“A lot of the men in my unit started getting sick and never got better. And we just didn’t know. I mean, all I want is to help build a group big enough that we might finally understand more about what’s happening to us.”
The veteran’s words were measured and resolute. I had just finished introducing myself and inquired how he had learned about the Burn Pit and Gulf War Registries. During this phone call, as with many others, this veteran proceeded to recount details of his deployment to Saudi Arabia and Kuwait from 1990 to 1991. I moved through my list of exposures as he enumerated, earnestly and methodically though not dispassionately, his deployment tasks and responsibilities that involved every health risk imaginable: physical injury, psychological trauma, high impact noise, toxic chemicals.
The veteran also proceeded to reveal that he had been experiencing chronic sinusitis, cough, reduced exercise capacity, gastroesophageal reflux disease and symptoms of irritable bowel syndrome since his deployment. Despite suffering severe depression, post-traumatic stress disorder, suicidal ideation and the loss of many fellow members of his unit to suicide, he assiduously redirected my questions about his own mental health and reinforced his mission: his testimony should benefit other veterans.
This veteran’s account is one of innumerable similar stories I heard during my rotation in the Post-Deployment Care and Environmental Contaminants Clinic at the Puget Sound Veterans Affairs (VA) Hospital in Seattle. The clinic evaluates and provides care for combat veterans who fought in Vietnam, the Gulf War and the Iraq and Afghanistan conflicts and sustained exposures to environmental hazards such as Agent Orange, burn pits and other toxic substances during their deployments. As a University of Washington Occupational and Environmental Medicine (OEM) Fellow I am frequently shocked — yet not altogether surprised — at how these stories crystallize into one of occupational and environmental medicine’s most vivid and arresting examples: military service is a dangerous occupation in a most hostile environment.
I was first involved in the medical care of veterans as a third-year medical student at the West Haven VA Hospital in Connecticut where I rotated on the surgical and medicine services. Every experience I’ve had as a student and trainee at the VA has been compelling and fulfilling for many reasons, including the attendings who taught me medicine through the veteran patient population. Furthermore, the degree to which veterans often downplay physical and psychological trauma sustained through their service is a salient feature of their medical care and has engendered in me a deep, enduring respect since I began my medical training. My current OEM clinic has further fortified my understanding of the health impacts of military service and, while no two stories are the same, there are many shared threads.
I have not personally served in the military and neither has any immediate family, so I often struggle as I assemble a comprehensive combat and military exposure history. I frequently apologize for how I phrase questions and ask for explanation of various terms including acronyms, specific military duties or geographical locations in Vietnam or the Middle East. Never losing patience when I ask for clarification, my patients delineate exposures such as burning trash, sand and dust storms, other airborne hazards and a vast array of chemicals and toxic agents and often downplay consequential and often protracted health effects they have endured. Between visits I reflect on how I would feel as a parent should my 17-year-old son enlist. Some of the hazards he would face as part of deployment and combat were previously evident but now I picture my son among these men and women exposed to all conceivable trauma and toxins: smoke from burn pits, detonated explosives, oil raining from the sky, particulates, fumes, fuels, defoliants and solvents, among others.
The sacrifice of these men and women, borne out by the conditions of deployment and the health repercussions, represent the apotheosis of service to one’s country. The adverse impacts of combat-associated exposures in veterans share elements with those experienced by other cohorts in high-stress, high-risk environments such as health care. Never have the similarities between health care the military been more salient as they have during the COVID-19 pandemic. I begin to see the latent harm from hazardous occupational exposures in veterans through a new OEM lens and I contemplate what can be learned and potentially applied to my health care colleagues weathering the pandemic. In the first several years of the COVID-19 pandemic, large numbers of health care workers sacrificed their health, well-being and sometimes their lives to its demands. In the past few years, many have left the medical profession due to untenable occupational hazards and moral injury wrought by the environment of COVID-19 care.
In dedication to patient care and a job that many consider a calling, many healthcare workers have been unable to sufficiently protect themselves, often out of concern or threat of risking timely and adequate patient care and safety. Similarly, veterans’ unrelenting loyalty and commitment to their unit, their mission, and their country often result in considerable personal and psychological harm, both acute and chronic. The veterans I speak with have yet to express any second thoughts about subjecting themselves to these risks at the time. To them the answer is an obvious “yes” if their service was needed, even when they did have some sense of the potential health implications. Their modest request now is to find relief from their symptoms and to receive the care requisite of a longer and healthier life. The veteran to whom I was speaking was not interested in connection or compensation but only earnestly hoped to help other veterans.
For those of us who have not served in the military, we must honor service and sacrifice by cultivating and optimizing systems of care for veterans that promote their rehabilitation and reintegration into healthy and fulfilling lives. While I may never fully understand the magnitude of military service and sacrifice, I will strive to apply the lessons learned from my VA OEM clinic to support other groups of workers who have been exposed, often with an incomplete or absent appreciation for the risks posed by occupational and environmental hazards.
Veterans have given so much already and they have also gifted insight into the connections between labor, health and sacrifice and what it means to put one of our most valuable possessions — our health — on the line to fulfill our mission for our country.
Author’s note: As a part of the PACT Act Legislation, all veterans enrolled in VA care will be screened for concerns they may have related to exposures to toxic substances (such as airborne hazards/burn pits, Agent Orange, Gulf War-related exposures, ionizing radiation and exposures in garrison such as Camp Lejeune and many other toxic exposures) during military service and deployment. The screening process will ensure that veterans receive the services, benefits, resources and health care that they need and deserve as a consequence of these exposures.