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1.  Influence of personal and environmental factors on mental health in a sample of Austrian survivors of World War II with regard to PTSD: is it resilience? 
BMC Psychiatry  2013;13:47.
Background
War-related traumata in childhood and young-adulthood may have long-lasting negative effects on mental health. The focus of recent research has shifted to examine positive adaption despite traumatic experiences, i.e. resilience. We investigated personal and environmental factors associated with resilience in a sample of elderly Austrians (N = 293) who reported traumatic experiences in early life during World War II and subsequent occupation (1945–1955).
Methods
After reviewing different concepts of resilience, we analysed our data in a 3-phased approach: Following previous research approaches, we first investigated correlates of PTSD and non-PTSD. Secondly, we compared a PTSD positive sample (sub-threshold and full PTSD, n = 42) with a matched control sample regarding correlates of resilience and psychometrically assessed resilience (CD-RISC). Thirdly, we examined factors of resilience, discriminating between psychologically healthy participants who were exposed to a specific environmental stressor (having lived in the Soviet zone of occupation during 1945–1955) from those who were not.
Results
A smaller number of life-time traumata (OR = 0.73) and a medium level of education (OR = 2.46) were associated with better outcome. Matched PTSD and non-PTSD participants differed in psychometrically assessed resilience mainly in aspects that were directly related to symptoms of PTSD. Psychologically healthy participants with an environmental stressor in the past were characterized by a challenge-oriented and humorous attitude towards stress.
Conclusions
Our results show no clear picture of factors constituting resilience. Instead, most aspects of resilience rather appeared to be concomitants or consequences of PTSD and non-PTSD. However, special attention should be placed on a challenge-oriented and humorous attitude towards stress in future definitions of resilience.
doi:10.1186/1471-244X-13-47
PMCID: PMC3598938  PMID: 23379932
2.  Mortality in Iraq Associated with the 2003–2011 War and Occupation: Findings from a National Cluster Sample Survey by the University Collaborative Iraq Mortality Study 
PLoS Medicine  2013;10(10):e1001533.
Based on a survey of 2,000 randomly selected households throughout Iraq, Amy Hagopian and colleagues estimate that close to half a million excess deaths are attributable to the recent Iraq war and occupation.
Please see later in the article for the Editors' Summary
Background
Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011.
Methods and Findings
We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74–5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000–751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005–2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study.
Conclusions
Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
War is a major public health problem. Its health effects include violent deaths among soldiers and civilians as well as indirect increases in mortality and morbidity caused by conflict. Unlike those of other causes of death and disability, however, the consequences of war on population health are rarely studied scientifically. In conflict situations, deaths and diseases are not reliably measured and recorded, and estimating the proportion caused, directly or indirectly, by a war or conflict is challenging. Population-based mortality survey methods—asking representative survivors about deaths they know about—were developed by public health researchers to estimate death rates. By comparing death rate estimates for periods before and during a conflict, researchers can derive the number of excess deaths that are attributable to the conflict.
Why Was This Study Done?
A number of earlier studies have estimated the death toll in Iraq since the beginning of the war in March 2003. The previous studies covered different periods from 2003 to 2006 and derived different rates of overall deaths and excess deaths attributable to the war and conflict. All of them have been controversial, and their methodologies have been criticized. For this study, based on a population-based mortality survey, the researchers modified and improved their methodology in response to critiques of earlier surveys. The study covers the period from the beginning of the war in March 2003 until June 2011, including a period of high violence from 2006 to 2008. It provides population-based estimates for excess deaths in the years after 2006 and covers most of the period of the war and subsequent occupation.
What Did the Researchers Do and Find?
Interviewers trained by the researchers conducted the survey between May 2011 and July 2011 and collected data from 2,000 randomly selected households in 100 geographical clusters, distributed across Iraq's 18 governorates. The interviewers asked the head of each household about deaths among household members from 2001 to the time of the interview, including a pre-war period from January 2001 to March 2003 and the period of the war and occupation. They also asked all adults in the household about deaths among their siblings during the same period. From the first set of data, the researchers calculated the crude death rates (i.e., the number of deaths during a year per 1,000 individuals) before and during the war. They found the wartime crude death rate in Iraq to be 4.55 per 1,000, more than 50% higher than the death rate of 2.89 during the two-year period preceding the war. By multiplying those rates by the annual Iraq population, the authors estimate the total excess Iraqi deaths attributable to the war through mid-2011 to be about 405,000. The researchers also estimated that an additional 56,000 deaths were not counted due to migration. Including this number, their final estimate is that approximately half a million people died in Iraq as a result of the war and subsequent occupation from March 2003 to June 2011.
The risk of death at the peak of the conflict in 2006 almost tripled for men and rose by 70% for women. Respondents attributed 20% of household deaths to war-related violence. Violent deaths were attributed primarily to coalition forces (35%) and militia (32%). The majority (63%) of violent deaths were from gunshots. Twelve percent were attributed to car bombs. Based on the responses from adults in the surveyed households who reported on the alive-or-dead status of their siblings, the researchers estimated the total number of deaths among adults aged 15–60 years, from March 2003 to June 2011, to be approximately 376,000; 184,000 of these deaths were attributed to the conflict, and of those, the authors estimate that 132,000 were caused directly by war-related violence.
What Do These Findings Mean?
These findings provide the most up-to-date estimates of the death toll of the Iraq war and subsequent conflict. However, given the difficult circumstances, the estimates are associated with substantial uncertainties. The researchers extrapolated from a small representative sample of households to estimate Iraq's national death toll. In addition, respondents were asked to recall events that occurred up to ten years prior, which can lead to inaccuracies. The researchers also had to rely on outdated census data (the last complete population census in Iraq dates back to 1987) for their overall population figures. Thus, to accompany their estimate of 460,000 excess deaths from March 2003 to mid-2011, the authors used statistical methods to determine the likely range of the true estimate. Based on the statistical methods, the researchers are 95% confident that the true number of excess deaths lies between 48,000 and 751,000—a large range. More than two years past the end of the period covered in this study, the conflict in Iraq is far from over and continues to cost lives at alarming rates. As discussed in an accompanying Perspective by Salman Rawaf, violence and lawlessness continue to the present day. In addition, post-war Iraq has limited capacity to re-establish and maintain its battered public health and safety infrastructure.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001533
This study is further discussed in a PLOS Medicine Perspective by Salman Rawaf.
The Geneva Declaration on Armed Violence and Development website provides information on the global burden of armed violence.
The International Committee of the Red Cross provides information about war and international humanitarian law (in several languages).
Medact, a global health charity, has information on health and conflict.
Columbia University has a program on forced migration and health.
Johns Hopkins University runs the Center for Refugee and Disaster Response.
University of Washington's Health Alliance International website also has information about war and conflict.
doi:10.1371/journal.pmed.1001533
PMCID: PMC3797136  PMID: 24143140
3.  Lifetime Prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War  
PLoS Medicine  2008;5(4):e61.
Background
There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon.
Methods and Findings
The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5–14.1), mood (OR 3.32, 95% CI 2.0–5.6), and impulse control disorders (OR 12.72, 95% CI 4.5–35.7).
Conclusions
About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.
In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.
Editors' Summary
Background.
Mental illnesses—persistent problems with thinking, with feelings, with behavior, and with coping with life—are very common. In the UK about a quarter, and in the US, almost half, of people have a mental illness at some time during their life. Depression, for example, persistently lowers a person's mood and can make them feel hopeless and unmotivated. Anxiety—constant, unrealistic worries about daily life—can cause sleep problems and physical symptoms such as stomach pains. People with impulse-control disorders, have problems with controlling their temper or their impulses which may sometimes lead to hurting themselves or other people. These and other mental illnesses seriously affect the work, relationships, and quality of life of the ill person and of their family. However, most people with mental illnesses can lead fulfilling and productive lives with the help of appropriate medical and nonmedical therapies.
Why Was This Study Done?
Recent epidemiological surveys (studies that investigate the factors that affect the health of populations) have provided important information about the burden of mental disorders in some industrialized countries. However, little is known about the global prevalence of mental disorders (the proportion of people in a population with each disorder at one time) or about how events such as wars affect mental health. This information is needed so that individual countries can provide effective mental-health services for their populations. To provide this information, the World Mental Health (WMH) Survey Initiative is undertaking large-scale psychiatric epidemiological surveys in more than 29 countries. As part of this Initiative, researchers have examined the prevalence and treatment of mental disorders in Lebanon and have asked whether war in this country has affected the risk of becoming mentally ill.
What Did the Researchers Do and Find?
The researchers randomly selected a sample of nearly 3,000 adults living in Lebanon and interviewed them using an Arabic version of the World Health Organization's “Composite International Diagnostic Interview” (CIDI 3.0). This interview tool generates diagnoses of mental disorders in the form of “DSM-IV codes,” the American Psychiatric Association's standard codes for specific mental disorders. The researchers also asked the study participants about their experience of war-related traumatic events such as being a civilian in a war zone or being threatened by a weapon. The researchers found that one in four Lebanese had had one or more DSM-IV disorder at some time during their life. Major depression was the single most common disorder. The researchers also calculated that by the age of 75 years, about one-third of the Lebanese would probably have had one or more DSM-IV disorder. Only half of the Lebanese with a mood disorder ever received professional help; treatment rates for other mental disorders were even lower. The average delay in treatment ranged from 6 years for mood disorders to 28 years for anxiety disorders. Finally, exposure to war-related events increased the risk of developing an anxiety, mood, or impulse-control disorder by about 6-fold, 3-fold, and 13-fold, respectively.
What Do These Findings Mean?
These findings indicate that the prevalence of mental illness in Lebanon is similar to that in the UK and the US, the first time that this information has been available for an Arabic-speaking country. Indeed, the burden of mental illness in Lebanon may actually be higher than these findings suggest, because the taboos associated with mental illness may have stopped some study participants from reporting their problems. The findings also show that in Lebanon exposure to war-related events greatly increases the risk of developing for the first time several mental disorders. Further studies are needed to discover whether this finding is generalizable to other countries. Finally, these findings indicate that many people in Lebanon who develop a mental illness never receive appropriate treatment. There is no shortage of health-care professionals in Lebanon, so the researchers suggest that the best way to improve the diagnosis and treatment of mental disorders in this country might be to increase the awareness of these conditions and to reduce the taboos associated with mental illness, both among the general population and among health-care professionals.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050061.
Read a related PLoS Medicine Perspective article
IDRAAC has a database that provides access to all published research articles related to mental health in the Arab World
The UK charity Mind provides information on understanding mental illness
The US National Institute of Mental Health provides information on understanding, treating, and preventing mental disorders (mainly in English but some information in Spanish)
MedlinePlus provides a list of useful links to information about mental health
Wikipedia has a page on DSM-IV codes (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Mental Health Survey Initiative and the Lebanese WHM study are described on the organizations' Web pages
doi:10.1371/journal.pmed.0050061
PMCID: PMC2276523  PMID: 18384228
4.  Use of health services and medicines amongst Australian war veterans: a comparison of young elderly, near centenarians and centenarians 
BMC Geriatrics  2010;10:83.
Background
Age and life expectancy of residents in many developed countries, including Australia, is increasing. Health resource and medicine use in the very old is not well studied. The purpose of this study was to identify annual use of health services and medicines by very old Australian veterans; those aged 95 to 99 years (near centenarians) and those aged 100 years and over (centenarians).
Methods
The study population included veterans eligible for all health services subsidised by the Department of Veterans' Affairs (DVA) aged 95 years and over at August 1st 2006. A cohort of veterans aged 65 to 74 years was identified for comparison. Data were sourced from DVA claims databases. We identified all claims between August 1st 2006 and July 31st 2007 for medical consultations, pathology, diagnostic imaging and allied health services, hospital admissions, number of prescriptions and unique medicines. Chi squared tests were used to compare the proportion of centenarians (those aged 100 years and over) and near centenarians (those aged 95 to 99 years) who accessed medicines and health services with the 65 to 74 year age group. For those who accessed health services during follow up, Poisson regression was used to compare differences in the number of times centenarians and near centenarians accessed each health service compared to 65 to 74 year olds.
Results
A similar proportion (98%) of centenarians and near centenarians compared to those aged 65 to 74 consulted a GP and received prescription medicine during follow up. A lower proportion of centenarians and near centenarians had claims for specialist visits (36% and 57% respectively), hospitalisation (19% and 24%), dental (12% and 18%), physiotherapy (13% and 15%), pathology(68% and 78%) and diagnostic imaging services (51% and 68%) (p < 0.0001) and a higher proportion had claims for care plans (19% and 25%), occupational therapy (15% and 17%) and podiatry services (54% and 58%) (p < 0.0001). Compared to those aged 65 to 74, a lower proportion of centenarians and near centenarians received antihypertensives, lipid lowering therapy, antiinflammatories, and antidepressants (p < 0.0001) and a higher proportion received antibiotics, analgesics, diuretics, laxatives, and anti-anaemics (p < 0.0001).
Conclusions
Medical consultations and medicines are the health services most frequently accessed by Australian veteran centenarians and near centenarians. For most health services, the proportion of very old people who access them is similar to or less than younger elderly. Our results support the findings of other studies which suggest that longevity is not necessarily associated with excessive health service use.
doi:10.1186/1471-2318-10-83
PMCID: PMC2989975  PMID: 21050484
5.  Post-Traumatic Stress Disorder in Adolescents in Lebanon as Wars Gained in Ferocity: A Systematic Review 
Significance for public healthPost traumatic stress disorder (PTSD) in adolescents has been implicated in developmental impairments, mental and scholastic problems, alcohol and drug abuse, and antisocial behavior in its victims among others. Absence of review studies regarding the prevalence of PTSD in adolescents in Lebanon, a country plagued by decades of civil strife and external occupation and invasion, is noted. Such information may reinforce the need to develop national public health policies to identify PTSD in children and adolescents, provide them with counseling and treatment, and formulate prevention strategies to protect vulnerable youth from devastations of war.For decades, Lebanon was war-torn by civil strife, and occupation and invasion by neighboring countries. In time, these wars have escalated in intensity from sniping, barricading streets and random shelling of residential quarters to the use of rockets, aerial bombing, and heavy artillery. Adverse mental health effects are noted in times of war with post traumatic stress disorder (PTSD) as a main outcome. The aim of this study was to carry out a systematic review of published studies documenting the prevalence of PTSD in the adolescent population of Lebanon, to investigate the increase in these rates with the escalation of war intensity, and to examine PTSD determinants. A search strategy was developed for online databases (PubMed and Google Scholar) between inception to the first week of January 2013. Search terms used were PTSD, adolescents and Lebanon. Eleven studies reporting PTSD in adolescents met the inclusion criteria for a total number of 5965 adolescents. Prevalence rates of PTSD ranged from 8.5% to 14.7% for the civil war, 3.7% for adolescents with sensory disabilities, 21.6% for the Grapes of Wrath War, and 15.4% to 35.0% for the 2006 July War. Some increase in PTSD rates in time is noted. Type of trauma such as bereavement, injury, house destruction, and economic problems, low self efficacy and scholastic impairment were related to PTSD. These findings may help in the development of public health policies for PTSD prevention and treatment for the protection of adolescents from war atrocities and their consequences.
doi:10.4081/jphr.2013.e17
PMCID: PMC4147728  PMID: 25170488
PTSD; adolescents; war; Lebanon; systematic review
6.  Causes of Death of Prisoners of War during the Korean War (1950-1953) 
Yonsei Medical Journal  2013;54(2):480-488.
Purpose
This study aimed at analyzing the causes of death of prisoners of war (POWs) during the Korean War (1950-1953) who fought for the Communist side (North Korea and the People's Republic of China). In 1998, the United States Department of Defense released new information about the prisoners including, 7,614 deaths of the POW during the Korean War. The data on the causes of death of the POWs during the Korean War provides valuable information on the both the public health and history of the conflict.
Materials and Methods
To analyze the causes of death of the POWs, we classified the clinical diagnosis and findings on 7,614 deaths into 22 chapters, as outlined in the International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10). Second, we traced changes in the monthly death totals of POWs as well as deaths caused by common infectious diseases and external causes of death including injury over time from August 1950 to September 1953.
Results
The most common category of causes of deaths of POWs was infectious disease, 5,013 (65.8%) out of 7,614 deaths, followed by external causes including injury, 817 (10.7%). Overall, tuberculosis and dysentery/diarrhea were the most common causes of death. Deaths caused by acute and chronic infection, or external causes showed different patterns of increases and decline over time during the Korean War.
Conclusion
The information and data on POWs' deaths during the Korean War reflects the critical impact of the POWs' living conditions and the effect of public health measures implemented in POW camps during the war.
doi:10.3349/ymj.2013.54.2.480
PMCID: PMC3575971  PMID: 23364985
Prisoners of war (POW); Korean War; causes of deaths; infectious diseases
7.  Children and war: the work of the Children and War Foundation 
European Journal of Psychotraumatology  2013;4:10.3402/ejpt.v4i0.18424.
The Children and War Foundation was established after the authors’ experiences following the civil war in former Yugoslavia in the mid-1990s. Many organizations tried to mitigate the effects of the war on children but few interventions were based on evidence and fewer were properly evaluated. The Foundation was established in Norway with the aim of promoting better evidence-based interventions to help children after wars and natural disasters.
The Foundation has developed a number of empirically grounded manuals that aim to help children learn strategies that will lessen the stress reactions that they have developed. The manuals are designed to be delivered by personnel who are not necessarily very experienced in child mental health. They are aimed at groups of children using a public health approach to reach large numbers in a short space of time. The strategies are not intended as individual therapy.
The Teaching Recovery Techniques manual has been used following a number of earthquakes and other natural disasters and data from a number of these will be discussed. A Writing for Recovery manual is aimed at helping adolescents and is based on the seminal work of James Pennebaker. It is currently being evaluated in three separate studies. A group-based manual to help children bereaved by war or disaster has recently been developed.
doi:10.3402/ejpt.v4i0.18424
PMCID: PMC3547281  PMID: 23330058
Children; war; disasters; evidence-based interventions
8.  Remains of War: Walt Whitman, Civil War Soldiers, and the Legacy of Medical Collections 
Museum history journal  2012;5(1):7-28.
The National Museum of Health and Medicine holds a collection of anatomical specimens from nearly 2,000 soldiers injured during the American Civil War. Originally collected as part of a study of trauma and disease during war, these specimens have been museum artifacts for over 140 years. During this time, they have been displayed and utilized in an array of interpretative strategies. They have functioned as medical specimens documenting the effects of gunshot wounds and infection to the human body, as mementos mori symbolizing the refuse of a nation divided by war, and as objects of osteological and forensic interest. The museum’s curators recently discovered four of these specimens from soldiers who the poet and essayist Walt Whitman nursed in the wartime hospitals of Washington, DC. Uniting these remains with Whitman’s words yields a new interpretation that bears witness to individual histories during a time of unprecedented conflict in American history.
PMCID: PMC3381362  PMID: 22741042
9.  Physical and Mental Health Costs of Traumatic War Experiences Among Civil War Veterans 
Archives of general psychiatry  2006;63(2):193-200.
Context
Hundreds of thousands of soldiers face exposure to combat during wars across the globe. The health impact of traumatic war experiences has not been adequately assessed across the lifetime of these veterans.
Objective
Identify the role of traumatic war experiences in predicting post-war nervous and physical disease and mortality using archival data from military and medical records of veterans from the Civil War.
Design
An archival examination of military and medical records of Civil War veterans was conducted. Degree of trauma experienced (POW experience, percentage of company killed, being wounded, early age at enlistment), signs of lifetime physician-diagnosed disease, and age at death were recorded.
Setting and Participants
US Pension board surgeons conducted standardized medical examinations of Civil War veterans over their post-war lifetimes. Military records of 17,700 Civil War veterans were matched to post-war medical records.
Main Outcome Measures
Signs of physician-diagnosed disease including cardiac, gastrointestinal (GI), and nervous disease, and number of unique ailments within each disease; mortality.
Results
Military trauma was related to signs of disease and mortality. Greater percentage of company killed was associated with signs of post-war cardiac and GI disease (IRR=1.34, p<.02), co-morbid nervous and physical disease (IRR=1.51, p<.005), and greater number of unique ailments within each disease (IRR=1.14, p<.01). Younger soldiers (≤18 years old), compared to older enlistees (> 30 years old), showed higher mortality risk (HR=1.52, p<.005), signs of co-morbid nervous and physical disease (IRR=1.93, p<.005), and a greater number of unique ailments within each disease (IRR=1.32, p<.005), controlling for length of time lived and other covariates.
Conclusions
Greater exposure to death of military comrades and younger exposure to war trauma was related to signs of physician-diagnosed cardiac, GI and nervous disease, and a greater number of unique disease ailments across the life of Civil War veterans. Physiological mechanisms by which trauma might result in disease are discussed.
doi:10.1001/archpsyc.63.2.193
PMCID: PMC1586122  PMID: 16461863
combat exposure; Civil War Veterans; war trauma; physical health; mental health
10.  Symptoms and medical conditions in Australian veterans of the 1991 Gulf War: relation to immunisations and other Gulf War exposures 
Aims: To investigate whether Australian Gulf War veterans have a higher than expected prevalence of recent symptoms and medical conditions that were first diagnosed in the period following the 1991 Gulf War; and if so, whether these effects were associated with exposures and experiences that occurred in the Gulf War.
Methods: Cross-sectional study of 1456 Australian Gulf War veterans and a comparison group who were in operational units at the time of the Gulf War, but were not deployed to that conflict (n = 1588). A postal questionnaire was administered and the likelihood of the diagnosis of self-reported medical conditions was assessed and rated by a medical practitioner.
Results: Gulf War veterans had a higher prevalence of all self-reported health symptoms than the comparison group, and more of the Gulf War veterans had severe symptoms. Increased symptom reporting was associated with several exposures, including having more than 10 immunisations, pyridostigmine bromide tablets, anti-biological warfare tablets, pesticides, insect repellents, reportedly being in a chemical weapons area, and stressful military service experiences in a strong dose-response relation. Gulf War veterans reported psychological (particularly post-traumatic stress disorder), skin, eye, and sinus conditions first diagnosed in 1991 or later more commonly than the comparison group. Over 90% of medical conditions reported by both study groups were rated by a medical practitioner as having a high likelihood of diagnosis.
Conclusion: More than 10 years after the 1991 Gulf War, Australian veterans self-report all symptoms and some medical conditions more commonly than the comparison group. Further analysis of the severity of symptoms and likelihood of the diagnosis of medical conditions suggested that these findings are not due to over-reporting or to participation bias.
doi:10.1136/oem.2003.009258
PMCID: PMC1740679  PMID: 15550607
11.  Social and environmental factors in lung cancer mortality in post-war Poland. 
Poland and other Eastern European countries have undergone heavy industrial development with marked increases in air pollution and occupational exposure in the nearly 50 years since World War II. These countries have also experienced substantial increases in chronic disease mortality in the past three decades. While it is tempting to assume a direct association between these phenomena, more detailed analyses are called for. Poland offers a potentially rich opportunity for comparing geographical patterns of disease incidence and of industrial change. In this paper we 1) elucidate the prospects for attributing lung cancer mortality to industrial emissions in Poland, using an ecological approach based on the hitherto unaddressed geographic differences, and accounting for regional differences in cigarette consumption; 2) propose explanatory hypotheses for the observed geographic heterogeneity of lung cancer; 3) begin systematic testing of the widely accepted but not well-scrutinized notion that pollution in Poland is a major contributor to declining life expectancy. Regions with the highest fraction of cancer that cannot be explained by smoking appear to be highly urbanized, have high population exposure to occupational carcinogens, experience the highest rates of alcoholism and crime, and are associated with the post- World War II population resettlement. Although the analysis does not rule out pollution as a significant contributor to lung cancer mortality, it indicates that other factors such as occupational exposures and various social factors are of at least comparable importance.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMCID: PMC1519032  PMID: 7628428
12.  Compensating for cold war cancers. 
Environmental Health Perspectives  2002;110(7):A404-A407.
Although the Cold War has ended, thousands of workers involved in nuclear weapons production are still living with the adverse health effects of working with radioactive materials, beryllium, and silica. After a series of court battles, the U.S. government passed the Energy Employees Occupational Illness Act in October 2000 to financially assist workers whose health has been compromised by these occupational exposures. Now work is underway to set out guidelines for determining which workers will be compensated. The National Institute for Occupational Safety and Health has been assigned the task of developing a model that can scientifically make these determinations, a heavy task considering the controversies that lie in estimating low-level radiation risks and the inadequate worker exposure records kept at many of the plants.
PMCID: PMC1240926  PMID: 12117658
13.  Gulf war illness—better, worse, or just the same? A cohort study 
BMJ : British Medical Journal  2003;327(7428):1370.
Objectives Firstly, to describe changes in the health of Gulf war veterans studied in a previous occupational cohort study and to compare outcome with comparable non-deployed military personnel. Secondly, to determine whether differences in prevalence between Gulf veterans and controls at follow up can be explained by greater persistence or greater incidence of disorders.
Design Occupational cohort study in the form of a postal survey.
Participants Military personnel who served in the 1991 Persian Gulf war; personnel who served on peacekeeping duties to Bosnia; military personnel who were deployed elsewhere (“Era” controls). All participants had responded to a previous survey.
Setting United Kingdom.
Main outcome measures Self reported fatigue measured on the Chalder fatigue scale; psychological distress measured on the general health questionnaire, physical functioning and health perception on the SF-36; and a count of physical symptoms.
Results Gulf war veterans experienced a modest reduction in prevalence of fatigue (48.8% at stage 1, 43.4% at stage 2) and psychological distress (40.0% stage 1, 37.1% stage 2) but a slight worsening of physical functioning on the SF-36 (90.3 stage 1, 88.7 stage 2). Compared with the other cohorts Gulf veterans continued to experience poorer health on all outcomes, although physical functioning also declined in Bosnia veterans. Era controls showed both lower incidence of fatigue than Gulf veterans, and both comparison groups showed less persistence of fatigue compared with Gulf veterans.
Conclusions Gulf war veterans remain a group with many symptoms of ill health. The excess of illness at follow up is explained by both higher incidence and greater persistence of symptoms.
PMCID: PMC292982  PMID: 14670878
14.  Toxicological assessments of Gulf War veterans 
Concerns about unexplained illnesses among veterans of the 1991 Gulf War appeared soon after that conflict ended. Many environmental causes have been suggested, including possible exposure to depleted uranium munitions, vaccines and other drugs used to protect troops, deliberate or accidental exposure to chemical warfare agents and pesticides and smoke from oil-well fires. To help resolve these issues, US and UK governments have sought independent expert scientific advice from prestigious, independent scientific and public health experts, including the US National Academies of Science and the UK Royal Society and Medical Research Council. Their authoritative and independent scientific and medical reviews shed light on a wide range of Gulf War environmental hazards. However, they have added little to our understanding of Gulf War veterans' illnesses, because identified health effects have been previously well characterized, primarily in the occupational health literature. This effort has not identified any new health effects or unique syndromes associated with the evaluated environmental hazards. Nor do their findings provide an explanation for significant amounts of illnesses among veterans of the 1991 Gulf War. Nevertheless, these independent and highly credible scientific reviews have proven to be an effective means for evaluating potential health effects from deployment-related environmental hazards.
doi:10.1098/rstb.2006.1825
PMCID: PMC1569627  PMID: 16687269
veterans; pesticides; uranium; pyridostigimine bromide; sarin
15.  Occupational health and health care in Russia and Russian Arctic: 1980–2010 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.20456.
Background
There is a paradox in Russia and its Arctic regions which reports extremely low rates of occupational diseases (ODs), far below those of other socially and economically advanced circumpolar countries. Yet, there is widespread disregard for occupational health regulations and neglect of basic occupational health services across many industrial enterprises.
Study design and methods
This review article presents official statistics and summarises the results of a search of peer-reviewed scientific literature published in Russia on ODs and occupational health care in Russia and the Russian Arctic, within the period 1980–2010.
Results
Worsening of the economic situation, layoff of workers, threat of unemployment and increased work load happened during the “wild market” industrial restructuring in 1990–2000, when the health and safety of workers were of little concern. Russian employers are not legally held accountable for neglecting safety rules and for underreporting of ODs. Almost 80% of all Russian industrial enterprises are considered dangerous or hazardous for health. Hygienic control of working conditions was minimised or excluded in the majority of enterprises, and the health status of workers remains largely unknown. There is direct evidence of general degradation of the occupational health care system in Russia. The real levels of ODs in Russia are estimated to be at least 10–100 times higher than reported by official statistics. The low official rates are the result of deliberate hiding of ODs, lack of coverage of working personnel by properly conducted medical examinations, incompetent management and the poor quality of staff, facilities and equipment.
Conclusions
Reform of the Russian occupational health care system is urgently needed, including the passing of strong occupational health legislation and their enforcement, the maintenance of credible health monitoring and effective health services for workers, improved training of occupational health personnel, protection of sanitary-hygienic laboratories in industrial enterprises, and support for research assessing occupational risk and the effectiveness of interventions.
doi:10.3402/ijch.v72i0.20456
PMCID: PMC3604356  PMID: 23519691
occupational diseases; occupational health care; occupational safety; labour conditions; Russian Arctic
16.  Interactions between Non-Physician Clinicians and Industry: A Systematic Review 
PLoS Medicine  2013;10(11):e1001561.
In a systematic review of studies of interactions between non-physician clinicians and industry, Quinn Grundy and colleagues found that many of the issues identified for physicians' industry interactions exist for non-physician clinicians.
Please see later in the article for the Editors' Summary
Background
With increasing restrictions placed on physician–industry interactions, industry marketing may target other health professionals. Recent health policy developments confer even greater importance on the decision making of non-physician clinicians. The purpose of this systematic review is to examine the types and implications of non-physician clinician–industry interactions in clinical practice.
Methods and Findings
We searched MEDLINE and Web of Science from January 1, 1946, through June 24, 2013, according to PRISMA guidelines. Non-physician clinicians eligible for inclusion were: Registered Nurses, nurse prescribers, Physician Assistants, pharmacists, dieticians, and physical or occupational therapists; trainee samples were excluded. Fifteen studies met inclusion criteria. Data were synthesized qualitatively into eight outcome domains: nature and frequency of industry interactions; attitudes toward industry; perceived ethical acceptability of interactions; perceived marketing influence; perceived reliability of industry information; preparation for industry interactions; reactions to industry relations policy; and management of industry interactions. Non-physician clinicians reported interacting with the pharmaceutical and infant formula industries. Clinicians across disciplines met with pharmaceutical representatives regularly and relied on them for practice information. Clinicians frequently received industry “information,” attended sponsored “education,” and acted as distributors for similar materials targeted at patients. Clinicians generally regarded this as an ethical use of industry resources, and felt they could detect “promotion” while benefiting from industry “information.” Free samples were among the most approved and common ways that clinicians interacted with industry. Included studies were observational and of varying methodological rigor; thus, these findings may not be generalizable. This review is, however, the first to our knowledge to provide a descriptive analysis of this literature.
Conclusions
Non-physician clinicians' generally positive attitudes toward industry interactions, despite their recognition of issues related to bias, suggest that industry interactions are normalized in clinical practice across non-physician disciplines. Industry relations policy should address all disciplines and be implemented consistently in order to mitigate conflicts of interest and address such interactions' potential to affect patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Making and selling health care goods (including drugs and devices) and services is big business. To maximize the profits they make for their shareholders, companies involved in health care build relationships with physicians by providing information on new drugs, organizing educational meetings, providing samples of their products, giving gifts, and holding sponsored events. These relationships help to keep physicians informed about new developments in health care but also create the potential for causing harm to patients and health care systems. These relationships may, for example, result in increased prescription rates of new, heavily marketed medications, which are often more expensive than their generic counterparts (similar unbranded drugs) and that are more likely to be recalled for safety reasons than long-established drugs. They may also affect the provision of health care services. Industry is providing an increasingly large proportion of routine health care services in many countries, so relationships built up with physicians have the potential to influence the commissioning of the services that are central to the treatment and well-being of patients.
Why Was This Study Done?
As a result of concerns about the tension between industry's need to make profits and the ethics underlying professional practice, restrictions are increasingly being placed on physician–industry interactions. In the US, for example, the Physician Payments Sunshine Act now requires US manufacturers of drugs, devices, and medical supplies that participate in federal health care programs to disclose all payments and gifts made to physicians and teaching hospitals. However, other health professionals, including those with authority to prescribe drugs such as pharmacists, Physician Assistants, and nurse practitioners are not covered by this legislation or by similar legislation in other settings, even though the restructuring of health care to prioritize primary care and multidisciplinary care models means that “non-physician clinicians” are becoming more numerous and more involved in decision-making and medication management. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers examine the nature and implications of the interactions between non-physician clinicians and industry.
What Did the Researchers Do and Find?
The researchers identified 15 published studies that examined interactions between non-physician clinicians (Registered Nurses, nurse prescribers, midwives, pharmacists, Physician Assistants, and dieticians) and industry (corporations that produce health care goods and services). They extracted the data from 16 publications (representing 15 different studies) and synthesized them qualitatively (combined the data and reached word-based, rather than numerical, conclusions) into eight outcome domains, including the nature and frequency of interactions, non-physician clinicians' attitudes toward industry, and the perceived ethical acceptability of interactions. In the research the authors identified, non-physician clinicians reported frequent interactions with the pharmaceutical and infant formula industries. Most non-physician clinicians met industry representatives regularly, received gifts and samples, and attended educational events or received educational materials (some of which they distributed to patients). In these studies, non-physician clinicians generally regarded these interactions positively and felt they were an ethical and appropriate use of industry resources. Only a minority of non-physician clinicians felt that marketing influenced their own practice, although a larger percentage felt that their colleagues would be influenced. A sizeable proportion of non-physician clinicians questioned the reliability of industry information, but most were confident that they could detect biased information and therefore rated this information as reliable, valuable, or useful.
What Do These Findings Mean?
These and other findings suggest that non-physician clinicians generally have positive attitudes toward industry interactions but recognize issues related to bias and conflict of interest. Because these findings are based on a small number of studies, most of which were undertaken in the US, they may not be generalizable to other countries. Moreover, they provide no quantitative assessment of the interaction between non-physician clinicians and industry and no information about whether industry interactions affect patient care outcomes. Nevertheless, these findings suggest that industry interactions are normalized (seen as standard) in clinical practice across non-physician disciplines. This normalization creates the potential for serious risks to patients and health care systems. The researchers suggest that it may be unrealistic to expect that non-physician clinicians can be taught individually how to interact with industry ethically or how to detect and avert bias, particularly given the ubiquitous nature of marketing and promotional materials. Instead, they suggest, the environment in which non-physician clinicians practice should be structured to mitigate the potentially harmful effects of interactions with industry.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001561.
This study is further discussed in a PLOS Medicine Perspective by James S. Yeh and Aaron S. Kesselheim
The American Medical Association provides guidance for physicians on interactions with pharmaceutical industry representatives, information about the Physician Payments Sunshine Act, and a toolkit for preparing Physician Payments Sunshine Act reports
The International Council of Nurses provides some guidance on industry interactions in its position statement on nurse-industry relations
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice website, which describes what is required of all registered doctors in the UK
Understanding and Responding to Pharmaceutical Promotion: A Practical Guide is a manual prepared by Health Action International and the World Health Organization that schools of medicine and pharmacy can use to train students how to recognize and respond to pharmaceutical promotion.
The Institute of Medicine's Report on Conflict of Interest in Medical Research, Education, and Practice recommends steps to identify, limit, and manage conflicts of interest
The University of California, San Francisco, Office of Continuing Medical Education offers a course called Marketing of Medicines
doi:10.1371/journal.pmed.1001561
PMCID: PMC3841103  PMID: 24302892
17.  Promoting Darfuri women’s psychosocial health: developing a war trauma counsellor training programme tailored to the person 
The EPMA Journal  2013;4(1):10.
Women are considered special groups who are uniquely vulnerable in the context of war exposures. To effectively target the resources aimed at mitigating mental health consequences and optimising and maximising the use of mental health provisions, culturally relevant war trauma counsellor training is required. The objectives of this study are to promote a new philosophy in the Sudanese mental health care by introducing an integrative approach for targeted prevention and tailored treatments to the Darfuri person in a cost-effective way. Furthermore, the study provides evidence- and theory-based guidelines for developing a war trauma counsellor training programme in Sudan, mainly based on qualitative and quantitative studies among war-affected Darfuri female students. Cultural conceptualisations such as gender roles and religious expectations as well as theories that emphasise resilience and other psychosocial adaptation skills have been operationalised to reflect the totality of the Darfuri women’s experiences. Furthermore, the results of four interrelated studies among war-traumatised undergraduate Darfuri women who are internally displaced provide the basis that guides an outline for qualification development, capacity building and skills consolidation among Sudanese mental health care providers. Explicit war-related psychosocial needs assessment tools, specific war-related trauma counsellor training and particular counsellor characteristics, qualities and awareness that pertain to strengthening the efficacy of war trauma Sudanese counsellors are recommended. The aim is to produce expertly trained war trauma counsellors working with war-affected Darfuri women in particular and with regards to their helpfulness in responding to the psychosocial needs of war-exposed Sudanese in general.
doi:10.1186/1878-5085-4-10
PMCID: PMC3623904  PMID: 23531430
Darfuri women; Psychosocial war-related needs assessment; Counsellor training; Trauma counsellor characteristics; Contextual-theoretical framework; Targeted prevention; Tailored therapy
18.  Ontario's accelerated war against Medicare misuse another sign of leaner health care times. 
A special-investigations unit is helping the Ontario Health Insurance Plan (OHIP) curb the fraud and abuse that has been draining millions of health care dollars from the province. The government is taking a tougher line on foreigners who use friends' or relatives' OHIP cards, people who use misplaced, stolen or counterfeit cards, and on snowbirds who deliberately bend residency requirements as they try to hang on to medicare benefits. In 1994-95, Ontario spent $74 million on health care for Ontarians travelling or living abroad.
PMCID: PMC1487640  PMID: 8630844
19.  Mortality of British coal miners in 1961 
Liddell, F. D. K. (1973).Brit. J. industr. Med.,30, 15-24. Mortality of British coal miners in 1961. In an earlier enquiry, a sizeable proportion of deaths officially ascribed to coalmining occupations was shown to have been in men who had worked in the industry but not in jobs specific to coalmining, or who had left the mines and taken up other employment. This led to overstatement of mortality among miners, and particularly among face workers.
A new coding of occupations was introduced in 1960, and the present investigation was concerned with all 5 362 men aged 20 to 64 who died in 1961 and were recorded as having last worked in a coalmining occupation or for the National Coal Board. The occupation at the time of last employment was determined from colliery records or after special enquiry by medical officers of health, and again was found to be at considerable variance with that on the death certificate. `Promotion' into coalmining occupations existed in all coalfields and depended on age at death and year of last appearance at work. `Promotion' to the face was particularly marked; however, more men had been working in the industry than were recorded as in specifically coalmining occupations. The effect of retirement from the coalface to other mining work was investigated.
In occupied miners underground, mortality was less than in all occupied and retired males, substantially so at the face. Miners generally had high rates of deaths from accidents and pneumoconiosis, and low rates for lung cancer. For most other causes, face workers had very low rates, while other underground workers and surface workers had rates below and above the national rates for occupied and retired males. Death rates were higher in Scotland than in the other British coalfields.
PMCID: PMC1009473  PMID: 4685295
20.  The challenges of exposure assessment in health studies of Gulf War veterans 
A variety of exposures have been investigated in Gulf War veterans' health studies. These have most commonly been by self-report in a postal questionnaire but modelling and bio-monitoring have also been employed. Exposure assessment is difficult to do well in studies of any workplace environment. It is made more difficult in Gulf War studies where there are a number and variety of possible exposures, no agreed metrics for individual exposures and few contemporary records associating the exposure with an individual. In some studies, the exposure assessment was carried out some years after the war and in the context of media interest. Several studies have examined different ways to test the accuracy of exposure reporting in Gulf War cohorts. There is some evidence from Gulf War studies that self-reported exposures were subject to recall bias but it is difficult to assess the extent. Occupational exposure-assessment methodology can provide insights into the exposure-assessment process and how to do it well. This is discussed in the context of the Gulf War studies. Alternative exposure-assessment methodologies are presented, although these may not be suitable for widespread use in veteran studies. Due to the poor quality of and accessibility of objective military exposure records, self-assessed exposure questionnaires are likely to remain the main instrument for assessing the exposure for a large number of veterans. If this is to be the case, then validation methods with more objective methods need to be included in future study designs.
doi:10.1098/rstb.2006.1822
PMCID: PMC1569629  PMID: 16687267
Gulf war veterans; exposure; chemical warfare; uranium
21.  Iatrogenic Blood-borne Viral Infections in Refugee Children from War and Transition Zones 
Emerging Infectious Diseases  2013;19(6):892-898.
Pediatric infectious disease clinicians in industrialized countries may encounter iatrogenically transmitted HIV, hepatitis B virus, and hepatitis C virus infections in refugee children from Central Asia, Southeast Asia, and sub-Saharan Africa. The consequences of political collapse and/or civil war—work migration, prostitution, intravenous drug use, defective public health resources, and poor access to good medical care—all contribute to the spread of blood-borne viruses. Inadequate infection control practices by medical establishments can lead to iatrogenic infection of children. Summaries of 4 cases in refugee children in Australia are a salient reminder of this problem.
doi:10.3201/eid1906.120806
PMCID: PMC3713815  PMID: 23739597
HIV; hepatitis B virus; hepatitis C virus; iatrogenic; children; war; pathogenesis; viruses; infections; transfusions
22.  Tobacco wars: the bloody battle between good health and good politics 
A battle to introduce new antitobacco legislation in Canada has caused political battles within the Liberal Party. While one side is worried about the need to protect people's health, another is worried about the potential loss of jobs within the tobacco industry--many of which are located in politically volatile Quebec. Charlotte Gray writes about the machinations that led to the introduction of new smoking legislation in the House of Commons in November.
PMCID: PMC1226917  PMID: 9012729
23.  Perspectives of Radioactive Contamination in Nuclear War 
The degrees of risk associated with the medical, industrial and military employment of nuclear energy are compared. The nature of radioactive contamination of areas and of persons resulting from the explosion of nuclear weapons, particularly the relationship between the radiation exposure and the amount of physical debris, is examined.
Some theoretical examples are compared quantitatively. It is concluded that the amount of radio-activity that may be carried on the contaminated person involves a minor health hazard from gamma radiation, compared to the irradiation arising from contaminated areas.
PMCID: PMC1936905  PMID: 6015741
24.  The mental health of UK Gulf war veterans: phase 2 of a two phase cohort study 
BMJ : British Medical Journal  2002;325(7364):576.
Objectives
To examine the prevalence of psychiatric disorders in veterans of the Gulf war with or without unexplained physical disability (a proxy measure of ill health) and in similarly disabled veterans who had not been deployed to the Gulf war (non-Gulf veterans).
Design
Two phase cohort study.
Setting
Current and ex-service UK military personnel.
Participants
Phase 1 consisted of three randomly selected samples of Gulf veterans, veterans of the 1992-7 Bosnia peacekeeping mission, and UK military personnel not deployed to the Gulf war (Era veterans) who had completed a postal health questionnaire. Phase 2 consisted of randomly selected subsamples from phase 1 of Gulf veterans who reported physical disability (n=111) or who did not report disability (n=98) and of Bosnia (n=54) and Era (n=79) veterans who reported physical disability.
Main outcome measure
Psychiatric disorders assessed by the schedule for clinical assessment in neuropsychiatry and classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
Results
Only 24% (n=27) of the disabled Gulf veterans had a formal psychiatric disorder (depression, anxiety, or alcohol related disorder). The prevalence of psychiatric disorders in non-disabled Gulf veterans was 12%. Disability and psychiatric disorders were weakly associated in the Gulf group when confounding was adjusted for (adjusted odds ratio 2.4, 99% confidence interval 0.8 to 7.2, P=0.04). The prevalence of psychiatric disorders was similar in disabled non-Gulf veterans and disabled Gulf veterans ( 19% v 24%; 1.3, 0.5 to 3.4). All groups had rates for post-traumatic stress disorder of between 1% and 3%.
Conclusions
Most disabled Gulf veterans do not have a formal psychiatric disorder. Post-traumatic stress disorder is not higher in Gulf veterans than in other veterans. Psychiatric disorders do not fully explain self reported ill health in Gulf veterans; alternative explanations for persistent ill health in Gulf veterans are needed.
What is already known on this topicGulf veterans report medically unexplained symptoms more often than non-Gulf veteransThe clinical characteristics of ill health in Gulf veterans are not well known, and factors associated with ill health in Gulf veterans are poorly understoodWhat this study addsMost ill Gulf veterans do not have a formal psychiatric disorderThe rates for post-traumatic stress disorder are lowPsychiatric morbidity is not strongly associated with ill health in Gulf veteransThe rates for somatoform disorders are three times greater in disabled Gulf veterans than they are in disabled non-Gulf veterans
PMCID: PMC124552  PMID: 12228134
25.  Respiratory health effects of opencast coalmining: a cross sectional study of current workers. 
OBJECTIVE: To identify whether there is evidence of pneumoconiosis and other respiratory health effects associated with exposure to respirable mixed dust and quartz in United Kingdom opencast coalmines. METHODS: A cross sectional study of current workers (1224 men, 25 women) was carried out at nine large and medium sized opencast sites in England, Scotland, and Wales. To characterise a range of occupational groups within the industry, full shift measurements of personal exposures to respirable dust and quartz were taken. Up to three surveys were carried out at each site, covering all four seasons. For the purposes of comparisons with health indices these groups were further condensed into five broad combined occupational groups. Full sized chest radiographs, respiratory symptoms, occupational history questionnaires, and simple spirometry were used to characterise the respiratory health of the workforce. Logistic or multiple regression techniques were used to examine relations between indices of exposure and respiratory health. RESULTS: None of the group geometric mean dust concentrations, based on 626 valid dust samples, exceeded 1 mg.m-3, and 99% of all quartz concentrations were below 0.4 mg.m-3, the current maximum exposure limit. The highest quartz concentrations were experienced by the rock drilling team and drivers of bulldozers (used to move earth and stone from layers of coal). There were clear differences in mean respirable dust and quartz concentrations between occupational groups. These were consistent across the different sites, but depended in part on the day of measurement. The variations between sites were not much greater than between days, suggesting that differences between sites were at least partly explained by differences in conditions at the time of the measurements. The prevalence of radiographic small opacities profusion category > or = 1/0, based on the median of three readings, was 4.4%. Five men had category 2 pneumoconiosis and two men (including one of these five) had progressive massive fibrosis category A. From regression analyses, the relative risk of attaining a profusion of category > or = 0/1 was estimated to be doubled for every 10 years worked in the dustiest, preproduction opencast jobs, after allowing for age, smoking, and site effects. Risk was not associated with time worked in any other occupation within the industry, nor with previous employment in underground mining or other dusty jobs. Symptoms of chronic bronchitis were present in 13% of the men. Frequency of chronic bronchitis was influenced by years worked in dusty jobs outside opencast mining, but not by time spent in occupations within the industry. Asthmatic symptoms were reported by 5% of the workforce, close to the mean frequency found in adult men. No positive associations were found between asthma and occupational exposures. Lung function on average was close to predicted value and showed no relation to time worked in opencast occupations. CONCLUSIONS: Frequency of (mostly mild) chest radiographic abnormalities is associated with working in the dustier, preproduction jobs in the industry. Although some of these mild abnormalities may be non-occupational (due to aging or smoking), the association with exposure indicates a small risk of pneumoconiosis in these men, and the need to monitor and control exposures, particularly in the high risk occupations.
PMCID: PMC1128802  PMID: 9245948

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