[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
AN ASSESSMENT OF THE POTENTIAL HEALTH EFFECTS OF BURN PIT EXPOSURE
AMONG VETERANS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, JUNE 7, 2018
__________
Serial No. 115-65
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
35-728 WASHINGTON : 2019
--------------------------------------------------------------------------------------
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
NEAL DUNN, Florida, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
BILL FLORES, Texas Ranking Member
AMATA RADEWAGEN, American Samoa MARK TAKANO, California
CLAY HIGGINS, Louisiana ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto BETO O'ROURKE, Texas
Rico LUIS CORREA, California
BRIAN MAST, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Thursday, June 7, 2018
Page
An Assessment Of The Potential Health Effects Of Burn Pit
Exposure Among Veterans........................................ 1
OPENING STATEMENTS
Honorable Neal Dunn, Chairman.................................... 1
Honorable Julia Brownley, Ranking Member......................... 3
Honorable Phil Roe, Chairman, House Veterans Affairs Full
Committee...................................................... 4
WITNESSES
Tom Porter, Legislative Director, Iraq and Afghanistan Veterans
of America..................................................... 5
Prepared Statement........................................... 35
Kenneth Wiseman, Associate Legislative Director, Veterans of
Foreign Wars of the United States.............................. 7
Prepared Statement........................................... 36
Ralph L. Erickson, M.D., Dr.PH , Chief Consultant, Post-
Deployment Health, Office of Patient Care Services, Veterans
Health Administration, U.S. Department of Veterans Affairs..... 9
Prepared Statement........................................... 38
Accompanied by:
Drew A. Helmer M.D., M.S., Director, War Related Illness and
Injury Study Center and Airborne Hazards Center of
Excellence, VA New Jersey Health Care System, Veterans
Health Administration, U.S. Department of Veterans
Affairs
STATEMENT FOR THE RECORD
Burn Pits 360 (Tom Porter)....................................... 42
Government Accountability Office (GAO)........................... 63
Victor J. Dzau, MD, President, National Academy of Medicine, on
behalf of The National Academies of Sciences, Engineering, and
Medicine....................................................... 68
Veterans Warriors................................................ 69
Whistleblowers of America........................................ 71
Tragedy Assistance Program for Survivors, Wounded Warrior
Project, Vietnam Veterans of America........................... 74
AN ASSESSMENT OF THE POTENTIAL HEALTH EFFECTS OF BURN PIT EXPOSURE
AMONG VETERANS
----------
Thursday, June 7, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health
Washington, D.C.
The Subcommittee met, pursuant to notice, at 3:01 p.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Dunn, Bilirakis, Radewagen,
Higgins, Mast, Roe, Brownley, Takano, Kuster, O'Rourke, and
Correa.
Also Present: Representatives Esty, Wenstrup, Ruiz, and
Gabbard.
OPENING STATEMENT OF NEAL DUNN, CHAIRMAN
Mr. Dunn. All right. Good afternoon, and thank you all for
joining us today. The subject of today's meeting is an
assessment of the potential health effects of burn pit exposure
among veterans.
And I would like to ask unanimous consent for the following
non-Subcommittee Members to sit on the dais and participate in
today's hearings: Congresswoman Esty from Connecticut,
Congressman Wenstrup from Ohio, Congressman Ruiz from
California, and Congresswoman Gabbard from Hawaii. Without
objection, that is so ordered.
Before we begin, I want to take a moment to say what an
honor it is to have been selected to serve as the Chairman of
this Subcommittee. I am the son of a multigeneration Army
family. I also had the privilege of serving as an Army surgeon.
I am also the father of a combat veteran.
I have treated many thousands of soldiers, sailors, airmen,
and veterans in my career. And I have treated them in VA
hospitals and clinics, DoD facilities, civilian facilities, and
intense and MASH units in a combat zone, so--I have worked in
most of the American territories, from Puerto Rico and the USVI
to the Trust Territories of Oceania. I feel personally familiar
with the health needs of our Nation's veterans, and I am
committed to meeting those needs.
We have great veterans, deserving veterans, in all of the
places that I mentioned. And as a Nation, I feel that we are
failing most of them to one degree or another.
I look forward to work with all of my colleagues on this
Committee, and I do mean all of my colleagues on this
Committee. And I thank you for your commitment to our veterans.
With that, I think we can also agree that this is a
critical time for the Department of Veterans Affairs health
care system, particularly with the signing of the MISSION Act
just this week. I am grateful to Chairman Roe and former
Subcommittee Chairman Wenstrup for their leadership and
support. I am very much looking forward to continuing this
Subcommittee's long history of rigorous oversight to ensure
that our veterans have the timely quality care that they
deserve.
Today's hearing concerns regarding the potential long-term
health effects of burn pit exposure. This is a critical issue
facing today's servicemembers and veterans, and should be an
equally critical issue for VA's clinical and research programs.
The testimony provided for today's hearings by the veteran
service organizations and other advocacy groups and the
anecdotal reports of serious issues following exposure to burn
pits in Iraq and Afghanistan are worrisome to say the least.
They also make it clear that, despite a high level of
attention, far more questions remain than answers on the exact
nature and impact of burn pit exposure.
The Airborne Hazards and Open Burn Pit Registry, which
Congress mandated in 2013, is an important tool for the VA to
use to track and monitor those who are exposed to burn pits
during their service. I have concerns that the Registry is not
being used to its greatest potential to communicate with
veterans exposed to burn pits who are worried about their
current and long-term health and well-being. This registry
should be used to guide the VA's research into toxic exposures.
Just 3 weeks ago, we held a joint hearing with the
Subcommittee on Oversight and Investigations that exposed fears
that the VA research program was not properly prioritizing
proposed research regarding veteran-specific conditions and
concerns. I have a hard time thinking of a topic that is more
relevant, important, or deserving of the attention and support
of the VA researchers than this one.
Moving forward, I would like to see the VA prioritize
supporting and conducting the epidemiological research that
will enable us to understand the relationship between burn pit
exposure and the pulmonary and respiratory issues that veterans
returning from deployment report experiencing.
That said, I fear that the narrow focus on burn pit
exposure could be blinding us to other potential in-theater
exposures, like particulate matter and unknown or unrecognized
infectious pathogens that could have an even greater risk to
those who have been deployed in the Middle East. And I believe
these subjects need to be carefully monitored and researched as
well.
I am grateful to our witnesses from the VA and from our
veteran service organizations partners for being here this
afternoon. I would also like to thank all of you who provided
statements for the record, as your input is extremely
beneficial and serves as an important part of the record as
well.
I will say that I am disappointed that the representatives
of DoD chose not to participate today. This is currently the
only planned panel on this subject. Their statement is
available for the record. However, as a potential key
contributor in what needs to be an ongoing research into this
problem, their presence today would have been valuable.
I will now yield to Ranking Member Brownley for any opening
statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman.
Every era of veterans has experienced some type of
environmental, radiological, chemical, biological hazard while
on the battlefield. Most recently, Operation Iraqi Freedom and
Operation Enduring Freedom era servicemembers were exposed to
airborne toxins, many of which we have yet to identify.
We send our servicemembers to fight abroad, and now DoD and
VA have a responsibility to properly address their health care
needs when they come home. The DoD and VA must work together
with clinicians and investigators to identify all veterans who
may have been exposed to airborne hazards.
This need to know has resulted in numerous VA-maintained
registries. While today's hearing is centered around only one
of these registries, I urge today's witnesses to consider
whether the value of these registries would be vastly improved
by consolidating them into one. One master registry would
likely be easier for both veterans, physicians, and
investigators to navigate.
With that said, today's hearing is focused in part on the
Airborne Hazards and Open Air Burn Pit Registry. The exposure
of post-9/11 veterans stationed in Iraq and Afghanistan to
airborne hazards because of the military's use of open air burn
pits has affected an untold number of servicemembers and
veterans.
For this reason, in 2012, Congress required VA to establish
the open burn pit registry. The open burn pit registry is an
effort to identify and monitor the health effects of toxic
airborne chemical and fumes on veterans exposed to those open
air burn pits. While in the current state it cannot be the
basis of scientific research, it can help the VA to define
research questions and allow the VA to update and track
participants.
However, it does have its limitations, as outlined by the
National Academy of Sciences. As this registry is voluntary and
based on self-reported information, investigators cannot link
airborne hazards and long-term health efforts. This is
disappointing because our veterans need our help now.
One way the VA has attempted to advance research is through
its war-related injury and illness center, Airborne Hazards
Center of Excellence, by flagging veterans with particularly
complex or unique symptoms or diagnosis that were exposed to
airborne hazards for more complete evaluations. But also, not
only is VA capturing much needed data, but also ensuring they
receive advanced clinical care through expertly prepared
treatment plans.
However, VA's ability to advance this type of research is
limited by DoD's cooperation and efforts to identify the
servicemembers exposed to burn pits. That is why it is both
unfortunate and disappointing, as the Chairman said, that the
agency who will need to be a true partner is unwilling to
participate in today's discussion.
Furthermore, until a fully interoperable electric health
record system is set up between two agencies, VA will continue
to be beholden to DoD's willingness to cooperate. For this
reason, it is of utmost importance that VA's Electronic Health
Record Modernization team is in direct communication with both
VA clinicians and VA investigators. And I look forward to
hearing more from the VA on this issue.
Mr. Chairman, thank you for holding today's hearing. It is
an important one. And I thank you to each of the witnesses for
the work you have done to ensure these veterans are neither
forgotten or overlooked. And I yield back.
Mr. Dunn. Thank you very much, Ranking Member Brownley.
I now yield 5 minutes to the overall Committee Chairman,
Dr. Phil Roe.
OPENING STATEMENT OF PHIL ROE, CHAIRMAN, HOUSE VETERANS AFFAIRS
FULL COMMITTEE
Mr. Roe. Thank you, Mr. Chairman and Ranking Member
Brownley. And I thank everyone for being in attendance today.
As a scientist in training in medical school, epidemiology
always tweaked my interest. And as a Member of this Committee
for the past several Congresses, I have been following the
issue of DoD toxic exposures with great interest. In fact,
Ranking Member Walz and I have been the lead sponsors
supporting appropriations for DoD's congressionally directed
medical research program on Gulf War illness the past several
years. However, I have shared my thoughts on toxic exposure
medical research methodology in past hearings. I maintain that
using data from self-reported registries creates a selection
bias and is an inherently flawed way to conduct research.
That being said, I see tremendous room for improvement in
this arena, especially with the ongoing development of a joint
electronic health record between DoD and VA. With this new EHR,
we have an incredible opportunity to ensure data integrity for
future environmental and toxic exposure epidemiological
studies. Granted, that joint health record will likely not be
deployed 10 years down road. But if DoD, VA, and Cerner can't
develop ways to use it to capture and mine deployment and
related health data during its development, we lose an
incredible opportunity to identify data to help us understand
whether a veteran's service to this country contributed to
their or caused their unexplained health conditions. I believe
we can and must use this opportunity to ensure that capability
is part of the design.
I also believe we should be taking a look, to the extent
possible, at the local populations of where these exposures are
believed to have originated. For example, we should be looking
to study local and native people of Kuwait and Iraq to see if
the conditions attributed to Gulf War illnesses are present
within the local population. If you actually have a whole two
sets of populations, you could study and compare. If we can
broaden the sample size of those infected beyond servicemembers
and veterans who self-report, we might have a better
opportunity to identify the causality of military practices and
related health conditions. Just some food for thought.
As I mentioned before, this is an incredibly important
subject to me, and I am disheartened that DoD declined to
participate today. Current and future servicemembers deserve to
know what steps DoD is taking to protect the health of the men
and women who sign up to serve. Veterans deserve to know what
steps VA is taking to advance research to identify and address
health hazards that may be related to exposure.
I will just harken back 40 to 50 years ago now to Vietnam
when we, you know, sprayed everything, and Korea also, where I
served, Thailand, other places where Agent Orange was sprayed.
The people who transported this, we didn't keep adequate
records. And we are going to vote on a bill hopefully on the
House floor in the next couple of weeks, the Blue Water Navy
bill, which every Member of this Committee--we have been trying
for 20 years to get it done. This Committee got it done.
We didn't keep adequate records. There is really no way to
determine the science behind that. That is just impossible. So
I finally said, look, let's just make this determination and do
it on the basis of what is right for the veteran to do, since
we cannot prove it one way or the other.
Again, I would like to thank Dr. Dunn for allowing me to
join the hearing today, as well as the panelists for sharing
your time with us.
And, Mr. Chairman, I yield back.
Mr. Dunn. Thank you very much to Chairman Roe.
Joining us this afternoon for our first and only panel is
Tom Porter, the Legislative Director for the Iraq and
Afghanistan Veterans of America. And also, Mr. Kenneth Wiseman,
the Associate Legislative Director for the Veterans of Foreign
Wars of the United States. And Dr. Ralph Erickson, the Chief
Consultant for Post-Deployment Health for the Office of Patient
Care Services for the Veterans Health Administration of the
Department of Veterans Affairs. Dr. Erickson is accompanied by
Dr. Drew Helmer, the Director of the War Related Illness and
Injury Study Center and Airborne Hazard Center of Excellence
for the VHA New Jersey Health Care System.
Thank you all for taking the time to participate in this
important hearing today.
And, Mr. Porter, I believe we will begin with you. You are
now recognized for 5 minutes.
STATEMENT OF TOM PORTER
Mr. Porter. Thank you, Mr. Chairman.
Before I get started, I would like to call your attention
to the many IAVA members that are here in town, many from
California and Tennessee and Texas. So I just wanted to ask you
to note that we have got folks in town storming the Hill on
burn pits issue.
On behalf of IAVA, thank you for allowing me to share our
views on what may now be the Agent Orange of our generation. I
am here not only for IAVA, but as an OEF veteran exposed to
airborne toxins from burn pits and other sources at many
locations I was deployed to in Afghanistan and Kuwait between
2010 and 2011.
Before I went down range, I had healthy lungs. Shortly
after I arrived in Kabul, where the air is particularly bad, my
lungs had a severe reaction and became infected. It was
controlled with medication over the next year. However, after
redeploying home, I stopped the medications and symptoms came
back. And I was diagnosed with asthma as a result of my
deployment.
Exposure to burn pits used by the military to destroy
medical and human waste, ordnance, plastics, and other waste
has been widespread. It is not just those working at burn pits.
Search for the Poo Pond song on YouTube and you will hear one
soldier's humorous take on the enormous lake of human waste
that tens of thousands of servicemembers lived, worked, and ate
around at Kandahar Airfield in Afghanistan.
You could also learn from many who have served in Kabul, an
enormous city with open sewers and whose population routinely
burns dry animal dung to keep warm in the winter. Our military
serving there are suffering the impacts from breathing airborne
feces and other toxins for extended period of time. There have
been burn pits there as well.
Our VSO friends, especially those who served in Vietnam,
know the depth of this problem. Dr. Tom Berger at Vietnam
Veterans of America will tell you they know too well the
hazards of these battlefield exposures saying, quote, that is
one of the reasons VVA is so involved in this issue. We don't
want to see the newest generation of vets go through the same
health care challenges we are still facing with toxic
exposures, especially with our children and grandchildren.
Army veteran Christina Thundathil, a member of ours, told
us recently of her deployment to Iraq. Although her specialty
was food prep, her job was to drag the full bins of Porta-John
refuse daily, douse it with jet fuel, and light it on fire,
stir it with her e-tool, then repeat it until she had a brick
that she could bury in the sand. She has got serious injuries
and she needs a cure now.
The examples are many. However, little is understood about
the long-term effects. We see an upward trend in the number of
members reporting symptoms associated with burn pits, with 80
percent of IAVA members reporting being exposed to burn pits on
deployment and over 60 percent of those suffering symptoms.
This year, IAVA will educate Americans about burn pits and
airborne toxic exposures and the devastating impact it could be
having on the health and welfare of millions of post-9/11 vets.
To see the enormous extent of interest in this issue by
veterans, you need to only look at the comments section on any
related article online or see our viral burn pits hash tag on
social media.
The VA has an airborne hazards and burn pit registry which
helps them collect and analyze data on health conditions
related to deployment exposures. Unfortunately, only 141,000
have completed the registry out of 3.5 million the VA says are
eligible. Only 1.7 percent of the post-9/11 veterans eligible
have completed it, and only 35 percent of IAVA members exposed
have.
A definitive link between exposure and specific illnesses
has not yet been made, and the registry is not well-known and
is underused. The result is that the data is not being
collected at the levels desired to inform the next steps. It is
for this reason that IAVA helped to develop new legislation.
On May 17, IAVA stood with Iraq war veteran Congresswoman
Tulsi Gabbard and Afghanistan veteran Congressman Brian Mast.
Thank you, Congressman. We also stood with the support of 23
other VSOs in support of the introduction of the Burn Pits Act.
The bill directly directs DoD to include periodic health
assessments done by the military and, at separation, an
evaluation of whether a servicemember has been exposed to burn
pits or toxic airborne chemicals. If they have, they will be
enrolled in the burn pit registry, unless they opt out.
The bill simply does what should have been done long ago.
It compels DoD to record exposures before the servicemember
leaves the military. Retired general and IAVA board member
David Petraeus, who once commanded all forces in Iraq and
Afghanistan, recently expressed his support for the bill
saying, quote: Veterans are currently experiencing illnesses
that are like--that likely are related to exposure to toxins in
the war zones and swift action is needed to understand the
impact on health from exposure to smoke from burn pits and
other sources.
We ask the Committee to hear the calls of the many exposed
veterans and enact the Burn Pits Accountability Act this year.
Again, I thank the Committee for inviting me to express our
views, and I stand by for any questions.
[The prepared statement of Tom Porter appears in the
Appendix]
Mr. Dunn. Thank you, Mr. Porter.
Mr. Wiseman, you are now recognized for 5 minutes.
STATEMENT OF KENNETH WISEMAN
Mr. Wiseman. Chairman Dunn, Chairman Roe, and Ranking
Member Brownley, and Members of the Subcommittee, on behalf of
the Veterans of Foreign Wars of the United States and its
auxiliary, thank you for the opportunity to testify on the
important issue of burn pits.
The use of open air burn pits in combat zones has caused
grave health complications for many servicemembers, past and
present. Harmful materials are present in burn pits creating
clouds of hazardous chemical compounds that are unavoidable to
those in close proximity.
While the VFW is glad to see more than 140,000 veterans
have enrolled in the VA's Airborne Hazards and Open Burn Pit
Registry, we are concerned that the results of the National
Academy study on the registry have not been fully implemented.
The VFW urges VA and Congress to act swiftly on these important
recommendations.
For example, a similar study operated by Burn Pits 360
allows the spouse or next of kin of registered veterans to
report the cause of death for the veteran. VA must add a
similar feature to its registry to ensure VA is able to track
trends.
The VFW hears from veterans about the lack of outreach from
the registry. The low rate of completion for the medical exam
associated with joining the registry is one of many reasons VA
must improve its outreach efforts.
As VA moves to implement the electronic health record, EHR,
special attention must be given to ensuring the record can
interact with the registry. This will ensure that data follows
the veteran from the time of the exposure through discharge and
life after the military. It will also allow doctors to provide
proper care knowing the full history of the veteran.
Much of the veterans' long-term health is dependent on what
happened to them while in the military. While ensuring the EHR
communicates with the registry is important, there is also a
need for other information from DoD. The VFW has long advocated
for better sharing of all relevant data on burn pits, to
include environmental studies and medical records of veterans
with related health issues. Congress must require DoD to share
all data related to burn pits.
The VFW supports passage of H.R. 5671, the Burn Pits
Accountability Act, and H.R. 5920, the Airborne Hazards and
Open Burn Pit Registry Improvement Act, which would improve the
Registry and the overall body of knowledge on burn pits.
The VFW is happy to learn that a joint project between DoD
and VA to create a database of exposure information is
underway. The individual longitudinal exposure record will
create a centralized database for records related to exposure,
feed data into needed research, allow doctors to know what the
veteran has faced, and will allow greater access to evidence
for a veteran's disability claim. The VFW knows that research
is being funded and performed by the VA. The VFW supports VA's
inclusion of oversight ensuring proper scientific methods are
used in the studies being funded.
We also support VA's efforts to hire more researchers and
to fund employee-led research like that conducted at the VA
medical center in Northport, New York, which found a connection
between deployments to Iraq and Afghanistan and adult onset
asthma among 6,200 veterans in the local area of the facility.
Several other studies are underway, and this will require
dedicated funding.
The VFW is pleased that VA will ask the National Academies
to review existing research to determine whether the evidence
supports a connection between exposure to burn pits and deadly
respiratory conditions. Veterans deserve to know what is making
them sick. The VFW urges this Subcommittee to ensure the
important study is commissioned and properly conducted.
Incorporating proper oversight and dedicated funding for
burn pit related research is why the VFW also supports
establishing a Congressionally Directed Medical Research
Program, or CDMRP, specific for burn pits. The Gulf War Illness
CDMRP has shown progress in identifying causes and effective of
treatments for Gulf War Illness, and a similar program for burn
pits will help exposed veterans.
The VFW also wants to highlight the impact of burn pits on
women veterans with particular regard to reproductive issues.
Medical research on the Gulf War has historically failed to
properly include women veterans. A VFW member who was exposed
to burn pits called me, and she told me how her children were
born with birth defects, including seizures, how they were born
with high levels of heavy metals in their blood, and how she
had to get a hysterectomy in her late 20s. This is not normal,
and this must be answered.
Women veterans deserve to understand how their military
service may or may not have long-term impacts on their health.
As such, the VFW calls on VA to improve research related to the
impact of burn pits as they relate to reproductive health
issues and birth defects.
In closing, the VFW sees that there are more miles in front
of us than behind us on the issue of burn pits.
Mr. Chairman, this concludes my testimony, and I am ready
for any questions you or the Subcommittee may have. Thank you.
[The prepared statement of Kenneth Wiseman appears in the
Appendix]
Mr. Dunn. Thank you very much, Mr. Wiseman.
Dr. Erickson, I now yield 5 minutes to you.
STATEMENT OF RALPH L. ERICKSON, M.D., DR.PH
Dr. Erickson. Good afternoon, Chairman Dunn, Ranking Member
Brownley, and Members of the Subcommittee. I appreciate the
opportunity to discuss the ongoing research and actions of the
Department of Veterans Affairs is taking to identify and care
for veterans who are exposed to burn pits during service in the
Armed Forces.
I am accompanied today by Dr. Drew Helmer, director of both
the War Related Illness and Injury Study Center, New Jersey,
and VA's Airborne Hazard Center of Excellence.
Veterans are appropriately concerned about burn pits and
airborne hazards during deployments, and so are we. These and
other exposures may be associated with the reported symptoms of
shortness in breath and diminished exercise capacity that we
hear from our veterans. The collaborative and ongoing efforts
of VA, DoD, and our partners in academia are being fully
employed to identify veterans who may be at risk and to better
understand potential short-term and long-term adverse health
effects that may be associated with their exposure. Our
combined aim is to limit future exposure to deployed forces and
to prevent the development of disease and disability.
Open burn pits were used as a common waste disposal method
at military bases in Iraq, Afghanistan, and other countries in
the region. The smoke and fumes created by these burn pits
added to the already existing complex burden of dust,
particulate matter, and general air pollution commonly present
in the Southwest Asia environment.
In 2013, Congress enacted legislation requiring VA to
establish and maintain an open burn pit registry for eligible
individuals who may have been exposed to toxic airborne
chemicals and fumes caused by open burn pits. In 2014, VA
established the Airborne Hazards Open Burn Pit Registry. This
is VA's fastest growing environmental health registry and
includes more than 144,000 participants as of today.
VA and DoD subject matter experts meet monthly to discuss
and plan joint actions for the study of deployment-related
exposures and their possible association with subsequent
adverse health conditions. In May of 2017, VA and DoD gathered
50 subject matter experts and held a symposium to address the
health effects of airborne hazards exposure during deployment.
This allowed VA and DoD to review and develop innovative
approaches to research and clinical care. VA investigators
recently convened a similar group of experts for a workshop at
the American Thoracic Society meeting in San Diego.
One specific early innovation by VA was the establishment
of the Airborne Hazards Center of Excellence in 2013 at the New
Jersey War Related Illness and Injury Study Center. The Center
of Excellence houses VA's only comprehensive clinical
assessment program dedicated to studying the adverse effects of
airborne hazards in veterans. Of special note, select registry
participants with high priority conditions and exposures will
be invited in for a comprehensive in-person clinical evaluation
with the option to volunteer for related research projects.
As part of our written testimony, we highlighted six major
VA and DoD studies which are addressing the potential adverse
health effects associated with burn pits and airborne hazards.
We also included a bibliography of recently published VA work
and provided two extensive lists of ongoing VA research
projects in this area.
VA is committed to the health and well-being of our
veterans and is dedicated to working with our interagency and
academic partners to determine the best possible care for our
veterans. VA hopes to ease the suffering of veterans, while
building on the momentum and gains made thus far. To this end,
your continued support is essential and greatly appreciated.
Mr. Chairman, this concludes my testimony. My colleague and
I are prepared to answer any questions. Thank you.
[The prepared statement of Dr. Ralph L. Erickson appears in
the Appendix]
Mr. Dunn. Thank you very much, Dr. Erickson.
I now yield myself 5 minutes for questions. And I will
start with you, Dr. Erickson.
One of the critiques we have heard regarding the assessment
of pulmonary health of returning servicemembers is the use of
PFTs. Specifically, we have heard that studies on post-
deployment servicemembers are simply read as normal or
abnormal, and the studies are not compared to any potential
test numbers prior to deployment because no pulmonary studies
are often performed before deployment. I am looking
specifically at the diagnosis of constrictive bronchiolitis.
Unless you have an abnormal PFT value, you really don't
have an indication of progress in your workup, yet the patient
says they don't--he or she doesn't feel as well as they--are as
fit as they used to be. And given that most of these servicemen
and -women are at the peak of health, would you agree that it
is possible that there is a significant decrease in pulmonary
function that can occur and yet the studies might still be read
as normal? And do you plan on performing a study that would
look at the differences in PFTs pre- and post-deployment?
Dr. Erickson. Absolutely, Chairman. Your question hits to
the heart of the limitation of pulmonary function tests. One of
our DoD collaborators in San Antonio, in fact, is trying to
look at pre- and post-deployment PFTs.
But one of the innovations that I was alluding to earlier
at the Airborne Hazard Center of Excellence, in fact, involves
actually looking at the molecular level, looking at the
diffusion of oxygen and CO2 across the alveolar membrane,
because we think, in fact, that PFTs are, in fact, inadequate
as a screening mechanism.
Mr. Dunn. Thank you very much.
Doctor, I think the next question is in the wheelhouse of
Dr. Helmer.
One of the major problems impacting the ability to find a
causative etiology from the burn pits for these illnesses is
the difficulty in separating local environmental factors, such
as the burning of dung for fuel, particulate matter, and local
microscopic flora.
Has any research been done or are you planning on doing any
research to look at the pathologic conditions endemic to the
local population? Do we have any indication that the local
population has been affected by the burn pits? If not, why do
you think this is so, and should we be looking into that? And
also, is it possible, because our servicemembers are not native
to the area, that they are having an inflammatory action to the
local environment which the native population may be--to which
the native population may be immune?
Dr. Helmer. That is a great question, because I think we
don't know a lot of those answers right now. And people are
looking at those issues, both the geologic dust and its effect
on our servicemembers and the local population. We are also
looking at the possibility of a genetic environment interaction
in our servicemembers that may be responsible for the symptoms
that develop and the various health conditions that we can
diagnose in servicemembers.
It is an ongoing question that we are looking at, and we
are actually partnering with the DoD to try to do some of that
work.
Mr. Dunn. Do you have any speculation on infectious
conditions that--and I am thinking, you know, because of my
deployments, honestly, of San Joaquin valley fever,
coccidiomycosis, or unknown or unrecognized other infectious
agents that behave like those in terms of respiratory
conditions?
Dr. Helmer. That is not my particular area of expertise,
but I know we are looking at that. And certainly, in terms of
some of the identifiable infectious agents, we have not found
them when we have gone looking for the underlying mechanism of
disease in the patients who are symptomatic. But we will need
to continue to look at that.
Mr. Dunn. Thank you.
So I suspect I speak for the entire Committee when I say we
will be interested in seeing some of the research that you are
doing to identify any of the many, many potential complicating
agents here, some of which are every bit as concerning as toxic
exposure.
With that, I am going to yield back my time, and we will
recognize Ranking Member Brownley for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman.
You know, I personally feel like the very best strategy to
address this issue altogether is just to eliminate the use of
burn pits. It seems to me that--I have a large Navy base in my
district. They are using biofuels to fly their airplanes. I
think that if we put our heads together, we could figure out a
better way in which to address these issues in the battlefield.
So I just wanted to say that for the record.
Dr. Erickson, I wanted to talk to you a little bit about--
you stated in your testimony that the DoD is making a concerted
effort to encourage servicemembers to enroll in the Registry.
Can you tell me a little bit about, you know, how they are
stepping up their efforts and what is really happening?
Dr. Erickson. Yes. Absolutely, Ranking Member. We very much
cherish the relationship with DoD because we need to be linked
at the hip. As we have had our monthly deployment health
workgroup meetings to deal with these issues, it has become
very clear that there needs to be no separation from when
someone takes the uniform off and then enters VA care. And to
that end, we have partnered with them.
DoD has, on their own, then, taken steps to actually
promote participation in the Registry, either after a
deployment or at the point of transition, which we think is
just exactly the teachable moment. It is just exactly the right
place.
At the present time, I mentioned we have 144,000 people who
are participating. About 30 percent of that 144,000 are
individuals who are currently on Active Duty, in the Guard, or
the Reserve. And we expect that percentage to actually
increase.
Ms. Brownley. And are you monitoring that increase? I mean,
it seems as though 144 is--you are stating that is a lot of
progress. But based on the entire population, it seems like a
drop in the bucket to me.
Dr. Erickson. We certainly are monitoring it. And yet I
will be the first to tell you that we can do better, and we
want to do better. This involves outreach through many
modalities right now, not just in partnering with DoD, but
through our newsletters, through our participation with VSOs,
our Web sites. We do a lot of education, townhalls. The list
goes on, because we want to get the word out. My hope would be
that, in fact, a hearing such as this would bring additional
attention to the need for more to participate.
Ms. Brownley. And I was disturbed to hear Mr. Wiseman's
testimony with regards to women and women really being
underrepresented. And I think it is--I think we know that many
times, not always, but many times, women, once they leave the
military, they sometimes don't see themselves and identify
themselves as veterans. So it seems to me we need to make a
special effort to make sure that we have a large enough
population of women to be able to ultimately get to the
research we need to find the treatments that we need. I mean,
to hear the testimony of a woman who is bearing children with
defections and so forth, it is very, very disturbing.
Can you speak to that?
Dr. Erickson. Yes. Absolutely. I am a third-generation
career Army officer. My daughter right now is a lieutenant
colonel in the Army. And she, in fact, is deployed right now to
that region.
This issue is very important to us. Our large epidemiologic
studies, six of which we mentioned, purposely oversample for
women, so an adequate number of women participating in those
studies. Because you are exactly right; women may, in fact,
have different adverse health effects. They may respond
differently.
As it relates to these intergenerational effects, the next
generation, we currently have two ongoing studies that we have
commissioned with the National Academy. One of them is the Gulf
War and Health, Volume 12, in which we have asked the National
Academy, in fact, to give us a roadmap, to give us a template
for how should we launch with other interagency partners to do
the proper study to actually look at those effects that might
be heritable, that might be passed to the next generation.
Ms. Brownley. Thank you.
I only have 30 seconds left. But do the VSOs have any
suggestions or ideas in terms of outreach to improve the
circumstances?
Mr. Wiseman. Every year, Madam Ranking Member, the VA sends
numerous employees to the VFW national convention. We would be
happy to continue that effort. We would also be happy to go to
our State level conventions and regional conventions. Outreach
is something that already happens. And so we can add this as
one more thing that we are working on through that outreach
process. And I think that would be easy, and it is a great
idea.
Ms. Brownley. Mr. Porter?
Mr. Porter. Congresswoman, thanks. Well, I think they need
to understand how veterans communicate and how they would like
to be communicated to. Whereas one generation might want a
newsletter, I can tell you the post-9/11 generation, they don't
read newsletters. I was walking through the Rayburn building
the other day outside the VA's office, and there was a
newsletter that said for post-9/11 veterans. I had never seen
that before. And that was the only time I have ever seen any
kind of outreach on burn pits. I thought, wow, this would be
great if it was on social media.
I mean, it would be great if they asked veterans how they
would like to be communicated to, and they would probably be
surprised. So they are going to have to get used to using
Twitter and Instagram and Facebook and Snapchat and all those
kind of things to be able to reach those folks.
Ms. Brownley. Thank you, Mr. Porter.
My time is up, and I yield back.
Mr. Dunn. Thank you very much, Ranking Member Brownley and
Mr. Porter.
I now turn to the Full Committee Chairman, Dr. Phil Roe. I
yield 5 minutes for questions.
Mr. Roe. Thank you. And welcome Dr. Ruiz back to the
Committee. We are glad to have you here.
And my generation likes to be communicated with smoke
signals, so we are all different.
And I hope--and I don't know what kind of physical exam
that people get when they go in the military now. But when I
went in, this is the truth, my physical examination to go into
the 2nd United States Infantry Division was, ``If I examined
you, would I find anything wrong?'' So nobody ever laid a glove
on me getting in the Army. I hope they do a little better now
than they were then.
I don't know whether PFTs are actually done or not, but
this is so intriguing to me. I would love to be involved in
this clinical study, because you have a population, Dr.
Erickson and Dr. Helmer, that were deployed. You also have a
group of people who never enlisted--never volunteered I mean.
They are the same cohort age. You also have a population that
were deployed, if you can identify them. And you also have the
Navy population. So it is really an amazing group of people
that you have. And I think it is important to try to
differentiate whether the burn pit had anything to do with it
or whether just being deployed.
I have been to Afghanistan many times. And I know 40, 50
years ago when--40-plus years ago when I was in Korea, it was
very different than it is today. And hopefully, Afghanistan and
Southeast Asia, Iraq will be different going forward. But it
looks to me like we could find that out. Is it just being there
in that environment where they said they are burning dung, or
whatever toxins may be just in the air, or whether it actually
had to do with how the military dispensed with its waste?
So is that being done? Because the Registry is--it is good
to sign the people up. You know who they are. But I think that
is very limited, what you can do. But are you doing that
population study? Because it is laid right out there for us to
do. And what do you need to do it? Because I would support that
in a heartbeat.
Dr. Erickson. Yes, sir. I am picking up exactly what you
are saying as it relates to epidemiology because, of course, we
would always want to have a comparison group. And the perfect
built-in comparison group are those who did not deploy.
Some of the studies, though, actually we might include a
second comparison group which involves the civilian population.
Of course, we would need to do some types of adjustments. You
can do matching, as you know, or post hoc analysis that
controls for those differences. But absolutely.
Mr. Roe. Are we doing that?
Dr. Erickson. So the large survey studies that were
mentioned in the written testimony actually are able to do
those comparisons.
Mr. Roe. And what did you find?
Dr. Erickson. Most of those are ongoing right now, so it is
too early to share all those results. But they are built into
the study design to--and it is intended to have those
comparison groups.
Mr. Roe. Well, it is the reason I want to go ahead is I got
tired of talking about cannabis, medical cannabis. And I said,
well, why don't we study it? And it makes sense to me to do
that. It has for 10 years. I don't know why we hadn't done it.
But the same thing here. So that study, when will we have
that data? Because that will help us a lot up here at the dais
to be able to make some decisions about these young people
sitting out here in the audience.
Dr. Erickson. Chairman Roe, I will get that for you, and
for each of those major studies, I will get you the expected
completion date. And, of course, the goal is for them to be
published in the peer-reviewed literature.
Mr. Roe. Well, I would hope that it would be.
Dr. Erickson. Yes.
Mr. Roe. And I think that will be incredibly helpful to us
as a Committee going forward to making the decisions we need to
make when we get that science-based study out there.
The other thing, and I will bring it up and only just to
mention, and I will yield my time back, is that we have a
phenomenal opportunity in the next few years when we roll out
this combined DoD EHR. If it can do what we need for it to do,
maybe not right now--and certainly, you know, my electronic
health record was this. I just carry it around. This is the
same as Thomas Jefferson's. But I think we have an opportunity
to be able to watch a population throughout their entire life
from when they are young adults until they pass on. So I hope
we do it right and can set that up, because the amount of data
we are going to have with this--millions of our American
citizens is going to be a treasure trove of information.
So I hope you all can help us with that so, when we are
guiding through that, we can use that information.
Dr. Erickson. Just if I can quickly say, the individual
longitudinal exposure record, which is piloted this fall, will
be the initial step in that direction. And through the
development of the EHR through Cerner, we are looking to have
that same capability carried into the record itself, so it will
be permanently available.
Mr. Roe. Well, please help us--any way we can help make
that happen, please let us know.
I yield back.
Mr. Dunn. Thank you very much, Mr. Chairman.
And we now recognize Representative Takano from California.
Mr. Takano. Thank you, Mr. Chairman.
Dr. Erickson, last month, as you know, the VA entered into
a contract with Cerner to support its efforts to modernize its
electronic health record system. With the development of a
system where VA and DoD may share electronic--or while the
development of a system where VA and DoD may share electronic
health records, it will directly increase the quality of and
access to health care for veterans. It will also significantly
improve the development of health care solutions as it will
allow for the mining and analysis of data on a much larger
scale, so big data. The impact of this type of data collection
is likely to have on the VA's research arm will be incredible.
What interactions have either post-deployment health
services or Airborne Hazards Center for Excellence had with the
EHRM team to ensure that the resulting EHR system is conducive
to the collection of data surrounding a servicemember's
encounter with hazardous environmental conditions such as open
air burn pits?
Dr. Erickson. Thank you for the question. Sir, we have a
member of our team, in fact, embedded with one of the subgroups
that is helping develop the EHR for exactly the purpose that
you express.
Mr. Takano. Well, my interest is, of course, that we have a
more proactive approach to anticipating these sorts of
symptoms. And I think if we can trace where somebody's been on
Google Maps and navigation systems, we should be able to know
where every servicemember has also been and correlate that to
place specific kinds of ailments. Am I correct in that?
Dr. Erickson. Absolutely. In fact, our goal, the end state,
would be that from induction to the point of discharge or
retirement from the military, we would then have captured
through the lifespan, the military lifespan of that individual,
all of those exposures, all of those deployments, all of the
medical encounters, both inpatient and outpatient.
Mr. Takano. So who would be responsible? Whose
responsibility would that be to try and track--to try to
correlate a servicemember's service record and any kind of
diseases, ailments, or symptoms that there may be a pattern--
recognized in that pattern? Is it DoD? Is it the VA research
function?
Dr. Erickson. This, in fact, is a shared responsibility
between DoD and VA. And, hence, the workgroup that I have
mentioned to you actively looks to find a common solution. And
sometimes, in fact, our studies will track someone from a given
unit when they were in uniform to when they entered the VA
medical system and points thereafter. So it is actually a
responsibility that we share.
Mr. Takano. Now, do we know for a fact that the data that I
am talking about, the geographic data of where that
servicemember's unit was involved, is that integrated into the
health record at the DoD?
Dr. Erickson. At the present time it is not.
Mr. Takano. Do we know if that is part of a future plan?
Dr. Erickson. You know, this is something, Representative
Takano, that it is under development, and so I can't speak to
that in a definitive way. I think this would be certainly a
good thing to have. However, I can't confirm that the exact geo
coordinates, for instance, would be included.
Mr. Takano. Because part of what we have experienced with
Agent Orange is, you know, where were these servicemembers?
Were they on ships and were they in waters or were they--how
far from--and do we know when we use certain kinds of
defoliants? It seems to me that when we deploy soldiers, that
we have an assessment of the environmental hazards that
preexist their deployment but also these burn pits, which also
add to the environmental hazards. So it seems to me that we
need to have, not only an integrated medical health record that
is interoperable between the DoD and the VA, but we need to be
able to integrate the data, the geographic data.
Do we need to kind of have a different kind of dog tag to
know where these servicemembers actually have been? So I think
the technology makes that available--makes it possible. Am I
correct?
Dr. Erickson. Absolutely. One of the related issues would
be classification of certain missions may make that not
possible.
Mr. Takano. I get that, yes.
Dr. Erickson. And, of course, operational security.
Mr. Takano. Okay.
Well, I yield back, Mr. Chairman.
Mr. Dunn. Thank you very much, Representative Takano.
Representative Bilirakis, you are recognized for 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it
very much. Congratulations on your chairmanship. I know you
will do an outstanding job. It is great to see a fellow
Floridian in the chair.
Folks, I would like to invite our veterans who were exposed
to the burn pits to my office, maybe after the hearing, if
they'd like to come and share their personal stories, those who
are here in the audience. I have seen documentaries and also I
have constituents who have gone through this. But I would love
to hear from you as well, so please don't hesitate. My office
is at 2112 Rayburn.
My first question is for Dr. Erickson. In his statement for
the record, Captain Torres recommends establishing a scientific
advisory committee to comprehensively review the full spectrum
of research on burn pit exposure, independently examining the
medical evidence both inside and outside of the VA. Other
testimonies mention this similar, they have the similar ideas.
Do you support this idea?
Dr. Erickson. Thank you for the question. At the present
time, we have a joint action plan with DoD that actually helps
us set priorities for this type of research, and so that is a
collaborative effort between DoD and VA which, no, it does not
include an outside independent body.
Mr. Bilirakis. And why not? Why not?
Dr. Erickson. I don't know.
Mr. Bilirakis. Well--
Dr. Erickson. I can tell you this, that we have relied, for
the most part, on the National Academy of Medicine to review
much of our work. In fact, right now, we are under negotiation
with the National Academy to do a new airborne hazards
consensus review of our work.
Mr. Bilirakis. I just don't understand why we can't have
some outside research. I mean, we have got to get in front of
this issue, sir. I don't want to see--I don't want to see what
happened with our Vietnam vets and the Agent Orange. This is
really tragic.
So what I would like to do now is ask Mr. Wiseman and Mr.
Porter. I am currently working on legislation that would
explore this idea of a separate independent Federal scientific
body solely charged with evaluating all the research in this
area.
Can you provide any additional insight and will you both
work with me on developing this further? And do you agree with
me that this should be both an outside and inside medical
evidence, obviously the VA but also outside the VA, so we can
tackle this issue for our heroes?
Mr. Wiseman. Well, we would agree with you, Mr. Bilirakis.
And your leadership on toxic exposure issues says that you
would be a great partner for the VFW.
Transparency is key. For too many years, we were told that
there were no servicemembers on the Korean DMZ exposed to Agent
Orange prior to April 1, 1968. And documentation has then been
declassified and that is why H.R. 299 now includes that section
for the Korea DMZ presumptive to start September 1, 1967. It is
that type of continued research and transparency that must be
had.
I mentioned in my testimony, both written and oral, the
need for DoD to be required to share everything. The oversight
mechanisms that Congress has in place will help with that. And
I will also point to Camp Lejeune where contaminated water was
found. It was reviews that found a spike in male breast cancer
that led us down that road.
And so absolutely more research. Absolutely more
transparency. And absolutely the VFW would be willing to work
with Congress because every day is Veterans Day.
Mr. Bilirakis. Sir, Mr. Porter.
Mr. Porter. We would support additional research
definitely. The higher quality of the research and data that we
can get produced, whether it is private or public, but we need
somebody like the VA to be able to pull all that together and
corral it so that it can reviewed and have it all in one spot.
The transparency is big to have DoD to be able to share all
that information with the VA and the public so that we can know
all the facts. So, yeah, we look forward to working with you on
that.
Mr. Bilirakis. All right. Very good. As far as I am
concerned, it is a no-brainer. So I look forward to working
with you all and other Members of the Committee.
Dr. Erickson--I know I don't have much time--it seems from
the witnesses' testimonies today and from colleagues on the
Committee that many of us have concerns about the scientific
validity, again, of the open burn registry. In fact,
stakeholders in my district have told me it is so poorly
designed that it results in data that is virtually useless.
You mentioned the National Academy study, but it is unclear
to me how far the VA has gone to implement the recommendations
from the study. Based on these concerns, what value do you
think the Registry has? And what concrete examples can you give
us of how the Registry has been used to advance clinical care
for veterans who may have been exposed to burn pits? And I know
you have addressed this, but can you address it one more time
for us, because this is vital. It is very--
Dr. Erickson. Yes. I will try and be very quick and, of
course, get back to you with additional information as
necessary.
The Registry, I think, excels in allowing members of the
service, veterans, to participate in a very difficult issue. So
by volunteering, they are participating, they are giving us a
lot of information about their experiences, their exposures,
their health. Though it is not an epidemiologic study that
would have the validity of a well-constructed prospective
study, et cetera, it still can generate hypotheses. It can give
us leads. It can give us ideas of things that we need to be
looking at.
And so as we look at trends, as we cross-reference what is
in the Registry with what is, for instance, in the electronic
health record for those who are enrolled at VHA, again, that
gives us additional ideas of what we need to be looking at,
where we need to prioritize our work.
Mr. Bilirakis. All right. Thank you very much.
I yield back, Mr. Chairman.
Mr. Dunn. Thank you very much, Representative Bilirakis,
for your questions and your comments.
Mr. O'Rourke, you are recognized for 5 minutes.
Mr. O'Rourke. Thank you, Mr. Chairman.
And Mr. Porter and Mr. Wiseman, thank you for your
testimony and for the advocacy of the members of your
organizations.
I am just constantly reminded that any progress we make in
Congress or on this Committee is thanks to the pressure that
you bring to bear. And I feel that today. And the urgency, just
at a personal level, and I think for the Committee, has been
raised. And I want to make sure that we are not having yet
another meeting on this issue trying to describe why it is
taking so long for us to do what is necessary for those who
have served this country, and also to the Ranking Member's
point, to stop this from continuing to happen. I feel like
those are the two basic charges: to make sure that we cared for
those who have been exposed and who are suffering and to stop
this from happening going forward.
And I know the Chairman of the Full Committee has left, but
I love that he reminded us of the example that we have with
Agent Orange, and that it took this country more than 40 years
to acknowledge our responsibility and our accountability and to
pony up and begin to take care of people who we should have
decades earlier been there for. Belatedly, but we got it done.
And we are about to do that with blue water veterans as well,
thanks to those veterans who have shown up at our townhall
meetings and forced the issue. So I know that when something
happens, it is going to be thanks to your advocacy. And I just
want to tell you I am grateful for that.
And to Dr. Erickson, I am really--this is not on you. I am
just really disappointed, and the Chairman of the Subcommittee
already said this, but I join him in just saying how
disappointed I am that the Department of Defense ducked this
meeting. They have every reason in the world to be here. Deeply
disappointing that they are not. But what I want to know from
you is how have they been as a partner?
Your title is chief consultant, Post-Deployment Health,
Office of Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs. So your
post-deployment, how are you doing in working with the
deployment side of the equation? As to the point as you can be.
Dr. Erickson. Again, we have a deployment health workgroup
which we, on a regular basis, work to discuss these issues.
Mr. O'Rourke. So let me get to this. You have 144,000 on
the voluntary registry out of 3.5 million eligible. Is DoD
doing everything within their power to identify those 3.5
million and connect you with them?
Dr. Erickson. Representative O'Rourke, I cannot speak for
DoD in that regard.
Mr. O'Rourke. I am asking you.
Dr. Erickson. My sense is that they have taken very strong
steps to that end, especially as it relates to the point of
transition.
Mr. O'Rourke. Is there something more that they could do?
Dr. Erickson. You know, I think all of us could partner to
do more. My sense is that, with having a much greater
enrollment in the Registry, we will be able to take this much
further than we have to date.
Mr. O'Rourke. Let me ask you this question. So the
Chairman, Chairman Roe, referred to his desire to study medical
cannabis. And while I support that effort, I also just support
allowing doctors at the VA to prescribe it today, because there
are doctors who would like to prescribe it today. There are
veterans who would like to receive it. And if those two agree,
then let's move forward. I don't need to study it anymore.
Are we at a point now where doctors can begin treating this
without more studies and where we can--we have enough
information, even if it is not, you know, studied, you know, to
the 10th degree. But there are veterans who are saying ``I am
experiencing this, and I need this help,'' and there are enough
doctors who are saying ``I can do the following to help those
veterans, and here are the kind of unique conditions that we
can respond to.''
Dr. Erickson. To the degree that a servicemember or a
veteran has a defined condition, bronchitis, a type of cancer,
et cetera, we certainly will aggressively pursue the normal
methods of treatment to the state of the art. As it relates to
answering all the questions that are surrounding this from
exposure, there is a lot we still need to learn. And we are in
that phase right now. We know there is an issue, but we don't
have all the answers for causation.
Mr. O'Rourke. Can we get to like a presumptive status akin
to Agent Orange where you just say, look, I was here in Iraq or
in Afghanistan at this time, and I can't tell you how many
kilometers away from a burn pit I was or the date or exactly
what was burned, but I am experiencing this, help me, and the
VA is going to help you?
Dr. Erickson. With Agent Orange, presumptions came into
effect both through legislation, which specified which diseases
would be presumptions. Also--
Mr. O'Rourke. Are you waiting on us to do that?
Dr. Erickson. No.
Mr. O'Rourke. Do you need that statutorily or can you
deliver that care?
Dr. Erickson. Or that the Secretary would have the
authority, through the authority that Congress has provided the
Secretary, to say that the level of evidence is sufficient for
us to make a presumption. At the present time, we don't have
sufficient evidence.
Mr. O'Rourke. Even if the veteran says, I was here, I
experienced this, and there were at least 150,000 other people
who have taken the time to register that same complaint, we
just don't have enough?
Dr. Erickson. We need those answers. We need those six
studies that I mentioned. We need those to go to completion. We
need to be able to work on a population.
Mr. O'Rourke. Last question because I am out of time. What
is the timeline to have those studies done?
Dr. Erickson. Again, I will provide that to you. That will
be one of my takeaways.
Mr. O'Rourke. Give me the ballpark.
Dr. Erickson. These can take several years.
Mr. O'Rourke. So at the earliest, 3 years from today?
Dr. Erickson. That is a possibility, but it will vary study
to study.
Mr. O'Rourke. Okay. Thank you, Mr. Chairman.
Mr. Dunn. Thank you, Mr. O'Rourke.
I now recognize the representative from Louisiana, Captain
Clay Higgins.
Mr. Higgins. Thank you, Mr. Chairman.
I would like to state for all present that it is quite
disturbing that DoD is not present. I interviewed a veteran
that was exposed to burn pit, a young man from my district,
yesterday. He described that the burn pit was run every day and
it was about 700 yards from their encampment, their permanent
encampment. He stated that the smoke would envelop at times the
camp and come into their tents, the large tents, their
barracks. What was most disturbing is that he described the
smoke as frequently being sort of sticky and was heavy, stayed
together.
And this reminded me of my own personal understanding of
chemical and biological weapons devised--the gas thereof to be
cohesive, and to be heavier than air whereby a large invisible
cloud of biological or chemical agent would be deployed.
So, Mr. Chairman, I am quite disturbed that DoD is not
here, because I would like to ask them who the genius was that
came up with this idea to create--we have essentially--we have
essentially as a Nation deployed chemical and biological
weapons upon our own troops. Wow.
Dr. Erickson, so as you know, the National Academy of
Medicine has found significant limitations to the burn pit
registry. It relies on self-reported information. Is that
correct?
Dr. Erickson. That is correct.
Mr. Higgins. Is there any sort of an organized outreach
program nationwide through social media, through VSOs, through
CBOCs, through VHA facilities? Is there any sort of an
organized effort to reach into the veteran population by the VA
or DoD?
Dr. Erickson. Yes. In fact, all of the above. Within VA, we
have environmental health coordinators and clinicians at each
of the medical centers which, in fact, for their catchment area
try to put the word out. We have educational opportunities
through webinars, one of which will be next week and will
involve hundreds of providers. We have an e-learning module
that is available to civilian providers to instruct them about
airborne hazards and about treatment. We have a training
conference which is coming up for hundreds of folks who work at
our medical centers to that end. I had mentioned Web sites,
townhalls, newsletters.
I take to heart your comment about social media. We will do
a better job beyond the blogs that we are doing--
Mr. Higgins. So there is an understanding that there must
be an organized outreach into the veteran communities through
existing avenues and pathways?
Dr. Erickson. There is.
Mr. Higgins. Thank you.
It is also my understanding that the Registry takes a
significant amount of time, and that we have nearly 40 percent
of the questionnaires are left incomplete, that submissions
cannot be made by family posthumously, and that very few
veterans choose to follow through with the free medical exam.
Is that correct?
Dr. Erickson. That is all correct.
Mr. Higgins. I ask you, good doctor, how can we properly
assess veteran's health and the effects of burn pits on exposed
veterans if the quantitative data is lacking?
Dr. Erickson. My answer would be that the Registry will not
give us the definitive answers. The other six studies which I
mentioned, in fact, are the place to go for those answers.
Mr. Higgins. Thank you for your answers, sir.
My final suggestion, Mr. Chairman, and to the panel and to
the VSOs present, is that the DoD should hear, as the noise of
thunder from all of us, that they were not present today. These
veterans have been subjected to a great deal of carnage from
enemy fire and from occasional friendly fire, as tragic as that
may be, in the form of munitions. But to think that we have
purposefully deployed burn pits and created chemical and
biological fumes and smokes to deploy upon our own troops is
very disturbing.
Mr. Chairman, I yield back.
Mr. Dunn. Thank you, Captain Higgins.
I do want to take as a point of privilege on the chair to
point out from the testimony that has been submitted that--the
DoD testimony, that GAO has estimated 273 burn pits in 2010 in
Afghanistan and Iraq combined. In 2016, they found a single
burn pit that was operated by the military. However, the
disposal of this refuse has been contracted to civilians,
presumably local civilians. I know not exactly what they are
doing, but some progress has been made. I don't want everybody
to think that this is still an active practice. But I share
your concern.
And I want to recognize Mr. Correa for 5 minutes for
questions.
Mr. Correa. Thank you, Mr. Chair.
First of all, let me thank Mr. Porter, Mr. Wiseman, and the
veterans that are here today for your service to our country.
And also, of course, for bringing these most important issues
to our attention. And I want to start out by saying that I
concur with Mr. Higgins and his comments about the DoD not
being here.
But, Dr. Erickson, is the DoD--do you work, coordinate
together on these issues? I presume you talk on what has been
going on, communication?
Dr. Erickson. Yes, Congressman. We talk on sometimes a
daily basis, but certainly a weekly basis about these airborne
hazards and burn pit issues.
Mr. Correa. So, you know, at every, you know, conflict that
we have had, every war, we seem to have these issues that pop
up. Agent Orange, Blue Water Navy, World War II, other issues.
Looking forward, are these registries open to veterans that
are now serving, let's say, for example, begin to complain of
certain issues? You begin to get these data points, you begin
to create information there that maybe indicate that something
is going on right now that we are not aware of. Do you keep
that data? Is this registry open to everybody or just to the
burn pit folks?
Dr. Erickson. Congressman, we have seven registries total.
The eligibility requirements for the airborne hazards'
registry, an individual would have had to have served in OIF,
OEF, OND, Desert Storm, Desert Shield, stationed in Djibouti,
Southwest Asia theater of operations after August of 1990.
Mr. Correa. So my question is more of a, kind of a--do you
have a situation, a process where if you have a person in the
service right now and believes that there is something
seriously wrong, where they can report this information so we
begin to discover what is going on right now as it develops? Or
do we have to wait years and years to figure out, ah, something
was going on in 2018, we should have done something then at the
early stages of this development?
Dr. Erickson. Congressman, that is a good question, and
that would be the responsibility of the DoD to answer that for
you. I am sorry.
Mr. Correa. Do you work with the DoD on--
Dr. Erickson. I certainly do.
Mr. Correa [continued].--on these kinds of processes?
Dr. Erickson. But I can't speak authoritatively or directly
as to what steps they do take.
Mr. Correa. I don't want you to answer for them. I am just
trying to figure out, if you work with them, if there is a
process like that so we can continue or begin to anticipate
these issues before they are actually on top of us. And we have
so many of our men and women in uniform that have to go through
this.
Dr. Erickson. Absolutely. In fact, that is our joint aim,
is that we could, as a team, actually prevent these exposures,
but in lieu of that, be able to detect early the development of
disease and disability, to take care of those individuals who
so proudly served our country.
Mr. Correa. I am a little slow here, so can you repeat that
to me again? Is that your aim or are we actually taking steps
in that direction?
I am not trying to put you on the spot. I am just trying to
ask, are you and the DoD working in something that could give
us an early indicator of these issues that are kind of before
us or is there no process there so that maybe this Committee
can begin to address that issue? It is a very simple yes-or-no
question.
Dr. Erickson. Yes.
Mr. Correa. Yes, you are working?
Dr. Erickson. Yes.
Mr. Correa. Thank you very much, sir. I have no questions--
further questions, sir.
Mr. Dunn. Thank you very much, Mr. Correa.
I now recognize Mr. Mast of Florida for 5 minutes for
questions.
Mr. Mast. Thank you, Chairman.
I do want to thank both the IAVA and Representative Gabbard
for their work on this issue. I know it has been vigilant, to
say the least, and so I do greatly appreciate that.
When I look back on my service, I think one of my least
favorite parts of training was when one of my sergeants would
yield out, gas, gas, gas. And we would have to do everything we
could to get on our MOPP gear and our masks within seconds or
whatever timeframe they set in front of us. And what is
absolutely disturbing to me is that the chemical attacks that
we really needed to fear were those that were coming from
within our own camps.
And it is in that that I want to start with asking you a
few questions, Mr. Porter. Of all of those veterans that you
know of within your ranks, do you know of veterans that were
exposed to burning vehicle parts?
Mr. Porter. That and a whole lot of other things.
Mr. Mast. How about burning tires?
Mr. Porter. Yes.
Mr. Mast. How about burning bottles?
Mr. Porter. Certainly. I think, though, that people don't
even know what they are exposed to because it is everything
burnt all together, so--
Mr. Mast. How about those square green batteries that the
military uses in basically everything that is electronic? They
burned some of those?
Mr. Porter. A good chance, yes. Everything from human waste
to medical waste to fuel to tires to excess clothing, and all
those bottles that 100,000 people in theater, in each theater.
They would drink 10 bottles of water a day. That has all got to
go somewhere. It is not going to the recycling center in
Jalalabad.
Mr. Mast. MRE wrappings?
Mr. Porter. Sure.
Mr. Mast. Mattresses?
Mr. Porter. Sure.
Mr. Mast. ChemLights?
Mr. Porter. Yep.
Mr. Mast. Chemical drums?
Mr. Porter. Yep.
Mr. Mast. Tarps.
Mr. Porter. Everything.
Mr. Mast. Movies? Magazines?
Mr. Porter. Everything.
Mr. Mast. You already mentioned human waste.
Mr. Porter. Right.
Mr. Mast. I think we could probably sit here all day and
list the things that anybody that spent time in uniform has
seen burned overseas and the stuff that they had to breathe in
constantly, the stuff they had to taste in their food on a
daily basis.
These airborne hazards, they do go well beyond just what is
burned. I can look back and I can think about those smoke
grenade holders that are right next to the driver's hatch on so
many of our fighting vehicles. You were expected to put those
smoke grenades directly next to where it was that you were
driving. The motor pools, lined with vehicle after vehicle that
were just running during PMCS, running JPA. Sandstorms, the
internal exhaust that you get while you are on a Black Hawk,
the CS chambers that you would go into, DU rounds from close
air support. All those folks that were working on flight decks,
breathing in that exhaust from aircraft. Bases, even here at
home, bases that we are tearing down old buildings filled with
asbestos and things like that. My fellow bomb technicians who
would detonate thousands of pounds of explosives at one time
and would be expected to go check out those shot holes
afterwards to make sure there was nothing additional laying in
there. Airborne hazards there. Of course, the burning oil
fields from the times of the Gulf War.
Is there any other experiences that you would wish to share
from your membership of those exposures to burn pits?
Mr. Porter. Well, I don't know very many servicemembers and
veterans that are complaining about having to go to these
places. You know, from the experience yourself, you put on the
uniform and you go where they tell you to go. And you even know
that there is bad stuff in the air and hazards, and a lot worse
than that, in the places that we are deployed to.
It is just that the expectation is, by servicemembers and
veterans, is that they get taken care of when they come home.
And so that is the key, is they are going to go places, they
are not going to complain about going those places, but they
want to be treated when they return back.
Mr. Mast. I think you are exactly right, Mr. Porter. We do
our job and we do it joyfully, even though there is not often
joyous things that we are doing. And the veteran should be
taken care of joyfully as well.
Mr. Porter. Yes, sir.
Mr. Mast. I do want to move to you, Mr. Erickson, while I
still have a minute here. How many burn pit exposure disability
claims have been filed?
Dr. Erickson. I actually have that number. My understanding
is a little over 9,000.
Mr. Mast. What percentage of the claims are approved for
disability compensation?
Dr. Erickson. That number, Congressman, I will have to get
for you.
Mr. Mast. Okay. What is the most common reason that
veterans who have been exposed to these burn pits are being
rejected for their disability claims?
Dr. Erickson. I will also have to take that for report
afterwards.
Mr. Mast. Perfect. I will look forward to hearing your
answers on those questions.
Dr. Erickson. Certainly.
Mr. Mast. With that, Chairman, I yield back. Thank you.
Mr. Dunn. Thank you very much, Representative Mast, for
that very vivid description of the environmental hazards of
combat theater. One might almost think you had been there.
And by the way, I think the entire Committee would be very,
very interested in seeing the numbers of adjudicated claims and
how that played out.
Representative Kuster, you are recognized for 5 minutes.
Ms. Kuster. Thank you very much, and congratulations. We
are pleased to have you on board as our chair.
So I think you can tell by the bipartisan response today
how concerned we are. And thank you to the VSOs and to every
one present for bringing this issue once again to the
forefront.
Just a brief point of personal privilege. In March of 2009,
I was in Alaska for a ski race, of all things, during a
volcano, Mount Redoubt. And I came home to New Hampshire,
having been in the ash for several days, and ended up with
several years of pulmonary difficulties: breathing, asthma, et
cetera. And it took me a while to piece this all together. It
certainly took my doctors at home a while to piece it together.
I continue to have asthma-related symptoms because it was
crushed glass, is my understanding, coming from--
So this is obviously very different than the experience you
all have had, the folks in the room. But my point being, I
think there is difficulty in just trying to piece together
these kinds of symptoms. And you pointed out, I think, that the
pulmonary function test is inadequate.
So I guess I want to hone in on two things. One is this
electronic health record and how we can make sure that there
are questions asked that specifically tease out what we know to
be the constellation of symptoms from illness related to burn
pits. Is that part of what this Committee is looking at that is
working with the electronic health record?
Dr. Erickson. Congresswoman, I think that would certainly
be the desired end state. Again, we are just at the front end
of the development of that new electronic health record, but I
can tell you that these environmental exposure equities are
going to be included.
Ms. Kuster. And I think for us, and what you are hearing
from us, and it may take bipartisan legislation that we would
draft to put together to say we should have a presumption
because I don't see why there is any reason to wait. Obviously,
we have got people in the audience today that have complex
symptoms, and they should be served. They should be treated.
So the other thing that I am interested in, though, is this
epidemiological studies that are going on. And I understand
from your testimony that you have requested the National
Academy of Science to be involved with this. They have a series
called Gulf War and Health. And you have asked that we have a
long-term study of health effects of airborne hazards. Can you
tell me the status of that particular study and what the
conclusions are to date?
Dr. Erickson. Yes, ma'am. We are at the front end of that
study in that, literally, we are working to draw up that
contract right now. We have the authority to work with the
National Academy because of legislation that enables us to do
that.
We are looking for what is called a consensus study, which
involves them putting together an ad hoc committee of blue
ribbon subject matter experts from around the United States,
and they will review all of the existing literature published,
unpublished, they will have public meetings, and they are going
to draw this together in the form of a report that we can work
with.
Ms. Kuster. So I guess, let me understand. There are two
parts of this, it seems to me. Looking for this direct causal
link, which would then, obviously, help us with the presumption
and we could move forward. Is there also a medical purpose? In
other words, then, pulmonologists will know what they are
looking for, for symptoms and they can come to consensus on
treatment. Is it two part?
Dr. Erickson. There certainly could be. Those of that
practice medicine use a term called index of suspicion, and we
also use a word called the differential diagnosis.
If, in fact, we know that a given patient has had certain
exposures, that cues us to be looking for certain types of
things, certain types of disease outcomes. So, in fact, that
could enhance treatment.
Ms. Kuster. So I guess--and I want to share the Ranking
Member's concern about the testimony about women veterans,
birth defects. You know, look, everybody is suffering, but
let's try not to go to a whole other generation here.
How do we convey our urgency for both, for both the causal
link, so that we can get to the presumption and make sure
people are served and treated, and as to helping to move
forward on the medical treatment?
Dr. Erickson. I certainly think that the urgency is
underscored by this hearing, and I thank the chair, the Ranking
Member, and all the Committee Members for bringing this to the
attention of the Nation.
Ms. Kuster. Well, I want to thank the chair, certainly for
your knowledge, and the Ranking Member. And my Subcommittee is
the Oversight Subcommittee, but we will continue to work with
the Health Subcommittee. And I think this is something that we
have got consensus on. We want to move forward. Thank you.
I yield back.
Mr. Dunn. Thank you very much, Representative Kuster.
And now we turn to the Representative from American Samoa,
Amata Radewagen, for 5 minutes.
Mrs. Radewagen. Thank you, Chairman Dunn and Ranking Member
Brownley for holding this hearing today. And thank you to the
panel for your testimony. Thank you all for your service.
Ensuring the long-term health of our veterans is a top
priority, and any potential hazards to our Armed Forces need to
be addressed swiftly and thoroughly. To that end, I am proud to
cosponsor Congresswoman Gabbard's H.R. 5671 and Congresswoman
Esty's H.R. 1279. I believe these pieces of bipartisan
legislation are good first steps towards addressing this issue,
and I hope this hearing will help flesh out other potential
steps we can take and address some of the concerns surrounding
this problem.
Research and data collection are paramount to understanding
a health risk with potential long-term effects, whether it be
burn pits or other environmental factors. And I would like to
focus my question on the burn pit registry and how it may serve
as an informational resource.
So, Dr. Erickson, just so I can better understand, from an
epidemiological perspective, what challenges arise when working
with data points collected via voluntary health survey and
registry such as that used in the burn pit registry? And as
time passes, since the initial point of exposure, does research
become more difficult? And if so, why?
Dr. Erickson. Those are excellent questions. From an epi
standpoint, there are two major biases that we are concerned
about. One bias is who is volunteering to participate. There is
the potential that the most sick individuals, in fact, will
participate, and, therefore, then give a nonrepresentative view
of who is being affected and who is not.
The second bias involves self-report, in that it is an
individual who is reporting their exposures, reporting what
they have been told by a doctor they have. And this is not to
impugn the character of anybody, but through time, it is true
that sometimes, you know, my recollection, perhaps all of us,
starts to wane. And so there can be a bias in that regard.
The second part of your question was--oh, with time.
Absolutely. We want to get out in front of this. In fact, I
hope that the written testimony that we submitted shows that,
in fact, VA desires and is getting out in front of this as best
we can. There are so many questions to be answered. We have got
the studies underway. We are doing a lot of really good things.
Can we do better? Yes, we can do better. We hope to do better.
We are looking to do better. But I think what we are doing is,
in fact, on the right track. And we need to get to it now. We
need to start these studies now. Because you are right, if we
waited 10 years, 20 years to start those studies, then that
would be Agent Orange all over again.
Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
Mr. Dunn. Thank you very much, Mrs. Radewagen.
I now recognize Congressman Ruiz from California for 5
minutes for questions.
Mr. Ruiz. Thank you, Mr. Chairman. It is great to be back
in my alma mater committee.
I am going to be very quick and to the point. My point is
this: If you have a high enough suspicion for a severe enough
consequence, then you need to act, and you need to act now.
So, Dr. Erickson, in your testimony, you say, quote, ``The
evidence for an association between the development of specific
respiratory diseases and exposures to combustion products was
found to be inadequate or insufficient.''
Oftentimes, the VA says that there is no scientific proof
between a link of burn pits and long-term health effects. That
statement is misleading and very intellectually dishonest, that
the VA makes. And I will explain why.
The 2011 Institute of Medicine report is the report that
you are telling us that you are commissioning the National
Academy of Science to do. I mean, it is not the report. I am
saying that they took a blue ribbon group to look at all the
other studies and to give us an update of what they thought.
And they state, quote: Information that would have assisted the
Committee in determining the composition of the smoke from the
burn pit and, therefore, the potential health effects that
might result from exposure to possible hazardous air pollutants
was not available. Specifics on the volume and content of the
waste burned at Balad Base as well as air monitoring data
collected during smoke episodes were not available.
In addition, the report states that, quote: The available
epidemiological studies are inconsistent in quality, were
conducted with various degrees of methodologic rigor, and had
considerable variations in design and sample size.
So, Dr. Erickson, if this critical data was not available
or the studies' methodologies were flawed, is it just as
accurate to say that studies fail to prove or disprove a causal
link between burn pits and adverse health outcomes?
I don't have much time. I need you to answer.
Dr. Erickson. No, it was the complex wording of the
question, sir.
Mr. Ruiz. So let me be very clear. There are no studies
right now that can prove and there are no studies that can
disprove that there is a link between the exposure to burn pits
and long-term health effects, correct?
Dr. Erickson. I think we need to look at the totality of--
Mr. Ruiz. I am looking at the totality. There is no studies
right now. I am a scientist. I am an emergency medicine doctor.
I am a public health expert. You know the literature. I know
the literature. Are there studies that can disprove that there
is no link?
Dr. Erickson. I don't think the point, sir, is a matter of
disproving, because as you--
Mr. Ruiz. That is the point exactly, because if we cannot
disprove, then it is very possible that there is a link between
the burn pits and the health effects that our veterans are
facing. And if we don't have that information, then we have to
go by how we practice in emergency medicine and public health.
Meaning, if you have a high enough suspicion, a severe enough
consequence, you have got to act. You have got to start taking
care of your veterans right now.
So do we have a high enough suspicion? So we have
independent research that raise suspicion of a causal link that
veterans exposed to burn pits are developing serious
respiratory issues, cancers, and autoimmune illnesses.
The same report found dioxins, dioxin-like compounds to be
of concerns because of their association to burn pits and
because some of the concentrations exceeded U.S. Air Quality
standards. We know that dioxin was present in Agent Orange.
The New England Journal of Medicine, a study by Robert
Miller from Vanderbilt University, performed lung biopsies in
49 soldiers exposed to burn pits in Iraq and Afghanistan who
were healthy before being deployed. 38 of the 49 were diagnosed
with constrictive bronchiolitis, a very rare disease.
In another study in Seton Hall University Law School,
Center for Policy and Research analyzed 500 veterans who were
exposed to burn pits while serving in Iraq and Afghanistan.
Seventy-four percent reported respiratory issues, including
severe shortness of breath. Twenty-six percent of them had more
severe illnesses such as brain cancer, lung cancer, hardened
bronchial tubes, and acute leukemia. We have found carcinogens
in the smoke, carcinogens in the soil, metals found in lung
biopsies in these patients.
There are case studies, like Jennifer Kepner, my
constituent, 39 years old, who died of pancreatic cancer. Her
oncologist did all the studies, genetic tests, all the other
history, exposure history. The only plausible source was
exposure to these burn pits.
So, Dr. Erickson, in your testimony, the evidence for an
association between the development of specific respiratory
diseases and exposure to combustion products was found to be
inadequate or insufficient. So would you say these studies and
other case examples of veterans like Jen Kepner show a high
suspicious enough for an association between burn pits and the
long-term consequences?
Dr. Erickson. The concern that you are voicing, sir, is in
fact the reason that we are asking the National Academy to--
Mr. Ruiz. Great. So you agree with me, there is high enough
suspicion for you to pursue these studies.
So now let's ask the question. Is there severe enough
consequences? Ask the family of Jennifer Kepner who died from
pancreatic cancer; Amanda Downing, who died to adrenal cancer
at the age of 24; Brandon Maddick, who died of esophageal
cancer at 26. If the outcome is severe enough. Ask the patients
sitting in this room if their dyspnea on exertion, their
autoimmune disease, their pulmonary fibrosis, their chronic
bronchiolitis, and others who are permanently disabled, oxygen-
dependent, with broken families, depression, exacerbated PTSD,
and possible suicidal ideations.
Do you think that the consequences of this exposure are
severe enough?
Dr. Erickson. I very much believe that their suffering is
real. I very much believe that--
Mr. Ruiz. Great.
Dr. Erickson [continued].--the exposures are real.
Mr. Ruiz. So if there is a high enough suspicion with
severe enough consequences, we must act. And let's keep in
mind, I know we are talking about registries, but registries
aren't going to remove cancer in a body. Registries aren't
going to provide the health care that the patients need or the
benefits that they need. We need to make sure that we give the
veterans their treatment, their benefits, and educate doctors
and veterans about this right now.
Mr. Dunn. Dr. Ruiz, your comments are well taken. We
appreciate that.
Mr. Ruiz. Thank you.
Mr. Dunn. Representative Tulsi Gabbard from Hawaii, you are
recognized for 5 minutes for questions.
Ms. Gabbard. Thank you very much, Chairman Dunn, Ranking
Member Brownley. I appreciate the opportunity to come and join
your Committee on this critical issue.
There obviously are some important pieces of legislation
that we are seeking to push through to begin to address some of
these issues. It is unfortunate that this remains an obscure
issue for too many Members of Congress and too many people who
either have not served themselves or have not been directly
impacted, to be friends with or related to someone who has.
The fear I know that we hear from fellow veterans is that
this will continue to drag on and on. And as soon as you talk
about a government study, this is something that can drag on.
Meanwhile, people here are suffering from illnesses, and they
wonder if they will be alive when these studies are complete.
It is a testament to the importance of this issue that we
see VSOs who are here, who have united from across generations
to help bring attention to this issue and to make it so it is
no longer obscure. It is not only impacting our veterans, but
it is impacting their family members.
I want to recognize a military spouse who is in the room,
Tori Seal. She has been a strong advocate on this issue. Her
husband, Jay, tended burn pits during his deployments and is
now suffering from stage IV cancer. Because this issue is not
resolved, she is not eligible for any caregiver benefits
because her husband was not diagnosed with PTSD or TBI, and his
illness is not being recognized as service-connected, even as
his specific job, his duty while deployed was to tend to these
burn pits directly.
What can be done for people like Tori at this point whose
full-time job is caring for her husband who has stage IV
cancer?
Dr. Erickson. Congresswoman, I am not a benefits expert,
and so I will have to get back to you with a more detailed
answer. Because there are things to be done, but I don't want
to misspeak and misrepresent. I know there are things that are
available for surviving spouses.
Ms. Gabbard. Something similar that I heard from another
veteran, who is working with Burn Pit 360, this morning was the
comparison between the types of exposure that our veterans have
had deployed throughout the Middle East, Iraq, Afghanistan,
Kuwait, elsewhere, both those who were working directly with
burn pits and those who were working within the area, as many
of us did, living and working and breathing the toxic fumes
that came from these burn pits every day, and how similar that
exposure is to the multitude of toxins that first responders
were exposed to after 9/11.
Congress passed the James Zadroga 9/11 Health and
Compensation Act of 2010 to address the very type of thing we
are talking about here, where first responders were getting
very sick with all kinds of illnesses and cancers and dying at
a very early age. And yet they were not receiving the benefits
or care or recognition that this is a result of their service.
We shouldn't be re-creating the wheel here, so I am
wondering what the VA has done in looking at what has already
happened with James Zadroga Act to help with the 9/11 first
responders so that we are not starting from scratch and
studying something for years that has already been studied in a
similar situation and applied and fixed.
Dr. Erickson. One area that we could collaborate in, and
this would be with all the Members of the Committee, would be
that if you have candidate diseases or health care outcomes
that you think are tied to exposure to burn pits and airborne
hazards, that we would be able to then work with you on that
list to see where the evidence is, where it is not. Because I
don't think you are looking for any and all health care
outcomes and proposed legislation that might match the World
Trade Center-type legislation, but I think you would want a
defined list.
Ms. Gabbard. So what has the VA done in this respect so
that we are not starting from scratch?
Dr. Erickson. As I mentioned, we have in our written
testimony a number of major studies, six major studies that are
underway with DoD. Also, there were attachments in the written
testimony which, in fact, provided examples of our published
studies. The bibliography that I provided. Also, two lists of
additional studies that are currently funded by VA.
Ms. Gabbard. Okay. That doesn't really answer the question
as far as an action. You listed a whole bunch of different
studies, but as far as what action steps are being taken to
make it so that we are recognizing the service-connected
illnesses.
Dr. Erickson. So specific actions--I apologize for not
understanding the question. The specific actions, currently,
those who serve in the military and are honorably discharged
receive 5 years of health care eligibility, I understand. So
that's an open door.
The registry which exists, which we are trying to now
encourage additional participation in, provides an entry point
where the individual who is participating can ask for a medical
exam. So this provides a clinical encounter which is then--
Ms. Gabbard. Excuse me, Dr. Erickson. I appreciate that you
are kind of starting from ground zero here. Everyone in this
room is aware of kind of the basic benefits that servicemembers
are eligible for, but it is not addressing the fact that we
have a lot of people in this room and a lot of people who can't
be here today who have tried over and over and over and over
again to get that care, and they have been denied. And they
have specifically attributed their illness to their exposure to
burn pits.
Dr. Erickson. As it relates to claims, again, this is not
my wheelhouse to discuss claims and how those are processed,
but I can put you in touch with those who will be able to
answer those questions.
Ms. Gabbard. Okay. Thank you, Mr. Chairman. I think that
the attention that you are placing on this issue is so, so, so
important. And the only way that we are going to get anything
done on this, whether we do it as a body in Congress or whether
we work with the VA to be able to help these veterans, either
way, I appreciate the urgency and attention that you are
placing on this as people's lives hang in the balance.
Mr. Dunn. Thank you, Representative Gabbard.
I will say, I don't want the veterans in the crowds to
think that they can't get treated for these illnesses. I think,
as I understand it, you can get treatment for these
disabilities. What we are having trouble with, the thing that
is in limbo is the disability recognition and the rights. I
will allow Dr. Ruiz to answer that.
Mr. Ruiz. And, Dr. Dunn, one of the things that we found in
the case study of Jennifer Kepner was that they need to report
this illness within 5 years.
Many of the presentation of pulmonary fibrosis, autoimmune
diseases, cancers, including even PTSD, our veterans don't even
understand or develop symptoms beyond 5 years. And so when they
get ill, they can't get care from the VA.
Mr. Dunn. Okay. Thank you for that clarification.
And I want to recognize Representative Esty from
Connecticut for 5 minutes for questions.
Ms. Esty. Thank you, Mr. Chairman. And I want to thank all
of you for joining us here today.
Mr. Wiseman, it is your second appearance before this
Committee today.
Mr. Wiseman. We are going strong, ma'am.
Ms. Esty. And again, I want to thank you. As people on the
Committee may or may not know, he will be leaving us, his
position to go to Virginia and help head things up over there.
But I want you to know, I know we would not be here today if it
were not for your personal fierce persistent advocacy on this
issue.
Mr. Wiseman. Thank you. And it is going to likely take
legislative action by this body. That is how we got Blue Water
Navy. That is how we got Agent Orange. That is how we have got
so many other things. Congress needs to act.
VA's hands, in their defense, are tied because of
Congress's previously passed laws. I am accredited to do VA
claims. I will still be doing those. I will still be inside the
VFW as a state commander, and I will be happy to come back any
time. I thank you.
Ms. Esty. Well, thank you very much. I am actually the
Ranking Member of the disability appeals Subcommittee, so we
are very much looking at this. And I think, you know, my
colleague, Ms. Gabbard, is right, this is going to require
congressional action. And it is completely unacceptable to
think that we are going to wait having just now really been
wrestling through the Agent Orange issues, that we would be
doing that to the present generation of veterans. It is wrong.
We should know better by now. And I know people here know that,
but we have to find the will to make that happen.
Shortly after I was elected in 2012, a decorated Iraq
veteran in my district came to me, Mike Zacchea. He has written
a book called The Ragged Edge. And he experienced the burn pits
and saw his colleagues, his men experience them too. And he
educated me as soon as I got elected. I wasn't on the
Committee. He said, you need to do something about this. You
need to understand how important that is.
And since his educating of me over 5 years ago, as everyone
on this Committee has seen, you begin to open the door on that
and you hear, you hear from people all over your district about
it. And I had a niece who served in Afghanistan. This is a real
problem.
So a couple of things I wanted to flag. The issue about
women's exposure is real and serious, and especially when the
consequences, again, may be outside this time period, the
exposure and then refusal to cover is unacceptable. And we
should do better. Congress needs to do better on that issue.
I have often wondered, if the Defense Department were
responsible for paying the bill after the fact, if they
wouldn't think a lot more about it before exposing people? Have
the payment for those come out of the DoD budget rather than
coming out of Veterans' budget and we might be in a different
place.
I don't know how we do that, but I will tell you, I think
that we need to seriously engage. And again, I will add my
voice to the chorus of my colleagues to express our extreme
disappointment that DoD did not come today. The fact that they
aren't here does not absolve them of responsibility. And they
have the opportunity to mitigate this at the time. And we need
to get them back to the table, because those serving deserve to
have them, their awareness of this at the time that it is
happening. It is not their only mission, but it is part of
their mission to take care of those who are serving while they
are serving. It is the VA's mission to take care of them when
they come home or don't come home.
So, again, I know we are looking forward to working with
you, but epidemiological studies take a really long time, and
people have direct needs right now. So this Committee is
committed to moving forward, taking care of the people who are
suffering right now, and do what we can to mitigate in the
future and reduce the exposures. Try to understand that, but
not wait till we have all the answers. I serve on the Science
Committee. We will never have all the answers. That should not
get in the way of our doing right by the people who wear the
uniform.
So again, I thank you for allowing me to join the Committee
today for this hearing. I have legislation, as I think you
know, on this topic, and have since early on in Congress. And I
am really grateful to the Chairman and Ranking Member and the
Full Committee's Chairman commitment for us to do whatever we
can to address this issue head on and not stick our heads in
the sand. Thank you.
Mr. Dunn. Thank you very much, Representative Esty.
With that, we have--all Members of the Committee have asked
questions.
I want to extend my gratitude as Chairman to all the panel
Members. I think you have all showed a great deal of work and
dedication to this. We appreciate you taking your time and
sharing your expertise and your personal stories. With the
Committee, clearly this is a subject that touches a wide
variety, a large number of people. You saw a great interest on
the part of the Committee, and I think that you will see that
continue. So please keep us in your thoughts. Please keep us
informed. And I will tell the panel, you are now excused. And
thank you for your service very much.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks and include extraneous
material. And without objection, that is so ordered. And this
hearing is now adjourned.
[Whereupon, at 4:45 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Tom Porter
Chairman Dunn, Ranking Member Brownley, and Members of the
Subcommittee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
our more than 425,000 members worldwide, thank you for the opportunity
to share our views, data, and experiences on the matter of burn pits
and airborne toxins, what may indeed now be the ``Agent Orange'' of our
generation.
I am here not only as IAVA Legislative Director, but as a veteran
of Operation Enduring Freedom who was exposed to a variety of airborne
toxins from burn pits and other sources at many locations I was
deployed to in Afghanistan and Kuwait between 2010 and 2011. Before I
went downrange during that period, I had zero breathing problems and
completely healthy lungs. In the first couple of weeks after I arrived
in Kabul, where the air is particularly bad, my lungs had a severe
reaction and became infected. It was controlled with medication over
the next year. However, after re-deploying home, I stopped the
medications and symptoms came back and I was diagnosed with asthma as a
result of my deployment.
Exposure to burn pits used by the military to destroy medical and
human waste, chemicals, paint, metal/aluminum cans, unexploded
ordnance, petroleum and lubricant products, plastics, rubber, wood, and
other waste has been widespread.
And it is not just those working at burn pits. Search for the ``Poo
Pond Song'' on YouTube and you will hear one Soldier's humorous take on
the enormous lake of human waste that tens of thousands of
international servicemembers lived, worked, and ate around at our
formerly large base at Kandahar, Afghanistan.
You could also learn from the many who have served in Kabul--an
enormous city with open sewers and whose population routinely burns dry
animal dung to keep warm. Our military serving there get a healthy
dose--and are suffering the impacts from breathing airborne feces for
extended periods of time. There have been burn pits there as well.
This is to say nothing of the other toxic chemicals and fine
particulates our men and women in uniform were exposed to everyday. Our
friends around the veteran space, especially those who served in
Vietnam, know all too well how detrimental toxic exposures and
environmental hazards can be. As Dr. Tom Berger, Executive Director at
Vietnam Veterans of America's Veterans Health Council explains,
``Vietnam veterans know only too well the health hazards of exposure to
toxic chemicals on the battlefield. That's one of the reasons VVA is so
involved in this issue--we don't want to see the newest generation of
vets go through the same health care challenges we're (still) facing
with toxic exposures, especially with our children and grandchildren.''
One of our members, Christina Thundathil, a U.S. Army veteran, told
us recently of her deployment to Balad, Iraq. Although her specialty
was in food preparation, her job in Balad was to drag the full bins
from port-o-johns daily, douse the contents with jet fuel, light on it
on fire, stir it with her e-tool, then repeat until she had a brick she
could then bury in the desert. She's severely injured because of these
exposures, and she desperately needs a cure for her ills.
The examples are many. However, little is understood about the
long-term effects of exposure to these burn pits and other airborne
hazards. With our presence in Iraq and Afghanistan no longer in the
headlines, the country must continue investing in the system of care
for veterans and their families.
Year after year, we have seen an upward trend in the number of
members reporting symptoms associated with burn pit exposure. Eighty
percent of IAVA members who responded to our latest survey report being
exposed to burn pits during their deployment; over 60% of those exposed
report associated symptoms.
Our members have made it clear: 2018 is the year IAVA will educate
Americans about burn pits and airborne toxic exposures and the
devastating potential impact they could be having on the health and
welfare of millions of Post-9/11 veterans and their families.
To see the enormous extent of interest in this issue by veterans,
you only need to look at the comments section of any related article,
or see our #BurnPits hashtag that has gone viral. These veterans need
help now.
The Department of Veterans Affairs has a ``Airborne Hazards and
Open Burn Pit Registry,'' which helps VA ``collect, analyze, and report
on health conditions that may be related to environmental exposures
experienced during deployment.'' Although established in 2014, only
141,000 have completed the registry questionnaire out of the 3.5
million veterans the VA says are eligible to register. Only 1.7% of the
post-9/11 veterans eligible to register have done so, and only 35% of
IAVA members exposed have.
A definitive scientific link between exposure and specific
illnesses has not yet been made, and the Burn Pit Registry is not well-
known and is underutilized. The result is that the data on these
exposures is not being collected at the levels desired to inform next
steps. Until this point, the Department of Defense (DoD) has not taken
formal accountability of toxic exposures by theater locations for
deployed servicemembers. It is for this reason that IAVA helped to
develop new legislation to tackle this problem.
On May 17, the IAVA team stood alongside Iraq War veteran,
Congresswoman Tulsi Gabbard, and Afghanistan veteran, Congressman Brian
Mast, with the support of 23 other veteran service organizations to
announce the introduction of the Burn Pits Accountability Act. The
legislation directs DoD to include in periodic health assessments and
during military separations an evaluation of whether a servicemember
has been exposed to open burn pits or toxic airborne chemicals. If they
report being exposed, they will be enrolled in the Burn Pit Registry
unless they opt out.
This legislation is bipartisan, commonsense, and simple. It simply
does what should have been done long ago--compels DoD to record
exposures before the servicemember leaves the military.
IAVA Board Member and retired General David H. Petraeus, who once
commanded all forces in Iraq and Afghanistan, in recently expressing
his support for this bill, said ``Veterans are currently experiencing
illnesses that likely are related to exposure to toxins in the war
zones and swift action is needed to understand the impact on health of
exposure to smoke from burn pits and other sources.
IAVA has supported and does support other VA-focused toxic exposure
legislation, and will continue to, but this is a new solution to
tackling this enormous problem.
We ask the Committee to hear the calls of the many exposed veterans
and get our arms around the problem now so VA can do the necessary
research and better support and inform treatment. Congress should enact
the Burn Pits Accountability Act THIS YEAR.
Again, I thank the Chairman and Members of the Committee for
inviting me to express our members' views on this critical issue. I am
happy to answer any questions.
Prepared Statement of Ken Wiseman
Chairman Dunn, Ranking Member Brownley and members of the
Subcommittee, on behalf of the Veterans of Foreign Wars of the United
States (VFW) and its Auxiliary, thank you for the opportunity to
testify on the important topic of burn pits.
The use of open air burn pits in combat zones has caused invisible,
but grave health complications for many service members, past and
present. Particulate matter, polycyclic aromatic hydrocarbons, volatile
organic compounds and dioxins--the destructive compound found in Agent
Orange--and other harmful materials are all present in burn pits,
creating clouds of hazardous chemical compounds that are unavoidable to
those in close proximity.
While the VFW is glad to see that more than 140,000 veterans have
enrolled in VA's Airborne Hazards and Open Burn Pit Registry, we are
concerned that the results of the National Academies of Science's study
on the burn pit registry have not been fully implemented. The findings
must be included in forging a path forward for research on conditions
caused by exposure to the toxins associated with burn pits. The VFW
urges the Department of Veterans Affairs (VA) and Congress to act
swiftly on recommendations from this important study.
For example, a similar registry operated by Burn Pit 360 allows the
spouse or next-of-kin of registered veterans to report the cause of
death for veterans. VA must add a similar feature to its registry to
ensure VA is able to track trends. Other improvements include
streamlining the registration process, updating duty locations based on
records provided by the Department of Defense (DoD), and eliminating
technical glitches to ensure veterans are able to register. Another
concern the VFW hears from veterans is the lack of outreach from the
registry. Veterans expect to receive notifications or updates from VA
on current research and VA's progress to identify and treat conditions
associated with exposure to burn pits.
As VA moves to implement the Electronic Health Record (EHR),
special attention must be given to ensuring this record can interact
with the Airborne Hazards and Open Burn Pits Registry. This will ensure
that data follows the veteran from the time of the exposure through
discharge and life after the military. It will also allow doctors to
provide proper care knowing the full history of the veteran.
Much of a veteran's long-term health is dependent on what happened
to them while in the military. Burn pit exposure can cause problems
while in service and this information must be shared with VA to ensure
proper care is given. While ensuring the EHR communicates with the
registry is important, there is also a need for other information to
come from DoD. The VFW has long advocated for better sharing of
information to include the location of burn pits used, types of
materials burned in the pits, data collected by industrial hygienists
regarding exposures, data collected from post-deployment health
assessments, and all information associated with a medical retirement
caused by health conditions related to burn pit exposures.
Such information from DoD will go a long way in ensuring veterans
receive the care and benefits they deserve. It would provide for data
needed to conduct longitudinal studies which contribute to the existing
body of research on health conditions. The VFW continues to hear from
members who suffer from debilitating respiratory conditions believed to
be caused by exposure to toxic burn pits. The VFW sees the publication
from The National Academies of Science, Engineering, and Medicine,
Assessment of the Department of Veterans Affairs Airborne Hazards and
Open Burn Pit Registry, as further proof that a connection between the
EHR and the VA's burn pit registry must be made.
The 2017 report noted that there was a connection between burn pit
exposure and numerous health conditions including emphysema, chronic
obstructive pulmonary disease (COPD), and asthma. However, the report
stated that the evidence for this connection was self-reporting by
veterans, that further research would be needed to make a more
definitive connection, and that medical records would be the best
source of the needed information about proper diagnoses of these
conditions. The VFW supports this call for further research and
inclusion of the veteran's VA medical records in this research.
There are three major areas where the VFW sees a need for action.
The VFW has always agreed that science must connect the medical
conditions of veterans to their military service. However, ensuring
research is properly funded and conducted in an academic manner remains
a concern.
The VFW is confident that research conducted with proper scientific
methods exists. One such study, New-onset Asthma Among Soldiers Serving
in Iraq and Afghanistan, published in the Allergy & Asthma Proceeding
and conducted by staff at the VA Medical Center in Northport, New York,
found a connection between deployment to Iraq and Afghanistan and
asthma among the 6,200 veterans reviewed. Other studies have shown
similar evidence of association between pulmonary conditions and
exposure to toxic burn pits. That is why the VFW urges VA and Congress
to commission a review of the existing body of research on burn pits to
determine what conclusions can be made and what research needs to be
conducted to find more answers.
While the VFW is glad to see VA has commissioned independent
research on the burn pit registry, more independent research is
necessary. That is why the VFW supports establishing a Congressionally
Directed Medical Research Program (CDMRP) specifically for burn pits.
The CDMRP has shown progress in identifying causes, effective
treatments, and biomarkers for Gulf War Illness, and the VFW is
confident a similar program for burn pits will help exposed veterans
finally determine whether their exposure to burn pits while deployed is
associated with their negative health outcomes.
An important finding in the Assessment of the Department of
Veterans Affairs Airborne Hazards and Open Burn Pit Registry is the
need for new research methods to be developed. The VFW is concerned
about the impact of sampling error on the results of some studies.
Specifically, several VA and DoD-sponsored epidemiologic studies
compare the difference in pulmonary health conditions between veterans
who deployed to Iraq and Afghanistan and those who did not deploy.
However, such studies do not control for the realities of deploying to
combat zones. Often, the deployed veteran's sample included veterans
who were deployed, but whose duties did not require them to work in or
near burn pits. Additionally, non-deployed samples include veterans who
may have deployed in support of previous operations such as the Gulf
War, during which they may have been exposed to other toxins.
Historically speaking, medical research has never exceeded at
including women. Another barrier also faced by VA is the need for women
veterans to be over-represented in medical research in order to produce
accurate and usable results. With this in mind, as well as budgetary
restrictions, the data on reproductive outcomes of women veterans who
have served is lacking. While there are plenty of anecdotal stories and
seeming trends surrounding infertility issues for women who served--be
it in combat, surrounded by toxic exposures, or in a training command--
there is minimal scientific data.
VA found some preliminary data showcasing that women who have
deployed may have higher rates of pregnancy loss and infertility, but
the researchers acknowledged that the study did not include enough
participants to confidently deem that data as valid. Women veterans
deserve to understand how their military service may or may not have
long-term effects on their health. As such, the VFW calls on VA to
improve research related to the impact of burn pits as they relate to
reproductive health issues.
An additional area of concern where research is needed is how burn
pit exposure impacts future generations. The biological children of
those veterans exposed may face health issues just like the children of
Vietnam veterans. There are two significant sections of the law that
cover spina bifida and other birth defects, and it was research that
connected these conditions. The Toxic Exposure Research Act was
designed to provide the type of research needed for connecting
conditions affecting children because of their parents' exposure, and
the VFW supports funding such research so that care can be provided to
those affected.
In closing, the VFW sees that there are more miles in front of us
than behind us on the issue of burn pits. We call on VA to take actions
under current regulations with regard to the processing of disability
claims and research so that veterans and their loved ones get the
answers they deserve. We also support additional funding and oversight
being provided by Congress to ensure that the research can be conducted
in a way that provides these needed answers. Considering the use of
open air burn pits is unique to the military, there is no escaping the
fact that veterans are sick and dying because of their military
service. This is an area where action must be taken.
Mr. Chairman, this concludes my testimony. I am prepared to take
any questions you or the Subcommittee members may have.
Prepared Statement of Dr. Ralph L. Erickson
Good afternoon Chairman Dunn, Ranking Member Brownley, and Members
of the Subcommittee. I appreciate the opportunity to discuss the
ongoing research and actions the Department of Veterans Affairs (VA) is
taking to identify and care for Veterans who were exposed to burn pits
during service in the Armed Forces. I am accompanied today by Dr. Drew
Helmer, Director, War-Related Illness and Injury Study Center, New
Jersey (WRIISC--NJ) and VA's Airborne Hazards Center of Excellence
(AHCE).
Introduction
Exposure to open-air burn pits and airborne hazards during
deployment may be associated with adverse health consequences. The
collaborative and ongoing efforts of VA, the Department of Defense
(DoD), and our partners in academia in the areas of clinical care,
research, education, and communications are being fully employed to
identify Veterans who may be at risk and to investigate and quantify
potential short-term or long-term adverse health effects that may be
associated with their exposure to contaminants or toxic substances from
open-air burn pits and other airborne hazards. Information obtained
through these collective efforts helps inform study designs and, in
time, helps advance clinical practice and standards, as medical
practice continually evolves based on new knowledge. Simply put, the
ultimate aim of these combined efforts is to place us in a position to
know how to better limit future deployed units' exposure to potentially
harmful contaminants and toxic substances and to prevent the clinical
manifestation of any associated diseases, or at least enable us to
clinically manage and control progression of any confirmed associated
adverse health outcomes in affected individuals.
Open burn pits were used as a common waste disposal method at
military sites in Iraq and Afghanistan. They have historically been
used in other parts of the world by the military, but the contents of
what was burned in these conflict areas, as well as the Southwest Asia
environment itself with dust, particulate matter, burning oil wells,
and general air pollution make these recent exposures more complex.
On January 10, 2013, Section 201 of Public Law 112-260 was enacted,
requiring VA to establish and maintain an open burn pit registry for
certain eligible individuals who may have been exposed to toxic
airborne chemicals and fumes caused by open burn pits. As implemented
and enhanced by VA, the registry was designed to include Servicemembers
who deployed to the Southwest Asia theater of operations (as that term
is defined in 38 Code of Federal Regulations Sec. 3.317(e) (2)) on or
after August 2, 1990, or on or after September 11, 2001, to include
Afghanistan and Djibouti. On June 16, 2014, in response to this
mandate, Veterans Health Administration's (VHA) Office of Public Health
(now managed by the Office of Post Deployment Health Services)
established the Airborne Hazards Open Burn Pit Registry (AHOBPR) for
eligible Servicemembers and Veterans. At present, this is VA's fastest
growing registry and has over 143,000 participants as of June 2018.
Smoke from open-air burn pits contained substances that may have
adverse health effects. Separate and distinct from potential open-air
burn pit hazards, ambient particulate matter (PM) was identified as a
potential threat to respiratory health early in Operation Iraqi Freedom
(OIF). Sampling conducted by preventive medicine personnel deployed to
the United States Central Command area of operation typically
demonstrated levels of PM (sometimes referred to as particle pollution
in public communications) above those the U.S. Environmental Protection
Agency's National Ambient Air Quality Standards, which are designed to
protect sensitive populations with an adequate margin of safety. A
major contributor to ambient PM in Southwest Asia was re-suspension of
dust and soil from the desert floor. During Desert Shield/Desert Storm,
Operation Enduring Freedom (OEF), Operation New Dawn (OND), and OIF,
open-air burn pits were used with high frequency. Burn pit emissions
contributed to the total burden of air pollutants, including gases and
PM, to which deployed personnel were exposed.
Potential Long-Term Health Effects of Exposure to Open Burn Pits and
Airborne Hazards
A 2011 Institute of Medicine Report on ``Long-term Health
Consequences of Exposure to Burn Pits in Iraq and Afghanistan''
determined that there is ``limited/suggestive evidence of an
association between exposure to combustion products and reduced
pulmonary function'' in the subject populations. The evidence for an
association between the development of specific respiratory diseases
and exposure to combustion products was found to be inadequate or
insufficient. Currently, it is unknown if reduced pulmonary function is
a consequence of exposure to PM during deployment or if combustion
products exposure during deployment is a risk factor for the
development of clinical disease later in life.
VA's Post Deployment Health Services (PDHS) is currently working to
match the health records of participants in AHOBPR. This will be a
long-term review as many disease processes, such as cancer or chronic
obstructive pulmonary disease, may have a long latency period. As
mentioned, this is the VA's fastest growing registry, and it was
recently critically evaluated by the National Academy of Medicine
(NAM). NAM noted that a limitation of this registry is that it is self-
reported information and therefore subject to inaccuracies. DoD is
making a concerted effort to encourage all eligible Servicemembers who
are separating from the service to enroll in the registry during their
transition period. Also, the optional Airborne Hazards registry
physical examination allows an objective recording of physical
manifestations of a condition/illness and current health status. PDHS
sends out approximately 5,000 emails and letters a month to encourage
completion of the medical exam. An estimated 3.7 million Veterans and
Servicemembers are eligible to join the registry.
PDHS continues to review and conduct original research with AHCE
located at WRIISC--NJ. Additionally, PDHS has requested that the next
consensus report from NAM in the series ``Gulf War and Health,''
(Volume 12) review what is known about the long-term health effects of
airborne hazards. We anticipate that these efforts will lead to better
understanding of these exposures.
VA and DoD continue to research possible relationships between
exposure to open-air burn pits and cardiopulmonary symptoms, such as
shortness of breath or decreased exercise tolerance. An illness of
particular interest and concern is constrictive bronchiolitis.
Constrictive bronchiolitis is a chronic debilitating lung condition and
can have many causes including chemical and other environmental
exposures, organ transplant rejection, medications, infection, and
smoking. Due to an early report of a case series of possible
constrictive bronchiolitis, there has been great interest in this
condition as a potential explanation for the cardiopulmonary symptoms
of Servicemembers after deployment. At this time, there is little
evidence that the diagnosis of constrictive bronchiolitis accounts for
more than a tiny portion of the Veterans with symptoms after
deployment. There is a growing consensus that the cardiopulmonary
symptoms experienced by some Veterans after deployment to Iraq and
Afghanistan are due to a heterogeneous collection of conditions that
may be either triggered or exacerbated by a variety of contributing
factors. VA is committed to continued research to identify any
statistically significant associations between this type of exposure
and the onset of constrictive bronchiolitis, including the mechanism of
injury and dysfunction, ultimately leading us to the identification of
more targeted effective treatments for Veterans with associated
cardiopulmonary symptoms (beyond what is now available to treat them
symptomatically).
Current and Anticipated Future VA Actions
VA and DoD Subject Matter Experts (SME) meet monthly to discuss and
plan joint actions for the study of deployment-related exposures and
their possible association with subsequent adverse health conditions.
Though many deployment-related topics are discussed, airborne hazards
and open-air burn pit-related issues are a frequent agenda item. In
particular, the VA/DoD Health Working Group Airborne Hazards Joint
Action Plan, in support of the VA/DoD Joint Executive Council Strategic
Plan, is updated annually by this group.
VA and DoD are also working jointly to improve real-time exposure
monitoring of deployed forces and to fully capture of these data in the
Individual Longitudinal Exposure Record (ILER) currently under
development. Once fully fielded, ILER will match a Servicemember's
deployments by date and location with the exposures they have
experienced.
In May 2017, VA and DoD gathered 50 SMEs and held the 4th Airborne
Hazards Symposium to address the health effects of airborne hazards
exposure during deployment to Iraq and other countries in the Southwest
Asia Theater of Operations. VA and DoD speakers provided updates on the
current status of the environmental exposure assessment, clinical care,
surveillance, education, outreach, and research on airborne hazards.
Representatives from Veterans Service Organizations provided insight on
the needs of Veterans and made recommendations on VA/DoD efforts.
Experts actively worked in breakout sessions to identify the
challenges, priorities, and gaps in each of these areas. These SMEs
also reviewed recommendations from NAM report, ``Assessment of the
Department of Veterans Affairs Airborne Hazards and Open Burn Pit
Registry, 2017.'' This Symposium has allowed VA to develop a cogent
direction regarding innovative approaches to research and clinical
care.
AHCE at WRIISC--NJ is located at the East Orange Campus of the VA
New Jersey Health Care System. AHCE was established in 2013 to provide
an objective and comprehensive evaluation of Veterans' cardiopulmonary
function, military and non-military exposures, and health-related
symptoms for those with airborne hazard concerns. As planned, AHCE has
expanded to become the VA's only comprehensive clinical assessment
program for airborne hazards concerns of deployed Veterans. However,
AHCE reach extends well beyond innovative clinical evaluations, as AHCE
has leveraged its experience to educate providers (e.g., national
webinars, symposia, fact sheets) and engage the research community
(e.g., conference presentations, invited research discussions,
publications, and grants).
Regarding clinical care, AHCE at WRIISC--NJ will link the self-
reported responses from the AHOBPR online questionnaire to VHA clinical
data. Building on this information, the AHCE team will screen targeted
participants and gather additional non-VHA medical records. AHOBPR
participants with high-priority conditions and exposures will be
invited in for a comprehensive in-person clinical evaluation with the
option to volunteer for related research projects.
Scientific Research Regarding Open-Air Burn Pit Exposure
The Cooperative Studies Program within the VA Office of Research
and Development (ORD) approved funding in 2016 for a large cohort study
to examine the potential effects of PM exposure on lung function. The
aim of the proposed study is to assess the association of previous
land-based deployments to Iraq, Afghanistan, and neighboring regions
with current measures of pulmonary health among a study cohort of 4,500
Veterans. The cohort will include a representative sample of U.S. Army,
Marine Corps, and Air Force military personnel who served during the
OEF/OIF/OND era, between October 2001 and December 2014, and who have
separated from the active military.
VA and DoD are working together and in partnership with various
private institutions on studies regarding possible adverse health
effects related to exposure to open-air burn pits as well as on the use
and effectiveness of AHOBPR. A few of these studies include:
The National Health Study for a New Generation of U.S.
Veterans: This population-based epidemiologic study of 22,000 Veterans
will determine if the Veterans of OIF and OEF have reported an
increased prevalence of health problems and behavioral risks following
deployment in combat theaters relative to non-deployed Veterans.
The Comparative Health Assessment Interview: This study
is currently surveying Veterans who served in Iraq and Afghanistan,
Veterans who served elsewhere, and a comparison group of civilians to
assess environmental and deployment related exposures and health
outcomes. Data analysis will begin in early 2019 with preliminary
results in late 2019 or 2020.
The Pulmonary Health and Deployment to Iraq and
Afghanistan Objective: This study is intended to assess the association
of deployment and potential exposure to airborne hazards during
deployment with current measures of respiratory health. The project is
funded for May 2016 through September 2022.
The Effects of Deployment Exposures on Cardiopulmonary
and Autonomic Function: The study evaluated cardiopulmonary function in
deployed OEF/OIF Veterans versus those deployed elsewhere to determine
whether deployment related exposures alter cardiovascular autonomic
control.
The Millennium Cohort Study: Led by DoD, this is the
largest prospective study in U.S. military history. It is designed to
assess the long-term health effects of military service both during and
after service time; 70 percent of the enrollees are now Veterans.
The Million Veterans Program: This is a VA ORD-funded
project that is collecting demographic, medical, and genetic data on 1
million Veterans who receive their care through VA. This study will be
invaluable in evaluating the genetic components of respiratory disease
risk.
As noted above, more than 143,000 Veterans are enrolled in AHOBPR
and an estimated 3.7 million Veterans and Servicemembers are eligible
to join. With continued outreach, VA hopes the number enrolling will
climb and more individuals will opt to have the Airborne Hazards
medical examination, which will allow us to obtain more data. These
data will inform current and future study designs and ultimately
translate into the clinical sphere, helping us to more fully address
the health-related concerns of potentially affected Veterans. Their
concerns are, of course, shared by VA, DoD, and Congress.
Investigators at VA ORD PDHS and AHCE have authored or co-authored
important peer-reviewed published manuscripts related to the
respiratory health of Iraq and Afghanistan Veterans, including
comprehensive literature reviews, evaluations of health and exposure
concerns, relationships between pulmonary function and deployment-
exposure, association of respiratory and cardiovascular conditions with
burn pit emissions, and a unique pattern of pulmonary function
abnormalities. AHCE researchers collaborate frequently with research
entities, such as Northwell Health Systems and National Jewish Health,
on joint projects, including presentations at national medical
professional meetings.
A bibliography of these scientific articles and other research is
submitted to the Committee as an appendix to this testimony.
Conclusion
VA is committed to the health and well-being of our Veterans and is
dedicated to working with our Interagency and academic partners
determine the best care possible for our Veterans. VA acknowledges the
many sacrifices Veterans make in service our country and remains
committed to outreach and research on potential adverse health effects
associated with exposure during deployment to open-air burn pits and
airborne hazards. This information is needed to improve therapeutic
approaches to care. VA also remains committed to conduct aggressive
outreach about AHOBPR to eligible populations to ensure that these
individuals are aware of the benefits of participating in AHOBPR and
are informed about the Departments' efforts, both joint and separate,
to determine if such exposures are associated with any specific adverse
health effects.
It is critical that we continue to move forward with the current
momentum and preserve the gains made thus far. To this end, your
continued support is essential. Mr. Chairman, this concludes my
testimony. My colleagues and I are prepared to answer any questions.
Statements For The Record
BURN PITS 360 (LE ROY TORRES)
Thank you, Chairman Dunn, Ranking Member Brownley, and Members of
the Subcommittee for today's hearing and for this opportunity to submit
a statement for the record.
Introduction
My name is Le Roy Torres, Captain, U.S. Army Reserve (Retired). I
am a 2007 Iraq War veteran, and Founder of the Burn Pits 360 veterans
organization. My wife Rosie Torres, co-founder and Executive Director
of Burn Pits 360 has provided a statement for the record on a previous
occasion, but today is especially notable. After a decade of advocacy
following my service in Iraq, we are grateful that the Committee today
is conducting a hearing on the health consequences of burn pits
exposure and investigating how the government is treating veterans
suffering from these toxic wounds of war. Today we ask each of you to
stand in solidarity with us to honor with substantive measures the
lives of thousands of my fellow comrades who lost their lives to the
``war that followed us home.''
I served a dual role as a Texas State Trooper for 14 years after
being discharged from state service and as a Soldier for 23 years
before being medically retired. I earned my graduate degree from the
University of the Incarnate Word with the hopes of becoming an Army
Chaplain. I deployed to Balad, Iraq from 2007 to 2008 where I was
exposed to the largest burn pit within the Operation Iraqi Freedom
(OIF) theatre of operations. As a husband, a father and a first
responder, I have been deprived of my dignity, honor and health. I
returned home from war to face a health care system that failed me and
an employer too afraid to understand an uncommon war injury resulting
in termination of my law enforcement career; subsequently facing
foreclosure, while at the same time receiving VA denial letters for
compensation for illnesses still not recognized by VA.
Since returning from Iraq, I have had over 250 medical visits and
was hospitalized immediately upon returning from the war. In November
2010, I was diagnosed with a debilitating lung condition (constrictive
bronchiolitis) following a lung biopsy at Vanderbilt University. My
medical doctors determined last month that I have toxic brain injury
due to exposure to toxins, likely resulting from my burn pits exposures
in Iraq.
For the past decade, Burn Pits 360, which Rosie and I co-founded,
has been at the forefront of this issue, advocating for the families of
the forgotten and those battling life-threatening illnesses. They stand
with us here today and will be standing with us later on the steps of
Congress, and many of their personal stories are included in Appendix
A, which we encourage you to review with the care that they deserve.
Burn Pits 360 is a 501(c)(3) non-profit veterans organization
located in Robstown, Texas.
Our mission is to advocate for veterans, service members, and
families of the fallen affected by deployment-related toxic exposures.
Burn Pits 360 created and maintains a burn pits exposure registry,
which we will discuss in more detail below.
Our organization's impact has included helping to provide impetus
to legislation creating the Airborne Hazards and Open Burn Pit Registry
(AHOBPR) signed into law in 2013, P.L. 112-260, which also directed a
longitudinal burn pits exposure study to be jointly conducted by the
U.S. Departments of Defense (DoD) and Veterans Affairs (VA).
We participated in the open comment period for registry revisions
submitted to the VA Office of Public Health (OPH), resulting in the
addition of constrictive bronchiolitis (CB) to the registry. We
presented our registry data to the National Academy of Sciences,
Engineering, and Medicine (NASEM) committee created under the 2013
legislation, which resulted in an insightful scientific publication
online in 2015 and in a peer reviewed medical journal in 2017. \1\ We
have presented key statements to the Defense Health Board and have
actively participated in every VA/DoD AHOBPR Burn Pit Symposium.
---------------------------------------------------------------------------
\1\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung
Injury (IAW-LI) Clinical Practice Recommendations: National Academy of
Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6):
1653-1663. https:// dx.doi.org/10.1177%2F1557988315619005
---------------------------------------------------------------------------
Burn Pits and Health Consequences
Numerous military bases in the Operations Iraqi Freedom (OIF) and
Enduring Freedom (OEF) theatres of operation produced several tons to
several hundred tons of solid waste per day. Open-air burn pits were
the primary waste disposal method during the majority of the duration
of these wars in Iraq and Afghanistan. This involved the burning of
plastics, medical waste including human body parts, expired
pharmaceutical drugs, chemicals including paint and solvents, petroleum
products, and unexploded ordinance, which according to some reports may
have also included Iraqi chemical warfare agents.
Additionally, some of the burn pits were reportedly built on top of
soil contaminated by chemical warfare agents. \2\ Due to the
unacceptable risk posed by these burn pits to our service members,
their use was eventually mostly banned, except under narrow
circumstances, in 2010. Tens of thousands of service members have been
exposed to toxic chemicals and microfine, highly respirable and
dangerous particulates from burns pits and they continue to suffer
serious, disabling health consequences upon their return.
---------------------------------------------------------------------------
\2\ Walker, Lauren, ``US military burn pits built on chemical
weapons facilities tied to soldiers' illness,'' The Guardian (UK),
February 16, 2016. https://www.theguardian.com/ us-news/2016/feb/16/
us-military-burn-pits-chemical -weapons-cancer-illness- iraq-
afghanistan-veterans
---------------------------------------------------------------------------
A defense contractor stationed at Al-Taqaddum in Iraq from 2006 to
2007--roughly the same time as I was also stationed in Iraq--described
the impact of burn pits and their health effects in a published news
story: ``Burn pit smoke would encircle the entire military base in an
enormous dark ring that settled to the ground after darkfall.. A lot of
people got rare cancers and died. Any exposed skin and mucous
membranes, as experienced by many of us, felt on fire, and burning.
Many of us developed shortness of breath.'' \3\
---------------------------------------------------------------------------
\3\ Elizabeth Hilpert, quoted by Dan Sagalyn, ``Photo essay: The
burn pits of Iraq and Afghanistan,'' November 17, 2014, PBS News Hour.
https://www.pbs.org/ newshour/world/ photo-essay-burn-pits-iraq-
afghanistan
---------------------------------------------------------------------------
The wars in Iraq and Afghanistan exposed U.S. service women and men
to an unprecedented array of airborne health hazards including from
open-air burning in vast burn pits; shock waves and toxic particulates
from improvised explosive devices (IEDs), including vehicle-borne
improvised explosive devices (VBIED) and those containing chemical
warfare agents; and hazardous microfine sand particles. \4\ Service
members with new-onset, post-deployment respiratory symptoms from these
hazards have been labeled as having Iraq/Afghanistan War-Lung Injury
(IAW-LI), \5\ a term we will also use throughout this document.
---------------------------------------------------------------------------
\4\ Szema, Anthony et al, ``Iraq dust is respirable, sharp, and
metal-laden and induces lung inflammation with fibrosis in mice via IL-
2 upregulation and depletion of regulatory T cells,'' J Occup Environ
Med. 2014 Mar;56(3):243-51. https://dx.doi.org/ 10.1097/
JOM.0000000000000119
\5\ Szema, Anthony et al, ``Proposed Iraq/Afghanistan War-Lung
Injury (IAW-LI) Clinical Practice Recommendations: National Academy of
Sciences' Burn Pits Workshop,'' Am J Mens Health, 2017 Nov; 11(6):
1653-1663. https:// dx.doi.org/ 10.1177%2F1557988315619005
Burn Pits Health Consequences Led to Creation of Burn Pits 360's
---------------------------------------------------------------------------
National Registry
In 2010, Burn Pits 360 created a national burn pits exposure
registry, joining forces with other affected families who were united
by the need to prove the correlation between the veterans' toxic
exposures during their deployments and the post-deployment illnesses
(that in some cases were resulting in death) that had since plagued
them. It appeared to be the only way to convince the federal government
that its denials--of the reality of our exposures and resulting health
issues, of granting us necessary health care, of approving our claims
for needed disability compensation, and, ``bottom line,'' of allowing
us the continued right to live--must stop.
Burn Pits 360 continues to manage this registry, which has since
grown to about 6,000 participants. This registry also allows
registrants the ability to later report a decline in health function,
and their survivors to record mortality information including the cause
of death.
Here is some of what we now know:
Air sampling data indicate that smoke from these burn
pits contained chemicals associated with cancers, lung diseases,
cardiovascular disease, kidney disease, neurological disorders, and
more.
The Burn Pits 360 national registry confirms that the
array of devastating health conditions being suffered by exposed
veterans include rare forms of cancer, pulmonary diseases, neurological
disorders, and many other otherwise-unexplained diseases and symptoms.
There are over 100 death entry submissions in the Burn
Pits 360 registry, including from rare cancers--and from suicide.
Burn Pits 360's registry data demonstrates the national
failure to adequately prevent, diagnose, treat, and compensate burn
pit-exposed service members and veterans.
Proposed Agenda
There are a number of crucial issues related to burn pit exposure
and IAW-LI that we strongly believe the House Veterans' Affairs
Committee should investigate and which require the focused attention of
the VA. The current lack of clear understanding of the health impacts
of these exposures should not circumvent our national obligation to
assist every affected military service member and veteran. In
particular, we highlight the following important focus areas:
1) Improving the VA's burn pit registry so that it is can be an
effective research tool for monitoring and identifying the health
consequences of burn pit exposure;
2) Conducting more and better research into the health consequences
of burn pit exposures and to develop effective treatments;
3) Establishing evidence-based clinical practice guidelines and a
specialized care program for IAW-LI and comorbid conditions;
4) Creating a scientific advisory committee related to burn pit
exposures and IAW-LI;
5) Improving VA disability compensation claims for burn pit
veterans, including establishing presumption of service-connection for
debilitating symptoms and diseases that have been linked to burn pit
exposure.
1) Improving the VA's Burn Pit Registry
As noted earlier, in 2013, DoD and VA were directed by Congress to
set up a registry to collect information from service members who may
have been exposed to toxic chemicals and fumes caused by open air burn
pits and other airborne hazards. The resulting Airborne Hazards and
Open Burn Pit Registry (AHOBPR) to date has 141,246 registrants who
completed and submitted the registry questionnaire. \6\
---------------------------------------------------------------------------
\6\ U.S. Department of Veterans affairs Web site, retrieved June 5,
2018, https://www.publichealth.va.gov/ exposures/ burnpits/
registry.asp Registrants completed and submitted the registry
questionnaire between April 25, 2014 and May 1, 2018, including from
OIF, OEF, Operation New Dawn, Djibouti since 9/11, and Southwest Asia
since August 1990.
---------------------------------------------------------------------------
And, on February 28, 2017, the NASEM committee mandated in P.L.
112-220 (the Committee on the Assessment of the Department of Veterans
Affairs Airborne Hazards and Open Burn Pit Registry) released its final
report, entitled, ``Assessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry.'' Several key points
emerged that we will mention shortly.
First, with a total of over 3.5 million eligible personnel,
participation in the VA's registry is far below expectations and there
is not yet a clear understanding why. Without a drastic increase in
registration, it is difficult to see how the VA's registry can provide
an accurate assessment of the health effects of open-air burn pits on
our service members and veterans.
Further, our constituents on the Burn Pits 360 registry have raised
concerns as to how the VA's registry functions. Currently, there is no
way for a service member or veteran to report a decline in health like
we allow in our registry. If registrants initially register as having
no ill effects from the burn pits but are subsequently diagnosed with a
disease or illness, they cannot later add that information to the A
registry. This limits the long-term effectiveness of using the VA
registry to assess the impact of toxic burn pits on our service
members' health over an extended period of their lives and to conduct
longitudinal studies regarding the health effects associated with burn
pit exposures.
We are also concerned with the participation rate in the VA
registry's initial in-person medical evaluation. As we understand it,
the evaluation's intent is to have a VA practitioner systematically
assess a service member or veteran for symptoms related to their toxic
exposures. This would allow for the creation of a fuller picture of the
patient's health than can be obtained through the self-reported survey
alone. However, according to a presentation given by Stephanie Eber and
Susan Santos of the VA, as of April 2017, only 2.8 percent of registry
participants have undergone this exam. We have also received reports of
inconsistent examinations, diagnoses, and treatments afforded to
service members seeking care associated with their toxic exposures.
Another serious shortfall of the VA registry is that it does not
allow family members to register the death of registry participants,
especially important when there is reason to believe the death was a
result of toxic exposure from burn pits (ours does). Without tracking
the mortality rate through methods such as allowing surviving family
members to report deaths and the cause of death, the registry's ability
to establish mortality rates related to conditions and diseases
associated with toxic exposure is precluded.
Most significantly, the NASEM committee on the assessment of VA's
registry stated in its final report: ``On the basis of its evaluation
of the data, the committee concluded that the exposure data are of
insufficient quality or reliability to make them useful in anything
other than the most general assessments of exposure potential.'' \7\
---------------------------------------------------------------------------
\7\ National Academy of Science, Engineering, and Medicine (NASEM),
Committee on the Assessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry, ``Report Highlights,''
February 28, 2017. http://www.nationalacademies.org/ hmd/reports/2017/
assessment-of-the-va-airborne-hazards- and-open-burn-pit-registry.aspx
---------------------------------------------------------------------------
The Committee concluded:
Attributes inherent to registries that rely on voluntary
participation and self-reported information make them fundamentally
unsuitable for addressing the question of whether burn pit exposures
have caused health problems. Addressing the issues identified by the
committee would, though, improve the AH&OBP Registry's utility as a
means of generating a roster of concerned individuals and creating a
record of self-reported exposures and health concerns.
All parties-service members, veterans, and their families; VA;
Congress; and other concerned people-would benefit from having a
realistic understanding of the strengths and limitations of registry
data so that they can make best use of them and, if desired, conduct
the kind of investigations that might yield salient health information
and improve health care for those affected. \8\
---------------------------------------------------------------------------
\8\ NASEM 2017
---------------------------------------------------------------------------
Finally, as of June 4, 2018, the VA's Web site currently states
that ``VA is working to improve the registry based on recommendations
in the report'' \9\ that was issued more than 15 months earlier. It
appears that this sentence of the Web site was recently changed.
Previously, the Web site stated, ``A workgroup of VA subject matter
experts is reviewing the report's nine recommendations to determine
ways to improve the health status and medical care of veterans.'' To
date, we are not yet aware of improvements to the VA's registry
recommended either by the NASEM report last year or the researchers'
recommendations published online in 2015 and in a medical journal last
year. \10\
---------------------------------------------------------------------------
\9\ ibid.
\10\ Szema et al, 2017
Recommendation. We encourage the Committee to seek answers from the
VA for the following important questions, and legislating or otherwise
---------------------------------------------------------------------------
ensuring changes as may be appropriate based on VA's responses:
1. Thousands of veterans who were exposed to toxic smoke from burn
pits in Afghanistan and Iraq are coming home and developing serious
illnesses like constrictive bronchiolitis, other respiratory
conditions, and cancers. Is it VA's position that prolonged exposure to
smoke from open burn pits burning of toxic waste can have lasting
negative health consequences?
2. The VA has not seriously researched the consequences of burn pit
exposure. Congress mandated that VA implement the Registry to monitor
health conditions affecting veterans and service members who were
exposed to toxic smoke from burn pits and other hazards. But, according
to a 2017 report from the National Academy of Sciences, the registry is
fatally flawed and ineffective as a way to investigate the true health
consequences of burn pits. Will VA commit to reforming the burn pits
registry to make it a genuinely useful tool for documenting the true
health consequences of burn pits?
3. Who is on the ``workgroup of VA subject matter experts'' that
was reviewing the nine recommendations? What records reflect their work
in response to the 2017 National Academy of Sciences report, including
their recommendations or determinations?
4. What records reflect the improvements that the VA is considering
to the Registry based on the recommendations of the 2017 report?
5. What records exist regarding complaints about the burn pit
registry, including complaints from individual veterans regarding the
registry?
6. What outreach methods are in place to ensure that service
members deployed to Iraq and Afghanistan post-9/11 are aware of the
registry and are encouraged to register if they believe they have been
exposed to toxic matter through open air burn pits?
7. What factors explain the discrepancy between the numbers of
service members potentially exposed, versus the number of registrants
to the burn pits registry?
8. What is the VA's strategy to increase participation in the
registry?
9. Does the VA regularly communicate with registrants?
10. How is the VA gathering data, if at all, to assess change or
decline in health among service members, to support a longitudinal
assessment? Why would the VA not support including an option for
updated reporting in the registry?
11. How is the VA gathering mortality data, if at all, associated
with toxic exposures through burn pits? Why would the VA not support
including an option for reporting deaths in the registry?
12. What factors explain the low participation rate of registrants
with the associated exam?
13. Has the VA adopted a strategy to increase the participation
rate in the initial exam?
14. Is there a uniform protocol in place that practitioners who
administer the exam are following? If yes, what is the protocol and has
it proven effective in recognizing common warning signs and symptoms
indicating toxic exposure?
15. What protocol does the VA have in place to ensure that its
practitioners are equipped to detect and treat medical issues
associated with toxic exposure among registry participants VA examines?
Recommendation. To encourage full Registry participation, Congress
should direct VA to conduct a national outreach campaign to include:
Newsletters to registry participants
Social media campaigns
Development of VA registry outreach written materials for
distribution in VA and veterans service organization (VSO) facilities,
at events, and on all social media sites operated by DoD and VA.
2) Conducting More and Better Research
The VA was directed under P.L. 112-260 to contract for an
independent scientific report that would contain the following: \11\
---------------------------------------------------------------------------
\11\ PUBLIC LAW 112-260-JAN. 10, 2013 126 STAT. 2423--SEC. 201.
ESTABLISHMENT OF OPEN BURN PIT REGISTRY.
(b) REPORT TO CONGRESS.-
(1) REPORTS BY INDEPENDENT SCIENTIFIC ORGANIZATION.- The Secretary
of Veterans Affairs shall enter into an agreement with an independent
scientific organization to prepare reports as follows:
(A) Not later than two years after the date on which the registry
under subsection (a) is established, an initial report containing the
following:
(i) An assessment of the effectiveness of actions taken by the
Secretaries to collect and maintain information on the health effects
of exposure to toxic airborne chemicals and fumes caused by open burn
pits.
(ii) Recommendations to improve the collection and maintenance of
such information.
(iii) Using established and previously published epidemiological
studies, recommendations regarding the most effective and prudent means
of addressing the medical needs of eligible individuals with respect to
conditions that are likely to result from exposure to open burn pits.
(B) Not later than five years after completing the initial report
described in subparagraph (A), a follow-up report containing the
following:
(i) An update to the initial report described in subparagraph (A).
(ii) An assessment of whether and to what degree the content of the
registry established under subsection (a) is current and scientifically
up-to-date.
(2) SUBMITTAL TO CONGRESS.-
(A) INITIAL REPORT.-Not later than two years after the date on
which the registry under subsection (a) is established, the Secretary
of Veterans Affairs shall submit to Congress the initial report
prepared under paragraph (1)(A).
(B) FOLLOW-UP REPORT.-Not later than five years after submitting
the report under subparagraph (A), the Secretary of Veterans Affairs
shall submit to Congress the follow-up report prepared under paragraph
(1)(B).
https://www.gpo.gov/ fdsys/pkg/PLAW-112publ260/pdf/PLAW-
112publ260.pdf
An assessment of the effectiveness of actions taken by
the Secretaries to collect and maintain information on the health
effects of exposure to toxic airborne chemicals and fumes caused by
open burn pits.
Recommendations to improve the collection and maintenance
of such information.
Using established and previously published
epidemiological studies, recommendations regarding the most effective
and prudent means of addressing the medical needs of eligible
individuals with respect to conditions that are likely to result from
exposure to open burn pits.
To date, it is unclear to us whether this has happened. Certainly
VA has not yet determined the ``most effective and prudent means of
addressing the medical needs of eligible individuals with respect to
conditions that are likely to result from exposure to open burn pits.''
Recommendation. We encourage the Committee to provide continued
oversight with regards to the status of this report and the
implementation of its recommendations.
According to VA's Web site, NASEM's 2011 report, Long-Term Health
Consequences of Exposure to Burn Pits in Iraq and Afghanistan, ``found
limited but suggestive evidence of a link between exposure to
combustion products and reduced lung function in various cohorts
similar to deployed Service members, such as firefighters and
incinerator workers. This finding focused on pulmonary (lung) function,
not respiratory disease, and noted that further studies are required.
There is little current scientific evidence on long-term health
consequences of reduced lung function.'' \12\
---------------------------------------------------------------------------
\12\ U.S. Department of Veterans Affairs Web site, retrieved June
4, 2018: https://www.publichealth.va.gov/ exposures/burnpits/health-
effects-studies.asp
---------------------------------------------------------------------------
VA goes on to say, ``VA and the Department of Defense will conduct
a long-term study that will follow Veterans for decades looking at
their exposures and health issues to determine the impact of deployment
to Iraq and Afghanistan. Read the February 4, 2013 notice in the
Federal Register to learn more.''
It has been more than five years since VA announced it planned to
conduct this long-term study. VA has had ample opportunity to conduct
it.
Recommendation. We encourage Congress to mandate an independent
epidemiologic research study--outside of VA, which has already had
ample opportunity to do so--that will help to more formally identify
the association our Burn Pits 360 Registry has already shown between
burn pit exposure and resultant health conditions and deaths.
Such research should include determining the incidence and
prevalence of IAW-LI and other potentially related health conditions
in: (1) military service members and veterans currently in treatment
for post-burn pit exposure health complaints; (2) Iraqi local
populations similarly exposed to U.S. burn pits; (3) healthy control
populations of Iraq and Afghanistan War deployed and non-deployed era
service members/veterans.
Recommendation. We encourage the Committee to seek answers from the
VA for the following important questions, and legislating or otherwise
ensuring changes as may be appropriate based on VA's responses:
1. Which specific office(s), working group(s) or people are
assessing the adequacy and effectiveness of data gathering and
surveillance of the health consequences of burn pits?
2. Does VA have any unpublished studies, reports, or similar
documents regarding health effects of burn pits?
3. How does VA review, assess, and assimilate studies into (i) its
assessment of the long-term health consequences of burn pits and (ii)
its screening for potential burn-pit related disease and (iii) its
treatment for burn-pit related disease?
4. What records exist that would reflect VA's assessment of such
studies (including, potentially, internal correspondence, memos, etc.)
5. What internal assessments, memos, or other documents underlie
the VA's determination that ``At this time, research does not show
evidence of long-term health problems from exposure to burn pits.''
6. Which specific office (or which officials) are involved in
internal reassessment or reevaluation of VA's determination that there
is currently no evidence of long-term health problems? What records
exist that would reflect any such ongoing assessment or evaluation?
7. The VA's ``fact sheet'' on burn pits, which describes ongoing
research into the health effects of burn pits and the inconclusive
nature of prior research. The last time we reviewed it, that fact sheet
was last updated in November 2013 and only referred to studies from
2009 and 2011. Which specific office (or which officials) are involved
in reassessing the statements in that fact sheet in light of more
recent research? What records exist that would reflect potential
reassessments or updates of the fact sheet?
DoD-CDMRP Burn Pit Exposure Medical Research
As many of the members of this Committee know from past hearings on
another toxic exposure issue, Gulf War Illness, many ill Gulf War
veterans are encouraged by ongoing treatment research directed by
Congress, including by many of you and other leaders and Members of the
House Veterans' Affairs Committee. Specifically, that treatment
research is being done by the Gulf War Illness Research Program
(GWIRP), part of the Congressionally Directed Medical Research Program
(CDMRP) that is funded under the Department of Defense (DoD) health
budget.
Like the GWIRP, many of the health research programs within the
CDMRP are standalone programs. However, others are congressionally
designated topic areas within broader programs like the CDMRP's Peer
Reviewed Medical Research Program (PRMRP). The specific topic areas to
be pursued are determined by Congress each year through annual Defense
appropriations.
For Fiscal Year 2018, there are several medical research topic
areas in the CDMRP-PRMRP that remain of strong interest to veterans
affected by burn pit exposure, including: Acute Lung Injury; Burn Pit
Exposure; Constrictive Bronchiolitis; Lung Injury; Metals Toxicology;
Mitochondrial Disease; Pulmonary Fibrosis; and Respiratory Health. We
are grateful to Congress for including all of these research topic
areas, particularly the restoration of the Burn Pits Exposure topic
area.
CDMRP is important for this treatment-focused research for several
reasons. First, CDMRP has the ability to fund any qualified research
team, not just those employed by the funding agency. By contrast, VA's
medical research program is solely intramural and open only to VA-
employed researchers. Much of the valuable medical research related to
burn pits exposure has been led by researchers at independent, academic
medical centers including Vanderbilt University, Stony Brook
University, the Deployment-Related Lung Disease Center at National
Jewish Health, and others.
Second, CDMRP includes in all levels of planning, proposal review,
and funding decisions the active participation of consumer reviewers--
patients (or their caregivers) who are actually affected by the
disease. This is of critical importance. VA offers no opportunity for
similar involvement in research decision-making by the patients who are
ultimately affected by such decisions.
Finally, CDMRP has already shown its effectiveness with regards to
other complex post-deployment, toxic exposure health conditions
including traumatic brain injury (TBI) and Gulf War Illness (GWI),
including through its emphasis on collaboration, treatment focus, and
effective two-tiered peer review.
Recommendation. We encourage Members of the Committee work to
create a Congressionally directed standalone Burn Pits Exposure
Research Program (BPERP) within the Congressionally Directed Medical
Research Program (CDMRP), modeled after the successes of other CDMRPs
including the treatment-focused Gulf War Illness Research Program, as
follows:
A standalone burn pits exposure CDMRP would ideally be laser-
focused on improving the health and lives of veterans suffering the
negative health effects of burn pit exposures and on learning all that
is possible from their health experiences to help future veterans
similarly exposed. Like the existing standalone CDMRPs, the proposed
Burn Pits Exposure Research Program would have its own dedicated staff,
focused exclusively on advancing the Congressional directives related
to this burn pit exposure medical research program. Ideally, it would
be focused on several major areas to more rapidly improve the health
and lives of veterans affected by burn pits exposure:
Accelerating the development of treatments and their
clinical translation for Iraq/Afghanistan War Lung Injury (IAW-LI) and
comorbid associated conditions
Improving scientific understanding of the pathobiology
resulting from burn pit exposures, including in both affected veterans
and in animal models of burn pit exposures, and including research
priorities to identify biomarkers of exposure, biomarkers of exposure
effect, and biomarkers of illness--all critical in improving the
definition and diagnosis, disease monitoring, and monitoring of the
effectiveness of tested treatments of veterans affected by burn pit
exposure
Assessing comorbidities, including the incidence,
prevalence, early detection and diagnosis, treatments for, and any
unique factors related to burn pits exposed veterans': constrictive
bronchiolitis (CB/OB), pulmonary fibrosis, sarcoidosis, chronic
obstructive pulmonary disease (COPD), post-exertional asthmas, and
other respiratory diseases; cancers including lung cancer, leukemia,
glioblastoma and other brain cancers, renal cancer, and other cancers
Identifying force health protection prevention measures
to prevent future burn pit exposures, and to provide early assistance
to future military service members exposed to burn pits?
Using other CDMRP successes as a model, investing
appropriated medical research funding to develop a collaborative,
inter-institutional, interdisciplinary burn pits exposure research
consortium, while investing other appropriated medical research funding
to support focused medical research in the areas described above
We understand the process for fiscal year 2019 Defense
appropriations has already moved forward. However, we have seen there
is great value in having a project like this led by Members of the
House Veterans' Affairs Committee. We would be pleased to work early
next year with any Members interested in creating, on a bipartisan,
bicameral basis, a cosigned request for fiscal year 2020 funding to
create such a Burn Pits Exposure Research Program.
3) Establishing Evidence-Based Clinical Practice Guidelines and
Specialized Treatment
According to a recent search of VA's Web site that appears to list
and link to all of the existing VA/DoD Clinical Practice Guidelines, VA
and DoD have not yet developed evidence-based Clinical Practice
Guidelines (CPG's) for health care providers to know how to identify,
evaluate, treat, and refer patients with IAW-LI or other conditions
that may be associated with exposure to burn pits. \13\ At least one
other VA/DoD CPG has come under harsh fire in a 2013 hearing before
this Committee for not being evidence-based, and worse. \14\
---------------------------------------------------------------------------
\13\ U.S. Department of Veterans Affairs Web site, retrieved June
5, 2018: https:// www.healthquality.va.gov
\14\ U.S. House Committee on Veterans' Affairs, ``Persian Gulf War:
An Assessment of Health Outcomes on the 25th Anniversary,'' https://
veterans.house.gov/ calendar/ eventsingle.aspx?EventID=1104
---------------------------------------------------------------------------
There remains an unmet need of adequately educating primary care
clinicians in the evaluation and treatment of burn pit related physical
illness, including in DoD, VA, and civilian health care environments.
There also remains an unmet need of describing evidence-based treatment
recommendations for IAW-LI (including post-exertional shortness of
breath and diagnosed respiratory conditions), toxic brain injury, and
all disease and illnesses associated with deployment toxic exposures
including from burn pits.
IAW-LI is debilitating to the affected veterans. This war-induced
disease impacts multiple dimensions of everyday life, such as the
ability to perform one's job and the ability to exercise. Research has
shown that service members and veterans suffering from this war-related
lung injury have new-onset asthma or fixed obstructed airways. Research
has also reported titanium bound to iron in fixed mathematical ratios
of 1:7, which is extremely rare in nature, in the lungs of soldiers,
suggestive of an anthropogenic, man-made source. In more severe cases,
these service members developed severe respiratory disability that
required a lung transplant. IAW-LI has been shown to be long-term and
does not improve, even though some of these veterans were exposed in
2003--fifteen years ago. Yet almost counter intuitively, symptoms as
severe as these are not detectable by routine testing and require
sophisticated specialty care.
Currently, there are no evidence-based treatments available for
this disease process, but researchers are investigating several
candidate medications in development, which have been found to reverse
IAW-LI injuries in mice exposure models. ??Because of the VA's
dereliction of duty to this matter for the last fifteen years; it is
our generation's Agent Orange.
IAW-LI sometimes is not easily diagnosed by physicians, because
many are still unaware of this injury. Also, it is difficult for
suffering patients to realize what their symptoms are because this is
an unconventional disease. Many believe the symptoms are attributed to
Post-Traumatic Stress Disorder (PTSD), not IAW-LI. Sophisticated tests
such as impulse oscillometry and analysis of lung tissue for metals are
only available at Quaternary Care Medical Centers. Quaternary care is
very specialized and highly unusual and not offered at most medical
facilities.
Recommendation. Congress should mandate that VA create evidence-
based clinical practice guidelines for IAW-LI that are appropriate for
DoD, VA, and non-VA health care providers to be able to identify,
evaluate, treat, and refer patients with conditions that may be
associated with exposure to burn pits including IAW-LI and comorbid
cancers, respiratory, and other diagnosed diseases.
VA Clinical Care: Establishing a Specialized Health Care Program
Develop deployment related toxic exposure specialty clinic within
the VA health care systems. Currently veterans are being misdiagnosed
and symptoms are being dismissed as psychosomatic and not for the true
illnesses they are suffering from.
Recommendations. We ask that Congress query VA leadership: Will VA
commit to establishing a dedicated research center to study and develop
treatments for health conditions resulting from burn pit exposure?
4) Develop a Burn Pits Exposure Scientific Advisory Committee
Currently, no federal advisory committee exists that is specific to
burn pits exposures. And, there are few opportunities within current
DoD and VA activities that allow for burn pit exposed service members
and veterans to actively participate in making recommendations related
to research or policymaking that directly affects their well-being.
Recommendation. Congress should mandate the establishment of a
federal scientific advisory committee to provide a comprehensive review
and recommendations on the full spectrum of burn pits exposure
research. It should include several VA, DoD, and independent scientific
researchers and clinicians who actively work on burn pits exposure
research or clinical care, and should include several clearly
representative, affected service members, veterans, and their
survivors. Its activities should include review the experiences of
affected service members and veterans, and scientific and medical
evidence in order to make recommendations to DoD, VA, and possibly also
the Department of Health and Human Services (HHS).
5) Improving VA Burn Pits Exposure Claims
VA's Compensation and Pension Manual, M21-1MR, provides guidance
for adjudicating claims resulting from various toxic exposures. The
relevant section, entitled, ``Service Connection for Disabilities
Resulting from Exposure to Other Specific Environmental Hazards,'' \15\
at least partially governs VA's burn pits exposure-related compensation
claims. Relevant identified hazards include ``large pit burns
throughout Iraq, Afghanistan, and Djibouti on the Horn of Africa'' and
``particulate matter in Iraq and Afghanistan.''
---------------------------------------------------------------------------
\15\ U.S. Department of Veterans Affairs, Veterans Benefits
Administration, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C,
Topic 12, ``Service Connection for Disabilities Resulting from Exposure
to Other Specific Environmental Hazards.'' https://www.benefits.va.gov/
WARMS/docs/admin21/m21--1/ mr/part3/subptiii/ ch05/pt03--sp03--ch05--
secj.doc
---------------------------------------------------------------------------
VA Training Letter 10-03, identified in the manual, provides more
specific policy guidance on processing burn pit claims.
Additionally, after the 1991 Gulf War, Congress enacted statutory
directives at 38 U.S.C.Sec. 1117, which addressed a range of
disabilities in veterans who served in Southwest Asia. VA then
promulgated its regulations at 38 C.F.R. Sec. 3.317. Although rarely
applied correctly by VA, the law provides for presumptive service
connection for a ``qualifying chronic disability.'' A qualifying
chronic disability means a chronic disability resulting from ``an
undiagnosed illness'' (UDX) or ``a medically unexplained chronic multi-
symptom illness [CMI] that is defined by a cluster of signs or
symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3)
functional gastrointestinal disorders'' [including irritable bowel
syndrome (IBS)]. If a veteran's disability pattern is either one of
these, then VA must grant service connection based on Sec. 3.317.
Veterans with burn pit exposure who served in the Southwest Asia
theatre of operations (which does not include Afghanistan or Djibouti)
anytime from August 1991 the present may also qualify to have their
claims adjudicated under these provisions.
VA should have little problem establishing exposure in burn pit
cases because nearly every forward operating base (FOB) in Iraq,
Afghanistan, and Djibouti had a burn pit. Given the widespread nature
of the burn pits, and the inability of military personnel records to
identify all duty locations, VA adjudicators are generally supposed to
accept the veteran's lay statement of burn pit exposure as sufficient
to establish the occurrence of such exposure if the Veteran served in
Iraq or Afghanistan.
VA Claims: Medical Diagnosis and Adjudication Practices
At times, VBA staff have exhibited confusion about relevant
diagnosis for veterans with burn pits exposures. Confounding burn pit
claims with Gulf War Illness claims, they have returned documentation
explaining that service-connection could not be granted because the
veteran did not have an undiagnosed illness (UDX) or a medically
unexplained chronic multi symptom illness (CMI). These are complex
regulations that VA has systemically failed in correctly applying to
the appropriate cases.
Burn Pit related claims are not the same claims as under the
Persian Gulf War regulations. Claims based on the Gulf War regulations
are granted, if at all, on a legal presumption that the disability is
related to service in Southwest Asia. Whereas, claims based on OIF/OEF
exposures, such as burn pits, are granted, if at all on a direct basis
(i.e., event or exposure during service; diagnosed disability; and, a
medical nexus between the two.)
There are times, however, when VA claims staff appropriately apply
both sets of rules. A good example is when a veteran who served in Iraq
after September 11, 2001 files a service connection claim for a
disability that could satisfy the ``qualifying chronic disability''
requirements of 38 C.F.R. Sec. 3.317 but is also a disability that may
be directly related to exposures in Iraq after September 11, 2001, such
as burn pits. In such a case, VA should consider both sets of rules
separately and then grant the veteran's claim under whichever is of
greatest benefit to the veteran.
Recommendation. The Committee should request detailed information
from VA on the gaps and overlaps between the application of these two
types of claims adjudication processes for veterans with burn pits
exposure and resultant disability.
VA Claims: Adjudication Issues
Most disability claims require a medical examination from a VA
practitioner or contracted VA examiner. In burn pit claims, these so-
called Compensation and Pension (C&P) exams are very important because
VA has not yet acknowledged a medical nexus between burn pit exposure
and the disabilities burn pit veterans are experiencing. Often, the
veteran's only chance to show a medical link between their symptoms and
contact with burn pit emission is a medical opinion issued by one of
these C&P examiners.
This makes it all the more troubling that VBA staff so routinely
fail to follow VA guidance on requesting C&P exams for burn pit
exposure claims. When they do follow the guidance, the only training
C&P examiners receive on burn pit emissions is a one-page ``fact
sheet'' produced by VBA when it issued Training Letter 10-03.
VBA staff also frequently neglect to send the minimalist fact sheet
required for all C&P exam requests pursuant to VBA's M-21 procedural
manual. This leaves examiners with little to no information about which
chemicals have been detected in burn pits emissions, how burn pits were
operated, and other potentially critical medical information.
Most examination reports serve little more purpose than to reveal
the person conducting the examination has no experience in burn-pit
related claims or are simply not aware they even exist. The status quo
answer in response to requests for VA medical opinions is quickly
becoming that VA has not found the particular veteran's disease process
is caused by service in Southwest Asia. Such opinions rarely
acknowledge the claim is even burn pit related, much less provide any
analysis on the chemicals produced by the burn pits in relation to the
veteran's disability.
If a veteran files a disability claim within a year of their
separation from service, a C&P exam is generally ordered for all
claims. A year or more after a Veteran's separation, C&P exams are
ordered if the claim meets a certain threshold of evidence. VBA usually
manages to verify exposure and thus request an exam in burn pit cases.
But confusion about burn pit claims has led to mistakes that could
prevent or delay the ordering of a C&P exam. Or, if the wrong type of
exam is ordered, a second exam may need to be requested. Veterans often
have to wait months to get an exam due to the longstanding backlog of
disability claims.
In developing for a medical nexus between burn pit exposure and the
veteran's diagnosis, VBA staff have ordered medical examinations for
the wrong condition (often Gulf War Illness related). Or, when claims
staff ordered the correct exam, they have requested medical opinions
from examiners who, by VA's own standards, are unqualified to give
them-for example, physicians assistants (PAs).
Inadequacy of training on burn pits exposure and Gulf War claims
appears to be a deciding factor in the negative outcomes veterans are
experiencing with these claims. This inadequate training appears to
extend from VHA and contractor medical examiners to VBA claims
adjudication staff.
These errors and confusion in the development process have led to
unnecessarily long wait times for veterans suffering from often
debilitating, and sometimes life-threatening, disabilities resulting
from their burn pits exposures.
Recommendation. Congress should make necessary statutory changes to
ensure appropriate outcomes for burn pits exposure claims, including
mandating training (and ensuring the appropriateness of that training)
for VHA and contractor medical examiners and VBA claims adjudication
staff.
VA Claims: Tracking Burn Pit Claims
Despite establishing the Airborne Hazards and Open Burn Pit
Registry where veterans can self-report burn pit exposure and related
symptoms, VA does not adequately identify or track VA compensation
claims related to burn pit exposure. VBA frequently uses ``Special
Issue Identifiers'' to track certain types of claims. Claims related to
military sexual assault, for example, would be marked so that VBA staff
or VHA researchers could see claim-specific trends in wait times,
approval rates, etc.
In VA Training Letter 10-03, VBA staff are instructed to use the
only identifier pertaining to exposure claims: ``Environmental Hazard
in Gulf War.'' This identifier covers a range of exposures too diverse
to draw any statistical conclusions about burn pit claims.
Without a tracking system, veterans' advocates are left in the
dark. We don't know how many burn pit-related claims have been
submitted, how many have been denied, which medical issues are being
reported, or how long veterans are waiting to get an answer.
Importantly, we cannot confirm that burn pit claims are being
incorrectly processed in a systemic way, as it often appears.
Recommendation. Congress should mandate that VA track and report on
a quarterly basis all relevant data for VA compensation claims related
to burn pit exposure, including numbers of claims submitted, approved,
denied, reasons for denial, and numbers of claims denied per reason for
denial.
VA Claims: Establishing presumptions of service-connection
Among the serious diagnosed medical conditions identified in
service members with IAW-LI is an extremely rare, irreversible, and
often fatal respiratory disease called constrictive bronchiolitis (CB)
and sometimes also called bronchiolitis obliterans (OB). The medical
literature reveals CB/OB to be caused by occupational exposure to
diacetyl (``popcorn lung''), in Iranian survivors of Iraqi sulfur
mustard (mustard gas) attacks during the 1981-88 Iran-Iraq war, and in
OIF/OEF veterans.
Currently, CB/OB can only be can only be identified by a highly
invasive lung biopsy conducted under general anesthesia, though medical
research is currently underway in the Congressionally Directed Medical
Research Program (CDMRP) that if successful would allow for non-
invasive diagnostic methods.
Biopsies have been performed on numerous OEF/OIF Veterans whose
worsening breathing problems including shortness of breath, especially
following even limited exertion, could not be diagnosed by traditional
tests, such as x-rays, CT scans, MRIs, or pulmonary function testing.
Lung biopsies have returned a positive diagnosis for CB/OB in
approximately 90 percent of these cases.
There are several issues of concern here. First, we are hearing
from veterans that VA is not currently service-connecting their CB/OB
without a confirmatory biopsy.
And, even with such confirmation, VA often denies service-
connection on the basis of lack of proof of in-service causation. For
veterans without a confirmatory biopsy of CB/OB, it is nearly
impossible for them to get VA (or DoD) to provide one.
And, veterans returning without a formal CB diagnosis but with
debilitating post-deployment respiratory and other chronic symptoms,
which for many veterans developed while they were still deployed, far
too often are denied by VA for service-connection.
In short, VA's requirements for these debilitating post-deployment
respiratory conditions are nearly impossible for most veterans to meet,
despite their serious disability. By contrast, the U.S. Social Security
Administration (SSA) has added CB as a Compassionate Allowance after
medical research identified the disease as causally related to
environmental toxins, including burn pits, in Iraq and Afghanistan. Not
so with VA.
Additionally, many of Burn Pits 360's members and constituents have
been diagnosed with unexplained cancers, including an array of
leukemias, brain cancers, and other cancers. Many of these veterans are
young. Many have died, without compensation or appropriate VA
assistance for themselves or their survivors.
Recommendations. We ask that Congress amend Title 38, United States
Code, to:
A.) Provide a presumption of service-connection for VA compensation
for symptom-based respiratory disability in veterans exposed with
presumed exposure to these airborne hazards;
B.) Provide a presumption of service-connection in cases where the
veteran has been given a diagnosis of CB/OB or other debilitating
respiratory diseases, including chronic obstructive pulmonary disease
(COPD), post-exertional asthma, pulmonary fibrosis, and other diagnosed
respiratory conditions;
C.) Provide a presumption of service-connection in cases where the
veteran has developed any of the array of post-deployment cancers that
we have identified in these veterans.
6) Legislation
We urge Congress to introduce a health care and compensation act.
APPENDICES
Appendix A: Burn Pits 360 Registry Testimonies
Appendix B: Medical Opinions
Appendix C: Burn Pits 360 Staff Biographies
Appendix D: Burn Pits Photos (Upon Request)
APPENDIX A: Burn Pits 360 Registry Testimonies
The following are testimonies of service members, veterans, and
Gold Star families affected by this generation's Agent Orange. They are
written in their own words.
Greg (Caro, Michigan)
Mrs. Torres, I talked to you a couple of years ago when my health
really started getting bad. Well, here I am and my health is more than
bad. I am standing at deaths door, my lungs are shutting down and the
VA will do nothing. I would just appreciate if you would help my wife
Theresa and my son Travis after I am gone...help them to go after the
VA, and get something for the hassle of it all and for having to watch
me slowly die. I would appreciate it, Thanks Greg
Jay Seals (Nashville, Tennessee)
In March 2008 my husband joined the Army. He went to Basic training
at Ft. Jackson, AIT at Ft Gordon, and then was stationed at Ft.
Campbell to be assigned the 101st airborne division 2-502 HHC from
November 2008 to August 2012. While serving with the 2-502 HHC he was
deployed to Howz-e Madad Afghanistan from June 2010 to April 2011. In
August of 2012 he was assigned to SHAPE in Belgium until November 2013.
While serving in Belgium he received surgery for a hernia. Shortly
before the surgery, according to documentation, a scan was done and a
small mass was found. This information was added to his Military
Medical records but no follow up was done and he was not informed of
the mass. In December 2013 Jay returned to Ft.Campbell and was assigned
to 101st airborne division 5-101 CAB HHC. During this time he had many
appointments with various medical staff about this stomach and
abdominal pain. He was given OTC pain meds and told to hydrate. Jay was
Honorably discharged from the Army April 19, 2016. He was then
hospitalized for a bowel blockage from April 27th to April 30th 2016 at
Blanchfield Army Community Hospital. He reported for duty with the
Tennessee National Guard in May of 2016. He filled out all of the
paperwork with the VA and was seen by VA doctors. He was experiencing
weight loss and esophageal spasms. On September 12, 2016 he was
diagnosed with stage 2 gastric cancer. On October 3, 2016 surgeons
installed a port for chemo and performed an exploratory laparoscopy.
During the laparoscopic procedure they found that the cancer had broken
through the stomach wall and ``spots'' of cancer was found throughout
the peritoneal cavity. This changed the diagnosis to Stage 4 gastric/
stomach (terminal) cancer and was placed on a palliative care plan.
After finding the document stating that a mass was found in 2012 was
reviled by the Tennessee National Guard, it was requested that Jay
receive Line of Duty status and be placed as Activated National Guard
assigned to the Warrior transition Battalion. He has been in this
position since November 29, 2016. Jay is currently being treated by the
VA and Vanderbilt Oncology teams in Nashville. I was told at the
beginning of this that Jay might have 6-9 months to live but he has
exceeded the expectations. Jay knows he will pass in the next year or
two and he hopes to still be with the WTB to make sure that I will have
a support base to fall back on when he is gone.
*A brief bio for me *
Cheryl ``Tori'' Seals is a mother, wife, advocate and palliative
caregiver. She is the mother of 2 children that have now ventured out
on adventures of their own. Tori is a full-time caregiver for her
husband, Jay, who is fighting terminal stage 4 stomach cancer. Care
giving for Jay includes everything from getting him to all his medical
appointments and chemo sessions to assisting him in all his daily
routines including but not limited to making sure he eats, personal
grooming, making him as comfortable and happy as possible and taking
medication. Since his cancer is terminal, we know we must prepare for
his end of life needs as well. When late night insomnia strikes she is
preparing for her future by working on becoming an advocate and
lobbyist for soldiers and their families by taking online training on
political science and advocacy. Prior to being a full-time caregiver,
she has had a variety of careers, Including but not limited to
Information Technology Specialist for a Defense Contractor; Designer,
Production Manager and Sales Representative for a Promotions Company;
Federal Compliance Officer for a Home Loan Company; Artist and Creative
designer/sales for a couple of Renaissance Festivals; Personal
Assistant to an Executive Sales Representative; and Talent/Celebrity
Handler, Physical Security, Logistics and Operations Specialist for
many Conventions and Festivals across many genres and locations
throughout the US.
Megan Kingston (Virginia)
My story begins in 2007, when I was deployed to Iraq for Operation
Iraqi Freedom. We were stationed at Camp Liberty, pad 12. We literally
ate, slept, and lived right next to one of the largest burn pits in the
country. Every morning we would wake up to go to work and be rained
upon by large pieces of black soot and debris from the pit. We would
walk through this to get to the chow hall, and we would be in it all
day long. On some nights, we were even able to see the flames change
different colors based on what they were burning. (Different colors
mean different types of heavy metals.) I can recall on many occasions,
I would have upper respiratory infections and I also treated many
people in my unit for the same. I was the medic. It was like this day
in and day out.
On some occasions, I even lit burn pits on fire using jet fuel and
a flare to get it going, so we could dispose of our trash while out in
the field. To paint the best picture, this is every day life in Iraq,
for over 365 days.
After returning home from the War, I remember coughing up so much
black stuff in the first six months. I though nothing of it other than
we are finally in clean air and it was my body getting rid of the
toxins of war. To my surprise, that was just the beginning of my
medical issues to come later. The year was 2014 and I was training for
a triathlon and remaining fit for work, as I was a plain-clothes
officer for the US Government. I went for a run one day, and couldn't
breathe the next. Over the course of two years, I finally underwent an
open lung biopsy to diagnosis Obliterative Bronchiolitis. This disease
is more commonly known as Constrictive Bronchiolitis and, it is
terminal. I continue to progress to the point where I am on oxygen 24/7
and can no longer do my job. I was medically retired and now I focus my
energy on school and remaining as healthy as possible. If it were not
for these Pits, I would still be able to have my career and my health.
I thank you for your time and understanding in this matter and I hope
that you have a pleasant rest of the day. I look forward to meeting
with you all on the 7th of June.
Staff Sgt. David L. Thomas (Colorado)
Noncommissioned officer in charge, S-2, 1st Space Battalion, was
diagnosed with Stage IV lung cancer that metastasized to the brain in
April 2013, but has chosen to continue his service. ??''I was given a
prognosis of six to 18 months survival rate,'' Thomas said. ``What I
was most disappointed about at that moment was the fact that I was
selling Bethe (his wife) and our children short. Second was the fact
that I would no longer be here serving in the U.S. Army doing what was
the most important thing: overseeing the safety of my family and our
great country via my service. Upon enlisting, he intended to be a
career service member. ??''Joining the Army was something that was
always on my mind since I was a child,'' Thomas said. ``The attacks
made up my mind for me. Defending my family and America itself was no
longer an option, but rather a duty.
Thomas deployed to Iraq for the first time. After 13 months in
Baghdad and a few months at home, he deployed again in September 2005,
back to Baghdad. He returned home in January 2007, reclassed his job
specialty, and in December 2008 deployed to Northern Iraq, first to
Kirkuk and then to Mosul. He returned home in September 2009 and began
preparing for his next deployment, this time to Kandahar, Afghanistan,
in May 2011. It was during this fourth deployment that he began to
notice a prevalent and chronic cough. He returned from this deployment
in May 2012, and in October 2012, Thomas transferred to the 1st Space
Battalion headquarters in Colorado Springs, Colo.??''I saw a doctor in
January 2013, and was told I had an upper respiratory infection or the
flu,'' Thomas said. ``I did not receive any diagnostic testing such as
a chest X-ray or lung function test. I was given an antibiotic and sent
on my way.''??Elizabeth had begun insisting that he go to the doctor
because of the chronic cough, and finally on April 19, Thomas decided
to seek medical advice. ??''My wife and I were in bed watching TV when
I had an episode of chest pain. I thought I had a mild heart attack,''
Thomas said. ``The next morning I went to the emergency room since sick
call could not see me for chest pain.''??After diagnostic testing,
Thomas was informed that he had a nodule in his medial left lobe, and
additional doctor visits and testing were conducted. ??''It was the day
after my 46th birthday that I was diagnosed,'' Thomas said. ``I also
learned that I had actually had lung cancer for more than two years,
including during my last deployment to Afghanistan.''??Elizabeth said
her initial reaction was shock. ??''I remember thinking, 'I can't
believe I'm hearing these words,'' she said. ``I felt cheated. This was
the first time in a while we were going to have uninterrupted family
time free from deployment. I thought we were going to have all of this
time together.''??Thomas began treatment in May 2013. ??''I determined
to fight cancer and have been undergoing chemotherapy,'' Thomas said.
``I have also undergone two cyber knife procedures to my brain for
tumors and a week of radiation to my chest.''??. Through David's fight
both internally and externally without complaint, we are witness to his
courage and commitment to complete the mission. ??Thomas, however, does
not feel like he is doing anything extraordinary. ??''Never did
quitting my career in the U.S. Army cross my mind,'' Thomas said. ``Nor
will I allow this illness to prematurely cause me to leave the Army. If
it is up to me, I will be a member of the armed forces until the day I
do leave this world to be with my father in heaven. ??''I have made a
decision that I will not let cancer change my duty to my country,
family or friends,'' he said. ``I will fight cancer and continue to
work as long as I am able. I will continue to place the mission first
while acting with professionalism and continuing to mentor my NCOs and
Soldiers.''??Upon learning of his cancer, Thomas began to research what
could have caused it. ??''I began to uncover the research and studies
on Iraq Afghanistan War Lung disease, and the devastating effects of
the 'burn pits' on service members and civilians who have served
overseas,'' Thomas said. ``Through my research I learned that IAWL is a
chronic pulmonary condition that will affect one in seven service
members who have served overseas. While Veterans Affairs and the
services have not officially recognized IAWL or the effects of the burn
pits, there are a lot of people suffering and awareness of IAWL needs
to be brought to the public's attention.''??Thomas established the
David Thomas IAWL Foundation to promote awareness of the disease.
??''Eventually, through fundraising, we hope that the foundation has
enough funds to provide basic testing for veterans or active duty
service members who might need to determine if they have IAWL,'' Thomas
said. ``In many ways, through my foundation, my last mission is to
bring awareness to IAWL and those who are suffering.''??Elizabeth said
that her husband is her hero, and not just because of his current
fight. ??''David kept saying, 'I'm never going to deploy again. I need
to be able to. It's my job,''' she said. ``He loves what he does. He's
always saying he wished he could do more; that what he's done isn't
enough. He's a hero to me. Not just that he's kept going, but his whole
Army career. Even with all of this, he doesn't take the praise. But
just by getting up every day and going to work, he shows everyone that
he doesn't quit. He always replies with, 'Where else would I be?'"
CSM James Hubbard (Kansas)
My name is Katie Hubbard, and I am the widow of Command Sergeant
Major James W. Hubbard, Jr. CSM Hubbard. He was a great husband,
father, grandfather, and soldier. CSM Hubbard served eight years on
active duty before becoming a soldier in the United States Army
Reserve.
CSM Hubbard's unit was called to Active Duty orders and sent to
Iraq as part of Operation Enduring Freedom and Operation Iraqi Freedom
1. During those campaigns, CSM Hubbard served as the Command Sergeant
Major for the 450th Movement Control Battalion, Talil Air Base in Iraq
and Camp Arifjan in Kuwait. CSM Hubbard stated that he had to climb
into check the remnants of tanks that were blown up by depleted uranium
as well as living and working around burn pits throughout the country.
CSM Hubbard noted the smells and smoke that he observed from the burn
pits and even noted on his post-deployment medical check that he was
concerned about the chemicals in the air at Talil, as well as smoke
from oil fires, pollution, other fuels, solvents, paints, radiation,
lasers, and other environmental exposure concerns.
Upon his return from Iraq, the medical doctors noted his blood was
``wonky'' and referred him to his civilian provider. He was followed
for six months after before being initially cleared. In 2007, CSM
Hubbard was deployed as the CSM for the 139th Med Group, Task Force
Falcon IX to Camp Bond steel in Kosovo. While there, he complained of
getting more tired easily and that his run was not as good as he was
used to. He would also often reflect on his service in Iraq, what he
saw, and the concerns he had about all the things that were released
into the air from all the stuff that they burnt in the burn pits.
When he returned in late summer of 2008, he was sent to the VA
hospital in Topeka, KS for a post-deployment check-up and is cleared to
return to his civilian job. The VA was concerned with his blood work
and called him to immediately return, stating he may have to be
hospitalized. CSM Hubbard and I were in shock and were not told what
may be going on. He went back to the VA for a follow-up after taking a
military trip to Washington State, where it was noted that his
hemoglobin levels were very concerning, and he was referred to the
oncology department. His first appointment the VA oncology doctor
stated to us that he did not think it was cancer that it was possibly
just a bug from his deployment, but if it were cancer it would not be
the ``bad'' kind. He ordered a bone marrow biopsy on October 24, 2008.
We were to return on November 14, 2008, where the VA oncologist told
him that he had cancer. Specifically, he was diagnosed with Acute
Lymphocytic Leukemia, or ALL, which is common in young children not
50+yr old men!
We were then sent to the VFW service office where we met with the
officer and the social worker for the VA. When meeting with the service
officer and social worker, we were told they had seen an increase in
the number of service members coming back from Iraq and Afghanistan
with leukemia and other cancers. Our doctor also stated he believed the
cancer was due to the burn pits and depleted uranium. CSM Hubbard was
given a 100% service connected disability rating from his leukemia
diagnosis. CSM Hubbard went to MD Anderson in Houston, TX for
treatment, where they stated that 85% of his blasts in his blood were
cancerous when he began treatment.
Unfortunately, during cycle four of treatment, he died suddenly on
May 21, 2009. He was serving as the interim brigade CSM for the 330th
Med Brigade in Fort Sheridan, IL and the CSM for the 139th Med Group in
Independence, MO, at the time of his death. After his death, I wanted
to learn more about the areas he served and what he may have been
exposed to that contributed to his death, which the Topeka VA had told
us that his leukemia was a result of the burn pits and depleted uranium
he was exposed to in Iraq. We were one of the lucky few that had his
cancer acknowledged and rated as service-connected.
I found many reports during my research that substantiated CSM
Hubbard's concerns about the toxins in the air from the burn pits,
including government documents listing chemicals found in the air in
Iraq. CSM Hubbard had also expressed difficulty running and tiredness,
which were the result of his leukemia. The VA also had told us that
they had noticed that it was taking five to ten years after deployment
for some of the cancers to be found, which fit in the timeline of
James' exposure and subsequent diagnosis. His cancer was also not
common at all for people his age, further connecting the effects of
deployment to his cancer. CSM Hubbard is greatly missed, and it is my
hope that his death will help shine a light on the toxic effects of the
burn pits and help to create the necessary steps to protect service
members, take care of the ones effected, and honor the ones that have
died as casualties of war.
Alyssa Holschbach
I appreciate all the great work Burn Pits 360 has been doing for
years. I first learned of your excellent organization in September of
2012, when I was stationed at Bagram and being sickened by a burn pit
that was moved very close to my camp (Sabalu-Harrison).
Over the course of about three weeks after that pit was moved close
to my camp, I got very ill. The smoke was so thick, you could taste it.
It engulfed our whole camp, including our living spaces. I guarded the
prison and was up in the towers most days. It would get so thick; you
couldn't see the next tower over. We all were suffering. They gave us
respirators you would maybe use for painting. They didn't do anything
to block the smoke and fumes. The cartridges were also only good for
eight hours and we never received replacements. We worked twelve-hour
shifts. They probably only gave them to us in an attempt to shut us up.
I developed symptoms similar to a severe allergic reaction. My face
swelled up with hives (which it hurt to put that useless respirator on
over). My skin, tongue, and lips tingled. I had sharp pains in my chest
while I breathed and it was very hard to breathe. I was so miserable; I
maybe could get one to hours of sleep a night because I felt like I was
suffocating. I was finally Medevaced to Germany on October 1, 2012.
In the years since, I've struggled with respiratory and skin
issues. I'm very worried about health consequences down the line, but
VA doctors blow off my concerns. Some don't even know what a burn pit
is.
Congress needs to take action to ensure that all service members
exposed are taken care of properly and receive appropriate screenings
given our risk for rare cancers and other diseases.
The ``Burn Pits Accountability Act'' is a great start, but it
doesn't impact veterans already out of the service from my
understanding. More needs to be done for all of us.
Thank you for your time and for letting me share my story,
P.S. I've attached pictures of the burn pit I was exposed to. One
is a picture of it engulfing our living area.
SFC Heath Robinson (Ohio)
The oncologist's first words were, ``WHAT THE HELL HAVE YOU BEEN
EXPOSED TO?'' before continuing on with my husband's diagnosis of Stage
IV terminal lung cancer with no primary tumor. He explained that this
type of cancer is ONLY caused by toxic exposure and in tears told us
that if the cancer can't be controlled the prognosis was 6 to 8 weeks
for Heath to live. With no primary tumor to target, we learned that any
treatment would be experimental. After consulting with 20 fellow
oncologists to determine the best course of treatment, no one had an
answer. The cancer is so rare that there aren't enough statistics
regarding life expectancy or which treatments have the best results. A
month prior to the cancer diagnosis, Heath was suffering from chronic
nose bleeds and eventually bleeding from his ears which was determined
to be manifestations of a rare autoimmune disorder, Mucous Membrane
Pemphigoid
The cancer had metastasized to Heath's mucous membranes, scapula,
pericardium, lymph nodes and his entire thoracic cavity. The
immunotherapy, Keytruda has extended his life and improved his quality
of life, however, we are unable to attend your hearing on June 7 due to
his scheduled treatment day and his condition right now isn't very good
for him to travel.
SFC Heath Robinson served as an army combat medic being deployed to
Kosovo and eventually Iraq for Operation Iraqi Freedom. He was exposed
to burn pits during both deployments and more so in Iraq. He lived on
Camp Liberty in late 2006 and worked a lot of the time on Camp Victory.
Both bases had notorious burn pits, however, one job he held for 3
months placed him within 75 yards of a burn pit for hours on end each
day.
Our family is devastated, as we have been living this nightmare
with him battling to stay alive for just over a year. Even more
devastating for us is worrying about what's going to happen to our 4
year old daughter and me if he doesn't survive this. It's even more
mortifying to hear the V.A. continuing to deny a connection between
toxic emissions from burn pits and illnesses while they claim research
and data supports their conclusion. This is ridiculous as other
credible studies have already proven and warned of the dangers of
serious health issues those in close proximity to those burn pits could
contract. These studies have been totally ignored by the V.A. and
that's shameful.
I am asking you today, as the wife of a terminally ill wounded
soldier and now his caregiver, counselor and the one making sure every
day he has left on this earth is a good one.to please stop this
nonsense of the V.A. commissioning burn pits research. An outside
entity not controlling the outcomes to favor the V.A. should be in
charge. Robert F. Miller, M.D. Pulmonary Medicine; Vanderbilt
University and Dr. Anthony Szema, 2500 Nesconset Highway, Suite 17A,
Stony Brook, New York 11790 have both done tireless studies and
research on why thousands of Iraq and Afghanistan War veterans have
succumbed or are battling serious, rare and unheard of diseases. It's
an injustice to all potential burn pit victims that these two
physicians were not invited to testify at your Subcommittee on
veterans' health hearing on June 7, 2018.
Thank you for reading my letter. My veteran husband is truly
discouraged and disappointed that he won't have an opportunity to
testify before a congressional committee. He's proud to have served his
country with honor and dignity and wouldn't hesitate to do it again,
however, he is deeply disturbed that his country refuses to acknowledge
his toxic wounds as combat related and that hurts.
Heath's wife, Danielle Robinson June 2, 2018
SFC Fred Slape (Texas)
My name is Diane Slape, I am the widow of SFC Frederick T Slape,
Retired US Army. When we retired in 2012, I was certain War Zone
dangers were behind us. In late August 2015, days after we'd sent our
daughter to her first year of college and started building our Forever
Home, Fred went to his routine VA Drs appointment. Just to be told
again ``your White Blood Cell count is elevated, you need to stop
smoking.'' But this time was different, The VA called to tell Fred,
they were concerned about the results, to call for a lab appointment,
one he couldn't get until October. Despite my 43yr old husband's
overall good health, according to his Oncologist Team, Fred died 9
weeks after he was diagnosed with Stage 4 Adenocarcinoma of the Brain &
Lung lymph nodes, a disease that usually strikes 70-80yr old people.
Most Veterans exposed to the Toxic Burn Pits, who are diagnosed with
cancer, aren't living past 18-24 months, due to the aggressive nature.
His exposure to the Toxic Burn Pits occurred during his 2
deployments, 2009 in Southern Afghanistan and 2011 in North Eastern
Afghanistan. Fred & his troops had their living & working quarters
combined in the same building, less than 25ft from the burn pits, that
burned 24 hours a day, 7 days a week; unless a General or the SECDEF
was coming. These burn pits were shoveled/raked by my husband's
soldiers, with little to no protective clothing on. The soldiers
breathed this black acrid smoke morning, noon and night, even in their
sleep. My husband had mentioned to his commanders that the Burn Pits
were causing difficulty breathing and that they were going to kill
somebody, to which they replied Stop being so dramatic, SFC Slape. My
husband told me that they burned items, such as vehicle fluids, aerosol
cans, computers, Styrofoam, human waste, plastic water bottles, medical
waste, amputated body parts, uniforms, dead animals--many things that
shouldn't be burned, much less burned together.
In August 2015, Fred still showed no symptoms, then 2 days of
sporadic headaches along with seriously impaired vision, an MRI
discovered the mass in Fred's brain. As if we had expected it, when the
Dr told us of the brain mass--Fred & I looked at each other and said
``Burn Pits''. After 5 days in the hospital, every infectious disease
test known to man, and a CAT scan, they discovered the mass in his
chest. Many asked Why didn't we go to the VA? My husband said chuckling
``What? And Die there?'' After reviewing 3 years of lab results, the VA
Drs should have been concerned about Fred's blood work since 2012.
Being Retirees, we had Tricare coverage too, as well as VA access. Most
non-retired veterans do not have the Tricare option, leading to
possibly better care.
In the remaining 5 weeks of Fred's life, he would have 1 round of
the most intense 3 day chemo treatment, his first and only seizure,
brain surgery to remove an aggressively growing brain tumor, during the
2 wk recovery from surgery, He had chest radiation & a stomach tube
inserted, just in case the radiation closed off his esophagus. During
this recovery period, 4 new inoperable tumors were growing quite
rapidly inside Fred's brain. 1 very large one in the Temporal lobe
where the initial one was removed, 1 in the Frontal lobe that tripled
in size and 2 in the cerebellum, never seen before in all the CAT Scans
previously. 3 days later Fred had started brain radiation, which
hospitalized him the next day. Oncologists informed us the chest/brain
radiation, as well as the 1 round of Chemo had no effect on the cancer
in his chest or brain. We opted for 1 more round of brain radiation,
which rapidly led to Fred's death 2 days later. Please help so that
Fred's young soldiers, who are 20 & 30 yrs old and currently healthy,
do not struggle or suffer as Fred did, but without Healthcare that is
specific to their exposures & services for their families.
Colonel Mc Cracken (Georgia)
Dear Mr. Vice President,
I am so very sorry for the loss of your son, Beau. My husband, USA
Colonel David A. McCracken served an active duty tour at Victory Base
Complex (VBC), Baghdad, Iraq in 2007. My husband also died of
glioblastoma multiform on September 2, 2011 after an 11-month battle. A
year after his death, it was brought to my attention that exposure to
toxic chemicals from the open-air burn pits were an attributing factor
to his cancer.
My husband was also mentioned in the book, ``The Burn Pits, the
Poisoning of America's Soldiers'' by Joseph Hickman, page 126. As you
know, grief is a powerful emotion and I make a choice everyday to
ensure that my journey is one of healing and hope. I can't imagine the
pain associated with the loss of a child. I can only see and experience
this loss from my own perspective and that of my children.
I have researched, spoken of and supported efforts regarding the
effects of these burn pit toxins. I do this so that my children will
see that this effort is a worthy one. It can be exhausting, frustrating
straight through to my soul. I've spent more restless nights than I
like relentlessly learning and researching this issue with limited
return on this particular `investment'.
It is a special breed of people who take up the calling to serve. I
will continue the fight with my small voice to keep my husband's memory
alive and to show my children that where there is a passion to make
things right, change can be affected.
My husband, a 45-year-old in perfect health returned coughing and
complaining of headaches. I watched his health decline rapidly as I'm
sure you have witnessed as well. If anything, I want my husband's death
to mean something. Some small thing. Not an `agent of change' but an
`angel of change'.
Sir, my spirit was renewed with your words during your recent
interview with PBS. It is my greatest hope that you are able to
embrace--with similar passion--an outlook of support that brings
awareness to the effects of burn pits on our loved ones. I have long
felt that I didn't want David's death to be simply a memory, but a
catalyst for change and action. I have every hope that you feel the
same.
Please continue this fight. Continue to engage and bring awareness
to this issue.
Signed with hope and renewed spirit,
Tammy J. McCracken
Proud Wife of deceased USA Colonel David A. McCracken
Timothy Johnson
Dear Vice President,
First off I was so very saddened to hear of your sons diagnosis and
eventual passing. I too am a parent whose son has died because of brain
cancer.
I am writing in regards to the burn pits in Iraq and their link to
cancers. My son Sgt. Timothy Lee Johnson of the USMC died of
glioblastoma multiform at the age of 35. He was a bomb dog handler
deployed to Iraq. Upon his diagnosis he was deemed 100% disabled
service connected with the VA. He had a wonderful doctor who believed
the exposure to these toxins were the contributing factor in his
cancer.
My hope is more investigation and subsequent help to victims will
take place.
I am glad to hear more safety and equipment is now in place.
I have attached the memorial from His funeral. The photo is him
with his dog in Iraq. I believe there are thousands of other veterans
who have suffered many illnesses and cancers because of the exposure to
the burn pit toxins. I believe many have not come forward not realizing
they are sick because of their exposure.
May the word continue to be declared so they too can get the
medical care they need. Sincerely, A hurting mom, Donna Johnson
P.S. If this letter can be added to many more of those whose lives
and loves were lost.
Major Kevin Wilkins ( Eustis, Florida)
Dear Vice President
I do not want to take up much of your time, so this letter to you
will be short and to the point.
My husband, USAF Major Kevin E. Wilkins, RN., served an active duty
tour at the Balad Air Force Base, Balad, Iraq in 2006 where your son
Beau was also stationed. My husband died of a glioblastoma brain tumor
in 2008 after exposure to the toxic chemicals from the open-air burn
pit at that base. (He was also mentioned in the book, ``Burn Pits'' by
Joseph Hickman on page 32). I won't go into the effect his death had on
my 2 children and me because you already know the pain.
VP Biden, you can help by talking about the effects these burn pits
have had on you, Beau's wife and the entire family. I know you promised
Beau that you would run for President, but I believe that standing up
for Beau in the light of what has happened to him and many other
soldier's and their families, is so much greater than being President
of the United States. Everything happens for a reason, and I believe it
is your calling to help the many other soldiers who are still alive but
fighting to live.
If you would like to see the work I have been doing to try to help
other families whose soldiers have been exposed to the toxic chemicals,
please Google ``Jill Wilkins Burn Pits'' and you will see the media
coverage I have been involved in including CNN.
Very Sincerely,
Jill R. Wilkins
Proud Wife of deceased USAF Major Kevin E. Wilkins, RN
Robert Elesky
I served four years active duty 1981-85 US Army. During that time,
I served in the 172nd, Fort Hood 2nd Armor Division, and in the Sinai
Desert Egypt on the MFO Peace Keeping Force.
When the war started in Afghanistan they needed Veterans to fill
crucial support roles for our military and I needed a job, so I signed
on with KBR. I ended up on Kandahar Airfield on January 2, 2004. I for
sure will never forget the stench of the five-acre sewage pond on the
west end of the base. When units would leave, anything they didn't take
with them went into a pile on the southwest end of the base. We would
go to that pile daily to salvage things we needed for repair of
vehicles and whatever else we might need. Then a big armored bulldozer
showed up, dug a big hole, and push the pile into it and it was set
afire, exactly when I can't recall, but not too long after the pile was
pushed into the pit. After they started burning the stuff my sinuses
were a disaster. The burn pit was set on fire every evening around
dark. I could see the burn pit from my tent is how close it was to us.
We slept in the fumes, worked in the fumes, and ate in the fumes.
In 2012 I developed difficulties in breathing out of my right
nostril and started developing nose bleeds. I then went to the Dr. and
they diagnosed me after scans a nasal biopsy with a solitary sphenoid
sinus plasmacytoma, very very rare, with most cases in the Middle East
to my understanding. When I was diagnosed I immediately wanted to know
what I had, and how I got it. All my research led me back to ``Toxic
Exposure'' The only place I was ever exposed to toxins that would cause
something like this was Kandahar Airbase in 2004-2005 and Balad, Iraq
2005.
During my research I discovered I could file a DBA claim which is
workers compensation for civilians who work oversea in support of our
military. I did that right away. My case drug on for years and KBR
eventually settled with me for an amount that was nowhere near what was
needed for such a situation, but we had no choice because of the
financial situation this illness had put us in.
After my diagnoses they immediately started radiation therapy on me
and was able to kill the plasmacytoma in my nasal cavity. However
subsequent PET scans revealed a bone lesion on my sternum which they
again radiated but it didn't work, so I ended up on sixteen weeks of
chemo therapy.
After recovery I went back to work in Medical sales. I then
developed other lesions on my right cheek bone about the size of a golf
ball. Again, I was put back into radiation treatment. Having to take
more time off work to go to Portland for radiation treatments again.
Devastating to our income. Again, the radiation was successful, but by
now my employer could see I couldn't do my job like I used to with my
illness and I was terminated in the hospital while undergoing
treatment. They didn't say my illness was the reason, I'm just if, but
based on my past performance and the current performance the conclusion
is a logical one.
So, after being terminated I found odd jobs to do to keep busy as
my wife was working at the time and I just needed some time to recoup.
I was sent for another PET scan that revealed multiple bone lesions
on my head, arm, knee, and femur. What has everyone a bit baffled is my
blood work is always unremarkable and my bone marrow biopsies always
come back clean. So currently I have been on chemo therapy since
January unable to work due to my treatments and on my way to Seattle
for a bone marrow transplant. My wife no longer works at the post
office to support us as her position there was seasonal, my youngest
son who is a firefighter and EMT is having to take leave of his work to
be my care provider in Seattle, so my wife can continue to work the
only job she can find to try and pay our mortgage and bills.
This has been devastating to us emotionally, financially, anyway
that you can't think of something like this can negatively affect your
life. The anxiety of the cancer, the anxiety of wondering if you'll
have a home to come home to is overwhelming. I'm not the only one in
this position. There are literally thousands of us who went down range
in defense of our nation who are being discarded as if we were garbage
with little to no compensation.
All we hear is that there's no direct link between the Burn Pits
and our illnesses. I find that insulting. If that's true, why don't we
just burn trash in our neighborhoods? Why do we have an EPA? The data
already exists. That's why we don't burn trash in our neighborhoods. We
already know breathing toxins make people sick, don't we?
I'm outraged that memos were sent to the pentagon as far back as
2000 with air quality reports saying that we should stop burning this
trash next to the bases. Those memos were ignored and shoved in
someone's desk drawer. Why? Who did that? I'd like to know.
So, for now we are just barely making it. I rarely see my wife,
children and grandchildren because of their work schedules and I fear
of getting a sickness from one of the grandkids. One of them always has
a runny nose or something. I live in constant pain and isolation
wondering how it's all going to end and I'm not alone. There are
``Thousands'' if not ``Tens of Thousands of us, and we'd like to know
what you're going to do for us after sending us down range in defense
of freedom, and knowingly poisoning us. Can you answer that question?
We willingly accepted the risk of war.
APPENDIX B: Medical Opinions
(see below)
APPENDIX C: Burn Pits 360 Staff Biographies
CPT (Army Ret.) Le Roy Torres, Founder
Le Roy Torres is the co-founder of Burn Pits 360 Veterans non-
profit organization. Torres was medically retired from the Army after
23 years with the rank of Captain following his diagnosis from a lung
biopsy to include other secondary medical diagnosis. He served 7 years
Active and 16 years Reserve. Torres also worked as a State Trooper for
the Texas Highway Patrol after he was forced to accept a medical
discharge following his 14 years of state service. Torres earned his
B.A. and M.A. in Administration--Organizational Development at the
University of the Incarnate Word. Torres also enrolled in Seminary and
completed several courses through Liberty University during his
application process for the Army Chaplaincy Program. Subsequently
Torres was medically boarded from the Army Reserve due to his medical
conditions associated with burn pit exposure forcing him to discontinue
the Army chaplaincy process.
Torres is an ardent advocate alongside his wife Rosie for the
military families and warriors battling illnesses associated with
deployment related environmental toxic exposures during the OEF/OIF War
Campaigns. Torres alongside his wife founded the first Burn Pits 360
Warrior Support Center in Robstown, Texas. Torres is also passionate
about assisting the first responder community that serve a dual role to
their state and country that are battling not only medical conditions
from exposure; but also those facing battles with invisible wounds, job
loss, and other challenges that arise from such hardships that have
taken a toll on so many Veterans and their families.
Rosie Torres, Executive Director
Rosie Lopez Torres is the co-founder of Burn Pits 360 Veterans
Organization. Rosie held a civil service position at the Department of
Veteran Affairs Health Care System for 23 years. Rosie advocates full
time for Veterans, Service members and families suffering from
deployment related illnesses. She co-founded Burn Pits 360 alongside
her husband Le Roy Torres. Rosie also co-founded the Warrior Support
Center, which is the organization's headquarters but also a center
where local Veterans and their families can seek access to training, a
computer room, recreation room, and peer support services. Rosie is
currently attending Liberty University where she is studying law.
Tammy McCracken, Secretary
Professionally, Tammy McCracken works full time as a Senior
Technical Architect with GISinc., a location analytics company. She has
managed over $250M in technical projects over the course of her career.
She is responsible for client relations and designing solutions that
meet the unique needs of her clients. She is a Certified Information
Systems Auditor and is currently pursuing her Master's in Data
Analytics at Georgia Tech.
In addition to her technical career, she is a military widow
serving on several non-profit boards promoting healing and health to
Veterans and Widows. Her passion is to ensure that her husband, Colonel
David A McCracken's memory and legacy live on and that no other widows
face the trials and challenges she has painfully navigated subsequent
to his untimely and unnecessary death.
Cindy Aman, Legislative Liaison
In her professional life, Cynthia Aman works full time for the
Delaware State Public Defender's office as a Mitigation Specialist. She
has her Master's in Forensic Psychology and continues to pursue
continued education in this field.
Cynthia is also a Veteran who was assigned to the 1138th Military
Police Company with the Missouri Army National Guard. She developed an
irreversible, progressive lung disease called Constrictive
Bronchiolitis, from her deployment to the Middle East. Since her
diagnosis she has worked as an advocate on Burn Pits and Toxic
Exposure. She is currently the Legislative Liaison with Burn Pits 360
and spends her free time working hard to represent and speak for those
who have been silenced.
Stacy Pennington, Legislative Liaison
Stacy Pennington has been an advocate for veterans fighting for
rights of those affected by toxic exposure caused from burn pits in
Iraq and Afghanistan. This deep commitment to fight for those affected
by toxic exposure occurred a decade ago after the onset of her
brother's sudden illness and death.
Stacy is the Community Outreach Director for AARP. She is dedicated
to the field of Gerontology. She is active in educating, providing
services and advocating for those 50 plus. Stacy has worked for the
AARP for thirty years.
In addition, Stacy is a part of several non-profit organizations
including Burn Pits 360, Leadership Cheatham County and Leadership
Middle Tennessee.
Diane Slape, Director of Gold Star Families Program
Diane Slape's professional career is currently the Project
Administrator for NNAC, Inc., a Commercial Construction firm with the
majority of their projects in the Military Sector, all over the
Northwest and Texas. Diane always knew she wanted to help Vietnam
Veterans with PTSD, but financial aid and family contribution couldn't
handle the requirement. So she volunteered for many non-profit Military
organizations, to give back as much of her free time in appreciation of
their sacrifices. She volunteered to be her husband's unit Family
Readiness Group leader. She developed a working relationship with the
unit's Chain of Command in garrison and downrange, as well as a loving,
supportive relationship with the soldiers and their families. She made
it her mission to support the soldiers and their missions and helps
guide their families through their military experience, to include
consecutive deployments and Duty Station moves, even after her husband
retired from Military Service.
Her career involvement with the Military didn't stop, after
becoming a military widow. She still had soldiers and Veterans to
support, as well as their families. She serves on several non-profit
organizations assisting Veterans reintegrating into Civilian life after
the Military, as well as promoting their mental & physical health,
despite their exposures. Her life's mission is to carry on her husband,
SFC Frederick T Slape's caring and compassion for his fellow soldiers
in need and to do whatever possible so that soldiers or widows do not
have to endure the same struggles and tragedies that she found herself
involved in, so abruptly and unprepared for.
Will Wisner, Program Manager
William is a Senior Director at CCS Fundraising, a strategic
fundraising firm that partners with nonprofits for transformational
change. Prior to joining CCS, William served as the Veteran Fellow for
Mission Leadership at the Sergeant Thomas Joseph Sullivan Center, a
nonprofit organization dedicated to the issue of toxic exposure
illnesses in Iraq and Afghanistan veterans. William holds a M.A. in
Nonprofit Management from Washington University in Saint Louis.
William was a Staff Sergeant in the United States Army and is a
veteran of Operation Iraqi Freedom having served as Cavalry Scout in
the 3rd Squadron of the 1st Cavalry Regiment, 3rd Heavy Combat Brigade,
3rd Infantry Division.
Daniella Molina, Director of Community Development
Daniella Molina currently serves as the volunteer Director of
Community Development with Burn Pits360 Veterans Organization. Outside
of her volunteer services Daniella is a full-time caregiver, mother of
two, and student. She is currently pursuing a degree in Psychology:
Military Resilience through Liberty University. Upon graduation, she
plans to assist active/veteran service members and their families
through the challenges associated with life after war. Daniella is the
wife of retired Army veteran, Jonathan Ray Molina.
Advisory Board Members
Former Congressman Solomon Ortiz
Solomon Ortiz Jr.
Ret. Colonel David Sutherland
Ret. Lt. Col Gregg Deeb
Ret. Lt. Col. Brian Lawler
Dr. Robert Miller
Dr. Steven Coughlin
Kerry Baker
APPENDIX D: Burn Pits photos (upon request)
(Ret. CPT. Le Roy Torres & his sons Kenneth and Christopher)
(Brian Alvarado & his daughter Rihanna)
(Ret. SSG Will Thompson, double lung transplant recipient)
Fallen Heroes
Major Kevin Wilkins
United States Government Accountability Office (GAO)
WASTE MANAGEMENT
DoD Needs to Fully Assess the Health Risks of Burn Pits
Statement for the Record by Cary Russell, Director, Defense
Capabilities and Management
Chairman Dunn, Ranking Member Brownley, and Members of the
Subcommittee,
I am pleased to submit this statement on our September 2016 report
covering the Department of Defense's use of burn pits. \1\ Since the
initiation of military operations in Afghanistan in 2001 and Iraq in
2003, the Department of Defense (DoD) has employed several methods to
dispose of the waste that U.S. forces have generated in both countries.
In general, the methods employed have been left to the discretion of
base commanders and include the use of incinerators, landfills, and
open-air burn pits on or near military bases. According to DoD
officials, when making these decisions base commanders may take into
consideration a number of factors, including the local security
situation, the number of personnel on the installation, and the amount
and type of waste generated by those personnel. As one of the options
available, burn pits help base commanders manage waste, but they also
produce smoke and harmful emissions that military and other health
professionals believe may result in acute and chronic health effects
for those exposed to the emissions.
---------------------------------------------------------------------------
\1\ GAO, Waste Management: DoD Has Generally Addressed Legislative
Requirements on the Use of Burn Pits but Needs to Fully Assess Health
Effects, GAO-16-781 (Washington, D.C.: Sept. 26, 2016).
---------------------------------------------------------------------------
My statement today focuses on the extent to which DoD has assessed
any health risks of burn pit use. This statement is based on our
September 2016 report. That work was conducted in response to section
313 of the Carl Levin and Howard P. ``Buck'' McKeon National Defense
Authorization Act for Fiscal Year 2015 (NDAA for Fiscal Year 2015). \2\
Specifically, we assessed the methodology DoD used in conducting a
review of the compliance of the military departments and combatant
commands with DoD Instruction 4715.19, Use of Open-Air Burn Pits in
Contingency Operations, \3\ and the adequacy of the subsequent report
DoD sent to the defense committees containing the results of its
review. \4\
---------------------------------------------------------------------------
\2\ Pub. L. No. 113-291, Sec. 313 (2014).
\3\ DoD Instruction 4715.19, Use of Open-Air Burn Pits in
Contingency Operations (Feb. 15, 2011) (incorporating change 3, July 3,
2014). The instruction was updated on Oct. 6, 2017.
\4\ Department of Defense, Report on Prohibition of the Disposal of
Covered Waste in Open-Air Burn Pits (March 2016).
---------------------------------------------------------------------------
To evaluate the extent to which DoD has assessed any health effects
of burn pit use, we reviewed relevant health assessments on the effects
of burn pits, including a 2011 report by the Institute of Medicine that
was contracted by the Department of Veterans Affairs, as well as prior
related reports by GAO and the Special Inspector General for
Afghanistan Reconstruction. We also interviewed officials from U.S.
Central Command (CENTCOM), U.S. Army Central Command, U.S. Air Force
Central Command, Department of Veterans Affairs, and Institute of
Medicine to discuss any effects of exposures to burn pit emissions,
among other things. Additionally, we obtained an update from DoD in May
2018 on actions taken regarding our findings and recommendations from
our September 2016 report.
We conducted the work on which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Burn pits-shallow excavations or surface features with berms used
to conduct open-air burning-were often chosen as a method of waste
disposal during recent contingency operations in the CENTCOM area of
responsibility, which extends from the Middle East to Central Asia and
includes Iraq and Afghanistan. In 2010, we reported that there were 251
active burns pits in Afghanistan and 22 in Iraq. \5\ However, in 2016,
we reported that the use of burn pits in the CENTCOM area of
responsibility had declined since that time. As of June 2016, DoD
officials told us that there were no military-operated burn pits in
Afghanistan and only one in Iraq. According to DoD officials, the
decline in the number of burn pits from 2010 to 2016 could be
attributed to such factors as (1) using contractors for waste disposal
and (2) increased use of waste management alternatives such as
landfills and incinerators. However, DoD officials acknowledged that
burn pits were being used to dispose of waste in other locations that
are not military-operated. Specifically, these officials noted
instances in which local contractors had been contracted to haul away
waste and subsequently disposed of the waste in a burn pit located in
close proximity to the installation. In such instances, officials
stated that they requested that the contractors relocate the burn pit.
According to a DoD official, as of May 2018 there are two active burn
pits in the CENTCOM area of responsibility.
---------------------------------------------------------------------------
\5\ GAO, Afghanistan and Iraq: DoD Should Improve Adherence to Its
Guidance to Open Pit Burning and Solid Waste Management, GAO-11-63
(Washington, D.C.: Oct. 15, 2010).
---------------------------------------------------------------------------
Although burn pits help base commanders to manage waste, they also
produce smoke and emissions that military and other health
professionals believe may result in acute and chronic health effects
for those exposed. We previously reported that some veterans returning
from the Iraq and Afghanistan conflicts have reported pulmonary and
respiratory ailments, among other health concerns, that they attributed
to burn pit emissions. \6\ Numerous veterans have also filed lawsuits
against a DoD contractor alleging that the contractor mismanaged burn
pit operations at several installations in both Iraq and Afghanistan,
resulting in exposure to harmful smoke that caused these adverse health
effects. We also previously reported on the difficulty of establishing
a correlation between occupational and environmental exposures and
health issues. \7\ For example, in 2012 we reported that establishing
causation between an exposure and an adverse health condition can be
difficult for several reasons, including that for many environmental
exposures, there is a latency period-the time period between initial
exposure to a contaminant and the date on which an adverse health
condition is diagnosed. \8\ When there is a long latency period between
an environmental exposure and an adverse health condition, choosing
between multiple causes of exposure may be difficult. In addition, in
2015 we reported that the Army had recently published a study that
evaluated associations between deployment to Iraq and Kuwait and the
development of respiratory conditions post-deployment. \9\ However, the
study was unable to identify a causal link between exposures to burn
pits and respiratory conditions.
---------------------------------------------------------------------------
\6\ GAO-11-63.
\7\ GAO, Defense Health Care: DoD Needs to Clarify Policies Related
to Occupational and Environmental Health Surveillance and Monitor Risk
Mitigation Activities, GAO-15-487 (Washington, D.C.: May 22, 2015).
\8\ GAO, Defense Infrastructure: DoD Can Improve Its Response to
Environmental Exposures on Military Installations, GAO-12-412
(Washington, D.C.: May 1, 2012).
\9\ GAO-15-487 and Abraham et al., ``A Retrospective Cohort Study
of Military Deployment and Postdeployment Medical Encounters for
Respiratory Conditions,'' Military Medicine, vol. 179 (2014): 540-546.
---------------------------------------------------------------------------
DoD Had Not Fully Assessed the Health Risks of Burn Pits
In our 2016 report, we found that the effects from exposing
individuals to burn pit emissions were not well understood, and DoD had
not fully assessed these health risks. Under DoD Instruction 6055.01,
DoD Safety and Occupational Health (SOH) Program, it is DoD policy to
apply risk-management strategies to eliminate occupational injury or
illness and loss of mission capability or resources. DoD Instruction
6055.01 also instructs all DoD components to establish procedures to
ensure that risk-acceptance decisions were documented, archived, and
reevaluated on a recurring basis. \10\ Furthermore, DoD Instruction
6055.05, Occupational and Environmental Health (OEH), requires that
hazards be identified and risk evaluated as early as possible,
including the consideration of exposure patterns, duration, and rates.
\11\ Notwithstanding this guidance, which applies to burn pit emissions
among other health hazards, DoD had not fully assessed the health risks
of use of burn pits according to DoD officials.
---------------------------------------------------------------------------
\10\ DoD Instruction 6055.01, DoD Safety and Occupational Health
(SOH) Program (Oct. 14, 2014).
\11\ DoD Instruction 6055.05, Occupational and Environmental Health
(OEH) (Nov. 11, 2008). This instruction was updated on November 21,
2017.
---------------------------------------------------------------------------
According to DoD officials, DoD's ability to assess these risks was
limited by a lack of adequate information on (1) the levels of exposure
to burn pit emissions and (2) the health impacts these exposures had on
individuals. With respect to information on exposure levels, DoD had
not collected data from emissions or monitored exposures from burn pits
as required by its own guidance. DoD Instruction 4715.19 requires that
plans for the use of open-air burn pits include ensuring the area was
monitored by qualified force health protection personnel for
unacceptable exposures, and CENTCOM Regulation 200-2, CENTCOM
Contingency Environmental Standards, requires steps to be taken to
sample or monitor burn pit emissions. \12\ However, DoD officials
stated that there were no processes in place to specifically monitor
burn pit emissions for the purposes of correlating potential exposures.
They attributed this to a lack of singular exposure to the burn pit
emissions, or emissions from any other individual item; instead,
monitoring was done for the totality of air pollutants from all sources
at the point of population exposure. As we reported in September 2016,
given the potential use of burn pits near installations and their
potential use in future contingency operations, establishing processes
to monitor burn pit emissions for unacceptable exposures would better
position DoD and combatant commanders to collect data that could help
assess exposure to risks.
---------------------------------------------------------------------------
\12\ CENTCOM Regulation 200-2, CENTCOM Contingency Environmental
Standards (Sept. 15, 2014).
---------------------------------------------------------------------------
In the absence of the collection of data to examine the effects of
burn pit exposure on servicemembers, the Department of Veterans Affairs
in 2014 created the airborne hazards and open-air burn pit registry,
\13\ which allows eligible individuals to self-report exposures to
airborne hazards (such as smoke from burn pits, oil-well fires, or
pollution during deployment), as well as other exposures and health
concerns. \14\ The registry helps to monitor health conditions
affecting veterans and servicemembers, and to collect data that would
assist in improving programs to help those with deployment exposure
concerns.
---------------------------------------------------------------------------
\13\ This registry was created in response to the Dignified Burial
and Other Veterans' Benefits Improvement Act of 2012, Pub. L. No. 112-
260, Sec. 201 (2013).
\14\ Eligible individuals include servicemembers or veterans who
served in Iraq, Afghanistan, or Djibouti on or after September 11,
2001, or the Southwest Asia theater of operations on or after August 2,
1990 (e.g., the Persian Gulf War).
---------------------------------------------------------------------------
With respect to the information on the health effects from exposure
to burn pit emissions, DoD officials stated that there were short-term
effects from being exposed to toxins from the burning of waste, such as
eye irritation and burning, coughing and throat irritation, breathing
difficulties, and skin itching and rashes. However, the officials also
stated that DoD did not have enough data to confirm whether direct
exposure to burn pits caused long-term health issues. Although DoD and
the Department of Veterans Affairs had commissioned studies to enhance
their understanding of airborne hazards, including burn pit emissions,
the then-current lack of data on emissions specific to burn pits
limited DoD's ability to fully assess potential health impacts on
servicemembers and other base personnel, such as contractors.
For example, in a 2011 study that was contracted by the Department
of Veterans Affairs, the Institute of Medicine stated that it was
unable to determine whether long-term health effects are likely to
result from burn pit exposure due to inadequate evidence of an
association. \15\ While the study did not determine a linkage to long-
term health effects, because of the lack of data, it did not discredit
the relationship either. Rather, it outlined a methodology of how to
collect the necessary data to determine the effects of the exposure.
Specifically, the 2011 study outlined the feasibility and design issues
for an epidemiologic study-that is, a study of the distribution and
determinants of diseases and injuries in human populations-of veterans
exposed to burn pit emissions. Further, the 2011 study reported that
there were a variety of methods for collecting exposure information,
but the most desirable was to measure exposures quantitatively at the
individual level. Individual exposure measurements could be obtained
through personal monitoring data or biomonitoring. \16\ However, if
individual monitoring data were not available, and they rarely are,
individual exposure data might also be estimated from modeling of
exposures, self-reported surveys, interviews, job exposure matrixes,
and environmental monitoring. Further, to determine the incidence of
chronic disease, the study stated that servicemembers must be tracked
from their time of deployment, over many years.
---------------------------------------------------------------------------
\15\ Institute of Medicine for the Department of Veterans Affairs,
Long-Term Health Consequences of Exposure to Burn Pits in Iraq and
Afghanistan (Washington, D.C.: The National Academies Press, 2011).
\16\ Biomonitoring assesses an individual's exposure to
environmental agents by measuring the concentrations of the agents in
biological samples, usually blood or urine but possibly adipose tissue,
hair, or nails. The biomarker can be the external substance itself (for
example, lead) or a metabolite of the external substance processed by
the body (for example, cotinine, a metabolite of nicotine) and it
indicates the absorbed dose or allows an estimate of the target-tissue
dose for the time of exposure.
---------------------------------------------------------------------------
While the Institute of Medicine outlined a methodology of how to
conduct an epidemiologic study, DoD had not taken steps to conduct this
type of research study, specifically one that focused on the direct,
individual exposure to burn pit emissions and the possible long-term
health effects of such exposure. Instead, some officials commented that
there were no long-term health effects linked to the exposures of burn
pits because the 2011 study did not acknowledge any. Conversely,
Veterans Affairs officials stated that a study aimed at establishing
health effect linkages could be enabled by the data in its airborne
hazards and open-air burn pit registry, which collects self-reported
information on servicemembers' deployment location and exposure.
In response to a mandate contained in section 201 of Public Law
112-260, the Department of Veterans Affairs entered into an agreement
with the National Academies of Sciences, Engineering, and Medicine to
convene a committee to provide recommendations on collecting,
maintaining, and monitoring information through the registry. The
committee assessed the effectiveness of the Department of Veterans
Affairs' information gathering efforts and provided recommendations for
addressing the future medical needs of the affected groups. The study
was conducted in two phases. Phase 1 was a review of the data
collection methods and outcomes, as well as an analysis of the self-
reported veteran experience data gathered in the registry. Phase 2 was
focused on the assessment of the effectiveness of the actions taken by
the Department of Veterans Affairs and DoD and provided recommendations
for improving the methods enacted. The committee released its final
report in February 2017. \17\ As we reported in September 2016,
considering the results of this review as well as the methodology of
the 2011 Institute of Medicine study as part of an examination of the
relationship between direct, individual exposure to burn pit emissions
and long-term health effects could better position DoD to fully assess
those health risks.
---------------------------------------------------------------------------
\17\ Since the committee's report was released after the release of
our September 2016 report we did not evaluate it. See National
Academies of Sciences, Engineering and Medicine, Assessment of the
Department of Veterans Affairs Airborne Hazards and Open Burn Pit
Registry (Washington, D.C.: The National Academies Press, 2017).
---------------------------------------------------------------------------
In our September 2016 report we recommended that the Secretary of
Defense direct the Under Secretary of Defense for Acquisition,
Technology, and Logistics \18\ to:
---------------------------------------------------------------------------
\18\ Effective February 1, 2018, the National Defense Authorization
Act for Fiscal Year 2017 provided for the restructuring of the Under
Secretary of Defense for Acquisition, Technology, and Logistics. Pub.
L. No. 114-328, Sec. 901 (2016) (codified at 10 U.S.C. Sec. Sec. 133a
and 133b). The position has been divided into the Under Secretary of
Defense for Research and Engineering and the Under Secretary of Defense
for Acquisition and Sustainment.
take steps to ensure CENTCOM and other geographic
combatant commands, as appropriate, establish processes to consistently
monitor burn pit emissions for unacceptable exposures; and
in coordination with the Secretary of Veterans Affairs,
specifically examine the relationship between direct, individual, burn
pit exposure and potential long-term health-related issues. As part of
that examination, consider the results of the National Academies of
Sciences, Engineering, and Medicine's report on the Department of
Veteran Affairs registry and the methodology outlined in the 2011
Institute of Medicine study that suggests the need to evaluate the
health status of service members from their time of deployment over
many years to determine their incidence of chronic disease, with
particular attention to the collection of data at the individual level,
including the means by which that data is obtained.
DoD concurred with the first recommendation, stating that the
department will ensure that geographic combatant commands establish and
employ processes to consistently monitor burn pit emissions for
unacceptable exposures at the point of exposure and if necessary at
individual sources. In a May 2018 status update regarding this
recommendation, DoD stated that it will be updating applicable
department policy and procedures, its tactics techniques and procedures
manual, and guidance for sampling and analysis plans to improve
monitoring of burn pit emissions and other airborne hazard emissions.
Specifically, DoD stated it will update DoD Instruction 6490.03,
Deployment Health; that the update will provide revised procedures on
deployment health activities required before, during, and after
deployments, including Occupational and Environmental Health Site
Assessments; and that it estimates this will be completed by the 4th
quarter of fiscal year 2018. In addition, the department stated it will
update its Occupational and Environmental Health Site Assessments
tactics, techniques, and procedures manual and update guidance for
sampling and analysis plans and that the updates will provide revised
tactics, techniques, and procedures that will improve the quality of
health risk assessment. The department expects this to be completed by
the 1st quarter of fiscal year 2019. GAO believes that upon completion
of these actions, DoD will have met the intent of this recommendation.
With respect to our recommendation to sponsor research, in
coordination with the Secretary of Veterans Affairs, to specifically
examine the relationship between burn pit exposure and potential
health-related issues, DoD partially concurred, stating that a
considerable volume of research studies had already been completed,
were ongoing, or were planned in collaboration with the Department of
Veterans Affairs and other research entities to improve the
understanding of burn pit and other ambient exposures to potential
long-term health outcomes and that the studies, where applicable,
consider and incorporate the methodology outlined in the 2011 Institute
of Medicine study. In a May 2018 status update regarding this
recommendation, the department stated that DoD and the Department of
Veterans Affairs continue to collaborate with each other and other
entities on research activities that address burn pit and other
airborne exposures, and potential long-term health outcomes.
Specifically, the department cited a DoD/Veterans Affairs Airborne
Hazards Symposium held in May 2017; an update to the Veterans Affairs/
DoD Deployment Health Working Group ``Airborne Hazards Joint Action
Plan'' to be completed by the 3rd quarter of fiscal year 2018; and the
completion of research to examine airborne hazard exposures and
potential health-related issues. GAO believes that to the extent that
continued studies consider and incorporate the methodology outlined the
2011 Institute of Medicine study, where appropriate, DoD will have met
the intent of this recommendation.
Chairman Dunn, Ranking Member Brownley, and Members of the
Subcommittee, this concludes my statement for the record.
GAO Contact and Staff Acknowledgments
If you or your staff have any questions about this statement,
please contact Cary Russell, Director, Defense Capabilities and
Management, at 202-512-5431 or [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. GAO staff who made key contributions
to this statement include Guy LoFaro (Assistant Director), Lorraine
Ettaro, Shahrzad Nikoo, Jennifer Spence, and Matthew Young.
This is a work of the U.S. government and is not subject to
copyright protection in the United States. The published product may be
reproduced and distributed in its entirety without further permission
from GAO. However, because this work may contain copyrighted images or
other material, permission from the copyright holder may be necessary
if you wish to reproduce this material separately.
GAO's Mission
The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site (https://www.gao.gov). Each weekday
afternoon, GAO posts on its Web site newly released reports, testimony,
and correspondence. To have GAO e mail you a list of newly posted
products, go to https://www.gao.gov and select ``E-mail Updates.''
Order by Phone
The price of each GAO publication reflects GAO's actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black
and white. Pricing and ordering information is posted on GAO's Web
site, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077,
or TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
Connect with GAO
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Subscribe to our RSS Feeds or E-mail Updates. Listen to our
Podcasts.
Visit GAO on the web at https://www.gao.gov.
To Report Fraud, Waste, and Abuse in Federal Programs
Contact: Website: https://www.gao.gov/fraudnet/fraudnet.htm
Automated answering system: (800) 424-5454 or (202) 512-7470
Congressional Relations
Orice Williams Brown, Managing Director, [email protected], (202)
512-4400, U.S. Government Accountability Office, 441 G Street NW, Room
7125, Washington, DC 20548
Public Affairs
Chuck Young, Managing Director, [email protected], (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Strategic Planning and External Liaison
James-Christian Blockwood, Managing Director, [email protected], (202)
512-4707, U.S. Government Accountability Office, 441 G Street NW, Room
7814, Washington, DC 20548
Victor J. Dzau, MD
President, National Academy of Medicine, on behalf of The National
Academies of Sciences, Engineering, and Medicine
Dear Chairman Roe:
Thank you for your invitation to submit a statement for the record
on scientific research regarding the potential long-term health effects
of burn pit exposure among veterans and, in particular, the use and
effectiveness of the Airborne Hazards and Open Burn Pit (AH&OBP)
registry that Congress mandated that VA create in 2013.
As you know, The National Academies of Sciences, Engineering, and
Medicine released the report Assessment of the Department of Veterans
Affairs Airborne Hazards and Open Burn Pit Registry on February 28,
2017. The report was written by a committee of experts assembled by the
National Academies in response to a request by the US Department of
Veterans Affairs (VA), who were fulfilling a provision of Public Law
112-260, Section 201 mandating a study. VA sponsored the effort but,
other than defining its statement of task at the beginning of the
study, had no influence on the content of the report.
The report offered several observations concerning how the AH&OBP
Registry questionnaire collects information and recommended changes
intended to improve and streamline it. It noted, though, that
registries like the AH&OBP that rely on voluntary involvement and self-
reported information on exposures and health outcomes are not suitable
for assessing the health effects of exposure due to respondents'
selective participation, inaccurate recall, or inadvertent or
intentional under- or overestimation. Such registries are thus an
intrinsically poor source of information on exposures, health outcomes,
and possible associations among these events. The report also concluded
that, given these inherent weaknesses, the best use of the AH&OBP
Registry is as a means for the eligible population to document their
concerns of health problems that may have resulted from their service,
bring those concerns to the attention of VA and their health care
providers, and supply VA with a roster of people who are interested in
burn pit exposure issues.
I have attached a summary of the report for your reference. The
entire document may be downloaded in PDF format without cost by anyone
via links available at the following URL: https://www.nap.edu/catalog/
23677/assessment-of-the-department-of-veterans-affairs-airborne-
hazards-and-open-burn-pit-registry
The National Academies would be pleased to answer questions the
Subcommittee may have concerning this work and assist in any other ways
requested.
Victor J. Dzau, M.D.
President, National Academy of Medicine
VETERAN WARRIORS
Chairman Dunn, Ranking Member Brownley, and members of this Panel,
Veteran Warriors expresses their gratitude for the opportunity to offer
our views on the potential health effects of exposure to burn pits
(operated in combat areas of operation).
There is currently legislation pending that would provide the
Department of Veterans Affairs (VA) with the impetus and budget to
institute a ``Center of Excellence''; in order to research what, if any
harm is done to those service members who are exposed to toxic
chemicals that are emitted from open-air burning of trash.
That particular legislation will only succeed in solidifying what
the ``burn pits'' have already been deemed; that being ``this war's
Agent Orange''. The term is not used lightly; rather it is in reference
to the over thirty years it took the Department to lawfully acknowledge
the effects of ``Agent Orange'' had on service members.
What many legislators, veterans and citizens are not aware of is
that the Department of Veterans Affairs already has a substantial and
specific policy in place regarding providing medical care and rating
claims; for those veterans who have been exposed to burn pits. That
policy; ``Training Letter 10-03'' (Environmental Hazards in Iraq,
Afghanistan, and Other Military Installations); was issued throughout
the VA on April 26, 2010. The only part of that policy that most do
recognize is the ``Camp Lejeune Water Contamination'' section; (which
is AFTER the burn pit policy section).
Since that policy was issued; thousands of veterans have succumbed
to burn pit related diseases. Just as many if not more, are dying. Yet,
the VA continues to deny benefits and medical care for the predominance
of those veterans who report illnesses associated with burn pit
exposure. As of May 1, 2018; there are 141,246 veterans registered on
the Burn Pit Registry.
The VA established the Burn Pit Registry on April 25, 2014.
Unfortunately, the Registry questions were so poorly designed as to
leave the resulting data useless. Veterans who succumbed to their
injuries before the Registry was initiated; are banned from being
registered. Most VA providers have no knowledge of it or its use. None
of the providers can ``see'' the veteran's answers. VA rating examiners
cannot see them either; leaving the veteran with no recourse to be
properly rated for their burn pit exposures.
In February 2017, The National Academies of Sciences, Engineering,
and Medicine, published their congressionally mandated study of the
VA's Burn Pit Registry. While the study results are lengthy and offer
other-use possibilities for the data collected; the most notable of the
comments are as follows:
``While registries that rely on voluntary participation and self-
reported information are a common means of collecting data on large
populations, they are an intrinsically poor source of information on
exposures, health outcomes, and possible associations among these
events. Even under the best of circumstances, there are substantial
limits to the accuracy of the data and-when the respondents constitute
only a small, unrepresentative fraction of the eligible population-the
generalizability of analyses made with them as well.
These weaknesses are apparent in the Airborne Hazards and Open Burn
Pit (AH&OBP) Registry questionnaire and in the data collected in the
registry's first 13 months. The weaknesses have been exacerbated by a
series of flaws in the structure and operation of the questionnaire and
in the questions that are asked and the way they are asked. The AH&OBP
Registry questionnaire is flawed in that it;
inappropriately uses questions that were validated for
and meant to be administered by other survey means such as a face-to-
face or computer-assisted phone interview;
asks questions that may be confusing for respondents
because they are ambiguous or otherwise poorly written;
elicits information on topics such as hobbies and places
of childhood residence that do not yield information that could be
productively used in any analysis that would be appropriate to
undertake using registry data;
fails to ask questions (regarding non-burn-pit trash
burning, for example) that could yield information related to relevant
exposures;
does not take full advantage of its Web-based format to
streamline and focus questions based on previous responses;
does not permit answers to be supplemented or updated
later in time; and
requires respondents to complete a sometimes lengthy set
of repetitive questions regarding deployments before addressing core
issues such as health, increasing the possibility of response
fatigue.''
For over a decade, both the Department of Defense (DoD) and
Department of Veterans Affairs (VA); have relied on their own internal
research facilities and staff; who at the direction of their respective
leadership; have denied that there is any correlation between service
members and contractors contracting rare and inexplicable (through
genetics or by other know impetus) diseases and the use of open-air
burn pits as a method of waste disposal in combat zones.
Both entities continue to deny the existence of any ``valid''
research which proves the direct causal links between open-air burning
and over 141,000* (This number is taken from the VA's ``Burn Pit
Registry''. It is not inclusive of all exposed and does not account for
those who have succumbed to their diseases; as they are banned from
being registered) service-members who are sick and in many cases dying.
These agencies' refusal to publically acknowledge these causal links
has had a direct impact on the service members receiving medical care
and specific benefits that they would otherwise be entitled to under
U.S. laws and regulations.
For decades, the United States government (USG) has created and
enforced specific laws to protect human life and the environment; with
regard to burning of household trash, chemical, medical, manufacturing
and even military waste. There has been literally hundreds of thousands
of man-hours spent researching the effects on humans, animals and the
environment when trash is burned in open-air pits.
Inside the U.S. borders, it is illegal (under numerous federal and
state statutes) to burn a wide variety of items in open-air burn pits.
Yet, as the conflicts in the Middle East have worn on; the use of open-
air burn pits not only was permitted, but it was openly sanctioned as
``necessary''.
Each and every item burned in these pits emits a chemical or group
of chemicals. Each of these chemicals has been studied by thousands of
researchers around the world. The consistency in the results of that
research is what the USG has used repeatedly to create and enforce laws
about open-air burning of trash, inside our borders; yet the DoD and VA
still refuse care and benefits to tens of thousands of service members
on the basis of their myopic and pigeon-hole research base.
The irony and insult to each service member is obvious and overt.
The DoD has lengthy and specific regulations regarding burning such
items as any piece of military equipment painted with CARC paint. As
all military equipment is painted with CARC paint, it is a logical
conclusion that no military equipment or part of such equipment be
burned in an open-air pit. Yet the DoD has sanctioned the burning of
all manner of military equipment painted with CARC paint for the entire
duration of the Middle East conflict.
1. https://phc.amedd.army.mil/PHC%20Resource%20Library/CARC--
Paint--37-011-0313.pdf
2. https://phc.amedd.army.mil/PHC%20Resource%20Library/TG144--
NOV2012.pdf
The VA also has a public policy about veterans who have been
exposed to burning CARC paint and acknowledges that this paint contains
toxic chemicals that can be harmful to humans.
1. https://www.publichealth.va.gov/exposures/carc-paint/index.asp
``Health problems associated with CARC paint:
Paint fumes present the most potential risk to users especially
when CARC is spray painted, rather than applied with a brush or roller.
CARC paint contains several chemical compounds that can be
hazardous when inhaled or exposed to the skin:
Isocyanyte (HDI)--Highly irritating to skin and
respiratory system. High concentrations can cause: itching and
reddening of skin; burning sensation in throat and nose and watering of
the eyes; and cough, shortness of breath, pain during respiration,
increased sputum production, and chest tightness.
Solvents--Inhaling high concentrations can cause
coughing, shortness of breath, watery eyes, and respiratory problems,
including asthma
Toluene diisocyanate (TDI)--High levels released during
the drying process can cause kidney damage.''
CARC paint is only one specific known chemical compound that has
been routinely burned in open-air pits. There are literally thousands
more.
On April 26, 2010; the VA issued the ``Environmental Training
Letter'' to all VA facilities nationwide. It is a policy document which
clearly directs all rating examiners and clinical providers on specific
chemicals known to be found in the open-air burn pits and how to rate
and treat veterans who claim exposures.
http://archive.sgtsullivancenter.org/wp-content/uploads/2014/11/
Training-Letter-10-03-OIF--OEF-Exposures.pdf
Most are familiar with parts of this document; as it has supported
the legislation surrounding the Camp Lejeune Water Contamination
presumption of exposure that the VA has granted to those who served on
that base.
The existence of this ``Training Letter'' provides yet another
layer of evidence that the VA is aware of the toxins veterans' who
served near open-air burn pits were exposed to and continues to defy
even its own edicts. Under this policy, the VA has granted
``Presumptive Status'' to those exposed to contaminated water at Camp
Lejeune (only); even though this very policy encompasses the burn pits
in Iraq, Afghanistan and Djibouti; as well as water contamination at
Camp Lejeune and Atsugi, Japan.
As nearly all trash burned releases toxic chemicals and the USG has
regulated this for decades; there is no excuse why it should even be an
option, let alone continue.
Those doing so are subject to fines and criminal sanctions inside
the U.S. borders. Those service members exposed to these chemicals
should not be denied access to any medical care or benefits when the
hazards are well known to the USG.
The Center for Disease Control (CDC) lists all of the chemicals
found in the Middle East conflict areas, in their top three-hundred (in
ranking of most dangerous); https://www.atsdr.cdc.gov/spl/previous/
07list.html
As a nation, forcing our service members to fight or die waiting
for rightfully earned benefits and services; solely based on two
agencies refusal to acknowledge peer accepted science; should be a
source of shame. To continue to behave as if these veterans are
fabricating their injuries is tantamount to denying their service.
Veteran Warriors has drafted legislation that will actually provide
relief to the tens of thousands of veterans who are contracted
illnesses associated with exposure to toxic chemicals in combat zones.
The draft of the text follows this statement.
Whistleblowers of America (WoA)
Statement of Ms. Jacqueline Garrick, LCSW-C
Dear Chairman Dunn and Ranking Member Brownley;
Whistleblowers of America (WoA) is submitting this statement
because we are concerned about the Department of Veterans Affairs (VA)
lack of a consistent process to handle the toxic exposures, illnesses,
and presumptions related to burn bits as the Gulf War continues. We
have heard from numerous veterans--Vietnam to Gulf War to Iraq and
Afghanistan (OIF/OEF) who feel that their concerns have been too long
ignored while they get sick and their claims are denied. Furthermore,
WoA also sees the fraud, waste and abuse of ignoring the Veterans
Disability Benefits Commission (VDBC) recommendations \1\ made over a
decade ago and VA ineffectiveness in implementing research because of
it. The VA has had the authority to create presumptions since 1921 and
has done so only 150 times. However, this piecemeal approach to
disability presumption decision-making has been laborious and
insufficient for almost a century. Too many veterans have died while
waiting. Congress should end this dysfunction before 2021.
---------------------------------------------------------------------------
\1\ VDBC. (2007) Honoring the call to duty: veterans' disability
benefits in the 21st century. Department of Veterans Affairs,
Washington, DC. Chapter 5.
---------------------------------------------------------------------------
The VA has confirmed that burn pits have been in existence since
1990, but we must do more than simply store veterans in a registry
while they get sick and die. In the documentary Delay, Deny, Hope You
Die: How America Poisoned its Soldiers, \2\ veterans describe the
expansive environmental contaminations that they endured while the
government neglected its responsibility to protect them. Among those
who the film follows is former Marine, Brian Alvarado, who at 70 pounds
is unable to speak because of his Squamous Cell Carcinoma that he and
his family attribute to his burn pit exposures yet unrecognized by VA
as related to his exposures. In 2016, Ben Krause \3\ wrote about the
death of a 36 year-old Minnesota Air National Guard mother who died of
Pancreatic Cancer after serving next to the 10 acre/100-200 tons a day
burn pit on the base in Balad, Iraq. In January 2013, I visited the
Bagram Air Force Base in Afghanistan on behalf of the Department of
Defense (DoD) and saw the defunct burn bit operation and was truly
taken aback by its enormity. Sadly, these stories are not new. In June
2018, The American Legion featured in its magazine, a feature story on
Exposed in Service \4\ related to Atomic Veterans from 1962 who were
dosed with ionizing radiation but are also unable to obtain VA benefits
because of the lack of evidence.
---------------------------------------------------------------------------
\2\ Lovett, G. (2017) Morningstar Media.
\3\ Krause, B. 36-year old mother possibly the newest burn pit
victim. DisabledVeterans.org, June 21, 2016
\4\ Olsen, K. Exposure wars: the long, connected and continuing
fight for accountability. June 2018. Pgs. 34-40
---------------------------------------------------------------------------
It its imperative that Congress fund VA research, plus research
done by independent laboratories that can validate VA data on the
impact of burn bit exposures as well as comorbid conditions more
prevalent among those who have deployed to toxic environments where
there is a likelihood of hazardous exposures. VA must have a research
strategy that fences these priorities and MUST have a focus to support
presumption decisions that can inform Veterans Benefits Administration
(VBA) policies. It must also provide the proper management of research
funds and oversight of execution.
In prior testimony, WoA, highlight its concerns with previous
generations of veterans who have been suffered toxic exposures and
environmental hazards. We outlined:
Agent Orange: A primary source of concern for veterans that have
contacted WoA has been related to toxic exposures and environmental
hazards. There are still so many Vietnam-era Veterans with Agent Orange
related issues that have not been appropriately recognized because of
the shortfalls in the research. For example, eye cancers are a
continuous issue that lack research support. VA continues to deny
claims for disability benefits, which in turn blocks veteran from
accessing care. As the Vietnam generation ages and has more complex
needs for care, the arguments over probable correlations need to be
resolved before there is no one left for the science to help.
Gulf War Illness: Although it has been more than 25 years since the
US invaded Iraq, the mysteries of Gulf War Illnesses haunt veterans
while perplexing VA. A July 2017 GAO report concluded that VA is still
inappropriately denying veterans claims. It found an 80 percent denial
rate, which is three times greater than any other type of claim
denials. Plus, it also took VA longer to adjudicate these benefits.
This delay means that sick veterans are not fully eligible for VA
health care. VA has promised better training and to develop a new plan
for research.
Fort McClellan: The VDBC included these predominately female
service members in its recommendations. Over 10 years later, the
American Legion is still reporting on the ``unknown toxic legacy'' of
Anniston and has a resolution that requires a toxic substance national
research center, comprehensive examinations for environmental
exposures, and improvement in these rules. \5\ (This is consistent with
the VDBC findings.)
---------------------------------------------------------------------------
\5\ Olsen, K. The long shadow of Ft. McClellan. The American Legion
Magazine. March 2018. Pgs. 22-28
Camp LeJeune: Due to the water contamination at the Marine Corps
Base, Camp LeJeune, NC, increased reports of cancers in veterans and
their families have been document over the last several decades related
---------------------------------------------------------------------------
to the cleaning solvents in the water.
Burn Pit Exposures: Similar to previous generations of veterans,
those who have served in Afghanistan and Iraq since 9/11 were exposed
to a concoction of burning substances on military installations that
has caused them to raise health concerns from cancers to respiratory
and gastrointestinal disorders. Although VA denies conclusive research
for these conditions and does not have a presumption for burn pits, it
has established a registry. However, this is an area yet again that the
VDBC recommendation could be informative and assistive to veterans'
wellness if implemented. A registry alone assists no one.
VDBC Recommendations for Reconsideration:
The VDBC conducted its work over a three-year period and reported
its findings and 113 recommendations in October 2007. It was a Federal
Advisory Committee established by President George W. Bush and its 13
commissioners were selected on a bipartisan basis. Presumption was a
major issue that it tackled. The VDBC enlisted the subject matter
assistance of the then Institute of Medicine (IOM) for its reliable and
valid scientific approach. To meet the requirements outlined by VDBC,
IOM established a committee that held meetings, reviewed research and
other literature, and rendered its own report. \6\ The IOM
recommendations were incorporated into the VDBC Final Report after a
full period of vetting and commentary by the community. In sum, the
VDBC recommended:
---------------------------------------------------------------------------
\6\ IOM. (2008) Improving the presumptive disability decision-
making process for veterans. National Academies Press. Washington, DC.
1. Congress should create a formal advisory committee on disability
---------------------------------------------------------------------------
related questions requiring scientific review
2. Congress should authorize a permanent independent Scientific
Review Board (SRB) with a well-defined process using evaluation
criteria
3. VA should develop and publish a formal process for disabling
presumptions that is uniform, transparent, and sets forth all
considered evidence.
4. The goal of presumptive disability should be to ensure
compensation for veterans whose diseases are caused by military service
(this goal is foundational for any related action)
5. The SRB should adapt a standard for ``causal effect'' based on a
more likely than not broad spectrum of evidence that is either
Sufficient, Equipoise and above, Equipoise and below, Against.
6. This calculation should include relative risk assessment,
epidemiology, animal studies, registries, mechanistic data, predictive
algorithms, and interfaces with DoD.
7. When evidence is at Equipoise or Above, an estimate of exposure
should be included.
8. The relative risk and exposure prevalence should be used to
estimate a service -attributable fraction.
9. Inventory all research related to veteran's health (VA, DoD or
the funded)
10. Develop a strategic plan for OIF/OEF veterans research
11. Develop a plan for augmenting research capabilities within VA
and DoD to more systematically generate health related evidence.
12. Assess enhancing research by linking VA and DoD health related
databases
13. Conduct a critical evaluation of Gulf War (this includes OIF/
OEF) tracking and environmental exposure monitoring data to categorize
exposures during deployments (with DoD)
14. Establish Registries based on exposures, deployments, and
disease
15. Develop an overall integrated (VA/DoD) surveillance plan
16. Include exposure monitoring in an VA/DoD Electronic Health
Record
17. Implement a strategy for immediate and proximate exposure
assessment and data collection
18. Interface VA and DoD exposure data systems
19. Mechanism to identify, monitor, track and treat individuals
involved in research and other activities that are classified and
secret
20. VA should consider environmental issues in a new presumption
framework
Given that a decade has passed since the VDBC made these
recommendations, Congress should ask the VA to relook at this
systematic approach and design a comprehensive way forward for
researching presumption related disabling conditions related to
environmental hazards and toxic exposures. It should consider the
comorbidity of chemical sensitivities and biological agents, especially
in relation to neurological and psychological concomitant factors that
may take years before onset.
Thank you for this opportunity to express our views on this
significant issue impacting thousands of disabled veterans, Service
members, and their families. We hope that this Committee will compel VA
to act on researching the presumptive conditions related to
environmental hazards and toxic exposures.
Jacqueline Garrick is a former Army social work officer who has
worked in the Departments of Veterans Affairs and Defense as well as
for the House Veterans Affairs Committee. She is a subject matter
expert in mental health and program evaluation. She is an advocate for
disabled veterans and the use of peer support to improve resilience in
traumatized populations. She founded Whistleblowers of America in 2017
based on her experience reporting attempted fraud with DoD Suicide
prevention funds.
Whistleblowers of America is a 501C3, EIN 82-3989539. Its mission
is to provide peer support to employees and veterans who have reported
wrongdoing and experienced retaliation.
Contact:
Jacqueline Garrick
[email protected]
202-309-1870
TRAGEDY ASSISTANCE PROGRAM FOR SURVIVORS (TAPS)
VIETNAM VETERANS OF AMERICA (VVA)
WOUNDED WARRIOR PROJECT (WWP)
Thank you, Chairman Dunn, Ranking Member Brownley, and
distinguished members of the Health Subcommittee, for allowing us to
present this statement for the record on behalf of the service members,
veterans, family members, and survivors who have been affected by
exposure to burn pits and other war related toxins.
For decades, veterans of overseas conflicts and families of our
nation's wounded, ill, injured, and fallen heroes have been advocating
to investigate and bring public awareness to the harmful effects of
toxic exposures in the military. Wounded Warrior Project (WWP), the
Tragedy Assistance Program for Survivors (TAPS), and Vietnam Veterans
of America (VVA) have partnered to give momentum to these causes and
deliver change. While not the only form of toxic exposure that we or
others wish to address, burn pits have become synonymous with our
community's interest in acknowledging the harm these exposures have
caused and ultimately delivering public policy changes that will ensure
longer, healthier lives for the men and women who serve our country.
As individual organizations, VVA, TAPS, and WWP have shared
concerns for several years about the emergence of toxic exposure as a
common thread among former service members who are sick, dying, or
already deceased from uncommon illnesses or unusually early onset of
more familiar maladies like cancer. In the past, we have advocated for
initiatives such as the creation of the Airborne Hazards and Open Burn
Pit Registry in June 2014 and the more recent passage of the Toxic
Exposure Research Act of 2016 (P.L. 114-315, Sec. Sec. 631-34). Given
our collective interest in prevention, treatment, and awareness,
Wounded Warrior Project decided in October 2017 to coordinate efforts
with TAPS and VVA and invested $200,000 in a needs assessment to guide
our future advocacy. Wounded Warrior Project remains committed to
continued investments of resources and expanding its partnerships to
include others passionate about this important issue.
Since joining together in partnership, we have concentrated our
efforts to raise awareness of toxic exposures among and on behalf of
Post-9/11 veterans. Our current undertaking is focused on gathering
research and data that will help us all better understand the risks and
effects of toxic exposure so that we may work to ensure service
members, veterans, families, and survivors have access to the care and
benefits they need. Thus far, we have built and maintain a database of
empirical research on toxic exposures, and with the help of the U.S.
Army, enlisted the help of the ``Soldier for Life Program'' to share
toxic exposure information with their network of over a million
veterans. We have created a flyer to be distributed nationally to help
veterans take the next steps in identifying and being screened for
symptoms of toxic exposures; recorded a podcast on toxic exposures
among Post-9/11 veterans, and are networking with other toxic exposure
awareness groups such as Burn Pits 360 to further share our message. We
have lent our support to the work of others, including the effort
behind the Burn Pits Accountability Act (H.R. 5671) introduced by Reps.
Tulsi Gabbard (HI-02) and Brian Mast (FL-18), and we are working
towards delivering an information paper to the Health Subcommittee that
provides a full landscape of what our partnership has been able to
bring to light over the past several months. More work needs to be done
however, and we hope to build upon our momentum in the months ahead.
Burn Pits
In the Post-9/11 era, it is estimated that as many as 3 million
American service members may have been exposed to dangerous toxins
during their deployments overseas. Potential sources of these exposures
include, but are not limited to, depleted uranium used in military
armor and munitions, toxins from burning oil refineries/destroyed
weapons plants, and more than 260 open-air burn pits used for the
disposal of all forms of waste on forward coalition bases around the
world.
In its 2011 study on Long-Term Health Consequences of Exposure to
Burn Pits in Iraq and Afghanistan, the Institute of Medicine stated
that it was unable to determine whether long-term health effects are
likely to result from burn pit exposure due to inadequate evidence of
an association. Although the study did not find a causal relationship
between burn pits and long-term health issues, it similarly did not
conclude that there is no relationship. That said, each of our
organizations continue to see anecdotal evidence to the contrary.
Accordingly, our organizations collectively agree that public policy
moving forward should aspire to:
Support research on the impact of service members exposed
to environmental toxins or hazardous substances, and/or deployment
illnesses that may have resulted from their military service (e.g.,
burn pit exposure in Iraq and Afghanistan and Camp Lejeune contaminated
water).
Ensure health care and benefits are established to
appropriately compensate and support service members and veterans,
family members, and survivors, particularly those experiencing
catastrophic and devastating cancers, diseases, other health
conditions, or death as a result of their service.
Implement the Government Accountability Office's
September 2016 Report (GAO-16-781) recommendation for the Department of
Defense (DoD) and the Department of Veterans Affairs (VA) to examine
the relationship between direct, individual, burn pit exposure and
potential long-term health-related issues as well as the Institute of
Medicine's 2011 report suggestion to evaluate the health status of
service members from their time of deployment over many years.
Beyond Burn Pits
As noted above, burn pits are just one of many ways that veterans
were exposed to harmful toxins in service. While any progress to bring
redress for the wounded, ill, and injured veterans, their families, and
the families of the fallen who were exposed to burn pits would be
meaningful, the most lasting impact will be made when we investigate
other potential causes of death and disease for which there is already
conspicuous correlation. In this context, our organizations are also
committed to developing public policies that:
Seek additional research by DoD and VA on the link
between cancers that may be caused by toxic exposures in combat zones.
Expand the current Burn Pit Registry so that it becomes a
Toxic Exposure Registry, and includes exposures to depleted uranium,
experimental medications, vaccinations, and aircraft fuels.
Create an education program for distribution in both DoD
and VA for veterans and family members that includes the known symptoms
associated with toxic exposures in order to initiate earlier
intervention.
Allow surviving family members who believe that their
service member/veteran may have died from a toxic exposure to add their
names to the Toxic Exposure Registry.
Encourage the VA to work with the Army Public Health
Center to summarize and identify common risks using their Periodic
Occupational and Environmental Monitoring Summary (POEMS).
Additionally, while we know this committee only has jurisdiction
over VA, we realize there is much to do by DoD. We would like Congress
to require DoD to assess and research the diseases and illnesses
resulting from toxic exposures by our Post-9/11 veterans in order to
help ensure longer, healthier lives for the men and women who serve our
country. Eventually, we would like to make sure that all exposures
would be delineated so that none are overlooked or fall through
loopholes. We would also like to see the list expanded to include
depleted uranium, radiation exposures, infectious diseases, and
occupational materials. We would hope that identifying each exposure is
a step in the right direction.
Lastly, we would like to see an evaluation of all duty locations in
which a member served, not just those with open air burn pits, to
ascertain the full measure of a service member's toxic exposures. The
recently released DoD report from March 2018, Addressing
Perfluorooctane Sulfonate (PFOS) and Perfluorooctanoic Acid (PFOA),
outlines the full magnitude of the presence of PFOS and PFOA in
drinking water and groundwater on our military bases and identifies 401
active and Base Closure and Realignment installations in the United
States with at least one area where there was a known or suspected
release of perfluorinated compounds. This exposure should not be
overlooked.
Final Remarks
In conclusion, we sincerely appreciate the Health Subcommittee's
commitment to assessing the potential health effects of burn pits.
While our organizations have found compelling evidence in the anecdotal
stories of death, early onset of disease, and lingering health ailments
that are difficult to attribute to other potential causes, we
understand that progress takes time. We are grateful that today's
hearing will contribute to a greater understanding and increased
information sharing related to burn pit exposure and the potential
effects of such exposures on America's heroes and their families.
In the future, we are eager to see the Health Subcommittee expand
the aperture further to include other toxic exposures including
depleted uranium, radiation exposures, infectious diseases, and
occupational materials. We are confident that the TAPS, VVA, and WWP
partnership--along with any others who may join or who share our
interest in raising awareness and driving change in this area--can
provide thoughtful, constructive, and informative assistance in
Congress' future efforts, and we look forward to continued engagement
with the Health Subcommittee on burn pits and other toxic exposures as
we seek to support service members, veterans, family members, and
survivors whose lives have been touched by exposure to burn pits.
Our Organizations
The Tragedy Assistance Program for Survivors (TAPS) is the national
organization providing compassionate care for the families of America's
fallen military heroes. TAPS provides peer-based emotional support,
grief and trauma resources, grief seminars and retreats for adults,
Good Grief Camps for children, case work assistance, connections to
community-based care, and a 24/7 resource and information helpline for
all who have been affected by a death in the Armed Forces. Services are
provided to families at no cost to them. We do all of this without
financial support from the Department of Defense; TAPS is funded by the
generosity of the American people.
TAPS was founded in 1994 by Bonnie Carroll following the death of
her husband in a military plane crash in Alaska in 1992. Since then,
TAPS has offered comfort and care to more than 75,000 bereaved
surviving family members. TAPS currently receives no government grants
or funding.
The national organization Vietnam Veterans of America (VVA) is a
Congressionally chartered non-profit veterans' service organization
whose founding principle is: ``Never again will one generation of
veterans abandon another.'' VVA promotes and supports the full range of
issues important to Vietnam veterans, to create a new identity for this
generation of veterans, and to change public perception of Vietnam
veterans. VVA knows what returning veterans face as we have been
through it before. We know that, despite all the rhetoric, returning
veterans will face major health problems and as such, VVA has a well-
known history of dealing with the health effects of toxic exposures
during military service.
In the 1970's, established veterans groups had failed to prioritize
issues of concern to Vietnam veterans. Thus VVA came into existence at
that time out of a clear necessity to advocate for and provide support
to veterans in need. VVA will be here for as long as it takes to make
sure that those who serve our country receive the care and respect they
have earned.
VVA is not currently in receipt of any federal grant or contract,
other than the routine allocation of office space and associated
resources in VA Regional Offices for outreach and direct services
through its Veterans Benefits Program (Service Representatives). This
is also true of the previous two fiscal years.
Wounded Warrior Project (WWP) is transforming the way America's
injured veterans are empowered, employed, and engaged in our
communities. Since 2003 we've been tireless advocates for our Nation's
finest, improving the lives of over half a million warriors and their
families.
Warriors never pay a penny for our programs-because they paid their
dues on the battlefield. Our free services in mental health, career
counseling, and long-term rehabilitative care change lives. WWP is
committed to helping injured veterans achieve their highest ambition.
When they're ready to start their next mission, we stand ready to
serve.
WWP is humbled to be recognized as a charity with great impact,
operating with efficiency, transparency, and accountability. We are an
accredited charity with the Better Business Bureau (BBB), top rated by
Charity Navigator, and hold a GuideStar Platinum rating. WWP has not
received any federal grants or funding.
[all]