Chapter 1 - Introduction

1.1 Korean War Veterans Mortality Study
1.1.1 Ethical approval
1.1.2 Study Aims
1.1.3 Study design
1.1.4 Study implementation
1.1.5 Definition
1.1.6 Data collection
1.1.7 Specific causes of death
1.2 Influences on Mortality
1.2.1 Medical assessment for entry into the military
1.2.2 Pesticide, solvent and chemical exposure
1.3 Report Structure

This research study of Australian male veterans of the Korean War was announced by the Minister for Veterans' Affairs on 13 October 1997. It was prompted by concerns from the Korean War veteran community that their death rates, particularly those due to heart disease, diabetes, prostate and other cancers, respiratory illnesses and renal failure were higher than the Australian male population, and that this increase was due to their service in Korea.

This is the first mortality study of Royal Australian Navy, Australian Army, Royal Australian Air Force who served in Korea.

The study identified both male and female veterans who served in the Korean War and the enforcement period following the cease fire. However, the study was only able to analyse mortality data relating to the male veterans. The number of female veterans (58) was too small to allow the derivation of reliable results.

1.1 Korean War Veterans Mortality Study

1.1.1 Ethical approval

A protocol for this study was completed in September 1999. It defined the study aims, methods of data collection and analysis, limitations of the study, reporting, and privacy and confidentiality considerations.

The protocol was accepted by the study's Consultative Committee, the Study Scientific Advisory Committee, the DVA Ethics Committee and the AIHW Ethics Committee. During the course of the study approval for several variations and corrections to the protocol was sought and obtained. The protocol is reproduced at Appendix A.

1.1.2 Study Aims

The aims of the Study were to:

develop a nominal roll of all Australian veterans of the Korean War;
develop a geographic profile of living Australian veterans of the Korean War;
determine mortality rates of Australian veterans of the Korean War; and
compare the mortality rates of Australian veterans of the Korean War with those of the Australian community.

1.1.3 Study design

The study is a study of all male Australian personnel - Navy, Army, Air Force- who served in Korea. The analysis determines mortality rates for the period from the veterans' last date of service in Korea until 31 December 2000. All comparisons have been standardised by age and calendar year of death.

The study compares the mortality rates of male Australian veterans of the Korean War with those of Australian males. In addition, it analyses whether mortality rates vary between different groups of Korean War veterans or by different measures of exposure to Korea.

1.1.4 Study implementation

Representatives of ex-Service organisations formed a Consultative Committee to represent the interests of Korean War veterans (Appendix F) while a Scientific Advisory Committee (Appendix G) was established to oversight the scientific aspects of the study. The study was conducted by DVA in conjunction with the AIHW (Appendix H).

1.1.5 Definition

For the purposes of the study, 'Korean War veterans' were defined as:

All members of the Royal Australian Navy, Australian Army, Royal Australian Air Force (including those airmen based in Japan who flew operational missions over Korea), who landed in Korea or entered Korean waters, including those who were seconded to the Army of the Republic of South Korea, the United States Air Force (USAF), the United States Navy (USN), the British Army, Navy or Air Force and any other allied Service; all members of philanthropic organisations; all members of the Australian Forces Overseas Fund and all official entertainers and war correspondents who saw service in Korea during the period between 27 June 1950 and 19 April 1956.

This definition excludes:

members of the diplomatic corps;
entertainers other than those who were regarded as 'official';
members of the Army of the Republic of Korea or of any other army who have become Australian citizens subsequently;
Australian citizens employed in Korea by overseas business organisations or governments;
civilian non-medical aid and charity workers other than members of philanthropic organisations who were accredited to the Australian Defence Force; and
merchant mariners.

The concluding date of 19 April 1956 was selected as this is the end-date for the Korean Operational Area specified in the Veterans' Entitlements Act 1986. Although there was no longer an active threat of enemy action, the living conditions and environmental exposures of individuals maintaining defensive positions or on cease-fire enforcement duties were held to be still comparable to those existing prior to the cease-fire.

1.1.6 Data collection

The starting point for the veteran cohort study was the compilation of a nominal roll of all Australian veterans of the Korean War. This defined the veteran cohort. In itself, this was a major goal of this study and its accomplishment meant that the study was not restricted to those Korean War veterans with whom DVA had had contact by way of the provision of benefits. In addition, the nominal roll provided a baseline for a cancer incidence study as well as a general health survey of surviving male Korean War veterans. These studies will be reported separately.

For each person on the nominal roll, the following data were recorded:

Service number;
surname;
up to three given names;
date of birth;
date of death;
State/Territory in which death was registered;
residential postcode for living veterans;
the database source of vital status information;
period/s of service in Korea;
ship/unit/ squadron in which the veteran served in Korea; and
the veteran's RAN branch or trade, Army Corps or RAAF category or mustering for service in Korea.

1.1.7 Specific causes of death

As well as assessing total mortality, specific causes of death, where it was considered that Korean War veterans may differ from Australian males, were also investigated.

The specific causes of death (shown in Table 1-1) were selected for one or more of the following reasons:

they were suggested by a comprehensive review of current, relevant literature (see Appendix B); and/or
they were suggested by veterans' organisations and the Consultative Committee to reflect the concerns of their members.

Table 1-1: Causes of death of a priori interest
Cause of death	ICD-9 Chapter/Code	ICD-10 Chapter/Code
Chronic bronchitis and emphysema	491, 492	J41, J42, J43.1-J43.9
Ischaemic vascular disease including myocardial infarction and peripheral vascular disease	410-414, 440.2	I21-I25, I70.2, I73.1. I73.9
Cerebrovascular accident (stroke)	430-438	I60-I66
Tuberculosis	010-018	A15-A19
Peptic ulcer disease	531-534	K25-K28
Cirrhosis of the liver	571.2, 571.5, 571.6	K70.3, K74.3-K74.6
External Causes (homicides, accidents and suicides)	E800-E999	V01-Y98
Malignant neoplasm of the oesophagus	150	C15, C26.8
Malignant gastrointestinal neoplasms (stomach, pancreas, colo-rectal)	151-154	C16- C21
Malignant colo-rectal neoplasms	153, 154	C18-C21
Malignant neoplasms of the oropharynx and larynx	141-149, 161	C01-C14, C32
Malignant neoplasm of the lung	162	C33, C34
Mesothelioma	163	C45
Malignant genito-urinary neoplasms including kidney, ureter, bladder, prostate and testicle	185-189	C60-C68
Malignant neoplasm of the prostate	185	C61
Hepatocellular carcinoma	155.0	C22
Malignant melanoma of the skin	172	C43
Leukaemia including Acute Myeloid Leukaemia	204-208	C91-C95
All Causes	-

Numbers of veteran deaths and specific causes of death were obtained from the AIHW from the National Death Index and from manual searching of pre-1980 records by the Registrars of Births, Deaths and Marriages. These deaths were coded using the International Classification of Diseases, Revision 10 (ICD-10) (see Table 1-1). These were compared with data from the National Mortality Database for all Australian males (for results see Chapter 6). Not all of the diseases of concerns to veterans were able to be assessed directly (such as diabetes and renal failure) and these exceptions were advised to the Consultative Committee.

1.2 Influences on mortality

Two factors that may affect the mortality rates reported in this study deserve particular mention and are discussed below. The first is that service personnel had to be fit for military service at enlistment, so those with life-shortening illnesses or behavioural disorders were excluded by the medical assessment and psychological screening process. This suggests that at the time of service in Korea, Service personnel were fitter on average than other Australian men. The second is that while serving in Korea, service personnel may have been exposed to a range of pesticides and other chemicals, including DDT and various petrochemicals. They were also exposed to periods of extreme hardship, boredom and stress, and a number of infectious diseases were endemic in Korea. Their mortality and health in general may have been affected by these exposures.

1.2.1 Medical assessment for entry into the military

Australian Army

At the time of the Korean War, those wanting to join the Army as a career and those recruited for service in Korea (known among Korean War veterans as 'K Force') were assessed before they were enlisted into the Army. The assessment consisted of a medical examination, an interview and for those with education less than New South Wales intermediate level or equivalent, a set of Army aptitude tests. The purpose of the assessment was to classify each person as:

medically fit for all service duties; or
apart from temporary circumstances, fit for all service duties; or
not fit for all service duties.

The medical examination consisted of a medical history, physical examination, urinalysis (for albumin and sugar) and a chest x-ray. The doctors conducting the examination could classify a recruit as not fit for all service duties for any of the following reasons:

cardiovascular disease, including systolic blood pressure outside 100-140 mm Hg or diastolic blood pressure outside 60-90 mm Hg;
chronic diseases of the respiratory, genito-urinary, alimentary, nervous, skeletal and/or haematopoietic systems;
endocrine and metabolic disease;
a history of malignancy;
chronic diseases of skin, ear, nose, throat, eyes; and/or
abnormalities of speech or dentition.

Those who did not meet the minimum educational standard were required to take psychological tests to screen out anyone with an IQ score of less than 80. The interview was designed to detect potential officer candidates, inconsistent scores on the tests or obvious personality problems. Those with long criminal records or who had committed major crimes were also rejected. Anyone classified as not fit for all service duties was ineligible to enlist.

Royal Australian Navy and Royal Australian Air Force

Those wishing to enter the RAN or the RAAF were also required to be assessed before they could enlist. There were no special enlistments as neither Service recruited specifically for the Korean War. The assessment was similar to that described above for the Army. Its purpose was to classify each applicant as either medically fit or not medically fit, for all service duties. The criteria for rejecting an applicant were similar to those used by the Army. However, there were some minor administrative differences, usually concerning whether, for particular conditions, the examining doctor or a specialist made the final decision to reject the applicant.

Summary

Those who were accepted into the RAN, Australian Army and RAAF differed from their peers. They were in good health, with no chronic diseases or serious congenital anomalies, and their IQ score was above 80. Furthermore, recruits did not include those with criminal records or overt personality problems.

1.2.2 Pesticide, solvent and chemical exposure

Australian troops were exposed, in varying amounts, to a wide range of pesticides, solvents and chemicals during their service in Korea. This range included DDT, solvents (including toluene), pharmaceutical drugs, and petrochemicals (including benzene). Levels of particular exposures have not been established for Australian veterans of the Korean War.

Without an index of exposure it is difficult to attribute adverse health outcomes or mortality directly to contact with pesticides or other chemicals. There are two indirect approaches which may be used to link outcome with exposure. The first approach assumes that the exposure occurred but is generally impossible to study directly, and hence the effects of exposure in other situations are used as surrogates for the effects of service in Korea. Using this approach, no attempt is made to take account of the variations in the level of exposure to pesticides of veterans in Korea compared with persons exposed in manufacturing or applying pesticides.

The second approach is to attribute any difference in mortality or health between the veteran and control groups to service in Korea in general rather than to pesticide or chemical exposure in particular.

In light of the lack of direct measures of exposure to pesticides, solvents and other chemical agents, any variations in mortality found in this study would need to be attributed to service in Korea, rather than exposure to particular agents.

1.3 Report structure

This introduction and Chapter 2 provide background to the study and the Korean War. The Nominal Roll is described in Chapter 3. The characteristics of the study cohort are presented in Chapter 4.

Chapter 5 is a key chapter in this report. It describes how vital status was determined and the statistical methods used in this study.

The mortality rates of male Korean War veterans compared with the Australian male population are presented in Chapter 6. Chapter 7 reviews the mortality findings and considers them in the context of other mortality studies. Finally, Chapter 8 summarises the study and formulates conclusions and recommendations.

The study protocol is reproduced in Appendix A. The literature review for the study is at Appendix B. Appendix C lists the units allotted by Australian and allied forces to the Korean War. Appendix D provides detailed mortality rates. The geographic profile of living Korean War veterans as at 31 December 1999 is contained in Appendix E. Members of the study's Consultative Committee, the Scientific Advisory Committee and project staff are listed in Appendices F, G and H respectively.