AGENT ORANGE AND VIETNAM
RELATED RESEARCH
NON-VA EFFORTS
CDC Epidemiologic Study (Epidemiologic Studies of the Health of Vietnam
Veterans - Mandated by Public Law 97-72 and Public Law 96-151) -
This project was actually three studies: the Vietnam Experience Study,
designed to evaluate the overall impact of military service in Vietnam
on those who served there; the Agent Orange Exposure Study, intended
to assess the possible adverse health effects on Vietnam veterans of
exposure to the herbicide; and the Selected Cancers Study, designed
to determine the risks of developing specific types of cancer among
Vietnam veterans. The Department of Veterans Affairs (VA) provided full
funding to the Centers for Disease Control (CDC) for this research.
Vietnam Experience Study - There were two components of this
study: mortality (death) and morbidity (disease).
The mortality effort (Postservice Mortality Among Vietnam veterans)
revealed that total mortality in Vietnam veterans was 17% higher than
for other veterans. The excess mortality occurred mainly in the first
five years after discharge from active duty and involved motor vehicle
accidents, suicide, homicide, and accidental poisonings. Thereafter,
mortality among Vietnam veterans was similar to that of other Vietnam-era
veterans, except for drug-related deaths, which continued to be elevated.
An unexpected finding was a deficit in deaths from diseases of the circulatory
system among Vietnam veterans.
The excess in postservice mortality due to external causes among Vietnam
veterans was similar to that found among men returning from combat areas
after world War II and the Korean War. The results of this study component
were published in the Journal of the American Medical Association in
February 1987. At the same time, CDC published a comprehensive report
on this project.
The morbidity component of the Vietnam Experience Study (Health Status
of Vietnam Veterans) indicated that the Vietnam and non-Vietnam veterans
studied were similar in terms of level of education, employment, income,
marital status, and satisfaction with personal relationships. Certain
psychological problems, however, were significantly more common among
Vietnam veterans than among non-Vietnam veterans. These included depression,
anxiety, and alcohol abuse or dependence. About 15% of Vietnam veterans
suffered from combat-related post-traumatic stress disorder at some
time during or after military service, and 2.2% had the disorder during
the month before the examination. During the telephone interview,
Vietnam veterans reported current and past health problems more often
than did non-Vietnam veterans, although results of medical examinations
showed few current differences in physical health. Vietnam veterans
had more hearing loss.
Among a subsample of participants who had semen samples evaluated, Vietnam
veterans had lower sperm concentrations and lower average proportions
of "normal" sperm cells. Despite differences in sperm characteristics,
Vietnam and non-Vietnam veterans fathered similar numbers of children.
Children of Vietnam veterans were not more likely to have birth defects
recorded on hospital birth records than were children of non-Vietnam
veterans. The rates of total, major, minor, and suspected defects were
similar among children of Vietnam and non-Vietnam veterans.
The results of the morbidity component were published in the Journal
of the American Medical Association in May 1988. CDC published a report
(five volumes plus three supplements) on this study component in January
1989.
Agent Orange Exposure Study - This study was designed to evaluate
the health effects, if any, of possible exposure to herbicides (primarily
Agent Orange), utilizing information contained in military records.
This component was put on hold in January 1986 because of problems related
to the exposure assessment of veterans who served in Vietnam. More specifically,
it was determined that a study based solely on military records was
not possible because of the considerable potential for misclassification
of exposure status.
Subsequently, the Centers for Disease Control conducted a TCDD validation
study to compare military records-based estimates with current serum
dioxin levels. The results of this study led the Domestic Policy Council's
Agent Orange Working Group and the Congressional Office of Technology
Assessment to conclude that the Agent Orange Exposure Study cannot be
conducted. Consequently, this study was canceled.
The results of the validation study were published in the Journal of
the American Medical Association in September 1988. The final report
was published by CDC in September 1989.
Selected Cancers Study - This study was designed to determine
if Vietnam veterans are at increased risk of contracting any of six
specific cancers: soft tissue and other sarcomas, non-Hodgkin's lymphomas,
Hodgkin's disease, nasal cancer, nasopharyngeal cancer, and liver cancer.
Data collection for this study component began in January 1985. Selected
Cancers Study findings, released in March 1990, indicated that Vietnam
veterans are at increased relative risk of developing non-Hodgkin's
lymphomas. CDC reported that for "men aged 35-59, the age of most
Vietnam veterans, the annual risk of developing non-Hodgkin's lymphoma
is 1 in 10,000. For Vietnam veterans, the risk appears to be about one
and one-half per 10,000."
The higher non-Hodgkin's lymphoma ratio was due to excessive non-Hodgkin's
lymphomas among men who served on ships offshore Vietnam. According
to the investigators, there was no similar increased risk among veterans
who served in locations other than Vietnam. CDC found that Vietnam veterans
were not at increased risk for developing any of the other five types
of cancers studied.
Because of the difficulty in estimating Agent Orange exposure in individual
veterans (see Agent Orange Exposure Study entry above), CDC only indirectly
evaluated the effects of such exposure for the Selected Cancers Study.
The study did not find any evidence that the increased risk of non-Hodgkin's
lymphomas might be due to Agent Orange exposure. In fact, the pattern
of risk among subgroups of Vietnam veterans seems to be the opposite
of the use of Agent Orange in Vietnam.
CDC published a "Final Report" on this study in September
1990. The study results were also published in the Archives of Internal
Medicine in December 1990.
As a result of the findings of the Selected Cancers Study, Secretary
Derwinski announced that VA would recognize non-Hodgkin's lymphomas
as service-connected for Vietnam veterans. For additional information
about this decision, see Agent Orange Brief,
B3.
Questions concerning the conduct of the studies described above should
be referred to the Centers for Disease Control and Prevention, Atlanta,
Georgia 30333.
Air Force Health Study (An Epidemiologic Investigation of Health
Effects in Air Force Personnel Following Exposure to Herbicides)
- In 1979, the Air Force began this epidemiologic study to determine
whether long-term adverse health effects exist following contact with
herbicides and whether these medical problems can be attributed to occupational
exposure to Agent Orange.
The 20-year study consists of mortality and morbidity components with
associated follow-up efforts plus reproductive outcome assessments.
The investigation focuses on the Air Force personnel attached to Operation
Ranch Hand, who were responsible for the great majority of herbicide
spraying missions. Members of the Ranch Hand unit had frequent and repeated
exposure to Agent Orange. Individuals in the comparison group served
in numerous flying organizations that transported cargo to, from, and
within Vietnam but were not involved in the aerial Agent Orange spray
operations.
Air Force investigators have issued a series of reports, beginning in
1983, describing the study results. The mortality analyses have not
shown any differences between the observed and expected number of Ranch
Hand deaths from all causes. There were significantly increased Ranch
Hand deaths due to digestive diseases. The 1991 mortality report revealed
an increased number of deaths due to circulatory system diseases among
the non-flying enlisted personnel. This new finding is being investigated
further.
Because of the "healthy veteran effect," (that is, only healthy
people are allowed to serve in our Armed Forces) both groups are surviving
significantly longer than similarly aged civilians.
The initial morbidity assessments showed only minor differences between
the Ranch Hands and the comparisons, and these differences
were not considered to be indicators of dioxin-related disease. The
1995 update indicated a possible association between dioxin and diabetes
and a relationship between dioxin exposure and heart disease.
A report on reproductive outcomes released in 1992 suggested that there
is no adverse relationship between dioxin levels and reproductive outcomes.
Investigators also reported no relationship between dioxin levels and
sperm count or percentage of abnormal sperm.
Mortality reports were published in 1983, 1984, 1985, 1986, 1989, and
1991. Morbidity assessments were released in 1984, 1987, 1990, and 1995.
Additional follow-up examinations are scheduled for 1997 and 2002. An
evaluation of the relationship between paternal serum dioxin in Ranch
Hand veterans and reproductive outcomes was published in 1995.
For additional information regarding the Air Force Health Study, contact
the Office of the Surgeon, Bolling Air Force Base, Washington, DC 20332-7050.
CDC Birth Defects Study (Vietnam Veterans' Risks for Fathering Babies
with Birth Defects) - This study, conducted by the Centers for Disease
Control with funding from VA, Department of Defense, and the Department
of Health and Human Services, assessed Vietnam veterans' risks for fathering
babies with major structural birth defects. Information regarding military
service in Vietnam was obtained from interviews with mothers and fathers
of babies in case and control groups and from review of military records.
Vietnam veterans did not have an increased risk of fathering babies
with defects. Vietnam veterans who had greater estimated opportunities
for Agent Orange exposure were not at greater risk for fathering babies
with all types of defects combined. The study results were published
in the Journal of the American Medical Association in August 1984. CDC
published a comprehensive report of the study findings in August 1984.
Agricultural Herbicide Use and Risk of Lymphoma and Soft-Tissue Sarcoma
- This population-based case-control study of soft-tissue sarcoma, Hodgkin's
disease, and non-Hodgkin's lymphomas in Kansas found farm herbicide
use to be associated with non-Hodgkin's lymphomas.
This National Cancer Institute study indicated that the relative risk
of non-Hodgkin's lymphomas increased significantly with number of days
of herbicide exposure per year and latency. Men exposed to herbicides
more than 20 days per year (regardless of the number of years of herbicide
use) had a 6-fold increased risk of non-Hodgkin's lymphomas relative
to non-farmers. Excess risk was associated primarily with long-term
use of the herbicide 2,4-D, one of the ingredients of Agent Orange.
(This ingredient did not contain the contaminant of Agent Orange
known as TCDD or dioxin which has caused a variety of illnesses in laboratory
animals.) Soft tissue sarcomas were not associated with herbicide exposure.
This study supports findings from Sweden and the U.S. that suggest non-Hodgkin's
lymphomas are associated with farm herbicide use.
The results of the study were published in the Journal of the American
Medical Association in September 1986.
Soft Tissue Sarcoma and Non-Hodgkin's Lymphoma in Relation to Phenoxyherbicide
and Chlorinated Phenol Exposure in Western Washington - This National
Cancer Institute-funded population-based case-control study was conducted
in western Washington State to evaluate the relationship between occupational
exposure of men aged 20-79 to certain herbicides and other chemicals
and the risks of developing soft tissue sarcomas and non-Hodgkin's lymphomas.
Occupational histories and other information were obtained by personal
interviews for 128 soft tissue sarcoma cases and 576 non-Hodgkin's lymphoma
cases, diagnosed between 1981 and 1984, for 694 randomly selected controls
without cancer.
The results demonstrated small but significantly increased risks of
developing non-Hodgkin's lymphomas in association with some occupational
activities where certain herbicides have been used in combination with
other types of chemicals, particularly for prolonged periods. They do
not demonstrate a positive association between increased cancer risks
and exposure to any specific herbicide alone. Moreover, these findings
provide no evidence of increased risks of developing non-Hodgkin's lymphomas
associated with chlorinated phenol exposure or of developing soft tissue
sarcomas associated with exposure to either class of chemical.
The results were published in the Journal of the National Cancer Institute
in May 1987.
In addition to the scientific investigations described above, the Department
of Agriculture, Environmental Protection Agency, Armed Forces Institute
of Pathology, National Cancer Institute, National Institute for Occupational
Safety and Health, and several other Federal agencies are doing or have
completed research to discover more about the possible adverse health
effects of exposure to Agent Orange and other herbicides used in Vietnam.
According to the final report issued by the Domestic Policy Council's
Agent Orange Working Group in 1994, there are 38 ongoing projects and
189 completed projects. The report indicates that over $127 million
has been spent on the completed projects and an additional $86 has been
spent on the ongoing projects. The report added that an additional $70
million will be required to complete ongoing projects.
A number of States have also conducted research on Agent Orange and
Vietnam veterans. Mortality studies of Vietnam veterans were completed
in New York, Wisconsin, West Virginia, and Massachusetts. Studies and/or
surveys have also been done in Iowa, New Jersey, and several other States.
The American Legion also did a study. That veterans group, in concert
with two other organizations, sponsored a review of herbicide literature
in 1990.
The Department of Veterans Affairs also is closely monitoring research
being conducted in other countries as well as studies being done throughout
the United States.
NAS Report (Veterans and Agent Orange - Health Effects of Herbicides
Used in Vietnam) - In 1992, the National Academy of Sciences (NAS),
a non-governmental organization, agreed to conduct a multi-year review
of all relevant scientific research and provide advice to the Secretary
of Veterans Affairs on a wide range of issues relative to herbicides
and dioxin. The NAS review is being undertaken in accordance with Public
Law 102-4, the Agent Orange Act of 1991, signed by the President
on February 6, 1991. The initial NAS report was released in July 1993.
The NAS found "sufficient evidence" to conclude that there
is a positive association between herbicides and (1) soft tissues sarcoma,
(2) non-Hodgkin's lymphoma, (3) Hodgkin's disease, (4) chloracne, and
(5) porphyria cutanea tarda (in genetically susceptible individuals).
The NAS also found "limited/suggestive evidence" of an association
between exposure to herbicides used in Vietnam and three other types
of cancer: respiratory cancers (including lung, larynx, and trachea),
prostate cancer, and multiple myeloma.
For most conditions reviewed, the NAS concluded that there was "inadequate/insufficient
evidence" to determine whether an association exists. The NAS Committee
included the following diseases and disorders in this third category:
hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female
reproductive cancers (breast, cervical, uterine, ovarian), renal cancer,
testicular cancer, leukemia, spontaneous abortion, birth defects, neonatal/infant
death and stillbirths, low birthweight, childhood cancer in offspring,
abnormal sperm parameters and infertility, cognitive and neuropsychiatric
disorders, motor/coordination dysfunction, peripheral nervous system
disorders, metabolic and digestive disorders (diabetes, changes in liver
enzymes, lipid abnormalities, ulcers), immune system disorders (immune
modulation and autoimmunity), circulatory disorders, and respiratory
disorders.
For a small group of cancers, the NAS found "limited/suggested
evidence" that there is "no association" with herbicides
used in Vietnam. This category included skin cancer, gastrointestinal
tumors (stomach cancer, pancreatic cancer, colon cancer, rectal cancer),
bladder cancer, and brain tumors. The Committee report noted, however,
that even for these conditions "the possibility of a very small
elevation in risk at the levels of exposure studied can never be excluded."
The greatest problem encountered in the review was a severe lack of
information about the exposure of individual Vietnam veterans to herbicides.
Except for particular groups, such as the individuals directly involved
in spraying operations, information on the extent of herbicide exposure
among veterans is practically nonexistent. Consequently, most studies
evaluated by the NAS did not involve Vietnam veterans. Rather, the
NAS focused on studies of people who were exposed to herbicides
as a result of their jobs or as a result of contact in the environment.
These types of exposures often were at high levels and for long periods
of time. Assessing health risks for Vietnam veterans is complicated
by the fact that the levels of exposure were extremely wide ranging.
While most Vietnam veterans probably had lower exposure levels, some
may have experienced levels as high as that of occupational or agricultural
exposures. What is uncertain is how many veterans may have been exposed
to those higher levels and who those individuals are.
The NAS concluded that a series of epidemiologic studies of veterans
could yield valuable information if a new, valid exposure reconstruction
model could be developed. The NAS urged the continuation of the Air
Force Health Study of Ranch Hand personnel and the expansion of that
investigation to include Army Chemical Corps veterans.
The NAS's research recommendations emphasized epidemiologic studies
of Vietnam veterans, rather than general toxicologic or epidemiologic
studies of occupationally or environmentally exposed populations. A
substantial amount of research on the toxicology of herbicides and herbicide
components is already under way in the United States and abroad. Many
of the studies on which the NAS's conclusions are based have been published
since 1991. Although not targeted specifically to Vietnam veterans,
it is likely that this ongoing research will also contribute to the
knowledge of potential health effects in this population.
The NAS made the following specific recommendations regarding epidemiologic
studies of Vietnam veterans:
Recommendation 1. The NAS endorses continued follow-up of the Air Force
Ranch Hand cohort and its comparison group, and recommends that members
of the Army Chemical Corps and an appropriate comparison group be followed
in a similar study. An independent, nongovernmental scientific panel
should be established to review and approve a new, expanded research
protocol for both study populations, and to commission and direct a
common analysis of the results.
Recommendation 2. The Department of Defense and the Department of Veterans
Affairs should identify Vietnam service in the computerized index of
their records.
Recommendation 3. Biomarkers for herbicide exposure should be developed
further.
Recommendation 4. A nongovernmental organization with appropriate experience
in historical exposure reconstruction should be commissioned to develop
and test models of herbicide exposure for use in studies of Vietnam
veterans.
Recommendation 5. The exposure reconstruction models developed according
to Recommendation 4 should be evaluated by an independent, nongovernmental
scientific panel established for this purpose.
Recommendation 6. If the scientific panel proposed in Recommendation
5 determines that a valid exposure reconstruction model is feasible,
the Department of Veterans Affairs and other government agencies should
facilitate additional epidemiologic studies of veterans.
The NAS also recommended that priority be given to additional research
on reproductive effects that would help clarify the possible effects
of herbicides. In particular, the NAS concluded that extensive reanalysis
of the Ranch Hand reproductive data could shed additional light
on these questions.
The NAS report noted that although there is sufficient evidence of an
association between occupational or environmental exposures to herbicides
and several conditions, the existing information on dose-response relationships
is incomplete, especially with regard to Vietnam veterans. If a valid
exposure reconstruction method can be developed, it might be applied
to the exposure data available from existing case-control studies to
provide additional dose-response evaluations. Additional refinement
of the clinical and pathological definitions of soft tissue sarcomas
in epidemiologic studies would also help to determine which of the specific
cancers in this class are associated with herbicides or TCDD.
The NAS observed that its recommendations for development of a historical
exposure reconstruction model and its use in epidemiologic studies might
seem at variance with the Centers for Disease Control, White
House Agent Orange Working Group, and Congressional Office of Technology
Assessment conclusions made in 1986 regarding the congressionally mandated
Agent Orange Study. The NAS offered four reasons for the different conclusion:
(1) the 1986 conclusions were based in large part on serum TCDD measurements,
which the NAS thinks are insufficient for validating exposure to herbicides
used in Vietnam;
(2) the arguments underlying the earlier conclusion that individuals
in combat units were widely dispersed and that troop movement data are
incomplete imply that exposure measurements may be imprecise, not that
they are invalid. However, these arguments do suggest that historical
reconstruction of exposure will have nondifferential misclassification
errors that will lead to underestimates of the relative risk of health
outcomes if an association is in fact present;
(3) the NAS is proposing the use of more, but less formal, information
on exposure than was considered in 1986. This includes the development
and use of informal information on perimeter spraying, which might account
for more meaningful herbicide exposure than the aerial spraying documented
on the HERBS tapes; and
(4) the NAS does not know whether the approach it proposes will prove
valid or whether new methods will identify a sufficient number of highly
exposed Vietnam veterans for an epidemiologic study. In the NAS's judgment,
however, the likelihood that this approach will be successful
is sufficient for it to be recommended.
The law that mandated the NAS review (Public Law 102-4, the Agent Orange
Act of 1991), required that NAS include in the initial NAS report an
evaluation of the feasibility and cost-effectiveness of four specific
programs that might be implemented by VA. The NAS conclusions are described
below.
Section 6 of that legislation requires VA to compile and analyze, on
a continuing basis, all clinical data that (1) are obtained in connection
with VA examinations and treatment of Vietnam veterans, and (2) are
likely to be scientifically useful in determining the association between
disabilities experienced by these veterans and exposure to dioxin or
herbicides. The NAS report indicated that such a system, called the
Agent Orange Registry, currently exists.
Section 7 concerned the establishment of a system for the collection
and storage of voluntarily contributed samples of blood and tissue of
veterans who served in Vietnam. Balancing the strengths and weaknesses
stored biological samples and clinical data for research purposes, the
Committee concluded that systems of this sort have scientific value,
but only to the extent that they are components of specific, well-designed
studies. In the absence of a clear study design to guide such activities,
and without resolution of important design, quality control, and ethical
issues regarding tissue banks, the NAS did not recommend the establishment
at this time of the clinical data (Section 6) and tissue archiving (Section
7) systems described in the law.
Section 8 related to the feasibility
of conducting additional scientific research on health hazards resulting
from exposure to dioxin and herbicides used in Vietnam. As stated above,
the NAS concluded that a series of epidemiologic studies of veterans
could yield valuable information if a new, valid exposure reconstruction
model can be constructed.
Section 9 would require VA to test for dioxin (TCDD) in any blood sample
voluntarily provided by Vietnam veterans who seek VA health care under
priority eligibility based on exposure to Agent Orange. The NAS report
noted that the purpose of this idea was not stated in the legislation
and is unclear. If research purposes are contemplated, the NAS's conclusions
about tissue archiving are applicable, and the NAS would not recommend
such a program at this time. The NAS realized that such a program might
be intended to provide information on individual exposure to dioxins
or herbicides to aid in individual compensation decisions. The NAS cannot
make recommendations for VA policy but noted that individual TCDD serum
levels in Vietnam veterans are usually not meaningful because of common
backgrounds exposures to TCDD, poorly understood variations in TCDD
metabolism, relatively large measurement errors, and exposure to herbicides
that did not contain TCDD.
Follow-up reports by the NAS are planned for once every two years for
ten years following the initial report (to the extent appropriations
are available).
NAS Report (Veterans and Agent Orange: Update 1996) - The first
NAS update was considerably shorter than the initial publication (384
pages compared to 832 pages). Unlike the 1992 report, it did not include
research recommendations. The same four categories were used to classify
health outcomes according to the likelihood of a positive association
with herbicide exposure, based on all available research data.
In its initial report, the NAS included the following conditions in
category one (sufficient evidence of an association): soft-tissue sarcoma,
non-Hodgkin's lymphoma, Hodgkin's disease, chloracne, and porphyria
cutanea tarda (PCT), in genetically susceptible individuals. The 1996
update dropped PCT to category two (limited/suggestive evidence of an
association). The other four conditions remained in category one, and
no additional health outcomes were included in this category.
In the initial report, the NAS included only three health outcomes in
category two: prostate cancer, multiple myeloma, and respiratory cancers.
Six outcomes were placed in this category in the update. In addition
to these three cancers and PCT, the NAS included the following in category
two: acute and subacute peripheral neuropathy in Vietnam veterans and
spina bifida in the children of Vietnam veterans.
The first report included peripheral neuropathy among "peripheral
nervous system disorders," finding that there is inadequate/insufficient
evidence to determine whether an association exists (category three).
Similarly, spina bifida was grouped with all other birth defects, and
the NAS declared that there is inadequate/insufficient evidence to determine
whether an association exists.
In the update, the NAS concluded that birth defects (except spina bifida)
as well as chronic peripheral nervous systems disorders should remain
in category three. Most conditions evaluated in 1996 report (as well
as in the 1993 effort) were listed in category three. In the 1996 report
the following outcomes were listed in this NAS category: hepatobiliary
cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive
cancers (cervical, uterine, ovarian), breast cancer, renal cancer, testicular
cancer, leukemia, spontaneous abortion, birth defects (other than spina
bifida), neonatal/infant death and stillbirths, low birthweight, childhood
cancer in offspring, abnormal sperm parameters and infertility, cognitive
and neuropsychiatric disorders, motor/coordination dysfunction, chronic
peripheral nervous system disorders, metabolic and digestive disorders
(diabetes, changes in liver enzymes, lipid abnormalities, immune systems
disorders (immune suppression and autoimmunity), ulcers), circulatory
disorders, respiratory disorders, and skin cancer.
The 1996 list for category three is very similar to the list in the
1993 report. The changes are the two noted above (that is, peripheral
nervous system disorders and birth defects) plus an elevation of skin
cancer from category four.
Few health outcomes were included in category four (limited/suggestive
evidence of no association). The 1996 report included gastrointestinal
tumors (stomach cancer, pancreatic cancer, colon cancer, rectal cancer),
bladder cancer, and brain tumors. The only change from the earlier NAS
report in this category was the elevation of skin cancer to category
three.
In two years, as required by the Agent Orange Act of 1991, the NAS will
re-evaluate current scientific evidence in conjunction with an assessment
of new information regarding the possible long-term health consequences
of herbicide exposure.
Single copies of the NAS books were distributed to all VA medical center
libraries: Organizations or individuals interested in purchasing these
documents can contact the publisher: National Academy Press, 2101 Constitution
Avenue, N.W. Box 285, Washington, DC 20055. The telephone numbers are
1-800-624-6242 and 202-334-3313. The NAS is a private, nonprofit society
of distinguished scholars engaged in scientific and engineering research.
Established in 1863, the NAS is dedicated to the furtherance of science
and technology and to their use for the promotion of general public
welfare.
Where can a veteran get more information about Agent Orange research
and studies on related matters?
Information on these subjects can be obtained at the VA medical center
libraries, from the Registry Physician or Agent Orange Coordinator at
every VA medical center, or from the Environmental Agents Service, (131),
Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington,
DC 20420.
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DioxinKills!
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