Health Care for Military Environmental Exposure Concerns

Almost 50% of Veterans seeking care at the US Department of Veterans Affairs (VA) have concerns about military environmental exposures. Addressing these concerns and providing exposure-informed care is foundational to the mission of VA. It is also complicated. There is a marked lack of data on the amount, duration, and frequency of exposures across military settings (ie, combat zones, garrisons), and the overall dose exposure for an individual Veteran. Research on the long-term impact of exposures is most often conducted at the population level and offers limited guidance to support clinician and Veteran decision-making. The legacy of Agent Orange looms when talking with Veterans about care for military environmental exposures. Many Veterans with exposure concerns report decreased trust in the VA for historically failing to recognize and improve care for conditions that may be related to military exposures. Some fear that the government is hiding information or believe that it is just a matter of time until certain exposures are deemed toxic. Few clinicians receive extensive specialized training in occupational and environmental medicine; as a result, clinicians report a lack of knowledge of military environmental exposures and lack confidence in implementing this into clinical care. The passing of the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act in 2022 was the largest expansion of benefits and clinical care in a generation and brought renewed attention to providing effective health care for military environmental exposure concerns. Despite recognition of the importance and difficulties inherent in addressing military exposure concerns, there has been relatively little research to guide the delivery of health care for these concerns. The goal of this special issue is to highlight military environmental exposures as an area of Veterans’ care, including epidemiological, clinical research, health science research, implementation science, and quality improvement. This special issue starts with a perspective from McAndrew et al,1 on how the Veterans Health Administration (VHA) is implementing exposure-informed care, which is a model of care that “recognizes previous possible or known exposures to environmental factors may impact health and cause concern, and seeks to create an environment that at every level of the health care system is validating, transparent, and proactively addresses environmental exposures.” This perspective provides concrete examples of how exposure-informed care is increasingly integrated into the fabric of VA’s health care system. The following article is a Delphi quality improvement study from Boska et al,2 which uses an iterative process with subject matter experts in military environmental exposures to identify the core components of exposure-informed care. The results of which are already being used to guide efforts in VA to improve care for military environmental exposures. The next series of articles explores Veterans’ perspectives on military environmental exposure concerns and health care for these concerns. In the first article, a survey by Solanki et al3 examines Veterans’ experiences with health care and disability compensation related to legislation for contaminated water exposure at Marine Corps Base Camp Lejeune in North Carolina. Then, Fix et al4 use qualitative focus groups to understand how Veterans with airborne hazards concerns prefer VA to communicate about military environmental exposures when the evidence is limited or unclear. Using qualitative interviews, Bloeser et al5 explore the journey of Veterans with Gulf War Illness as they navigate through the health care system for care for Gulf War Illness. This study provides an understanding of system-level barriers and facilitators to health care, providing insight into when and where interventions maybe be most effective in improving care for Gulf War Illness. The last series of articles explores associations between military environmental exposures and health conditions. Magnante et al6 uses evidence mapping methodology to evaluate the literature and determine what research exists on the co-occurrence of military environmental exposures and mental health conditions or symptoms. They also explore whether individuals with a history of military environmental exposures also report having co-occurring mental health conditions or symptoms. A cross-sectional survey with Veterans who deployed to the Persian Gulf from 1990 to 1991, completed by Phan et al,7 examines the relationship between self-report of symptom severity and self-report of military environmental exposures. Jones et al8 compares self-reports of sleep-related symptoms to data from the electronic medical record data in the VA to understand potential limitations and strengths of using self-reported case identification methods for Veterans who completed the Airborne Hazards and Open Burn Pits Registry Self-Assessment Questionnaire. Agrawal et al9 builds on this by examining the relationship between self-report of burn pit smoke exposure to sleep apnea prevalence and severity documented in the electronic medical record for Veterans who were enrolled in the VA’s Airborne Hazards and Open Burn Pits Registry from 2014 to 2022. While this special issue was open to all researchers, it is notable that all corresponding authors were VA researchers. Research conducted at the VA is focused on Veteran health and ensuring Veterans are provided with the high-quality care they deserve. This special issue is a critical step to define exposure-informed care, understand Veterans’ perspectives on military environmental exposure concerns, and improve our understanding of the relationship between military environmental exposures and health conditions. We hope this work informs exposure-informed care within VA, community care, and civilian settings and helps ignite future research on health care for military environmental exposures.