Protecting the Health of Those Who Protect the Nation

The Department of Defense (DoD) and the Department of Veterans Affairs (VA) share the responsibility of assuring that the men and women of the armed services receive the best possible support to be fit while on active duty, to be protected from preventable risks, to receive the highest quality health care, and to be appropriately cared for when their service ends. This is a complex challenge. Today’s warfare involves extended deployment in hazardous environments and the risks associated with combat. Exposure to high levels of various compounds—including chemicals, combustion products, and chemical warfare agents—creates potential long-term health risks. So, too, does the stress of living and working in extremely dangerous environments. The DoD faces the task of maintaining deployed forces at optimal readiness, taking all possible steps to protect their health, and delivering the highest standard of care for the injured. The DoD and VA also must assure military personnel a smooth transition from active duty to veteran status. The VA faces the long-term responsibility to provide health care and financial compensation for service-related injuries.

The Institute of Medicine (IOM) conducts studies and data analyses to assist the DoD and the VA and to protect the interests of active duty personnel, military families, and veterans.

PROTECTING THE HEALTH OF DEPLOYED FORCES

Congressional concern about the limited availability of medical countermeasures against biological warfare agents resulted in a request that the IOM review the Department of Defense’s efforts in developing such vaccines and pharmaceutical products. Giving Full Measure to Countermeasures: Addressing Problems in the DoD Program to Develop Medical Countermeasures Against Biological Warfare Agents (2004) points to problems that include fragmentation of responsibility and authority, changing strategies that resulted in lost time and expertise, and a lack of financial commitment adequate to meet the requirements of the program’s goals. The report’s recommendations include making the program to develop medical countermeasures a truly high priority, creating a Medical Biodefense Agency within the Office of the Secretary of Defense to lead the program, and establishing external oversight and accountability for program performance.



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Informing the Future: Critical Issues in Health, Third Edition Protecting the Health of Those Who Protect the Nation The Department of Defense (DoD) and the Department of Veterans Affairs (VA) share the responsibility of assuring that the men and women of the armed services receive the best possible support to be fit while on active duty, to be protected from preventable risks, to receive the highest quality health care, and to be appropriately cared for when their service ends. This is a complex challenge. Today’s warfare involves extended deployment in hazardous environments and the risks associated with combat. Exposure to high levels of various compounds—including chemicals, combustion products, and chemical warfare agents—creates potential long-term health risks. So, too, does the stress of living and working in extremely dangerous environments. The DoD faces the task of maintaining deployed forces at optimal readiness, taking all possible steps to protect their health, and delivering the highest standard of care for the injured. The DoD and VA also must assure military personnel a smooth transition from active duty to veteran status. The VA faces the long-term responsibility to provide health care and financial compensation for service-related injuries. The Institute of Medicine (IOM) conducts studies and data analyses to assist the DoD and the VA and to protect the interests of active duty personnel, military families, and veterans. PROTECTING THE HEALTH OF DEPLOYED FORCES Congressional concern about the limited availability of medical countermeasures against biological warfare agents resulted in a request that the IOM review the Department of Defense’s efforts in developing such vaccines and pharmaceutical products. Giving Full Measure to Countermeasures: Addressing Problems in the DoD Program to Develop Medical Countermeasures Against Biological Warfare Agents (2004) points to problems that include fragmentation of responsibility and authority, changing strategies that resulted in lost time and expertise, and a lack of financial commitment adequate to meet the requirements of the program’s goals. The report’s recommendations include making the program to develop medical countermeasures a truly high priority, creating a Medical Biodefense Agency within the Office of the Secretary of Defense to lead the program, and establishing external oversight and accountability for program performance.

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Informing the Future: Critical Issues in Health, Third Edition PROMOTING HEALTH AND IMPROVING PERFORMANCE The report identifies a number of promising biomarkers for predicting health deterioration…; describes technologies for monitoring metabolic status under field conditions; and reviews analytical techniques, or algorithms, for interpreting the data. The success of military operations depends greatly on the physical and mental status of the soldiers and other personnel involved. During combat operations, military commanders would like to be able to monitor the physiological and cognitive status of their troops. This ability would enable the leaders to determine when individual soldiers need to rest, eat, or consume fluids, and to determine whether their condition has deteriorated to the point that they need to be replaced rather than risk combat injury. Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance During Military Operations (2004) examines current and needed technologies and information that can inform command decisions concerning the “readiness” of individual service members during combat operations or training. The report identifies a number of promising biomarkers for predicting health deterioration (for example, muscle fatigue, dehydration, and impairments of renal function, cognitive function, and stress and immune responses); describes technologies for monitoring metabolic status under field conditions; and reviews analytical techniques, or algorithms, for interpreting the data. It also makes a “blue sky” forecast of research areas that may lead to revolutionary advances, such as developing techniques for using odors and tears as markers of metabolic status, developing new algorithms for integrating complex biological information, and developing genetic techniques that can help in predicting how individual soldiers will perform under the dietary and environmental conditions of combat. Soldiers involved in short-term, high-intensity assault missions need to perform at optimal efficiency. Ensuring that they maintain proper nutrition during such missions is a continuous challenge, mainly because individuals under stress typically have diminished appetites. In fact, soldiers in combat usually consume about half of the calories needed for optimal performance, leaving them prone to fatigue and mental impairments. In addition, weight and size ration constraints as well as food technology issues impose further limitations to ration design. With the number of such missions increasing, the military is placing high priority on developing new types of light-weight rations. Nutrient Composition of Rations for Short-Term, High- …soldiers in combat usually consume about half of the calories needed for optimal performance, leaving them prone to fatigue and mental impairments.

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Informing the Future: Critical Issues in Health, Third Edition Box Es-1 Assumptions Regarding Assault Missions Population Soldiers deployed to assault missions are male with an average body weight of 80 kg, apporoximately 16 percent body fat who are relatively fit and within an age range of 18–45 years (average < 25 years). Prior to Assault Mission Sodiers may be useing dietary supplements and caffeine. Immediately prior to a mission soldiers are well hydrated, not abusing alcohol, but may be using tobacco products. During Assault mission Soldiers may be on a mission for as many as 24 out of 30 days, with each mission lasting three to seven days. There may be as much as 20 hr/day of physical activity, with an average of 4 hr/day of sleep. Total daily energy expenditure will be approximately 4,500 kcal. Soldiers are likely to have an average energy intake of 2,400–2,800 kcal/day. Soldiers are likely to have access to 4-5 L of chlorinated water per day. Some soldiers may experience diarrhea, constipation, or kidney stones during the assault mission. Soldiers have different electrolyte intakes before a mission than during a mission; thus, during a mission a period of biological adjustment may occur. Ration The daily ration must fit within 0.12 cubic feet and weigh 3 lb or less. lt will be approximately 12–17 percent water but varying greatly from one item to the other; most items will be energy dense and intermediate in moisture. There will be no liquid food in the ration, although gels and powders may be provided. The food available during recovery periods, will provide, at a minimum, the nutritional standards for operational rations. Assumptions Regarding Assault Missions. SOURCE: Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations, p. ES-3. Intensity Combat Operations (2005) reviews the unique circumstances of soldiers deployed in such operations and provides recommendations for designing rations that contain all of the essential nutrients and food components needed to sustain physical and mental performance while minimizing adverse health consequences. In particular, the rations should contain set amounts of high-quality protein to preserve body lean mass, carbohydrates to provide fuel for optimal physical performance, and enough fat to enhance palatability. In addition to aiding military operations, the rations also may be of benefit to civilian workers, including firefighters and other emergency workers, who encounter similar conditions of high-stress, intense physical activity. …the rations should contain set amounts of high-quality protein to preserve body lean mass, carbohydrates to provide fuel for optimal physical performance, and enough fat to enhance palatability.

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Informing the Future: Critical Issues in Health, Third Edition In the military, as in civilian life, proper body weight supports good health. Soldiers who maintain proper body weight and composition also are best suited to the physical demands of military service, including combat. Weight Management: State of the Science and Opportunities for Military Programs (2003) reviews the scientific evidence on factors that influence body weight and the role of gender, age, and ethnicity in weight management, and it recommends optimal components for weight loss and weight management programs that can be used across the services. Among its recommendations, each service should provide training on diet and health (including the fundamentals of energy balance, the caloric content of foods, portion size, and the importance of maintaining high levels of daily activity); education programs should include components directed at military spouses and families; and base dining facilities should incorporate “heart healthy” menus as standard fare. Evaluation should be made an integral part of weight management programs in order to determine their effectiveness; this will require following personnel for at least 2 to 5 years after they have participated in the programs, and preferably for their entire military careers. …each service should provide training on diet and health…; education programs should include components directed at military spouses and families; and base dining facilities should incorporate “heart healthy” menus as standard fare. TABLE 1-3 Percent Body Mass Index (BMI) of Military Branchesa by Gender Compared with the General U.S Population   Army Navy BMI Men Women Men Women <18.5 0.3 0.6 0.5 1.8 18.5–24.9 39.6 58.8 30.4 52.2 25.0–29.9 46.0 34.4 52.9 38.6 30.0–34.9 13.2 5.6 14.3 6.5 35.0–39.9 0.9 0.5 1.7 0.8 ≥40 <0.1 <0.1 0.2 0.1 a No data available for U.S Marine Corps Adapted from Flegal et al. (2002); Freedman et al. (2002). BMI Categories for U.S population data are <25, 25.0–29.9, 30.0–39.9, ≥ 40 SOURCE: Army data: Personal communication, G.Bathalon, U.S.Army Medical Percent Body Mass Index (BMI) of Military Branches by Gender Compared with the General U.S. Population. SOURCE: Weight Management: State of the Science and Opportunities for Military Programs, p. 24.

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Informing the Future: Critical Issues in Health, Third Edition THE HEALTH OF VETERANS Just as the IOM conducts a range of studies to advise the DoD on how to maintain optimum health status of active-duty personnel and their families, it also advises the VA on a variety of issues relating to the health of veterans. During military service and especially in warfare, troops may be exposed to toxic agents and other conditions that may have long-term health effects. However, it can be difficult to discern whether health problems experienced by veterans are causally related to their military experiences. The Congress and many veterans groups rely on the IOM to provide objective analyses of health effects associated with military deployments as recent as the 1991 Persian Gulf War and the conflicts in Iraq and as long ago as World War II. The Congress and many veterans groups rely on the IOM to provide objective analyses of health effects associated with military deployments as recent as the 1991 Persian Gulf War and the conflicts in Iraq and as long ago as World War II. HEALTH PROBLEMS FOLLOWING THE GULF WAR Almost 700,000 U.S. troops, including many members of reserve units in the National Guard, took part in the 1991 war in the Persian Gulf. After returning home, a number of military personnel reported health problems that they believed to be service-connected. At the request of Congress, the IOM has conducted a series of studies examining the scientific and medical literature on the potential health effects of a variety of biological and chemical agents to which military personnel may have been exposed during the war. The first volume in the Gulf War and Health series, published in 2000, reviewed health effects related to exposure to depleted uranium, the chemical-warfare agent sarin, pyridostigmine bromide, and anthrax and botulinum toxoid vaccines. The second volume, published in 2003, examined health effects associated with exposure to pesticides and solvents. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants (2005) is the latest in the series. The report concludes that current scientific evidence is inadequate to determine whether there is—or is not—a causal link between exposure to the compounds in question and the majority of types of health problems experienced by Gulf War veterans. However, there is sufficient evidence of an association (if not a causal relationship) between combustion products and an increased risk of lung cancer. Military personnel may have encountered combustion products from diesel-fueled heaters in poorly venti-

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Informing the Future: Critical Issues in Health, Third Edition lated tents, cooking stoves, vehicle exhaust systems, and oil-well fires. There also is limited or suggestive evidence that exposure to combustion products is linked to asthma and to cancers of the nose, mouth, throat, and bladder, as well as to premature births and low birth-weight babies among women exposed during pregnancy. Similarly, there is limited or suggestive evidence that exposure to hydrazines, chemical components of the propellants used in Scud missiles, is associated with lung cancer. As with the previous reports in the series, the VA will consider these results in developing compensation programs for veterans who have developed health problems as a result of their wartime service. Following publication of the first volume in the Gulf War and Health series, some veterans and other observers continued to express concerns about possible adverse neurologic or cardiovascular effects of exposure to sarin and related chemical-warfare compounds. In response, the VA asked the IOM to review the scientific and medical literature published since the initial report. Gulf War and Health: Updated Literature Review of Sarin (2004) concludes that the evidence remains insufficient or inadequate to determine whether an association exists between low-dose exposures and any subsequent cardiovascular or neurological effects over the long term. Gulf War and Health: Updated Literature Review of Sarin (2004) concludes that the evidence remains insufficient or inadequate to determine whether an association exists between low-dose exposures and any subsequent cardiovascular or neurological effects over the long term. The IOM continues to examine a variety of health issues related to military service during the 1991 Persian Gulf War. The Committee on the Review of the Medical Literature Relative to Gulf War Veterans’ Health is reviewing and evaluating the medical and scientific literature to determine what that information, taken together, can reveal about the general health status of Gulf War veterans. The Committee on Gulf War and Health: Infectious Diseases is reviewing the literature regarding possible associations between deployment and infectious diseases, including shigellosis, leishmaniasis, sandfly fever, and diseases caused by pathogenic Escherichia coli bacteria. In addition, the Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress is examining the possible long-term health effects associated with the physiological, psychological, and psychosocial

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Informing the Future: Critical Issues in Health, Third Edition stresses of service during the 1991 Persian Gulf War as well as the current conflict in Iraq and Afghanistan. Recently, the VA has asked the IOM to conduct a study on amyotrophic lateral sclerosis (ALS) not only in Gulf War veterans, but in all deployed military personnel since World War II. Concern has been raised recently about an increase in the incidence in ALS in all veteran populations. VETERANS, AGENT ORANGE, AND VIETNAM From 1962 to 1971, U.S. forces sprayed significant amounts of herbicides over Vietnam. One of the main chemical mixtures sprayed was called Agent Orange. Following the war, many veterans and their families began to attribute varied chronic and life-threatening diseases to exposure to Agent Orange or to dioxin (a contaminant found in the mixture), and in 1991 Congress directed the IOM to study the issue. Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam (1994) provided the first comprehensive, unbiased review of the scientific evidence regarding links between such exposure and various adverse health effects, including cancer, reproductive and developmental problems, and neurobiological disorders. The IOM has since published a series a biennial updates to this pioneering report. Veterans and Agent Orange: Update 2004 is the latest in the series. The report builds on information gathered for previous reports, but also focuses on more recent scientific studies and other information developed since their release. Overall, the report reaffirms the conclusions of Veterans and Agent Orange: Update 2002 about specific health effects associated with herbicide exposure. There is sufficient evidence of a positive association between exposure and chronic lymphocytic leukemia, soft-tissue sarcoma, non-Hodgkin’s lymphoma, Hodgkin’s disease, and chloracne. There is limited or suggestive evidence of an association with respiratory cancers, prostate cancer, multiple myeloma, early-onset transient peripheral neuropathy, porphyria cutanea tarda, type 2 diabetes, and spina bifida in offspring of exposed individuals. The evidence is considered limited because the influences of chance, bias, and confounding—three factors that affect the confidence that can be placed in the results of epidemiologic studies—cannot be ruled out. There is limited or suggestive evidence that there is no association with

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Informing the Future: Critical Issues in Health, Third Edition gastrointestinal tumors and brain tumors. For other health concerns, however, the evidence remains inadequate or insufficient to determine either a positive or negative association. The report recommends that several lines of research should be continued to help answer remaining questions. EPIDEMIOLOGICAL STUDIES OF THE HEALTH OF VETERANS During warfare and overseas deployments, troops can be exposed to combat trauma, infectious agents, toxic chemicals, and other conditions that can cause disease or other adverse health effects, both immediately and over the longer term. The IOM’s Medical Follow-Up Agency, established shortly after World War II, conducts epidemiological studies involving original research on the health and well-being of military personnel following their terms of service. For these studies, the agency obtains and analyzes military records and other health outcome data and often collaborates with researchers from academic centers and federal agencies. Since the Medical Follow-Up Agency’s inception, its research has resulted in publication of more than 500 scientific papers in the peer-reviewed literature. Recent research articles from the Medical Follow-Up Agency are found in peer-reviewed journals. RECENT JOURNAL ARTICLES FROM THE MEDICAL FOLLOW-UP AGENCY Bullman, T.A., Mahan, C.M., Kang, H.K., Page, W.F., Mortality in U.S. Army Gulf War Veterans Exposed to 1991 Khamisiyah Chemical Munitions Demolition. American Journal of Public Health, Vol. 95, 2005, pp. 1382-1388. Mathes, R.W., Page, W.F., Crawford, H.M., McBean, A.M., Miller, R.N., Long-term sequelae of hemorrhagic fever for renal syndrome attributable to Hantaan Virus in Korean War veterans. Military Medicine, Vol. 170, 2005, pp. 315-319. Seddon, J.M., Cote, J., Page, W.F., Aggen, S.H., Neal, M.C. The U.S. twin study of age-related macular degeneration: relative roles of genetic and environmental influences. Ophthalmology. Vol. 123, 2005, pp. 321-327. Gurland, B.G., Page, W.F., Plassman, B.L., A twin study of the genetic contribution to age-related functional impairment. Journal of Gerontology: Medical Sciences, Vol. 59A, 2004, pp. 859-863. Rollinson, D.E.M., Page, W.F., Crawford, H., Gridley, G., Wacholder, S., Martin, J., Miller, R., Engels, E., Case-Control study of cancer among U.S. Army Veterans exposed to Simian Virus 40-contaminated adenovirus vaccine. American Journal of Epidemiology. Vol. 160, 2004, pp. 317-324.

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Informing the Future: Critical Issues in Health, Third Edition Wallin, M.T., Page, W.F., Kurtzke, J.F., Multiple sclerosis in US veterans of the Vietnam era and later military service: Race, sex, and geography, Annals of Neurology, Vol. 55, No. 1, 2004, pp. 65-71. Page, W.F., Hoaglund, F.T., Steinbach, L.S., Heath, A.C., Primary osteoarthritis of the hip in monzygotic and dizygotic male twins, Twin Research, Vol. 6, 2003, pp. 147-151. Page, W.F., Long-term health effects of exposure to sarin and other anti-cholinesterase chemical warfare agents, Military Medicine, Vol. 168, 2003, pp. 239-245. Page, W.F., The NAS-NRC Twin Registry of WWII military veteran twins, Twin Research, Vol. 5, 2002, pp. 493-496. Groves, F.D., Page, W.F., Gridley, G., Lisimaque, L., Stewart, P.A., Tarone, R.E., Gail, M.H., Boice, J.D., Beebe, G.W., Cancer in Korean War navy technicians: Mortality survey after 40 years, American Journal of Epidemiology, Vol. 155, 2002, pp. 810-818. Groves, F.D., Page, W.F., Gridley, G., Lisimaque, L., Stewart, P.A., Tarone, R.E., Gail, M.H., Boice, J.D., Beebe, G.W. Cancer in Korean War Navy technicians: Mortality survey after 40 years (abstract), Annals of Epidemiology, Vol. 12, 2002, p. 510.

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