Jodee C. Kayton
Landmark Bill Would Designate 12 Illnesses as Connected to Burn Pits
15 Sep 2020
Military.com | By Patricia Kime
Lawmakers introduced legislation Tuesday that would streamline the process for veterans to receive disability benefits for diseases that may be related to exposure to burn pits and other battlefield pollutants.
Bolstered by the support of advocate and comedian Jon Stewart, who successfully led the effort to continue financial support for victims of the Sept. 11 terrorist attacks, Sen. Kirsten Gillibrand, D-N.Y., and Rep. Raul Ruiz, D-Calif., announced a bill to remove a Department of Veterans Affairs requirement that veterans prove a link between a dozen diseases and exposure to burn pits and other toxins.
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Instead, former service members would only have to provide documentation to the VA that they served at least 15 days in one of 33 countries listed in the proposed legislation.
“This is a moral outrage. It’s also a looming crisis that must be addressed. Burn pits are so dangerous that they are outlawed on U.S. soil, but they were used all over the world. … Many of our veterans have no time to spare,” Gillibrand said during a press conference in front of the U.S. Capitol.
“Service members are coming home from the battlefield only to become delayed casualties of war … drawing parallels to Agent Orange and 9/11 exposures,” said Ruiz, who serves as co-chair of the Congressional Burn Pit Caucus.
The monumental proposal could have an impact on more than 3 million veterans who have served since Aug. 2, 1990, in one of the countries and have a listed illness, similar to the landmark Agent Orange Act of 1991, which designated more than a dozen diseases as presumed to be caused by exposure to toxic herbicides used in Vietnam.
The illnesses include: asthma diagnosed after deployment to a listed country or territory; any type of cancer; chronic bronchitis; chronic obstructive pulmonary disease; constrictive bronchiolitis; emphysema; granulomatous disease; interstitial lung disease; lymphoma; pleuritis; pulmonary fibrosis; and sarcoidosis.
The countries and territories listed include Afghanistan, Bahrain, Burkina Faso, Cameroon, Chad, Diego Garcia, Djibouti, Egypt, Ethiopia, Gabon, Ghana, Iraq, Jordan, Kenya, Kuwait, Kyrgyzstan, Libya, Mali, Niger, Nigeria, Oman, Pakistan, Philippines, Saudi Arabia, Somalia, South Sudan, Sudan, Syria, Tajikistan, Tunisia, Turkey, United Arab Emirates, Uzbekistan and Yemen.
Danielle Robinson’s husband, Army Sgt. 1st Class Heath Robinson, deployed with the Ohio National Guard to Iraq in 2006, where he worked at Camp Liberty, nicknamed “Camp Trashcan” for its large burn pit. Robinson later developed a rare type of lung cancer that his doctor said “could only be due to toxic exposure.”
He died in May.
Robinson said she was denied by the VA caregiver program even though she needed to quit her job as a physical therapist to care for her husband as he struggled with his illnesses.
“My husband is dead because America has poisoned its soldiers,” Robinson said during the press conference.
More than 250 burn pits operated at U.S. military bases in Iraq, Afghanistan and elsewhere, used to dispose of all types of garbage, including plastics, batteries, tires, computers, office equipment, animal carcasses, household trash and hospital waste.
Concern over the health threat they posed initially arose in 2006, when Air Force Lt. Col. Darrin Curtis, a bioenvironmental flight commander for Joint Base Balad, Iraq, noted that the 10-acre-wide burn pit there posed a “acute health hazard for individuals” and the “possibility for chronic health hazards associated with the smoke.”
But troops and military contractors weren’t made aware of the potential hazard until Army Times journalist Kelly Kennedy first began reporting on the issue in 2008.
In addition to respiratory illnesses, young service members have developed cancers and other illnesses not usually seen in people their age. After years of silence on the issue of his son Beau Biden’s death from glioblastoma, a brain cancer, presidential candidate and former Vice President Joe Biden told PBS reporter Judy Woodruff in 2018 that burn pits may have a “carcinogenic impact on the body.”
The National Academy of Sciences released a report Friday concluding that, while there is scientific evidence to link chronic respiratory symptoms like wheezing and coughing to burn pits, few studies exist that could conclusively connect exposure to burn pits and other airborne pollutants to diseases seen in veterans.
An 11-member advisory panel said their conclusions did not mean there is no link, only that the research or data did not exist to prove one.
The VA also has consistently cited a 2011 report by the same scientific advisory body that there is insufficient evidence to draw conclusions on the long-term health effects of burn pits.
Stewart called the arguments “bull—-.”
“The only difference between the first responders at Ground Zero who are dying of toxic exposures is that was caused as a result of a terrorist attack. … Veterans from Iraq and Afghanistan are suffering from the same illnesses and same exposures as the result of the actions of our own government,” Stewart said.
More than 212,000 veterans have enrolled in VA’s Airborne Hazards and Open Burn Pit Registry, a congressionally mandated database for veterans to self-report their deployments and any health-related consequences.
In addition to airborne exposures, the bill would cover former service members affected by contact to chemical weapons, nerve agents or other battlefield toxins, such as those encountered by troops assigned to Karshi-Khanabad Air Base in Uzbekistan, according to Gillibrand.
The bill, the Presumptive Benefits for War Fighters Exposed to Burn Pits and Other Toxins Act, has little chance of passing in the last 24 days of the legislative year. But Stewart said that he, along with advocate John Feal and numerous veterans service organizations, will continue fighting.
“We always have money for the war. We never have money for the warfighter,” Stewart said. “Today, we plant the flag, and we are going to exhibit the relentlessness of the warfighter.”
— Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime.
The U.S. Court of Appeals for Veterans Claims issued a decision last month that could make it easier for veterans with injuries to the back, neck, and joints to obtain higher disability ratings, even in cases where veterans are already receiving disability benefits for such injuries.
The recent case, called Sharp v. Shulkin, reviewed the Department of Veterans Affairs’ current system for assessing the origin and extent of a veteran’s disability and clarified the responsibilities of Compensation and Pension examiners and the Board of Veterans Appeals when it comes to giving an opinion on pain flare-ups caused by musculoskeletal disabilities. The court ultimately ruled that the system was inadequate, because not all C&P examiners consider flare-ups and pain when determining what disability rating a veteran should receive.
Bobby P. Sharp, an Army Korean War veteran who suffers from numerous musculoskeletal injuries, argued that VA medical examinations he received were inadequate because the examiner failed to “ascertain adequate information — i.e., frequency, duration, characteristics, severity, or functional loss — regarding his flares by alternative means,” according to court documents. Sharp contended that the 10% disability rating he received for his injuries was insufficient because his “September 2015 evaluation was inadequate for evaluation purposes and the Board’s finding to the contrary was clearly erroneous.” In September 2017, the claims court agreed.
The court’s decision means that the VA must now enact measures to ensure that C&P examiners do not overlook flare-ups and pain when assessing a disabled veteran. The VA must attempt to schedule a C&P examination when the veteran is experiencing a flare-up, but if it can’t the practitioner is still expected to offer a professional opinion on how the veteran could be “functionally limited during a flare-up,” notes Military1.
In theory, this will give examiners a more comprehensive understanding of the injury in question. If this isn’t feasible, the examiner must prove they’ve collected as much information and evidence as possible before saying to the board that they can’t offer a medical opinion “without resorting to speculation.” Further, the appeals board bears the burden of ensuring the examiner has done their due diligence or find an examiner experienced enough to offer a more informed medical opinion.
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So, if a C&P examiner doesn’t witness the flare-up, how can they form a non-speculative opinion about it? As Military 1 reported, the court decided that veterans themselves can submit evidence for consideration, such as their own description of the flare-ups and pain they experience, or “buddy statements” — written statements from people who know the veteran and can testify to the extent of their suffering.
All of which will make it a lot easier for veterans to secure higher disability ratings for injuries they sustained in the military. Meanwhile, the Sharp v. Shulkin case, which ruled that Sharp was entitled to another C&P assessment consistent with the new guidelines set by the court provides a precedent for other veterans who want to challenge their disability ratings. If you think this applies to your case, then we recommend you reach out to a veteran service officer to help you navigate the appeals process.
Adam Linehan is a senior staff writer for Task & Purpose. Between 2006-2012, he served as a combat medic in the U.S. Army, and is a veteran of Iraq and Afghanistan. Follow Adam Linehan on Twitter @adam_linehan
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Washington, DC — Senators Kristen Gillibrand (D-NY) and Steve Daines (R-MT) reintroduced the Blue Water Navy Vietnam Veterans Act on Friday.
The legislation would ensure that thousands of Navy veterans, known as “Blue Water” veterans are able to receive disability and health care benefits they need after exposure to Agent Orange while fighting in the Vietnam War.
Agent Orange is a toxic chemical that was used to remove foliage during the Vietnam war that had devastating health effects on millions serving.
In 2002, Veterans Affairs decided that it would only cover Veterans who could prove that they had orders for “boots on the ground” during the Vietnam War.
This exclusion prevented sailors from receiving benefits even though they had significant Agent Orange exposure from drinking and bathing in contaminated water just offshore.
“Thousands of Vietnam War veterans who were exposed to Agent Orange are now suffering from severe health problems,” said Senator Gillibrand. “The VA is continuing to deny health coverage to many of them because of an arbitrary rule that says veterans who served on boats off of Vietnam’s coast are not entitled to this coverage,”
The act would make it easier for the VA to process Vietnam War veterans’ claims for service-connected health conditions and alleviate a portion of the VA’s backlog by extending presumptive coverage of Agent Orange benefits to these veterans.
A recent VA study points to a possible breakthrough in differentiating between post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), otherwise known as a concussion.
The two disorders often carry similar symptoms, such as irritability, restlessness, hypersensitivity to stimulation, memory loss, fatigue and dizziness. Scientists have tried to distinguish between mTBI and PTSD in hopes of improving treatment options for Veterans, but many symptom-based studies have been inconclusive because the chronic effects of the two conditions are so similar. If someone is rating high on an mTBI scale, for example, that person may also rate high for PTSD symptoms.
The researchers used electroencephalogram, or EEG, a test that measures electrical activity in the brain. The size and direction of the brain waves can signal abnormalities.
Analyzing a large set of EEGs given to military personnel from the wars in Iraq and Afghanistan, the researchers saw patterns of activity at different locations on the scalp for mTBI and PTSD. They saw brain waves moving slowly in opposite directions, likely coming from separate places in the brain.
The researchers emphasize that these effects don’t pinpoint a region in the brain where the disorders differ. Rather, they show a pattern that distinguishes the disorders when the EEG results are averaged among a large group.
“When you’re looking at an EEG, you can’t easily tell where in the brain signals associated with TBI and PTSD are coming from,” said Laura Manning Franke, Ph.D., the study’s lead researcher and research psychologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. “You get kind of a coarse measure – left, right, anterior, posterior. We had a different distribution, which suggests that different parts of the brain are involved. In order to determine what patterns are tracking their TBI and PTSD, you need an average to do that,” Franke added.
The study linked mTBI with increases in low-frequency waves, especially in the prefrontal and right temporal regions of the brain, and PTSD with decreases in low-frequency waves, notably in the right temporoparietal region.
The differences in the levels of the waves may explain some of the symptoms of the two disorders, suggesting a decline in responsiveness for someone with mTBI, for example, and more anxiety for someone with PTSD.
Franke also noted that more low-frequency power has also been linked to cognitive disorders such as Alzheimer’s disease and less low-frequency power to problems such as drug addiction. Additionally, spotting distinct patterns of mTBI and PTSD in separate parts of the brain is key for two reasons: the possibility these conditions can be confused with each other is reduced. That can help improve diagnosis and treatment and the patterns show that electrical activity appears to be affected long after combat-related mTBI, suggesting long-term changes in neural communication, the signaling between cells in the nervous system. “That could help, in part, explain the reason for persistent problems.”
The study included 147 active-duty service members or Veterans who had been exposed to blasts in Iraq and Afghanistan. Of those, 115 had mTBI, which accounts for nearly 80 percent of all traumatic brain injuries. Forty of the participants had PTSD, and 35 had both conditions.
Despite the new findings, Franke and her team believe more work is needed to better explain the differences in the patterns of both conditions in the brain’s electrical activity. Researchers need to analyze the differences in scans from larger numbers of patients.
Meanwhile, though, she said she hopes the research will play a role in helping medical professionals better diagnose someone’s condition through an individual EEG—whether that person has PTSD, a brain injury, or a combination of the two.
“That’s the holy grail,” said Franke. “We want to use the EEG to differentiate the problems, but also to predict recovery and be able to measure how people are doing in a more biological way than just measuring symptoms, although those are still relevant. But symptoms are also problematic because they’re influenced by so many things that aren’t the disease that we’re interested in.”
For more information about VA research on PTSD and TBI, visit Posttraumatic Stress Disorder and Traumatic Brain Injury. Information about Franke’s study may be found at the International Journal of Psychophysiology
US Agrees to Pay Billions to Marines Affected by Toxic Water By HOPE YEN, ASSOCIATED PRESS WASHINGTON — Jan 13, 2017, 2:33 PM ET
After years of waiting, veterans who were exposed to contaminated drinking water while assigned to Camp Lejeune in North Carolina may now be able to receive a portion of government disability benefits totaling more than $2 billion.
The Department of Veterans Affairs described the new benefit Friday as “historic.” It is one of few instances in which former military personnel who weren’t deployed for war could become eligible for cash payouts.
Outgoing VA Secretary Bob McDonald determined there is sufficient scientific and medical evidence to establish a “strong association” between exposure to the contaminated water at Camp Lejeune and eight medical conditions.
“We have a responsibility to take care of those who have served our nation and have been exposed to harm as a result of that service,” McDonald said, adding that the VA’s decision will make it easier for veterans “to receive the care and benefits they earned.”
Beginning in March, the disability benefits may supplement VA health care already being provided to eligible veterans who were stationed at the Marine base for at least 30 cumulative days between Aug. 1, 1953, and Dec. 31, 1987. Veterans will have to submit evidence of their diagnoses and service information.
The estimated taxpayer cost is $2.2 billion over a five-year period. As many as 900,000 service members were potentially exposed to the tainted water, although the VA estimates that roughly 23,000 veterans will apply and qualify for the benefit.
“This is good news,” said retired Marine Master Sgt. Jerry Ensminger, whose daughter Janey was born in 1976 while he was stationed at Lejeune. Janey died from leukemia at age 9. Ensminger now heads a veterans group, The Few, The Proud, The Forgotten, which advocates for those seeking disability compensation.
“This has been a hard, long slog,” said Ensminger, who argues the government must go further in covering additional diseases. “This is not the end of the issue.”
The new rule covers active duty, Reserve and National Guard members who developed one of eight diseases: adult leukemia, aplastic anemia, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin’s lymphoma and Parkinson’s disease.
It allows veterans to qualify for government disability aid based on toxic harm sustained while at a garrison, as opposed to a battlefield. In 2015, McDonald also agreed to award disability benefits for another category of veterans who weren’t on the ground, those who had developed medical conditions after exposure to Agent Orange residue on planes used in the Vietnam War.
“It’s a major first,” said Dr. Ralph Erickson, a chief health consultant at the VA and former commander of the Walter Reed Army Institute of Research. Most disability awards, he said, involve “exposures that occurred during deployment.”
Documents uncovered by veterans groups over the years suggest Marine leaders were slow to respond when tests first found evidence of contaminated groundwater at Camp Lejeune in the early 1980s. Some drinking water wells were closed in 1984 and 1985, after further testing confirmed contamination from leaking fuel tanks and an off-base dry cleaner. The Marine Corps has said the contamination was unintentional, occurring when federal law didn’t limit toxins in drinking water.
Spurred by Ensminger’s case, Congress in 2012 passed a bill signed into law by President Barack Obama extending free VA medical care to affected veterans and their families. But veterans were not automatically provided disability aid or survivor benefits. The issue has prompted lawsuits by veterans organizations, which note that military personnel in Camp Lejeune housing “drank, cooked and bathed” in contaminated water for years.
Ensminger credited North Carolina Republican Sens. Richard Burr and Thom Tillis for their efforts. Burr introduced the 2012 legislation to provide free VA medical care.
“It’s about time,” Burr said, welcoming the VA news Friday. “These veterans put their lives on the line for our nation and they were negligently poisoned by the government.”
Affected veterans who were stationed at Camp Lejeune may now submit applications for benefits. Roughly 1,400 disability claims related to Lejeune are already pending, and will be reviewed immediately, according to the VA.
More than four decades after the end of the Vietnam War, research is still showing the effects of the herbicide Agent Orange. The latest findings: An association between exposure and high blood pressure.
This story was co-published with The Virginian-Pilot.
A new study has found a close relationship between Agent Orange exposure during the Vietnam War and high blood pressure, a conclusion that could lead the U.S. Department of Veterans Affairs to dramatically expand the number of veterans eligible for compensation.
The study, published last week by VA researchers in the Journal of Occupational and Environmental Medicine, found a higher rate of hypertension among members of the Army Chemical Corps who handled Agent Orange during the war compared to those who didn’t. Corps members who served in Vietnam but did not spray the chemicals also had a higher rate of hypertension than their peers who served outside Vietnam.
Both results were statistically significant and add to a body of evidence linking Agent Orange exposure and hypertension.
The findings come 41 years after the close of the Vietnam War and decades since the last supplies of Agent Orange were incinerated. Since then, veterans have become increasingly distrustful of the VA. They maintain that their exposure to Agent Orange, which contained the toxic chemical dioxin, has harmed their own health and has been passed on to their children.
A VA working group has been studying the latest scientific literature since March to determine if any illnesses should be added to the agency’s list of diseases for which vets are automatically entitled to compensation if they served in Vietnam. Specifically, the group has been looking at new evidence linking bladder cancer, under-active thyroid, Parkinson’s-like symptoms and hypertension to Agent Orange exposure.
The VA had been expected to announce its decision this year, but officials now say that will be left to the administration of President-elect Donald Trump.
Help Us Investigate the Impact of Agent Orange
We’re interested in hearing from veterans and family members for our ongoing investigation into the effects of Agent Orange on veterans and their children. Share your story.
“For this administration, the deadline for proposing new rules for potential new presumptions [of service connection to herbicide] has passed, and this will become work for the new administration to take to completion,” VA officials said in a written statement first reported last week in the newspaper Stars and Stripes.
Hypertension is the most common ailment among veterans seeking health care at the VA—indeed it is one of the most common ailments among older adults generally.
The study released last week found the prevalence of hypertension among members of the Army Chemical Corps to be higher than among other aging veterans. Although most of the Agent Orange used in Vietnam was sprayed from Air Force planes, the Army Chemical Corps also sprayed the herbicide from hand sprayers and helicopters.
Researchers analyzed responses from about 3,000 members of the Army Chemical Corps who participated in a 2013 survey. The research team then verified their self-reported exposure to Agent Orange by using dioxin levels in their blood and checked their self-reported blood pressure against medical records and in-home testing.
Among Chemical Corps members who sprayed herbicides in Vietnam, 81.6 percent said they had high blood pressure. That compares to 64.6 percent among Corps members who did not serve in Vietnam and did not spray herbicides. Researchers said that difference could not be explained away by other characteristics they analyzed, including age, race, weight, alcohol use and tobacco use.
It’s unclear if the results from the Army Chemical Corps apply to other Vietnam veterans, the researchers said.
For years, the VA has been weighing whether to provide Agent Orange benefits to vets with high blood pressure, which could potentially cost billions of dollars.
In 2009, a federal advisory panel said there was evidence suggesting a connection between Agent Orange exposure and several conditions, including Parkinson’s disease, ischemic heart disease and hypertension.
A VA internal working group of scientific experts wanted to recommend the department grant benefits to veterans with all of those conditions, according to Dr. Victoria Cassano, a member of the group who at the time was acting chief consultant for the VA’s Environmental Health Strategic Healthcare Group. But the group’s superiors at the VA told the panel to change its position and instead recommend against providing benefits for heart disease and hypertension, Cassano said. It recommended in favor of Parkinson’s disease.
In late 2009, then-VA Secretary Eric Shinseki said he would add ischemic heart disease and Parkinson’s disease to the VA’s list, but not hypertension. According to Shinseki’s testimony to Congress in 2010, “the evidence regarding hypertension was less compelling” than for the other conditions.
Instead, Shinseki called for the VA study completed last week.
“I wasn’t really surprised by these findings,” said Yasmin S. Cypel, the study’s principal investigator and a health science specialist at VA. “I just felt that based upon the research that there was evidence to indicate that there might be an association.”
Rick Weidman, legislative director of Vietnam Veterans of America, said the new report should add pressure to the VA to compensate vets for hypertension. His group has been pressing the VA to add the condition to its list of Agent Orange-connected diseases ever since the advisory panel first noted evidence of a link.
He can think of only one reason to explain the agency’s reluctance:
“Simple as that,” said Weidman, himself a Vietnam vet. “There are so many people who utilize the VA who have hypertension, they know it’s going to cost.”
An estimate of the cost of offering compensation for Vietnam vets with hypertension was not available.
Cassano, the former VA official who thought VA should have agreed to provide hypertension benefits in 2009, said the new research by Cypel and colleagues was “really well designed.”
“It’s a very definitive study,” Cassano said. “It’s showing that just being in Vietnam gives you a higher relative risk of developing hypertension.”
While hypertension affects many veterans, it is not as debilitating as other conditions and generally can be treated inexpensively with medications. Therefore, she said, the costs may not be as high as some have predicted. Waiting for vets to develop ischemic heart disease or suffer a stroke is “a pennywise pound foolish decision.”
Since last year, ProPublica and The Virginian-Pilot have compiled more than 6,000 stories from veterans and their families about how Agent Orange has affected them. We also have reported how the military and VA have turned to an herbicide expert who defends Agent Orange for guidance on handling vets’ claims.
Dr. Orange: The Secret Nemesis of Sick Vets
For decades, the military and the VA have repeatedly turned to one man to guide decisions on whether Agent Orange harmed vets in Vietnam and elsewhere. His reliable answer: No. Read the story.
Several veterans said that if the VA begins offering Agent Orange benefits for high blood pressure, they would apply for them.
“It has never been anything I considered,” said Ron Bass, 67, who served as an Air Force crew chief in Vietnam from 1969 to 1971 and takes medication for his condition.
“I would definitely file a claim for it,” said Ron Zatawski, 66, who served in the Army in Vietnam from 1970 to 1971. “We went through areas that they had sprayed Agent Orange. … We didn’t know how toxic this stuff was.”
Victoria Davey, another researcher on the hypertension study, said there’s still much to learn about the effects of Agent Orange on vets. She is leading a new study comparing the health of Vietnam vets with similarly aged U.S. residents who never served in the military.
“This doesn’t close the book on long-term health consequences of service in Vietnam,” Davey said of the hypertension study.
ProPublica and The Virginian-Pilot are interested in hearing from veterans and family members for our ongoing investigation into the effects of Agent Orange on veterans and their children. Share your story now at propublica.org/agentorange or hamptonroads.com/agentorange.
WASHINGTON — An expected 15,000 veterans whose serious illnesses are linked to a contaminated water supply at Camp Lejeune in North Carolina could receive compensation more quickly under a proposed Department of Veterans Affairs rule announced Friday.
The rule establishes that for veterans who served a minimum 30 days at Camp Lejeune between 1953 through 1987, the VA will automatically presume a connection to eight diseases: leukemia, anemia, multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s and bladder, kidney and liver cancer.
People serving at the Marine Corps base during that time were exposed to a metal degreaser and other chemicals in the drinking water supply. The national Centers for Disease Control and Prevention in 2014 determined the contaminants increased risk for the illnesses.
Water lines for a small unit water purification system prototype draw water from a reservoir at Camp Lejeune, N.C., May 9, 2014.
Paul Peterson/U.S. Marine Corps
“The change here is that up until now, each claim was processed on a case-by-case basis,” VA spokesman Randal Noller said in an email. “With the new presumptive, the conditions noted will be ‘presumed’ to be related to exposure at Camp Lejeune with no further evidential requirements.”
In order to be granted status for medical benefits, veterans will need to prove only that they served at Camp Lejeune for at least 30 days – a time frame on which the VA is still seeking public input. VA experts could not establish people exposed to the contaminated water for 30 days were more at risk than others who were at Camp Lejeune for a shorter amount of time.
“Therefore, VA welcomes comments on the 30-day minimum exposure requirement and will consider other practical alternatives when drafting the final rule,” a written statement from the VA reads.
A public comment period started Friday and is open until Oct. 10.
The VA announced in January its intention to fast-track compensation to the affected veterans. But the Office of Management and Budget had to review the proposed rule before it could be published.
In August, Sens. Richard Burr and Thom Tillis, both R-N.C., sent a letter to Office of Management and Budget Director Shaun Donovan, urging for a speedy review. The letter said people contaminated had faced “bureaucratic mistreatment.”
“The victims of Camp Lejeune’s water contamination disaster have waited far too long for justice, and prior OMB delays have been inexplicable,” Tillis said Friday in a written statement. “It’s a relief to see movement.”
According to guidelines of the Federal Register, once the public comment period ends Oct. 10 and a final rule is put forth, there must be another 30-day wait until a rule goes into effect. The guidelines state an agency can make a rule effective sooner if it shows “good cause” that it’s in the public interest.
When it goes into effect, the rule will apply to new and pending disability claims.
The case of a service member diagnosed with post-traumatic stress disorder but found instead to have brain damage caused by a malaria drug raises questions about the origin of similar symptoms in other post-9/11 veterans.
According to the case study published online in Drug Safety Case Reports in June, a U.S. military member sought treatment at Walter Reed National Military Medical Center in Bethesda, Maryland, for uncontrolled anger, insomnia, nightmares and memory loss.
The once-active sailor, who ran marathons and deployed in 2009 to East Africa, reported stumbling frequently, arguing with his family and needing significant support from his staff while on the job due to cognitive issues.
Physicians diagnosed the service member with anxiety, PTSD and a thiamine deficiency. But after months of treatment, including medication, behavioral therapy and daily doses of vitamins, little changed.
The patient continued to be hobbled by his symptoms, eventually leaving the military on a medical discharge and questioning his abilities to function or take care of his children.
It wasn’t until physicians took a hard look at his medical history, which included vertigo that began two months after his Africa deployment, that they suspected mefloquine poisoning: The medication once used widely by the U.S. armed forces to prevent and treat malaria has been linked to brain stem lesions and psychiatric symptoms.
While no test is available to prove the sailor suffered what is called “mefloquine toxicity,” he scored high enough on an adverse drug reaction probability survey to tie his symptoms to the drug, also known as Lariam.
The sailor told his Walter Reed doctors that he began experiencing vivid dreams and disequilibrium within two months of starting the required deployment protocol.
Symptoms can last years
Case reports of mefloquine side effects have been published before, but the authors of “Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine” say their example is unusual because it shows that symptoms can last years after a person stops taking the drug.
And since the symptoms are so similar to PTSD, the researchers add, they serve to “confound the diagnosis” of either condition.
“It demonstrates the difficulty in distinguishing from possible mefloquine-induced toxicity versus PTSD and raises some questions regarding possible linkages between the two diagnoses,” wrote Army Maj. Jeffrey Livezey, chief of clinical pharmacology at the Walter Reed Army Institute of Research, Silver Spring, Maryland.
Once the U.S. military’s malaria prophylactic of choice, favored for its once-a-week dosage regimen, mefloquine was designated the drug of last resort in 2013 by the Defense Department after the Food and Drug Administration slapped a boxed warning on its label, noting it can cause permanent psychiatric and neurological side effects,
50,000 prescriptions in 2003
At the peak of mefloquine’s use in 2003, nearly 50,000 prescriptions were written by military doctors.
That figure dropped to 216 prescriptions in 2015, according to data provided by the Defense Department. According to DoD policy, mefloquine is prescribed only to personnel who can’t tolerate other preventives.
But Dr. Remington Nevin, a former Army epidemiologist and researcher at the Johns Hopkins Bloomberg School of Public Health in Baltimore, said any distribution of the drug, which was developed by the Army in the late 1970s, is too much.
“This new finding should motivate the U.S. military to consider further revising its mefloquine policy to ban use of the drug altogether,” Nevin told Military Times.
While a case study is a snapshot of one patient’s experience and not an indication that everyone who took or takes mefloquine has similar issues, one randomized study conducted in 2001 — more than a decade after the medication was adopted by the military for malaria prevention — showed that 67 percent of study participants reported more than one adverse side effect, such as nightmares and hallucinations, and 6 percent needed medical treatment after taking the drug.
Yet mefloquine remains on the market while Walter Reed Army Institute of Research conducts research on medications in the same family as mefloquine, including tafenoquine, hoping to find a malarial preventive that is less toxic but as effective.
Mefloquine was developed under the Army’s malaria drug discovery program and approved for use as a malaria prophylactic in 1989. Shortly after commercial production began, stories surfaced about side effects, including hallucinations, delirium and psychoses.
Once considered ‘well-tolerated’
Military researchers maintained, however, that it was a “well-tolerated drug,” with one WRAIR scientist attributing reports of mefloquine-associated psychoses to a “herd mentality.”
“Growing controversies over neurological side effects, though, are appearing in the literature, from journal articles to traveler’s magazines and resulting legal ramifications threaten global availability,” wrote researcher Army Col. Wilbur Milhous in 2001. “As the ‘herd mentality’ of mefloquine associated psychoses continues to gain momentum, it will certainly affect operational compliance and readiness. … The need for a replacement drug for weekly prophylaxis will continue to escalate.”
Mefloquine was implicated in a series of murder-suicides at Fort Bragg, North Carolina, in 2002, and media reports also tied it to an uptick in military suicides in 2003.
A 2004 Veterans Affairs Department memo urged doctors to refrain from prescribing mefloquine, citing individual cases of hallucinations, paranoia, suicidal thoughts, psychoses and more.
The FDA black box warning nine years later led to a sharp decline in demand for the medication. But while the drug is no longer widely used, it has left damage in its wake, with an unknown number of troops and veterans affected, according to retired Navy Cmdr. Bill Manofsky, who was discharged from the military in 2004 for PTSD and later documented to have mefloquine toxicity.
He said the Defense Department and VA should do more to understand the scope of the problem and reach out to those who have been affected.
New concerns rising over antimalaria drug
“I’m kind of the patient zero for this and I now spend my life trying to help other veterans who have health problems that may have been caused by mefloquine. More needs to be done,” Manofsky said.
He said while there is no cure for the vertigo and vestibular damage or the psychiatric symptoms caused by mefloquine, treatments for such symptoms, such as behavior and vestibular therapy help.
And, he added, simply having a diagnosis is comforting.
Veterans can seek help
“Veterans need to come forward,” he said. “The VA’s War Related Illness and Injury Study Center can help.”
The patient in the case study written by Livezey continues to see a behavioral therapist weekly but takes no medications besides vitamins and fish oil.
He sleeps just three to four hours a night, has vivid dreams and nightmares and vertigo that causes him to fall frequently, and continues to report depression, restlessness and a lack of motivation.
The sailor’s experience with mefloquine has been “severely life debilitating” and Livezey notes that the case should alert physicians to the challenges of diagnosing patients with similar symptoms.
“This case documents the potential long-term and varied mefloquine-induced neuropsychiatric side effects,” he wrote.
Patricia Kime covers military health care and medicine for Military Times. She can be reached at email@example.com.
August this year many more thousands of Vietnam War veterans, those suffering from bladder cancer, hypothyroidism, Parkinson’s-like symptoms and even high blood pressure, could learn they will be eligible for Department of Veterans Affairs health benefits and disability compensation. Or perhaps not.
Difficult months of study lie ahead for a working group of senior scientists and health experts that VA Secretary Bob McDonald convened last week, following release of a 10th and final biennial review of evidence of health problems linked to Agent Orange and other herbicide exposures.
Every review in the series, going back two decades, has been conducted, as Congress mandated, by the Institute of Medicine (IOM), a division of the National Academies of Sciences. Its latest review, Veterans and Agent Orange: Update 2014, takes into account medical and scientific literature published from Oct. 1, 2012, through Sept. 30, 2014.
The IOM concludes that the research supports changing the strength of association to herbicide exposure for several ailments. For bladder cancer and hypothyroidism, it found “limited or suggestive” evidence of an association, an upgrade from previous “inadequate or insufficient” evidence.
This latest review looked again at scientific literature on cardiovascular conditions and herbicides. The IOM didn’t upgrade but it did affirm limited and suggestive evidence that hypertension may be linked to herbicides.
This review also considered whether conditions resulting in Parkinson’s-like symptoms, apart from Parkinson’s disease itself, should fall into the same limited or suggestive category of evidence. Yes it should, the IOM concluded, finding “no rational basis” for the current exclusion.
For only the second time, the IOM withdrew an earlier finding of that herbicide exposure may have caused an ailment, in this case spina bifida in children born to Vietnam veterans. For 20 years VA has used a preliminary finding of an association to grant children benefits. The IOM says it no longer believes the evidence merits retaining spina bifida in that category.
On March 9, the same day the IOM briefed senior VA officials on its report, McDonald ordered the VA working group convened to review not only the 1,100-page IOM report but original studies IOM refers to as well as any peer reviews on ailments and herbicides completed since October 2014, which would be research the IOM had considered in its final review.
Dr. Ralph Loren Erickson, chief consultant of post deployment health services for the Veterans Health Administration, is co-chair of the working group. He said the plan is to review carefully all of the studies and the IOM recommendations and then prepare “a response document” to be distributed “throughout our senior leadership, with suggestions and recommendations for action,” before presenting to McDonald for final decisions.
“No question when the [IOM] moves something to a higher category you can bet we will look even more closely at those particular diseases,” Erickson said. “It certainly is not within my purview to make any statement at this point as to how the secretary will decide. In the past there have been things in this (limited or suggestive evidence) category that have become presumptions, and there are things in this category that have not.”
The IOM says “llimited or suggestive” means the epidemiological evidence indicates there could be a link between herbicide exposure and increased risk for a health effect. For some ailments, including ischemic heart disease, past VA secretaries used “limited or suggestive evidence” to add diseases to the presumptive list. And yet for others, including hypertension, that same category hasn’t been viewed as enough.
Among provisions of the Agent Orange law Congress allowed to sunset last year was a requirement that the VA secretary take action on IOM recommendations within 60 days. Erickson said the working group hopes to give McDonald what he needs to make decisions on the IOM by late July.
“We feel that if we can move at a pace that gets this all taken care of within about four months, we’re be doing well,” he said.
It would be far longer before any veterans or survivors see more or higher disability pay, however. VA rulemaking following a decision to add diseases to the presumptive list involve writing and publishing proposed regulations, collecting and reacting to public comments, and then publishing final regulations, a process that could take more than a year with added delay possible from the change in administrations to occur in January.
Whatever decisions McDonald makes on the IOM recommendations will be “rooted in science” and “evidenced based,” said Erickson.
But doesn’t VA also take account of size of the population affected? For example, hypertension afflicts two-thirds of Americans age 65 and older.
It is true, Erickson said, that Vietnam veterans have moved into their 60s, 70s and 80s and many have chronic diseases of older age.
“Hypertension is one of them,” he said. “And so teasing those things out — [to decide] is it related to this veteran’s age [or] to their being in Vietnam where they were exposed to Agent Orange — sometimes can be difficult.”
Does it finally come down to a judgment call?
“Well, a judgment call based on the evidence,” Erickson said. “The secretary has made it very clear, certainly to me and to others who work on these types of technical working groups, he wants to know what does the science show? What does the evidence show?”
The final decision will be based on “whether the preponderance of the evidence will support a proposal of the new presumption,” Erickson said.
If McDonald does accept IOM recommendations, this review would be the first in six years to result in one or more diseases being added to list of ailments VA presumes are linked to herbicide exposure.
The eligible population would be any veteran who can show they stepped foot in Vietnam between Jan. 9, 1962 and May 7, 1975, including on ships in Vietnam’s inland waterways, also veterans who served in or near the Korean Demilitarized Zone any time from April 1, 1968, to Aug 31, 1971.
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The U.S. Department of Veterans Affairs has once again turned down an effort by Navy veterans to get compensation for possible exposure to Agent Orange during the Vietnam War.
In a document released Friday, the VA said it would continue to limit benefits related to Agent Orange exposure to only those veterans who set foot in Vietnam, where the herbicide was sprayed, and to those who were on boats in inland rivers. The VA compensates these veterans for a litany of associated illnesses, including diabetes, various cancers, Parkinson’s Disease, peripheral neuropathy and a type of heart disease.
‘I Didn’t Think It Was Going to Affect Me.’
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Advocates for some 90,000 so-called Blue Water Navy veterans who served off the coast of Vietnam have been asking the VA for more than a decade to broaden the policy to include them. They say that they were exposed to Agent Orange because their ships sucked in potentially contaminated water and distilled it for showering, drinking, laundry and cooking. Experts have said the distillation process could have actually concentrated the Agent Orange, which contained the toxic chemical dioxin and was used to kill vegetation and deny enemy cover.
ProPublica and the Virginian-Pilot profiled their effort to gain coverage in September as part of an ongoing project to chronicle the impact of Agent Orange on vets and their families.
The U.S. Court of Appeals for Veterans Claims last April struck down VA rules that denied compensation for sailors whose ships docked at certain harbors in South Vietnam, including Da Nang. Those ports, the court determined, may have been in the Agent Orange spraying area. The court ordered the VA to review its policy.
But on Friday, the VA largely stood by its old policy and once again asserted that there’s no scientific justification or legal requirement for covering veterans who served off the coast.
“Environmental health experts in VA’s Veterans Health Administration have reviewed the available scientific information and concluded that it is not sufficient to support a presumption that Blue Water Navy Veterans were exposed to Agent Orange,” the VA said in a fact sheet.
U.S. Sen. Richard Blumenthal, D-Conn., the ranking member of the Senate Veterans’ Affairs Committee, criticized the VA’s decision.
“Rather than siding with veterans, VA is doubling down on an irrational and inconsistent policy,” he said in a statement. “Young sailors risked their lives during the Vietnam War, unaware that decades later, they and their children and grandchildren would still feel the toxic effects of exposure. Veterans who served offshore and in the harbors of Vietnam were exposed and deserve the presumption of service connection for Agent Orange-related diseases.”
Blumenthal and others are seeking adoption of the Blue Water Navy Vietnam Veterans Act, which would ensure that all vets exposed to Agent Orange are compensated.
The VA opposes the legislation, as it has several previous iterations dating back to 2008.
The VA’s new review rejecting benefits relied on a 2011 report by the respected Institute of Medicine, as well as other published research, according to the agency’s fact sheet.
The Institute of Medicine report said there was no way to prove Blue Water vets were exposed to the chemicals, but it identified plausible routes that Agent Orange could have traveled out to sea and into a ship’s distillation system. Although military policy at the time recommended against distilling water closer than 10 miles to shore — where the chemical concentration would have been highest — veterans said doing so was often unavoidable, and their commanding officers routinely ordered it.
The VA said it is working with veterans groups to “initiate a groundbreaking study of Blue Water Navy Veterans health outcomes. We hope to have data gathered and analyses published in 2017.”
Veterans called the VA’s decision a betrayal. John Wells, a Louisiana lawyer who has spent more than a decade advocating for Blue Water veterans, said his group would continue challenging the VA and push for legislation that would mandate coverage for the Blue Water veterans.
“It wasn’t completely unexpected. We’re used to being betrayed by the VA,” Wells said. “We’re going to fight this thing until we’re done or dead.”
Jim Smith, who served aboard the ammunition ship Butte, has been diagnosed with prostate cancer and believes that Agent Orange exposure may have played a role. “My feeling is the VA is thumbing their nose and sending the middle finger back to the Blue Water people,” he said. “It’s like nobody at the VA has any kind of science background whatsoever.”
Blue Water vets — so named to set the sailors apart from their Brown Water Navy counterparts, who patrolled the murky rivers of South Vietnam — were initially deemed eligible for compensation under the Agent Orange Act of 1991, only to have the VA change its interpretation a decade later.
Correction, Feb. 9, 2016: A photo caption in this story originally misstated Jim Smith’s years of service in the Navy as 1972 to 1973. He served in the Navy from 1972 to 1979. He served aboard the U.S.S. Butte from 1972 to 1973.
ProPublica and the Virginian-Pilot are interested in hearing from veterans and family members for our ongoing investigation into the effects of Agent Orange on veterans and their children. Share your story.