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Caring for veterans who sustained injuries in the wars in Iraq and Afghanistan is one of the primary duties of the country’s system of veterans’ care. Today, because of advancements in medical technology and care on the battlefield, more veterans are surviving combat injuries than any previous generation. Many of these veterans will live their lives with complex injuries. Even more have sustained unseen injuries.

Like Vietnam veterans who only saw the impact of Agent Orange years after their service, today’s veterans may see lasting effects of the widespread use of burn pits to destroy all forms of waste. And the long-term impacts of the signature injuries of today’s wars—blast injuries such as Traumatic Bain Injury (TBI)—are still unknown. Without continued research, the country will be ill-prepared to handle the long-term effects of these injuries.

Meeting the demands of veterans of Iraq and Afghanistan will require investments in improving proven treatments and developing bold new treatments. Medical innovations coming out of the Deparments of Veterans Affairs (VA) and Defense (DoD) not only benefit our troops and veterans, but are soon adopted in the civilian medical community. Such innovations include improved technologies for the emergency treatment of hemorrhaging.

7.1: Improve Care for the Signature Injuries of the Wars in Iraq and Afghanistan
7.2: Expand Health Care Tracking and Research
7.3: Clarify and Support the Use of Service Dogs
7.4: Study and Field Innovative Health Care Treatments
7.5: Destigmatize the Use of Medical Marijuana

7.1: Improve Care for the Signature Injuries of the Wars in Iraq and Afghanistan

Blast injuries—including Traumatic Brain Injury, tinnitus (hearing loss) and musculoskeletal injuries (often resulting in chronic pain)— are the most prevalent injuries of today’s veterans and service members. Mental health injuries are also high on the list. The most recent data from VA shows that over half of new veterans diagnosed with mental health injuries at VA were diagnosed specifically with PTSD.56 However, it is also important to note that the most common diagnosis for Post-9/11 veterans at the VA is related to injuries of the musculoskeletal system, which translates to joint and muscle pain, and includes chronic pain.

Tinnitus, defined as a ringing in the ears, is often seen in today’s veterans. Yet many VA centers still do not provide adequate treatment for the injury and few treatments have been developed to cure it or alleviate its debilitating symptoms.

Genitourinary (GU) injuries have also become increasingly common among veterans of Iraq and Afghanistan.57 Despite having access to treatment while in service through the Department of Defense (DoD), veterans did not have access to reproductive services that give them a chance to start the family they hoped to have until IAVA-backed legislation was signed into law in 2016. This was a major victory.

IAVA Recommendations:
I.
Fully implement and fund new legislation allowing
veterans to have access to reproductive technologies in the VA, including in vitro fertilization technology.

II. Expand the stepped-case management system for chronic pain, where primary care physicians have the support of an integrated, multi-disciplinary team of providers to design and implement a comprehensive treatment plan for the patient. 

III. Research and develop medical treatment options to address tinnitus that draw on the best resources of the government, private and nonprofit sectors.

IV. Require that cognitive therapy be covered by TRICARE for veterans recovering from TBI.

V. Maximize the effectiveness of the TBI Veterans Health Registry by requiring DoD to share with the VA operational situation reports of all service members exposed to blasts and other causes of head and neck injury.

VI. Increase funding within the Department of Health and Human Services’ (HHS) budget for TBI programs that will increase access to care, train local health providers and provide long-term community support.

VII. Increase funding for nonprofit groups that support veterans with the signature injuries of war, like IAVA, Fisher House, UCLA’s Operation Mend and the Intrepid Fallen Heroes Fund.

7.2: Fully Understand and Support Injuries from Toxic Exposures and Burn Pits

Burn pits were a common way to get rid of waste at military sites in Iraq and Afghanistan, particularly between 2001 and 2010. Waste products in burn pits include, but are not limited to: chemicals, paint, medical and human waste, metal/aluminum cans, munitions and other unexploded ordnance, petroleum and lubricant products, plastics, rubber, wood, and discarded food. Additionally, there are other risk factors beyond burn pits that occurred in Iraq and Afghanistan that may pose danger for respiratory illnesses, like high level of fine dust and exposure to other airborne hazards.

According to IAVA’s most recent member survey, 80 percent of respondents were exposed to burn pits during their deployments and over 60 percent of those exposed to burn pits during deployment reported having symptoms.58 And while our members share stories of challenges they continue to have with their health, and particularly health related to their lungs and the respiratory system, the latest comprehensive assessment of health outcomes related to these exposures was published in 2011.

In 2010, the GAO published a report entitled DoD Should Improve Adherence to Its Guidance on Open Pit Burning and Solid Waste Management. In that report, it emphasized that DoD had been slow to implement alternatives or fully evaluate the benefits and costs of open air burn pits, such as avoided future costs of potential health effects. A report published in 201560 was opened with a letter by the Special Inspector General for Afghanistan Reconstruction in which he said:

Unfortunately, in many instances DoD officials did not take sufficient steps to ensure the proper management of contracts for the construction of the incinerators to address the problems identified during our inspections of particular incinerator facilities. Given the fact that DoD has been aware for many years of the significant health risks associated with open-air burn pits, it is indefensible that U.S. military personnel, who are already at risk of serious injury and death when fighting the enemy, were put at further risk from the potentially harmful emissions from the use of open-air burn pits.

And a report by the Institute of Medicine in 201161 found limited but suggestive evidence of a link between exposure and reduced lung function. Up until now, the emphasis on this issue has been on research. Thanks to legislation fought for by IAVA and other VSOs, the VA established the Burn Pit and Airborne Hazards Registry to better understand the health outcomes of those exposed. Yet, even that registry has its limitations.

Without due attention, this issue could be the Agent Orange of the Post-9/11 era of veterans. It’s past time that comprehensive action is taken to address the growing concern among post-9/11 veterans that these exposures have severely impacted their long term health.

IAVA Recommendations:
I. 
Mandate that the VA partner with an independent research body, such as the Institutes of Medicine, to conduct a biennial review and provide a summary of research concerning the association between exposure to airborne hazards and open burn pits and diseases suspected to be associated with such exposure.

II. Ensure that VA clinicians are trained to query and identify illnesses tied to toxic exposures and mandate screening for all veterans 

III. Update the Burn Pit and Airborne Hazards Registry to allow for (and prompt for) annual participation by registrants to provide for longitudinal health data concerning exposures.

IV. Provide training for non-VA doctors to educate them about toxic exposures in the veteran population and provide screening tools.

V. Require DoD identify all those exposed to burn pits and other toxics both at bases in CONUS or while deployed. Work with the VA to proactively reach out to encourage enrollment in the Burn Pit and Airborne Hazards Registry

7.3: Expand Health Care Tracking and Research

The tail of war can be long, and we may still not know the full scope or burden of health consequences for our veterans. Like we experienced with prior generations of veterans, it may be decades before we know the consequences of toxic exposures from burn pits, repeated traumatic brain injuries, or other environmental hazards. The continued creation and monitoring of health registries and a continued investment in research on the long-term health effects of the wars in Iraq and Afghanistan will help the VA and other health care systems identify and address nascent problems. For example, in 2008 RAND Corporation published a report on the invisible wounds of war that exposed the rates of invisible injuries, but since then there has been limited research to build upon this landmark study. Research must continue to support today’s veterans.

IAVA Recommendations:
I. 
Mandate and fund a comprehensive study investigating all potential long-term health effects from Iraq and Afghanistan veterans’ exposure to airborne hazards and open burn pits. This should integrate existing DoD and VA records with registry data to allow for a comprehensive, immediate and ongoing health outcomes analysis.

II.Fund and conduct a comprehensive study of the short and long-term effects of prophylactic medications such as the malaria drug Melfoquine (aka Larium) given to troops serving in Iraq and Afghanistan. The study should look at side effects, interactions with other medications, and the longterm effects of toxicity

III. Develop an electronic system to track the purchasing and referrals of prosthetic and sensory aid devices.

IV. Ensure the proper funding for the Vision Center of Excellence (VCE) for the prevention, diagnosis, mitigation, treatment and rehabilitation of military eye injuries that was authorized by the 2008 National Defense Authorization Act (NDAA).

V. Ensure proper funding and establish the Hearing Center of Excellence (HCE) and Limb Extremity Center of Excellence that were established in the 2009 NDAA.

VI. Fund interdependent research to expand public knowledge of the injuries of today’s veterans, like RAND’s Invisible Wounds of War report.

VII. Invest in research on pain and pain management to increase understanding of pain management and develop additional comprehensive interventions to best manage pain.

VIII. Expand public/private research partnerships, enlisting academic researchers to study VA data, enhancing understanding of the veteran population, its health risks and outcomes and developing new interventions to better address those risks and outcomes.

7.4: Clarify and Support the Use of Service Dogs

Service dogs, trained to assist injured veterans with daily tasks, are quickly becoming a more widely recognized treatment alternative for veterans. IAVA members continue to rely on service dogs and find them to be essential to their recovery. Approximately six percent of IAVA member survey respondents have used or are currently using a service dog. That number has been steadily increasing over the last few years. Still, many misconceptions exist about service dogs, which can result in them being illegally barred from entering businesses and medical facilities, further isolating struggling veterans.

In 2015, the VA updated its policy to allow service dogs on VA owned or leased property. In 2016, the VA also expanded its policy regarding the types of service dogs it would support for its veteran clients. Previously, the VA provided veterinary health benefits only for guide dogs for the visually impaired and partnered with non-VA affiliated guide dog training organizations to provide those dogs. However, the VA is also currently piloting a program to implement veterinary health benefits for mobility service dogs approved for veterans with a chronic impairment that substantially limits mobility associated with mental health disorders.

Yet, even as the VA advances its policies and popularity of service dogs as an aid to physical and psychological injuries continues to increase, many are still confused by what a service dog is, the requirements to receive a service dogs and there are no clear universal guidelines certifying service dogs. As a result, many veterans are seeking dogs without the proper training to fulfill their duties during the veteran’s recovery. It’s past time that we invest in research to better understand the benefits of service dogs and establish universal guidelines to ensure that those using service dogs are not taken advantage of.

IAVA Recommendations:
I. 
The DoD and VA, in partnership with stakeholders and subject matter experts, must coordinate to develop common service and guide dog policies and benefits.

II. Launch a public awareness campaign educating non-VA medical facilities and businesses in areas with high concentrations of veterans about access for service dogs. 

III. Train staff to understand the section of the American with Disabilities Act that pertains to service dogs and more broadly how to appropriately interact with someone with a service dog.

IV. The VA must partner with Assistance Dogs International accredited service dog agencies to educate VA staff and veterans on the availability of service dogs and the accompanying benefits.

V. The VA must improve its outreach and awareness efforts concerning the availability of service and guide dog benefits and clarify the application process.

VI. The VA and DoD must develop and improve their education and outreach efforts, both internally and externally, to educate providers on the new clinical guidelines, proper referral processes and the benefits available to veterans already using service and guide dogs.

VII. The DoD and VA must start tracking how many veterans currently use medically prescribed service and guide dogs and how many veterans are referred to service and guide dogs agencies, as outlined in the newly published clinical guidelines for VA providers.

VIII. Fund and conduct research to better define therapeutic and medical outcomes of veterans using service dogs.

IX. Identify and fund best-in-class programs that train and support service dogs for veterans.

7.5: Study and Field Innovative Health Care Treatments

The VA has long been a leader in innovative health care research, leading to many of the best practices in supporting veterans with service-connected injuries like amputated limbs or post traumatic stress disorder (PTSD). With more veterans surviving traumatic injuries, the VA must continue its legacy of investing in innovative research to develop new methods to care for the long-term health needs of post-9/11 veterans.

Treatment options should include the full range of traditional and experimental options that have proven to be effective. Non-traditional approaches may break down some of the barriers veterans often face in seeking care, such as telemedicine, which can close the distance between a rural veteran and a VA facility or can bypass the stigma of seeking mental health care

IAVA Recommendations:
I. 
Identify and invest in best-practices for traditional, non-traditional and experimental treatments of invisible wounds, including meditation and acupuncture. Set outcome metrics to better define the impact of these treatment methods.

II. Fund research to explore innovative uses of telemedicine to provide care for rural and infirmed veterans who do not have easy access to medical facilities. 

III. Provide grants to innovative nonprofits, like UCLA’s Operation Mend and Massachusetts General’s HomeBase, that provide life-changing surgeries and medical services to severely wounded warriors at no cost.

IV. Continue investments in adaptive sports to support disabled veterans.

7.6: Destigmatize the Utilization of Medical Marijuana

The debate around legalizing marijuana for medical purposes is ending. Twenty-eight states and the District of Columbia have legalized medical marijuana. And over 60 percent of IAVA survey respondents support the legalization of marijuana for medical use.65 IAVA members recovering from injuries have been extremely vocal in communicating the benefits for pain relief.

While marijuana has been used to alleviate the symptoms of a number of symptoms and illnesses, the medical evidence is still insufficient to support the widespread use of medical marijuana, lacking information on safety, tolerability and efficacy. Researchers state that this is in large part due to challenges in researching the drug because of its status as a Schedule I Controlled Substance under federal law.

However, the evidence for medical benefits is promising. Patients using medical marijuana for various illnesses have seen the benefits firsthand and have become among the most vocal proponents for legalizing marijuana for medical use. Clearly more needs to be understood about the potential benefits of medical marijuana to treat a variety of symptoms and illnesses impacting veterans. In the meantime, veterans who are lawfully prescribed medical marijuana need the peace of mind that they can discuss their medical
interventions with their VA clinician without fear of prosecution.

IAVA Recommendations:
I. 
Ensure that veterans using lawfully prescribed
medical marijuana, as determined by state law,
are protected from federal prosecution.

II. Ensure veterans will not lose their VA benefits if they use legal medical marijuana. 

III. Fund research to assess the effectiveness of medical marijuana to treat veterans’ common injuries and to relieve pain.

IV. Allow and encourage a dialogue between patients and clinicians at the VA on their lawful (per state law) use of medical (or recreational) marijuana.