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01 Apr 2014

As the nature of conflict and disaster relief has changed, so has the health issues and challenges faced by those who serve. This will be the topic of an expert-led discussion during the AMA National Conference, to be held from 23 to 25 May at the National Convention Centre, Canberra*.

For all the advances in weapon technology and military tactics that have occurred in the 100 years since World War One broke out, the brutal fact remains that soldiers – and often civilians – continue to die and suffer horrific injuries in battle – as well as away from the battlefield.

The casualty count might have shrunk, but for those at the sharp edge of conflict the threat of death or severe physical or emotional trauma is as real as it ever was.

But, as will be explored in the Overseas conflicts and disasters, the challenge of caring for those who serve session at the AMA National Conference in May, though the fact of death, injury and disability as a consequence of war has not changed in the past century, the way this challenge is met has.
For a start, soldiers are now far more likely to survive injuries that for much of the past 100 years would have been considered fatal.

Vast improvements in military tactics and equipment have made a huge difference in ameliorating the danger of combat, but the ability to quickly extract wounded soldiers from the field of combat, combined with advances in medical treatment and technology, has also helped drive mortality rates sharply lower.

In World War One, of almost 226,000 Australian soldiers, sailors and airmen who embarked for overseas service, 58,961 died out of a total enlistment of 416,809, for a mortality rate of 26 per cent. By comparison, of around 28,000 personnel deployed in the Middle East theatre of operations between 2001 and 2013, 42 died – a mortality rate of just 0.15 per cent.

While the huge drop in mortality rates is a great achievement, it has meant that many returning veterans have multiple, severe physical and mental injuries that require sophisticated long-term care, presenting a big challenge for doctors and therapists, as well as families and carers.

Injuries suffered as a result of blasts, such as from improvised explosive devices, were often terrible, including the loss of limbs, hearing, the long-term effects of concussion and PTSD.

A study by the Centre for Military and Veterans’ Health (CMVH) found hearing loss was one of the most common complaints of Afghanistan and Iraq War veterans.
Aside from the damage caused by blasts from improvised explosive devices, many reported being exposed to loud noises, often for extended periods, without protection.

The study found that many were also at elevated risk of developing respiratory problems such as asthma, bronchitis, sinus blockages and hay fever because they inhaled smoke, and were exposed to airborne dust, fibres, solvents and fuel fumes.

Veteran health experts add simple physical wear and tear to the list. Soldiers often develop musculoskeletal problems associated with the physical demands of active service, such as the strain caused by hauling heavy packs and equipment, sometimes weighing more than 70 kilograms, for hours and days at a time.
But, while physical injuries and problems are often visible and readily diagnosed, many soldiers return from active service with mental health problems that are much less obvious, and which they themselves may not acknowledge.

The fact that soldiers suffer mental health problems as well as physical injuries is nothing new.

During World War One and World War Two hundreds of thousands of the servicemen and women suffered what was called at the time shell-shock – what would now in many cases be diagnosed as post-traumatic stress disorder (PTSD).

According to the CMVH study, the risk of developing mental health problems increases up to 15-fold for those involved in combat, and can include PTSD, major depression, panic and other anxiety syndromes, and alcohol misuse.

Unfortunately, many in the past who carried deep mental scars from their war service felt they had few places to turn for help and suffered in silence.
Attitudes toward mental illness among veterans have not helped.

Often, as former Royal Marine Commando Adrian Talbot told the Sunday Mail, veterans are not even aware they have a problem until it becomes acute, or are reluctant to seek help.

This reluctance, combined with the hostility faced by many veterans returning from the Vietnam War faced, meant that many from that theatre of battle did not seek treatment, and mental health issues have blighted their lives ever since.

Although soldiers returning from more recent conflicts like East Timor, Iraq and Afghanistan have been welcomed home in a way Vietnam veterans were not, many are still hesitant to seek help with mental health problems for a number of reasons, not least because of fears it may compromise their chances of being included in further overseas deployments.

The challenge of encouraging returning servicemen and women to seek help for mental health problems is set to be a focus of the AMA National Conference session – attention that the CMVH study suggests is sorely needed.

A census of more than 14,000 current and former Defence Force personnel who served in the Middle East conducted by the Centre found ex-servicemen and women suffered “significantly poorer mental health” than those still on active duty, and that its prevalence increased two to three years after the most recent deployment, particularly among those who had left service.

 The CMVH said this had particular implications for the Department of Veterans’ Affairs, because it suggested ex-servicemen and women were likely to “require considerable support, possibly for many years. Prevalence of PTSD symptoms, suicidal thoughts and alcohol misuse among ex-serving members suggest that there will be on-going need for psychological and psychiatric treatment”.

Adding a further complication, the report found the onset of mental health problems stemming from deployment was often delayed, and noted that the DVA could not engage with such people until they lodged a claim.

“Therefore, Defence and the DVA need to work together to provide continuity of service and opportunities for longer-term support…after separation,” the study said.
Doctors and the AMA (and its predecessor the BMA) have historically worked in close partnership with the DVA in caring for returned servicemen and women, and this work will continue to be critical as many of the thousands who have been on active service in the past 15 years leave Defence and move to the next phase of their lives.

Adrian Rollins

* This is the first in a series of articles looking at issues that will be the subject of expert-led discussion during the AMA National Conference, to be held from 23 to 25 May at the National Convention Centre, Canberra. Issues to be examined in future editions include the global challenge of non-communicable disease, health funding, practising medicine overseas, and variations in medical practice.

Published: 01 Apr 2014