Continuing Education—November 2012
Honoring Our Veterans
When young American men and women join the military, they write a blank check for the value of
their lives. Whether they joined in the patriotic fervor of the days and weeks after the bombing of Pearl
Harbor or the World Trade Center towers, or were drafted in Vietnam, America’s Veterans have done
what was asked of them. And however they left our soil, it is never too late to give them a hero’s
welcome home. Hospice staff and volunteers may provide the last opportunity for Veterans to feel that
their service was not in vain, and that they are appreciated. Simple acts of gratitude at the end-of-life
may help make up for a perceived lack of appreciation or recognition during the Veteran’s lifetime,
especially for those Veterans who were never welcomed home or thanked for their service. As you
work with our Veterans, and chances are that you will since 25% of people dying in the US today are
Veterans, here are tips you can use to engage, honor, and recognize the Veterans you serve:
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Give Veterans an opportunity to tell their stories.
Respect Veterans’ service, their feelings, and any suggestions they might offer.
Thank Veterans for their service to our country.
Show appreciation for the families of Veterans.
Always be sincere, caring, compassionate and ready and able to listen to what a Veteran
or his or her family member has to share about the situation they are dealing with.
Be supportive and non-judgmental and always validate their feelings and concerns.
Be honest, sincere, caring and respectful.
Accept, without judgment, the Veteran as he/she is.
It might take longer for some Veterans to trust you. Be patient and listen.
Expect the Veteran’s sharing to occur over a period of time.
Your Veteran hospice patient may be of a different generation than your own. You may not remember
or have ever known even the slightest details about the military conflict that so affected his/her life.
The following brief summaries of the conflicts our troops served in may give you helpful background
in understanding your patient’s experiences.
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World War II
Battle Deaths: 291,557
Wounded: 671,846
WWII Veterans today are all over 70 years old and subject to all the diseases of aging: cardiovascular diseases, cancer,
dementias of the Alzheimer's type, etc. However, in the early 1940's, they were among the nation's fittest and participated
in modern warfare that coincided with major advances in modern medicine. The U.S. entered the war in December 1941
following the attack on Pearl Harbor. Before it was over, Americans had fought on the continents of Europe, Asia, and
Africa and in the Atlantic and Pacific Oceans. At various times, their service was carried out under severe winter
conditions, in the harshest of deserts, and in the hottest, most humid tropical climes. Those who joined up or were drafted
were in the military for the duration, however long that might be. The war in Europe ended on May 8, 1945, when the
Germans surrendered at Reims in France. The war continued in the Pacific for three more months. However, following the
dropping of the first atomic bomb on Hiroshima on August 6 and a larger bomb on Nagasaki two days later, the Japanese
surrendered aboard the USS Missouri in Tokyo harbor on September 2, 1945. World War II Veterans also were the first to
serve in the nuclear age and American POWs were employed in the clean-up of Hiroshima and Nagasaki, thus becoming
the first "atomic vets." Over 350,000 women served with a peak strength of 271,000 representing 2% of the personnel in
uniform, compared to the approximately 15% now in the military. Women, mostly nurses, were taken prisoners of war by
the Japanese when Bataan and Corregidor fell and were interned in the Philippines for four years.
WWII Health Risks
Infectious Diseases The advent of antibiotics began with the use of sulfonamides in the mid-1930's, and the WWII troops
had the benefits of sulfa and penicillin to treat both disease and wound infections. They also benefited from the availability
of blood transfusions, aero medical evacuation, better burn management, synthetic antimalarials and DDT, and a wide
range of preventive measures including immunizations against yellow fever, cholera, plague, influenza, typhus, typhoid
and tetanus. The result was a 4% died-of-wounds rate for British and American troops, (this rate was later reduced to 2.5%
in Vietnam) and death rates from disease markedly fell below the killed-in-action rate. During WWII, morbidity from such
diseases as tuberculosis (anti-tuberculosis agents did not begin to appear until 1949), rheumatic fever, hepatitis and tropical
diseases was high and the prime reason for residual disability and time lost from duty.
Besides infectious diseases and wounds, other health risks of WWII included:
Frostbite / Cold Injury Cold injuries may result in long-term health problems, including the following signs and
symptoms (at the site of exposure):
• Changes in muscle, skin, nails, ligaments and bones
• Skin cancer in frostbite scars
• Neurologic injury with symptoms such as bouts of pain in the extremities, hot or cold tingling sensations, and
numbness
• Vascular injury with Reynaud’s phenomenon with symptoms such as extremities becoming painful and white
or discolored when cold
Mustard Gas Testing In the 1940s, the Department of Defense recruited "volunteer soldier" subjects for experiments
using mustard agents to evaluate clothing, ointments and equipment to protect American troops from mustard agent
attacks. Nearly 60,000 military personnel were involved in a wide range of exposures, most of them participating in mild
exposures (a drop of agent on the arm in “patch” tests). Approximately 4,000 soldiers were subjected to severe, full-body
exposures carried out in gas chamber trials or as a part of field exercises over contaminated ground areas.
Exposure to Nuclear Weapons WWII Veterans may have participated in atmospheric nuclear weapons tests which were
conducted primarily in Nevada and the Pacific Ocean between 1945 and 1962.
Nuclear Cleanup Veterans who were involved in the occupation of Hiroshima and Nagasaki, Japan between August 6,
1945, and July 1, 1946 and Veterans who were prisoners of war in Japan during World War II may have participated in
nuclear cleanup.
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Korean War
June 25, 1950 - July 27, 1953
Total who served in all Armed Forces: 5,720,000
Battle Deaths: 33,741
Other Deaths (In Theatre): 2,833
Wounded: 103,284
The Korean War was fought from 1950 until 1953 and pitted the United States, South Korea and their UN allies against
North Korea and the Chinese Communists. The Korean War began on June 25, 1950 when North Korea, under a
Communist government, invaded South Korea. North Korea hoped to unite the peninsula under a single Communist
government. The newly formed United Nations condemned the actions of North Korea and ordered troops to withdraw.
The United States entered the conflict when the UN called on member states to aid South Korea. With the help of U.S.
troops, South Korea pushed North Korean troops all the way to the Yalu River. This counter invasion gained the attention
of the Communist Chinese government who quickly came to the aid of North Korea. While Soviet Union forces never
directly entered the conflict, the government supplied war materials to both the Chinese and North Korean governments.
After China entered the conflict, South Korean and U.S. forces were pushed back to the 38th parallel, which became the
center of the fighting for the remainder of the war. Heavy fighting continued and casualties mounted; the United States lost
36,574 soldiers and another 103,284 soldiers were injured. Finally an armistice was signed on July 27, 1953 which once
again designated the 38th parallel as the border between the two Koreas.
The Korean War is often called the “Forgotten War” because it was largely overshadowed by WWII and Vietnam. The
importance of this war in the history of the United States and the world is vastly understated; this conflict marked the first
clear battle of the Cold War. Tensions were already high between the Communist East and the Democratic West, and the
Korean War certainly exacerbated the mistrust between the two sides. While this war is often forgotten, it is important that
the Veterans who fought in this conflict are not also forgotten.
Korean War Health Risks
Cold injuries including frostbite and immersion (trench) foot constituted a major medical problem for U.S. service
personnel during the Korean War. Veterans of the Battle of the Chosin Reservoir suffered especially high rates of severe
cold injuries. Cold accounted for 16% of Army non-battle injuries requiring admission and over 5000 U.S. casualties of
cold injury required evacuation from Korea during the winter of 1950-1951. In many instances U.S. service members did
not seek or were unable to obtain medical care caused by cold injuries because of battlefield conditions. Documentation of
such injuries may never have been made in their service medical records or may no longer be available.
Long-term and delayed symptoms of cold injuries include peripheral neuropathy, skin cancer in frostbite scars (including
in such locations as the heels and earlobes), arthritis in involved areas, chronic tinea pedis, fallen arches and stiff toes,
nocturnal pain, and cold sensitization. These cold-related problems may worsen as Veterans grow older and develop
complicating conditions such as diabetes and peripheral vascular disease, which place them at higher risk for late
amputations.
Exposure to nuclear weapons Korean War Veterans may have participated in atmospheric nuclear weapons tests which
were conducted primarily in Nevada and the Pacific Ocean between 1945 and 1962.
Cold War
The Cold War generally refers to the period of tension between the U.S., its allies and the Soviet bloc from the end of
World War II in 1945 until the collapse of the Soviet Union in the 1990s. A major fear of the Cold War was nuclear war
with associated health concerns about exposure to ionizing radiation.
While the United States and the USSR were allies during WWII, the alliance broke up after the Axis Powers were defeated.
The main disagreement concerned the differences in opinion regarding how the post-war world ought to look. The United
States and other democratic Western nations believed that previously occupied countries ought to be given the opportunity
to hold free elections to form their new governments. The Soviet Union, on the other hand, wanted to install communism in
its zones of occupation. The differences in political ideology created mutual mistrust between the two superpowers. The
Soviet Union resented the intrusion of the United States into European affairs, and the United States felt threatened by the
expansionary policy of Communist Soviet Union. The Cold War never resulted in direct military conflict between the
United States and the Soviet Union, but was marked by economic competition, a nuclear arms race, military tension, and
proxy wars.
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Cold War Health Risks
Exposure to nuclear weapons The United States feared that tensions with the Soviet Union and its satellite states could
potentially result in a nuclear war. The United States performed nuclear arms tests to ensure that if such a war did occur,
they would have effective weapons. Because of these tests, the main health risk linked to the Cold War is nuclear exposure
due to nuclear weapons testing. Veterans from this conflict are often referred to as “atomic vets” because of their exposure
to atomic weapons and radiation. Approximately 200,000 US service personnel performed occupation duties in Hiroshima
and Nagasaki following the atomic bombing of Japan and a similar number of service members participated in atmospheric
nuclear weapons tests from 1945 to 1962. Exposure to radiation has been associated with a number of disorders including
leukemia, various cancers, and cataracts.
Vietnam
August 4, 1964 - January 27, 1973
Total who served in all Armed Forces: 8,744,000
Deployed to Southeast Asia: 3,403,000
Battle Deaths: 47,424
Other Deaths (In Theatre): 10,785
Wounded: 153,303
At its close the Vietnam War was the longest and most unpopular war in which Americans ever fought. The first combat
troops arrived in 1965 and fought the war until the cease-fire of January 1973. For many of the American Veterans of the
war, the wounds of Vietnam will never heal. America's involvement in Vietnam actually lasted from 1957 until 1975. In
1954, the French were defeated and the former colony of French Indochina was divided into Communist North Vietnam
and (non-Communist) South Vietnam. In 1957, the Vietcong began a rebellion against the South Vietnam government of
President Diem, whom the US supported with equipment and advisors. In 1963, the government was overthrown, Diem
was killed, and a new government was formed. In August of 1964, Congress passed the Tonkin Gulf Resolution giving the
President the power to take "all necessary measures" to "prevent further (Communist) aggression." Between 1965 and
1969, US troop strength rose from 60,000 to over 543,000 in country. Despite the US's superior firepower against the
guerilla forces of the enemy, the two sides fought to a highly destructive draw.
In January 1968, the Tet Offensive began a new phase with savage attacks on the cities of South Vietnam. In May of 1968,
the US began peace negotiations, which eventually broke down. However, a change in US policy led to the greater
emphasis on training and supplying South Vietnamese troops and US withdrawal began in July 1968. TV coverage brought
the war directly to America's living rooms in a way never before experienced.
Fighting again intensified in 1972, leading to heavy losses on both sides, but this also led to renewed peace efforts. A
cease-fire was signed in January 1973 providing for the withdrawal of all troops and return of all prisoners within 60 days.
The last US ground troops left Vietnam in March 1973, after which the peace talks once again broke down. Fighting
resumed and South Vietnam eventually surrendered to the forces of North Vietnam in April 1975.
In the US, because of increased casualties and higher taxes to support the Vietnam War, great public dissatisfaction and an
immense anti-war movement was also a part of this war. Anti-war demonstrations intensified during the war as did concern
over war crimes and the environmental impact of Agent Orange.
Approximately 2,700,000 American men and women served in Vietnam and it was the first war in which the US failed to
meet its objectives. It was also the first time America failed to welcome its Veterans back as heroes. Many Veterans were
attacked personally by their fellow countrymen, who opposed the war. This situation magnified the stress associated with
their combat experiences. Also contributing to the stress many Veterans experienced was the lack of unit cohesiveness as
many were sent to Vietnam as individuals and left when their year's tour was completed. They often traveled to and from
Vietnam by air, being an active combatant one day and a Veteran returning to a hostile civilian environment the next. They
reported being spat upon as they disembarked at the airport and being uncomfortable wearing their uniform in public.
Following the war, Veterans experienced many readjustment problems and adverse health effects, many of the latter
attributed to Agent Orange.
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Vietnam War Health Risks
Environmental Hazards In addition to the risks inherent to combat, troops experience many environmental hazards.
Pesticide and herbicide spraying was commonplace. In addition, Vietnam is a tropical country with high temperatures, high
humidity and a monsoon climate. Approximately 20 million gallons of herbicides were used in Vietnam between 1962 and
1971 to remove unwanted plant life and leaves which provided cover for enemy forces.
Infections and Diseases Many troops were unable to get dry for days, opportunities for bathing were infrequent, and skin
hygiene was poor. Bacterial and fungal infections of the feet were a major cause of temporary disability. Skin disease was a
leading cause of outpatient visits and hospitalization.
Tropical diseases were frequent. Malaria was the most important. Over 40,000 cases of Malaria were reported in Army
troops alone between 1965 and 70 with 78 deaths. However, this was less than had been seen in earlier wars because of the
effectiveness of weekly medication. Throughout the war, disease accounted for 70.6% of all admissions with the remaining
approximately equally divided between battle casualties (15.6%) and non-battle injury (13.8%). These increased survival
rates were attributed to rapid evacuation, the ready availability of whole blood and well-established semi-permanent
hospitals.
Agent Orange The name “Agent Orange” came from the orange stripe on the 55-gallon drums in which the herbicide was
stored. Shortly following their military service in Vietnam, some Veterans reported a variety of health problems and
concerns which some of them attributed to exposure to Agent Orange or other herbicides.
The VA now recognizes eight conditions which are presumed to be related to service in Vietnam for the purposes of
establishing service-connection: soft tissue sarcoma, non-Hodgkins lymphoma, Hodgkin's disease, chloracne, porphyria
cutanea tarda, respiratory cancers, multiple myeloma, prostate cancer, acute peripheral neuropathy, and spina bifida in
offspring.
Hepatitis C Virus (HCV) Hepatitis C Virus is the most common infection carried by blood in the United States and 63%
of enrolled Veterans testing positive for HCV are Vietnam Era Veterans. HCV infection is a major public health problem
in the United States (U.S.) because of its potential to lead to cirrhosis, hepatocellular carcinoma, and other life-threatening
conditions.
Post Traumatic Stress Disorder (PTSD) Deployment places Veterans at increased risk for symptoms of psychiatric
illnesses, particularly post traumatic stress disorder (PTSD), anxiety, depression and substance abuse.
Gulf Wars
The 1991 Gulf War was considered a brief and successful military operation with few injuries and deaths of U.S. troops.
The war began in August 1990, and the last U.S. ground troops returned home by June 1991. On August 2, 1990 Iraqi
forces, led by Saddam Hussein, invaded and annexed Kuwait. In 1988, Iraq signed a ceasefire with Iran which ended an 8year war between the warring countries. Iraq was initially angry with Kuwait because of its refusal to forgive Iraq’s war
debt. Tensions increased when Iraq accused Kuwait of providing excess oil to the market and thereby driving down the
price of oil. Iraq was in the midst of recovering from their conflict with Iran, and they needed oil prices to be high to gain
enough revenue to rebuild. More conflict over oil occurred when Iraq claimed that Kuwait was stealing Iraqi oil by tilting
its drill bits into Iraqi oil fields. Saddam Hussein also argued that his invasion and annexation of Kuwait was justified
because Kuwait was a territory of Iraq, not an independent state. After Iraq invaded Kuwait, the UN called for immediate
Iraqi troop withdrawal, and imposed economic sanction in the form of a naval blockade until the demand was met. The UN
told Iraq to peacefully withdraw troops by January 15, 1991, or face UN coalition force. Saddam Hussein did not comply
and Operation Desert Storm began on January 17, 1991. Operation Desert Storm began with aerial attacks aimed at
disabling Iraq’s air force and anti-aircraft weaponry. The U.S. led UN coalition had a great technological advantage in the
sky and quickly met their objective. The U.S. led UN coalition continued to dominate when on February 23, 1991, ground
troops went into Kuwait and quickly overtook Iraqi forces, which burned Kuwait’s oil fields as they retreated. Kuwait was
liberated and a ceasefire was declared on February 28, 1991.
Gulf Wars Health Risks
Exposure to Chemical or Biological Agents Although most Gulf War Veterans resumed their normal activities, many
soon began reporting a variety of unexplained health problems that they attributed to their participation in the Gulf War,
including chronic fatigue, muscle and joint pain, loss of concentration, forgetfulness, headache, and rash.
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Exposure to Smoke Exacerbation of asthma associated with oil-well fire smoke
Exposure to Depleted Uranium (DU) Depleted uranium is a byproduct of the uranium enrichment process that makes
nuclear fuel. The U.S. military uses tank armor and some bullets made with depleted uranium (DU) to penetrate enemy
armored vehicles. Depleted uranium has approximately 60 percent of the radioactivity and the same chemical toxicity as
natural uranium. The U.S. military began using DU on a large scale during the Gulf War in the early 1990s.
Amyotrophic Lateral Sclerosis(ALS) A VA study reveals that Persian Gulf War Veterans are more than twice as likely as
other Veterans to develop ALS.
Post Traumatic Stress Disorder (PTSD) Deployment places Veterans at increased risk for symptoms of psychiatric
illnesses, particularly post traumatic stress disorder (PTSD), anxiety, depression and substance abuse.
Afghanistan / Iraq
The ongoing news reports concerning these conflicts will likely be sufficient background for working with Veterans of
Operation Enduring Freedom and Operation Iraqi Freedom.
Afghanistan / Iraq Health Risks
Unique health risks associated with OEF/OIF include:
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Infectious Disease
Cold Injury
High Altitude illnesses
Environmental Hazards:
Exposure to sewage
Exposure to agricultural and industrial contamination of water and food
Air pollution
Severe sand and dust storms
Combined penetrating, blunt trauma, and burn injuries (blast injuries)
Traumatic Brain or Spinal Cord Injury
Vision Loss
Traumatic Amputation
Multi-drug Resistant Acinetobacter
Leishmaniasis (sand fly-transmitted infection of the skin)
Depleted Uranium (DU)
Mental Health Issues, including Post Traumatic Stress Disorder (PTSD)
Information consolidated from http://www.wehonorveterans.org
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