Good afternoon, Chairman Hall, Ranking Member Lamborn, and members of the Committee. My name is Lonnie Bristow. I am a physician and a Navy veteran, and I have served as the president of the American Medical Association. I’m joined on this panel by Drs. Dean Kilpatrick and Jonathan Samet, who will introduce themselves shortly. On their behalf, thank you for the opportunity to testify about the work of our Institute of Medicine (IOM) committees. Established in 1970 under the charter of the National Academy of Sciences, the IOM provides independent, objective advice to the nation on improving health.

My task today is to present to you the recommendations of the IOM committee I chaired, which was asked to evaluate the VA Schedule for Rating Disabilities and related matters. Dr. Kilpatrick will follow me to speak about his committee’s work, which focused on post-traumatic stress disorder, which is a particular challenge for the VA top evaluate. Dr. Samet will conclude our panel’s presentation by briefing you on the findings of his committee, which was asked to offer its perspective on the scientific considerations underlying the question of whether a health outcome should be presumed to be connected to military service.

I had the great pleasure and honor of chairing the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, which was established at the request of the Veterans’ Disability Benefits Commission and funded by the Department of Veterans Affairs (VA).

Updating the Basis for Disability Compensation

Our report, A 21st Century System for Evaluating Veterans for Disability Benefits, which was issued last July, makes a number of important recommendations regarding the VA Rating Schedule and related matters. Our first recommendation is to broaden the purpose of the VA disability compensation program, which currently is to compensate for average loss of earning capacity, or work disability. We recommend that VA also compensate for loss of ability to engage in the usual activities of everyday life other than work and, if possible, for diminished quality of life. We recognize that legislative action will be required to change the statutory purpose of the disability compensation program, but doing so would bring the compensation program in line with our current understanding that disability has broad effects (see attached figure 4-1 from the report).

Assessing the Rating Schedule

When the Committee reviewed the Rating Schedule, we found that:

• Although it is called the Schedule for Rating Disabilities, it currently evaluates degree of impairment (i.e., loss of a body part or function) rather than degree of disability (i.e., limits on a person’s ability to function at work or in life).

• Even in rating degree of impairment, the Schedule is not as current medically as it could and should be.

• The relationship of the rating levels to average loss of earning capacity is not known.

• The Schedule does not evaluate impact on a veteran’s ability to function in everyday life.

• The Schedule does not evaluate loss of quality of life.

Accordingly, we made a series of recommendations to update and revise the Rating Schedule.

Updating the Rating Schedule

First, the committee recommends that VA should immediately update the current Rating Schedule, beginning with those body systems that have gone the longest without a comprehensive update (i.e., the orthopedic part of the musculoskeletal system, the neurological system, and the digestive system). Revisions of the remaining systems could be done on a rolling basis, several a year, after which VA should adopt a system for keeping the Schedule up to date medically. Also, VA should establish an external disability advisory committee to provide advice during the updating process.

As part of updating the Rating Schedule, VA should move to the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM )diagnostic classification systems that are used in today’s healthcare systems, including VA’s.

Evaluating Traumatic Brain Injury

We were asked by your staff about improving the criteria for traumatic brain injury, or TBI. TBI is an excellent example of where the rating criteria in the Schedule need to be updated in accord with current medical knowledge and practice.

TBI is rated under diagnostic code 8045, “Brain disease due to trauma,” which was last updated substantively in 1961. Today, we understand much better how concussions from blast injuries can affect cognition even though there is no evident physical injury. In Iraq, many service members have been subjected to multiple improvised explosive device blasts. The current criteria emphasize physical manifestations, such as paralysis and seizures. The Rating Schedule recognizes that symptoms such as headache, dizziness, and insomnia are common in brain trauma but limits them to a 10 percent rating. It is time to review how to properly evaluate and rate TBI in light of current medical knowledge, along with the rest of the neurological conditions, most of which have not been revised since 1945.

Relating the Rating Schedule to Average Loss of Earnings

In addition to updating the Schedule medically, VA should investigate the relationship between the ratings and actual earnings to see the extent to which the Rating Schedule as revised is compensating for loss of earnings on average. This would build on the analyses done by the CNA Corporation at the body system level but use samples large enough to study the most prevalent conditions being rated. Just 38 conditions account for two-thirds of the compensation rating decisions. If VA finds disparities in average earnings, for example, that veterans with a mental disorder rated 70 percent earn substantially less on average than veterans rated 70 percent for other kinds of disabilities, it could adjust the rating criteria to narrow the gap.

Compensating for Non-Work-Related Functional Limitations

The Committee recommends that VA compensate for non-work disability, defined as functional limitations on usual life activities, to the extent that the Rating Schedule does not. To do this, VA should develop a set of functional measures—e.g., ADLs (activities of daily living), IADLs (instrumental activities of daily living)—and specific performance measures, such as time to ambulate a certain distance, or ability to do specific work-related tasks in both physical domains (e.g., climbing stairs or gripping) and cognitive domains (e.g., communicating or coordinating with other people). After the measures are validated in the disability compensation population, VA should conduct a study of functional capacity among applicants to see how well the revised Rating Schedule compensates for loss of functional capacity. There may be a close correlation between the rating levels based on impairment and degree of functional limitations (i.e., the higher the rating, the more functional capacity is limited), in which case the Rating Schedule compensates for both impairment and functional loss. But if the correlation is not high or does not exist, VA should develop a mechanism to compensate for loss of function that exceeds degree of impairment. This could be done by including functional criteria in the Rating Schedule or by rating function separately, with compensation based on the higher of the two ratings.

Compensating for Loss of Quality of Life

The Committee also recommends that VA compensate for loss of quality of life. We realize that quality-of-life assessment is relatively new and still at a formative stage, which makes this recommendation conditional on further research and development. VA should develop a tool for measuring quality of life validly and reliably in the veteran population, then VA should conduct research to determine the extent to which the Rating Schedule might already account for loss in quality of life. We might find that veterans with the lowest quality of life already have the highest percentage ratings, but if not, VA should develop a procedure for evaluating and rating loss of quality of life of veterans with disabilities where it exceeds the degree of disability based on impairment and functional limitations determined according to the Rating Schedule.

Evaluating Individual Unemployability

The Committee also reviewed individual unemployability, or IU, which has been a fast-growing part of the compensation program. Our main finding concerning IU is that it is not something that can be determined on medical grounds alone. IU is based on an evaluation of the individual veteran’s capacity to engage in a substantially gainful occupation, rather than on the Rating Schedule, which is based on the average impairment of earnings concept. Thus the determination of IU must consider occupational as well as medical factors. To analyze IU claims, raters have medical evaluations from medical professionals and other medical records but usually they do not have comparable functional capacity or vocational evaluations from vocational experts. Therefore, the Committee recommends that, in addition to medical evaluations by medical professionals, VA require vocational assessment in the determination of eligibility for individual unemployability benefits. Raters should receive training on how to interpret findings from vocational assessments for the evaluation of individual unemployability claims.

Other Recommendations

The Committee made additional recommendations on issues other than the VA Schedule for Rating Disabilities, which I am not reviewing today. They can be found in our report and our recommendations for improving the medical examination and rating processes were presented to you by our staff director, Michael McGeary, on February 14 (for example, mandating the use of the on-line medical examination templates and having medical consultants to advise the raters on medical evidence).

This concludes my remarks. Thank you for the opportunity to testify. I would be happy to address any questions the Subcommittee might have.

FIGURE 4-1 The consequences of an injury or disease.

From: A 21st Century System for Evaluating Veterans for Disability Benefits. National Academies Press, 2007.

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

REPORT BRIEF • NOVEMBER 2007

"A DUTY TO UPHOLD: MODERNIZING THE VETERANS' BENEFIT SYSTEM "

In times of war, the United States puts great demands on the men and women of our Armed Forces. We ask that they risk life and limb for our country, and they do so, willingly.

We honor our troops by providing them with the best medical support possible. Today, thanks to advances in battlefield medicine and logistics, a wounded soldier can be off the battlefield in minutes, in surgery within an hour, and recovering in the U.S. within days.

Surviving the initial trauma, however, is only half the battle. The impact of service-related injuries can last years, and indeed, a lifetime. And while our on-the-ground medical treatment is a model of science and efficiency, our system for handling veterans' disabilities is often mired in outmoded procedures. Worse, it is sometimes mired in World War II-era medical science.

This does not reflect a lack of will: Our nation is unwavering in its commitment to honor those who serve, and to compensate them for the sacrifices they make. But our benefits system does not currently measure up to this ideal.

Recognizing these disparities, the Congressionally established Veterans' Disability Benefits Commission asked the Institute of Medicine (IOM) to provide guidance in two critical areas:

• How veterans are evaluated and compensated for disability benefits; and
• How we determine if a veteran's disability was caused by their service to our country.

A 21 ST CENTURY SYSTEM FOR EVALUATING VETERANS FOR DISABILITY BENEFITS

Nearly three million veterans of the U.S. Armed Forces receive compensation for disabilities incurred as a result of their service. The financial burden of this compensation is significant: $30 billion per year, with dependents and survivors receiving an additional $5 billion. The system for managing this compensation is necessarily large and complex: In 2006, the Veterans Administration (VA) received over 650,000 claims for disability compensation, and made decisions on nearly 630,000.

The efficiency suggested by those numbers, however, is illusory. The average time to process a claim is 177 days, and appeals—some 100,000 annually—take almost two years. These delays come with significant costs to deserving veterans, creating frustration and hardship from those who most deserve our support.

EVALUATING THE CURRENT SYSTEM

The most critical component in deciding whether a veteran is eligible for benefits is the "VA Schedule for Rating Disabilities," better known as the "Rating Schedule," or simply the "Schedule." The Schedule is a list of more than 700 diagnostic codes, each with criteria for determining the extent of impairment in a particular limb, organ, or body system. A soldier who is shot in the arm, for instance, may see a 10 percent, 50 percent, or other percentage impairment in the use of that arm.

Clinical professionals medically evaluate claimants and provide assessments to a group of nonclinical professionals, who then apply the Schedule to determine a disability rating between a and 100 percent, in l0-percent increments. Veterans with a service-connected disability receive monthly payments tied to their ratings, currently ranging from $115 a month for a 100-percent rating to $2,471 per month for a l00-percent rating.

In principle, the VA disability benefits program is designed to compensate individuals for their loss in earning power. It's only fair: A soldier should not have to "pay" for their injuries by having their income reduced throughout their life. In practice, Congress and the VA have also recognized and compensated veterans for non-economic losses since the disability program was put in place at the end of World War I.

These targets, however, have been approached inconsistently. There has been no systematic attempt to evaluate the connections between medical conditions and actual earnings potential since the 1970s, and no effort to move beyond an ad hoc link between quality of life and benefit ratings. Moreover, the Schedule itself has lagged substantially behind changes in modem medicine.

In 2004, the Veterans' Disability Benefits Commission, an independent group created by Congress for the sole purpose of assessing the veterans' disability program, charged the IOM to study and recommend improvements in the rating system. The research agenda featured dozens of areas for investigation, including:

• How well does the current system evaluate and compensate losses of both quality-of-life and earnings capacity?
• How well does the system provide additional benefits (such as adapted housing and rehabilitation) where these benefits would be beneficial?
• Does the existing set of ratings and their application accurately reflect a veteran's ability to make a living?

The IOM established a committee to review these and other issues and has published its findings in A 21st Century System for Evaluating Veterans for Disability Benefits (2007).

A CALL TO ACTION

The committee called for immediate action. It found the current system to be out-of-date and out-of-touch with both modem medicine and our modem understanding of disability.

The most urgent finding was a call to reassess the fundamental link between disability and compensation, and to bring our understanding of the impact of different disabilities into the 21st century.

The Rating Schedule is predicated on compensating veterans for a loss of income related directly to their injury. And yet, there is no comprehensive process in place to ensure that the Schedule reflects an accurate connection between the two. Moreover, there is no system to systematically update this connection to reflect changes in jobs, lifestyles, health care, or living arrangements.

The committee noted that the entire Schedule needs an immediate update, beginning with those sections not systematically updated since World War II, and that the VA should establish an expert advisory committee to manage the change process. The sections that have not been overhauled since 1945 include the orthopedic (e.g., amputations), neurological (e.g., traumatic brain injury), and digestive (e.g., ulcers) sections. Most of the other sections, such as mental (e.g., PTSD) and endocrine (e.g., diabetes), have not been comprehensively updated for more than 10 years.

The very construction of the Schedule also needs to be re-evaluated. Currently, the Rating Schedule focuses on discrete body systems: A veteran may be 50 percent disabled in one leg and 30 percent disabled in one arm, etc. Today, we understand disability to be driven by the whole person, and that the interplay of disabilities has an important impact on a person's level of functioning. Moreover, a comprehensive system needs to be put in place to account for additional, non-medical factors like age, experience, education and location when evaluating individual disabilities. A person may face different challenges, after all, if they are a 50-year-old teacher living in New York City than if they are a corn farmer living in Ames, Iowa.

At a minimum, the Rating Schedule needs to be aligned with the work done in the International Classification of Diseases (ICD) codes and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Simply aligning codes and descriptions will help bridge a substantial gap between the existing schedule and the current medical understanding of injuries and diseases and their impacts on a person's ability to function.

While updating the evaluation process is a start, it is not enough to bring the VA disability system into the 21st century. In a truly modem disability program, veterans should be compensated for their difficulties in pursuing a fulfilling life apart from work; for a loss in the quality of their lives. While we have done this in practice historically, the current ad hoc process of accounting for reduced quality of life should be systematized and driven by research and science.

A FUNDAMENTAL CHANGE

These changes will not come easily, and the VA needs to make a commitment to ongoing research. This shift in perspective-from a simple "the postman cannot walk" mentality toward a true, holistic model of the human experience and the effect of disability is fundamental. It implies, and the committee recommends, that health care professionals be made accessible throughout the benefits process for consultation and advice. It also requires constant updating to keep pace with continued changes in medicine and the workplace.

The motivations of the VA benefits program are noble and no change in intent or focus could possibly be desired. What is needed is not a change in motivation, but a commitment to continuous improvement; a commitment to being veteran-focused; a commitment to refining and modernizing processes, criteria and tools; and a commitment to evidence-based decision-making.

The committee's full report outlines myriad ways in which these commitments can be met. To access a copy, visit www.iom.edu.

IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS

When a veteran applies for disability benefits, the VA has to make several decisions. The first step, outlined above, is to examine the individual and quantify their level of disability—work-related or otherwise. But this is only half of the equation. In order to receive benefits, a veteran's disability must be related to their military service. While these connections can be obvious (a battlefield wound), they can also be murky and complex (as with most environmental exposures).

Since the 1920s, the VA Administrator (now Secretary) and Congress having had the power to establish "presumptions": conditions that, if present, are "presumed" to be the result of military service. These presumptions are, important because they streamline the process of providing benefits to veterans in need. When a "presumption" is made, veterans do not have to prove that their particular disability or illness was caused by their service; if the served in a particular capacity and developed a particular ailment, they are entitled to benefits.

The best-known example is Agent Orange. In 1991, Congress passed law (the 1991 Agent Orange Act) requiring the VA to investigate the health impacts of Vietnam-era exposure to the herbicide Agent Orange. The VA asked the IOM to review the evidence, and on the basis of an IOM recommendation, decided that any soldier setting foot on Vietnamese soil during the war may have been exposed to Agent Orange. Moreover, a range of medical problems (including Hodgkin's disease and prostate cancer) were linked to this exposure. Therefore, any veteran developing these conditions after serving on Vietnamese soil was entitled to benefits, as it was "presumed" that their service led to these conditions.

Today, nearly 150 health conditions have been codified, allowing veterans to receive benefits based on presumptive service connection. However, the current system for determining presumptions has not been standardized.

In order to ensure that future decisions are based on sound science and evidence, the Veterans' Disability Benefits Commission asked the IOM to examine the current process and propose a framework for establishing presumptions in the future. The IOM appointed a committee experts from fields including epidemiology, toxicology, and industrial hygiene.

In its report, Improving the Presumptive Disability Decision-Making Process for Veterans (2007), the committee finds that the current process has met most noble goal: the VA has consistently given the benefit of the doubt to disabled veterans, in an effort to ensure that no veteran who might have been affected by their service is denied compensation. But this apparent generosity has come not from policy as much as from an inadequate process. Congress has been inconsistent in giving guidance when asking for assessments, and the VA has lacked clarity in its requests to IOM committees evaluating individual cases. There has been an inconsistent burden of proof: in some cases, Congress has required a causal link between a certain exposure and a cert health risk; at other times, only an "association" was required. In many cases, the Department of Defense has been unable to provide health and exposure data to inform the decision-making process.

Such a system cannot help but lead to flaws—granting benefits where disabilities are not service-connected or denying benefits to those entitled to them. Perhaps more damaging, the ad hoc and ill-defined process undermines veterans' confidence in the VA system, fostering discontent and confusion among those who have sacrificed for their country.

A CALL FOR STRUCTURE

The committee's findings are clear: What the system needs is structure. This structure must ensure that presumptive decisions are based on evidence, not emotion, and that decisions are made quickly, transparently, and consistently. Such a system must have the flexibility to grow and change as science advances, and cannot be a top-down government program: It needs the input and cooperation of all potential stakeholders to function well.

Toward this end, the committee took the unusual step of making broad recommendations to Congress, the Department of Veterans Affairs, and the Department of Defense, both individually and collectively. It is rare to make recommendations to multiple organizations, but in this case, cooperation and coordination are critical.

The committee laid out the structure in careful detail. It envisions a new system, created by Congress, consisting of two parts: an Advisory Committee and a Science Review Board. The Advisory Committee would be made up of stakeholders from government, the scientific community, veterans groups, and others. Its task would be to consider potential exposures, illnesses and circumstances that might require the establishment of presumptions. Based on this Advisory Committee's recommendations, the VA Secretary would then charge the Science Review Board—a completely independent group-to examine the evidence and provide recommendations.

The Science Review Board is the linchpin of this new system. Relying on evidence-based decision-making, the Board will consider how strong the link is between a given exposure and a particular medical ailment, classifying that connection into four categories:

1. Sufficient: A causal relationship exists.
2. Equipoise and Above: A causal relationship is at least as likely as not.
3. Below Equipoise: Either a causal relationship is unlikely, or there is insufficient information to make a scientifically informed judgment.
4. Against: The evidence suggests the lack of a causal relationship.

When the evidence permits, the Board would estimate how many veterans were exposed, to what extent, and what fraction of their medical condition was due to this exposure. These findings would then be delivered to the VA, which would determine if a presumptive ruling is merited.

This kind of structure will not be put into place overnight, and substantial work remains to be done. For instance, the VA needs to develop and publish a formal process for how these presumptions will be made. This must be consistently applied, and needs to be transparent from start to finish, documenting all evidence collected and the reasoning behind each decision—pro or con. But most importantly, the DoD and the VA need to make a commitment to work together. For example, evaluating causality is only possible for the VA if the DoD has accurate medical records, reports on pre-existing conditions, and information on what time individual veterans spent operating in different military theaters. The committee's report provides many recommendations, from strategic planning to computer data interfaces, where a commitment to joint research, knowledge-sharing, and resource allocation will be required. Without this cooperation, no new structure will succeed.

A COMMITMENT RENEWED

America remains steadfast in its commitment to the men and women of our Armed Forces, whether they still wear the uniform or have re-entered private life. The Department of Veterans Affairs, in recognizing the need for research and change, has shown its commitment to extending this commitment for as long as is necessary to support those harmed in the line of duty.

The way in which we compensate our disabled veterans is far from broken—millions of veterans rely on it and more are granted benefits every day. But it can and should be as effective as possible. Our veterans deserve nothing less.

FOR MORE INFORMATION ...

Copies of A 21st Century System for Evaluating Veterans for Disability Benefits and Improving the Presumptive Disability Decision-Making Process for Veterans are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, www.nap.edu. The full text of this report is available at www.nap.edu.

These studies were supported by funds from the Veterans' Disability Benefits Commission.

Any opinions, findings, conclusions, or recommendations expressed in the publications are those of the author(s) and do not necessarily reflect the views of the organization that provided support for the project.

The Institute of Medicine serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. For more information about the Institute of Medicine, visit the IOM web site at www.iom.edu.

Permission is granted to reproduce this document in its entirety, with no additions or alterations. Copyright © 2007 by the National Academy of Sciences. All rights reserved.

COMMITTEE ON MEDICAL EVALUATION OF VETERANS FOR DISABILITY COMPENSATION LONNIE R. BRISTOW, M.D., M.A.C.P. (Chair), Former President, American Medical Association, Walnut Creek, CA; GUNNAR B. J. ANDERSSON, M.D., Ph.D., Professor and Chair, Department of Orthopedic Surgery, Rush University Medical Center; JOHN E BURTON, JR., Ph.D., LL.B., Professor Emeritus, School of Management & Labor Relations, Rutgers University; LYNN H. GERBER, M.D., Director, Center for Chronic Illness and Disability, College of Nursing and Health Science, George Mason University; SID GILMAN, M.D., F.R.C.P., William J. Herdman Distinguished University Professor of Neurology, Director, Michigan Alzheimer's Disease Research Center, University of Michigan; HOWARD H. GOLDMAN, M.D., M.P.H., Ph.D., Professor of Psychiatry, University of Maryland at Baltimore, School of Medicine; SANDRA GORDON­SALANT, Ph.D., Professor, Department of Hearing and Speech Sciences, University of Maryland; JAY HIMMELSTEIN, M.D., M.P.H., Assistant Chancellor for Health Policy, Director, UMass Center for Health Policy and Research, University of Massachusetts Medical School; ANA E. NUNEZ, M.D., Associate Professor, Drexel University College of Medicine, Institute for Women's Health and Leadership; JAMES W. REED, M.D., M.A.C.P., Chief of Endocrinology, Grady Memorial Hospital, Professor of Medicine and Associate Chair of Medicine for Clinical Research, Morehouse School of Medicine; DENISE G. TATE, Ph.D., ABPP, FACRM, Professor, Director of Research, Division of Rehabilitation Psychology and Neuropsychology, Department of Physical Medicine and Rehabilitation, University of Michigan; BRIAN M. THACKER, Regional Director, Congressional Medal of Honor Society, Wheaton, MD; DENNIS TURK, Ph.D., John and Emma Bonica Professor of Anesthesiology & Pain Research, Department of Anesthesiology, University of Washington School of Medicine; RAYMOND JOHN VOGEL, M.S., President, RJ VOGEL and Associates, Mt. Pleasant, SC; REBECCA A. WASSEM, D.N.S., Professor of Nursing, University of Utah College of Nursing; ED H. YELIN, Ph.D., Professor of Medicine and Health Policy, Institute for Health Policy Studies, University of California at San Francisco.

STUDY STAFF

RICK ERDTMANN, M.D., M.P.H., Division Director; MORGAN A. FORD, Program Officer; REINE HOMAWOO, Sr. Program Assistant; SUSAN McCUTCHEN, Research Associate; MICHAEL McGEARY, Study Director; PAMELA RAMEY-MCCRAY, Administrative Assistant.

COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS

JONATHAN M. SAMET, M.D., M.S. (Chair), Professor and Chair, Department of Epidemiology, The Johns Hopkins University; MARGARET A. BERGER, J.D., Suzanne J. and Norman Miles Professor of Law, Brooklyn Law School; KIRSTEN BIBBINS-DOMINGO, Ph.D., M.D., Assistant Professor and Attending Physician, Departments of Medicine and Epidemiology and Biostatistics, University of California - San Francisco, San Francisco General Hospital; ERIC G. BING, M.D., Ph.D., M.P.H., Assistant Professor and Director, Department of Psychiatry, The Collaborative Public Health AIDS Research Center, Charles R. Drew University of Medicine and Science; BERNARD D. GOLDSTEIN, M.D., Professor and Dean (Emeritus), Graduate School of Public Health, University of Pittsburgh; GUY H. McMICHAEL III, J.D., President, GHM Consulting; JOHN R. MULHAUSEN, Ph.D., C.I.H., Manager, Corporate Industrial Hygiene, 3M Company; RICHARD P. SCHEINES, Ph.D., Professor and Head, Department of Philosophy, Carnegie Mellon University; KENNETH R. STILL, Ph.D., M.S., M.B.A., C.I.H., U.S. Navy Captain (Retired), President and Scientific Director, Occupational Toxicology Associates; DUNCAN C. THOMAS, Ph.D., Professor and Director, Biostatistics Division, Department of Preventive Medicine, University of Southern California; SVERRE VEDAL, M.D., M.Sc., Professor, Department of Environmental and Occupational Health Sciences and Occupational Medicine Program, University of Washington; ALLEN J. WILCOX, M.D., Ph.D., M.P.H., Senior Investigator, Epidemiology Branch, National Institute of Environmental Health Sciences; SCOTT L. ZEGER, Ph.D., Hurley-Dorrier Professor of Biostatistics and Chair, Department of Biostatistics, The Johns Hopkins University; LAUREN ZEISE, Ph.D., S.M., Chief, Reproductive and Cancer Hazard Assessment Branch, California Environmental Protection Agency.

VOLUNTEER SCIENTIFIC CONSULTANT:

MELISSA McDIARMID, M.D., M.P.H., D.A.B.T., Professor of Medicine, University of Maryland, IPA to VA, Director, Depleted Uranium Program.

STUDY STAFF

RICK ERDTMANN, M.D., M.P.H., Board Director; CATHERINE BODUROW, M.S.P.H., Study Director; ANISHA DHARSHI, B.A., Research Associate; CARA JAMES, M.S., Research Associate; PAMELA RAMEY-MCCRAY, B.A., Administrative Assistant; JON SANDERS, B.A., Senior Program Assistant.