Chapter Four - Research and Programs
4.1
Much of the
research previously undertaken has been based on retrospective analysis and
data collection, and has been directed at best to the provision of services
towards the end of veterans lives. A large number of other research projects
have only recently been undertaken on deployments or services that date back
several decades, although some countries have commenced study on these at
earlier periods.
4.2
The reasons for
this retrospective approach are multiple, and some have been addressed already,
including:
-
Policy decisions
which limit growth of the overall benefits/pensions bill through restriction of
service definitions and requirement for a level of connection between
disability and service higher than in some other countries; and
-
The structure of
the RMA and its role in determining cause of illness or injury.
4.3
However, there
are other factors which have limited the development of services, in spite of
the vociferous statements of many veterans. These include:
-
The belief that
ill effects from deployments would only manifest late in life;[367]
-
The atmosphere
surrounding various earlier deployments, service in which were seen as a duty
(World War 2 in particular) or which eventually became unpopular and less
acknowledged (eg Vietnam).[368] These
social contexts did not always limit the availability of benefits, but may have
limited recognition by individuals of the relationship between health and war,
and contributed to governments not actively seeking to investigate some health
issues;
-
Limited
acceptance of psychological/psychiatric problems which can have short and long
term effects;[369]
-
Reluctance to
acknowledge the effects of chemicals and other hazards, and of any longer term
effects of substances such as agent orange.[370]
4.4
According to the
Repatriation Commission, there was limited research undertaken of the effects
of war following both World Wars.[371]
Social factors[372] and possibly a
limited understanding of more immediate effects of deployment contributed to
this, as well as the absence of methodologies and technologies that can now
re-create data collection and identify a wider range of effects. DVA notes:
Epidemiology is a relatively recent
science, having developed as a mainstream area of study only in recent decades.
DVA commenced its current focus in 1994 with the study of the Mortality of
Vietnam Veterans. DVA has been building up its expertise since that study.[373]
4.5
Other
developments include a more expansive understanding of psychological illhealth,
links between physical and mental injury, the existence of complex syndromes,
and the effects of chemical and other hazards. These may have been discussed
but lacked the scientific basis achieved through long term study of substantial
numbers of persons, comparisons with others in the community not exposed, and
the identification of numerous viruses. Persons with visible injury or obvious
disease could be compensated but where no specific cause could be identified,
the relevant links could not be established.[374]
4.6
Even then, some
of the studies referred to on World War 2 veterans have dealt only with small
groups (such as prisoners of war in Nagasaki)[375] and
persons likely to have contracted hepatitis B and other disorders.[376] Where such studies have followed
directly upon medical discovery, they have been an appropriate response, but
where they have been undertaken only years after established awareness of
problems, they represent a failure to take a pro-active approach.
4.7
A number of
groups of older veterans, from World War 2 to Vietnam in particular, have considered they have been
excluded from war related disability compensation, that little consideration
was given to possible health effects of their service, or that their ill health
has been ignored for long periods. Some of these concerns are justified, even
though the context in which their service occurred did not include an
acceptance of a duty of care similar to that which is now current. In many of
these cases, a mixture of factors has affected outcomes, but in those where the
service is not war related, both the nature of service and the difficulty in
measuring exposures combine to limit access to a disability pension. Although
compensation has been paid in a number of cases relating to the British nuclear
tests,[377] each of these has been considered
separately, with some being settled out of court. There is no presumption of
cause which would reduce the burden of proof.
British Nuclear Tests in
Australia[378]
4.8
These were
carried out between 1952 and 1957, with some additional tests between 1953 and
1963.[379] Although evidence from Hiroshima and Nagasaki was available immediately on the effects of direct
exposure to nuclear weapons, the then Australian government approved of the
tests and of the involvement of both civilians and defence personnel. A Royal
Commission, reporting in 1985, effectively acceded that exposure to radiation
was instrumental in causing illness or death, through its recommendations
including the extension of provisions of the then Compensation (Commonwealth Government Employees) Act 1971 to
civilian personnel, and the establishment of a nominal roll. [380]
4.9
However,
these recommendations were not fully implemented and have not been considered
to have met identified needs. The first was seen as ineffective in that it was
impossible for most persons to demonstrate their exposure, or, sometimes, even
their presence at the site. The development of a nominal roll, which would have
helped in this regard, was considerably delayed, not commencing until 1999,
some fourteen years later.[381]
Further, the recommendation on extension of legislative provisions was
misunderstood, as is noted in the Clarke inquiry:
The Commission was, in fact,
recommending that those same provisions, which applied to members of the armed
services, be extended to civilians who were at the test sites at relevant
times, and Aborigines and other civilians who may have been exposed to the
Black Mist. This is very different from recommending a presumptive approach to
claims or recommending that a reverse criminal standard of proof be applied to
claims.[382]
4.10
As was noted by
the RSL, even if members of the forces concerned made a claim under the VEA,
the standard of proof now required by the RMA is expressed in terms of si everts.[383] This type of exact measurements of
likely doses is not available for all personnel present at the tests, although
DVA has accepted the use of dosimetry to calculate these doses as an integral
part of the project on exposure at test sites.[384]
4.11
With respect to the British
atomic tests, the Clarke Inquiry studied the issues of eligibility in
considerable detail[385] and concluded:
-
participation by
Australian Defence Force personnel in the British atomic tests be declared nonwarlike
hazardous and the legislation be amended to ensure that this declaration can
have effect in extending VEA coverage; and
-
the Government
move quickly to finalise the cancer and mortality study.[386]
4.12
The government
response was outlined by the Minister:
The Government will respond positively
to the needs of those affected by the British Atomic Tests programme when the
outcomes of the Australian Participants in the British Nuclear Test ProgrammeCancer
Incidence and Mortality Study, are published later in [2004].[387]
4.13
The Clarke
inquiry also studied the access of BCOF personnel to benefits as a result of
service in Japan. Its recommendations included that personnel who were
present in Japan as part of the BCOF, for a specific period, become
eligible for warlike service. The Committee recommended that service with BCOF
be declared: warlike from 21 February 1946 to 30 June 1947.[388] However, the government
has stated that it will not change access to benefits for BCOF personnel:
We would create anomalies if we were to
confuse a state of readiness, or presence in a former enemys territory, with the real and tangible risks
of facing an armed and hostile enemy.The Government therefore does not accept
the Committee's recommendations for an extension of Qualifying Service for
certain service in Northern Australia during World War II and in the British
Commonwealth Occupational Forces.[389]
4.14
The Clarke report
does not, and was not intended to; solve the medical issue of exposure to
ionising radiation. It only recommended extension of qualifying service, to a
limited extent. The same is true for personnel at the British atomic tests.
Thus, although access to war service is important, the relationship between
exposure and ill health remains a major issue for those persons who believe
their health status is linked to their time in Japan rather than to any other
service period.
4.15
Allocation of
responsibility for what is perceived by many to be governmental delay in
implementing earlier recommendations is complex. However, the above Ministerial
comment reflects a long-standing belief that warlike service is quite different
from either hazardous or peacekeeping service. Whether the community as a whole
still endorses this belief is not known, but there is little agreement among
the scientific community on the effects of exposure in either Japan several months after the war or during the British
atomic tests. This will remain a key factor for both Australian and British
personnel with respect to the latter.
New Zealand
4.16
The situation in
other countries is not necessarily the same, either because the definition of
eligible service is broader than in Australia, or the reverse onus of proof is higher. In the case
of New
Zealand
in particular, there is a level of proof which requires the government to
demonstrate that the illness or injury was not caused by an accepted war or
emergency, and the extent of eligible service is wide. With respect to World
War 2 and later occupation forces, this has allowed New Zealanders serving in
J Force in Japan between 14 August 1946 and 28 April 1952[390]
to also claim war disability.
4.17
As far as the nuclear
tests are concerned, the New Zealand response has been that service personnel able to
demonstrate a 70 per cent rate of disability from relevant service, including
service in Operation Grapplethe main involvement by New Zealand in the British nuclear testsare entitled to a war
disablement pension which is tax free. A separate, but tax assessed, veterans
pension may also be available.[391] The
government extended the provisions of Section 80A of the War Pensions Act to
Operation Grapple Servicemen on 31 March 1998. However, this situation does not easily correlate
with Australian experience, since Operation Grapple was a NZ Navy operation,[392] with very little likelihood of
exposure to radiation.[393]
4.18
Research
undertaken in New Zealand supported the lack of relationship between the role
of the ships involved and any ill effects by those on board:
In his report at Appendix Three, Dr
Andrew McEwan, Scientific Director, National Radiation Laboratory, noted that
analysis conducted by the National Radiological Protection Board in the United
Kingdom showed that of 21,358 participants in all British tests, only 1716 had
nonzero radiation doses recorded, most of which were insignificant. There is
no evidence, nor any suggestion from those responsible for radiological protection,
that any RNZN vessel or crew member received any significant exposure to
radiation during Operation Grapple.[394]
4.19
However, the same
report also concluded that:
18.9 Against this background, we
concluded that the children of Operation Grapple and Vietnam
veterans should be given a package of special assistance to deal with the
social and medical circumstances they face.[395]
4.20
Nonetheless,
veterans from the ships have continued to press for additional compensation,
and were funded to undertake additional research when a new method of
identifying radiation exposure was developed:
As a result of research being
undertaken in Dundee and St.
Andrews Universities,
a simple test has been developed that uses the saliva and blood of people who
claim to have been exposed to nuclear radiation. This test is able to clearly
demonstrate whether exposure had, in fact, taken place, enabling an accurate
assessment of the causal link to the levels of radiation and any health
problems suffered. the New Zealand Government has made funds available for
their own Test Veterans Association for this purpose.[396]
4.21
The current
status of New
Zealand
veterans in this respect therefore is that they are eligible for a war pension
if they can demonstrate a particular level of disability, with the connection
between that disability and war or emergency service being at a lesser level of
proof than that required by Australia.
United States
4.22
The RSL also
referred to what was seen as a much more preferable system adopted by the US government with respect to veterans and exposure to
radiation.[397] However, the history of
radiation-related compensation in the US has been long and not without some battles. There are
two main factors which govern the variety of legislationboth that relating to
veterans and to civiliansand these are a greater awareness of and willingness
to admit to the involvement by government in activities which affected both
civilians and the military,[398] and
reliance on specific scientific information to limit access to compensation.
4.23
Veterans have
been eligible for radiationrelated benefits since 1981.[399] The US legislation relating to
specific cancers was passed in 1988, [400] prior to legislation relating to
civilians who had been exposed during US based testing in the 1950s and
1960s.[401] The Radiation Exposure Compensation Act (RECA) of 1990 legislated for
presumptive status for civilians:
an additional law administered by the
Department of Justice (DOJ), P.L. 101426 (RECA)
was enacted in 1990. This was a compensation program for uranium miners and down
winders. Subsequently, an amendment to that law, P.L.
101510 was enacted benefiting onsite participants, test site workers and
atomic veterans physically present in an area affected by atmospheric nuclear
tests for specified periods from 1951 through 1962. Note: "Specified
periods" does not include any tests before 1951, or exposures in Japan.[402]
4.24
However, there
were limitations placed on causal factors, and also the same type of date
limitations as are currently used by the RMA:
Those cancers are leukaemia (other than
chronic lymphocytic leukaemia) provided that initial exposure occurred after
the age of 20 and the onset of the disease was between two and 30 years of
first exposure, and the following diseases, provided onset was at least five
years after first exposure: multiple myeloma, non-Hodgkin's lymphomas and
primary cancer of the thyroid (provided initial exposure occurred by the age of
20), female breast (provided initial exposure occurred prior to age 40), esophageus
(provided low alcohol consumption and not a heavy smoker), stomach (provided
initial exposure occurred before age 30), pharynx (provided not a heavy
smoker), small intestine, pancreas (provided not a heavy smoker and low coffee
consumption), bile ducts, gall bladder, or liver (except if cirrhosis or
hepatitis B is indicated).[403]
4.25
Payments were
also subject to offset if any other payment was made relating to the same
illness:
Benefits provided under the Act for any
onsite test participants including atomic veterans/widows is a lump sum of
$75,000 which would be offset by the amount of any payment made pursuant to a
final award or settlement on a claim (other than a claim for worker's
compensation), against any person of any payment by the Federal Government,
that is based on injuries incurred by the claimant for which his/her claim
under the Act was submitted. If any such award, (Social Security disability,
for instance, children and spouses), settlement of Federal payment was made,
the Assistant Director shall calculate the present value of such payments, and
subtract the present value from the payment to be made under the Act.[404]
4.26
Hence, the
benefits are not openended, and the reduction in standards of proof have
resulted only from lobbying and the acceptance that some facts are hard to
demonstrate. For example, the Justice for
Atomic Veterans Act was introduced in 1999:
to provide a presumption of
service-connection for certain radiation-related illnesses suffered by veterans
who were exposed during military service to radiation. These veterans include
those who participated in atmospheric testing of a nuclear device, who
participated in the occupation of Hiroshima
or Nagasaki between August 6, 1945 and July 1, 1946 and who were interned as prisoners
of war in Japan
during World War II and were therefore exposed to ionizing radiation.
Under present law, veterans who engaged
in radiation risk activities during military service are entitled to a
presumption of serviceconnection for some illnesses, but for other illnesses
must prove causation by "dose reconstruction estimates" which many
reputable scientists have found fatally flawed. Last year, the Department of
Veterans Affairs Deputy Under Secretary for Health, Dr.
Kenneth Kizer,
wrote that he personally recommended strong support for a similar bill
introduced by Senator Wellstone
as a "matter of equity and fairness".
It is not the fault of these veterans
that accurate records of their exposure were not kept and maintained. Many
veterans have been unable to obtain even medical records relating to their
exposure during military service. Records have been lost. Records of
radiation-related activities were classified and not made available to the
veterans seeking compensation.
According to Dr.
Kizer "the scientific methodology that
is the basis for adjudicating radiation exposure cases may be sound, the
problem is that the exposure cannot be reliably determined for many
individuals, and it never will be able to be determined in my judgement. Thus,
no matter how good the method is, if the input is not valid then the
determination will be suspect".[405]
4.27
For US veterans,
the relevant period in Japan after the end of the war is from September 11th
1945 to July 1, 1946,[406] whereas
the BCOF forces arrived in February 1946.
4.28
There has not
been an automatic acceptance by the US that presence at sites equals compensable illness.
There are two forms of status, relative to the type of condition suffered:
presumptive and nonpresumptive. Presumptive status entitles an individual to
health coverage, but under the nonpresumptive program, additional factors
must be considered to determine serviceconnection, including amount of
radiation exposure, duration of exposure and elapsed time between exposure and
onset of disease.[407] Presumptive
status may also entitle an individual to a disability benefit, which will vary
according to the level of disability and number of dependants.[408]
4.29
Changes to US veterans'
legislation in 2000 also required the Veterans Affairs Department to further
assist veterans with plausible (well grounded) claims including an enhanced
duty to provide relevant information.[409]
However, this did not mean that any claim would be accepted. The onus of proof
changed with the development of presumptive status, but some conditions are
still excluded. [410]
4.30
As far as the U.S
atomic tests are concerned, the potential for considerable effect on large
numbers of civilians has been a crucial factor, and therefore the US decision
may have been both a political and an administrative one, acknowledging what
now appears to have been total indifference to the ordinary citizen as well as
the need to minimise some of the effort involved in individuals making claims.
4.31
These instances
demonstrate again that policy decisions and the nature of legislation can be
paramount in the extension or contraction of eligibility. In New Zealand, the emphasis on a very limited burden of proof in
legislation with the onus being on government to demonstrate that a disease is not caused by a specific factor, and a
strong emphasis on the governments duty to service personnel, combine to
provide greater access to benefits:
The fundamental
philosophy on which New Zealand's war pension legislation is based is that of giving veterans
who have served in a war or emergency, the benefit of the doubt in terms of
demonstrating the attributability of a medical condition to their military
service. The establishment of absolute certainty or even limited suggestion
that a condition is attributable is not required. The balance of probability is
not used in war pensions' decision making. Pensions are payable where a medical
assessment of a condition states that it can not be disproved that the
condition could have had its genesis in the Service environment. This
characteristic of New
Zealand's War
Pensions Act makes it fundamentally different from other countries' war
pensions' legislation which, in general, requires legal proof before accepting
attributability. The New Zealand philosophy is indicative of our Government's acceptance of its
obligation to safeguard the welfare of Service men and women. [411]
4.32
The United States does rely more on scientific evidence, but has
conceded that radiation exposure has the potential to cause or contribute to
certain cancers, or, in the case of Vietnam, that all personnel were exposed to Agent Orange. As
noted, the current structure of Australian veterans legislation limits the
capacity of the RMA[412] and the
Repatriation Commission to act in the same way, apart from the S 180A
discretion.[413]
4.33
Notwithstanding
the numerous studies undertaken on the British nuclear tests, including in the United Kingdom, there has been considerable dissatisfaction from
some veterans in Australia. Some perceive the problem to be with administrative
approaches which, at best, are perceived as using the lack of definitive
conclusions from medical research to justify nonrecognition of various
symptoms as warcaused. However, governments have successively declined to
change the status of some service, perhaps under pressure from those
organisations seen as representing veterans who were directly involved in war,
as opposed to hazardous service, peacekeeping, or peacemaking.[414]
Ill effects of war likely to manifest only later in life
4.34
Information
provided by the Repatriation Commission suggests that the idea of undertaking
research into the ongoing effects of war on the lives of veterans did not
become common until relatively recently.[415]
This is not to deny that considerable efforts were made to assist veterans
adjust to society and to provide appropriate care for those visibly injured. It
rather indicates that the understanding of needs was limited, and that it was
not fully understood that different wars may have had different effects, over
different time periods, including the short term.[416] In its reference to an article on
the existence of some form of psychological response being demonstrated after
numerous conflicts, the Commission stated:
it generated a new way of thinking
about the health effects of being deployed. Previously, most people who were
concerned about the health of veterans had looked for specific exposures on
particularly deployments. The paper by Hyams et al indicated that it was the
fact of deployment that created feelings of illhealth.[417]
4.35
This appears to
be a step towards the situation prevailing in the UK, that feelings or symptoms can attract compensation.[418] However, while the UK is able to provide a pension, the direct flow on in Australia is at present limited to treatment:
The paper had an effect on the way we
treat veterans returning from a deployment. Under a policy change announced by
the then Minister, the Honourable Bruce Scott MP, any veteran returning from a
deployment with symptoms that are difficult to diagnose is provided with
treatment until the condition is diagnosed.[419]
4.36
In effect, this
will provide some support unless and until the situation has progressed to the
stage where the RMA is able to provide a SOP.
4.37
Effects will also
vary according to an individuals experiencefor example, some of the US studies have demonstrated an increase in psychiatric
problems among former prisoners of war, but these have been identified as
varying depending on the circumstances and type of imprisonment. Short and long
term effects from nutritional deficiency have also been suggested.[420]
4.38
Many of the
research projects recently undertaken, such as that on the health of survivors
of the Korean War,[421] might be
considered to reflect an approach which did not see health issues as
immediately relevant. The survivors of this conflict are now in their 70s and
80s,[422] may well have experienced
health problems specific to the particular conflict for some time,[423] and are likely to be less familiar
than younger veterans with disorders such as PTSD.[424] Their capacity to lobby as a group
with specific needs may have been reduced by all three factors, quite apart
from the limited research that may have been possible because of absence of
data or the lack of epidemiology.[425]
4.39
Another related
factor is that there is little data available on lifestyle from the
contemporaneous records, requiring gaps in methodology to be filled by
recollection. This strategy may be more effective when data collection is
undertaken shortly before deploymentfor example, the US study on the health of Gulf War veterans prior to
their deployment. The absence of data collection in Australia probably reflects a limited attention paid to
specific issues arising from the Korean War and also the limited knowledge at
the time of the long term effects of smoking, as well as other factors.
Korean War health studies
4.40
The Executive
Summary of the Australian Veterans of the Korean War Mortality Study 2003
states that the study was prompted by concerns from the Korean War veteran
community that their death rates were higher than the Australian male
population, and that this increase was due to their service in Korea.[426] This
study began in 1999, and concluded that there was an increase in mortality
relative to the general male population of the same age, due mostly to cancers
and respiratory and circulatory problems rather than other disease or
psychiatric illness.[427] However,
because there were limited environmental/social data available, the study
agreed that there were weaknesses in methodology:
There was a lack of measurement of
exposure to risk factors that might contribute to the observed associations,
such as cigarette smoking, alcohol intake, hepatitis B virus infection, endemic
parasites and bacteria, pesticides, solvents, chemical exposures and
environmental exposures in Korea;
and the exposure measures available were duration and period of service in Korea.
These could not reflect occupational variations or the variation in exposure to
Korean War service within and between the Royal Australian Navy, Australian
Army and Royal Australian Air Force. [428]
4.41
Consequently:
Although Korean War veterans have a
higher mortality for several causes of death that have been identified, there
is no way of determining whether this resulted from some exposure in Korea or
whether it was the result of lifestyle changes arising as a consequence of
Korean War service or a combination of both.[429]
4.42
United States research has indicated that cold injury and cirrhosis
of the liver (for former POWs of both World War 2 and Korea) are likely long term problems. The first arose from
the environment and, in some cases, inability to get appropriate treatment for
damage caused by the cold.[430] The
cause of the second, which is not attributable to alcohol use, is not yet
known. However, the causal link is not required to be demonstrated
individually:
This final amendment adds cirrhosis of
the liver to the list of conditions for which entitlement to service connection
is presumed for former prisoners of war (POWs) under 3.309 (c). This
regulatory change is based on scientific and medical research findings.[431]
4.43
Much of the United States research relating to Korean and World War 2
veterans has been undertaken by the Institute of Medicine, part of the National Academies of Health.[432] Some of the research began shortly
after World War 2, allowing for long term study results.[433]
IOM initially conducted a 30year
followup of American POWs of World War II and the Korean Conflict and found
evidence of increased mortality from cirrhosis in American former POWs
compared to the US
general population. Furthermore, the results of the October 2000 IOM [Institute
of Medicine] study are consistent with other studies, including a 1999
mortality followup of British POWs and a 1968 mortality study of Australian
World War II POWs.[434]
4.44
Unfortunately, little specific research was previously undertaken in Australia on these veterans, who may
have been considered as part of the World War 2 group because of the overlap in
service.
Vietnammental health and chemicals
4.45
Possibly the most
contentious health issues have arisen from the Vietnam War,[435] where large scale spraying and other
use of defoliants/herbicides affected not only the Vietnamese population but
also the military of several nations. The Vietnam conflict is also noted for a range of psychiatric
disorders, already known to the militarypsychiatric world from at least the
Korean War period, but not yet fully classified and accepted. Foremost among
these is PTSD.[436]
4.46
Vietnam is also the first war in modern times which was
opposed by some groups in both the United States and Australia. As a consequence, while military action was broadly
accepted by some in the community, there were strong feelings about this by
many groups, which had a long term effect. This has had no noticeable direct
consequence in the United States where research on effects has been long term, but may
have contributed to the relatively late date at which Australia commenced specific studies.
There have been many and varied studies
with regard to veterans of this conflict. There have been two mortality
studies, a cancer incidence study, a health census, several toxicological
laboratory studies, a morbidity study and several studies of the children of Vietnam
veterans. The more recent studies have shown that Vietnam
veterans suffer from an increase in illness and elevated mortality rate for
some conditions such as lung cancer, melanoma, prostate cancer, suicide and
ischaemic heart disease. The children of Vietnam
veterans have a higher incidence of spina bifida maxima, cleft lip/palate and
suicide.[437]
4.47
The Repatriation
Commission notes that such studies have helped to develop appropriate services
such as counselling, compensation, and services for children of Vietnam veterans.[438]
Again, however, the date at which research has commenced does not reflect any
lessons learnt from previous conflicts, nor any data collection which could
minimise the need for retrospective assessment of lifestyle factors and
calculation of pre-existing illness or vulnerability to certain situations.[439]
Herbicides/defoliantsthe
effects of Agent Orange
4.48
The United States had undertaken some research into Agent Orange by
1969 which led to its use being discontinued in Vietnam in 1971, although there was a lack of correlation
between outcomes of research and the beliefs of veterans. In 1991 Congress
required that a major study be undertaken:
Because of continuing uncertainty about
the long-term health effects of exposure to the herbicides used in Vietnam,
Congress passed Public Law 1024, the Agent Orange Act of 1991. This
legislation directed the Secretary of Veterans Affairs to request the National
Academy of Sciences (NAS) to conduct a comprehensive review and evaluation of
scientific and medical information regarding the health effects of exposure to
Agent Orange, other herbicides used in Vietnam,
and the various chemical components of these herbicides, including dioxin. A
committee convened by the Institute
of Medicine of the NAS conducted
this review and in 1994 published a comprehensive report entitled Veterans and
Agent Orange: Health Effects of Herbicides Used in Vietnam.
Public Law 1024 also called for the
NAS to conduct subsequent reviews at least every 2 years for a period of 10
years from the date of the first report. The NAS was instructed to conduct a
comprehensive review of the evidence that had become available since the
previous IOM committee report and to reassess its determinations and estimates
of statistical association, risk, and biological plausibility. [440]
4.49
The IOM
established the Committee to Review the Health Effects in Vietnam Veterans of
Exposure to Herbicides, which reported in 1994 and has provided updates in
1996, 1998, 2000, and 2002.[441] There
have also been other reports on Agent Orange from the IOM,[442] as well as studies from other
sources. Since that first report, the updates as well as additional research on
specific subjects have provided information demonstrating links between other
disorders and agent orange:
After years of debate, Congress
directed the National Academy of Sciences to conduct a comprehensive review and
evaluation of the available scientific and medical literature on Agent Orange
and the other herbicides used in Vietnam.
As a result of the first two reviews,
published in
1994 and 1996, VA now recognises eight conditions which are presumed to
be related to service in Vietnam for the purposes of establishing serviceconnection:
soft tissue sarcoma, nonHodgkin's lymphoma, Hodgkin's disease, chloracne,
porphyria cutanea tarda, respiratory cancers, multiple myeloma, prostate
cancer, acute peripheral neuropathy, and spina bifida in offspring.[443]
4.50
As noted above,
the US allows for a presumptive approach,[444] relying on scientific evidence, and
then adds the respective illnesses to its list of compensable disorders:
VA presumes that all military personnel
who served in Vietnam
were exposed to Agent Orange, and federal law presumes that certain illnesses
are a result of that exposure. This socalled "presumptive policy"
simplifies the process of receiving compensation for these diseases since VA
foregoes the normal requirements of proving that an illness began or was
worsened during military service.[445]
PTSD and other psychiatric
problemsunderdiagnosed
4.51
The Vietnam War
had a substantial effect on both military personnel and civilians, with
rejection of the war by parts of society probably a contributor to some level
of psychological problems among veterans. In 1991, a US report on Vietnam veterans estimated that:
15.2% of all male and 8.5% of all
female Vietnam theatre veterans currently suffer from PTSDapproximately
450,000 veterans in all. Furthermore, more than twice that number, (30.6% male
and 26.9% female) of theatre veterans have had the full PTSD syndrome at some
time since their warzone experience in South-East Asia.[446]
4.52
However, mental
health issues including readjustment problems, have not always been identified
or effectively addressed, reflecting the level of knowledge of such issues, and
the social context which provided little outlet for discussion of them.[447] PTSD itself was only formally
accepted in 1980,[448]
although other forms of reaction to war were recognised prior to that time.
4.53
The Repatriation
Commission has stated that the Vietnam Veterans Counselling Service was
established 20 years ago in recognition of the fact that there were Vietnam veterans who felt alienated from government
processes.[449] As
well as developing the Centre for Post Traumatic Stress Disorder, the
Commission has been instrumental in commissioning research on numerous mental
health issues both in recognition of the fact that mental health is a major
concern for veterans as well as current ADF personnel, and as part of the
National Mental Health Strategy.[450]
4.54
This process is
similar to that which occurred in the United States, where the US Veterans Affairs department has also
responded to identified needs, though with the impetus coming much more
obviously from Congress.[451] However,
although PTSD was originally seen as peculiar to the Vietnam conflict, it was subsequently recognised as a
disorder that affected other military veterans and the civilian population as
well, with the National Centre for PostTraumatic Stress Disorder also
providing service to civilians:
[PTSD] is no longer considered an
isolated problem for Vietnam
veterans. PTSD is recognised as a major public health problem and a behavioural
health problem for military veterans and active duty personnel subject to the
traumatic stress of war, dangerous peacekeeping operations, and interpersonal
violence.[452]
Gulf War/s
4.55
Notwithstanding
the perceived failure to learn lessons from the first Gulf War,[453] the United States has included various disorders deemed to have been
warrelated in its list of compensable illnesses (entitling the individual to
disability payments).[454] It has also
undertaken extensive research which addresses the existence of symptoms for which
there is no clear diagnosis:
Most have health problems similar to those experienced
by veterans of other eras. However, some veterans report chronic multisymptom
illnesses that often are difficult to diagnose. Thus, most of the symptoms
reported by veterans in VA registry examinations were found to be caused by
conventional illnesses.
However, in about 20 percent of examinations, primary
diagnoses of physical complaints could not be provided. (For comparison,
approximately 17 per cent of Vietnam veterans on VAs
Agent Orange registry examination have undiagnosed symptoms).[455]
4.56
Extensive
websites and research/information programs on all aspects of Gulf War disorders
including du, some by Veterans Affairs and some by the US Department of
Defence. Research on Gulf War veterans had begun in 1992[456] and, in conjunction with the
research undertaken by other agencies and the development of detailed health
guides, extensive information is available to veterans, their families and
doctors.[457]
4.57
The United States publicly acknowledges shortcomings in its capacity to
address the needs of veterans within short time frames.[458] It also acknowledges that veterans
have been critical of services, not just in respect of the Gulf War, but those
provided after earlier conflicts.[459] These
two factors are likely to be important to veterans and currently serving
personnel because they are recognition of the reality of their experience.
4.58
The development
of extensive medical guidelines and training programs for those treating
personnel involved in specific conflicts are also recognition of the reality of
the symptoms experienced and of the need for professional awareness of the
extent of these. This places the responsibility for dealing with identified
health issues on medical staff, rather than on the individual.
4.59
The awareness of
undiagnosed' symptoms or unexplained illnesses arising from all conflict[460] does not lead to a rejection of the
relevance of these, but more to a recognition of their inevitable appearance
after all conflict and therefore the importance of addressing them. In fact,
considering they are seen as almost inevitable, although varying in content,
appropriate services can be developed to meet such needs in advance.
4.60
The Australian Gulf War Veterans Health Study
2003[461] has identified a similar
pattern of unexplained illness in Australian veterans:
The Australian Gulf War Veterans
Health Study was prompted by several factors. These include:
-
the results of
several overseas studies, which had shown that the Gulf War veterans from coalition
partner countries were reporting poorer than expected health,
-
an increasing
number of reports among Australian Gulf War veterans of a wide range of medical
problems, which were difficult to explain,
-
concern amongst
Gulf War veterans about the possible health effects of some of the exposures
and experiences unique to the Gulf War, such as smoke and oil from burning oil
wells (SMOIL), exposure to depleted uranium and the possible use of chemical or
biological weapons.[462]
Australian Gulf War veterans have an
increased risk of psychological disorders including depression, anxiety,
posttraumatic stress disorder and substance use disorders in the post Gulf War
period and persisting within the previous 12 months. These psychological
disorders are strongly associated with reported military service experiences
that occurred in the Gulf War, especially the threat of attack
Australian Gulf War veterans have
increased rates of reporting of all symptoms, and some medical conditions; in
particular musculoskeletal, psychological, skin, respiratory and neurological
conditions and these are associated with several reported exposures and
experiences that occurred in the Gulf War. These include immunisations
(especially where 10 or more were reported), pyridostigmine bromide and being
in an area where chemical weapons had been used.[463]
4.61
The report
concluded, however, that although there was a higher level of reporting of some
symptoms, there was no unique symptom complex or cluster arising from the
Gulf War.[464] Although Gulf War
veterans may have been concerned that this study was not undertaken earlier,
there has been some access to treatment nonetheless, which may reflect an
increased awareness of the importance of acknowledging symptoms.
Effects of research on the development
of programs
4.62
The ADF now has
in place a more pro-active policy at least with respect to deployments, with
efforts made to identify potential hazards, to protect personnel from these and
to minimise injury.[465] It is also
involved in research relevant to deployment:[466]
Historically many Defence health
studies were reactive in nature, in response to perceived problems or issues
promoted by particular interest groups. DHSB is currently adopting a more
pro-active response to future health research in the ADF and has initiated the
conduct of operational health studies for more recent operations. Such studies
should ideally begin prior to deployment however the short planning timeframes
involved will not always allow this.[467]
4.63
It is also
apparent that relatively recent audits and other reviews have contributed to
some changes in the ADF health services and to the development of occupational
health and safety plans.[468] Generally
speaking, ADF has responsibility for research into more recent deployments,[469] with DVA being responsible for work
on older ones, although it is expected that the new Centre for Military and
Veterans Health will gradually take over the research capacity from DVA.[470] The amount of available funding will
remain a key determinant in how much can be achieved,[471] as far as Defence is concerned,
although its objective would be a structured research program which could
address a wide range of research issues.[472]
4.64
In Australia, the development of mental health services for both Vietnam veterans and others has increased considerably in
recent years. Factors which limit social acceptance of mental health issues,
including a tolerance of excessive alcohol consumption and violence, and a lack
of connection between experience and various behaviours, have probably helped
to disguise a level of need in society generally and veterans in particular.
Even ADF health professionals appear reluctant to use the very services which
they provide:
More of the 2002 group were aware of
the availability of counselling services than the 1999 group, but no survey
participants actually used counselling services. Most of the 1999 group and
half of the 2002 group indicated that they would not use counselling services
to cope with stress, even if they were available. This is of concern, as the
survey respondents were health personnel who should have had an understanding
of the value of mental health interventions.
The reluctance to use mental health
services may be attributable to a perception that using such services is an
admission of inability to cope and meet the obligations of a soldier.
Despite this reluctance, about 70% of
participants felt that counselling services should be deployed.[473]
4.65
This probably
results in specific programs having gradual rather than immediate effects:
The amount of information available to
veterans and health providers on mental health and related problems and coping
strategies has improved with the implementation of their respective mental
health and alcohol management strategies. However, as with the general
community, the problem of poor mental health literacy and concern about the
stigma of mental health disorders remain significant barriers for young
veterans. Continued work is required to improve awareness and understanding of
the nature of mental health problems experienced by veterans and ways to access
assistance and treatment.[474]
4.66
The ADF has set
up an extensive program which seeks to address both drug/alcohol related issues
and those arising from deployments. Information on these is provided in various
publications and on the internet, with an emphasis on the fact that such issues
are common and on providing advice on different sources for help.[475] There is therefore an effort to
demonstrate that psychological problems including PTSD and difficulties in readjustment
on return from deployment are to be expected, and not contrary to a military
culture. However, there is no mention in the pamphlets of the fact that many
people outside the military have similar problems, and that mental health
issues are a major health concern for the Australian community in general.
4.67
The ADF has also
changed its method of responding to critical events,[476] and reorganised mental health
services to provide regional teams that are working together:
A major limitation in the delivery of
mental health services to the ADF identified in the ADF Health Status Report
(2000) was the lack of integration between service providers. There are a
number of organisations within Defence that deliver comprehensive mental health
services, but due to a lack of integration they sometimes work at best in
parallel and have the potential to work in opposition. [477]
4.68
The increasing
emphasis on the contribution of lifestyle does reflect the community
expectation that individuals bear some responsibility for their own health.
This responsibility also demands, however, that there be a duty of care to
personnel to minimise the risks to which they are exposed, particularly in
peacetime, including limitation of the high rate of injury. For some veterans
and current personnel, there may be a belief that this duty of care is not well
developed and that various factors make it difficult for an individual to
ensure that the workplace has the appropriate standards and a commitment to
enforcing them.
Research priorities
4.69
Research
priorities are identified in various ways, with the joint Defence/DVA Medical
Advisory Panel (MAP) identifying needs.[478]
These decisions appear to be based on a range of data collected by Defence and
DVA,[479] and will include in time the
data from postdeployment reviews. Defence also stated that:
The ADF documents health and human performance research
requirements in a Master Plan, which is reviewed and updated annually. While
this document is heavily influenced by the extant capabilities of relevant research
organisations in Defence, the plan also indicates areas of research interest
for which there is no intrinsic capability. The intention is that the Centre
for Military and Veterans Health will link into external organisations that
may provide some of those capabilities and the Master Plan should evolve to
reflect more accurately research requirements that could be addressed in
these ways. Examples of areas where operationally relevant research might be
undertaken are in the areas of gastrointestinal disease and combat casualty
care.[480]
4.70
The protocols and
objectives for Defence health research are outlined in ADFP Personnel Series
1.2.5.3, Health and Human Performance
Research in DefenceManual for Researchers.[481] The manual states that:
The primary focus [in research on the
physical and/or mental health of personnel] is the study of the preventive,
evacuation, treatment and rehabilitation strategies that will improve the
management of health and health hazards encountered in areas of strategic
interest to Australia.
Human performance research is defined
as the group of investigations where the aim is to improve the normal
performance, output and capability of humans to complete tasks and maintain or
improve performance levelsthis research has a focus on the development of
human capacity and sustainability with respect to both physical and cognitive
performance.[482]
4.71
This approach may
include some measures to deal with non-deployment issues, but the emphasis is
primarily on operational service.
Repatriation Commission/DVA
4.72
DVA has a long
established research program which has increasingly been used to support new
services intended to meet the identified needs of veterans.[483] With the development of ADF data
collections, technology such as HealthKEYS and EpiTrack, the initiation of
health reviews following deployment, data from health plans, and the use of
environmental data, future research will benefit from information that is
collected before, during and within a short time of deployments. Such data will
help DVA undertake programs and identify issues that affect those leaving the
forces as well as current personnel, and place emphasis on younger veterans as
well as those from earlier deployments.
4.73
DVA has indicated
that the information which it obtains from its data collection and from
research informs the development of more appropriate programs:
Two examples are:
Results of the Vietnam Veterans
Morbidity Study which the Repatriation Commission developed into a range of
program responses to enhance health service delivery for this veteran cohort;
and
An analysis of mental health disorders
in the veteran community conducted to inform development of DVAs mental health
policy led to research on the pathways to care taken by veterans recently
compensated for a mental health disability. The Repatriation Commission will
consider the findings of this research in the near future.[484]
4.74
DVA also has a
somewhat different perspective of veterans, since it may see more directly the
needs of different groups through its knowledge of the nature of applications
being made for compensation and a range of other sources.[485] Given that DVA is aware of the
constancy of certain responses to deployments, and has gradually developed
programs to meet such needs, their input into research on current deployments
may also be of use in defining probable needs for current personnel, rather
than waiting for these to become veterans with illdefined needs. DVA was
responsible for the establishment of the then National Centre for WarRelated
PTSD, in 1995, which later became the CPMH:
The Australian Centre for Posttraumatic
Mental Health (ACPMH), working in collaboration with the Department of
Veterans' Affairs (DVA) and the Australian Defence Force (ADF), as well as with
clinicians, researchers, and consumers around Australia, acts as a focus for an
integrated approach to veteran and military mental health.
The active involvement of both the ADF
and DVA provides new opportunities to address psychiatric morbidity at every
stage, from recruitment through deployments and discharge to veteran status.[486]
4.75
This Centre has a
major role in the provision of clinical services, including early intervention,
training, and collection of data on outcomes of treatment. It therefore
provides an external view of services provided and covers both current ADF
personnel and veterans.[487] DVAs
continued involvement with this Centre will help provide it with insight into
current issues and an awareness of the ways in which the ADF is dealing with
these:
In 2000 the Repatriation Commission
determined that the role of the Australian Centre for Posttraumatic Mental
Health (ACPMH) should be expanded beyond a focus on PTSD to include broader
mental health conditions that impact on veterans. ACPMH has provided assistance
with the development of guidelines for the treatment of anger management
problems and currently is developing alcohol treatment guidelines. This work
specifically relates to treatment of veterans. However, the centre has also
established liaisons and other work with the Australian Defence Force (ADF)
with regard to postdeployment adjustment and development of the ADF alcohol
strategy.
Other research work undertaken by the
centre covers areas such as Alzheimers disease, psychiatric morbidity,
cognitive counselling techniques, anxiety disorders, depression, psychometric
analysis, Quality of Life assessments, military stress and performance and
schizophrenia.[488]
Research priorities
In determining the Commissions
research agenda, many factors are considered. These include the wishes of the
veteran community, the scientific interest in the questions that are raised,
the viability of the proposed research, the availability of resources, and
ethical, legal and moral considerations.[489]
Issues raised by veterans
4.76
Several issues
were raised by ESOs on research programs, including:
-
Lack of adequate
research undertaken on mental health.[490]
-
Limited holistic
approach to health, especially on the issue of the interaction of effect of
exposure to multiple substances or multiple exposures to substances; [491]
and
-
Concern that
research is being replicated, and therefore that decisions about some issues
could be made if existing research was accepted.[492]
Lack of research on mental health
4.77
There has been an
increase in mental health research, especially for younger veterans, which will
continue with the work of the ACPMH, which looks at all mental health issues.
DVA has also stated that the ACPMH has paid limited attention to the needs of
older veterans, and that its main focus has been on Vietnam veterans and those from more recent deployments:
The needs of older veterans has not
been a major focus for the centre to date. ACPMH accredits PTSD treatment
programs of which two programs are specifically tailored to the needs of older
veterans. Much of the centres work, since opening in 1995, has been focussed
on the group of Vietnam
veterans who have been highly represented in the cohorts of PTSD treatment programs.
It's more current collaboration with the ADF means it has been developing a
body of knowledge and experience about the needs of more recent young veterans
and current serving ADF personnel.[493]
4.78
In May 2004 DVA
circulated a consultation paper, Towards
Better Mental Health for the Veteran
Community, which notes proposed changes arising from reports and also from
the National Mental Health Plan.[494]
DVA has also released Mental
Health Disorders in the Veteran Community and their Impact on DVAs Programs,[495] based on 19971998 data. A total of
87,874 people met one or more of the inclusion criteria, representing 26% of
the DVA treatment population.[496]
4.79
Matters of
specific interest to some groups of veterans, such as the differing stressors
produced by different roles,[497] may
also be studied by individuals or units outside of the ADF and Repatriation
Commission research areas, including those with direct experience:
Peacekeeping missions, which bring
soldiers into war zones as noncombatants, present a wide variety of stresses
that have short and longterm effects on mental health. Frequently,
peacekeepers witness largescale devastation and atrocities. Soldiers are
trained to win the day by the application of tactics and up to date weaponry,
yet peacekeeping and humanitarian missions generally restrict tactical freedom
and the use of force, exposing soldiers to stresses for which they are not
prepared or trained, largescale devastation and atrocities. Various authors
have described UN personnel as exposed to a wider range of stressors than they
would be in combat. Isolation, boredom, feelings of frustration, rage and helplessness
due to strict UN rules of engagement, which only allow a soldier to shoot if
under direct threat of loss of life or limb, all increase the stress of
military personnel in a peacekeeping role.[498]
4.80
DVA is well aware
of the concerns of the younger veteran groups, and believes that ESOs are
familiar with the work undertaken by the ACPMH.[499] There seems no reason to suppose
that the specific issues raised on peacekeeping or peacemaking would not be
addressed. However, it may be that the relevant organisations need to outline
proposals for research which will cover areas of need.
Limited holistic research
4.81
One of the
problems identified by DVA in undertaking research on multiple exposures is the
difficulty of establishing cohorts:
More recent deployments have tended to
involve smaller numbers of personnel. Moreover, in many of these deployments
the same individuals have participated in multiple deployments, and each of the
deployments has multiple exposures. These circumstances of small deployments,
multiple deployments and multiple exposures make attributing causality
difficult.[500]
4.82
While there has
been some research on exposures, such as may have contributed to the Gulf War
syndrome, it could be impossible to separate out individual causal factors. It
may be possible to identify some cases where new personnel have deployed, such
as in some of the US forces in the 2nd Gulf War battles, because they have
limited previous exposure; but if they receive multiple exposures in conflict,
the benefit of such research may be minimal. It is possible also that if
similar effects are seen after all conflict, there will be a tendency to move
towards treating symptoms rather than seeking a diagnosis, which may put more
emphasis on psychiatric issues than on the physical effects of exposurenot
necessarily what veterans want.
Replication of research
4.83
This concern has
been addressed by the Repatriation Commission which outlines the reasons why
some research duplication is necessary, and how specific factors may mean the
experience of Australians in some deployments may differ from those of
personnel from other countries in the same deployment.[501]
It is important to note that DVAs
research efforts in these fields are not taken in isolationIts studies are
usually carried out at the same time that similar research is being undertaken
in the United States, the United Kingdom, Canada, New Zealand and other
nations.
Often, the research by other countries
is on deployments that are similar to those of the ADF. This similarity of
deployments, necessarily with some duplication of effort, has both advantages
and disadvantages. Often when there has been a good study of a particular
probleman argument might be raised that reduplication of what others have
already found is not a prudent use of limited resources. Conversely in science
there is a need to confirm finding made in other studies, and, when two groups
of researche[r]s make the same finding, working independently of each other,
the two findings have a synergistic value.[502]
4.84
It could also be argued
that in many cases, the research will cover somewhat different factors, given
that forces may have been subject to different types and amounts of exposures,
have different experience, and are undertaking different work. It may also be
that this difference is so great or the methodology is not acceptable that the
work of other bodies will not always be accepted as useful.[503]
4.85
A further issue
is that which has been referred to previously, that while much research may not
find a correlation between events and illness, political and policy factors may
result in different outcomes for veterans of different countries. The most
effective use of the research of other countries is to use what is generic,
where possible, and also to explain why it is that there is not sufficient
evidence to demonstrate causal links, or why different systems will accept some
situations.
Women
4.86
There was no
detailed reference to the specific needs of women in the ADF, or to any
research areas which they may wish to have addressed.[504] Given that their health needs are
different, it may be useful for both the ADF and DVA to consider the US military websites which have a specific website for
women members.
4.87
While women may
be included within the research into the needs of younger veterans, their
particular needs should be identified for all research on issues where they are
represented. However, it is noted that in many instances, the numbers of women
involved in deployments will often be too low to obtain any meaningful results:
Only 38 female Australian Gulf War
veterans took part in the study, which was 84% of those who served there. This
small number meant that there was limited statistical power for the analysis of
this group. However, a similar, but less marked, pattern in relation to adverse
psychological outcomes as for male Gulf War veterans was found. No firm
conclusions can be made about any of the other physical health indicators
studied, due to the very small numbers of female Gulf War veterans.[505]