Waiting for an Army to Die

by Fred A. Wilcox

  Before Yannacone sent me upstairs to talk with Keith Kavenagh, I asked about the lawsuit he has pending against the Veterans Administration. Yannacone explained that Dow had actually told him about the kind of treatment, or lack of treatment, veterans were receiving at VA clinics.

  “After the war the VA’s treatment of Vietnam veterans was so bad, Dow told us, that much of the illness and death and serious disability among Vietnam veterans might be due to the negligence, carelessness, and disregard of the Veterans Administration. We checked this out, and found it to be true, and that’s why we’re suing the VA. But it wasn’t our intention to sue them. We pleaded with the VA in private meeting after private meeting to please look at our victims, look at our data. And we asked the famous Dr. Paul Haber, the VA’s medical director, if he would consider our liver damage among Vietnam combat veterans. And he said, ‘I don’t see any cases of porphyria cutanea tarda.’ Now porphyria cutanea tarda is a terminal state of liver derangement where you turn jaundiced yellow, your eyeballs turn yellow, and you’re very, very sick. I said, ‘Doctor, I’m not interested in porphyria cutanea tarda. I’m interested in urinary porphyria derangements which are premonitory of the final stage. Let’s treat it before the guy dies!’ And he accused me of trying to practice medicine without a license. And I told him, I said, ‘I can’t believe that a physician at the head of the VA could be so stupid as to ignore the current scientific literature which I lay on the table in front of you, if you don’t have the wit and wisdom to read it in your own library.’ I said, ‘It’s not my quote. It’s from the literature. Here it is.’ And their reaction, by the way, was not to have physicians at this meeting, but there was Paul Haber and seven lawyers! I wasn’t suing the VA. That was February 1979, one month after we filed the lawsuit against Dow. But we were not suing the VA.”

  Yannacone persisted in his efforts to avoid a lawsuit and to persuade the VA to recognize that Vietnam veterans needed help. He talked to Max Cleland in Los Angeles, and agreed on an arrangement to meet again with Haber and other “experts” to work out a cooperative program of dermatological investigation. The plan was to use the expertise of World War II dermatologists who knew “what jungle rot really was,” as well as industrial dermatologists from Dow and the workmen’s compensation board who could recognize chloracne. Clinics would then be established in all the major veterans hospitals throughout the country on a “road-show basis,” and Yannacone would produce fifty to one hundred of his clients at each of the clinics to determine whether they had “chloracne or just spots.” All this was agreed, says Yannacone, in the presence of cameramen from one of the major networks. But “in front of ABC-TV in the Patriot’s Hall in L.A., Max Cleland reneged on that agreement and said there was no evidence and they would not cooperate with the plaintiffs on the Agent Orange suit. They were not going to do anything to help a lawsuit, Cleland said, that they believed to be nothing more than a publicity stunt. Well, Dow sure as hell doesn’t think it’s a publicity stunt.”

  Since he initiated the lawsuit against the VA, Yannacone says he has been placed under surveillance by the Justice Department, has received threats in writing, and has been threatened with an investigation to determine how he acquires his information on the medical effects of Agent Orange.

  “They think I’ve got a mole in the VA. They demand to know who my sources are. But they know they have more information than I do. They have withheld. They are lying. They are killing veterans!”

  Yannacone realizes that he has been shouting. He sighs, shuffles a stack of papers on his desk and, it appears, waits for the jury to return with its verdict. I talk with Mrs. Yannacone for a few moments and then, accepting Yannacone’s offer of another cup of coffee, wander upstairs to find his law partner. Shortly, after two Carol Yannacone invites me to lunch, but before I leave his office Kavenagh and I talk briefly about Ireland. I explain that I once lived on an island off the coast of Connemara, and he tells me that he and his family toured the country in a rented car just the year before. Driving through County Wicklow they decided to take a road that led up a mountain. But after considerable winding the road simply narrowed and then disappeared altogether. They stopped and an elderly farmer emerged from a clump of trees and Kavenagh’s wife asked if he knew where the road “really went.” Without a moment’s hesitation, says Kavenagh, the old man winked and replied, “To eternity, ma’am, to eternity.”

  A light snow is falling. Mrs. Yannacone is driving and Victor is pointing out the sights of the town. For a moment I have the urge to tell them Kavenagh’s story, but I assume they have already heard it, probably more than once. Then it occurs to me that the most remarkable thing about the Yannacones may not be that they have dedicated their lives to helping Vietnam veterans and their families, or that they spend every day working within the milieu of a monumental tragedy.

  The surprising thing about the Yannacones, Keith Kavenagh, and others who work at the law office in Patchogue is that they can still laugh, tell a joke, and on occasion take an hour off to go to Fadeley’s Deli Pub, where they serve German beer, Guinness stout, and corned beef sandwiches with exotic names. We eat our lunch in one corner of the deli while Yannacone leafs through stacks of legal papers, handing Carol a number of medical reports, and smiling, it seems to me, in anticipation of victory against Dow et al.

  8. Casualty Report

  Until a former Green Beret walking into his office complaining of symptoms that physicians call “exotic,” Dr. Ronald A. Codario had never heard of Agent Orange. “I don’t know how common my experience was,” says Codario, “but I went all through medical school and my training in internal medicine without ever hearing the word dioxin.” The veteran told Codario that since his return from Vietnam he had spent many hours each week practicing martial arts, becoming highly skilled in using vigorous physical exercises and meditation to control his emotions. But recently, he said, he had been losing the dexterity and speed that had taken him many long years of discipline and practice to develop. His muscular power seemed to decrease almost daily, and he suffered from headaches and numbness and was easily fatigued. But most bewildering, the self-discipline that had enabled him to survive Vietnam and the years following his discharge from the Special Forces seemed to be slipping away; he was afraid he was losing control. Although his training in martial arts helped to lessen his fear and enabled him at times to regain poise, he was disturbed because there seemed to be absolutely no reason for what was happening.

  Dr. Codario listened patiently for nearly three hours but, he confesses not without a considerable amount of skepticism. As a doctor he had been trained to perceive that certain causes produce readily identifiable effects, and nothing the veteran was telling him fit into this conceptual scheme. Still, he had an intuitive feeling that the man was more than a hypochondriac who, having run out of friends who would listen to his laments, had searched through the phone book until he found an MD.

  During the course of a routine physical examination, Codario discovered that his patient’s liver was slightly enlarged and his blood pressure was high. He admitted him to the hospital, where further tests showed signs of liver inflammation, and a liver-spleen scan suggested sclerosis. A liver biopsy found fibrosis of the liver and fatty degeneration. These are the findings, says Codario, that one might expect in the tissue of someone who had been a heavy drinker, but also what one could expect to find in someone exposed to a toxic material. When asked if he used alcohol excessively, the veteran said that the use of alcohol and drugs was incompatible with martial arts training, and an examination of the biopsy failed to show the alcoholic hyalins that are usual in cases of alcoholic liver disease.

  “So I simply told him,” Codario explains, “that he had been exposed to some type of toxic substance, but what it was I just didn’t know; and the most important thing was to make sure he didn’t expose himself to any further toxic substances. At the time he didn’t know anything about Agent Orange, and neither did I.”

 
During the next few months the veteran’s condition continued to deteriorate and, still unable to satisfactorily diagnose the source of his patient’s problems, Codario resorted to the explanation that, he now realizes, has been used all too often by VA and private physicians to dismiss the complaints of Vietnam veterans.

  “At the time I was just unable to come up with answers, so, like most doctors who can’t make sense out of what a patient is saying, I suppose I resorted to thinking that maybe his physical symptoms were getting worse because of the stress he was under, maybe as the result of his combat experiences in Vietnam. There were times when I did wonder if some of his problems weren’t psychological.” But Codario’s initial gut reaction resisted this as being too easy, a facile, unsatisfactory solution. On one visit the veteran asked if Codario had ever considered the possibility that Agent Orange might be responsible for his problems.

  “I said, ‘What’s Agent Orange?’” recalls Codario. “I thought it was something out of a McDonald’s hamburger ad or something. So he said, ‘It was a defoliant that was sprayed in Vietnam while I was there,’ I said that I thought it might be possible that a herbicide could cause liver damage, but that I really couldn’t say for sure. But I told him that it wouldn’t be unreasonable, considering the state he was in, for him to consider pursuing a claim for disability.”

  Codario was unaware at the time that the Veterans Administration had been routinely denying disability to Vietnam veterans, even those who were nearly totally disabled from the effects of their exposure to toxic herbicides. He sent his patient to his own lawyer for legal advice, and after listening to the veteran’s story, Codario’s lawyer suggested he see another attorney who was working with Victor Yannacone on the class action suit against wartime manufacturers of Agent Orange. The attorney, Hy Mayerson, was so impressed by the fact that an MD would show so much interest in a Vietnam veteran that on the following day he forwarded more than a thousand pages of information on Agent Orange and the effects of dioxin on animals and humans to Codario’s office. Included in the material were approximately one hundred articles from toxicology journals dating back more than a decade, as well as data about where herbicides had been sprayed, what the effects of dioxin had been on animals and humans, and every accident in factories where herbicides were produced or dioxin was a contaminant of some chemical reaction.

  Codario found the material fascinating. He read, for example, about a doctor in the Soviet Union who had examined four hundred workers in a herbicide factory over a ten-year period, describing symptoms that Codario would come across often during his examinations of Vietnam veterans: neurasthenia, headaches, loss of libido, personality changes, chloracne, and depression. A decade later researchers who had been studying fifty of the original four hundred workers found that 20 percent of them were suffering from porphyria cutanea tarda, an often-fatal stage of liver disease associated with exposure to TCDD-dioxin. Codario also read Lennart Hardell and M. Eriksson’s studies on the relationship between soft tissue sarcomas, malignant lymphomas, and exposure to chlorophenols and phenoxy acids, and he continued seeing veterans who seemed to have stepped from the pages of the material he was reading. Codario had wanted to believe that the Vietnam War was over, that the wounds of that era were at least beginning to heal, but he would discover that for many veterans the struggle for survival that began in mangrove forests, rice paddies, and jungles has not ended. And Codario would begin a war of his own—to save the lives of veterans poisoned by toxic herbicides.

  One of the more intriguing things Codario came across during his research was that workers exposed to dioxin during industrial accidents often had in their urine elevated levels of a substance called “intermediate porphyrins.” Porphyrins, he knew, are substances that act as building blocks for hemoglobin—it takes four porphyrin molecules with an iron molecule in the center to make hemoglobin—and hemoglobin is similar structurally to chlorophyll, the material that enables plants to carry out photosynthesis. Because they are extremely sensitive to light, conditions for testing for porphyrins must be carefully controlled if the test is not to be invalidated by a change in their chemical structure.

  Codario concluded that he needed expert advice if he was to find a way of analyzing the porphyrins in his patient’s urine, so he contacted Drs. Schwartz and Watson’s laboratory in Abbott Northwestern Hospital in Minneapolis, where a clinic had been established some years before to treat cases of porphyria. In the early 1970s researchers at the hospital had developed a “miracle drug” for treating patients with elevated porphyrins, and Codario was interested in the possibility of using this drug to help some of the veterans he had been seeing. After a brief correspondence, the clinic’s director, Dr. Petryka, agreed to organize the analysis of the veterans’ urine.

  Codario collected urine specimens in special dark containers kept in an ice bath, and sent the containers to Philadelphia’s St. Joseph’s Hospital, where a registered nurse had volunteered to help out with the project. Upon receiving the containers, the nurse measured the exact amount in each container, then poured out 100 ccs for packing convenience, and, mixing it with a preserving chemical, shipped it via Federal Express to Minneapolis, where Dr. Petryka would then use thin-layer chromatography to analyze the specimens for elevated levels of porphyrins. Over the next few months, Codario examined 270 Vietnam veterans, performing urinalysis on 120 of them and discovering that the same unmistakable pattern appeared again and again.

  “In fact,” he says, “68 percent of the people we’ve examined have an elevated level of one particular type of porphyrin in their urine, a type we call copro. In addition to the elevated level of coproporphyrins, 90 percent of the veterans I’ve examined have what we call a positive Ehrlich reaction. Now the Ehrlich reaction was a test that was done several years ago as a test for porphyrin problems. It is a reaction that takes place when a measured amount of urine is added to an acidified benzaldehyde solution. Before the advent of thin-layer chromatography and all the sophisticated methods of picking up the various types of porphyrins, it was a good screening test for picking up a particular type of porphyrin called porpho-bilinogen, which is an intermediate type of porphyrin. Dr. Petryka was the first person to actually describe a positive Ehrlich reaction in certain alcoholics because of the appearance of certain pyrroles in their urine.

  “But the important thing here is that in the world’s literature one can find only about ten different compounds that will cause a positive Ehrlich reaction, and to our surprise we’re finding that 90 percent of the Vietnam veterans we see have this positive Ehrlich reaction. So naturally Dr. Petryka was intrigued by this and he went about searching the urine samples to see if they contained any one of these ten chemicals. And he discovered that the veterans’ urine contains none of the them. So we concluded that the compound that is causing the positive Ehrlich reaction must be a new compound and I jokingly told Dr. Petryka that he should name it after himself, calling it the Petryka compound. But he went and named it after me, so now it’s called the ‘Codario-Ehrlich positive metabolism.’ But we do know the molecular weight—it is 220—of this compound, and Dr. Petryka is in the process of defining its chemical structure. And when he finds that chemical structure it may be very interesting because it could very well be a way of determining whether or not a person has been exposed to herbicides. Obviously, with the coproporphyrin elevation and the curious positive Ehrlich reaction, we now have a biochemical way of saying yes, these people are different. And there are abnormalities in these patients that we are not finding in those who didn’t serve in Vietnam.”

  In addition to his willingness to work for very little financial gain (Codario sees all Vietnam veterans initially for free and often spends his weekends flying free of charge to the home state of any veteran who has called for help), Dr. Codario has another remarkable quality. During our interview the phone would ring, as one might expect in a busy doctor’s office, and he would listen patiently, replying to the caller’s questions o
r complaints with genuine concern. Then almost before he had replaced the receiver, he would continue exactly where he had left off, even if this meant in the middle of a complicated compound sentence.

  “The other thing that is of interest is that Dr. Strik of the Netherlands, who is one of the world’s authorities on porphyrin problems resulting from exposure to chemicals, and has published several papers on what happens to people whose porphyrin levels are elevated due to their exposure to herbicides, has clearly stated that porphyria progresses in a stepwise fashion from asystematic coproporphyria auria to the much more devastating uroporphyria auria. And that disease is called porphyria cutanea tarda, which is a condition characterized by episodes of severe crampy abdominal pain, high fevers, schizophrenia, and often death. So it seems that the coproporphyria auria that we are seeing now merely represent the tip of the iceberg, or the beginning of the abnormality that if left unchecked may progress to porphyria cutanea tarda and death.”

  Codario feels that he may have discovered a way to check the progressively destructive effects of herbicide poisoning; however, he fears that he may only be able to arrest, rather than cure, the problem. “I’m hoping that once we have established a significant statistical correlation, which we seem to be moving toward right now, that we can get approval to treat some of these porphyrin problems with the drug that they have developed in Minnesota called Hematin. But that may be an oversimplification because Hematin was designed to treat patients with acute severe porphyria—for example, patients suffering from porphyria cutanea tarda. The results have been nothing short of miraculous and are well-publicized in the journals of internal medicine. But in those cases the porphyrins they were producing in their urines were thirty to forty times higher than those we are seeing in our veterans. And we have to keep in mind that Hematin has never been used to treat chemically induced porphyrin problems, so we’re really treading in new territory and can’t be certain that it will work this way. But based on the mechanism of its action, it is certainly possible that it will be beneficial here. The thing we don’t know is, even if we are able to reverse the production of excess porphyrins, will we stop it forever just by giving the patient Hematin? And even if we return the porphyrin count to normal, will their symptoms go away? In examining the veterans and listening to their stories, I suspect that even if Hematin works it will only be temporarily effective and that after a period of time the individual will probably relapse. And I also suspect that all of the symptoms about which Vietnam veterans are complaining are not due solely to porphyrin problems but rather are a direct toxic effect of the herbicide in general and dioxin in particular.”