victoria j. davey, phd, mph, rn chief officer office of public health vha/va
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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
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
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
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
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