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House of Representatives,
Subcommittee on Benefits,
Committee on Veterans' Affairs,
Washington, DC.

    The committee met, pursuant to notice, at 10 a.m., in room 334, Cannon House Office Building, Hon. Jack Quinn (chairman of the subcommittee) presiding.
    Present: Representatives Quinn, LaHood, Redmond, Filner, Mascara, Evans, Reyes, and Rodriquez.

    Mr. QUINN (presiding). The Subcommittee on Benefits will come to order.
    As we do that, instead of waiting until a little bit later this morning when possibly we lose some of our members or witnesses or members of the audience, I wanted to take a minute, Bob Filner and I, to mention to all of you who don't know that today's hearing—although we've sort of announced this before once or twice—is Michael Brinck's last hearing for this subcommittee. He was at the Full Committee I guess about 2 or 3 weeks ago before we broke, and a couple of people had nice things to say about him. I didn't step up and be counted that morning, but, Mike, from the subcommittee's point of view, and I know Bob and all of the members join me and the staff in saying thanks for the work that you've done here.
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    It's been a real delight since I've been the chairman to, first of all, have you close by here in Cannon just a few doors away from me, but, second of all, to take advantage of the great working relationship you've developed over the years with people in and outside of Government circles when it comes to veterans' activities. We also have a little present for you, and it fits within the ethics and how much you can accept and how much we can give you—as Filner's throwing candy bars at you—but this is just something, a little token oaf our appreciation from our side and all the members on the committee. Thank you so much.
    Mr. BRINCK. Thank you. (Applause.)
    Mr. QUINN. Ray LaHood thought that was for him when he walked in here this morning; little does he know.
    Good morning, and thanks for joining us. We're here today, the subcommittee, to discuss several issues confronting the Department of Veterans Affairs and some, I might add, as I read through the testimony last night and this morning, are somewhat complicated, medically as well as, I think, from a layperson's point of view to discover what's in here and then even for us to pose some questions.
    First on the list, though, if I may take a few minutes to review where we're going to try to be headed this morning. We want to see what progress the Department has made in ensuring consistent and fair processing of Persian Gulf veterans' compensation claims. We may mention a little bit later—unfortunately, we received that information late this morning, about 9:45 or 9:50—in recent history, we've seen the Department go from processing claims at regional offices to centralizing the processing at four regional centers and now back at the regional offices. Throughout all these moves we've been told that the latest decision would sort of clean up this processing problem. I'm not convinced it has.
    In the past few months, the Department finally suggested that the data collection was a little bit faulty and began an effort to improve the data, and we received some of that data this morning—Bob Filner and I were just talking about it. However, after considerable efforts to sort of systemize the collection, the VA staff member who's responsible for it has now been assigned temporary duties away from the Department. To say the least, we're a little bit disappointed with that, and I hope the Department can inform the subcommittee this morning how you will continue to improve the data on Persian Gulf claims, and we may have a suggestion for you on how to go about that.
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    The issue, then, of exposure to depleted uranium which was widely used in various missions during the Gulf War has made the press recently; we've all read about it. It's my understanding that depleted uranium is a toxic heavy metal and potentially dangerous. I'd like to note this problem is not limited to those who fought in the Gulf War, because DU is still being used in firing ranges for our services, so our people are still exposed to it. For example, somebody has to clean the weapons after they've been fired and used. Therefore, I'm asking the Department to coordinate a VA/DOD briefing on the issues surrounding the exposure to depleted uranium within the next 30 days.
    Second, we have asked the Department to discuss how it is handling claims involving hepatitis C. This a deadly disease that is also making front page news and magazines, and some scientists are saying this may be a bigger threat to national health than AIDS. I want to be sure. I think the subcommittee wants to be sure that if a veteran shows up at VA with hepatitis C and evidence of a possible infection opportunity while in the service, that veteran, first of all, will be taken care of. Initial VA data does not show that necessarily to be the case. So, my question to the Department, right up front, before we begin the hearing, do current laws and regulations inhibit a veteran's ability to be service connected for hepatitis C if he or she received a blood transfusion prior to the early 1990's or worked in the medical field?
    And the final topic this morning concerns the possibility that veterans who are judged to be suffering from PTSD may actually be exhibiting the effects of cerebral malaria. We're looking forward to hearing the Department's views in the study done by Dr. Varney and others.
    I also want to just finally spend a moment on what I see as a value and obligation of the VA Research Program. We've talked about research and the money we spend on research many times here at the subcommittee and, indeed, in the full committee. Today's hearing revolves around three examples of how VA research can contribute to a veteran's ability to be compensated for disabilities incurred in the service. While this subcommittee doesn't have jurisdiction over the Research Program—we understand that—we do want to make a point about how the VA chooses research topics.
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    I'm a little bit concerned that VA research has lost some of its focus on problems that, while not necessarily unique to veterans, occur with greater frequency than in the non-veteran population, and we will hear some testimony today reflecting that concern. To put in perspective, a research and development program focused on the relevant issues affecting large numbers of veterans is vital to any kind of fair compensation program.
    Typically, these are problems that our troops encountered in the field or the workplace throughout this past century; things like tropical diseases, cold weather injuries, combat-related stress, exposure to radiation, or even hazardous materials. The question that comes naturally, I think, then, is what portion of the VA's $300 million budget for research and development is going directly to talk about these kinds of problems? We'd like to hear back from the Department, hopefully, by the end of next week.
    And, also, finally, before I yield to Mr. Filner, without objection, I'd like to enter a letter from Chairman Stump to Secretary West into the record this morning—copies are available at the tables.
    Mr. QUINN. In his letter, Chairman Stump has asked the Secretary to review implementation of compensation laws on undiagnosed illnesses to determine whether chronic fatigue syndrome and fibro myalgia should be considered equivalent to undiagnosed illnesses for compensation purposes. The chairman makes a point that two veterans with exactly the same symptoms could be diagnosed completely differently by VA physicians; one receiving a diagnosis of CFS or fibro myalgia and the other suffering from an undiagnosed illness. I believe that the Legion's prepared testimony and statement later this morning does a very good job in making the case in support of Chairman Stump's position. Therefore, I asked that it be included in the record. We look forward to hearing the Department's views on Mr. Stump's letter.
    And, with that background, I'd like to yield to Mr. Filner for any opening remarks he has at this time.
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    Mr. FILNER. Thank you, Mr. Chairman. Thank you for your comments. I'm pleased that we'll be able to learn more about the problems veterans are having in obtaining service connection for illnesses related to their service in the Persian Gulf as well as for hepatitis C and cerebral malaria.
    It seems that every time we have an illness which is a little harder to identify and pin down than a clear cut obvious physical defect such as an amputated limb, we hear stories of veterans spending years trying to obtain the benefits that I think we agree are rightfully theirs.
    The VA describes itself as an organization which grants claims when it can and denies them only when it must. Unfortunately, the cases I hear about, both here and back in my hometown of San Diego, suggest the opposite. For example, Persian Gulf veterans have had their symptoms dismissed as due to combat stress even when laboratory data suggest that a mycoplasma infection may be present. Veterans who are ill enough to qualify for placement on a liver transplant list are rated at only 60 percent or less for service-connected hepatitis C. Veterans who are treated by medics under combat conditions with no access to a military hospital or sophisticated laboratory testing have their claims of service connection for malaria dismissed, because their history of malaria cannot be verified by a medical diagnosis or appropriate laboratory test in their military medical records.
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    From the perspective of such veterans and members of the this committee, the VA policy is perceived as denying claims whenever it can. Only when the evidence is so overwhelming are benefits, seemingly grudgingly, granted at the lowest possible rating. This is especially true of our combat veterans who are supposed to be given special consideration taking into the account the time, place, and manner of their military service. I hope today's hearings will address these concerns as well as what actions can be taken under current law to solve these problems.
    Let me add, also, that it seems—and I say this to the VA and anybody from DOD who's here—anytime a congressional committee gets into the area of the Persian Gulf illness, there is always the perception, somehow, that ends up being given, either unintentionally or by matter of policy, that there is something to hide and that we are stonewalling this and we refuse to look at it. Just at today's hearings, the hearing was on three subjects. The VA, Mr. Epley, gave us testimony on two and not until this morning, I guess, did we get anything on the Persian Gulf. Why does it always seem to be that we don't want to discuss this; that we're hiding something? That's always the impression, somehow, that's given.
    And the two pages that you gave us are a collection of statistics which, if I have any time to go over with you today, seem to be intended to hide what is happening rather than to tell us what is happening. The average person looking at what you gave us will say they are trying to dismiss this as an issue. They are trying to hide the severity of the situation. We can't glean anything that the average person can understand from these statistics. It's just that every time we ask a question—every time we ask this subject to be looked at, the method that is used to give us information; the timing of it; the kind of information; the stuff that is left out; the unanswered questions seem to say more about what this Government is trying to do and not do than get at source of the situation.
    Now, I don't mean to say, Mr. Epley, that that's what you intentionally tried to do. I just say that everybody from every department that comes before us and other congressional committees gives us the sense that you don't really want to get into this issue; that the responsibility that this Government has to these veterans is not taken seriously, and, as I have said on other occasions, I think the medical facts that are out there that seem to be known to everybody but the VA and the DOD seem to indicate a much more serious health situation than anybody wants to admit or that you can glean from these statistics, and until somebody comes before this committee or any committee that says, ''We have a problem, and we don't know—'' be honest with us, then we're going to just think you're lying every time we get a set of statistics like this. I start looking at it and say what are they hiding instead of saying what are they trying to tell me? This Government, it seems to me, owes this country and our veterans the truth on this, and I don't think we're getting it yet. Thank you, Mr. Chairman.
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    Mr. QUINN. Thank you, Mr. Filner. I yield now to the ranking member of the Full Committee, Mr. Evans? Lane?

    Mr. EVANS. Thank you, Mr. Chairman. Vietnam veterans, Gulf War veterans, atomic veterans, veterans with traumatic cold injuries, prisoners of war, veterans with malaria, Mr. Chairman, these veterans and others have two things in common: they have fought for their country, and they have been forced to fight again for their health care and other benefits that they deserve having served our country.
    In the non-adversarial system of the VA benefits, too often the VA has been the adversary. For example, lay evidence submitted by veterans—sometimes the only credible evidence available for veterans disabled in combat—has not been properly considered by the Veterans Administration.
    Mr. Chairman, veterans face unnecessary barriers at the VA as they seek the benefits that they have earned. These barriers must be broken down now. Veterans with these illnesses must not be forced to fight the same battles with their own Government for the benefits that they have earned that Vietnam and other veterans have been forced to fight for.
    A recently completed analysis of VA claims data indicates Persian Gulf War veterans exposed to munitions depot destruction are 20 times more likely to be rated 10 percent or more for undiagnosed illnesses than other combat veterans of the theater who didn't serve actually in combat. This important finding was made by the committee's Democratic staff based on analysis of VA claims data.
    Additionally, it must be noted that hepatitis infection among Vietnam veterans is increasing dramatically according to the VA data.
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    Mr. Chairman, thank you for scheduling this important hearing. It's timely, and I appreciate the opportunity to examine the standards by which the VA adjudicates claims. As a result of your efforts and the interest of other members, the standards by which the VA adjudicates claims, I believe, could be more veteran friendly.
    Before I close, I'd also like to take a moment to welcome Dr. Varney, from the VA Medical Center in Iowa City. He has assisted many veterans in my congressional district, and I'm pleased that he is here to talk about his groundbreaking work on malaria. Thank you, doctor, for coming. Mr. Chairman, thank you for your time.
    Mr. QUINN. Thank you, Mr. Evans. Other members who have opening statements? Mr. Mascara?
    Mr. MASCARA. I'd like to ask unanimous consent to place an opening statement into the record.
    Mr. QUINN. Without objection, so ordered.
    [The prepared statement of Congressman Mascara appears on p. 118.]

    Mr. QUINN. Mr. Rodriguez? Okay, and Mr. LaHood.
    Mr. LAHOOD. Mr. Chairman, could I include in the record the democratic staff analysis?
    Mr. QUINN. Without objection, the analysis is included in today's proceedings.

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    Mr. QUINN. Mr. Filner.
    Mr. FILNER. Mr. Chairman, I would also like to ask unanimous consent that the record remain open for 3 weeks so additional written testimony that I anticipate will be submitted can be included in the record.
    Mr. QUINN. Mr. Filner has asked that the record remain open for 3 weeks. I hear no objection. Hearing none, it is so ordered, Bob. Thanks, good idea; appreciate it.
    So, thank you all, and we have our first panel, Mr. Epley, and Dr. Wright, Dr. Varney, and Dr. Booss. But before we—and we're going to start from you, Mr. Epley and work over—I'd like to—in your prepared testimony, you point out—and this is the kind of information I think Bob and I were talking about. We just want the information; we don't suspect it, but if we don't get it or we get it late then we have reason—but at one point in time one of the numbers in there is that 29 hepatitis claims were denied by the board—and we can cite the page number for you; I was looking at it earlier this morning. I'd just like to know on what grounds they were denied is all. We don't have to have a separate case-by-case, but in those 29, by the end of next week, we'd like to know—I would like to know why they were denied. Thank you. You may proceed, Mr. Epley.

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    [Additional enclosures retained in committee files.]


    Mr. EPLEY. Mr. Chairman and members of the subcommittee, I want to thank you for inviting here today to talk to give you testimony. This is my first opportunity before the committee. As you have already said, the primary focus of my written testimony and my verbal comments are with regards to hepatitis C and cerebral malaria. I want to apologize for the late submission of the testimony. It was not my intent to delay or withhold the information.
    Mr. QUINN. If I may then, why was it submitted late. Is there a problem with staff? Are you short-staffed? Are the copy machines not working?
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    Mr. EPLEY. No, sir. When we were first advised of the hearing——
    Mr. QUINN. Yes?
    Mr. EPLEY (continuing). The two subjects that we were told to present testimony on were hepatitis C and malaria. We received a supplemental request, and it was written in addendum; it just didn't clear.
    Mr. QUINN. Thanks.
    Mr. FILNER. May I follow up? You said your last three words—''it didn't clear?''
    Mr. EPLEY. We didn't receive approval of the addendum that we wrote up.
    Mr. FILNER. What kind of approval do you have to go through for this?
    Mr. EPLEY. In the Administration people above me review and authorize testimony.
    Mr. FILNER. Explain that a little bit. Does it get approved just in VA or does it go to DOD? Does it go to the White House? Who has to approve any statement that you make here on Persian Gulf illness?
    Mr. EPLEY. Sir, excuse me, I'm pretty new in Central Office, and I understand that the Secretary's office approves it. I believe that in the Administration it goes over for review, at least in some instances, by OMB, but I'm not familiar enough to give you an exact run-through of the process. I'm sorry. This is the first time I've done this.
    Mr. FILNER. Well, it seems to me, if I were doing it for the first time, I'd like to know who is going to approve my testimony, but I don't mean to tell you how to do your job, I just have a different personality maybe. Could you get back to us by the next day or two? I want to know the route by which this testimony has to be approved, and I want to know if the process is different for other subjects. Did everything that's being said today go through the same route? I suspect not, but I'd like to know.
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    (See Letter of August 14, 1998 on p. 32.)

    Mr. FILNER. When you say something on Persian Gulf illness, does the Secretary of Defense have to approve that? Does the White House have to approve it? Again, I wish I didn't have to ask these questions. I've been sitting here, now, with my colleagues for a couple of years on this problem, and everything that happens seems to create suspicion, and we get something 10 minutes before the hearing—and it's not very interesting data I'll tell you—and then you tell me it has to be cleared. Then I'm saying well, who's clearing all this? Is it going to some mysterious czar of the Persian Gulf illness who's trying to keep information from us? I'd like to know, I mean, who has to approve? This data, it would seem to me, is objective data. Why would anybody have to clear it?
    Mr. EPLEY. Sir, I was just told that the Administration is asked to clear any testimony regarding Gulf War and that maybe an unusual circumstance.
    Mr. FILNER. Who in the administration? I mean, where?
    Mr. EPLEY. We'll provide that information.
    Mr. FILNER. I want to know who in DOD? I want to know who in the White House? I want to know who at NIH? I mean, who is clearing this testimony? Thank you.
    Mr. QUINN. Thank you, Mr. Filner, and I think—and I interrupted your testimony when you began, Mr. Epley. I apologize for doing that, but I think you sense our frustration here on both sides with not necessarily with what you have to say or the truthfulness of what you're about to say, but it's the whole situation of how we receive it or don't receive it, and we're in that business as elected people that perception sometimes is as important as the facts, and it seems like we're always fighting this battle, and we appreciate your understanding of that, and, Bob, I appreciate your comments. We'll let you get back to your testimony now.
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    Mr. REYES. Mr. Chairman?
    Mr. QUINN. Yes.
    Mr. REYES. I just have a question. Will we be provided that information as well, because——
    Mr. QUINN. Absolutely.
    Mr. REYES (continuing). This is a very real issue across the country.
    Mr. QUINN. Whenever we ask for information following even, for example, the question that I had on the 29 cases of hepatitis C that were denied, when we receive that written response, we'll make it available to the full subcommittee, and, indeed, to the ranking member and chairman of the Full Committee as well. Thank you. Sir?
    Mr. EPLEY. Hepatitis C is a growing public health concern and an issue that concerns us because it affects our veteran population. Since we became aware of this health threat, VA has initiated several actions pertinent to hepatitis C disability claims. For example, in April 1998, we issued an information letter to our field stations about the incidence of the disease in the general population; the persons most at risk; how the infection spreads; its manifestations, treatment, and prevention; and how our evaluators can address the disease under the current rating schedule. We asked all of our offices to prominently display posters published by the American Liver Foundation about the risks and symptoms of hepatitis C. We are revising our rating schedule criteria to be specific to hepatitis C and its complications. We're working with VHA, the Veterans Health Administration, to develop C&P exam guidelines so that physicians will be able to provide information sufficient for rating purposes.
    In May of 1998, the Board of Veterans' Appeals held training for its Board members on hepatitis issues. They've scheduled similar training for attorneys this month. In June of 1998, the Veterans Health Administration (VHA) issued an information letter outlining standards for testing for an evaluation of hepatitis C.
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    The issues VA must consider to determine service connection for hepatitis C-related disabilities include when the infection was incurred; how the infection was incurred; and what current manifestations are present. We know that individuals can be at risk for hepatitis C for a number of reasons. Among these, three major risk factors are: for recreational drug use, especially with shared needles; blood transfusions before universal testing of hepatitis C; and accidental exposure to blood by health care workers.
    People infected with the hepatitis C virus may have no symptoms. Many will not realize they've been infected. Nevertheless, they're at risk for developing serious complications such as cirrhosis of the liver or liver cancer. These complications may take up to 20 years to develop.
    To evaluate claims based on hepatitis C, VA needs the same kinds of evidence we need to service connect any disability. These include medical evidence of a current disability; evidence that the disease or injury causing the disability is related to service; and medical evidence that links the in-service injury or disease to the current disability.
    We will need to develop information that helps us to determine when and how the individual was infected. It's important to note that if hepatitis C infection is due to drug use, VA is prohibited by law from granting service connection or paying compensation. We will need to obtain a complete history from the veteran to include all risk factors to which the veteran was exposed before, during, and after service.
    In the final analysis, a medical opinion as to the most likely etiology of the disease will be a key to our determination. Our rating schedule already allows us to evaluate all types of hepatitis including hepatitis C. The evaluations range from 0 percent for non-symptomatic manifestations to 100 percent for severe manifestations.
    In addition, the schedule contains provisions that allow us to rate late complications of hepatitis C such as cirrhosis and liver cancer. While the current rating provisions are adequate to evaluate hepatitis C, the revisions already in progress will specifically mention hepatitis C and explain possible complications of all types of hepatitis.
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    As to the second issue, cerebral malaria, there is less medical and scientific information available. I think you'll hear about that from the other panel members. We do note from the literature and from discussions with the Veterans Health Administration that a diagnosis of malaria is not the same as a diagnosis of cerebral malaria. Cerebral malaria requires a diagnosis of falciparum malaria plus clear evidence of some neurologic disturbance.
    To determine if cerebral malaria is service connected, we need the same type of evidence we need for any other claim for service connection, and I elaborated on that earlier. Current rating criteria provide a 100 percent evaluation for active malaria. Once the active process resolves, we evaluate any residual disabilities such as liver or spleen damage using the body's system effect.
    We do not believe we're seeing a large number of claims based on either hepatitis C or cerebral malaria at the present time. A review of BVA decisions, which you alluded to earlier, for fiscal year 1997 shows that of 43,000 BVA decisions only 129 involved hepatitis C and only 3 involved cerebral malaria.
    We believe that the rules and procedures we use for any claim for service connection, as supplemented by revisions already under development, will be adequate to determine whether hepatitis C and cerebral malaria are service connected.
    We've begun with the Veterans Health Administration to determine if some change in law or regulation would be appropriate based on medical and scientific evidence, and we will of course initiate any changes we find necessary. Mr. Chairman, this concludes my verbal statement. I'll be happy to answer questions.
    [The prepared statement of Mr. Epley, with addendum, appears on p. 119.]

    Mr. QUINN. Thanks very much. I think, if it's okay with the rest of the members, Mr. Epley, we'll hear from our other witnesses first. Dr. Wright is scheduled to be next, and when everybody takes their 5 minutes, we'll come back with some questions. I do have one, but we'll let everybody have a break here and let you get a drink. Dr. Wright?
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    Dr. WRIGHT. Mr. Chairman and members of the subcommittee, I'm pleased to appear today to discuss the importance of hepatitis C infection in the VA health care system. I am chief of the gastroenterology section at the San Francisco VA. I've been treating veterans at the liver clinic there for more than 10 years. I'm also as associate professor of medicine at the University of California at San Francisco, and currently they hold research grants from the NIH, the VA, and from industry to study the epidemiology, pathogenesis, and treatment of hepatitis C.
    Hepatitis C affects 3.9 million Americans with a prevalence of 1.84 percent in the population as a whole but with a higher prevalence in minority populations: 3.2 percent in blacks and 2.1 percent in Mexican-Americans. The highest seroprevelance is between the ages of 30 and 39 and 40 and 49 years. In these groups, the prevalence is three-fold greater than in the population as a whole, and it's these data in conjunction with the long duration of infection before life-threatening complications occur that has led to the concern that mortality for hepatitis C may triple in the coming decade.
    The natural history of infection is highly variable with many being infected for 20 to 30 years without developing complications, yet some, albeit the minority, progress into cirrhosis and even liver failure within 10 to 20 years of onset. Nevertheless, hepatitis C is linked to 10,000 deaths annually in the U.S. and the development of liver cancer. HCV disease is also the most common indication for liver transplantation in U.S. transplant programs in general and VA transplant programs in particular.
    There is limited information about factors which influence or accelerate the natural history of HCV disease, but three factors have been independently associated with the progressive disease in one large study. These were excess alcohol intake, male gender, and age greater than 40 years at the time of acquisition of infection. The first two factors are directly relevant to our veterans. Other factors which are believed to contribute to the progressive disease are HIV coinfection and immunosuppression following organ transplantation.
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    The prevalence of hepatitis C in veterans is unknown but would be predicted to be higher than in the U.S. population as a whole, because risk factors for infection are common in our veteran population. HCV is transmitted by parenteral routes, i.e. through contact with blood. Injection drug use is the most common risk factor for HCV in the general population, accounting for 40 to 60 percent of all infections. Transfusion is also associated but accounts for only 5 percent of infections historically and many fewer today. HCV infection has also been associated with increasing numbers of sexual partners and in minority populations with cocaine and marijuana use.
    In the largest epidemiological study of HCV in the U.S., the NHANES III study, there was no association between HCV and education or military service for non-Hispanic whites. In Blacks and Mexican-Americans with military service, the prevalence was 3.3 and 1.9 percent respectively. What complicates determination of the mode or time of acquisition of HCV in an individual is that initial infection is typically silent and duration of disease must be inferred from presumed time of first exposure.
    From our own experience at the San Francisco VA Medical Center, HCV disease is a common problem. In those who are tested as part of a city-wide needle-stick study, 10 percent of hospitalized veterans were seropositive for hepatitis C. This is substantially lower, however, than the experience of San Francisco General Hospital where the seroprevelance was 30 percent. Of 195 seropositive veterans attending the San Francisco VA Liver Clinic, 78 percent are between the ages of 40 and 59 years.
    In a limited survey of 48 seropositive veterans, 24 percent had served in Vietnam; 2 percent had served in Korea; 4 percent has served in World War II, but more than 60 percent had never been to combat. A history of injection drug use was obtained in almost half of these veterans, but many had started using drugs after their military service. A history of transfusion was obtained in almost 20 percent. However, in this limited survey, prior use was also common in those without hepatitis C infection.
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    This study is too small in sample size to comment on the significance of these associations and is currently being extended to a larger number of seropositive and seronegative individuals. The distribution of HCV genotypes in our veterans was similar to that in the U.S. population as a whole, a finding which supports prior observations by Dr. Seeff at the Washington DC VA. These results imply that HCV infection is being acquired in veterans from the U.S. rather than European or Asian sources.
    Our study was not designed to assess the prevalence of hepatitis C in veterans as a whole or in subpopulations of veterans such as those who served in Vietnam. These questions are being addressed in a study which is currently getting underway at our VA and which is funded for the coming years.
    In a recent mandated look-back program of transfusion recipients, there has been much discussion about the importance or otherwise of infected individuals knowing their serological status. While initially skeptical about the benefits of such knowledge, I've been convinced over the past year that from talking to many with infection the vast majority want to know. Individuals with hepatitis C should avoid alcohol; they should be immunized against other hepatitis viruses; they should be counseled regarding modes of transmission, and they should be considered for treatment.
    There are three FDA approved formulations of interferon which has initial response rates of 40 percent but sustained response rates of only 20 percent. Interferon is not appropriate in those with significant psychiatric illness nor in those with ongoing substance abuse, problems which are frequently encountered in the patients we serve. Recently, the FDA approved an oral antiviral agent, ribavirin which in preliminary results would suggests you can get biological clearance in 40 percent of the time.
    I'd like to thank the subcommittee for allowing me to testify. Hepatitis C is a global public health problem which has only recently begun to get the attention it deserves. There are many reasons to believe that hepatitis C is a greater problem in veterans than in the U.S. population as a whole, although the seroprevalence of veterans is currently unknown. We should not lose sight, however, of the fact that most individuals with hepatitis C will never develop life-threatening complications from their infection. Nevertheless, this virus is an important cause of morbidity and individuals need to know their serological status. There is insufficient information currently to know whether hepatitis C is linked to military service, but preliminary data would suggest that many veterans are acquiring hepatitis C by traditional, non-combat-related means. Thank you.
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    [The prepared statement of Dr. Wright appears on p. 130.]

    Mr. QUINN. Thank you very much, and we appreciate your insight and statistics. I've written down all kinds of questions already, but, thanks, doctor, I appreciate it.
    Dr. Varney, we appreciate your sharing the research on Vietnam veterans particularly, as Mr. Evans point out, and you may proceed.

    Mr. VARNEY. I appreciate the opportunity to speak. Malaria may have afflicted as many as 250,000 ground troops in Vietnam, making malaria nearly as common as gunshot wounds. The statistics is relevant to Vietnam veterans today, because while they may have recovered from the malaria illness itself, a number of these veterans are left with neuropsychological and neuropsychiatric symptoms involving mood, temper, memory, and other symptoms that could be mistaken for PTSD.
    Let me start with a bit of history. There is a consistent body of clinical literature dating from the 500 B.C. through the early 20th century which has reported that individuals who survive cerebral malaria frequently developed depression, memory loss, personality change, and temper problems. This constellation of neuropsychiatric deficits was observed often enough among survivors of cerebral malaria in the turn-of-the-century in British-occupied India that the syndrome was christened Tropical Neurasthenia, and it was a disability category back then for the British Army. Forrester, who is a leading expert of his day, reported that cerebral malaria was the leading cause of mental illness in the British-occupied malarial endemic zones.
    Scores of papers were written about malaria and Tropical Neurasthenia during the 19th century. Many neurology books from that time contain long sections about cerebral malaria and its neuropsychiatric sequelae. It should be noted, in addition, that clinical observations about malaria leading to psychiatric-like symptoms were first recorded by Hypocrites and Galen 2,000 years before the experiences of the British in India or the Americans in Vietnam.
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    Among the acute brain-related complications of cerebral malaria are swelling of the brain with flattening of the gyri; brain and cell damage from high fever; small hemorrhages throughout the subcortical white matter; brain hemorrhages around large blood vessels; blockage of the capillaries with log jams of blood cells which in turn cause hypoxia; severe hypoglycemia, and, to top it off, it turns your brain blue-gray.
    The key point from this abundant literature is that malaria in its severest form may cause brain damage, and this will persist after the malaria illness itself has been cured and could not identified on any biological tests.
    In our research, the neurobehavioral status of 40 Vietnam veterans who reported being treated for malaria in Vietnam as compared with that of a group of combat veterans who sustained gunshot and shrapnel wounds but didn't have malaria. The purpose of requiring this comparison group was to control for exposure to combat and also to allow us to check for records of documentation. The results of the study suggested that cerebral malaria survivors have multiple neuropsychiatric symptoms that remain problematic years after the acute illness has been cured. As compared with the wounded combat Vietnam veterans, our study showed that people who contracted malaria manifested a variety of problems with depressed mood; feelings of subjective distress; memory problems; emotional liability; and neuropsychiatric symptoms very similar to small seizures such as memory gaps and staring spells. These findings are statistically and psychometrically more sophisticated and more reliable than the clinical observations over the last 2,500 years, and our study is just the most recent to show that cerebral malaria has long-standing neuropsychiatric symptomatology in adults that survive the illness.
    The message to be drawn from research is that there are some Vietnam veterans at risk for persistent neuropsychiatric syndrome which can produce a wealth of psychiatric, psychological, neuropsychological, neuropsychiatric, and neurological symptoms.
    Findings suggest that further investigation and attempted replication by other groups may be appropriate. If additional studies confirm that malaria and, more important, post-malarial neuropsychiatric syndrome, which was called Tropical Neurasthenia is a problem nationwide, then we can look into treatments.
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    It is, by the way, not my intent to complain about the VA, the Army, or Vietnam veterans. Our findings offer good news for an undetermined number of Vietnam veterans in that they may have mental symptoms which are the result of a neurological disease which they and others have failed to appreciate. With the change in the perspective regarding their symptoms, it would logically follow that there would be changes and improvements, we hope, in treatment. In our experience, many of the Vietnam veterans who have this disorder can be found in PTSD clinics and their lives are substantially improved by treatment. Thank you very much.
    [The prepared statement of Mr. Varney appears on p. 132.]

    Mr. QUINN. Dr. John Booss from the DVA is here, and we'd like you to continue. Doctor?

    Dr. BOOSS. Mr. Chairman, members of the subcommittee, thank you very much. Malaria is a disease of antiquity, without question. However, it was not until the end of the last century, in the 1880's that it was, in fact, demonstrated to be due to parasites. Furthermore, although it was called malaria or bad air, it was not until the end of the last century that it was demonstrated to be transmitted by the mosquito. Thus, it's an infectious disease caused by a parasite and transmitted by the mosquito.
    Now, if I could make a comment with respect to some of the preliminary remarks of the subcommittee, there's no question that the circumstances in Vietnam were awful. If you were a foot soldier under conflict circumstances which were terrible, and you developed a fever, there is no question about the horrible circumstances. However, even for troops treated in the field, they would then be taken to about—in the case of the Army—11 evacuation hospitals; get their acute treatment, and then go to a recovery hospital. This is well documented in the journal Military Medicine, for example. Thus, there was a fairly good procedure for how troops were treated in the field as I understand.
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    Now, with those preliminary remarks, let me get to my printed remarks which are rather long, and I may have to——
    Mr. FILNER. I'm sorry to interrupt you, but are you suggesting that under those conditions there are standard tests and laboratory reports done, and the records would all be standard because there's this protocol that everybody's going through? Are you suggesting that?
    Dr. BOOSS. I'm suggesting, sir, that the diagnosis would require an identification of the parasite in a blood smear; just seeing the parasite in a blood smear. I can carry that further if you like, but the reason would be——
    Mr. FILNER. But I can't imagine that under the circumstances of Vietnam and the situations of chaos and emergency and bloodshed that everybody had the same kind of standard test that you could then look back and rely on. As I understand it, many of the VA judgments are based on what's in those records, and if it's not in the records, tough, and, yet, I can't imagine that you could think that those records are either comprehensive enough or standardized enough that they're reliable enough for you to make all your judgments. That's what you seem to be suggesting unless I'm jumping to conclusions.
    Dr. BOOSS. Point taken.
    The office of research and development, Medical Research Service, reviewed a research proposal from Dr. Nils Varney from the IOWA City VA Medical Center in 1988 to carry out research on the neuropsychiatric consequences of cerebral malaria in Vietnam veterans. Following a competitive merit review process, funds were awarded to Dr. Varney for his proposed research from 1989 to 1992. A paper titled ''Neuropsychiatric Sequelae of Cerebral Malaria in Vietnam Veterans'' reporting on this research was published in 1997 in the Journal of Nervous and Mental Disease.
    Much of the controversy surrounding this report involves four issues. The first is that there was no medical or laboratory confirmation that the majority of the patients were, in fact, infected with malaria. Second, there is a lack of documented medical evidence that supports the diagnosis of cerebral malaria. Thirdly, Dr. Varney's interpretation of his data is inconsistent with other interpretations from documented malaria cases. Fourthly, Dr. Varney has made unfortunate and insupportable extrapolations from a study of 40 veterans to the entire Vietnam experience. This is not to say, however, that Dr. Varney's hypothesis lacks value. Indeed, further investigation could refine our understanding of the long-term consequences of malaria infection. What we suggest is that an assessment of Dr. Varney's work reveals some methodological and interpretational problems that should be carefully considered before we make decisions that change health benefits policy. We must look at Dr. Varney's work in the larger context of scientific knowledge about malaria.
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    Before I go on to discuss Dr. Varney's work in more detail, I would like to consider some background regarding malaria itself. Malaria is caused by infection of the human with a parasite of the genus, Plasmodium. The diagnosis of malaria is made by examination of blood smears for the parasites. Humans are infected with Plasmodium through inoculation by the Anopheles mosquito carrying the organism which it received by biting an infected human. There are several species of Plasmodium, one of which is Plasmodium falciparum. Infection with Plasmodium falciparum leads to falciparum malaria which is the cause of cerebral malaria. Of all falciparum malaria cases, many published studies have estimated that approximately 2 percent are diagnosable as cerebral malaria. One study, in particular, examined 1,200 cases of falciparum malaria among the troops in Vietnam and found that 19 fit the criteria for cerebral malaria. That paper was reported in the Journal of the American Medical Association in 1967.
    With this background, I will now turn to Dr. Varney's work, and with the middle light on, I'd better advance a page or so in the written testimony. Thank you very much, Mr. Chairman. An earlier study of malaria from Dr. Varney's group was reported in the journal, VA Practitioner, in 1989. In that paper, 30 Vietnam veterans were studied who reported having had malaria accompanied by at least 12 hours of amnesia. Twelve of 17 medical records supported the diagnosis of malaria but the remainder were recorded as lost or destroyed.
    There is no report of examination of blood smears for the malaria parasite nor was the diagnosis of cerebral malaria sought in the medical record. Hence, in the 1989 report, the diagnosis of cerebral malaria was not established medically. All subjects had coexisting medical conditions that could have contributed to the reported findings. Hence, there was ambiguity about the cause of the neuropsychological findings reported.
    Unfortunately, the report of Dr. Varney and his group in the November, 1997 issue of the Journal of Nervous and Mental Disease does not resolve the ambiguities. There is, again, no requirement for laboratory verification of the malaria group. Of 40 veterans studied, service records were found for 37, of whom 14 had a diagnosis of malaria cited. A search for the diagnosis of cerebral malaria was not reported and no report of blood smears was made. This is, in fact, in contrast to medical reports on malaria at the time of the conflict in Vietnam in which microbiologic confirmation of actual infection was obtained—and we give a couple of citations for that in our written testimony. To reiterate, the most recent report did not require medical diagnosis in order for a subject to be included in the malaria group nor did inclusion require a medical record citation of cerebral malaria. This is a significantly lower standard than the wartime reports themselves. Mr. Chairman, I'd be happy to proceed if you like or I can stop here.
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    Mr. QUINN. If it's okay with you, in the interest of time, Doctor, why don't we have you end there. Your written testimony is part of the record. I've followed along with you here and we can get to some questions.
    Dr. BOOSS. Thank you very much.
    Mr. QUINN. Thank you.
    [The prepared statement of Dr. Booss appears on p. 135.]

    Mr. QUINN. I'm going to go back, Mr. Epley, if I may for a minute, and begin with at least one question and then give all the members an opportunity as long as you're all here.
    At the end of your statement, you say that ''In conclusion, we believe the rules and procedures we currently apply to any claim for service connection to be supplemented by revisions under development are adequate to determine whether hepatitis C or cerebral malaria are service connected.'' And then at the second-to-the-last sentence, ''We do not believe that any legislative or regulatory changes are necessary at this time, and we're in the business of passing laws or regulatory changes unless they are necessary.''
    So, my question gets to the first sentence of your conclusion in which you say, ''We currently—the rules and procedures we currently apply to any claim for service connection to be supplemented by revisions under development.'' I take that to mean that you're taking a look at some revisions possibly that might change the regulations that you use. Now, for those of us concerned about hearing the medical part of this, for laypeople, that's good news. So, my question is, do you expect some revisions—the ones that you mentioned that are under development—to happen and when might we hear back from you as to some kind of change?
    Mr. EPLEY. We are actively writing a change to the rating schedule for hepatitis to make specific reference to the hepatitis C virus. The way the rating schedule is written right now, it relates to hepatitis——
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    Mr. QUINN. Right.
    Mr. EPLEY (continuing). And we can rate hepatitis when it is present in the blood. We feel, with the information coming available to us, we need to specifically outline a reference to hepatitis C, and that revision has been drafted, and we'll be moving it forward as fast as we can.
    Mr. QUINN. Assuming some of it needs to be checked by other people—we went through Mr. Filner's question—can you—I mean, will we be back here a year from now, 6 months, a month? Any idea?
    Mr. EPLEY. We'll have that regulation draft or revision out of my service within the next 2 months. We'll move it along. The process after that, I'll do all I can to speed it up, sir.
    Mr. QUINN. I understand. And let me also say that with all of these comments, questions, not only by myself or Mr. Filner or any of the members, we're here to help you do that. Believe me when I tell you that. We are here to help you move that through the process, if we can, through other members; through the administration. Anyway you think it helps you get that information, please let us know; we want to help you do that. That's what we're—one of our responsibilities. We want to work with you to do that, but we can't if you don't tell us you need the help. That's a fine answer, thank you. Mr. Filner?
    Mr. FILNER. Mr. Chairman, the second panel has testimony with regard to the Persian Gulf illness. I was wondering whether I could postpone my questions for Mr. Epley. Can he wait for the second panel, and we can have those questions with that testimony just on the Persian Gulf.
    Mr. EPLEY. I'd be happy to stay, sir.
    Mr. QUINN. It's fine with me.
    Mr. FILNER. I appreciate that. I'm almost tempted to say, I hope you don't need clearance for that, but I won't!
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    Mr. EPLEY. Thank you, Mr. Filner.
    Mr. FILNER. I was interested in the disagreement here. I appreciate the history lesson from both. I studied the history of medicine at Yale, by the way.
    Dr. BOOSS. A good education.
    Mr. FILNER. Yes. I had the best of both to paraphrase President Kennedy. I went to Yale University but I got a degree from Cornell.
    Dr. Varney, I'm sure you've heard these criticisms before. As I understand your research, your research was published in a peer review journal.
    Mr. VARNEY. Yes.
    Mr. FILNER. And I'm sure people who reviewed you—aware of such criticism. I don't want to get into a real debate here, but I was just wondering if you had any reaction to the criticisms?
    Mr. VARNEY. There's one criticism I'd like to address which is the regular selection of subjects. None of the patients that we had that were diagnosed with cerebral malaria for our study had medical records that indicated that they had not had a serious tropical disease associated with a very high fever, et cetera, meeting all diagnostic criteria for cerebral malaria. One of the problems with cerebral malaria from blood smears is when the illness is in the brain it is not in the blood. You cannot diagnose with a blood smear when the patient is cerebral. So, that's an option that I don't have. It's not possible, so it's not available. Finally, the missing records in our study we found 70 percent confirmation and 30 percent nonconfirmation. It was the same as for gunshot wounds; 70 percent confirmation and 30 percent of the records didn't confirm gunshot wounds, but we were able to confirm from their DD214s. So, I think the selection of subjects is as good as can be expected under combat circumstances and with this disease as it is diagnosable.
    Mr. FILNER. The thing that struck me by Dr. Booss' testimony is the general perception of the procedure under which the VA operates is that, number one, especially in a combat situation, the military records are seen as the bible, and much of your criticism came from ''Oh, it wasn't in the military record.''
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    As I said earlier, I just can't imagine under the conditions of Vietnam that that should be our only or even the best source of information. I would say testimony from folks, from the buddies who were there, testimony from the person who was involved would be as equally valid, and the VA ought to be looking at that and not just the bible of the medical file that may not have been complete. We just went through a Persian Gulf situation, and there's a claim made—I, frankly, don't believe it—but there's a claim made, that nobody kept any records of the inoculations and the vaccines that were given. We've asked for that material to even know what the soldiers under less than combat conditions received. I mean, these are soldiers being processed through in a civilian situation where supposedly the bureaucracy works and does everything in a standard way, and we're told ''We don't have any records of what vaccinations were given to these men and women.'' So, I can't believe that you should rely just on that.
    Second, knowledge changes; techniques improve. We may not have had at an earlier time what we have now. I know that there are some scientists—if I can get back to the Persian Gulf War—who claim that all veterans ought to be tested—and I'll ask this later—for the mycoplasmas—is it a bacteria? The infectious agent, mycoplasma.
    Mr. VARNEY. Yes.
    Mr. FILNER. Well, you could test the blood for that, but if the blood sample, as I understand it, is more than a few days old, you're not going to find it. So, we've had VA people say, ''We've tested all the blood, and we can't find it.'' Well, they tested blood that was a week old or 2 weeks or 3 weeks old, and you're not going to find it. So, the reliability of tests; the reliability of records just seems to me not to be at the level in which people are making judgments about their pension, their disabilities, their lives and whether we're going to get adequate treatment for them.
    And, one more thing on the record, as I understand it—correct me if I'm wrong—that a discharge examination is not required, and so it's hard to prove by the records whether a condition existed at the time of service or not, because it's not in the records. Well, somebody was anxious to get out or missed an appointment so it's not in the records. It just seems to me that the Veterans' Administration is supposed to be for the veteran, not to find a way to deny them their lawful and just claims but to find a way to figure out if what they're saying is accurate, and it just seems, we're not doing that, and I could just hear it from the testimony.
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    Mr. QUINN. Okay, thank you, Mr. Filner. Mr. Rodriguez, a question at this point in time?
    Mr. RODRIGUEZ. I guess, I have the same frustrations, and I just feel that maybe we need to look at the—and I don't know whether legislatively because it seems to—you know, if we don't have the documentation or we can't prove, we need to give—when in doubt, just provide them with the service. I think that's the only way we can—when in doubt, give them the benefit of the doubt instead of the reverse that they have to prove.
    Mr. QUINN. How many times have we said that, sir?
    Mr. RODRIGUEZ. Maybe we have to put it into legislation, unfortunately.
    Mr. QUINN. Thank you. I do have a question, Dr. Wright—thank you, Mr. Rodriguez. You mentioned in your study and your remarks and I followed in the written testimony that the study is being extended because there's not a big enough sample and what you found is interesting enough to take the next step. Do you know if those extended studies are funded through NIH or the VA. You said, I think, at one time, in future years—how many years out are you funded?
    Dr. WRIGHT. I'm funded for the coming 5 years. I started in April to start looking at the prevalence, the number of people in our hospital who have infections and the demographics of those people; whether they're Vietnam veterans; whether they have injections, transfusions——
    Mr. QUINN. See, I think that would really be important information; you're right on target there. So, you're funded out 5 years?
    Dr. WRIGHT. Correct, but, obviously, we need to extend it to other VAs, because we're an inner-city VA, and the other issue is we're not accessing veterans who don't come to our medical center which is a majority of veterans.
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    Mr. QUINN. Sure, like Buffalo, New York, for example.
    Dr. WRIGHT. I don't know how we'd get out there and do it.
    Mr. QUINN. I know how to get you out there, it's easy, but I don't know—yes, you'd never get back, that's the problem. And the funding is from——
    Dr. WRIGHT. The funding is from the VA.
    Mr. QUINN. VA, it is. Do you know how much?
    Dr. WRIGHT. I have three-quarters of a million dollars.
    Mr. QUINN. Okay, great. Thank you. Let's talk about that for just a second. Are we going to go outside San Francisco in the next 5 years? Can we look elsewhere? Do you need more money? What's the situation?
    Dr. WRIGHT. I think the VA is going to have to look, actually, in conjunction with the CDC and the NIH to look at this is a broader epidemiological problem, because it's going to take multi-institutional collaborations. Also, the Department of Defense will be involved.
    Mr. QUINN. Dr. Booss, can you comment on that at all? Or do you have an opinion from the VA?
    Dr. BOOSS. May I defer to a colleague who is here, Dr. Paul Hoffman who is head of medical research for the VA.
    Mr. QUINN. Absolutely, sure. Paul, would you please come to the microphone, so that we can—the end microphone on the last seat up there is active, if you turn the switch on.
    So, my question was to Dr. Wright, with the funding that the VA has put in place for San Francisco's—the beginning of the work that was done in San Francisco, will we be able to get outside of that and expand it far enough to be helpful nationally?
    Dr. HOFFMAN. Thank you. Yes, I think that the answer is that we do studies in single sites in the VA, and we do them in multiple sites. We have a program that's called the Cooperative Studies Program to do large-scale studies involving the multiple opportunities we have to do that in the VA, and, frequently, the studies that I'm responsible for funding which is the medical research single site studies such as this, would get translated into a cooperative study trial where we would look system-wide. It's one of the real advantages to a system like this for doing——
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    Mr. QUINN. Sure, and, after all, isn't that the idea? We find out something from a research point of view that interests us in one city and then we expand it.
    Dr. HOFFMAN. Absolutely. So, we would welcome applications for research programs that would extend this and would use not only VA sites, but we've done this in conjunction with other agencies such as the NIH and——
    Mr. QUINN. Now, how do you reach out to—excuse me—how do you reach out to make that known? You say you welcome applications. Unless someone is sitting in this room with us this morning that knows Dr. Wright's work, how would they even know enough to participate?
    Dr. HOFFMAN. Well, the process is known through the VA, through investigators that they have the opportunity to submit these types of proposals to the Cooperative Studies Program. In addition, we frequently will let the field know that we have interests in particular areas, and then we welcome——
    Mr. QUINN. Have you let them know that we have interest in this study?
    Dr. HOFFMAN. We had a solicitation for, what we call, emerging pathogens for Agents that are becoming prevalent in not only the VA but in other populations and for agents that one might be exposed to in combat; that was a VA-DOD Cooperative Program, and that will be extended. We funded, I think, 12 programs initially on that.
    Mr. QUINN. Excuse me just for one second. So, have you asked for outside involvement in this study that's begun in San Francisco?
    Dr. HOFFMAN. Outside of the agency, are you saying?
    Mr. QUINN. Outside of San Francisco.
    Dr. HOFFMAN. No, we have not done that.
    Mr. QUINN. Will you?
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    Dr. HOFFMAN. Yes.
    Mr. QUINN. When?
    Dr. HOFFMAN. I can't answer that.
    Dr. WRIGHT. We've just begun.
    Mr. QUINN. Pardon me?
    Dr. WRIGHT. We've just began in April.
    Mr. QUINN. Okay. Well, I—and, again——
    Dr. HOFFMAN. In the written testimony that we'll provide for you, we can certainly make some estimate.
    Mr. QUINN. I'd like for the subcommittee and the Full Committee to see that estimate.

    (Subsequently, the Department of Veterans Affairs provided the following information:)
    By September 30, 1998, we will convene experts from the VA, the National Institutes of Health, the Centers for Disease Control, and academic institutions to determine the feasibility of conducting a national epidemiology study on Hepatitis C. It requires approximately one year to plan such a study after it has been determined feasible. Therefore, we estimate that the project, if feasible, could begin in 12 to 18 months.
    Mr. QUINN. And here, again, it's not that we don't think it's going to happen. I think it's great news there, and we need to expand it, but rather than keep it a secret, I'd be interested to know who else you are soliciting. That's a good answer.
    Dr. WRIGHT. Mr. Quinn, to be fair to the VA, I think hepatitis C has been enormously underappreciated in general and that is changing. NIH has an RFP for $5 million that they're soliciting these kinds of studies, and we're planning to extend our study to Kaiser to look at a different population of patients for comparison.
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    Mr. QUINN. Great, good. And, Dr. Hoffman, I appreciate your coming to the microphone.
    Mr. FILNER. Can he stay there for a second?
    Mr. QUINN. Sure. Mr. Filner?
    Mr. FILNER. Just a follow up on the follow up. How about Dr. Varney's research, is that going to be followed up at all?
    Dr. HOFFMAN. Well, I think that there are problems that Dr. Booss had pointed out in terms of ascertainment that may not get any better by trying to do retrospective studies. As the length of time extends from the actual event, as you can see, it makes it harder to really determine that. We will extend studies in cerebral malaria as we do with all other emerging pathogens in terms of trying to get a better idea of how to treat these illnesses, and we do our supporting research in the area of malaria in terms of how organisms become resistant to treatment. Again, that was part of our endeavor in terms of——
    Mr. FILNER. I will try to be calm; I don't know if he's right or wrong but he is saying that up to a quarter million troops may have had malaria. Dr. Booss said that's ridiculous. If Dr. Varney is right, we have some real problems. I was struck by the neurological problems after the disease. For example, we have said again and again in this committee, we've heard the statistic; anywhere between a quarter and a half of homeless veterans are Vietnam vets. I'm only a layman here, but it seems if Dr. Varney is right—I don't know if you've gotten into this in your research—there seems to be some connection between some of these problems after malaria that might have great connection to why that homeless situation exists. That statistic, by the way, is incredible. I don't know if anybody has answered it besides saying, ''Well, you know, there's drug and alcohol abuse.'' But I have talked to some of these folks on the streets of San Diego, and I will tell you, again as a layman, I see the problems that Dr. Varney describes as post-malaria neurological——
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    Mr. VARNEY. Neuropsychiatric.
    Mr. FILNER. Thank you. Neuropsychiatric problems fit right into the folks I'm talking to. I don't know if you looked at that connection. But forget if he's right or wrong; he's saying something that seems to me is pretty important and just because a few guys say he's wrong who are his bosses, are we going to just throw this away and say no more, because, it just seems it has tremendous ramifications if he's right. Instead of proving him wrong, somebody should be asking, is he right? Do you have any comments on that, Dr. Varney? Would you like some of this stuff to be followed up?
    Mr. VARNEY. Very much so.
    Mr. FILNER. Is there any connection, the possibility, say, of the homeless situation and some of these neuropsychiatric disorders?
    Mr. VARNEY. It's possible. With regard to follow up, I'd like to make a point where speed may be of the essence. This population of malaria-afflicted Vietnam veterans are the only malaria-afflicted population of note in the industrialized West. When they die, this research will become historical and have no relevance to anything in particular. I'd like to see things done as expeditiously as possible, because these people are getting older, and when they die, there won't be any reason to have done it.
    Mr. FILNER. I hope we can, as a committee—again, I understand what the scientific method is. I understand peer review. I understand that if 20 people say he's wrong, you have a fiduciary responsibility, perhaps, to say it's not worth pursuing, but I will tell you, as a historian of science, that this is the kind of research that gets dismissed and is later found out to be accurate. This is the kind of research that, in hindsight, we wish we would have done. This is the kind of insight that people are not making that may provide an answer to things that we seem to be in the dark about, and there ought to be some little section of every bureaucracy that says we're going fund things that this bureaucracy is against.
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    Just as a check on the hubris of science and the hubris of expertise and the hubris of bureaucrats who run things. (Applause.)
    I don't know whether he's right or wrong, but, I tell you, I studied for 30, 40 years the history of science, and everybody who said something that was said to be wrong, at some point, was later seen to be right and vice versa, and so if we sit here with our hubris about scientific knowledge and say he's wrong and don't pursue it, I think we're making a big mistake.
    Mr. QUINN. Thank you, Bob. Mr. Reyes.
    Mr. REYES. Mr. Chairman, if somebody will yield me a few minutes.
    Mr. QUINN. You have your own time, sir.
    Mr. REYES. Okay, thank you. Well, I get frustrated because this comes under the category of been there and done that, because I spent 13 months in Vietnam, and I was troubled by the fact that, oftentimes, we hear the textbook version of the United States military in terms of—you made mention of 11 evacuation hospitals and all of that—I happened to have been a helicopter crew chief; did some medi-vac and can tell you that at times things were bad enough to where guys that were sick—we were told to suck it up, because there was nobody else, and you don't want to let your buddy down, and you don't want to wimp out on an operation, and I'm not talking about myself, I'm talking GI Joe, in general, in Vietnam. And part of the difficulty and part of why we get—and I won't speak for we, I'll speak for me—I get frustrated is because I hear repeatedly the horror stories of today's veterans that are now in the fifties that are suffering and are suffering by maladies that, perhaps, research has ignored, and I would hate to think that we are abdicating our responsibility as a Nation and as a country and that I, in particular, to my brothers in combat and of—this is one man's opinion—that I think there's a lot more to this, and I've seen it, and I will tell you from personal experience that I went through in 1974. It's easy when you get shot and there's a wound and there's medical evidence and all of these other things, but it's much more difficult when you're dealing about things such as malaria and hepatitis and swelling of the joints and all of these other things that everyone in Vietnam, at some point or another, might have been exposed to the effects of Agent Orange and all of these other things, and I am troubled very much by a bureaucracy that—you know, in baseball, the tie goes to the runner; in the VA, you've got to make compelling, overwhelming, and sometimes even then case, and it's still—the bureaucracy stonewalls.
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    The fact that you made mention, Dr. Booss, about a system that keeps careful records and all of that, I can tell you they don't. In my personal case, records were lost; a simple thing like loss of hearing in my right ear. Now, I have the evidence, obviously, I don't hear out of my right ear, and in 1974 in pursuing, I finally gave up in frustration because there's a magic formula in the VA that says that if you have less than 10 percent disability, there is no compensation other than saying, ''Thanks for doing a good job, folks.'' You were there in very terrible circumstances.
    But I guess one of the things that I would ask, if a veteran qualifies for a liver transplant, under what circumstances would the VA rate them at less than 100 percent disability? Can anybody answer that? Because that's a very rapid concern and question that I think needs to be answered, and I think it strikes to what I tried to articulate, and, forgive me, but I get a little frustrated at times and especially when I hear the textbook version of what combats all about. And I am proud to have fought for this country and worn the uniform of the United States Army, but I can tell you, what is drawn up in battle plans and battle strategies is carried out by human beings and is influenced by things that we never think about; things that happen either inadvertently or purposefully because you're fighting an enemy, and there are a lot of soldiers, veterans, that sucked it up at that time that are paying a terrible price today, and nothing is out there being done for them, and nothing was documented, and, in some cases, their anecdotal recollection of what happens is ignored and even revoked, and that, I think, should tell us a lot more about who we are as a society than anything else. And I think it's a condemnation of an attitude that needs to change.
    So, anyway, my original question, liver transplant.
    Mr. EPLEY. Sir, if a veteran came in with hepatitis and had marked liver damage, he would be rated at a 100 percent. If he underwent a liver transplant, he'd be rated after that fact based on his functional abilities. I can't say to you that they would be 100 percent or less at the moment, but we rate hepatitis based on degree of liver damage.
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    Mr. REYES. And, so, if they have a successful liver transplant, then it would depend—so, hypothetically, the veteran, once he gets a liver transplant, could be okay and would not——
    Mr. EPLEY. It is conceivable that person would be less than 100 percent.
    Mr. REYES. Any thoughts on some of my other observations, and I'll admit that I don't know what your backgrounds are, but I make those observations from having been there, and a lot of times, I hear people talk with a degree of certainty that weren't there and have heard or read and they're not correct, and that translates to people on the streets like Mr. Filner was talking about that are suffering and suffering because we have a very bad attitude about what happened to them during a tough time in their lives.
    Mr. EPLEY. We acknowledge, sir, that it is difficult to always obtain the kind of records that would make it easier to rate claims. We know from the volume that we look at, it's not an even deck. They're not always cleanly available to us. Our obligation—and I hope we're fulfilling it—is to pursue as far as we can to get all the evidence available, and, indeed, when it's obtained, if that veteran has well grounded his claim, to give him the benefit of the doubt using all the evidence available at that time.
    Dr. BOOSS. Thank you very much. I respect and admire that experience. I didn't have that experience. I was at the School of Aerospace Medicine in the Air Force in 1971 to 1973 when the human results were evident. So, I greatly respect what they went through.
    The second thing I would say is that your colleagues were sick, there's no question of that. It might not all have been malaria. There was Japanese B encephalitis; and there was Dengue; they were sick. My point is just that if they were sick, it might have been something else.
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    The third thing to say is that I actually talked to a colleague who was at an evacuation hospital, who examined the troops, and asked him to review the material at hand. What I have said is compatible with his response to me.
    Mr. REYES. But your colleague was at the evacuation hospital.
    Dr. BOOSS. That's correct.
    Mr. REYES. My point is not everybody made it to those evacuation hospitals.
    Dr. BOOSS. I accept that.
    Mr. REYES. Thank you.
    Mr. QUINN. I appreciate the comments from the gentleman from Texas which is evidence of why he's such a valuable member of the subcommittee and the Full Committee. We appreciate that, Mr. Reyes, very much.
    Dr. Hoffman, thanks for joining the panel. I think you sort of get our drift here, ladies and gentleman, and we appreciate your patience with us, and I'd like to thank you for being with us this morning and release you and ask for our second panel, Mr. Paul Sullivan, a single-person panel.
    Mr. Sullivan how are you?
    Mr. SULLIVAN. I'm doing fine.
    Mr. QUINN. Good, good. We're going to ask you, Mr. Sullivan, as the morning proceeds here, to—we know we've received your written testimony; we appreciate that a great deal—ask that you maybe give us about a 5-minute summary of those remarks. Your written remarks become part of today's record. We are scheduled to be called to a vote shortly, but I think we'll have more than enough time to have your oral comments on the record now, and then we'll see if we'll have to take a break then.
    The National Gulf War Resource Center, we're very, very pleased to have you with us today and look forward to a long working relationship with you in the future. You may begin.
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    Mr. SULLIVAN. Thank you, Mr. Chairman, members of the subcommittee. On behalf of the 51-member organizations of the National Gulf War Resource Center, I appreciate the opportunity to testify today regarding disability claims and other matters important to Gulf War veterans. The National Gulf War Resource Center is the first Washington-based veterans organization dedicated solely to Gulf War illnesses.
    I've shortened my remarks at your request, Mr. Chairman. I would appreciate being able to place two things into the record: the National Gulf War Resource Center's ''Government Relations Working Paper''——
    Mr. QUINN. Without objection, so ordered.
    Mr. SULLIVAN. Thank you. And the National Gulf War Resource Center, Swords to Plowshares, and Military Toxics Project, ''Depleted Uranium Exposures Case Narrative.''
    Mr. QUINN. Hearing no objection, again, it's so ordered. Thank you, Paul.
    Mr. SULLIVAN. Thank you, Mr. Chairman. You asked us to provide you with updated statistics on Gulf War veterans and that detailed information was provided to you, and we even have some newer information that the VA sent to us, and I wanted to thank them, because we asked for it and they sent it to us right away. So, we wanted to thank their policy——
    Mr. QUINN. Maybe what we should do is funnel our requests through you. (Laughter.)
    Mr. SULLIVAN. Well, there are cases—we do work together with the VA sometimes, and we get along.
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    Mr. QUINN. I'm sure you do. Thank you.
    Mr. SULLIVAN. You also, Mr. Chairman, wanted us to comment on VA's problems involving undiagnosed illness claims as well as diagnosed claims. We note an alarming rate of at least 78.5 percent of the Gulf War veterans who had their claims adjudicated for undiagnosed illnesses were denied. This rate does not address pending claims; the rate does not address the granting of one or more undiagnosed conditions along with the denial of one or more undiagnosed condition.
    The National Gulf War Resource Center in reviewing this complicated problem finds there are five sometimes conflicting points of view resulting in various interpretations of the law and widely varying out comes to frequently ill-served Gulf War veterans seeking benefits.
    The first point of view is that of the Gulf War veteran who is sick from a Gulf War toxic exposure and who wants to help restore their health. Veterans are interested in a timely, accurate adjudication of their claims, so evaluation and treatment can begin promptly. Gulf War veterans are not simply out for a check as the VA and DOD and independent medical practitioners have unanimously concluded that Gulf War veterans are ill and that they are ill in greater numbers than civilians in other groups. Gulf War veterans simply want health care, and they apply for benefits in order to obtain care. The National Gulf War Resource Center has distributed 10,000 self-help guides toward that end to make sure Gulf War veterans know about the process, and we have a special section on undiagnosed illness. We also note the American Legion is doing the same thing. So, the veterans' organizations are trying to help out the veterans.
    The Pentagon is another point of view. We're in this mess mainly because of the Pentagon. The Pentagon has failed to follow their own regulations and to train soldiers about toxic exposures, specifically, depleted uranium, to monitor toxins in the air, soil, and water. And Pentagon failures to note medical records and conduct required screenings, there is an absence of information regarding the toxic exposures. The Department of Defense has also failed to develop a case definition as required by Public Law 103–337.
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    Another point of view is the Department of Veterans Affairs. According to the GAO, there were significant problems with the adjudication of Gulf War veterans' claims, especially under the undiagnosed provisions. The important problems cited by the GAO were the underdevelopment of claims such as a failure to get lay statements and failure to review independent medical records. The VA should have taken such actions under their duty to assist.
    We have no new information to determine whether or not the corrections made by the VA and noted by the GAO have resulted in significant changes. We also note that the VA's reliance upon the DOD for exposure information and medical research delayed the research and treatment that could have provided answers in relief to tens of thousands of Gulf War veterans, especially those filing claims.
    Chairman Stump of the House Veterans' Affairs Committee also voiced his concerns in a recent letter to VA Secretary Togo West on June 3. The National Gulf War Resource Center agrees with the concerns of Mr. Stump. What he asserts in his letter is that a Gulf War veteran's claim under the undiagnosed provision could be very narrowly interpreted or widely interpreted, thus, causing serious problems. The Resource Center believes that if additional training was provided to VA adjudicators, we may be able to resolve this, and I understand some of that is being done.
    One thing that's new that we want to bring to the subcommittee's attention is VA physicians performing compensation and pension exams. Training of VA physicians places a heavy emphasis on stress as a major cause of the illness, according to the new Gulf War Illness Guide. The absence of toxic exposure data and training and an overreliance on stress as the cause may tilt the C&P exam in favor of the VA and against the veteran.
    Another point of view is veteran service organizations who are doing the best job possible to try to help veterans out. There isn't blame with the veterans' service organizations. We're trying to do the best we can in a difficult situation, but some veteran service organizations are pushing an undiagnosed claim, and some want to ignore the undiagnosed claim field all together. Thus, possibly skewing the data.
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    Another point of view is Congress. Congress acted wisely in passing these new laws, and they acted in the best interest of Gulf War veterans. We believe Congress should address the problems cited by us—and more extensively detailed in our written testimony—with new hearings, with getting better data, and with holding some investigation using the General Accounting Office to find out exactly what's going on. We do want to note, specifically, that we thank very much Congress for extending the 2-year limitation presumptive period to 10 years. That was a very helpful thing in helping resolve a lot of the undiagnosed illness claims.
    The National Gulf War Resource Center wanted to propose some solutions regarding this matter, and, as you noted earlier today, the first is the development of better data. Specifically, how many veterans have major types of illnesses, especially cancers? There's been significant discussion over that of whether or not the VA can or cannot do that well, determining the total number of different undiagnosed conditions claimed by veterans, because some veterans are claiming four or five, being granted on one, being denied on four. But the veterans is being counted as granted service connection for an undiagnosed condition. We don't have the data to sort out who's being denied on what, and we believe that that may provide some answers on this issue.
    Better DOD recordkeeping is essential; it's very much needed, and, today, the DOD has not yet begun noting medical records of Gulf War veterans known or suspected to have been exposed to radiotoxic waste in the form of depleted uranium, thereby continuing and perpetuating this problem. The DOD has not yet begun any screenings or medical research into the effects of inhaled or ingested depleted uranium, again, further complicating this problem and continuing it. The DOD has not yet completed or released any report on depleted uranium even after repeated public announcements to do so. In a related manner, DOD lacks firm data on as many as 908 Iraqi ammunition dump demolition incidents, 35 of which may have contained chemicals according to the Pentagon. Again, we're waiting for more data to come from the DOD to find out what exactly the soldiers were exposed to.
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    So, what we conclude is because of the serious nature of the illnesses, the National Gulf War Resource Center believes Congress should pass legislation that presumes exposure to toxins including allowing for the addition of new toxins yet to be revealed as well as combinations of toxins; funds the establishment of an independent oversight panel, because, clearly, the Department of Defense isn't doing anything, so someone needs to step in and do something; funds independent research; funds the provision of Public Law 103–446 that calls for evaluating spouses and children. This is because we believe this is important in a manner similar to Agent Orange, which now service connects the children who may have spina bifida. We need to be developing some data on the children of Gulf War veterans, and, as the GAO pointed out, the VA may or may or not be doing a good job on that, because it was delayed in setting it up.
    With those specific suggestions in mind, the National Gulf War Resource Center strongly supports the prompt passage of H.R. 4036 and or a combination of bills meeting our suggestions. We specifically thank you for agreeing to hold hearings on depleted uranium. We think that you will learn a lot about that, and it will be very good for everyone involved, and we also thank the members of this subcommittee who have co-sponsored H.R. 4036. We think that those members are definitely doing the right thing for Gulf War veterans.
    [The prepared statement of Mr. Sullivan appears on p. 140.]

    [The document entitled ''Depleted Uranium Exposures Case Narrative'' has been retained in committee record.]

    [The information on the Government Relations Working Paper follows:]

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Offset folios 46 to 70 insert here
Makes pp. 75 to 99

    Mr. QUINN. Thank you, Paul. Thanks very much. Is this your first trip to testify before the subcommittee? I think it is, is it not?
    Mr. SULLIVAN. Yes, Mr. Chairman.
    Mr. QUINN. Yes, it is. Well, thank you. We appreciate—I'm sure we'll see you again.
    Mr. Filner asked earlier, Mr. Epley, if you could be here for this questioning. I'd ask you to join us at the table just for a minute, please. Even though Mr. Filner said he was going to yield his time then for now, we gave him some time back then too, so I'm going to yield to you now, Bob, to get to those questions. All right?
    Mr. FILNER. Thank you, Mr. Sullivan, and I appreciate your testimony and your research. The fact that you have to be here is a statement in itself; I mean, that the National Gulf War Resource Center has to be here. That's what the VA and DOD ought to be, the National Gulf War Resource Center, but we have not been able to rely on them, and the statistics are an example of how we indicate whether we're taking this seriously or not. Just for example, Mr. Sullivan in almost his first statement gave a statistic. He said 78.5 percent of claims were denied. Mr. Epley, do you accept that figure?
    Mr. EPLEY. Congressman Filner, the numbers that we have indicate that about 13 percent of the veterans who were in the Gulf War conflict are getting benefits; approximately 76,000 of them. That includes receipt of service-connected benefits other than undiagnosed illness.
    Mr. FILNER. I didn't get an answer to the question, I don't think. Are 78.5 percent of claims for undiagnosed illness rejected?
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    Mr. EPLEY. I can't refute that information. I know that a significant majority of claims that are filed are rejected for undiagnosed illness.
    Mr. FILNER. It seems to me that when we pass a law that says that there's a presumption that there is need for treatment, it would seem to me that people would be treated and compensated for this undiagnosed illness. But let me say that how you present your statistics, Mr. Epley—which we just got—seems, in itself, to say something. I look at your first group of statistics. It says number of veterans with one or more undiagnosed service-connected conditions, 1,967 out of the biggest, and out of the smallest group, 1,866. I assume they're the same 1,866 as in the other one or included in 1967. This looks to me—anybody who looks at that says, ''Filner or anybody that's yelling about this Persian Gulf War illness and Sullivan, you're crazy. There's no problem here. We've looked at this—and out of 3 million people in my category or 785,000 in the theater or 560,000 members, only 1,808 have undiagnosed conditions. That seems to me that you're saying it's not a problem. Do you think this is a problem, by the way, the Persian Gulf War illness, beyond the statistics?
    Mr. EPLEY. Yes, sir, I do.
    Mr. FILNER. But look at what your first data—your first line of data says. It says to everybody who is an expert and everybody who reads this and everybody in the bureaucracy, it's no problem. I mean, I don't know where this figure comes from. We need to really sit down and go over this data table, because that many people in my district have come to me and said they have problems. You also have figured out a way to hide the data. Tell me, if somebody comes with—says I have these conditions which don't seem to have a diagnosis, and I have a loss of hearing, let's say, or a bad knee, wouldn't they then get a rating or a service connection based on the diagnosed situation?
    Mr. EPLEY. Yes, sir.
    Mr. FILNER. So, those people who may have undiagnosed but also something else that is diagnosed are not even considered in this data of undiagnosed conditions, right?
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    Mr. EPLEY. That's correct, sir. I tried to allude to that earlier.
    Mr. FILNER. Well, I'm looking at the table and the average person in the press who says, ''I'll ask the VA for data, because Filner's saying there's all this problem, and the data seems to say there's no problem here,'' because you have systematically—and there's about five other ways which I'd like to sit down when we have the time—you have systematically hidden the problem here. Now, I think that's intentional. You don't want to say that there's a major problem going on, because if you did, you would start off by saying how many claims have been filed? Is that in here somewhere?
    Mr. SULLIVAN. We've determined that, Mr. Chairman, to be approximately 212,000, but we're waiting for further clarification of that. (As of April 15, 1998, the number was 203,679).
    Mr. FILNER. All right. You say 212,000. I get this data from the official source, the source that should be the National Gulf War's Resource Center, and I don't see anything near that figure—let's assume you're right for a second—there's nothing on here that says there were 212,000 claims, is there?
    Mr. EPLEY. No, I don't believe there is, Congressman.
    Mr. FILNER. Well, what good is this data if I can't figure out how many people came in and said they had illnesses; how many folks did have the illness. This data systematically lies. The data is lying to me, sir, because I don't know—I cannot read from this—and this is the answer you gave us to official response—I cannot tell you any of that data that Mr. Sullivan says, I can't confirm it or deny it, and you can't either from this chart, and if he's wrong, I want to know; if he's right, I want to know, and the data you have here is basically worthless, because it hides what we should know.
    Mr. EPLEY. Congressman, the data that we have been gathering for Gulf War veterans has been a subject for previous committee hearings and there have been problems. There are continuing problems. We are working continuously to try to improve the situation since the last hearing before this committee——
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    Mr. FILNER. Can you just tell me how many people applied for benefits for undiagnosed illness?
    Mr. EPLEY. Approximately 76,000.
    [The information follows:]
    Approximately, 76,000 veterans of the conflict have been evaluated as service-
connected—10 percent or more. Over 17,000 veterans have been identified as claiming
''undiagnosed Illness.''
    Mr. FILNER. All right. You said 212,000?
    Mr. SULLIVAN. The information, Congressman Filner, that was sent to us from the Department of Veterans Affairs does not specifically state Gulf War illness of undiagnosed illness. We have asked for that information, because we don't know. It's one of the points in our testimony, but what we need is more information.
    Mr. FILNER. Mr. Chairman, you can see that we have a very reliable person who has devoted his present life to this; we have the official statistics, and they're different. We need to sit down and understand this in some seminar kind of fashion where we can discuss it. I hope we can do that.
    Mr. QUINN. Well, I think, Bob, one of the things that we've talked about—and, gentleman, I appreciate your candor in answering Bob's questions or any of the members here and, believe me, there are some questions on this issue outside of this committee and subcommittee in terms of Members of Congress too. I suggested to Bob this morning when we came in and looked over the testimony—some of it we had beforehand—that, likely, I think what needs to take place is some kind of a meeting or meetings here on the Hill with members of this subcommittee who are interested to get us to a point where we can at least be talking about apples and apples and oranges and oranges, because any of these statistics anybody can use to their advantage or disadvantage.
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    If we operate under the assumption that we're all here to help veterans—and I think we start from that premise—then there ought to be a way for us to do that, and I've suggested to Mr. Filner that we, as a subcommittee, draw up and prepare for you a list of areas that we're interested in just like the questions that Bob asked this morning in laymen's terms. Get those to both of you and others, and we don't have to do it, in my opinion, in a formal hearing session, because everything goes on the record, and we don't have a chance to work it through. I would suggest a seminar, some kind of a meeting here on the Hill; maybe one or two or three of those right after the August recess in early September where we don't have to be worried about official hearings and official documentation and on the record and off the record and who can help us and who can't, and Mr. Filner and I will put that to writing these next couple of days while we're here in Washington and share that with others. But, clearly, Bob, I think you and I are on the same wavelength that that's what needs to happen next.
    Mr. FILNER. Thank you, Mr. Chairman.
    Mr. QUINN. Are there any other questions for Mr. Sullivan who's here? Mr. Mascara?
    Mr. MASCARA. Thank you, and I would just like to say that I was involved with two young ladies—one from my district in Pennsylvania and another——
    Mr. QUINN. I think you better be careful how you say that, Mr. Mascara. (Laughter.)
    So far, you said you've been involved with two young ladies.
    Mr. MASCARA. Oh, yes, yes. I need an attorney.
    Mr. QUINN. I think you need an attorney. You need an attorney or an understanding wife, one of the two. (Laughter.)
    Mr. MASCARA. Or both. (Laughter.)
    Mr. QUINN. Or both, yes.
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    Mr. MASCARA. Well, after 44 years of marriage, I think I'm on safe ground. These ladies came to my office asking for help, both of whom had an illness; both of whom served in the Gulf War, one of whom was in the barracks that killed a number of people from my district. I also had the opportunity to introduce her to the President's Commission studying the Gulf War illnesses. Both my constituent and the constituent from Florida, received 100 percent disability. These were the sickest people I have ever met, and for us to have to push and prod to get the correct information from Veterans Affairs and this Government really frustrates me, and I'm sure all of my colleagues are frustrated here; that somehow everybody seems to be so defensive. Aren't we about trying to help veterans, and while I would admit there are those who might try to take advantage of the situation, but we've got to get this program on track, Mr. Chairman, even if it means—and, Bob, I want to associate myself with your remarks—having to question those people in the government who are supposed to be forthright with this country and its veterans. I'm just entirely frustrated. Thank you.

    Mr. QUINN. Mr. Reyes.
    Mr. REYES. Mr. Chairman, I don't have any questions other than just to express my gratitude for the work that your organization is doing on behalf of the Gulf veterans.
    Mr. QUINN. Thank you, Mr. Reyes. Mr. Epley, we appreciate your returning to the witness stand.
    Mr. FILNER. Just one quick question.
    Mr. QUINN. Yes, go ahead.
    Mr. FILNER. Just one question, do you know, Mr. Epley, if veterans who come in with undiagnosed illness or anybody who comes in from the theater are tested for this mycoplasma?
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    Mr. EPLEY. I don't know that, sir.
    Mr. FILNER. As far as I know, the answer is no. Now, it's a similar situation as we had with Dr. Varney and Dr. Booss. There are scientists, reputable scientists, who say that this is, perhaps, one of the indicators of Gulf War illness of one type. Other people say he's full of baloney. On the chance that he's right—and I have seen hundreds of patients, by the way, like yours, Congressman Mascara, who because of the protocol that has been figured out for antibiotic treatment for this, people who I've seen almost dying are now recovering but not from the VA treatment because the VA refused to accept it—so, in the chance that Dr. Varney is right—this is a test that's not difficult to administer—why not administer the test to do it for 1,000 people; do it for 5,000—to see if they have this ''mycoplasma incognitos'' on the chance that this may be part of an answer. Why should we not invest a few bucks when some portion of reputable scientists say this is one key? Just because the VA's experts say no, I want that little section that says, let's find somebody who they disagree with. I don't understand why we can't do that.
    Mr. QUINN. Well, I think, Bob, one of the things that Mr. Reyes said a little bit earlier was that if we don't get the cooperation that we're asking for, that it may be legislatively where we need to step up and either find that kind of money and designate to whom it goes and for what reason and do it through the subcommittee; through the Full Committee, and through our 435 Members on the floor.
    Mr. FILNER. That's what they're asking.
    Mr. QUINN. Yes, I think so. I'm going to thank the members for their questions and their comments and Mr. Sullivan and Mr. Epley. We've been called to a series of votes right now, and we're going to recess for probably what amounts to at least a half hour.
    Our final panel, Bill Russo, with Vietnam Veterans of America; Bill Frasure, Phil Ridley, who will represent the VBA, the Legion, the VFW, the DAV, respectively, will be on our third panel, but for all those interested, I'm going to recess for at least a half hour, and when we come back we'll hear from our third panel.
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    Mr. REDMOND (presiding). The committee will come to order.
    Our final panel is composed of representatives from veterans' service organizations. Bill Russo, Matt Puglisi, Bill Frasure, and Phil Ridley will represent the VA, the Legion, the VFW, and the DAV, respectively. Gentlemen, please begin.


    Mr. RUSSO. Mr. Chairman and members of the subcommittee, on behalf of Vietnam Veterans of America, I am pleased to have this opportunity to present our views on the issues here today.
    The issues surrounding VA processing of Gulf War Illness claims are constantly evolving, as is the state of scientific knowledge about these illnesses. It may be the relative newness of these types of benefits that is causing the VA so much problem in accurately and promptly processing these claims. We believe that the VA regional offices and Board of Veterans' Appeals staff are still improperly trained to handle Gulf War Illness claims.
    By way of illustration, our organization has filed a lawsuit in the U.S. Court of Veterans Appeals, on behalf of a Persian Gulf veteran, an appeal of a Board of Veterans' Appeals decision. In that decision, the Board of Veterans' Appeals did not even address or apply the Persian Gulf Illness—the undiagnosed illness statute or the regulations, simply ignored that whole structure and that whole process, and denied every one of this man's claims. I'm pleased to say that the VA General Counsel has agreed to settle this case to the extent that they will remand the case back to the Board of Veterans' Appeals for them to correct this error and, at least, process his claim under the proper regulations.
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    But that's just one case and this veteran was fortunate enough to have attorneys representing him. Many veterans don't get representation and they get denied by the VA this way, and they simply go away.
    VVA supports the premise contained in legislation offered by Senator Rockefeller, Congressman Evans, and Congressman Shays which would have an independent scientific body evaluate which medical conditions VA ought to allow service connection for. Our experience with the National Academy of Sciences with respect to Agent Orange has been very, very positive. NAS has done an outstanding job of evaluating what illnesses are caused by Agent Orange, and the VA has, frankly, been forced to begin paying service connection for those diseases as well as the birth defect, Spina bifida. So we urge Congress to follow that successful model that was contained in the Agent Orange Act of 1991 and use the National Academy of Sciences to work on Persian Gulf illnesses as well.
    VVA also agrees with the views expressed by the committee's Chairman Stump with respect to VA regulations being so strictly applied. We are heartened that VA is considering changing its regulations or, at least, instructing its staff to not apply the undiagnosed illness requirement so strictly. We applaud the Chairman for that letter.
    With respect to hepatitis C, Chairman Quinn asked about Board of Veterans' Appeals decisions. As part of my testimony, I've cited to a number of Board of Veterans' Appeals cases, the full text of which is available to you on CD-Rom which I know your staff has. These Board of Veterans' Appeals decisions—they're all from fiscal year 1997—they show that the Board of Veterans' Appeals and, I think, the regional offices are, frankly, very ignorant of hepatitis C.
    Now, I don't blame them necessarily. Until February, I'd never heard of it myself. But now we know about hepatitis C. It's been on U.S. News and World Report, it's been on Nightline, and we know that veterans have it at a much higher rate than the general population.
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    The major areas where VA is ignorant in processing these hepatitis C claims are as follows:
    The VA doesn't understand how the disease is transmitted, that it comes through a variety of sources, mainly through blood transfusions and other medical procedures or any veteran who is exposed to blood or blood products, whether in a combat or noncombat situation.
    Another area that the BVA doesn't seem to understand is that hepatitis C has a long latency period of up to 30 years. The BVA has been denying claims because they're saying, well too much time has elapsed between the veterans' service and his claim that he has filed. Well, scientists now know that there can be 10, 20, 30 years or more between when you're initially infected with this disease and when you develop the symptoms. So that's not a valid basis to deny the claims.
    Another thing we found in reviewing these BVA decisions is that they say, well, the veteran did not test positive for hepatitis C while in service or until the early 1990's. Well, there was no test for hepatitis C until 1991. So it's an impossibility for the veteran to have been tested for this. Again, it just reflects ignorance and this ignorance is resulting in unfair denials of service connection.
    What we're proposing is that Congress pass a statute allowing for a presumption of service connection. Mr. Epley stated this morning that VA is going to revise its rating regulations for hepatitis C. But that won't address the problem of getting the veteran service connected to begin with. What we need is a statute that will allow for presumptive service connection. For example, any veteran who was exposed to blood or blood products in service and now has hepatitis C, that they are presumed to have acquired that in service. Thank you.
    [The prepared statement of Mr. Russo appears on p. 150.]

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    Mr. FRASURE. Good morning, and thank you for this opportunity to present the views of the Veterans of Foreign Wars regarding the adjudication of VA compensation claims for Gulf War related undiagnosed illnesses. The VFW has been actively and extensively involved on issues involving claims processing for Gulf War related disabilities for over the past 6 years.
    Despite the intent of Congress, many Gulf War veterans with disabling illnesses that may be associated with service in the Gulf are being denied compensation. Currently, Gulf War veterans suffering from undiagnosed illnesses are eligible to receive compensation under Public Law 103–446. Unfortunately, too many of these veterans who file for compensation for an undiagnosed illness are subsequently diagnosed by the VA with a known condition that is similar to the signs or symptoms of an undiagnosed illness as prescribed by 38 C.F.R., section 3.317.
    It is all too common for a Gulf War veteran to be prematurely diagnosed with chronic fatigue syndrome or some other condition which bears resemblance to Gulf War undiagnosed illnesses. This usually results in the service connection being denied. Section 3.317 of 38 C.F.R. contains a list of 13 signs or symptoms which may be manifestations of, but do not define undiagnosed illnesses in Gulf War veterans.
    If a veteran is prematurely diagnosed with chronic fatigue syndrome or some other multi symptom condition, the veteran is thus not considered under Section 3.317 of 38 C.F.R. This is not keeping with the intent of Public Law 103–446 and, in our view, is patently unfair. Representative Stump, in his pointed letter to the VA Secretary, raised these concerns. We thank Representative Stump for this excellent letter and hope that Secretary West takes heed of it and amends the current regulation.
    The second area of concern for the VFW may be addressed by amending another aspect of 38 C.F.R., section 3.317. The current presumptive period for undiagnosed illnesses is mandated to expire in the year 2001. As of today, the medical community has yet to determine a date as to when symptoms associated with service in the Gulf War will manifest. In light of this lack of finite medical knowledge, any date that limits the time for when symptoms may appear is rather arbitrary and may be detrimental to Gulf War veterans.
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    The VFW has long held that any presumptive period should be based on available, credible medical and scientific evidence. There should be no limitation on a presumptive period in the absence of such evidence. We believe that the only appropriate presumptive period at this point is one that is temporarily open-ended.
    Two pieces of pending legislation aim to correct many of the problems associated with the adjudication of claims for undiagnosed illnesses. We thank Congressmen Stearns, Evans and Joe Kennedy for bringing about the Persian Gulf War Veterans' Health Care and Research Act of 1998. Additionally, we thank Representative Chris Shays for his subcommittee's investigation into Gulf War related problems that has resulted in H.R. 4036, the Persian Gulf War Veterans' Health Act of 1998. The VFW asks that the Committee on Veterans' Affairs work closely with Congressman Shays toward the passage of this legislation.
    This concludes my statement. John Mucklebar, a VFW Claims Consultant, is here today to answer any questions you may have. Thank you.
    [The prepared statement of Mr. Frasure appears on p. 159.]


    Mr. PUGLISI. Good afternoon, Mr. Chairman. The American Legion appreciates the opportunity to offer testimony today regarding the Department of Veterans Affairs' standards for adjudicating claims presented by veterans suffering from hepatitis C, Cerebral Malaria, and Gulf War illnesses. Your leadership and the leadership of Chairman Quinn on the issue of Persian Gulf undiagnosed illness claims last year, led directly to a significant decrease in the backlog of those claims. Your continued concern and oversight of this process has kept the pressure on VA to adjudicate these claims as well as possible.
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    Before I go further and before I forget, we'd like to wish a fond farewell to Mike Brinck, the counsel of the subcommittee. We wish him best of luck in his future pursuits.
    Yet, in spite of the committee's oversight and the oversight of The American Legion and the GAO, 9 out of 10 Gulf War veterans who file a disability claim for undiagnosed conditions are denied service connection and compensation from VA. This is also in spite of the fact that VA adjudicated most Persian Gulf undiagnosed illness claims twice, and overhauled the undiagnosed illness claims process. VA is failing to compensate disabled veterans with Gulf War Illnesses because its regulations implementing Public Law 103–446, the Veterans Benefits Improvements Act of 1994, were written too narrowly.
    The American Legion therefore has three recommendations for the committee:
    First, encourage VA to change its regulations regarding Persian Gulf undiagnosed illness compensation in order to bring them more in line with the letter and spirit of Public Law 103–446.
    Second, support legislation that closes the gap in the government's service to Gulf War veterans with Gulf War Illness. A number of bills were mentioned by my colleagues, H.R. 3980, H.R. 4036, and there are others as well and we encourage the committee to support those bills.
    And lastly, we encourage the Veterans Health Administration and the Veterans Benefits Administration to develop a more cooperative approach to Gulf War veterans health care and compensation.
    The Gulf War, as we now know well, was like all of our Nation's past wars in that it left thousands of disabled veterans in its wake. And like our past wars, thousands of deployed Gulf War veterans report with the what the Institute of Medicine calls Medically Unexplained Symptoms Syndromes, now known collectively as Gulf War Illnesses. Although some of the risk factors troops were exposed to in the Persian Gulf were the same as those found in past wars, some were different: low levels of chemical nerve agents, pyridostigmine bromide, and depleted uranium, just to name several.
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    As Gulf War veterans began reporting these hard to define illnesses, VA was confronted with compensating these disabled veterans. VA, however, did nothing. Faced with disabled war veterans, VA pointed to public laws and blamed them for its failure to act. Congress rose to the challenge, and passed historic legislation in 1994 that would help veterans suffering from Gulf War Illnesses.
    Congress' intent in this historic law was plain and simple. Aware of VA's claim that thousands of disabled Gulf War veterans were ineligible for disability compensation because Gulf War Illnesses remained ill defined and poorly understood, Congress passed a law that would permit VA to compensate these veterans. Yet, 90 percent of them who file a claim for undiagnosed illness compensation are denied compensation for those conditions. Why? VA regulations implementing the law codified in 38 C.F.R., section 3.317 strictly limit eligibility for this unique type of disability compensation.
    Mr. Chairman, a comparison of the language contained in the public law and VA's regulations, and a detailed analysis is provided in our written testimony, explain why many sick Gulf War veterans are denied compensation. VA wanted—Congress wanted VA to compensate veterans with Gulf War Illnesses, but VA wrote regulations that ensure it will not compensate most of these veterans.
    Mr. Chairman, Congress listened to sick Gulf War veterans in 1994 and acted by passing historic legislation granting VA the authority to compensate those with difficult to diagnose and ill-defined illnesses. VA has failed to implement the law, and thousands of Gulf War veterans would remain without compensation for these service-connected conditions. The American Legion is encouraged by your continued interest in this matter and we look forward to you taking action in the near future that would resolve this issue once and for all.
    Mr. Chairman, that concludes my statement. I'll be happy to answer any questions.
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    [The prepared statement of Mr. Puglisi appears on p. 162.]

    Mr. REDMOND. Mr. Ridley.
    Mr. WANNEMACHER. Mr. Chairman, I'm Dick Wannemacher, Disabled American Veterans. It's a Disabled American Veterans' tradition to introduce to the committee members our professional staff when they testify here for the first time.
    The Disabled American Veterans, with a membership of over 1 million members—wartime service-connected disabled veterans, employs veterans as national service officers throughout the country. The DAV is proud that, to this day, we have 160 veterans of the Persian Gulf War, Granada, Panama, Somolian and Bosnia conflicts. We are most proud to be able to state that these men and women corp compromises 60 percent of our entire national service officer corp.
    Mr. Ridley joined the DAV's professional national service office staff as a trainee and participated in our academy in Denver, CO in October 1995. He graduated from the academy in February 1996 as a spokesman for the academy class number 3. A native of North Carolina, he served in the Army, was disabled, and he stands before you or sits before you today to give the views of the Disabled American Veterans. Thank you very much for the opportunity.
    Mr. REDMOND. Welcome, Mr. Ridley.

    Mr. RIDLEY. Thank you very much, Dick, and thank you Mr. Chairman for this opportunity, on behalf of the 1.1 million members of the Disabled American Veterans and its auxiliary, to present our views on the adjudication of Persian Gulf War claims, and also on those veterans who are suffering from hepatitis C and Cerebral Malaria. I would first like to briefly address the issues of service connection for certain veterans suffering from the relatively new and highly infectious hepatitis C virus and related liver diseases.
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    Recently, the Centers for Disease Control and Prevention have determined that hepatitis C is the most widespread among the hepatitis C viruses, and for generations have plagued our armed forces serving in foreign countries. Research has also shown that while hepatitis C appears as an acute illness at the time of infection, it often shows significant symptoms only after 10 or 20 years of latency.
    In the case of many Vietnam veterans, particularly those who were wounded or underwent blood transfusions and worked in the medical care field, they are at risk and may be unaware of it. I certainly appreciate the comments of Congressman Reyes, giving his own personal experiences as to the difficulties of individuals who are in combat and as it relates to their inability to substantiate their possible exposures to blood transfusions or documentation of their having been exposed to the malaria. It really helps the committee and the group in general to understand how unique the circumstances were and how an individual may not be able to substantiate—or their medical records may not be able to substantiate their claim for service connection.
    In light of the many still unknowns regarding screening and treatment for hepatitis C, the DAV strongly asks that Congress allocates additional funding to the VA medical care account in order to provide additional research, as well as additional health care providers to address this issue.
    Our full comments regarding Cerebral Malaria have been submitted for the record as well as our full comments regarding hepatitis C. If you have any specific questions regarding our position, I'll be more than happy to provide you with a timely response.
    Mr. Chairman, there is no doubt that the adjudication of Persian Gulf War veterans' claims is complicated and made even more difficult by the increasing inability of rating board members to obtain and decipher the appropriate evidence needed to develop a veteran's claim for service connection. Comparatively speaking, when one considers the number of issues found and the complexity of Gulf War examinations, the timeliness of adjudication of Gulf War veterans' claims for service connection is virtually the same as non-Gulf War veterans' claims for service connection and this is due to a number of reasons.
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    This is due in part to the recent efforts by VA to better train its adjudicators to sift through the vast symptomatology and complex medical examinations, and other evidence of record to better evaluate Gulf War veterans' degree of disability. This is not to say the VA has done nothing to try to help their system and their personnel to address the needs of Gulf War veterans.
    Earlier this year, the VA Under Secretary for Benefits and Under Secretary for Health released a joint memorandum which stressed the need for VBA and the Veterans Health Administration personnel to take the initiative to pursue additional expert medical opinions to assist in determining the exact nature of a veterans' disability. And this was also a part of a continuing training project by VBA and VHA to ensure that their personnel were able to address the needs of Gulf War veterans in rating their claims. But we know that the system still lacks in being able to address the Gulf War veteran's claim.
    Our primary concern lies in the current guidelines for rating claims for undiagnosed illness. As stated by my colleagues from the Vietnam Veterans and VFW and American Legion, under the current guidelines if all issues claimed are not granted or cannot be granted under direct service connection, presumptive service connection, or service connection due to aggravation then it is to be considered under claim for undiagnosed illness. So if a veteran has filed a claim for undiagnosed illness and he has filed that claim more than 1 year from his date of discharge after the 1 year presumptive period therefore not qualifying for direct service connection and he is given a diagnosis, he is then denied service connection based on the fact that it is an undiagnosed condition, but he is not qualified for direct service connection. Therefore, thousands of Gulf War veterans are falling through the cracks, being diagnosed with unexplained conditions or being diagnosed with conditions and being unable to associate it to their military service because of poor documentation either in-service or post-service.
    It is based on this scenario that the DAV strongly advocates that this subcommittee carefully consider legislation such as H.R. 4036, introduced by Representative Chris Shays, or similar legislation that would provide presumptive exposures to certain hazardous and chemical toxins such as low-level mustard gases and solvents, several environmental pollutants such as hydrogen sulfide and oil fire by products, ionizing radiation such as depleted uranium, and disease endemic to the region such as leishmaniasis, sand fly fever, and malaria to name a few.
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     This type of legislation would allow the Secretary of Veterans Affairs to enter into contract with appropriate scientific medical bodies to review medical and scientific data to determine if there is an association between diseases and illnesses suffered by Persian Gulf War veterans and their exposures to these hazardous toxins. Based on these findings, such diseases that become manifest in Persian Gulf War veterans would then be presumed to be service connected.
    While the language in H.R. 4036 would cut off the date defining service in the Persian Gulf War as of December 31, 1991, the DAV would advocate for an extension of this date to the end of the Persian Gulf War which is yet to be determined by the President. In light of continued discoveries of Iraq's chemical capabilities and the use of chemical weapons, we must ensure that those members of our armed forces currently serving in the Persian Gulf theater are adequately cared for.
    Mr. Chairman, there are many uncertainties associated with Persian Gulf War veterans undiagnosed illnesses. The DAV believes that H.R. 4036 or similar previously introduced legislation would provide with a reasonable degree of certainty a viable resolution to the PGW veterans compensation nightmare. H.R. 4036 or other similar legislation, such as H.R. 3279 and S. 1320, would bridge the gap for those veterans who are suffering from either a diagnosed illness or an array of diagnosed and undiagnosed conditions associated with their service in the Persian Gulf, and possibly associated with their exposure to an array chemical, biological, or environmental toxins. This type of legislation would give veterans who served in the Persian Gulf the benefit of the doubt regarding their exposure to hazardous toxins.
    Mr. Chairman, I would again like to thank your subcommittee and urge you to act quickly to correct the flaws in the adjudication of Persian Gulf War claims. We believe that the language contained in current and pending legislation provides a solution to many of the problems Gulf War veterans are currently facing in the—our Nation's veterans' benefits system. Your kind attention to this legislation is greatly appreciated.
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    Thank you again, and I'm willing to answer any questions you may have.
    [The prepared statement of Mr. Ridley appears on p. 168.]

    Mr. REDMOND. Thank you. I do have one question for Matt. Matt, would you elaborate on your work—on your excellent work in the comparison of Public Law 103–446 and the VA's regulations?
    Mr. PUGLISI. Yes, Mr. Chairman. As a matter of fact, I think the easiest way to do it—and the way the U.S. Marines like to do things is simply—is when holding up the public law and the regulations and literally holding them side-by-side, one is struck that the language and the descriptions used in each are vastly different. If I could just read some exerts from each, I think I could make clear to yourself and those present the differences.
    Reading from the public law, ''the purposes of this title are to provide compensation to Persian Gulf War veterans who suffer from disabilities resulting from illnesses that cannot be diagnosed or defined and for which other causes cannot be identified.'' Reading from the regulations VA has written, ''VA shall pay compensation to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms.''
    And throughout the regulations you see phrases like ''objective indications of chronic disabilities,'' ''signs, in the medical sense, of objective evidence perceptible to an examining physician,'' and ''independent verification.'' These phrases and this criteria are found nowhere in the public law.
    And what we found is that when claims are submitted to VA, the adjudicators given the criteria and the regulations just cannot grant service connection or compensation to these veterans. Things like headaches, fatigue, joint muscle pain can't be seen by a physician. They can't be measured by a physician unless they do a very elaborate workup regarding the measurement of disability and functionality. Physicians don't have time to do that, especially in some VA medical centers that are short-handed. And so—although we commend our colleague from the VBA and the lawsuit they've brought and the case they've got before the Court of Veterans Appeals, we feel that the regulations as they are today make it impossible, in any way, to really win these claims in other than rare cases. And so that's why we recommend that the regulations be rewritten as Mr. Stump did in his letter to Togo West, and that we also recommend that pending legislation be considered by the committee because it would do more than just change the regs. VA would have to sit down and rewrite everything from scratch.
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    Mr. REDMOND. Thank you, Matt. I appreciate that.
    I'm going to read a script from Gone With The Wind cause because we can't find anything else here. (Laughter.)
    Here it is. Thank you.
    I want to thank everybody for coming today, the witnesses especially. But most importantly, I'd like to thank the Department. I would like the Department to understand that they're still deficient in their data collection and I believe they need to do whatever it takes to get the data question straightened out.
    The hearing stands adjourned.
    [Whereupon, 1:05 p.m., the subcommittee adjourned subject to the call of the chair.]