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Hi ~ ~ ~ ~ ~ ~
Military Personnel and Veterans
If the work that we have done here serves to assist in
resuscitating even one casualty that would have otherwise been
lost, as we believe it wig then this will have been a successful and
worthwhile endeavor.
David E. Longnecker, Chair, IOM Committee on
Fluid Resuscitation: State of We Science for Treating
Combat Casualties and Civilian Injuries
_ ~ he nation's armed services face complex challenges In assuring
the health of military personnel, whether on routine assign-
ments or when deployed in combat or in other remote, extreme
situations. The military also faces challenges in protecting and pro-
moting the health of the families of active-duty personnel, whether
posted with the service members or remaining in the United States,
and in providing health services to military retirees and their families.
The Institute of Medicine conducts a wide range of studies to ad-
vise the Department of Defense (DoD) on how to maintain optimum
health status of active-duty personnel,
retirees, arid their families. We also are In moclern warfare, troops are
very active in addressing issues relating exposer! to a variety of conditions
to the health of veterans. ~ modern and toxic agents that may have
warfare, Coops are exposed to a variety long-term health effects not dis-
of conditions and toxic agents that may cernable before discharge, hence
have long-term health effects not dis- clifficult to establish as causally
cernable before discharge, hence diffi- related to military experiences.
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Informing the Future: Critical Issues in Health
cult to establish as causally related to military expenences. The Con-
gress and many veterans groups rely on the TOM to provide objective
analyses of health effects associated with military deployments. The
deployments may be as recent as the Persian Gulf conflict, or as long
ago as World War H.
PROMOTING HEALTH AND REDUCING
THE RISK OF DISEASE
One of histo~r's Neatest generals, Napoleon Bonaparte, observed that
"an army marches on its stomach." Good nutrition is as important in
readiness today as it was in 1812. Since World War IT, the DoD has
relied on our Food and Nutntion Board (FrNB) for advice on military
nutntion. Studies conducted by the FNB's Committee on Military
Nutntion Research have answered such questions as how to make
meals-ready-to-eat (MREs) more palatable and nutritious, and what
healthy body weights, or "body compositional standards," are best
suited to the various physical performance expectations for active
duty personnel. Because body weight is a serious problem for the
military, we are also developing criteria for weight management pro-
grams designed specifically for service members. In addition we have
made recommendations related to standards for female service mem-
bers during pregnancy arid lactation.
,
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78
PROTECTING AND TREATING
COMBAT TROOPS
The U.S. military has long emphasized troop safety as a
top pnonty, as is evident in military strategy and tactics,
and in the development of sophisticated technology to
decrease risk to personnel. The commitment also is evi-
dent in DoD-sponsored research. One of the most impor-
tant safety goals involves the immediate resuscitation of
wounded soldiers in the field, to improve their survival
duping transport to a field hospital for advanced treat-
ment. Fluid Resuscitation: State of the Science for
Treating Combat Casualties and Civi1tia7~ Injuries (1999)
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Military Personnel and Veterans
0 minutes
40%
>30 minutes
20%
5 minutes
25%
Time from injury to death of battlefield
casualties. The single major cause of
death in potentially salvageable battlefield
casualties is massive bleeding. It is rea-
sonable to expect that with immediate'
,
appropriate care, a significant number of
<30 minutes these patients could be saved. SOURCE:
15% Fluid Resuscitation: State of the Science
for Treating Combat Casualties and Civil-
ian Injuries, 1999; page 1 1 .
recommends an entirely new approach to addressing the leading
cause of death in potentially salvageable battlefield casualties—hem-
orrhage. The report identifies which of
today's technologies are best suited. for One of the most important safety
acute treatment of massive blood loss on goals involves the immecliate
the battlefield, provides direction for resuscitation of wounded soIcliers
longer-term research that might lead. to in the field, to improve their
advances in the knowledge about hem- survival during transport to a fielcl
orrhagic shock and care for combat hospital for advancecl treatment.
casualties, and offers suggestions for
technologies or approaches that would apply to civilian emergency
trauma care as well. Other studies have provided advice on such sub-
jects as maintaining cognitive performance during extended combat
operations arid in extreme, high-altitude environments.
DEPLOYMENT-RELATED HEALTH EFFECTS
Many veterans arid their families attribute varied chronic and life-
threatening diseases to the effects of service in specific theaters of war
or presence at weapons test sites. The TOM conducts studies to assess
evidence of short-term and long-term health effects that may support
or disprove these connections. A number of reports have focused on
Agent Orange and other herbicides (including their contaminants, no-
tably dioxin) used dunng the Vietnam War. Veterans and Agent Or-
ar~ge: Health Elects of Herbicides Used in Vietnam (1994) provided
79
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Informing the Future: Critical Issues in Health
the first comprehensive, unbiased review of the scientific
evidence regarding a link between herbicide exposure and
such adverse health effects as cancer, reproductive prob-
lems, atop neurological disorders. This study, and updates
in 1996, 199S, and 2000, provides the scientific basis
upon which the Department of Veterans Affairs (VA)
awards disability compensation to Vietnam veterans. The
reports also recommend research that could provide more
definitive conclusions about potential health effects.
Almost 700,000 U.S. troops participated in the war in
the Persian Gulf, including a large number of reserve
units. Most returned home within a few months and re-
sumed their normal activities. Within a relatively short
time, a number of reservists and active duty personnel began to report
health problems they believed to be connected to their deployment.
Gulf War Veterans: Measuring Health (1999) concludes that no single
diagnosable illness or set of symptoms with a known etiology charac-
tenzes either Gulf War veterans in general or a subset of veterans who
are experiencing some kind of health problem. Yet, there does seem to
be a higher prevalence of some symp-
no single diagnosable illness
or set of symptoms with a known
etiology characterizes either
Gulf War veterans in general or a
subset of veterans who are
experiencing some kind of health
problem.
tome such as fatigue, memory loss,
headache, arid muscle and joint pain
among Gulf War veterans than among
nondeployed veterans. Major uncer-
ta~nties remain, however, and the re-
port recommends that the federal gov-
ernment sponsor a range of research
activities, including population studies,
health services research, and clinical and biomedical investigations, to
address fimdamental questions about the health of Gulf War veterans.
TOM committees are now studying the potential health effects of up to
33 toxic agents that Gulf War veterans may have encountered during
their service. As in the case of Agent Orange, the VA will rely upon
our reports to determine disability compensation for these veterans.
80
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Military Personnel and Veterans
Stressors of the Persian Gulf War
Chemical Environmental Combat Related
Oil fire smoke
Diesel and jet fuel
Solvents and other pet-
rochemicals
Insect repellents
CARC paint
Depleted uranium
Anthrax and botulinum
vaccines
Sand
Fleas and other insects
Extreme heat
Relatively primitive living
conditions
Unfamiliar character of region
Prohibition against interaction
with indigenous population
Exposure to dead and muti-
lated bodies
Pyridostigmine bromide Exposure to dead animals
pills
Rapid mobilization leading
to unexpected disruption
of lives, particularly for
Reserve and Guard units
Waiting for combat to begin
Potential cumulative effect
of repeated deployments
to conflict
Rapid demobilization, par-
ticularly for Reserve and
Guard units
SCUD missile attacks
Multiple chemical alarms
SOURCE: Gulf War Veterans: Measuring Health, 1999; page 13.
The Agent Orange and Gulf War studies, along with others examin-
ing the health effects of radiation exposures dunug 1950s atomic
tests, highlighted the absence of reliable information about the exact
location of individuals dunng deployments, their exposure levels to
venous dangerous substances, and other factors necessary to ade-
quately assess potential harm. Dis-
cussion of these issues with the DoD fOM committees are now studying
resulted in a request by the Depart- the potential health effects of up to
ment for comprehensive recommen- 33 toxic agents that Gulf War
cations about how to better protect veterans may have encountered
deployed forces in fixture combat or during their service.
peacekeeping operations. Strategies
to Protect the Health of Deployed U.S. Forces: Medical Surveillance,
Record Keeping, and Risk Reduction (1999) recommends urgent ac-
lion to improve procedures for recording health problems experienced
by military personnel in the field, documenting troop locations dunng
deployments, and communicating with military commanders about
81
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Informing the Future: Critical Issues in Health
environmental and medical hazards that may exist in war zones.
While achieving the mission of a military operation always will be
the paramount objective, soldiers must know that their health and
well-being are taken senously. Failure
Failure to incorporate improved to incorporate improved procedures
procedures may erocle the tradi- may erode the traditional trust be-
tional trust between the service tween the service member and the
member anc! the military leader- military leadership, impair morale,
ship, impair morale, and accelerate and accelerate early departures Tom
early departures from the services. the services.
Many people within and beyond the Unitary have begun to ask
whether there are health consequences of service in military conflicts
beyond the obvious war injuries and, if so, whether there are ways to
prevent or at least mitigate He consequences of war-related illnesses
and deployment-related health effects. Investigations of the health of
Gulf War veterans have generated infonnation suggesting that such
problems may be expenenced by some veterans of all military con-
flicts. In response to this emerging information, Congress asked the
TOM to advise the VA on creating a national facility devoted to war-
related illnesses and postbeployment health issues. National Center for
Military Deployment Health Research (1999) makes recommendations
to help Be VA in developing the center, which will be responsible for
compiling the comprehensive knowledge base necessary for moving
the nation forward in protecting all individuals who will participate in
fixture military deployments.
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Selected Recommendations for Global Health . . .
Global Health: The U.S. Government should form an Interagency
Task Force on Global Health to anticipate and address global health
needs and to take advantage of opportunities in a coordinated and
strategic fashion. (America's Vita/ /nferest in G/oba/ Health: Protect-
ing Our People, Enhancing Our Economy, and Advancing Our /nter-
nationa/ /nterests)
Infectious Disease Surveillance: The U.S. Government, along
with the private sector, should facilitate the development of an effec-
tive global system for surveillance of infectious diseases. Along with
that, the capacity of developing countries in biomedical surveillance
and communications should be fostered. The international infectious
disease surveillance activities of the U.S. government should be co-
ordinated by the Centers for Disease Control and Prevention (CDC).
CDC should continue leading the development of strategies that
strengthen state and federal efforts in surveillance. (Emerging /nfec-
fions: Microbia/ Threals lo Hea/fh in file United Stales)
Infectious Disease Research and Training: National Institutes of
Health-supported research on the agent, host, vector, and environ-
mental factors that lead to the emergence of infectious diseases
should be expanded and coordinated. Department of Defense infec-
tious disease laboratories should continue to be supported. (Emerging
/nfections: Microbia/ Threats to Health in the United Sfafes)
Tuberculosis Control: The United States should expand and
strengthen its role in global tuberculosis control efforts, contributing
through bilateral and multilateral international efforts. (Ending Ne-
g/ect: The Elimination of Tuberculosis in the Unite c] States)
Representative terms from entire chapter:
war veterans
