Institute of Medicine Criticizes VA & Air Force

In its C-123 Agent Orange Report, published under consulting contract to the Department of Veterans Affairs, the National Academy of Sciences Institute of Medicine made a startling accusation. Startling, because of the obvious intrinsic and extrinsic failures of which the IOM was accusing both the Department of Veterans Affairs and the United States Air Force. 

Citing numerous examples, the IOM broadly condemned these authorities for failure to accurately and objectively report, and then utilize, information about military toxic exposures and veterans' illnesses. From page 5:

Reports "from those in the military or associated with the VA tend to minimize the possibility of an increased risk of exposure and adverse health outcomes."

The IOM made clear the fact that veterans' exposures were treated by the VA in a manner calculated to either dismiss altogether or at least minimize the harm done military personnel whose duties presented toxic hazards.

This certainly made clear the VA failure to be pro-veteran and non-adversarial. Get the picture? Our VA doctors and scientists (including its consultant with his $600,000 no-bid sole source VA contract) were saying we were not exposed when they had facts in hand that we were exposed.

An analogy would be your doctor saying your arm isn't broken while both of you look at the x-ray of your broken arm. Plus, other medical experts and federal health agencies had already told your doctor the arm was broken. But the doctor and your insurance company had decided that they don't cover broken arms. Especially from you.

And for four years, our VA doctors in Post Deployment Public Health were determined to send us on our way untreated for our cancers and other illnesses because they had already reached a policy decision not to acknowledge any exposures. Especially from us.

In fact, as we were repeatedly told to our faces by VA officials, no amount of proof from whatever source would ever permit our claims even to come up to the minimum standard of "as likely to us not." And this was after the CDC/ATSDR had already informed the VA that we had a 200 times greater risk of cancer then screening standards. This was after dozens of university scientists and medical experts to Agent Orange aboard our old airplanes. But still, the VA Agent Orange Desk insisted to one and all, both inside and outside the VA, that VA had "an overwhelming preponderance of evidence" against us... But it didn't!

Remember, a veteran's claim is to be assumed truthful and factual on its face, but in case of a question the claim need only arise to equipoise – a level of "as likely to has not," or a 50-50 balance of the question. In fact, every benefit of the doubt is to be given the veteran in the claim. We know now, however, that no amount of proof would be accepted to support these claims – VA policy, rather than VA regulations and science had already been implemented at both VHA and VBA against the veterans.

Our association made accusations of ethical failures, all supported with documentation, against the Department of Veterans Affairs in our presentation to the Society of Toxicology at its 2014 Phoenix convention. Sponsored by a former president of the society ,we addressed the scheme by the VHA Post-Deployment Public Health Section which used a similar presentation to the SOT in 2012 which attempted to redefine the medical-scientific term "exposure." The VA presenters reinvented their use of the word exposure as "exposure = contamination field +bioavailability."

In fact, their redefinition of exposure by the addition of the word bioavailability as a required part to the concept of exposure made impossible most exposure claims from veterans, especially those like us, exposed years earlier and with illnesses such as prostate cancer or soft tissue sarcoma taking years to evolve after our toxic exposure event.

No expert we could find, insider or out of government, agreed with the VA redefinition. All took exception to it, even the director of the National Toxicology Program who said she had never heard of such a thing. She explained bioavailability is a separate but related term. Inventing its own definition rather than use the standard ATSTR glossary of terms Dorlands Illustrated Medical Dictionary (the VA standard reference,) Post-Deployment Public Health was driven by its unofficial, improper but rigidly applied policy to block C-123 Agent Orange exposure claims.

So one has to ask: Did the medical and scientific errors revealed by the IOM in the VHA Post-Dedeployment Public Health Section ever result in comment or criticism, or did they get their full bonuses? One wonders if questions arose about VHA intrinsic and extrinsic ethical failures as regards veterans health? At least one of the 2012 VA poster team still works in that section of VHA... were there any career implications for her participation in this campaign against C-123 veterans?

Finally one must also ask were these experts more disappointed in their failure to implement VA VHA policy against C-123 vets than in the IOM accusations?

VA Orders Claims Officials to Ignore C-123 Scientific Evidence

​The undated document shown below, titled C-123 Agent Orange Talking Points, was released on September 19 by VA Office of General Counsel under our FOIA lawsuit. It is a virtual dismissal order from VA leadership of any and all scientific evidence a veteran can submit to prove a C-123 exposure claim. That's right...in advance, VA tells its staff nothing a C-123 veteran submits can help a claim.

No due process. No notice even of VA's own rules and regulations. No honoring assurances from VA to the Senate that claims will be evaluated, if not with presumptive eligibility, at least for their own merits.

We note with dismay VHA's instructions that no amount of scientific evidence can be considered to overcome...or balance, "VHA scientific data showing no bioavailability." "Insufficient" is VA's judgement, even before the veteran's claim is submitted.

We note that VA did not remind its readers that the law makes no mention of bioavailability, but only of exposure. This amounts to denial of our rights to, as the empty promises put it, "a case-by-case evaluation."

Why Does VA Oppose C-123 Veterans' Agent Orange Valid Exposure Claims?

They've fought us since the first inquiry..."NO" was their first and only answer in a knee-jerk response, after which
they cast about to create reasons for that position. "NO" was their research objective.

Faced with veterans whose claims could very reasonably fit into VA's 21-1MR requirements, instead of seizing on existing rules, laws,  scientific proofs and Federal Register commitments to include C-123 vets, Post-Deployment Health automatically sought ways to exclude, not to include.

Clear? The C-123 vets met each requirement of the VA's to be granted presumptive service connection. Perhaps rules could be interpreted different ways, but VA's only thought was to create interpretations against the C-123 vets. They stretched their rules, not to help us, but to exclude us.

So why the big NO when the law and science were behind the C-123 vets? VA found (created?) several of reasons:

1. VA already said no, and they remain defensive of that decision, unable to modify their position – they want the victory and they disregard the cost to us veterans over the last three years in terms of illnesses, deaths, medical & burial expenses, denial of care, etc. That would mean acknowledging their moral failures. Even if claims are eventually approved, VA saves money by delaying as long as possible (currently three to four years at BVA) to avoid providing medical care. Presently there are over a quarter million veterans' claims in appeal, meaning a quarter of a million vets denied medical care for the illnesses and injuries already established (unless otherwise qualified for VA care.) While VA managers decry the claims and appeals delays, the savings in medical care thereby could exceed a billion dollars each year*
2. Recognizing the C-123 veterans' service connection will cost VA money for health care and disability compensation. Presently C-123 veterans are denied VA medical care and have to make arrangements elsewhere, and are denied the VA peripheral care provided totally disabled vets (dental, rehab, pharmacy, counseling, prosthetics, vision, etc.)
3. VA has the attitude of having to "draw the line somewhere" regarding exposure benefits and will fight any post-Vietnam claims, as Post Deployment Health told the Associated Press
4. Recognizing C-123 post-Vietnam exposures potentially affects other toxic situations well beyond our small group. The White House has been deeply concerned with this since the beginning of Agent Orange concerns, as Peter Sill's box Toxic War perfectly illustrates
5. VA Office of General Counsel has become defensive to the point of insisting on the Department's power to redefine "exposure" to its own purposes; success in that redefinition could help VA oppose other exposure situations such as burn pits, dirty water, biohazards, etc.

C&P Claims Motto

6. Perhaps in some way, their folks in C&P and Post Deployment Health actually believe they are
correct
7. Attitude. They don't like veterans arguing with them
7. Successful opposition to claims such as ours may result in extra praise in their annual performance reviews and perhaps, win them bonuses. They look more productive by denying claims then by approving them
8. Along with their consultants, VA recognizes the threat that would be caused by recognizing our unique long-term exposure. The differences between high intensity/short term exposures and our long term/low intensity exposures was recognized in the first Air Force study and continues to worry experts
9. VARO raters worry about opposing C&P which has ordered C-123 claims denied; raters take easy route of using the boilerplate claim denial language
10. Denying the claim gets it off the rater's desk and lets the veteran lose hope or at least, stick the claimant with a three-four year BVA wait
11. Encouraged by their "Agent Orange Never Hurt Anybody" consultants, Post Deployment Health eagerly accepted the bioavailability concept as a scheme as VA's end-run around the 1991 Agent Orange Act and Congress' elimination of the medical nexus requirement for exposure claims. Brilliant! VA redefines exposure to prevent exposure claims.
12. C&P has already directed C-123 claims denied on the basis of TCDD being harmless, and by citing non-existent VA "scientific studies" and non-existent "VA directives" and any change would necessitate revisiting the injustice of those denied claims
13. The longer VA delays, the more C-123 veterans die and claims die with them

* Harvard's Kennedy School of Government calculations using IEF statistics

VA Designs Institute of Medicine C-123 Study to Prevent Exposure Claims

Skillful folks, the staff at VA Post Deployment Health. And they're not there to let any more veterans onto the Agent Orange disability lists! As they told the Associated Press, "We have to draw the line somewhere."

But three years of their policy of simply telling us "no" began to face some opposition in early 2014 with publication in Environmental Research of the article, "Post Vietnam Military Herbicide Exposures in C-123 Spray Aircraft." While VA could, and would prefer to, ignore that and all other evidence of veterans' exposures, at about the same time Yale Law School released a detailed white paper confirming the C-123 veterans' rights to presumptive service connection for Agent Orange exposures.

Together, these developments added to political suggestions that VA pretend, at least, to follow the law. After all, VA had repeated three times via the Federal Register their commitment to treat non-Vietnam Agent Orange exposures the same as vets exposed in Vietnam. Those repeated commitments needed to be skirted somehow, which VA has successfully done by having reinvented the basic word, "exposure." Simply put, VA decided to redefine the word to include bioavailability, or the proven impact of Agent Orange on the body. Perfect solution...just change the words around so that nobody exposed to anything qualifies for any exposure claims. With Agent Orange, many decades after exposure, the bioavailability of dioxin is impossible for us to prove...and VA even prohibits the test anyway.

But VA had continuing pressure to comply with the 1991 Agent Orange Act, which is to refer fundamental disputes or inquiries about Agent Orange to the Institute of Medicine. Here VA excelled! They complied, yet insured that the IOM process will defeat veteran's exposure claims.

VA gets to make up the ground rules in this game. One is that VA issues a "charge," or assignment, to the IOM to investigate. Since the only question under the law regarding non-Vietnam exposures is exposure, the VA skillfully avoided tasking the IOM with deciding whether we'd been exposed. Instead, VA asked IOM to address fairly irrelevant issues, of interest of course, but irrelevant in terms of whether VA should be treating our Agent Orange illnesses.

Here's their "charge" to the IOM which is currently investigating C-123 issues:

This committee will determine whether there is an excess risk of adverse health among crew members who, after the Vietnam War ended in 1975, flew and/or maintained C-123 aircraft that had been used to spray Agent Orange in Vietnam. The committee will: 

• Evaluate the reliability (including representativeness, consistency, methods used) of the available information for establishing exposure; and, 

• Address (qualitatively as a degree of certainty, rather than in a quantitative fashion) whether any documented residues represent potentially harmful exposure (i.e., consider biological availability of dioxin), by characterizing the amounts available and the degree to which absorption might be expected.

You see it, don't you? The second bullet item specifically asks for an IOM conclusion about bioavailability, which isn't a requirement for any veteran, Vietnam or non-Vietnam, to prove in order to seek care for exposure to Agent Orange. But VA sneaks in the term, knowing in advance that forty years after the last spray missions and thirty years after our last flights in 1982, no such proof is possible.

The IOM committee can't but help to repeat conclusions about bioavailability from earlier IOM reports...that it can't be established for this population.

When the C-123 veterans spoke before the IOM C-123 committee on June 16, we asked them to act independently of their charge from the VA. They have that authority and responsibility. We have, however, repeatedly been told that the committee is interested only in the scientific data required to form a response to the VA charge.

If they do this, they play the VA's game. The IOM avoids meeting its responsibility to us, and avoids answering the only real question on the table: 

Were C-123 vets exposed and, if so, are they to be treated as per law?

Push Back: Resisting the VA Redefinition of Exposure

Veterans exposed to military herbicides (and we're talking Agent Orange in particular) are, by law, to be treated by the VA and considered "presumptively service connected" for the range of Agent Orange-presumptive illnesses. Key word, as we've seen for two years, is EXPOSED.

Exposed. No other qualifier.

But that word was hijacked by the VA a couple years ago.

By redefining exposure to their own perspective, clever folks at Post Deployment Health were able to explain away the scientifically-proven "as likely to as not" exposures of C-123 veterans. Although universities, scientists and other federal agencies continues issuing opinions and formal findings, VA keeps going back to their unique definition of exposure to prevent any C-123 veterans from qualifying for Agent Orange benefits.

Around 2012, VA was faced with the law's requirement that veterans claiming exposure...and proving it...were to be treated and provided benefits. To avoid this, VA invented their unique definition of exposure as: "Exposure = contamination field + bioavailability." 

Here, they didn't put the cart before the horse, but instead virtually put the horse into the cart. They put bioavailability into exposure, saying no exposure happened unless the veterans proved bioavailability also.

This was a very crafty, but ethically questionable, way to skirt the law's clear intent, which VA had recommitted to in several Federal Register postings. Veterans exposed to Agent Orange are to be treated...unless Post Deployment Health could find a way around the law. The physicians and scientists at Post Deployment Health, blocked C-123 veterans' exposure claims by redefining away the fact of the veterans' exposures.

VA's goal was to prevent these veterans gaining access to VA medical care for treatment of cancers, heart disease, ALS and other Agent Orange ailments. Theirs is a blanket policy of denials, despite the Secretary's assurances to the Senate that no such blanket policy exists.

Veterans couldn't very well prove bioavailability of dioxin exposures 40 years after the fact, so VA insisted they'd never been exposed and thus denied the veterans' disability claims.

VA is wrong, and not by accident but rather design. Keep reading.

Exposure is a specific, initial toxicological event. Other than a contaminant being physically present in some manner, exposure is the initial event in what the National Academy of Sciences named the activation of the toxicity pathway. No longer discrete events, the NAS considered them as a whole, as a pathway from toxin to eventual morbidity and mortality.

Repeat: Exposure is the first toxicological event in that pathway. Subsequently, the toxin enters tissues and that is followed by biological interaction. The NAS graphic presents it well, and in our case, helps prove that we've been exposed. Exposure first, then bioavailability down the line.

Not by the VA definition. Fortunately, the NAS graphic and the experts behind its creation show that the VA definition is wrong. Unscientific, as many have said. Ludicrous, as one scientist put it.

Exposure is the initial event in the cycle. Exposure is as simple as skin contact, or inhalation or ingestion of coffee, dust, toxins or other substances. Later, further along in the toxicity pathway, there is biologic interaction...or, as VA phrased it, "bioavailability." Other scientists use the term bioaccumulation, but in all cases exposure is a separate toxicological event, and bioavailability is not a part of exposure but its own event.

Dr. Linda Birnbaum, Director, NIEHS

VA is not only wrong, but completely alone. Their redefinition of exposure, by decree from that small office and not by scientific or legislative process, is wrong and perhaps illegal in that it was done to the great harm of a group of veterans, depriving them of rights without due process.

"We all die" was the response from Post Deployment Health when the veterans asked if the process could be addressed before their illnesses overtook them. We all die, indeed, but C-123 crews drew little comfort from Dr. Peterson's dismissal of our hopes to delay that a bit longer...perhaps as long as others who didn't fly these airplanes.

VA enforces its own rules and regulations, but is subject to outside judicial review. Reinventing exposure to prevent C-123 veterans claims will be eventually resolved, but the VA gains by denying thousands of such veterans all benefits for years...there is no recovery of the costs a veteran handles on his or her own over the years of waiting for VA to unlock their hospital doors. Rehab, pharmacy, prosthetics, dental, vision, survivor benefits, travel, specialty clinics...all denied for years. Either paid for by the veteran or, more likely, done without.

VA Claim Prevention System

Normally (until recent and very effective steps by Veterans Benefits to improve) after getting hurt and then discharged, a veteran has had to provide his/her own medical care for two to three years waiting for a normal disability claim to work through the system. Many find this a complete financial disaster, unless some other medical coverage is available. Savings, homes, marriages suffer while VA dithers for years whether to allow a disabled veteran to be treated.

In the case of the C-123 veterans, events have truly overrun the veterans. First, the Air Force had us fly
these airplanes for a decade, insisting to us there was no contamination from their earlier Agent Orange missions. After the planes retired to storage, when the Air Force by 1994 had definite confirmation of the C-123 toxicity, they ordered all contamination information kept from us, when the Air Force Office of Environmental Health directed "all information be kept in official channels only." The USAF Surgeon General agreed C-123 veterans were not to be notified of our previous exposures "to prevent undue distress."

A low-level of quasi-secrecy ("official channels only")  was maintained up through destruction of the toxic C-123s at Davis-Monthan AFB, Arizona. The consultant from the Office of Secretary of Defense helped craft press releases minimizing the C-123 Agent Orange legacy and touting, instead, the USAF "environmentally responsible" recycling of the metal.

Not mentioned in the press release, which was never released (!) was the fact that the smelting of the contaminated airplanes was necessary to avoid a threatened EPA fine of $3.4 billion for illegal HAZMAT storage over the decades.

Not mentioned was the fact that the regular manager for surplus military sales, the Defense Material Remarketing Service, considered the C-123 fleet hazardous material and insisted on special handling or they wouldn't cooperate without public bidding for HAZMAT processing...which the Air Force wanted very much to avoid. Too much notice would mean that veterans might learn of the problem, another concern expressed by the Office of Secretary of Defense that was to be prevented.

The point should be clear: The C-123 airplanes were to be eliminated without informing already-

exposed C-123 veterans. The OSD consultant's recommendations went to three Hill AFB authorities, including Major Carol McCready, and concerns about preventing veteran awareness were repeated as approvals were sought from higher headquarters..."don't let the C-123 veterans know of this or they'll apply to the VA for exposure benefits" seemed the approach used by the USAF.

I've written about this before in various posts and articles. Why keep repeating the message?

Because VA keeps ordering their regional offices to deny C-123 veterans' exposure claims. VA keeps telling our veterans to seek help elsewhere for Agent Orange illnesses.

VA keeps telling Diane Olmsted, widow of LtCol Aaron Olmsted and mother of an adult, disabled and
institutionalized son, that his VA claim remains denied because Olmsted wasn't exposed during the thousands of hours he flew the C-123...at least, not by the special VA definition of exposure crafted by Post Deployment Health to prevent acknowledging exposure!

New Science Supports C-123 Exposure Claims - but automatically dismissed by VA

What happened? What'd they do?

That’s right...dismissed. Automatically, with reasons to be developed later if necessary, but like all other evidence supporting C-123 veterans' claims, refused without evaluation.

The decision was against us was reached a year ago...that all evidence supportive of C-123 claims is to be dismissed...disregarded...ignored.(clarification...VA C&P told us that no evidence would ever be accepted to bring a claim to "as likely to as not" and that "probably" all claims would be denied...as all have been since we were told this by VA's Dr. Michael Peterson)

VA Post Deployment Health as well as Compensation and Pension Service (C&P) will not accept Friday’s Environmental Research article about C-123 veterans' exposures for support of the veterans' claims.

This has already been decided and the C-123 veterans informed of the decision. At our February 2013 meeting with the Compensation and Pension Service Director, he and his staff explained that no amount of support or evidence, such as the recent Environment Research article or even official findings confirming our exposures from CDC or other federal agencies, will be allowed to elevate a C-123 veteran's claim to "as likely to as not."

While this seemed extraordinary when we were told by the Director, Compensation and Pension, subsequent conversations with the Acting Chief Consultant Post Deployment Health did make things clearer. We learned, through Post Deployment Health, that none of the C-123 veterans were ever exposed.

As simple as that. Change the definition and the problem goes away. That is, their problem...our diseases still sit on our doorstep, if not theirs. The benefit to the VA is that the infamous backlog gets reduced, it goes into the appeals backlog which nobody cares about, and the decisions due the veterans are postponed for years, with tremendous savings in VA medical care denied in the interim which can be as much as five to seven years.

No dental, no vision, no audiology, no prosthetics, no pharmacy, no rehab, no surgery, no anything. Years with the veteran either doing without these services or paying privately, unless otherwise eligible for VA care for other wounds or injuries.

Any civilian or Civil Service employees out there willing to wait seven years to be treated for an on-the-job injury? Hello? Hello??

Which is why Post Deployment Health directed the regional medical centers to refuse requests from C-123 veterans to receive the Agent Orange Registry exam – VA has already decided these vets were not exposed, by having redefined exposure, so no need for the physical. This was double-checked with Post Deployment Health leadership who explained the policy.

Perhaps...it depends how you define the word exposure? To paraphrase a former president.

Post Deployment Health ruling was made based on her group’s internal redefinition of exposure (Exposure = contamination field + bioavailability.)

Thus, even though C-123 veterans have clearly qualified under the law for Agent Orange exposure benefits, no claims will be approved and, in fact, all claims will be ordered denied by C&P, which even provides the rating officials proper boilerplate language to use.

We're reminded of the Secretary's assurances to the Senate that claims will be carefully, individually evaluated without any blanket policy against C-123 veterans. Instead, claims are carefully, individually evaluated and all denied by policy, whatever name it goes by.

And even though C-123 veterans have clearly met scientific criteria for claiming Agent Orange exposure and proved their exposure as well as increased cancer risk and other health impacts, no claims will be approved. Just ask Post Deployment Health.

At first the C-123 veterans concluded that this was a blanket policy against our claims. Both the
Secretary and the Under Secretary for Benefits assured us and our legislators that VA has no blanket policy against C-123 claims. Apparently, VA uses a different word for blanket policy and can thereby nullify the law providing for our benefits.

No C-123 claims will be permitted to be approved, per VHA. They're right...none ever have been approved, although one denied claim was "reconsidered" once enough attention was generated by newspapers and legislators...LtCol Paul Bailey of Bath, NH. His claim was denied in Feb 2013 and reconsidered in August 2013, just after he entered hospice.

The VA blanket policy (I don't know the word VA uses to describe their universal denial of C-123 claims so I'll use that word for now) leaves only legislative relief, which is unlikely given our ages and illnesses, or federal court action. Court action is also unlikely due to the cost and well-known determination of VA to fight claims as far as possible, thus outspending any resources we might muster for the effort.

Nothing will ever help our claims get approved unless the Secretary takes notice of what has been done to us, or if DOD designates the C-123 spray planes retrospectively as Agent Orange Exposure Sites.

Even then, we can expect Compensation and Pension to fight every claim with passion. That’s their job, their mission. They do it well and with pride.

VA Definition of “EXPOSED” – Another Scientist Challenges VA

VA: “Exposure = contamination field + bioavailability.” 

The term exposure was redefined (from the VA perspective, not by regulatory authorities or industrial standards nor any other peer-reviewed action) to include bioavailability,VA's objective being evasion of requirements in the law for providing exposure care to C-123 veterans. The flyers’ exposures were redefined away with VA’s novel redefinition of exposure. No bioavailability = no exposure =denied claim.

The VA redefinition of exposure was apparently first utilized at the VA’s poster display for Society of Toxicology 2012, where the line appeared as part of the historical perspective of Agent Orange, the focus of the poster. It was an official VA poster, with none of the usual disclaimers about not necessarily reflecting agency typical…indeed, usually recommended, on such scientific displays. After SOT 2012, VA continues to deny veterans’ claims insisting the veterans failed to prove bioavailability.

In fact, the bioavailability requirement was grasped by VA’s Post Deployment Health and included by them in the VA’s poster, Agent Orange: 50 Years of History which staff of Post Deployment Health presented themselves. The VA need for a creative redefinition of exposure became apparent when the Federal Register of 31 August 2010 carried a VA statement that the Department would provide “presumptive service connection” to non-Vietnam War veterans able to prove their exposure to Agent Orange. 

Post Deployment Health was faced with either treating the exposed veterans, which policy opposed, plus yet another significant impact on the Department’s health care budget...or VA could create some ways preventing C-123 exposure from being acknowledged.

Thus was born the VA redefinition of a fundamental toxicological term. The VA redefinition is unique, not used elsewhere in science, medicine or government. VA has no statutory or regulatory authority to define such terms. The agencies which do have such authority include the CDC/Agency for Toxic Substances and Disease Registry, and the National Institutes of Health/National Toxicology Program. Both agencies have taken exception to the VA’s redefinition.

In particular, objections were voiced by Dr. Linda Birnbaum, Director of the National Toxicology Program. She wrote,” In all my years as a toxicologist, I have never heard bioavailability as part of the exposure field. Exposure is skin contact (or inhalation or ingestion) with a chemical of any type.”

courtesy of Professor. R.S. Pollenz, Univ. South Florida

Bioavailability itself MUST follow exposure , but not all exposures have the subsequent event of bioavailability. Further, bioavailability is a complex concept based on the chemical nature of the agent.  There is also the major concept of biotransformation since nearly all compounds are metabolized once they enter the body.  TCDD and PCBs however, are somewhat resistant to the biotransformation, since humans do not have enzymes that are able to remove the CL molecules (this is one reason why CL is used as a halogenating agent in creating T45T and other chemicals that kill stuff).  

Readers may be able to find similar schematics on line and in some of the toxicology text books.  Note that the connections may not be linear and are different for each chemical, but this gives the various terms to keep in mind and the complexity of the process.  If there has been an adoption of any term PRIOR to exposure, or definition of exposure to include another subsequent toxicological event as a required component, this is not correct because one MUST be exposed before anything can happen.  

Perhaps, VA has been focusing on the bioaccumulation from a standpoint of whether the amount that someone may carry is BIOAVAILBLE to do anything.  This has always been a hot area regarding the risk assessment of these halogenated compounds.