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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.
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).
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.
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.
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.
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
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.
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
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
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.
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.
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).
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
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
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
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.
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).
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.
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).
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.
PMCID: PMC2989975  PMID: 21050484
5.  Causes of Death of Prisoners of War during the Korean War (1950-1953) 
Yonsei Medical Journal  2013;54(2):480-488.
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.
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.
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.
PMCID: PMC3575971  PMID: 23364985
Prisoners of war (POW); Korean War; causes of deaths; infectious diseases
6.  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.
PMCID: PMC3547281  PMID: 23330058
Children; war; disasters; evidence-based interventions
7.  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
8.  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.
PMCID: PMC1740679  PMID: 15550607
9.  Physical and Mental Health Costs of Traumatic War Experiences Among Civil War Veterans 
Archives of general psychiatry  2006;63(2):193-200.
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.
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.
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.
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.
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.
PMCID: PMC1586122  PMID: 16461863
combat exposure; Civil War Veterans; war trauma; physical health; mental health
10.  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)
PMCID: PMC1519032  PMID: 7628428
11.  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
12.  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
13.  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.
PMCID: PMC1569627  PMID: 16687269
veterans; pesticides; uranium; pyridostigimine bromide; sarin
14.  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.
PMCID: PMC3623904  PMID: 23531430
Darfuri women; Psychosocial war-related needs assessment; Counsellor training; Trauma counsellor characteristics; Contextual-theoretical framework; Targeted prevention; Tailored therapy
15.  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
16.  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.
PMCID: PMC1569629  PMID: 16687267
Gulf war veterans; exposure; chemical warfare; uranium
17.  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
18.  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
19.  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.
PMCID: PMC3713815  PMID: 23739597
HIV; hepatitis B virus; hepatitis C virus; iatrogenic; children; war; pathogenesis; viruses; infections; transfusions
20.  The mental health of UK Gulf war veterans: phase 2 of a two phase cohort study 
BMJ : British Medical Journal  2002;325(7364):576.
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).
Two phase cohort study.
Current and ex-service UK military personnel.
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.
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%.
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
21.  Torture and war trauma survivors in primary care practice. 
Western Journal of Medicine  1996;165(3):112-118.
Close to 1 million refugees from around the world have entered the United States, fleeing repression, war, terrorism, and disease. It has been estimated that among these are thousands who have experienced torture. Many refugees and immigrants will appear in the offices of health care professionals with symptoms that may be related either directly or indirectly to torture. Both physical and psychological torture may result in long-term sequelae. Physical effects may be found in every organ system, but psychological effects are most commonly manifest in the symptoms of the post-traumatic stress disorder. For physicians to recognize how torture can affect health status, it is important to understand that history taking may be difficult and that little information may emerge that would explain the origins of scars, fractures, or disabilities. Recognizing the clues to a torture history allows physicians to assist patients in describing the trauma. In addition, knowing the subacute and chronic signs and symptoms of torture enables physicians to diagnose and treat often obscure symptoms with a much clearer understanding of the sources of the difficulty. Paying special attention to the interview process will support torture survivors in detailing often horrific events.
PMCID: PMC1303716  PMID: 8909162
22.  In the face of war: examining sexual vulnerabilities of Acholi adolescent girls living in displacement camps in conflict-affected Northern Uganda 
Adolescent girls are an overlooked group within conflict-affected populations and their sexual health needs are often neglected. Girls are disproportionately at risk of HIV and other STIs in times of conflict, however the lack of recognition of their unique sexual health needs has resulted in a dearth of distinctive HIV protection and prevention responses. Departing from the recognition of a paucity of literature on the distinct vulnerabilities of girls in time of conflict, this study sought to deepen the knowledge base on this issue by qualitatively exploring the sexual vulnerabilities of adolescent girls surviving abduction and displacement in Northern Uganda.
Over a ten-month period between 2004–2005, at the height of the Lord’s Resistance Army insurgency in Northern Uganda, 116 in-depth interviews and 16 focus group discussions were held with adolescent girls and adult women living in three displacement camps in Gulu district, Northern Uganda. The data was transcribed and key themes and common issues were identified. Once all data was coded the ethnographic software programme ATLAS was used to compare and contrast themes and categories generated in the in-depth interviews and focus group discussions.
Our results demonstrated the erosion of traditional Acholi mentoring and belief systems that had previously served to protect adolescent girls’ sexuality. This disintegration combined with: the collapse of livelihoods; being left in camps unsupervised and idle during the day; commuting within camp perimeters at night away from the family hut to sleep in more central locations due to privacy and insecurity issues, and; inadequate access to appropriate sexual health information and services, all contribute to adolescent girls’ heightened sexual vulnerability and subsequent enhanced risk for HIV/AIDS in times of conflict.
Conflict prevention planners, resettlement programme developers, and policy-makers need to recognize adolescent girls affected by armed conflict as having distinctive needs, which require distinctive responses. More adaptive and sustainable gender-sensitive reproductive health strategies and HIV prevention initiatives for displaced adolescent girls in conflict settings must be developed.
PMCID: PMC3536565  PMID: 23270488
Adolescent girls; Conflict; Sexual vulnerability; Displacement camps; Northern Uganda; Acholi; Qualitative; HIV/AIDS
23.  Health status and clinical diagnoses of 3000 UK Gulf War veterans 
Up to June 2001, 3000 British veterans of the Gulf War had sought advice from a special medical assessment programme established because of an alleged Gulf War syndrome. After assessment those attending were classified as completely well, well with symptoms, well with incidental diagnoses treated or controlled, or unwell (physically or mentally). Mental illness was confirmed by a psychiatrist. The first 2000 attenders have been reported previously. The present paper summarizes findings in all 3000.
2252 (75%) of those attending were judged ‘well’, of whom 303 were symptom-free. Medical diagnoses were those to be expected in such an age-group (mean age 34 years, range 21-63). No novel or unusual condition was found. In 604 of the 748 unwell veterans, a substantial element of the illness was psychiatric, the most common condition being post-traumatic stress disorder.
The healthcare requirements of the Gulf veterans seen in this programme can therefore be met by standard National Health Service provision.
PMCID: PMC1279174  PMID: 12356969
24.  Mortality in adults aged 26-54 years related to socioeconomic conditions in childhood and adulthood: post war birth cohort study 
BMJ : British Medical Journal  2002;325(7372):1076-1080.
To examine premature mortality in adults in relation to socioeconomic conditions in childhood and adulthood.
Nationally representative birth cohort study with prospective information on socioeconomic conditions.
England, Scotland, and Wales.
Study members
2132 women and 2322 men born in March 1946 and followed until age 55 years.
Main outcome measures
Deaths between 26 and 54 years of age notified by the NHS central register.
Study members whose father's occupation was manual at age 4, or who lived in the worst housing, or who received the poorest care in childhood had double the death rate during adulthood of those living in the best socioeconomic conditions. All indicators of socioeconomic disadvantage at age 26 years, particularly lack of home ownership, were associated with a higher death rate. Manual origins and poor care in childhood remained associated with mortality even after adjusting for social class in adulthood or home ownership. The hazard ratio was 2.6 (95% confidence interval 1.5 to 4.4) for those living in manual households as children and as adults compared with those living in non-manual households at both life stages. The hazard ratio for those from manual origins who did not own their own home at age 26 years was 4.9 (2.3 to 10.5) compared with those from non-manual origins who were home owners.
Socioeconomic conditions in childhood as well as early adulthood have strongly influenced the survival of British people born in the immediate post war era.
What is already known on this topicAssociations between socioeconomic conditions in childhood and mortality in adulthood suggest that risks to survival begin in early lifeStudies have been generally retrospective, been unrepresentative, used only one marker of childhood conditions, controlled inadequately for adult conditions, or not included womenWhat this study addsThe death rate for women and men between 26 and 54 years living in poor socioeconomic conditions in childhood was double that of those living in the best conditionsThose for whom socioeconomic disadvantage continued into early adulthood were between three and five times more likely to die than those in the most advantageous conditions
PMCID: PMC131184  PMID: 12424168
25.  Sexual Functioning in War Veterans with Posttraumatic Stress Disorder 
Croatian medical journal  2008;49(4):499-505.
To assess the sexual dysfunction among Croatian war veterans with combat-related posttraumatic stress disorder (PTSD).
The study included two groups – 101 war veterans with PTSD and 55 healthy control volunteers receiving outpatient general health care in several outpatient clinics in Split. tructured interviews on different aspects of sexual functioning were conducted from April to October 2007 by trained interviewers.
Respondents with PTSD reported significantly less sexual activity during the previous month than controls (sexual fantasies 2.5 ± 1.6 vs 3.7 ± 1.7, P<0.001; foreplay 2.4 ± 1.6 vs 3.5 ± 1.6, P<0.001; oral sex 1.6 ± 1.2 vs 2.6 ± 1.5, P<0.001; and sexual intercourse 2.4 ± 1.6 vs 3.8 ± 1.5, P<0.001) on a 7-point Likert type scale (from 1 – not a single time to 7 – more times a day). As reasons for reduced sexual activities, respondents with PTSD more frequently than controls reported their own health problems (3.2 ± 1.2 vs 1.5 ± 0.8; P<0.001) or health problems of their partner (2.4 ± 1.1 vs 1.9 ± 1.1; P = 0.004), whereas controls more frequently reported overwork than respondents with PTSD (2.6 ± 1.1 vs 2.1 ± 1.0; P = 0.007) on a 5-point Likert type scale (from 1 – not a single time to 5 – always). Respondents with PTSD reported antidepressant (n = 52, 51%) or anxyolitics use (n = 73, 72.3%). In a subgroup analysis, respondents with PTSD who were taking antidepressants masturbated less frequently than those who were not taking them (1.9 ± 1.3 vs 2.5 ± 1.6; P = 0.039), whereas premature ejaculation was more often experienced by respondents with PTSD who were not taking antidepressants than by those who were taking them (3.5 ± 1.8 vs 2.7 ± 1.5; P<0.049) both on a 7-point Likert type scale (from1 – not a single time to 7 – more times a day).
War veterans with PTSD had less sexual activity, hypoactive sexual desire, and erectile difficulties. Antidepressant therapy in veterans with PTSD may be associated with hypoactive sexual desire.
PMCID: PMC2525821  PMID: 18716997

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