STATEMENT OF VIETNAM VETERANS OF AMERICA SUBMITTED BY GEORGE C. DUGGINS NATIONAL PRESIDENT ACCOMPANIED BY RICHARD F. WEIDMAN DIRECTOR OF GOVERNMENT RELATIONS BEFORE THE HOUSE SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS' AFFAIRS, AND INTERNATIONAL AFFAIRS COMMITTEE ON GOVERNMENT REFORM JUNE 9, 1999 Mr. Chairman, my name is George Duggins, and I serve as National President of Vietnam Veterans of America. On behalf of Vietnam Veterans of America (VVA), I wish to congratulate and thank you and your distinguished colleagues for your leadership in holding this hearing this morning on the subject of the Hepatitis C virus, and the efforts of the Veterans Health Administration (VHA) at the United States Department of Veterans Affairs to effectively deal with this epidemic that is disproportionately affecting veterans. Hepatitis C has been referred to as the "silent virus" or the "silent killer" because it can remain dormant for at least twenty to thirty years, and perhaps longer. Until 1989, the Hepatitis C virus was not even identified, but rather referred to by physicians as "non-A, non-B hepatitis." While there is a relatively wide variance of opinion as to the prevalence among veterans, all who have looked into this issue appear to agree that the incidence among veterans is significantly greater among veterans than the general population. VVA believes that at least 8 to 10% of veterans are infected. Based on unofficial verbal reports of the results of the "snapshot" at VA Hospitals taken in March, we have reason to believe that the prevalence rate may be possibly as high as 14%. Whatever the rate actually turns out to be in retrospect, the problem for the men and women veterans in the so-called "high- risk" groups is a potentially devastating one for many thousands of veterans.
Of particular interest to VVA is the apparently high prevalence among Vietnam veterans, particularly those veterans who served "in country" (i.e., in the Vietnam theater of operations). Because of combat wounds, exposure to blood on the battlefield, and other factors that attend to the most basic and messy nature of warfare, a large number of veterans were exposed and are unaware that they should even be tested.
VHA Response
The Veterans Health Administration (VHA) has responded admirably following the outstanding report issued by this Subcommittee in October of 1998. The Policy Directive issued to all VHA facilities on June 11, 1998 is a very reasonable plan for a starting place to begin the process of testing and treatment. The Treatment Protocol issued by VHA to all Clinical Coordinators at the end of December 1998 is a reasonable approach, and a good starting basis for each medical facility to move forward with treatment. While we would hope that each of these policy statements and guidance documents will eventually be strengthened, they would be a reasonable start toward dealing with the veterans aspect of this epidemic, if there was a means of ensuring relatively uniform implementation.
"Don't Ask, Don't Treat"
Earlier this year, many of the VVA local leaders, in virtually every part of the Nation, told us that the VHA officials in their area were saying that the tests would be given when the VHA had the resources and the means to set up their system to properly treat those who are tested and are shown to have the Hepatitis C virus. In response to this concern, VVA asked Dr. Toni Mitchell to meet with our VVA Veterans Affairs Committee, our officers, and many of our state presidents in late March. It was only in response to action taken by Dr. Kizer and by Dr. Mitchell subsequent to that meeting that many facilities started to actually order the riboflavin and interferon needed for treatment, and
at least starting the systematic process of testing the veterans in the ten risk group categories.Today it is our belief that most facilities are still doing an inadequate job of actually testing for the Hepatitis C virus in a systematic manner, and are slow to treat in many cases. We are still hearing of Pharmacy Chiefs and VAMC Directors who are reluctant to order enough of the (relatively expensive) medications necessary to begin treatment in sufficient quantity to begin early treatment on suitable candidates for this very arduous process.
This lack of a concerted and highly visible outreach and rigorous testing campaign will have potentially devastating effects on the veterans involved as well as on the VA health care system that will have to deal with the aftermath of this not so benign neglect in the future. If left untreated many more of these veterans will develop symptoms of the virus, leading to very serious and debilitating diseases that may well result in liver transplant as the only option.
Lack of Resources
The extreme pressure on the Veterans Health Administration (VHA) of three years of "flat line" budget and the disastrous and woefully inadequate request from the President for the FY 2000 budget for VHA has cast a "chilling effect" on the motivation of the administrators in the field to move ahead with doing their job properly for veterans potentially infected with Hepatitis C. While it is unacceptable and unconscionable for medical personnel to act this way, it is inexcusable for the President and the Congress to put these people in this situation of extreme and needless scarcity.
As important, VVA is concerned about the preservation of the organizational capacity (and in many cases the restoration of the organizational capacity) to have the physicians, nurses, and allied health care personnel to actually do the needed testing and treatment. The actual cost of the drugs is significant, but much less than the cost of the professional people to actually properly care for these sick veterans.
We ask your help, Mr. Chairman, and that of your distinguished colleagues in helping secure a more reasonable budget for VHA for FY 2000. While VVA believes that $3 Billion more that the President's budget request is truly needed, obviously the $1.7 Billion more being currently discussed in the Congress would do much to help keep the system from diminishing any further.
What Should Be Done
VHA should work with the veterans service organizations, the American Liver Foundation, and other public and private entities to mount a comprehensive, significant, extended, and prolonged public service campaign to get veterans who may have been exposed to come into the VA, enroll, and be tested. Most veterans do not regularly use the VHA facilities for their health care needs, and since this virus is "silent" most do not know that they are infected or even potentially at risk. This would perhaps be most effectively done as part of an overall coordinated Federal response to the Hepatitis C epidemic, while it is still in a relatively early stage.
VVA stands ready to do our part in such an outreach effort to spur testing of veterans, encouraging individuals to get tested now. It is our belief that many private groups as well as public entities and the media will be responsive to such a concerted and organized effort. However, VHA must take steps to ensure that their key personnel at the local level stand ready to "partner" with the veterans groups and the rest of the community in a meaningful and sustained manner.
VVA would also note that such efforts must be designed and implemented in such a manner that allsubgroups in the veterans population are effectively reached. Ensuring that the community based groups that serve homeless veterans and other under served populations in greatest need is very important in this matter.
VHA should begin to rigorously ensure that all veterans currently registered for VHA services who meet the "at risk" profile have their blood tested for signs of the Hepatitis C virus. This is not happening at any medical facility we are aware of at the moment. Many veterans at risk (such as the former medic accompanying me today) have been trying to get tested for hepatitis C at a VHA facility, but it is on their initiative, not that of the VA.
It is our belief at VVA that this can be set up as a regular part of intake and yearly physicals by VHA by making it part of a computer program that indicates certain tests that must be given to a veteran based on his or her full military/medical history that is logged in as a matter of course. This is something that VVA believes should be done for many sound medical policy reasons in a "Veterans Health Care" system. VVA has engaged in discussions with top VHA leaders on this subject for several months, and VHA agreed this week to proceed with setting up a task group to begin the process of framing the design and implementation of this basic process.
VHA must also take steps to ensure that much more effective accountability mechanisms are put into place that would enable the key national managers to monitor what is happening in the field. VVA has consistently called for much better and more effective modern accountability mechanisms within VHA. The problem is one of the top officials in VHA not knowing what is going on at the service delivery level, except by anecdotes told to them by others. There is no mechanism for systematic quality assurance reviews in regard to Hepatitis C or for other vital measures. This is simply no way to manage a system as large and complex as the Veterans Health Administration.
VHA should work closely with the Surgeon General, the National Institutes of Health, and the Congress to help ensure that additional research is undertaken into more effective cures for eradicating the Hepatitis C virus. While VVA is appreciative that approximately $5 million in research funds will be made available this year, this sum is inadequate in the face of the potential danger of this medical epidemic. Our Nation can do better in pursuit of a more effective cure to this virus.
VVA would urge that the Department of Defense (DoD) be involved in this effort, and that you and your distinguished colleagues help DoD keep a positive attitude that is open to the virus being a potentially serious problem, as opposed to denying a priori that there could possibly be any substantial risk.
Mr. Chairman, that concludes my remarks. I would be pleased to answer any questions you might have. Thank you again for allowing us to present our views here today, and for your strong and vigorous leadership on so many vital issues that confront our Nation's veterans
VIETNAM VETERANS OF AMERICA Funding Statement June 9, 1999 The national organization Vietnam Veterans of America (VVA) is a non-profit veterans membership organization registered as a 501(c)(19) with the Internal Revenue Service. VVA is also appropriately registered with the Secretary of the Senate and the Clerk of the House of Representatives in compliance with the Lobbying Disclosure Act of 1995.
VVA is not currently in receipt of any federal grant or contract, other than the routine allocation of office space and associated resources in VA Regional Offices for outreach and direct services through its Veterans Benefits Program (Service Representatives). This is also true of the previous two fiscal years.
For Further Information, Contact: Director of Government Relations Vietnam Veterans of America. (202) 628-2700, extension 127
E-mail us at govtrelations@vva.org