House Committee on Veterans' Affairs

TESTIMONY OF

SIDNEY DANIELS

DEPUTY DIRECTOR

NATIONAL LEGISLATIVE SERVICE

VETERANS OF FOREIGN WARS OF THE UNITED

STATES

BEFORE THE

SUBCOMMITTEE ON BENEFITS

COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES HOUSE OF REPRESENTATIVES

WITH RESPECT TO

H.R. 1020, H.R. 3816, H.R. 3998, and H.R. 4131

WASHINGTON, DC APRIL 13, 2000

MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:

Thank you, Mr. Chairman, for the opportunity to testify today concerning the above-cited bills.

H.R. 1020

To amend title 38, United States Code, to establish a presumption of service connection for the occurrence of hepatitis C in certain veterans

This bill will establish a presumption of service connection for hepatitis C, notwithstanding, that there is no record of evidence of such illness during a veteran's military service, if the veteran meets certain criteria.

At our 100^th National Convention this past August the delegates passed Resolution Number 699, Establishing a Presumption of Service Connection for Veterans From Hepatitis "C." This resolution urges the Secretary of Veterans Affairs to authorize an open-ended presumption of service connection for veterans suffering from hepatitis C.

The hepatitis C virus (HCV) is a chronic, blood-borne disease that infects between 4 and 5 million Americans or 1.8 percent of the population. It is a disease that was virtually unknown before the virus was isolated in 1989 and before effective screening tests were perfected in 1992. Since then, it has emerged as a major public health concern.

Hepatitis C is often a hidden disease after infection. Studies show that the virus usually develops over a period of 10 to 30 years, usually without symptoms, until it surfaces as chronic active hepatitis. (Only five percent of those currently infected with HCV are aware that they have the disease and fewer than two percent have ever been treated.) Transmission of hepatitis C generally occurs through blood-to-blood contact. Most people currently carrying the disease, however, were infected sometime within the last 30 years when blood transfusions and blood products were a significant source of infection. Prior to 1992, hepatitis C was prevalent in the nation’s blood supply.

Hepatitis has historically been a disease associated with military service. Military training and combat offer many opportunities for transmission of blood-borne viral hepatitis through blood-to-blood contact. Field bleeding, surgery and transfusions, and exposure to blood by military medics and surgeons all constitute high risks.

Veterans of foreign combat are most at risk where prevalence of hepatitis C is particularly high. All major engagements of the last 50 years including World War II, Korea, and Vietnam have high rates of hepatitis. Viral hepatitis was viewed as a single disease in those years. Most treatments and documented cases were for acute forms of the disease.

Accordingly, veterans appear to have unusually high rates of hepatitis C. While the prevalence of hepatitis C in the nation as a whole is 1.8 percent, various special studies of veterans in VA facilities have shown rates of hepatitis C infection between 10 and 20 percent.

Vietnam veterans seem to be the group most directly affected by this problem today. Many veterans who contracted hepatitis C in Vietnam 25 to 30 years ago are now exhibiting symptoms of severe liver disease. When they were first infected, HCV had not been distinguished from other forms of hepatitis (in 85 percent of the cases, there would have been no acute symptoms at the time of infection).

Currently, there are 3.2 million surviving Vietnam veterans who were stationed in Southeast Asia during the Vietnam Conflict. A conservative estimate is that 10 percent (320, 000) of these veterans are now infected with HCV. There are a number of likely risk factors related to the transmission of hepatitis C during the Vietnam War. These include:

Southeast Asia has high rates of hepatitis C infection. Currently, between five and eight percent of the Vietnamese population is infected with hepatitis C. Hepatitis C could have been transmitted to military personnel through tattoos, medical contact, sexual contact, and shared needles.

Approximately 300,000 Americans were wounded and 153,329 were hospitalized during the Vietnam War. Between March 1967 and June 1969, there were 364,900 transfusions given in Vietnam. It is estimated that a minimum of ten percent of those who were transfused received infected blood.

Surgeons, nurses, medics, helicopter crews, and others involved in evacuation and treatment of the wounded all were at risk for transmission of hepatitis C. Of an estimated 41.1 percent of all military personnel deployed to Vietnam, approximately 2.1 million were exposed to combat. Many assisted the more than 300,000 wounded. In addition, many medical personnel, not exposed to combat because of their assignment to hospital ships, also handled the wounded in the Vietnam theatre of operations.

Unclean needles that pierce the skin can transmit hepatitis C. While transmission of hepatitis C through tattoos has not been documented in the United States, it has been documented elsewhere. An estimated 34 percent of active duty military personnel have tattoos. Many of these were acquired in regions where sanitation was not optimal.

The Department of Veterans Affairs (VA) has been monitoring HCV cases and has noted a decided increase in the number of cases over the last few years. There were 6,600 HCV cases reported in the VA in 1991. By 1994, this number had increased to 18,854. Between 1995 and 1997, the annual number of newly identified persons rose from 20,203 to 24,850. In 1998, an additional 29,799 unique cases were recorded within the VA. VA officials expect this number to continue to rise substantially. Of all veterans in the VA system testing positive for hepatitis C, 64 percent were Vietnam-Era veterans. The mean age of HCV-infected veterans is 49 years.

Veterans infected with hepatitis C during their military service are generally unable to establish a service connection. The lack of knowledge of hepatitis C and, until recently, the lack of a reliable test not to mention the long latency period of this disease makes it difficult to prove that the infection was acquired during military service. (Even today, when there are reliable tests for hepatitis C, the military does not conduct HCV tests as part of the discharge physical examinations. Without a presumption of service connection, most veterans who contracted hepatitis C in the military will not be eligible for treatment in VA facilities. In fact, in a review of all 1,599 cases of chronic hepatitis brought before the Board of Veterans Appeals between 1994 and 1996, only 37 cases resulted in an approval of a service-related disability rating for hepatitis.

Accordingly, Mr. Chairman, the VFW strongly supports this bill.

H.R. 3816

To amend title 38, United States Code, to provide that a stroke or heart attack that is incurred or aggravated by a member of a reserve component in the performance of duty while performing inactive duty training shall be considered to be service-connected for purposes of benefits under laws administered by the Secretary of Veterans Affairs;.

The Veterans of Foreign Wars supports this bill with no further comment.

H.R. 3998

To amend title 38, United States Code, to provide that the rate of compensation paid by the Department of Veterans Affairs for the service-connected loss of one or both breasts due to a radical mastectomy shall be the same as the rate for the service-connected loss or loss of use of one or more creative organs

With respect to H.R. 3998, we have a concern that the language, as currently written will create an inequity. In general, the rating schedule is gender neutral in the evaluation of disabilities, without the identification of a physiological impact. For example, a male veteran should be considered the same in this legislation because the disfigurement of a breast removal procedure (gynecomastia) would most likely be a result of a comparative disease that attacks either gender. Therefore, all veterans should be entitled to the same consideration for the surgical procedure of breast removal under the rating schedule contained in Part 4 "Schedule For Rating Disabilities," Title 38 of Code of Federal Regulations.

Accordingly, under the current version of the rating schedule, and to be inclusive in establishing equity (if that is the goal), the procedure known as mastectomy may result in the same disabling impact to the "average person." (The concept of the average person is the foundation principle found in 38 C.F.R. Part 4.) For instance, under Diagnostic Code 7626, "Breasts, surgery of:" (38 C.F.R. § 4.116), bilateral simple mastectomy is viewed as more disabling than an unilateral modified radical mastectomy (a 50% compensation rating versus a 40%). Under the proposed legislation, the veteran with the 40% rating as a result of a modified radical mastectomy involving one breast would receive a special monthly compensation under Title 38 United States Code § 1114(k) while the veteran rated at 50% does not although the 40 percent rating involves a more disabling condition (modified radical mastectomy).

Consequently, we recommend the proposed amended section 1114(k) instead be stated: "or one or both breast due to a mastectomy." The definition herein of "mastectomy" is meant to be either radical, modified radical, or simple. Making this change will guarantee true equality and gender equity in the rating schedule at 38 C.F.R. § 4.116.

H.R. 4131

To increase, effective December 1, 2000 the rates of disability compensation for veterans with service-connected disabilities and the rates of dependency and indemnity compensation for survivors of certain disabled veterans.

The Veterans of Foreign Wars also supports H.R. 4131 without further comment.

Once again, Mr. Chairman we thank you for the opportunity to lend our voice to today's most important testimony, and I will be happy to answer any questions you may have. Thank you.

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