Informing the Future: Critical Issues in Health: Fourth Edition (2007)

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Activty-Duty Military and Veterans: America’s Heros Active-Duty Military and Veterans: America’s Heroes The men and women who serve the United States in the armed services face challenges that most Americans can hardly imagine. Besides the dedication, ef- fort, and sacrifice required to do their jobs, those in the military have difficult and unique challenges in staying healthy during and after their service. Some of these risks are obvious, but the others are no less noteworthy. An active-duty military deployed near an armed conflict faces risks of injury and death directly from combat. Those away from the front lines may be subject to lengthy exposures to hazardous environments, either natural or man made. Chemical exposures often far exceed those that would be considered safe in a normal working environment. Also, beyond the immediate physical threats, the U.S. military must deal with the effects of being in a high-intensity, stressful, and dangerous environment—sometimes for months or even years at a time. The Department of Defense (DoD) and the Department of Veterans Affairs (VA) are charged with the weighty task of keeping active troops fit for service, protecting them from preventable risks, providing high-quality health care, and ensuring adequate care when their military service ends. Because the challenge is so exceptional, scientific knowledge must be relied on as a powerful ally. The Institute of Medicine (IOM) regularly conducts research and analysis in support of the DoD and the VA in their mission to protect the health of active-duty military personnel, their families, and veterans. The Impact of War: Veteran Health and the Gulf War In 1991, nearly 700,000 U.S. troops, including many members of reserve units in the National Guard, took part in the Persian Gulf War. On returning home, a substantial number of military personnel reported health problems that they believed to be service connected. At the request of Congress, the IOM has con- ducted a series of studies that examine the scientific and medical evidence on the potential health effects of biological and chemical agents to which military personnel may have been exposed during the war. 41 

Informing the Future: Critical Issues in Health The first volume in the Gulf War and Health series, published in 2000, re- viewed the scientific literature on the health effects of exposure to depleted uranium, chemical warfare agents (including sarin), and pyridostigmine bromide. It also reviewed data on the anthrax and botulinum toxoid vaccines. The second volume, published in 2003, examined the health effects associated with exposure to pesticides and solvents. The third volume, published in 2005, analyzed the long-term human health effects associated with exposure to selected environ- mental agents, pollutants, and synthetic chemical compounds, such as fuels and propellants, believed to have been present during the Gulf War. The report endorsed a policy of Following the publication of the first vol- appropriate pre- and postdeployment ume in the Gulf War and Health series, persistent medical screening of military concern was expressed by affected veterans and personnel. outside observers that there were unknown ad- verse neurological effects from exposure to sa- rin and related chemical warfare compounds. In response, the VA asked the IOM to review the scientific and medical literature published since its initial report, which resulted in the report Gulf War and Health: Updated Literature Review of Sarin (2004). Rather than focusing on specific causes, the fourth volume, Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (2006), focused on the actual state of veterans’ health in the years since the conflict. It concluded that service in the Persian Gulf during the 1990–1991 conflict places veterans at in- creased risk for developing psychiatric illnesses, particularly posttraumatic stress disorder, anxiety, depression, and substance abuse problems. In addition, the evidence suggests that there may be an elevated rate of the rare disorder amyo- trophic lateral sclerosis among Gulf War veterans. Ultimately, however, the report found that researchers lack the data needed to determine whether many long-term health problems are associated with ser- vice in the Persian Gulf, due to inadequate screenings and medical exams before deployment and only limited examinations of returning personnel. Predeploy- ment screenings would have established a baseline for comparing health status after deployment. The report endorsed a policy of appropriate pre- and postde- ployment medical screening of military personnel. The report also called for improved monitoring of exposure to contaminants by the military in the future. With little direct monitoring of Gulf War soldiers’ exposures to contaminants, it may never be possible to pinpoint whether expo- sures during service are associated with a specific illness. Conclusions often lie in 42 

Active-Duty Military and Veterans: America’s Heroes the realm of uncertainty: personnel were potentially exposed to sarin gas, pesticides, air pollutants, vaccines, solvents, and pharmaceuticals. The fourth report also looked at studies based on self- reports by Gulf War veterans, which have found a higher preva- lence of symptoms such as fatigue, memory loss, muscle and joint pain, and sleeping difficulties—symptoms that are among those associated with chronic, multisymptom conditions such as fibromyalgia, chronic fatigue syndrome, and multiple chemi- cal sensitivity. Not surprisingly, these studies find higher rates of chronic, multisymptom illnesses among Gulf War veterans as well, but there are no existing, objective diagnostic tests available to validate these self-reported disorders. The fifth report in the series, Gulf War and Health: Infectious Diseases (2007), examined the long-term health effects associated with infectious diseases perti- nent to Gulf War veterans, as well as veterans of the Afghanistan and Iraq wars that began in 2001 and 2003, respectively. The report detailed nine infectious diseases and found evidence, for example, of a connection between West Nile virus infection and long-term cognitive disabilities. Evaluating Disabilities The Department of Veterans Affairs uses the “VA Schedule for Rating Dis- abilities,” better known as “the Rating Schedule,” to determine compensation for veterans who acquire or aggravate injuries and diseases during their military service. The Rating Schedule is based primarily on degree of impairment, such as the loss of a limb or an impairment of organ function. The VA’s benefit policies are designed to reflect a grateful nation: the VA decides in favor of the veteran in cases of reasonable doubt, assists the veteran in gathering evidence, and identi- fies conditions that might make veterans eligible for compensation even if they don’t initially make a claim. Clinical professionals medically evaluate each claimant and provide their as- sessment to a separate group of nonclinical professionals who manage the claims process. They use this information to determine the applicant’s degree of disabil- ity according to the Rating Schedule, which is comprised of a list of about 700 diagnostic codes, each with criteria for determining the percentage of disability. Veterans who have a service-connected disability are eligible to receive monthly payments tied to their disability ratings, which currently range from $115 a month 43 

Informing the Future: Critical Issues in Health for a rating of 10 percent to $2,471 per month for a rating of 100 percent. By federal statute, the veterans’ disability benefits program is only required to compensate based on an average loss of earning capacity, although Congress and the VA also have recognized and compensated veterans for other, non-economic losses since the disability program was put in place in the 1920s. The Veterans’ Disability Benefits Commission requested that the IOM analyze the current state of, and recommend improvements to, this evaluation and rating system. The IOM published its findings in A 21st Century System for Evalu- ating Veterans for Disability Benefits (2007). The committee ad- vised that the VA expand the current statutory purpose of its disability compensation program to formally include compensation not just for work disability but also for disability related to non-work activity and a loss of quality of life. Furthermore, the report recommended that the Rating Schedule be revised more broadly to include factors that are more directly related to dis- ability, such as limitations in activities of daily living, rather than the current focus 30,000,000 Estimated and Projected Cumulative Number of Veterans 25,000,000 20,000,000 15,000,000 Post Gulf War Gulf War 10,000,000 Peacetime Before Gulf War 5,000,000 Vietnam Korea WWII 0 00 02 04 06 08 10 12 14 16 18 20 22 24 26 28 30 32 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Fiscal Year Estimated and projected cumulative number of veterans by period of service, 2000–2032. SOURCE: A 21st Century System for Evaluating Veterans for Disability Benefits, p. 31. 44 2-01 

Active-Duty Military and Veterans: America’s Heroes on specific body structures and functions (which may, in fact, be poor measures of long-term disability). In addition, the report recommended that the VA update the entire Rating Schedule and establish a regular process for keeping it up to date. Staff should be dedicated to maintaining the Rating Schedule, and an external advisory com- mittee of medical and other disability experts should assist in the updating process. Military Nutrition: Mineral Requirements As part of its mandate to promote the health and well-being of its soldiers, the U.S. military has focused much effort on improving the nutrient intake levels of active-duty service members. Because of the unique physical and mental demands of many military situations, dietary rec- ommendations for civilians can be insufficient. For example, a soldier on active duty loses many minerals through sweating in physically demanding training situations or in high temper- atures. Recommended mineral intake for the average civilian might be insufficient. The DoD requested that the IOM look at this issue in de- tail. In Mineral Requirements for Military Personnel: Levels Needed for Cognitive and Physical Performance During Garrison Training (2006), the IOM committee suggested that data to support new requirements for minerals for military personnel are scarce and that further research is needed in the unique sce- narios of garrison training. However, the report did find that higher intakes of certain minerals, specifically iron, magnesium, and zinc, are warranted. The report examined multiple factors that potentially affect mineral levels in military personnel, including physical activity, weight loss, stress, and the mineral content of military rations. The report prioritized critical research needs and outlined a program for evaluating and implementing changes in military nutrition requirements. The re- port’s research recommendations have since been incorporated in the U.S. Army Research Institute of Environmental Medicine nutrition research agenda. 45