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.
  • Thailand
  • Guam
  • State-side military facilities
  • Blue Water Navy
  • 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:
  • 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).
  • Bladder cancer: The relevant available epidemiologic evidence remains inadequate and insufficient to support an association. See Chapter 8 for specific discussion.
  • 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.
  • 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.
  • 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 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.
  • 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.
  • 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.
  • Peripheral vascular disease: See Chapter 12.
  • 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.
  • 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 chemical families of insecticides (see also Gulf War and Health: Volume 2—Insecticides and Solvents [IOM, 2003]).
  • CS gas: This cyanocarbon was used as the defining component of tear gas during military training and in Vietnam.
  • 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

SECOND PUBLIC MEETING

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

THIRD PUBLIC MEETING

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

FOURTH PUBLIC MEETING

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

REFERENCES

• IOM (Institute of Medicine). Gulf War and Health: Volume 2—Insecticides and Solvents. Washington, DC: The National Academies Press; 2003.
• IOM. Gulf War and Health: Volume 3—Fuel, Combustion Products, and Propellants. Washington, DC: The National Academies Press; 2005.