Despite many circumstantial differences, the government’s response to exposures in World War II, Vietnam, and the Gulf War shared one key similarity, according to Smith: Despite an obvious effort to anticipate, prevent, and document deployment-related exposures, the military and the VA still didn’t know much about what they didn’t know. The chaos of war made data-gathering difficult, and limited our understanding of many deployment-related exposures. For example, said Smith, “Keeping track of where every unit went at the end of the Second World War turned out to be really hard, because a lot of people were moving around and theater orders were not necessarily getting back to the central database. Those kinds of problems, of knowing where a unit is this month, have always been difficult for deployed military. The mission is the primary goal, and bookkeeping kind of secondary.”

This difficulty, and the determination of the military and the VA to overcome it, are at the heart of what’s different about today’s post-deployment health program.

 

The Post-9/11 ERA Environmental Health Program and the AH&OBP Registry

It’s worth pointing out a couple of things about the VA’s exposure-related registry programs and compensation:

• The Ionizing Radiation, Agent Orange, Gulf War, and AH&OBP registries are for the purpose of expanding knowledge: Registry data helps the VA understand and respond to health problems more effectively, alerts veterans to possible long-term health problems, and connects them with health care resources; it’s also used to help DOD and VA refine and update their clinical practice guidelines for the treatment of exposure-related diseases and disorders. The registry programs’ health examinations have nothing to do with assigning a disability rating, which is an entirely different process.
• In determining exposure-related disability compensation, the VA doesn’t place a burden of proof on veterans; it has the authority to establish a “presumption” that an illness was caused by exposure to an environmental hazard. An atomic veteran, for example, doesn’t have to prove that her ovarian cancer was caused by her exposure; nor does a Gulf War veteran have to link his chronic fatigue syndrome to a particular deployment-related hazard. Such a link, in fact, is impossible, said Smith, for the same reason that epidemiological studies that might pinpoint hazard-related health problems in the theater are impossible: “It’s not an experiment. It’s a war.”

Even so, preventive medicine experts with DOD and VA agreed, at the turn of the 21st century, that they could do a better job of gathering data both before and during military deployments during wartime. They collaborated on a program to collect data and track personnel individually, every day, throughout their deployments. “We’re tapped into a list of who deployed,” said Dr. Paul Ciminera, director of the Post-9/11 Era Environmental Health Program in the VA’s Office of Public Health, “and we receive country-level information. This type of information was nonexistent during Desert Storm/Desert Shield. That all had to be reconstructed after the fact. And that took up time. It delays our ability to respond.”

The DOD/VA collaboration has meant that the creation of the AH&OBP Registry differs from its predecessors in one significant way: It began long before Congress ordered it. “Before the registry was established,” said Ciminera, “DOD was providing a list to VA of everyone who had separated from service, and among those, who was deployed, and where. And so we had been looking at our health care data for those individuals, and producing quarterly reports. We’d been talking with DOD about the issue of respiratory symptoms that were reported in the DOD’s Millennium Cohort Study. And then we worked with the IOM to produce the burn pits study, which they released in October 2011.” When the AH&OBP registry was mandated, Ciminera said, it became another tool in the existing action plan for the VA to look at the overall population of deployed Iraq and Afghanistan veterans and to determine, and respond to, their health needs.

The new registry is open to anyone – veteran or active-duty military – who served in the wars in Iraq and Afghanistan, was stationed in Djibouti after Sept. 1, 2001, or who served in the 1991 Persian Gulf War and may have been exposed to oil fires and dust. Registrants may also request a free medical exam – which, unlike the examinations administered under previous VA registry programs, is optional. “It’s also an online registry,” said Ciminera, “which is a new approach that really improves access. Individuals can go on that registry, and create a snapshot of their health, and learn more about the health concerns and the science and summaries of science as it is today. They can also receive resources to help them with next steps, and to be evaluated or, if they wish, to file a compensation claim. The online registry also provides a way we can reach back to them if new developments occur.”

With these tools analyzing data collected both before and during deployments, DOD and VA are closer than ever to understanding the connections between deployment-related exposures and the health of individual service members.

As of May 2015, more than 43,000 participants had signed on to the AH&OBP Registry. The June report issued by the Office of Public Health was, for the most part, a summary of the basic raw data it’s collected so far on the participants themselves and the type of exposures they’re reporting. “That’s really the first step,” said Ciminera. “[That data] helps us focus our outreach. It helps us improve our education to our staff, based on the exposures people report. And it helps us guide research studies to see what exposures we should be focusing on.”

Ciminera hopes that in the future, more of the 2 million people eligible for the registry will participate – not only so more people will become more aware of what to expect, what resources are available to them, and what to do if they notice changes in their health, but also so that researchers can expand the knowledge base about exposures in Iraq and Afghanistan. “The statistical tools available to us are so much more robust and capable now,” he said. With these tools analyzing data collected both before and during deployments, DOD and VA are closer than ever to understanding the connections between deployment-related exposures and the health of individual service members.

This article was first published in The Year in Veterans Affairs & Military Medicine.