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Volume 27 Number 1 January 2019 Journal of Military and Veterans’ Health

Comparison of Two Co-Located Infantry Battalions during the 1918 Influenza Pandemic

RY ME A DI IT C L I The Australian Army’s Two ‘Traditional’ Diseases: Gonorrhea and Syphilis I N E M

A N

I S

O S

A C

L I

Compensation in the Australian Defence Force A

T R

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Image courtesy of Dept of Defence Table of Contents

Short Communication

Comparison of Two Co-Located Infantry Battalions during the 1918 Influenza Pandemic with Very Different Mortality Experiences ��6

Historical Articles

The Australian Army’s Two ‘Traditional’ Diseases: Gonorrhea and Syphilis — A Military-Medical History During the Twentieth Century �� 11

Original Articles

The Effects of Current Cold Chain Management Equipment in Controlling the Temperature of Thermolabile Medications and Temperature Sensitive Diagnostics, Dressings and Fluids in A Routine Australian Defence Force Operating/Exercise Environment �� 23

Combat, Posttraumatic Stress Disorder and Health of Australian Vietnam Veteran Conscripts and Volunteers in the Three Decades After Return �� 42

Compensation in the Australian Defence Force �� 58

Medical CBRN Defence in the Australian Defence Force �� 66

Review Articles

Systematic Review of The Impact of Deployment on Respiratory Function of Contemporary International and Australian Veterans’ �� 74

Homeless Indigenous Veterans and the Current Gaps in Knowledge: The State of the Literature �� 101

Front Cover

Title: “Stars over R2E”

Photo courtesy of James Savage

Volume 27 Number 1; January 2019 Journal of Military and Veterans’ Health

EDITORIAL BOARD CDRE Andy Robertson, CSC, PSM (Editor in Chief)

Associate Professor Martin Richardson (Deputy Editor)

Maj Gen Prof Dr Mohd Zin Bidin (Ret’d)

BRIG Anne Campbell

Dr Ian De Terte

CDRE Michael Dowsett

Dr Helen Kelsall

COL Prof Peter Leggat, AM

Benjamin Mackie

David Robertson

Tyler C Smith, MS, PhD

Dr Darryl Tong

Jason Watterson Australasian Military Medicine Association

PATRON STATEMENT OF OBJECTIVES RADM Jenny Firman The Australasian Military Medicine Association is Surgeon General Australian Defence Force Reserves an independent, professional scientific organisation of health professionals with the objectives of: COUNCIL • Promoting the study of military medicine President GPCAPT (Retd) • Bringing together those with an interest in Geoff Robinson, NSC military medicine

Vice President Dr Nader Abou-Seif • Disseminating knowledge of military medicine • Publishing and distributing a journal in military Secretary Dr Janet Scott medicine Treasurer CMDR Ian Young • Promoting research in military medicine

Council Members CDRE Andrew Robertson Membership of the Association is open to doctors, Dr Peter Hurly dentists, nurses, pharmacists, paramedics and Rachelle Warner anyone with a professional interest in any of the disciplines of military medicine. The Association is Past President Dr Greg Mahoney totally independent of the Australian Defence Force.

Public Officer Ms Paula Leishman

JMVH is published by the Australasian Military Medicine Association 227 Collins Street Hobart Tas 7000 Australia Ph: +61 3 62347844 Email: [email protected]

ISSN No. 1835-1271 Journal of Military and Veterans’ Health Editorial Wither Nuclear? Progress has been slower with other conventions. Bringing the Comprehensive Nuclear Test Ban Treaty In this issue, Heslop and Westphalen review medical into force would assist in reducing the numbers of chemical, biological, radiological and nuclear (CBRN) nuclear weapons.5 Progressing the Fissile Materials 1 defence in the Australian Defence Force. The ongoing Cutoff Treaty, first proposed in 2000, would also interest of militaries and non-state actors in these further restrict the availability of fissile materials weapons, while waxing and waning over the last 100 and, ultimately, nuclear devices.6 Recent issues years, continues, and requires appropriate military between Russia and the United States, however, health preparations. While chemical, biological and, have reversed some of the progress made with to a lesser extent, radiological weapons have received these treaties and will create further vulnerabilities. detailed attention, particularly since chemical Alleged violations of the Intermediate-Range Nuclear weapons use in Syria, nuclear terrorism and nuclear Forces Treaty, no progress on the Strategic Arms war have received less attention. This may be based Limitation Treaty, and plans for revitalisation of on the assumption that, with the exception of North nuclear arsenals, including developing smaller Kora, these weapons are better controlled and less tactical nuclear weapons, are also of concern.7 Closer likely to be used. But, given recent tensions, are scrutiny of this important area is required to ensure these assumptions valid? that we are better prepared for future conflicts.

Internationally, Australia and other countries are Our first issue of 2019 contains a diverse range of protected by a range of treaties designed to prevent articles from mental health and operational medicine the acquisition and use of nuclear materials and through to infectious disease history. We continue to weapons, the most important of these being the get a good range of articles, but other military and 2 Nuclear Non-Proliferation Treaty . Other treaties, veterans’ health articles are always very welcome such as the International Convention for the and we would encourage all our readers to consider Suppression of Acts of Nuclear Terrorism, which writing on their areas of military or veterans’ health came into force in July 2007, and the Convention interest. We would particularly welcome papers on the Physical Protection of Nuclear Material, based on our 2019 themes of recovery, rehabilitation which came into force in February 1987, are also and repatriation, but welcome any articles across important in increasing nuclear materials security the broader spectrum of military health. and preventing the export of nuclear material and related technologies.3 There are, however, serious Dr Andy Robertson, CSC, PSM challenges in these areas, with growing fissile material stockpiles in India, Pakistan, China and Commodore, RANR 4 Japan. Editor-in-Chief

References: 1. Heslop DJ, Westphalen N. Medical CBRN Defence in the Australian Defence Force, J Military Veterans Health, 2019; 27(1): 66-73. 2. Department of Foreign Affairs and Trade, Australia’s Uranium Export Policy, Commonwealth of Australia, Canberra, 2018 (Accessed on 12 August 2018 - https://dfat.gov.au/international-relations/ security/non-proliferation-disarmament-arms-control/policies-agreements-treaties/Pages/australias- uranium-export-policy.aspx). 3. Burt R, Lodal J. The Next Step for Arms Control: A Nuclear Control Regime, Survival 2011; 53 (6): 51-72. 4. Allison G. Nuclear Terrorism: Did We Beat the Odds or Change Them? Prism: Journal of the Center for Complex Operations 2018; 7(3): 2-21. 5. Kibaroglu M. The Threat of Nuclear Terrorism Requires Concerted Action. Strategic Analysis 2014; 38(2): 209-216. 6. Biswas S. Nuclear desire: Power and the postcolonial nuclear order. University of Minnesota Press; Minneapolis: 2014. 7. Gale RP, Armitage JO. Are We Prepared for Nuclear Terrorism? New England J Medicine 2018; 378(13): 1246-1254.

Volume 27 Number 1; January 2019 Page 5 Short Communication

Comparison of two co-located Infantry Battalions during the 1918 influenza pandemic with very different mortality experiences

D Shanks, M Waller

Abstract The 1918–1919 influenza pandemic was the greatest mortality event in recent history whose specific origins and mechanism remain largely unexplained. Wide ranges of mortality were observed in otherwise identical groups for unclear reasons. The 49th (n=1363) and 50th (n=1243) Battalions (BN) of the Australian Imperial Force (AIF) respectively had one of the highest and lowest influenza mortality rates of any Australian infantry unit. All non-combat mortality, specific pneumonia/influenza mortality and morbidity due to influenza-like illness were collected from both battalions 1916-1919. Mortality during the 1916-1917 epidemic of ‘purulent bronchitis’ was similar (8 deaths in both) whereas the 49th BN had 18 and the 50th BN had one pneumonia deaths during the influenza pandemic of late 1918-early 1919. Influenza morbidity was similar in both units except during mid-1918 when the 50th BN experienced more cases of a mild influenza-like illness (69 vs 103 cases in June). The 49th BN had more recorded cases of influenza than the 50th BN during the late 1918 pandemic (116 vs 62 cases in October). Recent influenza-like illness appeared to markedly decrease influenza mortality without greatly changing influenza morbidity in 1918.

Key words: influenza, pandemic, mortality, World War I Introduction certainly existed for centuries, but it did not cause annual epidemics until after 1918, likely due to Pandemic influenza can stop military operations limited population movements.3 Influenza rapidly when a large number of soldiers suddenly become changes its surface proteins (hemagglutinin H; ill. High mortality due to influenza in otherwise neuraminidase N) requiring adaption of the host and/ healthy adult males has only been observed during or annual revisions of influenza vaccine to respond the 1918–1919 pandemic for uncertain reasons.1 to viral evolution. An individual’s particular lifetime More people died during the influenza pandemic experience with influenza virus largely determines than during World War I, including greater than 1 how well the host is able to resist infection. 200 Australian soldiers in the Australia Imperial Force (AIF) deployed to Europe and the Middle East.2 Although reliable mortality data have been collected The unexpected and still unexplained propensity for over a century, it is extremely difficult to link of the 1918 influenza virus to kill young adult men historical mortality with previous morbidity records remains a unique observation thought to be linked to due to influenza. Military medical systems are one the massive population disruptions associated with of the few circumstances where one can confidently World War I. measure influenza morbidity and subsequent mortality in individuals using prospectively collected In the absence of effective influenza vaccines, one’s data over more than a single season. Only with this immunity depends on previous influenza infections level of detail is it possible to suggest why the 1918 producing immunological memory in the form of pandemic’s lethality was so different from all other either specific antibody or lymphocytes capable known pandemics. We have examined the Australian of killing infected respiratory cells. Influenza has National Archives online collection of AIF soldier

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Figure 1: Group of Australian soldiers from the 49th Figure 2: Group of Australian soldiers from the 50th Battalion Australian Imperial Force in Brisbane circa Battalion Australian Imperial Force in a trench near 1916 prior to deploying to France. (Source: Australian Ypres, Belgium in 1917. (Source: Australian War War Memorial, photo P12347.003) Memorial, photo E00761) records linked to both the AIF Database Project of the Denominator data required considerable estimation University of New South Wales and the Honour Roll due to the near constant movement of soldiers within of the Australian War Memorial in order to determine the AIF. if previous influenza illness changed a soldier’s mortality risk during the 1918–1919 influenza Results pandemic.2 The specific question asks how might co- Figure 3 displays the resulting information gathered located infantry units, appearing otherwise identical, from both AIF infantry battalions. Influenza mortality have such different influenza mortality rates? was primarily seen during two periods of World War Methods I in late 1916, early 1917, when it was labelled as ‘purulent bronchitis’ and in late 1918, early 1919, This study is a part of a much larger effort originally during the influenza pandemic.4 Most modern reported in 2010 which the reader is referred to for observers consider both episodes likely to have been details of the data collection methods and analytic caused by the same influenza virus that did not approach used.2 During this previous work it was manage to spread globally until 1918. Pneumonia/ noted that 1 363 men of the 49th Battalion (BN) and 1 influenza mortality in late 1916, early 1917, was 243 men of the 50th BN, despite being located in the identical (8 deaths) in both battalions (See Figure same 13th Infantry Brigade in France in 1918, had very 3A). However, in late 1918, early 1919, there were 18 different influenza mortality rates (See Figures 1 and influenza deaths in the 49th BN and one death in the 2). Given the uniformity of infantry units, especially 50 BN, giving a calculated mortality rate of 7 out of when co-located in the same brigade, detailed study 1000 men vs 0.8 of 1000 men. Figure 3B shows that of these two battalions was conducted to determine if half of all non-combat (mostly due to other infectious previous influenza experience was a key determinant diseases but including accidents) mortality was due of subsequent mortality risk. The National Archives to pneumonia/influenza in 1916–1919. Non-combat online (www.naa.gov.au) medical and administrative deaths that were not caused by pneumonia/influenza records of the men in these two infantry units were were similar (23 vs 25) between the two units. examined in detail collecting all recorded instances Influenza morbidity was similar in both units except of influenza-like illness to which the reader is during mid-1918 when the 50th BN experienced referred. Very accurate mortality information was more cases of a mild influenza-like illness (69 vs 103 available from the Roll of Honour from the Australian cases in June) (See Figure 3C). The 49th BN had more War Memorial (www.awm.gov.au) as well as detailed recorded cases of influenza than the 50th BN during demographic information from the AIF Database the late 1918 pandemic (116 vs 62 cases in October). Project of the University of New South Wales to which we were graciously given access by Prof Peter Dennis.2 Discussion Epidemic curves were constructed from these named Comparison of two co-located AIF infantry battalions individual soldier records measuring non-combat showed that although influenza mortality was mortality, pneumonia/influenza specific mortality, identical in the first epidemic in late 1916, early and influenza-like illness morbidity 1916–1919.

Volume 27 Number 1; January 2019 Page 7 Short Communication

Figure 3A–C: Epidemic curves in two co-located infantry battalions showing A. pneumonia/influenza deaths by month; during pandemic period this was a total of 18 deaths in 49th BN vs 1 in 50th BN B. all non-combat deaths by month; 23 deaths in 49th BN vs 25 in 50th BN and C. influenza-like illness by week during 1916–1919 in France/Belgium during World War I.

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1917, during the main wave of the influenza circulation through the island, influenza related pandemic occurring in late 1918, early 1919, a mortality in 1919 was not greatly different from the ninefold difference in mortality was observed. There previous 1860 and 1891 pandemics; particularly were no differences in non-combat deaths that were muted was the unique young adult mortality not attributable to pneumonia/influenza. Influenza signature of 1919.9 Across the world, highly variable morbidity differed during mid-1918 when the influenza mortality at the country and city level 50th BN had more cases of non-lethal illness. The suggests that these otherwise similar social units situation was reversed in late-1918 when the 49th BN had recent exposure to an influenza virus different experience more influenza cases. than the lethal H1N1 virus of late 1918, early 1919.10

Could mild influenza infections occurring during The utility of military records to address historical mid-1918 have protected soldiers against death epidemiological questions is obvious. What might later in the same year? This was true when a larger these findings mean for the next influenza pandemic? dataset (n = 8840), which included both the 49th and Taken together, the severe mortality seen in 1918– 50th BN as well as medical officers, military nurses, 1919 appears to have been driven by distinct engineers and flying corps, were studied using a Cox epidemiological events which are very unlikely to proportional hazards model.2 When a further case- reoccur. The global spread of influenza through the control analysis was done with all known influenza modern transportation network insures that many deaths (n=1238) during the 1918–1919 pandemic different viruses are simultaneously circulating; matched to an equivalent number of surviving all humans, other than infants, likely have some controls who joined the military at the same time, immunity from a previous infection. The same earlier influenza-like illness was protective against globalisation that brings seasonal influenza is also mortality (odds ratio, 0.37, 95% CI, 0.25 to 0.53).2 what may be protecting us against severe mortality during the next pandemic. These data have been previously reported. The remaining question was whether the same conclusion Contributors could be sustained when looking only at two co- located infantry battalions over time. The epidemic GDS was responsible for designing the epidemiological curves presented in this sub-study show that the project, initiating this particular report as well as only difference that can be discerned between the the writing of the first draft of the manuscript. MW two units was due to increased influenza morbidity was in charge of data collection and analysis. Both in the 50th BN around mid-1918. This fits multiple authors participated in writing the final manuscript. descriptions made during the war of the widespread Conflicts of interest statement: The authors do not nature of non-lethal influenza in mid-1918 serious claim any conflict of interest. enough to cause such concern that sufficient well soldiers would not be available to stop the final Funding: The lead author is a member of the 5 German offensives on the Western Front. The French Australian Defence Organisation but did not receive Army (approximately 4 million men) estimated their any specific funding for this report. mortality during the two waves at less than 100 in mid-1918 and 28 000 deaths during late 1918, early Acknowledgements: The authors thank the many 1919.6 librarians and archivists who helped locate information on the soldiers of the Australian Imperial However, infection with mild influenza in mid-1918 Force of World War I. did not protect against influenza morbidity in late 1918, a finding which has since been confirmed in Disclaimer: The opinions expressed are those of the two US military academies.7 The most parsimonious authors and do not necessarily reflect those of the explanation requires the existence of at least two Australian Defence Force. influenza viruses causing different pandemic events 8 in 1918; one mild, the other lethal. Cross-protection Corresponding Author: Dennis Shanks, occurred for mortality but not morbidity indicating [email protected] the viral surface proteins were likely different. This Authors: D Shanks 1,2, M Waller 2 interpretation is supported by mortality data from Author Affiliations: the different Australian states in 1919. Victoria and 1 Australian Defence Force Malaria and Infectious New South Wales had much greater mortality (two Disease Institute, Enoggera, Australia to threefold) in 1919 compared to the previous 1891 2 University of Queensland, School of Public Health, pandemic. In Tasmania, however, where the lethal Brisbane, Australia pandemic arrived after nearly a year of mild influenza

Volume 27 Number 1; January 2019 Page 9 Short Communication

References 1. Morens DM, Taubenberger JK. 1918 influenza, a puzzle with missing pieces. Emerg Infect Dis. 2012;18(2):332-5. 2. Shanks G, MacKenzie A, McLaughlin R, et al. Mortality risk factors during the 1918-19 influenza pandemic in the Australian army. J Infect Dis. 2010;201:1880-9. 3. Morens D, Taubenberger JK, Folkers G, Fauci AS. Pandemic influenza’s 500th anniversary. Clin Infect Dis. 2010;51(12):1442-4. 4. Abrahams A, Hallows N, French H. Influenzo-pneumococcal and influenzo-streptococcal septicaemia: epidemic influenzal pneumonia of highly fatal type and its relation to purulent bronchitis. Lancet. 1919;193(4 Jan 1919):1-11. 5. Shanks GD. How World War 1 changed global attitudes to war and infectious diseases. Lancet. 2014;384:1699-707. 6. Delater D. La grippe dans la Nation Armee de 1918. Revue d’hygiene. 1923;45:408-26. 7. Shanks GD, Burroughs S, Waters N, Sohn J, Smith V, Brundage JF. Effects of recent respiratory illnesses on clinical expressions of influenza during the 1918 pandemic. Mil Med. 2016;181(8):878-82. 8. Shanks GD, Milinovich GJ, Waller M, Clements A. Opinion: spatiotemporal investigation of the 1918 influenza pandemic in military populations indicates two different viruses. Epidemiology and infection. 2015;143(9):1816-25. 9. Shanks GD, Wilson N, Kippen R, Brundage JF. The unusually diverse mortality patterns in the Pacific Region during the 1918-1921 influenza pandemic: reflections at the pandemic’s centenary Lancet Infect Dis. 2018 Oct;18(10):e323-e332. 10. Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis. Lancet. 2006;368(9554):2211-8.

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The Australian Army’s Two ‘Traditional’ Diseases: Gonorrhea and Syphilis — A Military-Medical History During the Twentieth Century

Ian Howie-Willis

Abstract Two sexually transmitted diseases (STDs) marched in lockstep with the Australian Army in most, if not all, its overseas campaigns during the twentieth century. Gonorrhoea and syphilis, bacterial infections spread most commonly through sexual intercourse.

This article illustrates through reference to the Australian Army’s major overseas deployments; from the Boer War at the beginning of the century to the war in Vietnam, which ended in 1975.

The primary purpose of the paper is to demonstrate the scale of STD infections in the Army’s overseas deployments. There is, of course, a ‘human’ or ‘sociological’ aspect as well. When investigated, every STD episode can be seen to be a little disaster of its own; a mini-tragedy for the soldier contracting the STD, for the person who most often transmitted it to him and, beyond them, for their families. Subsequently, there is the medical aspect: the measures taken by the staff of the Army Medical Service to prevent the STDs and to treat those who contracted STDs.

Significant though the sociological and medical aspects of the Army’s experience of STDs are, this article does not dwell on them. Instead, the focus is statistical, showing the large scale of the STD problem during the Army’s overseas deployments of the twentieth century.

Key terms: sexually transmitted infection (STI), sexually transmitted disease (STD), venereal disease (VD), gonorrhoea, syphilis, twentieth century, Australian Army

Introduction: semantics of the ‘sexually Both STI and STD are euphemisms, ‘culturally transmitted infections’ sensitive’ terms for what are often distressing, debilitating and embarrassing diseases that can be The term sexually transmitted disease or STD became passed on to the innocent partners and children the preferred term among medical professionals of sufferers. A further reason for changing the during the mid-1970s. It replaced a previous terminology was that historically VD referred collective term Venereal Disease or VD, used by predominantly to syphilis and gonorrhoea, whereas previous generations. VD was part of common STI includes conditions such as chancroid, parlance in all English-speaking societies until the lymphogranuloma venereum, chlamydia, HIV-AIDS wish for a less values-laden phrase pushed doctors and other infections transmitted sexually. specialising in sexual health—itself a neologism— towards a semantic shift. Sexually transmitted In this article, the older term VD will be used generally disease has since been replaced by ‘sexually to reflect the accustomed term used at the time of transmitted infection’ (STI) in the early twenty-first most of the Army’s campaigns and deployments century.1 discussed.

Volume 27 Number 1; January 2019 Page 11 Historical Article

Similar semantic changes have occurred in the Gonorrhœa terms used for medical practitioners specialising in the STIs. Until the mid-1970s, such specialists were Gonorrhoea is caused by the gonococcus, a motile known as venereologists and their specialisation as diplococcal bacterium, Neisseria gonorrhoeae. venereology. They later became known as sexual Infection sites are typically the areas of sexual health physicians and their field of expertise as contact—the soft, moist membranes of the penis, sexual health. Whatever the profession might call vagina, anus, rectum, throat and eyes. The gonococci itself at any time, ‘pox doctor’, a derogatory 17th move through bodily fluids by twitching their hair- century term, remains extant, at least colloquially— like appendages and attaching themselves to tissue, as in the expression ‘all dressed up like a pox doctor’s which they then infect.3 clerk’.2

The venereal diseases The Australia Army, like most others, has often suffered high incidences of VD, which for much Australian military history has meant principally gonorrhoea and syphilis, rather than any of the other STDs; of which there are least 14. Gonorrhoea and syphilis have always been the most common forms of VD in the Army and those causing the most concern.

There were various reasons for this concern, Figure 1: Electron microscope image of Neisseria including: gonorrhoeae, the gonococcus causing gonorrhoea. (Source: US Centers for Disease Control and Prevention.) • Until the advent of penicillin in the mid-1940s, both diseases were difficult to treat and cure. In both men and women, gonorrhoeal infection Approximately six weeks in hospital, undergoing commonly spreads along the genital and urinary daily treatment was the standard regimen. That tracts. The gonococci cause acute urethritis (infection meant a huge diversion of scarce resources to and inflammation of the urethra), usually producing treat those infected. a discharge of pus from the urethra.

• The time required for treatment entailed a huge Before penicillin, the standard treatment was twice- loss of trained labour resulting in enormous daily irrigation of the urethra and bladder with a costs for the replacement of those in hospital combination of powerful antiseptics. These included undergoing treatment. Argyrol (a silver nitrate compound) and Benetol • VD was essentially self-inflicted. For that (b-napthol, also called hydroxynaphthalene, a toxic reason, it caused much annoyance among Army compound chemically similar to phenol or carbolic commanders, who consequently saw it as a acid, a corrosive antiseptic). These compounds were disciplinary as much as a medical matter. injected into the urethra and bladder and had to be retained there for several hours. The treatment was • VD also exasperated the medical officers, who prolonged, messy, uncomfortable and embarrassing. generally regarded their obligation to treat it as It was also lengthy as a five to seven week hospital a diversion from their essential role in treating stay was usually required before a patient was free combat injuries and other infectious diseases. of symptoms. • Those who suffered VD were the husbands, sons and brothers of Australian women, who would have been aghast to know that in many cases their men spent much of their time overseas in hospital being treated for diseases that were so taboo they could not be discussed around the family dinner table.

• There was a fear that soldiers returning from overseas service might bring VD with them and spread it through the Australian community. Figure 2: Metal syringe, with curved metal urethral catheter, used for irrigating the urethra with antiseptic compounds. (Source: Wellcome Images, an online source of the Wellcome Trust.)

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Syphilis is caused by Treponema pallidum, a infection in Australia spirochaete or small spiral-shaped bacterium.4 Like gonorrhœa, it can be congenital; passed from mother The number of cases of gonorrhoea Australia- to unborn baby. wide peaked at 12 352 in 1978 and syphilis at 3 594 cases in 1986. The incidence of both diseases Syphilis acquired through sexual intercourse goes subsequently fell away but then began climbing through a series of phases that may extend across again. Figure 4 indicates the changing epidemiology decades. The first of these is an incubation period of both diseases.5 lasting an average of three weeks, during which no symptoms are apparent. The second stage, known as primary syphilis, is when the first symptom appears—often a chancre or hard, usually painless ulcer at the infection site. If left untreated, the chancre disappears.

Secondary syphilis subsequently appears, from two to four months after infection. The most common symptom is a rash of red, flat lesions occurring over the whole body as the spirochaetes multiply Figure 4: Number of notified cases of syphilis and and spread via the blood to the skin, liver, joints, gonorrhoea in Australia, 1961–2010 (Source: Australian lymph nodes, muscles, brain, bones and mucous Yearbooks, Canberra, Australian Bureau of Statistics, membranes of the mouth and throat. The rash heals years 1961–2010) within several weeks and the disease will enter a Epidemiologists and venereologists have debated the dormant phase that may last for many years. reasons for these trends. The emergence of antibiotic- Tertiary syphilis may appear in 30–40% of untreated resistant strains of the bacteria responsible for individuals, in whom the spirochaetes reactivate, gonorrhoea and syphilis was one factor. Changing multiply and spread throughout the body. As they societal mores were another. Generations grown do, they irreversibly damage and eat away the parts indifferent about the risks of casual sex and less the of the body they attack, including the heart, eyes, social and religious sanctions against promiscuity brain, nervous system, bones, joints and facial were probably unconcerned about the stigma that appendages. The result is often gross disfigurement, had blighted the lives of gonorrhoea and syphilis insanity and then death. sufferers in earlier generations. The rising incidence of the Army’s ‘traditional’ STDs among the general Before penicillin, treatment was via intramuscular Australian population is consequently of great injections of highly toxic arsenic and mercury concern to public health authorities. compounds. The side effects included severe mouth ulcers, the loss of teeth and kidney failure. Because Pre-Federation deployments of the toxicity of the treatment, the death of the patient was always a risk. In the US Army, patient The incidence of the VD in the overseas conflicts to mortality of less than one per cent was considered which the pre-Federation Australian colonies sent ‘good’. A cure could not be guaranteed; and so until troops is unknown. These were the New Zealand penicillin the old adage remained true—‘An afternoon land wars of 1845–46 and 1860–72, the Sudan of Bacchus, an evening of Venus and a lifetime of campaign in 1885, the South African (or Anglo- Mercury’. Boer) War of 1899–1902 and the Boxer Rebellion in China in 1900–1901. Given the high rates of VD infection among Australian troops in later overseas deployments, it would be surprising if VD had not been a concern for the military-medical officers in these earlier conflicts as well.

The best documented of the late colonial era conflicts was the South African War, to which the colonies and then the new Australian Army sent contingents. The various histories of the war, both British and Australian, deal at length with the organisational arrangements made for the various field ambulances Figure 3: Pictomicrograph of spirochaetes of the Treponema and stationary hospitals set up to treat injured and pallidum species. (Source: US Centres for Disease Control)

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sick soldiers. The only infectious diseases discussed The Army’s losses to VD in World War I were enormous. in any detail are two other historical scourges of An estimated 63 350 VD cases occurred among the armies—dysentery and malaria. VD never rates a 417 000 troops of the 1st Australian Imperial Force mention. (AIF). That is, one in seven of the soldiers who joined the AIF contracted VD at some stage of the war. That For reasons unknown, perhaps the prudery of the many soldiers was the equivalent of three infantry era, VD is ignored in official accounts of the South divisions. Given that the average VD treatment time African War. Neither the 300-page report of the 1903 was six weeks, the high number of VD infections 6 British commission of inquiry into the war , nor the effectively meant that for six weeks of the war the AIF 395-page 1904 official British government report on commanders had lost three infantry divisions. Little the medical arrangements for the war by the Army’s wonder that VD perturbed them greatly! Surgeon-General7 include any reference to VD. Nor does the six-volume quasi-official British history of the war published by The Times newspaper of London.8

Despite the official silence on VD, we might surmise that some of the Australian troops arriving in South Africa either brought VD with them, acquired VD in Africa and took VD back home after their departure, as this was certainly the situation during the next Figure 5: The Isolation Hospital at the Broadmeadows Army Camp, World War I, possibly 1914–15. Little is war 12 years later—World War I. known about this ‘lock’ hospital. It was probably a secure section of a larger camp hospital at Broadmeadows, The most recent Australian historian of the war, established to manage contagious diseases such as Craig Wilcox, has suggested the possibility that measles, influenza, tuberculosis, meningitis and VD some Australians might have contracted VD during until specialised infectious disease hospitals could be their South African service. Wilcox describes the established elsewhere. Note the 5-strand barbed-wire Australian colonial contingents arriving at the port perimeter fence to prevent patients from absconding. (Source: Australian War Memorial, photograph no. of Beira in Mozambique, from where they caught H18401.) trains into South Africa. The Australians generally thought the town ‘immoral’; but many, appreciating Egypt in World War I the ‘free-flowing liquor’, went on ‘drunken sprees’.9 Did that lead to VD? Wilcox does not say, but the The first known VD epidemic suffered by the nexus between inebriated soldiers, readily accessible Australian Army occurred in Egypt. It began almost and cheap prostitutes and high rates of VD would be as soon as the 1st AIF arrived there for training in the a common theme in the Army’s subsequent overseas months before the Gallipoli campaign.12 deployments during the twentieth century. In 1915, the first year the Army spent in Egypt, 4 Eventually the British Army did publish the VD 046 out of some 30 300 Australians, or over 13%, figures for the South African War, but not until 1931 were admitted to hospital suffering from VD. The in the statistical volume of the official medical history rates in Egypt remained high. In 1916, the rate was of World War I. The 19,127 VD cases treated during 14% of strength, and in the last full year of the war, the war amounted to 4.7 per cent of all 404,126 1918, it was 11%. hospitalisations for disease.10 That many VD cases among the British troops strongly suggests that among Australian soldiers, too, VD was also problem for their medical officers.

Australian soldiers’ VD infection rates during World War I The first conflict in which the Australian Army medical units kept comprehensive medical statistics was World War I. Officially there were 181 separate ‘disabilities’ which caused soldiers to be ‘rendered unfit, temporarily or permanently, for service’ in the Army. VD was among the most common of these.11

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VD was not the most common affliction suffered by the AIF, at least on the Western Front. Respiratory tract infections were far more prevalent, amounting to 110 650 cases or 37.5% of disabilities. That was more than four times higher than the rate for VD. The higher figure for respiratory infections was hardly surprising considering that the AIF fought amid the cold, rain and mud of three northern European winters, following which the worldwide 1918–19 wave of pandemic influenza swept over the troops.

Figure 6: Soldiers (almost certainly staff) standing on the verandah of the X-ray and operating rooms of the No. 2 Australian Stationary Hospital at Moascar near Ismailia, Egypt, 1918. This hospital was the principal VD treatment centre for Australians serving in the Middle East. It was relocated several times, tending to move to where the troops were concentrated. (Source: Australian War Memorial, photograph no. B02450.)

Britain and the Western Front in World War I Figure 7: Administrative headquarters of the No. 1 Australian Dermatological Hospital, Bulford, Wiltshire, st The 1 AIF’s next VD epidemics occurred in Britain April 1919. The hospital was the principal VD treatment and on the Western Front between 1916 and 1919.13 facility for 1st AIF soldiers in Britain. Although a grim, depressing amenity for patients and staff alike, Some 295 000 troops of the 1st AIF were deployed to the it undertook effective medical work. In its peak year Western Front in France and Belgium during those of activity, 1918, it managed 9 404 patients. (Source: years. In that time, Australian soldiers in the UK, Australian War Memorial, photograph no. D00456.) France and Belgium suffered 584 248 disabilities requiring treatment by an Australian Army Medical The Australian Army’s VD infection rates Service unit. VD cases accounted for at least 48 880 during World War II of these, 22 265 in the UK and 18 165 in France nd and Belgium, i.e. 8.4% of all disabilities. Expressed During World War II, the 2 AIF again suffered high as a rate per thousand of overall troop strength, the VD infection rates. In the Middle East, the rate was Army’s VD ‘episodes’ amounted to 166 cases per 48 cases per thousand troops in 1941, the peak year. thousand soldiers. That was only two-thirds (65.7%) the rate among the 1st AIF on the Western Front in World War I; however, The total incidence of VD cases among Australian the Army’s commanders and medical officers agreed soldiers in the UK 1916–1918, 22 265, was 20% it was nevertheless ‘far too high’.14 higher than the 18 165 cases in France and Belgium. The rate of VD infection in the UK was also Later in World War II, the Army’s VD infection rates appreciably higher than in France and Belgium. For were appreciably lower than in the Middle East. In the example, in the middle year of deployment to the UK South West Pacific theatre, mainly the archipelagos and the Western Front, 1917, the rate in the UK was to Australia’s north, the highest rate was only eight 148 cases per thousand troops, whereas the rate in per thousand in 1945 or 0.08% of strength. Such a France and Belgium was 73 per thousand, only half low rate reflected a lack of opportunity for infection. the rate in the UK that year. The rates among troops in Australia were higher, for The main reason for the disparity in the incidence example 19 per thousand in 1942, which was only and rate of VD between the UK and France and around half the rate in the Middle East the previous Belgium was opportunity for infection. Soldiers in year. Nevertheless, that figure caused ‘considerable the UK were not currently engaged in combat; those anxiety’ that the troops would spread their on the Western Front were and consequently had gonorrhoea and syphilis into the general population. less time in which to contract VD. The discrepancy An estimated 34 180 cases of VD occurred among effectively illustrates the Army venereologists’ saying Australian troops during World War II. This was only that ‘the incidence of VD among soldiers is inversely 52% of the 63 350 cases of the 1st AIF during World proportional to their amount of combat’.

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War I. How may such a disparity be explained? The Australian VD rates in the British answer is complex, but it can be reduced to the Commonwealth Occupation Force in Japan following factors. The Army’s first post-war overseas deployment was There was greater awareness among soldiers of the to Japan, as part of the British Commonwealth risks, dangers and consequences of VD infection. Occupation Force. The deployment lasted for six This reflected the state governments’ enactment of years (1946–1952). In that time, 16 500 Australian legislation for controlling VD during the 1920s and military personnel served with the Occupation Force. 30s, their establishment of public VD treatment The Australians’ VD infection rate during this time clinics, their anti-VD propaganda campaigns and was extraordinarily high. The number of individual the influence of the Commonwealth Department Australians who contracted VD was 4 768 or 29% of Health in disseminating information about the of the Australians who served with the force. There diseases. were 7 350 separate VD episodes or cases, which means that 2 582 soldiers suffered more than one The Army vigorously promoted its ‘Blue Light’ episode. The record was 12 episodes, which means Prophylactic Ablution Centres (PACs), i.e. units that that particular soldier must have spent at least providing pre-emptive treatment for soldiers who 192 days out of his one-year deployment in hospital had exposed themselves to the risk of VD infection. being treated for VD.15 The Army recruited specialist venereologists to staff its VD hospitals. Their availability to the ‘Blue Light’ PACs, and their training of the PAC medical orderlies, meant that the PACs functioned more efficiently than previously.

The availability of the ‘sulpha’ drugs, e.g. sulphanilamide, from the late 1930s. Such drugs were particularly effective against gonorrhœa, greatly reducing treatment times. Many soldiers contracting gonorrhœa treated themselves with sulphanilamide without reporting to Army medical units—and without consequently becoming ‘VD statistics’.

In the Middle East, where the 2nd AIF’s infection rates Figure 9: Japanese female civilian employees ironing were the highest of the war, the Army introduced a clothes at the British Commonwealth Occupation Force system of controlled brothels in which the prostitutes base laundry, Hiro, Japan, June 1952. The Occupation Force was obliged to employ a large Japanese labour were regularly examined for symptoms of VD. force. Many Japanese civilians worked at such bases and much fraternisation between the workers and soldiers occurred, even though it was officially discouraged. Inevitably, fraternisation contributed to high Australian VD infection rates; however, it also meant that infection was transmitted through the workers into the Japanese community. (Source: Australian War Memorial, photograph no. 147948.)

The overall infection rate 1946–1962 was 446 cases per thousand troops, near enough to an infection rate of 45%. These figures mean that the Australians in the Occupation Force have the dubious distinction of ‘scoring’ the Army’s highest ever VD rate.

How were the Occupation Force soldiers able to Figure 8: Staff of No. 8 Australian Special Hospital, Kilo tally such a high rate? The answer partly lies in 89 Camp, Gaza Ridge, Palestine, December 1941. Left– the destitution of the Japanese population in the right: Staff Sergeant D. McDonald, Lieutenant Colonel DB Loudon (the Commanding Officer) and Lance Corporal immediate post-war years. The Australians Forces C. McHale. The 8th Special Hospital was the 2nd AIF’s were deployed to the Hiroshima Prefecture, the most main VD treatment centre in the Middle East 1940–1942. devastated and therefore the most poverty-stricken, (Source: Australian War Memorial, photograph no. region in Japan. Japanese culture had traditionally 100325.) tolerated prostitution and consequently, many

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Japanese women resorted to prostitution to help rates partly reflected the practice of sending the their families survive their post-war deprivation and troops to nearby Japan for their recreation leave. As poverty. These Japanese prostitutes were usually seen, prostitution at that time was commonplace in infected with VD. Japan and most prostitutes were infected with VD. As the official medical historian observed, resorting The other part of the answer lies with the soldiers to prostitutes was ‘the normal reaction of young men themselves. Without a war to fight, the well-paid spending five days’ leave in a big city, far from the Australians had ample leisure, few recreational hazards of war’. facilities and little to distract them from booze and sex, which usually went together. Pertinent here is The main factor, however, was the availability of the old Army venereologists’ adage that ‘Army VD penicillin. The widespread adoption of penicillin- rates are inversely related to the amount of battle based antibiotic drugs at the end of World War II activity’. had greatly lessened the burden of treating bacterial infections. In the case of gonorrhoea and syphilis, The Australian Army’s VD rates in Korea penicillin had obviated the previous messy, painful, protracted and toxic VD treatment regimens. The next major conflict to draw troops from Australia Information about the efficacy of the new ‘wonder was the Korean War of 1950–1953. In the three years drug’ in rapidly curing VD filtered down to the level it lasted, some 17 000 Australian military personnel of the common soldier. Assured of a rapid cure, they were deployed in Korea. They contracted VD at very were less concerned about contracting VD than high rates. The Australian rate, 386, was slightly above soldiers in previous wars. the overall Commonwealth figure but appreciably lower than the Canadian and New Zealand rates. The Malayan Emergency and Australian VD However, comparatively ‘good’ that was, except for the recent Occupation Force in Japan, the rate was rates more than 2.5 times the previous ‘worst’, 148 in the From 1955 to 1960, Australian soldiers fought with UK in 1917. An estimated 4 110 Australian soldiers British troops on the Malayan Peninsula in a war contracted VD while serving in Korea.16 known as the Malayan Emergency. The Emergency was essentially a Communist-led guerrilla war against British colonial rule and against the Malayan government that replaced it.17

As in the occupation of Japan and the Korean War in the recent past, the VD rates among the three Australian battalions successively deployed to Malaya were very high. The overall rate was 415 cases per thousand troops, or two-fifths of the soldiers sent to Malaya. An estimated 2 900 Australians serving in Malaya contracted VD.

VD rates in the Australian Army in Vietnam A decade after the armistice in Korea, Australian troops were engaged in another and longer war, this time in Vietnam. The Australian involvement in the Figure 10: Captain J. Bannerjee, a surgeon from India, Vietnam War lasted for 11 years, from June 1962 examines a British casualty in front of the 60th Indian until June 1973. The rates of VD infection were once Field Ambulance reception tent, Korea, 1950. Assisting again high. In the peak year for infection, 1967, the him are two 60th IFA orderlies while four others look on. The 60th IFA was the main early treatment centre rate was an astounding 478 cases per thousand for Commonwealth forces in Korea. The unit managed troops. The rate across all 11 years was 231 cases many Australian casualties. It also doubled as the main per thousand. An estimated 11 380 Australian VD treatment facility for Commonwealth troops and, as soldiers contracted VD during service in Vietnam.18 such, it handled most of the estimated 4 110 cases of VD that occurred within the Australian contingent. (Source: The reasons for the very high rate in Vietnam were Australian War Memorial, photograph no. HOBJ1894.) perhaps similar to those in Korea in the early 1950s. Why was the rate in Korea so much higher than The ‘mix’ included a reduced fear of VD among those in the First and Second World Wars? The high troops with ready access to effective antibiotics; an abundance of cheap prostitutes; high rates of

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VD infection among the prostitutes; ample liquor experience were any guide, such post-Vietnam in readily accessible bars that were almost always deployments would have yielded a continuing brothels as well; and the determination of virile number of STD cases, including both gonorrhoea young soldiers to ‘have fun’ during leave after the and syphilis and other ‘newer’ STDs such as HIV- stress of front-line action. In Vietnam, there was also AIDS and chlamydia. a reckless, hedonistic defiance, which the official medical historian of the war alluded to by writing that Little is known of the Army’s post-Vietnam STD ‘the Australian servicemen displayed no inclination infection rates. The dearth of data reflects what to exercise restraint or take precautions’.19 one senior Australian Defence Force (ADF) medical officer has termed ‘the confidentiality crisis’ generated by the HIV epidemic. Sensitivities over the confidentiality of STD data was such that from the 1980s few anonymised data sets existed, much less made accessible to historians.20

Vigilance over STD rates nevertheless remains a duty for the health professionals, military commanders and for individuals in the Armed Forces.

What measures did the Army adopt to reduce the incidence of its two ‘traditional’ diseases? Over the 75 years this paper covers, the Army Figure 10: Bar girls in the entrance to the ‘Texas Bar’, did everything possible to control and reduce the Vung Tau, chatting with American soldiers as a incidence of gonorrhoea and syphilis.21 At various Vietnamese boy claims the attention of one soldier. The times the Army commanders, administrators, bar, effectively a brothel, was also much patronised by Australians. Note the ‘Approved Premises’ sign (arrowed) medical officers and military police tried all of the in the bar window. This indicated that the bar girls had following: been medically examined and were purportedly ‘VD-free’. In reality, the ‘hostesses’ of the ‘approved’ bars often still • Semi-criminalising the contraction of VD, notably contracted VD as they were commonly infected by the by: (a) confining VD patients under guard customers they serviced after their examinations. to secure lock-hospitals; (b) stigmatising VD (Australian War Memorial, photograph P001510.021.) patients, e.g. by requiring them to use separate dining, ablution and toilet facilities); (c) treating In Vietnam, as in all the previous conflicts, the Army’s VD patients in separate, isolated VD hospitals; (d) commanders and medical officers were concerned as sending VD patients back to Australia in disgrace; much by manpower as by disciplinary, moral and (e) ensuring that the treatment regimens in the VD medical considerations. A high VD rate has always hospitals were harsh; (f) stopping the pay of VD meant a depleted fighting force because every soldier patients while they were undergoing treatment; being treated in hospital for VD represented one less and (g) curtailing leave and other privileges of VD man available for duty. If the 11 380 troops were patients. withdrawn from normal duties for just two days’ treatment—the average time for VD cases—then • Supervising soldiers’ off-duty time and behaviour 22 760 ‘man-days’ or 62.4 ‘man years’ were lost in to minimise their opportunities for fraternising Vietnam. Another way of expressing the manpower or visiting brothels and picking up streetwalkers. cost of VD would be if the Australian force in Such measures included: (a) provision of sporting Vietnam suffered 231 VD ‘casualties’ per thousand and recreation facilities; (b) declaring ‘red-light’ of strength, only 23% of the force would have been districts in towns frequented by soldiers to be available for service throughout the year. Such a rate out-of-bounds to troops; (c) military police patrols implied a large-scale reduction in military capability. through such districts to round-up soldiers and send them back to camp; and (d) frequent bed The STDs in the Army post-Vietnam checks after lights-out to ensure soldiers were in bed and not absent visiting prostitutes. After the end of the Vietnam War in 1975 dozens of overseas deployments lay ahead of the Australian • Education and propaganda on the nature, Army. They have included East Timor, Bougainville, causes and societal ramifications of VD infection, the Solomons, Iraq and Afghanistan. If previous including: (a) lectures by chaplains on the moral

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aspects of VD infection; (b) lectures by Medical Officers on VD causes and prevention; (c) compulsory written examinations on the types, nature, symptoms and treatment of VD; and (d) anti-VD posters, pamphlets, films, information leaflets and articles in Army newspapers.

Regular medical inspections of the troops to check for telltale symptoms of VD infection. Provision of free, well-publicised prophylactic measures, made available on a ‘no questions asked’ basis and preserving soldiers’ anonymity. These included: (a) issuing ‘Blue Light’ prophylactic kits containing condoms and antiseptic ointments to be rubbed into the genitals and surrounding areas immediately before and after sexual activity; and (b) conducting ‘Blue Light’ PACs at all major Army camps Figure 11: Comparative VD infection rates among and in red-light districts frequented by soldiers. Australian soldiers in nine theatres 1915 to 1973 Ideally, soldiers visited the PACs as soon as possible after sexual contact so that their genitalia could be Figure 11 shows the estimated overall rate of VD washed, irrigated with antiseptic compounds and infection per thousand of troop strength in nine dressed with antiseptic ointment. theatres to which Australian troops were committed between 1915 and 1973. The great disparity Establishing venereological hospitals in Australia and between the pre-1945 and post-1945 rates reflects the overseas theatres where Australian units were the impact of penicillin. After the introduction of deployed. Staffed by specialist venereologists and penicillin, soldiers had little to fear from VD because trained medical orderlies, these hospitals provided treatment required only several days in hospital—in treatment regimens that were the best available. contrast to the pre-penicillin era when a VD infection entailed many weeks in hospital undergoing painful, Regulating and punishing women accused of hazardous treatment regimens. transmitting VD. Such measures included: (a) identifying the women who had been the source of The Army as an institution most often behaved particular soldiers’ infections, then locating them responsibly by promptly adopting the measures, to insist on their treatment; (b) persuading civilian which, at the time, were thought best for preventing police to arrest and charge prostitutes, and have VD infections. Whatever measures were adopted, them convicted, imprisoned and compulsorily however, soon proved ineffective in prevention; and so treated; and (c) removing from the vicinity of Army the emphasis shifted. It was a change from moralistic camps the ‘part-time’ and ‘amateur’ prostitutes who concern with trying to prevent VD among soldiers, as congregated there. in World War I, to a pragmatic acceptance that VD would occur, that it was an occupational hazard for Authorising particular brothels and prostitutes troops serving overseas and should accordingly be to service Australian soldiers by issuing them controlled and minimised. The Army came round to with permits and regularly checking the for VD the latter viewpoint as a result of its experience in symptoms. In the Middle East in 1941-1942, and Vietnam. It came to realise that the best it could hope later in Vietnam, the Army effectively conducted its for was to minimise infection rates, not eliminate VD own Army-supervised brothels staffed by officially from among its troops. approved prostitutes.

Delaying the post-deployment return to Australia of How many Australian soldiers contracted VD VD-infected soldiers until there was certainty they during the twentieth century? were either cured or rendered non-infectious. Putting figures for VD infections on particular deployments is often problematic. For some deployments, no statistics are available; for others estimates must be made. Even where figures have been systematically compiled, inconsistencies exist. Further, often the statistics are understated because

Volume 27 Number 1; January 2019 Page 19 Historical Article

some soldiers managed to conceal their symptoms; The present author proffers no answers to such others escaped detection by self-treating; and others questions because he has none. Nevertheless, each were privately treated by civilian doctors. In such deployment that contributed to the 125 270 total had cases, the number of VD cases could not be included its own specificity, which produced its own number in the tables compiled by the official medical of VD cases. The reasons why each deployment historians. produced the VD incidence that it did were complex, relating to circumstances specific to the era and the Such provisos notwithstanding, the present author nations in which the episodes occurred. All that can estimates that during the twentieth century Army be said of the total is that VD was a major problem medical units treated over 125 000 VD cases among for the Australian Army throughout all its overseas 22 Australian soldiers. Table 1 provides a summary. deployments from the Boer War to Vietnam.

The actual total, 125 270, was a nominal figure as it Author’s affiliations: Dr Ian Howie-Willis is an does not include the unknown statistics for four of independent professional practising historian who the 10 sets of deployments. It was a very large sum— lives in Canberra. In July 2018, he finished writing a the equivalent of six World War I infantry divisions. manuscript with the working title ‘VD: The Australian Army’s experience of sexually transmitted diseases What might such a total signify? Does it reflect badly during the twentieth century’. This present article on the soldiers, on the Army that sent them to fight began as a paper presented to the ‘Lessons of War’ overseas, on the doctors who safeguarded their section of the Australian Historical Association’s health, or on the nation of which they were citizens? annual conference at the Australian National University on 3 July 2018.

Table 1: Estimated numbers of sexually transmitted disease cases in the Australian Army during the overseas deployments of the twentieth century

Deployment Estimated STD cases (rounded)

Boer War, 1898–1902 Unknown

Boxer Rebellion, 1900–1901 Unknown

World War I, 1914–1918 65,350

World War II, 1939–1945 34,180

Occupation Force in Japan, 1946–1952 7,350

Korean War, 1950–1953 4,110

Malayan Emergency, 1955–1963 2,900

Indonesian Confrontation of Malaysia, 1965–1966 Unknown

Vietnam War, 1962–1973 11,380

Post-Vietnam deployments, 1976–2000 Unknown

Total STD cases, twentieth century 125,270

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Abbreviations Corresponding author: Ian Howie-Willis, i 1st AIF the first Australian Imperial Force: the [email protected] Australian Army formation established to Authors: I Howie-Willis1 enable soldiers to enlist for overseas service Author Affiliations: during World War I 1 St John Ambulance Tasmania

2ndAIF the second Australian Imperial Force, i.e. Army formation established to enable soldiers to enlist for overseas service during World War II

AIDS Acquired immune deficiency syndrome

HIV Human immunodeficiency virus

PAC Prophylactic Ablution Centre(s): Army units during World Wars I and II, which provided pre-emptive treatment for soldiers who had exposed themselves to risk of VD infection

STD Sexually transmitted disease(s)

STI Sexually transmitted infection(s)

UK United Kingdom

US United States

VD Venereal disease(s)

References 1 Terminological usage in the Medical Journal of Australia [MJA], the Australian medical profession’s general ‘news magazine’, will often reflect semantic shifts in medical phrases. Thus, from its foundation in 1914 until the mid-1970s, the MJA commonly referred to ‘Venereal Disease(s)’. The MJA first used the term ‘Sexually transmitted disease’ in an editorial in February 1975. Over the next two years, ‘sexually transmitted disease(s)’ progressively replaced ‘venereal disease(s)’ in MJA terminology. The MJA’s first reference to ‘sexually transmitted infection(s)’ was in a letter-to-the-editor in June 2002. After that, in the MJA if not elsewhere this term superseded ‘sexually transmitted disease(s)’. 2 Oxford Living Dictionaries, online edition. Available from: https://en.oxforddictionaries.com/definition/ pox_doctor.[accessed 4 September 2018]. 3 Hart G. Reducing the impact of sexually transmitted diseases including HIV infection, Public and Environmental Health Division [of the] South Australian Health Commissioner, Adelaide, 1989, pp. 5–7. 4 see Hart G. op. cit., pp. 8–10. 5 Australian Bureau of Statistics. Australian Yearbooks, Canberra, years 1961–2010 (the years in which the data for the graph were published). 6 His Majesty’s Commissioners [on] the War in South Africa, Report of His Majesty’s Commissioners appointed to inquire into the military preparations and other matters connected with the War in South Africa, London, His Majesty’s Stationery Office, 1903. 7 Mitchell, T.J. and Smith, M.G., Medical Services: Casualties and Medical Statistics of the Great War, London, His Majesty’s Stationery Office, 1931, p. 273. (This book is Volume 1 in the 14-volume British official medical history of World War I.) 8 Wilson Sir WD. Report on the Medical Arrangement on the South African War, London, His Majesty’s Stationery Office. 1904. 9 Amery LS. (ed.), The Times History of the War in South Africa 1899–1902, London, Sampson, Low, Marston and Company Ltd. 1900–1909.

Volume 27 Number 1; January 2019 Page 21 Historical Article

10 Wilcox C. Australia’s Boer War: The War in South Africa 1899–1902, Melbourne, Oxford University Press and the Australian War Memorial. 2002: p 104. 11 The data on which this section is based is derived from the statistical tables of the official medical history of World War I, Butler AG. The Australian Army Medical Services in the War of 1914–1918, Volume III, Special Problems and Services, Australian War Memorial, Melbourne. 1943. 12 The material in this section is derived mainly from the official medical history of the war, see Butler AG. The Australian Army Medical Services in the War of 1914–1918, Volume I, The Gallipoli Campaign, The Campaign in Sinai and Palestine [and] The Occupation of German New Guinea, Australian War Memorial, Melbourne. 1938. 13 The material in this section is derived largely from the official medical history of the war, see Butler AG. The Australian Army Medical Services in the War of 1914–1918, Volume II, The Western Front Australian War Memorial, Melbourne. 1940. 14 This section is based on the official medical history of the war; see Walker AS. Clinical Problems of War, Australian War Memorial, Canberra. 1952; Middle East and Far East Australian War Memorial, Canberra. 1953; and The Island Campaigns Australian War Memorial, Canberra. 1957. 15 There was no official medical history of Australian participation in the Occupation of Japan, The material in this section is therefore based on archival sources in files held by the Australian War Memorial. See for example: (1) Thompson Lieutenant Colonel JS. (Deputy Provost Marshal, BCOF) to various BCOF recipients. 20 September 1946, ‘Control — Venereal Disease’ in AWM 114, item 267/6/17 (Part 1); (2) VD Control (Minutes of the Anti-VD Committee conducted on 13 May 1947) in AWM 114, item 267/6/17 (Parts 2 and 3); and (3) Administrative Instruction AG 108: Prevention of Venereal Disease–BCOF, 10 February 1948, in AWM 114, item 267/6/17, file BCOF. Control of Venereal Disease (Part 12). 16 This section is based on material available in the ‘Medical’ section of the official war history, see McIntyre D. ‘Australian Army Medical Services in Korea’ in O’Neill R. Australia in the Korean War 1950–53, Volume II, Combat Operations, Australian War Memorial and Australian Government Publishing Service, Canberra, 1985. See also Gandevia B. ‘Medical and surgical aspects of the Korean campaign, September to December 1950: Casualties and their evacuation’ in Medical Journal of Australia 11 August 1951, pp. 191–195; and ‘The Korean War: Australian medical services’, Korean War section of The Anzac Portal, the on-line military encyclopaedia of the Australian Department of Veterans’ Affairs, published on the website https://anzacportal.dva.gov.au/history/ conflicts/korean- war/. 17 The material on the Malayan Emergency is derived from data in the official medical history of the war, see O’Keefe BG. Medicine at War: Medical aspects of Australia’s involvement in Southeast Asia 1950– 1972, Part I, ‘Malaya and Borneo’, St Leonards, New South Wales, Allen & Unwin in association with the Australian War Memorial, 1994. 18 The material on the Vietnam War is derived from data in the official medical history of the war, see O’Keefe B. op. cit., Part II, ‘Vietnam’. The statistics are derived from his Table 21: ‘Total disease and injury admissions, Vietnam, July 1965–June 1972’. 19 O’Keefe B. op. cit., p.126. 20 Author’s correspondence: Shanks Professor G to Howie-Willis I. 17 July 2018. 21 The summary of anti-VD measures outlined in this section is based on the section ‘A century of the Australian Army’s attempts to manage the STDs’ in Chapter 12 (‘Post-Vietnam deployments, 1976– 2000’) of the author’s unpublished manuscript, ‘VD — The Australian Army’s experience of sexually transmitted diseases in the twentieth century’ (2018). 22 The figures and the table are borrowed from the author’s unpublished manuscript, ‘VD — The Australian Army’s experience of sexually transmitted diseases in the twentieth century’ (2018).

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E Daly, N Evans, S Holmes-Brown

Abstract The purpose of this pilot study was to analyse the current cold chain storage methods of Class 8 stores, specifically thermolabile medications and temperature-sensitive diagnostics, dressings and fluids, for the Australian Army in a training area within Australia. This research was designed to identify deficiencies in current storage methods, including the inability to maintain recommended temperatures of pharmaceuticals in accordance with the Therapeutic Goods Administration (TGA), as well as foster communication between key stakeholders, such as the Royal Australian Army Medical Corps and the Department of Defence Joint Health Command, to develop a cold-chain protocol specific for the Australian Army.

This pilot study identified the common occurrence of breaches in a specific climate, resulting in thermolabile medications, and temperature-sensitive diagnostics, dressings and fluids being commonly exposed to temperatures outside the range recommended by manufacturers. The study’s findings relate mainly to the current storage equipment for Class 8 stores used by the Australian Army and, as a result, recommends the replacement of this mission essential equipment to ensure that cold chain storage meets the TGA guidelines. The study discusses the need for clearly defined guidelines with accountability on the stakeholders to ensure the provision of health support to all Australian Defence Force (ADF) personnel in the field is in accordance with the standard of care expected at a civilian health facility.

Key terms: cold chain storage, thermolabile medications, temperature sensitive, Class 8 stores, storage temperature

Ethical approval and conflict of interest within the ADF. No ethical approval was required, as the research did not involve humans or animals, To ensure objectivity and transparency in conducting but focused on health materiel logistics. There was this pilot study, the Defence People Research – Low- no identified conflict of interest for the study, which Risk Ethics Panel was engaged to enquire if any was undertaken by a RAAMC General Service Officer ethical approval was required to conduct this study within work time with nil research grants or personal reimbursement provided.

Volume 27 Number 1; January 2019 Page 23 Original Article

BACKGROUND When medicines stored at room temperature are exposed to higher temperatures, not only do their Understanding the cold chain physical appearances change4, in some cases, their efficacy and potency can also be reduced. The cold chain is the temperature-controlled aspect of the supply chain and refers to the uninterrupted In accordance with the TGA, medications may be storage of pharmaceutical products including required to remain outside the specific temperature thermolabile medications, and temperature- range for a temporary period due to a number sensitive diagnostics, dressings and fluids. The of factors, including delivery, processing and cold chain commences from the time the product refurbishment. Accordingly, Section 8.9 of the TGA is manufactured, it includes transportation to the states that these temporary breaches of the cold distribution point, and ends when the product is chain must be prevented by all means through administered. An unbroken cold chain consists of forward planning including delivery time, climate an uninterrupted series of storage and distribution and the recommended storage temperature (as activities which maintains a given temperature per the product label).1 Any new equipment used range, based on the manufacturer’s recommended for the storage of cold chain medicines should be conditions for product stability and integrity stated commissioned according to the manufacturer’s on the Therapeutic Goods Administration (TGA) written procedure and the storage conditions approved product packaging.1 validated before becoming operational (TGA Sect 8.2).1 There is also the requirement for standard National storage and shipping requirements operating procedures (SOPs) to be established to ensure all personnel involved with the cold chain The cold chain refers to the transportation, storage process are aware of what actions to take if a breach and distribution of pharmaceutical products within occurs, including loss or destruction of the products. the temperature parameters, which are identified through the product packaging and documentation. THE AUSTRALIAN DEFENCE FORCE The cold chain parameters are outlined in Table 1. The Strategic Reform Program A ‘cold-chain breach’ or ‘adverse storage event’ refers to a situation in which a temperature-sensitive The ADF’s primary focus is to protect and advance product has been exposed to temperatures outside Australia’s strategic interests.5 This is achieved the specified range for the product – excluding through maximising defence capabilities by deviations of up to +12°C for less than 15 minutes conducting key training exercises, both domestically that may occur when opening the refrigerator door and internationally, in order to prepare and deploy routine use or restocking.3 The implications of a cold- personnel to military operations in regions including chain breach can have extensive implications on the Middle East and the South Pacific. the effectiveness of the product being administered.

Table 1. Parameters of the cold chain. Reprinted from Reed, C. (2005). COLD CHAINS ARE HOT! Mastering the Challenges of Temperature-Sensitive Distribution in the Supply Chain. Chain Link Research.2

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The Strategic Reform Program (2009) was published Current state of health logistics in the to strategically plan for and implement changes to Australian Army maximise the capability of the forces (Army, Navy and Air Force) while creating a more organised and From the early days of World War I, pharmacists in a efficient ADF. The overall goal of the Strategic Reform military hospital setting were required to work beyond Program is to ‘implement techniques to eliminate their role with additional responsibilities including duplication and waste in maintaining capabilities, the role of Medical Quartermasters. This added increase their operational availability and reduce the duty encompassed stocktaking, auditing, internal 7 cost of ownership’.6 In order to achieve these goals, checking and writing off damaged or deficient stock. three key elements are identified: Within the Australian Army, logisticians make up approximately 40% of the serving members. Health 1. Improved accountability in defence through logisticians are tasked with ensuring the provision of increasing transparency and accountability of the health care is provided to all serving ADF personnel defence budget; through organic medical assets, which include established medical facilities and field treatment 2. Improved defence planning through a strengthened teams and hospitals. link of planning and military preparedness and refinement of existing governance; and There is a considerable difference in the status quo for logistic management within the Army with 3. Enhanced productivity in defence through the current divide of logistical personnel divided improving the cost-effectiveness for military based on their trade or corps and not the ‘level’ of capability and procurement.6 logistics at which one has served in their logistics From a logistics perspective, the intent of the career.8 This is evident in the current technologies reform program is to implement better services and being utilised within the health space, specifically practices to improve the current logistics space. This the storage of pharmaceutical products required for includes the planning processes, forecasting, waste the maintenance of the cold chain. The existing cold management and technologies. The end state is that chain storage methods for close health clinicians, the Department of Defence has improved logistics excluding the Haemacol fridges, are not designed technologies, increased visibility on the supply chain specifically for the purpose, but are in accordance and generated a return on savings. with the packing and storage instructions issued by the Land Engineering Agency (LEA) within the Health logistics within the ADF ADF and are limited to general-purpose polymer containers. The ADF currently spends $5.2 billion per year across 23 categories of non-military goods and Role of the Land Engineering Agency services from external suppliers.6 Health services are one of these categories and encompass the logistics The purpose of the LEA is to ensure that every soldier of pharmaceutical supply and management. The is delivered equipment that is fit-for-service, safe and Strategic Reform notes that no less than 60% of environmentally compliant while delivering project any savings on the current budget will be derived outcomes in accordance with the Defence Capability from the analysis of any changes to policy, usage Plan and the Technical Regulatory Framework (TRF).9 and demand.6 As per Figure 1, the costs for health The TRF places emphasis on the need for informed are currently at 100% of the mature yearly savings (technical) ‘judgements of significance’ to be made and need a thorough analysis to consider changes to by appropriately qualified and competent staff.6 The current practices and processes.

Figure 1. Costs for non-equipment procurement including health services for FY 09/10 to 15/16. Source: Department of Defence. The Strategic Reform Program. 2009.

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Packaging, Handling, Storage and Transportation and replace any drugs that exceed their recommended (PHS&T) section of the LEA is responsible for storage temperature, as the main effort for the ADF ensuring that materiel system elements within the is identified as ensuring all training exercises are ADF are preserved, packaged, handled, stored and executed with limited interruption. Not only does transported properly until required for use, including this contravene existing national procedures, but it ensuring that materiel is protected from climatic, also increases the risk for all personnel participating biological and physical hazards and in accordance in these training exercises. with the Defence Electronic Supply Chain Manual (ESCM).10 The existing cold chain storage methods Maintenance of the cold chain within the highlight the need for significant improvements, Australian Army required by the LEA and PHS&T, of the fundamental requirements for maintaining the cold chain within This study focused on the current methods the ADF. employed for cold chain management within the Australian Army, specifically within the 1st Close Logistics Officers within the Army Health Battalion (1 CHB). The research is being conducted as a result of a previous continuous Logistics Officers are forced to conduct detailed quality improvement project focused on the storage mission appreciation to ensure that the inflow of of all non-refrigerated Class 8 stores during domestic Combat Service Support (CSS) sustainment meets training exercises. planned and unplanned mission demands.11 This planning is within the Army doctrine and while The roles of 1st Close Health Battalion the General Service Officers serving in the Royal clinicians Australian Army Medical Corps (RAAMC) are classed as Logistics Officers, the limited training 1 CHB clinicians are responsible for initial and and exposure prior to commencing their roles at the advanced treatment, including collection from respective health units has not set the corps up for point of injury (POI), resuscitation, stabilisation, success in regard to the current logistics processes. and evacuation and emergency diagnostics to land 12 Furthermore, the lack of process and protocols forces as far forward as possible. As per Figure 2, regarding health logistics, specifically the cold chain this casualty evacuation (CASEVAC) process directs management for close health clinicians, do not meet casualties from POI to appropriate health facilities the ‘train the way we fight’ philosophy of the Army.6 based on required treatment, evacuation platform Rather, the existing cold chain processes are not availability and capacity of the destination medical enforced in regards to the requirement to replenish facility (DMF).

Figure 2. Overview of CASEVAC within the ADF Source: Department of Defence. Defence Health Manual. 2016.

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The 1 CHB assets on the ground range from an integral medic at the POI (Figure 3a), an evacuation medic to move the patient (Figure 3b) and a treatment team, comprising of a doctor, nurse and three medics (Figure 3c).13 At all stages of the CASEVAC, the use of thermolabile medications and temperature-sensitive diagnostics, dressings and fluids are required to ensure that health support is effective and adequate.

Figure 3c. A 1 CHB Treatment Team stabilises a patient prior to Rotary Wing Aero-Medical evacuation. Source: Department of Defence. 1st Close Health Battalion. 2018

CURRENT 1 CHB STORAGE METHODS FOR THERMOLABILE MEDICATIONS AND TEMPERATURE-SENSITIVE DIAGNOSTICS, DRESSINGS AND FLUIDS

Shipment to the 1 CHB Pharmacy Figure 3a. 1 CHB Integral Medic responds to a casualty at the POI. Source: Department of Defence. 1st Close Health All pharmaceutical products are shipped from either Battalion. 2018 the Joint Logistics Unit (JLU) in NSW or the prime vendor to the pharmacy in its respective location (Darwin, Townsville, Adelaide or Brisbane). The method of transportation for products requiring refrigeration is a ‘cool cube’; a small expanded polystyrene container designed to maintain interior temperatures of 2°C to 8°C in an ambient temperature range of 5°C to 25°C for up to five days (if the cube remains unopened). The date and time group of when the cool cube was packed is detailed on the exterior of the container with suitable packing material such as foam or cardboard separating the products from the ice packs. A data logger is packed with the pharmaceutical products to continuously monitor the temperature. During transit, the cool cube is only to be removed for aircraft or vehicle stopovers and loading/unloading. It is required to be secured in an air-conditioned building or vehicle if it may be Figure 3b. 1 CHB Evac Medic loads a casualty in to exposed to ambient temperatures outside the 5°C to the Protected Mobility Vehicle (Ambulance variant) for 25°C range for more than one hour. Once delivered, surface evacuation. Source: Department of Defence. 1st the pharmacist is responsible for uploading the Close Health Battalion. 2018 data logger to ensure that no cold-chain breaches occurred. If the delivery period is not met, or the consignment does not maintain the cold chain, pharmacists are to notify Health Systems Program

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Office (HLTHSPO) or Joint Logistics Command (JLC), as appropriate, within 24 hours of delivery.(14)

The reporting by the pharmacist includes:

• basic description of the problem including the type of refrigerator or storage method;

• recording the length of time and temperature the stores have been exposed to once internal temperature exceeds 25°C;

• product details and expiry date recorded on the packaging; and Figure 4. Pelican Case used for storage of Schedule 8 • approximate combined cost of affected stores. drugs by integral medics. Source: Pelican Products, Inc. USA, 2018 A civilian contractor transports the shipment of thermolabile medications and temperature- • Evacuation medic – In addition to the Pelican sensitive diagnostics, dressings and fluids not Case, evacuation medics carry a larger volume of requiring refrigeration with no temperature loggers medications stored in a standard issue, general- or protocols implemented to report any breaches of purpose polymer trunk measuring 620 mm x 550 storage temperature en route from the prime vendor mm x 550 mm. While durable in nature, they are to the respective 1 CHB pharmacist. The absence of not designed for thermoregulation and are stored quality control mechanisms is not conducive to the in the side of an evacuation vehicle with no air products maintaining their recommended storage conditioning. temperatures noting the travel times from some vendors to the 1 CHB Pharmacy in Darwin is in excess of 3 days. Furthermore, products requiring shipment from the 1 CHB Pharmacy in Darwin to the 1 CHB Pharmacy in Adelaide, are sent through the Q-Store, which requires an additional 3 days of travel in a storage container without climate control.

Field exercises

The clinicians from 1 CHB are required to carry an extensive amount of medical equipment in addition to the basic soldier load list including rifle and ammunition. Dependant on the nature of the training exercise and the unit they are supporting, clinicians will be required to either carry all their Figure 5. Issued trunk for storage of class 8 stores by the equipment on them, have it loaded in an ambulance Treatment Team. Source: Department of Defence. Land Engineering Agency. 2018. or be able to self-lift alongside the treatment team with all equipment packed into two vehicles. Specific • Treatment team – Treatment teams are to the storage of Class 8 supplies, the clinicians configured to stock 7 days’ worth of supplies store the medications in the following defence issued and are required to store these medications in equipment: a number of larger general-purpose polymer • Integral medic – Integral medics are dismounted trunks measuring 1200 mm x 550 mm x 400 and required to carry their Schedule 8 drugs mm (Figure 5). They are also equipped with an in a Pelican Case (Figure 4). This equipment, Engel fridge (Figure 6) in temporary replacement measuring 211 mm x 109 mm x 57 mm, is of the Haemacool fridges, which are currently designed for all weather protection and has foam non-serviceable due to ongoing battery issues cushioning to protect the medications. It is not (which requires action through Chemtronics to able to provide any cooling mechanisms for the JLU). The Engel fridges are not certified to store medications stored within. medicines and are graded for foodstuffs only as they fail to remain between 2ºC to 8ºC without active management, which is not feasible during the road moves from Army bases to training

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areas (some of which can take four days). Out Medications carried in the training areas, the access to power is also limited, which affects the ability to provide The medications and diagnostic tests carried by thermoregulation consistently. The treatment 1 CHB clinicians span a diverse range of required teams are set up in a non-thermoregulated canvas storage conditions and methods of administration. tent, which can experience ambient temperatures Table 2 provides a number of examples of commonly of greater than 50ºC when deployed in the hotter carried Class 8 stores, which are representative of months of the year. this diversity and provide the basis for determining conditions that would be considered a breach of recommended storage temperatures in the pilot study.

PRIMARY RESEARCH QUESTION What are the effects of current cold chain management equipment in controlling the temperature of thermolabile medications and temperature-sensitive diagnostics, dressings and fluids in a routine Australian Army operating/exercise environment?

MATERIALS AND METHODS

Overview

The methodology used in this pilot study was a quantitative statistical analysis through continuous monitoring of ambient temperatures utilising an Environmental Stress Index Monitor (ESIM) and the placement of Tinytags in key storage equipment (Pelican Case, evacuation trunk and treatment team Figure 6. Engel fridge carried by the Treatment Team. Source: Engel Australia Pty Ltd. 2016 trunk) over a period of nine days within an Australian Army training area. Quantitative research is the preferred approach for testing objective theories

Branded product name Drug product Dosage Form Recommended Schedule storage temperature

Bactroban ® 2% Ointment Mupirocin 2% Topical Ointment Below 25ºC 4

Morphine Sulphate Injection Morphine Sulfate Solution for Below 25ºC 8 BP 10 mg – 1 ml 10 mg / ml injection

Sudafed Pseudoephedrine HCL Tablet Below 30ºC 4

Panadol Paracetamol 500 mg Tablet Below 30ºC 2

Amoxicillin Penicillin 250 mg Capsule Below 25ºC 4

Adrenaline (Epinephrine) Epinephrine 1 mg / ml Solution for Below 25ºC 4 Injection BP injection

Pregnancy Test Urine HCG sensitivity of 25 Diagnostic test Below 30ºC Diagnostic MIU / mL test test

Table 2. Manufacturer recommended storage temperature for scheduled medications and a diagnostic test carried out during EX WARFIGHTER

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by examining the relationship among variables.16 was utilised due to the timing of a field exercise, EX The purpose of this methodology was to identify WARFIGHTER, whereby health support was required breaches in the cold chain management through for the 800 soldiers deployed to this location for the comparison of real-time data from a variety of training. different levels of health support and locations within the Townsville Field Training Area (TFTA). Continuous monitoring systems

The purpose of this continuous monitoring was to The ESIM is a portable heat stress monitoring device gather definitive data to: which calculates an environmental stress index as an equivalent to a wet bulb globe temperature (WBGT) • measure peak temperature; (Figure 7).19 The waterproof and small design makes • calculate the proportion of time medications it the choice for the Army during training exercises and equipment spent above the manufacturers to determine safe work rates. The internal data recommended storage temperature; and logging ensures that all data is automatically saved, reducing the requirement for manual recording of • record the number of times the temperature temperatures and reducing the risk of the incorrect exceeded 40°C within the storage containers. temperature being manually recorded, or failing to be recorded. Sample size

The health support provided during this research was 1 integral medic, 1 evacuation medic and 1 treatment team. This provided an opportunity to measure and compare the temperature of a Pelican Case carried by an integral medic, two smaller trunks carried by an integral medic and evacuation medic and a single large trunk carried by a treatment team. The ambient temperature monitoring by three different personnel (located in different locations within the training area) provided a mean temperature to compare the internal temperatures as well as a contingency if one of the members were to fail to record the temperatures correctly or at all.

Stakeholders

Each stakeholder involved in an analysis is commonly required to have a stake in the phenomenon under investigation.17 It is important to seek the engagement of multiple stakeholders during the planning process to identify and address changes required to improve system effectiveness and efficiency.18 The planning for this research was conducted through the involvement of Army pharmacists, the Battalion Figure 7. ESIM for recording of ambient temperature Source: Instrulabs Pty. Ltd. Operations Officers, the Senior Nursing Officers and the Senior Medical Officer to devise the terms Tinytag loggers are designed for measuring of reference, key outcomes to analyse and what the temperature and humidity in a variety of harsh, proposed end state would be for the pilot study. outdoor and industrial applications (Figure 8).20 Housed in robust, waterproof casings, they are Location and time deployed within the ADF for monitoring the storage The data was collected in February and March 2018, temperatures of pharmaceutical products, both in at the TFTA located 60km south-west of Townsville barracks and out in the field. The Army pharmacist and spread out over 200 000 hectares of land. The uploads the data, and graphs and tables portraying average temperature during this period is 22–31°C(15) temperature changes over a specific period are with limited natural cover or shade. This location generated.

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in which the products were stored, while informing on the actual conditions and quality of the current storage methods for the ADF medications. The recording of ambient temperature identified the impact of the training area climate on storage temperatures.

Method for data analysis

Creating ambient temperature profiles was an essential element for this research with the methodical study providing actual data on temperature hazards used to improve storage solutions and advice for the ADF to meet applicable regulatory requirements. The data collected (Appendices A–C) was used to identify the external temperatures experienced throughout the TFTA to provide analysis of the definitive data identified above. This was completed through daily profiling to identify the trends in the ambient temperature and impact on storage methods Figure 8. Tinytag logger for recording of storage temperatures. Source: Gemini Data Loggers, UK. 2018 Using Microsoft Excel, each method of temperature collection was given its own recording column. The Tinytag was activated and placed in a This was used to create the temperature profiles consignment of refrigerated and non-refrigerated targeting the frequency of occurrences of a particular pharmaceuticals for the duration of the field exercise. temperature breach (30°C) and allowed abnormally Ambient temperatures during daylight hours were distributed data to be analysed with a high degree measured using the ESIM and manually recorded in of confidence. a spreadsheet. It was also noted if the equipment was in transit and the method of transport. This data was While the data analysis included all hourly used to compare the internal storage temperatures temperatures, some temperatures in the observed for the pharmaceutical stores and the impact of dataset were deemed not significant in the overall the ambient temperature. On return from exercise, view of the profile and were not considered when the Tinytag data was downloaded and analysed by creating the climate profiles due to the limited the pharmacist to determine the continued use or contribution. For example, anything below 25°C and disposal of the refrigerated and non-refrigerated above 41°C was classed as non-significant as these pharmaceuticals. lows/highs contributed to less than 5% of the overall data collected with nil contribution to the profile in a Continuous monitoring meaningful and representative way. The confidence interval level for this pilot study was 95% as shown With these continuous temperature-monitoring in Table 3. results, 1 CHB were able to identify temperature trends through the recorded data of the environments

Pelican Case Evac trunk Treatment Team Ambient temperature (°C ) (°C ) trunk (°C ) (°C ) 24.97 21.70 21.34 22.94 SD 3.99 0.92 1.25 2.73 SE 0.4 0.1 0.1 0.3 σx̅ 0.2 0.0 0.1 0.1 α 25.2 21.7 21.4 23.1 β 24.8 21.7 21.3 22.8 CI 0.4 0.1 0.1 0.3 Table 3. Confidence interval levels

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With the confidence interval and subsets established, ambient temperatures within their containers. This the number of temperature occurrences for the data was utilised to identify the trend of temperature Pelican Case and trunks versus ambient were fluctuations based on the average temperature of the calculated and a formula of ratios applied. This training area in order to identify if the cold chain and formula combined the effects of the temperature in supply methods were breached during the training the storage containers versus ambient to provide exercise. a representative, but usable, set of temperatures. From this, an overall summary was derived and is Pelican Case discussed below. The Pelican Case had a median temperature of 32°C RESULTS ranging from 24.4°C to 41.8°C. The temperature within the Pelican Case exceeded 30°C on 90 The analysis was performed with initial profiling different occasions including exceeding 40°C twice. created for each day based on the storage method. The percentage of time that the medications were This was then consolidated to determine the median stored beyond the manufacturer’s recommended ambient and internal temperatures for each storage storage temperatures (25°C–30°C) was 33% for the method (Figure 9). The median ambient temperature task duration (Figure 10). for this research was 29.4°C with a low of 22°C and a high of 34.9°C. It is noted that at the time of Evacuation and Treatment Team trunks measurement, the region experienced the heaviest rainfall in 12 years,15 which resulted in lower ambient The data collected for the evacuation and treatment temperatures on some days and increased humidity team trunks were similar with a median temperature on others. Overall, the data analysis indicated a of 27.6°C (evacuation trunk) and 26.9°C (treatment correlation between the ambient temperature and team trunk). While the temperatures within these the method of storage. The Pelican Case, on average, trunks did not exceed 30°C, it was consistently over recorded 3.2°C higher than the ambient temperature 25°C, which is significant (Figures 11 and 12) given and the evacuation trunk and treatment team that many of the items stored in these trunks are not trunks measured 2.1°C and 1.5°C cooler than the recommended to exceed 25°C.

Figure 9. Median temperatures for ambient and storage methods during operation of EX WARFIGHTER

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DISCUSSION Temperature ranges - Pelican case Size and dimension implications

While the results showed a number of fluctuations of the ambient temperature, a few key insights and trends were derived from the results including the percentage of time each storage equipment spent within a temperature range and the median heating/ cooling rate of each piece of equipment in response to the ambient temperature.

The first major feature of Figure 9 was the difference between the temperature measured in the Pelican Case versus the evacuation trunk and treatment team trunk. This considerable difference between the three storage methods and recorded temperatures is likely attributed to the size of the container with Figure 10. Proportion of time the Pelican Case was the Pelican Case, a smaller sized storage method, measured in each temperature range during operation of recording a considerably higher rate of temperatures, EX WARFIGHTER consistently exceeding the recommended storage guidelines. This can be linked to a higher heating rate due to the significantly smaller physical dimensions. When considering size as a determinant Temperature ranges - Evacuation trunk factor, the evacuation and treatment team trunks recorded almost exactly the same in regards to the management of their internal temperatures and it is assessed that this is due to their similar physical dimensions.

The Pelican Case is also insulated with foam, which may help retain heat in the container. Alternatively, it could be related to where an integral medic stores their Pelican Case versus where the treatment team and evacuation trunks are stored.

Recommendation

Figure 11. Proportion of time the evacuation trunk was For robust statistical analysis to occur, much larger measured in each temperature range during operation of sample sizes deployed in the same training area EX WARFIGHTER are required. It is also necessary to assess how each storage method responds when subjected to Temperature ranges - Treatment Team trunk exactly the same conditions to determine if it is the containers causing the difference or the individual storage conditions.

It is recommended that in future studies a larger number of storage containers are deployed and tracked in the one training area to provide a greater sample size for analysis based on the proportionate time to heat or cool (relative to their size).

Correlation of ambient temperatures

Within the sets of these different geometrics, the derived heating range was used to provide a basic guideline for the impact that the ambient temperature Figure 12. Proportion of time the treatment team trunk was measured in each temperature range during had on the current storage methods. Using Table 4 operation of EX WARFIGHTER

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as a guide, it is hypothesised that current storage products to expire in a shorter period of time.(21) The methods require review and potential replacement inability for the current cold chain storage methods if operating in any environment over 26°C (Pelican to maintain this recommended temperature can Case) or 28°C (evacuation and treatment team result in adverse effects when administering health trunks) as these temperatures have an impact on support in remote training areas. Not only can the the effectiveness of the Class 8 supplies by breaching medications become inactive, but adverse reactions the recommended storage range (25°C) of most may occur.4 thermolabile medications and temperature-sensitive diagnostics, dressings and fluids carried. Risk to drug administration While it is likely that the exposed medications have been compromised in shelf life and efficacy, the true Ambient Pelican Evac trunk Treatment risk of medication degradation and patient safety temperature Case (°C ) Team associated with temperature fluctuations can only (°C ) (°C ) trunk (°C ) be identified and realised with further technical 26 29.2 23.9 24.5 evaluation of these substances and products. The impacts on the medications vary by type, with a 28 31.2 25.9 26.5 number of changes to the potency and effectiveness 30 33.2 27.9 28.5 of administration. Semisolids, including creams like Bactroban, have been shown to exhibit changes in 32 35.2 29.9 30.5 consistency and, as noted by Atia, this can result in 34 37.2 31.9 32.5 a change to how the drug is released.22 Tablets, when 36 39.2 33.9 34.5 exposed to temperatures higher than recommended, can have changes in their appearance due to the 38 41.2 35.9 36.5 disintegration and an increase in density. At low 40 43.2 37.9 38.5 relative humidity, disintegration time is increased, while at high relative humidity disintegration time Table 4. Hypothesised correlation of heating / cooling decreases.23 range and ambient temperature

Recommendation Recommendation It is recommended that a separate study be conducted Further studies are required in other ADF domestic to analyse any changes to the efficacy and potency training areas including the Northern Territory, NSW of the medications that exceed the recommended and southern Queensland in order to provide a larger storage temperature using medications issued to sample size for analysis. This data will be imperative 1 CHB clinicians for the purpose of a task. It is to provide a robust discussion on the impact of the noted that the degradation of biological medicines provision of health support if this health support is is not usually amenable to kinetic analysis and to be deployed to the Middle East Region, which has extrapolation from accelerated testing(1) which may considerably higher ambient temperatures during affect the ability to test certain medications. summer than Australia, and what the ramifications are if no changes are made to the current storage Risk to provision of health support methods Despite the true risk remaining unidentifiable until IMPACT ON THERMOLABILE MEDICATIONS further analysis takes place, what is known is that AND TEMPERATURE-SENSITIVE the deployed clinical environment already exposes DIAGNOSTICS, DRESSINGS AND FLUIDS patients to a higher degree of risk than that within a tertiary health facility. Defence members are already Effect of high-temperature exposure on being treated and managed in austere environments administration methods with no temperature control and often with junior clinicians who generally have poor access to reliable As noted in the results, all thermolabile medications communications for diagnostic support. These and temperature-sensitive diagnostics, dressings and factors, coupled with medications, diagnostic tests fluids were exposed to storage temperatures beyond and fluids that have potentially degraded due to heat their recognised manufacturer guidelines, which exposure, have the potential to create significant can have adverse impacts on the effectiveness of the diagnostic confusion and may subsequently result medication when administered in a clinical setting. in suboptimal medical management of patients. The absence of temperature control can expedite the

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As per the Defence Health Manual, any clinical incidents involving ADF members can be reported through a suite of systems to identify the issues with the health care being provided. This includes defined Severity Assessment Codes (SAC) (Table 5) and reporting on clinical incidents and near misses through submissions of an AD441 – Health Incident Report. At all times, clinical incidents that have a work health and safety component which potentially or actually injures a worker or visitor must be reported via Sentinel.12

The regular breach of recommended storage temperatures of thermolabile medications and temperature-sensitive diagnostics, dressings and fluids, and the subsequent impact on the ability to provide effective health care is considered a clinical incident and should therefore, be included as a near miss. When utilising the SAC, the risk to the individual is moderate. However, the likelihood is certain, which demonstrates the requirement for an action plan to be enforced for this issue and tracked by Joint Health Command (JHC) and the ADF Pharmacy and Therapeutics Committee every time a breach of the cold chain occurs.

Recommendation

That an interim solution of cold chain storage methods is employed to assist in the prevention of any future breaches and clinical incidents. Furthermore, it is recommended a review of the JHC SAC is conducted to include cold- chain breaches as a reportable incident and all incidents included for reporting review in all ADF Pharmacy and Therapeutics Committee meetings.

Drug waste costs

In accordance with the TGA (Sect 8.9), if a storage temperature is found to deviate from the 5. Defence Healthcare Severity Assessment Code (SAC). Retrieved from Defence Health Manual Table

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manufacturer’s recommended temperature the OVERALL RECOMMENDATIONS manufacturer is to be contacted and the suitability of the medicine for use should be determined and the While cold chain management can vary greatly in the outcome recorded. Furthermore, as per the Defence levels of complexity, there are three principal tenants Health Materiel Manual14 pharmaceuticals must be taken from this pilot study that are simple in nature. destroyed and disposed of when storage has affected 1. The current storage methods for thermolabile the integrity of the item. The stock controlling medications and temperature-sensitive pharmacist is also required to record the destruction diagnostics, dressings and fluids are not in of medicines in the pharmacy information system. accordance with the TGA.

If an extreme breach is recorded, the recommended 2. There is a lack of communication, coordination outcome is the destruction of the drug, which will and policy across the ADF Health Logistics space have a financial impact for the ADF. It has been in regards to providing a viable cold chain system previously demonstrated that inefficiency of drug use that meets national standards. and waste production may lead to a distinct economic loss.24 Using the 1 CHB Integral Medic Load List with 3. There is a lack of monitoring to inform decisions the HLTHSPO Catalogue, the total cost of replacing adequately regarding medication disposals. all Class 8 stores (excluding consumables such as 4. Further studies are required in the various plasters, bandages and cups) would be $1772.37. training areas to increase data and to provide These costs include the Pelican Case and the Integral a more thorough analysis. It is recommended Trunk with the contents of the Pelican Case equalling that from these studies, the following objectives $280. Noting that the temperature within the Pelican be met in conjunction with the Strategic Reform Case exceeded 30°C 44 times over the period of this Program and the TGA requirements. pilot study, the cost of replacing the contents within the Pelican Case for the duration of the exercise OBJECTIVE 1 – COMMENCE TRIALS OF would be $12320 (excluding additional costs of COLD CHAIN SPECIFIC TECHNOLOGIES OR transport and labour to enact these replacements) EQUIPMENT if the TGA requirements were to be enforced and all medications were deemed unsuitable for use. There are a number of existing specific cold chain technologies and equipment currently employed As per Item 4 of the ADF Pharmacy and Therapeutics by coalition military forces and national health Committee meeting held 13 March 2018, the FY 17/18 organisations that could be trialled to identify a Budget Achievement indicates a slight increase over suitable in-service solution; beyond the existing the previous three years of the actual budget and general polymer trunk, for the maintenance of beginning to exceed the forecast budget. Noting that temperature ranges over a prolonged period. This cost analysis above, the budget would continue to be includes both continuous monitoring systems and exceeded if the ADF is held accountable by the TGA storage solutions. This trial will require collaboration and these destructions were to occur on a regular with the LEA to ensure that the capability is basis throughout all ADF training areas. serviceable as per the standards within the Defence 10 The SAC includes financial loss as a consideration ESCM. for assessing the consequences of clinical incidents. The financial loss of less than $100K is considered Continuous monitoring – FreshLoc minor; however, given the frequency of breaches the Temperature Monitoring System likelihood is certain. Health information systems can significantly bolster cold chain management.25 The FreshLoc Recommendation Temperature Monitoring System (TMP), used by the JHC and the ADF Pharmacy and Therapeutics US Army, functions by continuously monitoring and Committee conduct an analysis into current wastage recording temperatures of medication storage spaces versus forecasted IAW TGA guidelines of disposal with the ability to relay the readings wirelessly to the and compare to the costs of purchasing cold chain healthcare personnel via text, email or a phone call. specific equipment. It is also recommended that the This enables temperatures to be tracked continuously destruction of any medical kits due to a breach of the and allows healthcare personnel to intervene rapidly cold chain be classified as a reportable incident and to maintain the correct temperature within the included for reporting review in all ADF Pharmacy storage space. The flexibility and scalability of the and Therapeutics Committee meetings. system mean that it can monitor any location, from

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cold storage to incubators, in any size facility26 and cold chain directive for all ADF health personnel could be utilised as a health information system for that will ensure the responsibilities in managing the the ADF and their management of cold chain. various complexities of the cold chain are delegated appropriately. Storage solution – the Cryopak CryoCube Poor compliance with cold chain assurance is both The Cryopak CryoCube, a robust and reusable the responsibility of the individual health care temperature-controlled product, can sustain a cold professional and their supporting formation. The chain for prolonged durations ranging from 36 hours creation of a targeted education program for Health to 120 hours (Figure 13). The reusable insulated Logistic Officers, with a measurable competency cube maintains a 2°C–8°C range for 120+ hours. The for the management of the cold chain, will address trunks require insulation panels to be frozen for a the identified issues of health planning, prevention minimum 48 hours prior to a task commencing with a measures for cold-chain breaches, limited variety of sizes available and adequate for the current understanding of medication management and the load configurations of treatment and evacuation processes that must be followed if a cold-chain teams. The use of this product would reduce the breach occurs. This will significantly improve the number of cold-chain breaches, specifically during accountability of the Health Logistic Officers in not the travel time, and would ensure that the provision only maintaining a cold chain in accordance with of health support is IAW the TGA. national guidelines, but through the reduction of risk to the delivery of health care in remote training OBJECTIVE 2 – DEVELOP A CLEAR AND locations and reducing the cost of waste from CONCISE SET OF SOPS, ENDORSED BY the destruction of medications which exceed the JOINT HEALTH COMMAND AND IN LINE manufacturers recommended storage temperatures. WITH THE TGA, AND IMPLEMENT COLD CHAIN SPECIFIC TRAINING FOR HEALTH Summary LOGISTIC OFFICERS Meeting these objectives will enable the ADF to Delegating responsibility is critical to managinnng qualify and quantify the temperature exposure of the many moving parts of the cold chain. Army the medications and stores and engage with key demands from its people, a range of knowledge, a stakeholders to trial and apply new technologies level of competence, and a degree of accountability and processes for the management of the cold for actions in the performance of duties, and the chain. This will include working with the TGA to involvement of JHC in compiling and endorsing a meet the guidelines regarding commissioning of new

Figure 13. CryoCube Source: Cryopak A TCP Company, 2016

Volume 27 Number 1; January 2019 Page 37 Original Article

equipment for the storage of cold chain medicines training area analysed and the proximity of a civilian (Sect 8.2), utilisation of temperature-monitoring health care facility being over 45-minute drive away, equipment that is capable of alerting staff before there is potential for these compromised medications a temperature range has been compromised (Sect to affect the patient through significant diagnostic 8.4), and establishment of procedures detailing confusion. This creates an unacceptable level of risk the actions to be taken in the event of an deviation to patients and commanders and is not in line with outside the defined temperature range (Sect 8.9).1 the ‘train the way we fight’ theory.

CONCLUSION The inability of the Army to meet cold chain requirements for medications relates mainly to a lack The role of the RAAMC is to contribute to the ADF’s of suitable storage equipment. However, poor health operational capability through the conservation planning, complacency and poor understanding of manpower by promoting health and wellbeing, of medication management also contribute to the through the prevention of disease and injury, and problem. From a risk management perspective, through the care, treatment and evacuation of sick steps need to be taken to address each of these and wounded.(14) The inability for the current factors. Further research is required in this area to storage methods of thermolabile medications and ensure that cold chain management is in line with temperature-sensitive diagnostics, dressings and TGA requirements while meeting the conditions of fluids to maintain the recommended temperature, the Strategic Reform Project. fails to ensure that the care, treatment and evacuation of ADF personnel in training areas are Corresponding author: Elizabeth Daly, being achieved. Rather, this initial pilot study has [email protected] provided evidence that patients are being exposed Authors: E Daly1, N Evans, S Holmes-Brown to higher treatment risks in the field than a civilian Author Affiliations: health facility. When considering the physical 1 1st Close Health Battalion dispersion of Australian Army members within the

References 1. Department of Health; Therapeutic Goods Administration. Australian code of good wholesaling practice for medicines in schedules 2, 3, 4 & 8. Commonwealth of Australia. 2010. Available from: https://www. tga.gov.au/publication/australian-code-good-wholesaling-practice-medicines-schedules-2-3-4-8#cold 2. Reed C. COLD CHAINS ARE HOT! Mastering the Challenges of Temperature-Sensitive Distribution in the Supply Chain. Chain Link Research. 2005. 3. Department of Health. National vaccine storage guidelines: strive for 5. Commonwealth of Australia. 2013. 4. Arshad A, Riasat , Mahmood K. Drug Storage Conditions in Different Hospitals in Lahore. J Pharm Sci Technol. 2011;3:543–7. 5. Department of Defence. Capability Overview. 2018. Available from: http://www.defence.gov.au/ Whitepaper/AtAGlance/Capability-Overview.asp 6. Department of Defence. The Strategic Reform Program. 2009. Available from: http://www.defence.gov. au/publications/reformBooklet.pdf. 7. Kelly B. Military Pharmacy Today. The Newsletter of the Australian Academy of the History of Pharmacy. 2008;4(34):10–11. 8. Beaumont D. The case for an Army logistic narrative. Australian Army Research Centre. 2018. Available from: https://www.army.gov.au/our-future/blog/logistics/the-case-for-an-army-logistic-narrative 9. Department of Defence. Land Engineering Agency. 2018. Available from: http://drnet/DMO/LEA/ Functions/pages/Functions.aspx 10. Department of Defence. Electronic Supply Chain Manual. 2018. Available from: http://escmweb/ index-welcome.htm 11. Chen C. Combat Service Support on Exercise: The case for making them vulnerable again. Australian Army Research Centre. 2018. Available from: https://www.army.gov.au/our-future/blog/logistics/ combat-service-support-on-exercise-the-case-for-making-them-vulnerable-0

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12. Department of Defence. Defence Health Manual. 2016. Available from: http://intranet.defence.gov.au/ home/documents/data/ADFPUBS/DHM/Complete.pdf 13. Department of Defence. 1st Close Health Battalion. 2018. Available from: https://www.army.gov.au/ our-people/units/forces-command/17th-combat-service-support-brigade/1st-close-health-battalion 14. Department of Defence. Defence Health Materiel Manual. 2017. 15. Australian Government Bureau of Meteorology (BOM). Monthly climate statistics. 2018. Available from: http://www.bom.gov.au/climate/averages/tables/cw_032040.shtml 16. Cresswell J. Research Design Qualitative, Quantitative, and Mixed Methods Approaches. 4th Ed. Sage Publications. 2014. 17. Reed M, Graves AR, Dandy N, Posthumus H, Klaus H, Morris J, Prell C, Quinn C, Stringer L. Who’s In and Why? A typology of stakeholder analysis methods for natural resource management. J Environ Manage. 2009;90:1933–49. 18. Goodman MS, Sanders Thompson VL. The science of stakeholder engagement in research: classification, implementation, and evaluation. Transl Behav Med. 2017:7(3): 486–91. 19. InstruLabs. Environmental Stress Index Monitor. 2017. Available from: http://www.instrulabs.com.au/ index.php/products/heat-stress-monitors/environmental-stress-index-monitor-detail 20. Tinytag. Data Loggers. 2018. Available from: https://www.geminidataloggers.com/data-loggers/ tinytag-ultra-2 21. Lewis B. Update for Nurse Anaesthetists—Refrigerated Anaesthesia related Medications. AANA Journal Course. 2000;68:265–8. 22. Atia GF. Stability of Drugs in Coleiro, D. Storage of Medicines & Medical Device. The University of Malta, 2009. Available from: https://www.um.edu.mt/__data/assets/pdf_file/0016/153160/Storage_ of_Medicines_and_Medical_devices.pdf 23. Nokhodchi A, Javadzadeh Y. The effect of Storage Conditions on the Physical Stability of Tablets. Pharmaceutical Technology Europe. 2007;19:20–26. 24. Fasola G, Aita M, Marini L, Follador A, Tosolini M, Mattioni L, Aprile G. Drug waste minimisation and cost-containment in Medical Oncology: Two-year results of a feasibility study. BMC Health Services Research. 2008;8:70. 25. Conway M, Daniluk K, Felder J, Foo A, Goheer A, Katikineni V. Improving cold chain technologies through the use of phase change material. University of Maryland. 2012. 26. MesaLabs. Monitoring systems. 2018. Available from: https://monitoring.mesalabs.com/

Volume 27 Number 1; January 2019 Page 39 Original Article

Appendix A – Pelican Case Tiny Tag Results

Appendix B – Evac Trunk Tiny Tag Results

Page 40 Journal of Military and Veterans’ Health Original Article

Appendix C – Resupply Trunk Tiny Tag Results

Volume 27 Number 1; January 2019 Page 41 Original Article

Combat, Posttraumatic Stress Disorder and Health of Australian Vietnam Veteran Conscripts and Volunteers in the Three Decades After Return

B O'Toole, K Pierse, B Friedrich, S Outram, M Dadds, S Catts

Introduction the duration of their service than NSM of the same age who are not in service. Alternatively, military Australia’s involvement in the Vietnam conflict life places physical burdens on soldiers that would from 1962 until troop withdrawal in 1972,1 placed be more wearing the longer the exposure, although Australians into longer periods of risk of contact they may have greater access to medical and with an enemy than at any time in Australia’s health services than their non-military peers. The history since Gallipoli.2 The Australian Force implications of these competing hypotheses are yet Vietnam increased in size in 1965 and 1966 and, in to be tested. conjunction with the troop build-up, the Australian Government introduced conscription for overseas Earlier Australian research into the potential service1 to enhance the previous all-volunteer Army health effects of Vietnam Service focused on NSM3-7 to levels that would sustain the campaign. In the recruited solely to the Army. More recently, cancer early years of the conflict, National Servicemen incidence8 and mortality9 have been examined in (NSM) were used sparingly in Vietnam; however, as the whole Vietnam Veteran population, including the conflict continued, they became indispensable the Navy and Air Force, specifically in NSM;10 to the Australian effort and eventually constituted however, NSM were not compared with Regulars approximately 48% of the Australian Force Vietnam. in any of those studies. Therefore, there are gaps Registering at age 18, being balloted at 20, enlisting in knowledge due to the lack of previous research in the Army and serving until 22 became the destiny in Australia, or militaries elsewhere in the world, of nearly 64 000 young men of whom more than that has directly examined whether volunteers or 19 000 served in Vietnam.3 conscripts are at a differential risk of ill health in later life and, in particular, whether they differed in In Australia, the chances of entering the Army after combat experiences. Generalising from research on being called up, and medically and psychologically NSM to regular enlistees, or vice versa, is difficult in examined, was only of the order of 1 in 16.3; Appendix IX, the absence of comparative empirical data. p 193 Compared with Regular enlistment, conscription inevitably produced a different makeup of the force, Research into the health of Veterans has shown that often more educated, with higher socioeconomic exposure to combat increases the risk of physical standing and more stable pre-enlistment and psychological injury, particularly post-traumatic occupations.4 Both groups were arguably physically stress disorder (PTSD).11-15 This disorder was first fitter than their non-military peers and presumably codified in the American Psychiatric Association with less emotional instability. Diagnostic and Statistical Manual (DSM) in 1980;16 its prime progenitor in Veterans is combat. The Continued enlistment in the military is contingent prevalence of PTSD in Australian Vietnam Veterans upon maintenance of physical fitness. Thus, soldiers has been reported as 20-30%.14,15,17 Combat exposure with longer military careers may be expected to be also increases the risk of a number of other physical healthier than others suggesting that, compared and psychological conditions in Vietnam Veterans,13-15 with NSM, Regular soldiers might be healthier for in particular heart disease and circulatory disease

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and arthritis,15 alcohol use disorder, dysthymia and Interview assessments comprised standardised other disorders.14 PTSD itself is associated with a questionnaire instruments selected to permit direct range of physical health conditions.18 Given the comparison with national population statistics varying conditions in Vietnam over the course of and administered by trained clinical and research the conflict and the increased deployment of NSM, interviewers. In both waves, the study relied on the degree of combat may have been different for the Australian Bureau of Statistics (ABS) methods Regulars and NSM. If so, this might suggest that used to gather national statistics on the health NSM would have different risks for PTSD and other of the Australian population at approximate physical and psychological disorders known to be corresponding times, which enabled computation of associated with combat. Apart from combat, other relative prevalences compared with the Australian aspects of service known to increase risk for PTSD population.13, 15, 21 include age at first deployment, rank and duration of exposure to the conflict zone.12,16 Differences between The content of the interviews in both waves comprised NSM and Regulars in these factors may suggest a a physical health interview, a clinical assessment differential risk of PTSD. However, the competing of PTSD and standardised diagnostic assessment expectations arising from these considerations are of general psychiatric status. Physical health was yet to be tested empirically. assessed using the ABS National Health Survey (NHS) for physical health and associated risk factors that This paper reports analysis of data from a cohort were current at the time (the 1989/90 NHS22 in Wave study of a random sample of Australian Vietnam 1 and the 2004/05 NHS23 in Wave 2). Conditions Veterans who were assessed 20 and 35 years after were coded to prevailing ICD-9/10 rubrics. Combat- homecoming. The physical and mental health status related PTSD was assessed using the Structured of the whole cohort has been published previously13-15 Clinical Interview for DSM-III (SCID)24 in Wave 1 and and compared with national norms.13, 15 This paper the Clinician-Administered PTSD Scale for DSM-IV now describes the experiences of Australian NSM (CAPS)25 in Wave 2. General psychiatric status was and Regular enlistees during and after the Vietnam assessed using the Diagnostic Interview Schedule conflict and their socioeconomic, physical health and (DIS)26 in Wave 1 and the Composite International psychiatric status at two periods up to three decades Diagnostic Interview (CIDI)27 in Wave 2. The version following the war. We hypothesise that NSM and of the CIDI (V2.1) was that used by the ABS in the Regulars have had differential education, military Australian National Survey of Mental Health and training, service histories, and combat and combat Wellbeing, 1997.28 zone exposure and expect that these may be followed by differential health status, including PTSD and Prior to Wave 1, fieldwork data were extracted from other physical and psychological disorders. the Central Army Records and Psychology Corps Records Offices on the cohort. Data included service Materials and Methods details (postings, dates, service milestones), conduct and casualty information, pre-enlistment education Veterans were identified from a computer file and employment and the results of Army psychology developed during the Australian ‘Agent Orange’ classification tests. studies3-5 holding the Army Service numbers of all men who were posted to Vietnam.19 From the total Combat was assessed from Army records based on of 57 643 postings, after removing duplicates, a the roles that individual units played, as advised by random sample of 1 000 numbers was selected. The military advisers to previous Australian studies3 of Army supplied the name and date of birth of each Vietnam Veterans. The Army Combat Index grouped man for tracing, contact and in-person interview. the units that had been present in Vietnam into six, All Veterans signed formal consent before interview. depending on their role, presence on the field and Interviews occurred across Australia in Wave 1 their experience of combat and casualty risk. These between July 1990 and February 1993, and in Wave were then weighted by the length of time each soldier 2 between April 2005 and November 2006. Wave 1 was posted to each unit, aggregated over all tours, to was conducted an average of 21.96 years (SD = 1.91) produce a continuous scaled measure of exposure after first return to Australia; Wave 2 an average of to combat that was independent of Veterans’ self- 36.10 years (SD = 1.92) after, with an inter-interview report.19 interval average of 14.18 years (SD = 1.92). Deaths Members of the research team, volunteer counsellors were identified from electronic searches of the from the Vietnam Veterans Counselling Service National Death Index of the Australian Institute of (VVCS) or volunteer officers of the Australian Army Health and Welfare.20 Psychology Corps conducted interviews with Veterans

Volume 27 Number 1; January 2019 Page 43 Original Article

in Wave 1. In Wave 2, interviews were conducted five years before NSM and enlisted five years earlier by author A and independent clinician-counsellors at younger ages. Regulars had fewer years of school recruited via their then affiliation with the VVCS before enlistment, were older at first deployment or the Australian Centre for Military and Veteran to Vietnam and had longer pre-deployment Army Health. Ethics approvals for Wave 1 were obtained Service. Their first tour was longer, their total from the Human Research Ethics Committees duration in Vietnam was longer, and their durations (HRECs) of Sydney and Queensland Universities; of Army Service after Vietnam and overall were longer for Wave 2 from the HRECs of the Repatriation than the NSM. There was no difference in their General Hospital Concord in Sydney, The University AGC (intelligence test) scores but Regulars scored of Sydney, The Australian Government Department significantly higher on the Army Combat Index. of Veterans Affairs, and the Australian Institute of Health and Welfare. There were more Regulars (18.3%) than NSM (8.6%) who had a pre-enlistment ‘criminal record’ (mainly Data Analysis petty crimes; a serious record would preclude enlistment) (OR = 2.37, 95%CI: 1.61,3.50; χ2 = Bivariate statistical tests compared regular soldiers 19.658 (df = 1), P <0.0005) and more NSM (19.6%) with NSM using χ2 tests for categorical data and than Regulars (8.6%) who had trade training before t-tests for continuous data. Multivariate logistic enlistment (OR = 2.60, 95%CI: 1.75, 3.87; χ2 = 23.432 regression was used to compute Regular-NSM odds (df = 2), P < 0.0005). Corps allocation was dissimilar ratios (ORs) in three hierarchical models: Model 1 for NSM and Regulars (χ2 = 12.819, df = 4, P = adjusted for age at interview; Model 2 adjusted for 0.012); NSM were more likely to be in Infantry than age at interview and Army Combat Index; Model Regulars were (OR = 1.40, 95%CI: 1.08, 1.80). Rank 3 added other potentially important confounding in Vietnam also discriminated NSM from Regulars (χ2 variables that were identified from bivariate analysis = 231.246, df = 4, P <0.0005): only 1.7% of NS were of Army data. Statistical analysis used SPSS V14.0;29 officers, compared with 12.2% of Regulars; no NSM two-sided statistical significance was set atα = 0.05. were NCOs compared with 5.3% of Regulars; only 0.2% of NS were Sergeants compared with 15.1% of RESULTS Regulars; 12.6% of NSM were Corporals compared with 25.8% of Regulars, but 85.5% of NSM were In Wave 1, 641 Veterans participated, which was Privates compared with 41.6% of Regulars. 87% of locatable Veterans and 67.5% of those not known to have died (n = 50). In Wave 2, 450 Veterans Table 2 shows the proportion deceased, the age at participated, which was 51.4% of those not known interview, the marital and employment status and to have died (n = 125) and 79.4% of those who incomes of NSM and Regulars. More Regulars were could be located; 391 Veterans participated in both deceased by Wave 2, consistent with their birth waves. In Wave 1, 309 NSM and 332 Regulars were cohort. Marital status was not different at either interviewed (67.6% and 67.5% of surviving NSM and wave. More NSM were employed full-time and Regulars respectively) and in Wave 2, 209 NSM and fewer were retired at both waves, but their income 241 Regulars were interviewed (48.6% and 54.2% distributions were similar. of surviving NSM and Regulars respectively). There were no differences in response rates between NSM Tables 3-6 show prevalences of health conditions and and Regulars at either wave. ORs and 95% confidence intervals from hierarchical logistic regression models adjusted firstly for age, Comparing respondents with alive non-respondents (Model 1), then age and Army Combat Index (Model using the Army data revealed only two significant 2), then age, Army Combat Index, plus an additional items: the (intelligence) test AGC (OR = 1.12, 95%CI: set of potential confounders. This strategy was 1.06, 1.18) and having a charge of Absent Without chosen because age is an obvious confounder for Leave (AWOL) after return to Australia (OR = 1.52, health conditions and adding combat allows the 95%CI: 1.11, 2.09). A similar result was found for comparison between NSM and Regulars to take into Veterans who responded in both waves (AGC: OR = account different combat exposures and tests the 1.15, 95%CI: 1.09, 1.21; AWOL: OR = 1.93, 95%CI: effect of combat on each endpoint adjusted for age. 1.27, 2.93), indicating that respondents overall were The potential confounding variables comprised birth generally more intelligent and more affiliative toward cohort (year of birth), age at deployment, durations the armed services. of Army Service before, during, post-Vietnam and total, and rank in Vietnam. Table 1 shows temporal information on the Veterans: Regulars were born on average during World War II,

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Table 1. Means and Standard Deviations (in Parentheses) for Continuous Data From Army Records for Australian National Servicemen (NSM) (n = 309) and Regular Enlisted (n = 332) Vietnam Veterans, and t-statistics, degrees of freedom (in Parentheses) and statistical significance for t-tests comparing the two groups.

NSM Regular t (df) P Date of birth 1947.25 (1.81) 1942.46 (7.18) 14.761 (595.971) <0.0005 Enlistment date 1968.03 (1.70) 1962.57 (6.01) 19.921 (613.980) <0.0005 Age at enlistment 20.78 (0.70) 20.11 (3.39) 4.411 (572.003) <0.0005 Age at 1st deployment 21.81 (1.29) 25.81 (6.84) 13.132 (564.187) <0.0005 Years of schooling 9.96 (1.30) 9.38 (1.43) t = 6.079 (783.507) <0.0005 AGC Score 13.33 (3.63) 13.16 (3.44) 0.733 (856) 0.464 Years of service pre-Vietnam 1.04 (0.95) 5.70 (5.60) 18.791 (556.235) <0.0005 Duration of first tour (yrs) 0.77 (0.25) 0.83 (0.31) 3.434 (983.672) 0.001 Total duration of Vietnam Service (yrs) 0.77 (0.25) 0.94 (0.43) 7.581 (562.6524) <0.0005 Duration of post-Vietnam Service (yrs) 0.62 (2.28) 7.64 (6.64) 22.799 (655.423) <.0005 Duration of Army Service (yrs) 2.43 (2.76) 14.60 (9.02) 29.418 (629.135) <.0005 Army combat index 2.88 (1.48) 3.47 (2.42) 3.126 (403.459) .002

AGC Army General Classification Test

Volume 27 Number 1; January 2019 Page 45 Original Article

Table 2. Demographic Characteristics of Australian NSM and Regular Enlisted Vietnam Veterans at Wave 1 (July 1990 - February 1993; n = 309 and 332 respectively) and Wave 2 (April 2005 – November 2006; n = 209 and 241 respectively) and Statistical Tests (t-statistics or Chi Square) and P-values for tests comparing the two groups.

NSM Regular t or χ2 (df) P

Deceased Wave 1 3.6% 6.3% χ2 = 3.846 (1) .050 Deceased Wave 2 9.5% 15.2% χ2 = 7.756 (1) .006

Mean (SD) age at Wave 1 (yrs) 44.11 (1.63) 48.85 (7.07) t = 11.883 (368.461) <.0005 Mean (SD) age at Wave 2 (yrs) 58.25 (1.75) 62.35 (6.39) 9.556 (281.326) <.0005

Marital Status Wave 1: Married 86.3% 86.6% χ2 = 7.883 (4) .096 Widower 0.0% 1.2% Separated 3.4% 3.4% Divorced 5.1% 6.5% Never Married 5.1% 2.2%

Marital Status Wave 2: Married 78.8% 77.5% χ2 = 3.016 (4) .555 Widower 2.4% 2.9% Separated 2.9% 5.4% Divorced 12.0% 9.2% Never Married 3.8% 5.0%

Mean (SD) annual income Wave 1 $38 064 (17 343) $38 289 (23 751) t = 0.134 (577.928) .893 Mean (SD) annual income Wave 2 $52 596 (111 598) $40 539 (38 831) t = 1.560 (440) .119

Employment Wave 1: Employed full-time 27.1% 17.5% χ2 = 29.831 (4) <.0005 Employed part-time 10.6% 6.3% Not employed 21.7% 22.1% Permanently unable 40.6% 43.3% Retired 0.0% 10.8%

Employment Wave 2: Employed full-time 27.2% 17.6% χ2 = 29.905 (4) <.0005 Employed part-time 10.7% 6.3% Not employed 21.8% 21.8% Permanently unable 40.3% 43.5% Retired 0.0% 10.9%

Smoking status Wave 1: Current smoker 32.0% 37.7% χ2 = 22.379 (2) <.0005 Former smoker 35.6% 45.9% Never smoked 32.4% 16.4%

Smoking status wave 2: Current smoker 18.3% 20.7% χ2 = 2.191 (2) .334 Former smoker 54.3% 57.9% Never smoked 27.4% 21.5%

Page 46 Journal of Military and Veterans’ Health Original Article

Table 3. Prevalence of ICD-9 Chronic Physical Health Conditions in Wave 1 and Logistic Regression-Modelled Odds Ratios (ORs) and 95% Confidence Intervals (CIs) Comparing Australian Vietnam Veteran Regular Enlistees with NSM; Model 1 adjusted for age, Model 2 adjusted for age and combat, Model 3 adjusted for age, combat, date of birth, age at deployment, durations of Army Service before, during, and post-Vietnam, and rank in Vietnam.

Diagnosis NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

Infectious & parasitic 3.6 4.8 1.92 0.86, 1.87 0.83, 1.97 0.64, disease 4.28 4.24 6.06

Cancer 7.4 8.1 0.95 0.49, 1.02 0.53, 1.11 0.49, 1.82 1.97 2.54

Hypercholesterolaemia 11.3 10.8 0.91 0.53, 0.95 0.55, 0.76 0.37, 1.58 1.66 1.57

Diabetes 3.2 4.5 0.90 0.35, 0.81 0.30, 0.54 0.15, 2.36 2.19 1.98

Gout 10.7 8.1 0.47* 0.24, 0.49* 0.25, 0.48 0.21, 0.91 0.95 1.14

Other endocrine 5.8 6.3 1.27 0.64, 1.31 0.65, 2.37* 1.02, conditions 2.54 2.65 5.48

Nerves 11.0 10.8 1.13 0.67, 1.21 0.65, 0.96 0.47, 1.93 1.94 1.98

Depression 2.9 1.5 0.58 0.18, 0.59 0.17, 0.83 0.17, 1.92 2.00 3.99

Other mental disorders 6.1 4.5 0.79 0.37, 0.71 0.32, 1.79 0.73, 1.69 1.55 4.42

Disorders of refraction 44.0 53.3 1.06 0.75, 1.07 0.75, 0.97 0.61, 1.50 1.52 1.52

Deafness 28.5 31.9 0.95 0.65, 0.85 0.58, 0.70 0.42, 1.39 1.26 1.16

Migraine 7.1 6.6 1.13 0.59, 1.21 0.63, 1.27 0.53, 2.17 2.34 3.05

Other nervous system 11.0 14.2 1.11 0.65, 1.12 0.65, 1.21 0.62, 1.88 1.92 2.34

Hypertension 16.2 20.5 1.11 0.71, 1.10 0.70, 1.12 0.63, 1.74 1.07 2.00

Heart disease 1.3 5.7 3.77* 1.19, 4.41* 1.38, 4.87* 1.31, 11.95 14.05 18.10

Haemorrhoids 11.3 13.6 1.25 0.75, 1.22 0.72, 1.60 0.85, 2.95 2.06 3.03

Other circulatory 4.2 11.1 2.35* 1.16, 2.16* 1.05, 2.60* 1.14, conditions 4.76 4.45 5.95

Hayfever 21.4 16.9 0.73 0.47, 0.73 0.47, 0.73 0.41, 1.13 1.14 1.30

Asthma 3.6 4.2 1.13 0.46, 1.18 0.48, 0.78 0.23, 2.74 2.90 2.56

Bronchitis 8.1 9.0 0.95 0.51, 0.94 0.49, 1.16 0.51, 1.78 1.78 2.43

Volume 27 Number 1; January 2019 Page 47 Original Article

Diagnosis NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

Other respiratory 4.9 4.2 0.85 0.37, 0.91 0.39, 1.02 0.34, 1.95 2.11 3.13

Ulcer 7.1 6.6 0.60 0.28, 0.59 0.28, 1.03 0.43, 1.25 1.25 2.45

Hernia 6.8 9.6 1.23 0.65, 1.27 0.66, 1.03 0.43, 2.34 2.42 2.45

Other digestive 8.1 9.9 1.09 0.59, 1.16 0.63, 0.91 0.41, disorders 2.00 2.15 2.02

Genitourinary diseases 2.9 4.2 1.39 0.55, 1.55 0.61, 1.46 0.45, 3.54 3.97 4.70

Skin rash 5.5 8.1 1.87 0.96, 1.81 0.93, 2.34* 1.02, 3.61 3.55 5.34

Eczema 15.2 15.7 1.02 0.64, 0.95 0.59, 0.90 0.48, 1.64 1.54 1.67

Other skin conditions 6.1 7.8 1.40 0.72, 1.38 0.71, 1.40 0.60, 2.70 2.71 3.27

Arthritis 8.7 21.1 2.47** 1.48, 2.46* 1.46, 3.00** 1.62, 4.12 * 4.13 * 5.55

Rheumatism 1.9 3.0 1.88 0.64, 1.80 0.60, 2.19 0.57, 5.49 5.37 8.41

Back disorder 37.9 34.9 0.95 0.67, 0.90 0.63, 0.77 0.48, 1.35 1.30 1.23

Other musculoskeletal 10.7 13.6 1.34 0.80, 1.28 0.75, 1.21 0.61, 2.25 2.18 2.43

Disability 0.6 1.2 0.95 0.12, 1.01 0.13, 0.62 0.04, 7.34 8.09 10.36

Injury 5.8 8.1 1.57 0.81, 1.54 0.78, 1.13 0.47, 3.04 3.01 2.74

Symptoms and signs 10.4 7.8 0.71 0.39, 0.70 0.37, 0.51 0.22, 1.30 1.29 1.19

* P < 0.05 ** P < 0.01

Page 48 Journal of Military and Veterans’ Health Original Article

Table 4. Prevalence of ICD-10 conditions in Wave 1 and ORs and 95% CIs Comparing NSM with Regular Enlistees; Model 1 adjusted for age, Model 2 adjusted for age and combat, Model 3 adjusted for age, combat, date of birth, age at deployment, durations of Army Service before, during and post-Vietnam, and rank in Vietnam.

NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

Infectious and 3.8 3.3 0.98 0.34, 1.01 0.35, 1.18 0.30, parasitic 2.81 2.94 4.60 disease

Neoplasms:

- Skin 40.4 39.3 0.90 0.59, 0.92 0.60, 1.00 0.59, 1.36 1.40 1.68

- Melanoma 10.1 9.5 1.14 0.56, 1.19 0.58, 1.20 0.49, 2.29 2.45 2.94

- Prostate 2.4 6.2 1.78 0.1, 1.89 0.53, 0.60 0.12, 6.28 6.75 3.05

Endocrine, nutritional and metabolic diseases:

- Disorders of the 1.9 2.5 1.65 0.44, 1.91 0.51, 3.18 0.67, thyroid gland 6.13 7.19 15.03

- Diabetes Mellitus 7.7 15.7 2.32* 1.21, 2.32* 1.19, 2.27* 1.02, Type 2 4.45 4.49 5.06

- High sugar levels in 9.1 6.2 0.84 0.40, 0.82 0.39, 0.76 0.28, blood or urine 1.75 1.73 2.07

- High cholesterol 43.3 40.5 1.02 0.68, 1.04 0.69, 0.97 0.57, 1.54 1.58 1.63

Mental and behavioural problems

- Alcohol and drug 17.3 14.0 1.00 0.58, 0.96 0.55, 1.10 0.55, problems 1.70 1.65 2.20

- Mood (affective) 43.8 32.6 0.81 0.53, 0.73 0.47, 0.71 0.41, problems 1.22 1.11 1.23

- Anxiety and related 54.8 49.6 1.10 0.73, 0.97 0.64, 1.14 0.68, problems 1.66 1.48 1.94

- Other psychological 1.9 2.9 1.95 0.55, 2.10 0.58, 3.11 0.69, problems 6.97 7.59 14.05

Diseases of the nervous system:

- Migraine 10.1 9.9 1.33 0.69, 1.31 0.68, 1.06 0.44, 2.54 2.54 2.57

- Other diseases of the 2.9 2.1 0.71 0.19, 0.82 0.21, 0.52 0.08, nervous system 2.65 3.14 3.36

Diseases of the eye and adnexa:

- Cataract 2.9 9.9 2.45 0.90, 2.36 0.86, 2.35 0.73, 6.63 6.50 7.53

- Glaucoma 1.0 2.5 1.82 0.30, 1.45 0.22, 2.72 0.36, 10.93 9.43 20.56

- Other disorders of 1.4 2.1 0.73 0.13, 0.82 0.14, 1.27 0.17, the choroid and retina 4.28 4.82 9,74

Volume 27 Number 1; January 2019 Page 49 Original Article

NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

- Astigmatism 1.09 0.39, 1.19 0.42, 0.49 0.10, 3.8 3.3 3.05 3.36 2.44

- Presbyopia 47.1 41.3 0.76 0.51, 0.75 0.50, 0.89 0.51, 1.15 1.14 1.58

- Colour blindness 2.9 10.7 3.54* 1.36, 3.37* 1.28, 4.46* 1.50, 9.22 8.91 13.29

- Other diseases of the 4.3 2.1 0.55 0.17, 0.52 0.16, 0.41 0.07, eye and adnexa 1.77 1.74 2.41

Diseases of the ear and mastoid:

- Complete or partial 4.3 2.1 1.12 0.72, 0.98 0.63, 0.93 0.53, deafness 1.73 1.53 1.64

- Tinnitus 46.2 43.8 0.97 0.65, 0.91 0.60, 0.79 0.47, 1.46 1.37 1.33

Diseases of the circulatory system:

- Hypertensive disease 39.9 45.0 1.23 0.82, 1.21 0.80, 1.38 0.82, 1.85 1.84 2.36

- Ischaemic heart disease:

- Angina 6.7 12.4 1.63 0.79, 1.54 0.73, 1.51 0.62, 3.38 3.22 3.64

- Other ischaemic 7.7 17.8 1.97* 1.01, 1.88 0.96, 2.36* 1.07, heart disease 3.82 2.70 5.20

- Tachycardia 10.6 17.8 0.75 0.37, 0.79 0.39, 0.65 0.26, 1.53 1.63 1.60

- Cerebrovascular 1.4 9.9 4.30* 1.17, 3.72 0.98, 4.27 0.97, disease 15.84 14.08 18.70

- Oedema and heart 3.4 5.0 1.73 0.64, 1.82 0.67, 2.83 0.86, failure 4.68 4.98 9.37

- Diseases of arteries, 8.7 9.1 0.91 0.44, 0.97 0.47, 0.76 0.30, arterioles and 1.88 2.03 1.97 capillaries

- Haemorrhoids 19.7 16.5 0.89 0.53, 0.96 0.57, 0.81 0.40, 1.50 1.63 1.62

- Varicose veins 5.3 8.7 1.82 0.79, 1.92 0.83, 2.62 0.98, 4.18 4.44 6.97

- Low blood pressure 4.3 6.5 1.70 0.70, 1.72 0.70, 1.57 0.52, 4.13 4.23 4.78

- Other diseases of the 1.0 2.1 1.94 0.33, 1.59 0.25, 0.69 0.06, circulatory system 11.47 10.08 7.62

- Symptoms and 1.0 1.7 1.57 0.25, 1.85 0.29, 3.02 0.36, signs involving the 10.00 11.91 25.68 circulatory system:

Page 50 Journal of Military and Veterans’ Health Original Article

NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

- Cardiac murmurs 5.8 9.9 1.13 0.49, 0.97 0.41, 0.99 0.35, and sounds 2.59 2.29 2.75

Diseases of the respiratory system:

Chronic lower respiratory disease:

- Bronchitis 12.0 12.0 0.88 0.47, 0.87 0.46, 0.93 0.42, 1.66 1.66 2.07

- Emphysema 5.8 6.6 1.22 0.53, 1.18 0.51, 1.74 0.64, 2.78 2.75 4.73

- Asthma 11.1 15.3 1.25 0.68, 1.21 0.65, 0.87 0.39, 2.31 2.26 1.92

Other diseases of the respiratory system:

- Hayfever and allergic 23.1 21.5 1.10 0.69, 1.07 0.66, 1.04 0.57, rhinitis 1.77 1.74 1.92

- Chronic sinusitis 25.5 24.4 1.06 0.67, 1.09 0.68, 0.92 0.50, 1.68 1.74 1.67

- Other diseases of the 12.5 13.2 0.95 0.52, 0.94 0.50, 0.95 0.44, respiratory system 1.76 1.75 2.06

Diseases of the digestive system:

Diseases of the oesophagus, stomach and duodenum:

- Diseases of the 4.8 4.1 1.17 0.45, 1.10 0.41, 1.15 0.32, oesophagus 3.04 2.94 4.21

- Stomach/duodenal/ 9.1 12.4 1.24 0.64, 1.21 0.61, 1.32 0.57, gastrointestinal ulcer 2.42 2.38 3.02

- Hernia 13.5 16.5 1.13 0.64, 1.08 0.60, 1.27 0.63, 2.01 1.95 2.60

Other diseases of the intestines:

- Irritable bowel 1.4 2.9 1.91 0.44, 2.07 0.48, 0.62 0.08, syndrome 8.25 9.02 4.99

- Gallstones 1.4 2.9 2.41 0.59, 1.75 0.40, 1.60 0.27, 9.89 7.74 9.66

Diseases of the skin and subcutaneous tissue:

- Dermatitis and 3.4 2.5 0.88 0.28, 0.73 0.22, 0.18 0.02, eczema 2.82 2.47 1.36

- Psoriasis 8.7 5.4 0.66 0.30, 0.69 0.31, 0.89 0.31, 1.46 1.55 2.50

- Other diseases 6.7 6.2 0.88 0.38, 0.84 0.36, 1.09 0.39, of the skin and 2.01 1.96 3.08 subcutaneous tissue

Diseases of the musculoskeletal system and connective tissue:

Arthropies:

- Gout 23.1 22.7 0.80 0.49, 0.75 0.45, 0.69 0.37, 1.31 1.25 1.31

Volume 27 Number 1; January 2019 Page 51 Original Article

NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (n = 309) (n = 332) OR OR OR (%) (%)

- Osteoarthritis 27.9 40.1 1.54* 1.001, 1.61* 1.04, 1.63 0.94, 2.39 2.50 2.82

- Rheumatoid arthritis 5.8 6.6 0.93 0.40, 0.83 0.34, 0.96 0.33, 2.29 2.06 2.81

- Arthritis other and 10.1 14.5 1.47 0.76, 1.41 0.75, 1.39 0.64, type unknown 2.67 2.66 3.02

- Other arthropies 2.4 4.1 2.26 0.74, 2.21 0.71, 1.46 0.33, 6.90 6.86 6.49

Soft tissue disorders:

- Rheumatism 2.9 8.7 2.93* 1.01, 3.11* 1.16, 4.43* 1.46, 7.81 8.35 * 13.46

- Other soft tissue 1.9 0.8 0.52 0.09, 0.59 0.97, 0.49 0.03, disorders 3.09 3.63 7.27

Dorsopathies:

- Disc disorders 23.1 27.3 1.54 0.97, 1.54 0.97, 1.74 0.98, 2.44 2.46 3.11

- Back pain/problems 39.4 40.5 1.00 0.66, 0.99 0.65, 1.00 0.59, 1.51 1.51 1.69

Diseases of the genitourinary system

- Urinary calculus 5.3 6.6 1.36 0.58, 1.27 0.54, 1.09 0.36, 3.15 3.02 3.30

- Urinary incontinence 3.8 3.7 0.87 0.30, 0.87 0.29, 0.43 0.10, 2.57 2.64 1.90

Symptoms, signs and conditions nec:

- Speech difficulties 1.0 2.1 1.86 0.31, 2.08 0.35, 1.49 0.18, 11.10 12.51 12.69

Allergy- (undefined) 5.3 5.0 1.15 0.48, 1.18 0.49, 1.55 0.50, 2.75 2.88 4.84

- Other symptoms and 7.7 9.5 1.27 0.62, 1.32 0.64, 1.38 0.56, signs not elsewhere 2.61 2.74 3.38 classified

* P < 0.05 ** P < 0.01

Page 52 Journal of Military and Veterans’ Health Original Article

Table 5. Prevalence of DSM-III-R conditions in Wave 1 and ORs and 95% CIs Comparing NSM with Regular Enlistees; Model 1 adjusted for age, Model 2 adjusted for age and combat, Model 3 adjusted for age, combat, date of birth, age at deployment, durations of Army Service before, during and post-Vietnam, and rank in Vietnam.

National Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI Service (%) OR OR OR man (%)

Alcohol abuse 39.8 41.3 1.40 0.99, 1.35 0.95, 1.55 0.99, or dependence 1.98 1.92 2.45

Drug abuse or 2.3 2.2 1.40 0.48, 1.40 0.47, 4.52* 1.12, dependence 4.06 4.14 18.16

Depression 6.8 5.1 0.90 0.45, 0.89 0.43, 1.34 0.54, 1.82 1.81 3.28

Depression 11.4 7.7 0.94 0.54, 0.96 0.56, 1.73 0.82, (NOS) 1.63 1.73 3.64

Melancholia 4.2 2.7 0.84 0.34, 0.81 0.32, 1.41 0.43, 2.06 2.02 4.56

Dysthymia 10.0 7.8 0.85 0.47, 0.80 0.44, 1.21 0.56, 1.54 1.47 2.56

Gambling 4.5 3.3 1.07 0.48, 1.10 0.48, 0.96 0.25, disorder 2.42 2.51 3.72

Antisocial 4.5 6.6 2.02 0.99, 1.88 0.91, 3.64* 1.51, personality 4.11 3.90 * 8.80 disorder

Generalised 9.4 5.1 0.68 0.36, 0.63 0.32, 0.73 0.29, anxiety disorder 1.31 1.24 1.84

Posttraumatic 21.8 20.1 1.13 0.75, 1.09 0.71, 1.93* 1.14, stress disorder 1.70 1.65 3.29

Obsessive 2.6 2.4 0.29 0.06, 0.31 0.06, 0.42 0.01, Compulsive disorder 1.40 1.50 1.51

Panic disorder 4.2 2.1 0.72 0.28, 0.66 0.25, 1.99 0.45, 1.84 1.74 8.96

Agoraphobia 7.4 4.2 0.60 0.29, 0.60 0.28, 1.33 0.53, 1.28 1.29 3.31

Phobia 25.9 16.6 0.61* 0.40, 0.60* 0.39, 0.84 0.43, 0.94 0.92 1.65

Social phobia 18.8 9.9 0.54* 0.33, 0.54* 0.33, 0.98 0.52, 0.89 0.90 1.85

Simple phobia 11.7 8.4 0.73 0.41, 0.69 0.38, 0.83 0.39, 1.29 1.25 1.76

Somatoform 15.9 16.9 1.24 0.79, 1.21 0.76, 1.26 0.69, pain disorder 1.93 1.91 2.28

Volume 27 Number 1; January 2019 Page 53 Original Article

Table 6. Prevalence of DSM-IV lifetime Conditions in Wave 2 and ORs and 95% CIs Comparing NSM with Regular Enlistees; Model 1 adjusted for age, Model 2 adjusted for age and combat, Model 3 adjusted for age, combat, date of birth, age at deployment, durations of Army Service before, during and post-Vietnam, and rank in Vietnam.

NSM Regular Model 1 95% CI Model 2 95% CI Model 3 95% CI (%) (%) OR OR OR

Alcohol 23.6 17.9 1.16 0.72, 1.18 0.72, 1.21 0.65, dependence 1.89 1.93 2.82

Alcohol abuse 29.8 34.6 1.48 0.96, 1.48 0.96, 1.63 0.94, 2.89 2.30 2.81

Cannabis abuse 3.8 2.9 1.93 0.66, 2.43 0.81, 2.52 0.52, 5.63 7.26 2.22

Severe 25.0 18.8 0.86 0.49, 0.83 0.46, 0.95 0.47, depression 1.52 1.47 1.92 (single+recurrent)

Dysthymia 3.4 2.5 0.93 0.30, 0.79 0.24, 0.65 0.12, 2.93 2.62 3.40

Posttraumatic 31.1 32.4 1.17 0.76, 1.01 0.65, 1.32 0.75, stress disorder 1.79 1.56 2.31

Generalised 12.5 12.1 0.60 0.33, 0.54 0.29, 0.52 0.22, anxiety disorder 1.10 1.01 1.23

Obsessive 1.9 2.5 0.29 0.06, 0.31 0.06, 0.04 0.001, Compulsive disorder 1.40 1.50 1.51

Panic with 0.5 1.3 1.20 0.17, 1.24 0.17, 0.26 0.001, agoraphobia 8.72 9.30 50.57

Panic without 1.9 2.9 1.39 0.41, 0.97 0.26, 0.79 0.12, agoraphobia 4.73 3.62 5.10

Agoraphobia 2.9 5.4 1.66 0.61, 1.91 0.70, 3.13 0.98, without panic 4.53 5.23 9.99

Animal phobia 3.4 2.5 1.27 0.40, 1.18 0.36, 1.43 0.29, 3.98 3.81 7.06

Social phobia 3.8 7.5 1.20 0.52, 1.04 0.44, 1.47 0.52, 2.76 2.47 4.16

Page 54 Journal of Military and Veterans’ Health Original Article

Table 3 shows the prevalence of ICD-9 long term abuse and dependence (OR = 2.17, 95%CI = 0.59, or chronic physical health conditions assessed in 8.02; p = 0.247), for phobia (OR = 0.71, 95%CI = 0.44, Wave 1. Gout was significantly less prevalent among 1.15; p = .177), or for social phobia (OR = 0.68, 95%CI Regulars in Models 1 and 2, but not when the other = 0.38, 1.20; p = .183), but antisocial personality variables were controlled for. Endocrine conditions disorder remained significant (OR = 2.59, 95% CI became significant only after full adjustment. Heart = 1.13, 5.92; p = .025). We can therefore conclude disease, circulatory conditions and arthritis were that longer service in the Army after repatriation is more prevalent among Regulars in all models. Apart associated with decreased risk of these conditions, from these, no other condition discriminated NSM in addition to PTSD. from Regulars. Table 6 shows the prevalence of DSM-IV psychiatric Table 4 shows the prevalence of ICD-10 physical conditions assessed in Wave 2 did not differ health conditions assessed at Wave 2. Type 2 statistically between NSM and Regulars in any model. diabetes was more prevalent among Regulars in NSM and Regulars did not differ in the number of all models; ischaemic heart disease also in Models diagnoses and there was no difference in PTSD rates 1 and 3; cerebrovascular disease in Model 1 only; between NSM and Regulars in Wave 2 in any model. osteoarthritis in Models 1 and 2; and rheumatism in all models. Otherwise, no other conditions Discussion discriminated NSM from Regulars. It is well known that participation in war, particularly Table 5 shows the Wave 1 DSM-III diagnoses. Drug combat, has demonstrable consequences on the abuse or dependence and antisocial personality physical and mental health of former warriors. The disorder were significant only in Model 3. On the question of whether this is borne equally by volunteers other hand, phobia and social phobia were significant and conscripts has not previously been addressed. only in Models 1 and 2. PTSD risk was not different The overall results suggest little difference between in Models 1 and 2, indicating that PTSD rates were men who enlisted voluntarily and those who were similar even after adjusting for combat exposure. conscripted in terms of economic, marital, physical However, in Model 3, Regulars assumed a significant and psychiatric health two and three decades after risk over NSM. Thus, after adjusting for the longer return. Previous findings from this cohort indicate periods spent in the Army before, during and after that combat was a risk factor for arthritis and heart deployment, and for later age at deployment and and circulatory disease,15 osteoarthritis, angina higher rank, PTSD risk was significantly elevated in and cerebrovascular disease,13 and disc disorders Regulars compared with NSM. and joint injuries were associated with durations of service pre- and post-Vietnam. Given that Regulars However, PTSD has been reported to shorten military saw more combat and spent more time in the Army, careers,30 so that reduced Army Service post-Vietnam their risk of these conditions should be expected may be a marker of PTSD rather than a confounder, to be higher. In the Wave 2 cohort results, Regular and adjusting for it may represent over-adjustment. enlistment and duration of post-Vietnam Service There was no difference in length of service after were associated with osteoarthritis in regression repatriation for NSM with or without PTSD (M = prediction models; these results are confirmed 0.58 yrs, SD = 2.45 for NSM with no PTSD and M = here. It is also likely that military service carries 0.33 yrs, SD = 0.38 for NSM with PTSD at Wave 1; an increased burden of cardiovascular disease and t276.047 =1.511, p = .132), but Regulars with PTSD had musculoskeletal problems in later life. significantly shorter service than Regulars without PTSD (M = 8.96yrs, SD = 7.00 for Regulars with no Demographically, the differences at interviews PTSD and M = 6.42yrs, SD = 6.58 for Regulars with included age and employment status but not marital PTSD; t105.259 = 2.77, p = .007). When the modelling status or annual income. Notable is the lack of was repeated with post-Vietnam Service duration difference in economic circumstances, since the removed, the NSM-Regular odds ratio was reduced higher educational attainments of NSM and briefer to insignificance (OR = 1.64, 95%CI = 0.89, 3.01; p military careers would suggest that NSM might have = .112). had better career prospects that translated into higher incomes. The pattern of health risk factors When post-Vietnam Service was removed from Model also differed between the groups. Regulars had less 3 for other significant outcomes of drug abuse and education and trade training before enlistment, they dependence, phobia, social phobia and antisocial saw more combat and spent longer in the war zone, personality disorder, the differences between NSM all of which should increase their risk in particular and Regulars were also no longer significant for drug of PTSD compared with NSM. In contrast, Regulars

Volume 27 Number 1; January 2019 Page 55 Original Article

had more Army experience before deployment, were between-wave differences may be due to slightly deployed at older ages and at higher ranks, and different samples. Secondly, a large number of were less likely to be posted to Infantry Battalions, statistical tests were conducted, of which 5% could all of which would be expected to reduce their risk be expected to be significant by chance. However, of PTSD compared with NSM. While these patterns the pattern of results is cogent and points to of risk factors varied between the groups, the rates consistency of findings between the waves. However, of PTSD did not. This suggests that the lower risk some differences may have been missed due to small of PTSD conferred by longer training, older age at sample sizes; a number of lower confidence intervals deployment and higher rank is counterbalanced by a bordered 1.0 and narrower confidence bands from higher risk from combat and length of deployment in larger samples may have led to 95% CIs that did not Regulars. Conversely, in NSM the lower risk of PTSD contain 1.0. conferred by advantages of higher education, shorter exposure to the conflict zone and lower combat In conclusion, compared to volunteers, differential seem to be countered by higher risk conferred by advantages of conscripts did not improve their post- shorter training and deployment to Infantry. If these discharge socioeconomic status, nor protect them two opposed forces balance each other to provide from adverse mental health outcomes post-discharge. equality with the increased risk of PTSD borne by the PTSD may have been borne disproportionally by Regulars due to their higher combat and exposure Regulars at Wave 1 but this differential dissipated to the conflict zone, then this suggests that NSM over time. In addition, the similar rates of PTSD in may have been more vulnerable to PTSD, in spite of NSM and Regulars may hide a vulnerability conferred having seen less combat. by shorter training and Infantry Service among NSM. The notion that Army Service is overtaxing on the An interesting finding was the reduction to body and may raise the risk of cardiovascular and insignificance of the ORs for several conditions after musculoskeletal disease the longer it continues is removing one of the potential confounders, duration supported. Otherwise, there appear to be very few of service post-repatriation. Drug abuse and overall differences in health between National Service dependence, phobia and social phobia were rendered and Regular Vietnam Veterans in later life. non-significant, while antisocial personality disorder maintained significance. It is possible that this latter Corresponding Author: Brian O’Toole, disorder is predictive of a preference for serving [email protected] in the armed services, compared with randomly Authors: B O’Toole1, K Pierse2, B Friedrich 1,6, selected young men from the general population. S Outram 3,4, M Dadds 1, S Catts 1,5 It is also possible that differential screening and Author Affiliations: selection imperatives during recruitment of NSM and 1 University of Sydney, Brain and Mind Centre, Regulars acted to reduce the prevalence in NSM. It 2 ANZAC Research Institute, also suggests that length of service is a significant 3 University of Newcastle School of Medicine and confounder of the NSM-Regular comparison. Public Health 4 Health Behaviour Sciences The study here is not without weaknesses. Response 5 University of Queensland, Psychiatry rates were not perfect, and the two waves produced 6 Research Department of Epidemiology & Public slightly different samples at each wave. Thus, Health, University College London

References 1. Edwards PA. Nation At War, Vol. 6, The Official History of Australia’s Involvement in Southeast Asian Conflicts, 1948-1975, Allen and Unwin, Sydney, in association with the Australian War Memorial. 1997. 2. McNeill IG. An outline of Australian military involvement in Vietnam July 1962-December 1972. Defence Force J. 1980;24:43-53. 3. Fett MJ, Dunn M, Adena MA, O’Toole BI, Forcier L. The Mortality Report. Part I. A Retrospective Cohort Study of Mortality Among Australian National Servicemen of the Vietnam Conflict Era. Canberra; Australian Government Publishing Service. 1984. 4. Fett MJ, Adena MA, Cobbin DM, Dunn M. Mortality among Australian conscripts of the Vietnam Conflict Era. I. Death from all Causes. Am J Epidemiol. 1987;125:869-77. 5. O’Toole BI, Adena MA, Jones MP. Risk factors for mortality in Australian Vietnam-era National Servicemen: A case-control study. Commun Health Stud. 1988;XII:408-17. 6. O’Toole BI, Cantor C. Risk factors for suicide in Vietnam-era Australian National Servicemen. Suicide Life Threat Behav. 1995;24:474-87.

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7. O’Toole BI. Intelligence, behavior and motor vehicle accident mortality. Accident Anal Prev. 1990:22;211-21. 8. Wilson EJ, Horsley KW, van der Hoek R. Cancer Incidence in Australian Vietnam Veterans Study 2005. Canberra: Department of Veterans’ Affairs. 2005. 9. Wilson EJ, Horsley KW, van der Hoek R. Australian Vietnam Veterans Mortality Study 2005. Canberra: Department of Veterans’ Affairs. 2005. 10. Wilson EJ, Horsley KW, van der Hoek R. Australian National Service Vietnam Veterans Mortality and Cancer Incidence Study 2005. Canberra: Department of Veterans’ Affairs. 2005. 11. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam Generation. Report of findings from the National Vietnam Veterans Readjustment Study. Vol I. New York: Brunner/Mazel. 1990. 12. Marmar CR, Schlenger W, Henn-Haase C, et al. Course of posttraumatic stress disorder 40 years after the Vietnam War: Findings from the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry. 2015;72,875-81. Doi: 10100/amapsychiatry.2015.0803. 13. O’Toole BI, Marshall RP, Grayson DA, et al. The Australian Vietnam Veterans Health Study. II. Self- reported health of veterans compared to the Australian population. Int J Epidemiol. 1996;25:319-30. 14. O’Toole BI, Marshall RP, Grayson DA, Schureck RJ, Dobson M, Ffrench ML, Meldrum L, Bolton J, Pulvertaft B, Vennard J. The Australian Vietnam Veterans Health Study. III. Psychosocial health status and relation to combat. Int J Epidemiol. 1996;25:331-40. 15. O’Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans three decades after the war and its relation to military service, combat and PTSD. Am J Epidemiol. 2009;170:318-30. PMID: 9119558 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (3rd ed.). Washington, DC; American Psychiatric Association. 1980. 17. O’Toole BI, Catts SV. The course and correlates of combat-related PTSD in Australian Vietnam veterans in the three decades after the war. J Traumatic Stress. 2017;30:27-35. DOI: 10.1002/jts.22160 18. O’Toole BI, Catts SV. Trauma, PTSD and physical health: An epidemiological study of Australian Vietnam veterans. Journal of Psychosomatic Research. 2008;64:33-40. 19. O’Toole BI, Marshall RP, Grayson DA, et al. The Australian Vietnam Veterans Health Study. I. Study design and response bias. Int J Epidemiol. 1996;25:307-18. 20. O’Toole BI, Catts SV, Outram S, et al. Factors associated with civilian mortality in Australian Vietnam veterans three decades after the war. Mil Med. 2010;175(2):88-95 21. O’Toole BI, Marshall RP, Grayson DA, et al. Comparing subpopulations with official statistics: Some methodological issues and an empirical demonstration. J Official Statist. 1999;15:395-411. 22. Australian Bureau of Statistics Health Interview Survey, 1989-90, Australian Bureau of Statistics, Canberra. 1991 (www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4366.0). 23. Australian Bureau of Statistics Health Interview Survey 2004-05. Australian Bureau of Statistics Canberra. 2005. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/ DetailsPage/4364.02004-05 24. Spitzer R, Williams J, Gibbon M. Structured Clinical Interview for DSM-III-R, version NP-V. New York: New York State Psychiatric Institute, Biometrics Research Department. 1987. 25. Weathers FW, Keane TM, Davidson JRT. Clinician-administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety. 2001;13:132-56. 26. Robins LN, Helzer JE, Hesselbrook M, Wish E. The National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Arch Gen Psychiat. 1981;38:381-9. 27. World Health Organisation. Composite International Diagnostic Interview. CIDI-Auto 2.1. Administrator’s Guide and Reference; Geneva, WHO, 1997. 28. Australian Bureau of Statistics. Mental Health and Wellbeing: Profile of Adults, cat no. 4326.0, ABS Canberra. 1997. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/4326.0 29. IBM Corporation. IBM SPSS Statistics for Windows, Version 20.0, 2011. Armonk, NY: IBM Corporation. 30. Hoge CW, Auchterlonie MS, Milliken C. 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. doi:10.1001/jama.295.9.1023

Volume 27 Number 1; January 2019 Page 57 Original Article

Compensation in the Australian Defence Force

Neil Westphalen

Introduction because no application was made, or the application was rejected.4 Of the remaining 183 200 workers, This article follows previous papers by the author, Safe Work Australia showed that 117 815 were for regarding occupational and environmental medicine serious worker’s compensation claims (requiring in the Australian Defence Force (ADF).1 They assert a work absence of one working week or more), or that high rates of workplace illness and injury approximately 11 claims per 1000 employees.5 indicate the need to improve the management of hazards associated with ADF workplaces, with better The median time off work was 5.2 working weeks for emphasis on prevention. They also advocated that male and 6 working weeks for female employees. The the ADF’s health services should be premised on an agriculture, forestry and fishing industry had the occupational and environmental health paradigm, highest civilian serious claim incidence rate (21 per which would require reassessing the fundamental 1000 employees), followed by the transport, postal inputs to capability for both Joint Health Command & warehousing industry (19.1 per 1000 employees). (JHC), and Defence’s Work Health and Safety branch. Employees working as labourers had the highest The papers argue that such a reassessment could serious claim incidence rate of all civilian occupations lead to a holistic and sustainable workforce- (27 per 1000 employees), followed by machinery based health service delivery model by 2030. This operators and drivers (24.4 per 1000 employees). timeframe is based on the current state of the ADF’s The most common causes of serious claims were occupational and environmental health services, and manual handling accidents (33%), followed by slips, the small number of civilian specialist practitioners trips and falls (22%). The most commonly injured within the Australasian Faculty of Occupational part of the body was the back (22%), while other and Environmental Medicine. These considerations common locations were hands, fingers and thumbs suggest that a mature health delivery model would (13%), shoulders (10%) and knees (9%). take 10–15 years’ sustained effort with respect to occupational and environmental physicians alone. Despite comprising 52% of the total civilian workforce, 63% of serious workers’ compensation claims were This article expands on these papers, with respect to by male employees. Musculoskeletal injuries made facilitating the compensation of ADF personnel for up 90% of these claims, while another 6% were for their Service-related illness and injuries. mental health disorders.

Civilian worker’s compensation Although there is no equivalent ‘serious claim Civilian worker’s compensation claims in incidence rate’ for Defence members, the nature of Australia are subject to multiple federal, state and the ADF workforce and its workplaces, as previously 6 territory jurisdictions. Collating their data is not described by the author, suggests that it would straightforward; for example, Safe Work Australia be comparable to – and in fact, almost certainly states that during 2012–13, Australia had 10.599 significantly exceed – the maximal civilian industrial million employees,2 while the Australian Bureau of and occupational rates. Statistics’ Work-related Injuries Survey infers there Safe Work Australia indicates that the median cost7 were 12.367 million employees.3 of these civilian claims in 2011–128 was $8 900.9 The The Work-related Injuries Survey indicated that Work-related Injuries Survey showed that the total during this time, an estimated 531 800 workers economic cost was estimated to be $61.8 billion 10 (4.3%) experienced a work-related incident. 348 600 (4.1% of GDP), or $5 000 to $5 800 per Australian of these workers did not receive compensation, either civilian employee.

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ADF compensation legislation household services may include house cleaning, laundry, ironing, gardening and lawn mowing. The ADF is not responsible for determining The attendant care services may be provided for compensation entitlements for either current or ex- the essential and regular personal care of the Service personnel; this is a Department of Veterans’ injured member Affairs (DVA) responsibility. Determining eligibility is complex, as it may depend on up to three separate • help with the cost of vocational retraining to help pieces of legislation. Reserve and ex-Service members return to the work force, or with other forms of rehabilitation Veteran’s Entitlements Act (VEA).11 The VEA to help them cope with the effects of their injury, covers wartime Service and certain operational disease or illness. deployments, as well as certain peacetime Service between 7 December 1972 and 30 June 2004. For Military Rehabilitation and Compensation Act 14 peacetime Service eligibility, a Defence member who 2004 (MRCA). The MRCA provides rehabilitation had not completed a qualifying period of three years’ as well as compensation coverage for all Permanent, Service prior to 7 April 1994 is not covered, unless Reserve and other entitled personnel, who served on 15 they were medically discharged.12 Eligible personnel or after 1 July 2004. MRCA benefits may include: may receive: • vocational and other rehabilitation services

• a disability pension, if a disability is accepted • choice of periodic payments or lump sum as having been caused or aggravated during an compensation or a combination of both for eligible period of Service permanent impairment (non-economic loss)

• a service pension at age 60 if they have Qualifying • incapacity benefits, which are periodic payments Service, whereby they were allotted to, and have of compensation for economic loss due to served in, an operational area or warlike service incapacity for Service or work area • choice of a Special Rate Disability Pension • a White Repatriation Health Card for one or more (SRDP) ‘safety net’ payment for life or incapacity medical conditions deemed to be Service-related, payments up to age 65 (conditions apply) or a Gold Repatriation Health Card that provides treatment for all medical conditions, including • vehicle modifications or assistance with the cost those that are not Service-related. of a vehicle under the Motor Vehicle Scheme

Safety, Rehabilitation and Compensation • compensation for household services (Defence-Related Claims) Act 1988 (SRCA).13 The • compensation for attendant (personal) care SRCA provides rehabilitation as well as compensation services coverage, for injuries and diseases suffered as a result of peacetime and peacekeeping Service up • telephone allowance (conditions apply) to, and including, 30 June 2004, and operational • compensation for dependants in the event of a Service between 7 April 1994 and 30 June 2004. member’s death (conditions apply) These personnel may be eligible for: • funeral benefits • a lump sum compensation benefit, if they are permanently impaired • bereavement payments

• weekly compensation benefits, if they are unable • assistance with the cost of financial advice to work because of an accepted injury, disease or obtained in relation to certain permanent illness impairment, SRDP and death benefit choices

• DVA payment of all medical, hospital, • DVA White or Gold Cards in certain cases or pharmaceutical and other treatment costs otherwise payment of reasonable treatment costs that they may reasonably require due to their related to accepted medical conditions for those compensable injury, disease or illness who are not eligible for a White or Gold Card

• some additional rehabilitation services in specific • pharmaceutical allowance circumstances where they have an accepted claim for a Service-related injury. These entitlements • travel and accommodation costs associated are limited to the provision of household services, with medical appointments for treatment and aids and modifications and attendant care. The rehabilitation assessments and programs.

Volume 27 Number 1; January 2019 Page 59 Original Article

Compensation Entitlements. Which Act(s) apply to the Minister for Veterans’ Affairs. Its role is to when claiming for compensation, and the benefits review RMA determinations on request from an that may be received, depend on the: eligible person or organisation. It comprises a pool of medical practitioners and scientists appointed • date of the injury or illness (for SRCA and MRCA as Councillors by the Minister. The Specialist purposes), and/or Medical Review Council Convener select three to • period of service that the injury or disease relates five Councillors to conduct each review as required, 20 to (for VEA purposes). based on the relevance of their expertise.

Additionally, the Safety, Rehabilitation and ADF Veterans Compensation Legislation Amendment (Defence Force) Act 2017 (DRCA)16 replicates the current The author has previously noted that in 2015, SRCA entitlements for current and ex-Service ADF Australia had approximately 339 000 veterans, 21 members, with eligibility being determined by the including 150 200 with peacetime-only Service. Of Minister for Veterans’ Affairs rather than the Minister the total, 61.4% were receiving health care services for Employment. The DRCA does not affect VEA or from DVA for Service-related conditions, costing MRCA eligibility or entitlements. $5.525 billion in 2014-15. If the cost was borne (and funded) by Defence rather than DVA, it would Finally, in accordance with its Non-Liability Health constitute 15.9% of a recalculated Defence budget, Care provisions, ADF members with even one-day’s compared to around 9.5% of GDP in health costs for Service can get immediate ongoing treatment from the entire Australian population.22 DVA for up to five mental health conditions.17 The purpose of these provisions is to ensure the member’s A striking characteristic of ADF Service, therefore safety, without the delays inherent to assessing their pertains to the high treatment cost of Service- eligibility. related medical conditions (even for personnel with peacetime-only Service), despite high recruiting and 23 Repatriation Medical Authority retention health standards. The Repatriation Medical Authority was established Furthermore, these figures exclude another $3.22 in accordance with the VEA, as an independent billion spent by DVA on non-health disability services 24 statutory authority responsible to the Minister and compensation. To this end, 96 493 people for Veterans’ Affairs. It comprises five renowned received a VEA disability pension in 2015; while practitioners in the field of medical science. Their another 4 291 people received a weekly incapacity role is to determine Statements of Principles (SoPs) payment and an additional 18 537 received one-off for any disease, injury or death related to military permanent impairment payments per the SRCA or 25 service, based on sound medical-scientific evidence. MRCA. The SoPs state the factors that ‘must’ or ‘must as This means that, of approximately 440 000 current a minimum’ exist to cause the particular disease, and ex-serving ADF members,26 approximately injury or death. 18 270 per 1000 received some form of compensation Each condition determined by the RMA has two SoPs payment for at least one Service-related medical that list the factors relating the condition to ADF condition. This is at least 20 times the average service. These SoPs are based on two separate legal civilian serious claim incidence rate, and 10 times standards as to the weighting of the medical evidence. the highest civilian serious claim incidence rate, by The more generous SoP is based on the ‘reasonable both industry and occupation. hypothesis’ standard, which is applicable to current The size of the total DVA budget also means that and ex-Service ADF members with operational or the per capita cost of treatment, disability services warlike service. The marginally less generous SoP and compensation for these 440 000 current and is based on the ‘balance of probabilities standard’, ex-Serving ADF members is $19 875, which is up to which generally applies to claims where the veteran four times the median civilian Safe Work Australia or ADF member does not have operational service.19 and Work-related Injuries Survey rate. This figure Specialist Medical Review Council is consistent with the estimated average cost of $22 700 per gold card, and $2600 per White Card in The Specialist Medical Review Council (SMRC) was 2015-16.27 also established in accordance with the VEA, as Notwithstanding the differences between Defence another independent statutory authority responsible and civilian compensation entitlements, these

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Table 1: 15 most frequently claimed conditions under the VEA in 2014–15

Disability Claims accepted Acceptance rate Claims rejected Total claims

Osteoarthritis 1 623 76% 514 2 137

Sensorineural hearing loss 1 372 99% 14 1 386

Tinnitus 1 307 98% 26 1 333

Lumbar spondylosis 930 84% 181 1 111

Solar keratosis 640 99% 9 649

Post-traumatic stress disorder 472 76% 151 623

Non-melanotic skin cancer 533 99% 7 540

Depressive disorder 270 56% 211 481

Alcohol use disorder 218 55% 176 394

Hypertension 100 31% 219 319

Cervical spondylosis 82 28% 211 293

Ischaemic heart disease 154 53% 139 293

Acquired cataract 223 100% 1 224

Rotator cuff syndrome 70 32% 150 220

Chronic bronchitis 124 60% 84 208

Totals 8 118 79% 2 093 10 211 figures are consistent with the previous assertion of all claims, 53% of which were rejected as non- that ADF workplace injury rates and per capita Service-related. This suggests that the focus by JHC costs are comparable to – and almost certainly on healthy lifestyle promotion (per the College of significantly exceed – the aforementioned maximal General Practitioner’s ‘Red Book’29), at the expense of civilian industrial and occupational rates, even for workplace illness and injury prevention, is generally ADF members who have not deployed. misplaced, especially if 36% of Permanent ADF members serve for less than five years (6.25%) of Medical conditions their estimated 80-year lifespan.30 Table 1 lists the 15 most frequently claimed Compensation and the ADF’s health services conditions under the VEA (based on the RMA SoPs) in 2015. These made up 61.5% of all conditions The author has previously noted that the ADF claimed under the VEA. appears unique in that unlike other employers, its health services provide employee healthcare without Table 1 suggests that, generally consistent with the ascertaining whether their clinical presentations are 28 author’s original article, at least 22% of all VEA work-related.31 For example, JHC clinical records claims were for musculoskeletal conditions, while routinely document patient details such as their at least another 9% were for mental health issues Service and rank but not their rate (Navy), corps (including alcohol abuse). Other conditions, for (Army) or mustering (Air Force) that indicate the jobs which a relatively straightforward relationship to they perform. ADF employment exists, include hearing disorders secondary to workplace noise (16%), skin disorders Furthermore, JHC at present does not collect or report secondary to sun exposure (7%), and a small work-related illness/injury data, or record lost time number of eye disorders secondary to ultraviolet- or restricted duties, or identify the ensuing health light exposure (e.g. arc welding). care costs.32 Although some – but by no means all – of this information is provided via Defence’s Work However, Table 1 also indicates that lifestyle-related Health and Safety Compensation and Reporting conditions such as hypertension, ischaemic heart (WHSCAR) System, a recent study indicates that disease and chronic bronchitis (much of which only 11 to 19 percent of all Army Reserve and can be attributed to smoking), make up only 5%

Volume 27 Number 1; January 2019 Page 61 Original Article

Regular work-related injuries and illnesses are being This suggests that the ADF’s health services should reported.33 It seems likely that WHSCAR reporting by be premised on an occupational and environmental the other Services would be comparable. health paradigm, with revised fundamental inputs to capability that would lead to a genuinely holistic Collecting this baseline health information at the and sustainable workforce-based ADF health service point of treatment is essential, not only for monitoring delivery model by 2030. the effectiveness of the ADF’s occupational and environmental health services, or to account for the This paradigm would entail Defence medical healthcare costs incurred by JHC, or to account officers who accept the requirement to facilitate for the compensation and veteran health care the compensation entitlements of ill and injured costs incurred by DVA, but documenting the work- ADF personnel, as intrinsic to providing primary relatedness – and therefore compensation eligibility healthcare for a workforce. This specifically refers to – of each member’s illness or injury in the first place. the timely and accurate documentation of the work- relatedness of every ADF patient presentation. A previous article noted that JHC does not include occupational and environmental physicians as It also entails occupational and environmental part of its multidisciplinary rehabilitation teams, physicians who can help prevent high rates of despite anecdotal evidence suggesting that only 20- compensable workplace illnesses and injuries 40% of ADF clinical presentations are for (generally (potentially up to 20 times the average civilian rate), non-compensable) conditions typically seen in an by facilitating local command compliance with the equivalent Australian civilian population. It also Work Health and Safety Act. referred to the limitations of general practitioners with respect to medical fitness-for-work certification Author managing long-term work absence, work disability Dr Neil Westphalen graduated from Adelaide and unemployment and balancing the needs of University in 1985 and joined the RAN in 1987. He commanders against those of their patients.34 is a RAN Staff Course graduate and a Fellow of the However, the previous article also noted that Royal Australian College of General Practitioners, occupational and environmental physicians the Australasian Faculty of Occupational and have skills and expertise that can complement Environmental Medicine, and the Australasian general practitioners, with respect to facilitating College of Aerospace Medicine. He holds a Diploma compensation as intrinsic to providing primary of Aviation Medicine and a Master of Public Health. healthcare for the ADF workforce. Perhaps more His seagoing Service includes HMA Ships Swan, importantly, they can also facilitate local command Stalwart, Success, Sydney, Perth and Choules. compliance with the Work, Health and Safety Act Deployments include DAMASK VII, RIMPAC 96, 2011, thereby preventing compensable workplace TANAGER, RELEX II, GEMSBOK, TALISMAN SABRE illness and injury in the first place. 07, RENDERSAFE 14, SEA RAIDER 15, KAKADU 16 In summary, facilitating each ADF member’s future and SEA HORIZON 17. His Service ashore includes compensation entitlements by considering the work- clinical roles at Cerberus, Penguin, Kuttabul, relatedness of their illness or injury at the time of Albatross and Stirling, and staff positions as J07 presentation, is clearly intrinsic to their overall (Director Health) at the then HQAST, Director Navy healthcare. However, at present it is not recognised Occupational and Environmental Health, Director as such from a clinical management perspective, of Navy Health, Joint Health Command SO1 MEC with respect to the fundamental inputs to capability Advisory and Review Services, and Fleet Medical for either JHC’s garrison health services, or for the Officer (2013-2016). Defence Work Health and Safety branch. Commander Westphalen transferred to the Active Conclusion Reserve in July 2016. With ADF personnel arguably exposed to the most Disclaimer diverse range of occupational and environmental The views expressed in this article are the author’s hazards of any Australian workforce, high rates of and do not reflect those of the RAN or any of the preventable workplace illness and injury indicate the other organisations mentioned. need to improve the management of occupational and environmental health hazards, with added emphasis on prevention above treatment.

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Corresponding Author: Neil Westphalen, [email protected] Authors: N Westphalen 1,2 Author Affiliations: 1 Royal Australian Navy Reserve 2 Navy Health Service, C/O Director Navy Health

References 1 Westphalen N. Occupational and environmental medicine in the Australian Defence Force. Australian Defence Force Journal. November-December 2016;200:49-58. Available from: http://www.defence.gov. au/ADC/ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf [accessed 01 December 2018]; Westphalen N. Primary health care in the Australian Defence Force. Australian Defence Force Journal. July/August 2017;202:91-7. Available from: http://www.defence.gov.au/adc/adfj/Documents/ issue_202/Westphalen_July_2017.pdf [accessed 01 December 2018]; and Westphalen N. Assessing medical suitability for employment and deployment in the Australian Defence Force. Australian Defence Force Journal. January 2018;203:67-74. Available from: http://www.defence.gov.au/adc/adfj/ Documents/issue_203/ADF%20Journal%20203_Article_Westphalen.pdf [accessed 01 December 2018]. 2 Safe Work Australia. Australian workers’ compensation statistics, 2012–13. Available from: https:// www.safeworkaustralia.gov.au/system/files/documents/1702/australian-workers-compensation- statistics-2012-13.pdf. [accessed 01 December 2018]. This reference excludes compensation claims by ADF personnel. 3 Safe Work Australia. The Cost of Work-related Injury and Illness for Australian Employers, Workers and the Community 2012–13. Available from: https://www.safeworkaustralia.gov.au/system/files/ documents/1702/cost-of-work-related-injury-and-disease-2012-13.docx.pdf. [accessed 01 December 2018]. 4 Safe Work Australia. The Cost of Work-related Injury and Illness for Australian Employers, Workers and the Community 2012–13. Available from: https://www.safeworkaustralia.gov.au/system/files/ documents/1702/cost-of-work-related-injury-and-disease-2012-13.docx.pdf. [accessed 01 December 2018]. 5 Safe Work Australia explains that the definition used for the term ‘serious worker’s compensation claims’ is: ‘A workers’ compensation claim for an incapacity requiring an absence from work of one working week or more, lodged in the reference year, and accepted for compensation by the jurisdiction by the date the data are extracted for publication. Claims in receipt of common law payments are also included. Claims arising from a journey to or from work or during a recess period are not compensable in all jurisdictions, and are excluded.’ 6 Westphalen N. Occupational and environmental medicine in the Australian Defence Force. Australian Defence Force Journal. November-December 2016;200:49-58. Available from: http://www.defence.gov. au/ADC/ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf. [accessed 01 December 2018]. 7 Safe Work Australia explains that, because a small number of uncharacteristically long absences or high payments can skew the average (mean), median payment and median time lost from work of serious workers’ compensation claims approximate to a ‘typical’ claim. 8 Safe Work Australia explains that the median time lost and median payments for 2012–13, as those claims are likely to be open and the claimant may accrue more time off and payment in subsequent years. 9 Safe Work Australia explains that payments include compensation paid to claimants for: benefits paid to an employee or the employee’s surviving dependents; outlays for goods and services such as medical treatment, funeral expenses, rehabilitation services; non-compensation payments such as legal costs, transport and interpreter services; and common law settlements, which may incorporate estimates of future liability and indirect costs such as loss of productivity.

Volume 27 Number 1; January 2019 Page 63 Original Article

10 Safe Work Australia. The Cost of Work-related Injury and Illness for Australian Employers, Workers and the Community 2012–13. Available from: https://www.safeworkaustralia.gov.au/system/files/ documents/1702/cost-of-work-related-injury-and-disease-2012-13.docx.pdf. [accessed 01 December 2018]. 11 Federal Register of Legislation. Veteran’s Entitlements Act 1986. Available from: https://www. legislation.gov.au/Details/C2018C00334. [accessed 01 December 2018]. 12 Department of Veteran’s Affairs. Veterans’ Entitlements Act 1986. Available from: https://www.dva.gov. au/benefits-and-payments/compensation/veterans-entitlements-act-vea. [accessed 15 August 2018]. 13 Federal Register of Legislation. Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988. Available from: https://www.legislation.gov.au/Details/C2017C00334. [accessed 01 December 2018]. 14 Federal Register of Legislation. Military Rehabilitation and Compensation Act 2004. Available from: https://www.legislation.gov.au/Details/C2018C00329. [accessed 01 December 2018]. 15 Department of Veteran’s Affairs. Military Rehabilitation and Compensation Act 2004. Available from: http://www.dva.gov.au/benefits-and-payments/compensation/military-rehabilitation-and- compensation-act-mrca. [accessed 01 December 2018]. 16 Australian Government. Federal Register of Legislation. Safety, Rehabilitation and Compensation Legislation Amendment (Defence Force) Act 2017. Available from: https://www.legislation.gov.au/ Details/C2017A00108. [accessed 01 December 2018]. 17 Department of Veteran’s Affairs. Non Liability Health Care. Available from: https://www.dva.gov.au/ health-and-wellbeing/mental-health/non-liability-health-care. [accessed 01 December 2018]. 18 Repatriation Medical Authority. Introduction to the RMA. Australian Government. 2018. Available from: http://www.rma.gov.au [accessed 01 December 2018]. 19 Repatriation Medical Authority. FAQs. Australian Government. 2018. Available from: http://www.rma. gov.au/faqs [accessed 01 December 2018]. 20 Specialist Medical Review Council. About SMRC. Available from: http://www.smrc.gov.au. [accessed 01 December 2018]. 21 Department of Veteran’s Affairs. DVA Annual Reports 2014-15. available from: https://www.dva.gov. au/sites/default/files/files/about%20dva/annual_report/2014-2015/annrep2014-15.pdf. [accessed 01 December 2018]. 22 Australian Institute of Health and Welfare. Health expenditure Australia 2011-12 25 September 2013. Australia’s health series no. 14. Cat. no. AUS 178, p 241. Available from: https://www.aihw.gov.au/ getmedia/6b21b4dc-5fd6-4077-8c75-7a6bab09416d/15405.pdf.aspx?inline=true accessed 01 December 2018]. 23 See Defence Health Manual (DHM) Volume 2 Part 5 Health Standards and Assessments - Entry and Transfer, and DHM Volume 2 Part 6 Health Standards and Assessments - Serving Members (both only available on Defence intranet). 24 Department of Veteran’s Affairs. DVA Annual Reports 2014-15. Available from: https://www.dva.gov. au/sites/default/files/files/about%20dva/annual_report/2014-2015/annrep2014-15.pdf. [accessed 01 December 2018]. 25 Department of Veteran’s Affairs. DVA Annual Reports 2014-15. Available from: https://www.dva.gov. au/sites/default/files/files/about%20dva/annual_report/2014-2015/annrep2014-15.pdf. [accessed 01 December 2018]. 26 Includes approximately 339 000 veterans, 80 000 permanent and active reserve members, and about 20,000 inactive reservists. Department of Veteran’s Affairs. DVA Annual Reports 2014-15. Available from: https://www.dva.gov.au/sites/default/files/files/about%20dva/annual_report/2014-2015/ annrep2014-15.pdf. [accessed 01 December 2018]; Department of Defence. Defence Issues Paper 2014. Available from: http://www.defence.gov.au/Whitepaper/docs/DefenceIssuesPaper2014.pdf. [accessed 01 December 2018]; Australian Bureau of Statistics. Year book Australia, 2009-10. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/6D4CD661FDBA3226CA25773700169C59?ope ndocument . [accessed 01 December 2018].

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27 Department of Veteran’s Affairs. Statistics at a Glance. Available from: https://www.dva.gov.au/sites/ default/files/files/publications/datastatistical/statsataglance/SaaG_Sep2016.pdf. [accessed 01 December 2018]. 28 Westphalen N. Occupational and environmental medicine in the Australian Defence Force. Australian Defence Force Journal. November-December 2016;200:49-58. Available from: http://www.defence.gov. au/ADC/ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf. [accessed 01 December 2018]. 29 Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. Available from: http://www.racgp.org.au/your-practice/guidelines/redbook. [accessed 01 December 2018]. 30 Department of Defence. Defence census 2011 fact sheet (only available on Defence intranet); and Australian Institute of Health and Welfare (AIHW). Australia’s Health 2014. Available from: http://www. aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548150. [accessed 01 December 2018]. 31 Westphalen N. Occupational and environmental medicine in the Australian Defence Force. Australian Defence Force Journal. November-December 2016;200:49-58. Available from: http://www.defence.gov. au/ADC/ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf. [accessed 01 December 2018]. 32 JeDHI Helpdesk email Defence eHealth System - Occupational Aetiology - Quick Reference Guide dated 1503 12 July 2018 refers): It seems no guidance was provided for Defence health staff to ensure consistency as to what should and should not be considered work-related; Workplace- and sports-related injuries are not recorded separately, which precludes differentiating work- versus sports-related treatment costs or Lost Time Injury Frequency Rates’ and It does not initiate the compensation claims process (which still has to be done separately). Hence, most of the remaining shortfalls identified in this paper remain extant. 33 Pope R, Orr R. ‘Incidence rates for work health and safety incidents and injuries in Australian Army Reserve vs full time soldiers, and a comparison of reporting systems’, Journal of Military and Veteran’s Health [internet]. April 2017, Volume 25 Number 2; pp 16-25, Available from https://jmvh.org/wp- content/uploads/2017/07/Original-Artical-Incidence-rates.pdf. [accessed 01 December 2018]. 34 Westphalen N. Occupational and environmental medicine in the Australian Defence Force. Australian Defence Force Journal, Issue 200, November-December 2016, pp. 49-58. Available from: http://www. defence.gov.au/ADC/ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf. [accessed 01 December 2018].

Volume 27 Number 1; January 2019 Page 65 Original Article

Medical CBRN Defence in the Australian Defence Force

Major David J Heslop, Commander Neil Westphalen

Introduction were catapulted into the city of Caffa (now Feodosia in Crimea) by besieging Mongols. Even so, it was This article focuses on a specialist area of military not until the mid-19th century that investigators, medicine, following a series of recently published such as Louis Pasteur in France and Robert Koch in papers regarding occupational and environmental Germany, demonstrated that microorganisms could medicine in the ADF.1 They assert that high rates cause disease, while research into the industrialised of preventable workplace illness and injury indicate weaponising of potential biological agents only began the need to improve the management of occupational during World War I (WWI).3 and environmental hazards associated with ADF workplaces, with better emphasis on prevention Lethal chemical weapons were first used in 1915 by rather than treatment. the Germans near Ypres on the Western Front.4 The century since has seen many nations develop, and These papers advocate that, rather than replicating sometimes utilise, a chemical weapons capability.5 the treatment services used for Australian civilians, Although nuclear weapons were used twice in 1945,6 the ADF’s health services should be premised on an other radiological weapons have so far not been occupational and environmental health paradigm. employed on a mass scale.7,8,9 For this to occur, the health capability gaps in the current ADF health service delivery model demand Since the end of the Cold War, most CBRN events have reassessment of the fundamental inputs to (health) usually entailed the use of chemical and biological capability, for both Joint Health Command (JHC) weapons by non-state terrorist organisations.10 and Defence’s Work Health and Safety Branch. Examples include the 1995 attack on the Tokyo subway by the Aum Shinrikyo cult using sarin,11 and Such a reassessment, with implementation of the 2001 attack on the US Senate and two media necessary changes, could lead to a holistic and outlets by unknown perpetrators using anthrax.12 sustainable workforce-based ADF health service delivery model by 2030. This timeframe is based The development, production, stockpiling and use on the current state of the ADF’s occupational of chemical weapons is prohibited by the 1997 and environmental health services, and the Chemical Weapons Convention,13 while the 1975 small number of civilian specialist practitioners Biological Weapons Convention likewise prohibits within the Australasian Faculty of Occupational that for biological weapons.14 Nuclear weapons are and Environmental Medicine (AFOEM). These presently subject to the 1963 Partial Nuclear Test considerations suggest that a mature health delivery Ban Treaty15 and the 1970 Nuclear Non-Proliferation model would take 10–15 years’ sustained effort, Treaty.16,17 with respect to occupational and environmental However, several nations have not signed or ratified physicians alone.2 some or any of these treaties. In addition, North This article expands on the previous papers, with Korea withdrew from the Nuclear Non-Proliferation respect to how such a paradigm is essential to Treaty in 2003,18 and has recently threatened several the ADF’s defensive medical Chemical, Biological, regional neighbours, including Australia, with Radiological and Nuclear (CBRN) capabilities. nuclear weapons.19 Moreover, these treaties lack relevance with respect to compliance by non-state Global CBRN Threats non-signatories, such as terrorist organisations. CBRN weapons therefore, remain an important Hunter-gatherer communities have used biological global threat. weapons such as poisoned-tipped spears and arrows since prehistoric times. However, the first Furthermore, the goals and actions of non-state documented use of a biological agent for warlike terrorists in recent years have made the use of CBRN purposes was in 1346, when plague-infected corpses weapons more likely, while technological advances

Page 66 Journal of Military and Veterans’ Health Original Article

have made their use more feasible.20 Given the Japanese.29 Australia then provided three sites victims of a CBRN attack may vary from individuals and about 15,000 personnel for 12 British nuclear to whole populations – which may include military weapons tests between 1952 and 1957.30 personnel as well as civilians21 – defending against these weapons has become an important public More recently, the Australian deployments before health issue.22 and during the 1990-91 Gulf War were conducted in what was assessed as a high-threat chemical and Many nations including Australia have therefore biological warfare environment.31 Australians then focused their defensive CBRN measures against participated in a series of United Nations CBRN the public health threat posed to their civilian weapons inspections in Iraq.32 populations by terrorist organisations, particularly after the 2001 World Trade Center terrorist The ability of ADF personnel at sea, on land and in the attacks.23 This approach predicates managing health air to maintain operational capability before, during responses to deliberate CBRN terrorist attacks that and after a CBRN attack remains fundamental to are intended to cause harm, on comparable terms as defending Australian interests. To this end, all ADF for accidental hazardous material incidents.24 personnel undergo basic CBRN defensive training on entry and periodically thereafter (typically every five This article therefore, contends that occupational and years). It usually takes only one day and is generally environmental medicine has an important role with limited to describing the various types of CBRN respect to commanders applying a risk management hazards and practical demonstrations of respirators approach to the prevention and treatment of CBRN and other CBRN equipment. Navy incorporates casualties, while maintaining ADF operational this training into its non-CBRN shipboard damage capability. control courses.33

Civilian CBRN Defence in Australia Additional training is provided for the relevant instructors and for specific deployments that are Within Australia, the primary responsibility for assessed as posing a greater CBRN threat. protecting life, property and the environment lies with the states and territories. Each of these have ADF health support in CBRN environments is based their own plans and arrangements to respond on self- and buddy-aid, which are time-critical and to, and recover from, natural and human-caused complicated by the risk of further contamination. emergencies. To this end, some state and territory After decontamination, casualties require further health departments have dedicated disaster specialist CBRN treatment, perhaps concurrently management units.25 with resuscitation for other life-threatening injuries.

To complement their efforts in responding to Current ADF operational doctrine for CBRN defence emergencies, the Australian Government can also is therefore predicated on five pillars – Detection, provide physical and financial assistance. This is Identification and Monitoring (DIM); Warning and an Attorney-General’s Department responsibility Reporting (W&R); Physical Protection; Hazard through Emergency Management Australia (EMA).26 Management and Medical Countermeasures (MCM); and Medical Support. Although the medical Australia’s civilian CBRN defensive measures are contributions are predominantly centred on the final generally incorporated into a unified ‘All Hazards’ pillar, they still include all the others, which can be approach, for a range of different emergencies. Local summarised as: authorities initially respond to these emergencies, followed by a series of escalatory stages. In addition, CBRN occupational screening. This ensures that EMA has specific health guidance for dealing with at-risk personnel meet the appropriate physical, CBRN hazards.27 medical and psychological standards. This particularly refers to personal protective equipment ADF CBRN Defence suitability, fitting and kitting. The standards are difficult to justify, and are often subsumed within For a medium-sized power, Australia’s involvement broader medical standards, where their justification with CBRN issues has been surprisingly intimate. can be lost. This began in WWI, where 323 Australian Imperial Force (AIF) personnel died and 16,426 were wounded CBRN medical preparation. This includes physical by gas on the Western Front.28 Although they were conditioning activities, vaccinations, providing not used, Australia stockpiled its own chemical personal medical countermeasures and CBRN first weapons during WWII, as a deterrent against the aid items. Apart from high readiness elements, this is

Volume 27 Number 1; January 2019 Page 67 Original Article

usually conducted ‘just-in-time’. It is also contingent personnel is to conserve fighting strength, continue on sufficient quantities of in-date vaccinations and providing non-CBRN health services and support CBRN medications being available when required, to the maximum extent possible, protect health typically when other nations are competing for the personnel from CBRN injuries, minimise CBRN same items simultaneously. morbidity and mortality, avoid the spread of contamination into health vehicles and facilities, and CBRN medical training. This refers to the medical provide command advice. theory and recognition of CBRN agents, how to use personal medical countermeasures, protocols To this end, various Army and Navy units have for self- and buddy-aid, casualty evacuation, conducted medical officer CBRN courses over many decontamination and integrating each of these decades. Apart from a hiatus in 2003, these courses individual medical activities into overall CBRN were centralised at the Army Logistic Training Centre defences. This training tends to have a heavy from 1994 until 2007. Besides Australian CBRN theoretical component, is generally scenario-based subject matter experts, these courses employed and is difficult to access. presenters from the US Army Medical Research Institute of Infectious Diseases (USAMRIID),41 the In support of integrating wider activities across these US Army Medical Research Institute of Chemical pillars and their related medical activities, the ADF Defense (USAMRICD)42 and the US Armed Forces has an extensive range of non-health CBRN policy Radiobiology Research Institute (AFRRI).43 These 34 references. Additional guidance is also available together arguably constitute the Western world’s 35 from a range of NATO and other references. centres of medical CBRN expertise.

The development and maintenance of CBRN-related CBRN training for ADF health personnel has been a health policy, doctrine and procedures, and providing JHC responsibility since 2009. To this end, the ADF health input into strategic CBRN policy and doctrine, Medical Officer CBRN course was updated in 2011 36 is a JHC responsibility. However, at present, JHC to incorporate advances in technology and medical lacks the dedicated specialist health staff necessary practice. Its intent was to teach Permanent and to perform these tasks. Furthermore, JHC does not Reserve medical officers, nursing officers and senior have a dedicated ADF CBRN health manual. Instead, ADF medics how to apply their existing medical skills extant guidance is dispersed among and within to treat CBRN casualties.44 Although the updated 37 multiple operational health references. CBRN Health Course was piloted in 2012, it has not been conducted since.45 Current recruiting health standards38 for ADF members do not include factors such as CBRN respirator compatibility with their spectacles, Implications CBRN personal protective equipment compatibility Like many other military organisations, for many with their height and weight, or medical conditions years it has been ADF practice to deliver basic that may restrict their ability to use CBRN defensive CBRN instruction during entry training, countermeasures.39 While these factors may not followed by limited periodic refresher CBRN courses. affect their ability to undertake their normal duties, Additional training is provided for the relevant it may limit or preclude ADF members from doing so instructors and for specific deployments that are in a CBRN environment. Such cases should therefore assessed as posing a greater CBRN threat. be identified before they are called upon to do so. The rationale for this approach stems from the Apart from self- and buddy-aid, basic periodic substantial personnel and other resources necessary CBRN training does not include on-scene casualty to sustain a high level of CBRN preparedness. While treatment or specialist toxicological and emergency this gives every permanent and many reserve ADF management; since 2012, these capabilities have members at least some CBRN familiarity, it does resided only within Army’s Special Operations not provide the specialist medical or non-medical Engineer Regiment (SOER). SOER originated in expertise required to develop and implement 1999 as the Joint Incident Response Unit (JIRU), strategic-level CBRN policy and doctrine. as part of the ADF’s security arrangements for the 2000 Sydney Olympics. JIRU was formed from Furthermore, nearly 30 years after it ended, the amalgamating several specialised Royal Australian current ‘just-in-time’ approach still reflects Cold Engineer units, including its Chemical Biological War doctrine, despite the goals and actions of non- Radiological Response (CBRR) Squadron.40 state terrorists making the use of CBRN weapons more feasible and likely. In particular, this approach The intent of CBRN training for military health does not address unforeseen CBRN threats to ADF

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personnel that may arise mid-deployment or even CBRN hazards on comparable terms as other military within Australia. occupational and environmental hazards. As applied to the ADF population, this approach is consistent The ADF’s ability to treat its own and other military with current national guidance for managing CBRN casualties is presently constrained to that CBRN attacks on Australian civilians, while also which can be provided by SOER, which is limited maintaining ADF operational capability. to its supporting and enabling role for Special Operations in general. Additional training is required This paper therefore contends that, in collaboration for health staff who support and enable the ADF’s with other occupational and environmental health non-Special Operations capabilities, in particular practitioners and CBRN subject matter experts, its Role 2 health units46 such as Army’s 1st Close occupational and environmental physicians have Health Battalion47 and Navy’s Maritime Operational much to offer the ADF, with respect to leading and Health Unit.48 sustaining a holistic and time-critical responsive CBRN health planning, preparation and operational Yet, the fact that there has been no CBRN health course response capability. since 2012 means that JHC’s ability to conduct one has probably atrophied, to the point where it would Conclusion more-or-less entail starting from scratch. Even with overseas assistance, reconstituting the breadth and With ADF personnel arguably exposed to the most depth of specialist health CBRN expertise within the diverse range of occupational and environmental ADF to conduct this course will take several years, hazards of any Australian workforce, high rates of at a time when the use of CBRN weapons by terrorist preventable workplace illness and injury indicate the organisations in particular, is more feasible and need to improve the management of occupational and likely. environmental health hazards with better emphasis on prevention than treatment. This includes the In any event, future ADF CBRN health courses should accelerated pace and reduced warning of future still employ the expertise provided by USAMRIID, CBRN threats to ADF personnel. USAMRICD and AFRRI, either directly to course participants, or indirectly through ‘train-the-trainer’ These considerations suggest that the ADF’s courses. Additional clinical CBRN refresher training health services be premised on an occupational should be also provided on the same terms as other and environmental health paradigm, with revised clinical refresher training, such as the Advanced fundamental inputs to capability that would lead Trauma Life Support course. to a genuinely holistic and sustainable workforce- based ADF health service delivery model by 2030. The lack of CBRN expertise within JHC also compromises CBRN health policy currency and Among other attributes, this paradigm would entail precludes providing higher-level CBRN policy and military occupational and environmental physicians, doctrine health input. Furthermore, incorporating who already possess many of the specialist skills extant CBRN health policies into JHC’s generic to manage CBRN hazards, on comparable terms as operational health guidance implies that they are not other occupational and environmental hazards. considered a high priority. Many nations, including Australia, have focused The relevance and importance of occupational and their CBRN defensive measures against the civilian environmental medicine to the broader ADF has public health threat posed by terrorist organisations. previously been highlighted.49 In this instance, Military occupational and environmental physicians among their other attributes, occupational and can apply the same approach to the ADF population, environmental physicians undergo comprehensive with respect to the prevention and treatment of theoretical and practical education with respect to CBRN casualties, while also maintaining operational applying a risk management approach to the medical capability. aspects of preventing, assessing, managing, treating and advising on biological, chemical, radiological Authors and other hazards.50 Major David Heslop graduated his PhD in medicine Military occupational and environmental physicians in 2004 and medicine in 2006 from The University therefore, already possess many of the skill sets of Sydney as part of the ADF Graduate Medical required to provide specialist CBRN health training, Scheme, is a Fellow of the Royal Australasian College policy development and command advice. Their of General Practitioners and active clinician, and an participation would also be predicated on managing advanced fellowship trainee with the Australasian

Volume 27 Number 1; January 2019 Page 69 Original Article

Faculty of Occupational and Environmental His seagoing service includes HMA Ships Swan, Medicine. He is currently an Associate Professor at Stalwart, Success, Sydney, Perth and Choules. the School of Public Health and Community Medicine Deployments include DAMASK VII, RIMPAC 96, at University of New South Wales, Sydney specialising TANAGER, RELEX II, GEMSBOK, TALISMAN SABRE in disaster, CBRNE and health systems research. 07, RENDERSAFE 14, SEA RAIDER 15, KAKADU 16 He has extensive training and experience with the and SEA HORIZON 17. His service ashore includes military in CBRNE medicine, medical operations clinical roles at Cerberus, Penguin, Kuttabul, planning and execution and developing medical Albatross and Stirling, and staff positions as J07 capability for austere environments. He has deployed (Director Health) at the then HQAST, Director Navy on humanitarian assistance and community relief Occupational and Environmental Health, Director roles, OP SLIPPER and OP RESOLUTE. He was the of Navy Health, Joint Health Command SO1 MEC Officer Commanding and Senior Medical Officer at Advisory and Review Services, and Fleet Medical the CBRN medical troop of the Special Operations Officer (2013-2016). Engineer Regiment from 2013-2015, and has ongoing responsibilities as Senior Medical Adviser Commander Westphalen transferred to the Active CBRNE medicine to elements of Special Operations Reserve in July 2016. Headquarters. Disclaimer Dr Neil Westphalen graduated from Adelaide The views expressed in this article are the authors, University in 1985 and joined the RAN in 1987. He and do not necessarily reflect those of the Australian is an RAN Staff Course graduate and a Fellow of the Army, the RAN or any of the other organisations Royal Australian College of General Practitioners, mentioned. the Australasian Faculty of Occupational and Environmental Medicine, and the Australasian College of Aerospace Medicine. He also holds a Corresponding Author: Neil Westphalen, Diploma of Aviation Medicine and a Master of Public [email protected] Health. Authors: N Westphalen1, D Heslop2 Author Affiliations: 1 Royal Australian Navy Reserve 2 University of New South Wales, School of Public Health and Community Medicine

References 1 N. Westphalen, ‘Occupational and environmental medicine in the Australian Defence Force’ Australian Defence Force Journal, 2016 Issue 200, pp. 49-58, available from Chemical Warfare in World War I: The American Experience, 1917 – 1918’, Leavenworth Research Paper No 10, Combined Arms Research Laboratory, available from https://www.webharvest. gov/peth04/20041017045619/http://www.cgsc.army.mil/carl/resources/csi/Heller/HELLER.asp#1 5 During the interwar period, chemical weapons were used by the Italians against Ethiopians, and by the Japanese against the Chinese. Since WWII, they have been used by the Egyptians against Yemenis, Iraqis against Iraqi Kurds and Iranians, and most recently by the Syrians against rebels in 2013 and 2017. See Evison, D, Hinsley D, Rice P, ‘Chemical weapons’, British Medical Journal, 09 February 2002, Vol 324 No 7333 pp 332–335 available from https://www.ncbi.nlm.nih.gov/pmc/articles/

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PMC1122267/df; and Cumming-Bruce, N, ‘U.N. panel faults Syria’s military for chemical attack’, New York Times ,available from https://www.nytimes.com/2017/09/06/world/middleeast/syria-chemical- weapons.html?mcubz=0. 6 For a contemporaneous description, see ‘The Atomic Bombings of Hiroshima and Nagasaki, by The Manhattan Engineer District, June 29, 1946’, available from http://www.atomicarchive.com/Docs/ MED/index.shtml. 7 Operation PEPPERMINT refers to US preparations to counteract the use of radioactive poisons by the Germans, to disrupt of the 1944 Allied landings in Normandy. Fortunately, it transpired that the Germans had no such weapons. See ‘Operation Peppermint’, available from https://www.revolvy.com/ main/index.php?s=Operation%20Peppermint. 8 A radiological weapon using Polonium-210 was used to assassinate former Russian secret service officer Alexander Litvinenko on 23 November 2006. See White, RF, ‘Assassination Discourse and Political Power: The Death of Alexander Litvinenko’, 2008, available from http://www.assassinationresearch. com/v5n2/v5n2white.pdf. 9 For an example of a radiological contamination accident resulting in mass civilian casualties, see ‘The Radiological Accident at Goiânia’, International Atomic Energy Agency, 1988, available from http:// www-pub.iaea.org/mtcd/publications/pdf/pub815_web.pdf. 10 A probable exception was the assassination of Kim Jong-nam, in Kuala Lumpur on 13 February 2017 using VX nerve agent. His assassination has not been ascribed to a non-government terrorist organisation, but the North Korean government. See Colvin, M, ‘Nerve agent VX used to kill estranged half-brother of Kim Jong-un’, ABC News, 24 February 2017, available from http://www.abc.net.au/ pm/content/2016/s4625889.htm. More recently, the Russian government was implicated in an assassination attempt in March 2018 on former Russian secret service officer Sergei Skripal using Novichok nerve agent. The attack put himself, his daughter, a policemen and two bystanders in hospital, one of whom died. See ‘Skripal poisoning suspects reportedly identified amid doubt over eventual arrests’, ABC News, 20 July 2018, available from http://www.abc.net.au/news/2018-07-19/novichok-attack-on-the-skripals-suspects-reportedly- identified/10014420 11 Pletcher, K, ‘Tokyo subway attack of 1995’, Encyclopaedia Britannica, available from https://www. britannica.com/event/Tokyo-subway-attack-of-1995. 12 See ‘Amerithrax Investigative Summary’, Federal Bureau of Investigation, 19 February 2010, available from https://www.justice.gov/archive/amerithrax/docs/amx-investigative-summary.pdf. 13 ‘Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on Their Destruction’, Organisation for the Prohibition of Chemical Weapons, 1994, available from https://www.opcw.org/fileadmin/OPCW/CWC/CWC_en.pdf. 14 ‘Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction’, The United Nations Office at Geneva, available from https://www.unog.ch/80256EDD006B8954/(httpAssets)/C4048678A93B6934C125718 8004848D0/$file/BWC-text-English.pdf. 15 No 6964: Treaty banning nuclear weapon tests in the atmosphere, in outer space and under water, available from https://treaties.un.org/doc/Publication/UNTS/Volume%20480/volume-480-I-6964- English.pdf. 16 ‘Treaty on the Non-Proliferation of Nuclear Weapons’, United Nations Office for Disarmament Affairs, available from http://disarmament.un.org/treaties/t/npt/text. 17 The Comprehensive Nuclear-Test-Ban Treaty was opened for signature in 1996, but has not yet entered force. See ‘Comprehensive Nuclear-Test-Ban Treaty (CNBT)’, United Nations Office for Disarmament Affairs, available from https://www.un.org/disarmament/wmd/nuclear/ctbt. 18 See ‘North Korea’s Withdrawal from the Nuclear Nonproliferation Treaty’, American Society of International Law, 2003 , Vol 8 No 2, available from https://www.asil.org/insights/volume/8/issue/2/ north-koreas-withdrawal-nuclear-nonproliferation-treaty. 19 See Palin, M, Crew V, ‘North Korea warns Australia has committed a ‘suicidal act’’, 22 August 2017, news.com.au, available from http://www.news.com.au/technology/innovation/north-korea-warns-us- is-pouring-gasoline-on-fire/news-story/1921b8c27c4cf6dd64ce18c7196ead97.

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20 Sweijs, T, Kooroshy, J, ‘The future of CBRN’, The Hague Centre for Strategic Studies, 2010, Future Issue No 12, available from https://www.hcss.nl/sites/default/files/files/reports/HCSS_12_03_10_ The_Future_of_CBRN.pdf. 21 Although CBRN weapons were not involved, for an Australian example see Zammitt, A, ‘The Holsworthy Barracks plot: a case study of an Al-Shabab support network in Australia’, Combating Terrorism Centre, 21 June 2012, available from https://ctc.usma.edu/posts/the-holsworthy-barracks-plot-a- case-study-of-an-al-shabab-support-network-in-australia. 22 Mazzone, A, ‘The Use of CBRN Weapons by Non-State Terrorists’, Global Security Studies, 2013, Vol 4 No 4, available from http://globalsecuritystudies.com/Mazzone%20CBRN-AG.pdf. 23 See National Commission on terrorist attacks on the United States ‘911 Commission Report’, available from https://www.9-11commission.gov/report/911Report.pdf. 24 Examples of mass casualty hazardous material accidents include the industrial accident at Seveso Italy in 1976, and the disaster in Bhopal India in 1985. See ‘Icmesa chemical company, Seveso, Italy. 10th July 1976’, Health and Safety Executive, available from http://www.hse.gov.uk/comah/sragtech/ caseseveso76.htm; and Bowater, B, ‘An analysis of the Bhopal accident’, Project Appraisal, 1987 , volume 2, number 3, pp157-168, available from http://www.tandfonline.com/doi/pdf/10.1080/02688 867.1987.9726622. 25 For example, the Western Australian Department of Health’s Disaster Preparedness and Management Unit has a range of public health policy, planning and training programs. See ‘Disaster Management’, Government of Western Australia Department of Health, available from http://ww2.health.wa.gov.au/ Health-for/Government-and-NGO/Disaster-management. See also NSW Health Medical Services Supporting Plan, available from http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/ GL2010_011.pdf; ‘Emergency Type’, Health.Vic , , available from https://www2.health.vic.gov.au/ emergencies/emergency-type; ‘Queensland Health’s role in a disaster’, Queensland Health, available from https://www.health.qld.gov.au/public-health/disaster/management; ‘Emergency incident and disaster management’, SA Health, available from http://www.sahealth.sa.gov.au/wps/wcm/connect/ Public+Content/SA+Health+Internet/Health+services/Ambulance+and+emergency+services/Emergency +incident+and+disaster+management; ‘Plan for the Delivery of Integrated Emergency Management within the Department of Health and Human Services and Tasmanian Health Organisations’, Tasmanian Department of Health and Human Services Emergency Preparedness and Coordination Unit, available from http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/156144/PDIEM_DHHS_ and_THOs.pdf; ‘Health Disaster Management’, NT Department of Health, available from https://health. nt.gov.au/health-governance/department-of-health/health-disaster-management/introduction. 26 ‘Emergency Management Australia’, Attorney General’s Department, available from https://www.ag.gov. au/EmergencyManagement/Emergency-Management-Australia/Pages/default.aspx. 27 See Emergency Management Australia, Health Aspects of Chemical, Biological and Radiological (CBR) Hazards (Provisional). Manual Number 13. National Capital Printing, 2000. 28 See Butler, A.G. Official History of the Australian Army Medical Services, 1914–1918, Volume 3 Chapter 17, Table 26. Australian War Memorial, 1943. 29 See Plunkett, G. Chemical Warfare in Australia: Australia’s Involvement in Chemical Warfare 1914- 1945. Australian Military History Publications, Loftus NSW, 2007. 30 See Blakeway, D, Lloyd-Roberts, S. Fields of Thunder: Testing Britain’s Bomb. Unwin Paperpacks, Sydney and London, 1985. 31 See Horner, D, Australia and the ‘New World Order’: from peacekeeping to peace enforcement: 1988- 1991. The Official History of Australian Peacekeeping, Humanitarian and Post-Cold War Operations. Cambridge University Press, Melbourne, 2011. 32 See Barton, R, The Weapons Detective: The Inside Story of Australia’s Top Weapons Inspector. Griffin Press, Melbourne, 2006. 33 See RANSSSS Training Management Package: Standard Combat Survivability dated 22 Apr 2014, (only available on Defence intranet). 34 See Australian Defence Doctrine Publication Chemical, Biological, Radiological and Nuclear Defence, 2011; Australian Army Land Warfare Procedures – General LWP-G 7-2-5 Conduct of Chemical, Biological, Radiological and Nuclear Training dated 28 April 2014; LWD 3-9-7 Operations in a Chemical,

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Biological, Radiological and Nuclear Environment dated 13 May 2005; LWP-G 3-9-10 Chemical, Biological, Radiological and Nuclear Defence dated 6 December 2005; Australian Book of Reference 5476 — Volume 1 Royal Australian Navy Shipboard Combat Survivability—Damage Control Policy dated 09 August 2016, (all only available on Defence intranet). 35 See NATO Standardisation Agreement (STANAG) 2596 Allied Joint Medical Doctrine for Support to Chemical, Biological, Radiological and Nuclear (CBRN) Defensive Operations - AJMedP-7 Edition A; STANAG 2954 Training of Medical Personnel for Chemical, Biological, Radiological, and Nuclear (CBRN) Defence - AMedP-7.3 Edition A, accessed via search for ‘CBRN’], available from http://nso.nato.int/ nso/nsdd/_CommonList.html. 36 See Defence Instruction (General) Operations 15-1 Australian Defence policy for the development of the capability to conduct operations in a Chemical, Biological, Radiological and Nuclear Environment AL2 dated 29 Jan 2006 (only available on Defence intranet). 37 Guidance with respect to immunisation against biological warfare agents is in Volume 1 Part 7 Chapter 1 of the Defence Health Manual. Volume 2 Part 7 has 16 chapters on various operational health matters, of which only six pertain to CBRN. 38 Defence Health Manual Volume 2 Part 5 Health Standards and Assessments - Entry and Transfer (only available on Defence intranet). 39 For instance, personnel with immune disorders may not be able to be vaccinated against biological agents, while personnel who lack an enzyme called pseudocholinsterase, are more susceptible to nerve agents and are less responsive to nerve agent pre-treatment and post-exposure medications. For another example, personnel with asthma may be at an increased risk of an asthma attack on exposure to chemical agents, yet they cannot use their asthma medication while wearing a respirator. Some personnel may also have an increased risk of heat stress while wearing Mission Oriented Protective Posture (MOPP) suits. 40 See ‘Australia’s CBRNE Defense’ CBRNe Portal, available from http://www.cbrneportal.com/australias- cbrne-defense. 41 See ‘US Army Medical Research Institute of Infectious Diseases’, US Army Medical Department, available from http://www.usamriid.army.mil. 42 See ‘US Army Medical Research Institute of Chemical Defense’, US Army Medical Department , available from https://usamricd.apgea.army.mil/Default.aspx. 43 See ‘Armed Forces Radiobiology Research Institute’, Uniformed Services University, available from https://www.usuhs.edu/afrri. 44 ‘Chemical, Biological, Radiological and Nuclear (CBRN) Health Course’, ADF Headquarters Joint Health Command website (only available on Defence intranet). 45 It is understood a brief (one-day) medical CBRN session was conducted during Exercise BLUESTOKES at HMAS Penguin on 16-20 April 2018, while another was conducted prior to the 2018 Australasian Military Medicine Association Conference. These sessions cannot be considered in any way comparable to the pre-2012 Health Officer CBRN Course (two weeks). 46 For a description of NATO levels of health care or ‘Roles’, see ‘Chapter 16: Health Support’, NATO Logistics Handbook , available from http://www.nato.int/docu/logi-en/1997/lo-1610.htm. 47 See ‘1st Close Health Battalion’ Army’s ‘Our People’, available from https://www.army.gov.au/our- people/units/forces-command/17th-combat-service-support-brigade/1st-close-health-battalion. 48 For a description of Navy’s Maritime Operational Health Unit, see ‘Navy’s Fighting Chance’ Navy Daily, available from http://news.navy.gov.au/en/Jun2014/Fleet/1096/Navy%27s-%27Fighting-Chance%27. htm#.Wbk_EOQh. 49 N. Westphalen, ‘Occupational and environmental medicine in the Australian Defence Force’, Australian Defence Force Journal, 2016 , Issue 200, pp. 49-58, available from

Volume 27 Number 1; January 2019 Page 73 Review Article

Systematic Review of The Impact of Deployment on Respiratory Function of Contemporary International and Australian Veterans’

H Ighani, E Lawrence-Wood, SJ Neuhaus, A McFarlane

Abstract Current international literature suggests a higher prevalence of respiratory conditions in military personnel during and following deployment to the Middle East for reasons that are not well understood. Therefore, a systematic review of research into the impacts of deployment on respiratory function among international and Australian contemporary military Veterans was undertaken.

The findings from this review suggest that deployment-related environmental, psychological trauma exposures and other military factors such as physical activity, increased tobacco use and individual susceptibility markers could contribute to respiratory conditions and other health effects not yet identified.

Key words: respiratory conditions, Middle East, military veterans, deployment, risk factors, exposure

Introduction Although many studies have reported increases in respiratory conditions and symptoms among military During the last decade, over 2.5 million United personnel, existing knowledge regarding underlying States (US) and coalition troops have deployed aetiology is yet to be fully clarified. Therefore, a to Iraq and Afghanistan.1-3 In addition to combat systematic review of research into the impacts injuries, late health effects of operational service of deployment on respiratory function among are well recognised 4, particularly psychological contemporary military Veterans of deployments to the and physical effects of deployment exposures. MEAO was undertaken. The aim of this review was There is also increasing evidence suggesting a to examine the evidence regarding specific exposures higher prevalence of respiratory conditions among and risk factors in the deployment environment international military personnel deployed to the that could be associated with respiratory symptoms Middle East Area of Operations (MEAO).5-7 Although and illnesses among military Veterans, and to no specific risk factors other than deployment ascertain whether there are unique risk factors and have been definitively linked to these respiratory manifestations of respiratory health among deployed health outcomes, there are many characteristics personnel. In this review, we summarise the existing of deployment that may raise the risk of adverse published research related to the respiratory respiratory health effects, including exposure to health of military personnel deployed to Iraq and various airborne contaminants, burn pits, dust, Afghanistan, and examine evidence regarding particulate matter, industrial fires and traumatic associations between various deployment and other exposure.5, 6 In addition, evidence suggests tobacco factors, and respiratory health. To provide context smoking, physical activities and other individual for the review, we first describe key respiratory susceptibility factors such as age, sex, body mass health outcomes and potential exposures relevant index (BMI), blood pressure, physical fitness, pre- to the military and deployed environment, and how existing conditions and personal characteristics these could be associated with respiratory health of may also increase the risk of respiratory symptoms MEAO deployed Service members. Following this, the and may enhance susceptibility to environmental available evidence regarding the association between exposures.8-11

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military deployment risk factors and respiratory Key findings of articles, country of origin, health will be reviewed. measurement, population and sample size are presented in Appendix 1. Where possible a military Methods comparison group was preferred; however, broader criteria were used to provide the most comprehensive A systematic literature search of library databases overview of available published research. Due to the was undertaken in May 2016, including, Embase, limited research in this area, studies of lower levels of PubMed and Scopus. Emtree and MeSH Indexing evidence addressing issues of interest were retained, languages were used in Embase and PubMed although findings were interpreted with caution and databases respectively (there is no indexing language used as supporting rather than primary evidence available for Scopus). The following keywords were sources. A total of 172 papers were evaluated by the searched in titles, abstracts and texts: respiratory, lead author, with ~50% n=87) also evaluated by the respiratory tract diseases, lung disease, acute lung second author. Following this process, a total of 85 injuries, lung function test, respiratory function, papers were included in this review (see Figure 1). veterans, veteran’s health, military, military personnel, defence, deployment, armed conflicts, Figure 1: Studies obtained from initial database searches Afghan campaign 2001, Operation Enduring Freedom (OEF), Iraq wars 2003-2011,Operation Initial database searches n= 3630 (3526 from databases+104 by Iraqi Freedom (OIF), air pollutants, environmental pearling) exposure, inhalational exposure, air environmental pollutant, combat disorder, trauma and stressor Removed duplicates: n= 1029 related disorder, and tobacco smoking. Excluded based on tiltle, abstract: n=2320 To broaden the search, the reference lists of all included studies were examined to identify any other Excluded based on relevance and full text screening: n=109 potentially relevant papers (pearling). Results were limited to studies published in English from the year Excluded following evaluation: n=86 1997 to 2016.

Exclusion criteria from the initial search included: Total number of included papers: n=85

• Editorials or correspondence Results • Items that were not journal articles, reviews, clinical trials, government publications or Preliminary assessment of studies identified the observational studies following key areas where the impact of deployment on these respiratory outcomes could be examined. • Languages other than English • Environmental and/or chemical exposures • Published prior to 1997 including; particulate matter (including metal particles), burn pits and air pollution • Items not published in peer-reviewed journals • Trauma and combat exposures including; blast, • Included ages less than 18 trauma/stress • Items that did not involve military, veterans or • Other exposures/factors including; physical servicemen activity, smoking and individual susceptibility • Items that did not report respiratory problems. factors.

Included studies were assessed on their design and Papers were grouped accordingly. An assessment level of evidence according to the Australian National of the available evidence was summarised for each Health and Medical Research Council (NHMRC) outcome, and conclusions regarding the state of hierarchy of evidence.12 Inclusion criteria were evidence in the area as a whole presented, including further refined to focus on: an overview of notable gaps. Key study information and findings, organised by topic, are summarised in • Deployed Service members or Veterans of military Appendix 1. forces

• The impact of deployment exposures and associations with respiratory health.

Volume 27 Number 1; January 2019 Page 75 Review Article

Respiratory health outcomes in deployed candidates with mild asthma may be considered military populations for entry to the ADF subject to certain criteria, including normal spirometry and negative bronchial International studies have documented an increased provocation testing.18 However, rates of asthma incidence of respiratory disorders in military personnel among serving military personnel are generally low, who served in the Middle East compared with non- in comparison to the general population. Despite deployed populations.5-7 Overall, studies have low asthma rates at intake into the military, asthma reported increased rates of non-specific respiratory diagnoses have increased in the US military since symptoms, asthma and constrictive bronchiolitis the beginning of the Iraq Afghanistan war.6, 19 The in deployed military personnel, with evidence that US Department of Defense reported that 13% of US exposures while on deployment contribute to this Army Medical visits in Iraq were for new-onset acute via direct actions and by disturbance of the immune respiratory illness.16 system. Recently, an increasing number of studies have In a study of the causes underlying respiratory reported consistent positive associations between symptoms in military personnel returning from duty psychosocial stress and asthma6, 13, 16, 20 suggesting in Iraq and Afghanistan by Morris et al. (2013), 42% that, in the context of military service and deployment of US Veterans reported non-specific respiratory specifically, both environmental exposures and symptoms, although most did not reach the threshold also the psychological stress of deployment should for a specific clinical diagnosis.13 The majority of be considered as important contributing factors. patients who did receive a specific diagnosis had In relation to deployment specifically, several evidence of asthma or nonspecific airway hyper- studies provide evidence of an association between reactivity. This may have reflected aggravation of deployment and new-onset asthma and other pre-existing disease13 or hyper-activation of the respiratory symptoms.6, 16, 19 A retrospective review immune system.14 Smith et al. (2009) also reported of medical diagnoses by Szema et al. (2010) of more that deployment was associated with respiratory than 6 000 US military personnel deployed and symptoms in both US Army and Marine Corps subsequently discharged from military active duty, personnel, independent of smoking status and reported that deployment to Iraq was associated deployment length was positively associated with with a higher risk of having a new International increased symptom reporting in Army personnel. Classification of Diseases-9 (ICD-9) diagnosis This study concluded that specific exposures rather of asthma post deployment.16 Similar findings than deployment in general are determinants of post- were documented in occupationally exposed first deployment respiratory illness.6 Further recent US responders to the World Trade Center disaster.21-23 studies have also implicated inhalational exposures during deployment as predictors of constrictive In a case control study, Abraham et al. (2012) bronchiolitis and new-onset asthma in Veterans.15, 16 reported an increase in post-deployment respiratory symptoms and medical encounters for obstructive In this review, we describe the most prevalent pulmonary diseases, relative to pre-deployment respiratory health outcomes reported among rates, in the absence of an association with military personnel including asthma, constrictive cumulative deployment duration or total number of bronchiolitis (CB), chronic obstructive pulmonary deployments, indicating that it may be more specific disease (COPD), respiratory infection and acute exposures having an impact rather than deployment eosinophilic pneumonia (AEP). alone.24 However, in contrast, DelVecchio et al. (2015) evaluated 400 US Army personnel with a clinical Asthma diagnosis of asthma and found that there was no significant relationship between rates of diagnosis Asthma, a form of reversible bronchospasm, is or severity based on history of deployment.25 The usually connected to allergic reaction or other findings from this retrospective study may indicate forms of airway hypersensitivity. Given the nature that deployment-related lung conditions are subtle of deployment exposures, deployed populations may and require careful evaluation over time to determine be at risk of increased inflammation, which in turn the long-term impacts of deployment on the 17 can impact on respiratory function. Since 2004, US development of respiratory disease. Furthermore, military candidates diagnosed with asthma after the this study did not focus on deployment-related age of 13 have been excluded from military enlistment environmental exposures, which may explain why 16 unless exempted via medical waiver. Entry to the no association was found. Australian Defence Force (ADF) for people with asthma similarly changed post 2007. Currently Despite screening processes in many international militaries, pre-existing disease may also play a role

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in the development of respiratory symptoms. In a deployed military personnel, this study reported that prospective study Morris et al. (2007) examined the impact of deployment on increased diagnosis or airway hyper-reactivity in asymptomatic US military severity of COPD appears minimal.27 personnel.19 Asymptomatic airway obstruction had a prevalence of 14% in young military personnel with Infection evidence of worsening obstruction during exercise. This suggests that rates of asymptomatic asthma may Respiratory infections are the leading cause of be higher than previously recognised. Results of a outpatient treatment during deployment and account cross-sectional study by Roop et al. (2007) suggested for 25–30% of infectious disease hospitalisations in 28, 29 that asthmatics with good baseline symptom US Army personnel. Soltis et al. (2009) found control are similar to non-asthmatics in their risk that 39% of soldiers have had at least one respiratory 30 of developing worsening respiratory symptoms or infection while on deployment. The deployment functional limitations during deployment.26 environment may facilitate transmission of respiratory infections, thereby accounting for higher incidence Overall some studies show increased rates of asthma, rates than comparable civilian populations. Service which may or may not be related to deployment. There members may be exposed to high level of stress, are also suggestions that asymptomatic asthma may contagious novel pathogens, harsh environmental be underestimated, therefore deployment could conditions31 as well as overcrowding and inadequate possibly be exacerbating, rather than causing the hand-washing facilities.32 Respiratory bacteria condition. However, in the absence of mandated and viruses are transmitted person-to-person via pre-enlistment lung function testing, it is difficult to respiratory droplets, and typically result in acute determine the true prevalence of asthma or hyper- self-limiting infections.33 However, highly virulent reactive airways in the enlistment population. and transmissible strains of pathogens can lead to morbidity and mortality.34 Constrictive bronchiolitis (CB) Combat training programs are demanding, involving Constrictive bronchiolitis (CB) is a recognised form not only prolonged periods of physical activity but of non-reversible obstructive lung disease in which also exposure to psychological stressors, sleep bronchioles are compressed and narrowed by deprivation, shifts in daily rhythm, and exposure to fibrosis and/or inflammation. In a descriptive case thermal extremes and high-altitude environments. series by King et al. (2011), 49 soldiers that returned The effects of such challenges on a soldier’s health are from the Middle East with unexplained respiratory complex, resulting in a broad spectrum of changes symptoms underwent lung biopsy.15 Thirty-eight of in the immune system, which may predispose to these soldiers subsequently received diagnosis of various diseases, predominantly of the respiratory CB, an otherwise uncommon diagnosis. The majority tract.8 Although recent attention has been directed of biopsy samples showed polarisable material towards acute morbidities as a result of respiratory consistent with the inhalation of particulate matter, infections, the adverse long-term effects of respiratory even though most of the soldiers were lifelong non- infections are not well understood, specifically in smokers. In addition, thickening of the arteriolar military populations. Given the potentially high rates wall or occlusion in adjacent arterioles was observed, of respiratory infection in deployed personnel, this is which may have been the result of toxic inhalation. an important area for further research.

Chronic obstructive pulmonary disease Acute Eosinophilic pneumonia (AEP) (COPD) Acute eosinophilic pneumonia (AEP) is an A small number of participants in a prospective uncommon, idiopathic lung disease. The diagnosis study of Australian military personnel deployed to is typically based upon clinical testing that include the MEAO were found to meet the global initiative for bronchoalveolar lavage, blood test or smear and chest COPD criteria. A slight but statistically significant radiograph. Lung biopsy is rarely necessary. AEP change to lung function between pre-and post- is characterised by general respiratory symptoms, deployment was also observed among this group, alveolar and or blood eosinophilia, and peripheral specifically between small decreases in the lung pulmonary infiltrates on chest imaging.35 In most function and reported exposure to different chemical cases the acute illness lasts less than four weeks. and/or environmental exposures.1 In a retrospective Dry cough, dyspnoea and fever are present in almost review by Matthews et al. (2014), military personnel every patient. Associated symptoms and signs can diagnosed with COPD were investigated. Despite include malaise, myalgia, night sweats, chills and evidence of increased respiratory symptoms in chest pain.35 Some studies suggest that AEP is an

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acute hypersensitivity reaction to an unknown post deployment. These include type, severity and inhaled antigen in an otherwise healthy individual.36 duration of exposure to environmental hazards, Eighteen cases of AEP (including two fatalities) were such as desert dust storms, proximity and duration reported among over 180 000 military personnel of exposure to burn pits or fires, and frequency of deployed in or near Iraq between March 2003 and exposure to air pollution.5 March 2004. All AEP patients were smokers with 78% recently beginning to smoke during deployment Air pollution and all but one patient had significant exposure to fine airborne sand or dust; no other common source Air sampling studies, conducted by US researchers exposure could be identified. The study concluded suggest that multiple sources of air pollution including that ‘recent exposure to tobacco may prime the lung smoke from oil well fires, sand and dust storms, and in some way such that a second exposure or injury, not exclusively burn pit emissions, contribute to poor 46, 48 eg, in the form of dust, triggers a cascade of events air quality in the deployed environment. These that culminates in AEP’.5, 37 AEP was also reported in findings are supported by independent work from 47-49 at least one firefighter following the collapse of the investigators outside of the US; however, there is World Trade Center towers in 2001.38 no data available from longitudinal research studies with objective pulmonary assessments comparing As outlined above, current literature, including case lung function between those deployed to the Middle reports and retrospective cohort studies, suggest a East and non-deployed personnel. A review article by potentially higher prevalence of respiratory symptoms Falvo et al. (2015) summarised current knowledge and respiratory illnesses including asthma,5, 16, 26 about the impact of service and environmental CB,15 COPD,1, 39 and AEP37 among deployed military exposures on respiratory health of military Service personnel. Specific deployment-related exposures members deployed to Iraq and Afghanistan.21 The such as environmental (particulate matter, metal report reviewed 19 studies published from 2001 to particles, burn pit, air pollution), combat (blast, 2014. While studies of environmental exposures, stress) and other exposures (smoking, physical in particular airborne pollutants, have shown an activity, military living conditions) may relate to association with an increased burden of acute these impairments in respiratory function5, 10, 11, 15, 37, respiratory symptoms, studies reporting chronic 40-44 and are discussed below. respiratory diseases do not provide conclusive results, mainly because of the non-representative sample of Environmental and/or chemical exposures the study populations. Data associating airborne hazard exposures to respiratory disease are similarly Military personnel who have served in Iraq and inconclusive. Therefore, there is insufficient evidence Afghanistan have expressed concern about to support any association between air pollution in possible long-term health effects associated with the deployed environment and respiratory health of environmental exposures during deployment, military personnel.21 including toxic industrial chemicals, local combustion 5, 41, 42, 45-47 sources and poor air quality. US Veterans Particulate matter (PM) seeking treatment at Department Veterans Affairs (DVA) clinics after deployment, have reported a high US data suggests that deployment to both Iraq prevalence of environmental exposure and exposure and Afghanistan may pose additional risk factors concerns, although whether this concern translates to respiratory health because of the high levels of to actual adverse respiratory health outcomes is airborne PM and geologic dusts inherent in those unclear. regions.50 A majority (94%) of US Service personnel deployed to OIF and OEF reported exposure to high In line with these concerns, researchers have levels of airborne PM from a range of sources that hypothesised that there may be a relationship may have exceeded environmental, occupational between deployment exposures and respiratory and military exposure guidelines,43, 51 indicating 21, 43, 46, 47 symptoms. Korzeniewski et al. (2013) that these pose a real risk to health. McAndrew et reported that the prevalence of respiratory diseases al. (2012) reported that among MEAO deployed was closely related to environmental factors on personnel, the most prevalent exposures were air deployment, such as exposure to sand and dust pollution (94%), vaccines (86%) and petrochemicals storms, extreme temperature changes and poor (81%).43 Exposures and concern about exposures 7 public health measures. A medical research working were both related to greater somatic symptom group formed to consider lung disease in US soldiers burden, and concern about exposure was highly returning from Iraq and Afghanistan identified a correlated with symptom burden. number of potential risks for developing lung disease

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Metal particles medical encounter rates among personnel deployed to burn pit locations were compared directly to those Another exposure of relevance to the deployed among personnel deployed to locations without environment is metal PM. Biopsied lung tissue from burn pits. No significant differences in respiratory selected deployed US soldiers with unexplained outcomes between these groups were found. respiratory symptoms and history of inhalational exposure, identified the presence of metals including Furthermore, findings from Smith et al. (2012) do iron, titanium and crystalline material. This not support an elevated risk for respiratory outcomes deployment’s inhalational exposure was thought to among personnel deployed within proximity of be the cause of unexplained exertional dyspnoea and documented burn pits in Iraq.45 Comparing burn diffuse CB conditions in these soldiers.15 Exertional pit exposed and non-exposed groups, this study dyspnoea is excessive shortness of breath and mainly observed similar proportions of newly reported CB reflects poor ventilation or oxygen deficiency in and emphysema (1.5% vs 1.6% respectively), newly circulating blood. CB is a rare, small airway fibrotic reported asthma (1.7% vs 1.6%), and respiratory respiratory disease. The cause of this condition is still symptoms in 2007 (21.3% vs 20.6%). Similarly, unknown, although it is thought that environmental a study by Baird et al. (2012) reported that while factors and genetic susceptibility could be major potential exposure to sulphur plant fires was contributors to the development of the disease.52 King positively associated with self-reported health et al. (2011) found that in 38 of 49 previously healthy concerns and symptoms, it was not associated soldiers with unexplained exertional dyspnoea and with an increase in clinical encounters for chronic diminished exercise tolerance after deployment, respiratory health conditions.44 Powell et al. (2012) an analysis of biopsy samples showed diffuse CB, found no increase in chronic multi-symptom illness possibly associated with inhalational exposure.15 (CMI) symptom reporting in military personnel deployed to three selected bases with documented Burn pit burn pits compared with other deployment sites.53 However, limitations in standardising exposures A further identified exposure for respiratory insult, may have biased these results. again common in the MEAO, is open-air burning of rubbish and other waste. Although the extent of the Toxicological, epidemiological and clinical data chemicals released in burn pits is unknown, ambient are limited and prevent reliable evaluation of air sampling performed in selected Middle East the prevalence or severity of adverse effects of regions has revealed that smoke from burn pits is a inhalational exposures to PM or burn pit combustion major source of air pollution.42 Some air pollutants products in military personnel deployed to Iraq such as dioxins, carbon monoxide, volatile organic and Afghanistan. The current clinical evidence on compounds from burning of trash, vehicle/generator the effect of deployment on respiratory health is exhaust, oil well fires, gases from industrial facilities, primarily retrospective and does not provide clarity and contaminants from dust containing silica, regarding specific causative factors or the effect on asbestos, lead, aluminium and manganese are well the deployed population as a whole.21 Taken together, recognised carcinogens. Other agents may irritate these findings suggest that environmental exposures the respiratory system causing acute cough or including burn pits and air pollution may be shortness of breath, hypersensitivity pneumonitis, associated with subjective physical health symptom irritant induced asthma and CB, especially when reporting, but there is no evidence of increased rates exposures are repetitive or exceed recommended of objective respiratory health outcomes. concentrations.45 Regardless of the source, it seems likely that higher Evidence to support long-term adverse effects of levels of air pollution are common in many deployment exposure to burn pits is controversial. Although areas and could contribute to future pulmonary and some studies have found that deployment may be other health effects not yet identified.48 Together, associated with a subsequent risk of developing these findings indicate that while deployment appears respiratory conditions. Abraham et al. (2014) to be associated with adverse respiratory outcomes, suggests that elevated medical encounter rates this cannot be reliably attributed to environmental (visits to medical centres for respiratory outcomes exposures. Other deployment exposures that should including general respiratory system and other chest also be considered include trauma, particularly blast symptoms, asthma, COPD, bronchitis, emphysema, trauma and psychosocial stress associated with a bronchiectasis and extrinsic allergic alveolitis) were combat environment. not uniquely associated with burn pits.42 In this study,

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Combat exposures Trauma/stress In addition to the frequent and proximate exposures Blast to ambient airborne hazards, factors unique to In addition to air pollution and smoke from burn military service that may make military personnel pits, military Veterans who have served in Iraq more vulnerable to greater respiratory health risk and Afghanistan may have been exposed to other include high levels of psychological stress.21 Vocal significant respiratory stressors, such as aerosolised cord dysfunction (VCD) refers to abnormal closing of metals and chemicals from improvised explosive the vocal cords when inhaling or exhaling. It is often devices (IEDs), or to traumatic respiratory insult misdiagnosed as asthma in the clinical setting and such as blast overpressure or shock waves to the has been reported in military personnel.50 A study lung.54 of exertional dyspnoea in US military personnel demonstrated that 12% of patients evaluated had Concern about the effects from embedded metal evidence of VCD, most of which was exercise related. fragments from IEDs used in the Middle East conflicts Morris et al. suggested that the development of has been raised among Service members. As a result, VCD in the deployed environment might be related the US DVA established a special registry in 2008 for to nonspecific upper airway irritation, underlying medical surveillance and management of Veterans psychiatric conditions and/or significant stress with retained metal.51 Some of the embedded metal attributed to the combat environment.50 contaminants, including aluminium, arsenic, cobalt, chromium and nickel, may have immunogenic There is also growing evidence for an association respiratory health effects. In a recent report from the between exposure to traumatic stress, including Toxic Embedded Fragment Surveillance Centre, of childhood maltreatment or combat experience 89 urine samples tested, 47% exceeded the reference and pulmonary diseases such as asthma, CB and value for aluminium and 31% for tungsten.55 COPD.60-63 This relationship was also demonstrated in adult research populations exposed to the 11 Recently, publication of an unusual case report of September 2001 World Trade Center terrorist attack. chronic beryllium disease (CBD) was described in a More specifically, moderate associations between 41-year-old Israeli soldier who suffered mortar shell probable post-traumatic stress disorder and injury with retained shrapnel in the chest wall. This respiratory symptoms have been observed in first report raised the possibility of shrapnel- induced CBD responders to the World Trade Center disaster.22, 23, from long-term exposure to the surface of retained 60, 64 aluminium shrapnel fragments in the body.56 A cross-sectional study conducted by Spitzer et It has been proposed that Service members al. (2011), analysed the associations between lung who sustained subclinical blast injury may be function, trauma exposure and post-traumatic susceptible to long-term sequelae. Apart from stress disorder (PTSD) in 1 772 adults from the direct consequences of blast injuries such as blast general population using standardised questions pressure wave, fragments of debris or injuries and spirometry test.60 Those with a diagnosis of PTSD due to acceleration or deceleration, there are also had a significantly greater risk of having asthma less obvious injuries caused by a blast including symptoms than those without PTSD. However, psychological trauma, burns and toxic-substance those with a history of psychological trauma, but exposure from inhalation of hot contaminated no diagnosis of PTSD, did not have an elevated risk, air.57,58 Such injuries can have unpredictable long- suggesting the association is specific to disorder term outcomes including permanent fibrosis of the status rather than symptomatology or trauma bronchial mucosa.59 exposure. Analyses indicated that subjects with diagnosed PTSD had a significantly increased risk Despite the high plausibility of long-term adverse for airflow limitation independent of its definition. effects following acute pulmonary blast injury, there is an absence of data on the long-term outcomes. One possible mechanism underpinning the Furthermore, the possibility of other long-term association between stress and reduced respiratory pulmonary consequences of blast exposure, such function could be increased levels of systemic as the effect of explosion-related dust exposure, inflammatory markers.20, 65-68 Excessive pro- and other exposures such as smoking, has not been inflammatory responses may cause airway damage adequately examined. Overall there is limited data and consequently structural and functional to support a conclusion regarding an association pulmonary changes.31 Hypothetically, higher levels between exposure to blast and long-term respiratory of stress during deployment among personnel may, outcomes.57

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in part, explain the increased rate of respiratory reported respiratory illnesses during deployment; symptoms reported in recent studies. There is suggesting that factors other than tobacco use increasing evidence of associations between stress were likely to contribute to the observed respiratory related mental disorders such as PTSD and altered symptoms and morbidity. immune responses, and elevated circulating inflammation. The direction of this association Findings from a prospective study of Australian is not conclusive, however. Regardless, low level military personnel deployed to the MEAO showed that inflammation and altered immune response provide those respondents who began or resumed smoking plausible mechanisms by which trauma exposure while on deployment were also likely to have more may be associated with respiratory symptoms.20, 60, co-morbidities compared to those who did not smoke 1 65-68 on deployment. Similarly, those who smoked more than usual were likely to have more co-morbidities Other exposure factors compared to those who did not smoke.1 However, the relative impact of different exposures and other In addition to deployment specific risks, evidence non-smoking related risk were not examined in this suggests other military factors such as physical population. activity, increased tobacco use and other individual susceptibility factors may increase the risk of Since the 1960s, the rate of tobacco smoking has respiratory symptoms and enhance susceptibility declined in the US including in the military.71 to environmental and trauma exposures in this However, the rate of tobacco smoking among active population. duty military personnel remains higher (32%) compared to the general population (~20%).71 Within Physical activity the US military population, the prevalence of smoking is approximately 40% higher among Veterans and Researchers have suggested that physical activity 50% higher among deployed military personnel performed in stressful environments alters compared with their non-deployed counterparts.71 immune function.17 Light physical activity or In a cross-sectional study by Sanders et al. (2005), moderate environmental stress stimulate immune it was reported that 47.6% of US military personnel responses, but exhausting physical activity or severe deployed to Iraq and Afghanistan began or resumed environmental stress can have immune suppressant smoking while deployed and ~40% smoked half a effects, manifested by a temporary increase in pack of cigarettes or more per day.31 High rates of susceptibility to respiratory infections.9 Multiple tobacco smoking are not restricted to US military physical and psychological stressors, such as those personnel but are also increased 40%–60% among encountered on deployment, may induce alterations coalition militaries.72 in immune parameters (as discussed above) and/ or neurological and endocrine responses; these While specific factors contributing to smoking rates common exertion-induced pathways could result in have not been ascertained, the significant smoking respiratory tract syndromes.8 uptake observed in a number of studies is thought to relate to deployment stress particularly among Smoking those with prolonged deployments, or combat exposures.73 Combat exposure, military stressors Cigarette smoking has been associated with and PTSD have all been identified also as predictors 5-7, morbidity and mortality in a number of studies. for cigarette smoking.74, 75 As discussed above, 21, 31, 69, 70 Pathological mechanisms of smoking and these psychological risk factors and mental health its adverse health effects generally overlap with disorders have also been associated with respiratory environmental air pollution. Smoking has also been symptoms, abnormal lung function and diseases related to increased susceptibility to respiratory such as asthma.20, 76 Although tobacco smoke 70 insult from airborne hazards. Interestingly, there may differ in many respects from the ambient air is no clear evidence of direct effects of smoking pollution in deployed settings, the contribution of on respiratory outcomes in deployed military tobacco smoke exposure to military personnel’s populations. For example, Sanders et al. found that cumulative exposures to airborne hazards while on approximately 70% of US military personnel deployed deployment cannot be underestimated, given the to Iraq and Afghanistan reported at least 1 episode prevalence and intensity of tobacco use in stressful of an acute respiratory illness and 15% reported combat situations.21 The potential for smoking to 3 or more incidents of respiratory illnesses during interact with and/or exacerbate other environmental 31 their deployment. There was, however, no observed or stress exposures is of importance to examine. relationship between cigarette smoking and self-

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Individual susceptibility factors health. Cross-sectional studies are carried out at one period and do not indicate the series of events, Studies regarding the association between respiratory therefore it is difficult to determine the relationship health conditions and individual factors (age, sex, between exposure and outcome as it lacks the time BMI, blood pressure, physical fitness, pre-existing element. conditions and personal characteristics) in general the population and deployed military personnel Previous studies have largely relied on self-report generally focus on single respiratory outcomes and data to measure the impact of exposures on are usually assessed using different methods. respiratory health. This type of measurement is open to recall bias, particularly when data is collected well In a cross-sectional study, data collected from a after exposures have occurred.31, 26 Medical record European Community Respiratory Health survey of reviews are predominantly retrospective7, 16, 39 and 16 countries were examined. The aim of this study therefore also subject to potential biases (reflected in was to estimate the age and sex-specific incidence documentation and health care seeking). of asthma from birth to the age of 44 in men and women across several countries, and to evaluate the Discussion main factors influencing asthma incidence in young adults. This study demonstrated that there are Long-term psychological and physical health effects different patterns of asthma incidence in men and following deployment are of concern to Veterans, women. During childhood, girls had a significantly healthcare providers and the community. While some lower risk of developing asthma than did boys. international literature suggests a higher prevalence Around puberty, the risk was almost equal in the two of respiratory conditions in military personnel during sexes, while after puberty, the risk in women was and following deployment to the Middle East, findings significantly higher than that in men.77 are equivocal and the exact reasons underpinning any elevated respiratory health consequences In a case control study of active duty and retired are not well understood. Some inconsistencies in US military members, increasing BMI, younger findings could be due to difficulties retrospectively age, gender, non-active duty beneficiary status and standardising for exposure; reliance on self-reported arthritis were significant independent predictors of symptoms or conditions, or inconsistent application 78 asthma in this population. Similarly, Abraham et of ICD codes, making it difficult to say with certainty al. (2012) reported that gender, enlisted and Army which conditions are increasing in incidence or personnel remained independent predictors of having prevalence. Furthermore, many studies have 39 a new obstructive pulmonary disease encounter. focused on limited exposure and outcome variables. Age and combat occupations were not statistically The potential interaction of these factors, and their significantly associated with a post-deployment effects on multiple respiratory outcomes, has not obstructive pulmonary disease diagnosis. The way in been thoroughly considered. which these factors might interact with deployment exposures to influence respiratory health outcomes Current evidence (mainly from US studies) indicates has not been thoroughly studied. This deserves that deployment-related environmental (PM, burn further attention in larger epidemiological studies, pit, air pollution, metal particles), combat (blast, particularly given emerging evidence of their stress) and other exposures (smoking, physical influence on physical and psychological health. activity, military living conditions), and psychological trauma more generally, may be associated with Limitations several respiratory conditions in military personnel, such as asthma,5, 16, 26 CB,15 COPD,1, 39 sinusitis,40 Due to the limited research regarding respiratory and AEP37. These associations may be via direct health of MEAO deployed Service members, studies actions and by disturbance of the immune system. of lower levels of evidence addressing issues of Psychological stress, while highly prevalent in interest were discussed in this review, although relation to deployment, is a less investigated risk findings were interpreted with caution and used as factor for respiratory health outcomes and its supporting rather than primary evidence sources. contribution to respiratory health outcomes and A number of studies in this review were of cross- potential mechanisms underlying associations, as sectional design; consequently, any respiratory well as potential predictors of good or poor health 61, 68, 79-85 health issues in existence before an exposure were over time, are not well understood. not accounted. Without baseline data, it is not Taken together, further prospective and cross- possible to accurately assess the impact of specific sectional analyses are needed to clarify relationships deployment exposures on a person’s respiratory

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between the individual and combined impacts of environmental and psychological exposures Corresponding author: Honey Ighani, on deployment, and any potential moderating or [email protected] 1,2 1,2 mediating effects of other factors on respiratory Authors: H. Ighani , E. Lawrence-Wood , 1 1,2 outcomes. S. J. Neuhaus , A. McFarlane Author Affiliations: 1 The University of Adelaide 2 Centre for Traumatic Stress Studies

References 1. Davy C, Dobson A, Lawrence-Wood E, et al. The Middle East Area of Operations (MEAO) Health Study: Prospective Study Report. University of Adelaide, Centre for Military and Veterans Health, Adelaide, Australia. 2012. 2. Veterans for Common Sense, ‘Iraq and Afghanistan Impact Report’. January 2012. 3. UK Ministry of Defence. Defence Statistics.17 August 2015. Available from: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/498068/PUBLIC_1439893241.pdf. 4. Hyams KC, Wignall S, Rosewell R, War syndromes and their evaluation: from the US Civil War to the Persian Gulf War. Ann of Intern Med 1996;125:398–405. 5. Rose C, Abraham J, Harkins D, et al. Overview and recommendations for medical screening and diagnostic evaluation for postdeployment lung disease in returning US warfighters. J Occup Environ Med. 2012;54(6):746–51. 6. Smith B, Wong CA, Smith TC, et al. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 2009;170(11):1433–42. 7. Korzeniewski K, Nitsch-Osuch A, Konarski M, et al. Prevalence of acute respiratory tract diseases among soldiers deployed for military operations in Iraq and Afghanistan. Adv Exp Med Biol. 2013;788:117–24. 8. Korzeniewski K, Nitsch-Osuch A, Chciałowski A, et al. Environmental factors, immune changes and respiratory diseases in troops during military activities. Respir Physiol Neurobiol. 2013;187(1):118–22. 9. Shephard RJ. Immune changes induced by exercise in an adverse environment. Can J of Physiol and Pharmacol. 1998;76: 539–46. 10. Miller D, Kalman D, Ren X, et al. Health behaviours of veterans in the VHA: Tobacco abuse: 1999 large health survey of VHA enrollees. Washington, DC: VHA Office of Quality and Performance, Department of Veteran Affairs. 2001. 11. McKinney WP, McIntire DD, Carmody TJ, et al. Comparing the smoking behaviour of veterans and nonveterans. Public Health Rep.1997;112:212–17. 12. Merlin T, Weston A, Tooher R. Extending an evidence hierarchy to include topics other than treatment: revising the Australian ‘levels of evidence’. BMC Medical Research Methodology, 2009;9(1):34–41. 13. Morris MJ, Dodson DW, Lucero PF, et al. Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures. Am J Respir Crit Care Med. 2014;190(1):77–84. 14. Flierl MA, Perl M, Rittirsch D, et al. The role of C5a in the innate immune response after experimental blunt chest trauma. Shock. 2008;29 (1):25–31. 15. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011;365(3):222–30. 16. Szema AM, Peters MC, Weissinger KM, et al. New-onset asthma among soldiers serving in Iraq and Afghanistan. Allergy Asthma Proc. 2010;31(5):67–71. 17. Gomez-Merino D, Drogou C, Chennaoui M, et al. Effects of combined stress during intense training on cellular immunity, hormones and respiratory infections. Neuroimmunomodulation. 2005;12(3):164– 172. 18. Bailey J, Williams F. Asthma and eligibility for the Australian Defence Force. Aust Fam Physician. 2009;38(11):897–900.

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19. Morris MJ, Schwartz DS, Nohrenberg JL, et al. Airway hyperreactivity in asymptomatic military personnel. Mil Med. 2007;172(11):1194–7. 20. Douwes J, Brooks C, Pearce N. Asthma nervosa: old concept, new insights. Eur Respir J. 2011;37(5):986–90. 21. Falvo MJ, Osinubi OY, Sotolongo AN, et al. Airborne Hazards Exposure and Respiratory Health of Iraq and Afghanistan Veterans. Epidemiol Rev. 2015;37:116–30. 22. Banauch GI, Alleyne D, Sanchez R, et al. Persistent hyperreactivity and reactive airway dysfunction in firefighters at the World Trade Center. Am J Respir Crit Care Med. 2003;168(1):54–62. 23. Glaser MS, Webber MP, Zeig-Owens R, et al. Estimating the time interval between exposure to the World Trade Center disaster and incident diagnoses of obstructive airway disease. Am J Epidemiol. 2014;180(3):272–9. 24. Abraham JH, Baird CP. A case-crossover study of ambient particulate matter and cardiovascular and respiratory medical encounters among US military personnel deployed to southwest Asia. J Occup Environ Med. 2012;54(6):733–9. 25. DelVecchio SP, Collen JF , Zacher LL, et al. The impact of combat deployment on asthma diagnosis and severity, J of Asthma. 2015;52(4):363–9. 26. Roop SA, Niven AS, Calvin BE, et al. The prevalence and impact of respiratory symptoms in asthmatics and non-asthmatics during deployment. Mil Med. 2007;172(12):1264–9. 27. Matthews T, Abraham J, Zacher LL, et al. The impact of deployment on COPD in active duty military personnel. Mil Med. 2014;179(11):1273–8. 28. Pazzaglia G, Pasternack M. Recent trends of pneumonia morbidity in US Naval personnel. Mil Med. 1983;148:647–51. 29. Armed Forces Health Surveillance Center. Surveillance snapshot: influenza reportable events, Service members and other beneficiaries, 2009–2010. Med. Surveill Mon Rep. 2010;1,17. 30. Soltis BW, Sanders JW, Putnam SD, et al. Self-reported incidence and morbidity of acute respiratory illness among deployed U.S. military in Iraq and Afghanistan. PLoS One. 2009;4(7):e6177. 31. Sanders JW, Putnam SD, Frankart C,et al. Impact of illness and non-combat injury during operations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73(4):713–9. 32. Harris MD, Johnson CR. Preventive medicine in Task Force 1st Armored Division during Operation Iraqi Freedom. Mil Med. 2006;171,807–12. 33. Lee, SE, Eick A, Ciminera P, et al. Respiratory disease in Army recruits: surveillance program overview, 1995–2006. Am. J. Prev. Med. 2008;34(5) 389–95. 34. Brundage JF. Interactions between influenza and bacterial respiratory pathogens: implications for pandemic preparedness. Lancet Infec Dis. 2006;6:303–12. 35. Rhee CK, Min KH, Yim NY, et al. Clinical characteristics and corticosteroid treatment of acute eosinophilic pneumonia. Eur Respir J. 2013;41:402. 36. Badesch DB, King TE Jr, Schwarz MI. Acute eosinophilic pneumonia: a hypersensitivity phenomenon? Am Rev Respir Dis. 1989;139:249. 37. Shorr AF, Scoville SL, Cersovsky SB, et al. Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. JAMA. 2004;292(24):2997–3005. 38. Rom WN, Weiden M, Garcia R, et al. Acute eosinophilic pneumonia in a New York City firefighter exposed to World Trade Center dust. Am J Respir Crit Care Med 2002;166:797. 39. Abraham JH, DeBakey SF, Reid L, et al. Does deployment to Iraq and Afghanistan affect respiratory health of US military personnel? J Occup Environ Med. 2012;54(6):740–5. 40. Barth SK, Dursa EK, Peterson MR, et al. Prevalence of respiratory diseases among veterans of Operation Enduring Freedom and Operation Iraqi Freedom: results from the National Health Study for a New Generation of U.S. veterans. Mil Med. 2014;179(3):241–5. 41. Engelbrecht JP, McDonald EV, Gillies JA, et al. Characterizing mineral dusts and other aerosols from the Middle East–Part 1: ambient sampling. Inhal Toxicol. 2009;21(4):297–326. 42. Abraham JH, Eick-Cost A, Clark LL, et al. A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions. Mil Med. 2014;179(5):540–6.

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43. McAndrew LM, Teichman RF, Osinubi OY, et al. Environmental exposure and health of Operation Enduring Freedom/Operation Iraqi Freedom veterans. J Occup Environ Med. 2012;54(6):665–9. 44. Baird CP, DeBakey S, Reid L, et al. Respiratory health status of US Army personnel potentially exposed to smoke from 2003 Al-Mishraq Sulfur Plant fire. J Occup Environ Med. 2012;54(6):717–23. 45. Smith B, Wong CA, Boyko EJ, et al. The effects of exposure to documented open-air burn pits on respiratory health among deployers of the Millennium Cohort Study. J Occup Environ Med. 2012;54(6):708–16. 46. Helmer DA, Rossignol M, Blatt M, et al. Health and exposure concerns of veterans deployed to Iraq and Afghanistan. J Occup Environ Med. 2007;49(5):475–80. 47. Magnusson R, Hägglund L, Wingfors H. Broad exposure screening of air pollutants in the occupational environment of Swedish soldiers deployed in Afghanistan. Mil Med. 2012;177(3):318–25. 48. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. Washington, DC: The National Academies Press. 2011-2015;180:601–603. 49. Wingfors H, Hägglund L, Magnusson R. Characterization of the size-distribution of aerosols and particle-bound content of oxygenated PAHs, and n-alkanes in urban environments in Afghanistan. Atmos Environ. 2011;45(26):4360–9. 50. Morris MJ, Oleszewski RT, Sterner JB, et al. Vocal cord dysfunction related to combat deployment. Mil Med. 2013;178(11):1208–12. 51. Rose CS. Military service and lung disease. Clin Chest Med. 2012;33(4):705–14. 52. Keicho N, Hijikata M. Genetic predisposition to diffuse panbronchiolitis. Respirology. 2011;16:581–8. 53. Powell TM, Smith TC, Jacobson IG, et al. Prospective assessment of chronic multisymptom illness reporting possibly associated with open-air burn pit smoke exposure in Iraq. J Occup Environ Med. 2012;54(6):682–8. 54. American Thoracic Society. ‘Occupational lung diseases in Iraq and Afghanistan veterans.’ ScienceDaily. 18 May 2011. Available from: www.sciencedaily.com/releases/2011/05/110518105515.htm. 55. Squibb KS, Gaitens JM, Engelhardt S, et al. Surveillance for long-term health effects associated with depleted uranium exposure and retained embedded fragments in US veterans. J Occup Environ Med. 2012;54(6):724–32. 56. Fireman E, Bar Shai A, Lerman Y, et al. Chest wall shrapnel-induced beryllium-sensitization and associated Lung Dis, in press. 57. Institute of Medicine, & Board on the Health of Select Populations committee on Gulf War Health. Gulf War and Health, Long-Term Effects of Blast Exposures. Washington: National Academies Press. 2014;9. 58. Mackenzie IMJ and Tunnicliffe B. Blast injuries to the lung: epidemiology and management. Phil Trans R Soc B. 2011;366: 295–9. 59. Krzywiecki A, Ziora D, Niepsuj G, et al. Late consequences of respiratory system burns. J Physiol & Pharmacol. 2007;58(Suppl 5)(Pt 1):319-25. 60. Spitzer C, Koch B, Grabe HJ, et al. Association of airflow limitation with trauma exposure and posttraumatic stress disorder. Eur Respir J. 2011;37(5):1068–75. 61. Bandoli G, Ghosh JK, von Ehrenstein O, et al. Psychosocial stressors and lung function in youth ages 10–17: an examination by stressor, age and gender. J Pub Health. 2016;1–7. 62. Goodwin RD, Stein MB. Association between childhood trauma and physical disorders among adults in the United States. Psychol Med. 2004;34:509–20. 63. Scott KM, Von Korff M, Alonso J, et al. Childhood adversity, early onset depressive/anxiety disorders, and adult-onset asthma. Psychosom Med. 2008;70:1035–43. 64. Farfel M, DiGrande L, Brackbill R, et al. An overview of 9/11 experiences and respiratory and mental health conditions among World Trade Center Health Registry enrollees. J Urban Health. 2008;85: 880–909. 65. Gan WQ, Man SF, Senthilselvan A, et al. Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis. Thorax. 2004;59: 574–80. 66. Provencal N, Binder E. The effects of early life stress on the epigenome: from the womb to adulthood and even before. Exp Neurol. 2014;268:1–10.

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67. Hẫnsel A, Hong S, Cấmara RJ et al. Inflammation as a psychophysiological biomarker in chronic psychosocial stress. Neurosci Biobehav Rev. 2010;35:115–21. 68. Wright RJ. Epidemiology of stress and asthma: from constricting communities and fragile families to epigenetics. Immunol Allergy Clin North Am. 2011;31(1):19–39. 69. Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses–United States, 2000–2004. MMWR Morb Mortal Wkly Rep. 2008;57(45):1221– 48. 70. Peters A. Air quality and cardiovascular health: smoke and pollution matter. Circulation. 2009;120(11):924–7. 71. Institute of Medicine: Combating Tobacco Use in Military and Veteran Populations. Washington, DC: The National Academies Press, 2009. 72. Bray I, Richardson P, Harrison K. Smoking prevalence amongst UK Armed Forces recruits: changes in behaviour after 3 years follow-up and factors affecting smoking behaviour. J R Army Med Corps. 2013;159(1):44–50. 73. Smith B, Ryan MAK, Wingard DL, et al. Cigarette smoking and military deployment: a prospective evaluation. Am J Prev Med. 2008;35(6):539–46. 74. de Silva VA, Jayasekera NE, Hanwella R. Smoking among troops deployed in combat areas and its association with combat exposure among navy personnel in Sri Lanka. Subst Abuse Treat Prev Policy. 2012;7:27. 75. Harte CB, Proctor SP, Vasterling JJ. Prospective examination of cigarette smoking among Iraq-deployed and non-deployed soldiers: prevalence and predictive characteristics. Ann Behav Med. 2014;48(1):38– 49. 76. Luft BJ, Schechter C, Kotov R, et al. Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers. Psychol Med. 2012;42(5):1069–79. 77. de Marco R, Locatelli F, Sunyer J et al. Differences in incidence of reported asthma related to age in men and women. A retrospective analysis of the data of the European Respiratory Health Survey. Am J Respir Crit Care Med. 2000;162(1):68-74. 78. Young SY , Gunzenhauser JD, Malone KE et al. Body mass index and asthma in the military population of the northwestern United States. Arch Intern Med. 2001:161:1605-11. 79. Weese CB, Abraham JH. Potential health implications associated with particulate matter exposure in deployed settings in southwest Asia. Inhal Toxicol. 2009;21(4): 291–6. 80. Krefft SD, Meehan R, Rose CS. Emerging spectrum of deployment-related respiratory diseases. Curr Opin Pulm Med. 2015;21(2):185–92. 81. Szema AM, Salihi W, Savary K, et al. Respiratory symptoms necessitating spirometry among soldiers with Iraq/ Afghanistan War lung injury. J Occup Environ Med. 2011;53(9):961–5. 82. Morris MJ, Lucero PF, Zanders TB, et al. Diagnosis and management of chronic lung disease in deployed military personnel. Ther Adv Respir Dis. 2013;7(4):235–45. 83. Panos RJ, Krywkowski-Mohn SM, Sherman SN, et al. Patient Reported Determinants of Health: A Qualitative Analysis of Veterans with Chronic Obstructive Pulmonary Disease, COPD: J COPD. 2013;10(3):333–47. 84. Korzeniewski K, Nitsch-Osuch A, Konior M et al. Respiratory tract infections in the military environment. Respir Physiol Neurobiol. 2015;76–80. 85. Carroll D, Philips AC, Gale CR, et al. Generalized Anxiety Disorder is Associated With Reduced Lung Function in the Vietnam Experience Study. Psychos Med. 2011;73:716-20.

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Page 86 Journal of Military and Veterans’ Health Review Article Key Findings - The effects of deployment challenges on a soldier’s health are complex - Could result in a broad spectrum of changes in the immune system and numerous cases of various diseases, with a predominance of respiratory tract infections . - Development and persistence of hyper-reactivity and reactive airways dysfunction were strongly and independently associated with exposure intensity - Hyper-reactivity shortly post-collapse predicted reactive airways dysfunction at 6 months in highly exposed workers - There were higher rates of new-onset obstructive airway disease (OAD) among the high exposure group during the first 15 months and, to a lesser extent, throughout follow-up - No statistically significant associations between PM and cardiorespiratory outcomes were observed in young, relatively healthy, deployed military population Sample size NA - 179 - 8 930 - 2 838 cases Population NA - World Trade Center (WTC) rescue workers - FDNY firefighters who first arrived at the WTC site - US military personnel in southwest Asia Level of evidence NA III-2 II III-1 Design Literature review Retrospective cohort Prospective cohort Case-crossover Measurement NA - Presence of bronchial hyperreactivity - Respiratory objective measures at 1, 3 and 6 months post exposure - Demographic data (FDNY employee database) - Physician diagnoses (electronic medical records) - Self- reported health questionnaires, obtained information regarding WTC exposures, smoking status, and current respiratory symptoms - Personnel and medical record -Meteorological data - ICD-9 codes - Linked ambient PM data with personnel, medical and meteorological data Country Poland USA USA USA Year 2013 2003 2014 2012 Title Environmental factors, immune changes and respiratory diseases in troops during military activities Persistent Hyperreactivity and Reactive Airway Dysfunction in World Trade Firefighters at the Center Estimating the Time Interval Between Exposure to the Trade Center Disaster World and Incident Diagnoses of Obstructive Airway Disease A Case-Crossover Study of Ambient Particulate Matter and Cardiovascular and Respiratory Medical Encounters Among US Military Personnel Deployed to Southwest Asia Key findings of the systematic review of the impact of deployment on respiratory function of contemporary international and Australian Veterans Appendix 1 . Key findings of the systematic review of the impact deployment on respiratory function of contemporary international and Australian Environmental, chemicals, other exposures Author 8 Korzeniewski K 22 Banauch IG 23 Glaser MS 24 Abraham JH

Volume 27 Number 1; January 2019 Page 87 Review Article - This study shows the three main air pollutant types to be geological dust, smoke from burn pits and heavy metal condensates (possibly from metals smelting and battery manufacturing facilities) - OIF deployment is associated with subsequent risk of respiratory conditions - Elevated medical encounter rates were not uniquely associated with burn pits - OEF/OIF veterans seeking clinic treatment at a DVA reported a high prevalence of environmental exposures and exposure concerns . Both negatively impacted health outcomes - Potential exposure to the sulphur fire was positively associated with self-reported health concerns and symptoms - Not associated with clinical encounters for chronic respiratory health conditions - Findings do not support an elevated risk for respiratory outcomes among personnel deployed within proximity of documented burn pits in Iraq - No increased risks if deployed within 3 miles of burn pit of military - Veterans operations in Southwest Asia have deployment-related health and exposure concerns - This will need to be addressed by their ambulatory care physicians NA - 18 430 deployed with burn pit exposure - 6 337 deployed without burn pit exposure - 157 053 non deployed - 469 - 6 352 potentially exposed to sulphur fire; - 4 153 not exposed - 22 297 - 3 585 were within 3 miles of burn pit - 56 NA - Active US military personnel (OIF) - USA OEF/ OIF veterans seen at the Department of Affairs Veterans NJ WRIISC, a tertiary specialty care clinic - US army personnel - US Army and Air Force personnel - OIF and OEF veterans consecutively evaluated at the NJ WRIISC from June 2004 to January 2006 NA III-2 IV III-2 III-2 III-2 Air sampling Retrospective cohort Cross-sectional Retrospective cohort Retrospective cohort Retrospective - Scanning electron microscopy with energy dispersive spectroscopy was used to analyse the chemical composition of small individual particles - Medical record review, ICD-9 codes 490–496, 786 -16-item self-report exposure measure created by a WRIISC Occupational and Environmental Medicine physician - Health survey questionnaire - ICD-9 codes at pre- and post- deployment - Health survey questionnaire at baseline and follow-up - Review of clinical notes in Computerized Patient the DVA Record System (CPRS) USA USA USA USA USA USA 2009 2014 2012 2012 2012 2007 Characterizing Mineral Dusts and Other Aerosols from the Middle East—Part 1: Ambient Sampling A Retrospective Cohort Study of Military Deployment and Post-deployment Medical Encounters for Respiratory Conditions Environmental Exposure and Health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans Respiratory Health Status of US Army Personnel Potentially Exposed to Smoke From 2003 Al-Mishraq Sulphur Plant Fire The Effects of Exposure to Documented Open-Air Burn Pits on Respiratory Health Among Deployers of the Millennium Cohort Study Health and exposure concerns of veterans deployed to Iraq and Afghanistan 41 Engelbrecht JP 42 Abraham JH 43 McAndrew LM 44 Baird CP 45 Smith B 46 Helmer DA

Page 88 Journal of Military and Veterans’ Health Review Article - This study shows the three main air pollutant types to be geological dust, smoke from burn pits and heavy metal condensates (possibly from metals smelting and battery manufacturing facilities) - OIF deployment is associated with subsequent risk of respiratory conditions - Elevated medical encounter rates were not uniquely associated with burn pits - OEF/OIF veterans seeking clinic treatment at a DVA reported a high prevalence of environmental exposures and exposure concerns . Both negatively impacted health outcomes - Potential exposure to the sulphur fire was positively associated with self-reported health concerns and symptoms - Not associated with clinical encounters for chronic respiratory health conditions - Findings do not support an elevated risk for respiratory outcomes among personnel deployed within proximity of documented burn pits in Iraq - No increased risks if deployed within 3 miles of burn pit of military - Veterans operations in Southwest Asia have deployment-related health and exposure concerns - This will need to be addressed by their ambulatory care physicians - High concentrations of PM were identified as the main potential health hazard, with PM2 . 5 and PM10 exceeding both long-term marginal Air-MEGs and short-term negligible Air-MEGs outdoors - In Kabul, the organic chemical composition of particulates revealed high and oxy-PAHs, levels of PAHs which are toxic combustion- related pollutants - Characterisation of PM revealed large differences between the Afghan cities - The largest differences were the significantly higher and concentrations of PAHs for which Kabul had oxy-PAHs, the highest concentrations - There was no increase in CMI symptom reporting in those deployed to three selected bases with documented burn pits compared with other deployers - A significant decrease in DLCO was observed in the victims (98 . 4% vs 85 4%), but not in the control group - A significant decrease in FEV1 (96 . 4% vs 83 4%) was observed in the control subjects - This finding is likely due to smoking and exposure to heavy pollution NA - 18 430 deployed with burn pit exposure - 6 337 deployed without burn pit exposure - 157 053 non deployed - 469 - 6 352 potentially exposed to sulphur fire; - 4 153 not exposed - 22 297 - 3 585 were within 3 miles of burn pit - 56 NA NA - 3 578 - 41 exposed miners - 25 healthy miners NA - Active US military personnel (OIF) - USA OEF/ OIF veterans seen at the Department of Affairs Veterans NJ WRIISC, a tertiary specialty care clinic - US army personnel - US Army and Air Force personnel - OIF and OEF veterans consecutively evaluated at the NJ WRIISC from June 2004 to January 2006 NA NA - US deployers with at least one deployment to an area within 3 miles of a documented burn pit - 41 miners fell victims to a methane explosion with documented thermal injury of the respiratory tract - 25 healthy miners who served as controls NA III-2 IV III-2 III-2 III-2 NA NA II III-2 Air sampling Retrospective cohort Cross-sectional Retrospective cohort Retrospective cohort Retrospective Active air sampling As part of ‘Health risks in military operations’, research project Prospective Retrospective cohort - Scanning electron microscopy with energy dispersive spectroscopy was used to analyse the chemical composition of small individual particles - Medical record review, ICD-9 codes 490–496, 786 -16-item self-report exposure measure created by a WRIISC Occupational and Environmental Medicine physician - Health survey questionnaire - ICD-9 codes at pre- and post- deployment - Health survey questionnaire at baseline and follow-up - Review of clinical notes in Computerized Patient the DVA Record System (CPRS) - Particulate matter (PM10 and PM2 . 5), polycyclic aromatic hydrocarbons (PAHs), n-alkanes, oxygenated PAHs, nitrogen dioxide (NO2), sulfur dioxide, toxic metals, and volatile organic compounds (VOCs) - Samples were collected for 14 consecutives 24 hr periods at two military camps in Afghanistan, Camp Northern Lights (CNL) in Mazar-e Sharif and the ISAF Headquarters in Kabul - Particulate matter (PM10 oxygenated and PM2 . 5), PAHs, n-alkanes, NO2, sulfur PAHs, dioxide, toxic metals, and VOCs - Samples were collected for 14 consecutives 24 hr periods at two military camps in Afghanistan, CNL Mazar-e Sharif and the ISAF Headquarters in Kabul - Data from the 2004–2006 and 2007–2008 survey cycles of the Millennium Cohort Study - Changes in the pulmonary function tests (PFTs) after six years of follow-up in miners who survived a methane explosion USA USA USA USA USA USA Sweden Sweden USA Poland 2009 2014 2012 2012 2012 2007 2012 2011 2012 2007 Characterizing Mineral Dusts and Other Aerosols from the Middle East—Part 1: Ambient Sampling A Retrospective Cohort Study of Military Deployment and Post-deployment Medical Encounters for Respiratory Conditions Environmental Exposure and Health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans Respiratory Health Status of US Army Personnel Potentially Exposed to Smoke From 2003 Al-Mishraq Sulphur Plant Fire The Effects of Exposure to Documented Open-Air Burn Pits on Respiratory Health Among Deployers of the Millennium Cohort Study Health and exposure concerns of veterans deployed to Iraq and Afghanistan Broad Exposure Screening of Air Pollutants in the Occupational Environment of Swedish Soldiers Deployed in Afghanistan Characterization of the size-distribution of aerosols and particle-bound content PAHs, of oxygenated PAHs, and n-alkanes in urban environments in Afghanistan Prospective Assessment of Chronic Multi symptom Illness Reporting Possibly Associated with Open-Air Burn Pit Smoke Exposure in Iraq Late consequences of respiratory system burns 41 Engelbrecht JP 42 Abraham JH 43 McAndrew LM 44 Baird CP 45 Smith B 46 Helmer DA 47 Magnusson R 49 H Wingfors 53 Powell TM 59 Krzywiecki A

Volume 27 Number 1; January 2019 Page 89 Review Article - After 9/11, 67% of adult enrollees reported new or worsening respiratory symptoms -3% reported newly diagnosed asthma, 16% screened positive for probable PTSD, and 8% for serious psychological distress - Newly diagnosed asthma was most common among rescue and recovery workers who worked on the debris pile (4 . 1%) - Exposure was more strongly associated with respiratory symptoms than with PTSD or lung function - The SEM model suggested that PTSD statistically mediated the association of exposure with respiratory symptoms - Paper discussed what is currently known about the effects of PM on human health, focusing on the limited evidence specific to US personnel - Outlined current and planned efforts to utilise sampling data to assess health outcomes in deployed military populations - 71 437 - 8 508 police -12 333 nontraditional responders NA - World Trade - World Center Health Registry (WTCHR) enrollees - 8 508 police and 12 333 non-traditional responders to WTC terrorist attack NA IV IV NA Cross-sectional Cross-sectional Literature review - The WTCHR protocol, including the baseline survey completed using computer- assisted telephone interviewing (CATI) and computer- assisted in-person personal interviewing (CAPI) - Data were derived from the initial examinations that took place ~4 years after 11 September 2001 - Structural equation modelling (SEM) were used to explore patterns of association among exposures, other risk factors, probable WTC- related PTSD based on PCL, physician-assessed respiratory symptoms arising after 9/11, and abnormal pulmonary functioning defined by low forced vital capacity NA USA USA USA 2008 2012 2009 An Overview of 9/11 Experiences and Respiratory and Mental Health Conditions Trade Center among World Health Registry Enrollees Exposure, probable PTSD and lower respiratory illness among Trade Center rescue, World recovery and clean-up workers Potential health implications associated with particulate matter exposure in deployed settings in southwest Asia 64 Farfel M 76 Luft BJ 79 CB Weese

Page 90 Journal of Military and Veterans’ Health Review Article - Current data not adequate to reliablyprevalencethe evaluate or severity of adverse effects of inhalational exposures to PM or burn pit combustion products - The current clinical evidence is primarily retrospective in nature and does not provide any clear information on specific causative factors or the effect on the deployed population as a whole Key Findings - Light physical activity or a moderate level of environmental stress stimulates the immune response - Exhausting physical activity or more severe environmental stress have a suppressant effect, manifested by a temporary increase in susceptibility to viral infections - Emotional stress, anxiety and PTSD precedes the development of asthma both in children and adults - There is evidence that asthma precedes panic disorders and that panic disorders may exacerbate pre-existing asthma (adjusted for smoking, socioeconomic status, BMI and familial and genetic factors) - Among active duty military personnel with career limiting asthma, there is no significant relationship between rates of diagnosis or severity based on history of deployment to SWA NA Sample size NA NA - 400 NA Population NA NA -Army personnel with a clinical diagnosis of asthma were evaluated NA Level of evidence NA NA III-2 Literature review Design Literature review Editorial review Retrospective NA Measurement NA - Editorial review - Electronic medical record USA Country Canada New Zealand USA 2013 Year 1998 2011 2014 Diagnosis and management of chronic lung disease in deployed military personnel Title Immune changes induced by exercise in an adverse environment Asthma nervosa: old concept, new insights The impact of combat deployment on asthma diagnosis and severity 82 Morris MJ Trauma/Combat exposures Author 9 Shephard RJ 20 Douwes J 25 SP DelVecchio

Volume 27 Number 1; January 2019 Page 91 Review Article - The majority of casualties with blast-related lung injury have been very successfully managed with conventional ventilatory support employing a lung protective strategy - Only a small minority requiring non-conventional support in the form of high-frequency oscillatory ventilation - Findings suggest an association of trauma exposure and PTSD with airflow limitation, which may be mediated by inflammatory processes - Study observed reductions in lung function in males related to the absence of a father in the house and family conflict; - Associations were stronger in older males ages 15–17 years for each stressor - Childhood physical abuse was associated with increased risk of lung disease peptic ulcer and arthritic disorders - Childhood sexual abuse was associated with increased risk of cardiac disease - Childhood neglect was associated with increased risk of diabetes and autoimmune disorders . - Childhood adversities and early-onset depressive/anxiety disorders independently predict adult-onset asthma, suggesting that the mental disorder-asthma relationship is not a function of shared background of childhood adversity - 135 - 1 772 - 584 children aged 5 – 17 - 5 877 -18 303 - Military casualties admitted to University Hospital Birmingham’s critical care services, during the period 1 July 2008 to 15 January 2010 - Adults from the general population: with PTSD (n=28), trauma - With (n=887), no - With trauma (n=857) - Adolescents in the Los Angeles Family and Neighborhood Survey - Individuals age 15 to 54 in the non- institutionalised population 2104 Colombia - - Belgium 980 - France 1326 - Germany 1283 - Italy 1698 - Netherlands 1017 - Spain 2006 - Japan 856 - Mexico 2064 - USA 4969 IV IV III-3 IV III-3 Case series Cross-sectional Cross-sectional Cross-sectional Cross-sectional - Plain chest films taken for the diagnosis of adult respiratory distress syndrome - Trauma exposure, PTSD and respiratory symptoms were assessed using standardised questions - Lung function was assessed using spirometry . - Self-report measures - Lung function test with spirometry - Data were drawn from the National Comorbidity Survey - Composite International Diagnostic Interview (CIDI 3 . 0) Mental as part of the World Health surveys - Face to face interview UK Germany USA USA USA 2010 2011 2016 2004 2008 Blast injuries to the lung: epidemiology and management Association of airflow limitation with trauma exposure and post-traumatic stress disorder Psychosocial stressors and lung function in youth ages 10–17: an examination by age and gender stressor, Association between childhood trauma and physical disorders among adults in the United States Childhood Adversity, Early- Onset Depressive/Anxiety Disorders, and Adult-Onset Asthma 58 Mackenzie IMJ 60 Spitzer C 61 Bandoli G 62 Goodwin R 63 Scott K

Page 92 Journal of Military and Veterans’ Health Review Article - The majority of casualties with blast-related lung injury have been very successfully managed with conventional ventilatory support employing a lung protective strategy - Only a small minority requiring non-conventional support in the form of high-frequency oscillatory ventilation - Findings suggest an association of trauma exposure and PTSD with airflow limitation, which may be mediated by inflammatory processes - Study observed reductions in lung function in males related to the absence of a father in the house and family conflict; - Associations were stronger in older males ages 15–17 years for each stressor - Childhood physical abuse was associated with increased risk of lung disease peptic ulcer and arthritic disorders - Childhood sexual abuse was associated with increased risk of cardiac disease - Childhood neglect was associated with increased risk of diabetes and autoimmune disorders . - Childhood adversities and early-onset depressive/anxiety disorders independently predict adult-onset asthma, suggesting that the mental disorder-asthma relationship is not a function of shared background of childhood adversity - There is increasing evidence for a prominent role of epigenetic mechanisms in embedding long-term effect of stress at different developmental stages as well as across generations - These epigenetic mechanisms are distinct for the different stages of stress exposure - Job stress, low socioeconomic status, childhood adversities as well life events, caregiver stress and loneliness were all shown to exert effects on immunologic activity - Evidence increasingly links psychosocial stress to asthma, atopic disorders more broadly and lung function - In models that adjusted for age and height, both GAD (p=0 . 001) and MDD (p = 0 004) were associated with lower FEV1 - In models additionally adjusting for weight, service, ethnicity, marriage, smoking, alcohol consumption, income, education and major illness, GAD was still associated with poorer lung function (p = 0 . 01), whereas MDD was not (p =0 . 18) - 135 - 1 772 - 584 children aged 5 – 17 - 5 877 -18 303 NA NA NA - 4 256 - Military casualties admitted to University Hospital Birmingham’s critical care services, during the period 1 July 2008 to 15 January 2010 - Adults from the general population: with PTSD (n=28), trauma - With (n=887), no - With trauma (n=857) - Adolescents in the Los Angeles Family and Neighborhood Survey - Individuals age 15 to 54 in the non- institutionalised population 2104 Colombia - - Belgium 980 - France 1326 - Germany 1283 - Italy 1698 - Netherlands 1017 - Spain 2006 - Japan 856 - Mexico 2064 - USA 4969 NA NA NA - Participants from the Vietnam Experience Study Entered military service between 1965-1971; served only one term of enlistment; served at least 16 weeks of active duty IV IV III-3 IV III-3 NA NA III-2 III-2 Case series Cross-sectional Cross-sectional Cross-sectional Cross-sectional Literature review Literature review Epidemiological review Cross-sectional - Plain chest films taken for the diagnosis of adult respiratory distress syndrome - Trauma exposure, PTSD and respiratory symptoms were assessed using standardised questions - Lung function was assessed using spirometry . - Self-report measures - Lung function test with spirometry - Data were drawn from the National Comorbidity Survey - Composite International Diagnostic Interview (CIDI 3 . 0) Mental as part of the World Health surveys - Face to face interview NA NA NA - One-year prevalence of Generalized Anxiety Disorder (GAD) and major depressive disorder (MDD) was determined using DSM-III criteria - Forced expiratory volume in 1 second was measured by spirometry UK Germany USA USA USA Germany USA USA USA 2010 2011 2016 2004 2008 2014 2010 2011 2011 Blast injuries to the lung: epidemiology and management Association of airflow limitation with trauma exposure and post-traumatic stress disorder Psychosocial stressors and lung function in youth ages 10–17: an examination by age and gender stressor, Association between childhood trauma and physical disorders among adults in the United States Childhood Adversity, Early- Onset Depressive/Anxiety Disorders, and Adult-Onset Asthma The effects of early life stress on the epigenome: From the womb to adulthood and even before Inflammation as a psychophysiological biomarker in chronic psychosocial stress Epidemiology of Stress and Asthma: From Constricting Communities and Fragile Families to Epigenetics Generalized Anxiety Disorder Reduced is Associated With Lung Function in the Vietnam Experience Study 58 Mackenzie IMJ 60 Spitzer C 61 Bandoli G 62 Goodwin R 63 Scott K 66 Provençal N 67 Ha ̈nsel A 68 RJ Wright 85 Carroll D

Volume 27 Number 1; January 2019 Page 93 Review Article Key Findings - The likelihood of ever having smoked cigarettes was higher for veterans than nonveterans and for women veterans than for women nonveterans . - The prevalence of current smoking was higher for veterans than for non-veterans and higher for those seeking system care within the DVA than for other veterans . - There were clear differences between service, rank and trade groups in smoking prevalence at recruitment - Smoking levels increased in the 3 years after recruitment to the Armed Forces . - Military deployment is associated with smoking initiation and, more strongly, with smoking recidivism, particularly among those with prolonged deployments, multiple deployments or combat exposures - There was significant association between current smoking and combat experiences - Current smoking was strongly associated with current alcohol use - Prevalence of current smoking was less among military personnel than in the general population . - Prevalence of smoking was significantly higher among Special Forces personnel . Sample size - 3 372 veterans vs 18 606 nonveterans - 133 female veterans vs 12 063 female nonveterans - 173 veterans using DVA system vs 2 218 veterans who sought care elsewhere . - 10 531 - 48 304 - 259 Special Forces - 412 regular navy personnel Population - Random sample of veterans and the civilian, non- institutionalised population of the United States . - UK recruits in 1998/1999 - US military personnel - SLN Special Forces and regular forces deployed in combat areas Level of evidence III-3 II IV Design Cross-sectional Cohort 3 years follow-up Prospective Cross-sectional Measurement - Self-reported questionnaire data from the 1987 - National Medical Expenditure Survey (NMES) - Survey of the health behaviours -The incidence of new smoking in baseline never-smokers and the prevalence of resumed smoking in baseline past smokers were calculated - The 28 page questionnaire used in the study “Health of UK military personnel deployed to the 2003 Iraq war” was used as the data collection instrument Country USA UK USA Sri Lanka Year 1997 2013 2008 2012 Title Comparing the Smoking and Behavior of Veterans Nonveterans Smoking prevalence amongst UK Armed Forces recruits: changes in behavior after 3 years follow-up and factors affecting smoking behavior Cigarette Smoking and Military Deployment A Prospective Evaluation Smoking among troops deployed in combat areas and its association with combat exposure among navy personnel in Sri Lanka Other exposures/factors Author 11 McKinney WP 72 Bray I 73 Smith B 74 De Silva VA

Page 94 Journal of Military and Veterans’ Health Review Article - Approximately 48 % of participants smoked at both time points, with 6 % initiating smoking and 6 % quitting - Smoking initiation was associated with warzone stress exposure; - female gender and high military unit support predicted cessation - Military rank and alcohol use were associated with both smoking initiation and cessation - Military service is strongly associated with smoking Key Findings - Poorly understood war syndromes have been associated with armed conflicts (Fatigue, shortness of breath, headache, sleep disturbance, forgetfulness and impaired concentration) - Many types of illness were found among evaluated veterans, including well- defined medical and psychiatric conditions, acute combat stress reaction, PTSD, possibly the chronic fatigue syndrome - n total= 1082 - 773 Iraq- deployed - 309 non deployed - n total= 475 - 319 veterans - 156 civilians Sample size NA - 1082 US Army soldiers serving between April 2003 and September 2006 - Data were drawn from a population- based probability telephone sample of Korean adults in California Population NA II IV Level of evidence NA Prospective Observational study . Quasi- Experimental Design Design Literature review article - Smoking Characteristics, Alcohol Use, Sociodemographic , Military Characteristics, Deployment-Related Stressful Experiences, Nondeployment- Related Stressful Experiences, Traumatic Stress - Telephone interview questionnaire regarding smoking status and behaviour before, during and after military service Measurement NA USA USA Country USA 2014 2012 Year 1996 Prospective examination of cigarette smoking among Iraq-deployed and nondeployed soldiers: prevalence and predictive characteristics South Korean Military Service Promotes Smoking: A Quasi- Experimental Design Title Syndromes and Their War Evaluation: From the U . S Civil to the Persian Gulf War War 75 Harte CB, 86 Allem JP Respiratory health outcomes Author 4 Hyams CK

Volume 27 Number 1; January 2019 Page 95 Review Article - The Working Group - The Working recommended: (1) standardised approaches to pre- and post-deployment medical surveillance (2) criteria for medical referral and diagnosis (3) case definitions for major deployment- related lung diseases -New-onset respiratory symptoms higher in deployers (14% vs . 10%), rates of obstructive disease similar at 1% - Deployment length was linearly associated with increased symptom reporting in Army personnel - Elevated odds of symptoms were associated with land- based deployment as compared with sea-based deployment - Respiratory tract diseases were the most common health problem treated on an outpatient basis, with a prevalence ranging from 46 to 63 cases per 100 persons - The prevalence of respiratory diseases was closely related to the environmental factors, extreme temperature changes, unsatisfactory sanitary conditions - 42% had non-diagnostic evaluation - 20% had airway hyperreactivity - 66% had mental health and sleep disorders NA - 55 021 - 6 071 - n total=50 - 40male - 10 female NA - Millennium Cohort Study participants - Polish Military Contingents relocated to Iraq and Afghanistan - Returning US military personnel NA III-2 III-2 IV Literature review and Recommendations Retrospective cohort Retrospective cohort Descriptive case series NA - Health survey questionnaire at baseline and follow-up - Medical record review - Pulmonary function testing, cardiopulmonary exercise testing, methacholine challenge test, bronchoalveolar lavage, impulse oscillometry system testing and high resolution computed tomography imaging USA USA Poland USA 2012 2009 2013 2014 Overview and Recommendations for Medical Screening and Diagnostic Evaluation for Postdeployment Lung Disease in Returning US Warfighters Newly Reported Respiratory Symptoms and Conditions Among Military Personnel Deployed to Iraq and Afghanistan: A Prospective Population-based Study Prevalence of Acute Respiratory Tract Diseases Among Soldiers Deployed for Military Operations in Iraq and Afghanistan Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE) 5 Rose C 6 Smith B 7 Korzeniewsk 13 Morris MJ

Page 96 Journal of Military and Veterans’ Health Review Article - Blunt chest trauma leads to systemic activation of complement and robust C5a generation, which causes perturbations in defensive functions of neutrophils - C5a might represent a potential target for therapeutic immunomodulation to prevent immune dysfunctions post- trauma - 38/49 soldiers received diagnosis of constrictive bronchiolitis, an otherwise rare illness, which was possibly associated with inhalational exposure - New-onset asthma diagnoses are more common among US veterans returning from Iraq and Afghanistan compared with stateside-stationed troops - Deployment to Iraq and Afghanistan is associated with new-onset asthma - Asymptomatic airway obstruction has a prevalence of 14% in young military personnel - A significant percentage of individuals also have evidence of worsening obstruction during exercise - Screening spirometry may identify early reactive airway disease in asymptomatic individuals - Published data based on case reports and retrospective cohort studies suggest a higher prevalence of respiratory symptoms and respiratory illness consistent with airway obstruction - 4-8 for each experimental condition - 49 - 920 deployed, - 5 335 state side-stationed troops (not deployed) - 222 NA - Wistar Rats - Wistar - US soldiers from Kentucky, with inhalational exposures during service in Iraq and Afghanistan - All US soldiers deployed and discharged from military service during 2004 -2007 - Soldiers who attended the OEF Clinic DVA - Healthy, asymptomatic, US military personnel with no previous history of asthma and <1 year on active duty status NA III-3 III-3 III-2 III-1 II Clinical/ Observational study using animal model Descriptive case series Retrospective Prospective Epidemiologic review - C5a ,Neutrophil, Factor H, Complements, Cytokines, chemokines - Cardiopulmonary exercise, pathology testing, pulmonary gas exchange and minute ventilation, high-resolution computed tomography (CT) - Participants identified through existing database and compared asthma proportions of Iraq/Afghanistan War veterans with deployed stateside - Data source: CD-9 codes 493 . 00–493 92c - Baseline spirometry examination NA Germany UK USA USA USA 2008 2011 2010 2007 2015 The role of C5a in the innate immune response after experimental blunt chest trauma Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan New-onset asthma among soldiers serving in Iraq and Afghanistan Airway Hyperreactivity in Asymptomatic Military Personnel Airborne Hazards Exposure and Respiratory Health of Iraq and Afghanistan Veterans 14 Flierl MA 15 King MS 16 Szema AM 19 Morris MJ 21 Falvo MJ

Volume 27 Number 1; January 2019 Page 97 Review Article - Asthmatics with good baseline symptom control are similar to non-asthmatics in their risk of developing worsening respiratory symptoms or functional limitations during deployment - Similar increase in respiratory symptoms during deployment (10% vs . 13%); more prevalent in asthmatics - Respiratory disease is responsible for 25%–30% of infectious disease–related hospital admissions, with pneumonia cited as the leading medical cause of lost workdays - 39 . 5% had acute respiratory illness, of these, 18 . 5% sought medical care and 33 . 8% reported having decreased job performance because of acute respiratory illness - 69 . 1% had acute respiratory illness during deployment - More than two-third had at least one respiratory illness and 17% of these individuals sought medical care - 2% have been diagnosed with mild pneumonia - 47% either began smoking or restarted smoking during deployment - AEP occurred at an increased rate among this deployed military population and resulted in 2 deaths 78% recently beginning - With to smoke during deployment - There was an increase in post-deployment respiratory symptoms and medical encounters for obstructive pulmonary diseases - 1 073 non- asthmatics - 58 asthmatics - 29 281 - 15 463 - 15 459 - 18 - 532 cases, - 2 128 matched controls - Non- asthmatics, and asthmatics active duty soldiers and Department of Defense contractors returning from OEF - Active duty Naval personnel admitted for pneumonia by primary diagnosis - US troops to Iraq, deployed Afghanistan and the surrounding region - US Military personnel who were deployed to Iraq or Afghanistan in 2003-2004 - US military personnel deployed in or near Iraq - US military personnel with post-deployment medical records IV III-3 IV IV IV III-3 Cross-sectional Retrospective Cross-sectional Cross-sectional study Descriptive case Series Nested case- control - Health survey questionnaire - Medical record data - Health survey questionnaire during deployment - Health survey questionnaire on return from deployment - Morbidity, mortality related to AEP - Medical record review - ICD-9 codes 490–496 USA USA USA USA USA USA 2007 1983 2009 2005 2004 2012 The Prevalence and Impact of Respiratory Symptoms in Asthmatics and Nonasthmatics during Deployment Recent trends of pneumonia morbidity in US Naval personnel Self-Reported Incidence and Morbidity of Acute Respiratory Illness among Deployed U . S Military in Iraq and Afghanistan Impact of illness and non-combat injury during Operation Iraqi Freedom and Enduring Freedom(Afghanistan) Acute Eosinophilic Pneumonia Among US Military Personnel Deployed in or Near Iraq Does Deployment to Iraq and Afghanistan Affect Respiratory Health of US Military Personnel? 26 Roop SA 28 Pazzaglia LTG 30 Soltis BW 31 Sanders JW 37 Shorr AF 39 Abraham JH

Page 98 Journal of Military and Veterans’ Health Review Article - Deployed veterans are at increased risk for sinusitis compared to nondeployed . (odds ratio = 1 . 3) There was no significant difference in asthma or bronchitis risk between deployed and nondeployed veterans - 48% had a truncated flow- volume loop - 83% had a negative methacholine challenge test - 3 of 48 had abnormal spirometry test results - Respiratory illnesses affect mission readiness, burden active duty military and veterans’ health care systems, and may lead to significant morbidity and mortality - Reduced lung function is associated with increased levels of systemic inflammatory markers, which may have important pathophysiological and therapeutic implications for subjects with stable COPD . - Investigators from Vanderbilt University, Nashville, TN, found constrictive bronchiolitis on 38 surgical lung biopsies in a case series of army deployers with unexplained chest symptoms - In a group of 50 consecutive deployed patients evaluated at San Antonio Military Medical 36% were found to Center, have airway hyperreactivity, whereas 42% were undiagnosed - 20 563 - 48 NA NA NA - US veterans - US military personnel (OIF,OEF) evaluated at Landstuhl Regional Medical Center with a new VCD diagnosis post- deployment NA NA NA IV III-2 NA II NA Retrospective cohort Retrospective review/ Descriptive case series Literature review Systematic review Literature review - Health survey questionnaire (National Health Survey for a New Generation of U . S Veterans) - Medical record review, laryngoscopy, spirometry and methacholine challenge test NA NA NA USA USA USA Canada USA 2014 2013 2012 2004 2015 Prevalence of Respiratory of Diseases Among Veterans Operation Enduring Freedom and Operation Iraqi Freedom: Results From the National Health Study for a New Generation of U . S Veterans Cord Dysfunction Vocal Related to Combat Deployment Military Service and Lung Disease Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta- analysis Emerging spectrum of deployment-related respiratory diseases 40 Barth SK 50 Morris MJ 51 Rose C 65 Gan Q 80 Krefft SD

Volume 27 Number 1; January 2019 Page 99 Review Article - New onset Iraq/Afghanistan war lung injury is common and rates of symptoms leading to a diagnosis requiring spirometry are high - Symptomatic soldiers requiring spirometry were more frequent in the Iraq/ Afghanistan group compared with the elsewhere group, with rates of 14 . 5% and 1 8%, respectively - COPD causes pervasive and extensive effects on all aspects of patients’ lives that have significant consequences for their care and management . - ~40–70% of all soldiers participating in recent military operations in Iraq and Afghanistan report to medical treatment facilities due to upper respiratory tract infections - Respiratory health hazards: extreme air temperatures, desert dust, emissions from burn pits, industrial pollutants and airborne contaminants originating from degraded soil - 1816 deployed, - 5 335 non deployed - 42 NA - Compared Iraq/ Afghanistan war veterans to veterans deployed stateside (all soldiers deployed and discharged from military service during March 1, 2004, to December 1, 2010) with - Veterans COPD and high utilisation of VHA healthcare NA III-2 IV NA Retrospective cohort Qualitative study focus group Literature review - Medical record review( data smoking included age, gender, history, deployment location, discharge date, whether they received spirometry, branch of service, diagnoses of TBI and PTSD - Transcripts demonstrated five major themes: (1) Physical and Functional Limitations; (2) Restricted Social Interactions/ Altered Social Networks; (3) Emotional Effects; ( 4) Limitations in the Understanding of COPD; and (5) Complex Healthcare Interactions NA USA USA Poland 2011 2013 2015 Respiratory Symptoms Necessitating Spirometry Iraq/ Among Soldiers With Lung Injury Afghanistan War Patient Reported Determinants of Health: A Qualitative with Analysis of Veterans Chronic Obstructive Pulmonary Disease Respiratory tract infections in the military environment 81 Szema AM 83 Panos RJ 84 Korzeniewski K

Page 100 Journal of Military and Veterans’ Health Review Article

Homeless Indigenous Veterans and the Current Gaps in

- New onset Iraq/Afghanistan war lung injury is common and rates of symptoms leading to a diagnosis requiring spirometry are high - Symptomatic soldiers requiring spirometry were more frequent in the Iraq/ Afghanistan group compared with the elsewhere group, with rates of 14 . 5% and 1 8%, respectively - COPD causes pervasive and extensive effects on all aspects of patients’ lives that have significant consequences for their care and management . - ~40–70% of all soldiers participating in recent military operations in Iraq and Afghanistan report to medical treatment facilities due to upper respiratory tract infections - Respiratory health hazards: extreme air temperatures, desert dust, emissions from burn pits, industrial pollutants and airborne contaminants originating from degraded soil Knowledge: The State of the Literature - 1816 deployed, - 5 335 non deployed - 42 NA

J Serrato, H Hassan, C Forchuk

Abstract

- Compared Iraq/ Afghanistan war veterans to veterans deployed stateside (all soldiers deployed and discharged from military service during March 1, 2004, to December 1, 2010) with - Veterans COPD and high utilisation of VHA healthcare NA Background & purpose: The unique experiences of homelessness for Indigenous Veterans are currently understudied. The purpose of this review was to assess the current literature on homelessness among Indigenous Veterans, to identify the gaps in the existing knowledge base and to provide an insight into future

III-2 IV NA research.

Materials & methods: Electronic databases including CINAHL, PsycINFO, ScienceDirect, Scopus, Homeless Hub and the Journal of Military, Veteran and Family Health were searched for relevant research studies. Search terms included ‘Aboriginal’, ‘Indigenous’, ‘First Nations’, ‘Native’, ‘Métis’, ‘homeless’, ‘homelessness’ and ‘Veterans’. References within articles were also searched. To meet inclusion criteria, articles needed to focus specifically on homeless Indigenous Veterans, and be written in English. Retrospective cohort Qualitative study focus group Literature review

Results: The initial search resulted in 32 research articles. No previous systematic or literature reviews were identified, making this review the first of its kind. One study from the United States (US) met inclusion criteria. This identified study reported that homeless Indigenous Veterans were more likely to use alcohol and spent a greater number of days intoxicated but were less likely to use drugs and experience psychiatric problems compared to white homeless Veterans.

Conclusion: There is currently an inadequate amount of research to draw concrete conclusions, thus further investigation is urgently needed. Only one paper was identified indicating that this is not solely a lack of North American literature, but also a lack of research conducted by the international community. This review - Medical record review( data smoking included age, gender, history, deployment location, discharge date, whether they received spirometry, branch of service, diagnoses of TBI and PTSD - Transcripts demonstrated five major themes: (1) Physical and Functional Limitations; (2) Restricted Social Interactions/ Altered Social Networks; (3) Emotional Effects; ( 4) Limitations in the Understanding of COPD; and (5) Complex Healthcare Interactions NA encourages greater emphasis on future research for potential policy change and recommends an increase in cultural-specific services.

USA USA Poland Keywords: Homelessness, Veterans, Aboriginal, Indigenous, Mental Health, Addiction.

The Homelessness Partnering Strategy, Employment and Social Development

2011 2013 2015 Conflict of Interest Statement: Canada supported this research.

Introduction duration (particularly as housing status can change rapidly) and the type of shelter utilised,1 as well as Homelessness among Veterans has become a research methods, such as point-in-time counts and significant issue for many Western countries yet night-time counts lacking in validity and reliability.2 there has been a lack of censuses investigating Mobility among Indigenous homeless individuals the number of homeless individuals and the in Canada has been found to be frequent with over demographics of such individuals.1 This is largely 40% of respondents stating they had moved more

Respiratory Symptoms Necessitating Spirometry Iraq/ Among Soldiers With Lung Injury Afghanistan War Patient Reported Determinants of Health: A Qualitative with Analysis of Veterans Chronic Obstructive Pulmonary Disease Respiratory tract infections in the military environment due to the challenging nature of enumerating than three times in 6 months and 18% reporting the hidden homeless population with no fixed returning to their home communities seasonally.3 In address, no method of communication and who Canada, it is estimated there are 2 250 Veterans who can migrate nationally as well as locally. There are use homeless shelters every year exact numbers are also differences in defining homelessness based on currently unknown;4 especially as not all homeless 81 Szema AM 83 Panos RJ 84 Korzeniewski K

Volume 27 Number 1; January 2019 Page 101 Review Article

people use shelters. Recent statistics in Canada number of issues including, but not limited to, the suggest that Indigenous peoples make up 28% lack of identification of ethnicity across services to 34% of the homeless population despite only and agencies, an unwillingness to self-identify accounting for 4.3% of the Canadian population as Indigenous for fears of discrimination, a lack with a tendency for higher rates of homelessness of Indigenous-led/Indigenous-specific services in western and northern communities in Canada.5 (including a lack of dissemination regarding these In a study conducted across four Canadian cities services), which has been found to lead to sampling (Calgary, London, Toronto and Victoria), it was and recruitment difficulties, and differences in social found that Indigenous and Métis Veterans made up policy development between municipal/provincial/ 9.7% of the homeless Veterans sample.6 Currently federal and on-Reserve/Indigenous governance there is a lack of research investigating homeless which can lead researchers to make errors.10 As such, Veterans within Canada but in particular there is a it makes the task of identifying specific demographics dearth of literature specifically focusing on homeless (i.e. Veteran status) within this population even Indigenous Veterans. more difficult to ascertain. Further, Kramer et al. highlighted the issue of Veteran identification in the There are unique experiences living in Canada as US across Veteran health services, revealing that there is differentiation among various Indigenous 32 259 of Indigenous Veterans were enrolled on groups (First Nations, Inuit, Métis) as well as the Veterans Health Administration database but geographical and housing differences (on-reserve, only 44% of this sample was identified as having 3 off-reserve, rural, urban, Northern Territories). Veteran status according to the Indian Health Given this, it is important to investigate the issue of Service National Patient Information Reporting Veteran Indigenous homelessness from a Canadian System.11 Although literature from the US exists perspective. Gaetz et al. note that although the Truth regarding these particular issues among Veterans, and Reconciliation Commission report of 2015 does Indigenous participants are often underrepresented; not specifically discuss homelessness, the report less than 2% of the sample.12,13 Additionally, similar states that the legacy of residential schools used studies that have been conducted in the US report for cultural assimilation has resulted in Indigenous participants that do not identify as white, black or individuals being disproportionally affected by Hispanic are considered ‘other’.14 ineffective child protection services, poorer health outcomes, greater rates of substance misuse and In Canada, it has been noted that alcoholism and an overrepresentation within the criminal justice other substance misuse have been cited as key system;5 all of which may be potential factors in factors in contributing to homelessness among increasing the likelihood of homelessness occurring. Veterans followed by mental health issues and Unfavourable historical occurrences such as difficulty in successfully transitioning from the residential schooling may play a role in influencing military to civilian life.5,15 To ease this transition from the homeless rates of Indigenous Veterans. Similarly, military life to civilian life, Forchuk et al. note that the ‘Sixties Scoop’, during which Indigenous children an integrated approach to adopting the housing first were removed from their families’ homes by social model, that is, assisting in the attainment of housing workers and adopted by non-Indigenous families, may as well as intensive case planning and support to have influenced homelessness among Indigenous assist with independent living skills and health, Veterans in Canada. The problematic issues that as well as harm reduction practices can improve arose included a lack of social identity, physical access to addiction and mental health treatments abuse and racism (perceived and experienced) in addition to income support.6 Among Indigenous within adoptive homes.7 This was supported by Ray adults in Eastern Canada, one study revealed that and Abdulwasi8 (as cited by Abdulwasi, Evans, & 71% of the sample consumed alcohol and 29% Magalhaes7) who performed a secondary analysis of endorsed needing help with alcohol consumption.16 data obtained from a previous study9 and reported Previous research in the US has reported that that Indigenous Veterans considered their adoptions alcohol dependency, suicidal behaviour, and mental as contributing factors towards homelessness with health issues such as depression, anxiety and post- many reporting physical and emotional abuse as traumatic stress disorder (PTSD) have been found children, and a lack of connection and belonging to be more prevalent among Indigenous peoples to their culture and biological families.8 Further compared to the general population.16,17 Despite the research is required to investigate the underlying findings from these latter two studies, there has been causes of homelessness within this population. extremely limited literature regarding addiction and Difficulties in studying and analysing homelessness the psychiatric needs specific to homeless Indigenous among Indigenous individuals can be due to a Veterans. A survey by the Wilder Research Group of

Page 102 Journal of Military and Veterans’ Health Review Article

Figure 1. Flow chart of search strategy and study selection

Citations retrieved from CINAHL, ScienceDirect, Scopus, PsycInfo, Homeless Hub, CIMVHR and reference lists n=32 Abdulwasi et al.7, Bourque et al.21, Boyd et al.12, Finlay et al.22, Gaetz et al.5, Goldstein et al.23, Grant & Brown24, The Homeless Hub25, Jacobson & Eckstrom26, Jarvis27, Kasprow & Rosenheck28, Kasprow & Rosenheck28, Kasprow & Rosenheck28, Kasprow & Rosenheck28, Kaufman et al.29, Kaufmann et al.30, Koegel et al.31, Kramer & Barker32, Kramer et al.11, Ledesma33, Manson34, Montgomery et al.13, Noe et al.35, Peters & Robillard36, Peters37, Ray & Abdulwasi8, Ray & Forchuk15, Shore et al.38,Thurston et al.10, Tovar et al.39, Tsai et al.14, Whitbeck et al.40. Excluded: Duplicate citations Title and abstract review (n=3): Kasprow & Rosenheck28, Kasprow & Rosenheck28, Kasprow & Rosenheck28. Full text review n=29 Abdulwasi et al.7, Bourque et al.21, Boyd et al.12, Finlay et al.22, Gaetz et al.5, Goldstein et al.23, Grant & Brown24, The Homeless Hub25, Jacobson & Eckstrom26, Jarvis27, Kasprow & Rosenheck28, Kaufman et al.29, Kaufmann et al.30, Koegel et al.31, Kramer & Barker32, Kramer et al.11, Ledesma33, Manson34, Montgomery et al.13, Noe et al.35, Peters & Robillard36, Peters37, Ray & Abdulwasi8, Ray & Forchuk15, Shore et al.38,Thurston et al.10, Tovar et al.39, Tsai et al.14, Whitbeck et al.40.

Excluded: Did not focus on, or stratify, Indigenous veterans (n=9): Bourque et al.21, Boyd et al.12, Gaetz et al.5, Goldstein et al.23, Jacobson & Eckstrom26, Jarvis27, Koegel et al.31, Montgomery et al.13, Ray & Forchuk15, Tsai et al.14. Did not focus on homelessness (n=8): Abdulwasi et al.7, Kaufman et al.29, Kaufmann et al.30, Kramer et al.11, Ledesma33, Noe et al.35, Shore et al.38, Tovar et al.39. Did not focus on veterans (Homelessness only) (n=6): The Homeless Hub25, Kramer & Barker32, Peters & Robillard36, Peters37, Thurston et al.10, Whitbeck et al.40. Discussed Indigenous Veterans and homelessness but separately (n=3): Finlay et al.22, Grant & Brown24, Manson34. Currently unpublished (n=1): Ray & Abdulwasi8.

Met inclusion and exclusion criteria (published): n=1 Kasprow & Rosenheck28. Gray literature n=16 Casteel41, Fogarty42, Gilman43, Graef19, Joseph44, Kelly45, Neuman46, Press47, Sylvester20, Seguert & Bauer4, Toohey48, US Dept of Housing and Urban Development49, US Dept of Housing and Urban Development50, US Dept of Veteran Affairs51, Veteran Affairs Canada52, Wilder Researcher Group18.

Excluded: Did not focus on Indigenous veterans (n=5): Kelly45, Neuman46, Press47, Seguert & Bauer4, Toohey48, Veteran Affairs Canada52. Subjective opinion piece/Blog (n=1): Joseph44.

Studies included in review n=1 Kasprow & Rosenheck28. Gray literature n=9 Casteel41, Fogarty42, Gilman43, Graef19, Sylvester20, US Dept of Housing and Urban Development49, US Dept of Housing and Urban Development50, US Dept of Veteran Affairs51, Wilder Researcher Group18.

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homeless and near-homeless people on Indigenous Figure 1 outlines the literature selection process. In tribal reservations in Minnesota revealed that 8% order to meet the inclusion criteria for this study, of men had served in the military and not only peer-reviewed articles had to focus on homeless demonstrated higher rates of physical and mental Indigenous Veterans specifically, be written in health concerns, but were also twice as likely to English, and not have been included in a prior review consider themselves alcohol or drug dependent as prior systematic and literature reviews were compared to non-Veterans.18 Furthermore, in the US, included. Articles that were perceived to be potentially policy conflicts between the 1996 Native American useful or contained a title pertaining to homeless Housing and Self-Determination Act and the Housing Veterans or Indigenous were initially included. After Act of 1937 has prevented Indigenous Veterans from reading the full text, articles were excluded if they using rent vouchers for federally subsidised houses did not focus specifically on homeless Indigenous on reservations. As most reservation housing is Veterans, or if they did not stratify the results of federally subsidised, this results in homelessness or homeless Indigenous Veterans from the rest of the inadequate housing.19,20 study sample. Articles that described homeless Veterans or Indigenous Veterans separately were The objective of this review is to provide an overview excluded. Furthermore, no exclusion criteria were and assess the literature regarding homeless set for research design, type of intervention, country Indigenous Veterans. It is hoped this will inform of origin, nation served or the age of the sample. Grey policy and interventions, and highlight the gaps in literature was included; however, opinion pieces current knowledge that need to be addressed by were excluded due to their subjective nature. future research. This review aims to examine the issues surrounding homelessness among Indigenous Selection of articles and data extraction Veterans and places a primary focus on homeless Indigenous Veterans’ unique needs and risk factors Articles found as part of the search strategy we that predispose them to, or as a result of, becoming reviewed by title and abstract to assess whether the homeless. article was relevant to the purposes of this review. Duplicates were also removed at this stage. The Method remaining articles were then read in full to determine whether they met inclusion criteria. Grey literature Search strategy was observed and selected for background context using the same selection approach but was not The search strategy for this review of all literature included in the review. It was planned that identified published up until 14 February 2017, utilised five studies would be categorised into one of the following academic databases; CINAHL, The Homeless Hub, topic areas: epidemiology, health and services PsycINFO, ScienceDirect, SCOPUS as well as the access/utilisation and quality care/effectiveness. official journal of the Canadian Institute for Military and Veteran Research (CIMVHR), The Journal of Variables extracted from the identified articles Military, Veteran and Family Health. Searches included study design, the objective of the study, were conducted using the terms ‘Homeless or participant demographics, sample size, methodology, Homelessness’, ‘Veterans’ and ‘Native, Aboriginal, whether an intervention was provided (and if so, what Indigenous, First Nations or Métis’. To supplement the intervention was) and the results of the study. the search, additional articles were retrieved An evidence table was created with these variables by investigating references cited within articles (see Table 1). For the purpose of this review, an obtained from the database search. Grey literature epidemiological study was defined as any study was also sought through searches on the Veteran that included estimates of the size of the population Affairs Canada (VAC), US Department of Housing and prevalence of homelessness among Indigenous Development (HUD), US Department of Veterans Veterans, characteristics of homeless Indigenous Affairs (VA), Australian Department of Veterans Veterans, factors associated with the likelihood of Affairs and New Zealand Veteran Affairs websites an Indigenous Veteran to experience homelessness, as well as a generic Google search. Identifying grey or other epidemiological information concerning literature was considered to be important to the search homelessness among Indigenous Veterans. strategy as there was potential for there to be a less- developed body of literature concerning homeless Indigenous Veterans. Two reviewers conducted the database searches, reviewed the database results, arbitrated disagreement and consensus was reached after discussion.

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Results reporting homelessness than expected. The difference between these two estimates of homelessness reached Search results statistical significance (p=0.044). This would suggest that there is an overrepresentation of Indigenous Of the databases and reference lists searched, 32 Veterans experiencing homelessness. articles were identified. This number reduced to 29 once duplicates had been removed and was further Experiences of homeless Indigenous Veterans reduced after the full text of the articles had been compared with the non-Indigenous homeless read and verified. Of the 29, nine articles did not Veteran population focus on Indigenous Veterans and only focused on homeless Veterans in general, eight did not Kasprow and Rosenheck reported that Indigenous investigate homelessness but did focus on Indigenous Veterans were notably more likely to consume Veterans, six did not focus on Veterans and three alcohol and averaged a significantly greater number explored Indigenous Veterans and homelessness but of days under the influence of alcohol in the past independently of each other. One article had not been 30 days (both p<0.010).28 This finding was further published at the time of the search and therefore the supported by clinician ratings of alcohol dependency full text could not be accessed. The results of this with Indigenous homeless Veterans demonstrating unpublished study were discussed in a later article a higher odds ratio (OR=1.46) when compared with by one of the authors7. This resulted in only one white Veterans. Overall, Indigenous Veterans’ scores epidemiological paper being identified. There were on all alcohol misuse and dependency measures no previous literature review or systematic review were approximately 40% greater than white homeless papers found, making this review the first of its kind. Veterans. Sixteen articles were identified in the search for grey However, it was also reported that Indigenous literature. Eight were news articles from newspapers Veterans were less likely than white Veterans to report or online news outlets, two were press releases from drug misuse and there was no significant difference the HUD, one was a report from the VAC concerning between Indigenous and white homeless Veterans future plans for Veteran homelessness, one was a in regards to the number of days of drug misuse. report on homelessness on tribal reservations in In addition, Indigenous Veterans demonstrated Minnesota, USA, one was a grants report from the the lowest rates of hospitalisations due to drug VA, one was a doctoral dissertation and one was a dependency compared to all other ethnic groups. blog post. Of this literature, six were not specific to Homeless Indigenous Veterans reported significantly Indigenous Veterans and the blog post was excluded fewer cases of psychiatric problems and psychiatric due to the subjective nature, thus leaving nine used hospitalisations than white homeless Veterans to supplement this review. (both p<0.001). Furthermore, clinician ratings of psychiatric problems verified the latter findings as Summary of study the ratings suggested serious psychiatric problems The only study identified for the purposes of this were lower for Indigenous Veterans compared to review was conducted by Kasprow and Rosenheck white Veterans (also p<0.001). However, it should who investigated alcohol and drug misuse among be noted that this does not imply that Indigenous Indigenous Veterans at 71 Veteran Affairs Health Veterans demonstrated low rates of psychiatric Care for Homeless Veterans (VA-HCHV) sites across issues. All of the homeless Veterans in the study the US.28 However, the study did not focus on the reported high levels of psychiatric problems but the causal factors for homelessness, instead providing results reveal that significant differences between an insight as to the struggles of homeless Veterans. ethnic groups were observed. The Indigenous Veterans in the study (n=950) were stratified from the total sample population which Discussion included other ethnicities including white, black and The purpose of this review was to review the Hispanic (n=36 938). From a prevalence perspective, literature concerning homeless Indigenous Veterans. there were significantly fewer Indigenous Veterans Of concern, only one paper was identified that had who were ‘literally homeless’ compared to white been conducted in 1998 within the US. This is an Veterans (p<0.010). However, when a comparison was alarming amount of time to pass with little to no made between the number of Indigenous Veterans research conducted on this specific population. Of in the VA-HCHV program and the proportion of course, this is not to suggest that no research has Native American Veterans in the 1992 National been conducted at all as our search demonstrated Survey of Veterans, it was revealed that there were a number of studies assessing Indigenous Veterans approximately 19% more Indigenous Veterans

Volume 27 Number 1; January 2019 Page 105 Review Article

and homeless Veterans separately, but there is a lack of evidence investigating homeless Indigenous Veterans. There was one paper identified in the search that focused specifically on homeless Indigenous Veterans in Canada, but this article is an unpublished thesis8 that had been referenced in another article.7

The prevalence of homelessness among Indigenous Veterans in the US was found to be higher than expected by Kasprow and Rosenheck28. However, the authors go on to note that the national survey (used for comparisons with the study sample) included Veterans from both urban and rural areas whereas the HCHV sample was predominantly from urban areas, thus indicating that if geographical differences were accounted for, the difference in the proportion of homeless Indigenous Veterans may have been higher. The second major finding from Kasprow and Outcomes who were literally - The number of Indigenous Veterans homeless was sig . less compared to white Veterans (p<0 . 010) were sig . more likely to report - Indigenous Veterans (p<0 . 010) and alcohol abuse than white Veterans averaged more days of intoxication in the past 30 (5 . 4 days vs 3 9 days, p<0 010) did not differ sig . from white - Indigenous Veterans regarding drug abuse . Veterans reported significantly fewer - Indigenous Veterans cases of psychiatric problems and psychiatric (both hospitalisations compared to white Veterans p<0 . 001) - Clinicians’ ratings of serious psychiatric problems compared to were sig . lower among Indigenous Veterans (p<0 . 001) white Veterans Rosenheck28 was the higher prevalence of alcohol misuse among Indigenous homeless Veterans relative to white homeless Veterans. However, the study did not assess the nature of the alcohol misuse

Intervention N/A (i.e. binge drinking or frequent consumption of smaller quantities). The authors suggest that further research into the behavioural aspect of alcohol misuse among homeless Indigenous Veterans is needed to provide greater clarity. One potential issue with the data was the reliance on face validity as standardised assessment scales were not used although the authors argue that due to the large Objective To estimate the proportion of Indigenous people among homeless and Veterans compare the prevalence of alcohol, substance and psychiatric issues among other ethnicities . sample, biases may have been reduced as they would had to have been applied consistently over such a large number of Veterans and clinicians. Kasprow Sample 36 938 and Rosenheck28 recommend that preventative treatment services should aim to target homeless Indigenous Veterans and that further research assessing the appropriateness and effectiveness of services available are culturally specific. As this study was conducted almost 21 years ago in the Participants Indigenous (n=950): Male=919, Female=31 . Mean Age=44 . 9+9 7yr Literally homeless=684 Days worked in past 30d = 3 . 3+6 7d US, it re-emphasises the need for a new study, particularly in Canada.

Further to the issue of health-compromising behaviours such as alcohol and substance misuse,

Method Data collected during intake interviews when entering the HCHV program was obtained and analysed . Assessment was conducted at intake using an 87-item including psychiatric diagnoses based on DSM- IV criteria . mental health issues such as PTSD, depression and anxiety have also been found to be prevalent. Co-occurring disorders that include at least one alcohol/drug use disorder and at least one non-drug Design Case Control related mental disorder was reported among 37% of homeless Veterans sample.53 In particular, PTSD was Year 1998 also found to be more prevalent among Indigenous Veterans compared to non-Indigenous Veterans.22,24 A recent literature review revealed that homeless Veterans were significantly more likely to report a chronic health condition compared to homeless Study Kasprow & Rosenheck28 (USA)

Table 1. Overview of Identified Literature Table non-Veterans and more likely to have a hepatic

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disease, HIV/AIDS and a psychiatric disorder when also be applicable to Indigenous Veterans. It would compared to non-homeless Veterans.54 Homeless also appear that action is being taken in the US as Veterans in the US were also found to have a higher $5.9 million in grants from the HUD and the VA has rate of diabetes compared to previously published been awarded to 26 tribes to provide permanent data on the general homeless population (19% vs housing and support services to homeless Veterans 8%).55 Furthermore, it has been found that Veterans including rental assistance vouchers,41,43,50 as well experiencing homelessness for the first time as an expansion of the HUD-VA Supportive Housing were significantly associated with heart disease, program to Veterans living on tribal lands.42,49 hypertension and joint pain disorder.56 Overcoming the legislative barriers in place, as outlined by Graeff19 and Sylvester,20 is a promising A literature review written in the US by Tovar, step in providing greater support for Indigenous Patterson Silver Wolf and Stevenson suggests that homeless Veterans in need. community rituals and ceremonies can help bring a sense of belonging for Veterans by reaffirming tribal As this review has demonstrated, there is a great need identity and to absorb any trauma the Veterans have for further Canadian research. The key limitation for experienced.39 Culturally-informed rehabilitation has this review is the fact that no Canadian research also begun to rise with the VA in the US providing articles were identified for analysis. Future research transportation for Indigenous Veterans attending needs to explore the cultural-specific causes of VA facilities and the opening of a tribal VA clinic.39 homelessness among Indigenous Veterans in order Outcomes who were literally - The number of Indigenous Veterans homeless was sig . less compared to white Veterans (p<0 . 010) were sig . more likely to report - Indigenous Veterans (p<0 . 010) and alcohol abuse than white Veterans averaged more days of intoxication in the past 30 (5 . 4 days vs 3 9 days, p<0 010) did not differ sig . from white - Indigenous Veterans regarding drug abuse . Veterans reported significantly fewer - Indigenous Veterans cases of psychiatric problems and psychiatric (both hospitalisations compared to white Veterans p<0 . 001) - Clinicians’ ratings of serious psychiatric problems compared to were sig . lower among Indigenous Veterans (p<0 . 001) white Veterans This represents a shift in healthcare by providing to fill the gaps in the current knowledge. In doing so, for a specific population that requires greater post-discharge services can better equip Indigenous assistance. In addition, Kaufmann, Buck, Floyd Veterans upon transitioning into civilian life and and Shore reported that the VA has implemented a address the risk factors for homelessness. Further, as 28

Intervention N/A community outreach program designed to engage Kasprow and Rosenheck revealed, the consequences Indigenous Veterans in the US with VA information linked with being a homeless Indigenous Veteran and assist with paperwork as well as encouraging also require greater attention such as the health- Veterans to seek help through the VA’s American compromising behaviours associated such as Indian Telemental Health Clinics.30 The program alcoholism, drug use and psychiatric disorders. As has since expanded across the US, including remote the article was conducted in the US 21 years ago, areas of Alaska. Although these studies represent a modern analysis within a Canadian context is promising signs of improvement for Indigenous certainly warranted. However, it is clear that this is Objective To estimate the proportion of Indigenous people among homeless and Veterans compare the prevalence of alcohol, substance and psychiatric issues among other ethnicities . Veterans’ healthcare, there still appears to be a not just an issue specific to Canada, but for other lack of additional services specifically aimed at Indigenous populations across the Western world as homeless Veterans. Cultural-specific services and international literature was also found to be lacking. Sample 36 938 treatment may be recommendable as a recent study This suggests that ethnographic research would be in the US reported that being an Indigenous Veteran essential in identifying the cultural differences of was associated with lower odds of treatment entry homeless Indigenous Veterans in their transition to compared to white Veterans.22 The interventions civilian life. Ethnographic research would also allow described by Tovar et al.39 and Kaufmann et al.30 have a greater understanding of the challenges faced by been implemented in the US, but not in Canada. Indigenous Veterans and of what more can be done Participants Indigenous (n=950): Male=919, Female=31 . Mean Age=44 . 9+9 7yr Literally homeless=684 Days worked in past 30d = 3 . 3+6 7d in targeting this specific group of the homeless Despite the lack of research, the grey literature population. There is also a need for an Indigenous- identified in this review revealed that homeless led community-based study to provide further Indigenous Veterans are receiving more recognition context in order to enhance the current knowledge of and that further assistance is being provided. The VAC homeless Indigenous Veterans. Qualitative research

Method Data collected during intake interviews when entering the HCHV program was obtained and analysed . Assessment was conducted at intake using an 87-item including psychiatric diagnoses based on DSM- IV criteria . have reported that homelessness and the transition studies are needed to understand further the from the military to civilian life will be addressed with unique experiences of Indigenous Veterans and their a series of planned initiatives starting in 2015 and perspectives on homelessness. Not only would this 2016 through to 2019 and 2020 including improved

Design Case Control allow for a rich source of data directly acquired from identification of homeless Veterans, new employment Indigenous Veterans, it may also be possible to further strategies and greater mental health support for inform future interventions, services and policy in Year 1998 Veterans and their families.52 Although a much-

the prevention and support of homelessness for needed and welcomed sign of progress, there was no this distinct group within the homeless population. further detail as to how Indigenous service providers With further investigation could highlight the social, and Veterans would be supported specifically. Given health and psychological issues, could provide 10 the issues highlighted by Thurston et al. earlier in greater emphasis and inspiration for future studies Study Kasprow & Rosenheck28 (USA) Table 1. Overview of Identified Literature Table this review, it is conceivable that these issues could internationally.

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Conclusion Corresponding Author: Jonathan Serrato, The present state of the literature is alarmingly [email protected] inadequate in assessing the prevalence and needs Authors: J Serrato 1, H Hassan 1, C Forchuk 1,2 of homeless Indigenous Veterans. There seems to Author Affiliations: be a greater volume of attention towards homeless 1 Parkwood Institute, MHNRA Indigenous Veterans in the US. The only study 2 Western University Arthur Labatt Family School of identified in the search was conducted in the US and Nursing suggested that homeless Indigenous Veterans are at great risk of homelessness and alcoholism compared to white homeless Veterans but may demonstrate fewer psychiatric concerns and lower rates of drug dependency. Further research is required to assess the current trends in homelessness among Indigenous Veterans and greater attention from policymakers in working with this population.

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15. Ray SL, Forchuk C. The Experience of Homelessness Among Canadian Forces and Allied Forces Veterans. Department of Human Resources and Skills Development Canada. 2011. Available from: http://homelesshub.ca/resource/experience-homelessness-among-canadian-forces-and-allied-forces- veterans 16. Spillane NS, Greenfield B, Venner K, Kahler CW. Alcohol use among reserve-dwelling adult First Nation members: Use, Problems, and Intention to Change Drinking Behaviour. Addict Behav. 2015;41:232- 237. 17. Brave Heart MYH, Lewis-Fernandez R, Beals J, Hasin DS, Sugaya L, Wang S, et al.. Psychiatric Disorders and Mental Health Treatment in American Indians and Alaska Natives: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. Soc Psychiatry Psychiatr Epidemiol. 2016;51(7):1033-1046. 18. Wilder Research Group. Homeless and near-homeless people on Minnesota Indian reservations. 2009. Available from: http://www.wilder.org/Wilder-Research/Publications/Studies/Homelessness in Minnesota, 2009 Study/Homeless and Near-Homeless People on Minnesota Indian Reservations, Full Report.pdf 19. Graeff C. Breaking new ground for homeless Native veterans. Mint Press News. 2016 Feb 5. Available from: http://www.mintpressnews.com/breaking-new-ground-homeless-native-veterans/201880/ 20. Sylvester T. Tribes struggle to house their ‘invisibly homeless’ veterans. High Country News. 2014 Jan 6. Available from: http://www.hcn.org/issues/45.22/indian-countrys-invisibly-homeless-veterans-cutoff-from-a-key-federal-housing-program?b_start:int=1#body 21. Bourque J, Van Til L, Gibbons C, LeBlanc SR, Landry L, LeBlanc J, et al.. Impact of a Housing First intervention on homeless Veterans with mental illness: a Canadian multisite randomized controlled trial. J Mil Veteran Fam Health. 2015;1(2):52-60. 22. Finlay AK, Smelson D, Sawh L, McGuire J, Rosenthal J, Blue-Howells J, et al.. U.S. Department of Veterans Affairs Veterans Justice Outreach Program: Connecting Justice-Involved Veterans With Mental Health and Substance Use Disorder Treatment. Crim Justice Policy Rev. 2016;27(2):203-222. 23. Goldstein G, Luther JF, Haas GL. Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans. Psychiatry Res. 2012;199(1):37-43. 24. Grant J, Brown T. American Indian & Alaska Native Resource Manual. 2003. Available from: http:// homelesshub.ca/resource/american-indian-and-alaska-native-resource-manual. 25. The Homeless Hub. Lack of Reliable Homelessness Statistics on Aboriginal Peoples in Canada. 2014. Available from: http://homelesshub.ca/resource/lack-reliable-homelessness-statistics-aboriginal- peoples-canada-homeless-hub-research. 26. Jacobson JM, Eckstrom DL. Assessing Homeless Veterans Using the Omaha Assessment Tool in a Nontraditional Home Care Setting. Home Care Provid. 1997;2(1):22-27. 27. Jarvis J. Individual determinants of homelessness: A descriptive approach. J Hous Econ. 2015;30:23- 32. 28. Kasprow WJ, Rosenheck RA. Substance use and psychiatric problems of homeless Native American veterans. Psychiatric Serv. 1998;49(3):345-350. 29. Kaufman CE, Brooks E, Kaufmann LJ, Noe T, Nagamoto HT, Dailey N, et al.. Rural Native Veterans in the Veterans Health Administration: Characteristics and Service Utilization Patterns. J Rural Health. 2013;29(3):304-310. 30. Kaufmann LJ, Buck WJ, Floyd J, Shore J. Tribal Veterans Representative (TVR) Training Program: The Effect of Community Outreach Workers on American Indian and Alaska Native Veterans Access to and Utilization of the Veterans Health Administration. J Community Health. 2014;39(5):990-996. 31. Koegel P, Burnam MA, Farr RK. The Prevalence of Specific Psychiatric Disorders Among Homeless Individuals in the Inner City of Los Angeles. Arch Gen Psychiatry. 1988;45(12):1085-1092. 32. Kramer BJ, Barker JC. Homelessness among older American Indians, Los Angeles, 1987-1989. Hum Organ. 1996;55(4):396-408. 33. Ledesma R. Entrance and Exit from the Military: Reflections from American Indian and Alaska Native Veterans. J Ethn Cult Divers Soc Work. 2006;15(1-2):27-53.

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34. Manson SM. Meeting the Mental Health Needs of American Indians and Alaska Natives. 2004. Available from: http://homelesshub.ca/resource/meeting-mental-health-needs-american-indians-and-alaska- natives. 35. Noe TD, Kaufman CE, Kaufmann LJ, Brooks E, Shore JH. Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities. Am J Public Health. 2014;104(Suppl.4):S548-554. 36. Peters EJ, Robillard V. “Everything you want is there”: The Place of the Reserve in First Nations’ Homeless Mobility. Urban Geogr. 2009;30(6):652-680. 37. Peters EJ. ‘I like to let them have their time’. Hidden homeless First Nations people in the city and their management of household relationships. Soc Cult Geogr. 2012;13(4):321-338. 38. Shore JH, Brooks E, Anderson H, Bair B, Dailey N, Kaufmann LJ, et al.. Characteristics of Telemental Health Service Use by American Indian Veterans. Psychiatric Serv. 2012;63(2):179-181. 39. Tovar M, Patterson Silver Wolf DA, Stevenson J. Toward a Culturally Informed Rehabilitation Treatment Model for American Indian/Alaska Native Veterans. J Soc Work Disabil Rehabil. 2015;14(3-4):163-175. 40. Whitbeck LB, Crawford DM, Hartshorn KJS. Correlates of Homeless Episodes Among Indigenous People. Am J Community Psych. 2012;49(1-2):156-167. 41. Casteel C. Federal grants to Oklahoma tribes will aid homeless veterans. NewsOK. 2016 Jan 8. Available from: http://newsok.com/article/5471573 42. Fogarty M. Feds expand homeless services for Native veterans. Indian Country Media. 2011 Nov 11. Available from: https://indiancountrymedianetwork.com/news/veterans/feds-expand-homeless- services-for-native-veterans/ 43. Gilman A. New federal program to house homeless Native American veterans. Al-Jazeera America. 2016 Jan 9. Available from: http://america.aljazeera.com/articles/2016/1/9/new-program-allocates-money- to-homeless-native-american-veterans.html 44. Joseph B. Aboriginal Veterans: Equals on the Battlefields, but not at home [Blog post]. 2012. Available from: http://www.ictinc.ca/blog/aboriginal-veterans 45. Kelly D. Plan for a homeless veterans village in Eklutna takes shape. Alaska News. 2016 May 30. Available from: https://www.adn.com/alaska-news/2016/05/30/plan-for-a-homeless-veterans-village- in-eklutna-takes-shape/ 46. Neuman MJ. Policies, Practices, Factors and Unintended Consequences Associated with Monitoring Substance Use Disorder Treatment Continuity of Care within the Veterans Health Administration [Doctoral Dissertation]. 2012. Available from: PsycINFO. (Accession No. 2013-99060-246). 47. Press J. More supports needed for homeless veterans, Indigenous people: report. The Globe and Mail. 2017 Jan 26. Available from: http://www.theglobeandmail.com/news/national/more-supports-needed- for-homeless-veterans-Indigenous-people-report/article33771772/ 48. Toohey P. How Australia is failing its veterans. Herald Sun. 2016 April 16. Available from: http://www. heraldsun.com.au/news/special-features/in-depth/out-of-order-the-battle-australian-veterans-face- with-homelessness-posttraumatic-stress-disorder-after-serving-our-country/news-story/3000d28397b 6a037429dee8ec2370f99 49. US Department of Housing and Urban Development. HUD-VA Program that Serves Homeless Veterans to Expand into Native American Communities for the First Time [Press Release]. 2015. Available from: https://archives.hud.gov/news/2015/pr15-009.cfm 50. US Department of Housing and Urban Development. HUD and VA award $5.9 million to 26 tribes to provide permanent homes for Native American veterans experiencing homelessness [Press Release]. 2016. Available from: https://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_ advisories/2016/HUDNo_16-001 51. US Department of Veteran Affairs. Ending veteran homelessness on Tribal Lands: A Tribal HUD-VASH Grants Guide. 2016. Available from: https://portal.hud.gov/hudportal/documents/ huddoc?id=tribalhudvashguide.pdf 52. Veterans Affairs Canada. Report on Plans and Priorities 2016-17. 2016. Available from: http://www. veterans.gc.ca/eng/about-us/reports/report-on-plans-and-priorities/2016-2017/report

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53. Ding K, Slate M, Yang J. History of co-occurring disorders and current mental health status among homeless veterans. BMC Public Health. 2018;18(1):751. 54. Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: A review of the literature. Public Health Nurs. 2017;34(5):505-511. 55. Iheanacho T, Rosenheck R. Prevalence and correlates of diabetes mellitus among homeless veterans nationally in the Veterans Health Administration. J Soc Distress Homeless. 2016;25(2):53-59. 56. Creech SK, Johnson E, Borgia M, Bourgault C, Redihan S, O’Toole TP. Identifying Mental and Physical Health Correlates of Homelessness among First-time and Chronically Homeless Veterans. J Community Psychol. 2015;43(5):619-627.

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October 2019 – Conference Abstracts

27 4 October 2019 As per AMMA Conference Submission Process 1 September 2019

The Editor would be delighted to receive articles for consideration on these themes. However, please note that although these are the suggested themes, we encourage authors to continue to submit articles on a range of topics on military medicine and veterans’ health including operational articles.

Categories for the above include: Original Research/Original Articles, Short Communication, Review Articles, Reprinted Articles, Case Studies, Abstracts from the Literature, Biographies, History, Book Reviews, Commentary and View from the Front.

Please submit via the JMVH website www.jmvh.org just click the ‘Submit your article’ button on the home page. Ensure you read the ‘Instructions to Authors’ that can also be found on the JMVH website by clicking on the ‘AUTHORS’ tab.

Should you have any queries in relation to submitting to JMVH, please do not hesitate to contact JMVH Editorial Office on +61 3 6234 7844 or [email protected] Y ME AR D T IC I I IL N E M

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DISCLAIMER The views expressed in this journal are those of the authors, and do not reflect in any way official Defence Force policy, or the views of the Surgeon General, Australian Defence Force, or any Military authority www.jmvh.org