Illnesses and Injuries from Military Deployments Caring for Veterans: Moving Forward In Providing Quality Care August 9, 2011 Victoria J. Davey, PhD, MPH, RN Chief Officer Office of Public Health VHA/VA

Outline Veterans voices Physical, Mental, Exposure Signature health outcomes WWI WWII Korea Vietnam Gulf War OIF/OEF VA takes care of Veterans Conclusions

Definitions Deployment ? War? Combat? All of these have consequences….

Veterans tell us about deployments Sleeplessness Smoke Insects Fear Pride Bullets Agony Stench Chemicals Pain Discomfort Courage Noise Damp Horror Radiation Cold Hot Sand Shame Homesickness, worry about family, unhealthy eating, substance use, boredom—fear,

Common exposures Burning trash Harsh Weather Conditions Poor Sanitary Conditions Pesticides, herbicides Insects Hazardous Weapons Systems Occupational Chemical Hazards

Health Concerns of Veterans What are the risks of war? Physical environment injury noise temperature sleep deprivation diet austere conditions toxic agents infectious agents immunizations blast wave exposure

Health Concerns of Veterans What are the risks of war? Psychological environment anticipation of combat combat trauma non-combat trauma (including military sexual trauma) separation from family/home boredom/deprivation/hyperstimulation

Health Concerns of Veterans What are the risks of war? Psycho-social factors Marital/family disruption Financial challenges Vocational impacts Disrupted social networks

What are combat theater health risks? Psychological Risk Physical Risk Psycho-social risk

International Combat Deployments World War I (1914-18) World War II (1941- 45) Korean War (1950- 1953) Vietnam (1961-1975) Grenada (1983) Panama (1989) First Gulf War/Desert Storm (1990-91)

International Combat Deployments Somalia (1993) Bosnia (1993-95) Kosovo (1998-99) Operation Enduring Freedom/OEF (2001- present) Operation Iraqi Freedom/OIF/ (2003-2010) Operation New Dawn (2010-present)

World War I Europe, Africa, Middle East, Pacific Islands, China Trench warfare—weather, infections (1918 Flu), battlefield injuries Mustard Gas ‘Shell Shock’ Staring eyes Violent tremors Blue, cold extremities. Unexplained deafness, blindness, or paralysis F. C. Hitchcock. Stand To: A Diary of the Trenches 1915–1918. London: Hurst & Blackett, 1937; report, Heath field, England: The Naval & Military Press, Ltd., 2001.

World War II Europe, Pacific, Atlantic, Southeast Asia, China, Middle East, Mediterranean, Africa Weather, battlefield injuries, prisoner of war camps, infections (“jungle rot”, malaria), concentration camp liberations Deadliest conflict in history—50 to 70 million deaths ‘Combat Fatigue’

Korean War Korean Peninsula Cold POW mistreatment Starvation DSM-1 Frostbite Limb loss Long term sequelae ‘cold injury’ POW mistreatment Starvation Korean Forces Citizenry DSM-1 “Stress Response Syndrome”

Frostbite 2nd degree Frostbite

Vietnam South Vietnam, North Vietnam, Cambodia, Laos Agent Orange Other exposures? Napalm Malaria, insects, insecticides Burning trash Poor hygiene sanitary conditions Stress response syndrome Situational disorders

Vietnam – Agent Orange Presumptively Service Connected Conditions Acute and Sub-acute Peripheral Neuropathy AL Amyloidosis Chloracne Chronic Lymphocytic Leukemia Hodgkin’s Disease Multiple Myeloma Non-Hodgkin's Lymphoma

Vietnam – Agent Orange Presumptively Service Connected Conditions Porphyria Cutanea Tarda Soft tissue Sarcoma Prostate Cancer Respiratory Track Cancer Diabetes Mellitus-Type II B Cell Leukemias Ischemic Heart Disease Parkinson’s Disease All sequelae thereof

Gulf War/Desert Storm Iraq, Kuwait, Saudi Arabia Exposures of concern Protective gear/alarms (82.5%) Diesel, kerosene, other petrochems (80.6%) Oil well fire smoke (66.9%) Local food (64.5%) Insect bites (63.7%) Harsh weather (62.5%) Smoke from burning trash or feces (61.4%) Within 1 mile of missile warfare (59.9%) Repellants and pesticides (47.5%) Paint, solvents (36.5%) Schneiderman, Lincoln, Wargo, et. al., APHA, 12-14-05

Operation Iraqi Freedom Operation Enduring Freedom Operation New Dawn Iraq, Afghanistan IEDs, Snipers Exposures Weather/cold heat Sand Noise Blasts Smoke from trash Vehicle exhaust Jet propellant 8 (JP8) or other fuel MSMR Vol. 12 / No. 8 – Nov. 2006 and other

Psychological Trauma 94% received small arms fire 86 % know someone who was seriously injured or killed 68 % saw dead or seriously injured Americans 51 % handled or uncovered human remains 77% shot at or directed fire at the enemy 48 % responsible for the death of an enemy combatant 28% responsible for the death of a non combatant NEJM, July 2004

Health Concerns of Combat Veterans Returning from Iraq and Afghanistan Leishmaniasis

The Department of Veterans Affairs VHA saw 6M Veterans in FY 10 431,543 OEF/OIF/OND (7%) From 2001 thru 2010, VHA provided care to 683,521 separated OEF/OIF/OND of 1.3 M who have left the military (>50%) Characteristics 94% were seen as outpatients 6% as inpatients Most visits in VISN 7, 8, 17 88% male; 12% female

Summary The U.S. military maintains national security. In war, medical departments of the military maintain the fighting force. The U.S. military constantly improves protection of the fighting force. Yet, the readiness and strength of the fighting force can never be subordinated to the potential for long term sequelae of combat.

Summary It is the Department of Veterans Affairs’ mission to care for those who have born the burden of our wars. There are ‘signature illnesses’, but common health outcomes as well. We will continue to elucidate the health outcomes of Veterans’ military service and strive to find ways to treat them effectively.

America’s Wars Total (1775 -1991) U.S. Military Service during Wartime 41,892,128 Battle Deaths 651,031 Other Deaths (In Theater) 308,800 Other Deaths in Service (Non-Theater) 230,279 Non-mortal Woundings 1,431,290 Living War Veterans 11,745,600 Living Veterans (Periods of War & Peace) 23,442,000

Thanks Julie Chapman Ron Teichmann Victoria Cassano Terry Walters