VA Research: Actions Insufficient to Further Strengthen Human Subject Protections
Published: 2003-06-18T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Every year thousands of veterans volunteer to participate in research projects under the auspices of the VA. Research offers the possibility of benefits to individual participants and to society, but it is not without risk to research subjects. VA studies, like other federally funded research programs, are governed by regulations designed to minimize risks and protect the rights and welfare of research participants. VA must ensure that veterans have accurate and understandable information so that they can make informed decisions about volunteering for research. In September 2000, GAO reported on weaknesses it found in VA's systems for protecting human subjects. VA concurred with GAO's recommendations that its human subject protections could be strengthened by taking actions in five domains--guidance, training, monitoring and oversight, handling of adverse event reports, and funding of human subject protection activities. (VA Research: Protections for Human Subjects Need to Be Strengthened, (GAO/HEHS-00-155, Sept. 28, 2000)). GAO was asked to assess whether VA has made sufficient progress in implementing the recommendations and to examine the recent changes in VA's organizational structure for monitoring and overseeing human subject protections.
section_title: What GAO Found
paragraphs: VA has not taken sufficient actions to strengthen its human subject protection systems since GAO made recommendations nearly 3 years ago. Continuing weaknesses VA has not sufficiently addressed include ensuring that its policy for implementing federal regulations for the protection of human subjects is up to date; training occurs periodically for all personnel involved in human subject protections; those charged with reviewing risks have information that can help them interpret reports of adverse events; and sufficient funding is allocated to support human subject protection activities. VA has taken some important steps to strengthen aspects of its human subject protections by providing some necessary guidance and offering training to research personnel. Moreover, it strengthened its internal oversight and instituted an external accreditation program, with reviews of all its medical centers' human subject protection programs scheduled through summer 2005. VA is now in the midst of a reorganization of its headquarters research offices that was begun without adequate planning and notice. VA did not initially ensure the independence of compliance activities although more recent actions appear to have restored the integrity of the compliance function. VA has not clarified responsibilities for education, training, and policy development. Until it does so, it is unclear how the reorganization will affect VA's efforts to further strengthen its human subject protections.

section_title: Letter
paragraphs: I am pleased to be here to discuss the protection of human subjects who  participate in research conducted through the Department of Veterans  Affairs (VA). Every year thousands of veterans volunteer to participate in  research projects under the auspices of VA. Research offers the possibility  of benefits to individual participants and to society, but it is not without  risk to research subjects. VA studies, like other federally funded research  programs, are governed by regulations designed to minimize risks and  protect the rights and welfare of research participants. VA must ensure  that veterans who agree to become subjects in VA research are given  accurate and understandable information about procedures, risks, and  benefits so that they can make informed decisions about volunteering.  Concerns about VA’s protection of its human research subjects came to  national attention in March 1999. At that time, all human research was  suspended at the West Los Angeles VA Medical Center after officials there  failed to correct long-standing problems with its system for protecting  human subjects. Recently, serious concerns were raised about the safety  of research programs at several VA medical centers, including the Albany  VA medical center, where the possibility of patient deaths related to  research is under investigation.
In September 2000, we testified before this subcommittee on weaknesses  we found in VA’s systems for protecting human subjects. VA concurred  with our recommendations to take immediate steps to ensure that human  subjects would be protected in accordance with all applicable regulations.  We made specific recommendations for actions in five domains— guidance, training, monitoring and oversight, handling of adverse event  reports, and funding of human subject protection activities. You asked us  to assess whether VA has made sufficient progress in implementing our  recommendations and to examine the recent changes in VA’s  organizational structure for monitoring and overseeing human subject  protections.
My testimony is based on an update of VA’s progress in implementing our  September 2000 recommendations and a review of VA’s recent and  ongoing reorganization of its research offices. To do our work, we  reviewed documents, including VA memorandums, policies, and guidance  and interviewed key officials in VA headquarters. We conducted our work  from May through June 2003 in accordance with generally accepted  government auditing standards.
In summary, VA has not taken sufficient action to strengthen protections  for human subjects, although it has made some progress. VA needs to  address continuing weaknesses we identified nearly 3 years ago.  Specifically, VA has not revised its policy for implementing federal  regulations for the protection of human subjects. VA also has not  established training requirements, in policy, to ensure that all research  personnel will be informed of, and stay current with, ways to comply with  all applicable regulations for the protection of human subjects. VA actions  regarding two other recommendations are incomplete. VA has not ensured  that those charged with reviewing risks related to ongoing research  activities have information that can help them interpret reports of actual  adverse events that research subjects experience while participating in  studies. VA has also not ensured that sufficient funding is allocated to  support human subject protection activities. On the other hand, VA has  strengthened aspects of its human subject protections by providing some  necessary guidance and offering training to research personnel. Moreover,  it strengthened its internal oversight and instituted an external  accreditation program, with reviews of all its medical centers’ human  subject protection programs scheduled through summer 2005.
In 2003, VA began a reorganization of its research offices without adequate  planning and notice. We found that VA did not initially ensure the  independence of compliance activities although more recent actions  appear to have restored the integrity of the compliance function. In  addition, VA has not clarified responsibilities for education, training, and  policy development. Until these responsibilities are clarified, it is unclear  how the reorganization will affect VA’s progress in further responding to  our recommendations to strengthen its human subject protections.
subsections: section_title: Background
paragraphs: Conducting research is one of VA’s core missions. VA researchers have  been involved in a variety of important advances in medical research,  including development of the cardiac pacemaker, kidney transplant  technology, prosthetic devices, and drug treatments for high blood  pressure and schizophrenia. In fiscal year 2002, VA supported studies by  more than 3,000 scientists at 115 VA facilities. VA researchers receive  additional grants and contracts from other federal agencies, such as the  National Institutes of Health, research foundations, and private industry  sponsors, including pharmaceutical companies.
To protect the rights and welfare of human research subjects, 17 federal  departments and agencies, including VA, have adopted regulations  designed to safeguard the rights of subjects and promote ethical research.  These regulations, known as the Common Rule, establish minimum  standards for the conduct and review of research to ensure that studies  are conducted in accordance with certain basic ethical principles. These  principles require that subjects voluntarily give their informed consent to  participate in research, that the risks of research are reasonable in relation  to the expected benefits to the individual or to society, and that  procedures for selecting subjects are fair.
The Common Rule creates a system in which the responsibility for  protecting human subjects is assigned to three groups:  Investigators are responsible for conducting research in accordance with  regulations.  Institutions are responsible for establishing oversight mechanisms for  research, including committees known as institutional review boards  (IRB), which are to review both research proposals and ongoing research  to ensure that the rights and welfare of human subjects are protected. VA  medical centers engaged in research involving human subjects may  establish their own IRBs or secure the services of an IRB at an affiliated  university or other VA medical center.
Agencies, including VA, are responsible for ensuring that their IRBs  comply with applicable federal regulations and have sufficient space and  staff to accomplish their obligations.
VA is responsible for ensuring that all human research it conducts or  supports meets the requirements of VA regulations, regardless of whether  that research is funded by VA, the research subjects are veterans, or the  studies are conducted on VA grounds. In addition, two components of the  Department of Health and Human Services (HHS) have oversight  responsibilities for some VA research. The Food and Drug Administration  (FDA) is responsible for protecting the rights of human subjects enrolled  in research with products it regulates—drugs, medical devices, biologics,  foods, and cosmetics. HHS-funded research is subject to oversight by its  Office for Human Research Protections (OHRP). Both FDA and OHRP  have the authority to monitor those studies conducted under their  jurisdiction, and each can take action against investigators, IRBs, or  institutions that fail to comply with applicable regulations. To facilitate  assurance of compliance with federal regulations for the protection of  human subjects, VA awarded a contract to the National Committee for  Quality Assurance (NCQA) to provide external accreditation of its medical  centers’ human research protection programs in August 2000.
Two VA headquarters offices have responsibilities that are directly related  to human subject protections. Responsibility for the administration of VA’s  research program rests with its Office of Research and Development  (ORD), which allocates appropriated research funds to VA researchers. To  help ensure that VA research is conducted ethically, legally, and safely, VA  created an independent office to conduct compliance and oversight  activities—the Office of Research Compliance and Assurance (ORCA)—in  1999. This office was given responsibilities for promoting and enhancing  the ethical conduct of research and investigating allegations of research  noncompliance; it reported directly to the Under Secretary for Health. In  early 2003, VA reorganized its research offices and replaced ORCA with a  new office, the Office of Research Oversight (ORO). ORCA’s  responsibilities for education, training, and policy guidance were  transferred to ORD. ORCA’s responsibilities for compliance activities were  assigned to ORO.
In March 2003, ORD issued a memorandum announcing a 90-day national  “stand down” for VA human subject research to be effective from March 10  through June 6, 2003, although research was permitted to continue during  this period. The stand down was intended to focus efforts on identifying  and correcting problems with VA’s systems for protecting human subjects  and to notify investigators that disciplinary actions may result from  noncompliance with federal regulations governing the conduct of their  research. ORD also asked medical center managers to attest that their  IRBs are constituted as required by VA regulations and that they meet  regularly enough to review research protocols and adverse events; that  their research staff has obtained training in human subject protections;  and that they have checked the credentials of all personnel involved in  research, including investigators, research team members, IRB members  and staff, and research and development committee members.
subsections: section_title: Earlier Evaluation Showed VA Needed to Strengthen Human Subject Protections
paragraphs: In 2000, we concluded that medical centers we visited did not comply with  all regulations to protect the rights and welfare of research participants.  Based on our review of eight medical centers, we documented an uneven,  but disturbing, pattern of noncompliance with human subject protection  regulations. The cumulative weight of the evidence indicated failures to  consistently safeguard the rights and welfare of research subjects. Among  the problems we observed were failures to provide adequate information  to subjects before they participated in research, inadequate reviews of  proposed and ongoing research, insufficient staff and space for IRBs, and  incomplete documentation of IRB activities. We found relatively few  problems at some sites that had stronger systems to protect human  subjects, but we observed multiple problems at other sites. Although the  results of our visits to medical centers could not be projected to VA as a  whole, the extent of the problems we found strongly indicated that human  subject protections at VA needed to be strengthened.
Although primary responsibility for implementation of human subject  protections lies with medical centers, their IRBs, and investigators, we  identified three specific systemwide weaknesses that compromised VA’s  ability to protect human subjects. First, VA headquarters had not provided  medical center research staff with adequate guidance about human subject  protections and thus had not ensured that research staff had all the  information they needed to protect the rights and welfare of human  subjects. Second, insufficient monitoring and oversight of local human  subject protections by headquarters permitted noncompliance with  regulations to go undetected and uncorrected. Third, VA had not ensured  that funds needed for human subject protections were allocated for that  purpose at medical centers, with officials at some medical centers  reporting that they did not have sufficient resources for the staff, space,  training, and equipment necessary to accomplish their mandated  responsibilities.
To strengthen VA’s protections of the rights and welfare of human  subjects, we recommended that VA take immediate steps to ensure that  VA medical centers, their IRBs, and VA investigators comply with all  applicable regulations for the protection of human subjects. The specific  actions we recommended involved guidance, training, monitoring and  oversight, handling of information about adverse events, and funding of  human subject protection activities. VA concurred with our  recommendations.
section_title: Insufficient Action Taken to Strengthen Protections for Human Subjects, Although VA Has Made Some Progress
paragraphs: VA has not taken sufficient action to strengthen protections for human  subjects since we made our recommendations nearly 3 years ago although  it has taken some important steps. ORD has not revised its policy on  human subject protections, and it has not established training  requirements, in policy, to ensure that research personnel obtain periodic  training. Moreover, VA has not established a mechanism for handling  adverse event reports to ensure that IRBs have the information they need  to safeguard the rights and welfare of human research participants and it  has not ensured that sufficient resources are allocated to support human  subject protection activities. On the other hand, VA has strengthened  aspects of its human subject protection systems. ORCA developed a  training program and conducted oversight activities by investigating  claims of research improprieties or noncompliance and restricting or  suspending four medical centers’ research activities when it found  evidence of serious problems. VA also instituted an external accreditation  program that has the potential to further strengthen VA’s oversight of  human subject protections.
subsections: section_title: Policy for Human Subject Protections Has Not Been Revised, but Other Important Guidance Was Issued
paragraphs: In 2000, we reported that we had found problems with VA’s policy for  implementing federal regulations for the protection of human subjects.  These problems included requirements for obtaining and documenting  informed consent. For example, the policy requires use of a particular  form to document a subject’s consent to participate in research. This form  calls for the signature of a witness, but does not indicate who may serve as  a witness, to what the witness is attesting, or the circumstances under  which a witness is needed.
In its comments to that report, VA indicated that ORD was in the process  of updating its policy on human subject protections and that it expected to  submit that policy for internal review by the end of August 2000. When we  followed up in September 2001, VA reported that comments were being  incorporated into the draft policy. In September 2002, VA reported that it  was awaiting final review but has not issued its revised policy as of June  2003. As a result, investigators, IRB members and staff, and other research  personnel do not yet have a clear, up-to-date policy to follow when  implementing human subject protections. Consequently, VA cannot ensure  that research staff know what they need to do to protect the rights and  welfare of human research subjects.
In addition to the problems we noted with VA’s policy, we reported in 2000  that VA headquarters had not provided medical center staff with adequate  guidance to help them ensure the protection of human research subjects.  VA has made some progress in this area. For example, ORCA had begun  distributing some information to medical centers in early 2000. By January  2003, it had posted about 60 information letters and 14 alerts on its web  page and through electronic mail to research facilities. These letters and  alerts provide information about new HHS guidance and policies regarding  human subject protections, reports on research ethics, and problems that  ORCA staff observed during site visits to VA medical centers. In addition,  ORCA developed guidance about human subject protections. For example,  ORCA published a best practices guide for IRB procedures in September  2001 and a tool for medical centers to use to assess their human subject  protection programs in October 2001.
section_title: Training Requirement Not Established in Policy, Although Training Opportunities Offered
paragraphs: In 2000, we found that VA did not have a systemwide educational program  focused on human subject protection issues. Although VA’s human subject  protection regulations do not include any specific educational  requirements, we concluded that periodic training for investigators, IRB  members, and IRB staff is necessary to ensure that they can meet their  obligations to protect the rights and welfare of human research subjects.
VA has not established training requirements in policy, although on two  occasions it has issued memorandums that required training. In August  2000, ORD issued a memorandum to medical center associate chiefs of  staff for research stating that all VA investigators had to meet specific  education requirements before submitting research proposals during 2001.  ORD’s memorandum regarding the March 2003 stand down stated that all  research personnel must provide documentation that they have completed  both a course on the protection of human research subjects and a course  on good clinical practices within the past year; otherwise all research  personnel must complete this training by June 6, 2003. These additional  personnel include research coordinators and research assistants involved  in human research; all members of VA research offices, research and  development committees, and IRBs; and IRB staff (except secretarial  staff). According to VA’s policy for distributing information, however,  memorandums are not used to establish permanent requirements or  policy, and education and training requirements for investigators were not  published in a directive or handbook, which are the documents VA uses to  communicate policy requirements. As a result, headquarters cannot  systematically ensure that all VA personnel involved in human subject  research will be informed of, and stay current with, ways to comply with  all applicable regulations for the protection of human subjects.
Despite the lack of policies requiring human subject protections training,  both ORD and ORCA have provided information since we made our  recommendation about available educational programs to investigators  and other research personnel. ORCA worked with academic institutions to  develop an optional training program for use by VA investigators, IRB  members, IRB staff, research administrative staff, and medical center  officials. This web-based training program includes quizzes after each  module; certification of successful completion requires achieving a score  of at least 75 percent correct. ORCA also presented a seminar on research  compliance and assurance to senior managers of each of VA’s networks,  and ORD recently began providing training to senior managers about their  responsibilities regarding human subject protections.
section_title: Internal and External Oversight Strengthened
paragraphs: In 2000, we reported that VA had not identified widespread weaknesses in  its human subject protection systems because of its low level of  monitoring. VA has made progress in strengthening its oversight. ORCA,  which was created in 1999, was charged with advising the Under Secretary  for Health on all matters related to human subject protections, promoting  the ethical conduct of research, and conducting prospective reviews and  “for cause” investigations. Since becoming operational, ORCA has  investigated claims of improper conduct of research and noncompliance.  In about a dozen cases, it sent teams to medical centers to conduct  intensive for cause reviews. ORCA also conducted six on-site reviews to  follow up on findings from external accreditation reviews. As a result of its  investigations, ORCA restricted or suspended research at four VA medical  centers until identified problems were corrected. For example, in March  2001, ORCA restricted one medical center’s human research activities by  suspending enrollment of new subjects in research after its investigation  revealed noncompliance with several regulations pertaining to IRBs.
ORCA lifted this restriction in February 2002 after the medical center  corrected the identified problems.
In addition to its internal oversight mechanisms, VA became the first  research organization to arrange for external accreditation of human  subject protection systems. External accreditation has the potential to  significantly strengthen oversight of human subject protections. In August  2000, VA awarded a $5.8 million, 5-year contract to NCQA to operate an  accreditation program to assess medical centers’ compliance with federal  regulations for the protection of human subjects. VA’s contract with NCQA  requires it to develop accreditation standards, to conduct a site visit every  3 years to each VA medical center conducting human research, and to  decide on the accreditation status of each facility. According to a 2001  report by the Institute of Medicine, the accreditation standards developed  by NCQA provide a promising basis for accreditation because they are  explicitly linked to federal regulations and pay attention to quality  improvement. The Institute of Medicine recommended that the NCQA  standards be strengthened, for example, by specifying how research  subjects will be involved in human subject protection systems.
NCQA began accrediting VA medical centers and has revised its  accreditation process. NCQA conducted accreditation visits to 23 VA  facilities from September 2001 through May 2002. An ORD official told us  that, of those 23 facilities, 20 were accredited with conditions, 2 were not  accredited, and 1 withdrew from the process. A facility accredited with  conditions met most of the accreditation standards. On the basis of its  experience and feedback on its standards, NCQA proposed—and ORD  approved—revising the standards. NCQA discontinued accreditation  reviews while it revised its standards for evaluating human subject  protection programs. Revisions involved clarification of standards,  reduction of redundancies, and changes to the scoring system. Some  revisions were designed to respond to comments from the Institute of  Medicine. For example, NCQA adopted standards to encourage a facility  to obtain input from research subjects to improve its human subject  protection system. ORD approved a new set of standards in April 2003.  Site visits are expected to resume in October 2003, with accreditation  reviews of all VA facilities involved in human subject research planned for  completion by summer 2005.
section_title: Actions Regarding Adverse Event Reports and Funding for Human Subject Protection Activities Are Incomplete
paragraphs: In 2000, we reported that IRBs have difficulty handling adverse event  reports and often lack key information necessary for their interpretation.  Since then, VA has not developed a mechanism for handling adverse event  reports to ensure that IRBs have information that can help them interpret  reports of actual adverse events that research subjects experience while  participating in studies. Federal regulations require investigators to report  to the IRB unanticipated problems involving risks to subjects. In turn,  IRBs are to review these adverse event reports as part of their continuing  assessment of the adequacy of a study’s protections for human subjects.  ORD issued guidance stating that analyses of adverse events should be  provided to IRBs for those clinical trials that VA funds at multiple medical  centers. ORCA staff participated in interagency discussions about how to  help IRBs handle adverse event reports and developed guidance regarding  what adverse events IRBs are to report to ORCA. As of June 2003, this  guidance has not been issued and VA still lacks comprehensive guidance  to help IRBs interpret reports of adverse events.
In 2000, we reported that VA did not know what level of funding was  necessary to support human subject protection activities and research  officials at five of eight medical centers we visited told us that they had  insufficient funds to ensure adequate operation of their human subject  protection systems. In May 2000, ORD provided networks with suggestions  for the level of administrative staffing of IRBs. ORD also commissioned a  study of the costs of operating IRBs within VA, which was completed in  June 2002. On June 13, 2003, VA issued a policy regarding funding for  human subject protection programs that medical centers are to obtain  from external sponsors of VA research. Specifically, the sponsor of each  industry-funded study is to be charged 10 percent of the direct costs of the  study or a flat fee of $1,200, whichever is greater, by the medical center to  help cover the costs of the human subject protection program. We have  not had the opportunity to study the potential for this mechanism to help  ensure sufficient funding. VA has not specified a procedure for ensuring  that its medical centers—which conduct VA-funded research and research  funded by federal agencies and research foundations as well as  industries—-will be allocated the funds necessary for their human subject  protection programs.
section_title: Recent Reorganization Appears to Maintain Independent Compliance Function, but Other Roles and Responsibilities Unclear
paragraphs: In 2003, VA began a reorganization of its research offices without adequate  planning and notice. We found that VA did not initially ensure the  independence of compliance activities, although more recent actions  appear to have restored the integrity of the compliance function. In  addition, VA has not clarified responsibilities for education, training, and  policy development.
VA’s initial action to reorganize its research offices failed to ensure the  independence of compliance activities. In January 2003, officials  announced that the existing compliance office, ORCA, would be disbanded  and the compliance function and staff reassigned to ORD. As a result,  compliance field personnel began reporting their activities to ORD,  potentially compromising the independence of their compliance  investigations. In a series of memorandums issued from March through  May of 2003, VA announced that a new office, ORO, would replace ORCA.  VA memorandums indicated that ORO, like ORCA, would be independent  of ORD, and that ORO would be organizationally responsible to the Under  Secretary for Health.
According to generally accepted government auditing standards, offices  with responsibility for assessing regulatory compliance should be  organizationally independent of the offices they review and should report  to, and be accountable to, the head or deputy head of the government  entity. Because VA considered making ORD responsible for compliance  activities—where its independence would be compromised—legislation  was proposed in the House of Representatives to establish an independent  office within VA to oversee research compliance with federal regulations.
According to VA memorandums and discussions with agency officials,  ORO will have responsibility for investigating allegations of research  noncompliance, misconduct, and improprieties. However, it is not clear  whether ORO will have authority to review a medical center’s human  subject protection program in the absence of a prior allegation of a  problem; that is, whether it can conduct prospective investigations. While  VA memorandums indicate that ORO will have the same compliance  responsibilities that ORCA had and specify that for cause inspections will  be conducted; they are silent on routine inspections. Experts in human  subject protections have said that these routine inspections, sometimes  referred to as prospective inspections, are an essential way to help prevent  noncompliance. As of June 2003, a directive to formalize the authorities  and responsibilities of ORO has not been issued. Consequently, ORO’s  compliance responsibilities remain unclear.
Other roles and responsibilities are also unclear. For example, ORCA  previously had responsibilities for education and training. VA’s  reorganization now assigns these responsibilities solely to ORD. The  implications of this transfer of responsibilities for strengthening human  subject protections are unclear. For example, when ORCA conducted  compliance reviews or followed up on results of accreditation reviews, it  provided instruction about what steps would be necessary to correct  identified problems. It is not clear whether or to what extent such  instruction, including technical assistance regarding a specific area of  noncompliance, would be considered to be education and training and  therefore not within ORO’s responsibilities.
ORCA also had responsibility to participate in the development of policies  involving human subject protections. Under the reorganization, ORD  would have responsibility for policy development. Existing memorandums  are silent on whether ORO will have any role in, or can contribute its  expertise to, policy development. ORCA had been created with the  understanding that it would collaborate with ORD on dissemination of  information, communication, and policy development. It is not clear to  what extent VA’s efforts to strengthen its human subject protections will  bring to bear the collective expertise of the staff in its compliance and  operational research offices. However, having ORD take the lead on  policies regarding compliance functions or activities could be  inappropriate to the extent that it interferes with ORO’s independence in  executing its compliance functions.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to  answer any questions you or other members of the subcommittee may  have.
section_title: Contact and Acknowledgments
paragraphs: For further information regarding this testimony, please contact Cynthia  A. Bascetta at (202) 512-7101. Kristen Joan Anderson, Jacquelyn Clinton,  Pamela Dooley, Lesia Mandzia, Marcia Mann, and Daniel Montinez also  contributed to this statement.
section_title: Related GAO Products
paragraphs: Human Subjects Research: HHS Takes Steps to Strengthen Protections,  but Concerns Remain. GAO-01-775T. Washington, D.C.: May 23, 2001.
VA Research: Protections for Human Subjects Need to Be Strengthened.  GAO/HEHS-00-155. Washington, D.C.: September 28, 2000.
VA Research: System for Protecting Human Subjects Needs  Improvements. GAO/T-HEHS-00-203. Washington, D.C.: September 28,  2000.
Scientific Research: Continued Vigilance Critical to Protecting Human  Subjects. GAO/T-HEHS-96-102. Washington, D.C.: March 12, 1996.
Scientific Research: Continued Vigilance Critical to Protecting Human  Subjects. GAO/HEHS-96-72. Washington, D.C.: March 8, 1996.
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