March 2002

Following the terrorist attacks on the World Trade Center and the Pentagon on September 11, 2001, the United States (U.S.) began deploying military personnel to South Asia. Before the New Year, over 30,000 active duty men and women were involved in this deployment, on land, sea, and air; and, about 50,000 reserve personnel were called to active duty. Today, U.S. troops are on the ground in Afghanistan, Pakistan, and neighboring former Soviet Republics.

As in all hazardous deployments abroad, some service members will return with deployment-related health problems. In Afghanistan, they are especially at risk for local infectious diseases, traumatic injuries, and injuries due to cold exposure and operations at higher altitudes. As in all wars, some returning troops will suffer from the psychological effects that can result from surviving any dangerous experience, and some will return with symptoms that are difficult to explain.

This brochure describes the main health concerns for service in Afghanistan, Pakistan and surrounding areas, and answers questions that veterans, their families, and their health care providers may have about this deployment. It also describes medical care programs that the Department of Veterans Affairs (VA) has developed for veterans returning from combat or peace-keeping missions, and how to contact these programs.

Afghanistan Background

Afghanistan is an extremely poor, landlocked country that is about the size of Texas. Traditionally, Afghanistan is highly dependent on farming and raising livestock. Its capital is Kabul, and the geography of its 30 provinces mostly includes rugged mountains as high as 24,560 feet, as well as lower plains in the North and Southwest. The climate is arid to semiarid, with cold winters and hot summers; the rainy season lasts from October to April.

After gaining independence from the United Kingdom in 1919, Afghanistan experienced ongoing political and military upheavals, including nearly 10 years of Soviet military occupation and more recent terrorism-related activities. On top of that, 3 years of continuous drought has led to widespread crop failures and water shortages.

Health Risks to U.S. Service Members

Recently, about one-third of its estimated population of nearly 27 million fled the country; about 6 million refugees are thought to be in Pakistan and Iran. These events have badly damaged Afghanistan’s health and economic infrastructure, producing a short average life expectancy of about 46 years and per capita purchasing power equivalent to $800 per year.

According to the Department of Defense (DoD), troops may be exposed to a variety of infectious diseases, cold injury, and high altitude illnesses because of this area’s very high mountains. Environmental hazards also may pose a health risk to deployed forces, including exposure to sewage, agricultural and industrial contamination of water and food supplies, localized air pollution, and severe sand and dust storms.

The military is dealing with these risks by providing vaccinations, securing potable water and food from outside Afghanistan, and using standard pest control procedures. The remarkably low rates of serious infectious diseases during the Gulf deployment in 1990 and 1991 were the result of rapid medical care, extensive preventive medicine efforts, use of insecticides and repellents, camp sanitation measures, and inspection of food and water supplies. DoD has implemented similar preventive health programs in Afghanistan. This fact sheet outlines the potential health risks and some of the DoD health programs developed for this new conflict.

High-Altitude Health Hazards. Temperature and altitude extremes in this region may affect the health of deployed service members. High mountainous areas in Afghanistan and Pakistan, with elevations of 6,000 feet or more, increase the risks of cold injury due to reduced oxygen and lower air pressure. Working at high altitudes without proper acclimatization can result in serious illness. Common immediate symptoms of mountain sickness include headache, nausea, vomiting, dizziness, fatigue, irritability, and coughing.

Environmental Health Hazards. Some deployed service members might experience short-term health effects from exposure to sand, wind, and dust, particularly to skin, eyes, throat, and lungs. Dry air, dust and wind dry out the nose and throat and can also cause nosebleeds, coughing, wheezing, and other short-term respiratory problems. Troops in Afghanistan also could face health risks from exposure to industrial chemicals and hazardous waste. DoD has warned U.S. service members to be cautious of local plant and animal hazards, including poisonous snakes, scorpions, spiders, and, plants with thorns, stinging hairs, or toxic coatings that can lead to skin irritation, rashes, infections, and poisoning if eaten.

Infectious Disease Hazards

Food shortages, inadequate public health programs, refugee movements, cold weather, and crowds of malnourished people in Afghanistan have increased the likelihood of spreading respiratory diseases such as diphtheria, tuberculosis, measles, and influenza. Tuberculosis rates in Afghanistan are among the highest in the world. Refugee camps are commonly vulnerable to widespread typhoid fever outbreaks.

Based in part upon U.S. experience with infectious diseases among Allied troops sent to the Persian Gulf region during World War II, troops in Afghanistan and surrounding areas could be at increased risk of sandfly fever, malaria, diarrheal diseases including cholera, typhoid fever, amoebic dysentery, giardiasis, viral hepatitis, and cutaneous (skin) leishmaniasis. Common traveler’s diarrhea may be a frequent health problem, as it was during the Gulf War.

U.S. troops are well protected against most infectious diseases through vaccination and other preventive health measures. However, potential infectious diseases of concern for troops and peacekeepers include:

• Hepatitis A and E, typhoid fever and diarrheal diseases such as cholera, amoebic dysentery, and giardiasis from consuming contaminated food and water (water contaminated with human or animal waste is considered to be widespread).
• Malaria, West Nile fever, and dengue fever from mosquito bites, Crimean-Congo hemorrhagic fever from tick bites, leishmaniasis and sandfly fever from sand flies, West Nile virus from mosquito bites, and louse-borne typhus.
• Tuberculosis from close person-to-person respiratory transmission.
• Leptospirosis from swimming, wading, or other skin contact with contaminated water.
• Rabies from animal contact.
• Sexually transmitted diseases.

Leishmaniasis. Sandfly-transmitted leishmaniasis infection of the skin (cutaneous infection) is common in this region and causes a characteristic rash. Internal visceral) leishmaniasis, is much less common. Visceral leishmanial infection might show up later on as a chronic infection, and leishmaniasis should therefore be considered when suggested by the doctor. Diagnosis may require repeated and painful tissue sampling of bone marrow or lymph nodes to identify the parasite because currently there is no accurate skin or blood test.

Treatment for visceral leishmaniasis can be hazardous and is not recommended unless a confirmed infection is causing chronic health problems.

Sexually Transmitted Disease Risks. Sexually transmitted diseases are common in Afghanistan and surrounding regions, including gonorrhea, chlamydia, and hepatitis B. According to the World Health Organization (WHO), Human Immunodeficiency Virus (HIV) cases are rapidly increasing in the central Asian republics, including Afghanistan and Pakistan, particularly among injection drug users who share needles. Among central Asian republics, the highest HIV and Acquired Immune Deficiency Syndrome (AIDS) rate is recorded in Kazakhstan.

Preventive Measures. Deployed service members are directed not to consume any locally produced raw or unprocessed food products. Troops are instructed that local water and food items including dairy products, fish, fruits, and vegetables, may contain unsafe levels of pesticides, chemical fertilizers, bacteria, and viruses. U.S. troops receive potable water and clean food supplies on deployment.

Pesticides and Health. To protect against insect-, tick- and other pest-borne illnesses, individual U.S. service members are provided standard countermeasures. These include anti-malaria pills, the insect repellents DEET (applied to exposed skin), and permethrin (applied to clothing and bed nets).

Although many pesticides, including permethrin and DEET, have been widely used for many years in the United States and elsewhere without health problems, some scientists and non-scientists have expressed concerns about the possible long-term health consequences of pesticide exposure. DoD’s pesticide policy specifies the controlled use of only those pesticides that have been approved by the Environmental Protection Agency (EPA) or the Food and Drug Administration (FDA) for general use in the United States. Permethrin and DEET are commonly used pesticides that are widely available at grocery, garden supply, and other stores.

Both are approved for unrestricted use in the United States.

Permethrin has very low human toxicity, and is widely used in the United States for protection against insect pests. However, following very large exposure by swallowing or inhaling, clinical signs of permethrin poisoning can become evident within a few hours. Even in rare cases of human permethrin poisoning there is no evidence of long-term health problems following recovery from the initial poisoning.

The common insect repellent DEET is estimated to be used by at least 50 million Americans each year to keep away insect pests such as mosquitoes and ticks. There have been a few reports of tingling, mild irritation, and skin peeling following repeated skin application. In adults, ingestion of enormous doses of DEET has been associated with immediate toxic effects, but no long-term health effects have been documented.

Some researchers have suggested that exposures to a combination of pesticides and other compounds might cause health problems not seen with exposure to the same compounds individually. Such effects may not be important to humans except perhaps under extraordinary exposure conditions. Ongoing federally funded research efforts will help to clarify this matter.

Deployment Stress and Health. DoD advised service members deploying to Afghanistan that stress, fatigue, and depression during deployment could lead to injury and illness.

Deployment-related stresses include jet lag, change of diet, longer work hours carrying heavy gear, rapid and continuous pace of deployed military activities, and psychological stress. According to DoD, service members particularly at risk include those who are exposed to human suffering, death, or combat, or who are distracted by worries about home and family.

Service members are warned that though return from deployment can be festive and cheerful, a homecoming can turn into a stressful event for personnel and their families who are not alert to the impact of changes that occurred during separation. Further, the individual returning from deployment may still be experiencing the effects of deployment. DoD advises service members to recognize symptoms of depression, including changes in or withdrawn behavior, excessive tiredness or insomnia, changes in appetite, or feelings of despair.

Preventive measures include seeking help from health care professionals, a chaplain, or other medical personnel, maintaining physical fitness, increasing sleep when possible, proper using of over-the-counter medications, avoiding alcohol and tobacco products, and establishing a reliable support network of family and friends.

The vast majority of veterans seeking health care at VA medical facilities come in with common diagnoses and receive effective treatments. However, based on experience with veterans returning from previous U.S. conflicts abroad, it is now understood that some veterans will return from hazardous military deployments with difficult-to-diagnose but nevertheless serious symptoms. In fact, concerns about chronic physical symptoms have arisen after every major conflict, and the same types of health problems are frequently seen among civilian Americans.

Veterans, their families and their health care providers must anticipate these deployment-related health problems in veterans returning from the current deployment to South Asia and Afghanistan. In response, VA has established new Centers for the Study of War-Related Illnesses, and developed new clinical practice guidelines that give health care providers the critical tools they need to help veterans with difficult-to-diagnose illnesses.

Health Care Resources for Returning Veterans.

VA has extended health care benefits for those veterans who have served in combat. Based on what was learned from veterans from previous conflicts, VA has developed new programs for providing treatment and other assistance to those veterans.

In 1998, VA was authorized to provide a broad range of health care services to U.S. veterans who served on active duty in a designated theater of combat operations. Such veterans are eligible for 2 years after leaving the military for VA hospital care, medical services, and nursing home care for any illness, even if there is insufficient medical evidence to conclude that their illness was a result of their combat service (see Public Law 105-368, Section 102, codified at Title 38 United States Code (U.S.C.)1710(e)((1)(D).)).

This law means that combat veterans will have access to high-quality health care at VA medical facilities for 2 years, based on their service in combat, without having to prove that their health problems may be related to their combat service or to toxic exposures during their active service. For locations of VA medical facilities, check the telephone book, or www.va.gov, or call 1-877-222-VETS 8387).

VA’s New Centers for the Study of War-Related Illnesses. These two new centers in Washington, DC, and East Orange, NJ, are focusing on the difficult-to-diagnose illnesses seen in veterans following all wars. Information regarding these and future centers can be obtained by contacting the nearest VA medical center.

VA’s Vet Centers. There are more than 200 community-based Vet Centers located around the country. This program was originally developed in response to the readjustment needs of returning Vietnam veterans.

Based upon their successes, today Vet Centers are open to other veterans who served in combat and who suffer from psychological war trauma. They also offer accessible readjustment counseling, extensive case management and referral activities, and other supportive social services.

For many veterans who might not otherwise seek VA assistance, the Vet Centers serve as a local resource for VA health care. Phone numbers for local VA Vet Centers can be found in the telephone book, or go to www.va.gov, or call 1-877-222-VETS (8387).

VA’s Website on Afghanistan Health Issues.

VA’sWebsite on Afghanistan health issues is available at www.va.gov/About_VA/Orgs/VHA/VHAProg.htm.

VA Health Care and Assistance for Veterans. VA is here to help all U.S. veterans. VA’s mission is to serve America’s veterans and their families with dignity and compassion and be their principal advocate in ensuring they receive medical care, benefits, social support, and lasting memorials in recognition of their service to this Nation.

Additional Information. Through its Veterans Health Administration, VA offers primary care, specialized care, and related medical and social support services for veterans. This care is provided by about 163 hospitals, over 800 ambulatory care and community-based clinics, 135 nursing homes, 43 domiciliaries, 206 readjustment counseling (Vet) centers and various other facilities. VA also conducts research on veteran health issues, and fosters education of health care providers. More information about the range of services available at the local VA facilities can be obtained through the telephone book, or by checking online at www.va.gov. Also see the following:

“The World Factbook 2001 -- Afghanistan” available on line at http://www.odci.gov/cia/publications/factbook/index.html; U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM) at http:/chppm-www.apgea.army.mil/; World Health Organization (WHO) Updates available at http://www.who.int/disasters/; and U.S. Army Center for Health Promotion and Preventive Medicine, “A Soldier’s Guide to Staying Healthy in Afghanistan and Pakistan,” December 2001.

Source: Department of Veterans Affairs