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Post-Deployment Injuries: A Core Responsibility and Challenge

History has long acknowledged the immediate and physical wounds of war. The less visible wounds have also been recognized throughout history, with each war bringing a unique perspective to the same fundamental problem -- an often debilitating reaction to the stress of combat. An expanding knowledge of the nature of combat stress has led to a greater appreciation of the range and complexity of both the visible and less visible and/or delayed wounds of war. The management of these unique aspects of "deployment-related injuries" has been a core responsibility of the Veterans Health Administration (VHA) dating back to the Civil War.

VHA has become increasingly focused on providing a patient-centered approach to care when addressing the short-term needs of the newly returning Veteran as well as the long-term needs of an aging Veteran population, including the treatment of acute illness and injury and the management of chronic diseases. However, all combat-related injuries, both physical and psychological, can impact the health of the Veteran in unique ways.

Deployment health is increasingly recognized as a complex constellation of issues that involves a variety of physical, mental, and environmental exposures. According to the Institute of Medicine, deployment health is defined as health issues that arise prior to, during, and following armed forces deployments.1 These health issues include specific diagnosable conditions, e.g., conditions associated with Agent Orange (AO) exposure, radiation exposure, prisoner of war status, Gulf War associated conditions, and others. Seemingly unexplained symptoms, both physical and mental, affect health-related quality of life, can impair family and social relationships, and can contribute to substance use disorders. These are among the more significant sequelae attributed to combat injuries. While some of these health challenges are immediately apparent when Veterans return from deployment, others may not arise until much later.

Mental health conditions once referred to as "soldier's heart," "shell shock," "war neurosis," and "combat fatigue" are now better understood as discrete illnesses secondary to Post Traumatic Stress (PTS). Mental health experts are still not in full agreement as to when PTS becomes a disorder, commonly known as Post Traumatic Stress Disorder (PTSD). Further, the myriad manifestations of traumatic brain injury (TBI) are better recognized, including its late complications. Yet, even as new treatment approaches have been put in practice and research into disease mechanisms and potential treatments has yielded encouraging opportunities, there remains much to learn.

With regard to environmental exposures, the nation became more aware of deployment health risks when it was acknowledged that Agent Orange was associated with a number of human health disorders including cancer, diabetes, and heart disease. Veterans' concerns about exposure to pollutants associated with burning trash (and oil wells) in the Persian Gulf conflicts have increased interest in both their potential ill-effects as well as the appropriate management of waste at these sites. Because the health effects of these practices may come to light years and even decades after the time of exposure, it is extremely difficult to develop conclusive epidemiologic evidence linking a specific exposure to specific disease(s).

In addition, out-of-U.S. deployments can lead to infectious disease exposures rarely encountered at home. Despite efforts to inoculate troops against endemic agents common at the sites of deployment, much is left uncovered. That, along with social behaviors of troops deployed in foreign lands, can create unique problems for a specific cohort of patients not recognized until late after demobilization (e.g., hepatitis C in Vietnam Veterans).

VHA strives to understand and manage the secondary contribution that deployment-related conditions like TBI, PTSD, and depression have on the incidence and progression of chronic diseases such as ischemic heart disease, heart failure, diabetes, etc. VHA has implemented system-wide health screening for all Veterans who come to VA for health care services with a focus on depression, PTSD, military sexual trauma, TBI, risk of suicide, and problem drinking, with the explicit intent to both understand and to provide treatment for these conditions and their sequelae. In recent years, VHA has enhanced its mental health and suicide prevention teams to facilitate mental health care access through integration into primary care in order to identify problems early, to offer appropriate intervention, and to destigmatize the need to seek help for mental health issues.

A recent initiative focused on improving patient-centered care is the development of Patient Aligned Care Teams (PACT), designed to improve access, care coordination, communication, and continuity of care. A principal goal of PACT is that Veterans take an active role in their health care by utilizing enhanced communications and building long-term relationships with their care team. VHA has supported the development of a number of unique PACT care models, which in collaboration with VA researchers, will be evaluated to determine the most effective approaches for enhancing Veterans' care.

An improved understanding of Veterans' health care issues, which includes the development of new approaches to treatment and the appropriate research tools, is a priority for VHA. These tools include registries, cohort management studies, and an understanding of the genomic contribution to disease. For this reason, the Million Veteran Program (MVP), which utilizes strict privacy and confidentiality controls, was established to provide one of the largest databases of genetic, military exposure, lifestyle, and health information. By combining knowledge of the human genome with longitudinal data from the electronic health care record, researchers will have the tools to develop greater understanding of disease risk and insight into the fundamental etiologies that provide the foundation for new potential treatments. This will indeed be a national treasure!

Another example is the active medical surveillance program associated with Veterans who served at the Qarmat Ali water treatment facility near Basrah, Iraq, between April and November of 2003. Environmental health physicians will examine these Veterans at regular intervals to determine in particular the status of the respiratory system and skin—areas known to be affected by exposure to hexa-valent chromium. The examination will focus on nasal-septal ulcerations and chronic irritation; reactive airway disease and other lung abnormalities; skin ulcerations or chronic dermatitis. It will also look for and catalog other health conditions that occur in this well-defined cohort over time in order to identify any potential late complications from this exposure that might not yet be appreciated.

Hand in hand with these new approaches and tools is collaboration with researchers to understand and develop new approaches to improve care for Veterans. This collaboration occurs through a broad spectrum from basic to applied research as well as population health and implementation sciences. VHA's development and sustained focus on deployment health—a focus that engages the Nation's best investigators on the cutting-edge of research—enables VHA to provide the highest quality care for Veterans. This remains a key priority for the Department.

1. Hernandez LM, Liverman CT, and Greenlick MR, Editors. National Center for Military Deployment Health Research.National Academy Press: Washington, D.C. 1999.

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