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VA to decide on new Agent Orange presumptive diseases

August 9, 2017
Agent Orange Presumptive List Additions Nov. 1 2017

Secretary of the Department of Veterans Affairs David Shulkin will decide “on or before” November 1 whether to add to the list of medical conditions the VA presumes are associated with exposure to Agent Orange or other herbicides sprayed during the Vietnam War, according to a department spokesman.

Potential Additions to the Presumptive List

Currently, there are 14 medical conditions – including a variety of cancers, ischemic heart disease, diabetes, Parkinson’s disease, and other ailments – that the VA considers “presumptive diseases,” meaning veterans who served with boots on the ground in Vietnam do not have to individually prove that those diseases are the result of Agent Orange exposure.

The potential additions to the presumptive list include bladder cancer, hypothyroidism, and “Parkinson-like symptoms” (without a diagnosis of actual Parkinson’s disease). Hypertension (i.e. high blood pressure) and stroke are also being considered, though some predict that the time and cost of granting benefits for these common ailments might deter the VA from embracing them.

Strength of the Evidence

In March of 2016, the National Academy of Medicine (formerly the Institute of Medicine) published its 10th and final review of medical research related to the health effects of herbicide exposure in Vietnam. The 1,100 report concluded that recent research has strengthened the scientific link between herbicide exposure and bladder cancer, hypothyroidism, and Parkinson-like symptoms. Previous reviews found “inadequate or insufficient” evidence to scientifically link these conditions to herbicide exposure. This round of review found “limited or suggestive” evidence of a link.

That same level of evidence was enough to prompt former VA Secretary Eric Shinseki to add ischemic heart disease and Parkinson’s disease to the presumptive list in 2010. Though the National Academy of Medicine (NAM) found — in past reports as well as this one — “limited or suggestive” evidence that hypertension and strokes were associated with Agent Orange exposure and did not add those conditions to the list. There have been instances of stronger evidence for other ailments in the past. In 2010, for example, Shinseki added chronic lymphocytic leukemia after the NAM found a “positive association” with herbicide exposure.

Secretary Shulkin has the power to use NAM findings to add all five diseases to the presumptive list if he so chooses. But he can also choose to look at other scientific research to justify adding fewer conditions or none at all.

What’s the hold up?

The NAM presented its report – Veterans and Agent Orange: Update 2014 – to then-Secretary Bob McDonald over 15 months ago. McDonald called together a technical work group to review NAM’s findings, to evaluate the quality of the studies it relied on, and to look at other relevant science. That group’s findings were then reviewed by a second (strategic) work group, according to reporter Tom Philpott of Mother Jones.

After Shulkin’s confirmation as VA Secretary, the report was delivered to his desk in mid-February. Philpott points out that for the previous 18 months, Shulkin was VA undersecretary for health and would have been familiar with the NAM’s review as well as the findings of the work groups. So why has it taken so long for him to announce whether these conditions will be added to the list?

Costs, Skeptics & a Lack of Deadlines

One reason for the delay may be pressure from the White House’s Office of Management and Budget (OMB) which likely resists adding presumptive diseases to the list because of the enormous cost of doing so.  In 2010, the OMB tried to block Shinseki from adding three new conditions (including heart disease) to the presumptive list. Shinseki brushed off the OMB and instead went directly to then-President Barack Obama, who granted the request. Three years after the decision, the added conditions (ischemic heart disease, Parkinson’s, and leukemia) accounted for 280,000 additional disability compensation claims and about $4.5 billion in retroactive payments, according to Mother Jones.

Another potential factor: The senior staff in charge of monitoring and setting VA policy on compensation for Agent Orange-related claims. VA officials in the Compensation Service, which works on disability rating policy and procedure, have consistently downplayed the risk of herbicide exposure and questioned the findings of some scientists, including the NAM. They’ve relied on Agent Orange “experts” such as Dr. Alvin Young whose work, critics say, has been compromised by inaccuracies, inconsistencies and omissions of key facts, and rely heavily on his previous, some of which was funded by Monsanto Co. and Dow Chemical Co., the makers of Agent Orange.

Perhaps the most likely reason for the delay is the absence of deadlines previously associated with the NAM’s studies. Past VA secretaries had strict timetables for accepting or rejecting NAM findings. They also had to maintain certain standards and procedures when determining if other NAM-identified diseases should be added to the list, and to explain in writing if they declined to add them. But in October 2015, Congress allowed those provisions of the Agent Orange Act of 1991 to “sunset,” or expire, just six months before NAM delivered its last report.

If VA officials keep their word, we’ll know by November 1 whether these obstacles were overcome.