For years I have kept on my desk a copy of a workup done in 1973 by a very insightful psychiatrist describing the case of a 26-year-old Vietnam Veteran. At the age of 20 this young man had been drafted into the US Army, serving for a year with an infantry unit in Vietnam.
The work-up describes numerous patrols and ambushes in which unit members were killed and injured, inadequate words describing horrific realities. After returning from Vietnam he married his high school sweetheart. They had a child. The marriage unraveled as his drinking increased. Jobs came and went. He avoided crowds, living in isolation on the outskirts of his small town. He was “jumpy and nervous”. Sleep gave way to nightmares. He reported frequent “hallucinations of events, sights, sounds and smells” that had occurred in Vietnam.
He met all of the criteria for the clinical diagnosis of PTSD, but it would be another seven years before the term PTSD would enter the medical lexicon. No one could have understood then that his “hallucinations” were actually flashbacks of traumatic events. The work-up concluded with these diagnoses: maladjustment, anxiousness and depression with psychotic features. Regardless, there were few effective strategies or established treatments to help this Veteran in 1973.
I thought of this Veteran while giving a talk on VA health care at an international conference in Seoul recently. I began by saying, “VA medical facilities have provided services for over 1.2 million combat Veterans from the Iraq and Afghanistan conflicts over the past decade.” My colleagues’ jaws dropped. They had been caring for Canadian, Australian, German and South Korean Veterans who had deployed with coalition forces in Iraq and Afghanistan, but their combat Veterans numbered in the thousands or tens of thousands.
“Our combat Veterans are all screened for PTSD, depression, traumatic brain injury, alcohol misuse and for case management needs. All had post deployment health assessments done in the military that I could access from my VA computer. Over three quarters of them were seen in VA clinics that had integrated post-combat care teams: primary care providers, psychologists, social workers and various specialty care providers in rehabilitation medicine, traumatic brain injury and pain care.” I continued, “There has never been a time in human history when Veterans returning home from war have been greeted with such a systematic and comprehensive approach to their assessment, treatment and reintegration.”
During deployment, these individuals benefited from the fact that battlefield medical care has never yielded such high rates of survival and long-term recovery. In the Civil war if you were injured on the battlefield, you had a 50 percent chance of surviving. In WWII your chances were 65 percent, in the Vietnam War 75 percent. In Iraq/Afghanistan if you were injured on the battlefield you had a 90 percent chance of surviving.
I reminded my international colleagues that our understanding of PTSD and other mental health conditions, traumatic brain injury, burns and devastating physical injuries and our approaches to the management of these conditions have never been more sophisticated and effective.
Unmentioned in the 1973 workup on my desk was that during his year in Vietnam the Veteran had spent much of his time in terrain sprayed with Agent Orange. Exposure to this dioxin-contaminated herbicide contributed to health consequences that would often be decades in emerging. Sadly, there were equivalent delays in our acknowledging those risks and responding to them. In the past decade, however, increasingly proactive policies and appropriate resources have been made available to Vietnam Veterans exposed to Agent Orange.
VA Puget Sound Deployment Health Clinic team: An inter-professional team of health techs, program support personnel, nurses, physicians, nurse practitioners, physician assistants, social workers, psychologists, psychiatrists, polytrauma specialists: it takes a team.
The largest group of new Veterans enrolling in VA over the past several years has been Vietnam Veterans. What many of them experienced when they returned home from their deployments from Vietnam 50 years ago reflected failures not only of VA but of us as a nation. Many of our Vietnam Veterans, treated so shamefully and unconscionably when they returned from Vietnam, are at last “coming home” to the support and appreciation that their service and sacrifice warranted, that they so deeply needed decades ago.
I told my international colleagues that I could not think about the Agent Orange exposures in our Vietnam Veterans without also thinking about the numerous exposures faced by Veterans of the 1990-1991 Gulf War. Our delay in acknowledging their Gulf War Illnesses resulted in delays in care and unnecessary suffering for them and their families. Once again our response reflected our lack of understanding of the nature of combat and the impacts of war on the health of those whose lives are touched by it. Many concluded in 1991, “Since it was only a four day ground war, these Veterans probably won’t experience many significant combat related health concerns.”
In retrospect it seems inconceivable that anyone would have come to that conclusion for a group of over 700,000 military personnel who spent six or more months in the desert, often in very austere or hostile physical environments, anticipating combat and possible death at any moment, enduring frequent Scud missile attacks setting off chemical alarms and scrambles into cumbersome protective gear. Individual physiologies were further jolted by multiple concurrent pre-deployment immunizations, prophylactic medications and exposures to petrochemicals and a variety of other toxic agents.
Between a quarter and a third of these Veterans had health concerns causing significant impairments in quality of life following deployment. Once again, our responses as a VA and a nation were reactive rather than proactive and while programs and resources were eventually put in place to support these individuals, the delays took a toll on another cohort of combat Veterans. More lessons painfully learned.
So I described to my international colleagues in Seoul the Burn Pit Registry that has been established during the current conflicts in Iraq and Afghanistan. (link to Burn Pit) It is a much more proactive approach to deployment related exposures, allowing Veterans to document their exposure concerns immediately upon returning from deployment and receive a medical evaluation to assess for any health conditions related to these exposures, ensuring timely diagnosis and treatment of associated health conditions, streamlined access to resources and more dependable and responsible long term follow-up.
Resources including educational opportunities, training programs, vocational rehabilitation services, housing, financial assistance and caregiver support have never been more comprehensive and accessible than those available to our most recent group of combat Veterans. The 1.2 million combat Veterans who have received care in VA facilities represent approximately half of the 2.5 million individuals who have been deployed since 2003. Those seeking care and support from non-VA sources have had a wide array of options including the DoD facilities, community providers, non-profit organizations as well as a burgeoning network of federal, state and local community based efforts sponsored by governmental, business and non-profit groups to support Veterans and their families.
We have taken enormous steps forward in our approaches to post-deployment care as a VA and as a nation. This progress has been made in part as a consequence of painful lessons we learned from our inadequate, misguided and in some cases unconscionable responses to our Veterans returning home from earlier conflicts. Though we have made considerable progress in our approaches to taking care of returning combat Veterans, what we have accomplished is not nearly good enough; there are gaps, there have been obstacles to access, there have been too many failures in care at both the individual Veteran level and the broader systems level. We have done well by many Veterans on many occasions in numerous locations, but that is not good enough. As a nation and as a VA, our goal must be to support every Veteran and every Veteran’s family, every time.
That said, if we do not see what we have accomplished, if we do not recognize and acknowledge the work that has been done and the progress we have made in our post-deployment care in the DoD, VA and the broader community, if we do not build upon what we have learned and implemented over the past decade, the well-being of combat Veterans returning from deployments in the years ahead may be at great risk.
With the recent reduction in the numbers of service members being deployed, there may be a temptation to shift our focus away from post-deployment care and Veterans’ health care in general. This is not the time to “turn the page” or “move on to a new chapter” or dismantle in any way the systems we have in place to care for our Veterans. It is a time to make the shift from “times of war to times of peace” in a way that strengthens these capacities even as we scale them down to align them with diminishing numbers of newly returning combat Veterans.
It is important that we make this shift in a manner that ensures the retention of established models and nascent systems for post-deployment care that can be scaled up during times of war. It is crucial that we take this opportunity to create institutional memory for how to provide good post deployment care as a VA and as a Nation, to ensure preparedness for the inevitable deployments that will occur in the future. And this is a time to reassure our current Veterans that we will be there for them not simply on the day of their welcome home parade. We will be there for them and their families over the long haul.
Our Veterans deserve no less, every one of them, including our Vietnam Veteran described in the 1973 workup sitting here on my desk, wherever he may be today.
About the Author: Stephen C Hunt, MD MPH is the Director of the VA Post-Deployment Integrated Care Initiative