BLUE WATER NAVY VIETNAM VETERANS AND AGENT ORANGE EXPOSURE

Committee on Blue Water Navy Vietnam Veterans and Agent Orange Exposure

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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BLUE WATER NAVY VIETNAM VETERANS AND AGENT ORANGE EXPOSURE Committee on Blue Water Navy Vietnam Veterans and Agent Orange Exposure Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101 (93) P-2136 (Task Order 21) between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-16247-0 International Standard Book Number-10: 0-309-16247-5 Additional copies of this report 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, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. IOM (Institute of Medicine). 2011. Blue Water Navy Vietnam Veterans and Agent Orange Exposure. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON BLUE WATER NAVY VIETNAM VETERANS AND AGENT ORANGE EXPOSURE ROBERTA B. NESS, M.D. (Chair), Dean, School of Public Health, University of Texas PATRICK N. BREYSSE, Ph.D., Professor, Department of Environmental Sciences, Johns Hopkins University Bloomberg School of Public Health RICHARD CLAPP, D.Sc., Professor, Department of Environmental Health, Boston University MIRIAM DIAMOND, Ph.D., Professor, Department of Geography and Program in Planning and Department of Chemical Engineering and Applied Chemistry, Dalla Lana School of Public Health, University of Toronto MENACHEM ELIMELECH, Ph.D., Chair, Department of Chemical Engineering, Yale University KIMBERLY L. JONES, Ph.D., Professor and Chair, Department of Civil Engineering, Howard University SAMUEL KACEW, Ph.D., Professor of Pharmacology, McLaughlin Centre for Population Health and Risk Assessment, University of Ottawa DAVID KALMAN, Ph.D., Chairman and Professor, Department of Environmental and Occupational Health Sciences, University of Washington JUDY LAKIND, Ph.D., President, LaKind Associates, Associate Professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine, and Adjunct Associate Professor, Department of Pediatrics, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center JOSE SERICANO, Ph.D., Research Scientist, Geochemical and Environmental Research Group, Texas A&M University KENNETH R. STILL, Ph.D., Director and Toxicology Consultant, Occupational Toxicology Associates Inc., and Professor, Environmental Health, School of Community Health, Portland State University v

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Study Staff ROBERTA WEDGE, Study Director MARGOT IVERSON, Program Officer DOMINIC BROSE, Associate Program Officer CARY HAVER, Associate Program Officer JOSEPH GOODMAN, Senior Project Assistant JONATHAN SCHMELZER, Senior Project Assistant NORMAN GROSSBLATT, Senior Editor CHRISTIE BELL, Financial Officer RICK ERDTMANN, Director, Board on the Health of Select Populations vi

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REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s (NRC’s) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of the report: YORAM COHEN, Ph.D., University of California, Los Angeles SEYMOUR DEITCHMAN, Independent Consultant MICHAEL GALLO, M.D., UMDNJ–Robert Wood Johnson Medical School DAVID H. GARABRANT, M.D., University of Michigan ROBERT HERRICK, S.D., Harvard School of Public Health WILLIAM LUTTRELL, Ph.D., Oklahoma Christian University JOEL MICHALEK, Ph.D., University of Texas Health Science Center CLAUDIA S. MILLER, M.D., University of Texas Health Science Center at San Antonio DAVID RICHARDSON, Ph.D., University of North Carolina THOMAS J. SMITH, Ph.D., Harvard University RICHARD WANG, D.O., Centers for Disease Control and Prevention Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Rogene Henderson, Ph.D., Lovelace Respiratory Research Institute, and Kristine M. Gebbie, Dr.P.H., R.N., Flinders University of South Australia. Appointed by the NRC and the Institute of Medicine, they were responsible for making certain that an independent examination of vii

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viii REVIEWERS the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the author committee and the institution.

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PREFACE The committee has been asked to consider whether Blue Water Navy veterans might have been exposed to herbicides used in Vietnam, specifically Agent Orange and its contaminant, 2,3,7,8-tetrachloro- dibenzo-p-dioxin (TCDD), and whether this exposure could lead to an increased risk of long-term adverse health outcomes. When Congress passed the Agent Orange Act of 1991 (Public Law 102-4), which provided for presumption of service connections for diseases associated with exposure to certain herbicide agents, initially the law was interpreted to apply to all service men and women deployed to Vietnam including members of the Blue Water Navy. But in 2002, the Department of Veterans Affairs (VA) took the position that for a Vietnam veteran to be presumed to have been exposed to Agent Orange, the veteran must demonstrate that he or she actually set foot in Vietnam, and in 2008, that VA position was upheld by the US Court of Appeals for the Federal Circuit. This position effectively excluded most Blue Water Navy veterans from receiving a presumption of service connection for diseases associated with exposure to herbicides. Nevertheless, Blue Water Navy Vietnam veterans continue to have concerns that they were exposed to Agent Orange and TCDD during their wartime service. A 2002 Australian study showing that TCDD could be enriched in a simulation of the distillation process used on the US Navy and Royal Australian Navy ships during the Vietnam War era to produce potable water raised awareness among Blue Water Navy veterans that a unique mechanism might exist by which they might have been exposed to TCDD. These concerns and a 2009 Institute of Medicine (IOM) Veterans and Agent Orange report that supported the findings of the Australian study prompted VA to ask the IOM to establish a committee to specifically study whether the Vietnam veterans in the Blue Water Navy experienced exposures to herbicides and their contaminants comparable with those of veterans who served on the inland waters of Vietnam (the Brown Water Navy) and those who served on the ground in Vietnam. In approaching its task, the committee attempted to collect as much scientific and historical information as possible to shed light on the question of possible herbicide exposure by Blue Water Navy veterans. The committee was surprised and disheartened to find a dearth of ix

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x PREFACE information on environmental concentrations of TCDD during the Vietnam War, in spite of the large volumes of Agent Orange sprayed throughout South Vietnam. Such information is vital to determining possible exposures not only of Navy veterans but also veterans who served on the ground and on the inland waterways of Vietnam. The committee struggled with how to deal with the lack of scientific data on which to base its conclusions. Because of the paucity of data available, the committee decided that it would be necessary to approach its task by evaluating whether Blue Water Navy personnel were or were not exposed to Agent Orange and its associated TCDD, and whether it is possible to state with certainty that exposure of Blue Water Navy personnel, taken as a group, was qualitatively different from that of their Brown Water Navy and ground counterparts. Despite this limited framework for asking the question, the committee could not find enough data to determine whether or not Blue Water Navy personnel were exposed to Agent Orange–associated TCDD. At the same time, the committee could not clearly delineate whether there were overlapping exposures between personnel categories. Indeed the committee believes that given the lack of measurements taken during the war and the almost 40 years since the war, this will never be a matter of science but instead a matter of policy. The committee appreciates the importance of this issue for many Blue Water Navy Vietnam veterans, and the committee owes a tremendous thanks to the many individuals and groups who generously gave of their time and expertise to share with committee members their insight into particular issues, to provide copies of reports and research articles, and to answer queries about their work and experiences during the war. The committee is especially grateful to the many veterans who shared their personal stories and who provided historical documents. Among the many people who provided helpful information to the committee are David Barrans, Victoria Cassano, Michael Peterson, and James Sampsel of the Department of Veterans Affairs; Susan Belanger; Thomas Boivin, Hatfield Consultants; Joseph Carnevale, US Navy (retired); Michael Cassady, US Navy; William G. Jeff Davis and Michael Teaney, Veterans Association of Sailors of the Vietnam War; Frederick Gersh; Charles Gordon, Mac McLaughlin, and the docents of the USS Midway; Thomas Hamrick, US Navy (retired); Clint Hoffmann, US Department of Agriculture; Mary Ellen McCarthy, Committee on Veterans’ Affairs, US Senate; Paul McCarthy, US Navy (retired); John

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PREFACE xi Paul Rossie, Blue Water Navy Vietnam Veterans Association; Jeanne Stellman, Columbia University; and John Wells, US Navy (retired). The committee is also very grateful to Roberta Wedge, who served as study director for this project, and to all of the IOM staff members who contributed to this project: Dominic Brose, Joseph Goodman, Cary Haver, Margot Iverson, and Jonathan Schmelzer. A thank you is also extended to William McLeod who conducted database and literature searches. Roberta B. Ness, Chair Committee on Blue Water Navy Vietnam Veterans and Agent Orange Exposure

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CONTENTS SUMMARY 1 Charge to the Committee, 2 Committee’s Approach, 3 Historical Background, 5 Selected Chemicals Used During the Vietnam War, 7 Fate and Transport of Agent Orange and TCDD in the Vietnamese Environment, 8 Exposure Routes and Mechanisms, 10 Long-Term Adverse Health Effects, 11 Conclusions, 12 1 INTRODUCTION 15 Committee’s Charge, 18 Committee’s Approach to Its Charge, 19 Organization of the Report, 27 References, 27 2 HISTORICAL BACKGROUND 29 American Involvement in the Vietnam War, 29 The Debate Over Blue Water Navy Exposure to Agent Orange, 36 References, 44 3 SELECTED CHEMICALS USED DURING THE VIETNAM WAR 47 Herbicide Use in Vietnam, 47 Other Chemical-Exposure Opportunities, 52 Chemicals Used Aboard US Navy Ships, 53 References, 57 xiii

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xiv CONTENTS 4 FATE AND TRANSPORT OF HERBICIDES USED IN VIETNAM 61 The Vietnamese Environment, 62 Fate and Transport of Agent Orange–Associated TCDD in the Vietnamese Environment, 65 Limitations of and Uncertainties on Fate and Transport of TCDD, 78 Conclusions, 79 References, 80 5 EXPOSURE ROUTES AND MECHANISMS 87 Previous Exposure Modeling Efforts, 88 Exposure Pathways, 89 Conclusions, 105 References, 106 6 LONG-TERM ADVERSE HEALTH EFFECTS 109 Vietnam Veteran Studies, 114 Other Navy Veteran Studies, 121 Conclusions, 122 References, 124 7 SUMMARY AND CONCLUSIONS 127 Prior Exposure Assessments, 128 Limitations of and Uncertainties in the Available Information, 129 Conclusions, 131 References, 133 APPENDIX. CODISTILLATION DURING POTABLE WATER TREATMENT: ANALYSIS OF THE AUSTRALIAN STUDY 135 Tables, Figures, and Box TABLE 3-1 Major Herbicides Used in Operation Ranch Hand, 1962– 1971, 50 TABLE 3-2 Examples of Adverse Health Effects Associated with Chemical Exposure, 54 TABLE 6-1 Summary of Seventh Biennial Update of Findings of Occupational, Environmental, and Veteran Studies Regarding Associations Between Exposure to Herbicides and Specific Health Outcomes, 110

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CONTENTS xv TABLE 6-2 Association of Selected Characteristics of Military Service in Vietnam with NHL in the Selected Cancers Study, 1984–1988, 119 TABLE 6-3 Association of Selected Characteristics of Military Service in Vietnam with Hodgkin’s Disease in the Selected Cancers Study, 1984–1988, 120 FIGURE 2-1 Aerial herbicide spraying missions in southern Vietnam, 1965–1971, 37 FIGURE 4-1 Environmental fate and transport processes for Agent Orange and TCDD, 66 FIGURE 5-1 Exposure pathways for Agent Orange–associated TCDD, 91 BOX 1-1 Veterans’ Diseases Associated with Agent Orange Exposure, 16

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