1. 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

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

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

4. 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,

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

6. 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

7. 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

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

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

10. International Combat Deployments
World War I ( )
World War II ( )
Korean War ( )
Vietnam ( )
Grenada (1983)
Panama (1989)
First Gulf War/Desert Storm ( )

11. International Combat Deployments
Somalia (1993)
Bosnia ( )
Kosovo ( )
Operation Enduring Freedom/OEF (2001- present)
Operation Iraqi Freedom/OIF/ ( )
Operation New Dawn (2010-present)

12. 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.

13. 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’

14. 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”

15. Frostbite
2nd degree Frostbite

16. 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

17. 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

18. 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

19. 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,

20. 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 and other

21. 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

22. Health Concerns of Combat Veterans Returning from Iraq and Afghanistan Leishmaniasis

23. 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

24. 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.

25. 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.

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

27. Thanks Julie Chapman Ron Teichmann Victoria Cassano Terry Walters