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Mr. MATHEWS. Unless there is objection, the entire page of that schedule will be inserted in lieu of the paragraph that I read, at the point that I read it.

Mr. STEVENS. Also, may I say, sir, H. R. 3650, concerning which Mr. Patterson spoke, requires that there be a diagnosis within 1 year of separation from active service of such tropical disease. It is entirely possible that unavailability of a physician or inaccessibility of the veteran to medical care will make it impossible for him to introduce other than lay evidence but that 13 or 14 or 15 months after discharge a positive evidence of the disease is established by a physician and then a continuity of evidence of disability between discharge and diagnosis could be shown by lay evidence, proving its inception in service.

Mr. MATHEWS. I believe Dr. Shapiro brought that out.

Dr. SHAPIRO. Yes. Except there is one thing: That you establish the service connection for the disease the question, again, of the rating would be based upon the medical evidence showing the frequency of the attacks, and there, again, the same principle would apply if the veteran could furnish satisfactory proof.

As to the unavailability of the doctors, I think lay evidence should be accepted.

Mr. MATHEWS. Under the principles of general law, I certainly think that would be admissible. As soon as the disease has been medi. cally established, I think that lay evidence would be admissible to establish the condition of the veteran.

Dr. SHAPIRO. I will insert the bulletin, TB 8-6, Veterans' Administration Technical Bulletin, dated January 3, 1947, if you desire.

Mr. MATHEWS. Just the portion. Dr. SHAPIRO. Paragraph 5, and I will read this: Duration of ratings for malaria based on relapses or recurrences only. When any evaluation of disability from malaria has been assigned on the basis of relapses or recurrences only, and so forth, it says: such rating will be for a period of 1 year only. If medical evidence of the persistence of disability based on relapses or recurrences is received, the rating will be amended and extended to a date 1 year after the date of the last recurrence established by the medical evidence and so forth.

Mr. MATHEWS. Is that in the technical bulletin?

Dr. SHAPIRO. That is in the technical bulletin, and we don't think it should be limited to medical evidence, such as the chairman has established.

Mr. Mathews. I agree with you thoroughly. Also, that could be adjusted by amending.

Dr. SHAPIRO. That is true also.

Mr. SARBACHER. Would it not be true in some cases that a veteran may not want to run to a doctor and pay a doctor bill every time he has a small attack of malaria?

Dr. SHAPIRO. That is right.

Mr. MATHEWS. In other words, in a situation in which a man cuts his finger, does not go to the doctor, and the cut heals up, there is no medical evidence in the world to prove the existence of the fact that he had cut his finger.

Dr. SHAPIRO. Yes.

Mr. STEVENS. Mr. Mathews, in view of the fact that Technical Bulletin 8Z6 of Veterans' Administration is the latest Veterans' Administration pronouncement on disability ratings for malaria and chronic diseases characteristically tropical in origin, it might be considered that the entire regulation is in point with H. R. 3650, and would give a good explanation of the present situation. If you permit, I suggest that it be inserted in its entirety.

Mr. MATHEWS. The whole thing?
Mr. STEVENS. Yes, sir.

Mr. MATHEWS. All right. If you think it is valuable. Is there any objection?

If not, the whole bulletin will be inserted. ; (The document referred to is as follows:)

TB 8-6

VETERANS' ADMINISTRATION TECHNICAL BULLETIN

Washington 25, D. C., January 3, 1947

DISABILITY RATINGS FOR MALARIA AND CHRONIC DISEASES CHARACTERISTICAILY

TROPICAL IN ORIGIN

This technical bulletin follows TB 8-5, distributed to central office, branch office, regional offices, and centers.

1. Purpose.—In view of inquiries received, the purpose of this technical bulletin is to clarify and supplement section VII, VA Circular 22, 1946, disability ratings for malaria and chronic diseases characteristically tropical in original.

2. Wartime service connection for malaria and chronic diseases characteristically tropical in origin.-(a) Conditions which may be considered under subparagraphs (2) and (3) below are restricted to the following: amebic dysentery; bacillary dysentery; filariasis (Bancroft's type); leishmaniasis, including kalaazar; schistosomiasis; trypanosomiasis; yaws; and malaria.

(6.) Wartime service connection for the above-enumerated conditions may be granted where:

(1) There is available an cfficial record of the presence of the disease during wartime service, without clear and unmistakable evidence, including medical principles, of the existence of the disease prior to such service.

(2) Such chronic disease is shown by proper diagnosis, made within 1 year from date of termination of active wartime service, in cases of veterans who had such service in the tropics, or, in a locality having a high incidence of the disease under consideration, and the record is without evidence of inception prior or subsequent to war service; provided that residence during the year following this service was not in the tropics or in a region where the particular disease is endemic.

(3) A notation was made at discharge of a history of the presence of the disease during wartime service, in cases of veterans who had such service in the tropics or in an area having high incidence of the particular disease, and the history is not negatived by evidence of inception prior or subsequent to

war service; provided the claim is filed within 1 year from date of discharge. (c) In making a determination under subparagraph (2) or (3) above, allowing service connection for any of these conditions other than malaria, it is necessary that the condition under consideration be shown to have been properly diagnosed on VA examination.

3. Ratings for chronic diseases, enumerated above, other than malaria.—Determinations of disablement of compensable degree, resulting from the chronic diseases enumerated above, other than malaria, will be based on the clinical findings recorded on Service Department records or on VA examinations.

4. Initial ratings for malaria based on relapses or recurrences where claim is filed within 1 year from date of discharge.-The ratings provided for malaria in extension 7, 1933 rating schedule, section VII, VA Circular 22, 1946, and in the

1945 rating schedule, section VII, VA Circular 22, 1946, and in the 1945 rating schedule, remain unchanged. The following explanatory remarks are for the purpose of clarification :

(a) A rating of 10 percent from date of discharge will be assigned on the basis of a notation on the service records of a history furnished by the veteran of a recurrence or relapse of the disease during service within the year preceding discharge (but not on a history referring to original attack with no relapse within the preceding year). Where the service record or other competent evidence shows a recurrence or relapse of malaria within 1 year prior to the date of discharge, a minimal rating of 10 percent will be assigned from date of discharge. When service connection is established on any authorized basis, a rating not to exceed 10 percent may be assigned from date of discharge or date of receipt of the evidence on the veteran's sworn statement of relapses or recurrences of attacks within 1 year from date of discharge. This rating may be assigned provided such statement was received within 1 year from date of separation from service and where the statement is not inconsistent with other evidence.

(0) A rating of 30 percent will bz assigned from date of discharge where the service records, exclusive of any history furnished by the veterans, show two relapse within a period of 6 months prior to date of discharge. A rating of 50 percent will be assigned from date of discharge where the service records, exclusive of such history, show three or more relapses during the 6 months pieceding discharge.

5. Duration of ratings for malaria based on relapse or recurrences only.- When any 'evaluation of disability from malaria has been assigned on the basis of relapses or recurrences only, i. e., without medical findings of splenomegaly, anema, hemoglobinuria, cerebral complications, or other pathological involvement, such rating will be for a period of 1 year only. If medical evidence of the persistence of disability based on relapses or recurrences is received, the rating will be amended and extended to a date 1 year after the date of the last recurrence es-ablished by the medical evidence. If medical evidence of the persistence of disability is not received within the year covered by the rating, notice will be given under R. & P. R-1009 (E) with additional instruction as to the necessity for submitting medical evidence showing the disease has persisted with the physician's observations with respect to signs and symptoms during attacks, treatment prescribed, and reaction of the patient to treatment, and any laboratory findings. If such medical evidence is not received, the rating will be terminated. A statement from a physician to be acceptable as a basis for a compensable rating should record sufficient clinical findings when considered in asscc:ation with all other data of record to support the conclusion that there exists disablement of compensable degree from malaria. It is desirable that laboratory examinations be made whenever possible.

6. Rating for malaria based on relapses or recurrences only, occurring more than 1 yar subsequent to service.—After more than 1 year has elapsed following date of discharge, the veteran's statement alone may not be accepted to establish relapses or recurrences. The evidence of others, under oath, may be accepted to establish frequency of relapses or recurrences over a period of 1 year from date of last medical confirmation subsequent to the 1-year period following discharge.

7. Thirty-month follow-up.Cases in which compensable ratings have been in effect for 30 months without official confirmation after discharge, of the disabling effects, will be referred for physical examination with such sp cal examinations as may be indicated to determine the existence of active malaria or residual disability therefrom. In the event examination is negative for malaria or: residuals and claimant gives history of recent recurrences, field examination and/or „hospitalization may be utilized to clarify question of disability.

8. Residuals of malaria.-In rating disability for malaria, attention is to be given to all significant residuals as well as to the freqeuncy and severity of recurrences and the clinical course of the disease.

9. Malaria diary file. -An appropriate diary file will be maintained in malaria cases for the purpose of the 12-month and 30-month follow-up, as provided above.

10. Eramination policy.--The medical schedule, file of examinations will be reviewed, and requests based on malaria will be returned for action as above. As time permits, the calendar file of scheduled future examination requests will be similarly reviewed and referred for rating action. As scheduled future examination requests based on malaria become due, they will be referred with the case folder for rating on the evidence of record under the provisions of this. If medical evidence as required by paragraph 5 above is not in file, notice will be forwarded to the veteran under R. & P. R-109 (E), including a statement that his compensation will be discontinued unless he submits evidence from a physician showing recurrent attacks or other disabling effects of malaria. By direction of the Administrator:

O. W. CLARK,

Executive Assistant Administrator. Distribution:

CO (Assistant Administrators) (7) (8A) (8B) (8C) (8D)
BO (D) (P) (PD) (3) (8) (10)
RO (M) (P) (3) (8) (10)
CN—Regional Activity (M) (P) (3) (8) (10)
CN—Domiciliary and Hospital Activities (M) (P) (3) (10)
HP (M) (P) (3) (10)

OR (Headquarters) Mr. STEVENS. May I say one more thing, sir? I do not think that it has been brought out that the endemic area can be in this country as well as in the tropics.

Dr. SHAPIRO. I meant to say in any areas where the malaria is endemic. Yes, we have had troops down in South America and in Central America.

Mr. MATHEWS. Well, there are certain parts of the United States where malaria is endemic?

Dr. SHAPIRO. Yes, that is right. We have malaria in the United States.

Mr. KRAABEL. Mr. Chairman, this is off the record. (Discussion off the record.)

Mr. MATHEWS. Is there anyone else here that wants to be heard on H. R. 3650 ?

STATEMENTS OF FRANCIS SULLIVAN, NATIONAL LEGISLATIVE

DIRECTOR, DAV; QUINTIS E. CAMP, ASSISTANT NATIONAL DIRECTOR OF CLAIMS OF THE DAV; AND DR. CLAYTON WOOD, MEDICAL SUPERVISOR OF THE DAV

Mr. SULLIVAN. Mr. Chairman, I would like to present Mr. Quintis E. Camp, assistant national director of claims, and Dr. Clayton Wood, our medical advisor.

Mr. CAMP. There is little that I can add to what has been stated here by the representatives of the American Legion. I do wish to concur in their statements regarding H. R. 3650.

I want to bring out a little further

Mr. MATHEWS. Well, you do not think that 3650 as it is presently prepared is adequate?

Mr. CAMP. Our statement is that it is not adequate. Mentioning further, though, about the malaria and the requirement for its being diagnosed medically, we know that in these times doctors are nearly all worked to death, and many times unable to answer all of the calls that they receive from persons, and many times they will simply prescribe atabrine or quinine by telephone, and then as a result when the patient finally does reach the doctor after the attack is over, the maiaria plasmodia are not found. You do not have conclusive medical evidence of the diagnosis, therefore lay evidence should have top consideration of those who have witnessed the attack.

Mr. MATHEWS. Are there any questions by members of the committee?

Dr. DONOHUE. I would like to ask a question: How could a lay person determine it was a malaria attack?

Mr. Camp. He can describe the fact that the patient had a chill, he had the shakes, and then he had fever, and he perspired, and so on, describe it in lay language that anyone who reads can know what he is talking about.

Mr. MATHEWS. In other words, it is like an insanity case. Lay evidence is always admissible to show what the patient did, how he acted, and what appearance he had. That is always admissible in insanity cases, in my State at least.

Are there any further questions?

Mr. SARBACHER. In your experience, have you had very many complaints from the veterans from this section that they are not adequately taken care of as far as receiving their 10-percent disability? They cannot prove it.

Mr. Camp. Yes; we receive daily complaints regarding such cases because, as I say, the doctors are busy. They cannot answer every call, and the man might live in a city, not necessarily some isolated area where the doctor cannot get to him, and by the time the doctor does get there he is over his chill.

Then we have a great number of complaints from people who live in the isolated areas, particularly from people out in the Western States, where it may be 100 miles to a doctor, and those people cannot bring a doctor in here, but they are suffering just the same.

Mr. SARBACHER. Well, then, in your opinion, a man that is ratedit is 10 percent when you have proven malaria; is that correct-receives about $13.80 a month; is that correct?

Mr. CAMP. That is correct.

Mr. SARBACHER. That would go somewhat to compensate him for days he loses from work, and possibly the private medical bills that he would incur during these attacks which could not be set out with frequency! He might have one in 8 months, he might have one every other day, and he might have one in 2 years. But that, you think, is a compensation for the attacks?

Mr. Camp. That depends on the number of attacks he has, and the number of clinical evidences he has, and then he has to go through the same thing again next year.

Mr. SARBACHER. But it would establish a service connection?

Mr. CAMP. Yes; it would establish the service connection. That is another question the American Legion brought up about filing a claim in 1 year. Why would you pick on a case of malaria, for instance, when you would not necessarily require a man to file a claim in 1 year for arthritis, say, when they are on all fours?

Mr. MATHEWS. According to the rating schedule, it does not seem to make sense. I agree with you. . Mr. CAMP. I agree with you.

Mr. MATHEWS. I think we can speak for the committee. We would be glad to have a letter from your people setting forth what you think should be contained in the bill.

Would you mind giving it to us! ?

Mr. CAMP. Mr. Mathews, I would say that particularly paragraph 2, of page 64, should have legislative sanction.

Mr. MATHEWS. Well, if that had legislative sanction, do you think that would completely and adequately cover all cases?

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