US MILITARY MEMBERS have served in many wars and peacetime intervals around the globe, often in harm's way. Their healthcare needs may be fundamentally different from those of civilians due to unique environmental hazards, endemic country diseases, harmful biologics, toxic fumes, traumatic events, and the accompanying psychological factors of war.
Many veterans from World War II, the Korean War, the Vietnam War, the Gulf Wars (Desert Storm and Desert Shield), Iraq (Operation Iraqi Freedom or OIF), Afghanistan (Operation Enduring Freedom or OEF and Operation New Dawn or OND), and many other conflicts and peacetime operations are living among us and may seek care in civilian healthcare facilities. To provide them the very best care possible, healthcare professionals must first be able to identify them.
The "Have You Ever Served?" campaign1,2
The Have You Ever Served in the Military? campaign, a partnership with the Joining Forces Initiative, is an awareness initiative created by the American Academy of Nursing.2 Its purpose is to inform healthcare providers on how to identify US military members and veterans by asking questions specific to their military histories, and to help providers gain insights into possible etiologies of health issues that will inform assessments, therapeutic interventions, and consultations.1
Ask every adult patient if they have ever served in the military. If the answer is "yes," ask these follow-up questions (see Have You Ever Served? Pocket Card3).
* Which branch did you serve in?
* When? Where did you serve?
* What was your job?
* Were you deployed to a combat area?
* Did you see combat? Receive enemy fire? Witness casualties?
* Were you wounded or injured? Were you hospitalized?
* Did you participate in any experimental projects or tests?
* Were you exposed to loud noises or explosives?
* Were you exposed to chemicals, gases, demolition, smoke, or other hazardous substances?
Also ask:
* Have you ever used the Veterans Health Administration (VHA) for your healthcare?
* Do you have a service-connected disability or condition?
* When was your last visit to the Veterans Affairs (VA)? Do you have a VA primary care provider?
Where veterans and military members seek healthcare
Approximately 9.8 million (49%) of the US veteran population are enrolled in the VA healthcare system, while 10.2 million (51%) are not enrolled and seek care elsewhere or receive no care.4 Since 2014, when President Obama signed the Veterans Access to Care Through Choice, Accountability, and Transparency Act of 2014/Veterans' Choice Act (H.R.3230; Pub.L. 113-146)5 into law, veterans living more than 40 miles from a VA healthcare facility or who are unable to schedule an appointment within a reasonable time could access non-VA hospitals for their care.5 In 2017, President Trump signed an extension to the law, enabling more veterans to have access to non-VA hospitals and clinics.6
In June 2018, the Veterans Mission Act replaced the Veterans Choice Act, expanding non-VA healthcare options to veterans who have to drive for more than 30 minutes to access a VA healthcare facility. The Department of Veterans Affairs has contracted with a private agency to assist with contracting with a private network of providers.7
Changes are occurring in the Department of Defense Healthcare System (DHS). A 2019 article noted that the US Army, Navy, and Air Force hospitals and clinics will be merged "within the next two years" under the auspices of the Defense Health Agency (DHA) to support the primary mission of supporting warfighter readiness.8 The DHA is working with Tricare and local healthcare providers to assure that military healthcare beneficiaries will have access to high-quality care in civilian facilities.8
General healthcare issues that may affect any veteran
Posttraumatic stress (PTS) and Posttraumatic stress disorder (PTSD)
PTSD has impacted veterans who have been exposed to combat. It was called "shell shock" during WWI, "battle fatigue" in WW II, and "Post-Vietnam Syndrome." PTSD was officially classified as a diagnosis in 1980 by the American Psychiatric Association.9 This mental health diagnosis is evidenced by life-altering severe persistent symptoms. (See Symptoms of PTSD.) PTS, on the other hand, is an exposure-response and not a diagnosis. It happens to someone who has been exposed to a traumatic event. PTS symptoms, such as anxiety, fear, re-experiencing the traumatic event, and tachycardia, are common postdeployment, typically resolve within a month, and do not have life-altering sequelae. Not everyone with PTS has PTSD.10,11
In a 2019 Wounded Warrior Project Survey, 57% of wounded warriors from OIF and OEF self-reported experiencing PTSD.12 Eighty percent of OIF and OEF veterans have friends who were seriously wounded or killed in action. Seventy-five percent of OIF and OEF veterans report memories of traumatic experiences that have haunted them in the past month. Thirty-five percent have been diagnosed with PTSD.13
The following questions can be asked to identify possible PTSD:1
* Have you experienced an event when your life or the lives of those around you have been in danger?
* Have you experienced trauma-related thoughts or feelings?
* Are you having nightmares, vivid memories, or flashbacks?
* Do you feel anxious or jittery?
* Do you feel a sense of panic that something bad is about to happen?
* Are you having difficulty concentrating or sleeping?
Regardless of the length of time since deployment, it is never too late to get help for PTSD. The Veterans' Crisis Line is available 24/7 at 800-273-8255 (press 1).
Veteran homelessness
Ask, "Do you have a place to live?"
In January 2020, the the US Department of Housing and Human Development Annual Homeless Assessment reported that 37,252 veterans were experiencing homelessness, making up 8% of all homeless adults. Of these, 22,048 were sheltered and 15,204 were unsheltered.14,15 The number of homeless female veterans is increasing. Approximately 3,126 female veterans (8.4% of homeless veterans) experienced homelessness; 12% are likely to have children under the age of 18. Female veterans are three times more likely than female non-veterans to become homeless. According to VHA researchers, the increase may be due to military sexual trauma, intimate partner violence, substance abuse, post-traumatic stress disorder, childhood adversity, unemployment, medical illnesses, or relationships that have ended.16
Overall, homelessness may be due to unemployment, unaffordable housing, financial challenges, and mental health issues, such as PTSD and those related to a traumatic brain injury (TBI).2,9 Seven percent of veterans live below the poverty line, and 1.3 million veterans receive help from the Supplemental Nutrition Assistance Program (SNAP; formerly known as the Food Stamp Program).17,18 More than 778 US communities and three entire states (Connecticut, Delaware, and Virginia) have essentially ended Veteran homelessness with their accessible housing and comprehensive job training programs. The VA National Call Center for Homeless Veterans is 877-424-3838.
Amyotrophic lateral sclerosis (ALS)
Although veterans are twice as likely to develop ALS (also known as Lou Gehrig disease) than those who have not served, extensive research has not been able to determine the causative link between military service and ALS.19 Any veteran with ALS who served 90 or more days on continuous active duty in any branch of the military, in any location, at any time is entitled to full VA benefits.20 Note that ALS has not been found to be related to Agent Orange exposure.
Military sexual trauma (MST)
The military has done extensive work on MST prevention and awareness. A military member who alleges sexual trauma can choose to file a restricted report, wherein the information and data are kept confidential, or an unrestricted report, which launches an investigation. This has resulted in increased reporting without fear of retribution. The VA has done excellent work identifying and treating those who have delayed reporting a sexual assault that occurred while on active duty. Any veteran may receive MST-related care at no cost in the VA healthcare system, even if they are not eligible for other VA services. In FY 2017, the VA provided 1,325,000 MST-related mental health care services for outpatients.21 If a veteran's PTSD is associated with MST, VA benefits may be available.
Ask these questions to male and female veterans:1
* During your military service, did you receive uninvited or unwanted sexual attention, such as touching, pressure for sexual favors, or sexual remarks?
* Did anyone ever use force or threat of force to have sexual contact with you?
* Did you report the incident to your commander and/or military or civilian authorities?
* Did you receive treatment?
* Were you offered medical or legal advice or both?
* Did you report this to the VA?
Of the homeless female veterans that have been identified, one in four reported being sexually assaulted while in the military.22 They often feel betrayed and are reluctant to identify themselves as veterans.
Blast concussions, TBI, and hearing loss
Many veterans may not be aware of the physiologic and mental health changes that occur as a result of a blast concussion/mild TBI (concussion) such as memory loss, personality change, and/or loss of attention. Ask if they have experienced heavy artillery fire, explosions, such as occur with improvised explosive devices (IEDs), rocket-propelled grenades (RPGs), or an aircraft accident.3
Do they have any shrapnel fragments or bullet wounds above the shoulders?1
If they experienced any of the above, ask the following questions:1
* Did you have a loss of consciousness or being "knocked out"?
* Were you dazed ("seeing stars")?
* Are you having difficulty remembering the event?
* Have you been diagnosed with a concussion or other head injury?
* Do you have hearing loss?
Many veterans who have been in the range of artillery fire or other blast explosions have hearing loss. When you are talking with a veteran, make certain they can hear you and understand what you are saying.
Suicide and suicidality
Suicide is a major concern in the Veteran population.21 Veterans account for approximately 8.5% of the US adult population, yet they account for about 13.8% of US adult deaths by suicide.21 The suicide rate in veterans was 27.5 per 100,000 in 2018, with the highest increase in 18- to 34-year-old male OEF and OIF veterans. The highest suicide rate is among male veterans between the ages of 55 and 74, the largest population of US veterans. Female veterans have 2 to 5 times the suicide rate as non-veteran females. An average of 17.6 veterans and one active duty military member commit suicide every day.23 Veteran suicide prevention is a VA top priority.
Suicide risks
Clinicians must be on heightened alert for signs that a veteran is at risk for suicide.23,24 This information may also be shared by family members. (See Signs of possible suicidal ideation.)
You may observe signs of a deteriorating physical condition, irrational thinking, paranoia, agitation, irritability, and neglect for their welfare.
The 24/7 VA Crisis Line number is 800-273-8255 (Press 1), or text message 838255, or start a chat session with someone at the VA Crisis Line at veteranscrisisline.net/get-help/chat.25
Identified health risks by specific military assignment and/or location and date
World War II radiation exposures-Hiroshima and Nagasaki
US prisoners of war in Japan and veterans who were involved in the occupation of Hiroshima and Nagasaki during and after the bombings from August 6, 1945 to July 1, 1946 may have been exposed to ionized radiation.26 Postbombing rescue teams were also exposed to radiation. Veterans were involved in nuclear weapons tests in Nevada and the Island of Amchitka, Alaska, from 1945 to 1962. These ionized radiation exposures may be the cause of certain cancers.27
Korean War
In addition to many of the above issues, veterans who fought in Korea were often exposed to extreme cold conditions without proper protective clothing and footwear and may have sustained extensive hypothermia injuries.28
Vietnam War
Agent Orange
From 1962 to 1971, Agent Orange, a tactical herbicide and defoliant developed by the US Department of Defense, was sprayed to destroy the thick tropical foliage and expose the enemy in the jungles. Any veteran who served in Vietnam during this period is presumed to have had an Agent Orange exposure (Agent Orange Act of 1991). Many diseases are presumed to be related to Agent Orange exposure. Veterans and their survivors may be eligible for VA benefits for these diseases.29 (See Presumptive diseases caused by Agent Orange)
Veterans who served in any of these locations may have had exposures to Agent Orange:29
Exposures in-country (in Vietnam)
* On land
* On watercraft on the inland waterways
* On ships operating not more than 12 nautical miles from the demarcation line of the waters of Vietnam and Cambodia (Public Law 116-23, Blue Water Navy Vietnam Veterans Act 2019)
* C-123 aircraft ground maintenance, pilots, and air medical crews when aircraft were flown during and after the Vietnam War29
Those possibly exposed outside of Vietnam include Korean Demilitarized Zone personnel (Sept 1, 1967-August 31, 1971), US military base personnel in Thailand (January 9, 1962-May 7, 1975), and personnel at herbicide storage locations and test sites at various military bases in and outside of the US.29
Hepatitis C virus (HCV) infection
HCV infection prevalence rates differ by time of military service. The highest prevalence was in Vietnam between 1964 and 1975. This was due to blood products not being screened for HCV; battlefield exposures to blood infected with HCV; and sharing dirty needles, razors, toothbrushes, and other personal items of people infected with HCV.30
The American Liver Foundation recommends HCV testing for anyone born between 1945 and 1965. Because most Vietnam veterans were born within this time frame and because veterans who served in Vietnam were at high risk for HCV, it is recommended that they be tested for HCV.31
Camp Lejeune, North Carolina (January 1, 1957-December 31, 1987)
Toxic Water
Military members and their family members who lived in enlisted family housing or the barracks and/or drank water in schools, base administrative offices, and recreation areas in Camp Lejeune, N.C., were exposed to chemicals in the groundwater from two water supply systems contaminated with industrial solvents. This was due to improper disposal of chemicals from an off-base dry cleaner, on-base industrial site spills, and leaks from storage tanks and drums of chemicals at dumps and storage lots.32
The 2012 Camp Lejeune Healthcare Law authorizes cost-free healthcare for veterans who served a minimum of 30 days of active duty at Camp Lejeune from August 1, 1953, to December 31, 1987. Family members who lived there during this period are eligible for reimbursement of out-of-pocket medical expenses not covered by other healthcare plans for certain diagnoses.32 (See Presumed diagnoses due to Camp Lejeune toxic water consumption)
Gulf Wars-Operation Desert Shield and Operation Desert Storm
Gulf War Syndrome
Gulf War Syndrome has affected many veterans of the 1990-1991 Persian Gulf War.33 It is a prominent cluster of chronic symptoms, such as fatigue, musculoskeletal pain, diarrhea, headaches, short-term memory loss, poor concentration, and skin rashes, the cause(s) of which is (are) unknown.33-35
Military members may have been exposed to pesticides, antinerve agents (pyridostigmine), anthrax and botulinum toxoid vaccinations, oil well fires, and chemical and biological warfare agents.33 Those who exhibit any of the following chronic disorders during active duty or up until December 31, 2021, and who are at least 10% disabled may receive benefits from the VA:35
* Myalgic encephalomyelitis/chronic fatigue syndrome
* Fibromyalgia
* Functional gastrointestinal disorders
* Unclassified illnesses (currently under investigation): cardiovascular disease, menstrual disorders, neurologic disorders, Parkinson disease, multiple sclerosis, ALS, cancers (especially brain and lung), abnormal weight loss, mental health disorders, migraine headaches, respiratory disorders, sleep disorders, cognitive impairments, and dermatologic disorders.
Ask about exposures. Gulf War Veterans who are eligible should enroll in the VA's Gulf War Registry Health Exam and/or the Airborne Hazards and Open Burn Pit Registries.28,35
Gulf Wars, Bosnia, Afghanistan
Depleted Uranium
Depleted uranium is found in the soil and sand and air in Iran, Bosnia, and Afghanistan. Because of the high density of uranium, heavier than lead, it is used in munitions created to penetrate armor plates and reinforce military vehicles. The chemical and radiologic properties of uranium and depleted uranium target the kidneys and lungs.
Exposure can occur through inhalation, ingestion, or contact with or penetration of the skin by foreign bodies, such as shrapnel, carrying depleted uranium.36
Iraq (OIF,OND) and Afghanistan (OEF)
Open-air burn pits
Open-air burn pits have been prevalent in Iraq, Afghanistan, and Djibouti since 1990. Ignited by jet fuel, these pits are used to burn trash, nonserviceable uniforms, medical and surgical waste, chemicals and pesticides, electronics, and other materials. The toxic smoke and fumes were and are inhaled by military members living and working in the area.37 The Wounded Warrior Project 2019 Annual Survey found that 70.4% of the Wounded Warriors who served in OEF and/or OIF reported exposure to toxins.12
In a news release on September 11, 2020, the National Academies of Sciences, Engineering, and Medicine stated that "New approaches are needed to better answer whether respiratory health issues are associated with deployment. The current uncertainty should not be interpreted as meaning that there is no association-rather, the issue is that the available data are of insufficient quality to draw definitive conclusions...The effect of exposures, including burn pits, related to deployment may take time to manifest..."38
The Burn Pits 360 veteran advocacy group has reported that 76% of veterans exposed to toxic fumes from burn pits have been denied VA benefits.39 On September 15, 2020, Senator Gillibrand (D-NY) and Senator Marco Rubio (R-FL) proposed a bill in the Senate, The Presumptive Benefits for War Fighters Exposed to Burn Pits and Other Toxins Act of 2021 - SB-952-117th Congress (2021-22).40 At the time of this writing, the bill has not yet reached the floor of the Senate.40 A similar bill has been proposed by US Representatives Raul Ruiz, MD, (D-CA) and Brian Fitzpatrick (R-PA).
The VA has several environmental health registries used to track military members with potentially toxic exposures. (See Active duty occupational toxic exposures.41) Care providers should encourage veterans to enroll in the Airbourne Hazards and Open Burn Pit Registry and other registries if they have had any exposure.
Infectious diseases
Infectious diseases, such as malaria and typhoid fever exist in Iraq, Afghanistan, and many African nations. Military members are required to be immunized against typhoid fever and given antimalarial medications. Viral hepatitis, tuberculosis, leishmaniasis (from sandfly bites), and rabies are also prevalent in these countries.
Shrapnel
Shrapnel, embedded fragments of debris from munition shells, land mines, IEDs, bombs, and RPGs may contain toxic materials.42
Veterans who have retained shrapnel may be eligible for medical surveillance by the Toxic Embedded Fragment Surveillance Center at the Baltimore VA Medical Center. They may request a registry evaluation through their local VA OEF/OIF coordinator, environmental health coordinator, or VA primary care team.42
Remember to ask each patient the question, "Have you ever served in the military?" If the answer is "Yes," identify possible diagnoses and etiologies of their diseases and injuries that may be related to military duty; provide appropriate interventions and support; and arrange for consultations to determine their eligibility for VA services, ratings, and/or financial assistance. We owe this diligence to our military members and veterans.
Symptoms of PTSD9,10
* Intrusive thoughts
* Recurring nightmares
* Extreme sleep disturbances
* Flashbacks
* Social avoidance
* Negative thoughts
* Distorted beliefs
* Hyperarousal
* Hypervigilance
* Angry outbursts
* Reckless behaviors
* Social isolation
Signs of possible suicidal ideation23,24
Generalized anxiety
Depression
Expressing thoughts of:
* feeling trapped; no way out
* failure
* humiliation
* shame
* desperation
* hopelessness
* isolation
* a purposeless life
* life not worth living
* being a burden to their family
A history of:
* family violence (domestic abuse/child abuse)
* relationship issues
* workplace difficulties
* PTSD
* sexual trauma
* TBI
* chronic pain
* sleep disorders
Presumptive diseases caused by Agent Orange29
* Chronic B-cell Leukemias
* Chloracne
* Diabetes mellitus type 2
* Hodgkin disease
* Ischemic heart disease
* Multiple myeloma
* Non-Hodgkin lymphoma
* Parkinson disease
* Peripheral neuropathy (early onset)
* Primary amyloidosis
* Prostate cancer
* Respiratory cancers (lungs, larynx, trachea, and bronchus)
* Soft tissue sarcomas
* Birth defects in children (especially spina bifida)
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