Victoria J. Davey, PhD, MPH, RN Chief Officer Office of Public Health VHA/VA.

Illnesses and Injuriesfrom Military Deployments

Caring for Veterans: Moving Forward In Providing Quality Care

August 9, 2011

Victoria J. Davey, PhD, MPH, RNChief Officer

Office of Public HealthVHA/VA

Veterans voices Physical, Mental, Exposure Signature health outcomes

◦ WWI◦ WWII◦ Korea◦ Vietnam◦ Gulf War◦ OIF/OEF

VA takes care of Veterans

Conclusions

Outline

Deployment ? War? Combat?

All of these have consequences….

Definitions

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

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

Common exposures

What are the risks of war?

Physical environmentinjury noise temperature sleep deprivation diet austere conditions toxic agents infectious agentsimmunizations blast wave exposure

Health Concerns of Veterans

What are the risks of war?

Psychological environmentanticipation of combatcombat traumanon-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 factorsMarital/family disruptionFinancial challengesVocational impactsDisrupted social networks

Health Concerns of Veterans

What are combat theater health risks?

PhysicalRisk

Psycho-socialrisk

PsychologicalRisk

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)

International Combat Deployments

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 I

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’

World War II

Korean Peninsula Cold

◦ Frostbite◦ Limb loss◦ Long term sequelae ‘cold injury’

POW mistreatment Starvation

◦ Korean Forces◦ Citizenry

DSM-1◦ “Stress Response Syndrome”

Korean War

2nd degree Frostbite

Frostbite

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

Acute and Sub-acute Peripheral Neuropathy AL Amyloidosis Chloracne Chronic Lymphocytic Leukemia Hodgkin’s Disease Multiple Myeloma Non-Hodgkin's Lymphoma

Vietnam – Agent OrangePresumptively 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

Vietnam – Agent OrangePresumptively Service Connected Conditions

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

Gulf War/Desert Storm

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

Operation Iraqi FreedomOperation Enduring FreedomOperation New Dawn

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

Psychological Trauma

Health Concerns of Combat Veterans Returning from Iraq and Afghanistan

Leishmaniasis

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

The Department of Veterans Affairs

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.

Summary

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 ChapmanRon TeichmannVictoria CassanoTerry Walters