Veterans Exposed to Agent Orange: Legislative History, Litigation, and Current Issues
Released: 2014-11-18T00:00:00

Summary:
The U.S. Armed Forces used a variety of chemical defoliants to clear dense jungle land in Vietnam during the war. Agent Orange (named for the orange-colored identifying stripes on the barrels) was by far the most widely used herbicide during the Vietnam War. Many Vietnam-era veterans believe that their exposure to Agent Orange caused them to contract several diseases and caused certain disabilities, including birth defects in their children, and now their grandchildren.
The Department of Veterans Affairs (VA) received the first claims asserting conditions related to Agent Orange in 1977. Since then, Vietnam-era veterans have sought relief from Congress and through the judicial system. Beginning in 1979, Congress enacted several laws to determine whether exposure to Agent Orange in Vietnam was associated with possible long-term health effects and certain disabilities. The Veterans' Health Care, Training and Small Business Loan Act (P.L. 97-72) elevated Vietnam veterans' priority status for health care at VA facilities by recognizing a veteran's own report of exposure as sufficient proof to receive medical care, absent evidence to the contrary. The Veterans' Health Care Eligibility Reform Act of 1996 (P.L. 104-262) completely restructured the VA medical care eligibility requirements for all veterans. Under P.L. 104-262, a veteran does not have to demonstrate a link between a certain health condition and exposure to Agent Orange; instead, medical care is provided unless the VA determines that the condition did not result from exposure to Agent Orange. This authority was permanently authorized by the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163).
Likewise, Congress passed several measures to address disability compensation issues affecting Vietnam veterans. The Veterans' Dioxin and Radiation Exposure Compensation Standards Act of 1984 (P.L. 98-542) required the VA to develop regulations for disability compensation to Vietnam veterans exposed to Agent Orange. In 1991, the Agent Orange Act (P.L. 102-4) established a presumption of service connection for diseases associated with herbicide exposure. P.L. 102-4 authorized the VA to contract with the Institute of Medicine (IOM) to conduct scientific reviews of the evidence linking certain medical conditions to herbicide exposure. Under this law, the VA is required to review the reports of the IOM and issue regulations, establishing a presumption of service connection for any disease for which there is scientific evidence of a positive association with herbicide exposure. Based on these IOM reports, currently 15 health conditions are presumptively service-connected.
Under current regulations, a servicemember must have actually set foot on Vietnamese soil or served on a craft in its rivers (also known as "brown water" veterans) to be entitled to the presumption of exposure to Agent Orange. Those who served aboard deep-water naval vessels (commonly referred to as "Blue Water Navy" veterans) do not qualify for presumption of service connections for herbicide-related conditions unless they can prove that the veteran's service included duty or visitation within the country of Vietnam itself, or on its inland waterways.
Recently, Vietnam-era veterans have increasingly expressed concerns about all types of medical issues occurring in their children, regardless of age, and in successive generations. Furthermore, they have asserted that more research should be done on paternally mediated birth effects, so that compensation policies might be developed similar to those that address maternally mediated birth effects of Vietnam-era progeny.

subsections: section_title: Introduction
paragraphs: Almost four decades since the end of the Vietnam War, the controversy surrounding the spraying of an herbicide known as "Agent Orange" and the exposure of Vietnam-era veterans to this herbicide continues. Since the late 1970s, Vietnam-era veterans have voiced concerns about how exposure to Agent Orange may have affected their health and caused certain disabilities, including birth defects in their children, and now their grandchildren. The Department of Veterans Affairs (VA) received the first claims asserting conditions related to Agent Orange in 1977. Since then, Vietnam-era veterans have made efforts to obtain disability compensation and health care from Congress and through the judicial system. In response to issues raised by Vietnam-era veterans, Congress has passed legislation to research the long-term health effects of Agent Orange on Vietnam veterans and to provide benefits and services to those who may have been exposed to it. In addition, the courts have addressed some concerns of Vietnam-era veterans. 
This report provides an overview of how Congress and the judiciary have addressed the concerns of Vietnam-era veterans and briefly describes some of the current issues raised by Vietnam-era veterans. This report should be read in conjunction with CRS Report R41405, Veterans Affairs: Presumptive Service Connection and Disability Compensation . 
The first part of the report discusses previous legislative efforts to address health care and disability compensation issues of Vietnam-era veterans exposed to Agent Orange. The second part discusses litigation pertaining to Agent Orange. The last part of the report briefly addresses current major issues related to Agent Orange and Vietnam-era veterans. In addition, the appendixes contain three tables. Table A-1 provides a summary of congressional action related to health care for Vietnam-era veterans. Table B-1 provides a list of diseases and conditions that are presumptively service-connected with exposure to Agent Orange. Lastly, Table B-2 provides a list of diseases and conditions not presumed to be service-connected.
section_title: What Is "Agent Orange"?
paragraphs: As part of a military strategy to remove foliage that provided cover for the enemy, to destroy enemy crops, and to destroy tall grasses and bushes from the perimeters of U.S. military bases, the U.S. military—from 1962 to 1971—sprayed tactical herbicides in combat military operations in Vietnam. The U.S. Air Force sprayed nearly 19 million gallons of herbicides in Vietnam, of which at least 11 million gallons were Agent Orange—making it the most widely used herbicide in the war. "Agent Orange (so named because of orange color stripes on the barrels used to store and ship the chemical) was a 50-50 mixture of the herbicides 2,4,5-T and 2,4-D." This mixture was contaminated with varying concentrations of numerous dioxins, including 2,3,7,8-tetrachlorodibenzo-pdioxin (TCDD) during the manufacturing process. This contaminant was shown to be highly toxic in animals, and it was implicated in birth defects seen in mice. However, its effects on humans have not been fully understood. It is important to note that "Agent Orange" and "dioxin" are not the same. For simplicity the term Agent Orange is used throughout this report. 
Spraying of Agent Orange occurred over inland forests at the junction of the borders of Cambodia, Laos, and South Vietnam; inland jungles north and northwest of Saigon; mangrove forests on the southernmost peninsula of Vietnam; and mangrove forests along major shipping channels southeast of Saigon.
section_title: Movement to Obtain Compensation and Health Care for Agent Orange Exposure
paragraphs: Initially, the Department of Defense (DOD) maintained that only a limited number of U.S. military personnel could be positively identified as having been exposed to Agent Orange in South Vietnam (e.g., the crews of aircraft that were used to spray herbicides). However, following the publication of a 1979 General Accounting Office (GAO, now called Government Accountability Office) report documenting ground troop exposure, DOD acknowledged that ground troops were also exposed to Agent Orange. Likewise, the Department of Veterans Affairs (VA) consistently took the position that because the long-term exposure to Agent Orange was unclear, and because of scientific uncertainty of the evidence linking Agent Orange to specific illnesses, it could not compensate veterans who alleged that exposure to Agent Orange had caused their diseases. In testifying before the House Committee on Veterans' Affairs, the then Administrator of Veterans Affairs stated: 
Unless or until some such latent effects of Agent Orange or its derivative components are scientifically documented there are intrinsic limitations to VA's authority to allow these [Agent Orange] claims under current law. Though I cannot emphasize enough our policy to resolve reasonable doubt as to service incurrence of disabilities in favor of claimants, there is currently no medical basis upon which adverse health effects of late-post-exposure onset can be reasonably tied to Agent Orange. 
In December 1979, Congress passed the Veterans Health Programs Extension and Improvement Act of 1979 ( P.L. 96-151 ) and directed the VA to investigate the long-term effects of dioxin exposure during the Vietnam War. In 1981, Congress passed the Veterans' Health Care, Training, and Small Business Loan Act of 1981 ( P.L. 97-72 ) and required the VA to include the study of other environmental exposures that may have occurred during the Vietnam conflict. However, the VA never designed a protocol for conducting the study, and responsibility for conducting the study was transferred to the Centers for Disease Control and Prevention (CDC). In 1987, the CDC ceased attempts to produce a study and never released any findings. Although Vietnam-era veterans continued to urge Congress to establish policies for health care and disability compensation (see text box "Eligibility for Health Care and Disability Compensation") for Agent Orange exposure, a lack of a substantial, scientific consensus on the potential health effects of Agent Orange in Vietnam veterans and their offspring impeded those efforts. 
Since the late 1970s and early 1980s, disability compensation policies and health care for possible adverse health outcomes pertaining to veterans exposed to Agent Orange have proceeded on two parallel tracks: through legislation and through the judicial system.
section_title: Legislative Track
subsections: section_title: Health Care Services
paragraphs: In April 1970, Congress held the first of many hearings on the health effects of Agent Orange. Policy makers began to address the health concerns of Vietnam-era veterans in 1981 with the passage of the Veterans' Health Care, Training and Small Business Loan Act ( P.L. 97-72 ). Since the enactment of P.L. 97-72 , Congress has from time to time passed legislation to provide medical care to veterans—and to some of their offspring—who may have been exposed to Agent Orange. In particular, Congress has addressed specific health care concerns of male and female Vietnam-era veterans. These concerns typically involve adverse reproductive effects. For instance, for male veterans, service in Vietnam has been associated with one particular adverse reproductive outcome: spina bifida. However, among female veterans, Vietnam service has been associated with the risk of having children with a wide range of birth defects. Therefore, special programs have been established based on gender. Table A-1 summarizes major legislation pertaining to health care for Vietnam-era veterans who served in Vietnam or other select locations. 
section_title: Disability Compensation
paragraphs: In general, Congress has passed legislation to provide health care to Vietnam-era veterans and, when warranted, their children—even though according to the Institutes of Medicine (IOM) there was no definitive scientific evidence showing that the disorders treated were related to the exposure. Nevertheless, for the purposes of disability compensation, Congress and the VA have relied on scientific evidence concerning Agent Orange exposure during Vietnam service and diseases and conditions suspected to be associated with such exposure. Since the 1980s, two major laws have affected disability compensation policies of Vietnam-era veterans exposed to Agent Orange. 
The Veterans' Dioxin and Radiation Exposure Compensation Standards Act of 1984 ( P.L. 98-542 ) required the VA to develop regulations for disability compensation to Vietnam veterans who may have been exposed to Agent Orange. Veterans seeking compensation for a condition they thought to be related to herbicide exposure had to provide proof of a service connection that established the link between herbicide exposure and disease onset. P.L. 98-542 authorized disability compensation payments to Vietnam veterans for the skin condition chloracne, which is associated with herbicide exposure. 
In 1991, the Agent Orange Act ( P.L. 102-4 ) established a presumption of service connection for diseases associated with herbicide exposure (see text box "What is Presumption of Service Connection ?"). The act directed the VA to "prescribe regulations providing that a presumption of service connection is warranted for [a] disease" when a positive statistical association exists between Agent Orange exposure and the occurrence of that disease in humans. In making this determination, P.L. 102-4 authorized the VA to contract with the Institute of Medicine (IOM) of the National Academy of Sciences (NAS) to review and summarize the scientific evidence concerning the association between exposure to herbicides used in support of military operations in Vietnam during the Vietnam era and each disease suspected to be associated with such exposure. P.L. 102-4 mandated that IOM determine, to the extent possible, (1) whether there is a statistical association between the suspect diseases and herbicide exposure, taking into account the strength of the scientific evidence and the appropriateness of the methods used to detect the association; (2) the increased risk of disease among individuals exposed to herbicides during service in Vietnam during the Vietnam era; and (3) whether there is a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the health outcome. 
The law requires the VA, within 60 days of receiving a report from IOM regarding the relationship between exposure to herbicides used in Vietnam during the Vietnam War and certain diseases, to consider whether a presumption of service connection is warranted for any of the diseases discussed in the report, as well as all other available sound medical and scientific information. Within 60 days of making such a determination, the VA is required to issue proposed regulations setting forth that determination. Within 90 days of issuing the proposed regulations, the VA must issue final regulations establishing a presumption of service connection for any disease for which there is scientific evidence of a positive association with herbicide exposure. Once the VA has established a presumption of service connection for a certain disease or medical condition, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam (or its inland waterways) during the Vietnam era shall be presumed to have been exposed during such service to Agent Orange, and a service connection for that disease or condition will be granted. Those who did not serve in in the Republic of Vietnam or its inland waterways could still establish service connection on a direct basis. Based on the most recent IOM report, "Veterans and Agent Orange: Update 2012," the VA decided not to establish any new presumptions. Table B-1 provides a list of diseases and conditions that are presumptively service-connected. The VA's authority to issue regulations establishing additional presumptions of service connection for diseases found to be associated with Agent Orange exposure will expire on September 30, 2015.
The Agent Orange Act of 1991 ( P.L. 102-4 ) also mandated the VA to publish a notice when the VA determines that a presumption of service connection is not warranted. On April 11, 2014, based on the 2010 and 2012 IOM reports on Agent Orange, the VA issued a notice that a presumption of service connection is not warranted for certain diseases and conditions based on exposure to herbicides used in Vietnam during the Vietnam era. Table B-2 provides a list of diseases and conditions that are not presumptively service-connected.
section_title: Judicial Track
paragraphs: With regard to Agent Orange exposure and disability compensation, litigation has largely focused on two questions. First, which diseases are presumed to be caused by exposure to Agent Orange? Second, which veterans have been presumptively exposed to Agent Orange? These questions have been resolved by two lines of cases. Nehmer claims involve which diseases are presumed to be caused by exposure to Agent Orange, and Haas claims involve which veterans have been presumptively exposed to the herbicide. This section provides a discussion of the laws, regulations, and court decisions that have emerged from these cases. 
subsections: section_title: Nehmer v. U.S. Veterans' Administration
paragraphs: In 1986, numerous Vietnam veterans brought a class action lawsuit against the VA, arguing that their previous claims for service-connected compensation for disabilities allegedly caused by exposure to Agent Orange were improperly denied. At the time, the VA had promulgated a rule that found only one disease, chloracne, associated with exposure to Agent Orange. When promulgating this rule under the Veterans' Dioxin and Radiation Exposure Compensation Standards Act, the VA had used a stringent "cause and effect" test for determining which diseases would be associated with Agent Orange exposure. The veterans argued that the "cause and effect" standard was too stringent and contrary to the legislative intent of Congress. In 1989, the U.S. District Court for the Northern District of California agreed and declared that the VA was required to use a more lenient "significant statistical association" standard when determining whether a disease is associated with Agent Orange exposure. The court invalidated the VA regulations and voided all benefit denials made under those regulations. In response to this court decision, Congress enacted the Agent Orange Act of 1991 in February of that year.
After the enactment of the Agent Orange Act of 1991, the parties from Nehmer entered into a Final Stipulation and Order (Final Stipulation) that established the actions that the VA would take in response to the 1989 court decision. Most notably, the VA was required to issue new regulations regarding which diseases are associated with exposure to dioxin under the Agent Orange Act of 1991 and then readjudicate the claims that were previously denied by the VA under the invalid regulations. The Final Stipulation also stated that any benefits awarded upon such readjudication or adjudication shall be paid retroactively. Generally, when claims are awarded based on a new regulation, the effective date of the award can be no earlier than the date in which the regulation came into effect; however, under the Final Stipulation, the effective date would be either the date the claim was filed or the date the disability arose, whichever was later.
subsections: section_title: Clarifying the Scope of Nehmer
paragraphs: Following the Final Stipulation, the VA began to readjudicate the voided Agent Orange claims. However, the VA established a policy only to readjudicate claims in which the veteran had specifically alleged Agent Orange to be the cause of disease. The veterans again sued the VA, and in February 1999, the court clarified which compensation claims were voided by the 1989 decision. The court again agreed with the veterans and struck down the VA's policy. The court noted that the 1989 decision "voided those decisions in which the disease or cause of death is later found – under valid Agent Orange regulation(s) – to be service connected." Therefore, the 1989 decision voided all VA decisions in which the disease or condition is later found to be associated with Agent Orange, regardless of whether the veterans specifically alleged that their diseases were caused by Agent Orange. Finally, later litigation clarified that the VA must pay the full retroactive benefit to the estates of deceased class members.
section_title: Nehmer Claims and the Sunset Provision of the Agent Orange Act
paragraphs: In 2001, Congress extended the sunset date of the Agent Orange Act from September 30, 2002, to September 30, 2015, thus requiring the Secretary to continue issuing regulations designating service-connected diseases in response to scientific reports. In 2003, the VA found Chronic Lymphocytic Leukemia (CLL) to be associated with Agent Orange exposure. However, the VA did not readjudicate the prior claims of Vietnam veterans suffering from CLL and did not pay them retroactive benefits. The VA contended that the Final Stipulation did not apply to diseases that it determined to be service-connected after September 30, 2002, the original sunset date of the Agent Orange Act of 1991. In 2004, the plaintiff class, disputing this interpretation, filed a motion for clarification and enforcement of the Final Stipulation as to disease determinations made after September 30, 2002. 
In 2005, the court again agreed with the veterans and rejected the VA's interpretation. The court stated that the extension of the sunset provision also extended the duration of the Final Stipulation. Therefore, so long as diseases are determined to be associated with dioxin under the Agent Orange Act, the VA is required to readjudicate any previously denied claims for those conditions. The U.S. Court of Appeals for the Ninth Circuit in 2007 upheld the decision and ordered the VA to reajudicate all prior claims related to CLL and to provide retroactive benefits on such claims.
On October 13, 2009, after reviewing an independent study by the Institute of Medicine, the VA announced that three additional conditions would be granted presumptive service connection as associated with exposure to Agent Orange. On August 31, 2010, the VA published the final rule in the Federal Register , officially adding B-cell leukemias (such as hairy cell leukemia), Parkinson's disease, and ischemic heart disease to the list of conditions associated with exposure to dioxin. Because these conditions were added pursuant to the Agent Orange Act, which does not expire until 2015, the VA is required to readjudicate any claims previously denied for these conditions in order to comply with the Nehmer Final Stipulation.
section_title: Blue Water Veteran Litigation
paragraphs: According to the Agent Orange Act of 1991, certain veterans of Vietnam have been presumptively exposed to Agent Orange. If a veteran falls within such a presumption, he does not have the burden of proving that he was actually exposed to the herbicide in order to obtain disability compensation. According to the statute, if a veteran proves that he "served in the Republic of Vietnam" between January 9, 1962, and May 7, 1975, any disease determined to be associated with exposure to Agent Orange will "be considered to have been incurred in or aggravated by" his service in Vietnam. 
The VA has interpreted this statutory language to include only veterans who have actually set foot on the landmass of Vietnam or served in the inland waterways of Vietnam (veterans who served in the inland waterways are generally known as "brown water" veterans). Veterans who served on ships that remained off the coast of Vietnam (generally referred to as "Blue Water Navy" veterans) do not satisfy the test and are not considered to be presumptively exposed to Agent Orange. This interpretation of the statute was challenged in court. Although the Court of Appeals for Veterans Claims (CAVC) found the VA's interpretation to be invalid, the Court of Appeals for the Federal Circuit overturned the CAVC's decision and, therefore, the VA's "foot-on-land" test remains the current standard. The following section provides the details of the litigation.
subsections: section_title: Haas v. Nicholson
paragraphs: In 2001, a Vietnam veteran, Jonathan Haas, applied for disability compensation for Type 2 Diabetes allegedly caused by his exposure to Agent Orange. Mr. Haas claimed that he was entitled to a presumptive service connection because he "served in the Republic of Vietnam." Mr. Haas never physically went ashore to Vietnam but instead served on a U.S. vessel that remained off the coast during his service. Both the VA Regional Office and the Board of Veterans' Appeals (BVA) denied Mr. Haas the presumption of service connection, stating that a veteran must have actually "set foot on land in the Republic of Vietnam" to qualify for a presumption of service connection for exposure to Agent Orange. Mr. Haas appealed the decisions to the CAVC, arguing that his service off the coast of Vietnam should entitle him to a presumptive service connection based on his "service in the Republic of Vietnam."
In 2006, the CAVC agreed with Mr. Haas and overturned the BVA's decision. The CAVC found the regulation to be ambiguous and determined that the current interpretation conflicted with the agency's earlier interpretations. Furthermore, the court stated that the VA could not make such a change in its interpretation without undertaking proper notice and comment rulemaking procedures. The CAVC also found the "foot-on-land" test to be an unreasonable interpretation of the law, and stated that there could be "the same risk of exposure" for veterans who served on ships near the coast. 
As a result of the CAVC's ruling, the VA directed the BVA to stay all proceedings involving Agent Orange exposure claims of veterans who only served on ships off the coast of Vietnam. The VA also published a notice of proposed rulemaking in the Federal Register declaring its intent to clarify its interpretation. Finally, the VA also appealed the CAVC's decision to the U.S. Court of Appeals for the Federal Circuit.
section_title: Haas v. Peake
paragraphs: On appeal, the case name was changed to Haas v. Peake after James Peake became the Secretary of Veterans Affairs. The U.S. Court of Appeals for the Federal Circuit reversed the decision of the CAVC, ruling in favor of the VA. As a result of this decision, the VA still maintains its "foot-on-land" policy for a Vietnam veteran to qualify for a presumption of exposure to Agent Orange. Although "Blue Water" veterans can still receive compensation for Agent Orange exposure if they prove they were actually exposed to Agent Orange, they will not receive a presumption of exposure due to their service.
Throughout its opinion, the court reversed each basis of the CAVC's ruling. The court stated that the agency's interpretation of the statute was due deference under the Chevron doctrine. The court found the "foot-on-land" rule to be a reasonable interpretation of the statute, noting that Congress had been silent regarding the scope of the statutory language, and stated that the VA's interpretation was a reasonable line to draw. The court also noted that the agency had consistently applied this interpretation for an extended period of time. Finally, the court declared that because this was an interpretive rule, not a substantive rule, the agency did not have to follow notice and comment rulemaking procedures when promulgating its interpretation. Therefore, there was no violation of the Administrative Procedure Act. The court reversed the CAVC decision and remanded the case. Although it ruled in favor of the VA, the court noted that Mr. Haas was free to "pursue his claim that he was actually exposed to herbicides while on board his ship.... However, he [was] not entitled to the benefit of the presumptions set forth in [the Agent Orange Act of 1991]." The Supreme Court of the United States denied certiorari on Mr. Haas's appeal.
section_title: Current Issues
paragraphs: Currently, three major issues pertain to Vietnam-era veterans and their exposure to Agent Orange: (1) providing presumptive service-connected disability compensation for those who served in the waters surrounding Vietnam and in other areas that Agent Orange may have been stored or used; (2) providing disability compensation and health care for paternally mediated birth defects; and (3) researching and providing disability compensation and health care services to biological grandchildren and later generations of Vietnam-era veterans. Each of the three issues is briefly discussed in detail.
subsections: section_title: Veterans Potentially Exposed to Agent Orange in Areas Outside Vietnam
paragraphs: Under current law, veterans who have diseases or conditions listed in Table B-1 are entitled to service-connected disability compensation as long as they (1) stepped foot on land in Vietnam or (2) served on the inland waterways of Vietnam during active duty at any time between January 9, 1962, and May 7, 1975. Other veterans who have an Agent Orange-related disease or condition are entitled to these benefits if they can prove they were exposed to Agent Orange during active duty service. However, there are some exceptions to this general requirement (see text box on "Presumption of Exposure to Agent Orange in Veterans who served in Korea").
Furthermore, only veterans who served in Vietnam are entitled to retroactive benefits. As discussed under the " Blue Water Veteran Litigation " section, some veterans of the Vietnam era who served aboard deep-water naval vessels off the coast of Vietnam—referred to as "Blue Water Navy" veterans—have been pressing Congress and the judicial system to expand the definition of service in Vietnam, thereby qualifying this group to receive disability compensation for diseases or conditions presumed to be associated with Agent Orange. These veterans contend that they were exposed to Agent Orange while on board vessels anchored offshore, either directly through contact with aircraft that sprayed Agent Orange or while handling drums of Agent Orange or by drinking distilled water. 
In late 2009, the VA asked the Institute of Medicine (IOM) to conduct a study and prepare a report on whether Vietnam-era veterans who served in the waters off Vietnam ("Blue Water Navy" veterans) or who served on boats or ships that operated on the inland waterways and delta areas of Vietnam ("brown water" navy veterans) experienced a comparable range of exposures to Agent Orange as the veterans who served on the ground. In 2011, IOM announced that it was unable to determine whether "Blue Water Navy" veterans were exposed to Agent Orange. IOM's report stated: 
The committee was unable to state with certainty that Blue Water Navy personnel were or were not exposed to Agent Orange and its associated [2,3,7,8-Tetrachlorodibenzo-p-Dioxin] TCDD. Owing to a lack of data on environmental concentrations of Agent Orange and Agent Orange–associated TCDD and an inability to reconstruct likely concentrations, as well as the dearth of information about relative exposures among the ground troops and Brown Water Navy personnel and Blue Water Navy personnel, it is impossible to compare actual exposures across these three populations. Furthermore, the committee concludes that because of the small number of studies and their limitations, there is no consistent evidence to suggest that Blue Water Navy Vietnam veterans were at higher or lower risk for cancer or other long-term adverse health effects associated with Agent Orange exposure than shore-based veterans, Brown Water Navy veterans, or Vietnam veterans in other branches of service. The committee's judgment is that exposure of Blue Water Navy Vietnam veterans to Agent Orange-associated TCDD cannot reasonably be determined.
In addition, several groups of Vietnam-era veterans have asserted that they may have been exposed to Agent Orange based on storage and transportation of Agent Orange. For example, veterans have contended that they came into contact with Agent Orange on Guam in the late 1960s during the Vietnam War. Moreover, some veterans have asserted that Agent Orange had been used in testing performed in the Panama Canal Zone in the 1960s and 1970s, and others have contended that they were exposed during storage at Johnston Island in the North Pacific between 1971 and 1977. Furthermore, some Vietnam-era veterans have asserted that they were exposed to Agent Orange in C-123 airplanes used after the Vietnam War. All these veterans groups have sought to establish a presumption of exposure, thereby qualifying them to receive disability compensation for diseases or conditions presumed to be associated with Agent Orange. The VA is reviewing all these claims on a case-by-case basis.
section_title: Paternally Mediated Birth Defects
paragraphs: Currently, the VA provides disability compensation and health care services for only one paternally mediated birth defect: spina bifida in the children of male Vietnam-era veterans. Nevertheless, the VA provides disability compensation and health care for a range of maternally mediated birth defects in children of female Vietnam-era veterans. This more liberal compensation for female Vietnam-era veterans was based on the results of a health study of 8,280 women Vietnam-era veterans (half of whom served in the Republic of Vietnam and half of whom served elsewhere), completed in October 1998 and titled "Women Vietnam Veterans Reproductive Outcomes Health Study." This study was conducted by the Environmental Epidemiology Service of the Veterans Health Administration of the VA.
The most recent 2012 Agent Orange report from IOM stated that there was inadequate or insufficient evidence to determine whether an association exists between exposure to Agent Orange and birth defects in the offspring of male Vietnam-era veterans. However, some veteran service organizations have asserted that more research should be done regarding paternally mediated birth defects and that eventually disability compensation policies should be developed for disabilities and health conditions that appear in later generations. 
section_title: Disability Compensation and Health Care for Later Generations
paragraphs: Some Vietnam-era veterans have raised concerns that the genetic effects of Agent Orange may skip a generation and reappear in third or subsequent generations. In November 2010, some veterans made presentations to the IOM, requesting that it assess the "transgenerational effects resulting from exposure-related epigenetic changes, either in the parents or exposed fetuses, which would lead to adverse health effects in later generations, such as grandchildren." During previous reviews of Agent Orange studies, the IOM focused "only on birth defects (primarily limited to problems detectable at birth or within the first year of life) and childhood cancers (usually restricted to particular cancers that characteristically appear in infants and children and are diagnosed before the age of 18 years)." However, beginning with the 2010 review, the IOM extended its focus to include all types of medical conditions occurring in Vietnam-era veterans' children, regardless of age, and to include such conditions in successive generations. According the most recent 2012 Agent Orange report from IOM, there is inadequate or insufficient evidence to determine whether an association exists between exposure to Agent Orange and specific health issues such as endometriosis; semen quality; infertility; spontaneous abortion; stillbirth; late fetal, neonatal, or infant death; low birth weight or preterm delivery; birth defects other than spina bifida; childhood cancers; or diseases in more mature offspring or later generations. However, the report from IOM states that
The committee [the IOM Agent Orange study committee] favors renewed efforts to conduct epidemiologic studies on all the developmental effects in offspring that may be associated with paternal exposure . In addition, new studies should evaluate offspring for defined clinical health conditions that develop later in life, focusing on organ systems that have shown the greatest effects after maternal exposure, including neurologic, immune, and endocrine effects. Finally, although the committee recognizes that there is evidence that environmental exposures can affect later generations through fetal and germ-line modifications, epidemiologic investigation designed to associate toxicant exposures with health effects manifested in later generations will be even more challenging to conduct than research on adverse effects on the first generation. 
Appendix A. Health Care Legislation for Vietnam Veterans
Appendix B. Diseases and Conditions Presumed/Not Presumed to Be Service-Connected with Exposure to Agent Orange