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Director of Clinical and Professional Development at MercyOne Dubuque Medical Center

When I joined the U.S. Army in 1999, I never envisioned myself being sent to war. However, on September 11, 2001, the world drastically changed, and by May of 2003, I was boarding a plane to Southwest Asia. That year — as a combat medic with the 389th Engineer Battalion in Baghdad, Iraq — was the part of my military experience, if not of my life, that led me to some deep realizations.

More than anything, that time taught me how to evolve. The year was full of challenges, and some of those issues still continue today. But my time in Iraq taught me how to intentionally use those difficult experiences to learn and drive change that may help others, and possibly myself, in the process. It is through this lens that I approach my work as a medical provider, particularly when working with veterans at MercyOne in Iowa. Understanding and responding to the health concerns and challenges specific to the military community is critical in providing personalized care to our veteran patients. As a veteran, I know I have a unique opportunity, and I hold a unique sense of commitment to ensure our veterans receive excellent care.

CLOSING HEALTH CARE GAPS FOR VETERANS
One of the biggest misconceptions of community health organizations is that all veterans primarily rely on the U.S. Department of Veterans Affairs (VA) for their health care needs. In reality, not all veterans are eligible for VA benefits, and about half of VA enrollees report using at least some health care services that are provided and paid for outside the VA.¹ A little more than 45% of veterans are enrolled in the VA system,² and only about 30% report that they rely on the VA as their sole source of health care.³ Also, about 80% of VA enrollees report having some type of public or private insurance coverage in addition to VA benefits, such as employer-provided private insurance, TRICARE or Medicare, which allows them to choose whether they want to receive health care through the VA or local providers.⁴ Since most veterans rely on the community for at least some, if not all, of their health care, it's crucial that community health care workers are prepared to meet these veterans' unique health needs.

MercyOne's Military and Veterans Health Care, commonly called MILVET, is one way that the health system is driving change and closing gaps between veterans and health care by having processes in place to initially help our team identify veterans. All patients are asked about their military status when they visit our hospitals, which allows us to identify veterans and understand the military's impact on their health history, an important aspect which might otherwise have gone unrecognized.

Additionally, all our patient-facing staff are educated on specific military and veteran health needs within their first days in the organization. This one-and-a-half-hour training is presented live on the second day of orientation by two veterans, Gerald Meyers, business support specialist at MercyOne Dubuque Medical Center and U.S. Army veteran, and myself. Together, we use our personal experiences to complement the data and engage colleagues in this important mission. The awareness training covers:

• Understanding of military culture, including the nuances of various military branches.
• Common diseases, illnesses, injuries and exposures associated with military service and military deployments.
• Effects of military service and deployments on family members.

A UNIQUE APPROACH TO CARE FOR VETERANS
Military experiences affect veterans in multiple ways, therefore it's beneficial for health care workers to draw from this knowledge to provide appropriate care. For those who interact with and treat patients who served in the military, it's helpful to know:

• Veterans' experiences and where they served geographically are key to understanding medical issues they could be facing, and learning more about these aspects of someone's life may help with diagnoses and treatment decisions. For example, veterans who served in Vietnam may have been exposed to Agent Orange, a chemical herbicide, which can cause cancer and life-threatening health complications.
• Post-traumatic stress disorder (PTSD) is prevalent in the veteran community, and not only due to combat. Sexual trauma and traumatic head injuries can also cause PTSD and can be a key factor in the high rates of alcohol use or misuse among veterans.
• "Moral injury" can take a toll on veterans. According to the VA, moral injury, in the context of war, comes from participation in actions related to combat warfare where one feels they may have violated their conscience or moral compass. Returning from combat and having to adjust to a new moral system in a noncombat environment can sometimes prove challenging for veterans, and therefore requires special care.

MY PERSONAL PATH TO CARE
It wasn't until we started our Military and Veterans Health Care in 2019 that I realized the significance of these health care gaps for veterans, and how important this initiative could be in eliminating those disparities. Even as a credentialed nurse and veteran, I was overwhelmed with new knowledge when we started learning about the health implications of military service, as very little is taught about veterans in standard health care curriculum.

Not only did this education help me provide better care for patients, I was also personally affected by the program. Though my service was fulfilling and honorable, I began having breathing issues when I returned home in 2004. Running became more challenging, and I struggled to take a deep breath anywhere from several hours to several days after a run. I scheduled an appointment with the VA at that time, and they ran several tests. When everything came back normal, they suggested that the issue could be a result of anxiety. As a college sophomore who recently returned from war, I accepted that as the cause. For many years, I worked to calm myself down whenever I had difficulty breathing, and I thought I was managing the issue as best I could.

It wasn't until I learned through MercyOne's program for veterans about the high rates of respiratory issues in veterans returning from Iraq and Afghanistan⁵ — a trend that was not yet identified during my initial 2004 visit to the VA — that I started wondering if anxiety was not the source of my breathing issues. When the air hunger and coughing turned to wheezing, I finally returned to my physician and was eventually placed on a steroid inhaler. The change in my breathing was incredible, and I was able to tolerate exercise once again.

After my diagnosis, I knew I had to share my experience and ensure that I could help remove some of the barriers veterans have accessing health care. One of the ways I help is through my community outreach work with the Military and Veterans Health Care.

The program partners with the VA and other community organizations to advocate for veterans through frequent community health education sessions and building connections. In early 2021, we partnered with the Dubuque County Veterans Affairs office to provide hundreds of veterans aged 65 and older with their first and second doses of the COVID-19 vaccine. MercyOne's mobile medical unit also plays a key role in our outreach efforts by meeting veterans where they are, including the Veteran's Freedom Center and farmers markets, and through administering vaccines or providing resources to help connect them to their earned health care or benefits.

THE JOYS OF SERVING WOMEN VETERANS
One of my favorite aspects of the community outreach work I facilitate through Military and Veterans Health Care is working with other women veterans. I am personally most committed to:

• Improving community peer support for women veterans, who often struggle connecting with others after discharge. Many also report not feeling a sense of belonging in traditional veteran communities, as most veteran communities are predominantly male and have been developed for a demographic with significantly different needs and interests. While I can't speak for all women, I have always been welcomed into these communities. But being allowed into a group that was made for someone so unlike me carries a much different feeling than entering a community that was tailored for me. Creating local peer support networks that promote belonging for women can help connect them to resources, and more importantly, to other women veterans.
• Advocating for increased research on the impact of military deployments on reproductive health, specifically birth defects. In 2000, approximately 25 years after the Vietnam War ended, a study titled "Pregnancy Outcomes Among U.S. Women Vietnam Veterans" was published.⁶ The study found that women who served in Vietnam were significantly more likely to have children with moderate to severe birth defects than women who served in the same era and did not go to Vietnam. While this is a useful resource, I believe there should be more funding and research to better understand how military deployments affect the reproductive health of women veterans and subsequent correlations to birth defects.

Some of the greatest successes that come from veteran-focused initiatives like MercyOne's program are the connections made with other veterans. I didn't realize this was a void in my life until I returned to the veteran circles. Interestingly, I joined these circles to help others, and ended up helping myself in the process. As a veteran, you don't realize sometimes how much you're "faking it" to fit in with the rest of society — but having a community of people that have shared these unique experiences, both good and bad, is incredibly important. Some of the strongest connections I've made have been with other women veterans in our tri-state area through a peer support network we have created called the Tri-State Women Warriors. This has turned into a dynamic and growing community focused on supporting and empowering veterans everywhere.

HOW WE CAN HELP
In health care, one of the ways that we can provide necessary support and care for veterans seeking medical attention is educating our staff members to ask veterans about their military experiences. Military and Veterans Health Care helps colleagues better understand the physical, emotional and spiritual impact of operational deployments on service members and their families. With this enhanced awareness of patients' military experiences, MercyOne positions itself to provide a more comprehensive health care experience for its military community.

MercyOne Clinton Medical Center, MercyOne Dubuque Medical Center, MercyOne Siouxland and MercyOne Waterloo Medical Center provide Military and Veterans Health Care. To find out more about the program and MercyOne's community benefits for veterans, visit the Military and Veterans Health Care webpage at https://www.mercyone.org/military-and-veterans-care/.

CHRISTINA J. SCHAUER is director of clinical and professional development at MercyOne Dubuque Medical Center in Dubuque, Iowa, and leads MercyOne's Military and Veterans Health Care for the health system's Eastern Iowa Region. Schauer served in the U.S. Army during Operation Iraqi Freedom as a combat medic, which included a one-year deployment in 2003 to Baghdad, Iraq. She is also an advocate for veterans through the Iraq and Afghanistan Veterans of America.

NOTES

1. Z. Joan Wang et al., "2021 Survey of Veteran Enrollees' Health and Use of Health Care," Advanced Survey Design, September 24, 2021, https://www.va.gov/VHASTRATEGY/SOE2021/2021_Enrollee_Data_Findings_Report-508_Compliant.pdf.
2. "Veterans as a Percent of County Population (FY2019)," U.S. Department of Veterans Affairs, https://www.datahub.va.gov/stories/s/7g2p-v3sr.
3. Wang et al., "2021 Survey of Veteran Enrollees' Health."
4. Wang et al., "2021 Survey of Veteran Enrollees' Health."
5. "Study: Iraq, Afghanistan Veterans at Increased Risk of Respiratory Illness," U.S. Department of Veterans Affairs, August 26, 2014, https://www.research.va.gov/currents/summer2014/summer2014-24.cfm#.
6. Han K. Kang et al., "Pregnancy Outcomes Among U.S. Women Vietnam Veterans," American Journal of Industrial Medicine 38, no. 4 (October 2000): 447-54.
   

This article was updated in July 2023 to correct the source and year of the study on pregnancy outcomes for women who served in the Vietnam War.