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Veterans and Agent Orange: Update 2012 (2014)

Chapter: Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee

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Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

Appendix A


Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee

ISSUES RAISED BY THE PUBLIC

Following delivery of the committee’s charge by a VA representative at the first meeting, the open session continued with brief presentations by other members of the public. It has been the practice of VAO committees to conduct open sessions, not only to gather additional information from people who have particular expertise on points that arise during deliberations but also especially to hear from individual Vietnam veterans and others concerned about aspects of their health experience that may be service-related. Open sessions were held during the first four of the committee’s five meetings.

Having solicited input, the committee feels a responsibility to address the concerns raised, even if it is only to the extent of noting that a topic does not fall within the committee’s charge. The issues raised by veterans or their advocates during the current updating period fell into five general categories. The following is a summary of the topics raised at the open sessions or in submitted written statements with the committee’s responses to them.

•  Veterans exposed to Agent Orange in places other than Vietnam: Veterans noted several locations or situations (listed below) where they believe they were exposed to Agent Orange and so are entitled to coverage of those diseases recognized as service-related for veterans who had “boots on the ground” in Vietnam. Evaluating data on the basis of where veterans may have experienced herbicide exposure is not within the scope of this committee’s charge.

image  Thailand

Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

image  Guam

image  State-side military facilities

image  Blue Water Navy

image  Post-Vietnam exposure of reservists to residual Agent Orange contamination in C123 aircraft

•  Health problems in children and grandchildren of Vietnam veterans: Chapter 10 addresses evidence related to the possibility that the herbicide exposure of Vietnam veterans has had adverse consequences for their progeny. It discusses the current paucity of information on the general phenomenon of the transmission of adverse effects to offspring following paternal exposure to toxic agents.

•  Health outcomes not currently treated as being related to Vietnam service:

image  Autoimmune conditions (such as negative rheumatoid-factor arthritis and fibromyalgia): The paucity of evidence from human studies on herbicide exposure and immunologic responses, despite the substantial toxicologic evidence of TCDD’s role in such health problems, motivated the committee for Update 2010 to address this issue in considerable depth. The current committee endorses the usefulness of its predecessor’s discussion of factors that may contribute to this apparent discrepancy (see Chapter 7).

image  Bladder cancer: The relevant available epidemiologic evidence remains inadequate and insufficient to support an association. See Chapter 8 for specific discussion.

image  Squamous-cell cancer of head and neck: The relevant available epidemiologic evidence remains inadequate and insufficient to support an association, but the committee continues to recommend that VA endeavor to use its own data to determine whether they constitute supportive evidence. See Chapter 8 for specific discussion.

image  Ocular melanoma (particularly choroidal melanoma): A Vietnam veteran who had choroidal melanoma submitted information received from VA after a Freedom of Information Act (FOIA) request. The data are not adequately explained and labeled, but they suggest that the condition is being treated in VA facilities far more often than expected on the basis of national incidence rates. Without more details on how the statistics were abstracted, it is not possible for the committee to interpret their meaning. The paucity of information on this specific form of malignancy is discussed in Chapter 8. The committee recommends that VA systematically evaluate the information on the condition that is available in its records.

image  Myelodysplastic syndrome (MDS): The relevant available epidemiologic evidence remains inadequate and insufficient to support an association of MDS with exposure to the herbicides constituting the

Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

     committee’s COIs. See Chapter 9 for specific discussion. Exposure to benzene is recognized as being a risk factor for MDS, and it is a component of the petroleum products used as dispersants with the herbicides. Benzene is so highly volatile that it would no longer be part of the sprayed herbicides as they reached ground level, and so it is not covered under the committee’s charge. Several epidemiologic studies addressing risk factors for MDS were identified in the recent update period, but the available evidence remains insufficiently specific with respect to the COIs to provide a basis of a decision concerning association other than the default decision of inadequate or insufficient.

image  Neurologic problems (delayed-onset peripheral neuropathy, restless leg syndrome, Willis-Ekbom disease or periodic limb-movement disorder, migraines, and anterior ischemic optic neuropathy): VAO committees continue to consider any relevant information concerning possible associations between the COIs and the delayed-onset form of peripheral neuropathy (see Chapter 11). The other neurologic conditions have not been subjects of epidemiologic research identified in VAO literature searches.

image  High blood pressure: Although VA has not regarded this health outcome as presumptively compensable for Vietnam veterans, the committee continues to endorse the finding of the committee for Update 2008 that there is limited or suggestive evidence of an association between hypertension and exposure to components of the herbicides used in Vietnam.

image  Peripheral vascular disease: See Chapter 12.

image  Endocrine effects: See Chapter 13.

•  Health effects of chemicals other than Agent Orange: All chemicals in the herbicides used in Vietnam (picloram, cacodylic acid, phenoxy herbicides, TCDD, and dioxin-like compounds) are considered COIs by VAO committees. It should be noted, however, that studies of Vietnam veterans addressing only deployment status, rather than characterizing specific agents of exposure of individual subjects, have always been regarded as contributors to the evidentiary database in keeping with the provision of the Agent Orange Act that veterans serving in Vietnam were presumptively exposed to herbicides.

image  Petroleum-based dispersants used in spraying Agent Orange: These dispersants are recognized to contain benzene, which is acknowledged to be a causal agent of AML and MDS; this volatile chemical would not remain present in sprayed herbicides. There is a vast toxicologic literature on petroleum products and their constituents (for example, see Gulf War and Health: Volume 3—Fuel, Combustion Products, and Propellants [IOM, 2005]) and on the various

Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

    chemical families of insecticides (see also Gulf War and Health: Volume 2—Insecticides and Solvents [IOM, 2003]).

image  CS gas: This cyanocarbon was used as the defining component of tear gas during military training and in Vietnam.

image  Vietnam veterans may have experienced multiple potentially harmful exposures in addition to herbicide exposure: Addressing interactions or synergies of other substances (such as benzene-containing petroleum products, the extensively used insecticides, or CS gas) with the several components of the herbicides is beyond the scope of the committee’s charge. People are continually exposed to many chemicals whose possible adverse effects might be exacerbated by exposure to other agents. The number of pairs that could be addressed is enormous, and it would rise exponentially if triads and larger combinations were considered.

•  Exposure modeling for Agent Orange (AgDrift [Ginevan and Ross] vs Exposure Opportunity Model [Stellmans]: The merits of these two exposure models and their potential usefulness for resolving outstanding issues are discussed in Chapter 3.

•  Issues with VA procedures: These topics are not within the scope of the committee’s statement of task.

•  Living overseas prevents getting VA medical care.

•  IOM’s standard for evaluating health outcomes should not be changed from association to causality by Congress or any other party.

•  VA’s claims process takes too long.

•  Judgments made in VA’s appeals process for claims of service-related health outcomes are not consistent for a given condition—for example, squamous-cell carcinomas of the head and neck (tonsil cancer), bladder cancer, AML, and MDS.

FIRST PUBLIC MEETING

June 28, 2012
NAS Building, Room 125
2100 C Street, NW
Washington, DC 20418

Presentations

•  Welcome; Goals and Conduct of the Public Meeting; Introduction of Committee Members
Mary Walker, Committee Chair

Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

•  Charge to the Committee
Wendi Dick, MD, US Department of Veterans Affairs

•  Similar Health Conditions of Era Veterans with Agent Orange Exposure on Guam
LeRoy Foster
Frank Stanton

•  Agent Orange Exposure at Fort McClellan, Alabama
Helena Van Clief, Army Staff Sergeant

•  Injustice to Vietnam Veterans
Placido Salazar

•  Vietnam-era Veterans Exposed Outside of Vietnam
Carlo Albanese

•  Herbicide Use in Thailand
Ken Witkin, President, Airborne Battlefield Command Control Center Association

•  Advocate of Vietnam Veterans
William G. Jeff Davis, Founder and Senior Legislative Advocate, The Veterans Association of Sailors of the Vietnam War, Inc.

•  Children of American Vietnam Veterans
D. Karen Reyes, Co-Founder, Agent Orange Legacy, Children of American Vietnam Veterans

•  Speaking on Behalf of Vietnam Veterans
Rick Weidman, Executive Director for Policy and Government Affairs, Vietnam Veterans of America

Additional written statements received from:

   David A. Aswad
Thomas Jefferson Barr, Jr.
  Bladder cancer
Delayed peripheral neuropathy and restless leg syndrome
   Gary J. Chenett   On behalf of the Order of the Silver Rose, recognize health problems in veterans exposed to Agent Orange outside Vietnam; personally, diagnosed with four cancers
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
   Michael Eckstein   Willis-Ekbom disease/Periodic Limb Movement Disorder
   Charles W. Griesler   Migraines daily from 1967 and other neurological problems
   Debbie J. Gunn   Husband lost nose to squamous cell carcinoma
   Geraldine Hall-Bast   First Vietnam Veteran husband died at 48 of cardiac disease; their daughter has asthma and other respiratory problems; second Vietnam Veteran husband had post-traumatic stress disorder (violent), hepatitis, and died of cancer; third VV husband peripheral numbness due to Parkinson’s and post-traumatic stress disorder
   Michael P. Hartmaier   All chemicals in herbicides used in Vietnam should be covered, not just Agent Orange
   Damiana Hortas-Dowdy   Basic training at Ft. McClellan; now, negative rheumatoid arthritis/fibromyalgia
   Floyd McKinney   Exposed to Agent Orange at Fort Sill, OK; type 2 diabetes and prostate cancer
   Mark and Beth Rutz   Veterans Administration responded to their Freedom of Information Act request with information indicating choroidal (type of ocular) melanoma is treated more often than expected among veterans
   Larry Sauger   Myelodysplastic syndrome; benzene in petroleum products used to thin Agent Orange
   Jim Wallace   Exposed to Agent Orange at several military locations stateside; he and son have Agent Orange-related conditions
   Wane Wolcott   Anterior ischemic optic neuropathy, numb toes, high blood pressure, borderline diabetes, autoimmune disorder related to connective tissue; lives overseas so not getting VA medical care
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

SECOND PUBLIC MEETING

August 9, 2012
Courtyard Marriott
Meeting Room A
300 West Michigan Street
Milwaukee, WI 53203

Presentations

•  Welcome; Goals and Conduct of the Public Meeting; Introduction of Committee
Mary Walker, Committee Chair

•  Speaking on Behalf of Wisconsin Vietnam Veterans
Kim Michalowski, Director of Bureau of Claims, Wisconsin Department of Veterans Affairs

•  Veteran Concerned about Effects in Offspring
John Crespi

•  Veteran Concerned about Effects in Offspring
Mike Demske, Agent Orange Committee of National Vietnam Veterans of America

•  Concerns about Congress Changing IOM’s Standard from Association to Causality
Kent Draper

•  Veteran with Peripheral Vascular Disease
Eugene Pogorzelski

•  Veteran Speaking on Myelodysplastic Syndromes (MDS)
Larry Sauger

•  Blue Water Navy Veteran with Agent Orange Health Conditions
James W. Sobotta

Additional written statements received from:

   Donald Lund   Concern about exposure to CS gas
   James Wachtendonk   K-9 handler in Vietnam
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
   Zachary James Wachtendonk   (deceased at age 30) Son of Vietnam veteran with congenital problems exacerbated by exposure as child to 2,4-D in park
   Mary S. Wachtendonk   (wife of Vietnam veteran)

THIRD PUBLIC MEETING

November 27, 2012
Hotel Monteleone
Royal Salon D
214 Royal Street
New Orleans, LA 70130

Presentations

•  Welcome; Goals and Conduct of the Public Meeting; Introduction of Committee
Mary Walker, Committee Chair

•  Metabolic and Vascular Diseases (Invited Speaker)
Lisa Cassis, Ph.D., Professor and Chair, University of Kentucky

•  Speaking on Behalf of Vietnam Veterans
Suzanne Moore

•  Concerns about Endocrine Effects
Marc McCabe, Bureau Chief/Regional Director, St. Petersburg Regional Office, Vietnam Veterans of America

•  Department of Veterans Affairs—Past and Present Research (Invited Speaker)
Han Kang, Ph.D., retired Director, Environmental Epidemiology Service, Department of Veterans Affairs

Additional written statements received from:

   James Tomes   Exposure of Vietnam-era veterans stateside
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×

FOURTH PUBLIC MEETING

January 16, 2013
Arnold and Mabel Beckman Center
National Academies of Sciences & Engineering
100 Academy
Irvine, CA 92612-3002

Presentations

•  Welcome; Goals and Conduct of the Public Meeting; Introduction of Committee
Mary Walker, Committee Chair

•  Health Concerns of Vietnam Veterans
Ken Holybee, Director at Large, Vietnam Veterans of America

•  National Health Committee co-chair, Associates of VVA—paternally mediated birth defects
Elayne Mackey

•  Health Issues and Effects in Children
Conrad T. Gomez

•  Health Problems as Daughter of Vietnam Veteran and Data Collection by Children of Vietnam Veterans Health Alliance (COVVHA)
Jenna Van Leer, COVVHA

•  Widow of Vietnam Veteran
Debra Kraus, artist

•  Contamination of C123 Aircraft Used by Reservists
Wes Carter

Phone conversation (invited speakers)—Paternal transmission of adverse effects to offspring

•  Andy Olshan, PhD, Chair of Epidemiology, University of North Carolina

•  Kim Boekelheide, MD, PhD, Professor of Medical Science, Brown University

Additional written statements received from:

   Dale Hemrick   Health issues in veterans and their offspring
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
  Nancy McMaa   Oral squamous cell carcinoma of her Vietnam veteran husband
   Jim Purtell   Song composed concerning damage from Agent Orange
   Martha Sidwell   (wife of Vietnam veteran, Dale Hemrick) Relationship difficulties of returning deployed veterans
   Jeanne Stellman, PhD   Response to Ginevan and Ross on exposure opportunity model

REFERENCES

IOM (Institute of Medicine). 2003. Gulf War and Health: Volume 2—Insecticides and Solvents. Washington, DC: The National Academies Press.

IOM. 2005. Gulf War and Health: Volume 3—Fuel, Combustion Products, and Propellants. Washington, DC: The National Academies Press.

Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 948
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 949
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 950
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 951
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 952
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 953
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 954
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 955
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 956
Suggested Citation:"Appendix A: Issues Raised by the Public and Agendas of Public Meetings Held by the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) and Other Written Submissions to the Committee." Institute of Medicine. 2014. Veterans and Agent Orange: Update 2012. Washington, DC: The National Academies Press. doi: 10.17226/18395.
×
Page 957
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From 1962 to 1971, the US military sprayed herbicides over Vietnam to strip the thick jungle canopy that could conceal opposition forces, to destroy crops that those forces might depend on, and to clear tall grasses and bushes from the perimeters of US base camps and outlying fire-support bases. Mixtures of 2,4-dichlorophenoxyacetic acid (2,4-D), 2,4,5-trichlorophenoxyacetic acid (2,4,5-T), picloram, and cacodylic acid made up the bulk of the herbicides sprayed. The main chemical mixture sprayed was Agent Orange, a 50:50 mixture of 2,4-D and 2,4,5-T. At the time of the spraying, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), the most toxic form of dioxin, was an unintended contaminant generated during the production of 2,4,5-T and so was present in Agent Orange and some other formulations sprayed in Vietnam.

Because of complaints from returning Vietnam veterans about their own health and that of their children combined with emerging toxicologic evidence of adverse effects of phenoxy herbicides and TCDD, the National Academy of Sciences (NAS) was asked to perform a comprehensive evaluation of scientific and medical information regarding the health effects of exposure to Agent Orange, other herbicides used in Vietnam, and the various components of those herbicides, including TCDD. Updated evaluations are conducted every two years to review newly available literature and draw conclusions from the overall evidence.Veterans and Agent Orange: Update 2012 reviews peer-reviewed scientific reports concerning associations between health outcomes and exposure to TCDD and other chemicals in the herbicides used in Vietnam that were published in October 2010--September 2012 and integrates this information with the previously established evidence database. This report considers whether a statistical association with herbicide exposure exists, taking into account the strength of the scientific evidence and the appropriateness of the statistical and epidemiological methods used to detect the association; the increased risk of disease among those exposed to herbicides during service in the Republic of Vietnam during the Vietnam era; and whether there exists a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the disease.

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