2
History of the Controversy Over the Use of Herbicides

The United States has been involved for more than two decades in a controversy over the military use of herbicides in Vietnam during the Vietnam era. The controversy centers around both the use of herbicides in Vietnam and the purported health problems associated with exposure to herbicides, primarily Agent Orange and its contaminant 2,3,7,8-TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), known scientifically as TCDD and to the general public as dioxin1 (Young and Reggiani, 1988). The controversy is further complicated by public fears over exposure to herbicides and dioxin resulting from domestic herbicide spraying, chronic exposure to dioxin of workers in the chemical industry, accidents in chemical plants that exposed workers, and dioxin released to the environment from several sources.

This chapter reviews the use of herbicides, the early history of the controversy, the concerns that Vietnam veterans have voiced about health problems they believe are related to exposure to herbicides, the Agent Orange product liability litigation, and the response to concerns of Vietnam veterans and the public by the federal government, state governments, veterans organizations, and others. The events and issues surrounding the domestic use of 2,4-D (2,4-dichlorophenoxyacetic acid) and 2,4,5-T (2,4,5-trichlorophenoxyacetic acid) and occupational exposure to 2,4,5-T and its

1  

2,3,7,8-TCDD is actually one specific member of the family of chemicals known as ''dioxins." In other chapters of the report, TCDD is specifically used to denote 2,3,7,8-tetrachlorodibenzo-p-dioxin, but because public concern focuses on "dioxin," that term is also used in this historical review.



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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam 2 History of the Controversy Over the Use of Herbicides The United States has been involved for more than two decades in a controversy over the military use of herbicides in Vietnam during the Vietnam era. The controversy centers around both the use of herbicides in Vietnam and the purported health problems associated with exposure to herbicides, primarily Agent Orange and its contaminant 2,3,7,8-TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), known scientifically as TCDD and to the general public as dioxin1 (Young and Reggiani, 1988). The controversy is further complicated by public fears over exposure to herbicides and dioxin resulting from domestic herbicide spraying, chronic exposure to dioxin of workers in the chemical industry, accidents in chemical plants that exposed workers, and dioxin released to the environment from several sources. This chapter reviews the use of herbicides, the early history of the controversy, the concerns that Vietnam veterans have voiced about health problems they believe are related to exposure to herbicides, the Agent Orange product liability litigation, and the response to concerns of Vietnam veterans and the public by the federal government, state governments, veterans organizations, and others. The events and issues surrounding the domestic use of 2,4-D (2,4-dichlorophenoxyacetic acid) and 2,4,5-T (2,4,5-trichlorophenoxyacetic acid) and occupational exposure to 2,4,5-T and its 1   2,3,7,8-TCDD is actually one specific member of the family of chemicals known as ''dioxins." In other chapters of the report, TCDD is specifically used to denote 2,3,7,8-tetrachlorodibenzo-p-dioxin, but because public concern focuses on "dioxin," that term is also used in this historical review.

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam dioxin contaminant are also addressed in this chapter. As a result of several major events relating to dioxin exposure, the public became aware of the potential health effects of exposure to dioxin in tandem with the increased concern over possible health effects of exposure to herbicides sprayed in Vietnam. Researchers studied populations (described in this chapter) that had potential health effects from exposure to herbicides and TCDD, including production workers in chemical plants, agricultural and forestry workers, pulp and paper mill workers, and residents environmentally exposed in specific areas, such as Times Beach, Missouri; Alsea, Oregon; and Seveso, Italy. For the studies introduced in this chapter, the methodological framework is described in Chapter 7, and the results are discussed in the health outcome chapters (8-11). MILITARY USE OF HERBICIDES IN VIETNAM The military use of herbicides in Vietnam began in 1962, was expanded during 1965 and 1966, and reached a peak from 1967 to 1969. Herbicides were used extensively in Vietnam by the U.S. Air Force's Operation Ranch Hand to defoliate inland hardwood forests, coastal mangrove forests, and, to a lesser extent, cultivated land, by aerial spraying from C-123 aircraft and helicopters. Soldiers also sprayed herbicides on the ground to defoliate the perimeters of base camps and fire bases; this spraying was executed from the rear of trucks and from spray units mounted on the backs of soldiers on foot. Navy riverboats also sprayed herbicides along riverbanks. The purpose of spraying herbicides was to improve the ability to detect enemy base camps and enemy forces along lines of communication and infiltration routes, and around U.S. base camps and fire bases. Spraying was also used to destroy the crops of the Vietcong and North Vietnamese (Dux and Young, 1980). Herbicide Development and Testing Experiments with chemicals for the control of vegetative growth were first conducted around the turn of this century. The practical purpose of these early compounds was to control weeds that competed with crops for available water, nutrients, and sunlight (NAS, 1974; Buckingham, 1982). It was not until the 1940s that agricultural chemical research led to the development of a number of synthetic compounds capable of regulating or suppressing plant growth. Some compounds, when applied at high doses, killed certain plants but did not harm others; these compounds were termed selective herbicides (NAS, 1974). Two of the most successful developments during that period were the discoveries of 2,4-D and 2,4,5-T. These chemicals were effective against broadleaf plants and several crops.

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Throughout World War II and after, classified military research on these chemicals and nearly 1,100 other substances was conducted at the War Research Service in Fort Detrick, Maryland (MRI, 1967). Although defoliants were not introduced into the World War II conflict, the military potential of chemicals for reducing or removing heavy vegetative growth was further investigated. The research program at Fort Detrick involved screening and evaluation of candidate defoliants (Warren, 1968). One component of the research program was organized to solicit "the best research and industrial competencies" to develop and evaluate various chemical defoliants and formulations (U.S. Army, 1964). Compounds for military consideration were also received from private companies as part of unsolicited proposals, and from individuals working in universities in other areas of chemical synthesis. The chemicals were evaluated in terms of their effectiveness at low doses, cost, availability or capability of being manufactured in large quantities, nontoxicity to man and animals, stability in storage, and corrosive properties. For chemicals that passed initial screening tests, field trials were conducted on major vegetational types using airplane dissemination equipment. Formulations and mixtures of chemicals were evaluated at various rates, volumes, and seasons of application as a basis for selection and standardization of defoliants (U.S. Army, 1964). In addition to research and development on chemical herbicides during the 1950s, anticrop aerial spray trials for improving the delivery equipment were also conducted. In particular, U.S. military authorities were concerned about the various time lags in defoliation evidenced by different species of plants to which the herbicides were applied (U.S. Army, 1964; Huddle, 1969). The military assessment of chemical defoliants also appears to have involved questions such as the feasibility of developing techniques by which large, slow-moving, and low-flying aircraft could traverse enemy-occupied jungle terrain without being shot down; the selection of the appropriate chemicals for particular types of foliage to be removed; and the optimum timing of spraying with regard to humidity, wind conditions, temperature, and topography of the area to be sprayed (Huddle, 1969). During this time the Hourglass spray system—the archetype for the spray equipment used initially aboard the Ranch Hand C-123s—was developed. The Hourglass, or MC-1, spray system was capable of distributing herbicide at a rate of 1 to 1.5 gallons per acre; however, after evaluation and modification, the 1,000 gallon C-123/MC-1 spray system was capable of depositing 3 gallons per acre on swaths 240 feet wide when flying at an airspeed of 130 knots and an altitude of 150 feet. In 1966, the MC-1 was replaced in all C-123s by a modular spray system designed for internal carriage in cargo aircraft (Young et al., 1978). In June 1959, an experiment led by Dr. James Brown at Camp Drum,

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam New York, demonstrated the long-term effectiveness of aerially dispensed herbicides in improving visibility for military operations (Buckingham, 1982). An improvised helicopter spray system delivered a 1:1 mixture of 2,4-D and 2,4,5-T over a 4-square-mile area at a quantity of one-half gallon per acre. Evaluation of the effectiveness of the defoliants on vegetation was made one year later and again in October 1962. In 1960, no signs of regrowth had occurred in the sprayed area. Upon reexamination in 1962, it was observed that maple trees, which had been predominant in the area, appeared to be dead. Sprouting had occurred in some other species of trees, and one species appeared to have recovered from the chemicals' effects. In general, trees throughout the area had been killed, and visibility had been improved nearly 100 percent (Warren, 1968). Additional field tests in the Florida Everglades and Puerto Rico demonstrated the chemicals' defoliant activity (MRI, 1967). By 1960, the U.S. Army had tested numerous herbicides and aerial delivery techniques (MRI, 1967). With the anticipated intensified involvement of U.S. military advisory forces in Vietnam, the large-scale use of herbicides was pursued. In 1961, the U.S. Department of Defense conducted the first operational field tests in Vietnam of 2,4-D and 2,4,5-T, the major herbicides to be disseminated in Vietnam over the next 10 years. The primary purpose of the early missions was to test the soundness of the defoliation concept as well as to measure optimum chemical concentrations and methods of delivery (Collins, 1967; Warren, 1968). Results of these early defoliation tests were mixed, and military authorities urged continued testing and evaluation of the herbicides in Vietnam (Buckingham, 1982). A test program was conducted in Thailand during 1964-1965 to evaluate the effectiveness of aerial applications of various formulations of 2,4-D, 2,4,5-T, and other chemicals in the defoliation of jungle vegetation representative of Southeast Asia on several 10-acre plots. Aerial spray treatments were applied at rates of 0.5 to 3.0 gallons per acre, and at two- to three month intervals, to determine minimal effective rates and proper season of application. Defoliation effectiveness was measured in terms of rate, volume, canopy penetration, vegetation response, and season of application. Results of the test program showed that (1) 2,4-D and 2,4,5-T were effective for long-term defoliation, with more complete defoliation and longer duration of effective defoliation at higher rates of application; (2) best results were achieved during the rainy or growing season; (3) defoliation responses were influenced more by rate than by volume of chemical applied; (4) woody species varied in the duration and degree of defoliation; and (5) complete defoliation of all species in mixed forest types was not achieved (Warren, 1968).

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Use of Herbicides in Vietnam Phenoxy herbicides are synthetic chemical analogues of hormones found in plants that regulate the rate and pattern of plant growth; these herbicides cause aberrant growth or death of certain plant species. The types of herbicide used in Vietnam were very effective at killing certain types of tropical vegetation, and the aerial spraying of herbicides allowed for easy application over a large-area. The herbicides were applied aerially at a rate of approximately 3 gallons per acre. According to military records of Operation Ranch Hand, from August 1965 to February 1971, a total of 17.6 million gallons of herbicide was sprayed over approximately 3.6 million acres in Vietnam (NAS, 1974). The different types of herbicide used by U.S. forces in Vietnam were identified by a code name referring to the color of the band around the 55 gallon drum that contained the chemical. These included Agents Orange, White, Blue, Purple, Pink, and Green. From 1962 to 1965, small quantities of Agents Purple, Pink, and Green were used. From 1965 to 1970, Agents Orange, White, and Blue were employed, and from 1970 to 1971, only Agents White and Blue were used in the defoliation program (Young and Reggiani, 1988). Agent Orange was the most extensively used herbicide in Vietnam; it consisted of a 50:50 mixture by weight of the n-butyl esters of two phenoxy acids: 2,4-dichlorophenoxyacetic acid (2,4-D) and 2,4,5-trichlorophenoxyacetic acid (2,4,5-T). A synthetic contaminant of 2,4,5-T is the compound 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), informally known as dioxin. TCDD is an unavoidable by-product of the manufacture of 2,4,5-T and a contaminant in Agent Orange (Gough, 1986). Levels of TCDD contamination in Agent Orange ranged from less than 0.05 to almost 50 parts per million, with a mean of about 2 parts per million (NAS, 1974). An estimated 368 pounds of dioxin was sprayed in Vietnam over a six year period (Gough, 1986). The military use of 2,4,5-T, and thus Agent Orange, was suspended by the Department of Defense in April 1970 (Young and Reggiani, 1988). Following the suspension of 2,4,5-T, the White House announced on December 26, 1970, that it was initiating an orderly yet rapid phaseout of the entire herbicide operation. On February 12, 1971, U.S. Military Assistance Command, Vietnam announced that herbicides would no longer be used for crop destruction in Vietnam and the last Ranch Hand fixed-wing aircraft (C-123) was flown. Subsequent spraying of herbicides was limited to controlled use around U.S. fire bases by helicopter or ground troops (MACV, 1972). On October 31, 1971, nearly 10 years after the herbicide program began in Vietnam, the last U.S. helicopter herbicide operation was flown (NAS, 1974). The military use of herbicides is discussed in further detail in Chapter 3.

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam EARLY CONCERNS ABOUT THE USE OF HERBICIDES IN VIETNAM Early Accounts of Dioxin (TCDD) Dioxin (TCDD) arises during the hydrolysis of tetrachlorobenzene to form 2,4,5-trichlorophenol, the industrial precursor of 2,4,5-T. TCDD is a solid that is insoluble in water and slightly soluble in fats or hydrocarbons. TCDD decays slowly in the soil under normal environmental conditions, which indicates that "its potential hazards may be very persistent" (NAS, 1974). Further characteristics of dioxin can be found in Chapter 4 on toxicology. In 1872, two German chemists prepared the first chlorinated dioxin, but its structure was not understood until much later. In 1957, Dr. W. Sandermann of the Institute of Wood Chemistry in Hamburg published results of his synthesis of TCDD. While working on the synthesis, his laboratory assistant was exposed to the substance being tested when some of it blew into his face. He soon developed skin lesions over his entire face and decided to seek treatment from Dr. Karl Schulz, a dermatologist who treated chemical workers and had observed chloracne in some of them (Gough, 1986). After examining Sandermann's laboratory assistant, Schulz identified the skin lesions on his face as chloracne. When the laboratory assistant explained that the compound he was synthesizing was TCDD, Schulz was the first to correlate the presence of chloracne with exposure to dioxin. To further confirm this assumption, Schulz applied a TCDD solution to the skin of his forearm and noted that chloracne appeared (Young and Reggiani, 1988). In September 1971, an early account of research on the appearance of TCDD in trace quantities in samples of 2,4,5-T was presented at a session on the origin and fate of chlorodioxins at the American Chemical Society meeting. TCDD was defined to be the most toxic of all chlorodibenzodioxins studied at that time (Young and Reggiani, 1988). Further accounts of dioxin's toxicity were presented at a meeting on "Perspectives on Chlorinated Dibenzodioxins and Dibenzofurans" sponsored by the National Institute of Environmental Health Sciences in North Carolina in April 1973. The major findings indicated "… that there was a variation of sensitivity among species, the liver was the target organ, the toxic effects were delayed after absorption, and the mechanism of teratogenesis was still incompletely understood … patterns of absorption and of distribution among organs were beginning to emerge" (Young and Reggiani, 1988). In 1974, the National Academy of Sciences' Committee on the Effects of Herbicides in Vietnam reported that "TCDD is extremely toxic to some laboratory animals. … TCDD has been found to be teratogenic in mice; results with other laboratory animals have not been conclusive. The lethal

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam dose in humans is not known, nor is that required to cause birth defects, if indeed there is such an activity. TCDD is strongly implicated as the main cause of chloracne, a disease that has affected employees in some plants manufacturing 2,4,5-T or its precursor, 2,4,5-trichlorophenol" (NAS, 1974). Concerns Over the Long-Term Use of Herbicides Public concern over the use of herbicides in Vietnam began in 1964, even before the toxicity of TCDD was first reported. At that time, the Federation of American Scientists urged the government not to use chemical and biological weapons unless they were used first by the enemy. The federation was concerned about the use of defoliants in Vietnam because the government was not discriminating between fighting forces and civilians while using the herbicides, and that constituted biological and chemical warfare (Young and Reggiani, 1988). In January 1966, 29 scientists banded together to protest the U.S. policy on the use of herbicides and demand their complete abolition. They requested that President Lyndon B. Johnson begin discussions with the allies on adherence to the ban on the use of herbicides in Vietnam. "Even if it can be shown that the chemicals are not toxic to man, such tactics are barbarous because they are indiscriminate; they represent an attack on the entire population of the region where the crops are destroyed, combatants and non-combatants alike. [This is] … a precedent for the use of similar but even more dangerous chemical agents against our allies and ourselves" (Dux and Young, 1980). In December 1966, the Council of the American Association for the Advancement of Science (AAAS) sent a letter to the Secretary of Defense, Robert McNamara, calling for studies of the short- and long-term consequences of the massive use of herbicides in Vietnam (Young and Reggiani, 1988). In February 1967, a second petition signed by more than 5,000 scientists, including 17 Nobel laureates, was delivered to President Johnson requesting that he end the use of herbicides in Vietnam (Dux and Young, 1980). A Department of Defense (DOD) official, responding to criticisms regarding the questionable military use of herbicides, stated that "qualified scientists, both inside and outside the government, and in the governments of other nations, have judged that seriously adverse consequences will not occur. Unless we had confidence in these judgments, we would not continue to employ these materials." Several members of the AAAS council agreed that this statement was unjustified, noting that there was insufficient evidence to arrive at this conclusion (Wolfle, 1989). Noting the strong opposition by some of the nation's leading scientists to the military use of herbicides, the Department of Defense commissioned a study by the Midwest Research Institute (MRI) in Kansas City, Missouri, to assess whether the use of the herbicides would have a long-term ecological

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam impact. The MRI assessment did not include field studies or trips to Vietnam, but involved a review of approximately 1,500 scientific papers. The study, Assessment of Ecological Effects of Extensive or Repeated Use of Herbicides, was completed in December 1967 (MRI, 1967). The report could not provide conclusive answers about the long-term effects of chronic exposure to herbicides on the ecological system or on the population, and recommended further studies of the long-term effects on the environment and the population in order to assess properly the consequences of repeated use of herbicides (MRI, 1967). In 1965, the National Cancer Institute contracted with Bionetics Research Laboratory in Maryland to investigate the possible teratogenic effects of a number of pesticides and herbicides. The study, Evaluation of Carcinogenic, Teratogenic, and Mutagenic Activities of Selected Pesticides and Industrial Chemicals, noted that among the herbicides tested on mice and rats were 2,4-D and 2,4,5-T (Bionetics, 1968). This study provided the first indication of the teratogenicity and fetotoxicity of 2,4,5-T (Lilienfeld and Gallo, 1989). The researchers determined that 2,4,5-T was teratogenic, causing malformations and stillbirths in mice when administered in high doses, and that 2,4-D was potentially harmful. This report was released to the public in 1969. Bionetics later reanalyzed the 2,4,5-T used for its initial study and revealed that the cause of toxicity was the contaminant TCDD and that 2,4,5-T itself was not teratogenic (Young and Reggiani, 1988). Another study, Congenital Malformations, Hydatidiform Moles and Stillbirths in the Republic of Vietnam, 1960-1969, was conducted by R.T. Cutting on behalf of the government of South Vietnam and the U.S. Military Assistance Command, Vietnam (Cutting et al., 1970). Cutting examined maternity records of 22 hospitals for two time periods: the buildup of herbicide use (1960-1965) and larger-scale military herbicide use (1966-1969). He found that there were no differences in the incidence of stillbirths, congenital malformations, and hydatidiform moles between the two periods (Cutting et al., 1970; U.S. Congress, House, 1978). It was later revealed that the study was biased because of unreliable data and hospital records (Young and Reggiani, 1988). In early 1970, the AAAS set up a commission to assess the effects of large-scale use of herbicides on the environment and population of Vietnam. The members of the Herbicide Assessment Commission (HAC) were Matthew Meselson, Arthur Westing, John Constable, and Robert Cook. In June 1970, HAC held a conference at Woods Hole, Massachusetts, with individuals who had experience with the herbicide program in Vietnam. They determined what HAC members would investigate and observe while in Vietnam, and prepared questionnaires for use in interviews of Vietnamese residents. In August 1970, they traveled to Vietnam on an inspection field trip to

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam examine the extent to which the herbicides had destroyed the vegetation and local food crops in areas where they had been sprayed. After returning from Vietnam, HAC members wrote a report on the defoliation of Vietnam in which they noted that the Department of Defense had stated that the herbicides were used "for crop destruction of small, isolated crop patches along infiltration routes …" (Wolfle, 1989) and limited to areas of low population. HAC, however, found that "crops had been sprayed in an area with an estimated population of 180 persons per square kilometer and that nearly all of the food being destroyed would have been used by mountain-dwelling Montagnard civilians instead of by enemy troops" (Wolfle, 1989). The commission maintained that the military use of herbicides had been considerably more destructive than previously imagined—half of the mangrove forests had been destroyed and there were indications of serious health effects (Wolfle, 1989). The HAC members documented reports of stillbirths and birth defects in Vietnamese, noting that these adverse reproductive effects were possibly associated with 2,4,5-T (Young and Reggiani, 1988) and its contaminant, TCDD. On December 26, 1970, the White House announced that it was initiating an orderly yet rapid phaseout of the herbicide operation. The AAAS council adopted a resolution commending the U.S. government for its intention to phaseout the use of herbicides in Vietnam (Wolfle, 1989). At the end of 1970, Congress directed the Department of Defense to contract with the National Academy of Sciences (NAS) to study the ecological and physiological effects of the widespread military use of herbicides in Vietnam. The NAS recruited a 17-member committee and 30 consultants to carry out the study. Committee members and consultants spent approximately 1,500 man-days in Vietnam in order to develop an inventory of the areas sprayed by herbicides, review the effects on various vegetation types, study the persistence of herbicides in soil, examine the effects of herbicides on animal populations in estuaries of Vietnam, and attempt to identify the effects of herbicides on resident populations exposed to them (NAS, 1974). The resulting report, The Effects of Herbicides in South Vietnam (NAS, 1974), concludes that (1) the committee was unable to gather any definitive indication of direct damage by herbicides to human health, although there were reports from Montagnards of respiratory distress in children; (2) although attempts to assess the social, economic, and psychological effects of the herbicide spraying were less than satisfactory, the effect of herbicide spraying on the health of the Vietnamese appeared to have been smaller than feared; (3) the evidence of spraying on food crops indicated that they were highly vulnerable to the herbicides; (4) the mangrove forests were found to have been extremely vulnerable to herbicide spraying; and (5) although it was difficult to assess the damage to the inland forests because

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam the committee had to rely on aerial photographs, the committee concluded that most of the damage occurred in overused open or thin forests and in young secondary forests. Public concern about the military use of herbicides during the Vietnam conflict did not end when Operation Ranch Hand terminated with the last official herbicide spraying in 1971 or with the final departure of American troops in 1975. In April 1975, President Gerald Ford issued Executive Order 11850, in which the United States renounced the first use of herbicides in war except "under regulations applicable to their domestic use, for control of vegetation within U.S. bases and installations or around their immediate defensive perimeters." In a historical account of Operation Ranch Hand, it was noted, "As long as this policy stands, no operation like Ranch Hand could happen again" (Buckingham, 1982). CONCERNS ABOUT EXPOSURE TO AGENT ORANGE Vietnam Veterans Return Home Historians have noted that during the 1970s, many Vietnam veterans returned to a society that did not welcome them (Schuck, 1987). The country had been greatly divided over the war, and a strong antiwar sentiment pervaded most of the final years of the Vietnam conflict (Karnow, 1991; Spector, 1993). There were antiwar demonstrations held throughout the country during these years, and when the veterans came home, many Americans did not want to acknowledge their patriotic effort (Bonoir et al., 1984; Salisbury, 1985). There was also a lack of unanimity among veterans about their service in the Vietnam conflict. Some veterans were bitter at having served in a war they felt could not be won; however, an equal number of veterans would have returned to Southeast Asia if they were called upon by their country (Wilcox, 1989). The returning veterans were also presented with more difficult adjustments than veterans of other foreign wars. Because of improved emergency medical care, more disabled veterans returned home. Of those discharged for disabilities during World War II, 18 percent were amputees and 3.1 percent were paralyzed; the comparable figures for Vietnam were 28.3 percent and 25.2 percent, respectively (Schuck, 1987). The returning veterans also had a difficult period of adjustment due to the fact that most of them were discharged from service one at a time. Since their tour of duty was for only one year, many veterans did not forge close attachments with each other as in earlier wars. Following the war, some veterans began to develop health problems, and in time, more veterans reported serious illness and claimed that their children were born with birth defects (Gough, 1986).

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam The Beginning of the Controversy During the early and mid-1970s, a growing number of veterans began to question the possible linkage between their conditions or diseases and their exposure to herbicides, mainly Agent Orange, in Vietnam. In 1977, Maude deVictor, a benefits counselor in the Chicago regional office of the Veterans Administration (VA), was contacted by the wife of Charles Owen, a Vietnam veteran who believed his terminal cancer was the result of exposure to Agent Orange. After learning that Charles Owen had died and that the VA had refused his widow's claim for benefits, deVictor began to research the health effects of exposure to Agent Orange (Wilcox, 1989). She contacted Alvin L. Young, Major, U.S. Air Force, an expert in plant physiology, and inquired about the types of herbicides used in Vietnam. DeVictor recorded the conversation in a memorandum to the file, which explained the use and toxicity of Agent Orange and Agent Blue (DeVictor, 1977). In response to this memorandum, a line-by-line commentary was prepared by Dr. Young, and a copy was recorded in a congressional hearing (U.S. Congress, House, 1980b). DeVictor continued her inquiries into the possible connection between Agent Orange and certain health outcomes. She began gathering statistics on veterans' exposure to Agent Orange by questioning veterans who visited her office for benefits, widows of veterans, and wives of veterans about the health of their husband and children. When the VA learned that she was carrying out this research, she was asked to cease these additional inquiries and concentrate on her assigned duties, but she continued her research on Agent Orange. Soon after, someone contacted Bill Kurtis, a local television reporter, about deVictor's inquiries on veterans' exposure to Agent Orange (Linedecker et al., 1982). On March 23, 1978, WBBM, a CBS affiliate in Chicago, aired Kurtis' documentary Agent Orange, the Deadly Fog. Subsequently, local and national media began to report on Agent Orange and veterans' complaints with more frequency (Wilcox, 1989). Early in 1978, Paul Reutershan, a former helicopter crew chief responsible for transporting supplies to the 20th Engineering Brigade, appeared on the ''Today" show and shocked many of the show's viewers by announcing: "I died in Vietnam, but I didn't even know it." He told of how he flew almost daily through clouds of herbicides being discharged from C-123 cargo planes, and how he observed the dark swaths cut in the jungle by the spraying, and watched the mangrove forest turn brown and die (Wilcox, 1989). Even though he observed this destruction of the jungles and forests, he did not worry about his own health. He said that he was told by the Army that Agent Orange was "relatively nontoxic to humans and animals" (Wilcox, 1989). Upon returning home from Vietnam, Reutershan was diagnosed with cancer. On December 14, 1978, at the age of 28, Reutershan

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam frame, that the number of health end points to be followed was too large, and that the public perception of the study's credibility would suffer if it were conducted by the Air Force (NRC, 1980). The Ranch Hand study was eventually conducted by the Air Force, over a longer time period than originally intended. In 1977, the Italian government invited the National Academy of Sciences-National Research Council to join in a collaborative effort to investigate the effects of area-wide chemical contamination at Seveso, Italy. The NAS-NRC recommended the development of a continued relationship between U.S. and Italian scientists for the purposes of exchanging scientific and technical information, conducting complementary research, and organizing conferences to examine the impacts on health and the environment. In 1980, the ALS, as part of this collaborative effort, established the Committee on Response Strategies to Unusual Chemical Hazards. This committee published the proceedings of its international workshop on plans for clinical and epidemiologic follow-up after area-wide chemical contamination, which was held in Washington, D.C., in March 1980 (NRC, 1982b). In 1982, the NRC Commission on Life Sciences (CLS) reviewed and commented on a proposed epidemiologic study of the health effects of exposure to Agent Orange and Vietnam service in general. This report made a number of recommendations about a study protocol proposed by the Veterans Administration, including the need for separate studies of exposure to Agent Orange and of Vietnam service in general, rather than one combined study; the need for a formal review of the methods used to classify subjects according to degree of exposure to Agent Orange; and the need for quality control and other validity studies (NRC, 1982a). The protocol that the CLS reviewed was never carried out by the VA, but some of the committee's recommendations were consistent with studies that were eventually carried out by CDC. In a series of letter reports from 1986 through 1990 (IOM, 1986a,b, 1987a-e, 1988a-e, 1989a,b, 1990a,b), the IOM advised the CDC on its conduct of studies on the health effects of Vietnam service (Advisory Committee on the CDC Study of the Health of Vietnam Veterans). These studies, mandated by Public Laws 96-151 and 97-72, were to determine the long-term health effects of veterans' exposure to herbicides (the Agent Orange Study), the possible long-term effects of military service in Vietnam (the Vietnam Experience Study), and the risk of selected cancers among veterans (the Selected Cancers Study). Although the Agent Orange Study was canceled, the IOM committees reviewed study protocols and preliminary results for the VES and SCS (IOM, 1990a,b), and their recommendations were incorporated into the analyses and final results published by CDC. The IOM advisory committee did review and comment on the validation study results that contributed to the decision not to complete the Agent

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Orange Study (IOM, 1987c) but it was not asked, and did not make, a recommendation about the cancellation of that study. REFERENCES Agent Orange Product Liability Litigation (In re). 1985. MDL 381, 611 F Supp 1221, 1260 (DED NY 1985). Agent Orange Task Force (AOTF). 1990. The Science Panel of the Agent Orange Task Force Status Report. Domestic Policy Council, Health Policy Working Group. Agent Orange Working Group (AOWG). 1985. Status Report. Washington, DC: Cabinet Council Agent Orange Working Group. Agent Orange Working Group. 1987. Science Panel Status Report. Washington, DC: Domestic Policy Council, Agent Orange Working Group. Air Force Health Study. 1983. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Baseline Mortality Study Results. Brooks AFB, TX: USAF School of Aerospace Medicine. NTIS AD-A130 793. Air Force Health Study. 1984a. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Baseline Morbidity Study Results. Brooks AFB, TX: USAF School of Aerospace Medicine. NTIS AD-A138 340. 362 pp. Air Force Health Study. 1984b. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Mortality Update: 1984. Brooks AFB, TX: USAF School of Aerospace Medicine. Air Force Health Study. 1985. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Mortality Update: 1985. Brooks AFB, TX: USAF School of Aerospace Medicine. Air Force Health Study. 1986. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Mortality Update: 1986. Brooks AFB, TX: USAF School of Aerospace Medicine. USAFSAM-TR-86-43. 12 pp. Air Force Health Study. 1987. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. First Follow-Up Examination Results. Brooks AFB, TX: USAF School of Aerospace Medicine. USAFSAM-TR-87-27. 2 vols. 629 pp. Air Force Health Study. 1989. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Mortality Update: 1989. Brooks AFB, TX: USAF School of Aerospace Medicine. USAFSAM-TR-89-9. 35 pp. Air Force health Study. 1990. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Brooks AFB, TX: USAF School of Aerospace Medicine. USAFSAM-TR-90-2. 2 vols. Air Force Health Study. 1991a. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Mortality Update: 1991. Brooks AFB, TX: Armstrong Laboratory. AL-TR-1991-0132. 33 pp. Air Force Health Study. 1991b. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Serum Dioxin Analysis of 1987 Examination Results. Brooks AFB, TX: USAF School of Aerospace Medicine. 9 vols. Air Force Health Study. 1992. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Reproductive Outcomes. Brooks AFB, TX: Armstrong Laboratory. AL-TR-1992-0090. 602 pp. Atwood PL. 1990. Agent Orange: Medical, Scientific, Legal, Political and Psychological Issues. Boston: William Joiner Center for the Study of War and Social Consequences. Australian Senate Standing Committee on Science and the Environment. 1982. Pesticides and the Health of Australian Vietnam Veterans. First report. 240 pp.

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Bertazzi PA, Zocchetti C, Pesatori AC, Guercilena S, Sanarico M, Radice L. 1989a. Ten year mortality study of the population involved in the Seveso incident in 1976. American Journal of Epidemiology 129:1187-1200. Bertazzi PA, Zocchetti C, Pesatori AC, Guercilena S, Sanarico M, Radice L. 1989b. Mortality in an area contaminated by TCDD following an industrial accident. La Medicina del Lavoro 4:316-332. Bionetics Research Laboratories. 1968. Evaluation of Carcinogenic, Teratogenic and Mutagenic Activities of Selected Pesticides and Industrial Chemicals. Bethesda, MD: Bionetics Research Labs. 3 vols. NTIS PB223 161 . Bisanti L, Bonetti F, Caramaschi F, Del Corno G, Favaretti C, Giambelluca SE, Marni E, Montesarchio E, Puccinelli V, Remotti G, Volpato C, Zambrelli E, Fara GM. 1980. Experiences from the accident of Seveso. Acta Morphologica Academiae Scientarum Hungaricae 28:139-157. Boeri R, Bordo B, Crenna P, Filippini G, Massetto M, Zecchini A. 1978. Preliminary results of a neurological investigation of the population exposed to TCDD in the Seveso region. Rivista di Patologica Nervosa e Mentale 99:111-128. Bonoir DE, Champlin SM, Kolly TS. 1984. The Vietnam Veteran: A History of Neglect. New York: Praeger. Breslin P, Kang H, Lee Y, Burt V, Shepard BM. 1988. Proportionate mortality study of U.S. Army and U.S. Marine Corps veterans of the Vietnam War. Journal of Occupational Medicine 30:412-419. Buckingham WA. 1982. Operation Ranch Hand: The Air Force and Herbicides in Southeast Asia 1961-1971. Washington, DC: U.S. Air Force Office of Air Force History. Bullman TA, Kang HK, Watanabe KK. 1990. Proportionate mortality among U.S. Army Vietnam veterans who served in Military Region I. American Journal of Epidemiology 132:670-674. Bullman TA, Kang H, Thomas TL. 1991. Posttraumatic stress disorder among Vietnam veterans on the Agent Orange Registry: a case-control analysis. Annals of Epidemiology 1:505-512. Calvert GM, Sweeney MH, Morris JA, Fingerhut MA, Hornung RW, Halperin WE. 1991. Evaluation of chronic bronchitis, chronic obstructive pulmonary disease, and ventilatory function among workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin. American Review of Respiratory Disease 144:1302-1306. Calvert GM, Hornung RV, Sweeney MH, Fingerhut MA, Halperin WE. 1992. Hepatic and gastrointestinal effects in an occupational cohort exposed to 2,3,7,8-tetrachlorodibenzo-para-dioxin. Journal of the American Medical Association 267:2209-2214. Centers for Disease Control (CDC). 1987. Postservice mortality among Vietnam veterans . Journal of the American Medical Association 257:790-795. Centers for Disease Control. 1988a. Health status of Vietnam veterans. I. Psychosocial characteristics. Journal of the American Medical Association. 259:2701-2707. Centers for Disease Control. 1988b. Health status of Vietnam veterans. II. Physical health. Journal of the American Medical Association 259:2708-2714. Centers for Disease Control. 1988c. Health status of Vietnam veterans. III. Reproductive outcomes and child health. Journal of the American Medical Association 259:2715-2717. Centers for Disease Control. 1989a. Comparison of Serum Levels of 2,3,7,8-Tetrachlorodibenzo-p-Dioxin with Indirect Estimates of Agent Orange Exposure Among Vietnam Veterans: Final Report. Atlanta: U.S. Department of Health and Human Services. Centers for Disease Control. 1989b. Health Status of Vietnam Veterans. Vietnam Experience Study. Atlanta: U.S. Department of Health and Human Services. Vols. I-V, Supplements A-C. Centers for Disease Control. 1990a. The Association of Selected Cancers with Service in the

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam U.S. Military in Vietnam: Final Report. Atlanta: U.S. Department of Health and Human Services. Centers for Disease Control. 1990b. The association of selected cancers with service in the U.S. military in Vietnam. I. Non-Hodgkin's lymphoma. Archives of Internal Medicine 150:2473-2483. Center for Disease Control. 1990c. The association of selected cancers with service in the U.S. military in Vietnam. II. Soft tissue and other sarcomas. Archives of Internal Medicine 150:2485-2492. Centers for Disease Control. 1990d. The association of selected cancers with service in the U.S. military in Vietnam. III. Hodgkin's disease, nasal cancer, nasopharyngeal cancer, and primary liver cancer. Archives of Internal Medicine 150:2495-2505. Clapp RW, Commoner B, Constable JD, Epstein SS, Kahn PC, Olson JR, Ozonoff DM. 1990. Human Health Effects Associated with Exposure to Herbicides and/or Their Associated Contaminants—Chlorinated Dioxins: Agent Orange and the Vietnam Veteran. A Review of the Scientific Literature. Agent Orange Scientific Task Force. Clapp RW, Cupples LA, Colton T, Ozonoff DM. 1991. Cancer surveillance of veterans in Massachusetts, 1982-1988. International Journal of Epidemiology 20:7-12. Collins CV. 1967. Herbicide Operations in Southeast Asia, July 1961-June 1967. San Francisco: Headquarters, Pacific Air Forces. NTIS AD-779 796. Conway F. 1993. Memorandum to the Institute of Medicine Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides. Washington, DC: Department of Veterans Affairs. May 18, 1993. Cutting RK, Phouc TH, Ballo JM, Benenson MW, Evans CH. 1970. Congenital Malformations, Hydatidiform Moles and Stillbirths in the Republic of Vietnam 1960-1969. Washington, DC: U.S. Government Printing Office. No. 903.233. 29 pp. DeVictor M. 1977. Defoliation Operations from 1955-1969 During Vietnam War. Memorandum to the file. Chicago: Veterans Administration Regional Office. Dux J, Young PJ. 1980. Agent Orange: The Bitter Harvest. Sydney: Hodder and Stoughton. Erickson JD, Mulinare J, McClain PW, Fitch TG, James LM, McClearn AB, Adams MJ. 1984. Vietnam Veterans' Risks for Fathering Babies with Birth Defects. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control. Evatt P. 1985. Royal Commission on the Use and Effect of Chemical Agents on Australian Personnel in Vietnam, Final Report. Canberra: Australian Government Publishing Service. 9 vols. Farberow NL, Kang H, Bullman T. 1990. Combat experience and postservice psychosocial status as predictors of suicide in Vietnam veterans. Journal of Nervous and Mental Disease 178:32-37. Federal Register. 1992. Diseases associated with service in the Republic of Vietnam. 57 (133):30707-30708. Fingerhut MA, Sweeney MH, Halperin WE, Schnorr TM. 1987. Epidemiology of populations exposed to dioxins. In: Exner J, ed. Solving Hazardous Waste Problems: Learning from Dioxins. Washington, DC: American Chemical Society. Fingerhut MA, Halperin WE, Marlow DA, Piacitelli LA, Honchar PA, Sweeney MH, Greife AL, Dill PA, Steenland K, Suruda AJ. 1991a. Cancer mortality in workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin. New England Journal of Medicine 324:212-218. Fingerhut MA, Halperin WE, Marlow DA, Piacitelli LA, Honchar PA, Sweeney MH, Greife AL, Dill PA, Steenland K, Suruda AJ. 1991b. Mortality Among U.S. Workers Employed in the Production of Chemicals Contaminated with 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD). Final Report. Cincinnati, OH:NIOSH. NTIS PB 91-125971. Gelband H. 1993. Memorandum to the Institute of Medicine Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides. May 11, 1993.

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Gough M. 1986. Dioxin, Agent Orange: The Facts. New York: Plenum Press. Gough M. 1988. The political assessment: a congressional view. In: Young AL, Reggiani GM, eds. Agent Orange and Its Associated Dioxin: Assessment of a Controversy. Amsterdam: Elsevier. Hardell L. 1990. Phenoxy herbicides, cancer, and Swedish forestry workers. In: Atwood PL. 1990. Agent Orange: Medical, Scientific, Legal, Political and Psychological Issues. Boston: William Joiner Center for the Study of War and Social Consequences. Henneberger PK, Ferris BG Jr, Monson RR. 1989. Mortality among pulp and paper workers in Berlin, New Hampshire. British Journal of Industrial Medicine 46:658-664. Hickman JG. 1993. Letter to the Institute of Medicine Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides. Washington, DC: U.S. Department of Veterans Affairs, Compensation and Pension Service. April 26, 1993. Hoar-Zahm S, Blair A. 1990. Cancer risk among agricultural workers. In: Atwood PL. 1990. Agent Orange: Medical, Scientific, Legal, Political and Psychological Issues. Boston: William Joiner Center for the Study of War and Social Consequences. Hoar SK, Blair A. Holmes FF, Boysen CD, Robel RJ, Hoover R, Fraumeni JF. 1986. Agricultural herbicide use and risk of lymphoma and soft tissue sarcoma. Journal of the American Medical Association 256:1141-1147. Hoffman RE, Stehr-Green PA, Webb KB, Evans RG, Knutsen AP, Schramm WF, Staake JL, Gibson BB, Steinberg KK. 1986. Health effects of long-term exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin. Journal of the American Medical Association 255:2031-2038. Huddle FP. 1969. A Technology Assessment of the Vietnam Defoliant Matter. Report to the Subcommittee on Science, Research, and Development of the Committee on Science and Astronautics, U.S. House of Representatives. August 8, 1969. 91st Cong., 1st sess. Institute of Medicine (IOM). 1986a. Review of the CDC Proposals for Inclusions of Semen Analysis in the Health Examinations and for Follow-up of Preliminary Data on Birth Outcomes. First Letter Report, March 1986. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine (IOM). 1986b. Review of CDC Mortality and Interim Interview Reports and Birth Records Review Study from the Vietnam Veterans Experience Study. Second Letter Report, September 1986. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1987a. Review of Drafts of Introduction, and Data and Methods Chapters of the Telephone Interview Component of the Vietnam Experience Study. Part I: Self-Reported Morbidity Among Vietnam Veterans. Third Letter Report, February 1987. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1987b. Review of Preliminary Results of the Medical and Psychological Examinations of the Vietnam Experience Study. Fourth Letter Report, April 1987. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1987c. Review of Comparison of Serum Levels of 2,3,7,8-TCDD with Indirect Estimates of Agent Orange Exposure in Vietnam Veterans. Fifth Letter Report. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1987d. Review of Interim Drafts of Parts A and B of the VES Study of Reproductive Outcomes and Health of Veterans' Children. Sixth Letter Report. October 1987. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1987e. Review of the Interim Draft of Findings from the Psychological Examination Component of the VES. Seventh Letter Report, December 1987. Washington,

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1988a. Review of Self-Reported Morbidity Among Vietnam Veterans: Results from the Telephone Interview Component of the VES. Eighth Letter Report, January 1988. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans . Institute of Medicine. 1988b. Review of the Second Draft of the CDC Monograph on the Reproductive System of VES Subjects. Ninth Letter Report, January 1988. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1988c. Review of the VES Monograph on Reproductive Outcomes and Health of Veterans' Children. Tenth Letter Report, January 1988. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1988d. Review of Prepublication Drafts. I. Psychosocial Characteristics. II. Physical Health. III. Reproductive Outcomes and Child Health. Eleventh Letter Report, April 1988. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans. Institute of Medicine. 1988e. Review of the Selected Cancers Study Analysis Plan. First Letter Report, October 1988. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans: Selected Cancers Study. Institute of Medicine. 1989a. Review of Preliminary Data Analysis. Second Letter Report, April 1989. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans: Selected Cancers Study. Institute of Medicine. 1989b. Review of Preliminary Data Analysis. Third Letter Report, July 1989. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans: Selected Cancers Study. Institute of Medicine. 1990a. Review of Preliminary Data Analyses and Plans for Presentation of Final Results. Fourth Letter Report, January 1990. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans: Selected Cancers Study. Institute of Medicine. 1990b. Review of CDC Draft Reports. Fifth Letter Report, April 1990. Washington, DC: IOM Advisory Committee on the CDC Study of the Health of Vietnam Veterans: Selected Cancers Study. Jacobs JB, McNamara D. 1986. Vietnam veterans and the Agent Orange controversy. Armed Forces and Society 13:57-79. Kahn PC, Gochfeld M, Nygren M, Hansson M, Rappe C, Velez H, Ghent-Guenther T, Wilson WP. 1988. Dioxins and dibenzofurans in blood and adipose tissue of Agent Orange-exposed Vietnam veterans and matched controls. Journal of the American Medical Association 259:1661-1667. Kahn PC, Gochfeld M, Lewis WW. 1992a. Dibenzodioxin and Dibenzofuran Congener Levels in Four Groups of Vietnam Veterans Who Did Not Handle Agent Orange. The Pointman II Project. New Jersey Agent Orange Commission. Kahn PC, Gochfeld M, Lewis WW. 1992b. Immune Status and Herbicide Exposure in the New Jersey Pointman I Project. New Jersey Agent Orange Commission. Kahn PC, Gochfeld M, Lewis WW. 1992c. Semen Analysis in Vietnam Veterans with Respect to Presumed Herbicide Exposure. New Jersey Agent Orange Commission. Kang HK, Weatherbee L, Breslin PP, Lee Y, Shepard BM. 1986. Soft tissue sarcomas and military service in Vietnam: a case comparison group analysis of hospital patients. Journal of Occupational Medicine 28:1215-1218. Kang HK, Enzinger FM, Breslin P, Feil M, Lee Y, Shepard B. 1987. Soft tissue sarcoma and military service in Vietnam: a case-control study. Journal of the National Cancer Institute

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Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam Spector RH. 1993. After Tet: The Bloodiest Year in Vietnam. New York: Free Press. Stockbauer JW, Hoffman RE, Schramm WF, Edmonds LD. 1988. Reproductive outcomes of mothers with potential exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin. American Journal of Epidemiology 128:410-419. Suskind RR, Hertzberg VS. 1984. Human health effects of 2,4,5-T and its toxic contaminants. Journal of the American Medical Association 251:2372-2380. Sweeney MH, Fingerhut MA, Arezzo JC, Hornung RW, Connally LB. In press. Peripheral neuropathy after occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Thomas TL, Kang HK. 1990. Mortality and morbidity among Army Chemical Corps Vietnam veterans: a preliminary report. American Journal of Industrial Medicine 18:665-673. Thomas TL, Kang H, Dalager N. 1991. Mortality among women Vietnam veterans, 1973-1987. American Journal of Epidemiology 134:973-980. True WR, Goldberg J, Eisen SA. 1988. Stress symptomatology among Vietnam veterans. Analysis of the Veterans Administration Survey of Veterans II. American Journal of Epidemiology 128:85-92. U.S. Army. 1964. Proceedings of the First Defoliation Conference 29-30 July 1963. Fort Detrick, MD: U.S. Army Biological Laboratories. U.S. Congress, House of Representatives. 1978. Committee on Veterans' Affairs, Subcommittee on Medical Facilities and Benefits. Hearings on Herbicide ''Agent Orange." 95th Cong., 2d sess. U.S. Congress, House of Representatives. 1979. Committee on Interstate and Foreign Commerce, Subcommittee on Oversight and Investigations. Hearing on Involuntary Exposure to Agent Orange and Other Toxic Spraying. 96th Cong., 1st sess. June 26 and 27, 1979. U.S. Congress, House of Representatives. 1980a. Committee on Interstate and Foreign Commerce, Subcommittee on Oversight and Investigations. Hearing on Exposure of Vietnam Veterans to Agent Orange. 96th Cong., 2d sess. September 25, 1980. U.S. Congress, House of Representatives. 1980b. Committee on Veterans' Affairs, Subcommittee on Medical Facilities and Benefits. Oversight Hearing to Receive Testimony on Agent Orange. 96th Cong., 2d sess. February 25 and July 22, 1980. U.S. Congress, House of Representatives. 1980c. Committee on Veterans' Affairs, Subcommittee on Medical Facilities and Benefits. Scientific Community Report on Agent Orange. 96th Cong., 2d sess. September 16, 1980. U.S. Congress, House of Representatives. 1981. Committee on Veterans' Affairs, Subcommittee on Oversight and Investigations. Hearing on the Current Status of Agent Orange Studies. 97th Cong., 1st sess. Serial No. 97-22. May 6, 1981. U.S. Congress, House of Representatives. 1982. Committee on Veterans' Affairs, Subcommittee on Oversight and Investigations. Hearing on Federal Agent Orange Activities. 97th Cong., 2d sess., September 15, 1982. U.S. Congress, House of Representatives. 1983a. Committee on Veterans' Affairs, Subcommittee on Oversight and Investigations. Hearing on Federally Conducted Agent Orange Studies. 98th Cong., 1st sess. May 3, 1983. U.S. Congress, House of Representatives. 1983b. Committee on Veterans' Affairs, Subcommittee on Compensation, Pension, and Insurance, Hearings on H.R. 1961—Vietnam Veterans Agent Orange Relief Act. 98th Cong., 1st sess. Serial No. 98-18. U.S. Congress, House of Representatives. 1984a. Committee on Veterans' Affairs. Report on Mission to Vietnam: Agent Orange in Vietnam. 98th Cong., 2d sess. Serial No. 48. January 31, 1984. U.S. Congress, House of Representatives. 1984b. Committee on Veterans' Affairs, Subcommittee on Hospitals and Health Care. Hearing on the Centers for Disease Control's Birth Defects Study. 98th Cong., 2d sess. October 3, 1984. U.S. Congress, House of Representatives. 1988. Committee on Veterans' Affairs, Subcommittee

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