Apr112013
Hearing Transcript on Health Effects of the Vietnam War – The Aftermath.
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HEALTH EFFECTS OF THE VIETNAM WAR–THE AFTERMATH
HEARING BEFORE THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED ELEVENTH CONGRESS SECOND SESSION MAY 5, 2010 SERIAL No. 111-75 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director 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. |
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C O N T E N T S
May 5, 2010
Health Effects of the Vietnam War–The Aftermath
OPENING STATEMENTS
Chairman Bob Filner
Prepared statement of Chairman Filner
Hon. Cliff Stearns
Hon. John J. Hall
Prepared statement of Congressman Hall
Hon. Harry E. Mitchell, prepared statement of
Hon. John H. Adler, prepared statement of
WITNESSES
U.S. Government Accountability Office, Randall B. Williamson, Director, Health Care
Prepared statement of Mr. Williamson
U.S. Department of Veterans Affairs, Joel Kupersmith, M.D., Chief Research and Development Officer, Veterans Health Administration
Prepared statement of Dr. Kupersmith
American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and Rehabilitation Commission
Prepared statement of Mr. Wilson
Blue Water Navy Vietnam Veterans Association, John Paul Rossie, Executive Director
Prepared statement of Mr. Rossie
Fenske, Richard A., Ph.D., M.P.H., Professor and Acting Chair, Environmental and Occupational Health Sciences, School of Public Health and Community Medicine, University of Washington, Seattle, and Chair, Committee on the Review of the Health Effects in Vietnam Veterans of Exposure to Herbicides, (Seventh Bienniel Update) Board on the Health of Select Populations, Institute of Medicine, The National Academies
Prepared statement of Dr. Fenske
Gold Star Wives of America, Inc., Vivianne Cisneros Wersel, Au.D., Chair, Government Relations Committee
Prepared statement of Dr. Wersel
Marmar, Charles R., M.D., Chair, Department of Psychiatry, New York University Langone School of Medicine, New York, NY
Prepared statement of Dr. Marmar
Veterans Association of Sailors of the Vietnam War, Commander John B. Wells, USN (Ret.), Cofounder and Trustee
Prepared statement of Commander Wells
Vietnam Veterans of America, Richard F. Weidman, Executive Director for Policy and Government Affairs
Prepared statement of Mr. Weidman
SUBMISSION FOR THE RECORD
Reserve Officers Association of the United States, and Reserve Enlisted Association, joint statement
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
HEALTH EFFECTS OF THE VIETNAM WAR–THE AFTERMATH
Wednesday, May 5, 2010
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:05 a.m., in Room 334, Cannon House Office Building, Hon. Bob Filner [Chairman of the Committee] presiding.
Present: Representatives Filner, Michaud, Herseth Sandlin, Hall, Perriello, Teague, Rodriguez, Donnelly, Walz, Adler, Stearns, Boozman, Bilbray, and Roe.
OPENING STATEMENT OF CHAIRMAN FILNER
The CHAIRMAN. Good morning. The Committee on Veterans' Affairs will come to order.
I ask unanimous consent that all Members may have 5 legislative days in which to revise and extend their remarks. Hearing no objection, so ordered.
I believe it is appropriate that as we talk about the Vietnam War today, that we mention the Vietnam veteran tee-shirt vendor who first alerted us to the car that had bomb material in it in New York City. He is the President of the Vietnam Veterans of America (VVA) Chapter 817. We want to add our thanks, the Nation's thanks to this Vietnam veteran who may have saved thousands of lives.
Thank you all for being here this morning. The purpose of today's hearing is to examine the health effects that our veterans sustained during the Vietnam war as a result of being exposed to the toxic dioxin-based concoctions that we now generally refer to as Agent Orange.
As such, we will follow-up on the U.S. Department of Veterans Affairs' (VA's) long outstanding promise to conduct a National Vietnam Veterans Longitudinal Study, the NVVLS. We ought to stop the stovepiping in VA and look at how all of these issues relate to providing benefits for presumptive conditions under current law for Agent Orange combat veterans.
I want to ensure that we do not leave any of our veterans who were exposed to Agent Orange while fighting overseas uncompensated for their injuries and left behind due to VA technicalities.
It has been 10 long years since Congress mandated that the VA study the long-term, lifetime psychological and physical health impact of the Vietnam War on the veterans of that era.
In 2000, Congress required that the VA conduct this longitudinal study by building on the findings of the National Vietnam Veterans Readjustment Study in 1984. That study was a landmark report, which provided a snapshot of the psychological and physical health of Vietnam veterans.
A follow-up longitudinal study, of course, is needed to understand the life course of health outcomes and comorbid events that have resulted from the traumas our men and women endured during the Vietnam War.
Initially the VA adhered to the letter of the law, but halted the NVVLS study in 2003 by not renewing a 3-year, noncompetitive, sole-source contract that they awarded in 2001. The VA cited cost reasons, noting that the original estimate for completing the study had ballooned from $5 million to $17 million.
The VA took no further steps and ignored the law until this Committee received a proposal from former Secretary Peake in January of 2009. The Secretary recommended substituting the NVVLS with a study of twins who served in the Vietnam War and a study of women Vietnam War veterans, which would cost around $10 million.
Given the cost of the alternative option, it seemed to me that the VA could have completed the original study on time had the Department chosen to allocate the $10 million to the original contract award back in 2003.
This Committee and others do not see the merit of the alternative proposal and has continued to advocate for the completion of the original study that was mandated.
In September 2009, Secretary Shinseki committed to carrying out this study. And, while I applaud the Secretary for his commitment, I remain very vigilant about the issue.
In today's hearing, I would like to better understand the progress that VA has made in conducting the study. I also hope to learn about the potential barriers that we can proactively address so that the VA remains on track to complete the study.
Also, Congress passed several measures to address disability compensation issues for Vietnam veterans. The Veterans Dioxin Radiation Exposure Compensation Standards Act of 1984 required the VA to develop regulations for disability compensation to Vietnam veterans exposed to Agent Orange.
In 1991, the Agent Orange Act established, for the first time, a presumption of service-connection for diseases associated with herbicide exposure. The Agent Orange Act authorized the VA to contract with the Institute of Medicine (IOM) to conduct a scientific review of the evidence linking certain medical conditions to herbicide exposure.
Under this law, the VA is required to review the biennial reports of the Institute of Medicine and to reissue regulations to establish a presumption of service-connection for any disease for which there is scientific evidence of a positive association with herbicide exposure.
However, apparently VA illogically backtracked on the Agent Orange Act regulations by reversing its own policy to move to require a foot on land occurrence by Vietnam veterans in order to prove service-connection. This means that the Vietnam Service Medals and other such awards would no longer be accepted as proof of combat.
This change excluded nearly one million Vietnam veterans who had served in our Navy, Air Force, and in nearby border combat areas. This is an unfair and unjust result that has been litigated endlessly and ultimately against the veterans.
I am trying to undo this injustice in a bill that I have introduced called the Agent Orange Equity Act of 2009, H.R. 2254. More than a majority of the Congress has in fact, been added as co-sponsors to this bill and I urge everyone to become a co-sponsor.
Today, I hope to hear from the VA as to why it reversed its policy that now excludes our Blue Water servicemembers from presumptive consideration for service-connection and treatment.
I also want to know why it is ignoring the latest 2009 IOM recommendation that members of the Blue Water Navy should not be excluded from the set of Vietnam era veterans with presumed herbicide exposure. I know the VA has asked the IOM to issue a report on Blue Water veterans in 18 months, but that is 18 months too long.
The foot on land requirement is especially unreasonable when you consider that these servicemembers were previously treated equally to other Vietnam veterans for benefit purposes.
Moreover, several Australian Agent Orange studies long ago concluded that their Blue Water veterans who served side by side with our Blue Water veterans were exposed to Agent Orange and because of the water distillation process on the ships ingested it even more directly.
While I applaud the VA for recently adding three new presumptions for Parkinson's disease, ischemic heart disease, and B-cell leukemias for Agent Orange exposed veterans, those are three new presumptions for which Blue Water veterans may suffer and will not be treated or compensated.
I urge the VA to start compensating these veterans immediately. Just like it reversed the decision in 2002, I strongly urge VA to reverse back and compensate these deserving veterans.
Finally, I want to know for sure that VA plans to make the Blue Water veterans included in the NVVLS so that they and their families and survivors have a chance to get the benefits they deserve on equal footing with other Vietnam veterans.
I look forward to hearing from all of our witnesses today and thank you for being here to examine these long-standing issues.
I now recognize Mr. Stearns for an opening statement.
[The prepared statement of Chairman Filner appears in the Appendix.]
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. STEARNS. Good morning, everybody.
And thank you, Mr. Chairman.
I would like to welcome everyone here this morning for obviously a very important hearing on the health effects from the Vietnam War. The focus of this discussion is to further examine the negative health impact the war has had on our veterans.
Like many in the audience, I served during the Vietnam era and many of my colleagues were killed or suffered injuries.
We want to ensure that our government is taking every possible measure to alleviate the physical and mental health afflictions these men and women have faced since the Vietnam War ended 35 years ago.
Some veterans struggle today with post-traumatic stress disorder (PTSD), cancer, neurological disorders, and a number of other diseases that are associated with Vietnam and now they are suffering quite considerably. These veterans, so many years after the war ended, still fight their own battles every day. For some, the battle is with the intrusive memories of horrific events. For others, it is simply with the debilitating effects of diseases and their treatment.
Regardless of what they face, they should not also have to battle the VA for their benefits. Our government was far too slow in recognizing the effects of the Vietnam War on veterans. But from this lesson, we have improved diagnoses, treatments, and compensation for our veterans.
Congress passed the Agent Orange Act of 1991 as part of this effort. The legislation directed the National Academy of Sciences to conduct a comprehensive review and evaluation of the health effects of herbicide exposure.
The Institute of Medicine completed the initial study in 1994 and conducted subsequent periodic reviews of evidence as it became available.
In these reviews, IOM evaluates scientific data to determine if there is a statistical association between various pathologies and exposure to herbicide agents.
If it is shown that there is an increased risk for particular disease among those veterans who were exposed and that there is a plausible connection between exposure and the disease, then VA has the authority to establish a presumptive service-connection.
We applaud Secretary Shinseki for recently utilizing this authority to add three new diseases to the VA's list of illnesses associated with exposure to herbicide agents. I understand the rule-making process is underway but that a number of steps remain before the final rule can take effect.
So I look forward to hearing from our VA panel today and getting an update on what needs to be accomplished and how soon veterans can begin receiving compensation.
Moreover, I am deeply concerned about VA's ability to handle the brunt of the hundreds of thousands of new claims it will potentially receive and the impact it will have on the unacceptable backlog that exists today for disability claims.
Besides cancers and other debilitating conditions associated with Agent Orange, many Vietnam veterans are haunted by lingering memories of their involvement in the war. And tragically upon returning home from Vietnam, many veterans were personally attacked by those who opposed the war. Such disrespect magnified the stress associated with their combat experiences and not surprisingly left many of our war heroes bitter and emotionally scarred.
Homelessness, substance abuse, and suicide are all too tragic problems that in many cases can be attributed directly to post-traumatic stress disorder. Unfortunately, so many of our veterans, including Vietnam veterans suffering from PTSD, have shunned any involvement with the government including tragically, the VA.
A few years back, the VA along with several representatives from the VA, the veterans community, and community organizers visited a large veterans' encampment in my hometown of Ocala, Florida. This was part of a homeless veterans outreach program. It was discovered that some of the residents there were recipients of Purple Hearts and other combat awards who had never even sought VA benefits or care because of their mistrust of the United States Government.
Fortunately, these veterans agreed to receive the assistance they had earned through their service. Sadly, there are still many more who remain isolated from VA and the care that is available to them.
Over the past several years, VA has expanded its outreach efforts and the number of veterans receiving compensation for PTSD has grown dramatically.
VA has also recently provided a regulatory change that more closely reflects the intent of Congress to provide due consideration to the time, place, and circumstance of a veteran's service. This change will facilitate the timely resolution of PTSD claims and provide compensation to those who suffer as a result of their service to our country.
So I applaud the VA for this and the other steps it has taken on behalf of Vietnam veterans, but I am sure we all recognize that much remains to be accomplished and that is the purpose of our hearing today.
I look forward to the testimony of our panels today, for this very important discussion.
And I thank you, Mr. Chairman, for this hearing.
The CHAIRMAN. Thank you, Mr. Stearns.
I now call our first panel. We have watched for at least 40 years, the bureaucratic “movement” on this issue. It took more than a decade to even recognize the effects of Agent Orange and when it was recognized, the VA set up incredible bureaucratic hurdles for the veteran to get disability compensation. We have waited years and years for this longitudinal study.
It seems to me that our veterans have suffered enough. I think sometimes that veterans suffer more from fighting the VA than they probably do from their original injury or disease. Many people who have gone through this think VA means veterans' adversary instead of veterans' advocate. It seems to me that we ought to end this suffering.
As I mentioned, I have a bill, that honors all the Agent Orange claims as of today. People have suffered enough. All this bureaucracy about what is presumptive, what qualifies, and the requirement of boots on the ground just puts people through more suffering.
Not only should we honor those claims, but it would also help with the claims backlog that Mr. Stearns mentioned. I suspect there are a couple hundred thousand Agent Orange claims in the process. Let us just get those off the books.
It is not too late to say thank you for those veterans that we did not honor, as Mr. Stearns again pointed out, when they came home. Let us not only say we are sorry as a Nation, but let us actually do something on their behalf.
I hope people will respond to my modest proposal.
If the first panel would please join us? Dr. Richard Fenske is the Professor and Acting Chair of the Environmental and Occupational Health Sciences at the School of Public Health and Community Medicine and he is here on behalf of the Institute of Medicine.
Dr. Charles Marmar is the Chair of the Department of Psychiatry at New York University Langone School of Medicine, and Mr. Randall Williamson is a Director of Health Care at the U.S. Government Accountability Office (GAO).
We thank you all for being here. Each one of you will be recognized for 5 minutes for an oral presentation and your complete written statement will be included in the hearing record.
We will start with Dr. Fenske. Thank you again for being here.
STATEMENTS OF RICHARD A. FENSKE, PH.D., M.P.H., PROFESSOR AND ACTING CHAIR, ENVIRONMENTAL AND OCCUPATIONAL HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH AND COMMUNITY MEDICINE, UNIVERSITY OF WASHINGTON, SEATTLE, AND CHAIR, COMMITTEE ON THE REVIEW OF THE HEALTH EFFECTS IN VIETNAM VETERANS OF EXPOSURE TO HERBICIDES, (SEVENTH BIENNIEL UPDATE) BOARD ON THE HEALTH OF SELECT POPULATIONS, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES; CHARLES R. MARMAR, M.D., CHAIR, DEPARTMENT OF PSYCHIATRY, NEW YORK UNIVERSITY LANGONE SCHOOL OF MEDICINE, NEW YORK, NY; AND RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
STATEMENT OF RICHARD A. FENSKE, PH.D., M.P.H.
Dr. FENSKE. Thank you very much, Chairman Filner, and good morning to Members of the Committee.
My name is Richard Fenske. I am at the School of Public Health at the University of Washington. I served as a member of the Veterans and Agent Orange (VAO) Committee established by the Institute of Medicine for updates 2002, 2004, and 2006 and then I became the Chair for update 2008. So I am here on behalf of the Institute of Medicine to briefly describe the process that we have used in those reports.
The National Academy of Sciences was chartered by Congress in 1863 to advise the government on matters of science and technology and the Institute of Medicine was established in 1970 by the National Academy to enlist the services of appropriate professionals to examine science and policy matters pertaining to the health of the public.
As has been said, Congress established a mandate for a series of veterans and Agent Orange reports in the Agent Orange Act of 1991 and the legislation directed the Secretary of Veterans Affairs to have the National Academy of Sciences perform a comprehensive evaluation of scientific and medical information regarding the health effects of exposure to the herbicides used in Vietnam and it called for an update every 2 years.
Agent Orange was only one of several herbicide mixtures used in Vietnam. The name refers to the color band on the herbicide barrels. Agent Orange was a mixture of the phenoxy herbicides 2,4-D and 2,4,5-T.
In addition to other herbicides, picloram and cacodylic acid were applied in Vietnam and a dioxin compound known as TCDD was an unwanted contaminant in the 2,4,5-T herbicide, so dioxin-like chemicals have also been considered in our Committee reviews.
The legislation from 1991 directs VAO Committees to evaluate the evidence of statistical associations between specific health outcomes and exposure to the herbicides used by the military in Vietnam. The legislation does not ask the Committees to establish causality, which generally requires a more stringent standard of evidence. This charge is in keeping with judicial history related to Agent Orange exposure.
In reaching consensus about an association between exposure and health effects, the Committee considers only peer-reviewed, published scientific literature. VAO Committees have viewed epidemiologic studies of Vietnam veterans to be central to their decision making, working on the assumption that service in Vietnam was a proxy for exposure at levels in excess of what would have been experienced by nondeployed individuals.
The Committees have also drawn upon relevant epidemiologic studies of other exposed populations and much useful information has come from these nonveteran studies.
The original VAO Committee established a set of categories of association for adverse health outcomes. A chart with these categories has been provided in my written testimony.
The starting point or default category is inadequate or insufficient evidence of an association. Any health outcome that is not explicitly listed falls into this category.
Health outcomes that appear to be associated with exposure are placed in one of two categories, either of sufficient evidence or limited or suggestive evidence. There is not a discrete dividing point between these categories, so the choice depends on the number, the strength, and the consistency of the studies that indicate increased risk as well as consideration of factors like bias and confounding.
Since Committee decisions focus on statistical associations, the placement of the health outcome in the sufficient category does not necessarily imply that a causal relationship has been established between exposure and disease.
The original VAO Committee also established a category of suggestive evidence of no association. But over time, Committees have decided to move all but one health outcome from this category into the default category of inadequate or insufficient evidence since it is very difficult to determine that there is really no association.
The summary chart details those health outcomes that have been placed in the sufficient or the limited or suggestive evidence categories and it also indicates the year of the VAO finding and any subsequent adjustment.
The most recent VAO Committee update 2008 reviewed the scientific literature published from October 2006 through September 2008. We moved two conditions, Parkinson's disease and ischemic heart disease, to the limited or suggestive evidence category. We also concluded that hairy cell leukemia and chronic neoplasms belong with chronic lymphocytic leukemia in the sufficient evidence category.
That concludes my testimony. Thank you. And I will be happy to answer questions.
[The prepared statement of Dr. Fenske appears in the Appendix.]
The CHAIRMAN. Thank you.
Dr. Marmar?
STATEMENT OF CHARLES R. MARMAR, M.D.
Dr. MARMAR. Good morning, Chairman Filner, Congressman Stearns, and Members of the Committee.
Nearly 25 years ago, Congress enacted Public Law 98-160 directing the Veterans Administration to arrange for an independent scientific study of the adjustment of Vietnam veterans. The purpose of that study was to provide an empirical basis to formulate policy related to veterans' psychosocial health.
In response to this mandate, the National Vietnam Veterans Readjustment Study or NVVRS was conducted. I was fortunate to have served as a member of the NVVRS research team. The survey component of the study was conducted in 1986 and 1987 with a nationally representative sample of all who served in Army, Navy, Air Force, and Marines during the years of the war.
Findings from the NVVRS were an important ingredient in the mix of social and political forces that brought about major changes in VA policy towards post-war readjustment problems of Vietnam veterans and other veterans and in the public's understanding and acceptance of the concept of PTSD.
For the past 13 years, I have been Chief of Psychiatry at the San Francisco VA where I have had a chance to implement many of those important findings into clinical care policy.
Briefly what were the major findings from the NVVRS? At the time study was conducted in the late 1980s, the majority of Vietnam theater veterans had made a successful reentry into civilian life speaking to their resilience.
However, an important minority, nearly one in three, met criteria for PTSD related to their war-zone deployment at some time following their service and strikingly half of the men and one-third of the women who ever developed war-zone PTSD continued to suffer with the disorder a decade or more following the conclusion of the war.
Those with PTSD had higher rates of depression, alcohol and drug abuse, problems affecting work, family relations, and physical health. Families of veterans with PTSD have been affected with problems in marital adjustment, parenting skills, interpersonal violence, and children were affected with more adjustment behavioral problems.
Finally and importantly, at the time the survey was conducted in the late 1980s, most Vietnam veterans had never used the VA for mental health services. There has been controversy about this study.
In 2006, there was an important re-analysis done based on the use of military records to validate combat exposure. The major findings from that re-analysis were that there was, one, little, if any, falsification or dramatization of combat exposure. Overall, rates were found to be slightly lower at one in five rather than one in three veterans being affected. But I think it is important to also note that the study excluded as current combat PTSD cases anyone with a pre-military diagnosis of PTSD and we know that pre-military PTSD is a risk factor for developing war-zone PTSD.
I would like to speak briefly to the imperative need to conduct a long-term follow-up to the NVVRS, that is the NVVLS. Because of the high rates of PTSD, the strong evidence for the persistence of this syndrome, its strength of association with war-zone stress exposure, it is imperative that VA have information about the current functioning of the participants in the original study in order to make projections about how the entire Vietnam generation is functioning today because of the representative nature of the sample.
What would the NVVLS accomplish? As has been noted by the Chairman, there was a law in 2000 requiring the study to be conducted, but what would be the major benefits?
One, provide important information about the current functioning of veterans of the Vietnam War 20 years downstream from their Vietnam experience. Of great interest would be an understanding of how new cases form, how some people have recovered, and what the course has been over time as well as the possible impact of VA programs on effecting the recovery of Vietnam veterans with PTSD.
I want to emphasize that the NVVLS provides an unparalleled opportunity to determine if and how war-zone related PTSD is a risk factor for physical health problems. There are very great reasons to be concerned, that chronic post-traumatic stress increases the risk for high blood pressure, diabetes, heart attacks, stroke, and even possibly dementia. This study would answer those questions.
Determine the long-term impact of war-zone deployment on spouses and families and determine what has happened with respect to mental health care utilization, barriers to care, and satisfaction with VA health services, as well as to plan for future services for aging veterans.
Finally, the importance of the NVVLS must be placed in the context of the current readjustment of Iraq and Afghanistan veterans. To date, an estimated 1.9 million American men and women have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) and they are at risk for similar problems suffered by the Vietnam generation.
There is an urgent need to plan for their long-term adverse health consequences of OEF and OIF and these are underscored by recent studies showing a substantial minority of veterans from this new conflict are suffering from the same problems, PTSD, depression, alcohol and drug abuse, and risk of heart disease.
The NVVLS will generate critical knowledge about risk and resilience, course and complications of war-zone related PTSD on veterans and their families. This knowledge will serve as a blueprint for better preparing for the readjustment needs of those serving in Operation Enduring Freedom and Iraqi Freedom as well as for our aging Vietnam veterans.
Thank you.
[The prepared statement of Dr. Marmar appears in the Appendix.]
The CHAIRMAN. Thank you, sir.
Mr. Williamson?
STATEMENT OF RANDALL B. WILLIAMSON
Mr. WILLIAMSON. Good morning, Mr. Chairman and Members of the Committee. I am pleased to be here today as you discuss the VA's National Vietnam Veterans Longitudinal Study, which I shall refer to as the NVVLS.
This study, which the Congress mandated VA to conduct in 2000, is intended to be a follow-on study to an earlier comprehensive study that VA completed in 1988 on post-traumatic stress disorder and related post-war psychological problems among Vietnam veterans.
Experts estimate that as many as 30 percent of Vietnam veterans may have experienced PTSD and currently Vietnam era veterans constitute the largest group receiving VA care for PTSD.
In my testimony today, which is based on our report released this morning for the Committee, I will discuss VA's recent progress in conducting the NVVLS and the challenges it faces in this regard.
VA's early progress on the NVVLS was slow. After the Congress mandated that VA conduct the NVVLS in 2000, VA awarded a contract in 2001 to an outside contractor for this follow-on study.
However, in 2003, before data collection for the study began, the study contract was terminated and VA's Office of Inspector General (OIG) later found that VA did not properly plan or administer the contract.
Thereafter, efforts to restart the study in earnest languished until September 2009 when the Secretary of Veterans Affairs announced that the Agency planned to award a new contract to an outside entity to conduct the NVVLS.
Since September 2009, VA has taken or plans to take a number of important steps towards conducting the NVVLS. VA convened a project team for the NVVLS consisting of VA officials and PTSD experts within VA and outside of VA. According to VA officials, the NVVLS project team developed a draft performance work statement, which outlines VA's requirements for the contractor.
VA expects to issue a request for proposals soon and select a contractor for this study this summer. VA officials say the study will be completed in 2014.
Conducting the NVVLS study is not without challenges, however. In conducting the NVVLS follow-on study, VA is required to use the same database and sample as the original study and address specific areas such as the long-term course and medical consequences of PTSD and whether particular veteran subgroups are at risk of chronic or more severe problems with PTSD.
One challenge pertains to locating prospective study participants and VA officials are unsure about how many veterans that participated in the first study will participate in the NVVLS.
The majority of researchers and methodologists we contacted—
The CHAIRMAN. I am sorry. I just cannot contain myself. You are reporting that the VA says it has problems finding these people?
Mr. WILLIAMSON. Well—
The CHAIRMAN. Any one of us can get you all the people you want. I do not understand. Well, you are not responsible, but, I can find as many veterans as you need. Ask the Vietnam Veterans of America. They will give you their list of members and you can start the study, right?
How many members do you have, Rick?
Mr. WEIDMAN. Sixty-two thousand.
The CHAIRMAN. I can find them in 5 minutes so I do not know why the VA has so much trouble. This idea that the study can’t start until 2014 is because they are having a study of how to do the study. This is just ridiculous. I think we should end it all and just give everybody their benefits.
Mr. WILLIAMSON. And I am just reporting what VA told us.
Well, the majority of researchers and methodologists that we contacted within and outside of VA said that while locating participants from the first study is a formidable challenge, it is doable. They offered a number of suggestions such as data sources and methods that could be used.
Another challenge involves gaining consent from prospective participants. Virtually all researchers and methodologists we contacted thought it was important that NVVLS participants receive assurances of confidentiality as a condition of participating.
However, VA has not yet given such assurances and plans to take possession of all data including data identifying participants at the conclusion of the study.
VA officials said that participation in the study will not affect participants' VA benefits or VA health care.
The bottom line is that VA officials told us that they do not know whether the NVVLS can be completed given the challenges they face.
During the initial phase of the study, VA expects the contractor ultimately selected to assess the feasibility of the NVVLS. In doing so, we believe it is critical that the contractor and VA thoughtfully address the challenges that VA has told us about and thoroughly assess potential ways to mitigate them.
What is clear is this. Virtually all the experts with whom we had detailed discussions agreed that starting and completing the NVVLS soon is important not only because potential participants are aging but also it provides insights for treating PTSD not only for Vietnam veterans but for future generations of veterans as well.
Mr. Chairman, that concludes my remarks.
[The prepared statement of Mr. Williamson appears in the Appendix.]
The CHAIRMAN. Mr. Stearns just pointed out that all my anger management sessions have been destroyed by your testimony.
Mr. Hall?
OPENING STATEMENT OF HON. JOHN J. HALL
Mr. HALL. Thank you, Mr. Chairman and Ranking Member Stearns.
And thank you to our panelists for your testimony.
I would like to join the Chairman in praising the efforts of two Vietnam veterans whose brave actions this weekend saved many lives in Times Square. Today Duane Jackson and Lance Horton are once again heroes and true examples of the remarkable character of the men and women who wear the uniform of our country.
I have the honor of representing Mr. Jackson in Congress and I am sure that I join everyone here today in extending our thanks to him and Mr. Horton for choosing action over inaction. And that is what our soldiers and veterans have been trained to do and their quick thinking as well.
The subject before us today is vitally important. The war in Vietnam may have ended 35 years ago, but Vietnam veterans have not stopped suffering at that point. They continue to this day. And the fact that we need to have this hearing speaks to the inaction, the decades of inaction, dishonesty, and willful ignorance regarding the devastating impacts of both Agent Orange and PTSD.
It is clear that we need more research on the long-term health effects that were suffered by Vietnam veterans. I commend the work of the Institute of Medicine, especially their recommendations last year that found three new diseases that are associated with Agent Orange. This will help thousands of sick veterans access the health care and benefits that they deserve.
Unfortunately, I also find these reports to be limited because they only consider existing research. VA bills itself as a world-class health research institution. Why is VA not directing more of its resources or sponsoring independent research to study the full impact of the health crisis the U.S. Armed Forces created for its own servicemembers, our fellow citizens?
In 1991, Congress established guidelines for the VA to determine scientifically if a particular illness or disorder is associated with Agent Orange. In a claims system that is supposed to be nonadversarial, Congress tilted the standard of proof even further in favor of veterans. However, Congress was not able to slay the one enemy that still plagues our vets and that is inertia.
By not mandating new research focused on the health impacts of Agent Orange, Congress gave the VA the means to stall benefits for thousands of veterans. I think it is time for Congress to revisit that decision and also to acknowledge and for the VA to acknowledge that Agent Orange exposure goes far beyond those who set foot on Vietnamese soil, which is why I support the Chairman's Blue Water Bill, H.R. 2254, an important step in the right direction.
Veterans who served in Guam, Thailand, and even air bases in the U.S. may have been exposed to toxic herbicides. Establishing their exposure might be difficult, but we owe it to them to raise this issue.
I strongly support restarting the National Vietnam Veterans Longitudinal Study 8 years after Congress mandated it. I am interested in learning the VA's response to the GAO findings.
And this weekend, I was reminded of the hurdles still facing veterans with PTSD. There was an Associated Press story that took a tiny sample of fraud cases and blew them out of proportion in my opinion to imply that it is too easy for veterans to obtain their benefits for PTSD. I suspect that many in this room would find that laughable. And, of course, the opposite is true.
Just this week, I sat down in my district and spoke with a Vietnam veteran, sat at his kitchen table and talked about his case which dragged on for years until my office got involved, at which point we were quickly able to get him 100 percent disability rating for PTSD from his service in Vietnam four decades ago.
While I am proud to help him, Mr. Berkowitz had earned those benefits and it is unacceptable that he had to wait so long and also that he had to come to his Congressman to get that help.
The VA should automatically have a system for granting reasonable claims without having to have a Congressional office get involved because there is not enough of us to do that work. Congressmen are not going to solve the claims backlog personally by taking on every one of these hundreds of thousands of cases. It has to be done by the VA.
So the topics covered here are extremely important. And I have used most of my time in a statement, which I will end and just ask a question perhaps for each of our panelists and submit more questions in writing if that is acceptable.
[The prepared statement of Congressman Hall appears in the Appendix.}
Mr. HALL. I would like to ask your opinion on the VA's proposed rule change to create a presumption of service-connected disability for veterans diagnosed with PTSD, which I have a bill, H.R. 952, which just passed this Committee unanimously and is waiting for floor action. And the VA has proposed to do a rule change that would accomplish much of the same thing.
Do you believe that these changes are supported by the statistical evidence and the NVVRS and other studies? Dr. Fenske?
Dr. FENSKE. Well, I am afraid I have not really studied that area of the mental health aspects, so I would defer to Dr. Marmar.
Dr. MARMAR. It is a difficult area. I would say in overview, the available evidence suggests that the large majority of Vietnam veterans when asked about either their symptoms of psychiatric distress related to PTSD, nightmares, flashbacks, startle reactions, or their actual details of their war-zone experience, where they served and what they were exposed to in combat in the theater, that the vast majority are truthful in their reports.
Second, I think it should be emphasized that while occasionally there may be individuals for whatever reasons who dramatize their suffering following combat exposure, there is also a large number of men and women who serve in the military and in other important roles in our society who are reluctant to disclose their psychiatric problems because of reasons for stigma.
So, in fact, the dangers of under-reporting of psychiatric distress may well be greater than the dangers of over-reporting. So in general, I would say the majority of people seeking compensation do so for truthful reasons.
Mr. HALL. Mr. Chairman, if Mr. Williamson could answer, then I would yield back.
Mr. WILLIAMSON. I cannot address that. I am not up on that issue.
Mr. HALL. Thank you.
The CHAIRMAN. Thank you, Mr. Hall.
Mr. Stearns?
Mr. STEARNS. Thank you, Mr. Chairman.
Dr. Fenske, when we start talking about threshold of benefits, the criteria that is used involves a couple of statistical associations. And I just think the Committee needs to understand those thresholds and this goes to a little larger question when the Chairman says he would like to get everybody who is suffering have the benefits, but I think there should be some threshold level at which we understand whether a veteran is qualified.
Can you explain the difference between a "significant statistical association" and a "positive association" and a "sufficient association?" These evidently are statistical terms that are used to determine the threshold. And I would like you to explain that briefly, I only have a small amount of time, as it relates to the presumption of service-connection for herbicide exposure. Does that question make sense to you?
Dr. FENSKE. Yeah.
Mr. STEARNS. Can you pull the microphone a little closer to you too?
Dr. FENSKE. Yes. I should turn it on too.
Mr. STEARNS. Yeah. Turn it on. That is the problem, yes.
Dr. FENSKE. Threshold, well, yes. So in terms of the categories that we use, these were, it is on here, but—well, I will just speak up—established by the first Committee back in 1992. And we have used them. I think they have held up very well. They are very similar to the categories that are used by the International Agency for Research on Cancer, which has to classify chemicals.
Mr. STEARNS. Can you just hold and find out what the problem is.
The CHAIRMAN. We are going to try to fix the microphones.
Mr. STEARNS. Mr. Chairman, perhaps I can put this into a way that you can answer yes or no.
Should these three statistical things be continued to be used as thresholds or are they obsolete? In other words, when you talk about a significant statistical association, are these sufficient now to determine a threshold or should they be sufficient, some additional statistical—I guess I am trying to understand. Do we have in place the right thresholds? That is the question. Yes or no?
Dr. FENSKE. Well, I think the categories we are using are the right categories, yes. As far as determining whether or not there should be benefits associated with a disease that is put in one of those categories, that is up to the VA. That is not part of the Institute of Medicine’s charge.
Mr. STEARNS. So you say these thresholds are the problem? Are they working?
Dr. FENSKE. Yes.
Mr. STEARNS. Does someone have to make a subjective interpretation or is it very quantitative that comes from the statistical? Is it something that when I see it, I know it and it means something or is it very subjective?
Maybe the other panelists would like to help us out. It is a rather technical question. What I am trying to understand is if it is subject to luck?
Dr. FENSKE. In a particular study, we review many, many studies, and in any particular study, it is very quantitative. We talk usually about relative risk and confidence intervals and this provides us with evidence essentially yes or no as to whether a study demonstrates an association.
When we do our evaluation, we look at many studies and so we look at combinations of studies and we look at weaknesses in studies. So those judgments can be qualitative. So there is a mixture of quantitative and qualitative.
Mr. STEARNS. Okay. Thank you.
Mr. Chairman, I would probably just request additional time just because the speaker went out if you do not mind.
Dr. Marmar, how satisfied are you with the VA's recently announced plans to complete the longitudinal study after sort of the failure there as required by law and do you believe that they will meet the established timeline?
Dr. MARMAR. Well, it is difficult for me to answer that question on behalf of VA. Perhaps that is a better question for Dr. Kupersmith to address in his role in directing research at VA.
But as someone who has spent the last 13 years as the Chief of Psychiatry at the San Francisco VA and now is outside of VA, but following this with great interest, I would say that moving forward at this point along the lines that has been suggested by yourself and the Chairman is the right thing to do. It is realistic. The contracting can be accomplished.
And none of the obstacles that have been raised at this morning's discussion, whether locating subjects, guaranteeing confidentiality, or other aspects, none of those are obstacles that would prevent the timely conduct of the study.
So the short answer is it is feasible to do the study. It is urgent to do the study and the time frame for doing the open contract and accomplishing the goal by 2014 appears reasonable to me.
Mr. STEARNS. Dr. Marmar, I am just looking from the outside. It looks like 2014 is too long. I mean, they started the study. They stopped it. They knew what the objectives were. They know what the problem is.
Why would it take 4 years to do a study in your opinion? I guess a larger question is, could we do it in a shorter amount of time than 4 years?
Dr. MARMAR. It is possible to fast track it. I would say—
Mr. STEARNS. Not fast track it. I mean, it seems like 4 years is 4 years and they have all the data. And they also have been through one race on this and they did not accomplish it.
Dr. MARMAR. Some work was accomplished during that time.
Mr. STEARNS. Yes. So they can build on whatever they had.
Dr. MARMAR. Yes. I would say to implement this study, to complete all of the human subjects' requirements for this study, to locate and evaluate all the subjects, to make the important—
Mr. STEARNS. So the bottom line is you think they need 4 years?
Dr. MARMAR. I think if the study is to be comprehensive with regard to both the psychological and most importantly adverse physical health effects of serving in Vietnam, it will take 2 to 4 years.
Mr. STEARNS. Okay. Okay. Mr. Chairman, I think the Committee should get a report in less than 4 years, that we find out what they are doing, a draft form of some report. I do not think we should wait 4 years to see what happens. Just my suggestion.
I would like to ask Mr. Williamson my last question.
Mr. Williamson, you know, you are with the U.S. Government Accountability Office. What is your opinion? Do you think the VA can meet the challenges they face with this longitudinal study and can it be accomplished in 4 years or give me your feeling on some of what Dr. Marmar—
Mr. WILLIAMSON. Well, we contacted ten researchers and three methodologists who are experts in PTSD and experts in doing studies of this nature. And, yes, they think that all the challenges that the VA told us about are not insurmountable. There are ways to do the study.
It takes a can-do attitude. And, quite frankly, until recently I do not think VA has had the will to do it.
Mr. STEARNS. So you are saying that VA did not have a "can-do" attitude? Is that what you are saying?
Mr. WILLIAMSON. Well, I mean, it has been 10 years since the law passed.
Mr. STEARNS. That is your perspective. I mean, somebody has got to say something here.
Mr. WILLIAMSON. Yes.
Mr. STEARNS. And do you think that has changed?
Mr. WILLIAMSON. I think under—
Mr. STEARNS. What has happened that made a change?
Mr. WILLIAMSON. I think under the new Secretary, it appears that it has.
Mr. STEARNS. And what has happened to make a change in your opinion?
Mr. WILLIAMSON. I think coming to the Committee for one and getting Chairman Filner to—
Mr. STEARNS. Okay. Yeah.
Mr. WILLIAMSON. Yes.
Mr. STEARNS. I would just urge that the Committee ask for an interim report so that we do not sit here dumbfounded in 2014.
The CHAIRMAN. I am sick of the reports since they are rarely ever completed on time. The question really is, how many people will die between the interim and the report? This has gone on forever.
Mr. Rodriguez?
Mr. RODRIGUEZ. Thank you, Mr. Chairman.
I want to also congratulate you on staying on this subject and for moving forward. This just brings to light the need to do additional areas of study.
I know one of the things that has concerned me is the numbers, and I have some friends included in this, that when they came back from Vietnam, they got involved with drugs and part of it, I assume, was, due to self-medication because of what they were dealing with, and I would hope that maybe we can also look at additional studies and assessments as to how deal with this.
Additionally, I really believe we might have a case here, and although I do not have any proof of this, I would like to know if in the future, Mr. Chairman, we could look at how many of our veterans may have gone into our prison system, because of the use of drugs.
Second, and I do not know if any of you might want to comment; however, I know we have some new veterans coming home with the onset of PTSD now, as compared to those that have had it for 20 or 30 years. As said I would like to see if there are any different approaches to treatment that we could come up with that respond to this immediate onset in PTSD that might be helpful versus the approaches used for those individuals that have been suffering from PTSD for 20 or 30 years, for example.
And if there are any of these studies doing this and, if not, I would like to see how we might approach this and be able to reach out more veterans and even put more resources in this area and get independent groups to do it and maybe not the VA, but other groups to do these studies separate from the VA. I believe this is, something that might make sense from a research perspective.
I was wondering if any of you would make any comments.
Dr. MARMAR. Yes, briefly. The NVVLS would not be primarily directed at the development of new treatments. It would make an assessment of which treatments may have been helpful or not over the course of Vietnam veterans’ lives with PTSD.
Congressman, to answer your question briefly about there are major advances in the understanding and treatment of combat-related PTSD which need to be and are being delivered to Iraq and Afghanistan veterans, as well as those from other eras suffering from the more chronic form.
And in particular, there is research supported by VA, U.S. Department of Defense (DoD), and the National Institute of Mental Health to try to develop new treatments to help people at the time of battlefield exposure, to help them more quickly calm down so as they do not develop the chronic stress condition.
And, second, we now have safe and effective medications and behavioral treatments for treating PTSD in the first months after it occurs. To the extent that those are provided, we can prevent a lifetime of mental health disabilities.
Mr. RODRIGUEZ. Now, because you are not directly treating those soldiers that are out there, because you do not get to them until after they leave the military, what do we need to do to get to them since you indicated the research indicates the quicker we get to them, the better? Is that what you said?
Dr. MARMAR. Yes. That is what I am saying. And this involves—
Mr. RODRIGUEZ. How do we get to them since they are not with the VA at that point?
Dr. MARMAR. Right. Well, the DoD and the VA are in a partnership to answer that question. There has been a recent DoD Blue Ribbon Panel to try to answer that question and to develop best practices for how to manage combat stress and other problems in theater before the war fighters even become veterans.
Mr. RODRIGUEZ. I really would want for you to offer with the recommendations on this because serving 8 years on the Armed Services Committee, I know how a military leader or military person thinks and to them this might be secondary in terms of providing this support—their main goal is the mission and sometimes providing this access to the need of those soldiers might not necessarily be there.
This is very important for us to get as it points to what we might need to do from a Congressional perspective in this specific area. So I would, ask you to please get this to us.
And especially there is a need to do some, I hate to say this, additional studies here, but if that is the case or t
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