PM2ch49.pdf

Medical Issues in Redeployment

Chapter 49

MEDICAL ISSUES IN REDEPLOYMENT

Sterling S. Sherman, MD, MPH

INTRODUCTION

HISTORICAL PERSPECTIVES ON RECURRING ISSUES IN REDEPLOYMENT

Surviving Battle Trauma

Combat Stress

Infectious Disease

Political Ramifications

THE REDEPLOYMENT MEDICAL PLAN AND ITS GOALS

BEFORE WRITING THE REDEPLOYMENT MEDICAL PLAN

ELEMENTS OF THE REDEPLOYMENT MEDICAL PLAN

Education

Medical Screening

Postdeployment Surveillance

Setting the Priorities

ROLE OF THE DEPARTMENT OF DEFENSE, THE DEPARTMENT OF VETER-

ANS AFFAIRS, AND SELECTED ADVISORY PANELS

The Department of Defense

The Department of Veterans Affairs

Selected Advisory Panels

SUMMARY

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

S.S. Sherman , Commander, Medical Corps, US Navy; Head, Threat Assessment Department, Naval Environmental and Preventive

Medicine Unit No. 5, 3235 Albacore Alley, San Diego, CA 92136

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Medical Issues in Redeployment

INTRODUCTION

Problems related to the health of military person-

nel returning home after serving abroad are varied

and not easily solved. Veterans expect and deserve

recognition for the sacrifices that they have made

in service to their country. The expected health effects

of a deployment and the normal occurrence of dis-

eases among veterans often blend with the hazards

of the war zone to blur the line between expected

and unexpected health events among veterans. Be-

cause of this, veterans and their health may become

a focus of national discussion and inquiry. When

this occurs, the most influential triad will be—as it

always has been—the veterans, their elected repre-

sentatives, and the military medical community.

Other interested parties will be families of veterans,

the press, other coalition forces, and the scientific

community. The general public angst that can oc-

cur during and after a major military action often

leads to suspicion of the military establishment. In

this atmosphere, it can be difficult to establish the

cause of service member health problems. As an

outgrowth of this, some of the ties between health

problems and military service will be tenuous, if not

specious. The military’s primary response to this

situation and to its responsibility to safeguard the

health of service members is the redeployment

medical plan. While risk communication teaches

that perception is reality, the task of the military

medical officer is to prepare the redeployment

medical plan so that its reality shapes perception.

HISTORICAL PERSPECTIVES ON RECURRING ISSUES IN REDEPLOYMENT

Throughout the long history of warfare, there

have been medical problems associated with the re-

deployment of military personnel to their home coun-

try. In the United States, these problems have included

such psychiatric manifestations as “nostalgia” in the

Civil War, 1 shell shock in World War I, 2 and post-trau-

matic stress disorder in the Vietnam War. 3 Other

problems have included “gas lung” after World War

I and the question of that condition’s association

with the subsequent development of tuberculosis. 4

After the Vietnam War, veterans and scientists be-

came concerned that the wide use of herbicides

might have contributed to a number of postdeploy-

ment medical problems. 5 A similar argument has

been made that a possible multiple chemical sensi-

tivity or new clinical syndrome (from the combined

use of anti–biological warfare vaccinations and

anti–nerve agent medications or exposure to insect

repellents, pesticides, or chemical warfare agents)

may have resulted in the protean manifestations of

Persian Gulf War illnesses. 6-10

War became the duty of the Bureau of Refugees,

Freedmen, and Abandoned Lands within the War

Department. 11 This responsibility grew out of the

Congressional requirement in 1862 that the Army

provide prostheses to veterans below the rank of

captain. From this program developed the military’s,

and ultimately military medicine’s, greatly ex-

panded and improved mission of postwar care of

veterans.

Combat Stress

Psychological issues, though incompletely un-

derstood, have always been important in returning

veterans and are addressed more fully in Chapter

48, Psychological Aspects of Deployment and Re-

union. Practical experience with combatants has

shown that the immediate treatment veterans re-

ceive is an important factor in their likelihood of

developing long-term psychiatric morbidity. The

simple measures employed since World War I, illus-

trated by the PIE acronym (proximity, immediacy,

expectancy) or the expanded BICEPS (brevity, imme-

diacy, centrality, expectancy, proximity, simplicity),

remain effective guidelines for the treatment of

acute combat stress reactions. Use of these prin-

ciples to return the majority of service members to

duty quickly decreases long-term morbidity as

manifested in chronic post-traumatic stress disor-

ders. 12 Since the military has been unable to develop

an efficient method to “screen out” all personnel

who are at increased risk for combat stress reactions,

medical providers must be ever vigilant to mini-

mize this postdeployment problem.

Surviving Battle Trauma

War affects the returning population of veterans

and society not just by disease but also in another

way: disability. Historically, most of those seriously

injured during combat died on the field of battle or

in the forward aid stations near the line of battle.

Beginning with the Civil War, advances in medical

and surgical practice resulted in greater numbers

of veterans surviving to return home with amputa-

tions or other medical problems. In 1865 assistance

to refugees, freed slaves, and veterans of the Civil

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

Infectious Disease

Political Ramifications

The potential for infectious disease is another

redeployment medical issue. There has long been

great concern, particularly relating to tropical dis-

eases and diseases with longer incubation periods,

of introducing or reintroducing these illnesses into

the United States. 13-16 All countries recognize the

potential for disease transmission given the ease of

international travel and have established various

quarantine measures to help prevent transmission

of diseases and vectors of concern. During the great

plague pandemic of the 14th century, the Venetians

established a council of three men that was to su-

pervise and safeguard the public health of the city.

Over time, the Venetians and other cities adopted a

40-day isolation period for ships, goods, and per-

sons, hence the term “quarantine,” derived from the

Italian and Latin words for forty. 17 The first record

of such restrictions in America was a law enacted

by the Massachusetts Bay Colony in 1647. 18 In sub-

sequent years, quarantine regulations were ex-

panded and modified as situations required for the

safeguarding of the population. Cholera, plague,

and yellow fever were the primary concerns in the

early years of the United States. Later, when people

began to travel by air more than by ship, the regu-

lations were modified and updated to meet the new

challenges of air travel.

This potential for the international transmission

of infectious disease is never more pronounced than

in time of war. The influenza pandemic of 1918 and

1919 and the transmission of hepatitis to United

Nations peacekeepers assigned to Haiti are two

examples at opposite ends of the 20th century. 19–22

At the conclusion of hostilities, the fighting force is

wounded, tired, parasitemic, and incubating vari-

ous diseases but anxious to get back home to their

loved ones at the first opportunity. In the modern

age, the time frame for this return can be literally

hours. Because of the modern military’s ability to

rapidly transport large numbers of the returning

force, service members can lift off the ground half

a world away and be on leave with their relatives

in as little as 48 hours. Table 49-1 gives a few ex-

amples of important medical problems that have

few, if any, early symptoms and have been or po-

tentially may be important in redeploying veterans.

Another important consideration of redeployment

is the political ramifications of veterans who return

complaining of new medical problems. A recent

example shows how public policy goals can appear

to be at odds with the science of the day when con-

sidering postdeployment medical syndromes. The

Clinton administration announced the day after

Memorial Day 1996 that veterans who had served

in or near the Republic of Vietnam during the

United States’ participation in the Vietnam War are

presumed to have a service-connected disorder at-

tributable to Agent Orange exposure if they develop

prostate cancer or peripheral neuropathy. These

conditions were additions to the list of conditions

for which the Department of Veterans Affairs (VA)

already compensates Vietnam veterans, including cer-

tain respiratory cancers, multiple myeloma, porphy-

ria cutanea tarda, soft-tissue sarcoma, non-Hodgkin’s

lymphoma, Hodgkin’s disease, and chloracne. 23 For

the first time in history, the administration extended

the service-connected presumption to the children

of Vietnam veterans by designating spina bifida in

veterans’ children as being service-connected. These

new designations were an outgrowth of an Insti-

tute of Medicine’s report 24 that concluded there was

“limited/suggestive evidence” of an association

between Agent Orange exposure and these condi-

tions. Secretary of the VA Jesse Brown pointed out

that public policy as illustrated by pertinent legis-

lation “is clear: If the evidence for an association to

Agent Orange is equal to the evidence against, the

veteran must be given the benefit of the doubt.” 25pA20

The validity of the science, however, remains to be

established when the exposure of interest becomes

“stationed in the Republic of Vietnam” and not the

“exposure to Agent Orange.” In choosing to com-

pensate veterans who were in or near the theater-

and not necessarily exposed to the presumptive

agent, the government has based its decision on

factors other than epidemiologic data. 26

The question thus becomes not if there will be

redeployment medical issues but rather what type

will they be, how they will present, and how they

can best be detected and managed. If history is any

guide, the medical aspects of redeployment will

continue to be important in future operations.

THE REDEPLOYMENT MEDICAL PLAN AND ITS GOALS

To address these problems that recur after so

many conflicts, the military has developed the re-

deployment medical plan. Its goals are to enable the

military to identify and treat diseases and disabil-

ity among returning service members, characterize

new diseases or new presentations of old diseases

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Medical Issues in Redeployment

TABLE 49-1

SOME PREVENTABLE, DEPLOYMENT-ASSOCIATED HEALTH CONDITIONS WITH MINIMAL

EARLY SYMPTOMS AND POTENTIALLY SERIOUS DELAYED MANIFESTATIONS

Condition

Complication

Latency

Intervention

Example

Tuberculosis

Active tuberculosis

Years

PPD/Rx

WW I, 1 Vietnam 2

Leishmaniasis

Skin sores,

Skin examinations,

Persian Gulf War 3

espundia, kala azar

serology

Strongyloidiasis

Dissemination

Decades

Stool examinations

WW II 4–6

Syphilis

Tertiary syphilis

Decades

RPR

WW II, 7 Vietnam 8

Hookworm

Anemia

Months

Stool examinations

Grenada 9

Malaria

Weeks/years

Terminal prophylaxis

Vietnam, 10 Korea, 11 Somalia

(Operation Restore Hope) 12

Toxoplasmosis

Dissemination

Stool examinations

Panama

Stress

PTSD

Months/years

Counseling

Vietnam 13

Toxic exposure

Cancer

Decades

Education

Vietnam, WW II 14,15

radiation

HIV

Immunodeficiency

Years

Screening, counseling,

Uruguayan soldiers 16

treatment

PTSD: posttraumatic stress disorder

PPD: purified protein derivative

RPR: reactive plasma reagin

1. Medical Aspects of Gas Warfare . Vol 14. In: The Medical Department of the United States Army in the World War . Washington, DC:

US Army Surgeon General; 1926: 876.

2. Greenberg JH. Public health problems relating to the Vietnam returnee. JAMA . 1969;207:697–702.

3. Magill AJ, Grogl M, Gasser RA Jr, Sun W, Oster CN. Visceral infection caused by Leishmania tropica in veterans of Operation

Desert Storm. N Engl J Med . 1993;328:1383–1387.

4. Byard RW, Oliver NW, Rowbottom DJ. Strongyloidiasis in veterans. JAMA . 1987;258:3258–3259.

5. de Sa Pereira M. Persistence of strongyloidiasis. JAMA . 1980;244:2264.

6. Genta RM, Weesner R, Douce RW, Huitger-O’Connor T, Walzer PD. Strongyloidiasis in US veterans of the Vietnam and other

wars. JAMA . 1987;258:49–52.

7. Sternberg TH, Howard EB, Dewey LA, Padget P. Venereal diseases. Coates JB Jr, Hoff EC, Hoff PM, eds. Communicable Diseases

Transmitted through Contact or by Unknown Means . Vol V. In: Preventive Medicine in World War II . Washington, DC: Office of the

Surgeon General, Dept of the Army; 1960: 183–188.

8. Minkin W. Treatment of gonorrhea by penicillin in a single large dose. Mil Med . 1968;133:382–386.

9. Kelley PW, Takafuji ET, Wiener H, et al. An outbreak of hookworm infection associated with military operations in Grenada.

Mil Med . 1989;154:55–59.

10. Waterhouse BE, Riggenbach RD. Malaria: potential importance to civilian physicians. JAMA . 1967;202:683–685.

11.Rosemary B, Fritz RF, Hollister AC Jr. An outbreak of malaria in California, 1952-1953. Am J Trop Med . 1954;3:779–788.

12. Centers for Disease Control and Prevention. Malaria among U.S. military personnel returning from Somalia, 1993. MMWR .

1993;42:524–526.

13. Health status of Vietnam veterans, I: psychosocial characteristics. The Centers for Disease Control Vietnam experience study.

JAMA . 1988;259:2701–2707.

14. Bullman TA, Kang HK. The effects of mustard gas, ionizing radiation, herbicides, trauma, and oil smoke on US military

personnel: the results of veteran studies. Annu Rev Public Health . 1994;15:69–90.

15. National Research Council Committee on the Biological Effects of Ionizing Radiation. Health Effects of Exposure to Low Levels of

Ionizing Radiation: BEIR V . Washington, DC: National Academy Press; 1990.

16. Artenstein AW, Coppola J, Brown AE, et al. Multiple introductions of HIV-1 subtype E into the western hemisphere. Lancet .

1995;346:1197–1198. Published erratum: Lancet . 1995;346:1376.

promptly, compensate fairly those with known dis-

abilities, and safely and expeditiously return the fit

to duty or home. There are generally three purposes

for the medical plan for the redeployment of per-

sonnel to home or the redistribution of forces within

a theater.

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