OEF/OIF demographics compared to previous cohorts: implications for medical issues

Calhoun: The NPS Institutional Archive Faculty and Researcher Publications Faculty and Researcher Publications 2013 OEF/OIF demographics compared to previous cohorts: implications for medical issues Hendricks, Ann Hendricks, A., Amara, J. (2013). OEF/OIF demographics compared to previous cohorts: implications for Medical issues. In J. Amara, & A. Hendricks (Eds.). Military medical care: From pre-deployment to post- separation. Abingdon: Routledge http://hdl.handle.net/10945/42150

Page 1 OEF/OIF DEMOGRAPHICS COMPARED TO PREVIOUS COHORTS: IMPLICATIONS FOR MEDICAL CARE Ann Hendricks and Jomana Amara INTRODUCTION Since 2001, the United States (US) has deployed more than two million troops to Afghanistan and Iraq for Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), often for more than one tour of duty (Tan, 2009). These major international conflicts were the first since the Vietnam War that required a great number of troops on the ground. About 50 nations have contributed troops to both conflict areas, but the majority of those deployed at any one time have been from the US. For example, in 2009, 90,000 of the 130,000 troops deployed in Afghanistan were from the US with the next largest contingents from the United Kingdom (9,500) and Germany (4,818) (ISAF, 2012). The nature of the OEF/OIF conflicts has translated into health care needs that have concerned not only US service members and their families, but also the US Congress, the Department of Defense (DoD) and the Department of Veterans Affairs (VA) (e.g., see S. HRG 112-95 or S. HRG. 112-267). The signature conditions of the wars for US veterans are traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), but the majority of health complaints for both active duty military and veterans are relatively mundane, such as gastro-intestinal or musculoskeletal complaints. For example, Deyton (2008) reported that the largest proportion (46.6%) of OEF/OIF veterans accessing VA health care had diagnoses for musculo-skeletal conditions. Haskell et al., (2012) found that the odds for musculo-skeletal and joint problems were even greater (both AORs > 1.3) for female OEF/OIF veterans compared to males.

Page 2 The concern about the nation s ability to provide medical care for service members returning from active war duty must be assessed in the context of the other demands on the system, however. For example the Vietnam War cohort outnumbers the OEF/OIF cohort more than threefold and is entering old age, the period of life with the greatest health burden from chronic disease. In fact, demand for immediate post-deployment services by the OEF/OIF veterans is overshadowed nationally by the demands of the Korean and Vietnam War cohorts in terms of the number of patients and the average cost of care. This chapter describes the US veteran population today and places the OEF/OIF cohort in the context of all living US veterans. It relies on publicly available data and information. It does not explore the ramifications for veterans education, insurance, loans, burial, compensation, or pensions. Although the pressing needs of newly discharged veterans require immediate attention, long-term care needs for aging veterans is a concern not only for the future of the OEF/OIF cohort, but more immediately for the veterans of past conflicts. We first present information about overall trends in the total numbers of US veterans and compare demographic characteristics of OEF/OIF veterans and the overall veteran population. The discussion then moves to some of the health care needs of veterans who separated from the military in the past ten years. THE US VETERAN POPULATION

Page 3 Over the past seventy years, the number of veterans grew following the nation s involvement in World War II, the Korean conflict, and the Vietnam War, all of which used drafts to enlist military personnel (Figure 1). The total number of veterans peaked around 1980. Since then it has generally declined as many older veterans died and the military downsized at the end of the Cold War. However, the large cohorts from World War II, the Korean conflict and the Vietnam War still make up the majority of today s veterans. In 2012, most (55.5 %) of the 21.8 million US veterans are age 60 or older; only 5.5 percent are age 30 or younger (VETPOP 2007). Figure 1. Active Duty and Veteran Populations, 1940 2012 US Department of Defense, Personnel, Publications, Selected Manpower Statistics, Annual, http://siadapp.dior.whs.mil/personnel/pubs.htm. Note: The increase in the veteran population is an artifact of the decennial census in 2000, which identified more veterans than had been projected from the 1990 census. Some experts believe that increased life expectancy was the reason for this difference

Page 4 Military conscription ended in 1973 and today s members of the armed forces join voluntarily. Across all services, there are over 1.4 million active military personnel today (http://siadapp.dmdc.osd.mil/personnel/military/ms0.pdf). The relatively stable or perhaps declining (Feickert & Henning, 2012) numbers of active military projected for the next few decades imply that the total number of veterans will continue to decline through 2030 to about 14 million (Figure 2). By that time, the number of veterans over age 75 will be greater than the number under the age of 40. Figure 2: Forecast of Veteran Population by Age Group, 2000 through 2033 30,000,000 20,000,000 10,000,000 0 2000200520102015202020252030 <40 40-64 65-74 Year 75-84 85+

Page 5 Source: http://www1.va.gov/vetdata/docs/1l.xls, accessed April 23, 2012. Women make up 8.7 percent of all living veterans, almost 1.9 million individuals (VETPOP, 2007). They are younger than male veterans; about half of women veterans are currently younger than 50 while only about a quarter of the men are that young. This difference in age reflects increased military opportunities for women after the Vietnam War, which in turn increased the number of female recruits. Women have been a much larger proportion of active military from the 1980s onward. Projections through 2030 show the total number of women veterans increasing to over 2.1 million or one out of every seven veterans (VETPOP, 2007). In the 1990s, DoD changed the way women are assigned and the positions they are assigned to. The combat exclusion was removed and the number of positions to which women could be assigned increased. Given these changes in the active military, OEF/OIF are the first military engagements to result in substantial numbers of female service members in the theater of war. The racial make-up of the US veteran population is also changing. In the early 1990s, non- Hispanic white Americans were 85 percent of all veterans; in 2012, the proportion has fallen to 78 percent. Another 11.8 percent are non-hispanic African Americans. Hispanic Americans make up 6.1 percent and the remaining 3 to 4 percent are Native Americans, Asian Americans, those of Pacific Island descent, or people who identify as having mixed racial heritage. Based on current active military enrollments, the racial composition of veterans in 2033 is projected to

Page 6 become more diverse, but non-hispanic white Americans will still be the majority (over 70 percent) with the other groups proportionately larger than they are today (US DVA, VETPOP, 2007). The largest cohort of current veterans, almost 7 million, is from the Vietnam War (http://www.va.gov/vetdata/demographics/demographics.asp, Table 5L). Another 5.5 million or so are counted as peacetime veterans with service between major conflicts. There are more than 3.4 million living veterans from World War II and the Korean War combined, but in another twenty years, there will be virtually no veterans still alive from either of these wars. About 2.5 million Vietnam veterans will still be alive, but the rest of the veteran population will have served from 1980 onward. THE IMPACT OF OEF/OIF ON VETERANS What is the impact of the last decade s actions in Iraq and Afghanistan on the number of US veterans? The number of veterans who separated from the military since 2002 and served in OEF/OIF is about 2 million, over half of whom were reservists or members of the National Guard and may have already had veteran status from service in the regular Army, Navy, Marines or Air Force. During those same years, the total number of veterans discharged is estimated at about 2.7 million, approximately 12.4 percent of all living veterans. Thus, OEF/OIF did not increase the numbers or change the characteristics of US veterans compared to expected separations in the absence of these conflicts. However, these conflicts did affect the health conditions of veterans.

Page 7 Physical casualties in recent wars are far more numerous than deaths. Table 1 details the US military deaths and casualties from the Civil War to OEF/OIF. The table indicates the ratio of casualties to deaths increased over time starting at about one casualty per death during the Civil War and ending at about 7.5 casualties per death for OEF/OIF. This change can be attributed to the improvement in medical services, particularly those located close to hostilities, over the years. Battlefield medicine, evacuation procedures, and battlefield medical support services have evolved tremendously, leading to greater survival rates for troops. In addition, the very high ratio of casualties to deaths for OEF/OIF may be due in part to the use of body armor and helmets, among other changes. This protective gear shields the user from bullets and shrapnel, improving overall survival rates. Table 1 US Military Deaths and Casualties from Principal Wars a Conflict Number Serving Worldwide Death Casualty Ratio Casualty:Death Civil War (1861 1865) 2,213,363 364,511 281,881 1:1 Spanish-American War 306,760 2,446 1,662 1:2 World War I 4,734,991 116,516 204,002 2:1 World War II 16,112,566 405,399 671,846 2:1 Korea (1950 1953) 5,720,000 36,574 103,284 3:1 Vietnam (1964 1973) 8,744,000 58,209 153,303 3:1 Persian Gulf War (1990 1991) 2,225,000 382 467 3:1 OEF/OIF b (2001 to present) 2,200,000 6,386 47,784 7.5:1 a Data as of April 2, 2012, Department of Defense, http://siadapp.dmdc.osd.mil/personnel/casualty/gwot_reason.pdf accessed May 1, 2012. b Number of deployed service members from Analysis of VA Health Care Utilization Among US Southwest Asian War Veterans, VHA Office of Public Health and Environmental Hazards

Page 8 Despite the high ratios of casualties to deaths, the absolute number of physical casualties in OEF/OIF is small compared to the number of disabled veterans from earlier actions. For example, veterans from the Vietnam War era still comprise over 40 percent of today s disabled veterans, in large part because the largest number of veterans who are still alive served during those years. In addition, several important conditions were recognized as service-connected only after the Vietnam War adding to the ranks of the disabled. The primary one is PTSD, which the American Psychiatric Association added as an official diagnosis only in 1980. Because this condition may not be recognized as disabling until years after a service member has become a veteran, the number of Vietnam veterans with disabling mental or emotional conditions far exceeds the 153,000 recognized by the military at the end of the war. Signature Conditions The OEF/OIF wars are the most sustained combat operations since Vietnam. Two major veteran health conditions stemming from these conflicts have received particular attention from Congress and Veterans Health Affairs (VHA): TBI and PTSD. Neither of these is unique to OEF/OIF, but the needs of these two groups of patients have garnered attention. In addition, amputations have been prominent in the news, even though the absolute numbers are relatively small: fewer than 1,500 as of September 1, 2010 (Fischer, 2010). Congress, recognizing the special needs of OEF/OIF veterans, included funds for prosthetic research and increased funding for the Defense and Veteran s Brain Injury Center (DVBIC), the facility that coordinates treatment and research for TBIs. Additional funding for programs for mental health care in general and PTSD specifically has also been made available.

Page 9 TBI: According to DVBIC (2012), from 2000 through the fourth quarter of 2011, 233,425 soldiers had had a TBI, either combat- or non-combat-related. Non-combat-related brain injuries can result from vehicle accidents, falls, and blows that could occur during training, recreational activities or other pursuits. Symptoms of TBI may not be evident on first examination since some cases of closed brain injury are not diagnosed properly at the time and may manifest later (Okie 2005). DVBIC (2012) reports that 2.7 percent (over 6,000 cases), were penetrating or severe injuries and 76.7 percent (almost 180,000) were mild. The VHA has instituted a post-deployment TBI screening and evaluation process for veterans accessing its services. The screening involves four sets of questions about events, immediate and current symptoms. A positive screen (answering yes to at least one question in each of the four sets of questions) leads to a referral for a comprehensive evaluation by a clinician (Figure 3). In fiscal 2008 and 2009, the rate of positive screens was 21.6%. Insert Figure 3 about here Not all patients who have had a TBI will screen positive, because they do not have current symptoms. On the other hand, not all patients who screen positive have a history of TBI. Positive screens may be due to the presence of other conditions, such as PTSD or inner ear injury (Iverson, et al., 2009). Based on experience from past conflicts, VHA screening aims to be inclusive, evaluating Veterans with lower probability of having TBI to ensure that all those

Page 10 potentially needing care receive appropriate assessment and treatment, especially those with mild injury [US GAO, 2008; Hoge, et al., 2006). On average, veterans with a diagnosis of combat-related TBI report a larger variety of symptoms than those with TBI that is not combat-related. Vision impairment, sensitivity to light or noise, sleep disturbance, and PTSD are among the symptoms experienced more by those veterans with combat-related injury. Receiving timely treatment and rehabilitation may, at a minimum, help veterans adapt to the physical outcomes caused by mild or moderate TBI. For example, understanding the cause of physical symptoms like loss of hearing or feeling in the extremities and learning coping strategies may forestall a variety of negative feelings. In this way, getting treatment earlier is more cost effective than getting it at a later time. For a history of the development of treatment, see Chapters 10 and 11 in this volume. PTSD: The VHA has undertaken many efforts to improve PTSD care delivered to veterans. It has developed a guide for clinicians and implemented a clinical reminder to prompt clinicians to assess OEF/OIF veterans for PTSD, depression, and substance abuse. The VHA has implemented a national system of 144 PTSD programs in all states and required all VHA outpatient clinics to have either a psychiatrist or psychologist on staff full time. VHA has also established Mental Illness Research, Education, and Clinical Centers (MIRECCs) to focus on issues of post-deployment health of OEF/OIF veterans such as PTSD and suicide prevention. In the case of OEF/OIF, 15.6 to 17.1 percent of veterans deployed to Iraq reportedly displayed symptoms of PTSD and 11.2 percent of veterans deployed to Afghanistan reportedly did so

Page 11 (Hoge et al. 2004). Of the OEF/OIF veterans who have used VHA services, however, almost 37 percent had a diagnosis for any mental health condition (Deyton, 2008). Within this broad category, PTSD was the most common diagnosis listed, with substance use disorders, major depression, and neurotic disorders also reported for at least a quarter of the patients (VHA Office of Public Health and Environmental Hazards 2007). Among women OEF/OIF veterans, PTSD is potentially identified for at least as large a proportion of women as men (see Chapter 14). Studies indicate that more frequent and more intense involvement in combat operations increases the risk of developing mental health problems (Office of the Surgeon Multinational Force, 2006). Due to the intensity of combat in OEF/OIF, returning veterans are at a high risk for mental health problems specifically those resulting from TBI or PTSD. These two injuries often coincide. Because of its chronic nature, it is difficult to predict the pattern of utilization and therefore the costs for treatment of PTSD (Hendricks, et al, 2011). Outpatient treatment for mental health issues is the norm in VHA; some specialized residential treatment programs do exist, but these programs are not located in every state. VHA AND HEALTH CARE FOR OEF/OIF VETERANS Both DoD and the VHA are responsible for the wellbeing and welfare of veterans, especially those who were injured or disabled while on active military duty. Bass, et al. (Chapter 3, this volume) show that veterans with disabilities connected to their military service (whether from combat or non-hostile activities) are given the highest priority for care within the VHA. This emphasis on service-related injuries and disabilities was also the case under precursors to the

Page 12 VHA, which were first established in 1930 when Congress authorized the President to consolidate the activities of all government activities affecting war veterans. World War II resulted in a massive increase in the number of veterans. Congress enacted a large number of new benefits for veterans, most significantly the World War II GI bill of 1944. Further acts were passed for the benefit of veterans of the Korean conflict, the Vietnam War, and the all-volunteer force. In 1989, the Department of Veterans Affairs was established as a cabinet-level position. It is second in size only to the DOD The VHA health care benefit is funded by discretionary allocations that Congress reviews every year. Thus, the level of VHA funding for veterans health care is not guaranteed and changes year to year. Since 2001, it has expanded from $21 billion to about $53 billion requested for FY 2013, a 151 percent increase (Testimony, Secretary Shinseki, Feb 29, 2012). VHA s national health care delivery system is divided into twenty-one Veterans Integrated Service Networks (VISNs). Each network includes between five and eleven hospitals as well as community based outpatient clinics (CBOCs), nursing homes, and readjustment counseling centers (Vet Centers). In 2012, VHA operated 157 hospitals, 134 nursing homes, 43 residential rehabilitation treatment centers, and 711 CBOCs. In addition, the VHA provides grants for construction of state owned nursing homes and domiciliary facilities. VHA estimates that in 2013 it will treat over 600,000 OEF/OIF veterans, about 9 percent of all veterans expected to receive VHA health care that year. OEF/OIF veterans receive care in all of the VHA networks around the country, but are disproportionately affecting VHA medical centers in California, Texas, Florida, and the southeastern states. These include states with some of the

Page 13 largest veteran populations, but the OEF/OIF patient loads represent larger percentages of this veteran cohort than is true for other veterans. This pattern may be due to the existence in these states of more military bases where military families reside and to which the veterans return. The pattern has important implications for the future costs of care for OEF/OIF veterans because it may indicate the need to expand VHA capacity more in these states than in other areas of the country. COSTS FOR CARE It is currently difficult to quantify the costs and the amount of care that the OEF/OIF cohort requires because of all the unknowns: Politically mandated changes in eligibility The nature, severity, and number of PTSD, TBI, and physical disabilities To which VHA centers the veterans will turn for care Medical discoveries and new treatments How much the veterans rely on VHA for care from one year to the next. Because the range of estimates for OEF/OIF veterans with severe physical or mental conditions is so large (e.g., 15 to 40 percent of OEF/OIF veterans possibly have PTSD, depending on the sample and the measure of PTSD), translating those lower and upper bounds into amounts of utilization or funding for more than a few years into the future is not policy relevant today. Conventional wisdom holds that caring for returning veterans is placing a large burden on the VHA system (Bilmes 2007). However, demand for immediate post-deployment VHA services

Page 14 by the OEF/OIF veterans will be overshadowed nationally by the demands of the aging Korean and Vietnam Wars cohorts in terms of the number of patients and the average cost of their care. The importance of the aging veteran cohort is apparent from Figures 2.1 and 2.2. In 2012, not only were more than half of all veterans over age 60, almost two-thirds were 55 and older. The healthcare needs of these older veterans are those of most elderly Americans with complex chronic conditions such as diabetes or heart failure. Elderly veterans, however, often have additional complications from disabilities sustained during military service, including mental health disorders. These veterans will continue to comprise most of the demand on VHA funding and services until the majority of World War II, Korean War, and Vietnam War cohort pass through the system. By 2030, veterans from OEF/OIF will be middle-aged or older and will have additional disabilities that are not service-connected, but that will require health services nevertheless.

Page 15 BIBLIOGRAPHY Amara, J. & Hendricks. A. (2009). The deferred cost of war: Short and long term impact of OEF/OIF on veterans health care. Defense & Security Analysis, 25(3), 285-298. Bilmes, L. (2007). Soldiers Returning from Iraq and Afghanistan: The Long-Term Costs of Providing Veterans Medical Care and Disability Benefits (RWP07-001). Working paper by John F. Kennedy School of Government-Harvard University, Cambridge, MA. Buddin, R., & Kapur, K. (2005). An Analysis of Military Disability Compensation. Santa Monica, CA: RAND National Defense Research Institute. Congressional Research Support Report for Congress. (May 2006a). Veterans Medical Care: FY2007 Appropriations (Order Code RL33409). Washington, DC: The Library of Congress.. (October 2006b). Veterans Health Care Issues in the 109th Congress (Order Code RL 32961). Washington, DC: The Library of Congress.. (April 2007). Veterans Benefits: Issues in the 110th Congress (Order Code RL33985). Washington, DC: The Library of Congress. Department of Veterans Affairs Office of Research and Development, National Institute of Mental Health, United States Army Medical Research and Materiel Command. (May 2006). Mapping the Landscape of Deployment Related Adjustment and Mental Disorders. A Meeting Summary of a Working Group to Inform Research. Rockville, MD: U.S. Department of Veterans Affairs.

Page 16 Deyton L, Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans, Presentation at AcademyHealth, June 2008, Accessed April 29, 2012, http://www.academyhealth.org/files/2008/monday/tmarshalls/6_9_2008_11_30/deytonl.pdf DVBIC: DOD WORLDWIDE NUMBERS FOR TBI (NON-COMBAT AND COMBAT INJURIES)* Source: Defense Medical Surveillance System (DMSS) and Theater Medical Data Store (TMDS) Prepared by Armed Forces Health Surveillance Center (AFHSC) http://www.dvbic.org/tbi-numbers.aspx accessed 4-4-12 Feickert A, Henning CA, Army Drawdown and Restructuring: Background and Issues for Congress, April 20, 2012, Congressional Research Service, 7-5700, www.crs.gov, R42493. Fischer, H, U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, September 28, 2010, Congressional Research Service Report for Congress, 7-5700, www.crs.gov, RS22452. Haskell SG, Ning Y, Krebs E, Goulet J, Mattocks K, Kerns R, Brandt C, Prevalence of Painful Musculoskeletal Conditions in Female and Male Veterans in 7 Years After Return From Deployment in Operation Enduring Freedom/Operation Iraqi Freedom, Clinical Journal of Pain, 2012, 28(2):163-167. doi: 10.1097/AJP.0b013e318223d951, accessed 5-4-2012 at http://journals.lww.com/clinicalpain/abstract/2012/02000/prevalence_of_painful_musculo skeletal_conditions.11.aspx Hendricks, A., & Amara, J. (2008). Demographics of the current veterans population and its implication for the future disability and health care needs of veterans. In N. Ainspan, & W. Penk (Eds.), War s Returning Wounded, Injured and Ill: A Handbook. (pp. 13-29). Westport, Conn.: Praeger Publishers.

Page 17 Hoge, C., Castro, C., Messer, S., McGurk, M., Cotting, D., Koffman, R. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. The New England Journal of Medicine, 351 (1), 13 22. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006; 295:1023 32. ISAF (International Security Assistance Force), Troop Numbers and Contributions Accessed 4-2-12 at http://www.isaf.nato.int/troop- numbers- and- contributions/index.php Iverson GL, Langlois JA, McCrea MA, Kelly JP, 2009, Challenges Associated with Post- Deployment Screening for Mild Traumatic Brain Injury in Military Personnel, The Clinical Neuropsychologist, 23:1299-1314. Lew, H. L., Poole, J., Guillory, S., Salerno, R. M., Leskin, G., Sigford, B. (2006). Persistent Problems after Traumatic Brain Injury: The Need for Long-Term Follow Up and Coordinated Care. Journal of Rehabilitation Research Development, 43 (2), 7 10. National Center for Veterans, Analysis and Statistics, Assistant Secretary for Policy and Planning. (March 2003). National Survey of Veterans. Washington, DC: U.S. Department of Veterans Affairs.. (April 1995). National Survey of Veterans (Depot stock no. P92493). Washington, DC: U.S. Department of Veterans Affairs. Office of the Surgeon Multinational Force - Iraq and Office of the Surgeon General, United States Army Medical Command. (November 2006). Mental Health Advisory Team (MHAT) IV Operation Iraqi Freedom 05-07.

Page 18 Okie, S. (2005). Traumatic Brain Injury in the War Zone. New England Journal of Medicine, 352 (20), 2043 2047. S. HRG. 112 95, THE FISCAL YEAR 2012 BUDGET FOR VETERANS PROGRAMS HEARING BEFORE THE COMMITTEE ON VETERANS AFFAIRS UNITED STATES SENATE, ONE HUNDRED TWELFTH CONGRESS FIRST SESSION, MARCH 2, 2011 at http://www.gpo.gov/fdsys/pkg/chrg-112shrg65905/pdf/chrg-112shrg65905.pdf accessed April 29, 2012 S. HRG. 112-267, VA MENTAL HEALTH CARE: ADDRESSING WAIT TIMES AND ACCESS TO CARE November 30, 2011 at http://www.gpo.gov/fdsys/pkg/chrg-112shrg72248/pdf/chrg-112shrg72248.pdf Accessed April 29, 2012. Tan, M. (Dec. 18, 2009) 2 MILLION TROOPS HAVE DEPLOYED SINCE 9/11, Marine Corps Times US Department of Veterans Affairs, Demographics, VetPop2007 National Tables, Table 1L http://www.va.gov/vetdata/demographics/demographics.asp Accessed April 4, 2012. Table of ARMED FORCES STRENGTH FIGURES FOR JANUARY 31, 2012 Accessed April 4, 2012, at http://siadapp.dmdc.osd.mil/personnel/military/ms0.pdf U.S. Government Accountability Office. (2006a). Disability Benefits. Benefit Amounts for Military Personnel and Civilian Public Safety Officers Vary by Program Provisions and Individual Circumstances (GAO-06-04). Washington, DC: U.S. GAO.. (2006b). Veterans Disability Benefits. VA Should Improve Its Management of Individual Unemployability Benefits by Strengthening Criteria, Guidance, and Procedures. (GAO-06-309). Washington, DC: U.S. GAO.

Page 19. (2008), VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented of OEF/OIF Veterans, but Challenges Remain, Report to Congressional Requesters, February 2008, GAO 08-276. Veterans Health Administration Office of Public Health and Environmental Hazards. (April 2007). Analysis of VA Health Care Utilization among US Southwest Asian War Veterans: Operation Iraqi Freedom, Operation Enduring Freedom. Washington, DC: U.S. Department of Veterans Affairs.