1. Service Related Diseases, Illnesses, and Conditions Military History Toolkit Produced by the Veterans Advisory Council A Taskforce of the National Hospice and Palliative Care Organization

2. Military History Checklist

3. Veteran Population 23.8 million living Veterans 7.5% women 37 million dependents (spouses and dependent children) of living Veterans and survivors of deceased Veterans Together, they represent 20% of the US population

4. Veteran Population Most Veterans living today served during times of war Vietnam Era Veteran – 7.9 million, representing the largest segment of the Veteran population

5. Veteran Population Median age of all living Veterans in 2007: – 61 for men – 47 for women Median ages by period of service: – Gulf War, 37 years old – Vietnam War, 60 years old – Korean War, 76 years old – WW II, 84 years old

6. Veteran Population Sixty percent (60%) of the nation’s Veterans live in urban areas States with the largest Veteran population are CA, FL, TX, PA, NY and OH, respectively 6 states account for 36% of total Veteran population

7. Service Connected Disability VA pays disability compensation to Veterans with injuries or illnesses incurred during, or aggravated by, their military service VA must determine that the disability is “service-connected” A Veterans Services Representative is available at VA medical centers and regional offices to explain and assist Veterans who need help in applying for disability benefits

8. “Tell me about your military experience…” When and where did you serve? What did you do while you were in the service? Why ask these questions?....Because it may influence both health and quality of life…

9. World War II “World War II (1939-1945) killed more people, destroyed more property, disrupted more lives, and probably had more far reaching effects than any other war in history.” WORLD BOOK ENCYCLOPEDIA

10. World War II December 7, 1941 – December 31, 1946 Total who served in all Armed Forces: 16,112,566 Battle Deaths: 291,557 Wounded: 671,846 Medals of Honor: 433 In what theatre of operations did the Veteran serve? Pacific? Asia? Europe?

11. World War II Fighting occurred on the continents of Europe, Asia, and Africa and in the Atlantic and Pacific Oceans Service was carried out under severe winter conditions, in the harshest of deserts, and in the hottest, most humid, tropical climates Joining up, or being drafted, meant that you were in the military for the duration

12. Flag pole at Hickam AFB, Hawaii on Dec 7th 1941… …and today in 2007

13. World War II Unique Health Risks – Infectious Diseases – Wounds – Frostbite / Cold Injury – Mustard Gas Testing – Exposure to nuclear weapons – Nuclear Cleanup

14. Cold War “Atomic Veterans” Cold War refers to the period of tension between the US and its allies and the Soviet bloc from the end of WW II in 1945 until the collapse of the Soviet Union in the 1990s Major fear of the Cold War was nuclear war with associated health concerns about exposure to ionizing radiation

15. Cold War “Atomic Veterans” Approximately 200,000 US Service personnel performed occupation duties in Hiroshima and Nagasaki following the atomic bombing of Japan Similar numbers of service members participated in atmospheric nuclear weapons testing from 1945 to 1962

18. Cold War “Atomic Veterans” Exposure to radiation has been associated with a number of disorders including leukemia, various cancers, and cataracts Unique Health Risks – Nuclear Testing – Nuclear Cleanup

19. Cold War “Atomic Veterans” Every VA medical facility has a registry physician for Agent Orange, Gulf War, and Ionizing Radiation - a resource for additional information

20. Korean War Korean War pitted the United States, South Korea and their UN allies against North Korea and the Chinese Communists

21. Korean War June 25, 1950 – July 27, 1953 Total who served in all Armed Forces: 5,720,000 Battle Deaths: 33,741 Wounded: 103,284 Medals of Honor: 131 Unique Health Risks -- Cold Injury -- Exposure to nuclear weapons -- Lasting Effects -- Chemical warfare experiments

22. Korean War Cold injuries, including frostbite and immersion (trench) foot, constituted a major medical problem for US Service personnel Cold accounted for 16% of Army non- battle injuries requiring admission Over 5000 US casualties of cold injury required evacuation from Korea during the winter of 1950-1951

23. These cold-related problems may worsen as Veterans grow older and develop complicating conditions such as diabetes and peripheral vascular disease, which place them at higher risk for late amputations Korean War

24. Many Veterans who have experienced cold injuries will be living with long-term and delayed sequelae which include: – peripheral neuropathy – skin cancer in frostbite scars (heels, earlobes) – arthritis in involved areas – chronic tinea pedis – fallen arches and stiff toes – nocturnal pain – cold sensation

26. Vietnam War “No event in American history is more misunderstood than the Vietnam War. It was misreported then, and it is misremembered now.” - RICHARD M. NIXON, 1985

27. Vietnam Vietnam Veterans now 50 to 75 yrs old By 2014, 60% of Veterans over the age of 65 will be Vietnam Veterans Will we be ready to care for them? – Mental Health Issues: PTSD, Depression – Substance Abuse – Hepatitis C – Agent Orange Growing list of service connected illnesses

28. Vietnam War August 4, 1964 – January 27, 1975 Statistics – Total who served in all Armed Forces: 8,744,000 – Deployed to Southeast Asia: 3,403,000 – Battle Deaths: 47,424 – Other deaths (In Theatre): 10,785 – Wounded: 153,303 – Medals of Honor: 238 Unique Health Risks: – Length and Time of Service – Exposure to Agent Orange – Infectious Diseases

29. Those who have fought for freedom, and have lost it, know a sadness and sense a loss beyond bearing.

30. Vietnam War Lack of unit cohesiveness – Many Veterans were sent to Vietnam as individuals – Left when their year’s tour was completed Often traveled alone to and from Vietnam by air – An active combatant one day – A Veteran returning to a hostile civilian environment the next

31. Vietnam War Environmental Hazards Pesticide herbicide spraying Tropical country – High temperatures – High humidity – Monsoon climate (unable to get dry for days) – Few opportunities for bathing – Poor skin hygiene Bacterial and fungal infections Skin disease

32. Agent Orange

33. Herbicide used to kill unwanted plants and to remove leaves from trees that otherwise provided cover for the enemy Used to protect US troops No special Agent Orange (AO) tests are available – no way to show that AO or other herbicides caused individual medical problems VA makes a presumption of AO exposure for Vietnam Veterans

34. Agent Orange Under Section 102, Public Law 104-262, the Veterans’ Health Care Eligibility Reform Act of 1996, VA shall furnish hospital care, medical services and may furnish nursing home care to Veterans exposed to herbicides in Vietnam

35. Veterans’ Diseases Associated with Agent Orange Exposure: A partial list... Malignant Diseases – Lung cancer – Prostate cancer – Hodgkin's and Non-Hodgkin’s Lymphoma – Sarcomas – Multiple Myeloma – Chronic Lymphocytic Leukemia Non-malignant Diseases – Birth Defects: Spina Bifida – Diabetes – Peripheral Neuropathy www.publichealth.va.gov/exposures/agentorange/diseases.asp#veterans

36. Hepatitis C Virus (HCV) HCV is the most common infection carried by blood in the United States. 63% of enrolled Veterans testing positive for HCV are Vietnam Era Veterans – Average age: 49 years old – 96% male – 4% female

37. Gulf War

38. It’s important to understand that there were, and continue to be: Many concerns about the association between the illnesses and symptoms Veterans report and: – their exposure to toxic agents – their exposure to environmental and wartime hazards – the preventive medicines and vaccines they received

39. Gulf War Outcomes Based Primarily on Symptoms or Self- Reports No unique syndrome, unique illness, or unique symptom complex in deployed Gulf War Veterans Multi-symptom-based medical conditions reported to occur more frequently among deployed Gulf War Veterans include fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity Deployment places Veterans at increased risk for symptoms of psychiatric illnesses, particularly post traumatic stress disorder (PTSD), anxiety, depression and substance abuse

40. Gulf War Studies of returning Gulf War Veterans with at least one commonly reported symptom (fatigue, memory loss, confusion, inability to concentrate, mood swings, somnolence, gastrointestinal distress, muscle and joint pain or skin or mucous-membrane complaints) demonstrated poorer performance on cognitive tests than by returning Gulf War Veterans who did not report such symptoms.

41. Gulf War Among studies that examined pulmonary outcomes in associations with specific exposures in the Gulf War Theater, exacerbation of asthma associated with oil-well fire smoke has been indicated.

42. Gulf War On September 23, 2008, Veterans' Affairs Secretary, Dr. James B. Peake, announced that ALS will become a presumptively compensable illness for all Veterans with 90 days or more of continuously active service in the military.

43. Gulf War Unique Health Risks: Exposure to smoke Chemical or Biological Agents

44. Gulf War Unique Health Risks Immunizations Infections Depleted Uranium (DU)

45. Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF)

46. OEF/OIF Unique Health Risks: – Infectious disease – Cold injury – High altitude illnesses Environmental Hazards: – Exposure to sewage – Exposure to agricultural and industrial contamination of water and food – Air pollution – Severe sand and dust storms

47. OEF/OIF Additional Risks Combined penetrating, blunt trauma, and burn injuries (blast injuries) Traumatic brain or spinal cord injury Vision loss Traumatic amputation Multi-drug resistant acinetobacter Leishmaniasis (sandfly-transmitted infection of the skin) Depleted uranium (DU) Mental health issues

48. Haunted by combat… “War means something different to those of us that have looked through the sights of a rifle at another human being’s face. Collateral damage means something different to those of us that have seen the lifeless body of a 9-year-old girl caught in the crossfire. Or for those of us that have struggled to save the life of a 7-year-old boy. I’ve only mentioned a fraction of what still haunts me from Iraq. I’ve been diagnosed with PTSD…” – An Iraq Veteran from New Jersey (Meagher, 2007, p. xix)

49. OEF/OIF Resource

50. Honoring Veterans preferences at the end of life…