EXECUTIVE SUMMARY

Study background and methods

• The Australian Korean War veterans’ Health Study was designed to complement the recently completed Australian Korean War veterans’ Mortality and Cancer Incidence Studies. Together, these three studies constitute a major study program of health in this Australian veteran population. This study program represents one of the most comprehensive investigations of health in an entire veteran group ever conducted internationally.
• The major aim of the Health Study was to compare Australia’s surviving, male Korean War veterans with similarly aged Australian men, who resided in Australia at the time of the Korean War, on several measures of physical and psychological health, quality of life and life satisfaction. Further, the study aimed to investigate whether specific service-related characteristics of the Korean War deployment were associated with current health.
• The Health Study was commissioned by the Department of Veterans’ Affairs (DVA) and was undertaken by Monash University in consultation with the Study Scientific Advisory Committee and Consultative Committee. The DVA and Monash University Human Research Ethics Committees provided approval for the research.
• The study commenced in March 2004 and included 7,525 male Korean War veterans thought to be alive and residing in Australia. Approximately 57% of Australia’s original 17,872 Korean War veterans were deceased at this time. The study also included a general population sample of 2,964 Australian men aged 65 years and above drawn from the Australian Electoral Roll.
• Participants completed a self-report questionnaire which included instruments measuring life satisfaction, depression, anxiety and posttraumatic stress disorder, smoking and alcohol consumption, several dimensions of quality of life, medical conditions and hospitalisations, and Korean War service characteristics including severity of combat experience, and war-related injury. Data on additional Korean War service characteristics such as Navy, Army or Air Force Service, rank, age and duration of deployment, were obtained from the DVA Korean War Nominal Roll.
• Australia’s surviving Korean War veteran population enthusiastically supported the Health Study, with over 81% participating and providing high quality, complete questionnaire data. Recruitment in the population sample was lower at 64%, but also satisfactory and their data quality was excellent.
• Study participants ranged in age from 66 to just under 100 years old.

Results

• Overall, the results of the study showed that surviving Australian Korean War veterans, approximately five decades after the Korean War, are experiencing significant excesses in several measures of psychological ill health, lower life satisfaction and poorer quality of life, and excess medical conditions and hospitalisations compared with a group of similarly aged Australian men who were residing in Australia at the time of the Korean War.
• Korean War veterans have also experienced a lifetime pattern of alcohol and cigarette consumption in excess of that reported by the comparison group. 79% of Korean War veterans report being current or former smokers, compared with 60% of the comparison group. Korean War veterans are one and a half times more likely to meet criteria for current hazardous alcohol consumption, and three times more likely to meet criteria for a history of alcohol related problems at some point in their lifetime.
• The proportions of veterans meeting criteria for posttraumatic stress disorder (PTSD), anxiety, and depression are substantially elevated, with veterans five or six times more likely to have these disorders than the comparison group. Up to 33% of Korean War veterans meet criteria for PTSD, 31% meet criteria for anxiety and 24% meet criteria for depression.
• Korean War veterans report poorer overall life satisfaction than the comparison group. Taking into account what has happened to them in the last year and what they expect to happen in the future, Korean War veterans are less likely than the comparison group (18% versus 40% respectively) to report feeling delighted or pleased about their life as a whole, and more likely (11% versus 3%) to report feeling unhappy or terrible.
• Korean War veterans also report poorer quality of life on multiple dimensions, including physical health, psychological functioning, social relationships and environment. Korean War veterans are more likely than the comparison group (22% versus 6% respectively) to report their quality of life as poor or very poor, and less likely (45% versus 80%) to report their quality of life as good or very good.
• Fifteen medical conditions investigated in the study are all reported one and a half to three times more frequently by Korean War veterans than the comparison group. These include asthma, high blood pressure, stroke (or after effects of stroke), heart attack or angina, rapid or irregular heart beat, liver disease, arthritis, kidney disease, diabetes, melanoma, other skin cancer, other cancer (not skin), stomach or duodenal ulcer, partial or complete blindness (not corrected by glasses) and partial or complete deafness. The study did not attempt to independently validate the self-reported medical conditions, however the overall pattern of excess medical conditions reported by Korean War veterans is consistent with the findings of the Australian Korean War veterans’ Mortality and Cancer Incidence Studies, and also with the likely health effects of excessive lifetime exposure to cigarettes and alcohol.
• Korean War veterans report an increased rate of hospitalisation in the previous 12 months, consistent with their overall pattern of increased psychological and physical ill health.
• Two service-related characteristics of the Korean War deployment are most strongly associated with poorer psychological health, lower life satisfaction and poorer quality of life in Korean War veterans. They are:
  
  Combat exposure: Veterans who reported experiencing heavy combat during Korea, using the Combat Exposure Scale (CES), were 15 times more likely to meet criteria for PTSD, six times more likely to meet criteria for anxiety, or depression, and two times more likely to meet criteria for a history of alcohol problems, compared with veterans who report no combat exposure. Further, veterans reporting heavy combat also report lower life satisfaction, and poorer quality of life, than veterans reporting no combat exposure.
  
  Rank during the Korean War: Lower ranked Korean War veterans are much more likely, than higher ranked veterans, to have poor health. There is a 54% increase in the prevalence of PTSD, a 56% increase in the prevalence of anxiety, a 43% increase in the prevalence of depression, and a 26% increase in the prevalence of having a history of alcohol problems, per categorical decrease in rank from officer, to non-commissioned officer, to enlisted rank. Further, veterans who served with an enlisted rank report lower life satisfaction, and poorer quality of life than veterans who served as non-commissioned officers, or officers. These findings are independent of the effects of age and education.

These associations between Korean War related combat exposure, and rank, and current PTSD, anxiety and depression are demonstrated in Figures A and B.

Figure A. Percentage of Korean War veterans with PTSD, anxiety, or depression across levels of combat exposure

Figure B. Percentage of Korean War veterans with PTSD, anxiety, or depression across levels of rank

• There are also other service-related characteristics of the Korean War associated with some health outcomes: They include:
  
  Service branch: PTSD, anxiety, depression and history of alcohol problems are most prevalent in Army veterans (prevalences of approximately 30%, 34%, 26% and 39% respectively), less prevalent in Navy veterans (22%, 29%, 21% and 36%), and least prevalent in Air Force veterans (14%, 22%, 17% and 29%). Army veterans also consistently report the poorest life satisfaction and quality of life, however the magnitude of these differences across Service branches is small.
  
  Being wounded in action: Veterans who report being wounded in action during Korea are approximately two times more likely to have PTSD, and 1.6 times more likely to have anxiety or depression, than veterans who report not being wounded. The type of evacuation reported for the injury or illness, which may be indicative of severity, was not associated with these health outcomes.
  
  Age at time of deployment: Veterans who were aged 20 years or less at the time of deployment to the Korean War are approximately two times more likely to have PTSD, and 1.4 times more likely to have anxiety or a history of problem drinking, than veterans who were aged 31 years or older.
  
  Years of previous Australian armed forces service: Veterans who had fewer years of service experience prior to the Korean War are more likely to have PTSD, anxiety, and a history of alcohol problems than veterans who were more experienced. There is a 14%-16% increase in the prevalence of these disorders per categorical decrease in years of previous service experience from 4 or more years, to 1 to < 4 years, to < 1 year.
  
  Duration of Korean War deployment: Veterans who deployed for more than 12 months are 1.5 times more likely to have PTSD, 1.2 times more likely to have anxiety, and 1.3 times more likely to have a history of alcohol problems, than veterans who deployed for less than 6 months.
  
  Korean War deployment era: Veterans who first deployed to Korea during the mobile, or static, phases of the Korean War are more likely to have PTSD, anxiety and depression than veterans who first deployed after the armistice.

Discussion and conclusions

• The Health Study has demonstrated that the long-term health effects of war service can be severe, and can still be present fifty years after the end of hostilities.
• The combined results of the Australian Korean War veterans’ Mortality, Cancer Incidence and Health Studies show that Korean War veterans have experienced post-war mortality and some cancers at excessive rates compared with similarly aged Australians, and that survivors continue to experience extremely poor psychological and physical health and a low level of life satisfaction and quality of life.
• Our observed group differences in the direction of poorer health in veterans in the study are likely to represent an underestimation of the true magnitude of the health differences which could be attributable to Korean War service. This is due to two possible factors. Firstly, the "healthy soldier" effect literature suggests that veterans are likely to have been healthier than the comparison group prior to the Korean War. Secondly, because it was limited to survivors, this Health Study has been unable to detect excess morbidity and adverse health outcomes likely to have been experienced by deceased veterans.
• Smoking and alcohol consumption data collected in the Health Study assist in the interpretation of the findings of the Australian Korean War veterans’ Mortality and Cancer Incidence Studies. For example some, but not all, excesses in cancer incidence observed in Korean War veterans in the Cancer Incidence Study, can be explained by the level of smoking reported by veterans in the Health Study. A pattern of excessive alcohol consumption may also partly explain increased mortality among veterans from specific causes including accidents and suicide, alcoholic liver disease and other digestive diseases found in the Mortality Study.
• The major methodological strengths of the study relate to the inclusion of the entire population of surviving Australian male Korean War veterans residing in Australia, the direct comparison of their health with that of an appropriately matched comparison group, and the use of well-validated data collection instruments, where possible.
• Methodological weaknesses in the study include the reliance on self-reported health measures, particularly self-reported medical conditions which could not be medically validated, and the necessity for retrospective assessment of some lifestyle and deployment-related factors fifty years after the Korean War. The study was also unable to investigate possibly important Korean War environmental and chemical risk factors, and additional military and non-military characteristics, which may have contributed to post war illness. These limitations highlight the advantages of utilising longitudinal study designs which commence shortly after war deployment and follow veterans forward in time.
• The adverse impact of psychological disorders, such as PTSD and depression, and chronic medical conditions, upon the lives of sufferers can be severe. Effective treatment in the elderly will require integrated intervention approaches which reflect the complexity of veterans’ prevailing symptoms. Importantly, elderly sufferers from long-standing conditions can achieve symptomatic and functional improvement.
• It is clear that some of the ill-health experienced by veterans is attributable to the severity of combat associated with Korean War service. Other service-related factors include lack of seniority, inexperience, perhaps youthfulness and war-related injury. Other military, and non-military factors such as socioeconomic disadvantage, may have also contributed to veterans’ vulnerability to illness and the persistence of symptoms over time. Excessive consumption of cigarettes and alcohol in the post-war period has also contributed to poor health, including cancer, and excess mortality.
• While we cannot change the war-related experiences, and lifestyle risk factors, of the past, health interventions have been shown to be effective in alleviating significant ill health experienced by ageing veterans. The results of this study should be useful in identifying the most appropriate types of health interventions, and levels of service provision, required by surviving Australian Korean War veterans.
• Importantly, the results of the study should also be useful in identifying those veterans of more recent conflicts who may be at greatest risk of adverse health outcomes, and in developing appropriate strategies to prevent or reduce long-term ill-health in these younger veteran groups.
• More than fifty years after the war, less than 45% of Australia’s Korean War veterans remain alive. The deceased Korean War veterans cannot benefit from health interventions, or changes to health service provisions, which may arise from the findings of this study. Younger veterans of more recent conflicts, however, may benefit more from future studies if these can investigate deployment-related risk factors and health outcomes in closer proximity to the time of the deployment.
• Combined, the Australian Korean War veterans’ Mortality, Cancer Incidence, and Health Studies contribute substantially to the existing international body of knowledge on the long-term health effects of war deployment. The results should assist in improving the health of future generations of military personnel, both in Australia and abroad.