Institute of Medicine Reports Related to Veterans’ Health
and the Provision of Disability Benefits
Judith A. Salerno, M.D., M.S.
Institute of Medicine
The National Academies
submitted to the
Subcommittee on Disability Assistance and Memorial Affairs
Committee on Veterans’ Affairs
U.S. House of Representatives
Hearing on Bills Related to Veterans’ Health and Disability Issues
June 12, 2008
Chairman Hall asked the Institute of Medicine (IOM) of the National Academies to provide testimony regarding several bills under consideration by the Subcommittee. In response, we have prepared this testimony on issues raised in these bills that are addressed by recent IOM reports.
My name is Dr. Judith Salerno and I am the Executive Officer of the Institute of Medicine. I serve as IOM’s chief operating officer and executive director of the Institute, and am responsible for managing IOM’s research programs. My past work includes positions at the Department of Veterans Affairs (VA), where I directed the continuum of VA’s Geriatrics and Extended Care programs across the country. I also previously served as Associate Chief of Staff at the VA Medical Center in Washington, D.C., where I coordinated clinical services for older veterans. I am honored to have had the opportunity to serve veterans for nine years in these capacities.
The reports I will be discussing today were written by committees of experts convened under the auspices of the Institute of Medicine. IOM was created in 1970 as a component of the National Academy of Sciences, which was chartered by Congress in 1863. The National Academies’ role is to provide independent, non-partisan, evidence-based advice to the government and the nation. As an independent voice, we neither support nor oppose the legislation under discussion at today’s hearing.
I will address provisions in seven of the bills that touch on topics covered in IOM reports.
H.R. 1197: Prisoner of War Benefits Act of 2007
H.R. 1197 addresses issues related to the establishment of presumptions of service connection. The 2008 IOM report Improving the Presumptive Disability Decision-Making Process for Veterans describes the current process for making presumptive decisions for veterans who have health conditions arising during military service and proposes a scientific framework for making such decisions in the future. The report was requested by the Congressionally-constituted Veterans’ Disability Benefits Commission. Its findings and recommendations were previously delivered to the subcommittee in testimony presented on February 26, 2008 by Jonathan M. Samet, MD, MS, and, in the interest of brevity, won’t be repeated here. H.R. 3795, 5454, 5954, and 6032—which also deal with presumptions of service connection—are discussed below.
H.R. 3795: You Were There, You Get Care Act of 2007
H.R. 3795 would add a presumption of radiation exposure for the purpose of service connection for veterans of the 1991 Persian Gulf War and subsequent conflicts in that theatre. The bill also calls for an independent study to determine diseases that may result from exposure to depleted uranium.
In 1998, VA asked the IOM to convene a committee and to evaluate the scientific literature regarding potential health effects from exposure to depleted uranium. The committee’s report—Gulf War and Health: Volume 1. Depleted Uranium, Pyridostigmine Bromide, Sarin, and Vaccines—was released in 2000. It concluded that there was inadequate or insufficient evidence to determine whether an association exists between uranium exposure and 14 health outcomes—lymphatic cancer, bone cancer, nervous system disease, reproductive or developmental dysfunction, nonmalignant respiratory disease, gastrointestinal disease, immune-mediated disease, effects on hematologic measures, genotoxic effects, cardiovascular effects, hepatic disease, dermal effects, ocular effects, and musculoskeletal effects. The committee also concluded that there was limited or suggestive evidence of no association between uranium and clinically significant renal dysfunction and between uranium and lung cancer at cumulative internal doses lower than 200 mSv.
IOM is preparing an update of this report, which will include reviews of new scientific literature available since publication of the 2000 report. This update is expected to be released in the fall of 2008. In addition, the IOM has been asked by the Department of Defense to determine if it is feasible to conduct an epidemiological study of veterans who were exposed to depleted uranium while on active duty. A report addressing this question will be released later this year.
H.R. 5448: Full Faith in Veterans Act of 2008
H.R. 5448 includes provisions that instruct the VA to update the rating criteria used to evaluate Posttraumatic Stress Disorder (PTSD) for compensation purposes and to create a training and certification program for the employees who perform the ratings.
In June 2007, a committee convened by the IOM at the request of the VA completed a report entitled PTSD Compensation and Military Service. The committee’s review identified several areas where changes in current practice might result in more consistent and accurate ratings for disability associated with PTSD. Such ratings are performed by VA raters using information gathered in a compensation and pension examination and criteria set forward in the Schedule for Rating Disabilities. Currently, the same set of criteria is used for rating all mental disorders. They emphasize symptoms from schizophrenia, mood, and anxiety disorders. The committee found that these criteria are at best a crude and overly general instrument for the assessment of PTSD disability. It recommended that new criteria be developed and applied that specifically address PTSD symptoms and that are firmly grounded in the standards set out in the Diagnostic and Statistical Manual of Mental Disorders used by mental health professionals.
Determining ratings for mental disabilities in general and for PTSD specifically is more difficult than for many other disorders because of the inherently subjective nature of symptom reporting. In order to promote more accurate, consistent, and uniform PTSD disability ratings, the committee recommended that VA establish a certification program specifically for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. Rater certification should foster greater confidence in ratings decisions and in the decision-making process.
H.R. 5454: To amend title 38, United States Code, to establish a presumption of service connection of amyotrophic lateral sclerosis for purposes of the laws administered by the Secretary of Veterans Affairs
H.R. 5454 would establish a presumption of service connection for ALS. The available research on ALS in veterans was evaluated in an IOM study requested by the VA that resulted in the 2006 report Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature. Only five studies on this topic were identified. The committee charged with performing the review found that there was limited or suggestive evidence of an association between military service and development of ALS. It recommended that additional studies on the relationship between military service and ALS be conducted and that, in addition, research was needed to explore what might be causing ALS among veterans: for example, involvement in traumatic events, intensive physical activity, or chemicals or other substances or activities that might be encountered during military service.
H.R. 5709: Veterans Disability Fairness Act
H.R. 5709 would require the Secretary of the Department of Veterans Affairs to perform annual reviews of the accuracy and consistency of decisions on disability compensation and take those results into account in reviewing the performance of Veterans Benefit Administration and Board of Veterans Appeals adjudicators. The June 2007 IOM report A 21st Century System for Evaluating Veterans for Disability Benefits found that VA’s quality assurance effort has improved the accuracy of disability benefit decisions from less than 60% in 2000 to 88% in 2006, which is commendable but still leaves considerable room for improvement. This report was requested by the Veterans’ Disability Benefits Commission.
The 21st Century System report also found that VA’s quality assurance system did not address consistency of decisions across VA’s 58 field offices. The report recommended ongoing or periodic evaluations of inter-rater reliability as well as the accuracy and validity of ratings across field offices and impairment categories (Recommendation 5-4). The report similarly recommended periodic assessment of the inter-rater reliability of the disability examinations performed by the Veterans Health Administration, which are a key input to the disability determination process (Recommendation 5-3). It should be noted, however, that the report stated that variability cannot be totally eliminated in evaluating most disabling conditions, because there will always be conditions with significant subjective elements such as mental disorders and back and joint pain. The report, therefore, emphasized using quality assurance results to improve the controllable elements of the decisions making system, for example, by revising guidelines, training, and/or rater qualifications and performance standards. It should also be noted that the main finding of the 21st Century System report was that the VA Schedule for Rating Disabilities is badly out of date for certain body systems such as musculoskeletal disorders, thereby hindering raters from providing accurate assessments of veterans’ disabilities. The report recommended that VA immediately update the Rating Schedule using current medical knowledge, which should itself improve the accuracy and consistency of rating decisions.
H.R. 5954: To amend title 38, United States Code, to provide veterans for presumptions of service connection for purposes of benefits under laws administered by Secretary of Veterans Affairs for diseases associated with service in the Armed Forces and exposure to biological, chemical, or other toxic agents as part of Project 112, and for other purposes.
H.R. 5954 establishes a mechanism for determining presumptive service connections for diseases that could be related to participation in Project 112, which included an effort referred to as Project SHAD. The 2007 IOM report Long-Term Health Effects of Participation in Project SHAD (Shipboard Hazard and Defense), which was requested by the VA, found no clear evidence that specific long-term health effects were associated with participation in Project SHAD. The IOM study compared the health of veterans who participated in SHAD with the health of a similar group of veterans who did not participate. Although more SHAD veterans have died of heart disease, overall mortality rates among both groups of veterans were similar. Moreover, the differences in the rates of medical symptoms and conditions experienced by each group were generally slight, and the committee responsible for the report found no consistent, specific patterns of ill health among SHAD veterans. However, because of limitations in the study response rates and the size of the study, the report’s findings should not be viewed as clear evidence that there are no possible long-term health effects related to SHAD involvement. Additionally, there have been very few hypotheses about specific health problems that could be related to the materials used in the SHAD tests to serve as a starting point for further investigation.
H.R. 6032: To amend title 38, United States Code, to direct the Secretary of Veterans Affairs to provide wartime disability compensation for certain veterans with Parkinson’s disease.
The IOM has convened several committees under a mandate contained in the Agent Orange Act of 1991 (Public Law 102–4), charged with evaluating the scientific evidence regarding associations between diseases and exposure to dioxin and other chemical compounds in herbicides applied during the Vietnam War. These committees have produced a series of reports on the topic, the most recent of which is Veterans and Agent Orange: Update 2006. Their work is supported under a contract with the VA.
One health outcome examined in these reports is Parkinson’s disease. The committee responsible for Update 2006 found that the evidence is inadequate or insufficient to determine whether there is or is not an association between Parkinson’s disease and exposure to the herbicides used in Vietnam and their contaminants. Several studies have reported associations of Parkinson’s disease with exposure to “pesticides” or to “herbicides” in general, but none yet reviewed have established a relationship with the specific herbicides sprayed in during the war. This condition continues to be of great interest to the committee and the latest research on the topic will be a subject of the next update, which will be released in 2009.
The reports discussed here addressed a number of other topics related to veterans health and disability policy and also reached a series of other recommendations regarding these topics. The National Academies would be pleased to provide members of the subcommittee with hard copies of these reports upon request. The reports are also freely accessible on-line at the URLs listed in the references below.
Thank you for the opportunity to present this testimony before the Subcommittee today. I would be happy to address any questions you may have.
Institute of Medicine Reports Cited in This Testimony:
A 21st Century System for Evaluating Veterans for Disability Benefits. (2007). http://www.nap.edu/catalog.php?record_id=11885
Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature. (2006). http://www.nap.edu/catalog.php?record_id=11757
Gulf War and Health: Volume 1. Depleted Uranium, Pyridostigmine Bromide, Sarin, and Vaccines (2000). http://www.nap.edu/catalog.php?record_id=9953
Improving the Presumptive Disability Decision-Making Process for Veterans. (2008). http://www.nap.edu/catalog.php?record_id=11908
Long-Term Health Effects of Participation in Project SHAD (Shipboard Hazard and Defense). (2007). http://www.nap.edu/catalog.php?record_id=11900
PTSD Compensation and Military Service. (2007). http://www.nap.edu/catalog.php?record_id=11870
Veterans and Agent Orange: Update 2006. (2007). http://www.nap.edu/catalog.php?record_id=11906