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Military and Veterans:
Protecting the Protectors
The men and women of the U.S. military face many health threats. Combat
carries risks of injury or death. Personnel serving away from battle zones
may also encounter toxic chemicals or other hazardous materials that are
used in or arise from warfare or the environment. Deployment in danger-
ous areas can generate extreme stress. The health effects of these and other
threats may be immediate or develop later, even long after a service mem-
ber has returned home. Some effects can last a lifetime.
The Department of Defense (DoD) bears the primary responsibility
for protecting service members on active duty and providing them with
high-quality health care. The Department of Veterans Affairs (VA) pro-
vides health care to service members after they leave the military. To help
in carrying out their missions, the DoD and the VA regularly request that
the Institute of Medicine (IOM) study and recommend actions on a range
of health-related topics.
Health effects of serving in Iraq and Afghanistan
Protecting the health and well-being of the military personnel who are
serving or have served in Afghanistan and Iraq stands as an immediate
challenge to the federal government. Roughly 2.1 million men and women,
including those drawn from military reserve units and the National Guard,
have served in Iraq during Operation Iraqi Freedom and in Afghanistan
during Operation Enduring Freedom, often experiencing multiple
deployments.
59
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60 INFORMING THE FUTURE: Critical Issues in Health
At the end of their deployments, most of the troops successfully
readjust to life away from war. But others have difficulty in returning or
transitioning to family life, to their jobs, and to living in their communities
after deployment. Numerous media reports
For many service members, have suggested that for many service mem-
the challenge of readjustment bers, the challenge of readjustment is made
is made worse by various worse by various health problems, includ-
health problems, including ing post-traumatic stress disorder (PTSD)
post-traumatic stress disorder and traumatic brain injury (TBI).
and traumatic brain injury. In response to these concerns, Con-
gress, in the National Defense Authoriza-
tion Act for Fiscal Year 2008, directed the
DoD, in consultation with the VA, to sponsor an IOM study of the physi-
cal and mental health and other readjustment needs of current and former
service members deployed to Iraq and Afghanistan and their families. The
IOM appointed a committee of experts to conduct the study, which would
be done in two phases.
In its report on the first phase, Returning Home from Iraq and Afghan
istan: Preliminary Assessment of Readjustment Needs of Veterans, Service
Members, and Their Families (2010), the committee identified the most
pressing needs of this population, based in large part on a review of the
scientific literature and on testimony from veterans and their families at
several town-hall meetings across the country. The
report commended the DoD and the VA for their
efforts to help returning troops and their families
but concluded that critical gaps remain.
One key need is to improve scientific under-
standing of long-term management of TBI, which
has been called the signature wound of the fight-
ing in Iraq and Afghanistan. The VA established a
comprehensive system of rehabilitation services
for TBI, focused on needs that arise in the initial
months and years after injury. But protocols to man-
age the lifetime effects of TBI have not been studied
in either military or civilian populations. The com-
mittee recommends that the VA sponsor research to determine the efficacy
and cost effectiveness of potential protocols for managing TBI—as well as
other types of injuries resulting from multiple traumas—over the long term.
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61
Military and Veterans: Protecting the Protectors
300
250
200
150
100
50
0
Active Air Force
Guard Air Force
Reserve Air Force
Active Marine Corps
Reserve Marine Corps
Reserve Navy
Active Navy
Guard Army
Active Army
Reserve Army
Average time spent deployed in days by branch of military subdivided by active component and
reserve component and reserve component.
SOURCE: Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment
Needs of Veterans, Service Members, and Their Families, p. 27.
Figure 2.5 (New)
300
The DoD and the VA also need to ensure there are enough mental
health professionals in the healthcare systems serving current and former
250
military personnel and their families to provide treatment to those who
suffer from PTSD, substance abuse, and other mental health problems, and
200
that these providers are located where they are needed. On an overarching
level, the VA needs to institute a process for forecasting the amount and
150
types of resources necessary to meet health requirements of the veterans
and their families well into the future. Requests for disability care and com-
100
pensation by veterans of previous wars did not peak until 30 years or more
after their service ended, and this pattern may hold for Iraq and Afghani-
stan military personnel and their families as well. The VA currently lacks a
50
mandate and resources to make such long-range projections, limiting the
0
Active Air Force
e Marine Corps
Guard Air Force
serve Air Force
e Marine Corps
Reserve Navy
Active Navy
Guard Army
Active Army
Reserve Army
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62 INFORMING THE FUTURE: Critical Issues in Health
agency’s ability to plan for the infrastructure, workforce, and other needs
when demand is likely to be greatest.
In the report, the committee also presents a framework for the sec-
ond phase of its study. The aim is to provide a systematic review of inter-
ventions to ease readjustment to civilian life, to identify gaps in research,
and to identify challenges in accessing care. The second report is expected
in spring 2013.
Concurrently, the IOM is looking at the long-term health effects of
exposure to burn pits, used to dispose of waste in Iraq and Afghanistan.
Using the Balad Burn Pit in Iraq as an example, an IOM committee is exam-
ining the feasibility and design issues of an epidemiologic study of veterans
exposed to the burn pit and their health outcomes as well as exploring back-
ground information on the use of burn pits in the military. A final report is
expected in fall 2011.
The IOM also is studying ongoing efforts in the treatment of PTSD.
The two-part study, mandated by Congress, will collect and analyze data on
DoD and VA programs and methods available for the prevention of PTSD
and the screening, diagnosis, treatment, and rehabilitation of members
of the Armed Forces and veterans diagnosed with PTSD. The first of two
reports is expected in summer 2012.
Treating Traumatic Brain Injury
As Returning Home from Iraq and Afghanistan and other reports have
made clear, TBI is common among soldiers who have fought in Iraq and
Afghanistan. By one estimate, 10 to 20 percent of veterans returning from
those conflicts have sustained a traumatic
brain injury. The IOM has substantial
10 to 20 percent of veterans
experience in this area, having published—
returning from those
sometimes with other units of the National
conflicts have sustained a
Academies—at least eight reports dealing
traumatic brain injury.
with TBI in both military and civilian con-
texts over the past decade.
In recent studies of methods for treating TBI, there is evidence that
nutritional interventions in the minutes or hours following injury may be
effective in improving health outcomes and may even offer some degree of
resilience to TBI. In light of such findings, the DoD asked the IOM to convene
an expert committee to review the potential role of nutritional interventions.
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63
Military and Veterans: Protecting the Protectors
In Nutrition and Traumatic Brain Injury: Improving Acute and Sub
acute Health Outcomes in Military Personnel (2011), the committee describes
what is known—and unknown—about a number of potential interventions.
Given the complexity of TBI and the current gaps in scientific knowl-
edge, the committee could identify only one method that can immediately
improve treatment efforts: early feeding of patients with severe TBI. This
approach involves giving patients specified levels of energy and protein
within the first 24 hours and continuing the course for at least 2 weeks.
Early feeding is likely to limit the person’s inflammatory response, which
typically is at its peak during the first 2 weeks after an injury, and thereby
improve the ultimate health outcome. The committee recommends that the
DoD take the lead in developing feeding protocols that require standard-
ized early nutrition delivery for patients with severe TBI, and that hospital
intensive care units that treat military personnel should include these pro-
tocols in their critical care guidelines.
Although not as far advanced, a num- Early feeding is likely to limit the
ber of other nutritional interventions show person’s inflammatory response,
therapeutic promise as well. The interven- which typically is at its peak
tions target specific physiological processes during the first 2 weeks after
involved in TBI, and they act by restoring an injury, and thereby improve
cellular energy processes, reducing inflam- the ultimate health outcome.
mation and oxidative stress, or repairing
brain functions by regenerating neurons or revascularizing damaged tis-
sue. Researchers within the DoD and elsewhere should expand studies of
these interventions to demonstrate their effectiveness and safety.
Outside of the laboratory, the DoD should improve assessment of the
nutritional status of military personnel, especially those deployed in com-
bat areas, to determine whether there are nutrients that need to be added
to their diets to help provide at least some resistance to TBI.
Beyond nutritional interventions, the IOM continues to study TBI
and consider treatment options. A study currently under way is tasked
with designing a methodology to review, synthesize, and assess the avail-
able evidence and experience from the field to determine the efficacy of
cognitive rehabilitation therapy (CRT) for the treatment of TBI. The DoD
asked the IOM to convene a committee to determine the effects of spe-
cific CRT treatment on improving attention, language and communication,
memory, visuospatial perception, and such executive functions as problem
solving and awareness. The IOM’s final report is expected in fall 2011 and
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64 INFORMING THE FUTURE: Critical Issues in Health
will include recommendations pertaining to the safety, efficacy, and effec-
tiveness of CRT.
Health effects of the Gulf War
The federal government also conducts programs to monitor and protect the
health of military personnel who served in the Persian Gulf War. Following
Iraq’s invasion of Kuwait, the United States led an international coalition of
armed forces in Operation Desert Shield, which began in January 1991 and
ended roughly 3 months later with a ceasefire agreement. Almost 700,000
U.S. troops, including many members of the Reserves and National Guard,
took part in the conflict.
On returning home, a substantial number of the troops reported
health problems that they believed to be connected to their service. At
the request of Congress, the IOM has conducted a series of studies that
have examined the scientific and medical evidence on the health effects
of the various agents to which military personnel may have been exposed.
Beginning in 2000, the IOM has reported on numerous health outcomes
related to possible exposures in the Gulf; that work has resulted in the
studies in the Gulf War and Health series, which currently includes eight
volumes.
As part of this effort, the Department of Vet-
erans Affairs in 2005 asked the IOM to appoint
an expert committee to review what was known
about the current status of veterans’ health. In
its report, Gulf War and Health, Volume 4: Health
Effects of Serving in the Gulf War (2006), the com-
mittee found that many veterans reported that
they were troubled by a combination of medically
unexplained symptoms, often including chronic
fatigue, muscle and joint pain, sleep disturbance,
difficulty with concentration, and depression. Vet-
erans also reported numerous other health prob-
lems, including chronic pain, gastrointestinal dis-
orders, skin disorders, and respiratory disorders.
Research on the conditions continued, and in 2009 the VA asked the
IOM to update its earlier work, based on the latest scientific literature. In
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65
Military and Veterans: Protecting the Protectors
Summary of Findings Regarding Associations Between
Deployment to the Gulf War and Specific Health Outcomes
Sufficient Evidence of a Causal Relationship
• PTSD.
Sufficient Evidence of an Association
• Other psychiatric disorders, including generalized anxiety disorder,
depression, and substance abuse, particularly alcohol abuse. These
psychiatric disorders persist for at least 10 years after deployment.
• Gastrointestinal symptoms consistent with functional gastro
intestinal disorders such as irritable bowel syndrome and func-
tional dyspepsia.
• Multisymptom illness.
• Chronic fatigue syndrome.
Limited/Suggestive Evidence of an Association
• ALS.
• Fibromyalgia and chronic widespread pain.
• Selfreported sexual difficulties.
• Mortality from external causes, primarily motorvehicle accidents,
in the early years after deployment.
Inadequate/Insufficient Evidence to Determine Whether an
Association Exists
• Any cancer.
• Diseases of the blood and bloodforming organs.
• Endocrine, nutritional, and metabolic diseases.
• Neurocognitive and neurobehavioral performance.
• Multiple sclerosis.
• Other neurologic outcomes, such as Parkinson’s disease, demen-
tia, and Alzheimer’s disease.
• Incidence of cardiovascular diseases.
• Respiratory diseases.
• Structural gastrointestinal diseases.
• Skin diseases.
• Musculoskeletal system diseases.
• Specific conditions of the genitourinary system.
• Specific birth defects.
• Adverse pregnancy outcomes such as miscarriage, stillbirth, pre-
term birth, and low birth weight.
• Fertility problems.
Limited/Suggestive Evidence of No Association
• Peripheral neuropathy.
• Mortality from cardiovascular disease in the first 10 years after
the war.
• Decreased lung function in the first 10 years after the war.
• Hospitalization for genitourinary diseases.
SOURCE: Gulf War and Health, Volume 8: Update of Health Effects of Serving in the
Gulf War, p. 8.
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66 INFORMING THE FUTURE: Critical Issues in Health
Gulf War and Health, Volume 8: Update of Health Effects of Serving in the
Gulf War (2010), the committee notes there is considerable evidence that
deployment is associated with the type of chronic, multisymptom illness
reported by many veterans, as well as with various other conditions and
diseases, including gastrointestinal disorders such as irritable bowel syn-
drome; substance abuse, particularly alcoholism; chronic fatigue syndrome;
and some psychiatric disorders, including anxiety disorder and depression.
In addition, there is suggestive, though limited, evidence for an association
with amyotrophic lateral sclerosis (ALS), fibromyalgia and chronic wide-
spread pain, sexual difficulties, and death from external causes, including
automobile accidents, in the early years after deployment.
For the many other diseases with a suggested possible link to
deployment—including various cancers, Parkinson’s disease, Alzheimer’s
disease, and dementia—the committee judged the evidence to be insuffi-
cient for making a determination. For a very few health outcomes, includ-
ing death from cardiovascular disease within 10 years of the war, the com-
mittee found some evidence that deployment has no impact, though data
are far from complete.
Concluding that there is a pressing need to answer lingering ques-
tions, the report offers a detailed action plan. On one front, the government
should continue its surveillance of deployed and nondeployed Gulf War
veterans. This effort should include assembling methodologically robust
cohort groups and carefully tracking their development of a number of dis-
eases, including ALS, multiple sclerosis, brain cancer, and psychiatric con-
ditions, as well as health problems that occur at a later age, such as other
cancers, cardiovascular disease, and neurodegenerative diseases.
On another front, renewed effort
is needed to better understand the multi-
Renewed effort is needed
symptom illness that affects an estimated
to better understand the
250,000 Gulf War veterans. Research-
multisymptom illness that
ers should undertake studies comparing
affects an estimated 250,000
genetic variations and other differences
Gulf War veterans.
in veterans with and without symptoms.
It is likely that the illness results from interactions between genes and
environmental exposure, with genetics predisposing some individuals to
illness. A consortium involving the VA, the DoD, and the National Insti-
tutes of Health could coordinate this effort and contribute the necessary
resources. Similarly, expanded clinical trials are needed to develop more
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67
Military and Veterans: Protecting the Protectors
effective methods to treat or even cure multisystem illness—and, ideally,
to find ways to prevent such disorders from affecting troops in future
deployments.
The VA took quick action. Citing the IOM report, in July 2010 the
agency announced a national research program to identify and adopt more
effective treatments for multisymptom illnesses in Gulf War veterans. The
$2.8 million program, which incorporates recommendations of the VA’s
Gulf War Veterans’ Illnesses Task Force, will feature three new research
projects. Included will be a 5-year study to evaluate the impact of resis-
tance exercise training in treating chronic musculoskeletal pain and related
symptoms, a 4-year study using an animal model of multisymptom illness
to assess therapies designed to enhance mood and memory, and a 2-year
pilot study to compare the effectiveness of certain stress-reduction thera-
pies with conventional care in treating Gulf War veterans. In addition to
funding new research, the VA has asked the IOM to evaluate treatments
being used to manage chronic multisymptom illness and to recommend
those that seem to offer the most benefit and improved health outcomes
in those veterans experiencing chronic symptoms.
Tracking the health effects of Agent Orange
From 1962 to 1971, the U.S. military sprayed herbicides, including a mix-
ture called Agent Orange, over parts of southern Vietnam and surround-
ing areas in order to achieve a number of military goals. Most large-scale
sprayings were conducted from airplanes and helicopters, but herbicides
were also dispersed from boats and ground vehicles and by soldiers wear-
ing back-mounted equipment. Following the war, many veterans and their
families began attributing various chronic and life-threatening diseases to
exposure to Agent Orange or to its toxic contaminant, dioxin.
In 1991, Congress directed the IOM to study the veterans’ claims.
Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam
(1994) provided the first comprehensive, unbiased review of the epide-
miological evidence regarding links between such exposure and the full
spectrum of adverse health effects, including various cancers, reproduc-
tive and developmental problems, and neurobiological disorders. Since
then, the IOM has published a series of biennial updates. Collectively,
these reports—integrating all the peer-reviewed published literature—
provide the scientific basis on which the VA awards disability compen-
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68 INFORMING THE FUTURE: Critical Issues in Health
sation to Vietnam veterans. The reports also recommend research that
could provide more definitive conclusions about possible health effects.
Veterans and Agent Orange: Update 2008 was released in 2009.
Among key findings, the report concluded
that there is suggestive but limited evidence
There is suggestive but limited
that exposure to Agent Orange and other
evidence that exposure to
herbicides is associated with an increased
Agent Orange and other
chance of developing ischemic heart dis-
herbicides is associated
ease and Parkinson’s disease in Vietnam
with an increased chance of
veterans. Ischemic heart disease is charac-
developing ischemic heart
terized by reduced blood supply to the heart
disease and Parkinson’s
that can lead to heart attack and stroke. Par-
disease in Vietnam veterans.
kinson’s disease is a degenerative disorder
of the central nervous system that can cause
movement-related problems and, in later stages, behavioral and cognitive
problems.
In response to a request for clarification by the VA, the committee
that conducted the study also affirmed that hairy cell leukemia should be
classified with chronic lymphocytic leukemia (CLL) and lymphomas for
compensation purposes. Previous reviews in the series had found sufficient
evidence to state that there is an association between herbicide exposure
and increased risk for CLL and lymphomas.
But many health questions remain, and the study committee iden-
tified a number of areas where continued research is needed. For exam-
ple, development of animal models of various chronic health conditions
and their progression would be useful for understanding whether and
how Agent Orange and other herbicides contribute to problems in aging
Vietnam veterans. Work also needs to be undertaken promptly to resolve
questions regarding several health outcomes, most urgently tonsil cancer,
melanoma, and paternally transmitted transgenerational effects.
As a result of the IOM report, Secretary of Veterans Affairs Eric
Shinseki announced plans in October 2009 to add Parkinson’s disease,
ischemic heart disease, and hairy cell leukemia to the list of conditions
presumed to be associated with exposure to Agent Orange. These plans
became final August 31, 2010. The change makes it substantially easier for
thousands of veterans to claim that those ailments were the direct result
of their service in Vietnam, thereby smoothing the way for them to receive
monthly disability checks from the VA. Veterans and Agent Orange: Update
2010, the latest report in the series, will be released in fall 2011.
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Military and Veterans: Protecting the Protectors
In another study, the IOM examined whether Navy personnel
who served aboard deep-water vessels operating off Vietnam might face
increased health risks from exposure to Agent Orange or other herbicides.
Several recent studies have raised the possibility that these sailors might
have been exposed to Agent Orange and its dioxin contaminant, perhaps
via onboard distillation systems that converted seawater into potable
water. If so, the sailors might face the same health risks as ground troops
or sailors in the Brown Water navy who served on vessels that operated in
Vietnam waters and along the coastline. Such concerns prompted the VA to
commission an IOM study.
During its deliberations, the IOM study committee considered
many data sources, including published peer-reviewed literature, models
for assessing environmental concentrations of Agent Orange and dioxin,
memoirs and other anecdotal information from veterans about their expe-
riences during and after the war, government documents, and ships’ deck
logs. The committee also held several open meetings to gather testimony
directly from Navy veterans about their experiences with Agent Orange
while they served in the Vietnam War.
In its report, Blue Water Navy Veterans and Agent Orange Exposure
(2011), the committee concludes that the available evidence is not suffi-
cient to reasonably determine exposure of these sailors to Agent Orange or
dioxin. Thus, it is currently impossible to judge whether Blue Water Navy
Vietnam veterans might be at higher, lower, or similar risk of long-term
adverse health effects associated with Agent Orange exposure than shore-
based veterans or Brown Water Navy veterans.
Safeguarding mental health
Combat troops in today’s wars in Iraq and
Afghanistan, as well as their counterparts Combat troops in today’s
in other wars, face exposure to a range of wars in Iraq and Afghanistan
traumatic events that can cause immediate face exposure to a range of
or delayed mental health conditions. The traumatic events that can
DoD provides an array of mental health ser- cause immediate or delayed
vices, along with other types of health care, mental health conditions.
through TRICARE, a single-payer program
that combines the resources of military treatment facilities with networks
of civilian healthcare professionals and medical facilities. A variety of men-
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70 INFORMING THE FUTURE: Critical Issues in Health
tal health professionals, with differing education, training, and expertise,
provide care through the program.
This cadre includes mental health counselors, professionals who typ-
ically hold master’s degrees and who are obligated by state licensure and
other requirements to have demonstrated clinical experience in order to
practice. Under current TRICARE rules, counselors are required to practice
under a physician’s supervision, and their patients must be referred to them
by a physician in order for their services to be eligible for reimbursement.
In the National Defense Authorization Act for Fiscal Year 2008,
Congress requested that the IOM convene a committee to examine the
credentials, preparation, and training of licensed mental health coun-
selors. In Provision of Mental Health Counseling
Services Under TRICARE (2010), the committee
reports that it found no compelling evidence that
distinguishes mental health counselors from other
classes of practitioners in their ability to serve in
an independent capacity or to provide high-quality
care. Accordingly, the committee recommends
that TRICARE change its policy to permit mental
health counselors to practice independently in cir-
cumstances where their education, licensure, and
clinical experience have helped to prepare them
to diagnose and, where appropriate, treat condi-
tions in the beneficiary population. It offered a
set of guidelines for determining when these cir-
cumstances were fulfilled. The committee recom-
mends that counselors who do not meet the proposed requirements still
be allowed to practice within the system to maintain the continuity of care,
and that TRICARE consider supervising them in a manner that provides
for successively greater levels of independent practice as experience and
demonstrated competence increase.
The committee also recommends a more fundamental step, that
TRICARE implement a comprehensive quality management system for all
of its mental health professionals. This recommendation is built on other
IOM reports that suggest that the best way for healthcare providers to
deliver high-quality care is by setting appropriate standards of education
and training for providers and then promoting evidence-based care stan-
dards and the monitoring of results.
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Military and Veterans: Protecting the Protectors
After the report’s release, the IOM, at the request of the DoD, held
a 3-day workshop in October 2010 to explore the possible structure and
implementation of the recommended quality management system. The
workshop brought together participants from a variety of groups and with
a range of interests, and the discussions are expected to inform efforts
to improve the way that TRICARE serves the mental health needs of its
beneficiaries.
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