Morbidity of Vietnam Veterans:

A Study of the Health of Australia's Vietnam Veteran Community

Volume I Male Vietnam Veterans Survey and Community Comparison Outcomes

Executive Summary

[Drawn directly from a final draft of the Report, prepared by DVA. Any errors are those introduced by my transcription - Clive Mitchell-Taylor. A direct cross-reference to the final document will be provided in place of this extract, when and if the information is posted to the Internet. DVA copyright applies to this extract as it does to the Report itself.]

Background

This study of the morbidity of Vietnam veterans was established by the Commonwealth Government following Ex-Service Organisation (ESO) representation and the study by the Department of Veterans' Affairs, Mortality of Vietnam Veterans: The Vietnam Veteran Cohort Study, released in May 1997. Two other morbidity studies of the Vietnam veterans' health exist, one undertaken in 1983 titled Australian Veterans Health Studies and the other The Australian Vietnam Veterans Health Study, by O'Toole et al, published in 1996.

This report presents the results of a survey of male Vietnam veterans.  A separate report will be published to cover the results of a survey of female Vietnam veterans.  It is anticipated that a final report covering the results of validation arising from the recommendations contained in the male and female survey findings will also be published.

Aims of the Study

The aims of the study are to:

1.  Survey the health and well being of Vietnam veterans, their spouses and their children.
2. Compare the health and well being of Vietnam veterans, their spouses and their children, with Australians of comparable age, in the general population, where comparative data exists.
3. Obtain health-related baseline data about Vietnam veterans which could be used for short, medium and longer term policy development.

Study Planning and Design

A study Advisory Committee was established in April 1996, to oversee the conduct of the study.  The Advisory Committee was chaired by the Repatriation Commissioner.  In addition to medical officers, senior officers and supporting staff from DVA, its membership comprised a representative from the Return and Services League of Australia (RSL), Vietnam Veterans Association of Australia (VVAA) and the Australian Veterans and Defence Services Council (AVADSC).  Professionals in statistical methodology and epidemiology were engaged to provide data and professional advice to the Committee.  ACNielsen Research Pty Ltd were engaged to conduct the survey of veterans, and representatives of ACNeilson also joined the Advisory Committee.

For the purposes of the study, the Advisory Committee accepted the definition of Vietnam veterans contained in the Nominal Roll of Vietnam Veterans:

All members of the Australian Defence Force (ADF) and the Citizen Military Forces (CMF) who landed in Vietnam or entered Vietnamese waters including those who were seconded to the Army of the Republic of Vietnam (ARVN), the United States Air Force (USAF), the United States Navy (USN) and any other allied service, all members of Australian Army Training Teams Vietnam, all members male and female, of civilian medical and surgical teams, all members of philanthropic organisation, all members of the Australian Forces Overseas Fund and all official entertainers and war correspondents who saw service in Vietnam during the period between 23 May 1962 and 1 July 1973

After consideration of all options, the Advisory Committee decided that the study should survey all Vietnam veterans who could be located.   The Committee believed in important for all veterans to have the opportunity to participate.  ESO advice was that this was the expectation of the veteran community itself, and a full survey gave reasonable confidence of detecting rare medical conditions.   Once taken, the decision to survey all locatable veterans meant that the survey instrument would be a mailed-out, self-reporting questionnaire.  Three distinct questionnaires were developed - male veteran; female veteran; and widow(er)s/divorced and separated partner(s).

The Advisory Committee agreed that the study should be conducted in three phases, with the need for Phases 2 and 3 dependant upon the outcome of Phase 1.  The agreed Phases were:

Phase 1 - A mailed survey of all surviving Vietnam veterans

Phase 2 - Analysis of Phase 1, production of a report on the outcome of Phase 1, and a decision on potential Phase 3 studies.

Phase 3 - Follow-on investigations if required, including the possibility of interview of a representative sample of Vietnam veterans.

Study Strengths and Limitations

The design of the study engendered both strengths and limitations.

The limitations of the study design were:

• Self-reported data has been obtained and over-reporting, under-reporting or mis-reporting is known to occur in this type of data (for example, because of the use of unfamiliar medical terminology).
• The size of the survey questionnaires encouraged veterans to respond but limited the number and specificity of questions.
• The survey lacked a comparable control group, that is, a group of people of the same age and gender who did not go to Vietnam, but who would have answered the same questionnaire as the veterans surveyed.  In its place comparison was drawn by reference to community data for those of comparable age, where such data was available.
• The effects of contributing life style factors and experiences post-service could not be ascertained without Phase 3 being implemented
• There was a lower return of completed questionnaires from widow(er)s/divorced and separated partner(s), and the data that was returned could not be merged with that of the male veterans.

Nonetheless, the study design had considerable strengths:

• The survey was inclusive and afforded all veterans the opportunity to participate
• The large number of participants gave the survey great statistical power.
• The survey size allowed reasonable confidence of detecting rare medical conditions.
• The study design was effective in that 79% of those who received a questionnaire returned a completed questionnaire.

Survey Methodology

For ACNielsen Research Pty Ltd to conduct the mail-out survey, the address of each veteran was sought by cross matching the names on the Nominal Roll with the Electoral Rolls, and a copy of the relevant questionnaire was posted to the address so obtained.  Cross matching was performed by the Australian Institute of Health and Welfare (AIHW).

In total 51,753 questionnaires were posted, comprising 49,944 male Vietnam veterans, 278 female Vietnam veterans and 1,531 widows/divorced and separated partner(s) of Vietnam veterans.

Survey Response

Out of 49,944 male veterans to whom a questionnaire was posted, 40,030 returned a completed questionnaire (80%).  Some 6,470 did not respond (13%), and 2,379 questionnaires were returned to the sender (4.8%).

Widow(er)s/divorced and separated partner(s) questionnaires could generally only be sent on request as limited address data were held for this group.  1,531 questionnaires were posed, 691 completed questionnaires were returned (45.1%), 797 recipients did not respond (52.1%).

At the completion of the survey a telephone follow-up of non-respondents was conducted.  Having examined the data obtained from non-respondents, ACNielsen concluded that the results from the mail-out phase could be used with confidence, and that non-respondents did not pose a significant bias problem.

Comparative Data

Where practical, community data was obtained on the prevalence of conditions surveyed in the questionnaires to allow comparison of the veterans responses with the expected response from Australians of a similar age.

The data obtained allowed comparisons to be made between the reported prevalence of conditions (that is, number of veterans reporting the condition) and the expected prevalence of the condition in a community cohort of the same size as the veteran cohort.  Comparisons were presented only for those conditions where reasonable comparable estimates of expected community prevalence could be made.

The comparisons were not a complete literature review of all material written about the conditions, nor did they provide aetiological reasons for the findings.  They were designed to provide reasonable community comparisons, with brief discussion as to why, methodologically, expected findings may have differed from the reported findings.  They were also designed to allow conclusions to be drawn about what differences were likely to be real and whether more detailed inquiry or action was required.

Where possible, comparisons used Australian data.  However, Australian data is not available for all conditions covered in the questionnaires and on occasions while available, it was not collected in a fashion comparable to the veterans' questionnaire.  In these cases, data from international sources has been used.

General Comment On Survey Findings

The findings from the male survey are summarised below.  This summary is the result of initial analysis.  More detailed analysis of the survey data to follow particular lines of enquiry or to allow comparison of response between questions of a like nature is feasible, but has not yet been undertaken given the requirement to publish the initial data.  Analysis of this type, in selected areas, will form a part of the future work on the study.

Self-Reported Medical History of the Veterans (Questionnaire Parts A and E)

When asked to asses their health as excellent, very good, good, fair or poor, (Question E1 of the survey), 5% of veterans rated their health as excellent, 14% as very good, 29% as good, 34% as fair and 16% as poor.   These ratings, when compared to community expectations, show that veterans are three times less likely to report their health as excellent.  The responses to this question are directly comparable with community data.  Data for this question and data from the community were ascertained in a similar fashion.

The response to Question E1 reflects the higher than expected reported prevalence for most of the conditions surveyed in Part A of the questionnaire, which sought information on 43 specific conditions.  In particular in Part A, veterans indicated a high and consistent (30% or greater) experience of mental health conditions; panic attacks, anxiety disorder, depression and Post Traumatic Stress Disorder.  Further, 25% of veterans reported that they had been diagnosed with a cancer of some description since their first day of service in Vietnam.

The responses support the hypothesis that the general health of Vietnam veterans is worse than that of Australians of a comparable age.   The responses are not inconsistent with the hypothesis that the prevalence of cancer and some specific disease conditions are are greater in Vietnam veterans.   Validation of the self-reported responses to questions relating to cancers, multiple sclerosis and motor neurone disease in recommended to establish unequivocal evidence as to the prevalence these conditions.  This evidence is considered essential as the basis for further policy action and a foundation of studies into causality.

While it would be advantageous to validate responses to other conditions surveyed in Part A, as a general rule, such validation is not recommended.  Treatment, compensation and counselling, if required, for the majority of the conditions surveyed are readily available upon acceptance following diagnosis.  The survey results can thus be accepted as indicative, and veterans reporting suffering these conditions should be urged to seek entitlement to treatment and compensation if they have not already done so.

Compensation in particular is governed by Statements of Principles (SoPs) prepared for individual medical conditions by the Repatriation Medical Authority (RMA).  It is recommended that the survey results be referred to the RMA, for particular attention where SoPs may not exist or the factors within the SoP are restrictive.  Examples of the latter are noted in the report and reflected in the recommendations stemming from the survey.  Likewise, it is recommended that the Department of Veterans' Affairs uses the responses to Part A as a guide in planning the coverage of treatment and counselling services, and of preventive programs.

Current Marital Status (Questionnaire Part B)

Part B of the survey sought to ascertain the marital status of veterans.  Responses to this Part show that the current marital status of male Vietnam veterans approximated that of the Australian male population.

This finding refutes the hypothesis that the marital status of these veterans is different to that of the general population.  The responses to Part B are reliable, in that data from the survey and data from the community are considered to be directly comparable.

Health of Partner(s) (Questionnaire Part C)

Part C of the questionnaire sought to ascertain the effect of the health of veterans on the health of partners.

In Part C, 36% of veterans report that service in Vietnam, or health problems arising as a consequence of their service in Vietnam, have had a serious adverse effect on current or past partners.  Some 40% report physical or psychological health problems in their partners that they feel may be related to the veterans' Vietnam service.  Stress (40%), anxiety (34%), and depression in partners are the most commonly cited conditions.  Thirty nine percent (39%) of all veterans with partners report that treatment has been required for these conditions.  Those with greater length of service in Vietnam report higher levels of problems.

Community comparisons are not available for this data.  The responses themselves tend to support the hypothesis that the health status of the veteran has an effect on the health status of his immediate family.  Responses to this Part should be read alongside veterans' reports on themselves in Part A.   Here, relatively high general levels of problems, particularly of psychological problems, are reported.  These could be expected to create stress on a partner.   For these reasons it is recommended that the level of resources available for counselling on mental health conditions experienced by veterans and their families be reviewed for adequacy.

Health of Children (Questionnaire Part D)

Part D of the survey sought responses in the areas of:

• Fertility and adverse pregnancy outcomes;
• Sight problems;
• Hearing/ear problems;
• Congenital abnormalities;
• Cancers;
• Other major illnesses;
• Deaths; and
• Psychiatric disorders in the veterans' children.

Responses to these questions indicate a potentially serious problem.  The responses, particular the high reported rates of suicide, congenital abnormalities and cancer in the children of Vietnam veterans, suggest that the effects of Vietnam service may extend to the children of Vietnam veterans.   Verification of the self-reported responses in these three areas is recommended.   The results, if confirmed, have significant policy implications for veterans' welfare and that of their families.

Congenital Abnormalities and Death of Children

Responses to these two Parts of the questionnaire potentially constitute the most disturbing findings from the survey:

• Congenital Abnormalities.   Depending on the condition surveyed, congenital abnormalities reported varied from three to eleven times the expected rate; and
• Deaths of Children.  Deaths from suicide of children were reported at three times the expected rate, and deaths from accident or other causes were reported at twice the expected rate.

The responses support the hypotheses that a greater level of congenital abnormality and greater mortality rates are found in the children of Vietnam veterans.  The report notes difficulties that may have affected the accuracy of reporting and the accuracy of the comparison data.

Not withstanding these difficulties, the veterans' responses raise major concerns about the health of veterans' children, and thus the recommendation is made that the reported rates be validated as a matter of urgency.

Cancer

Responses were sought to three specific forms of cancer (leukaemia, Wilms' tumour and cancer of the nervous system), in veterans' children.   An opportunity was also provided to report other forms of cancer if suffered.   Incidence of 11, 7 and 18 per 10,000 children were reported for leukaemia, Wilms' tumour and cancer of the nervous system respectively.

The reported incidence of cancers amongst the children of veterans is higher than that expected.  As previously recognised, this is a worrying finding, one which lends support to the hypothesis that greater rates of cancer are to be found in the children of Vietnam veterans.

Because of the markedly higher rates reported, and the possibility of mis-classification of specific forms of cancer, the data should be validated.  Validation would also be useful as a foundation for future studies into causality.

Fertility and Adverse Pregnancy Outcomes

Responses to questions relating to fertility and adverse pregnancy outcomes indicate that 21% of veterans had tried for more than 12 months without success to conceive a child.  Some 22% of veterans' partners have had a miscarriage, 5% have had a termination, and 5% of veterans had fathered a child that was stillborn.

A general lack of comparable data obtained in a similar fashion to that in this survey means that firm conclusions from the reported data cannot be drawn.  From the comparative data that is available, there is a suggestion of greater difficulty of achieving conception in veterans and their partners, but this is counterbalanced that the number of veterans who had ever fathered children is not greatly different from that expected by cross-reference to community data.

Other Specific Disease Conditions

8% of veterans report that at least one of their children has suffered an eye condition not correctable by spectacle, and 10% report long-term hearing or ear problems.  Some 27% of veterans indicate that a child has suffered a major illness.  In regard to mental health issues, 11% of children are reported as having been diagnosed with a psychiatric problem and 16% with an anxiety disorder.

The occurrence of sight and hearing problems in veterans' children appears to be lower than the community expectation, although the report notes difficulties with obtaining accurate comparative data.  For the other conditions, comparative data is not available.  Thus it is not possible to conclude with any degree of certainly whether the prevalence of these conditions in the children of Vietnam veterans is higher of lower than expected.

Validation

Several findings recommending validation or verification of data that is currently self-reported are made in this report.  As noted, validation is seen as an essential tool to remove the possibility of mis-classification of specific conditions, to provide incontrovertible evidence as the basis for future policy formulation and to provide a foundation for studies into causality.

It is recognised that validation may cause concern to veterans and their families.  There are sensitivities relating to confidentiality, the possibility that families will be surveyed more than once, and potential hostility to yet more surveys.  Because of these concerns, a single, integrated validation exercise is recommended.  Further, it is recommended that appropriate levels of support are offered to those undergoing validation.  Such support could include a needs assessment process, facilitating access to rehabilitation services for affected veterans and their families, and appropriate educational campaigns in the ex-service community with the support of ESOs.  A suggested protocol for validation is being drawn up by the Advisory Committee and will be forwarded separately to the Repatriation Commission and Minister for Veterans' Affairs.

This survey was not designed to ascertain the causes of medical conditions that Vietnam veterans or their families may be experiencing.   The proposed validation will not identify causation.  Validation is designed to confirm the association between the identified condition and Vietnam service.   Confirmation would provide strong evidence that there are causal agents arising from military service and in particular Vietnam service that have had an adverse health effect in Vietnam veterans and their families.  A variety of potential exposures could explain such health effects.  These include chemicals, stress, various infectious agents, unknown agents, or such exposures in combination.

Recommendations

As a result of the outcomes of the male veteran survey the following recommendations are made:

Male Vietnam Veterans

• It is recommended that the results obtained for the following conditions reported by veterans be validated as a matter of urgency:

• all cancers (with the exception of non-melanotic skin cancers);
• motor neurone disease; and
• multiple sclerosis.

• It is recommended that the Department of Veterans' Affairs uses the responses to Part A and E of the survey as a guide in planning the coverage of treatment and counselling services, and of preventive programs.

• It is recommended that while recognising the importance of PTSD, there be a broader diagnostic and treatment focus on other common mental health conditions in veterans.
• It is recommended that the findings of the survey be referred to the RMA for their consideration, particularly in developing or amending SoPs relating to:

• panic attacks;
• anxiety disorders;
• high blood pressure;
• asthma;
• male breast cancer;
• cancer of the eye;
• diabetes;
• dermatitis/eczema;
• psoriasis; and
• microtrauma in musculo-skeletal systems.

• It is recommended that DVA notify oncologists that Vietnam veterans are an at risk group for strongyloides.

Children of Male Vietnam Veterans

• It is recommended that the responses which taken together indicate an increased level on congenital abnormalities in the children of veterans be validated as a matter of urgency.
• It is recommended that the responses which taken together indicate increased mortality rates in the children of veterans be validated as a matter of urgency.
• It is recommended that the responses which indicate increased rates of leukaemia, Wilms' tumour and cancer of the nervous system in the children of veterans be validated as a matter of urgency.

Male Vietnam Veterans and Families

• If validation confirms the survey findings, therapeutic and preventive interventions to assist veterans and their families are recommended as a matter of urgency.
• It is recommended that the level and type of treatment resources available for counselling on mental health conditions experienced by veterans and their families be reviewed for adequacy.

Validation

• It is recommended that, if practical, a single integrated validation exercise be undertaken and that appropriate levels of support be offered to those undergoing validation.

General

• It is recommended that the findings of the survey be drawn to the attention of the Australian Defence Force for use in the refinement of preventive measures.