record those specific questions that we ask about airborne hazards. we're not only looking at the occupational environmental health risk assessments of when the member was down range multiple times and reviewing those exposures, it's taking those little bit of questions that the member answered regarding hazards from the post-deployment assessment and the periodic health assessment. and we also have a few separation health assessment that's been under development for the last year, should be released this fall, and it also goes into detail about airborne hazards and chemicals of that nature. and that will also be documented. >> thank you. thank you for the question. any further questions? >> just one. i just want to echo senator gillibrand or reemphasize on current active burn pits. some of the process that a led to these being operation

operationally necessary, i think, would be very helpful for the committee. thank you for being here. >> thank you very much for your testimony. i'll welcome the second panel to come up. thank you very much. [inaudible conversations] [inaudible conversations]

>> now welcome the second panel, dr. anthony szema if, northwell health foundation, mr. tom porter, executive vice president for government affairs, iraq and afghanistan veterans of america, [applause] ross city torres, and mr. steve patterson, combined joint task force, afghanistan 2008-2009. thank you so much, and each of you can give your opening statements. dr. szema, you can go first. >> thank you, chair gillibrand, ranking member tillis, members of the subcommittee, armed services committee, for the opportunity to participate in today's hearing. between 1998-2015 i was at the me call center, northport, new york, and my expertise stems from the following: my team

first reported new onset is asthma among soldiers deemployee -- deployed in iraq and afghanistan with exposure to burn pits in 2007. we described -- [inaudible] in 2008, copy the term lung injury in 2011 based on lung function it's testing, developed animal models in 2014, tested candidate trucks in these mice in 2008 and co-invented new medicine this year. i am testifying because as a physician, i care about the health and well-being of my patients who are our soldiers. my office sees new a patients post-deployment with a variety of symptom which include shortness of breath, cough and chest pain which is accentuated with exercise. i have diagnosed non-smoking related accelerates copd, burn

lung. titanium lung, hung fibrosis, balad -- lung fibrosis, bladder cancer and bone in the lung. in one severe case, for example, one of my patients underwent two lung transplants. he just died in december. as an expert in the field, i've concluded that these lung disorders are directly related to exposure to burn pits, dust storms, improvised explosive devices and pressure from mortar-fired rounds. as doctors treating these patients, one challenge we face is that there's inned adequate screening of these military personnel. lack of screening means they never get diagnosed, they get diagnosed late or when it's irreversible. the dilemma with military personnel who typically do not have as a many ma who pass basic training outdoors who must be fit for deployment is that they do not have pre-deployment pulmonary assessments. unlike the fire d. of new

york -- fire department of new york of. an otherwise healthy soldier who goes down to 80% has a significant decrease. another challenge we face is that doctors treating these service members, it's a lack of information we receive. without knowing what they're exposed to or potentially exposed to, it's hard to prove what caused the ailment. for example, last month one patient of mine was denied a consult to the -- war-related injury and illness center because the local v.a. doctor said he did not believe that that military fire fighter's sleep apnea, sciencitis -- [inaudible] and were related to deployment. even ifs it is known for toxic sites, often soldiers visit our center without complete if dock you taxes of location to their -- so their direct exposure cannot be proven. this is especially the case if they were forward operating bases like camp striker whose

exact location is not on the map. i have several recommendations to address these challenges and insure we are taking care of our service members. one, conduct breathing tests before and after deployment. two, revamp the dod method of documenting locations where military personnel serve. three, utilize newer technology such as wearables. first, by conducting breathing tests before and after deployment, we can determine if there's a reduction in lung function much earlier than if we wait. this these days -- screening protocols to identify who are soldiers at risk. second, by revamp ising the dod method of documenting where personnel serve, we'll have a better understanding of what they're exposed to, of the illness and how to treat it. third, by utilizing newer technologies such as wearable particle monitors for gps, we'll be able to assess the given soldier's exposure and location. by utilizing this for contingent and military personnel, the

dod will be better able to move. troops away from airborne hazards. if exposure does happen, it would provide creatal information for treatment. we know that screening and monitoring programs have been extremely e effective post-9/11, and this is an analogous exposure with burn pits. it is our say cred -- sacred duty to care for the women and men who sacrifice their lives for our freedom. >> thank you, doctor. mr. porter. >> thank you for having us here, senator gillibrand and senator tillis. appreciate everything you're doing on in this issue. like to introduce my daughter, 13-year-old daughter, elizabeth porter, she's playing hooky from school today, so hopefully she gets something out of this. [laughter] i also, on a more serious note, i want to take this opportunity to say that my thoughts and prayers are with dr. kate

hendricks thomas, advocate on this issue. she's going through a very particularly tough time with regard to her burn pit-related illness. so i'm here not only as an iav advocate, but as one who was exposed to a variety of sox -- toxins when deployed. before i went down range, id had completely healthy lungings. shortly after i arrived in kabul, 2010, my lungs had a severe reaction and became infected. it was rolled -- it was controlled with medication, but i was diagnosed with asthma as soon as i got back home a year later. i have to still take the medications to keep my breathing under -- to keep breathing. exposure to burn pits used by the military to destroy medical and human wastes chemicals, petroleum, other trash, it's been widespread. we've talked about a lot here already. it's not just burn pits.

you could learn a lot from those who have served in kabul, for example. it's an enormous city without a no earn sewage system. many who served there suffering the impacts from breathing airborne feces for extended periods of time. and there are also burn pits there at many of the bases in that city alone. at every location where u.s. and coalition military were stationed, there were many port-a-johns. it was somebody's job to pull out that metal bin from the port-a-john every day and douse it with jet fuel and burn it down to a brick, and that's how you got rid of the waste. it's minute if's job to do that. it's somebody's job to do that. that's a particularly nasty job, i don't immediate to describe it. the military and veteran community know all too well how detrimental these toxic exposures can be. refer to our new member survey that's just out this month for 2022, we surveyed our members. 82% of our members say they

experienced toxic exposures during their service. of those, 90% say they have or may have symptom as a result. of the 82% who were exposed, just 53% had that their exposure withs documented in their dod periodic health assessments. just 53%. in this data shows the enormous percentage of those who are suffering service-related exposure, especially considering the estimate the v.a. has of as many as 3.5 million that could have been exposedded. when iava saw a previous survey, we conceived of and worked hard to pass the act passed in 2020 within the ndaa. so this would -- the law required service members to be evaluated for exec pose yours during routine health exams. service members were required to be enrolled in the burn pit rebel city unless they opt out. -- registry. they suffered exposure withs or if they were stationed near a

burn pit. 76% of iava members were registered -- aware of the registry, but only 59% are registered in it. not just informed of it as the law requires, it requires them to be enrolled in the registry. that's the intent behind the law in the first place, and we know this because we worked to develop the bill and pass it. i ava would like dod to confirm if the letter and intent of the act is being executed including whether service members are actually being required to enroll in the registry or simply being advised of its existence. we heard a lot of talk about the iler database. that's really critical, we believe. it would help inform service members, veterans and the medical providers of the exposures by your location and time you were deploy. i think we heard it was supposed to be operational in 2023, september of 2023, is what i

understand. we supported legislation that required that veterans have access to their iler database online. so hopefully that is, that that stays on track for implementation by september 2023, and we'd like your assistance to try to insure that that happens. there's also been some talk in the news about the red hill fuel storage facility in hawaii. this is another toxic exposure. so it's not all burn pits. the -- we want to make sure that the dod documents those exposures to not only the service members that are serving there now, but have been dislocated. but hen also those that have been -- then also those that have been impacted over the life of the fuel storage facility. that's important. how are they going to be doing that? ...

>> and by refusing obligations teacher servicemembers do not actually have their backs. is half of the 55 million servicemembers and veterans you may have toxic exposures to ensure dod has recent laws

of those have suffered exposures has spared no effort not only in anticipating new hazards that advise them of the risks ahead of time for medical professionals to address emergent health impacts. >> . >> thank you chairwoman gillibrand and ranking member tellis for today's hearing for this opportunity to testify. some members of congress believe that the health risks are based on anecdotal evidence, we have data today that shows or otherwise those who bravely defended our country exposed to toxic chemicals. my story begins with my husband retired captain what

the story state trooper 14 years before being medically retired through the military. and will expose within the operation iraqi freedom and was with the toxic plume of black smoke with a land and ate and slept returning home to face the healthcare system to afraid to understand that on cold war injury resulting in termination of the law enforcement career. he attempted to end his life in 2016 sense returning he had 400 medical visits he was finally diagnosed with autoimmune disease toxic brain injury following a lung biopsy at vanderbilt.

the dod refused to recognize or diagnose environmental injuries often misdiagnosing them as psychosomatic are dismissing them as compensation driven care seeking. the more we heard this is my 12 years ago we were a nonprofit for nonveterans servicemembers followed by toxic exposures of 10000 participants to track the exposure in diseases and death and then together with other families to pass the registry act and then to far too many funerals husband and children with the government failure to

treat veterans and to persevere over the years despite the v.a. and instead of providing them with treatment early cancer diagnostics and benefits spending the last year's telling veterans there is some evidence that inhaling toxic black smoke causes respiratory illnesses and cancers that the stories or anecdotes are not in that treating them as too costly i cannot help but wonder what is the cost of their lives and sacrifice? are now more than ever we need to pass legislation that time is past due for the department of defense veteran affairs to acknowledge these injuries as a direct result of armed conflict to the instrumentality of war. we are asking from the department of defense to honor these injuries with compassionate common sense and invitation to begin the healing process following the

environmental hardships of war. serving in the united states marine in iraq suffering from intestinal ulcerations and he died in 2009. serving in the u.s. army was applied twice to iraq the doctor said he was later diagnosed with pneumonia and treated and sent home eventually he was diagnosed with pulmonary fibrosis after a lung biopsy he was informed he had titanium, magnesium, iron and silica in his lungs he underwent two transplants and passed away this december at 50 years old. the environmental officer warned his supervisors about the health effects of the black fumes of burning of

waste isaiah james deployed to iraq in afghanistan and then to say this now is a supplemental oxygen that it is my hope you not only listen to the testimony but to hear it most importantly to act on it. we've always done best i believe churchill said never has so much been owed to so few by so many how will the american people pay their debt? >> thank you for this opportunity. this falls into larger preventive medicine community mentioned earlier. i'm here to look at burn

passed on —- burn pits and in 2008 and 2009 as a senior departmental science officer with a combined joint task force while on afghanistan. and then traveled the nation extensively saw most where the forces were deployed in my job was a fighting force to identify environmental health exposures it's very challenging and difficult to document in such a setting with the equipment to quantify exposures is lacking is a trained personnel in remote locations because we also have exposures as well as the challenge of putting a certain person in a location at a given time this is made worse looking back ten or 20 years and a personnel system does not operate down to the

person. almost all locations had burn pits operating at that time and few if any separated waste before burning it. pressurized lumber, galvanized metal, plastics and lithium batteries. these are not pits were just burned they literally smoldered which is important because combustion is not complete more toxic compounds can form and they are not listed away with the air around the camp mostly burn prints for security reasons are outside of the camp most of the small camps have few if any due to limited transportation challenges. we had roughly 20 people to attend the environmental exposures of 37000 people roughly the size of texas i do not think that is the ideal solution. the environmental health data

of soil and water samples cannot be linked to a person but only to a location and even if they cannot affirm they were at that location does not mean they had that exposure it could have been much worse or better than our sample indicated we must address it because we cannot face these particular challenges we struggle since desert storm you must look at different options moving forward and leverage technology some possible options to consider creation of a joint program to focus the research and funding on surveillance or providing a location in the future. and silicone bracelets to provided to track exposure as mentioned earlier this has been shown to capture more

than 1500 different chemical compounds to allow us to mitigate exposures much sooner while providing a service member with personal exposure data to build replacement for the silicone bracelet would have real-time information for those servicemembers. to create a repository of frozen soil samples so they may be tested in the future as needed when new concerns are identified. improve the personal reporting systems of each individual can be located rather than the unit headquarters which is hundreds of miles away this allows for individual exposures to be much more actively documented should be researched for gaps environmental surveillance key for those operating in those environments which never have environmental health professional visit down further research biomarker they had over the military career finally educate leaders on the toxic exposures and

hold them responsible if they are needlessly exposed to people. thank you for your time i'm open to your questions. >> thank you for being here. >> it sounds as if there is consensus of what i brought up for individualized monitoring and sensors. but speaking for active duty serving on the v.a. committee in making progress and again want to give senator gillibrand credit i'm sorry for the situation with your husband and the others that you mentioned so we need to do better upstream how do you judge the dod for those you

have delineated in your opening comments? where they falling short? >> spirit my team applied for congressionally directed grant funded by the dod recently months ago this was for a monitor the size of the beeper the soldier can wear but even for sarah and gas specifically and i don't know why they are asking us to apply for grants if there is no money. >> that's a question we can get to the bottom of. >> one of the biggest things i mentioned is that there is a big lack of transparency from federal agencies for what

people were exposed to and other deployments at the big thing will adjust be useful to the service member and the veteran? that is key. >> you also mentioned the idea the registry is available but i for one think we should be in the opt out position everybody should be registered in the registry if they want to explicitly opt out the nation that we should probably flip the script. >> right from what the law requires is for them to be entered into and less they opt not to is not mandatory if you don't want to be in the registry but the law says if somebody is exposed our station next to a burn pit the nation be entered into the registry. >> i agree. is still fall short in so many ways it is the self-reported data but it is important

everyone is a participant of that effort it on track mortality that's that we have talked about for years that i agree. that should be mandated. >> there are so many challenges in the space. the previous individuals talking so much that is self-reported so a 20 -year-old individual returns from overseas and you ask what happened over 15 months and then not to mention that that individual they cannot say i was exposed to some bad stuff happened to me. they cannot say anything to help that clinician through the v.a. system. so so much of what is being

done now is not effective. >> that's why getting down to the atomic level that's the only way we will really be able to capture it. >> so we are coming up and i appreciate your opening testimony. there were a lot of priorities as we move forward. thank you, mr. chair. >> first of all thank you for your advocacy on behalf of the servicemembers to suffer debilitating injuries and the effects of the burn pit —- burn pet. what is the top challenge soldiers returned from deployment about accessing treatment? >> first of all senator, it

brings up so many ideas in my mind with that private registry enough the top of my head it is access that with the dod active servicemembers and those reservist it is a challenge. when you have trained occupational medicine and doctors assessing these underlying issues. and then filing for a presumption for these illnesses that and so you don't have that specialized healthcare how can they properly transition through the compensation on —- compensation and disability process? >> what would be most helpful to servicemembers you work with when they return from deployment to make sure they're getting what they

need? >> mandating that clinicians be trained. but absolutely every nurse trained in the area to document and then to be identified as undergoing some type of exposure. and to say the least have had this conversation recently even something as small as signage. with the world trade center there is communication and outreach and signage if you are experiencing these issues people have to access care and they have to fly to new york and to vanderbilt and exhaust their life savings and that

should not be happening in america. so we need to start now. thank you very much. >> mr. porter thank you for sharing the results. why do you think only 59 percent of members are registered in the burn pit registry? with those steps the dod is taking to increase participation. what do you think can be done to encourage more servicemembers to better participate? >> thank you for the question. this came up when we developed the accountability act looking at the v.a. website has a running total of those that are registered and the time we looked at it back in 2017 there is only 140,000 countries in the registry i

haven't looked recently at that that is out of the v.a. estimate those that have been exposed that has a big challenge so that mean challenge for that is how anybody knows about the registry. so through that bill we talked about it a lot. and we also encourage the v.a. to do more and that's why somebody should be in it. i can understand every health exam if you are in the system but it's not qualifying someone for presumption. and for that disability and they are being turned down a three quarters of the people that apply.

>> if done right servicemembers will have exposure into their exposure what are the critical part that makes a difference of the care servicemembers receive? >> if somebody was deployed to iraq in 2006 then they should be able to give them the data from what they were probably exposed to in 2006 i traveled around afghanistan all over the place to pinpoint 21 oh one location it shows how complex it is i traveled around the country frequently. so it's harder for that but it should specify what you are exposed to during your deployment during a set period of time. >> senator warren will chair

the meeting while i go vote. >> i voted early so i can be here while the chairwoman goes to vote and a big thank you for holding this hearing. think it's really important that this committee look at the real cost of war including where the department of defense failed to take steps that were necessary to prevent exposing members of the military to toxic chemicals many witnesses on this panel have been fighting for over a decade for dod and the v.a. to recognize how burn pit exposure has had devastating effects on servicemembers lives. know there is some debate over the data that it is just common sense that these toxins

would cause significant problems to human beings. it is important for dod to study this issue to improve our understanding of the science, but we can't keep waiting for action we need to take care of our veterans now the focus of today's hearing is dod's role to determine eligibility for care but we also have considered the toll of this entire process on families. seven like to ask you about your experiences i read your testimony and i understand how hard you had to fight and how long to get the care that you

deserve and other veterans deserve. so let me ask you how this process makes your family feel? >> thank you for that question. it has been a journey, a hellish journey of delay and deny for thousands or millions of families i know for my husband being stripped of his integrity and dignity losing his job being on the brink of foreclosure when you say how do we get here how is this happening in america's backyard? the nation has turned its back when you are attempting to access care we attempted from the healthcare institutions and throughout those ten years

it was always an excuse there is no science or no proof. so myself including many families is that we have to exhaust our life savings just to access doctors like the doctors to be away from our children is time loss that we will never get back not only does it impact the veteran and spouse but the children so to see some momentum it gives us hope. >> but when you say you feel as if our government, our country has turned its back on you and your family and thousands in the same position no veteran should feel that

way and no family of a veteran should feel that way. >> you have done a tremendous amount of advocacy to change the rules how veteran on —- veterans must prove they are impacted by the burn pits in order to get care of. i support you in your work on this. i know it is a hard and only journey what you have done remarkable work let me see if i can turn this around. what does it mean to you and other veterans families of the rules were changed i'm sorry so the dod and the v.a. believed veterans when they said their health was harmed by burn pits rather than making them jump through so many hoops? >> it is remove the burden of proof to beer on researchers

and all of those things we have to come be has mobilized and congregated to share that common denominator of delay and denies so to finally see historic legislation passed so we don't have to be all those things so those that call us weekly expressing how heart-wrenching it is for them to spend the last moments of their loved one's life gathering statements and evidence when they should be embracing their loved one. it would mean everything to us and to those families and for those still waiting on an answer from the v.a. >> i commend you for your advocacy work and helps us

start to move in the right direction and i appreciate that making a change like this there's a lot of money at stake. >> but it is urgent that we treat families that are injured without delay we cannot allow veterans to wait another minute for healthcare. so i work we do here today will help to put more momentum behind change. this committee regularly advocates for spending on weapons that don't work or weapons that are not needed as all it is inexcusable to claim that we need to balance the

budget on the backs of veterans and their families who have been injured. i it comes out of our work today is a stronger push on that. if i can i have a few more questions mr. patterson if i could ask about the advances in technology that can be made to improve the way that shows how toxic exposure can be documented can you say a bit about that quick. >> thank you senator as far as desert storm sadly it hasn't been very significant. we replaced particular matters sampler but there is still significant challenges those

simply capture the particulate matter in the air then you send it to a lab and many months later get a report back of what was possibly in that sample the downside is any organic compounds will not be in that sample because they will have cooked off in the transportation in the months for you to get the sample back so the progress has been extremely slow and challenging and i'm just looking at my time in from desert storm to afghanistan. i made some recommendations in my testimony and i believe the biomarkers have some significant capabilities with them the silicone bracelets is an excellent idea because then we can now much sooner and that we were building the

buildings at the soldier slept in. i have no reason to expect to find formaldehyde in a pristine river valley in afghanistan. why is that fair i have no reason to go look for that but if we had those silicone bracelets on those individuals we could have had them back i would have known quickly rather than a year or two later what is this? and we could have mitigated that and i could have protected the next group of soldiers that went in there. it is key moving forward if we do dispersed operations of small groups there's a lot of atmospheric analysis with the satellite imagery it's an immature space but if you are talking special operations units that are very small they will never have the medicine person visit them so that will give you some idea and i

believe the problem with all of these things as they are not perfect we have been pushing too much for perfect rather than taking reasonable steps forward. >> just to get that comparison can you say when you were in afghanistan in 2008 and 2009 how was an individual's exposure to a burn pit measured and documented? >> some were not documented at all which is a very frustrating point for me because what could've been a platoon so 50 people maybe 100 individuals with a staff of approximately 20 people there is no way i could get them out there to do that surveillance which should have been done

weekly you want to do it once a week rotating so you never repeated on the same weekday suffer some of those i would grab a soil sample. that's all that i could do the air monitors take 24 hours to capture a sample properly it could be very high or low the average over 24 hours. so a lot of them there's probably little or no data to address the soldiers concerns the larger compounds fared better but even then i cannot tell you what i was exposed to in those 13 months and this is my job so for an individual who is a demand of the space and things they are vulnerable on —- not vulnerable that twentysomething they have no idea.

>> so when servicemembers are headed home what kind of information were they given about their exposure and what type of risks they might be facing in the future? >> it was also for reporting sometimes • something in the medical record that said you had a burn pit exposure or heavy metal exposure but that was a unit by unit situation and as mentioned earlier they ask a 20 -year-old invincible individual what you exposed to? i'm fine, i don't have any problems in the name of out. another concern is those individuals never end up going to the v.a. at all. you do your tour you are 22 years old you are bulletproof

and i never go into the system they approach at ten or 20 years later now it is a tougher fight in the compound names change constantly there some individuals that the compound no longer existed and five years later but they changed every year but to link this to the individual exposure unless the system has changed that identification code links everybody to the company level but that operated three sites with their platoons broken out to the other sites that data is not accurate for that individual has to be a lot of challenges so if we go back there is more challenges with

linking people to exposure. >> thank you very much. >> thank you for your testimony today you have informed the committee but we have to accomplish i appreciate the specific request you made to the committee specific changes to the law and the benefit of the committee so we can write to these requirements into the law so you have given us really good information about why this is getting the data that it needs how it collects the data we do need and what is lacking in terms of when personnel get their medical exam and what the baseline is pre- deployment and post appointment look like. i don't know if this was

addressed but did you discuss what is the best way to transfer the medical records from active duty service members and what you would like to see in the transfer of information and what you might need to create? >> . >> that should work with the electronic health record reform so when that looks right with a seamless transition from dod to the v.a. in that servicemember or veteran can have easy access to that information. >> and access to the system. >> and definitely consider making it accessible to the survivors to communicate with v.a. to access as she was filing for presumption or death benefits and it was

difficult because i didn't date back to the time he was in service so lots of challenges there. >> doctor you call don dod to revamp their method the documentation so officials could understand their exposure so what information is most helpful to you to screen and treat patients what obstacles do you face when trying to gather information about exposure and further what training do you think should be provided to better screen and treat for toxic exposure. >> what type of munitions they were exposed to how trash was disposed of including the burn pits what was in the trash and the weather patterns of dust

storms if uranium was used in for example there are armor piercing and tank shells and whether that soldier use personal protective equipment all of these things are important and regarding training in the v.a. system as compensation doctors that we have dealt with our primary care doctors. they are not a pulmonologist and they are unaware that is flabbergasting that we have a case where somebody could not go to the injury center which has been an arbiter and an advocate so they go to the v.a. to conform what we suspected or wanted confirmation of and one stumbling block they are using as a hurdle. >> do you think the v.a. need to have a pulmonologist on

staff? >> yes. >> thank you for your recommendations. think the panel has been extremely effective to layout a set of requirements and proposals for how to better adjust the diseases caused by burn pits and document through active duty so when they become better status they have all the information they need to protect to take five or ten or seven years depending on the life of the individual we need to have that in place at the ready so when they do go from active duty to veteran status as part of the record we leave this open for a week if there is any testimony that you think of it like to give in terms of recommendation or anything else please submit it we are grateful for your advocacy today it was the roman extremely helpful for our baseline personal markup. thank you very much.

we are adjourned. [inaudible conversations]

[inaudible conversations]

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