DANIEL L. COOPER
UNDER SECRETARY FOR BENEFITS
SENATE COMMITTEE ON VETERANS' AFFAIRS
July 10, 2002
Chairman and Members of the Committee, thank you for the opportunity to testify today on the efforts of the Departments of Defense ( DoD) and Veterans Affairs ( VA) to provide health care information and support to veterans who were exposed to environmental hazards during military service. Accompanying me today is Dr. Susan Mather, Chief Officer, VA Office of Public Health and Environmental Hazards, and Mr. Robert Epley, Associate Deputy Under Secretary for Policy and Program Management.
War and training for war have always exposed America's men and women in uniform to a wide variety of health hazards. Each war in the last century has produced unique hazardous exposures. In World War I, chemical warfare agents, including chlorine and mustard gas, were used. World War II saw the first deployment of nuclear weapons. Korea exposed many American POWs to psychological brainwashing techniques and to extremely cold weather conditions. The widespread use of herbicides during the Vietnam War is now associated with several adverse health effects. Military personnel encounter a broad array of environmental hazards, infectious disease, and psychological health risks any time they deploy outside the United States.
During peacetime, America's Armed Forces prepare for health hazards through research and by developing better preventive measures and conducting appropriate training. Many of these efforts have been well publicized, while others have been conducted in secret. For example, the testing of nuclear weapons during the Cold War exposed many American veterans to increased levels of radiation. Similarly, VA became aware in 1991 of approximately 4,000 American servicemen who had been exposed to high concentrations of mustard gas in both study chambers and field tests as a part of a larger chemical defense research program begun in World War II. In response, the National Academy of Sciences assessed the medical literature on health effects from those exposures, leading to new VA compensation regulations.
Following the Gulf War in 1991, Congress identified thirty-three separate hazardous substances to which Gulf War veterans may have been exposed. Public Laws 105-277 (signed Oct. 21, 1998) and 105-368 (signed Nov. 11, 1998) required VA to establish an agreement with the National Academy of Science to review and evaluate the medical literature on possible health outcomes from these exposures. The first phase of this study was published in 2000 and additional studies are underway. In addition, extensive analysis has been conducted to determine the potential health effects of exposure to sarin and cyclosarin at Khamisiyah following the Gulf War.
Most recently, VA became aware of the exposure of an undetermined number of U.S. service members to a variety of biological and chemical agents in secret tests called Project SHAD (Shipboard Hazard and Defense) conducted during the 1960s.
Because of this long history of hazardous exposures of U.S. military populations, we must carefully examine our methods for identifying exposed veterans, studying the potential effects of the contaminants, and for providing our veterans with appropriate health care and deserved disability compensation.
In the past, VA has established special programs for specific groups of veterans potentially exposed to environmental health hazards. For instance, VA responded to Gulf War health issues through a comprehensive program of health care, research, outreach, and special compensation for "undiagnosed illnesses." About 12 percent (84,000) Gulf War veterans have participated in a clinical registry program. The principal finding from this clinical evaluation program is that these veterans are suffering from a wide variety of recognized illnesses that respond to conventional treatments. Subsequent research studies have supported these findings, as have similar results from studies conducted in the United Kingdom and Canada among their Gulf War veteran populations.
Although special programs are useful, VA has learned many lessons since the Gulf War and is now taking a more pro-active approach in establishing policy and programs that will address environmental health concerns as early as possible.
Clinical Practice Guidelines
Special clinical programs, such as the Gulf War Registry reach only a limited number of eligible veterans. Therefore, the VA, in cooperation with DoD, has taken concrete steps to better understand and to routinely manage post-deployment health problems. A further goal is to improve veterans' satisfaction with their health care. VA is using an evidence-based approach to develop clinical practice guidelines for the evaluation of military veterans following hazardous deployments. Just completed in collaboration with DoD are a "Post-Deployment Health Evaluation and Management Guideline" and a second clinical practice guideline for unexplained fatigue and muscle pain, which was recently released. These guidelines will provide VA physicians with the best medical practices for dealing with veterans following deployment. A clinical guideline for PTSD, now in the planning stage, will be the next step in the development of a sound strategy for the screening, assessment, and care of all veterans returning from military deployments.
The regular use of standardized clinical practice guidelines that outline the best medical practices will decrease the need for ad hoc registries. Troops will be specifically screened early in the primary health care setting for illnesses that may be related to a military deployment. The Gulf War registry programs only reached a minority of veterans and the clinical findings from examinations of self-selected populations were difficult to interpret. In contrast, the post-deployment clinical practice guidelines will ensure that the health problems of all veterans returning from hazardous deployments are addressed whenever they seek care in the DoD or VA health systems. These new Guidelines will give VA primary care providers the tools they need to diagnose and treat veterans who had participated in hazardous deployments.
War-Related Illness and Injury Study Centers (WRIISC)
For veterans with severe symptoms that remain unexplained after examination, the local VA physician can refer them to one of VA's two War-Related Illness and Injury Study Centers ( WRIISC) (formerly known as Centers for the Study of War Related Illnesses). Many of these veterans are concerned that their illnesses are related to environmental hazards they encountered during deployment. The two Centers are located at the VA medical centers in Washington, DC, and East Orange, NJ. They are charged with identifying current effective treatments, developing new treatments, providing environmental hazard health risk communication to veterans and their families, and promoting education for VA health care personnel on the "difficult-to-diagnose" illnesses found among veterans from all military deployments.
Veterans Health Initiative/Independent Study Guides
Recognizing the need to educate health care providers about the unique medical care needs and concerns of veterans -- including the effects of environmental hazards -- VA began an ongoing training program known as the Veterans Health Initiative. Two key products are our independent study guides "A Guide to Gulf War Veterans' Health," and "Vietnam Veterans and Agent Orange Exposure." In addition, VA has developed other new independent study guides on a broad range of unique veteran health issues, including Cold Injury, Hearing Impairment, Post Traumatic Stress Disorder ( PTSD), Prisoner of War ( POW), Radiation, Spinal Cord Injury, Visual Impairment, and Traumatic Amputation and Prosthetics.
The Gulf War emphasized to us the value to veterans and their families of timely access to reliable information about the environmental health risks during military deployment. Acting on these lessons, VA developed a new brochure that addresses common health concerns for military service in Afghanistan and South Asia. It answers questions about health care and eligibility for VA benefits that veterans, their families, and their health care providers will have following this military deployment in the war on terrorism. The brochure also describes relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. This outreach material has been distributed to all VAMCs and Regional Offices.
The recent revelations concerning a series of Cold War tests known as Project SHAD reinforces the potential environmental hazards that our military forces face. This project was part of a DoD chemical and biological warfare test program conducted between 1963 and 1970 to evaluate the vulnerabilities of U.S. warships to attacks with chemical or biological warfare agents. Project SHAD exposed veterans to potentially harmful biological and chemical agents.
VA first learned of SHAD when a veteran filed a claim for service connection for disabilities he felt were related to his participation in Project SHAD. In two meetings held with DoD in late 1997, VA was advised that all material was classified and access to material was not assured and could only be given on a case-by-case basis. VA was able to grant that particular veteran's claim without reliance on classified information.
In May 2000, the Under Secretary for Benefits responded to a Congressional inquiry requesting assistance for veterans involved in Project SHAD. A VA/DoD workgroup was subsequently established and met the first time in October 2000. Since that time, DoD and VA have worked together collaboratively to develop the facts surrounding Project SHAD.
DoD began the formal process of declassification, compiling rosters of participants, and providing VA with names and service numbers of test participants. Initially, information was provided for 1,149 veterans involved in the tests Autumn Gold, Copper Head, and Shady Grove. Over a period of several months, VBA engaged in the labor intensive task of identifying the participants of those three tests identified initially. The social security numbers of 703 veterans were found. Using social security numbers, VA worked through the National Institute for Occupational Safety and Health to obtain from IRS the current addresses for 622 of these individuals. On May 21, 2002, outreach letters were mailed to the 622 identified participants involved in the three initial tests.
VA has initiated a significant outreach program to contact Project SHAD veterans once they are located. For SHAD veterans we have so far been unable to identify, VA has established a SHAD Hotline (at 1-800-749-8387), Internet web-site (at www.va.gov/SHAD), and e-mail address (at SHADHELPLINE@VBA.VA.GOV). The VA Internet website provides veterans with information currently available and a link to DoD's web page. To date, approximately 260 SHAD hotline inquiries and 43 e-mail messages have been received. Approximately 14 SHAD related claims for service connection are currently pending.
Since the beginning of calendar year 2002, DoD has provided VA with information on nine additional tests. Information on three tests was provided in January:
VA received information on six additional tests in May of this year:
DoD has identified one hundred and three potential SHAD tests. However, the number of tests actually conducted is unknown. Furthermore, the total number of service members involved in these tests is not known at this time. Unfortunately, the number of veterans who participated in multiple tests, the names of those tests, and the potentially harmful agents to which they may have been exposed cannot be determined until all relevant documentation has been collected, reviewed, and declassified.
DoD continues to review documentation and declassify additional SHAD tests. As names and service numbers or social security numbers are provided, VA will conduct the efforts required to identify the individuals who participated in these tests and then to locate their current address. We will engage in an aggressive outreach program to provide appropriate information to SHAD veterans.
Project SHAD information has been provided to VA medical staff through annual publication of Information Letters from VA's Under Secretary for Health. The Information Letters provide VA health care personnel with background information on Project SHAD, along with information about the potential short- and long-term health effects of the specific chemical and biological agents that DoD tells us were used in these tests. This information has been made available on our SHAD web site at www.va.gov/SHAD, including the information letter and other relevant information. As more information becomes available, satellite video-conferences are planned to broadcast relevant information to all VA health care facilities.
In addition, VA will begin to work with the National Personnel Records Center in St. Louis to review personnel and medical files for individuals listed as participants in tests for whom we have been unsuccessful in finding social security numbers. This represents approximately half of all the known participants provided to date. We are not particularly optimistic that this search will be fruitful but we believe that it represents a possible source of at least a few numbers otherwise unknown.
Importantly, a contract with the Medical Follow-up Agency of the National Academy of Sciences is being developed to include a formal epidemiological study of mortality and morbidity among SHAD participants. In contrast to a clinical registry, which cannot provide scientific data, this independent study will give us the clearest picture of the health status of SHAD veterans and tell us whether their health was harmed by prior chemical and biological exposures.
In the meantime, it should be stressed that there are no markers or laboratory tests for the exposures currently known to have occurred in Project SHAD. However, the provision of appropriate medical care for any of the conditions that have developed in the ensuing 40 years since the SHAD tests were begun is not dependent on specific information about prior exposures. High quality medical care can be provided right now for each SHAD veteran who seeks a clinical evaluation in the VA.
In order for VA to make accurate rating decisions on claims for service connection for disabilities associated with SHAD, complete evidence is necessary when the issue is first decided. Because of the piecemeal and fragmented approach of declassifying and providing information, VA may be required to readjudicate claims as additional evidence becomes available for those service members involved in multiple tests. Likewise, as evidence is declassified and made available, VA may find that the new evidence regarding SHAD tests supports grants of service connection previously denied.
VA will continue to send outreach letters to participants as additional tests are declassified and participant names and Social Security numbers are made available. Because it now appears that many of the service members participated in more than one test, our initial outreach efforts run the risk of being incomplete until DoD's declassification efforts are finished. It should be noted that in those cases where inquiries have come from veterans regarding tests not yet declassified, VA has been able to provide names to DoD and they have responded by providing relevant information on a timely basis.
VA also realizes that we cannot understand all the potentially hazardous exposures experienced by members of the Armed Forces without consultation and cooperation with other government agencies, particularly DoD, but also HHS, EPA, and DOE. This coordination is being addressed at the highest levels in VHA through the VA/ DoD Executive Council.
In conclusion, the Department of Veterans Affairs shares this Committee's concern about the adverse effects of hazardous exposures during military service and will continue to aggressively address them. VA sponsors research to assess the effects of these exposures; is actively contacting veterans of Project SHAD to notify them of potential exposures; and has developed numerous studies with the Institute of Medicine to determine the health effects of hazardous exposures.
This concludes my testimony. My colleagues and I will be happy to answer any questions that the Committee may have.