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Less well known: The powerful herbicide combination was also routinely used to kill weeds at domestic military bases. Those exposed to the chemicals at the bases are still waiting for the same benefits and, in some cases, are hitting a familiar obstacle — government opacity.

In February, VA proposed a rule that for the first time would allow compensation for Agent Orange exposure at 17 U.S. bases in a dozen states where the herbicide was tested, used or stored.

But the list excludes about four dozen bases where Pat Elder, an activist and director of the environmental advocacy group Military Poisons, says he’s documented the use or storage of Agent Orange. Among them is Fort Ord, a former Army base in Monterey County, Calif. Documents gathered by Elder and others, including a report by an Army agronomist, a journal article and records related to hazardous material cleanups, establish the use of Agent Orange at the facility.

“In training areas, such as Fort Ord, where poison oak has been extremely troublesome to military personnel, a well-organized chemical war has been waged against this woody plant pest,” reads a 1956 article in the journal the Military Engineer.

“Until Fort Ord is recognized by VA as a presumptive site, it’s probably going to be a long, difficult struggle to get some kind of compensation,” said Mike Duris, a veteran who trained at the base and was later diagnosed with prostate cancer.

VA considers prostate cancer a “presumptive condition” for Agent Orange disability compensation, meaning the agency presumes the illness is linked to exposure to the chemical. It acknowledges that those who served in specific locations were likely exposed and their illnesses are tied to military service. The designation expedites affected veterans’ disability claims.

Agent Orange is a 50-50 mixture of two chemicals known as 2,4-D and 2,4,5-T. Herbicides with the same chemical structure, although slightly modified, were widely available in the 1950s and ‘60s, sold commercially and used on practically every base in the United States, said Gerson Smoger, a lawyer who argued before the Supreme Court for Vietnam veterans to have the right to sue Agent Orange manufacturers.

2,4,5-T contains the dioxin TCDD, a known carcinogen linked to a number of cancers, chronic conditions and birth defects. The Environmental Protection Agency banned the use of 2,4,5-T in the United States in 1979.

VA says it based its proposed rule on information provided by the Defense Department, and that the Pentagon’s review “found no documentation of herbicide use, testing or storage at Fort Ord.”

Patricia Kime contributed reporting.

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“They were marching the snot out of us,” he said, recalling his year and a half stationed on the base, from 1979 to 1980. He also remembers, not so fondly, the poison oak pervasive across the 28,000-acre installation that closed in 1994. He went on sick call at least three times because of the overwhelmingly itchy rash.

Mounting evidence shows that as far back as the 1950s, in an effort to kill the ubiquitous poison oak and other weeds at the Army base, the military experimented with and sprayed the powerful herbicide combination known colloquially as Agent Orange.

While the U.S. military used the herbicide to defoliate the dense jungles of Vietnam and adjoining countries, it was contaminating the land and waters of coastal California with the same chemicals, according to documents.

The Defense Department has publicly acknowledged that during the Vietnam War era it stored Agent Orange at the Naval Construction Battalion Center in Gulfport, Mississippi, and the former Kelly Air Force Base in Texas, and tested it at Florida’s Eglin Air Force Base.

According to the Government Accountability Office, however, the Pentagon’s list of sites where herbicides were tested went more than a decade without being updated and lacked specificity. GAO analysts described the list in 2018 as “inaccurate and incomplete.”

Fort Ord was not included. It is among about four dozen bases that the government has excluded but where Pat Elder, an environmental activist, said he has documented the use or storage of Agent Orange.

According to a 1956 article in the journal The Military Engineer, the use of Agent Orange herbicides at Fort Ord led to a “drastic reduction in trainee dermatitis casualties.”

“In training areas, such as Fort Ord, where poison oak has been extremely troublesome to military personnel, a well-organized chemical war has been waged against this woody plant pest,” the article noted.

Other documents, including a report by an Army agronomist as well as documents related to hazardous material cleanups, point to the use of Agent Orange at the sprawling base that 1.5 million service members cycled through from 1917 to 1994.

‘The Most Toxic Chemical’

Agent Orange is a 50-50 mixture of two ingredients, known as 2,4-D and 2,4,5-T. Herbicides with the same chemical structure slightly modified were available off the shelf, sold commercially in massive amounts, and used at practically every base in the U.S., said Gerson Smoger, a lawyer who argued before the Supreme Court for Vietnam veterans to have the right to sue Agent Orange manufacturers. The combo was also used by farmers, forest workers, and other civilians across the country.

The chemical 2,4,5-T contains the dioxin 2,3,7,8-tetrachlorodibenzo-p-dioxin or TCDD, a known carcinogen linked to several cancers, chronic conditions, and birth defects. A recent Brown University study tied Agent Orange exposure to brain tissue damage similar to that caused by Alzheimer’s. Acknowledging its harm to human health, the Environmental Protection Agency banned the use of 2,4,5-T in the U.S. in 1979. Still, the other weed killer, 2,4-D is sold off-the-shelf today.

“The bottom line is TCDD is the most toxic chemical that man has ever made,” Smoger said.

For years, the Department of Veteran Affairs has provided vets who served in Vietnam disability compensation for diseases considered to be connected to exposure to Agent Orange for military use from 1962 to 1975.

Decades after Osborn’s military service, the 68-year-old veteran, who never served in Vietnam, has battled one health crisis after another: a spot on his left lung and kidney, hypothyroidism, and prostate cancer, an illness that has been tied to Agent Orange exposure.

He says many of his old buddies from Fort Ord are sick as well.

“Now we have cancers that we didn’t deserve,” Osborn said.

The VA considers prostate cancer a “presumptive condition” for Agent Orange disability compensation, acknowledging that those who served in specific locations were likely exposed and that their illnesses are tied to their military service. The designation expedites affected veterans’ claims.

But when Osborn requested his benefits, he was denied. The letter said the cancer was “more likely due to your age,” not military service.

“This didn’t happen because of my age. This is happening because we were stationed in the places that were being sprayed and contaminated,” he said.

Studies show that diseases caused by environmental factors can take years to emerge. And to make things more perplexing for veterans stationed at Fort Ord, contamination from other harmful chemicals, like the industrial cleaner trichloroethylene, have been well documented on the former base, landing it on the EPA’s Superfund site list in 1990.

“We typically expect to see the effect years down the line,” said Lawrence Liu, a doctor at City of Hope Comprehensive Cancer Center who has studied Agent Orange. “Carcinogens have additive effects.”

In February, the VA proposed a rule that for the first time would allow compensation to veterans for Agent Orange exposure at 17 U.S. bases in a dozen states where the herbicide was tested, used, or stored.

Fort Ord is not on that list either, because the VA’s list is based on the Defense Department’s 2019 update.

“It’s a very tricky question,” Smoger said, emphasizing how widely the herbicides were used both at military bases and by civilians for similar purposes. “On one hand, we were service. We were exposed. On the other hand, why are you different from the people across the road that are privately using it?”

The VA says that it based its proposed rule on information provided by the Defense Department.

“DoD’s review found no documentation of herbicide use, testing or storage at Fort Ord. Therefore, VA does not have sufficient evidence to extend a presumption of exposure to herbicides based on service at Fort Ord at this time,” VA press secretary Terrence Hayes said in an email.

The Documentation

Yet environmental activist Elder, with help from toxic and remediation specialist Denise Trabbic-Pointer and former VA physician Kyle Horton, compiled seven documents showing otherwise. They include a journal article, the agronomist report, and cleanup-related documents as recent as 1995 — all pointing to widespread herbicide use and experimentation as well as lasting contamination at the base.

Though the documents do not call the herbicide by its colorful nickname, they routinely cite the combination of 2,4-D and 2,4,5-T. A “hazardous waste minimization assessment” dated 1991 reported 80,000 pounds of herbicides used annually at Fort Ord. It separately lists 2,4,5-T as a product for which “substitutions are necessary to minimize the environmental impacts.”

The poison oak “control program” started in 1951, according to a report by Army agronomist Floyd Otter, four years before the U.S. deepened its involvement in Vietnam. Otter detailed the use of these chemicals alone and in combination with diesel oil or other compounds, at rates generally between “one to two gallons of liquid herbicide” per acre.

“In conclusion, we are fairly well satisfied with the methods,” Otter wrote, noting he was interested in “any way in which costs can be lowered or quicker kill obtained.”

An article published in California Agriculture more than a decade later includes before and after photos showing the effectiveness of chemical brush control used in a live-oak woodland at Fort Ord, again citing both chemicals in Agent Orange. The Defense Department did not respond to questions sent April 10 about the contamination or say when the Army stopped using 2,4,5-T at Fort Ord.

“What’s most compelling about Fort Ord is it was actually used for the same purpose it was used for in Vietnam — to kill plants — not just storing it,” said Julie Akey, a former Army linguist who worked at the base in the 1990s and later developed the rare blood cancer multiple myeloma.

Akey, who also worked with Elder, runs a Facebook group and keeps a list of people stationed on the base who later were diagnosed with cancer and other illnesses. So far, she has tallied more than 1,400 former Fort Ord residents who became sick.

Elder’s findings have galvanized the group to speak up during a public comment period for the VA’s proposed rule. Of 546 comments, 67 are from veterans and others urging the inclusion of Fort Ord. Hundreds of others have written in regarding the use of Agent Orange and other chemicals at their bases.

While the herbicide itself sticks around for only a short time, the contaminant TCDD can linger in sediment for decades, said Kenneth Olson, a professor emeritus of soil science at the University of Illinois Urbana-Champaign.

A 1995 report from the Army’s Sacramento Corps of Engineers, which documented chemicals detected in the soil at Fort Ord, found levels of TCDD at 3.5 parts per trillion, more than double the remediation goal at the time of 1.2 ppt. Olson calls the evidence convincing.

“It clearly supports the fact that 2,4,5-T with unknown amounts of dioxin TCDD was applied on the Fort Ord grounds and border fences,” Olson said. “Some military and civilian personnel would have been exposed.”

The Department of Defense has described the Agent Orange used in Vietnam as a “tactical herbicide,” more concentrated than what was commercially available in the U.S. But Olson said his research suggests that even if the grounds maintenance crew used commercial versions of 2,4,5-T, which was available in the federal supply catalog, the soldiers would have been exposed to the dioxin TCDD.

The half dozen veterans who spoke with KFF Health News said they want the military to take responsibility.

The Pentagon did not respond to questions regarding the upkeep of the list or the process for adding locations.

In the meantime, the Agency for Toxic Substances and Disease Registry is studying potential chemical exposure among people who worked and lived on Fort Ord between 1985 and 1994. However, the agency is evaluating drinking water for contaminants such as trichloroethylene and not contamination or pollution from other chemicals such as Agent Orange or those found in firefighting foams.

Other veterans are frustrated by the VA’s long process to recognize their illnesses and believe they were sickened by exposure at Fort Ord.

“Until Fort Ord is recognized by the VA as a presumptive site, it’s probably going to be a long, difficult struggle to get some kind of compensation,” said Mike Duris, a 72-year-old veteran diagnosed with prostate cancer four years ago who ultimately underwent surgery.

Like so many others, he wonders about the connection to his training at Fort Ord in the early ’70s — drinking the contaminated water and marching, crawling, and digging holes in the dirt.

“Often, where there is smoke, there’s fire,” Duris said.

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More than 100 million Americans don’t have regular access to primary care, a number that has nearly doubled since 2014. Yet demand for primary care is up, spurred partly by record enrollment in Affordable Care Act plans. Under pressure from increased demand, consolidation, and changing patient expectations, the model of care no longer means visiting the same doctor for decades.

KFF Health News senior correspondent Julie Appleby breaks down what is happening — and what it means for patients.

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Realiza diagnósticos rápidos, sin la presencia de un médico.

Sus clínicas, Tarzana Treatment Centers, son de las primeras en adoptar un sistema de IA que promete expandir drásticamente la detección de retinopatía diabética, la principal causa de ceguera entre adultos en edad laboral y una amenaza para muchos de los cerca de 38 millones de estadounidenses con diabetes.

“Ha sido una bendición para nosotros”, dijo Espinoza, citando los beneficios de un examen rápido y fácil que puede realizarse con poco entrenamiento y que brinda resultados inmediatos.

Y a sus pacientes también les gusta. Joseph Smith, quien tiene diabetes tipo 2, recordó la engorrosa tarea de tomar el autobús hasta el oftalmólogo, dilatar sus pupilas, y luego esperar una semana por los resultados. “Era horrible”, dijo. “Ahora, toma solo unos minutos”.

En medio de todo el revuelo en torno a la inteligencia artificial en la atención médica, la tecnología de exámenes de la vista está surgiendo como uno de los primeros casos de uso probados de diagnósticos basados en IA en un entorno clínico.

Si bien la Administración de Drogas y Alimentos (FDA) ha aprobado cientos de dispositivos médicos basados en la IA, la adopción ha sido lenta mientras los proveedores navegan por el proceso regulatorio, la cobertura del seguro, los obstáculos técnicos, las preocupaciones sobre la equidad y los desafíos de integrarlos en los sistemas de proveedores.

Los exámenes de la vista muestran que la capacidad de la IA para proporcionar resultados inmediatos, así como el ahorro de costos y la conveniencia de no necesitar hacer una cita adicional, pueden tener grandes beneficios tanto para los pacientes como para los proveedores.

De unos 700 exámenes de la vista realizados durante el último año en las clínicas de Espinoza, casi una cuarta parte detectaron retinopatía, y los pacientes fueron remitidos a un especialista para recibir atención adicional.

La retinopatía diabética se produce cuando el alto nivel de azúcar en la sangre daña los vasos sanguíneos en la retina. Si bien el control de la diabetes de un paciente a menudo puede prevenir esta afección, y existen tratamientos para etapas más avanzadas, los médicos dicen que las evaluaciones regulares son cruciales para detectar los síntomas temprano.

Las tres compañías con exámenes de la vista con IA aprobados por la FDA para retinopatía diabética —Digital Diagnostics, con sede en Coralville, Iowa; Eyenuk, de Woodland Hills, California; y la empresa de software israelí AEYE Health— han vendido sistemas a cientos de consultorios en todo el país.

Unas pocas docenas de compañías han realizado investigaciones en este campo específico, y algunas han obtenido autorización regulatoria en otros países, incluyendo gigantes tecnológicos como Google.

Digital Diagnostics, antes Idx, recibió la aprobación de la FDA para su sistema en 2018, después de décadas de investigación y un ensayo clínico que involucró a 900 pacientes diagnosticados con diabetes. Fue el primer sistema de IA totalmente autónomo en cualquier campo médico, lo que hizo que su aprobación fuera “un momento histórico en la historia de la medicina”, dijo Aaron Lee, especialista en retina y profesor asociado de la Universidad de Washington.

Al sistema, utilizado por Tarzana Treatment Centers, puede operarlo alguien con un diploma de escuela secundaria y unas horas de entrenamiento, y solo lleva unos minutos generar un diagnóstico, sin dilatación de los ojos la mayoría de las veces, dijo John Bertrand, CEO de Digital Diagnostics. Se puede instalar en cualquier habitación poco iluminada, y los pacientes apoyan su barbilla en un soporte, y miran fijo a la cámara mientras un técnico toma imágenes de cada ojo.

La Asociación Americana de Diabetes (ADA) recomienda que las personas con diabetes tipo 2 se hagan exámenes de la vista cada uno o dos años; sin embargo, solo alrededor del 60% de las personas con diabetes se los realizan cada año, dijo Robert Gabbay, director científico y médico de la ADA.

Las tasas pueden ser tan bajas como el 35% para los menores de 21 años con diabetes. En grandes áreas del país, la escasez de optometristas y oftalmólogos puede dificultar la programación de citas, por las que a veces hay que esperar meses. Además, las barreras de viajar a una cita adicional para dilatar los ojos —lo que significa tomar tiempo libre del trabajo o la escuela, y tener transporte— pueden ser particularmente difíciles para pacientes de bajos ingresos, quienes también tienen un mayor riesgo de diabetes tipo 2.

“El 90% de nuestros pacientes son trabajadores manuales y de fábricas”, dijo Espinoza sobre sus clínicas del sur de California, que atienden principalmente a poblaciones minoritarias. “Si no trabajan, no comen”.

Un posible inconveniente de no tener un médico que realice el examen es que el algoritmo solo busca retinopatía diabética, por lo que podría pasar por alto otras enfermedades de cuidado, como el melanoma coroideo, dijo Lee. También los algoritmos generalmente “pecan de precavidos” y mandan demasiado a los pacientes a ver a especialistas.

Pero esta tecnología ha mostrado un gran beneficio: es tres veces más probable que el paciente haga un seguimiento después de un resultado positivo con el sistema de IA, según un estudio reciente realizado por Universidad de Stanford.

Eso se debe a la “proximidad del mensaje”, dijo David Myung, profesor asociado de Oftalmología en el Instituto de Ojos Byers en Stanford. Cuando el resultado se entrega de inmediato, en lugar de en semanas o incluso meses, es mucho más probable que el paciente tome acciones.

Myung lanzó el programa de teleoftalmología automatizado de Stanford en 2020, enfocándose originalmente en telemedicina y luego cambiando a IA en sus clínicas del área de la Bahía.

Ese mismo año, el National Committee for Quality Assurance amplió su estándar  de detección de retinopatía diabética para incluir los sistemas de IA. Myung dijo que llevó alrededor de un año filtrar los sistemas de ciberseguridad y TI del sistema de salud de Stanford para integrar la nueva tecnología.

También se aprendió a tomar fotos de calidad que la IA pueda descifrar, dijo Myung. “Incluso alcanzando nuestro ritmo, siempre hay algo que mejorar”, agregó.

La prueba de IA ha sido reforzada por un código de reembolso de los Centros de Servicios de Medicare y Medicaid (CMS), que puede ser difícil y llevar mucho tiempo obtener para dispositivos innovadores. Pero los proveedores de atención médica necesitan esa aprobación gubernamental para obtener reembolsos.

En 2021, los CMS establecieron la tasa de pago nacional para exámenes de retinopatía diabética con IA en $45.36: bastante por debajo de la tasa promedio  negociada de manera privada, que es de $127.81, según un estudio reciente del New England Journal of Medicine sobre IA.

Cada empresa tiene un modelo de negocio ligeramente diferente, pero en general cobran a los proveedores tarifas de suscripción o licencia por su software. Las compañías no quisieron compartir cuánto cobran por el programa.

Las cámaras pueden costar hasta $20,000 y se compran por separado o se alquilan como parte de la suscripción del software.

El mayor cumplimiento de las recomendaciones, junto con las referencias a especialistas, hace que valga la pena, dijo Lindsie Buchholz, líder de informática clínica de Nebraska Medicine, que a mediados de diciembre comenzó a usar el sistema de Eyenuk. “De alguna manera, ayuda a que la cámara se pague por sí sola”, dijo.

Hoy en día, el sistema de Digital Diagnostics se encuentra en alrededor de 600 sitios en todo el país, según la compañía. AEYE Health dijo que a su examen de la vista lo utilizan cientos de proveedores en el país. Eyenuk se negó a compartir detalles sobre su alcance.

La tecnología continúa avanzando, con estudios clínicos para cámaras adicionales —incluyendo un dispositivo portátil que puede examinar a los pacientes fuera de las clínicas— y diagnosticar otras enfermedades oculares, como el glaucoma.

Estas innovaciones ponen a la oftalmología, junto con la radiología, la cardiología y la dermatología, como especialidades en las que la innovación en IA está ocurriendo rápidamente.

“En un futuro cercano va a haber cámaras que se pueden usar en la medicina de calle, y van a ayudar a mucha gente”, dijo Espinoza.

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His clinics, Tarzana Treatment Centers, are among the early adopters of an AI-based system that promises to dramatically expand screening for diabetic retinopathy, the leading cause of blindness among working-age adults and a threat to many of the estimated 38 million Americans with diabetes.

“It’s been a godsend for us,” said Espinoza, the organization’s director of clinic operations, citing the benefits of a quick and easy screening that can be administered with little training and delivers immediate results.

His patients like it, too. Joseph Smith, who has Type 2 diabetes, recalled the cumbersome task of taking the bus to an eye specialist, getting his eyes dilated, and then waiting a week for results. “It was horrible,” he said. “Now, it takes minutes.”

Amid all the buzz around artificial intelligence in health care, the eye-exam technology is emerging as one of the first proven use cases of AI-based diagnostics in a clinical setting. While the FDA has approved hundreds of AI medical devices, adoption has been slow as vendors navigate the regulatory process, insurance coverage, technical obstacles, equity concerns, and challenges of integrating them into provider systems.

The eye exams show that the AI’s ability to provide immediate results, as well as the cost savings and convenience of not needing to make an extra appointment, can have big benefits for both patients and providers. Of about 700 eye exams conducted during the past year at Espinoza’s clinics, nearly one-quarter detected retinopathy, and patients were referred to a specialist for further care.

Diabetic retinopathy results when high blood sugar harms blood vessels in the retina. While managing a patient’s diabetes can often prevent the disease — and there are treatments for more advanced stages — doctors say regular screenings are crucial for catching symptoms early. An estimated 9.6 million people in the U.S. have the disease.

The three companies with FDA-approved AI eye exams for diabetic retinopathy — Digital Diagnostics, based in Coralville, Iowa; Eyenuk of Woodland Hills, California; and Israeli software company AEYE Health — have sold systems to hundreds of practices nationwide. A few dozen companies have conducted research in the narrow field, and some have regulatory clearance in other countries, including tech giants like Google.

Digital Diagnostics, formerly Idx, received FDA approval for its system in 2018, following decades of research and a clinical trial involving 900 patients diagnosed with diabetes. It was the first fully autonomous AI system in any field of medicine, making its approval “a landmark moment in medical history,” said Aaron Lee, a retina specialist and an associate professor at the University of Washington.

The system, used by Tarzana Treatment Centers, can be operated by someone with a high school degree and a few hours of training, and it takes just a few minutes to produce a diagnosis, without any eye dilation most of the time, said John Bertrand, CEO of Digital Diagnostics.

The setup can be placed in any dimly lit room, and patients place their face on the chin and forehead rests and stare into the camera while a technician takes images of each eye.

The American Diabetes Association recommends that people with Type 2 diabetes get screened every one to two years, yet only about 60% of people living with diabetes get yearly eye exams, said Robert Gabbay, the ADA’s chief scientific and medical officer. The rates can be as low as 35% for people with diabetes age 21 or younger.

In swaths of the U.S., a shortage of optometrists and ophthalmologists can make appointments hard to schedule, sometimes booking for months out. Plus, the barriers of traveling to an additional appointment to get their eyes dilated — which means time off work or school and securing transportation — can be particularly tricky for low-income patients, who also have a higher risk of Type 2 diabetes.

“Ninety percent of our patients are blue-collar,” said Espinoza of his Southern California clinics, which largely serve minority populations. “They don’t eat if they don’t work.”

One potential downside of not having a doctor do the screening is that the algorithm solely looks for diabetic retinopathy, so it could miss other concerning diseases, like choroidal melanoma, Lee said. The algorithms also generally “err on the side of caution” and over-refer patients.

But the technology has shown another big benefit: Follow-up after a positive result is three times as likely with the AI system, according to a recent study by Stanford University.

That’s because of the “proximity of the message,” said David Myung, an associate professor of ophthalmology at the Byers Eye Institute at Stanford. When it’s delivered immediately, rather than weeks or even months later, it’s much more likely to be heard by the patient and acted upon.

Myung launched Stanford’s automated teleophthalmology program in 2020, originally focusing on telemedicine and then shifting to AI in its Bay Area clinics. That same year, the National Committee for Quality Assurance expanded its screening standard for diabetic retinopathy to include the AI systems.

Myung said it took about a year to sift through the Stanford health system’s cybersecurity and IT systems to integrate the new technology. There was also a learning curve, especially for taking quality photos that the AI can decipher, Myung said.

“Even with hitting our stride, there’s always something to improve,” he added.

The AI test has been bolstered by a reimbursement code from the Centers for Medicare & Medicaid Services, which can be difficult and time-consuming to obtain for breakthrough devices. But health care providers need that government approval to get reimbursement.

In 2021, CMS set the national payment rate for AI diabetic retinopathy screenings at $45.36 — quite a bit below the median privately negotiated rate of $127.81, according to a recent New England Journal of Medicine AI study. Each company has a slightly different business model, but they generally charge providers subscription or licensing fees for their software.

The companies declined to share what they charge for their software. The cameras can cost up to $20,000 and are either purchased separately or wrapped into the software subscription as a rental.

The greater compliance with screening recommendations that the machines make possible, along with a corresponding increase in referrals to specialists, makes it worthwhile, said Lindsie Buchholz, clinical informatics lead at Nebraska Medicine, which in mid-December began using Eyenuk’s system.

“It kind of helps the camera pay for itself,” she said.

Today, Digital Diagnostics’ system is in roughly 600 sites nationwide, according to the company. AEYE Health said its eye exam is used by “low hundreds” of U.S. providers. Eyenuk declined to share specifics about its reach.

The technology continues to advance, with clinical studies for additional cameras — including a handheld imager that can screen patients in the field — and looking at other eye diseases, like glaucoma. The innovations put ophthalmology alongside radiology, cardiology, and dermatology as specialties in which AI innovation is happening fast.

“They are going to come out in the near future — cameras that you can use in street medicine — and it’s going to help a lot of people,” said Espinoza.

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A group of chemicals collectively known as PFAS are found in hundreds of consumer goods, including dental floss, rain jackets and nonstick cookware. Over decades, these chemicals have spewed from manufacturing plants and landfills into local ecosystems, polluting surface water and groundwater, as well as the wildlife living there. 

PFAS, or perfluoroalkyl and polyfluoroalkyl substances, are called “forever chemicals” because they don’t break down quickly in the environment, instead accumulating in soil, water, fish and our bodies. Hundreds of military bases have been pinpointed as sources of PFAS leaching into nearby communities’ groundwater.

In 2022, the National Academies of Sciences, Engineering and Medicine published a sweeping federally funded report that associated PFAS exposure with health issues such as cancer, low birth weight and decreased responses to vaccines.

Federal efforts to curb PFAS exposure have focused mostly on drinking water. In March, the Environmental Protection Agency proposed the nation’s first PFAS drinking water standards, which would limit contamination from six types of chemicals. Levels for the two most common compounds would be set at just four parts per trillion. The agency says it expects to finalize the rule early this year.

But some scientists worry that regulations for freshwater fish are lagging. A recent study from The Environmental Working Group found that just one serving of fish can be equivalent to a month of drinking water contaminated with 48 parts per trillion of the common chemical PFOS. 

“PFAS in freshwater fish is at such a concentration that for anyone consuming, even infrequently, it would likely be their major source of exposure over the course of the year,” said David Andrews, a co-author of the study and researcher at EWG. “We’re talking thousands of times higher than what’s typically seen in drinking water.”

At least 17 states have issued PFAS-related fish consumption advisories, KFF Health News found, with some warning residents not to eat any fish caught in particular lakes or rivers because of dangerous levels of contamination.

But there’s no federal guidance on the matter. So, what’s considered safe to eat varies significantly among states — and most provide no regulation. “Do not eat” thresholds for the general population range from 25.7 parts per billion in New Hampshire to 800 ppb in Alabama.

Levels for children, pregnant people and other “at-risk” groups are usually lower. 

That’s especially unnerving for rural, Indigenous and low-income communities that depend on subsistence fishing. Fish are a large part of many communities’ diets, and aside from forever chemicals — and in some species, mercury — they’re a healthy source of protein and omega-3 fatty acids.

The regulatory picture is changing fast, however. For example, on Dec. 8, Maryland updated its fish consumption guidance for PFAS to cover 15 species in 71 advisories. Previously, the state had just one advisory from 2021 for Piscataway Creek, which flows out of Joint Base Andrews just outside of D.C. 

The state’s new guidance is almost 10 times more stringent. The concentration of PFOS in fish that would warrant an “avoid” recommendation for the general population is now 41 parts per billion, according to Maryland spokesperson Jay Apperson, compared with 408 ppb before the December update. 

This shifting science has big consequences for anglers. Up until December, Maryland said the general population could eat three largemouth bass meals per month from Piscataway Creek. Now, it says no one should eat any of the creek’s bass or sunfish. 

While the EPA has tested hundreds of fish for PFAS and found some samples with concerningly high concentrations, it has no plans to provide national fish consumption advisories.

“For people who eat freshwater fish caught in local rivers and lakes, EPA recommends that they consult their state, tribe or territory for information on local fish advisories to determine the safe number of freshwater fish to eat,” EPA spokesperson Remmington Belford said in an email.

However, the EPA added hundreds of PFAS compounds to its list of “chemicals of special concern” last year, requiring manufacturers to start reporting their inclusion in products, even in small amounts or in mixtures, as of Monday. And the EPA plans to publish a list of which PFAS chemicals to watch for in state, tribe and territory fish advisory programs in early 2024. (That list had been expected last spring.)

If there’s any good news, it’s that the Food and Drug Administration tested saltwater fish and shellfish sold in grocery stores — including Atlantic salmon and canned tuna — and generally found far lower levels of PFAS contamination.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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