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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. 77

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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. , Resuscitabon Is - ~~ .. ..... ...' .. 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 casualtieshem- 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. 82

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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)