Showing posts with label mary paxton. Show all posts
Showing posts with label mary paxton. Show all posts

31 May 2015

Veterans' Rights Violated – VA Ignores Veterans Claims Assistance Act of 2000

 Ultimately, “[t]he government’s interest in veterans cases is not that it shall win, but rather that justice shall be done, that all veterans so entitled receive the benefits due to them.” Barrett v. Nicholson, 466 F.3d 1038, 1044 (Fed.Cir.2006).

There's a law for that but too often VA ignores it, breaching the government's duty to claimants. For the veteran it can be a great loss, but for the VA, it is never a problem when that law is violated. Specifically, the law is the Veterans Claims Assistance Act of 2000 (VCAA.) It reinforced and detailed a range of pro-veteran steps the VA must take to assist a claimant or appellant for VA benefits.

Key is the law's requirement that VA disability claims system be non-adversarial and pro-veteran. Congress has imposed on VA a duty to assist claimants. VA is required to notify a claimant of what information is required to obtain an award of the benefits requested. One significant part of the law imposes on VA the duty to obtain a veteran’s service records, service medical records, VA treatment records, and any other government records (such as Social Security Administration records) that reasonably may contain information supporting the claim. These duties on VA are supposed to significantly ease the burden on veterans in assembling the evidence needed to support a claim.

At least, that's the law. In practice, it's a law the VA obeys or violates at its pleasure. Abusing a veteran's VCAA rights and prejudicial errors per 38 U.S.C. § 7261(b)(2) also directly abuses rights under the US Constitution's Fifth Amendment and the Due Process Clause. Veterans and other citizens must obey laws or endure consequences. Violate a law, and once faces civil penalties, fines, loss of property, loss of civil liberties, imprisonment.

For VA and its officials, however, violating the Veterans Claims Assistance Act of 2000 carried no such penalties. When VA, in wrongly opposing a veteran, is slapped down by a Board of Veterans Appeals ALJ or the Court of Appeals for Veterans Claims, all that happens is punishment of the veteran! The worst thing for VA is a nasty comment from BVA or a CAVC judge. This is because when VA violates a veteran's rights under VCAA, rather than the vet's claim being corrected for VA's errors the claim is "remanded," – simply left unresolved and sent back to the same VA staffers who committed the violation to start the claims process all over again with a three to five year wait wasted.

So the veteran ups up "punished" by the claim being delayed yet further when the VA abuses the VCAA. There are no penalties for VA or its folks who deliberately failed the veteran. In fact, the VA actually benefits by delaying any medical care or other benefits. It denies or at least postpones paying any disability compensation, and it keeps veterans out of VA hospitals which helps keep existing appointment lines shorter.

In the case of C-123 veterans, VA ignores the VCAA, creating an adversarial rather than the statutory non-adversarial process, following the requirements of the law when and if it wanted to. Generally, VA has helped locate Social Security records (although it twice lost mine.) It generally locates service medical records (although it ignores mine from Bethesda Naval Hospital.) VA generally locates and acts on military service records (although it ignored my line-of-duty determinations, ignored details on my separation physical, and ignored both medical and military details on my PEB hearing, and ignored details of my Air Force Board of Correction of Military Records.)

But that's just me. VA also abused the VCAA rights of every other C-123 veteran. Their abuse cost us four years delay in getting our veterans into VA hospitals and able to use other VA benefits, such as CHAMPVA family medical care, nursing home, primary care, pharmacy, dental, audiology, prosthetics, survivor benefits and other vital services. Veterans pay the price for VA's abuse of us, but VA and its staffers have absolutely no consequences at all.

VA hasn't acted to honor its statutory duty to assist, and operate in a pro-veteran, non-adversarial manner with a low threshold for the burden of proof. Here's how VA ignores the VCAA.

How VA violates VCAA and trashes C-123 veterans' rights:

I. The worst violations were VA's determined avoidance of official input from the DOD Joint Services Records Research Center (JSRRC) and suppression of  that input for two years for two years after receipt. JSRRC informed VA's JSRRC Coordinator in March 2013 that the government had official records confirming C-123 veterans' Agent Orange exposures. Among other records, JSRRC provided Air Force and Center for Disease Control/Agency for Toxic Substances and Disease Registry reports identifying the C-123's as "heavily contaminated with dioxin on all test surfaces" and "a danger to public health." The ATSDR's director informed JSRRC that C-123 veterans experienced a 200-fold greater cancer risk...but VA's JSRRC coordinator sat on these official government records for two years.

For two years VA blithely ignored the VCAA and doomed claims at the regional VA offices as well as claims appealed to the Board of Veterans Appeals. Withholding official government records (here, the JSRRC March 2013 report) directly abused veterans' rights under VCAA. No problem at all for VA. Big problem for veterans who were forbidden VA medical care merely because of the preferences of VA staffers. The veteran and the VA are subject to VAM21-1MR which has the force of law (Evidentiary development procedures provided in the Adjudication Procedure Manual are binding.  See Patton v. West, 12 Vet. App. 272, 282  (1999))

Below is VBA's Agent Orange Desk explaining to other VA staff why VA opted to ignore JSRRC proof of C-123 claims, although no mention is made of why VA kept the evidence from claimants and the BVA considering such issues. Apparently a point was made that VA would only accept JSRRC reports which referenced military documents. No mention was made of VA having rejected Rear Admiral R. Ikeda (MD USPHS) and Captain A. Miller (MD USPHS) input, which was military because USPHS commissioned officers are by statute military officers. Further, VA regulations describe JSRRC as inputting to VA relevant "primary" evidence, not just evidence selected by the Agent Orange desk.

In this case, it was not USPHS evidence, but appropriately USPHS expert analysis of contemporary (1979-2010) military toxicology reports. As Admiral Ikeda was then Acting Director CDC/Agency for Toxic Substances and Disease Registry, such input seems both accurate and relevant, as well as military in nature. The question screams out..."how much proof does the Agent Orange desk demand to permit 'benefit of the doubt? Why set uniquely high standards for C-123 claims, rejecting JSRRC, DOD, CDC, NIH, USPHS, dozens of physicians and scientists, university researchers and VA physicians?'

II. Rather than be non-adversarial and even-handed in evaluating exposure claims per the law, VBA issued a 2012-2014 $600,000 no-bid sole source contract for monographs supporting VHA and VBA current policies and perspectives on herbicide exposures. That consultant's largest single target in two years was C-123 veterans' hopes with the Institute of Medicine C-123 committee. VA spent hundreds of thousands of dollars on its favored outside consultant specifically for his coaching against against and to target C-123 veterans' exposure proofs.

There were no studies allowed to support C-123 veterans' scientific position (we asked VBA for funding to prepare a pro-C-123 study but they didn't respond.) Veterans never could have funded the research provided pro bono by Columbia University, Oregon Health Sciences University, University of Texas Medical School and the many federal agencies like CDC.

All expert input supporting the C-123 veterans' scientific argument was unpaid – besides, the veterans had no source of funding and didn't spend a penny to counter the government's hundreds of thousands of dollars. On the other hand, all input used by VA to obstruct the C-123 veterans was paid either by VA, Dow or Monsanto. When peer-reviewed articles were published confirming the veterans' exposures, VA immediately opposed their findings.

The scientists and physicians in Veterans Health Administration represent a huge body of knowledge, skill and talent, none of which came to help us. They followed their company line, which was no more Agent Orange claims. All of those experts opposed C-123 veterans' service connection. They must have seen the totality of the evidence and realized there was no "overwhelming preponderance of evidence" against us, but more likely, for us. It is easy to look at the past four years and see that these professionals should have established service connection for C-123 veterans within existing law and science. The law sets a low threshold of proof for veterans, but no amount of proof would make VBA honor our claims (as Mr. Murphy confirmed at his office on 28 Feb 2013.)

Some of the many adversarial studies funded by VBA to oppose veterans were titled:
A. "Discussion Points Supporting Compensation Services' UC-123K Claims"
B.  "Investigations into the Allegations Concerning 2-4-5-T Herbicide"
C. "Investigative Report: Assessment of New Information on the Former UC-123Ks Post-Vietnam Issue"
D.  "Investigations into the Allegations of Agent Orange/Dioxin Exposure from Former Ranch Hand Aircraft"
E. "Supplement to Investigative Report: New Information on Former UC-123K Post-Vietnam Issue"
F. "Al Young Letter to Acting Secretary Gibson requesting reversal of IOM report conclusions"
G. "Al Young Letter to Dr. Mary Paxton, Institute of Medicine C-123 Committee Staff Director arguing scientific failure of committee report"
H. "Al Young Letter to Dr. Terra Irons to answer questions put to VA by Institute of Medicine C-123 committee."
• Some of the studies or efforts by VA to consider possible merit to the veterans' claims:
Oh...there weren't any. VA permitted no such effort. Actually, there was one, the IOM C-123 report. Although VA argued hard and spent huge funds against the veterans through its proxy consultant, IOM, contracted with VA's hopes of finally blocking C-123 claims, instead independently concluded VA had been wrong all along and veterans had been correct all along. The real preponderance of evidence agreed with the C-123 veterans.

VA only sought material to oppose C-123 veterans. VA only recognized material if useful by VA against C-123 veterans. Nearly all material VA had was paid for by VA. Everything supporting C-123 veterans was from other federal and state agencies, and physicians and scientists without any compensation for their input. VA bought materials tailored to oppose or accepted it from the chemical industry. Veterans didn't buy evidence tailored to their objectives and never had funds to do so anyway. While the VA's consultant frequently referred to his monographs as "peer reviewed" there were not, as it is not acceptable for a researcher or author to select the reviewers himself. Peer reviewers should be objective, independent and not pre-selected by the author.

VA deliberately avoided uncovering or acknowledging any evidence or support for C-123 veterans. Their web pages discussing the C-123 investigation fail to mention a single resource not pre-selected to meet VA's policy objective. VA characterized all pro-C-123 exposure evidence as unacceptable because it conflicted with VA's predetermined policy objectives. Nearly all outside input VA sought was from its Agent Orange consultant, who previously also consulted with Dow Chemical against Vietnam Veterans' exposure claims, and two other scientists paid by Dow and Monsanto specifically to opine against C-123 exposures.

VBA's consultant also appeared as VA's proxy at the June 16 2014 IOM C-123 committee hearing to oppose the veterans' position. Without mention of his VA contract, nor the coordination of his IOM presentation and materials with VA, nor his role in 2009 recommending destruction of the C-123 fleet as toxic waste, he was an extremely authoritative and long-term dedicated opponent of all Agent Orange claims.

III. Acting in bad faith and utilizing resources known to be flawed in order to oppose veterans' claims, VA used without updating and correction the 2006 DOD Agent Orange site report used by VA to verify veterans' claims for non-Vietnam exposures. When a servicemember claims to have been exposed outside Vietnam, VBA checks against the DOD list and approves or denies the application.

The problem is the DOD list is seven years old, yet VA cites it in VARO decisions, and BVA cites it in appeals. It is fundamentally wrong for a government agency to permit use of a reference they know to be inaccurate. VA and DOD have rejected numerous entreaties by the C-123 Veterans Association to update their lists.

How does VA know the DOD list is unreliable? Because the list author himself, Dr. Al Young, prepared it for DOD in 2006 and then in 2013 proposed a contract for correcting identified errors and general updating. Nonetheless, VA approves or denies disability claims based on this terribly flawed document. It is as unacceptable error on VA's part.

Thus, VA violates the VCAA by knowingly deciding claims on flawed evidence, a "clear and unmistakable error."

From the first page of the consultant's report, "Investigations into Sites Where Agent Orange Exposure to Vietnam-era Veterans Has Been Alleged."
(From the VA's 2013 Agent Orange site report)


IV. Violating its duty to assist as well as performing in an anti-veteran manner, VBA opposed C-123 claims citing potential difficulty verifying aircrew or maintenance veterans' duty aboard specific former Agent Orange spray aircraft. Actually, this information was provided VA in 2011 by Headquarters Air Force Reserve Command and also by the Air Force Historical Records Agency. In any case, VBA in the spring of 2015 was able to identify eligible veterans by cooperating with other agencies such as Social Security and the Air Force

V.VBA and VHA orders to regional claims offices to deny C-123 disability claims violated VCAA by inappropriate guidance to those offices, and failure thereby to notify veterans of evidence needed to establish a claim. Specifically, veterans were not informed of proofs needed to overcome VHA and VHA's order to deny C-123 claims.

Further, VHA and VBA were wrong in their science since C-123 claims were first denied in 2007. As the Institute of Medicine C-123 report concluded, the aircraft were contaminated and the veterans were exposed and harmed. There was no new science behind the IOM conclusion but rather the proper interpretation of existing material. VA was simply wrong in its leap to construct unscientific arguments to block C-123 claims and was obviously anti-veteran and adversarial.

The proper VCAA pro-veteran approach should have been, if serious question existed as to the scientific foundation of the veteran's claims, to approve all applications until the science made clear the issue one way or the other. This is especially true considering the affirmation provided by ATSDR, NIH, US Public Health Service and the DOD JSRRC report in March 2013. VA clung to every possible negative interpretation it could devise and refused to admit an overwhelming body of evidence proving VA wrong...at the very least all that evidence introduced the "benefit of the doubt" which VA violated, despite the VCAA.

VI. VA has never permitted consideration of the possibility C-123 veterans might have been exposed.; no VA document released under FOIA questioned VA's consistent opposition to veterans or questioned whether the veterans might be correct. VA's adversarial as well as anti-veteran approach is quite clear and violated VCAA. Beginning with opposition to C-123 veterans VA never wavered.

VII. VA has never admitted locating any evidence supporting C-123 claims was ever identified by VA. Rejecting everything it disagreed with, VA was unscientific, and prejudicial in the extreme with blinders on regarding any contrary input.

VA denigrated every scientific and medical expert opinion supporting C-123 veterans as unpersuasive, lacking authority. Every scientist's input, even that from CDC and the National Institutes of Health as well as subject matter experts VA and IOM had previously relied upon, was immediately dismissed by VBA. VBA insisted its scientists were far more credible than experts who might not agree with them. VA insisted that its experts concluded that all evidence and expert input supporting veterans' claims of having been exposed to Agent Orange failed to create an element of doubt in favor of the veterans' claims.

"Overwhelming preponderance of evidence" is how VBA quite inaccurately described the VA's position against veterans. Four years of VA opposing C-123 claims eventually made perfectly clear that no matter how substantial the veterans' evidence and how unsubstantial the VA's, VA's was automatically but falsely characterized as an overwhelming preponderance of evidence.

VIII. VA created an in-house, novel and unscientific (per NIEHS) redefinition of "exposure" attempting to disqualify veterans' exposure claims.VHA's Public Health/Post Deployment Section redefined exposure to be "exposure=contamination field+bioavailability." This was introduced as a line in VHA's 2012 Society of Toxicology poster displays.

The redefinition was in contrast to standard definitions used elsewhere in VA, by the CDC, NIH and other authorities. It was even in contrast with VA's standard reference for definitions, Dorlands Illustrated Medical Dictionary.

VHA overlooked the fact that unique, home-made scientific definitions aren't scientific, especially when other federal agencies with statutory authority in the field label VA's exposure definition unscientific. "Whoever invented that certainly is no toxicologist" reported the director of a major federal research program. Veterans were invited by the Society of Toxicology to present a response at its 2014 conference, under sponsorship of the NIEHS.

IX. In a manner similar to VA's rejection of the March 2013 JSRRC exposure confirmation, VA also elected to ignore the expert input of Rear Admiral R. Ikeda, MD US Public Health Service and Acting Director, CDC/ATSDR.  USPHS commissioned officers are military officers, and her concurrence with earlier ATSDR findings of C-123 veterans' Agent Orange exposure was suppressed after its receipt in June 2013. Captain A. Miller, MD US Public Health Service, also submitted an expert medical opinion in March 2013 confirming veterans' exposure but as with all other evidence behind C-123 claims, VA's Agent Orange desk disregarded it and withheld it from VAROs and the BVA. Disregard for and suppression of these two expert military medical opinions was in clear violation of the VCAA.

Conclusion:
Violation of the Veterans Claims Assistance Act of 2000 were numerous and unrelenting. It didn't matter how much evidence supported veterans' exposure claims because VA predetermined it had "an overwhelming preponderance of evidence" regardless of all reason. VA's policy of preventing C-123 exposure claims led it to conceal pro-veteran evidence such as the March 2013 JSRRC confirmation. Suppression of any evidence within the government's possession violated VCAA, and the JSRRC email was critical evidence kept from veterans and the BVA.

VCAA was violated more generally with VA's stubborn resistance to any scientific or medical evidence supporting C-123 veterans' exposure claims. This was anti-veteran and adversarial. This deliberately avoided admitting any benefit of the doubt due veterans.

That VA was wrong in all this is clear from the Institute of Medicine C-123 report to Secretary McDonald. Despite all its money spent to oppose veterans, science spoke louder than specie.

The VCAA failed C-123 veterans. Nothing in it prevented violation of C-123 rights by the VHA Post Deployment Health Section and the VBA Agent Orange desk in the Department of Veterans Affairs. Nothing in the law prescribes a remedy for such abuse of office or prevents its abuse again. The same VA staffers perform the same duties, electing whether to obey or disobey the VCAA.

Only veterans were impacted and only veterans paid the price for VA's campaign against us. Still barred from VA hospital and refused VA benefits, we are still paying the price. As for the VA staffers, they're annoyed with our resistance for these four years but nothing more: it's just not their problem.

10 January 2015

C-123 Post-Vietnam Aircrew and Maintainers: Agent Orange Exposure CONFIRMED by IOM!

Exposure CONFIRMED! Last hurdle overcome!

In a clear message to the VA and USAF, yesterday the Institute of Medicine dismissed any questions of C-123 post-Vietnam Agent Orange exposure with their press release announcing conclusion of a year-long investigation. IOM confirmed the post-Vietnam exposures of C-123 aircrews and maintenance personnel in their VA-sponsored research.

This is a game-changer as VA has stated, through Under Secretary Allison Hickey, that whichever way the IOM report recommended the VA would likely follow. VA executives were briefed on Thursday and the IOM released their C-123 investigation to the public, legislators and the press on Friday. Following the report's presentation, VA leaders said staff was already working on the implications of the IOM's finding and details were being resolved.

The VA has been hit hard this last year, which with justification will be remembered as the year of the scandals. This is a scandal resolved, through the efforts of the scientific community )to include IOM as well as the independent scientists and physicians who continued to reveal the basis for C-123 veterans' exposure claims,) and VA staff which opened the door and their hearts with determination to resolve this mess.

So the resolution is on its way. We should see changes in VA web pages, communication from VA to their staff, press releases from VA on its views regarding the IOM report, and we hope...claims being released from the current suspended status ordered for all such claims.

Let's hope this is as much as win-win as it seems. In my mind, it leaves all involved a solid justification for feeling their duty to America's veterans has been satisfied. Congratulations!

09 January 2015

Good News from the Institute of Medicine

Initial thoughts: the IOM agreed that Reservists were exposed. Their comment:
It is the Committee's opinion that it is quite plausible that, for some Reservists, the exposures received during their work on C-123s exceeded TCDD guidelines for workers in enclosed settings.

Now to read the report more carefully, and just as important, find out the impact of this on the VA's processing of our veterans' exposure claims.

The briefing starts in a few minutes and I'll update further when possible.

Again...good news!

27 August 2014

Current Status - Institute of Medicine C-123 Agent Orange Exposure Committee

Actually, the full name just doesn't quite flow off the tongue, nor is it easily typed...I always have to look it up: Committee to Evaluate the Potential Exposure to Agent Orange/TCDD Residue and Level of Risk Adverse Health Effects for Aircrew of Post-Vietnam C-123 Aircraft."

They've been meeting and working very hard since the spring and apparently are about finished with their draft copy, according to the cryptic summation of the recent committee teleconferences. Once the draft is complete, it begins another process before reaching the Secretary of Veterans Affairs:
• Prior to release, report is reviewed by individuals who are not involved in authoring the report and whose names are not revealed to the committee or the study director during review.
Reviewers are selected by the major unit responsible for the project, in consultation with the National Academy of Sciences’ Report Review Committee.
• The review is overseen by a review monitor and/or coordinator.
• Each committee must respond to, but need not agree with, reviewer comments in a detailed “response to review” that is examined by the monitor and/or coordinator, who ensure that the report review criteria have been satisfied.
• The report may not be released to sponsor or the public until the chair of the Report Review Committee (or designee) signifies that the review process has been satisfactorily completed.
• The Department of Veterans Affairs will not be given an opportunity to suggest changes in the report.
• The names and affiliations of the report reviewers will be made public when the report is released.
The second bullet could be fatal: VA, as the "major unit responsible" will select reviewers already determined to prevent C-123 exposure claims, so whatever pro-C-123 exposure conclusions will be severely challenged, and whatever anti-C-123 exposure conclusions will be amplified. So whatever the committee itself recommends will be amended in some way at this point to a position more acceptable to the VA's Post Deployment Health Section. And you can bet they've already got their reviewers picked out! Only when its released and too late to be challenged, are the reviewers identified and in any case, nobody sees the committee's draft, or original version.

Remember: VA did not refer this to the IOM because there is any scientific question that we've been exposed. They referred it, and worded the charge to the committee, to create a basis for continuing to deny all C-123 exposure claims even though each C-123 veteran with an Agent Orange-recognized illness is presently legally entitled to presumptive service connection.

A strong point still in our favor is a fundamental IOM rule: In reaching consensus about an association between exposure and health effects, the Committee considers only peer-reviewed, published scientific literature. The committee also realizes that this group of veterans was never tested at any time for dioxin, and that VA rules for the Agent Orange registry actually prohibit such tests.

The committee realizes that our C-123s are unique in that they were tested to be contaminated – "highly contaminated," in the words of the toxicologists, long after we'd retired them to storage. No other such situation...boats, ships, tanks, trucks, helicopters...was ever determined to be contaminated as were our C-123s. "A danger to public health" as AF toxicologists offered in sworn testimony in 2000. And then, all aircraft destroyed as toxic waste, with special note made for this to be done because exposed vets would seek their exposure benefits.

The material gathered by the VA for IOM, including from its $300,000/year Agent Orange consultant and the Dow/Monsanto sponsored letters, was never peer reviewed. Of course, many other documents submitted to the IOM by the VA and the veterans weren't peer-reviewed, either.

And the only peer-reviewed scientific literature available which directly addressed the situation was Lurker, et. al. "Post-Vietnam Military Herbicide Exposures in UC-123K Agent Orange Spray Aircraft."

The committee is doing what it has to. We asked them also to exercise their independence and address the yes/no question of exposure.

We'll wait and hope for the best.We'll look forward with great hope to the end of September or, if delayed, maybe sometime in October bringing us the IOM report.

03 April 2014

Institute of Medicine Begins C-123 Study; Results Anticipated Late September

Acting on an important work project contracted from the Veterans Affairs, the National Academy of Sciences, through its Institute of Medicine, is beginning the initial organizational efforts for an intensive focus on the C-123 Agent Orange contamination and the exposures of aircrews and maintenance personnel.

According to information received yesterday from committee director Dr. Mary Paxton, the format will be a workshop and the goal to complete their response to the Secretary of Veterans Affairs by lat September. The work will be done in Washington, D.C. rather than the IOM conference center at UC Irvine.

Details:
1. Title of Assignment: Committee to Evaluate the Potential Exposure to Agent Orange/TCDD Residue and Level of Risk of Adverse Health Effects for Aircrew of Post-Vietnam C-123 Aircraft
2. Format: workshop. Invitations to presenters, but there will be an open session for public comment
3. Good Manners: best to submit all materials and conversations to the committee through the staff director
4. Charge to the Committee by the VA:
– The IOM committee will also 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:
Report Available September
·         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, and, place in context.The possible health effects would be assumed to be those characterized in prior Veterans & Agent Orange reports, and would not be re-assessed for this report. VAO activities to date have found the information concerning the exposure of Vietnam Veterans inadequate to establish dose-response relationships for individual health outcomes or to quantify the risk of a particular Veteran experiencing any adverse effect. 

01 March 2012

Vietnam Vets of America - Agent Orange Statement

{Following is a statement by Mr. Alan Oates, Agent Orange Committee chairman. I regret not posting it earlier but just received it today. We are grateful for his mention of our C-123 crews in his presentation. Mr. Oates first brought our aircrew concerns to the Vietnam Veterans of America leadership!)


Agent Orange/Dioxin Committee Report 
Alan Oates
An Update

On September 29 2011 the Institute of Medicine (IOM) released the eighth biennial update of the Vietnam Veterans Agent Orange Review.You can read the report at http://www.iom.edu/ Reports/2011/Veterans-and-Agent-Orange-Update-2010.aspx

There are several important changes from the 2008 update. Mary Paxton, the IOM staff director for the study, presented an overview of the update at the October meeting of the Agent Orange/Dioxin and Other Toxic Substances Committee.

The first important change was a request from the VA that IOM, “when summarizing the evidence available to support the association of a health effect with exposure to the components of the herbicides used by the military in Vietnam, the committee address whether or not all the points that have rather imprecisely become known as the Bradford Hill (1965) ‘criteria’ for causality (strength, consistency, specificity, temporality, biologic gradient, plausibility, coherence, experiment, and analogy) had been satisfied by the information available.”

This request was a result “arising from the decision-making at VA necessitated by the findings of Update 2008.”

It is important to look at the events leading up to and after the VA’s request. After the 2008 Veterans Agent Orange Update was released, the VA Secretary declared three new diseases presumptively service connected to Agent Orange. The cost of adding these new diseases caused Sen. Jim Webb (D-Va.) To question the VA’s decision-making processes. That brought about a hailstorm of discussion, scrutiny, awareness, and even a hearing by the Senate Committee on Veterans’ Affairs. The end result was that the new diseases became presumptive, but the process opened the door for some legislators to target the Agent Orange Act of 1991, which was the basis for the Secretary’s decision.

Sen. Tom Coburn (R-Okla.) Offered an amendment in late July that sought to change the law to block more conditions from being added to VA’s list of Agent Orange presumptive diseases unless medical science could show a causal effect and veterans could prove that they were exposed to the herbicide. This would have changed the current standards based on association and established a standard of proving final causation. It also would have taken the presumptive exposure away and required each veteran to prove his or her exposure to Agent Orange.

It can never be proven that exposure to Agent Orange is the only scientific cause of any disease in Vietnam veterans. There are a lot of reasons for this. First, there was a failure to collect timely data, to document exposures, and to do the necessary studies. The studies that were done failed to examine all the exposures and only looked at the TCDD dioxin.

You can’t go back and rebuild this data forty years after the fact.You can’t reestablish the conditions and environment to which each individual was subjected. You cannot establish if there were genetic changes that might have occurred. And you cannot subject humans to these toxins to gain better knowledge.

IOM pointed out in the 2008 update that it wasn’t feasible for them to evaluate the impact of a combination of toxins on Vietnam veterans. So how can our government expect veterans to prove causality?

The IOM Veterans Agent Orange Review Committee’s response to the VA’s request for a causality checklist approach was: “This committee gave careful consideration to the request from VA that, in addition to its usual discussion of biologic plausibility, the committee should state the degree to which each of the other ‘Hill criteria for causality’ are satisfied by the existing scientific information. As well known as these standards or those developed by the U.S. Surgeon General when first assessing the health consequences of smoking are, there is in fact no sufficient set of criteria for declaring that causality has been established. In accord with the current thinking of epidemiologists, the committee concluded that adopting a checklist approach would be inappropriate.” The Veterans Agent Orange Review Update 2010 Committee was right.

The current political climate of reducing spending will bring attacks on veterans’ benefits. There will be many opportunities for legislators to incorporate unreasonable changes into the Agent Orange Act of 1991.Veterans need to stay vigilant.

The second important item from the report deals with hypertension. This is the third report and the third IOM committee that has agreed there is an association between hypertension and “Agent Orange” herbicides. In the new 2010 report, the IOM committee concluded: “After carefully examining the new evidence, the present committee deemed that the new information justified the continued placement of hypertension (ICD-9 401–405)…in the limited and suggestive category.”

By law, the VA Secretary must consider the positive association found by the IOM Agent Orange Review and any other credible evidence in granting presumptive service connection for an Agent Orange-related disease. He must apply the standards established by the Agent Orange Act of 1991. That standard says: “An association between the occurrence of a disease in humans and exposure to an herbicide agent shall be considered to be positive for the purposes of this section if the credible evidence for the association is equal to or outweighs the credible evidence against the association.”Without credible evidence against an association that outweighs the positive association in the Veterans Agent Orange Review updates, the Secretary of VA should not continue to deny presumptive status for hypertension.

The third important change deals with acute and subacute peripheral neuropathy. In past reports only acute and subacute peripheral neuropathy (which occurs within one year of exposure) that was transit (that cleared up with in two years of onset) had an association. VA currently grants presumptive service connection for the transit acute and subacute, but not if it is persistent. This new update finds that both the transit and persistent acute and subacute peripheral neuropathy have an association.The update still finds that there is inadequate evidence to support an association between delayed onset chronic peripheral neuropathy, in which onset takes place later than one year from exposure.We hope that the Secretary grants presumptive service connection for persistent acute and subacute peripheral neuropathy.

The last item I want to cover in the report comes out of the recommendations made by the committee: “Although progress continues to be made in understanding the health effects of exposure to the chemicals of interest and in elucidating the mechanisms under lying them, gaps in our knowledge remain.The scope of potential research on the chemicals is far reaching, and what follows here is not an exhaustive list of future research that might have value. There are many additional opportunities for progress in such areas as toxicology, exposure assessment, the conduct of continuing or additional epidemiological studies, and systematic and comprehensive integration of existing data that have not been explicitly noted here. It is the committee’s conviction, however, that work needs to be undertaken without delay, particularly to address questions regarding COPD; the potential for paternally mediated, clinically defined health outcomes in offspring; and the effective utilization of VA’s medical database.”

What is important to note is the lack of action by the VA on the recommendations from past updates. VA must act on these recommendations in order for the system created by the Agent Orange Act of 1991 to work as intended.

This committee urges all veterans to ask their U.S. senators to support and co-sponsor Senate bill S. 1629, The Agent Orange Equity Act of 2011, for blue-water veterans. Go to http://thomas.loc.gov/cgi-bin/ bdquery/z?d112:s.1629:

There are many issues that deserve our support. They include the health effects of Agent Orange on our children and grandchildren, Agent Orange exposures outside Vietnam, the use of contaminated aircraft such as the C-123s that were used long after the war ended, and other environmental exposures such as TCE, solvents, and fuels. Let us not forget those veterans from every era who suffer from toxic exposures. Caring for these veterans is a cost of maintaining a military force and of war. Failing to provide the necessary funding cannot be an option