Short essay

Agent Orange During the Vietnam War: The Lingering Issue of Its Civilian and Military Health Impact

See also Morabia, p. 714; Freudenberg, p. 724; Wodka,

p. 728; Laurell, p. 730; and Phillips, p. 731.

Between 1961 and 1971, US and Republic of Vietnam forces sprayed more than 20.2 million gallons of military herbicides to defoliate forests and mangroves in what was then South Vietnamto deny cover to enemy troops and makebombingtargetsmorevisible. Relatively small quantities (2%) were usedfordefoliationofmilitary base perimeters; 9% of the total was used to destroy “unfriendly” crops as a means of reducing enemy food supplies. The herbicides were also used in the United States, but at application rates at least an order of magnitude lower and with some- what differing formulations.

The military herbicides were nicknamed in accordance with the colored stripes on their 55-gallon drums. Agent Orange was a mixture of butoxyethanol esters of 2,4-dichlorophenoxy- acetic acid (2,4-D) and 2,4,5- trichlorophenoxyacetic acid (2,4,5-T). Agent Blue, which consisted of dimethylarsinic acid (cacodylic acid), was used pri- marily for crop destruction. Agent White was a mixture of 2,4-D and picloram. The herbi- cides that contained 2,4,5-T were contaminated with dioxin (2,3,7,8-tetrachlorodibenzo-p- dioxin [TCDD]). The extent and implications of the TCDD con- tent were not widely known or appreciated until well into the 1970s, when 2,4,5-T was banned from most US domestic uses owing to evidence of its teratogenicity.1

“ECOCIDE”: THE FIRST DEBATE

Public health debate originally focused on “ecocide” from the massivedefoliation.In1970,theUS Congress commissioned a National Academy of Sciences (NAS) study with Department of Defense (DOD) cooperation. The DOD created the HERBS file, an elec- tronic record of the flight path coordinates of more than 9000 missions flown by C-123 aircraft used in the Air Force’s Operation Ranch Hand, the code name given to Air Force military herbicide operations carried out in the Re- public of Vietnam between 1962 and 1971. NAS developed a prim- itivegeographicinformationsystem using computer programs and line-printer graphics to document sprayinganddefoliation.TheDOD added spray records in 1985, pri- marily records of Army helicopter spraying of basecamp perimeters.2

We later developed a more modernized geographic in- formation system, also under an NAS contract. Using primary sources (in close collaboration with DOD experts), we expanded the original HERBS file in two ways. First, we were able to correct about 10% of the records that had pre- viously been discarded by NAS because they were clearly errone- ous; we corrected the records through examination of primary source materials. Second, we dis- covered archival data on approxi- mately 200 missions in which more than two million liters of Agent

Purple had been sprayed prior to 1965. Agent Purple was an early form of Agent Orange that was almost certainly more heavily TCDD contaminated. The HERBSfileremainsacoreresource for studying the herbicides used in Vietnam. Figure 1 illustrates many of the nearly 500 spray targets that we digitized from military records.

MILLIONS OF VIETNAMESE DIRECTLY SPRAYED

We estimated that at least 366 kg of TCDD were sprayed on South Vietnam. We used a conservative estimate of three parts per million of dioxin contamina- tion and did not include poorly documented herbicides sprayed by Vietnamese, US Army, and US Navy trucks, boats, hand sprayers, and helicopters. Data on more than 100000 gallons of highly con- taminated Agent Pink shown in procurementrecordsbutnotfound in any recorded missions are also missing from our estimate. Agent Pink consisted only of 2,4,5-T as a 60:40 mixture of its n-butyl and isobutyl esters. Forty-two missions intended to spray 30000 gallons of herbicideareknownto haveended with emergency dumps in which the herbicide was jettisoned in

about 30 seconds, as compared with the usual four to five minutes. At least five herbicide-loaded air- craft crashed. Hundreds of thou- sands of drums contaminated with residual herbicides made their way through the impoverished coun- tryside for a variety of uses.1

Atleast3851ofthe5958known fixed-wing missions had targeted flight paths directly over South Vietnamese hamlets. We calculated thatatleast2.1millionbutperhapsas many as 4.8 million people in 3181 hamlets were sprayed.1 Population estimates for an additional 1430 sprayed hamlets are unavailable. Few systematic data exist on pop- ulation exposures through residual contamination of soils or con- sumption of herbicidal chemicals takenupinthefoodchain,although “hot spots” are known.3

MANY PROBLEMS, LITTLE CORROBORATION

Despite reports in the press of possible health problems of ex- posed US military personnel emerging in the late 1970s, few peer-reviewed studies involving credible herbicide exposure measures have been carried out. Data on relationships between herbicide exposures and diseases for which veterans can receive medical attention and benefits are largely derived from environ- mental and toxicological studies not associated with Vietnam; rather, this information is based on systematic studies conducted by the Institute of Medicine

ABOUT THE AUTHORS Jeanne Mager Stellman is with the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY. Steven D. Stellman is with the Department of Epidemiology, Mailman School of Public Health, Columbia University.

Correspondence should be sent to Steven D. Stellman, PhD, MPH, Department of Epi- demiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link.

This editorial was accepted March 13, 2018. doi: 10.2105/AJPH.2018.304426

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biennially since 1994 (see the box on this page). Many studies of veterans are compromised by se- vere misclassification: some have definedveterans’merepresencein Vietnam as “exposure,” whereas others have focused on service in the four military combat tactical zones despite the fact that spraying varied dramatically within each zone (e.g., one zone contained unsprayed Saigon and the heavily sprayed Iron Triangle).

A 20-year Air Force study of Ranch Hand air and ground crews gathered massive amounts of sur- vey and medical data and reported herbicide-related diabetes; how- ever, because of its small size (the study involved approximately 2800 men), it has low power with respect to many of the health endpoints of interest, and numer- ous TCDD assays relied on blood

drawn decades after exposures occurred. Army Chemical Corps personnel are a source of many health reports, but they handled very small amounts of herbicides and large quantities of other chemicals. (Ranch Hand was an Air Force as opposed to an Army operation.)Theseandotherstudies are often based on unreliable self- reports of handling of herbicides.4

EXPOSURE OPPORTUNITY MEASURES REFINED

Beginning in the 1980s, we refined the NAS HERBS-file methodology to derive “exposure opportunity” scores in cross- sectional studies of a random sample of 12000 American Le- gionnaires. We demonstrated that

a sizeable number of troops served in sprayed areas and were at ele- vated risk of selected health out- comes.5 In 1983, the Centers for Disease Control and Prevention (CDC) initiated a large Agent Orange cohort study of combat battalions whose daily locations were meticulously assembled by the DOD and the CDC employed an exposure algorithm almost identical to ours; the agency abruptly abandoned the study in 1987, however, declaring it impossible to use troop location data for estimating exposures be- cause scores were inconsistent with serumdioxin levels.The CDCalso asserted that ground troops who did not directly handle the herbi- cides were not “heavily” exposed.

Two separate Institute of Medicine panels rejected these assertions. NAS issued a request for application to further develop

a methodology based on military records for estimating exposures to military herbicides in Viet- nam.4 We responded to that request and were awarded a contract under which we de- veloped our updated geographic information system.6 Our data sets related to spraying, troop locations, and exposure oppor- tunity scores are available on a Web site funded by the National Library of Medicine (http://www.workerveteranhealth. org/milherbs/new/).

CONCLUSIONS The Agent Orange story is one

of massive exposure of civilian and military populations to toxic chemicals once thought safe. Few studies exist of the long-range effects of the Vietnam War on the

Note. Spraying operations were directed at specific targets, 487 of which are shown; we digitized some of the images from original hand-drawn maps (colored areas at upper left) in files rediscovered in the National Archives. Some areas were targeted in multiple projects at different times, resulting in mission overlaps. Red and green outlines are for 1965 and 1966; blue lines are waterways.

FIGURE 1—Illustration of Vietnamese Spray Targets Digitized From Military Records

DISEASES FOR WHICH MILITARY SERVICE IN VIETNAM MAY BE CONSIDERED PRESUMPTIVE OF EXPOSURE BY THE DEPARTMENT OF VETERANS AFFAIRS FOR THE PURPOSE OF TREATMENT AND COMPENSATION

Amyloid light-chain amyloidosis

Chronic B-cell leukemias

Chloracne

Diabetes mellitus type 2

Hodgkin’s disease

Ischemic heart disease

Multiple myeloma

Non-Hodgkin’s lymphoma

Parkinson’s disease

Peripheral neuropathy, early onset

Porphyria cutanea tarda

Prostate cancer

Respiratory cancers, including lung

Soft tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi’s

sarcoma, and mesothelioma)

Spina bifida in offspring

Note. DatawerederivedfromtheUSDepartmentofVeteransAffairs(https:// www.publichealth.va.gov/exposures/agentorange/conditions/index. asp) and reflect compensable diseases and conditions as of April 15, 2018.

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health of soldiers or civilians, or on the general environment. There is a strong suspicion that elevated rates of birth defects may be attributable to herbi- cides, but scientific corrobora- tion is limited. Studies of South Korean troops who served in Vietnam have revealed in- creased risks of diabetes and other disorders.7 Much of the existing literature on US veterans relies on exposure methodologies with severe misclassification limitations or on populations too small to al- low questions regarding cancer and other chronic diseases to be addressed.

Faced with this dilemma, the Institute of Medicine oversaw development of a peer-reviewed,

military records–based exposure methodology, similar to early NAS and CDC studies, for esti- mating exposures; sufficient funding to carry out epidemio- logical studies has not been forthcoming despite strong con- gressional mandates. The at-risk veteran population is now at an age at which chronic diseases become manifest, so the time is optimal for conducting such studies, crafting health programs for veterans to better meet their needs, and truly assessing, addressing, and ameliorating health conditions and continuing exposures to lingering traces of Agent Orange in Vietnam.

Jeanne Mager Stellman, PhD Steven D. Stellman, PhD, MPH

CONTRIBUTORS Both authors contributed equally to this editorial.

ACKNOWLEDGMENTS This work was supported by National Academy of Sciences subcontract NAS-VA-5124-98 and National Library of Medicine grant 1G13LM009137.

REFERENCES 1. Stellman JM, Stellman SD, Christian R, Weber T, Tomasallo C. The extent and patterns of usage of Agent Orange and other herbicides in Vietnam. Nature. 2003;422(6933): 681–687.

2. National Research Council Com- mittee on the Effects of Herbicides in South Vietnam. The Effects of Herbicides in South Vietnam: Part A. Washington, DC: National Academy of Sciences; 1974.

3. Dwernychuk LW, Cau HD, Hatfield CT, et al. Dioxin reservoirs in southern Viet Nam—a legacy of

Agent Orange. Chemosphere. 2002; 47(2):117–137.

4. Institute of Medicine Committee on the Assessment of Wartime Exposure to Herbicides in Vietnam. Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam. Washington, DC: National Academies Press; 1994–2014.

5. Stellman SD, Stellman JM, Sommer JF Jr. Health and reproductive outcomes among American Legionnaires in relation to combat and herbicide exposure in Vietnam. Environ Res. 1988;47(2): 150–174.

6. Stellman JM, Stellman SD, Weber T, Tomasallo C, Stellman AB, Christian R Jr. A geographic information system for characterizing exposure to Agent Or- ange and other herbicides in Vietnam. Environ Health Perspect. 2003;111(3): 321–328.

7. Yi SW, Hong JS, Ohrr H, Yi JJ. Agent Orange exposure and disease prevalence in Korean Vietnam veterans: the Korean veterans health study. Environ Res. 2014; 133:56–65.

OSHA 1971: Bringing Government to Protect the Lives of Industrial and Farm Workers

See also Morabia, p. 714; Freudenberg, p. 724; Stellman

and Stellman, p. 726; Laurell, p. 730; and Phillips, p. 731.

On May 28, 1971, one month after the Occupational Safety and Health Act (OSHA) went into effect, OSHA issued its first citation against an employer. Citation No. 1 found that:

Visible pools and droplets of mercury have been allowed to accumulate and remain on the cellroom floor, in the basement, and in other working areas and working surfaces contributing to airborne concentrations of mercurywhichsignificantlyexceed levels generally accepted to be safe levels of such concentration. . . . Instances of excessive airborne concentrations of mercury had beenmade known tothe employer onoccasionspriortothedateofthis inspection. (see Appendix A,

available as a supplement to the online version of this article at http://www.ajph.org)

The cited employer was the Allied Chemical Corporation, one of America’s oldest chemical companies, which had been formed in 1920 from 4 chemical companies with roots as far back as 1881. For more than one year prior totheissuanceofthecitation,Allied Chemical knew that its workers were being overexposed to mer- cury as a result of an investigation conducted by the Bureau of Oc- cupational Safety and Health (BOSH), the predecessor to the National Institute for Occupational Safety and Health (NIOSH).

BEFORE OSHA That a major American cor-

poration, as late as 1971, could knowingly expose its workers to the classic health hazard of mercury poisoning, described by Ramazzini in 1713 as “the most cruel bane of all that deals with death and destruction,”1(p308) was emblematic of working conditions in the United States that led to the passage of the Occupational Safety and Health Act. Until OSHA, the United States lacked any govern- mental structure that provided workers with the right to complain

and force employers to correct hazardous conditions.

“Unfortunately, our legisla- tors and others who are re- sponsible for the safety of all our citizens are lethargic about this major problem of health and safety,” wrote Anthony Mazzocchi in the forward to the March 29, 1969, edition of Hazards in the Industrial Environ- ment.2(foreward) Mazzocchi, a leading labor advocate for the passage of OSHA, was the Citizenship-Legislative Director of the Oil, Chemical, and Atomic Workers International Union (OCAW). His union was at the receiving end of the post–World War II explosive growth in the US chemical in- dustry, which had barreled ahead with new products, with little thought of the consequences to

ABOUT THE AUTHOR Steven Wodka is an attorney-at-law in Little Silver, NJ.

Correspondence should be sent to Steven Wodka, 577 Little Silver Point Rd, P.O. Box 66, Little Silver, NJ 07739-0066 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link.

This editorial was accepted March 11, 2018. doi: 10.2105/AJPH.2018.304417

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