May212013
Hearing Transcript on Veterans at Risk: The Consequences of the U.S. Department of Veterans Affairs Medical Center Non-Compliance.
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VETERANS AT RISK: THE CONSEQUENCES OF THE U.S. DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER NON-COMPLIANCE
FIELD HEARING BEFORE THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED ELEVENTH CONGRESS SECOND SESSION JULY 13, 2010 SERIAL No. 111-90 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
LBRAY, California |
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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
July 13, 2010
Veterans at Risk: The Consequences of the U.S. Department of Veterans Affairs Medical Center Non-Compliance
OPENING STATEMENTS
Chairman Bob Filner
Prepared statement of Chairman Filner
Hon. Jeff Miller
Prepared statement of Congressman Miller
Hon. Russ Carnahan
Prepared statement of Congressman Carnahan
Hon. Roy Blunt
Hon. Jerry F. Costello
Prepared statement of Congressman Costello
Hon. John Shimkus
Prepared statement of Congressman Shimkus
Hon. Wm. Lacy Clay
Prepared statement of Congressman Clay
Hon. W. Todd Akin
Hon. Blaine Luetkemeyer
WITNESSES
U.S. Department of Veterans Affairs, Hon. Robert A. Petzel, M.D., Under Secretary for Health, Veterans Health Administration
Prepared statement of Dr. Petzel
American Legion, Barry A. Searle, Director, Veterans Affairs and Rehabilitation Commission
Prepared statement of Mr. Searle
Johnson, Earlene, St. Louis, MO
Prepared statement of Ms. Johnson
Maddux, Susan, Festus, MO
Prepared statement of Ms. Maddux
Odom, Terri J., Imperial, MO
Prepared statement of Ms. Odom
SUBMISSIONS FOR THE RECORD
Hare, Hon. Phil, a Representative in Congress from the State of Illinois
McCaskill, Hon. Claire, a United States Senator from the State of Missouri
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
VETERANS AT RISK: THE CONSEQUENCES OF THE U.S. DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER NON-COMPLIANCE
Tuesday, July 13, 2010
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 1:04 p.m., in the En Banc Courtroom of the Thomas F. Eagleton U.S. Courthouse, 111 South 10th Street, St. Louis, Missouri, Hon. Bob Filner [Chairman of the Committee] presiding.
Present: Representatives Filner and Miller.
Also present: Representatives Carnahan, Costello, Clay, Blunt, Shimkus, Akin and Luetkemeyer.
OPENING STATEMENT OF CHAIRMAN FILNER
The CHAIRMAN. Good afternoon. This is an official hearing of the U.S. House of Representatives Veterans' Affairs Committee. I'm the Chairman of the Committee, Bob Filner from San Diego, California. The Ranking Member for this hearing is Mr. Miller from Florida.
Thank you, Mr. Miller, for joining us.
Mr. MILLER. Uh-huh.
The CHAIRMAN. I'm glad to see all of you, but this is not the kind of occasion which merits any celebration. I appreciate everybody's interest in looking into the sad and tragic events that occurred here in St. Louis with the oversight responsibility of Congress.
I ask unanimous consent, Mr. Miller, for Mr. Carnahan, Mr. Costello, Mr. Blunt, Mr. Shimkus, Mr. Akin, Mr. Clay, and Mr. Luetkemeyer to be invited to join us for the full Committee hearing today.
Hearing no opposition, we welcome all of you. This is a very large delegation of Members of Congress who are not on the Committee. They are here because of the importance of the issue, so we thank you all for being here.
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 do want to thank the staff of the Thomas F. Eagleton Courthouse for their generosity in providing the space for us at today's hearing. We are all here because we are concerned about what happened with the dental clinic and the dental equipment at the U.S. Department of Veterans Affairs (VA) Medical Center in St. Louis.
As a result of the lapse in the protocol for cleaning dental equipment, more than 1,800 veterans have been put at risk, risk for having been exposed to hepatitis B, hepatitis C, and HIV (human immunodeficiency virus).
On behalf of all of us, we want to make sure you know how bad everybody feels about this situation. We want to apologize to the citizens of St. Louis for putting them through this very tragic situation. The probabilities of infection in this situation are low but they are there, and that puts families and the whole community at risk.
We are not only sorry for the citizens of St. Louis, but we are outraged that this could occur when we are dealing with the veterans of our Nation—those who we always pay the highest honors, respect, and gratitude for their service—and now in our own medical system they have to face these risks.
We want to get to the bottom of the events both leading up to the lapse in protocol for cleaning the equipment, and in the examination of the steps that VA officials took once they learned of this incident, and evaluate whether they have been effective in providing timely information to our veterans.
I'm also very concerned with what I see as a lack of transparency. Members of Congress were not informed until the matter became public. I came off a plane from San Diego to Washington and Congressman Carnahan approached me in the cloakroom of the House of Representatives and said, "Have you heard what went on here in St. Louis?" I was very embarrassed because I had not heard.
I want to especially thank Congressman Carnahan for being on top of this and making sure all of us were aware of what was happening, because the information did not come to us from our Executive Branch—as it should have.
Thank you again, Mr. Carnahan, for being on top of all of this so quickly, as were all of you from both Missouri and I guess they say "across the river" here, don't they?
When mistakes are made, the only way to deal with them, in our view, is through honesty and truthfulness. You have to do that to make sure you have the trust, and in this case, I think we have to rebuild the trust with the public.
How are we going to make sure that not only this doesn't happen again in terms of the actual cleaning of the instruments, but of the way the public was informed and treated with that information? Accountability is our bottom line here. We want to see who was at fault and what accountability measures will be taken to deal with that.
We are going to hear from veterans who were treated at the clinic and who have received the letter that says they are at risk. We want to understand their situation, their fears, and their questions while they are dealing with this.
Unfortunately, I have to tell the audience this is déjà vu all over again. We've had this kind of problem in other places, and each time we are told it won't happen again. In December of 2008, we had improper reprocessing of endoscopes, which put thousands of veterans in Tennessee and Florida at risk of hepatitis and HIV. In February of 2009, another 1,000 veterans in Augusta, Georgia, received notification that they were at risk for hepatitis and HIV because of ear, nose and throat endoscopes that were not cleaned properly. Just last week, Mr. Miller, in your State, another 80 or so veterans were notified that they were at risk. Clearly, we have some problems here and I don't think we've remedied them when they keep occurring.
I just want to raise some issues, which my colleagues then will take up, with the timeline of this whole thing.
Dr. Petzel, when you get here on your panel, I hope you will respond to this.
When you look at the timeline for what occurred, apparently the procedures were not being followed for a whole year, between February of 2009 and March of 2010. They were discovered in a routine inspection but if your routine inspections find things that have been going on for a year, there is something wrong with that routine inspection. Why do we only find out after a year of this going on? It seems to me that this has to be an ongoing issue. But whatever you do, Dr. Petzel, in the VA there has to be more rigorous and more regular inspections. If they take place quarterly or bimonthly, we can't let things go on for a year.
When they discovered this in March of this year it took until May for the VA to put together a Clinical Risk Assessment Advisory Board to look at the risk. That's 2 months after they first discovered this.
I don't understand that at all. I think what should have happened when the risk was discovered was to announce it. Stand here with the Governor of the State, with the Members of Congress, with the Senators. Let's stand here and say, look, this has occurred and we are investigating it. All of the veterans who visited the dental clinic in the last year had better come in right away for some tests.
Two months go by and they call a board, who decided, as I understand it, Dr. Petzel, that the risk was sufficiently high—it wasn't zero—and they said we ought to notify everybody who was there at that time. That took another 2 months. On June 28th, the letters went out and they had their meeting on May 6th.
This is a serious issue. To allow that kind of waiting period and I know there is a cautiousness, but you are dealing with potentially fatal diseases of hepatitis B and C. We know the horrific consequences of HIV. You had 4 months where people could have given blood to your blood bank because they didn't know it wasn't safe or potentially unsafe—not to mention any sexual behavior. People might have changed their behavior had they known there was a risk. They didn't even know about it. I think that's intolerable, that it took that 4 months before anybody was notified.
As Congressman Carnahan points out, the letter that was sent out seemed a little cold. You have the option of being tested. Call up our 800 number. Now, I hope that 800 number is being staffed. They say 24-hours a day but we all know people who call 800 numbers and are on hold for hours, or somebody answers that doesn't even know what they are talking about.
I was going to call the 800 number this morning but I didn't have time. I was flying here but I wanted to see how they would actually respond to somebody. I hope they are responding.
I will tell you if you have 1,800 people with serious risk, I would have called in 1,800 VA employees—we have 250,000—and said, each of you is responsible for one of these veterans. Make sure you call them, counsel them, and give them the emotional support they need. Advise them of what the tests mean and when they are going to happen, and provide them with information about follow-up tests.
If you can't have one-on-one, call in 600 VA employees and put three to one, or call in 300 and make it 6 to 1. As far as I understand it, we sent out these letters and the veterans are supposed to call in. Maybe we are following up, but I doubt if we are following up the way a case worker would where they track down these veterans. Such as address changes, phone number changes, etc. You've got to track people down. You've got to find them, and you've got to hold their hands and make sure they understand what's going on. We are not doing that. We are just not doing it. They are not only American citizens, they are our veterans.
It seems to me that we have to do a far better job not only in the transparency of a mistake, but then in counseling and helping people. I think we will have a panel on this. Even if you get a negative test for HIV, you are not always sure it's really negative. You've got to re-test 6 months later, but I'm sure somebody could testify to the exact process. We are going to have to stay with these people and be with them long term.
We owe it to them. They have fought for our Nation and we cannot let them just wander around, call up an 800 number, figure out when a test is going to be, and then maybe they will hear about it in a few weeks. Somebody has to be responsible for each of those 1,812 people. That's how I'm looking at this.
Mr. Miller, I appreciate, again, you coming from Florida to be with us to make this an official hearing as we need two Members of the Committee present, and I thank you for your commitment to our veterans that you have shown for all of your career in Congress.
You are recognized.
[The prepared statement of Chairman Filner appears in the Appendix.]
OPENING STATEMENT OF HON. JEFF MILLER
Mr. MILLER. Thank you, Mr. Chairman.
I, too, share the anger and the frustration that you hear in the Chairman's voice. He has already recognized those Members that are here.
I do want to specifically mention one that could not be here because of a scheduling conflict, and that was Congresswoman Jo Ann Emerson. She does have a staff member here today.
And I, too, want to say that when this first became public, Roy Blunt and I had a very serious conversation in our cloakroom and he has sent a letter to Secretary Shinseki asking very pertinent questions. And I hope that today we will get the answers to some of those questions without waiting on a response from the Secretary.
But suffice it to say that we have had incidents like this all across the country. There are dedicated VA employees out there and we salute them, but mistakes like this have happened over and over and over again and as the Chairman said, Florida just had another incident that had been notified to the Congressional delegation in Miami.
The problem I have is that every time we have a hearing on one of these incidents, the VA comes forward and says, "We are putting in new procedures, new controls. It's not going to happen again." But it happens again and again and again. And unfortunately, I would have to say that promises from VA in issues such as this ring very hollow, and that is not something that we would expect from anybody in government, least of all, those from within the Department of Veterans Affairs.
I've got a lengthy statement and I want to ask that it be entered into the record because there are so many of my colleagues here who have a vested interest. I represent the First Congressional District in Florida, which is Pensacola to Destin, and I have the most veterans of any Congressional district in the country in my Congressional district.
I specifically asked to be on this Committee when I came to Washington in 2001 because I wanted to make sure that the veterans of our Nation were getting the care that we, as Americans, have promised to those who have borne the battle and worn the uniform of this country.
But without further comment, I would like to ask again that my statement be entered into the record without objection.
[The prepared statement of Congressman Miller appears in the Appendix.]
The CHAIRMAN. Thank you. Thank you, Mr. Miller.
As I said, Congressman Carnahan from St. Louis has been on top of this from the beginning and has acted as our liaison for knowledge. We thank you for all the work you have done and you are recognized for an opening statement.
OPENING STATEMENT OF HON. RUSS CARNAHAN
Mr. CARNAHAN. Thank you, Mr. Chairman, and to Mr. Miller for being here traveling from Florida, as well. For my colleagues from both sides of the aisle and both sides of the river, we thank you for being here.
Mr. Chairman, your prompt response to the request of myself and Congressman Clay to hold these field hearings in St. Louis and to formally begin this Congressional investigation into how our veterans were put at risk by the safety lapses at Cochran Medical Center.
Since we learned early this month that veterans throughout St. Louis and Illinois could have been exposed to blood-borne pathogens such as hepatitis B, hepatitis C, and HIV while receiving dental care at Cochran, I've heard from many constituents, veterans and their families who are gravely concerned about this matter.
After their service to our country, this is not a fight our veterans should face. They deserve answers to this dental debacle, and relevant quality personnel and management questions. They deserve the best care available in our country. On behalf of the veterans that I am honored to represent, I'm here to demand answers and action to make this right.
From where I stand, there are five core issues that I would like to see addressed here today. First and foremost, those 1,812 veterans who received that cold letter in the mail just a few weeks ago, to be sure they are getting the special care and follow-up they need.
Second, we need clear answers on how this happened and how it could have gone on for so long uncovered.
Third, I'm determined to get to the bottom of whether an employee of the medical center was terminated, in part, because she raised concerns about the sterilization procedures as far back as August of 2009. And I have to say any sign of retaliation or intimidation of employees throughout this process should not be tolerated and needs to be reported immediately.
I want to know what concrete steps are being taken to reach out to current and former employees, to be sure they are providing the necessary information to be sure we get to the bottom of this. We must make sure employees who have information that is relevant to this matter or any other problem are not only aware of their rights, but are encouraged to come forward and cooperate.
Fourth, I want to determine whether this latest incident at the dental clinic is limited to that incident or is part of a larger systemic problem at this facility. The VA Medical Center has been cited for serious infractions, which leads me to suspect there may be broader issues that need to be addressed. In April of 2010, the VA Office of Inspector General (OIG) conducted an inspection to, "Determine the validity of allegations regarding ongoing issues with the Supply Processing and Distribution (SPD) departments related to reprocessing endoscopes. The inspectors found that the SPD department did not have defined clean and dirty areas and there was severe communication breakdowns between staff regarding proper reprocessing procedures.
Moreover, in the 2009 Survey of Health Expectancies of Patients, the VA approved Patient Satisfaction Survey that tracks satisfaction responses from inpatient and outpatient veterans showed that Cochran scored the lowest score out of 128 VA hospitals around the country in inpatient services. A score of 46 percent is unacceptable.
And lastly, and most importantly, we need action. We need to determine what next steps need to be taken to restore and rebuild the faith of our veterans.
Let me be clear. This should not be an exercise to paint with a broad brush in a negative way our Veterans Administration or our health care services. As was said earlier, there are many professional and committed people that work in the VA. They should be commended and there are some important quality measures that we should all be proud of. But there is broad acknowledgment that serious mistakes have been made and there is much work to be done.
This past week I met with a group of 30 veterans, many on my Congressional District Veterans' Advisory Committee. There was a strong belief in the quality of care, but also a deep concern about these recent problems. At the end of the day it's critical the VA identify and rectify any existing problems, make sure this never happens again, and takes actions needed to rebuild our veterans' shaken confidence.
To all the witnesses here before us today, thank you for being here to appear before us to get to the bottom of how this happened, to help us determine the answers, reforms and actions that honor our veterans with health care they earned and that they deserve and that is the best.
Thank you, Mr. Chairman, and Mr. Miller.
[The prepared statement of Congressman Carnahan appears in the Appendix.]
The CHAIRMAN. Thank you, Mr. Carnahan. Thank you for putting that so clearly before us.
Mr. Blunt, you have shown your commitment to veterans here during your time in Congress. We thank you and thank you for being here.
You are recognized.
OPENING STATEMENT OF HON. ROY BLUNT
Mr. BLUNT. Well, thank you, Mr. Chairman, and thank you for being here. Thank you and Congressman Miller for taking time to call attention here in St. Louis where we have the most access to witnesses. And our staff, some of our staff was in the facility again yesterday to talk to people at the facility. I thank both of you for being here.
You know, recently I've had a chance to speak at the annual meeting of both the Veterans of Foreign Wars (VFW) in Missouri and the American Legion, and at both of those meetings I told them that of all our obligations as a country, at the top of the list of obligations is our obligation to our veterans. It should be a priority for us. I know it's a priority, Mr. Chairman and Mr. Miller, for your Committee. And thanks for your good work on this Committee.
Most of what needs to be said here we are going to hear from the witnesses, and I would just share my sense that one of the questions are, how could 1,800 people have been exposed to this risk over such a long period of time? How does this go undetected, or perhaps even detected and ignored? That's a possibity that's been raised here today.
Secondly, as the Chairman pointed out, how can we wait from March until almost July to notify people?
And then third, the callousness of that notification all were unacceptable. All were unacceptable.
If, as the Chairman suggested, as Mr. Costello has told me about an event in his district in recent years, this is déjà vu over again, it's unacceptable all over again. And Mr. Chairman, Yogi Berra, who is one of the most famous given credit for that comment, grew up just a few blocks from here. And he grew up in a country that understood its obligation to those who fight for freedom, and to those who are willing to fight for freedom. And that's what your Committee focuses on. That's why we are all so upset about this problem.
And you know, I've heard even earlier today, that some unsophisticated person getting this notice would be scared by it. My view is the more you know, the more you would have been scared by it. And the notice was unacceptable the way it went out, and apparently it's the way the VA always deals with these issues. And this is at the top of our list of obligations.
And Mr. Chairman, again, thank you for drawing attention to this in a way, hopefully, that will make the future problems like this dealt with in a better way, and make this problem dealt with in a better way from now until every single veteran, and their family who is affected by it, is beyond the impact of it and hopefully and prayerfully all beyond the impact of that in a positive way.
And I give it back.
The CHAIRMAN. Thank you, Mr. Blunt.
Mr. Costello, you are our senior Member here today. We thank you for all of your years of service and commitment to veterans.
You are recognized.
OPENING STATEMENT OF HON. JERRY F. COSTELLO
Mr. COSTELLO. Mr. Chairman, thank you. And I want to thank you for calling this hearing here in St. Louis on very short notice.
I thank Mr. Miller for traveling here today from Florida to participate in the hearing. And let me just say that I have a lengthy statement that I will enter into the record so that we can continue with our witnesses. We have three panels.
But let me say that we are here to get answers. I think Mr. Carnahan outlined what some of the questions are. We have 1,812 veterans who have been put at risk. Three-hundred seventy of those veterans live in the Congressional district that I'm privileged to represent.
It's an absolute outrage that this happened, given that this is not the first time that this has happened. You outlined in your statement, and Mr. Miller made reference to, the fact that over 10,000 veterans were put at risk in Tennessee, Georgia and Florida. And as a result of that, these veterans now here in St. Louis know that they have been exposed but they do not know if they have life-threatening diseases as a result of this.
This Committee held a hearing, at my request, in 2008 as a result of what happened at the Marion Veteran's Hospital in Marion, Illinois. In 2007, nine veterans died as a result of substandard care at the Marion Veterans' facility. How many veterans have to be exposed and put at risk? How many veterans have to die before the VA gets it right?
Let me say that, finally, as Mr. Carnahan pointed out and others, the vast majority of the employees at the VA facility in Marion, Illinois, are outstanding, dedicated employees. It's the management that was at fault. It was the lack of aggressive oversight that was at fault.
And finally, in addition to the questions that Mr. Carnahan and you raised, Mr. Chairman, I want to know if, in fact, anyone is going to be fired as a result of this, as opposed to reassigned or located somewhere else. That happened in Marion. As opposed to firing the Director, they just reassigned him to another facility.
So I want to know what action is going to be taken to the people who are identified that, in fact, both in the Administration and the on-line employees, that are responsible, I want to know what's going to happen there. Are they going to be pushed to another facility or are they going to be fired?
I think it's about time that agencies like the VA start firing individuals that do not do their job. And that may send a message out to everyone throughout the entire Department that, in fact, your job could be in jeopardy if you do not follow proper procedures.
And with that, Mr. Chairman, I thank you and I look forward to asking questions of our witnesses.
[The prepared statement of Congressman Costello appears in the Appendix.]
The CHAIRMAN. That you so much, Mr. Costello.
Mr. Shimkus, you've joined us from across the river, too. Thank you for being here.
OPENING STATEMENT OF HON. JOHN SHIMKUS
Mr. SHIMKUS. Thank you, Mr. Chairman. And I appreciate my colleague Congressman Miller coming up from Florida, and of course my good friend, Jerry Costello, who has already weighed in on the issues that we dealt with at the Marion VA.
And I'm sure the folks out in the audience are hearing these stories and they are saying, why are we continuing to put up with this stuff? And so I knew you would probably elaborate that.
We need to know who knew what, and when, and then we need to do, as Jerry said, when are we going to hold someone accountable? When, in a big Federal agency, are we going to start holding people accountable for in essence dereliction of duties?
There is a cultural issue here. There is a cultural issue that we've dealt with in Marion and we've dealt with in other States that has to be changed. I was on a major radio station this morning in the St. Louis area and I had a, one of the call-ins was a veteran named Jason and he said, you know, I visit Cochran and I can't get the Patient Advocate to talk to me. Now, here is a veteran who called in to a talk show to let me know that there is more of a problem than just this.
I have a long-established relationship with Secretary Shinseki and I'm very biased in my high regard and my opinion of him, and my faith, and my trust. If he needs tools to separate the wheat from the chaff, then we need to help him get those tools. And it's unfortunate that we are here.
I welcome my colleagues to the bi-State area and I apologize to the veterans who have been affected on not only this but on other issues. And I think you've heard from the voices of my colleagues that we are going to continue to stay on-focus on this and start demanding change from the Veterans Administration.
Thank you, Mr. Chairman. I give it back.
[The prepared statement of Congressman Shimkus appears in the Appendix.]
The CHAIRMAN. Thank you, Mr. Shimkus.
Mr. Clay, again, you've been on top of this from the beginning. We appreciate your commitment to St. Louis and welcome.
OPENING STATEMENT OF HON. WM. LACY CLAY
Mr. CLAY. Thank you, Chairman Filner and Ranking Member Miller, for holding hearing and for inviting me to join the investigation regarding John Cochran St. Louis VA Medical Center, which I represent in Congress.
Today we will examine and hopefully learn the truth about the improper processing of dental instruments, including a failure to clean dental equipment with a special detergent before it's sterilized.
It is unacceptable that procedures were conducted from February of 2009 to March of 2010 without proper safeguards in place to protect the health of veterans receiving treatments. Making matters worse, the VA knew about the possibility of exposure in March of 2010, yet veterans were not notified of the problem until June of 2010. That is shameful and there is no excuse for withholding that information. This Nation owes an enormous debt to the brave men and women who served our country with courage and honor.
Mr. Chairman, this is about a failure to follow proper procedure, a failure of supervision, and a failure to keep faith with all the brave Americans who have defended our freedom.
The truth about this incident will be revealed in this Committee hearing, but we certainly need honest answers to some critical questions. And one is, what is the chain of command that had primary responsibility to oversee procedures at the VA dental clinic at Cochran?
Two, what was the supervisor in charge—who was the supervisor in charge and when did he or she first become aware of the failure to follow proper procedure? And how did the supervisor find out about the problem during the time that the information about the potential contamination was withheld and did anyone else know about it? Who made the decision not to disclose that information immediately?
And finally, have the individuals involved been disciplined in any way, as my colleague Mr. Costello has asked?
Mr. Chairman, I thank you for conducting this hearing, and I yield back the balance of my time.
[The prepared statement of Congressman Clay appears in the Appendix.]
The CHAIRMAN. Thank you.
Mr. Akin, again, thank you for joining us and we welcome your participation.
OPENING STATEMENT OF HON. W. TODD AKIN
Mr. AKIN. Well, thank you, Mr. Chairman. And I likewise have some notes that can be submitted for the record, but I just wanted to sort of digress a little bit and be a little more brief.
First of all, as a Member of the Armed Services Committee, I'm familiar with our soldiers. I'm familiar with their commitment, I'm familiar with their service, and also with the sacrifices that they make. And I guess it's maybe more personal. I have three sons that have been serving as Marines, and I've served in the Army myself. So what's gone on here is unacceptable.
My concern largely centers around what increasingly smells like a systems problem. I don't believe that what we've seen was a result of one or two people who failed to do their job. I believe, rather, that it is a broader organizational management kind of problem that we are dealing with, and it's also a culture that appears to be suffering from misdirected understanding of what their priorities need to be.
Just as our sons and daughters serve us, this should be a service organization and service must come first. And it appears that at a number of levels organizationally, this is just not the culture. So, and if it were just limited to this one incident, we would say, well, okay, maybe there is one location where there has been some difficulties. Maybe some management problems or whatever.
This appears to be a broader kind of problem, and so my questions are going to be particularly from a systems point of view and from a culture point of view. What are we going to do to make this time different? Because we will not, as Members of Congress, put up with lousy service when we are asking people to give even their lives, at times, for this country.
Thank you, Mr. Chairman.
The CHAIRMAN. I think you hit the nail on the head, Mr. Akin. Thank you so much.
Mr. Luetkemeyer, we welcome you. This is your first term in Congress and you are getting a great introduction to what we do.
OPENING STATEMENT OF BLAINE LUETKEMEYER
Mr. LUETKEMEYER. Thank you, Mr. Chairman and Ranking Member Miller. Thank you, gentlemen, for your service in helping to set this Committee hearing up, and in coming all the way to our beautiful part of the Midwest here.
I've got a very brief statement. I will keep it brief because I know we've got a lot to talk about today.
Commitment to our Nation, to those who fought for it, is a solemn obligation. Providing safe, sanitary health care is the least we can do for them in light of their service and sacrifice. It is absolutely unacceptable that procedures were conducted between February 1st, 2009, and March 11th, 2010, with a lapse in the safeguards in place to protect the health of veterans receiving treatment.
It is deplorable that any assistance less than the best health care available, along with possible exposure due to unsterile equipment, is the level of care being offered to our veterans. In this hearing today, we must determine what were the causes in the breach of standards and what the Department plans to do to remedy this situation to ensure that it does not happen again. Also, that we discern why, upon discovery of this problem, information was not distributed in a timely matter to impacted veterans and to other VA health facilities.
While we are here in St. Louis today, this situation impacted veterans all over the bi-State region and a number of other States. Constituents of mine in at least 12 counties were put at risk.
Finally, I will also point out that my colleague, Mr. Clay, and I are both Members of the House Committee on Oversight of Government Reform, the chief investigative Committee of the House of Representatives, and we requested that that Committee conduct a full investigation of the situation, as well. And we will look forward to that hearing and disclosure, as well.
Mr. Chairman, with that, I thank you and look forward to today's testimony.
The CHAIRMAN. Thank you.
As the first panel begins to come forward, Mr. Carnahan is going to introduce you, but I would like to make one other comment.
Panel one please come forward. Ms. Maddux?
In a July 2nd issue of the St. Louis Post Dispatch, the Chief of Dental Services at the Cochran VA Medical Center is quoted as saying, "Things are done to get votes, and that's a shame." That is, we are here today for show.
We are not here for a show. We are a bipartisan group that wants to get to the bottom of this for the, as all of you have stated, our veterans. That's our only concern here. I think that by blaming politics, it just looks like you are trying to shift the attention away from the mistakes that were made. I challenge—
Mr. SHIMKUS. Mr. Chairman, can you yield on that?
The CHAIRMAN. Of course, I will yield to you.
Mr. SHIMKUS. Just, with my colleague, Jerry Costello, so the public understands, when people die in hospital facilities like they did in the Marion VA, we have to take action. So I really find that egregious on the part of that employee to make that claim, because this is serious business. We don't take this lightly.
Thank you.
The CHAIRMAN. Thank you, Mr. Shimkus.
I challenge the Chief of Dental Service, in fact, I challenge all of you who are here on behalf of the Department of Veterans Affairs, to take responsibility for this disgraceful incident and show all of America, not just St. Louis, but all of our veterans what they are doing to better understand the why and the how of this inexcusable lapse in procedure happened.
I think the VA is already facing an uphill battle, but you must work harder and longer to improve training, implement standardized procedures and, most importantly, regain the trust of the veterans that you serve.
I would—Mr. Shimkus, I share your high regard, as I think we all do, for Mr. Shinseki, former Chief of Staff of the United States Army, now the Secretary for the Department of Veterans Affairs. As far as I know—and we will ask our panel—I don't think he was told about this until late in the process. And if that's true, they've got more problems than this little incident shows.
Mr. Carnahan, again, I think these are your constituents. I ask you to introduce the panel.
Mr. CARNAHAN. Thank you, Mr. Chairman.
I would just echo that. I think you can tell from the statements here from all the panelists that all the folks up here, there couldn't be a more united and focused and bipartisan effort here. So I appreciate all those kind of comments.
I'm honored to introduce two veterans, Susan Maddux, who is a Gulf War veteran, served in the United States Air Force. She is married to another service-connected disabled veteran; and also Terry Odom, also a disabled veteran, suffering from post-traumatic stress disorder, who served in the Navy. Both of these veterans received one of those cold letters in the mail.
I want to thank you first for your service, and I want to thank you for being here to share what happened to you and to help us find answers here today.
The CHAIRMAN. You will be recognized for an oral statement and any written statement you have will be made part of our record.
Susan, you are now recognized.
STATEMENTS OF SUSAN MADDUX, FESTUS, MO (VETERAN); AND TERRI J. ODOM, IMPERIAL, MO (VETERAN)
Ms. MADDUX. Thank you for allowing me to speak today.
The CHAIRMAN. And we know how difficult this is for you but we are very grateful that you are sharing your experiences.
Ms. MADDUX. My name is Susan Maddux. I'm a 40-year-old Gulf War era veteran. I served in the United States Air Force from 1988 to 1998 as an Aerospace Propulsion Specialist. I'm married to another service-connected disabled veteran and we are the parents of four teenage boys.
On June 29th I received a certified letter from the John Cochran VA Hospital stating I may have been exposed to hepatitis B, hepatitis C and HIV. I found this letter to be very impersonal. In fact, there was little difference in the contents of this letter than from any other communication from the VA. It may have read just like an appointment cancellation letter if not for the signature required to receive it.
I was very angry with the Veterans Administration after reading this letter. For something as significant as this, it should have warranted a more delicate approach than a form letter. The VA has advised us that there is minimal chance of being affected by these diseases. However, I feel that any chance of instruments becoming contaminated is unacceptable within a modern medical facility.
The veterans that are eligible to use dental services at the VA Hospital are not normal veterans. Rather, they are among a select population and are also the most susceptible to harm due to being previously compromised by other illnesses.
Those of us that are privileged to use the dental service are 100-percent service-connected, service-connected for dental health, or POW's. Then there are some veterans that have been hospitalized for more than 120 days that also have access to this dental clinic.
To hear that there are some who think that the reaction of this incident is solely political angers me significantly. Hospital employees are not political appointees but, rather, are employed to perform a job, and that is to care for our Nation's veterans. It is their directive to follow the policies and procedures of their respected profession to ensure they do no harm.
As an Aerospace Propulsion Specialist it was necessary to perform tasks following procedures and policies. This allowed the air crews to have confidence that I had installed or repaired their aircraft engines properly. If I didn't follow those procedures accurately, I put their lives at risk.
In the same sense, the VA employees should strive to instill our trust in that they are doing everything the appropriate way since our lives are in their hands. In this instance, instead of strengthening our trust, the St. Louis VA has weakened our confidence by potentially risking over 1,800 veterans lives.
On June 1st of 2005, I was admitted to the intensive care unit at the John Cochran VA Hospital with bacterial meningitis. This was several months after having neurosurgery at this VA facility. Two forms of bacteria were found in my cerebral fluid. One of these infections is normally found in the gastrointestinal tract. I nearly lost my life due to this infection. After recovering from meningitis, I was just happy to be alive and I didn't think to ask more questions as to how this happened.
After the disclosure by the VA over sterilization at their dental clinic, it brought me concerns that the VA sterilization issues are not just confined to this one clinic. It also raises questions in my mind as to how long these failures in sterilization policies have truly been going on.
I would also like to express my concern about the length of time for the VA to notify us about this incident. It makes me speculate if there was an attempt to conceal this from the veterans. It has also taken an extended amount of time to get the test results back to us. They need to realize that we have put our lives on hold while we wait for these results.
I would ask that VA employees speak out about policies and procedures that are not being followed; that it should be their duty to ensure our safety, and the managers and administrators should be willing to listen when informed about these issues.
I would also ask or request the VA administrators and managers to look beyond saving money and follow their own motto by "Putting Veterans First."
Thank you for allowing me to testify today, not only for myself, but as a voice for all veterans that use the VA medical facilities.
[The prepared statement of Ms. Maddux appears in the Appendix.]
The CHAIRMAN. Thank you, Ms. Maddux.
Ms. Odom?
Ms. ODOM. Yes, my name is Terri Odom. I am actually an Army and Navy Vet and proudly served.
First of all, I just want to say that all of my care providers at both John Cochran and Jefferson Barracks, from the dentists, to the psychiatrists, to doctors, to therapists, nurses, et cetera, have always shown me professionalism, compassion, and I can't say anything more for that. That's just me personally.
Now, in regards to the dental lapse, I obviously have some major concerns. On behalf of what happened, basically we just want answers. There are more questions coming out of there right now than answers. And I also have major concerns about why it took them so long to notify me and I was notified via certified mail in a very, very cold letter. Like this lady said, it basically might have said, Hey, the parking lot is being paved. Park on the left side. That's how it felt.
I know this mistake by the VA has made my anxiety disorder even worse, for obvious reasons. Like she said, our life is on hold and it's horrifying to know how many more tests we are going to have to have. There has been conflicting reports that perhaps we won't know for 5, to 10, to 20, to 30 years if we have hepatitis C or HIV. And that's a long time to put your life on hold, especially if you already have some serious health issues. And anyone that's seeking dental care at John Cochran has some serious health issues that are normally service-connected.
In the information number that was attached to the certified letter that I received, I must say, with all due respect to the panel, that the people answering the phone were rude, knew nothing more than I knew, and I realize they were thrown together last-minute.
I even called to verify my blood test, which was scheduled for July 6, 2010, at Jefferson Barracks Hospital. I called on July 5th, 2010, and a nurse actually laughed at my concerns. She said there was such a low risk that I had absolutely nothing to worry about. I asked her if the blood test being offered was because of zero risk or risk.
Looking back now, I realize something in the dental department was wrong. After my first oral surgery I did have severe pain for 28 straight days, and some must ask why did I not return to the dental clinic, or call.
We were taught in the military to suck it up, keep going, and that stride and toughness is still embedded in us veterans today. I had another oral surgery later and some teeth filled. I did receive partial dentures from the VA, but after three visits they still do not fit and my speech is bad with them.
I also, looking back now, remember when the dentist reached for the metal molding piece to make my impressions for my partial plates, that they appeared dirty and rusty. Having a severe anxiety disorder, my attention to detail is somewhat greater than others, and I will leave it at that.
In February of 2010, I was scheduled for a colonoscopy at the St. Louis John Cochran division but had a severe panic attack on the table, with extreme heart rate and elevated blood pressure. I looked around the room and it was beyond filthy. I felt that I could not continue with the procedure. As a result, I did end up in the ER and the procedure was canceled, thankfully, to my benefit.
Also, during a 2009 inpatient stay at the John Cochran division for over 5 days, I was unable to shower due to the mold and unsanitary conditions of my bathroom. The nurses on the ward were very nice and just said, No, honey, you don't want to dare use that nasty shower. They did offer me washcloths and things of such to bathe with. I did offer to clean it myself.
There must be a change in the VA. What has recently happened in St. Louis with the exposure is third-world treatment, if not less. And yes, we are angry and we have every right to be. The VA put our health at great risk and there has to be some accountability. This issue must not just be swept away like it never happened.
I already have major trust issues due to my disability, and now I feel that the very people who are supposed to have my back are trying to put me in harm's way, and I'm not sure why. We deserve better than this. We are not just veterans, but human beings. People make mistakes. I understand that. But when you are dealing with people's lives, there is no room for failure. And I'm outraged at the lack of seriousness the St. Louis VA seems to be putting on this horrible issue. How would any of them like to wait in horror for test results, and then have to wait again and again and again?
I thank you all for being here.
[Applause].
[The prepared statement of Ms. Odom appears in the Appendix.]
The CHAIRMAN. Thank you both. You do have a right to be angry.
Mr. Carnahan?
Mr. CARNAHAN. Thank you both for your honest testimony and description here.
As you said, Ms. Odom, obviously there has been a toughness instilled in you, and a commitment to service, and we recognize that and we do want to get to the bottom of this.
I want to ask both of you, you have very well described the coldness of those letters that you received. I want to ask, did you make that first phone call to the VA to set up those appointments, or was there any other outreach to you beyond that letter?
Ms. ODOM. I made the call immediately, and the person that answered the phone was a young man and he did not know anything about it. He said he was just hired to answer the phone and that a nurse would call me in approximately 1 to 3 hours to discuss any further details about the possible risk.
Mr. CARNAHAN. And Ms. Maddux?
Ms. MADDUX. I called the following day. I already had an appointment that day to go to John Cochran, so while I was there I went down to their clinic to get the testing, and I've received no other calls.
Mr. CARNAHAN. And can you describe the process when you got to the clinic in terms of doing the test and any counseling that was provided to you? Any answers at that point that were provided?
Ms. MADDUX. Well, we were given a folder with materials to read. Since I already had an appointment, they kind of walked me through it. I didn't sit through their orientation but I sat down with a nurse and he asked if I had any questions at the time. And then I went across the hall for the blood testing.
I found when I got to the VA facility, there was people stationed at every turn in the hallways and those people had smiles on their face, asking if you needed help finding anything, and that went all the way down to the basement and into the clinic. And I found that to be very fake. And you would never see that on a normal day. And it was just ridiculous.
Mr. CARNAHAN. Let me ask you both, are you satisfied with the advice that you have been given in terms of what kind of follow-up care you are going to need?
Ms. ODOM. No. I was not, I had my blood test, as I mentioned earlier, drawn at Jefferson Barracks July 6th. And when I got to the blood draw clinic, I was told I could not have it drawn until I spoke with a Mrs. Bart Thompson on the second floor.
I immediately went to the second floor. The personnel there said they knew of no such person. I called the 800 number again. The lady informed me that she was from out of Missouri, out-of-state. She knew of no Ms. Thompson on the list.
So I went back to the staff on the second floor and said, I've called the number. What is it? And finally I come across a nurse, I believe she was a nurse that said she did know of a Mrs. Thompson who had been at the last minute thrown into it but went on leave, and that she would personally call back to the blood lab and say it was okay for me to be tested. But I had no counseling or anything like that, sir.
Mr. CARNAHAN. And then have you been advised in terms of the length of time you are going to have to wait to get results?
Ms. ODOM. I was told that because of the incubation period, that I can possibly return in late August, but they are going to be doing some investigation on how long they may have to follow us. That it may be 2, 3, 10 to 20 years. I had different stories about it, sir.
Mr. CARNAHAN. And Ms. Maddux?
Ms. MADDUX. I was called yesterday with my results and I was told since my dental treatment was at the beginning of March, I would have to be re-tested around September 2nd. And that's all I've gotten.
Mr. CARNAHAN. But no advice about any testing beyond that?
Ms. MADDUX. No.
Mr. CARNAHAN. I guess have you had an opportunity to talk to anyone about how this occurred or about improvements that are being made there to help rectify this?
Ms. MADDUX. No, I haven't.
Ms. ODOM. No, sir.
Ms. MADDUX. I find I take it upon myself, when told I was exposed to this, going on the internet and researching it myself, as I do with any medication or any treatment that I have been given, to inform myself as best as possible.
Mr. CARNAHAN. And I guess the last question for both of you. If you could, in brief, tell the Committee here, what would you like to be done to help you in terms of being sure you get the right care you need going forward?
Ms. ODOM. I would like just honest answers. And I would not always appreciate it always having to come from the media. No disrespect, but I think it should come from the VA. Honest answers. It seems like, you know, I've received ten different answers on one question. That's unacceptable.
And I would like to know, how long do you plan on following this group of veterans and their families? I have a 19-year-old son. You know, I would like to know this. I have enough issues to deal with currently that I don't think I need extra anxiety to worry, do I get re-tested in August and then wait for results? And then again in December and so forth and so on? I would like somebody to let us just know the truth. We are not blaming anyone. We just want answers, that's all. The truth.
Mr. CARNAHAN. And Ms. Maddux.
Ms. MADDUX. Yes, I would like to have someone appointed that we can call one person and not go through being directed or misdirected all different places to get the answers that we need.
Mr. CARNAHAN. Thank you both.
The CHAIRMAN. Mr. Blunt?
Mr. BLUNT. Thank you, Chairman. And thank you both for testifying. Let me ask a couple more questions.
On the letter, Ms. Odom, you mentioned that you called. How long did you wait until you called?
Ms. ODOM. I fell down to my knees—
Mr. BLUNT. Uh-huh.
Ms. ODOM [continuing]. I'm just being honest, sir, in shock. It was the last thing I expected. You don't normally get certified letters from the VA Hospital. You might get them from the Veterans Benefits Administration (VBA) but never from the hospital.
Mr. BLUNT. Right.
Ms. ODOM. So I opened it, read it three times, let it sink in, fell down to my knees and said, you've got to get back up. I will call. It must not be that big of a deal because, you know, we are finding out by a certified letter.
Mr. BLUNT. Right.
Ms. ODOM. I called and, as I stated earlier, the young gentleman said he had just gotten hired for the 24-hour, 7-day a week manned thing. The Educational Department at John Cochran Division. He said, I'm sorry, ma'am. I can't help you. I don't know anything. But a nurse will be calling you in 1 to 3 hours, and he or she at that time will discuss any concern that you have.
And I waited, literally looking at my phone for it to ring, and it did ring in about 2 1/2 hours.
Mr. BLUNT. And when you talked to that person, what did they tell you?
Ms. ODOM. They told me that the risks were minimal. They told me not to have unprotected sex, use razors, fingernail clippers, share any
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