potential health effects in order to prevent and mitigate
    exposures and clinically assess, treat, and care for our
    servicemembers and veterans.
        Madam Chairwoman, that concludes my opening remark, and we
    stand ready to address your questions.
        [The joint prepared statement of Dr. Terry M. Rauch, Dr.
    Raul Mirza, Colonel Adam J. Newell, and Captain Brian L.
    Feldman follows:]

    Joint Prepared Statement by Dr. Terry M. Rauch, Dr. Raul Mirza, Colonel
                  Adam J. Newell, and Captain Brian L. Feldman
        I thank Chair Gillibrand, Ranking Member Tillis and the Members of
    the Personnel Subcommittee of the Senate Armed Services Committee for
    the opportunity to participate in today's hearing.
        My name is Dr. Anthony Szema, Clinical Associate Professor of
    Medicine (Divisions of Pulmonary/Critical Care and Allergy/Immunology),
    and Clinical Associate Professor of Occupational Medicine, Epidemiology
    and Prevention at the Donald and Barbara Zucker School of Medicine at
    Hofstra/Northwell where I am Director, International Center of
    Excellence in Deployment Health and Medical Geosciences. At Stony Brook
    University, as adjunct faculty, I am Research Assistant Professor,
    Department of Technology and Society, College of Engineering and
    Applied Sciences.
        Between 1998 and 2015 I was Allergy Section Chief, Veterans Affairs
    Medical Center, Northport, NY. My expertise on this issue stems from
    the following: my team first reported new onset asthma from Iraq and
    Afghanistan Deployments among burn pit exposed soldiers in 2007,
    described deployment related rhinitis in 2008, coined the term Iraq
    Afghanistan War Lung Injury (IAW-LI) in 2011, based on lung function
    testing data, developed animal models with burn pit base dust in 2014,
    tested candidate drugs in mice in 2018, and co-invented new candidate
    medicines this year.
        I agreed to testify because, as a physician, I care about the
    health and well being of my patients who are our soldiers.
        The team in my office sees numerous patients post deployment with a
    variety of symptoms which include shortness of breath, cough, and chest
    tightness that is accentuated with exercise. I have diagnosed post burn
    pit exposed soldiers with asthma, chronic obstructive pulmonary
    disease, lung fibrosis, carbonaceous lung, constrictive bronchiolitis,
    titanium lung, bladder cancer as well as pulmonary ossification or bone
    in the lung. These are previously healthy, non-smoking, fit for
    deployment soldiers who have newly acquired lung disorders after their
    tours of duty. In one severe case, for example, my patient with lung
    fibrosis required two lung transplants and died last December.
        As an expert in the field, I have concluded that these lung
    disorders are directly related to exposure to airborne hazards. These
    ailments resulted from inhalational exposures to: burn pits, dust
    storms, improvised explosive devices, as well as blast overpressure
    from mortar fired rounds.
        My conclusions are based on our analyses of lung biopsies
    containing particles from these soldiers' lungs. These particles were
    subsequently processed at two different sites with two different types
    of technical machinery for analysis.
        1)  Center for Extraplanetary Exploration, Rahman Spectroscopy,
    Department of Geosciences, Stony Brook University
        2)  Brookhaven National Laboratory, National Synchrotron Light
    Source II Beam ID-5.
        Analyses from both laboratories conclude that the particles from
    soldiers' lung biopsies sustained exposure to high combustion
    temperatures consistent with burning. Chemicals identified included
    polycyclic aromatic hydrocarbons (PAH), and metals such as titanium and
    iron. These metals were bound together. These metals were also
    oxidized--which is evidence they were burned.
        As doctors treating these patients, one challenge we face is that
    there is inadequate screening for those military personnel who are
    predisposed to lung injury. Lack of screening is a challenge for
    diagnosing and treating patients for several reasons. First, if
    individuals are not screened, then they may never get correctly
    diagnosed. In addition, if they are not screened, and therefore not
    treated properly, by the time they present to the doctor, the disease
    is already severe and therefore, more difficult to treat.
        The dilemma with military personnel, who typically do not have
    asthma, since it is an exclusion diagnosis for enlistment, who must
    pass basic training outdoors, and who must be fit for deployment at
    Fort Hood prior to deployment, is that they usually do not have pre-
    deployment pulmonary assessments.
        Unlike the Fire Department of New York which requires annual
    spirometry breathing tests and was able to assess respiratory changes
    after 9/11, soldiers most often do not have a baseline for comparison
    other than their 2-mile run time. An otherwise healthy young soldier
    may be 100 percent or more predicted on spirometry and oxygen
    consumption from a cardiopulmonary exercise test predeployment. So,
    reduction to 80 percent predicted post-deployment is a significant
    decrease even though 80 percent is the cutoff for normal.
        Another challenge we face as the doctors treating these
    servicemembers is the lack of information we receive. Without knowing
    what they were exposed, or potentially exposed, to, it is hard to prove
    what caused the ailment. For example, in one recent case last month, a
    military firefighter, a patient of mine, was unable to get a referral
    to the East Orange WRIIC. The primary care doctor in the local VA did
    not believe that the military firefighter's sleep apnea, sinusitis,
    asthma, and rhinitis were related to deployment, even though he had a
    positive sleep study during his Active Duty.
        Even if it is known that there were toxic materials at a certain
    site, too often, soldiers visit our academic center without complete
    documentation of locations of their deployment so their direct exposure
    cannot be proven. This is especially the case if they were at forward
    operating bases or places like Camp Stryker whose exact location is not
    on the map.
        I have several recommendations to address these challenges and
    ensure we are taking care of our servicemembers:
        1.  Conduct breathing tests before and after deployment.
        2.  Revamp the DOD method of documenting locations where military
    personnel served.
        3.  Utilize newer technology such as wearable particle monitors.
        First, by conducting breathing tests before and after deployment
    for our troops, we can determine if there is a reduction in lung
    function much earlier than if we wait until disease is severe. In
    addition, these data will enable better screening protocols to identify
    ahead of time those soldiers at increased risk.
        Second, by revamping the DOD method of documenting locations where
    military personnel served, we will have a better understanding of what
    these soldiers were exposed to, and therefore, a better understanding
    of the cause of the illness as well as how to treat it. For example, it
    is important for those treating these soldiers to know which regions of
    the country an individual soldier was in; what types of munitions they
    were exposed to; what the chemical makeup of these munitions are; how
    trash was disposed of in that region, including burn pits; what the
    weather patterns were, i.e., dust storms in that region; whether
    depleted uranium was used in that region, for example, in armor
    piercing rounds PGU-14 and tank shells, as well as ship ballast; and
    whether that soldier used personal protective equipment and what types
    of PPE they used.
        Third, by utilizing newer technology such as wearable particle
    monitors with GPS [Global Positioning System], we will be able to
    assess a given soldier's exposure and location. By utilizing this for a
    contingent of military personnel, the DOD will be better able to move
    troops to regions of safety away from airborne hazards. If exposure
    does happen, it will also provide critical information for treatment.
        Our research team applied for a Congressionally Directed Medical
    Research Program (CDMRP) grant, got a great score, but was told there
    are insufficient DOD funds for the grant. We proposed to build on a
    beeper sized belt mounted device which measures particle counts, sarin
    and other toxic gas exposure, and gunshot sounds. Wearable tech is a
    mature enough field such that the industry should be able to respond to
    the needs of the DOD.
        These recommendations will ease the burden on both soldiers and
    physicians when those soldiers seek medical care. My recommendations do
    not prevent exposure but they do allow us to provide data so we can
    intercede early with diagnosis and initiation of treatment; by doing
    so, then we may see the overall cost of medical care go down and, more
    importantly, more lives being saved.
        We know that screening and monitoring programs have been extremely
    effective in preserving the health of those exposed to the World Trade
    Center disaster which is an analogous plume with JP-8 in burn pits. It
    is our sacred duty as Americans to protect the health of all the brave
    women and men who sacrifice their lives for our freedom.

        Senator Gillibrand. Thank you, so much, Dr. Rauch.
        Dr. Rauch, what does DOD do in the field to track toxic
    exposure for individual servicemembers, and are there any
    innovative ways the Department is working to do so?
        Dr. Rauch. Thank you for the question. I will start off and
    my colleagues can provide any more detail.
        It primarily starts, if we are talking about the deployed
    environment, it primarily starts onsite with our preventive
    medicine teams that are collecting environmental data, whether
    it be airborne data, soil data, water data. All of that data
    that is being collected--and it does, obviously, include data
    that is generated from military operations, to include burn
    pits, where there are--that data is collected by our preventive
    medicine units. It is captured in a large database called
    DOEHRS [Defense Occupational and Environmental Health Readiness
    System--Industrial Hygiene], and specific to DOEHRS, it is
    called DOEHRS-IH. IH stands for ``industrial hygiene.'' That
    database will then become available to then feed into the ILER,
    which is the longitudinal exposure record, and in addition, the
    ILER will not only scrape environmental health assessment data
    from DOEHRS, it will also scrape data from personnel location.
    So you can match the individual servicemember and his or her
    location to the environmental health data that is being
    captured in DOEHRS, and then ILER will present that data in
    what we call a joint longitudinal viewer and summarize that
    data for the health care professional. So he or she will be
    able to see where that servicemember was, at any point in time,
    what they were exposed to, and be able to----
        Senator Gillibrand. What is the time point this data
    starts, data going back to what point in time?
        Dr. Rauch. Well, preventive medicine units are part of the
    deployed force, and so they could be doing their environmental
    health basis on a weekly basis, they could be hanging air
    monitor----
        Senator Gillibrand. But when did you start collecting this
    data?
        Dr. Rauch. When I was on Active Duty in 1999, we were
    collecting it in Bosnia and Kosovo, so it has been a while.
        Senator Gillibrand. Great. Now you mentioned also--so you
    have it back to 1999, at least, and you said there are active
    burn pits today that you are monitoring. Where are those burn
    pits located?
        Dr. Rauch. It is my understanding that there are active
    burn pits in the CENTCOM area of operations. I can get with
    CENTCOM and we can provide more detailed information.
        Senator Gillibrand. Yes, please. Because I understood that
    the DOD now, as a matter of policy, has determined that they
    will no longer use burn pits as a way to dispose of waste. So
    if that is not the case I just need to know that, and second, I
    would like to know all existing burn pits that members of the
    military are being exposed to today, because that would be of
    great concern.
        Dr. Rauch. I will get with CENTCOM. I will provide that
    information. By policy, by DOD directive, we only will use burn
    pits when it is a military operational necessity. Everything
    else, the COCOM, the way he or she manages that waste, will not
    be managed by open burn pits.
        [The information referred to follows:].

        Mr. Rauch. Syria, Yemen, Iraq, Egypt, and Chad.

        Senator Gillibrand. So have they determined that all past
    burn pits of the last 20 years were operationally necessary?
        Dr. Rauch. Can you repeat that question?
        Senator Gillibrand. Have they already determined that the
    hundreds of burn pits that were used in the past were all
    operationally necessary?
        Dr. Rauch. Burn pits that were used in the past were used
    because when you establish a base camp in an immature theater,
    and each servicemember in the deployed force is generating 10
    pounds or more of waste every day, and you have 300 to 3,000,
    that is a lot of daily waste, and we have to manage it somehow.
    In an immature theater, before you can install incinerators or
    contract to have it removed, burn pits were used.
        Senator Gillibrand. Understood, and then my final question,
    which I think you answered, but what is the process that is
    currently being used by DOD and each of your services to
    determine whether a servicemember returning from deployment has
    been exposed to toxic fumes from burn pits during his
    deployment, and how and where is that information recorded, and
    who is given access to that information? Is it shared with the
    VA? I think you answered that question in the beginning. Could
    you just restate the answer?
        Dr. Rauch. Yeah. So there a number of ways that it is
    captured. We have a pre-deployment assessment and a post-
    deployment assessment, and that includes questions on airborne
    hazards, location exposure. In addition, we have the separation
    assessment, which also includes similar questions on health
    hazards and airborne contamination and location, and the
    separation assessment is sent to the VA with the servicemember.
    In addition, all of that is captured in databases that is
    captured under ILER.
        Senator Gillibrand. You believe that this data has been
    captured to at least since 1999?
        Dr. Rauch. The airborne monitoring that I am talking about,
    that we did at Camp Bondsteel and other areas of Kosovo were
    stationary air monitors. We did not have the current systems
    and databases that we have today. I mean, we were writing it
    down on paper and pencil, the data, back then. Now it is all
    captured electronically.
        Senator Gillibrand. So can you provide for the committee
    what years you have environmental data for air quality in
    different deployments around the globe?
        Dr. Rauch. Sure. Of course.
        Senator Gillibrand. Thank you.
        Dr. Rauch. It would go back before 1999.
        Senator Gillibrand. It would?
        Dr. Rauch. Oh yes.
        Senator Gillibrand. Okay. So that is excellent.
        Dr. Rauch. I mean, we were doing it in the first Gulf War.
        Senator Gillibrand. So we can get that information. So if
    we wanted to know air quality at K2 we could get air quality
    from K2?
        Dr. Rauch. If I can get air quality at K2, I should be able
    to, yes.
        [The information referred to follows:].

        Mr. Rauch. In DOEHRS, deployment air quality data exists
    from 1996-present for certain locations/operations. Outside of
    DOEHRS we should have at least hard copy data from Kuwait in
    the early 90's (Oil Well Fires).

        Senator Gillibrand. Okay. So that is kind of information we
    need, because we know where there were open burn pits from
    testimony of our servicemembers, and if we can get air quality
    from those locations it will make their ability for the DOD to
    fully understand that exposure did take place, because we have
    that data. Thank you.
        Dr. Rauch. I understand.
        Senator Gillibrand. Thank you.
        Senator Tillis. Thank you, Chairman. Thank you all for
    being here. I wanted to go back. You were saying, in 1999, I am
    sure that sensors have changed dramatically since then. So give
    me an idea now about the training for preventative medicine
    personnel about the nature of the sensors, whether or not we
    are considering--I know these are area sensors, probably--but
    what is the state of the art or the state of thinking in the
    DOD for wearable sensors, those sorts of things, so that we can
    track it down to the potential exposures of an individual in a
    situation?
        Dr. Rauch. Thank you, Senator. I will start that answer off
    and then I am going to defer to my colleagues to add a little
    bit more detail from their perspective.
        We are very interested in wearables. The reason is because
    our emphasis, our focus really needs to be on individual
    exposure monitoring. The things that I was talking about
    before, the data that we are capturing out of the environment--
    --
        Senator Tillis. More macro level?
        Dr. Rauch. There you go, and so, you know, you are going to
    have 100 or 30 or more individuals, and that data is very
    difficult to pinpoint exactly what an individual was exposed
    to. You know, there is kind of an old saying in science, ``It
    all matters to dose response,'' and if we cannot figure out
    what the dose of the exposure was, and what they were exposed
    to, then it is very difficult to capture their response.
        I will defer to my colleagues on their preventative
    medicine units and how they train, and the technology that they
    use. Captain?
        Captain Feldman. Thank you, Senator. A couple of different
    things from Navy Medicine. We are very proud of our forward-
    deployed preventive medicine units. They are agile,
    expeditionary teams that have quite a robust capability. So for
    example, they have got portable sampling devices that are now
    part of a tri-service, standardized program. They support all
    services. In fact, they have been deployed with the Army
    mostly, including currently. But those devices can conduct a
    pretty comprehensive evaluation of soil, air, water, water
    vapor, at an individual, portable level device having a static
    sensor. So that is a robust capability that is really cutting
    edge.
        With regard to wearables, one unique thing that Navy
    Medicine is doing with research and development, we have got
    some very robust submarine atmospheric monitoring, quite a
    robust and safe program, and Research and Development (R&D) is
    looking at silicone bands, wearables, that you can get
    individual level exposure data on a submarine.
        In addition to that, our research labs in Dayton have an
    Environmental Health Directorate that are looking at biomarkers
    and other correlates, translating from animal models, that will
    help us in the future get down to individual-level exposure.
        Senator Tillis. Colonel, do you have anything to add?
        Colonel Newell. Thank you, Senator. For the Department of
    the Air Force it is very similar. We are looking into
    wearables. We have not instituted them yet but there are in
    development.
        Senator Tillis. Dr. Mirza?
        Dr. Mirza. Sir, thank you for the opportunity. Myself, like
    my colleagues, we are also very interested in wearable
    technology. I think it is also important to underscore that the
    Army preventative medicine detachments are quite skilled and
    equipped to conduct the ambient samplings that they do as part
    of missions when they are forward deployed. Certainly air
    quality is not the exclusive issue of concern as well as other
    environmental issues, such as vector-borne diseases, pest
    control management, communicable diseases, and they are
    equipped and trained in that respect with environmental
    engineers, scientists, and also complementary clinical staff
    and public health and preventive medicine that are able to
    provide adjunctive and consultive support on-site, and not only
    within the PM community but also for all providers that are
    downrange.
        It is a pretty synchronized and robust capability that the
    Army provides in a contingency operation to assess exposures
    and respond to them.
        Senator Tillis. You know, I think one of the reasons why we
    should focus so much on wearables is we get an atomic view of
    exposures, and then hopefully, as a part of the process that is
    being captured in the electronic health record of the
    individual servicemember and ultimately being transferred to
    the electronic health record for the veteran, now that we have
    a joint office for the Center implementation for the VA
    electronic health record.
        I think it is going to be very important to have a seamless
    transition, and then hopefully we get to a point, if you are
    able to capture enough data, to where we can apply predictive
    analytics to maybe identify an exposure long before any
    symptoms have manifested themselves.
        Dr. Rauch, did you have something to add?
        Dr. Rauch. Well, I would also add, Senator, that in
    addition to wearables we need to understand more about how the
    individual responds to environmental exposures. What risks do
    they bring, other backgrounds, lifestyle factors such as, are
    you smoking a pack a day, you know, before you deployed, other
    lifestyle factors, or even what genetic background individuals
    bring. We need to understand those because they are going to
    have an impact, and the science is not there yet but we are
    pursuing it.
        Senator Tillis. [Presiding.] Thank you. Senator Hawley.
        Senator Hawley. Thank you, Senator Tillis. Dr. Rauch, if I
    could just start with you. You testified in your written
    testimony that since 2001, over 4 million now veterans as well
    as DOD civilians and DOD contractors deployed to the Southwest
    Asia theater of operations. How many of these individuals would
    have been exposed to airborne hazards, including toxic
    exposures from burn pits? Do you know? In that time frame.
        Dr. Rauch. Well, I cannot imagine that--all of them should
    have been exposed to some types of airborne hazards if they
    were deployed in various base camps and environments in
    Southwest Asia, because Southwest Asia, just the military
    operational environment--vehicles, burn pits, everything else,
    to include sandstorms created a lot of potential for airborne
    hazards. If you are there, you are exposed to it.
        Senator Hawley. What is DOD's estimate for the number of
    individuals who would qualify for the presumption of service-
    related connection, given how many individuals were exposed,
    and so on?
        Dr. Rauch. I have got to take that for the record. I will
    get you as much detail as I can, but I cannot get that to you
    off the top of my head, Senator.
        [The information referred to follows:].

        Mr. Rauch. Thus far, VA has established three presumptions
    for asthma, rhinitis, and sinusitis related to fine particulate
    matter, along with nine rare respiratory cancers. At present it
    is unknown how many individuals (veterans) would qualify for
    one of these presumptions. Additional analysis in coordination
    with the VA is required to provide an answer to the question.

        Senator Hawley. That is fine. We will take it for the
    record and I will look forward to your answer.
        What was the practice of burn pits in other theaters during
    this period of time, from 2001 forward? Do you know, Dr. Rauch,
    aside, that is, Southwest Asia?
        Dr. Rauch. What other burn pits in other combatant
    commands?
        Senator Hawley. Mm-hmm.
        Dr. Rauch. I will take it for the record. Most of them
    should have been in the CENTCOM AOR [area of responsibility],
    though.
        [The information referred to follows:].

        Mr. Rauch. Since 2001, burn pits were predominately used in
    Southwest Asia, Afghanistan, and Africa (specifically Egypt,
    Chad, and Djibouti). DOEHRS includes an environmental report
    indicating a burn pit operated by Philippine forces in the
    vicinity of where United States Force were stationed during
    Operation Enduring Freedom.

        Senator Hawley. Okay. So if they are in the CENTCOM AOR
    then they are in this same region that we have been talking
    about, roughly.
        Tell me about DOD's collection of this data. I mean, we are
    dealing with servicemembers' exposure to toxins, burn pit
    toxins, other airbornes. It seems like we have very limited
    data for a lot of this. Why is that? Why is it the DOD has not
    collected this kind of data for so long? Can you give me any
    insight?
        Dr. Rauch. Well, I think we have always improved on the
    extent of the data and the technologies that we collect the
    data with, and we continue to improve. I mean, we collect a lot
    of environmental health assessment data, you know, the number
    of compounds and the number of airborne compounds, particulate
    matter, compounds that are in the motor pool over there, the
    compounds in the soil that get aerosolized as a result of
    operations. A lot of that is collected, and it goes into a
    database that we call DOEHRS, and DOEHRS is a large database
    that can then feed into ILER, which is what I was talking
    about, which is Individual Longitudinal Exposure Record, that
    pinpoints the location of the servicemember with all of that
    environmental data. Therefore, the health care provider can
    take a look and get kind of a summary of where the
    servicemember was, what the environmental hazards were in that
    area, and can best form a treatment regime for that
    servicemember.
        Senator Hawley. What about data available for assessing the
    linkages between exposure that we have been talking about, to
    airborne toxins, including particularly from burn pits, and
    certain kinds of illnesses? What has DOD been doing to improve
    data collection on that score, and data analysis?
        Dr. Rauch. Well, so it is a part of the data that we
    already collect, by preventive medicine units, and store in our
    databases. But linking those exposures to illnesses has been
    somewhat challenging. A couple of years ago, the National
    Academy of Sciences said that there is consistent data from
    exposures in Southwest Asia to our deployed force and illnesses
    such as persistent cough, asthma, and a few other respiratory
    disorders.
        More data is needed, and more specific data linking
    individuals to certain airborne hazards and their health
    outcomes is needed to be able to expand that list.
        Senator Hawley. I will circle back to you on the questions
    for the record. I will probably have a few more as well. Thank
    you, Mr. Chairman.
        Senator Tillis. Just a couple of follow-ups. Senator
    Gillibrand went to vote. She is probably waiting on the second
    vote to be called. I am kind of curious about when ILER will be
    fully interoperable with DOD electronic health record and the
    VA's electronic health record. What is the timeline?
        Dr. Rauch. Yeah, the timeline for full capability is 2023,
    but it is capable now but a little bit less limited.
        Senator Tillis. With the DOD electronic health record,
    because I guess the VA electronic health record is in a
    multiyear implementation, so that would probably have to track
    along with their ultimate build-out?
        Dr. Rauch. That is my understanding.
        Senator Tillis. Okay. Tell me a little bit about DOD-funded
    research on taking the information that we have about
    potentially toxic exposures and making certain presumptions
    about how that exposure could have caused a bad outcome for a
    servicemember, so-called presumptions.
        Dr. Rauch. Sure. So with regard to human studies, most of
    the human studies, human research that we sponsor, and continue
    to sponsor, really compares a group of deployers to a control
    group of non-deployers, to take a look at location,
    environmental health assessments, what were the threats over
    there, and then look at the differences in terms of the
    incidence of health outcomes between the deployed force in that
    area and the control or non-deployers.
        In addition to that, we also have experiments. We have
    animal experiments at the Air Force, at Wright Patt, up at the
    711th, which are looking at exposure to experimental animals of
    different airborne hazards, to include compounds that you would
    see in burn pits and also airborne sand and dust that you would
    see in that deployed environment, and looking at the health
    effects, health outcomes in experimental animals.
        Those are just a few. If my colleagues want to add
    anything, please do.
        Senator Tillis. Captain?
        Captain Feldman. Thank you, Senator. I am aware of a lot of
    work by the Navy Medical Research Command and the Naval Health
    Research Center, which is based in San Diego. They have got, in
    addition to collaborating with the VA on these studies they
    have got a Millennium Cohort, which is a powerful source of an
    extremely large population that is allowing them to explore all
    of these questions. I will defer to my colleagues before
    getting into specifics. Thank you.
        Colonel Newell. We already--thank you, Senator--we already
    know that there are a lot of medical symptoms and diseases that
    are associated with open burn pits and other airborne toxins,
    but it is difficult to find a direct link to those at this
    time. But there are many studies that are underway that are
    looking into that, and hopefully in the future we will be able
    to link that.
        I think the important thing with the ILER is the ILER
    captures the data, it links it to the individual, and it also
    capture data from when the individual returns from deployment,
    and asks them specifically if they have any symptoms or have
    any concerns with airborne hazards or chemicals. If they answer
    that to the affirmative there is always a provider that is
    going to talk to them one-on-one and address that with them.
        They also have a post-deployment health assessment that
    occurs 90 to 180 days after they get back, and it is the same
    questions. They ask them, do you have any symptoms or any
    concerns you have with airborne hazards and chemicals, and once
    again, if those are answered in the affirmative then the
    provider gets with them and they talk to them.
        Again, during the preventative health assessment that
    specifically goes into those questions again, and this is
    something that every member of the Department of Air Force gets
    annually. They ask the same questions and they also go into the
    Open Burn Pit Registry. They courage all members to register
    for that if they have been in a deployed area with an open burn
    pit. Even if they do not have any symptoms or any concerns they
    are encouraged to go ahead and register for that, and once
    again, a provider will reach back and talk with them and go
    over any questions or concerns that they might have.
        Senator Tillis. Dr. Mirza?
        Dr. Mirza. Thank you, Senator. In our organization, at the
    Army Public Health Center, we have engaged in several
    epidemiological studies, and in those studies we essentially
    use deployment history as a proxy for exposures. Of course,
    that can include exposures to burn pits but also to the poor
    air quality conditions within the area of operations. We also
    take that information and we look at the health status of those
    individuals before they deployed and after they deployed, to
    make determinations about whether or not associations existed
    for particular respiratory disorders of interest.
        What we have found is that these epidemiological studies
    are not always very conclusive, and a lot of that has to do
    with limitations of the study, because we do not necessarily
    have individualized exposure information tied to individuals
    and their health outcomes. That is significant limitation.
        But what we do have the strongest evidence to suggest is
    that respiratory symptoms are present in many deployers into
    the CENTCOM area of operations, as a function of the air
    quality issues that are there. So their symptoms are like
    shortness of breath, cough, phlegm production, decrements in
    their ability to successfully pass their physical performance
    tests, and things of that nature. So we have that information.
        Other studies have been conducted looking at deployers
    themselves, and looking at them prospectively, how they have
    been managed clinically and what conditions they have suffered
    as a consequence of their deployment, particularly looking at
    respiratory conditions. A small study that was conducted looked
    at those particular deployers and determined about half of
    those individuals did not have necessarily diagnosable
    respiratory conditions per se, despite the fact that they had
    symptoms that they complained about, but the other half seemed
    to have symptoms consistent with asthma and hyperreactivity of
    the airway and such.
        So the bottom line is there has been a lot of studying
    occurring about deployers and their respiratory health and the
    potential associations that exist with their deployment, but
    based on limitations on exposure data it is very difficult to
    make strong conclusions about the source of exposure and those
    health outcomes.
        Senator Tillis. Thank you.
        Senator Gillibrand. [Presiding.] The Department's prepared
    statement for this hearing states that peer-reviewed published
    research documents that military personnel deployed to Iraq and
    Afghanistan appeared to experience elevated rates of acute
    upper respiratory symptoms during deployment and may be at
    greater risk for post-deployment respiratory symptoms and
    respiratory illnesses. Dr. Mirza, Dr. Newell, and Dr. Feldman,
    please describe what your service does to ensure that
    servicemembers concerned about potential health effects of
    exposure to airborne hazards receive appropriate health care,
    and is this care documented in their health records, and will
    this information be available to the VA when the servicemember
    leaves service and receives care through the VA?
        Colonel Newell. Senator, thank you for that question. I
    will walk you through essentially a process that we undertake.
    First, when individuals are in a deployed environment and they
    are suffering with any respiratory illness--let me take a step
    back--any illness or any symptoms, we have medical personnel,
    we have medical centers that are deployed, or MTFs that are
    deployed there with the personnel to respond to those concerns.
    Those get documented and are available throughout the course of
    that servicemember's service treatment record, to be looked at
    prospectively.
        When these individuals redeploy, they come back home, they
    undergo post-deployment health assessment, and there are
    essentially two parts to that. One is a screening
    questionnaire, in which these individuals self-report concerns
    about their health, their respiratory symptoms, and other
    organ-associated symptomatology of interest, and we also ask
    about their concerns about environmental exposures, a whole
    scope of exposures, not necessarily airborne but chemical and
    so on.
        Once they complete that self-assessment these individuals
    then are evaluated by a provider and they are given that option
    for a focused medical evaluation, based on any concerns that
    they have advocated for on that self-assessment.
        Routinely, we conduct periodic health assessments. This has
    a couple of purposes. The first is to assure that individuals
    are assessed annually, that they maintain the medical standards
    and a certain level of physical fitness to be able to do their
    job. The second is to also identify any health outcomes or
    health issues of personal concern that need to be evaluated and
    managed further, either by a primary care provider or a
    specialist that is going to be referred in for their care. But
    also as a function of that periodic health assessment, it is an
    additional opportunity to ascertain any personal concerns that
    individual may have about exposures within the environment in
    which they operate, soldier, or deployed to.
        You know, essentially there are three main points of care,
    in my view, in which these individuals are evaluated, is
    downrange if they are experiencing symptoms, it is when they
    return home, as a function of the post-deployment health
    assessment process, and it is also at least annually, on a
    periodic basis, when they are going through a period health
    assessment.
        Captain Feldman. [Off microphone]--but that information
    comes back as the deployers come home, with both their pre- and
    post-deployment surveys and periodic health assessments and
    there are specific questions that are verbally reviewed on this
    questionnaire to ensure that dialogue happens with the
    clinician. If you know you were exposed to a location it is in
    the registry. If those clinicians do not have the expertise in
    their primary care [inaudible] environmental health
    specialists, industrial health hygiene specialists who consult
    with those clinicians are available. In addition to that
    [inaudible] are another layer of consultative expertise for
    those specific questions that, when a patient comes to a clinic
    visit and has that concern, those are resources that
    [inaudible] that individual patient.
        Senator Gillibrand. Thank you, and Colonel Newell.
        Colonel Newell. Thank you, Senator. I agree with my
    colleagues. I will just add on that the ILER does report those
    specific questions that we ask about airborne hazards, and so
    it pulls that. So not only are you looking at the occupational
    environmental health risk assessments of when the member was
    downrange, multiple times, and you are reviewing those
    exposures, it is taking those little bits of questions that the
    member has answered regarding airborne hazards from the post-
    deployment health assessment and the periodic health
    assessment.
        We also have a new separation health assessment that has
    been under development for the last year. It should be released
    this fall. It also goes into detail about airborne hazards and
    chemicals of that nature, and that will also be documented.
        Senator Gillibrand. Thank you. Any further questions?
        Senator Tillis. Just one. I just want to echo Senator
    Gillibrand, or re-emphasize Senator Gillibrand on current
    active burn pits. Some of the process that led to these being
    operationally necessary I think would be very helpful for the
    committee.
        Thank you for being here.
        Senator Gillibrand. Thank you very much for your testimony.
    I welcome the second panel to come up. Thank you very much.
        [Pause.]
        Senator Gillibrand. I now welcome the second panel, Dr.
    Anthony M. Szema, Director, International Center of Excellence
    in Deployment Health and Medical Geosciences, Northwell Health
    Foundation; Mr. Tom Porter, Executive Vice President for
    Government Affairs, Iraq and Afghanistan Veterans of America;
    Mrs. Rosie Torres, Executive Director, Burn Pits 360; and Mr.
    Steven Patterson, Former Environmental Science Officer,
    Combined Joint Task Force, 101 Headquarters, Afghanistan, from
    2008 to 2009.
        Thank you so much, and each of you can give you opening
    statements. Dr. Szema, you can go first.

     STATEMENT OF ANTHONY SZEMA, MEDICARE, DIRECTOR, INTERNATIONAL
      CENTER OF EXCELLENCE IN DEPLOYMENT HEALTH AND GEOSCIENCES,
                      NORTHWELL HEALTH FOUNDATION

        Dr. Szema. Thank you, Chair Gillibrand, Ranking Member
    Tillis, members of the Personnel Subcommittee of the Senate
    Armed Services Committee for the opportunity to participate in
    today's hearing.
        Between 1998 and 2015, I was Allergy Section Chief,
    Veterans Affairs Medical Center, Northport, New York, and my
    expertise on this issue stems from the following. My team first
    reported new-onset asthma among soldiers to Iraq and
    Afghanistan with exposure to burn pits in 2007. We described
    deployment-related rhinitis in 2008; coined the term Iraq
    Afghanistan War Lung Injury, IAW-LI, in 2011, based on lung
    function testing data; developed animal models with burn pit-
    based dust in 2014; tested candidate drugs in these mice in
    2018; and co-invented new candidate medicines this year.
        I am testifying because as a physician I care about the
    health and well-being of my patients who are our soldiers. The
    team in my office sees numerous patients post-deployment with a
    variety of symptoms, which include shortness of breath, cough,
    and chest pain which is accentuated with exercise. I have
    diagnosed post-burn pit-exposed soldiers with asthma, non-
    smoking-related accelerated COPD, constrictive bronchiolitis,
    carbonaceous burned lung, titanium lung, lung fibrosis, bladder
    cancer, and pulmonary ossification, or bone in the lung. In one
    severe case, for example, one of my patients with lung fibrosis
    underwent two lung transplants. He just died in December.
        As an expert in the field I have concluded that these lung
    disorders are directly related to exposure to airborne hazards,
    including burn pits, dust storms, improvised explosive devices,
    and blast-over pressure from mortar-fired rounds.
        As doctors treating these patients, one challenge we face
    is that there is inadequate screening of these military
    personnel, who are predisposed to lung injury. Lack of
    screening means they never get diagnosed, they get diagnosed
    late, or they get diagnosed when it is irreversible.
        The dilemma with military personnel who typically do not
    have asthma, who pass basic training outdoors, whose masks must
    be fit for deployment at Fort Hood, is that they do not have
    pre-deployment pulmonary assessments, unlike the Fire
    Department of New York, which was able to determine lung
    function reduction after 9/11. An otherwise healthy soldier who
    has 100 predicted pre-deployment who goes down to 80 percent
    has a significant decrease.
        Another challenge we face is that doctors treating these
    servicemembers is a lack of information we receive. Without
    knowing what they are exposed to or potentially exposed to it
    is hard to prove what caused the ailment. For example, last
    month one patient of mine was denied a consult to the East
    Orange War-Related Illness and Injury Center because the local
    VA doctor said he did not believe that that military
    firefighter's sleep apnea, sinusitis, asthma, and rhinitis were
    related to deployment, even though he had a positive sleep
    study during Active service.
        Even if it is known that there are toxic materials at
    certain sites, often soldiers visit our academic center without
    complete documentation of locations of their deployment, so
    their direct exposure cannot be proven. This is especially the
    case if they were at forward operating bases like Camp Stryker,
    whose exact location is not on the map.
        I have several recommendations to address these challenges
    and ensure we are taking care of our servicemembers. One,
    conduct breathing tests before and after deployment. Two,
    revamp the DOD method of documenting locations where military
    personnel serve. Three, utilize newer technology such as
    wearable particle monitors.
        First, by conducting tests before and after deployment we
    can determine if there is a reduction in lung function much
    earlier than if we wait. In addition, these data will better
    enable screening protocols to identify who are soldiers at
    risk.
        Second, by revamping the DOD method of documenting
    locations where military personnel service we will have a
    better understanding of what they are exposed to, a better
    understanding of the illness and how to treat it.
        Third, by utilizing newer technology such as wearable
    particle monitors with GPS, we will be able to assess a given
    soldier's exposure and location. By utilizing this for a
    contingent of military personnel, the DOD will be better able
    to move troops to regions of safety, away from airborne
    hazards. If exposure does happen, it would also provide
    critical information for treatment.
        We know that screening and monitoring programs have been
    extremely effective for those victims of the World Trade Center
    disaster post-9/11, and this is an analogous exposure with JP-8
    and burn pits. It is our sacred duty to care for the women and
    men who sacrifice their lives for our freedom.
        [The prepared statement of Dr. Anthony Szema follows:]

                    Prepared Statement by Dr. Anthony Szema
        I thank Chair Gillibrand, Ranking Member Tillis and the members of
    the Personnel Subcommittee of the Senate Armed Services Committee for
    the opportunity to participate in today's hearing.
        My name is Dr. Anthony Szema, Clinical Associate Professor of
    Medicine (Divisions of Pulmonary/Critical Care and Allergy/Immunology),
    and Clinical Associate Professor of Occupational Medicine, Epidemiology
    and Prevention at the Donald and Barbara Zucker School of Medicine at
    Hofstra/Northwell where I am Director, International Center of
    Excellence in Deployment Health and Medical Geosciences. At Stony Brook
    University, as adjunct faculty, I am Research Assistant Professor,
    Department of Technology and Society, College of Engineering and
    Applied Sciences.
        Between 1998 and 2015 I was Allergy Section Chief, Veterans Affairs
    Medical Center, Northport, NY. My expertise on this issue stems from
    the following: my team first reported new onset asthma from Iraq and
    Afghanistan Deployments among burn pit exposed soldiers in 2007,
    described deployment related rhinitis in 2008, coined the term Iraq
    Afghanistan War Lung Injury (IAW-LI) in 2011, based on lung function
    testing data, developed animal models with burn pit base dust in 2014,
    tested candidate drugs in mice in 2018, and co-invented new candidate
    medicines this year.
        I agreed to testify because, as a physician, I care about the
    health and well being of my patients who are our soldiers.
        The team in my office sees numerous patients post deployment with a
    variety of symptoms which include shortness of breath, cough, and chest
    tightness that is accentuated with exercise. I have diagnosed post burn
    pit exposed soldiers with asthma, chronic obstructive pulmonary
    disease, lung fibrosis, carbonaceous lung, constrictive bronchiolitis,
    titanium lung, bladder cancer as well as pulmonary ossification or bone
    in the lung. These are previously healthy, non-smoking, fit for
    deployment soldiers who have newly acquired lung disorders after their
    tours of duty. In one severe case, for example, my patient with lung
    fibrosis required two lung transplants and died last December.
        As an expert in the field, I have concluded that these lung
    disorders are directly related to exposure to airborne hazards. These
    ailments resulted from inhalational exposures to: burn pits, dust
    storms, improvised explosive devices, as well as blast overpressure
    from mortar fired rounds.
        My conclusions are based on our analyses of lung biopsies
    containing particles from these soldiers' lungs. These particles were
    subsequently processed at two different sites with two different types
    of technical machinery for analysis.
        1)  Center for Extraplanetary Exploration, Rahman Spectroscopy,
    Department of Geosciences, Stony Brook University
        2)  Brookhaven National Laboratory, National Synchrotron Light
    Source II Beam ID-5.
        Analyses from both laboratories conclude that the particles from
    soldiers' lung biopsies sustained exposure to high combustion
    temperatures consistent with burning. Chemicals identified included
    polycyclic aromatic hydrocarbons (PAH), and metals such as titanium and
    iron. These metals were bound together. These metals were also
    oxidized--which is evidence they were burned.
        As doctors treating these patients, one challenge we face is that
    there is inadequate screening for those military personnel who are
    predisposed to lung injury. Lack of screening is a challenge for
    diagnosing and treating patients for several reasons. First, if
    individuals are not screened, then they may never get correctly
    diagnosed. In addition, if they are not screened, and therefore not
    treated properly, by the time they present to the doctor, the disease
    is already severe and therefore, more difficult to treat.
        The dilemma with military personnel, who typically do not have
    asthma, since it is an exclusion diagnosis for enlistment, who must
    pass basic training outdoors, and who must be fit for deployment at
    Fort Hood prior to deployment, is that they usually do not have pre-
    deployment pulmonary assessments.
        Unlike the Fire Department of New York which requires annual
    spirometry breathing tests and was able to assess respiratory changes
    after 9/11, soldiers most often do not have a baseline for comparison
    other than their 2-mile run time. An otherwise healthy young soldier
    may be 100 percent or more predicted on spirometry and oxygen
    consumption from a cardiopulmonary exercise test predeployment. So,
    reduction to 80 percent predicted post-deployment is a significant
    decrease even though 80 percent is the cutoff for normal.
        Another challenge we face as the doctors treating these
    servicemembers is the lack of information we receive. Without knowing
    what they were exposed, or potentially exposed, to, it is hard to prove
    what caused the ailment. For example, in one recent case last month, a
    military firefighter, a patient of mine, was unable to get a referral
    to the East Orange WRIIC. The primary care doctor in the local VA did
    not believe that the military firefighter's sleep apnea, sinusitis,
    asthma, and rhinitis were related to deployment, even though he had a
    positive sleep study during his Active Duty.
        Even if it is known that there were toxic materials at a certain
    site, too often, soldiers visit our academic center without complete
    documentation of locations of their deployment so their direct exposure
    cannot be proven. This is especially the case if they were at forward
    operating bases or places like Camp Stryker whose exact location is not
    on the map.
        I have several recommendations to address these challenges and
    ensure we are taking care of our servicemembers:
        1.  Conduct breathing tests before and after deployment.
        2.  Revamp the DOD method of documenting locations where military
    personnel served.
        3.  Utilize newer technology such as wearable particle monitors.
        First, by conducting breathing tests before and after deployment
    for our troops, we can determine if there is a reduction in lung
    function much earlier than if we wait until disease is severe. In
    addition, these data will enable better screening protocols to identify
    ahead of time those soldiers at increased risk.
        Second, by revamping the DOD method of documenting locations where
    military personnel served, we will have a better understanding of what
    these soldiers were exposed to, and therefore, a better understanding
    of the cause of the illness as well as how to treat it. For example, it
    is important for those treating these soldiers to know which regions of
    the country an individual soldier was in; what types of munitions they
    were exposed to; what the chemical makeup of these munitions are; how
    trash was disposed of in that region, including burn pits; what the
    weather patterns were, i.e., dust storms in that region; whether
    depleted uranium was used in that region, for example, in armor
    piercing rounds PGU-14 and tank shells, as well as ship ballast; and
    whether that soldier used personal protective equipment and what types
    of PPE they used.
        Third, by utilizing newer technology such as wearable particle
    monitors with GPS, we will be able to assess a given soldier's exposure
    and location. By utilizing this for a contingent of military personnel,
    the DOD will be better able to move troops to regions of safety away
    from airborne hazards. If exposure does happen, it will also provide
    critical information for treatment.
        Our research team applied for a Congressionally Directed Medical
    Research Program (CDMRP) grant, got a great score, but was told there
    are insufficient DOD funds for the grant. We proposed to build on a
    beeper sized belt mounted device which measures particle counts, sarin
    and other toxic gas exposure, and gunshot sounds. Wearable tech is a
    mature enough field such that the industry should be able to respond to
    the needs of the DOD.
        These recommendations will ease the burden on both soldiers and
    physicians when those soldiers seek medical care. My recommendations do
    not prevent exposure but they do allow us to provide data so we can
    intercede early with diagnosis and initiation of treatment; by doing
    so, then we may see the overall cost of medical care go down and, more
    importantly, more lives being saved.
        We know that screening and monitoring programs have been extremely
    effective in preserving the health of those exposed to the World Trade
    Center disaster which is an analogous plume with JP-8 in burn pits. It
    is our sacred duty as Americans to protect the health of all the brave
    women and men who sacrifice their lives for our freedom.

        Senator Gillibrand. Thank you, Dr. Szema. Mr. Porter?

     STATEMENT OF TOM PORTER, EXECUTIVE VICE PRESIDENT, GOVERNMENT
           AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA

        Mr. Porter. Thank you for having us here, Senator
    Gillibrand and Senator Tillis. I appreciate everything you are
    doing on this issue.
        I would like to introduce my daughter, 13-year-old daughter
    here, Elizabeth Porter. She is playing hooky from school today,
    so hopefully she gets something out of this.
        On a more serious note, I want to take this opportunity to
    say that my thoughts and prayers are with Dr. Kate Hendricks
    Thomas, advocate on this issue. She is going through a very
    particularly tough time with regard to her burn pit-related
    illness.
        So I am here not only as an IAVA advocate but as one who
    was exposed to a variety of airborne toxins from burn pits and
    other sources while I was deployed. Before I went downrange I
    had completely healthy lungs. Shortly after I arrived in Kabul,
    in 2010, where the air was particularly bad, my lungs had a
    severe reaction and became infected. It was controlled with
    medication, but I was diagnosed with asthma as soon as I got
    back home a year later. But I have to still take the
    medications to keep breathing.
        Exposure to burn pits used by military to destroy medical
    and human waste, chemicals, petroleum, other trash, it has been
    widespread. We have talked about this a lot here already. It is
    not just burn pits. You could learn a lot from those who have
    served in Kabul, for example. It is an enormous city without a
    modern sewage system. Many who served there are suffering the
    impacts from breathing airborne feces for extended periods of
    time, and there are also burn pits there, at many of the bases
    in that city alone.
        At every location where U.S. and coalition military were
    stationed there were many port-o-johns. It was somebody's job
    to pull out that metal bin from the port-o-john every day,
    douse it with jet fuel, and burn it down to a brick, and that
    is how you get rid of the port-o-john waste. It is somebody's
    job to do that, and I do not need to describe it, but it is a
    particularly nasty job.
        The military and veteran community know all too well how
    detrimental these toxic exposures can be. I will refer to our
    new Member Survey that is just out this month, for 2022. We
    survey our members. Eighty-two percent of our members say they
    experienced toxic exposures during their service. Of those, 90
    percent say they have or may have symptoms as a result. Of the
    82 percent who were exposed, just 53 percent said they had
    their exposures documented in their DOD Periodic Health
    Assessments, so just 53 percent.
        This data shows the enormous percentage of those who are
    suffering service-related exposures, especially considering the
    estimate the VA has of as many as 3.5 million that could have
    been exposed.
        When IAVA saw similar data in a previous Member Survey we
    conceived of and worked hard to pass the Burn Pits
    Accountability Act that was passed in 2020, within the NDAA.
    The law required servicemembers to be evaluated for exposures
    during routine health exams. Servicemembers were required to be
    enrolled in the Burn Pit Registry, unless they opt out, if they
    suffered exposures or if they were stationed near a burn pit.
        Seventy-six percent of IAVA members were aware of the
    registry but only 59 percent are registered in it. DOD must
    maximize its efforts to ensure all who are eligible get
    enrolled, not just informed of it, as the law requires. It
    requires them to be enrolled in the registry, and that is the
    intent behind the law in the first place, and we know this
    because we worked to develop the bill and passed it.
        IAVA would like DOD to confirm if the letter and intent of
    the Burn Pits Accountability Act is being executed, including
    whether servicemembers are actually being required to enroll in
    the registry, or simply being advised of its existence.
        We heard a lot of talk already today about the ILER
    database. That is really critical, we believe. That would help
    inform servicemembers, veterans, and the medical providers of
    the exposures by your location and the time you were deployed.
    I think we heard that it was supposed to be operational in
    2023, September of 2023 is what I understand. We supported
    legislation that required that veterans have access to their
    ILER database online. So hopefully that stays on track for
    implementation by September 2023, and we would like your
    assistance to try to ensure that that happens.
        There has also been some talk in the news about the Red
    Hill fuel storage facility in Hawaii. This is another toxic
    exposure, so it is not all burn pits. We want to make sure that
    the DOD documents those exposures to not only the
    servicemembers that are serving there now but have been
    dislocated, but then also those that have been impacted over
    the life of the fuel storage facility. That is important. How
    are they going to be doing that?
        Serving in the military is tough on one's body. I do not
    think that is surprising to anybody here. Although not specific
    to toxic exposures, a significant indicator of IAVA members'
    health, when asked in our Member Survey how they would rate
    their overall health before joining the military, 91 percent
    rated their health as excellent or good. When asked how they
    rated their heath after they left the military, just 33 percent
    said it was excellent or good.
        The military service can be hard and cause adverse health
    impacts. It is not a surprise. But those who may want to
    encourage their sons and daughters to enter the military except
    that if one does suffer injuries our government will care for
    them when they come home. Failure to care for the many who
    suffered toxic exposures many diminish the value of military
    service in the public's eyes, and by refusing to satisfy our
    obligations to them we communicate to current and future
    servicemembers that we do not actually have their backs.
        So on behalf of the 3.5 million servicemembers and veterans
    who may have suffered toxic exposures I implore you to ensure
    that DOD follows recently enacted laws meant to increase
    transparency and information-sharing with those who have
    suffered exposures and to spare no effort in not only
    anticipating new hazards our personnel may encounter but advise
    them of their known risks ahead of time so they and medical
    professionals are better equipped to address emergent health
    impacts.
        Again, thank you very much for having me today, and I am
    happy to answer any questions.
        [The prepared statement of Mr. Tom Porter follows:]

                      Prepared Statement by Mr. Tom Porter
        Chair Gillibrand, Ranking Member Tillis, and Members of the
    Subcommittee, thank you for having me here today to talk about the most
    widespread health impact suffered by the post-9/11 generation.
        On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
    our more than 425,000 members, thank you for the opportunity to share
    our views, data, and experiences on the matter of burn pits and other
    toxic exposures, what many are saying is the ``Agent Orange'' of our
    generation.
        I am here not only as an IAVA advocate for post-9/11 veterans, but
    as one who was exposed to a variety of airborne toxins from burn pits
    and other sources at many locations when I was deployed to during the
    Global War on Terror in Afghanistan and the Middle East between 2007
    and 2014.
        Before I went downrange during that period, I had zero breathing
    problems and completely healthy lungs. In the first couple of weeks
    after I arrived in Kabul, where the air is particularly bad, my lungs
    had a severe reaction and became infected. It was controlled with
    medication over the next year. However, after re-deploying home, I
    stopped the medications and symptoms came back and I was diagnosed with
    asthma as a result of my deployment.
        Exposure to burn pits used by the military to destroy medical and
    human waste, chemicals, paint, metal/aluminum cans, unexploded
    ordnance, petroleum and lubricant products, plastics, rubber, wood, and
    other waste has been widespread.
        It is not just burn pits. Search for the ``Poo Pond Song'' on
    YouTube and you will hear one soldier's humorous take on the enormous
    lake of human waste that tens of thousands of international
    servicemembers lived, worked, and ate around at our formerly large base
    in Kandahar.
        You could also learn from the many who have served in Kabul--an
    enormous city without a modern sewer system. Many of our veterans who
    served there are suffering the impacts from breathing airborne feces
    for extended periods of time. There have been burn pits at the numerous
    previous bases there as well.
        At every location where U.S. and coalition military were stationed,
    there were many many port-o-johns. The waste from all those toilets had
    to be disposed of on a regular basis. It was someone's job to routinely
    pull out the metal bin of waste, douse it with jet fuel, and burn it
    down. Of course, we cannot forget the omnipresent diesel generators to
    power our operations wherever we have been deployed that emitted black
    smoke around the clock. These presented another constant airborne
    assault on the health of our servicemembers.
        The military and veterans community knows all too well how
    detrimental all these toxic exposures and environmental hazards can be,
    and the associated health impacts. As an example, IAVA's 2022 Member
    Survey of our mostly-post-9/11 veterans and Active Duty personnel,
    being released this month, show the following:
        Eighty-two percent of our members surveyed across all services,
    with slightly more in the Army and Marine Corps, say they experienced
    toxic exposures during their service. Of those, 90 percent say they
    have or may have symptoms resulting from their exposures. Also of the
    82 percent who were exposed, just 53 percent said they had their
    exposures documented in their DOD Periodic Health Assessment.
        This aforementioned data shows the enormous percentage of those who
    are suffering service-related exposures, especially when referenced in
    the context of the VA estimate of 3.5 million it says may have
    experienced exposures.
        When IAVA saw similar data in a previous Member Survey, we
    conceived of and worked hard to pass the Burn Pits Accountability Act
    (BPAA) sponsored by Sens. Amy Klobuchar and Dan Sullivan, which was
    signed into law as part of the 2020 NDAA. The BPAA language in Section
    704 required servicemembers to be evaluated for exposure to toxic
    airborne chemicals during routine health exams and directs the DOD to
    record and share whether servicemembers were based or stationed near an
    open burn pit, including any information recorded as part of the
    Airborne Hazards and Open Burn Pit Registry, the Periodic Health
    Assessment (PHAs), Separation History and Physical Examination (SHPEs),
    and Post-Deployment Health Assessment (PDHAs). Members were also
    required to be enrolled in the Burn Pit Registry, unless they choose to
    opt out, if they were exposed to toxic airborne chemicals or stationed
    near an open burn pit.
        Seventy-six percent of IAVA members are aware of the Burn Pit
    Registry, but only 59 percent are registered, according to our Member
    Survey. DOD must maximize its efforts to ensure all who are eligible
    and are willing to enroll, get enrolled.
        IAVA would like this Committee to confirm with DOD if the letter
    and intent of the BPAA is being executed, including whether
    servicemembers are actually being required to enroll in the Registry
    (unless they opt out) or are simply being advised of the existence of
    the Registry.
        An important next step forward for servicemembers and veterans who
    have been exposed is the joint VA-DOD development of the Individual
    Longitudinal Exposure Record (ILER) database. The ILER will record
    potential and known exposures throughout a servicemember's time in
    uniform in order to provide DOD and VA clinicians, claims adjudicators,
    and benefits advisors actionable data needed to improve the care
    provided to servicemembers and veterans. Data from those receiving
    treatment for illnesses through DOD and VA should be fed back into the
    ILER, ultimately increasing VA's ability to develop a presumptive
    illness database of evolving illnesses.
        If this system is done right, it will provide servicemembers and
    veterans significant transparency into their exposures that many have
    been saying has been lacking by DOD and VA. However, while this system
    has tremendous potential in allowing servicemembers, veterans, and
    their medical providers access to critical exposure information, ILER
    is not available currently to servicemembers and veterans.
        IAVA supported language included in the Mac Thornberry NDAA for
    Fiscal Year 2021 that required the VA Secretary to ``provide to a
    veteran read-only access to the documents of the veteran contained in
    the [ILER] in a printable format through a portal accessible through [a
    VA website].'' The VA-DOD Joint Executive Committee has said in its
    2019 Annual Report that the ILER achieved initial operating
    capabilities on September 30, 2019 and that it will achieve full
    operating capabilities by September 2023.
        IAVA asks that this Committee confirm with DOD that the ILER is
    indeed operationally capable and accessible for servicemembers and
    veterans on schedule for use in 2023.
        As we recently learned, Defense Secretary Austin announced on March
    7 that he decided to defuel and permanently close the Red Hill bulk
    fuel storage facility in Hawaii. The Secretary committed to
    environmental remediation of the location, and he also addressed the
    associated workforce and their families, recognizing that their health,
    lives and livelihoods have been impacted and that ``We owe you the very
    best health care we can provide, answers to your many questions, and
    clean, safe drinking water . . . '' and a ``return to normal.'' IAVA
    would like to know specifically how they are tracking the effects on
    the people who have suffered exposures. Not just the ones who live
    there now, or that have been evacuated, but those who have been
    affected over the life of the impacts by the facility. Will these
    exposures be included in the servicemembers' health records that will
    be transferred to the VA when they leave service? IAVA would have
    similar concerns with how DOD is tracking the health effects in
    military personnel and their families who were exposed at any DOD
    facility or military base.
        Serving in the military is an honorable calling, but it is tough on
    one's body.
        Although not specific to toxic exposures, a significant indicator
    of IAVA members' health, when asked in our Member Survey how they would
    rate their overall health before joining the military, 91 percent rated
    their health excellent (65 percent) or good (26 percent). When asked
    how they rated their health after they left the military, just 33
    percent said it was excellent (6 percent) or good (27 percent).
        This is probably not a surprise to many, that military service can
    be hard and cause adverse health impacts, and those joining the
    military likely understand that too. But our servicemembers, recruits,
    and parents who may want to encourage their sons and daughters to enter
    service expect that if one does suffer injuries, our government will
    properly care for them when they come home.
        Failure to care for the many thousands who suffered military toxic
    exposures may diminish the value of military service in the public's
    eyes. By refusing to satisfy our obligations to them we communicate to
    current and future servicemembers that we do not actually have their
    backs.
        So, on behalf of the 3.5 million servicemembers and veterans who
    were exposed to burn pits and other airborne hazards, I implore you to
    ensure that DOD follows recently enacted laws meant to increase
    transparency and information sharing with those who have suffered
    exposures, and to spare no effort in not only anticipating new hazards
    our personnel may encounter, but advise them of their known risks ahead
    of time so they and medical professionals are better equipped to
    address emergent health impacts.
        Again, thank you for allowing me to present testimony to this
    Committee on behalf of IAVA.
        Biography of Tom Porter
        Tom Porter joined IAVA in 2015 and now leads IAVA's Washington, DC
    government relations team in advocating for our Nation's veterans. He
    has led successful campaigns to protect military and veterans education
    benefits, combat suicide, address military toxic exposures like from
    burn pits, and fill gaps in care for women veterans. Also a media
    spokesman for IAVA, he has contributed to CNN, Fox News, NBC, ABC, PBS,
    NPR, BBC (and local affiliates), Wall Street Journal, Washington Post,
    POLITICO, and many others.
        Prior to joining IAVA, Porter was Vice President at the energy firm
    Morgan Meguire since 2004, representing energy utilities nationwide. He
    was successful in achieving goals on behalf of a nationwide client base
    through aggressive and bi-partisan advocacy before Congress and federal
    agencies. He also served more than eight years on the staff of three
    senior Members of Congress. Porter is a U.S. Navy Captain with Reserve
    and Active service since 1996, including deployments to Afghanistan and
    the Middle East.

        Senator Gillibrand. Thank you. Mrs. Torres?

            STATEMENT OF ROSIE TORRES, EXECUTIVE DIRECTOR,
                             BURN PITS 360

        Mrs. Torres. Thank you, Chairwoman Gillibrand, Ranking
    Member Tillis, and members of the subcommittee for today's
    hearing and for this opportunity to testify.
        It seems like yesterday when some Members of Congress
    believed that the health risks of toxic exposures and burn pits
    were based on anecdotal evidence. While we have data today that
    shows otherwise, I am here to tell you personally about the
    stories of the men and women who bravely defended our country,
    exposed to toxic chemicals that for many cost them their life.
        My story begins with my husband, Retired Captain, Le Roy
    Torres, who served as a Texas State Trooper for 14 years and as
    a soldier for 23 years before being medically retired. He
    deployed to Balad, Iraq, from 2007 to 2008, where he was
    exposed to the largest burn pit within the Operation Iraqi
    Freedom theater of operations, which was the size of
    approximately a football field. He lived and worked next to the
    toxic plume of black smoke that infiltrated where they lived,
    ate, and slept.
        He returned home from war to face a health care system that
    failed him, and an employer too afraid to understand an
    uncommon war injury, resulting in termination of his law
    enforcement career. As a result of these injustices, Le Roy
    attempted to end his life in 2016.
        Since returning from Iraq he has had over 400 medical
    visits, until he was finally diagnosed with autoimmune disease,
    toxic brain injury, and constrictive bronchiolitis following a
    lung biopsy at Vanderbilt University. The VA and DOD refused to
    recognize or diagnose these environmental injuries, often
    misdiagnosing them as psychosomatic or dismissing them as
    compensation-driven care-seeking. The more veterans we talk to,
    the more we heard about stories like Le Roy's. This is why, 12
    years ago, Le Roy and I co-founded Burn Pits 360, a nonprofit
    that advocates for veterans, servicemembers, and families of
    the fallen affected by toxic exposures.
        We created a health registry of about 10,000 participants
    to track their exposures, diseases, and deaths, working with
    doctors like Dr. Szema. We then joined in Washington and
    gathered with other families to pass the Airborne Hazards Open
    Burn Pit Registry Act of 2013.
        We have been too far too many funerals and counseled
    countless wives, husbands, and children left alone by our
    government's failure to treat our Nation's veterans. Burn Pits
    360 has persevered through the years, despite the indifference
    of the VA, DOD, and Congress. Instead of providing them with
    treatment, early cancer diagnostics, and benefits, our
    government spent the last years telling veterans there is no
    evidence that inhaling toxic black smoke causes respiratory
    illnesses and cancer that their stories are anecdotes and not
    data, and that treating them is too costly. I cannot help but
    wonder what is the cost of their lives and sacrifice?
        So now more than ever we need to pass legislation that
    addresses presumption. The time is well past due for the
    President, the Department of Defense, Veteran Affairs to
    acknowledge these injuries and disease as a direct result of
    armed conflict or caused by an instrumentality of war. We are
    asking for the Department of Defense and Veteran Affairs to
    honor these injuries with compassionate common sense. This is
    an invitation to begin the healing process for these families
    who have lost loved ones to illness or death following the
    environmental hardships of war.
        Yet Le Roy's story is not the only one. Sergeant Thomas
    Joseph Sullivan served with the United States Marines in Iraq.
    He suffered from intestinal ulcerations and bleeding,
    hypertension, respiratory disease, asthma, and liver disorder.
    Tom died in 2009 at 30 years old.
        Will Thompson served with the United States Army for 23
    years and was deployed twice to Iraq. His doctors treated his
    cough as allergies. He was later diagnosed with pneumonia,
    treated with antibiotics, and sent home. Eventually he was
    diagnosed with pulmonary fibrosis. After a lung biopsy he was
    informed that he had titanium, magnesium, iron, and silica in
    his lungs. Will underwent two transplants and passed away this
    December at 50 years old.
        Lieutenant Colonel Dan Brewer, CENTCOM Environmental
    Officer, deployed to Afghanistan and warned his supervisors
    about the health effects of the black fumes caused by burning
    of waste and plastic at night.
        Lastly, Isiah James served with the United States Army,
    deployed to Iraq 2006 to 2008, 2008 to 2009, in Afghanistan,
    2010 to 2011. Isiah says this. He is now suffering from lung
    disease and is on supplemental oxygen. He says, ``It is my hope
    you not only listen to the testimony but to hear it, to feel
    it, to understand it, and most importantly, to act on it.
    History is the ultimate judge, and we in this country have not
    always done best by those who send in our stead. I believe it
    was Churchill who said, 'Never has so much been owed to so few,
    by so many.' How will you be judged and how will America and
    the American people pay their debt?''
        [The prepared statement of Mrs. Rosie Torres follows:]

                    Prepared Statement by Mrs. Rosie Torres
        Thank you, Chair Gillibrand, Ranking Member Tillis and Members of
    the Subcommittee for today's hearing and for this opportunity to
    testify.
                                  introduction
        My husband Ret. Captain Le Roy Torres served as a State Trooper for
    14 years before being discharged from State Service as a solider for 23
    years before being medically retired. He deployed to Balad, Iraq from
    2007 to 2008 where he was exposed to the largest burn pit within the
    Operation Iraqi Freedom (OIF) theatre of operations. As a husband, a
    father, grandfather and a first responder, he has been deprived of his
    dignity, honor and health. He returned home from war to face a health
    care system that failed him and an employer too afraid to understand an
    uncommon war injury resulting in termination of his law enforcement
    Career. As a result of this injustice Le Roy's USERRA case will be
    heard before the United States Supreme Court next week on March 29,
    2022. This is just one example of the bureaucratic inertia our former
    and current military members are facing.
        Since returning from Iraq he has had over 400 medical visits. In
    November 2010 he was diagnosed with a debilitating lung disease
    constrictive bronchiolitis following a lung biopsy at Vanderbilt
    University. His doctors also diagnosed him with toxic brain injury due
    to exposure to toxins, likely resulting from exposure to burn pits
    exposures in Iraq. For years The VA and DOD have refused to recognize
    or diagnose these environmental injuries, often misdiagnosing them as
    psychosomatic or dismissing them as ``compensation driven care
    seeking.''
        For the past 12 years, Burn Pits 360, which Le Roy and I cofounded,
    has been at the forefront of this issue, advocating for the families
    and those battling life threatening illnesses. We established an
    independent health registry tracking the illnesses and deaths for
    present and former members of the United States military services,
    particularly those with environmental and occupational illnesses. As
    families we feel left behind without the support of a grateful Nation.
    We have had to fight for that support everyday of our lives, while
    dealing with illness or death of a loved one. We are asking for DOD and
    VA to honor these injuries with compassionate common sense. This is an
    invitation to begin the healing process for these families who have
    lost loved ones to illness or death following the environmental
    hardships of war.
        Burn Pits 360 is a 501(c)(3) non-profit veterans organization is
    headquartered in Robstown, Texas with the mission to advocate for
    veterans, servicemembers, and families of the fallen affected by
    deployment-related toxic exposures. Burn Pits 360 owns and manages a
    health registry of about 10,000 participants that serves as a national
    model.
        Our impact includes the legislation creating the Airborne Hazards
    and Open Burn Pit Registry (AHOBPR) signed into law in 2013 (P.L. 112-
    260). The law also directed a longitudinal burn pits exposure study to
    be jointly conducted by the U.S. Department of Veteran Affairs (VA) and
    Department of Defense (DOD). We participated in the open comment period
    for registry revisions submitted the VA Office of Public Health (OPH),
    resulting in the addition of constrictive bronchiolitis to the
    registry. We have presented our registry data to the National Academy
    of Science committee created under the 2013 legislation, and we have
    presented statements to the Defense Health Board and have participated
    in every VA/DOD AHOBPR Burn Pit Symposium. Most recently our efforts
    were successful in the passage of the Honoring Our Pact Act legislation
    now making it's way over to the Senate.
        The time is well past due for the President, Departments of Defense
    and Veterans Affairs to acknowledge these injuries and disease as a
    direct result of Armed conflict or caused by an instrumentality of war.
    Burn Pits Health Consequences and Impact
        Numerous military bases in the Operations Iraqi Freedom (OIF) and
    Enduring Freedom (OEF) theatres of operation produced several tons to
    several hundred tons of solid waste per day. Open-air burn pits were
    the primary waste disposal method during the majority of the duration
    of these wars in Iraq and Afghanistan. This involved the burning of
    plastics, body parts, expired pharmaceutical drugs, chemicals from
    paint and solvents, unexploded ordinance, petroleum, and according to
    some reports, nuclear and biological waste.
        Additionally, some of the burn pits were reportedly built on top of
    soil contaminated by chemical war agents. Due to the unacceptable risk
    posed by these burn pits to our servicemembers, their use was
    eventually mostly banned, except under narrow circumstances, in 2010.
    Tens of thousands of servicemembers have been exposed to toxic
    chemicals and micro fine, highly respirable and dangerous particulate
    matter from burns pits and they continue to suffer serious, disabling
    health consequences upon their return.
        A defense contractor stationed at Al-Taqaddum in Iraq from 2006 to
    2007 described the impact of burn pits and their health effect in a
    November 2014 news story: ``Burn pit smoke would encircle the entire
    military base in an enormous dark ring that settled to the ground after
    darkfall . . . . A lot of people got rare cancers and died. Any exposed
    skin and mucous membranes, as experienced by many of us, felt on fire,
    and burning. Many of us developed shortness of breath.''cancers and
    died. Any exposed skin and mucous membranes, as experienced by many of
    us, felt on fire, and burning. Many of us developed shortness of
    breath.''cancers and died. Any exposed skin and mucous membranes, as
    experienced by many of us, felt on fire, and burning. Many of us
    developed shortness of breath.'' \1\
    ---------------------------------------------------------------------------
        \1\ Elizabeth Hilpert, quoted by Dan Sagalyn, ``Photo essay: The
    burn pits of Iraq and Afghanistan,'' November 17, 2014, PBS News Hour.
    https://www.pbs.org/newshour/world/photo-essay-burn-pits-iraq-
    afghanistan
    ---------------------------------------------------------------------------
        The wars in Iraq and Afghanistan exposed United States service
    women and men to an unprecedented array of airborne health hazards
    including from open-air burning in vast burn pits; shock waves and
    toxic particulates from improvised explosive devices (IEDs), including
    vehicle-borne improvised explosive devices (VBIED) and those containing
    chemical warfare agents; and hazardous microfine sand particles. \2\
    Servicemembers with new-onset, post-deployment respiratory symptoms
    from these hazards are being labeled as having Iraq/Afghanistan War-
    Lung Injury (IAW-LI). \3\
    ---------------------------------------------------------------------------
        \2\ Szema, Anthony et al, ``Iraq dust is respirable, sharp, and
    metal-laden and induces lung
    inflammation with fibrosis in mice via IL-2 upregulation and depletion
    of regulatory T cells,'' J Occup Environ Med. 2014 Mar;56(3):243-51.
    https://dx.doi.org/10.1097/JOM. 000000000 0000119
        \3\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung
    Injury (IAW-LI) Clinical Practice Recommendations: National Academy of
    Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6):
    1653-1663. https://dx.doi.org/10.1177 percent2F1557988315619005
    ---------------------------------------------------------------------------
        Here is some of what we now know:
          Air sampling data indicate that smoke from these burn
    pits contained chemicals associated with cancers, lung diseases,
    cardiovascular disease, kidney disease, neurological disorders, and
    more.
          The Burn Pits 360 national registry confirms that the
    array of devastating health conditions being suffered by exposed
    veterans include pulmonary diseases, rare forms of cancer, and many
    unexplained diseases and symptoms.
          The VA's national registry, though it contains over
    260,000 registrants, fails to account for the true impact of burn pits
    exposure by underperforming participation rates, failing to track
    comorbid conditions that develop following initial registration, and
    failing to allow for the entry of cause of death information.
          It is a national failure to adequately prevent, diagnose,
    treat, and compensate burn pits-exposed Active Duty troops and
    veterans.
        There are a number of crucial issues related to burn pit exposure
    and IAW-LI that we strongly believe this Committee should investigate
    and which require the focused attention of the DOD.
        The current lack of clear understanding of the health impacts of
    theses exposure should not circumvent our national obligation to assist
    every affected military servicemember and veteran. In particular, we
    would highlight the following important focus areas:
        1.  Improving the burn pit registry so that it can be an effective
    research tool for monitoring and identifying the health consequences of
    burn pit exposure;
        2.  Improving VA compensation claims for burn pit Active
    servicemembers, including establishing presumption of service-
    connection for debilitating symptoms and diseases that have been linked
    to burn pit exposure;
        3.  Conducting more and better research into the health
    consequences of burn pits and to develop effective treatments for them;
        4.  Establishing evidence-based clinical practice guidelines with
    effective screening and treatment protocols for physicians caring for
    veterans exposed to burn pits, and a specialized care program for IAW-
    LI and comorbid conditions;
        5.  Disability needs to be based on injury or disease as a direct
    result of Armed Conflict or caused by an instrumentality of war.
        6.  Adopt Force Protective Measures, Institute measures to equip
    personnel deployed to high risk areas with masks or other devices to
    protect against toxic airborne exposures.
        7.  Improving collection of servicemembers health records of
    exposure.
    Testimonies

          CPT (Ret.) Le Roy Torres, Co-founder, Burn Pits 360 Veterans
    Organization.

        ``Many servicemembers have returned from the Iraq and Afghanistan
    wars with a multitude of illnesses that are invisible and are
    associated with burn pit exposure and may remain dormant for years. As
    our motto says, ``the war that followed us home'' has become a reality
    and dreadful journey for many veterans. I for one, these invisible
    wounds from toxic exposure have taken a toll on my health and cost me
    my military and civilian career as a Texas state trooper. As citizen-
    soldiers, we deserve to keep our jobs when we return from serving our
    Nation overseas if we return with limitations. We honored our oath to
    this Nation; We should not have to bear the burden alone due to
    exposure to an instrumentality of war.''

          Sergeant Thomas Joseph Sullivan, U.S. Marine, Tom died 2009, 30
    yrs old

        Tom went to Iraq in top health, assigned to an elite Force
    Reconnaissance unit. He reported on his post deployment health form
    that among other things he was exposed to ever present dust, fumes from
    local chemical plants and burning feces and that while deployed he
    experienced rectal bleeding and congestion. After he
    returned his medical problems multiplied in number and severity and
    included intestinal ulcerations and bleeding, hypertension, respiratory
    diseases, sleep apnea and asthma and a liver disorder. He suffered from
    extreme and diffuse pain and swelling.
        Tom had what the military medical system sometimes refers to as
    chronic multi-symptom illness, and sometimes as medically unexplained
    symptoms (MUPS). His health declined despite several months of
    treatment. At this critical juncture, he asked for a fresh, multi-
    disciplinary reassessment. He was sent to a clinic that specializes in
    MUPS and was offered only a program of exercise that was precluded by
    his pain and psychological counseling. Six months later he died. Tom's
    principal physician later told us he had believed Tom had a somatoform
    disorder (i.e., psychological illnesses).1 The Virginia Medical
    Examiner's autopsy report found previously undetected heart damage that
    was designated as a contributing cause of his death. It also found that
    the combination of prescribed medications (including one after Tom
    died, his widow and I requested physician emails discussing the
    somatoform disorder which had been withheld from Tom's health records.
    Walter Reed Army Medical Hospital denied the request: No written record
    of the emails had been retained and they had been deleted from the
    computer system, and it would cost $500,000 to search digital records
    to retrieve them.
        At the time Tom was deployed and upon his return the military
    medical system was aware of environmental health hazards in theater and
    the symptoms and illnesses they might produce. If warnings were issued
    to our troops before, during or after deployment, I have seen no record
    of them. The airborne hazards from dust and fumes could have been
    mitigated to a large extent by issuing simple N395 dust masks that can
    be purchased in bulk for a couple of dollars. Indeed, recommendations
    had been made to the military to take such measures, but were ignored.
        Despite Tom's failing health and his exposure history, his
    physicians did not tell him that many airborne troops at Fort Campbell
    who had served in Iraq and Afghanistan had been diagnosed with a rare
    lung disease; or that particulate matter to which he was exposed in
    Iraq far exceeded USG standards and was carrying toxic metals,
    bacteria, viruses and fungi, including toxins found naturally, plus
    those added by USG burn pits and local industrial pollution. He was
    basically treated at though he never had left the United States, rather
    than as a person who might be suffering from a toxic wound received in
    a war zone.
        The symptoms Tom exhibited, as did those by the Airborne soldiers
    at Ft. Campbell, and many thousands more who have served in Iraq and
    Afghanistan, are consistent with toxic exposure of one or more kinds.
    Yet, Tom's health care was apparently not informed by the body of
    knowledge available to the military medicine at the time. Apparently
    baffled by his symptoms, medical judgment defaulted to the notion that
    they were psychosomatic. This is the same discredited explanation that
    had previously been ascribed to Gulf War Illnesses.

          William Thompson, SSG, U.S. Army (Ret.) Will Passed away 12/2021

        My name is retired SSG William Thompson. I served 23 years, 3
    months and 11 days in the United States Army and WVARNG. I have
    deployed twice with the WVARNG to Iraq. During my last deployment, I
    was stationed at Camp Stryker at the Victory complex. My symptoms of
    frequent coughing started around September of 2009 while in Iraq, in
    which my doctors and PA's treated me for what they thought were
    allergies. I returned to Fort Stewart, GA and after I mentioned to the
    doctors, I was having frequent cough, they did a CXR that revealed
    bilateral pneumonia. They treated me with antibiotics and sent me home
    to WV to follow up with my PCP in one week. After a week, I followed up
    with my PCP 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 miners' 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
    lbs. 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 as high as 10 liters
    continuously. On June 6, 2012, I received a double lung transplant,
    after 2 months of follow ups, I was able to return home to 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.
    On March 9, 2016, I underwent another double lung transplant. Lung
    transplants unfortunately 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's hard to hang out with my kids only to tell them ``I can't do
    that''.
    ``Dad, let's go skiing'' . . . sorry kids, I can't' do that
    ``Dad let's go swimming'' . . . sorry kids, I can't do that
    ``Dad, can you give me a piggyback ride?'' Sorry Ava, I can't do that
    ``Dad, let's go fishing'' Sorry Ethan, I can't do that because of the
    bacteria on fish ``Dad let's go to the beach'' Sorry kids, I can't 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, 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 don't feel like a man because my wife has had to take that role
    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 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 don't know how to treat you'', or ``you
    don't qualify or fit into our parameters for benefits''. I have been
    denied TSGLI because the army does not think having a lung transplant
    is a ``traumatic event''. Luckily, we found the group, Semper Fi fund/
    America's 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 are 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 in 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 don't 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.

          Testimony from LTC Dan Brewer, CENTCOM, CCJ4-E
          CENTCOM Environmental Officer

        At approximately 1745 hours, 30 September 09, LTC Daniel Brewer,
    CENTCOM CCJ4-Environmental Officer (deployed forward to Afghanistan),
    Mr. William Porter, Afghanistan Environmental Manger for RC-East
    (Bagram), and Katherine ``Kat'' Blesi, Afghan Engineer District Realty
    Specialist for RC-East (Bagram) noticed a very large column of black
    smoke covering the sky when coming out of the North DEFC. We
    immediately proceeded to investigate, driving toward the source of the
    plume. As we got closer, we found the smoke to be coming from the
    Bagram Solid Waste (SW) yard. When we got within a mile of the yard, we
    could also see a huge fire burning.
        After arriving at the SW yard we were met by Mr. William Powell,
    KBR General Foreman for Solid Waste, and one of his assistants (name)
    who told us they burn ``on the hill'' every night about this time. When
    asked what they were burning Mr. Powell said it was items they were
    told to burn (by the military) because they were sensitive items and
    could not be recycled. I asked him who from the military told him to
    burn those ``sensitive items'' and asked him what those items were.''.
    Mr. Powell couldn't answer either question, but said it was a lot of
    plastic. I asked him why they were burning them at night, and he said
    they couldn't burn during the day because of the ``birds''. I told him
    it was wrong to be burning those items due to the health risks it was
    causing.

          Statement from Geoff Dardia, Special Forces, Task Force Dagger
        Consider areas that Special Operations deploy to that are not
    common knowledge and the fact that medical providers are not aware of
    the amount of toxins SOF soldiers are exposed to from ammunition and
    explosives both deployed and in the garrison environment. There is no
    type of screening process in place to check servicemembers post
    deployment. Special operations soldiers shoot more ammunition in one
    day than an entire infantry brigade shoots in an entire year. The
    volume of exposure in SOF areas are not being tracked.

          Isiah James,
          Senior Communications and Policy Director, The Black Veterans
    Project.
          Advocate, Burn Pits 360.

        To the distinguished Members of this Committee, thank you for
    taking the time to address this most pressing and critical of issues
    laid out before you today. Many of you may have members of your family
    that have served and surely you have numerous constituents who have
    worn the uniform. Knowing that I, have the utmost confidence that my
    words here today will not fall on deaf ears.
        As our Nation, and the world moreover is glued to our tv's looking
    at the horrors of war as the now ravage Europe, I want you to think
    about that knowing that American service men and woman had to endure
    these trials and tribulations for some twenty years. Thousands of young
    men and woman came back home missing limbs, ravaged with the wounds and
    scars of battle and they were given the best care America could muster.
    Yet those who came back home with the invisible wounds, those wounds
    sitting there, waiting like a chemical time-bomb primed to detonate
    months and years after they doffed their uniform; I'm of course
    referring to the tens of thousands of servicemembers exposed to toxic
    but pits.
        Today you are going to hear gut-wrenching testimony from subject
    matter experts of the effects of such exposure. It is my hope you not
    only listen to the testimony but to hear it. To feel it. To understand
    it, and most importantly to act on it. History is the ultimate judge
    and we in this country have not always done best by those who we send
    in our stead. I believe it was Churchill who said: never has so much
    been owed to so few, by so many.
        How will you be judge and how will America and the American people
    pay their debt.

        Senator Gillibrand. Thank you. Mr. Patterson?

      STATEMENT OF STEVEN PATTERSON, FORMER ENVIRONMENTAL SCIENCE
         OFFICER, COMBINED JOINT TASK FORCE 101 HEADQUARTERS,
                         AFGHANISTAN, 2008-2009

        Mr. Patterson. Senators, thank you for this opportunity. I
    am Steven Patterson, a retired environmental science and
    engineering officer. This falls into the larger preventive
    medicine community that was mentioned earlier.
        I am here today to assist you with your understand of burn
    pits, environmental health exposures, and how those were
    documented. Primarily, I can speak to the time of 2008 to 2009,
    when I was a senior environmental science officer for Combined
    Joint Task Force 101 while it was the headquarters for
    Afghanistan. In this position, I traveled the Nation
    extensively and saw most of the locations where U.S. Forces
    were deployed. My job was to conserve the fighting force and
    identify environmental health exposures.
        The deployed environment is very challenging, and it is
    very difficult to document a person's exposure in such a
    setting. The equipment to identify and quantify exposures is
    often lacking as are trained personnel, especially in remote
    locations. This is made more difficult as we often have
    exposures which one would not anticipate, as well as the
    challenge of accurately placing a certain person in a location
    at a given time. This is made worse when attempting to look
    back 10 or 20 years as camp names often changed and the
    personnel system does not operate down to the person.
        Almost all of the locations I visited had burn pits
    operating at that time, and few, if any, separated their waste
    before burning it, so many contained pressure treated lumber,
    galvanized metal, significant quantities of plastics, and
    lithium batteries. These were not pits, but simply low-lying
    areas where the waste was thrown and burned. Typically, they
    smoldered a great deal which is important as the combustion is
    not complete, more toxic compounds may form, and these toxins
    will not be lifted away so stay in or near the air around the
    camp.
        Most of these burn pits were within the perimeter fence for
    security reasons, or very close to the perimeter if outside of
    the camp. Most of the small camps had few, if any, air samples
    taken at them due to limited personnel, equipment,
    transportation challenges, and time.
        We had roughly 20 people to attempt to document the
    environmental exposures of over 37,000 people spread over an
    area roughly the size of Texas. However, I do not think that
    more environmental health people are the ideal solution.
        The limited environmental health data, mostly air samples
    with some soil and water samples, cannot be linked to a person
    but only to a location, and even if the person can confirm that
    they were at that location it does not mean that they had that
    exposure. Their exposures could have been much worse or much
    better than that sample indicated.
        The DOD has this responsibility and must address it as
    industry likely will not do so as they do not face these
    particular challenges. We have struggled in this space since
    Desert Storm, and we must look at different options moving
    forward. We must leverage technology and address policy issues
    to fix these gaps.
        Some possible options to consider:
        One, creation of a Joint Program Executive Office in order
    to focus the research and funding on environmental health
    surveillance while also providing a central location to hold
    responsible in the future.
        Two, silicone brackets could be provided to servicemembers
    to track their exposures, as mentioned earlier. These have been
    shown to capture more than 1,500 different chemical compounds
    and would allow us to mitigate exposures much sooner while also
    providing the servicemember with personal exposure data.
        Three, research and build a replacement for the silicone
    bracelet which would provide near real-time information on
    exposures and dose for a servicemember.
        Four, create a repository of frozen soil samples from each
    deployment location so they may be tested in the future as
    needed when new concerns are identified.
        Five, improve the personnel reporting system so that each
    individual can be located rather than their unit headquarters
    which may be hundreds of miles away from them. This will allow
    for individual exposures to be more accurately documented.
        Six, remote sensing should be researched to address gaps in
    environmental surveillance. This will be key for small teams
    operating in remote areas or dense urban environments which may
    never have an environmental health professional visit them.
        Seven, further research biomarker monitoring to document
    exposures a person had during their deployment or over their
    military career.
        Finally, eight, educate leaders on the hazards of toxic
    exposures and hold them responsible if they needlessly expose
    their people.
        Thank you for your time. I am open to any questions.
        [The prepared statement of Mr. Steven Patterson follows:]

                   Prepared Statement by Mr. Steven Patterson
        I am Steven Patterson, a retired Army Environmental Science and
    Engineering officer.
        I am here today to assist with your understanding of burn pits,
    environmental health exposures, and how those were documented.
    Primarily, I can speak to the time of 2008 to 2009 when I was the
    senior Environmental Science officer for CJTF-101 while it was the
    headquarters for Afghanistan. In this position I traveled the Nation
    extensively and saw most locations where U.S. Forces were deployed. My
    job was to help conserve the fighting force and identify environmental
    health exposures.
        The deployed environment is very challenging and it is very
    difficult to document a person's exposure in such a setting. The
    equipment to identify and quantify exposures is often lacking as are
    trained personnel, especially in remote locations. This is made more
    difficult as we often have exposures which one would not anticipate as
    well as the challenge of accurately placing a certain person in a
    location at a given time. This is made worse when attempting to look
    back 10 or 20 years as camp names often changed and the personnel
    system doesn't operate down to the person.
        Almost all of the locations I visited had burn pits operating at
    that time and few, if any, separated their waste before burning it so
    many contained pressure treated lumber, galvanized metal, significant
    quantities of plastics, and lithium batteries. These were not pits, but
    simply low lying areas where the waste was thrown and burned.
    Typically, they smoldered a great deal which is important as the
    combustion is not complete, more toxic compounds may form, and these
    toxins will not be lifted away so stay in or near the air around the
    camp.
        Many of these burn pits were within the perimeter fence for
    security reasons, or very close to the perimeter if outside of the
    camp. Most of the small camps had few, if any, air samples taken at
    them due to limited personnel, equipment, transportation challenges,
    and time.
        We had about 20 people to attempt to document the environmental
    exposures of roughly 37,000 people spread over an area roughly the size
    of Texas. However, I do not think that more environmental health people
    are the ideal solution.
        The limited environmental health data; mostly air samples with some
    soil and water samples cannot be linked to a person but only to a
    location, and even if the person can confirm that they were at that
    location it does not mean that they had that exposure. Their exposures
    could have been much less or much more than that sample indicated.
        The DOD has this responsibility and must address it as industry
    likely will not as they do not face these particular challenges. We
    have struggled in this space since Desert Storm and we must look at
    different options moving forward. We must leverage technology and
    address policy issues to fix these gaps.
        Some possible options to consider:
        1.  Creation of a Joint Program Executive Office in order to focus
    the research and funding on environmental health surveillance while
    also providing a central location to hold responsible in the future.
        2.  Silicone brackets could be provided to servicemembers to track
    their exposures, these have been shown to capture more than 1,500
    different chemicals and would allow us to mitigate exposures much
    sooner while also providing the servicemember with personal exposure
    data.
        3.  Research and build a replacement for the silicone bracelet
    which would provide near real time information on exposures and dose
    for a servicemember.
        4.  Create a repository of frozen soil samples from each deployment
    location so they can be tested in the future as needed when new
    concerns are identified.
        5.  Improve the personnel reporting system so that each individual
    can be located rather than their unit headquarters which may be 100s of
    miles away. This will allow for individual exposures to be more
    accurately documented.
        6.  Remote sensing should be researched to address gaps in
    environmental surveillance. This will be key for small teams operating
    in remote areas or dense urban environments which may never have an
    environmental health professional visit them.
        7.  Further research biomarker monitoring to document exposures a
    person had during a deployment or over their military career.
        8.  Educate leaders on the hazards of toxic exposures and hold them
    responsible if they needlessly expose their people.

        Senator Gillibrand. Thank you. Senator Tillis?
        Senator Tillis. Thank you all for being here. I guess you
    heard the testimony--I think most of you were in the room--
    during the first panel. It sounds as if there is consensus on
    one of the questions that I brought up, on individualized
    monitoring and sensors. But speaking for Active Duty, Mrs.
    Torres, I do a lot of work, I serve on the VA Committee. We
    have got a lot of work to do and we are making progress, and
    again, I want to give Senator Gillibrand credit for focusing on
    that issue. We are going to make more progress there. I am
    sorry for the situation with your husband and for the others
    that you mentioned.
        But with respect to what we need to do better upstream, how
    would you judge the DOD in making a priority, the priorities
    that you all have delineated in your opening comments? Where
    are they falling short?
        Mrs. Torres. My team applied for a congressionally directed
    medical research program grant, funded by the DOD, recently,
    months ago. We got a great score. This was a for a monitor the
    size of a beeper that a soldier could wear, that would not only
    measure particulate matter but even sarin gas, specifically,
    and gunshot sounds. Despite a good score they said there are no
    funds. So I do not know why they are asking us to apply for
    grants if there is no money.
        Senator Tillis. Well, that is a question we can get to the
    bottom of.
        Mr. Porter. Thank you, Senator. One of the biggest things,
    and I mentioned it in the testimony, but one of the biggest
    problems is we have experienced a big lack of transparency from
    Federal agencies on what people were exposed to on their
    deployments. That is the big thing, and I think the ILER is
    meant to tackle that. It is just a matter of, is it going to be
    useful to the servicemember and to the veteran. That is key.
        Senator Tillis. You also mentioned the idea that the
    registry is available, but I, for one, think that we should be
    in an opt-out position, that everybody should be registered in
    the registry, and if they want to explicitly opt out I supposed
    they should, but we should probably flip the script on that.
    Would you agree?
        Mr. Porter. Right. The Burn Pit Registry, what the law
    requires is for them to be entered into it unless they opt not
    to. So it is not mandatory if you do not want to be in the
    registry, but the laws that if somebody is exposed or they are
    stationed next to a burn pit, then they should be entered into
    the registry.
        Mrs. Torres. I agree. I mean, the Burn Pit Registry still
    falls short in so many ways. It is basically just self-reported
    data that you could print out and carry around. But it is
    important that everyone be a participant of that effort. You
    know, they do not track mortality, which is, I think, one area
    that we have talked about for years, Dr. Szema. But I agree,
    Senator Tillis, that that should be mandated.
        Senator Tillis. Mr. Patterson?
        Mr. Patterson. Senator, there are so many challenges in
    this space. The previous individuals talked that so much of it
    is self-reported. So a 20-year-old individual returns from
    overseas, and you ask him what happened to him over 15 months.
    Not to mention the fact that that individual, they are not
    going to be able to say, ``I was exposed to TCE or benzene or
    toluene.'' Just, ``Some bad stuff happened to me. There was a
    lot of smoke.'' They cannot say anything that is going to help
    that clinician when they end up in the VA system. So so much of
    what is being done now is just not terribly effective.
        Senator Tillis. That is why I get to the need for us to get
    down to the atomic level sooner rather than later. That is the
    only way we are really going to be able to capture it, and then
    have the level of specificity with respect to the specific
    exposures. So I agree with you all.
        We are coming up on the end of a vote. I thank you all for
    being here. I also appreciate your opening testimony. There
    were a lot of priorities put in there, and they will be
    instructive to me as we move forward. Thank you.
        Thank you, Madam Chair.
        Senator Gillibrand. Thank you. Mrs. Torres, first of all I
    want to thank you for your advocacy on behalf servicemembers,
    veterans, and their families who have suffered debilitating
    injuries and effects of burn pits. What is the top challenge
    that you hear from soldiers when they return from deployment
    about accessing treatment?
        Mrs. Torres. Well first of all, Senator, thank you for
    having me. Lots of challenges. That question just brings up so
    many ideas in my mind of things that we have tracked through
    our own private registry, and off the top of my head it is
    access to health care monitoring, specialized health care, both
    on the DOD and VA side, but primarily DOD. For those Active
    servicemembers, for those reservists it is a challenge when
    they do not have trained occupational medicine doctors
    assessing these underlying issues.
        Then secondly is filing for presumption for these illnesses
    that are underlying. So if you do not have the specialized
    health care, how can they properly transition them through the
    compensation and disability process?
        Senator Gillibrand. Right. Thank you. What information and
    resources would be most helpful to the servicemembers you work
    with when they return from deployment to ensure they are
    getting the screening and treatment they need?
        Mrs. Torres. I think, you know, definitely mandating that
    the clinicians be trained, and I think Dr. Szema can help me
    here, but absolutely having every clinician, every nurse
    trained in the area of airborne hazards, documenting in the
    record, you know, in the electronic health record on the VA and
    the DOD side, that they are identified as having undergone some
    type of exposure.
        To say the least, I have had this conversation recently
    with many people about even just something as small as signage,
    right? Like during the World Trade Center, there was
    communication and outreach and signage on ``if you are
    experiencing these issues.'' People are having to access care
    through people like Dr. Szema, and they have to fly to New York
    and fly to Vanderbilt and exhaust their life savings, like our
    family did. That should not be happening in America, and so we
    need to start now.
        Senator Gillibrand. Thank you very much.
        Mr. Porter, thank you for sharing the survey results of
    your members. Why do you think only 59 percent of IAVA members
    are registered in the Burn Pits Registry? Dr. Rauch testified
    as to some of the steps the DOD is taking to increase
    participation in the registry. Have you seen an increase in
    those registered over the years among your members, and what do
    you think can be done to better encourage more servicemembers
    and veterans to participate?
        Mr. Porter. Thank you for the question. This came up when
    we developed the Burn Pits Accountability Act a few years ago,
    because if you look on the VA website it has a running total of
    those that are registered in it. At the time when we looked at
    it, back in 2017, there were only 140,000 entries in the
    registry. I think it is probably double that now. I have not
    looked recently. But it was only 140,000, and that is out of,
    again, VA's estimate is as many as 3.5 million have been
    exposed. So for only 140,000, that presented a big challenge.
        I think that the main problem with that, the reason for
    that, is because hardly anybody knows about the registry. So
    through the passage of that bill we talked about it a lot, and
    we put out a lot of social media on that, and we have also
    encouraged the VA to do more about that, to get the word out to
    veterans that this registry is here and then why somebody
    should be in it. You get, I understand, a free health exam if
    you are in the system. But again, it is not qualifying somebody
    for presumption. I think there is a misunderstanding there too.
    Veterans should apply for their disability, and they are
    getting turned down, about three-quarters of the people that
    apply.
        Senator Gillibrand. You testified that if the ILER system
    is done right servicemembers and veterans will have significant
    transparency into their exposure. What does ``done right'' mean
    to you, and what are the critical components of ILER that must
    be implemented to make a difference in the care servicemembers
    and veterans receive?
        Mr. Porter. Well, what ``right'' looks like is if somebody
    was deployed to Balad, Iraq, in 2006, then that ILER should be
    able to give them the data from what they were probably exposed
    to in 2006 in Balad. Same thing with me. I traveled around
    Afghanistan all over the place, so it really can't pinpoint to
    one location. So that just shows how complex it was. So I
    traveled around the whole country, frequently, so it would be
    harder for that.
        But again, it should specify what you were exposed to
    during your deployment, during a set period of time.
        Senator Gillibrand. Now I am going to turn it over to
    Senator Warren, and she is going to chair the meeting while I
    go vote.
        Senator Warren. [Presiding.] So thank you. We are tag-
    teaming here. I voted early so that I could be here while the
    chairwoman goes to vote. I want to say publicly a big thank you
    to the chairwoman for holding this hearing. I think it is
    really important. I think it is important that this committee
    look at the real costs of war, including where the Department
    of Defense failed to take steps that were necessary to prevent
    exposing members of the military to toxic chemicals. I know
    that many of our witnesses on this panel have been fighting for
    over a decade for DOD and the VA to recognize how burn pit
    exposure has had devastating effects on servicemembers' lives.
        I know that there is some debate over the data, but it is
    just common sense that these toxins would cause significant
    problems to human beings. It is important for DOD to continue
    to study this issue, to improve our understanding of the
    science, but we cannot keep waiting for action. We need to take
    care of our veterans now--not later, now.
        I know that the focus of today's hearing is DOD's role in
    determining eligibility for care, not the VA's, but we also
    have to consider the toll of this entire process on families.
    So Mrs. Torres, if you do not mind, I would like to be able to
    ask you about your experiences. I read your testimony. I
    understand about how hard you have had to fight, how long you
    have had to fight to get the care that your husband deserves
    and that other veterans deserve. So if I can let me just ask
    you a little bit about how this process makes your family feel.
        Mrs. Torres. Thank you so much for that question. It has
    been a journey, a hellish journey, of delay and deny, not just
    for myself, the Torres family, but for thousands, possibly
    millions of families. I know for my husband, being stripped of
    his integrity and dignity, you know, losing his job, being on
    the brink of foreclosure, repossession of cars, and you ask
    yourself, how did we get here and how is this happening in
    America's backyard, it feels as if the Nation has turned its
    back when you are attempting to just access care. We attempted
    to access care from both DOD and VA health care institutions,
    and throughout those 10 years it was always an excuse of there
    is no science, there is no proof.
        So myself, including, I know, many, many families, maybe to
    include yours, Tom, is that we have to exhaust our life savings
    just to access doctors like Dr. Anthony Szema, like Dr. Robert
    Miller, like the doctors over at National Jewish. Being away
    from our children that is time lost that will never get back,
    and so not only does it impact the veteran and spouse but the
    children.
        To this day, to finally see some momentum, as we are seeing
    now, it really gives us hope.
        Senator Warren. Well I am glad to hear you end that on
    hope, but when you say you feel as if our government, our
    country, has turned its back on you and your family and
    thousands, maybe millions of families in the same position, no
    veteran should feel that way, and no family of a veteran should
    feel that way.
        You have done a tremendous amount of advocacy related to
    changing the rules for how veterans must prove they were
    impacted by burn pits in order to get care. I support you in
    your work on this. I know it is a hard and lonely journey, but
    you have done remarkable work here.
        So let me see if I can turn this around just a little bit.
    Mrs. Torres, what would it mean to you and other veterans'
    families if the rules were changed so that the DOD and the VA
    believed veterans when they said their health was harmed by
    burn pits rather than making them jump through so many hoops?
        Mrs. Torres. Well, it would remove the burden of proof of
    us having to be our own lawyers, our own researchers, our own--
    all of those things that we have become, right? We have sort of
    mobilized and congregated online, all sharing that common
    denominator of delay and deny. So to finally see historic
    legislation passed so that we do not have to be all those
    things, so that the Gold Star spouses that call us weekly,
    expressing how heart-wrenching it is for them to spend the last
    moments of their loved ones' life gathering buddy statements
    and evidence when they should be holding the hand and embracing
    their loved one, it would mean everything to us and to those
    families that are still struggling to this day, and for those
    still waiting on an answer from the VA.
        Senator Warren. Well, as I said, I commend you for your
    advocacy work here. It at least helps us start to move in the
    right direction. I appreciate that making a change like this is
    not inexpensive. There is a lot of money at stake here. I also
    understand it is not all in the jurisdiction of this committee.
    But it is urgent that we treat families, we treat those who are
    injured without delay. We cannot allow veterans to wait another
    minute for health care, and so I hope that the work we do here
    today will help put more momentum behind change.
        You know, this committee regularly advocates for spending
    on weapons that do not work or weapons that are not needed at
    all. It is inexcusable to claim that we need to balance the
    budget on the backs of veterans and their families who have
    been injured. So I hope that what comes out of our work today
    is that we can give a stronger push on that.
        If I can, I have got a few more questions here, questions
    that the chair also wanted me to ask. Mr. Patterson, if I could
    ask you about the advances in technology that have been made,
    and can be made to improve the way that troops' toxic exposure
    can be documented. Could you say a bit about that please?
        Mr. Patterson. Thank you, Senator. As far as advances since
    Desert Storm, sadly it has not been very significant. We
    replaced the miniVOL with another type of particulate matter
    sampler, but there are still significant challenges. Those
    samplers simply capture the particulate matter that is in the
    air, and then you can send it to a lab, and many months later
    get a report back of what was possibly in that sample.
        The downside of that is any volatile organic compounds are
    not going to be in that sample, because they will have cooked
    off in the transportation and those months for you to get the
    sample back. So the progress has been extremely slow and
    extremely challenging, and I am just looking at my time in from
    Desert Storm to Afghanistan.
        I made some recommendations in my testimony. I believe that
    the biomarkers have some significant capabilities with them.
    The silicone bracelets, I think, is an excellent idea, because
    then we would be able to know much sooner. For instance, in
    Afghanistan we had formaldehyde-treated lumber from China that
    we were using to build the small buildings that the soldiers
    slept in. I had no reason to expect to find formaldehyde in a
    pristine river valley in Afghanistan. Why is that there? I have
    no reasons to go look for that.
        If we had had those silicone bracelets on those individuals
    we could have had them back, and there is time to this. But I
    would have known quickly rather than a year or two later, what
    is this, and then we could have mitigated it and I could have
    protected the next group of soldiers that went in there.
        The remote sensing that I mentioned, I believe is very key
    moving forward. If we are going to do dispersed operations with
    small groups, there is a lot of atmospheric analysis that can
    be done with satellite imagery. It is a bit of an immature
    space, but if you are talking special operations units that are
    very small, they are never going to have a preventive medicine
    person visit them. So that would give you some idea.
        I believe the problem with all of these things is they are
    not perfect, but they will further the science significantly,
    and we have been pushing too much for perfect rather than
    taking some reasonable steps forward.
        Senator Warren. Just so I can get the comparison here, can
    you say a little bit about when you were in Afghanistan in 2008
    and 2009, how was an individual's exposure to a burn pit
    documented?
        Mr. Patterson. Senator, some of them were not documented at
    all, which is a very frustrating point for me. We were
    operating down in the small FOBs where it might have been a
    platoon on a FOB, so 50 people, maybe 100 individuals. With a
    staff of approximately 20 people there was no way that I could
    get them out there to do that surveillance, which should have
    been done weekly. Ideally you want to do it once a week,
    rotating, so you never repeat it on the same weekday.
        So some of those FOBS, I would grab a soil sample, because
    that was all that I could do. Those air monitors take 24 hours
    to capture a sample properly. If you just go and take a grab,
    it could be very high or very low. You need the coverage over
    24 hours.
        So a lot of them, there is probably little to no data in
    the DOEHRS system, which was mentioned earlier, to be able to
    address that soldier's concerns. The larger compounds fared
    better. But even then, I cannot tell you what I was exposed to
    in those 13 months, and this was my job. So for an individual
    who is ignorant of the space and things they are invulnerable,
    at 20-something, they are not going to have any idea.
        Senator Warren. So let me just ask a follow-on question to
    that. When servicemembers are headed home, what kind of
    information were they given about their exposure and what kind
    of risks they might be facing in the future?
        Mr. Patterson. It was all self-reporting, that I recall.
    Sometimes some units would put something in their medical
    record that said, ``You had a burn pit exposure'' or ``You had
    a heavy metal exposure from the location that you were in.''
    But that was a unit-by-unit situation. Then as mentioned
    earlier, they asked this 20-year-old, invincible individuals,
    ``What were you exposed to?'' ``I'm fine. I don't have any
    problems,'' and they move out.
        Another concern is then those individuals that never end up
    going to the VA at all. You did your tour, you were 22 years
    old and bulletproof, and they never went into the VA system.
    Then they approach the VA 10 or 20 years later. Now they have
    that much of a tougher upstream fight, and the FOB, the
    compound names changed constantly. There are some individuals
    that probably--you know, that compound no longer existed 5
    years later. Quite often they changed every year.
        The gentleman talking about being able to link this to an
    individual's exposure, unless the personnel operating system
    has changed, that unit identification code links everybody to
    usually the company level. But if that company operated three
    sites, with their platoons broken out to those other sites,
    that data is not accurate for that individual. So there are
    going to be a lot of challenges, and the further we go back,
    the more challenges there are going to be with linking people
    to location to exposure.
        Senator Warren. Thank you. Thank you very much, Mr.
    Patterson.
        Mr. Patterson. Thank you, Senator.
        Senator Warren. I am going to yield back to the chair.
    Thank you very much.
        Senator Gillibrand. [Presiding.] Thank you all for your
    testimony today. I think you have really informed the committee
    what we have to accomplish. I particularly appreciated the
    specific requests that you have made of this committee,
    specific changes in the law you would like to see. The benefit
    of this committee is we are the personnel subcommittee, so we
    can write these requirements into law for this year's NDAA. So
    you have given us really good information about where the
    system is lacking, why it is not getting the data that it
    needs, how we actually collect the data we really do need, what
    is lacking in terms of when our personnel are getting their
    medical exams, and what the baseline is, and what pre-
    deployment and post-deployment look like.
        I do not know if this was addressed, but did you guys
    discuss what is the best way to transfer the medical records
    from Active Duty servicemembers to veteran status? What you
    would like to see in that transfer of information, and what we
    might need to create if we do not have it?
        Mr. Porter. Sure, Senator. That should work with the
    electronic health record reform. So when that looks right,
    which means a seamless transition from the DOD to the VA, and
    that that servicemember or veteran can have easy access to that
    information.
        Senator Gillibrand. And access to the ILER system.
        Mr. Porter. Yes, ma'am.
        Mrs. Torres. On that point, Senator--sorry, Tom--definitely
    consider making ILER accessible to the survivors. I had one
    survivor call me and asking assistance in communicating with VA
    to access ILER, as she was filing for death benefits, and it
    was difficult because ILER did not date back to the time that
    he was in service. So lots of challenges there.
        Senator Gillibrand. Thank you, and Dr. Szema, you called on
    DOD to revamp their method of documentation so that medical
    professionals could have better understanding of their
    patients' potential exposures. What information would be most
    helpful to you to have as you screen and treat patients? What
    obstacles do you face with the patients when you are trying to
    gather needed information about exposure? Then further, what
    training do you think should be provided to medical
    professionals so they can better screen and treat their
    patients for toxic exposure?
        Dr. Szema. We would like to know which region in the
    country an individual soldier was in, and what types of
    munitions they were exposed to, what the chemical makeup of the
    munitions were, how trash was disposed of in that region,
    including burn pits, what was in the trash itself, what the
    weather patterns were, because of dust storms in the region,
    whether depleted uranium was used in that region--for example,
    there are armor-piercing rounds, PGU-14, and tank shells with
    depleted uranium, as well as even ship ballasts--and whether
    that soldier used personal protective equipment. All these
    things are important.
        Regarding training, in the VA system most compensation and
    pension doctors that we have dealt with in the VA are primary
    care doctors. They are not pulmonologists, and they are unaware
    of burn pit issues, which actually is flabbergasting at this
    point in time. But as I mentioned, last month we had a case
    where somebody could not go to the War-Related Illness and
    Injury Center, which has been an arbiter and an advocate for
    us. So they would go to East Orange VA to confirm what we
    suspected or wanted a second confirmation of, and one stumbling
    block is the local VAs are using it as a hurdle to not get them
    benefits.
        Senator Gillibrand. Do you think the VAs need to have
    pulmonologists on staff?
        Dr. Szema. Yes.
        Senator Gillibrand. Well, thank you for all your
    recommendations. I think this panel has been extremely
    effective in laying out a set of requirements and proposal for
    how to better address the diseases caused by burn pits and how
    to document them through Active Duty, so that when these
    individuals become veteran status they have all the information
    they need to protect them. Because a lot of these diseases take
    5 years, or take 7 years, or take 10 years, depending on the
    length of the service of the individual. So we need to have
    that information in place, at the ready, so that when they do
    go from Active Duty to veteran status it is part of their
    record.
        We are going to leave this record open for a week, so if
    there is any testimony that you think of that you would like to
    give, in terms of recommendations, in terms of data,
    information, anything else that you want us to have, please
    submit it. We are really grateful for your advocacy and your
    testimony today. I think it was thorough and extremely helping
    in our writing our baseline personnel markup.
        Thank you very much. Hearing adjourned.
        [Whereupon, at 4:41 p.m., the Committee adjourned.]

        [Questions for the record with answers supplied follow:]

               Questions Submitted by Senator Kirsten Gillibrand
                    individual longitudinal exposure record
        1. Senator Gillibrand. Dr. Rauch, you testified that the Individual
    Longitudinal Exposure Record (ILER) will be fully operable in June
    2023. As you develop its capabilities, what challenges are you facing
    in ensuring the information included is comprehensive?
        Dr. Rauch. One of the challenges we are facing with the information
    in ILER assuring that we have identified and accessed all available
    exposure monitoring data. Due to the varying austerity of the multiple
    deployment locations, some of these locations have more environmental
    data than others and are linked to an exposure pathway. One particular
    difficulty is that location data are not standardized. Locations are
    entered into the Defense Occupational and Environmental Health
    Readiness System--Industrial Hygiene as the name of the military base
    or geo-coordinates so these need to be validated and quality assurance
    approved. The data sources from which ILER is consolidating location
    data do not have a standardized data format. All the information needs
    to be digested, cross-referenced, and adapted to fit into the ILER data
    framework so that it can be displayed in the exposure summaries.
    Additionally, receiving individual deployment location data is critical
    to linking the servicemember to environmental exposure assessments
    completed for his/her location.

        2. Senator Gillibrand. Dr. Rauch, what collection gaps will prevent
    you from ensuring the data is fully captured?
        Dr. Rauch. Some deployment locations have more environmental data
    available than others, particularly the larger military bases.
    Personal, individual exposure monitoring is a collection gap that the
    ongoing Comprehensive Exposure Monitoring Capabilities Based Assessment
    is aiming to address. Area monitoring that was conducted at deployment
    locations may not be associated with an individual, but can be tied to
    a location, thus extrapolation of the data to all servicemembers at the
    location is necessary. Declassification of individual deployment
    location and classified environmental exposure assessments are
    necessary since ILER is an unclassified information technology system.

        3. Senator Gillibrand. ly able to access ILER data and when will
    servicemembers and veterans be able to directly access their data?
        Dr. Rauch. Health care providers, health researchers, and the U.S.
    Department of Veterans Affairs (VA) claims adjudicators are able to
    access ILER. Servicemembers and veterans are able to access their
    respective Individual Exposure Summary through their health care
    providers during a medical visit. Per statutory requirement, the VA is
    currently working to provide direct access to veterans through the ``My
    HealtheVet'' Portal in 2023. The Department of Defense (DOD)
    servicemember direct access is in the planning phase.
                            informing servicemembers
        4. Senator Gillibrand. Dr. Rauch, what does the Department of
    Defense (DOD) tell servicemembers and their families about the risks of
    toxic exposure when they are deployed?
        Dr. Rauch. Preventive Medicine threat briefings are provided to
    servicemembers prior to deployment. The threat briefings include
    information on a wide range of threats, e.g., vector-borne disease,
    heat and or cold exposures, water quality, and environmental exposures.
    Additionally, servicemembers and their families have direct access to
    various DOD-sponsored websites.

        5. Senator Gillibrand. Dr. Rauch, what assessments are done when
    servicemembers return from deployment to determine whether there was
    exposure?
        Dr. Rauch. The post-deployment health assessment is conducted
    within 30 days of returning from deployment at qualifying locations. A
    post-deployment health reassessment is also completed within 90 to 180
    days of return from deployment. The deployment-related health
    assessments contain a section for documenting occupational and
    environmental exposures, including questions on whether the
    servicemember was stationed at a location where a burn pit was
    operated. The questions in this section on exposure to open burn pits
    and other airborne hazards are pursuant to the requirements of Section
    704 in the National Defense Authorization Act (NDAA) for Fiscal Year
    2020. Pre-and post-deployment blood serum samples are also collected.
    An extensive periodic health assessment of all servicemembers is
    conducted every year irrespective of deployment status. There are
    specific questions about being based or station near open burn pits,
    exposure to toxic materials, and enrollment in the Airborne Hazards and
    Open Burn Pit Registry.
         dod's health response and treatment of exposed servicemembers
        6. Senator Gillibrand. Dr. Rauch, other than recordkeeping, what
    measures is the Department of Defense currently taking to treat early
    onset respiratory illnesses in soldiers exposed to burn pits or toxins?
        Dr. Rauch. The DOD is conducting deployment-related health
    assessments before and after deployment to assess for any exposure
    concerns or onset of respiratory illness. Once a respiratory concern of
    illness is identified, an individual is referred to a health care
    provider for further evaluation and appropriate medical treatment.

        7. Senator Gillibrand. Dr. Rauch, what measures does the Department
    of Defense take to detect cancer early when soldiers return from
    deployment after burn pit or toxic exposure?
        Dr. Rauch. Military personnel have several opportunities to express
    concerns about the risk of developing cancer with health care
    providers. Screening for cancer without any risk factors, such as age,
    family history, or signs or symptoms of cancer, is not recommended by
    the American Cancer Society. Most cancers take years to decades develop
    and a screening program immediately after return from deployment would
    not provide the medical information that a screening program is
    designed to provide. Health care providers will weigh the concerns of
    the servicemember with the known risk factors before recommending a
    cancer screening.

        8. Senator Gillibrand. Dr. Rauch, does the Department of Defense
    have the proper technology to diagnose and treat respiratory illnesses
    and cancers when soldiers return back from deployment where they were
    exposed to burn pits or other toxins?
        Dr. Rauch. The DOD has trained physicians and other medical
    providers to either diagnose and treat respiratory illnesses and
    cancers or provide a referral to a specialist when warranted. The DOD
    routinely seeks assistance from the wider specialty medical community
    whenever a case requires more sophisticated technology or treatments
    than is available at the military treatment facility.
          sharing information with the department of veterans affairs
        9. Senator Gillibrand. Dr. Rauch, how does DOD inform the
    Department of Veterans Affairs (VA) that an Active Duty servicemember
    has been exposed to airborne hazards, including toxic fumes from burn
    pits?
        Dr. Rauch. The VA Airborne Hazards and Open Burn Pit Registry
    (AHOBPR) captures those DOD servicemembers and veterans that that have
    AHOBPR exposures or concerns of exposures that register. Both DOD and
    the VA have ongoing outreach and education about the AHOBPR to promote
    its use. Servicemembers are encouraged to register if they have any
    airborne hazards and burn pit concerns which provides the VA visibility
    of servicemember registrants.
        Servicemember's ILER exposure summaries are accessible to VA health
    care providers, which provide a summary and history of the
    servicemember's exposures based on their location. If a servicemember
    is determined to have been exposed to burn pit emissions at a deployed
    location, a VA health care provider can access the available
    environmental health data associated with that exposure.
        The DOD Separation Health Physical Examination is performed on all
    servicemembers prior to their separation from military service. The
    examination includes a section on environmental exposures, including
    exposures to burn pits. The completed examination is provided to the
    VA, and thus accessible to a VA health care provider if the separated
    servicemembers seeks medical care at a VA facility.
                       training for health care providers
        10. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
    in the Fiscal Year 2022 National Defense Authorization Act (NDAA),
    Congress required DOD to implement mandatory training for all medical
    providers working under DOD on the potential health effects of burn
    pits. What type of training do health care providers in each of your
    Services currently receive regarding potential effects of burn pits?
        Dr. Mirza. The Department of the Army coordinates with the
    Department of Veteran Affairs on an annual symposium to exchange
    information and train providers on the health effects of airborne
    hazards, relevant epidemiological research, the progress of the
    Airborne Hazards & Open Burn Pit Registry (AHOBPR), and status of the
    implementation of the Individual Longitudinal Exposure Record. The Army
    Public Health Center coordinates with the Department of Defense in an
    ongoing campaign to educate providers and servicemembers on the
    availability and purpose of the AHOBPR and has established asynchronous
    online training for providers on the registry available on the
    platform, Joint Knowledge Online. The Army trains Occupational &
    Environmental Medicine and Preventive Medicine specialists with the
    knowledge required to conduct exposure and clinical risk assessments,
    medically manage acute casualties from hazardous exposures, and conduct
    prospective surveillance of personnel exposed to occupational and
    environmental hazards. The Army offers training courses containing
    education on environmental hazards available to medical providers,
    environmental engineers, industrial hygienists, preventive medicine
    technicians, and safety personnel. These courses are available
    throughout the year and include, Fundamentals of Occupational Medicine,
    Medical Management of Biological and Chemical Casualties, the Army
    Public Health Course, and the Military Preventive Medicine Course.
    Additional tailored training is offered to preventive medicine
    detachments by the Army Public Health Center before their deployment
    into a Combatant Command theater. Last, medical school students at the
    Uniformed Services University of the Health Sciences attend a 5-day
    field training event that prepares them for providing medical care and
    responding to environmental exposures in an operational environment.
        Colonel Newell. See attachments Tab 2 and Tab 3 in the Appendix.
        Per direction of acting ASD, Honorable Mullen, AFMRA prepared a
    NOTAM conveying the information within Tab A. It directed all
    physicians and privileged providers to accomplish the standardized DHA
    training module located on JKO titled ``Airborne Hazards and Open Burn
    Pit Registry Overview.'' The training conveyed information and training
    for physicians and privileged providers on the health effects of
    airborne hazards, relevant epidemiological research, the progress of
    the Airborne Hazards & Open Burn Pit Registry (AHOBPR), and status of
    the implementation of the Individual Longitudinal Exposure Record.
        Captain Feldman. Senator Gillibrand, to support our primary care
    providers, the Navy has a variety of specialized health care staff who
    are highly-trained and certified to address servicemembers concerns
    regarding environmental or toxic exposures such as occupational and
    environmental medicine physicians, occupational health nurses,
    toxicologists, pulmonologists, family medicine physicians,
    environmental health officers, preventive medicine physicians, and
    industrial hygienists. They are well-trained and qualified in
    comprehensive evaluation and management of occupational and
    environmental health concerns and are widely available to address any
    exposure-related medical concerns during appointments scheduled
    specifically for this purpose at any time, including after deployment.
    They are trained in the management of acute and chronic medical
    conditions from hazardous exposures, and conduct surveillance of
    personnel exposed to occupational and environmental hazards
    prospectively, to include operational environments. A history of any
    known exposure is also a component of certain medical encounters, such
    as occupational medicine examinations.
        Additionally, the Defense Health Agency has developed a
    comprehensive health care provider focused course on airborne hazards
    and open burn pits. The Navy coordinates with the Department of Defense
    in an ongoing campaign to educate providers and servicemembers on the
    availability and purpose of the Airborne Hazards and Open Burn Pit
    Registry (AHOBPR) and has established an accredited asynchronous online
    training for providers on the registry available on the platform, Joint
    Knowledge Online. The course is titled DHA-US035 Airborne Hazards and
    Open Burn Pit Registry Overview.
        Through the Airborne Hazards and Open Burn Pit Registry,
    servicemembers and veterans can document their potential exposure to
    airborne hazards while deployed overseas and are encouraged to
    participate in a medical evaluation. For more information about the
    registry, or to view and download materials, go to https://
    www.Health.mil/AHBurnPitRegistry.
        Additional training information and resources are available at the
    following: https://www.health.mil/Military-Health-TopicsHealth-
    Readiness/Environmental-Exposures/VA-Airborne-Hazards-and-Open-Burn-
    Pit-Registry https://www.health. mil/Military-Health-Topics/Health-
    Readiness/Environmental-Exposures

        11. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
    are there plans to expand that training, and, if so, what information
    will be covered?
        Dr. Mirza. The Army Public Health Center collaborates with the
    Department of Defense to coordinate outreach and education for
    providers. While existing training and distributable material are made
    available to all providers, current efforts seek to maximize resources
    to expand and update training and broaden provider participation.
    Recent efforts include several tools to expand training and education.
    These include an updated web-based asynchronous course (including the
    purpose of the AHOBPR, the registry process, and components of the
    medical examination), a Health Care Provider Guide about airborne
    hazards, an online Clinical Toolbox, and a to-be-published Memorandum
    from the Defense Health Agency Director instructing clinicians in
    military medical treatment facilities to receive these tools.
        Colonel Newell. As stated, acting ASD, Honorable Mullen directed
    that all privileged physicians, nurse practitioners and physician
    assistants in primary care, aerospace medicine, occupational health and
    medical readiness must complete course DHA-US035 on JKO and view the
    Clinical Toolbox by January 31, 2023, and monitor compliance with this
    requirement. Future training initiatives by the Defense Health Agency
    (DHA) and Airborne Hazards and Open Burn Pit Registry (AHOBPR) Center
    for Excellence will be incorporated into annual training requirements
    within the AFMS.
        Captain Feldman. Yes, the Defense Health Agency has developed and
    continues to refine a comprehensive health care provider focused course
    on airborne hazards and open burn pits. The training is structured to
    provide background to airborne hazards and open burn pits since the
    1990s, an introduction to the Airborne Hazards and Open Burn Pit
    Registry (AHOBPR), a breakdown to the components of the registry, and a
    comprehensive overview of the medical examination for those exposed to
    airborne hazards. The training also provides DOD health care providers
    a clinical toolbox, resources needed to provide care for those exposed
    to burn pits and a comprehensive guide to assist servicemembers who
    have been exposed to burn pits. This course explains the registry's
    history, eligible deployment dates and locations, and the process
    servicemembers and veterans follow to participate in the registry. In
    addition, this course will look at why airborne hazards and open burn
    pits are of concern and provide references to research on the health
    effects of these exposures. This course also describes clinical
    considerations for the optional registry medical evaluation and uses
    two case studies to enhance learning and interactivity. Upon completing
    this course, health care providers will be able to better counsel
    servicemembers about the registry and exposure concerns and conduct the
    associated medical evaluation. In addition, this course offers numerous
    resources for providers to download for future reference. This training
    is currently under review to ensure that it meets quality of care and
    NDAA requirements. It will be available to all DOD health care
    providers online through the Joint Knowledge Online learning management
    platform.
                          health effects of burn pits
        12. Senator Gillibrand. Dr. Mirza, Colonel Newell, Captain Feldman,
    in the Fiscal Year 2021 NDAA, the Secretary of Defense was required to
    provide a briefing to this Committee on DOD's research and studies
    conducted on the health effects of burn pits and while it was reported
    that studies showed consistent evidence of an association between
    exposure to airborne hazards and chronic respiratory symptoms, there
    seemed to be a need for more and larger studies to determine more
    conclusive findings for respiratory and other diseases. What are the
    Department's plans to fund more research in this area?
        Dr. Mirza. The Army Public Health Center has led and coordinated
    public health studies with the goal of better understanding
    servicemembers' health after deployment and exposure to environmental
    hazards, including burn pits. The Army Public Health Center resources
    these public health studies from its operating budget via the Defense
    Health Program authorized by the National Defense Authorization Act.
    These public health studies include:
        a. Army Public Health Center:
        Garshick E, Abraham JH, Baird CP, Ciminera P, Downey G, Falvo MJ,
    Hart JE, Jackson DA, Jerrett M, Kuschner W, Helmer D, Jones KD, Silpa
    D. Krefft SD, Timothy Mallon T, Miller RF, Morris MJ, Proctor S,
    Redlich CA, Cecile Rose C, Rull R, Saers J, Schneiderman AI, Smith NL,
    Yiallouros P, Blanc PD. Respiratory health after military service in
    Southwest Asia and Afghanistan: An official American Thoracic Society
    workshop report. Annals of the American Thoracic Society. 16(8):e1-e16.
    2019.
        Holley AB, Sobieszczyk M, Perkins M, Cohee BM, Costantoth CB, Mabe
    DL,
        Liotta R, Abraham JH, Holley, PR, Sherner J. Lung function
    abnormalities among servicemembers returning from Iraq or Afghanistan
    with respiratory complaints. Respiratory Medicine. 118:84-87. 2016.
        Falvo MJ, Abraham JH, Osinubi OY, Klein J, Sotolongo A, Ndirangu
    DS, Patrick-DeLuca LA, Helmer DA. Bronchodilator responsiveness and
    airflow limitation are associated with deployment length in Iraq and
    Afghanistan veterans. Journal of Occupational and Environmental
    Medicine. 58(4):325-8. 2016.
        Sharkey JM, Abraham JH, Clark LL, Rohrbeck P, Ludwig SL, Hu Z,
    Baird, CP. Post-deployment respiratory healthcare encounters following
    deployment to Kabul, Afghanistan: A retrospective cohort study.
    Military Medicine. 181(3):265-271. 2016.
        Sharkey JM and Abraham JH. Evaluation of post-deployment cancers
    among active duty military personnel. US Army Medical Department
    Journal. 68-75. 2015.
        Sharkey JM, Harkins DK, Schickedanz TL, Baird CP. Department of
    Defense Participation in the Department of Veterans Affairs Airborne
    Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and
    Communication. The US Army Medical Department Journal. 2014. July-
    September 2014. 44-50. http://www.cs.amedd.army.mil/
    FileDownloadpublic.aspx'docid=e358fb9a-c3f2-41d6-93ef-63d352ef3b82
        Matthews T, Abraham JH, Zacher LL, Morris MJ. The impact of
    deployment on COPD in active duty military personnel. Military
    Medicine. 179(11):1273-1278. 2014.
        Abraham JH, Clark LL, Sharkey JM, Baird CP. Trends in rates of
    chronic obstructive conditions among US military personnel. US Army
    Medical Department Journal. p. 33-43. July, 2014.
        Abraham JH, Eick-Cost A, Clark LL, Hu Z, Baird CP, DeFraites R,
    Tobler SK, Richards, EE, Sharkey JM, Lipnick RJ, Ludwig SL. A
    retrospective cohort study of military deployment and post-deployment
    medical encounters for respiratory conditions. Military Medicine.
    179(5):540-546. 2014.
        Abraham JH, Baird CP. A Case-crossover study of ambient particulate
    matter and cardiovascular and respiratory medical encounters among
    United States military personnel deployed to Southwest Asia. Journal of
    Occupational and Environmental Medicine. 54(6):733-739. 2012.
        Rose C, Abraham JH. Harkins D, Miller R, Morris M, Zacher L, Meehan
    R, Szema A, Tolle J, King M, Jackson D, Lewis J, Stahl A, Lyles MB,
    Hodgson M, Teichman R, Salihi W, Matwiyoff G, Meeker G, Mormon S, Bird
    K, Baird C. Overview and recommendations for medical screening and
    diagnostic evaluation for post-deployment lung disease in returning US
    warfighters. Journal of Occupational and Environmental Medicine.
    54(6):746-751. 2012.
        Abraham JH, DeBakey SF, Reid L, Zhou J, Baird CP. Does deployment
    to Iraq and Afghanistan affect respiratory health of United States
    military personnel? Journal of Occupational and Environmental Medicine.
    54(6):740-745. 2012.
        Baird CP, DeBakey SF, Reid L, Hauschild VD, Petruccelli B, Abraham
    JH. Respiratory health status of U.S. Army personnel potentially
    exposed to smoke from 2003 Al-Mishraq sulfur plant fire. Journal of
    Occupational and Environmental Medicine. 54(6):717-723. 2012.
        Weese C and Abraham JH. Potential health implications associated
    with particulate matter exposure in deployed settings in southwest
    Asia. Inhalation Toxicology. 21(4):291-296. 2009.
        Airborne Hazards Related to Deployment. Baird, Coleen P., Harkins,
    Deanna K., Editors. Borden Institute, Fort Sam Houston, Texas. United
    States. Department of the Army. Office of the Surgeon General.
    Textbooks of Military Medicine. 2015. Available at https://
    medcoe.army.mil/borden-tb-airborne, and including:
        Abraham JH, Clark L, Schneiderman A. Epidemiology of airborne
    hazards in the deployed environment. In: Textbooks of Military
    Medicine: Airborne Hazards Related to Deployment. (Chapter 6) Borden
    Institute. 2015. Falls Church, VA 2015.
        Abraham JH. Defining health outcomes in epidemiologic
    investigations of populations deployed in support of Operations Iraqi
    Freedom and Enduring Freedom. In: Textbooks of Military Medicine:
    Airborne Hazards Related to Deployment. (Chapter 7) Borden Institute.
    2015. Falls Church, VA 2015.
        Sharkey J, Baird CP, Eick-Cost A, Clark LL, Hu Z, Ludwig S, Abraham
    JH, Clark L, Schneiderman A. Review of epidemiological analyses of
    respiratory health outcomes after military deployment to burn pit
    locations with respect to feasibility and design issues highlighted by
    the Institute of Medicine. In: Textbooks of Military Medicine: Airborne
    Hazards Related to Deployment. (Chapter 30) Borden Institute. 2015.
    Falls Church, VA 2015.
        b. Armed Forces Health Surveillance Division et al.
        AFHSD, NHRC, APHC. Epidemiological Studies of Health Outcomes among
    Troops Deployed to Burn Pit Sites, May 2010
        Colonel Newell. Per USAFSAM, they are not currently engaged in any
    discussion or research regarding burn pits at this time.
        Captain Feldman. Our Naval Medical Research & Development (NMR&D)
    Enterprise support numerous efforts focused on the potential exposures
    of Naval Forces to environmental contaminants. While we are dependent
    on funding from program sponsors to execute our research activities, we
    have continued to maintain a robust portfolio for decades.
    Determination of funding amounts and project selection are at the
    discretion of the program sponsors.
        Within the NMR&D Enterprise, the Environmental Health Effects
    Directorate at Naval Medical Research Unit-Dayton studies the potential
    health effects related to exposure to chemical stressors (chemicals,
    fuels, oils, exhaust fumes, particulate matter) and physical stressors
    (temperature, humidity, pressure, noise). The lab is able to evaluate
    exposures for virtually any health effect of interest, from memory or
    performance related-effects to anxiety, immunosuppression or disease
    susceptibility, to reproductive effects and cancers. The Naval Health
    Research Center continues to utilize the Millennium Cohort study to
    identify novel potential risk factors for diseases and examine whether
    environmental contaminants related military deployments could be
    associated. Efforts to study environmental contaminants within the Navy
    are not only on land, the Naval Submarine Medical Research Laboratory
    studies exposure risks in the submarine atmosphere, to include
    assessing the use of silicone wristbands as personal environmental
    exposure monitors. The lab maintains a database of atmospheric
    constituents in this unique environment to enable long-term analysis of
    potential effects on submariner health.
                                   __________
                 Questions Submitted by Senator Mazie K. Hirono
                                    red hill
        13. Senator Hirono. Dr. Rauch, I am not sure how familiar you are
    with the ongoing crisis at Red Hill. This massive bulk fuel storage
    facility has contaminated the Navy's water system--displacing almost
    4,000 families since December. As a result, the State of Hawaii has
    directed the Navy to defuel the tanks, and DOD will be shutting down
    the facility. It seems like DOD has not learned from its past mistakes.
    Though not an airborne contamination issue, families who were exposed
    to petroleum contaminated water must be treated with the same level of
    care, to include tracking long-term effects, as those exposed to toxins
    as a result of burn pits. What is DOD doing to prevent these types of
    environmental tragedies from occurring in the future?
        Dr. Rauch. The DOD conducts extensive routine assessments of all
    operations to assure required environmental compliance, hazardous
    material management, and system safety procedures are in place to
    prevent accidental releases of hazardous substances. Deficiencies
    identified during the assessments are prioritized for mitigation and
    repair. Various actions are implemented during the mitigation and
    repair process to assure individuals are not exposed to any hazardous
    substances. In addition, we learn from each occurrence to apply lessons
    and try to proactively prevent them in the future.

        14. Senator Hirono. Dr. Rauch, what has DOD done as far as
    establishing procedures to help track and address petroleum exposures,
    and other contaminants, among servicemembers and their families?
        Dr. Rauch. An official record of the potentially exposed population
    was established as an Incident Report (IR) (# 894583) in the Defense
    Occupational and Environmental Health Readiness System (DOEHRS). This
    DOEHRS IR was created to collect names of individuals potentially
    exposed to contaminated drinking water from the Navy distribution
    system at Joint Base Pearl Harbor-Hickam. There are currently over
    24,000 individuals in the IR. DOEHRS is the DOD system of record for
    entering, assessing, managing and reporting occupational and
    environmental exposures for DOD personnel, and has been expanded in
    this case to include family members as well. The data will be retained
    in DOEHRS for a minimum of 30 years, and is available for any future
    action, research or analysis. The DOD public health enterprise intends
    to use the IR as a roster for assisting in conducting future health
    surveillance, as indicated.
        There has been significant interagency collaboration between
    Department of the Navy, the Agency for Toxic Substances and Registry
    (ATSDR) and Hawaii DOH. ATSDR conducted a web-based health survey for
    Hawaii DOH open to all potentially affected individuals who received
    water from the Navy water distribution system. The ATSDR survey was
    completed on 7 Feb 2022. On February 16, 2022 a preliminary
    presentation of the results of the survey was provided. The survey
    included 2,314 participants on the Navy water distribution system, 88
    percent of whom identified as DOD-affiliated. To date and based on
    available data, ATSDR has not recommend that Hawaii DOH establish a
    health registry at this time and recommended a 6-month followup survey
    with continued collaboration with Hawaii DOH.

        15. Senator Hirono. Dr. Rauch, how will DOD use electronic health
    records integration, in conjunction with the VA, to ensure that
    potential exposures are being tracked during service and that that
    information is going with a servicemember when they transition out, to
    include retirees who continue to access healthcare via Tricare?
        Dr. Rauch. At full functionality, the ILER will be interoperable
    with the EHR. Servicemembers' ILER exposure summaries are accessible to
    VA health care providers, which provide a summary and history of the
    servicemember's exposures based on their location. If a servicemember
    is determined to have been exposed to burn pit emissions at a deployed
    location, a VA healthcare provider can access the available
    environmental health data associated with that exposure. Additionally,
    the DOD and VA are working toward an interoperable EHR that will allow
    a servicemember separating from Service continue to receive continuity
    of care through the VA.

                              burn pit registries
        16. Senator Hirono. Dr. Rauch, what is DOD doing to ensure
    servicemembers know about the registry and sign up?
        Dr. Rauch. The DOD, in collaboration with the VA, are engaged in an
    extensive ongoing education and outreach campaign to spread awareness
    and information about the registry and eligibility. The DOD and VA have
    reached out to potentially eligible servicemembers directly through
    physical mailers, social media, and outreach on leave and earnings
    statements. Servicemembers are made aware of the Registry on the post-
    deployment and post-deployment health reassessments, as well.

        17. Senator Hirono. Dr. Rauch, how does DOD track exposures for
    those who don't opt-in?
        Dr. Rauch. It is DOD policy to conduct routine deployment health
    assessments before, during, and after deployments to track exposures
    and manage health risks from potentially hazardous occupational or
    environmental exposures. The health assessments become part of
    servicemembers' medical record and is available via the servicemember's
    individual exposures summaries within in ILER. These practices are
    standard regardless of whether an enrollment status in the AHOBPR.

        18. Senator Hirono. Dr. Rauch, what is DOD's long-term plan to
    accommodate medical care for those exposures?
        Dr. Rauch. The DOD provides complete medical care for all
    servicemembers prior to their separation. Retired servicemembers are
    eligible for continued medical care through the TRICARE benefit.
    Similarly, the VA provides complete medical care for eligible
    servicemembers upon separation. For service-connected medical
    conditions, the VA will continue to provide medical care.

        19. Senator Hirono. Dr. Rauch, are Tricare providers trained to be
    attentive to conditions that are associated with burn pit exposure?
        Dr. Rauch. The DOD and VA are providing training to providers on
    airborne hazards and burn pit exposures.
        The DOD and VA will assess opportunities to make this training
    available to TRICARE providers.
                           areas for future attention
        20. Senator Hirono. Dr. Szema, Mr. Porter, Mrs. Torres, Mr.
    Patterson, in your opinion, what other unheard or underfunded military
    health concerns associated with the work environment need to be
    identified and addressed?
        Dr. Szema. There are three themes regarding unexplored, unheard, or
    underfunded military health concerns associated with the work
    environment that need to be identified and addressed.
        1. Remote Biometric Monitoring
        2. Environmental Metrics
        3. New candidate drugs
        Firstly, as you continue to explore methods of funding in this
    area, we request that you consider the opportunities that Remote
    Biometric Monitoring may offer these soldiers. We have been working
    together for several years with Play-it Health Company in Kansas since
    2019 to provide remote monitoring to our patients. We were able to
    augment care acutely to our patient population during the onset of the
    COVID pandemic in March 2020 when access to in-person contact was
    limited; we had significant improvement in outcomes. A manuscript is
    under review for publication. We have used Bluetooth continuous pulse
    oximeter ring devices to wear on fingers and have handheld Bluetooth
    spirometers to measure lung function.
        Several years ago, we applied unsuccessfully to the NIH with
    pulmonologist Elizabeth Tam, MD, at the University of Hawaii, for a
    grant to do wristband remote monitoring of particulate matter exposure
    for Hawaiians exposed to wildfires. I was there in Maui on the highway
    when the fire approached Oprah's house and my family evacuated to
    Kauai.
        Secondly, now with United States soldiers on the eastern European/
    Ukraine front and the threat of chemical and biological weapons from
    Russia, and pandemic-related infections worldwide is real, similar
    monitoring of temperature for fever, oxygen saturation, heart rate,
    plus additional Environmental Metrics such as particulate matter
    exposure, sarin gas, and direction of gunshots is critical. I applied
    for a Congressionally Directed Medical Research Grant with the
    Cornerstone Research Group (CRG) in Ohio to develop a wearable device
    on a soldier's belt. It would measure particulate matter concentration
    exposure, sarin gas levels, and gunshot sounds, We got a good score
    (outstanding 1.3) but were told that the DOD does not have sufficient
    funding for burn pits even though the request for applications was for
    burn pits research. GRANT ID GRANT13460409 CDMRP LOG PR21113.
        We are now launching projects to explore remote biometric
    monitoring in these burn pit victims. We have noted that standard
    monitoring, which usually involves static measurements at rest in
    clinics, likely misses significant components of the dysfunction these
    patients experience. We are working with patients to better document
    their biometrics with symptoms and activity, to lend more insight into
    better methods of treatment and rehabilitation.
        We believe that providing funding to monitor these patients more
    closely would be very beneficial and that the findings will also be
    generalizable to other groups, such as those experiencing Long COVID.
        Thirdly, we have already published a mouse model of burn pit lung
    injury (both Iraq and Afghanistan) and have 9/11 dust to make a model
    of World Trade Center Lung Injury. We have tested candidate drugs and
    have coinvented potent New Candidate Drugs. However, the next stage in
    startup drug development for my company RDS2 Solutions, Inc.
    (RDS2solutions.com) requires $2.5 million to send these candidate
    compounds to so-called GMP labs to test in several species of animals
    for toxicology (safety), pharmacokinetics (time course of drug
    absorption, distribution, excretion, metabolism) and pharmacodynamics
    (intensity of drug effect in relation to concentration). Then, a report
    can be submitted to the FDA for an investigational new drug (IND) to
    test in humans. This is costly and not funded with academic grants. So,
    funding from the DOD would allow us to tailor a drug specifically for
    burn pit and war airborne hazards lung injury.
        Mr. Porter. I don't have any underfunded DOD matters, but I do have
    top priority VA concerns I am happy to discuss with her staff, but I
    know that is not within the SASC jurisdiction. If they would like to
    discuss that I am happy to.
        Mr. Patterson. Deployed environmental health surveillance, as a
    whole, is underfunded and under prioritized within the DOD. A review of
    our progress in this space since Desert Storm shows rather limited
    advancements when compared to many other areas of military medicine,
    weapons, or equipment.
        Creation of a small, light, wearable sensor for environmental
    exposures needs funding. The DOD needs to look at new and unique
    solutions in this space to push the science forward for an individual
    monitor. Ideally, it would provide near real time information to the
    individual and/or to senior leaders who can address exposures as
    needed.
        Better, deployable area monitors/sensors also need to be developed.
    Drone based options for deployment or air droppable units which could
    be sent in prior to entry of U.S. personnel would also be valuable
    options.
        Remote sensing for environmental exposures needs to be funded so
    that small teams or unique releases may be tracked in future
    operations.
        The synergistic effects and outcomes of multiple exposures is an
    area which is not well understood. However, the variables there are
    significant and the potential combinations would create a very large
    challenge to evaluate. With 50,000+ toxic industrial chemicals and
    materials which could be mixed in many ways one can see the challenge
    there.
        This is why I would suggest looking at the biomarkers which are
    changed during a servicemember's deployment or over their career due to
    environmental exposures. This could also allow for improved treatment
    of people if their individual exposure can be defined. It could also
    allow us to rule out certain exposures which would improve treatment as
    well as bringing some people peace of mind if they could be shown that
    suspected exposures did not occur to them.
        Allow for easier testing of people who think they have been exposed
    to certain substances. This could put many people's mind at ease if
    they are found to have not been exposed and allow for more efficient
    treatment of people if the testing shows that they did have an
    exposure.
        The combustion products created by the burn pits is not well
    understood. Some studies have been conducted in this space. However,
    they were not done as a burn pit in a deployment is actually operated
    which will impact what is created. A larger concern though is that the
    studies did not include the lithium batteries, pressure treated lumber
    (often with arsenic or formaldehyde), galvanized metal, nor the
    quantities of plastic which were typical.
        A study needs to be conducted as to why, in a mature theater of
    operations, the DOD relied so heavily on bottled water shipped into the
    theater. This resulted in millions of plastics bottles being burned
    which added to those potential exposures from the burn pits. A second
    concern is if the DOD has the ability to provide safe water on the
    battlefield of the future when logistics may prevent the massive
    shipment of water onto and around the battlefield. One must be
    confident that the water they are producing in bulk on a future
    battlefield isn't creating an environmental exposure for those
    servicemembers.
        Review policy and doctrine and have the risks of environmental
    exposures included in them as a factor in future decision-making
    processes.
                                   __________
                   Questions Submitted by Senator Thom Tillis
                                   burn pits
        21. Senator Tillis. Dr. Rauch, the VA has estimated that 3.5
    million servicemembers have been exposed to toxic materials from burn
    pits over the past 20 years. Does this number reflect DOD records?
        Dr. Rauch. Yes, approximately 3.5 million servicemembers have been
    exposed to airborne hazards, specifically fine particulates, which
    include organic and inorganic dusts, diesel generator and vehicle
    emissions, automobile and industrial pollutants. A subset of these
    servicemembers include those exposed to burn pits, which also generate
    particulates.

        22. Senator Tillis. Dr. Rauch, what are known locations of existing
    burn pits?
        Dr. Rauch. Syria, Yemen, Iraq, Egypt, and Chad.

        23. Senator Tillis. Dr. Rauch, what are the sizes/dimensions of
    existing burn pits?
        Dr. Rauch. Currently, the size or dimensions of each burn pit are
    not available.

        24. Senator Tillis. Dr. Rauch, how many servicemembers are
    stationed at the locations of the existing burn pits? Please speak to
    the record keeping and tracking of these servicemembers in proximity to
    burn pits currently in use.
        Dr. Rauch. As of April 15, 2022, the DOD is aware of seven active
    burn pits being operated by host nations or allies proximate to where
    U.S. Forces are stationed. These locations are:
        a.  Syria (2 locations, approximately 234 and 249 United States
    Personnel);
           i. 300 and 800 meters away from work/sleep areas
           ii. Periodic occupational and environmental health sampling and
    assessments are conducted.
        b.  Yemen (approximately 150 United States personnel);
           i. 3,000 meters away from work/sleep areas
           ii. Occupational and environmental health sampling and
    assessments are conducted.
        c.  Iraq (approximately 50 United States personnel);
           i. 3,000 meters away
           ii. Occupational and environmental health sampling and
    assessments are conducted.
        d.  Egypt (approximately 93 United States personnel);
           i. 1,000 meters away
           ii. Occupational and environmental health sampling and
    assessments are conducted.
        e.  Chad (2 Burn pits; approximately 60 United States personnel)
           i. 1000 meters and 700 meters away from common living spaces
           ii. Occupational and environmental health sampling and
    assessments are conducted.

        25. Senator Tillis. Dr. Rauch, what are suspected/unconfirmed
    locations of burn pits? Please speak to the types of waste being
    disposed of at these burn pits and any mitigation efforts in use to
    limit exposure and risk to troops in proximity.
        Dr. Rauch.
        A. A list of unconfirmed locations is not available.
        B. Only non-hazardous and non-infectious solid waste is being
    disposed and burned in active burn pits
        C. Mitigation efforts include moving the pits further away from
    personnel to 2,000 meters from perimeter of base/camp and prominent
    down wind direction, conducting quarterly site assessments,
    establishing personal protective equipment use and training as needed,
    conducting OEH sampling, limiting burn pit use; replacing the burn pits
    with dumpsters or incinerators, hauling waste away in place of burning,
    and assessing health risks.

        26. Senator Tillis. Dr. Rauch, please provide environmental reports
    associated with the existing burn pit locations, as well as
    confirmation that the environmental reports have been added to the
    Individual Longitudinal Exposure Record (ILER) system.
        Dr. Rauch. ILER system provides environmental health risk
    assessments for populations. The environmental reports (such as OEHSAs,
    Base Camp Assessments, and various surveys) provide a foundation of
    information to assist with identification and prioritization of
    potential health threats to the deployed population. Those potential
    threats are assessed to generate an estimate of the health risk to the
    servicemembers. The health risk estimate reports (or health risk
    assessments (HRAs)) are uploaded into the DOD system of record
    (DOEHRS), and ILER imports those HRAs. The ILER also pulls the Periodic
    Occupational and Environmental Monitoring Summaries that are completed
    periodically to summarize all occupational and environmental health
    risks to the population at a deployed location.
        Health Risk Assessment Reports (HRAs) have been completed for both
    Syria locations and North Camp, Egypt. Yemen also has an HRA currently
    in progress. DOD will follow the operations security process required
    to release HRAs outside of DOD.

        27. Senator Tillis. Dr. Rauch, please provide the Committee with a
    copy of the pre/post deployment health assessments that are issued to
    each servicemember.
        Dr. Rauch. Current pre deployment health assessment, post
    deployment health assessments, post deployment health re-assessments,
    and periodic health assessment (Page 4) are attached. Please see the
    appendix for this information.
                                   __________

                   Questions Submitted by Senator Josh Hawley
                                airborne hazards
        28. Senator Hawley. Dr. Rauch, what is DOD's estimate for the
    number of individuals who would qualify for the presumption of service-
    related connection, given how many individuals were likely exposed
    since 2001?
        Dr. Rauch. Thus far, VA has established three presumptions for
    asthma, rhinitis, and sinusitis related to fine particulate matter,
    along with nine rare respiratory cancers. At present it is unknown how
    many individuals (veterans) would qualify for one of these
    presumptions. Additional analysis in coordination with the VA is
    required to provide an answer to the question.

                                    Appendix

        Supporting documents for Colonel Newell question #10.

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Supporting documents for Dr. Rauch question #27.

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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