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1.  The Health of the American Slave Examined by Means of Union Army Medical Statistics 
The health status of the American slave in the 19th century remains unclear despite extensive historical research. Better knowledge of slave health would provide a clearer picture of the life of the slave, a better understanding of the 19th-century medicine, and possibly even clues to the health problems of modern blacks. This article hopes to contribute to the literature by examining another source of data. Slaves entering the Union Army joined an organization with standardized medical care that generated extensive statistical information. Review of these statistics answers questions about the health of young male blacks at the time American slavery ended.
PMCID: PMC2561819  PMID: 3881595
2.  Risk Exposures in Early Life and Mortality at Older Ages: Evidence from Union Army Veterans 
Population and development review  2009;35(2):275-295.
This study examines the relation between risk exposures in early life and hazard of mortality among 11,978 Union Army veterans aged 50 and over in 1900. Veterans’ risk exposures prior to enlistment–as approximated by birth season, country of origin, residential region, city size, and height at enlistment–significantly influence their chance of survival after 1900. These effects are robust irrespective of whether or not socioeconomic well-being circa 1900 has been taken into account; however, they are sensitive to the particular age periods that have been selected for survival analysis. Whereas some of the effects such as being born in Ireland and coming from big cities became fully unfolded in the first decade after 1900 and then dissipated over time, the effects of birth season, being born in Germany, residential region in the U.S., and height at enlistment were more salient in the post-1910 periods. Height at enlistment shows a positive association with risk of mortality in the post-1910 periods. Compared to corresponding findings from more recent cohorts, the exceptional rigidity of the effects of risk exposures prior to enlistment on old-age mortality among the veterans highlights the harshness of living conditions early in their life.
PMCID: PMC2832117  PMID: 20209063
3.  Health, Information, and Migration: Geographic Mobility of Union Army Veterans, 1860–1880 
The journal of economic history  2008;68(3):862-899.
This article explores how injuries, sickness, and the geographic mobility of Union Army veterans while in service affected their postservice migrations. Wartime wounds and illnesses significantly diminished the geographic mobility of veterans after the war. Geographic moves while carrying out military missions had strong positive effects on their postservice geographic mobility. Geographic moves while in service also influenced the choice of destination among the migrants. I discuss some implications of the results for the elements of self-selection in migration, the roles of different types of information in migration decisions, and the overall impact of the Civil War on geographic mobility.
PMCID: PMC2838394  PMID: 20234796
4.  Military positions and post-service occupational mobility of Union Army veterans, 1861–1880 
Explorations in economic history  2007;44(4):680-698.
Although the Civil War has attracted a great deal of scholarly attention, little is known about how different wartime experiences of soldiers influenced their civilian lives after the war. This paper examines how military rank and duty of Union Army soldiers while in service affected their post-service occupational mobility. Higher ranks and non-infantry duties appear to have provided more opportunities for developing skills, especially those required for white-collar jobs. Among the recruits who were unskilled workers at the time of enlistment, commissioned and non-commissioned officers were much more likely to move up to a white-collar job by 1880. Similarly, unskilled recruits assigned to white-collar military duties were more likely to enter a white-collar occupation by 1880. The higher occupational mobility of higher-ranking soldiers is likely to have resulted from disparate human capital accumulations offered by their military positions rather than from their superior abilities.
PMCID: PMC2838376  PMID: 20234792
Military service; Civil War; Rank; Duty; Human capital; Training; Occupational mobility; Union Army; Veteran
5.  Wealth Accumulation and the Health of Union Army Veterans, 1860–1870 
The journal of economic history  2005;65(2):352-385.
How did the wartime health of Union Army recruits affect their wealth accumulation through 1870? Wounds and exposure to combat had strong negative effects on subsequent savings, as did illnesses while in the service. The impact of poor health was particularly strong for unskilled workers. Health was a powerful determinant of nineteenth-century economic mobility. Infectious diseases’ influences on wealth accumulation suggest that the economic gains from the improvement of the disease environment should be enormous. The direct economic costs of the Civil War were probably much greater than previously thought, given the persistent adverse health effects of wartime experiences.
PMCID: PMC2840618  PMID: 20300440
6.  Occupational Career and Risk of Mortality among Union Army Veterans 
Social science & medicine (1982)  2009;69(3):460-468.
Previous studies have extended the traditional framework on occupational disparities in health by examining mortality differentials from a career perspective. Few studies, however, have examined the relation between career and mortality in a historical U.S. population. This study explores the relation between occupational career and risk of mortality in old age among 7,096 Union Army veterans who fought the American Civil War in the 1860s. Occupational mobility was commonplace among the veterans in the postbellum period, with 54 percent of them changing occupations from the time of enlistment to 1900. Among veterans who were farmers at enlistment, 46 percent of them changed to a non-farming occupation by the time of 1900. Results from the Cox Proportional Hazard analysis suggest that relative to the average mortality risk of the sample, being a farmer at enlistment or circa 1900 are both associated with a lower risk of mortality in old age, although the effect is more salient for veterans who were farmers at enlistment. Occupational immobility for manual labors poses a serious threat to chance of survival in old age. These findings still hold after adjusting for the effects of selected variables characterizing risk exposures during early life, wartime, and old age. The robustness of the survival advantage associated with being a farmer at enlistment highlights the importance of socioeconomic conditions early in life in chance of survival at older ages.
PMCID: PMC2852134  PMID: 19552993
Career; Occupational Mobility; Mortality; Union Army Veterans; USA
7.  Testing the influenza–tuberculosis selective mortality hypothesis with Union Army data⋆ 
Social science & medicine (1982)  2009;68(9):1599-1608.
Using Cox regression, this paper shows a weak association between having tuberculosis and dying from influenza among Union Army veterans in late nineteenth-century America. It has been suggested elsewhere [Noymer, A. and M. Garenne (2000). The 1918 influenza epidemic’s effects on sex differentials in mortality in the United States. Population and Development Review 26(3), 565–581.] that the 1918 influenza pandemic accelerated the decline of tuberculosis, by killing many people with tuberculosis. The question remains whether individuals with tuberculosis were at greater risk of influenza death, or if the 1918/post-1918 phenomenon arose from the sheer number of deaths in the influenza pandemic. The present findings, from microdata, cautiously point toward an explanation of Noymer and Garenne’s selection effect in terms of age-overlap of the 1918 pandemic mortality and tuberculosis morbidity, a phenomenon I term “passive selection”. Another way to think of this is selection at the cohort, as opposed to individual, level.
PMCID: PMC2677170  PMID: 19304361
USA; Influenza; Tuberculosis; Selection; Mortality; Historical demography; Historical epidemiology; Union Army veterans
8.  Pensions and Retirement Among Black Union Army Veterans 
The journal of economic history  2010;70(3):567-592.
I examine the effects of an unearned income transfer on the retirement rates and living arrangements of black Union Army veterans. I find that blacks were more than twice as responsive as whites to income transfers in their retirement decisions and 6 to 8 times as responsive in their choice of independent living arrangements. My findings have implications for understanding racial differences in rates of retirement and independent living at the beginning of the twentieth century, the rise in retirement prior to 1930, and the subsequent convergence in black-white retirement rates and living arrangements.
PMCID: PMC3004158  PMID: 21179379
9.  Health, Wartime Stress, and Unit Cohesion: Evidence From Union Army Veterans 
Demography  2010;47(1):45-66.
We find that Union Army veterans of the American Civil War who faced greater wartime stress (as measured by higher battlefield mortality rates) experienced higher mortality rates at older ages, but that men who were from more cohesive companies were statistically significantly less likely to be affected by wartime stress. Our results hold for overall mortality, mortality from ischemic heart disease and stroke, and new diagnoses of arteriosclerosis. Our findings represent one of the first long-run health follow-ups of the interaction between stress and social networks in a human population in which both stress and social networks are arguably exogenous.
PMCID: PMC3000013  PMID: 20355683
10.  Socioeconomic Differences in the Health of Black Union Army Soldiers 
Social science history  2009;33(4):427-457.
This paper investigates patterns of socioeconomic difference in the wartime morbidity and mortality of black Union Army soldiers. Among the factors that contributed to a lower probability of contracting and dying from diseases were (1) lighter skin color, (2) a non-field occupation, (3) residence on a large plantation, and (4) residence in a rural area prior to enlistment. Patterns of disease-specific mortality and timing of death suggest that the differences in the development of immunity against diseases and in nutritional status prior to enlistment were responsible for the observed socioeconomic differences in wartime health. For example, the advantages of light-skinned soldiers over dark-skinned and of enlisted men formerly engaged in non-field occupations over field hands resulted from differences in nutritional status. The lower wartime mortality of ex-slaves from large plantations can be explained by their better-developed immunity as well as superior nutritional status. The results of this paper suggest that there were substantial disparities in the health of the slave population on the eve of the Civil War.
PMCID: PMC3427919  PMID: 22933827
11.  Rationale and design of a multicenter randomized controlled trial on a 'minimal intervention' in Dutch army personnel with nonspecific low back pain [ISRCTN19334317] 
Researchers from the Royal Netherlands Army are studying the potential of isolated lumbar extensor training in low back pain in their working population. Currently, a randomized controlled trial is carried out in five military health centers in The Netherlands and Germany, in which a 10-week program of not more than 2 training sessions (10–15 minutes) per week is studied in soldiers with nonspecific low back pain for more than 4 weeks. The purpose of the study is to investigate the efficacy of this 'minimal intervention program', compared to usual care. Moreover, attempts are made to identify subgroups of different responders to the intervention.
Besides a baseline measurement, follow-up data are gathered at two short-term intervals (5 and 10 weeks after randomization) and two long-term intervals (6 months and one year after the end of the intervention), respectively. At every test moment, participants fill out a compound questionnaire on a stand-alone PC, and they undergo an isometric back strength measurement on a lower back machine.
Primary outcome measures in this study are: self-assessed degree of complaints and degree of handicap in daily activities due to back pain. In addition, our secondary measurements focus on: fear of movement/(re-) injury, mental and social health perception, individual back extension strength, and satisfaction of the patient with the treatment perceived. Finally, we assess a number of potential prognostic factors: demographic and job characteristics, overall health, the degree of physical activity, and the attitudes and beliefs of the physiotherapist towards chronic low back pain.
Although a substantial number of trials have been conducted that included lumbar extension training in low back pain patients, hardly any study has emphasized a minimal intervention approach comparable to ours. For reasons of time efficiency and patient preferences, this minimal sports medicine approach of low back pain management is interesting for the population under study, and possibly for comparable working populations with physical demanding job activities.
PMCID: PMC533884  PMID: 15535881
12.  An Occupational Health Nursing Computer Application in Medical Care: An Army Approach 
Occupational health nursing has become an increasingly important specialty in the field of nursing during this century. In the broadest concept, occupational health is concerned with all factors which influence the health of people at work. Nurses, as well as other health care professionals, are attempting to apply the evolving technology of the computer to direct client care applications in the workplace. One such relevant use of the computer has been that of targeted disease surveillance in an occupational health setting. This paper will address the process utilized by community health nurses to assess, plan, implement and evaluate a computerized disease surveillance program in an occupational health setting. The program was a joint effort between the United States Army Medical Department Activity, Fort Irwin, California and the Epidemiology Consultant Service of the Division of Preventive Medicine, the Walter Reed Army Institute of Research, Washington, DC. (WRAIR).
PMCID: PMC2578424
13.  Nonfatal Suicidal Behaviors in U.S. Army Administrative Records, 2004–2009: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2015;78(1):1-21.
Although the U.S. Army suicide rate is known to have risen sharply over the past decade, information about medically documented, nonfatal suicidal behaviors is far more limited. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among regular Army soldiers.
Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty during the years 2004 through 2009 (n = 1.66 million).
We identified 21,740 unique regular Army soldiers with a nonfatal suicidal event documented at some point during the HADS study period. There were substantial increases in the annual incidence rates of suicide attempts (179–400/100,000 person-years) and suicide ideation (557–830/100,000 person-years), but not suspicious injuries. Using hierarchical classification rules to identify the first instance of each soldier's most severe behavior, we found increased risk of all outcomes among those who were female, non-Hispanic White, never married, lower-ranking enlisted, less educated, and of younger age when entering Army service. These sociodemographic associations significantly differed across outcomes, despite some patterns that appear similar.
Results provide a broad overview of nonfatal suicidal trends in the U.S. Army during 2004 through 2009 and demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.
PMCID: PMC4503376  PMID: 26168022
14.  Predicting U.S. Army suicides after hospitalizations with psychiatric diagnoses in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2015;72(1):49-57.
The U.S. Army experienced a sharp rise in suicides beginning in 2004. Administrative data show that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder.
To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded post-hospital care.
There were 53,769 hospitalizations of active duty soldiers in 2004–2009 with ICD-9-CM psychiatric admission diagnoses. Administrative data available prior to hospital discharge abstracted from a wide range of data systems (socio81 demographic, Army career, criminal justice, medical/pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees, penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.
Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.
68 soldiers died by suicide within 12 months of hospital discharge (12.0% of all Army suicides), equivalent to 263.9 suicides/100,000 person-years compared to 18.5 suicides/100,000 person-years in the total Army. Strongest predictors included socio-demographics (male, late age of enlistment), criminal offenses (verbal violence, weapons possession), prior suicidality, aspects of prior psychiatric inpatient and outpatient treatment, and disorders diagnosed during the focal hospitalizations. 52.9% of post-hospital suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3,824.1 suicides/100,000 person years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse post-hospital outcomes (unintentional injury deaths, suicide attempts, re-hospitalizations).
The high concentration of risk of suicides and other adverse outcomes might justify targeting expanded post-hospital interventions to soldiers classified as having highest post-hospital suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
PMCID: PMC4286426  PMID: 25390793
Army; machine learning; elastic net regression; military; penalized regression; predictive modeling; risk assessment; suicide
British Medical Journal  1905;2(2340):1211-1213.
PMCID: PMC2322683  PMID: 20762362
21.  The Reliability and Validity of the Self-Reported Drinking Measures in the Army’s Health Risk Appraisal Survey 
The reliability and validity of self-reported drinking behaviors from the Army Health Risk Appraisal (HRA) survey are unknown.
We compared demographics and health experiences of those who completed the HRA with those who did not (1991–1998). We also evaluated the reliability and validity of eight HRA alcohol-related items, including the CAGE, weekly drinking quantity, and drinking and driving measures. We used Cohen’s κ and Pearson’s r to assess reliability and convergent validity. To assess criterion (predictive) validity, we used proportional hazards and logistical regression models predicting alcohol-related hospitalizations and alcohol-related separations from the Army, respectively.
A total of 404,966 soldiers completed an HRA. No particular demographic group seems to be over- or underrepresented. Although few respondents skipped alcohol items, those who did tended to be older and of minority race. The alcohol items demonstrate a reasonable degree of reliability, with Cronbach’s α = 0.69 and test-retest reliability associations in the 0.75–0.80 range for most items over 2- to 30-day interims between surveys. The alcohol measures showed good criterion-related validity: those consuming more than 21 drinks per week were at 6 times the risk for subsequent alcohol-related hospitalization versus those who abstained from drinking (hazard ratio, 6.36; 95% confidence interval=5.79, 6.99). Those who said their friends worried about their drinking were almost 5 times more likely to be discharged due to alcoholism (risk ratio, 4.9; 95% confidence interval=4.00, 6.04) and 6 times more likely to experience an alcohol-related hospitalization (hazard ratio, 6.24; 95% confidence interval=5.74, 6.77).
The Army’s HRA alcohol items seem to elicit reliable and valid responses. Because HRAs contain identifiers, alcohol use can be linked with subsequent health and occupational outcomes, making the HRA a useful epidemiological research tool. Associations between perceived peer opinions of drinking and subsequent problems deserve further exploration.
PMCID: PMC2141695  PMID: 12766628
Alcohol; Military; Reliability; Validity; Survey
22.  Suicide and the United States Army: Perspectives from the Former Psychiatry Consultant to the Army Surgeon General 
Editor’s note:
The suicide rate of active-duty soldiers doubled between 2003 and 2010. In response, the Department of Defense and the United States Army improved their data collection methods to better understand the causes of military suicides. As retired colonel Dr. Elspeth Cameron Ritchie writes, unit history and the accumulation of stressors—from relationship problems to chronic pain—are significant suicide risk factors among soldiers. But, she argues, Army officials must use this knowledge to design more-effective strategies for suicide reduction, including limiting access to weapons, especially post-deployment, and better connecting soldiers with their communities.
PMCID: PMC3574805  PMID: 23447787
23.  The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2014;77(2):107-119.
Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings.
Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004–2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.
Main outcome measures
Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates.
Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004–2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47–60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets.
Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.
PMCID: PMC4075436  PMID: 24865195
24.  Response bias, weighting adjustments, and design effects in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable recommendations to reduce U.S. Army suicides and increase knowledge about determinants of suicidality. Three Army STARRS component studies are large-scale surveys: one of new soldiers prior to beginning Basic Combat Training (BCT; n=50,765 completed self-administered questionnaires); another of other soldiers exclusive of those in BCT (n=35,372); and a third of three Brigade Combat Teams about to deploy to Afghanistan who are being followed multiple times after returning from deployment (n= 9,421). Although the response rates in these surveys are quite good (72.0-90.8%), questions can be raised about sample biases in estimating prevalence of mental disorders and suicidality, the main outcomes of the surveys based on evidence that people in the general population with mental disorders are under-represented in community surveys. This paper presents the results of analyses designed to determine whether such bias exists in the Army STARRS surveys and, if so, to develop weights to correct for these biases. Data are also presented on sample inefficiencies introduced by weighting and sample clustering and on analyses of the trade-off between bias and efficiency in weight trimming.
PMCID: PMC3992816  PMID: 24318218
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
25.  Design of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce U.S. Army suicides and increase basic knowledge about the determinants of suicidality. This report presents an overview of the designs of the six component Army STARRS studies. These include: an integrated study of historical administrative data systems (HADS) designed to provide data on significant administrative predictors of suicides among the more than 1.6 million soldiers on active duty in 2004–2009; retrospective case-control studies of suicide attempts and fatalities; separate large-scale cross-sectional studies of new soldiers (i.e., those just beginning Basic Combat Training [BCT], who completed self-administered questionnaires [SAQ] and neurocognitive tests and provided blood samples) and soldiers exclusive of those in BCT (who completed SAQs); a pre-post deployment study of soldiers in three Brigade Combat Teams about to deploy to Afghanistan (who completed SAQs and provided blood samples) followed multiple times after returning from deployment; and a platform for following up Army STARRS participants who have returned to civilian life. DoD/Army administrative data records are linked with SAQ data to examine prospective associations between self-reports and subsequent suicidality. The presentation closes with a discussion of the methodological advantages of cross-component coordination.
PMCID: PMC3992857  PMID: 24318217
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling

Results 1-25 (50966)