JAMA Forum: “Have You Ever Served?” The VA and the Private Sector

Diana Mason, PhD, RN

Diana Mason, PhD, RN

I’m a veteran. I served in the US Army Nurse Corps for 3 years after I graduated from nursing school, the last 2 years of which were paid for by the Army. From 1970 to 1973, I served as a lieutenant, then a captain, at Walson Army Hospital at Fort Dix, NJ, while colleagues of mine were serving in Vietnam. Now we’re all eligible for health benefits through the Department of Veterans Affairs (VA), although those who served in Vietnam have access to a higher level of benefits and priority for enrollment in the VA health system than I do. I have never used the VA health system as a patient, but by most reports, veterans in the system receive very good care.

The VA runs the largest integrated health system in the country, with a budget set by Congress. Until recently, it has received widespread acclamation as a leader in patient safety and use of electronic health records with patient access. Recent disclosures of excessive wait times for veterans to enroll in the VA health system and the administrative cover-ups and falsification of wait-time data led to the resignation of VA secretary Eric Shinseki in late May. Congress called for the resignation despite the Senate’s failure to confirm 2 of 3 open assistant secretary positions for more than a year. And Congress has also passed House and Senate versions of bills that would, among other things, increase the private sector’s involvement in the care of veterans. But the private sector may be ill-prepared to ensure better care for US veterans.

In April of this year, the VA released a report showing that, of the approximately 22 million veterans, roughly 5.7 million received treatment at a VA facility in 2013.* Only about a quarter of our veterans receive care through the VA health system. Why aren’t more using it? According to the 2010 National Survey of Veterans, 72% of veterans report being in good to excellent health and are able to carry out activities of daily living without assistance. But 42% of those who have never used VA health benefits said they didn’t know about them and 26% didn’t know how to apply.

Clearly, the VA health system would be even more overwhelmed if more veterans tried to use it. With about three-quarters of veterans either not getting health care or getting it from the private sector, the suggestion that non-VA health care clinicians and facilities play a greater role in providing care to veterans seems reasonable. But Linda Schwartz, RN, PhD, commissioner of the Connecticut Department of Veterans’ Affairs and a veteran who served as an Air Force nurse during the Vietnam War (and who, for the past 10 months, has been awaiting confirmation by the Senate as assistant secretary of the VA’s Office for Policy and Planning), has argued that the private sector may be ill-equipped to deal with the special health problems arising from veterans’ occupational and military exposures—exposures that vary according to when and where they served and what work they did. For example, veterans could have health problems arising from exposure to Agent Orange (Vietnam and Korea), contaminated water (Camp Lejeune, 1957-1987), oil-well fires and open burn pits (Iraq and Afghanistan), and radiation (“Atomic Veterans”).

The VA’s health care professionals are experts in the diagnosis and management of the consequences of these exposures. Most clinicians in the private sector are not. In fact, a 2011 online survey of community-based mental health and primary care professionals found that 56% of the respondents failed to ask patients whether they have ever served in the military or are family members of those who have served. If this is never asked, it’s easy to understand how, as Schwartz noted in her commencement address at Quinnipiac University School of Nursing in May, a veteran may be living with chronic pain or other debilitating condition arising—perhaps unknowingly by even the veteran and his or her health care providers—from a service-related injury or exposure that may be treatable if properly diagnosed.

Schwartz was instrumental in the development of an initiative of the American Academy of Nursing (disclosure: Schwartz is an academy fellow and I am the academy’s current president), in partnership with the National Association of State Directors of Veterans Affairs, called “Have You Ever Served in the Military?” The initiative seeks to raise the awareness of veterans’ health needs among clinicians in the private sector and includes materials for health care professionals that link time and site of military service, occupation, potential exposures and injuries, and relevant diagnoses. In addition, the initiative aims to embed the question “Have you ever served?” into electronic health records and include an algorithm to direct clinicians’ subsequent line of assessments.

It all begins by asking: “Have you ever served in the military?”

In May, the state of Connecticut passed Public Act 14-141, requiring, among other things, that “Whenever a person is admitted to a hospital, such person shall be asked if he or she is a veteran.”  Schwartz told the graduates at Quinnipiac about the genesis of that law. A couple of years ago she was involved in helping a veteran from Maine, a man hospitalized with a life-threatening condition while visiting his mother in Connecticut. A veterans services officer questioned the patient about his service; the officer realized that the man had been exposed to Agent Orange in the 1960s. The patient was subsequently diagnosed with non-Hodgkin’s lymphoma—a possible consequence of the exposure.

In writing this blog post, I realize that I have never disclosed to any health care provider in the past 40 years that I am a veteran. Even as a nurse, I never thought to offer the information during a health care visit. And no one has ever asked.

*Exact numbers on veterans are difficult to obtain and vary by source.

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About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: DDT Byproduct Is Associated With Increased Alzheimer Risk

Jason R. Richardson, PhD, of the Rutgers Robert Wood Johnson Medical School and Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey, and colleagues found higher exposure levels to a byproduct of DDT were associated with increased risk for Alzheimer disease (Image: Wilson Rodriguez)

Jason R. Richardson, PhD, of the Rutgers Robert Wood Johnson Medical School and Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey, and colleagues found higher exposure levels to a byproduct of DDT were associated with increased risk for Alzheimer disease (Image: Wilson Rodriguez)

Although the cause of Alzheimer disease remains unknown, researchers believe genetic, lifestyle, and environmental factors influence a person’s risk of developing the late-onset form of the disease, the disorder’s most common form. Now research appearing today in JAMA Neurology may shed light on a possible environmental risk factor, exposure to a byproduct of the pesticide DDT (dichlorodiphenyltrichloroethane).

The United States made wide use of DDT from the 1940s through the early 1970s in agriculture as a pesticide and for controlling vector-borne diseases in military and civilian populations. Although the US Environmental Protection Agency banned its use in 1972, a DDT metabolite, dichlorodiphenyldichloroethylene (DDE), which has a long half-life (estimated to be between 8 to 10 years), remains in the soil and water. DDT is also still used in some countries, both legally and illegally.

In a case-controlled study, researchers looked for the presence of DDE in existing serum samples from 86 patients with Alzheimer disease and 79 control participants. They found that although DDE was detected in 80% of patients with Alzheimer disease and 70% of control participants, levels of DDE were 3.8-fold higher in those with the disease when compared with control participants. The highest tertile of DDE exposure was associated with a 4.18-fold increased risk for Alzheimer disease compared with the lowest tertile. The researchers also found a genetic association: carriers of a particular variant of the gene encoding apolipoprotein E (APOE 4) appeared to be more susceptible to the effects of DDE.

Lead author, Jason R. Richardson, PhD, of the Rutgers Robert Wood Johnson Medical School and Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey, talks with news@JAMA about his team’s findings.

news@JAMA: How did you happen to consider DDE as something to study for Alzheimer disease risk?

Dr Richardson: In 2009 we published a study in the then Archives of Neurology looking at pesticide chemicals and Parkinson disease. While we were doing that, we had a control group but thought to add another neurodegenerative disease. So we took 20 samples from patients with Alzheimer disease and we found higher levels of DDE in the Alzheimer’s samples. It was intriguing, but you don’t want to get too excited about 20 samples. So we cobbled together some funds and now we’ve confirmed that original sample.

news@JAMA: So what comes next?

Dr Richardson: Our data calls for more research to find out why this association occurs. I hope our colleagues in the scientific community, with a much larger cohort, can replicate our findings.

 news@JAMA: If your findings are confirmed and added to, what are the potential clinical implications?

 Dr Richardson: Early detection and treatment is important for neurodegenerative disease, so if you can identify those at higher risk and get them to the clinic earlier maybe your intervention will be more successful.

 news@JAMA: It seems a lot of us have DDE circulating in our bodies. Why?

 Dr Richardson: We have legacy contamination in the United States and DDE has a long half-life. So especially meat, fish, and diary can harbor these types of chemicals.

news@JAMA: Does it surprise you that the World Health Organization has called for the reintroduction of DDT for malaria eradication while the research community continues to caution about a potential association with neurodegenerative diseases?

 Dr Richardson: From a medical standpoint, DDT was an amazing insecticide. Where used, it eradicated malaria, so this is not a black and white issue. I asked my medical school students to determine as best they could whether DDT should be reintroduced. They looked at all the evidence and said it should be brought back to eradicate malaria in the developing world, but you need to be cognizant to reduce exposure as much as you can. They determined the benefits outweigh the risk.

Whatever Health Risks May Be Associated With Workplace Stress, Increased Risk for Cancer Appears Unlikely, Study Says

New research could find no association between workplace stress and increased risk for cancer. (Image: Otmar Winterleitner/iStockphoto.com)

New research could find no association between workplace stress and increased risk for cancer. (Image: Otmar Winterleitner/iStockphoto.com)

People worried about the effects of workplace stress on their health can probably relax on one count: research appearing today in BMJ suggests that work-related stress is unlikely to be an important risk factor for cancer.

About 90% of cancers have been linked to nongenetic factors—environmental exposures and lifestyle choices such as smoking—but the evidence that psychosocial factors such as stress might increase cancer risk is tentative. In theory, stress could play a role in increasing cancer risk through its association with the physiological stress response, which is characterized by increased secretion of hypothalamic and pituitary stress hormones. These hormones can trigger and maintain chronic inflammation, which has been shown to play various roles in cancer promotion and progression. Continue reading

Certain Jobs May Put Women at Greater Risk of Developing Breast Cancer

Researchers have found an association between certain occupations and increased breast cancer risk. (Image: BEZERGHEANU Mircea/iStockphoto.com)

Certain occupations with potentially high exposures to carcinogens and endocrine disruptors are associated with an increased risk of breast cancer, say researchers whose findings appear today online in Environmental Health.

The researchers, using data collected from 2002 to 2008, found that working in automotive plastics manufacturing increased breast cancer risk by 168%; food canning, by 135%; metalworking, by 73%; and agriculture, by 36%. Premenopausal breast cancer risk was highest for women who had worked in food canning (470%) or automotive plastics (376%). In other sectors, such as construction, petrochemicals, printing, and textile manufacturing, there was a lack of statistical power to draw conclusions about exposure associations with breast cancer. Continue reading

After Decades of Antibiotic Treatment of Honeybee Colonies, Tetracycline-resistant Bacteria Often Found in US Bees

After years of preventive treatment with antibiotics, the guts of domesticated honeybees in the United States harbor numerous genetic variants that confer resistance to the antibiotic tetracycline, a recent study found. Image: Agricultural Research Service/Jack Dykinga

First it was pigs and chickens that were found to harbor antibiotic-resistant bacteria as a consequence of widespread use of antibiotics in the animals for preventive purposes. Now researchers have discovered that honeybees similarly exposed to antibiotics for decades carry bacteria in their guts that are resistant to tetracycline, according to a study published online today in the journal mBio.

The finding of antibiotic-resistant bacteria in honeybees doesn’t pose a direct threat to human health because these bacteria are not found in the honey produced by the bees. But the study provides insights into the consequences that widespread antibiotic use can have on gut flora and health in another species.

For more than 50 years, US beekeepers have applied oxytetracycline to honeybee colonies to prevent a bacterial disease called foulbrood. To assess the effect of this use on the gut bacteria of bees, a team of researchers used genetic sequencing and other techniques to compare bacteria in the gut of US domesticated bees, wild bees (which presumably wouldn’t be exposed to the antibiotic), and domesticated bees from parts of Europe and New Zealand where use of antibiotics on bees has been forbidden. The researchers found that gut bacteria in US bees carry 8 genetic variants that confer resistance to tetracycline, compared with 1 or 2 such resistance-conferring variants in wild bees or in those from countries that don’t use antibiotics on bees. Continue reading

Author Insights: Air Pollution Levels During Beijing Olympics Associated With Changes in Heart Risk Biomarkers

Junfeng (Jim) Zhang, PhD, professor of environmental and global health, University of Southern California, Los Angeles, and colleagues found that changes in air pollution levels during the 2008 Beijing Olympics were associated with biomarkers linked to heart risks. (Image: University of Southern California)

When the Chinese government agreed to temporarily and substantially improve air quality in highly polluted Beijing for the 2008 Summer Olympics, researchers saw a unique opportunity to study air pollution effects on biomarkers linked to cardiovascular disease. What they found was that reductions in certain air pollutants during the Olympics were associated with decreased levels of various biomarkers linked to inflammation and blood clotting. After the games ended, both air pollution and these biomarkers rose to pre-Olympic levels.

The findings, which appear today in a global health theme issue of JAMA, are based on a study of 125 healthy young medical residents at a central Beijing hospital who were each tested between June 2 and October 30 in 2008, before, during, and after the games. Junfeng (Jim) Zhang, PhD, the corresponding author and a professor of environmental and global health at the University of Southern California in Los Angeles, discusses his team’s findings:

“There have been a lot of epidemiology studies showing a connection between cardiovascular mortality and morbidity with increased air pollution levels, but we do not know how air pollution affects the heart. So this study tries to understand how air pollution affects young and healthy hearts. Inflammation biomarkers and blood-clotting biomarkers, which are activation markers, rose with pollution levels [following completion of the games]. That explains how air pollution affects cardiovascular health very quickly, because these were acute effects. Continue reading

FDA: Potentially Unsafe Handheld X-ray Devices Sold Online

The US Food and Drug Administration is asking health care professionals to verify that any handheld x-ray units they use meet the agency’s radiation safety and medical device requirements. (Image: Jeremy Suess/iStockphoto.com)

The US Food and Drug Administration (FDA) is warning health care providers, including dentists, dental care professionals, and veterinarians, against purchasing or using certain potentially unsafe handheld dental x-ray units. The FDA issued a safety communication today after the Washington State Department of Health alerted the agency that tests it conducted on a device purchased online revealed that the device did not comply with x-ray performance standards.

The FDA said it was investigating the extent of the problem and notifying state regulatory authorities, dental professional organizations, and other health organizations about the safety risks. To date, no adverse events have been reported. Continue reading