Category Archives: Military

Disease and National Defense

Posted by on July 29, 2013 Comments Off on Disease and National Defense

In Biblical times, where historical accounts and historical myth sometimes mingle, there are accounts of great armies being destroyed by disease. Conflicting accounts of the siege of Jerusalem circa 701 BCE by the Assyrian king Sennacherib are of that nature.

Fast forward two thousand years. Evans, Kleinman, and Pagano write:

In 1334 an epidemic struck the northeastern Chinese province of Hopei. This “Black Death” claimed up to 90% of the population, nearly five million people. The epidemic eventually reached and decimated Tartar forces that had been attacking Kaffa, a Genoese colony on the Crimean Peninsula. In 1347, the departing Tartars catapulted plagueinfested bodies into Kaffa. The Genoese quickly dumped these bodies into the sea, however it was too late. Four ships escaped back to Italy carrying the plague that in just two years killed one-third of the European population.

The relationship between disease and national defense is not a new one in the US. Just a simple web search revealed this 72-year-old article from the American Journal of Public Health on the dangers of venereal disease to military preparedness. Another article in the Journal of the American Medical Association (JAMA) of the same year reports that venereal disease has been a concern of the US Army and Navy since 1778.

There is continued concern about the impact of infectious disease on national defense, for example, the emergence of antibiotic-resistant pathogens and the threat from tick-borne diseases, and from influenza.

Indeed, with anthrax and ricin scares, preventing and managing bio-terrorism is a major part of contemporary national preparedness.

In addition, the Department of Defense is participating in prevention initiatives. As Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs in the Department of Defense, put it:

At the Department of Defense, we’ve moved from a concept of health care to health, meaning that we understand health really is a much more involved concept other than just freedom from disease. It relates to healthy communities and healthy and active lifestyles and also addresses mental wellness and spiritual wellness as well. For us to create a fit and ready force, we need to make sure that we’re paying attention to all these dimensions of health and wellness.

All of these efforts center upon a single premise: national defense depends upon maintaining the health of the civilian and military populations.

That raises an important question: does it matter whether the threat to our health is a foreign enemy, a small band of domestic terrorists, or what we do to ourselves?

As we eat too much, as we eat too much of the wrong foods, as those foods provide biological encouragement to continue those habits, as we exercise too little, and as we create our own national health epidemic, is that not more than what any adversary could do to us?

Or as Walt Kelly’s cartoon Pogo once famously stated: We is met the enemy, and he is us.

PTSD: Military and Civilians

Posted by on July 1, 2013 Comments Off on PTSD: Military and Civilians

As I was surfing my car’s radio dial for some music–not much luck at the time–I heard a DJ defending his decision to discuss PTSD in the military. I guess some other listeners had been unsuccessful in finding music but found a serious discussion of trauma and war on a music show unacceptable.

What used to be called “shell shock” or “battle fatigue,” has the medical diagnosis of Post Traumatic Stress Disorder (PTSD). It is the kind of thing that got General George Patton in trouble, when he slapped a soldier suffering from it.

In many areas of brain disorder (ADHD, bi-polar, OCD, and PTSD), we can now provide a medical diagnosis rather than a moral diagnosis. Suffering from one of these disorders is no more evidence of moral shortcomings than diabetes, heart disease, or cancer–just different organs involved.

PTSD results from a shock or trauma–perhaps war is the most common and severe emotional trauma. I regret to note that having a volunteer army has resulted in the unintended consequence of making troops expendable to the civilian population. Now, we think nothing of sending them into combat with minimal reason or provocation, as they are volunteers, while we are in no way inconvenienced by doing so–no rationing, no higher war taxes, zilch.

As a result, we have decade-long wars (2 at last count in recent years) that cannot help but create PTSD along with other casualties of confict. And, of course, we need to make sure those needs are met along with the amputations and prostheses that the civilian population associates with war. The Veterans Administration (VA) maintains a National PTSD Center, and I have no idea how good the programs are, but they can be found by consulting the VA PTSD Locator

A related point, however, is that civilians as well as military are subject to the traumas that trigger PTSD. As the National Institute for Mental Health notes:

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

While our primary concern may be with the direct effects (psychological and emotional) of PTSD, just this week an Emory University study of identical twin Vietnam War veterans found that risk of heart attacks was more than doubled in those with a history of PTSD.

Mental illness or brain disorders of any type require considerable investment of resources, professional and financial, to address. As a society we have dragged behind on this–mental health parity laws at the state level commonly had loopholes for high financial impact. There is a federal law in place, but it is not clear how effective it is. Change is occurring, but slowly.

Just within the past week, we learned that the California Department of Managed Health Care had imposed the second largest fine ever on Kaiser Permanente for failure to provide long term mental health care.

This country was founded by emptying Europe’s jails, and has been populated by escapees from prisons and hospitals around the world, along with other immigrants. As a nation, we have our share of people with “issues.” Some of the benefit has come from their creativity and willingness to challenge frontiers; however, in the 21st Century we need to help those folks adjust to what passes for civilization. Our veterans deserve it, but so do a lot of civilians, too. Let’s work to see they receive the necessary services–having mentally stable neighbors and colleagues improves life for all of us.

The Casualties Do Not End With The War

Posted by on February 7, 2013 Comments Off on The Casualties Do Not End With The War

We know that casualties do not end with a war, but we don’t often think about it. Unless we are directly affected, the symptoms are invisible to us.

Among the casualties are those who suffer from CMI (Chronic Multisymptom Illness). During the 1991 Gulf War there were 700,000 military personnel in the war theater. About 25-35 percent of them have reported symptoms consistent with CMI.

CMI_IOM_20130201

A Congressionally-mandated, consensus report by the Institute of Medicine Committee on Gulf War and Health lists some of the symptoms, based upon the following working definition:

CMI_Definition_IOM_20130201

Reported symptoms are:

CMI_symptons 20130201

As treatments, the reporting committee considered:

  1. Pharmacological interventions (medications)
  2. Other Biological Interventions (such as electrical brain stimulation)
  3. Cognitive Behavioral Therapy (Individual and Group)
  4. Brief Psychodynamic Therapy (Individual and Group)
  5. Biofeedback
  6. Cognitive Rehabilitation Therapy
  7. Complementary and Alternative Therapies
  8. Exercise

My observation is that the Committee recommendations are guarded and limited because of the absence of unbiased, unambiguous research studies. Use of antidepressants along with cognitive behavioral therapy, as well as symptomatic treatment, such as NSAIDs for pain.

Many of the report recommendations deals with programmatic approaches to the problem by the Veterans Administration as well as teaching clinicians how to deal with patients who have a chronic illness, to be managed not fixed.

As citizens we are obligated to pay the full costs of the wars that we support, not just the military hardware and the salaries of military personnel, but the care of those with casualties. Those casualties may be invisible to us, may be difficult to treat, but the distress they cause is real, and the risks their victims have taken on our behalf are just as real. We are without honor as a people if we do not provide them with treatment for all their wounds, visible and invisible.

Are the troops healthier than before?

Posted by on January 10, 2013 Comments Off on Are the troops healthier than before?

Military troops are healthier than before with less arterial plaque than previous studies showed. So says a study published in the Journal of the American Medical Association

Whether our military is healthier is an important question, going to the heart of the reason for this blog. The study also makes clear how difficult answering that question is.

The study compares arterial plaque from autopsies of US soldiers in Iraq to the findings from similar studies on soldiers in the Vietnam and Korean conflicts.

The implicit assumption is that deceased soldiers are a random sample of the larger military population, or at least that deceased soldiers from different wars are comparable samples.

For example, the sampling is quite different in the 3 conflicts, with a larger number and larger percentage of deceased soldiers available to the Iraq War study than from the earlier conflicts, which had much higher number of combat deaths.

Table 3 JAMA 20121226

The authors, as in all good science, do an admirable job of listing in the Comments section all the possible variables unaccounted for. Probably the most striking change between the earlier and current study subjects is that in earlier wars tobacco consumption was encouraged, while by the time of the latest conflict the military had successfully lowered smoking rates within the ranks. That rate is over 30% while the civilian rate is closer to 20%.

In addition, both military and civilian populations have profited from the availability of statin drugs. The military may have improved arterial health today, but that health may be better, the same, or worse than civilian equivalents. I cannot help but assume that the Army still produces bacon for breakfast nearly every morning by baking it in its own grease per this recipe, under Note.

Even with the limitations that the authors list, the study provides an intriguing look at disease across demographic categories.

Table 1 JAMA 20121226

It appears that older more sedentary occupations, ranks, services are all likely to show greater evidence of arterial plaque.

For example, the Marines show the least while the Air Force shows the most. Higher ranks show more plaque. Higher educational levels show more plaque, as education is a likely correlate of rank, implying more sedentary activity and perhaps greater age.

If you don’t think this is a matter of national defense

Posted by on December 20, 2012 Comments Off on If you don’t think this is a matter of national defense

Well, the Department of Defense does.

During the period 1998-2010, discharges from the US Armed Forces for obesity have risen at a rate that should concern all of us.

Presumably, the military problem reflects the similar civilian problem; however, we expect soldiers to be more physically fit than civilians.

In this inter-service rivalry no one is winning:

AFHSC_obesitypct_201101

The entire report: Diagnoses of Overweight/Obesity, Active Component, U.S. Armed Forces, 1998-
2010