Rucksack of health risks: Military souvenirs no one wants
■ Physicians need to be alert to the unique problems that soldiers returning from tours of duty in Iraq and Afghanistan might bring back.
By Victoria Stagg Elliott — Posted March 21, 2005
The hundreds of thousands of soldiers who serve in Iraq and Afghanistan live a daily existence marked by hazard. When they make their return home, it seems they finally could be out of harm's way. But the health issues they face related to their military service can run deep and might not appear until long after they are back living their civilian lives.
They could bring home infectious diseases rarely seen in the United States. Their lungs might have been damaged by the desert's dusty environment. Their time at battle could trigger anxiety or depression -- with 8% to 15% of such cases developing into full-blown posttraumatic stress disorder.
"Deployments in general are challenging for soldiers," said Brian Bacak, MD, who was in Afghanistan for three months in the fall of 2002 as part of Operation Enduring Freedom. He is now assistant professor of family medicine at the University of Colorado Health Sciences Center. "When soldiers get back, they're relearning how to function in regular society, and there are some problems that are unique to that population."
Good population-based data on the health of the most recent generation of veterans is lacking. And in many cases, soldiers such as Dr. Bacak come home without any deployment-related issues that require medical intervention. Still, this experience is not always the case -- which creates challenges for many primary care physicians.
One of the main reasons is that this generation of veterans is far more likely to receive care from civilian primary care physicians than from military or Veterans Health Administration medical facilities.
Operation Enduring Freedom and Operation Iraqi Freedom involved the largest call-up of reservists and the National Guard since World War II, but these service people might not have as much access to military resources as those who are full-time active military. According to the Dept. of Defense, approximately 80% of those discharged return to the same physicians and medical care that they used before.
As a result, military health experts are nervous that service-related ailments could be misdiagnosed or treated inappropriately, particularly in the wake of increasing recognition that some medical issues might develop long after the conclusion of active duty.
"People are leaving the military and are back out in the civilian community," said Michael E. Kilpatrick, MD, the Defense Dept. deputy director of deployment health support. "The civilian physicians are not going to be aware of what these individuals have experienced."
For example, a study published in the July 1, 2004, New England Journal of Medicine focusing on mental health issues, found that assessing soldiers three to six months after their return home was more likely to detect anxiety and depression associated with combat.
In this study, 15% to 17% of those who had served in Iraq met criteria for major depression, generalized anxiety or posttraumatic stress disorder. Just over 11% of those who served in Afghanistan also met the criteria. More important, the study concluded that only 23% to 40% of those with mental health issues sought assistance, primarily because of the stigma.
"People get home, and the adrenaline rush of being home -- everything's fine," Dr. Kilpatrick said. "In three, four, five months, the data are showing us that people are experiencing problems and don't necessarily know where to go."
The upshot is that findings from studies such as this are combining with complaints about inadequacies in the post-discharge care of Gulf War veterans to lead the Defense Dept. to become more involved in post-deployment health care.
"There's a broad commitment to be concerned about the health of the troops in a much more productive way than we may have in the past," said Bernard Rostker, PhD, who ran the government's Gulf War illness office and is now a senior fellow on military manpower at the RAND Corp., a nonprofit research organization.
In January, the Defense Dept. announced that all those discharged would receive an additional mental and physical health assessment three to six months after discharge. The details have not yet been worked out, although experts suspect it will be administered by a combination of military and private-sector physicians, depending on local resources.
The Defense Dept. also has established the Deployment Health Clinical Center at Walter Reed Army Medical Center in Washington, D.C., to address any emerging concerns, and, in conjunction with the Dept. of Veterans Affairs, developed and published the Post-Deployment Health Practice Guidelines.
Despite the Defense Dept.'s increasing involvement in post-deployment health, experts say, many ex-soldiers could be lost to such follow-up, and the role of primary care physicians will be key.
"It really does flow over into civilian practice," said Lt. Col. Charles Engel, MD, MPH, associate professor and assistant chair of the Dept. of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and director of the Deployment Health Clinical Center. "It's important to make sure that people who return from war are asked the right questions."
PTSD is often the first concern. Still, experts point out that it's not the only worry, some of which lean toward the exotic.
For example, among presentations at the American Academy of Family Physicians annual meeting in Orlando last October, one concentrated on leishmaniasis, an infectious disease also known as the Baghdad boil, which could turn up in returning soldiers. Infectious disease experts are also wary of malaria, which can show up as much as a year after a soldier's return.
"Just because it walks like a duck and quacks like a duck doesn't mean it's a duck, especially in a returning soldier," said Maj. Andrew Shorr, MD, MPH, chief of the pulmonary clinic at Walter Reed.
Unexplained respiratory ailments also could be an issue. A study published in the Dec. 21, 2004, Journal of the American Medical Association noted that 18 soldiers developed eosinophilic pneumonia, with two cases resulting in death. Although the numbers were low, the disease is so rare that the authors urged physicians to be on the alert for the condition, which can be mistaken for community-acquired pneumonia.
"It does serve as an example of respiratory diseases that you don't expect to find that may show up," said Dr. Shorr, lead author of that JAMA paper. "And a lot of soldiers do return with respiratory complaints because of the quality of the air there."
But military health experts also warn that these concerns are not limited to those who went to Afghanistan and Iraq wearing a uniform. With thousands of civilian contractors also in the region, experts say a good travel history, as well as a military history, is key -- although it isn't always easy even in the most obvious of settings.
"Even as a military practitioner, that kind of occupational history is often overlooked," said Lt. Col. Glenn Wortmann, MD, program director of the infectious disease fellowship at Walter Reed. "Sometimes you just forget to ask."
Primary care physicians with veterans in their practices also add that combat issues often spill over to affect family members.
"There's a lot of depression and anxiety because of deployment issues, financial concerns and worry about whether this person will come back," said Lisa Corum, MD, a family physician from Rock Hill, S.C. "We try to hook them up with military services, if they can use those resources, or mental health providers to help them through that. And we remain available for any needs they have."
And while many physicians are increasingly making note of health concerns related to deployment in Afghanistan and Iraq, sometimes their efforts also are hampered by access-to-care issues.
For example, a January report published by the Government Accountability Office found that injured Army reservists and National Guardsmen and -women had significant problems accessing military medical care, with some going into debt for medical bills incurred after their active duty ended -- although they were sometimes unable to return to their civilian jobs.
Even without an injury, access to care can be a challenge because some returning soldiers and their families are covered by TRICARE, the military health insurance plan. The American Medical Association has several policies calling for action to address the system's deficiencies. Its low reimbursement and administrative hassles have led many physicians not to accept it.
"They don't pay much, and sometimes it isn't worth the headache of it," said Nick Eskandar, MD, an internist from Hinesville, Ga., who treats many former soldiers and their families. "But we take it, because it's part of the community we serve."
There also are many veterans who get care from both the private sector and the Veterans Affairs system, making coordination a challenge. The AMA Council on Medical Service published a report in June 2003 calling on physicians to advise patients about the importance of facilitating the flow of information between the VA and the private sector and to advocate the creation of single points of contact for health information on patients that use both systems.
"At times it can be shaky," said Robert D. Habig, MD, a family physician in Westfield, Ind. "They're very well taken care of by the VA, but I tell them to get a list of their medicines and a copy of their blood tests, because if they ask for these to be sent to their family doctor, it's just not going to get done."
In the face of all these issues that might make care for former soldiers a challenge, primary care physicians say the most important thing to do is also the most simple -- listen.
"It's important for physicians to take a complete, compassionate history where they ask not only about a soldier's medical history, but also about family dynamics, about occupational and social functioning, and that they use this information to work with the soldier and acknowledge the uniqueness of the deployment experience," Dr. Bacak said.