Morbidity of Vietnam Veterans:
A Study of the Health of Australia's Vietnam Veteran
Volume I Male Vietnam Veterans Survey and Community
[Drawn directly from a final draft of the Report, prepared by
DVA. Any errors are those introduced by my transcription - Clive
Mitchell-Taylor. A direct cross-reference to the final document
will be provided in place of this extract, when and if the
information is posted to the Internet. DVA copyright applies to
this extract as it does to the Report itself.]
This study of the morbidity of Vietnam veterans was
established by the Commonwealth Government following Ex-Service
Organisation (ESO) representation and the study by the Department
of Veterans' Affairs, Mortality of Vietnam Veterans: The Vietnam Veteran
Cohort Study, released in May 1997. Two other morbidity
studies of the Vietnam veterans' health exist, one undertaken in
1983 titled Australian Veterans Health Studies and the other The
Australian Vietnam Veterans Health Study, by O'Toole et al,
published in 1996.
This report presents the results of a survey of male Vietnam
veterans. A separate report will be published to cover the
results of a survey of female Vietnam veterans. It is
anticipated that a final report covering the results of
validation arising from the recommendations contained in the male
and female survey findings will also be published.
Aims of the Study
The aims of the study are to:
- Survey the health and well being of Vietnam
veterans, their spouses and their children.
- Compare the health and well being of Vietnam veterans,
their spouses and their children, with Australians of
comparable age, in the general population, where
comparative data exists.
- Obtain health-related baseline data about Vietnam
veterans which could be used for short, medium and
longer term policy development.
Study Planning and Design
A study Advisory Committee was established in April 1996, to
oversee the conduct of the study. The Advisory Committee
was chaired by the Repatriation Commissioner. In addition
to medical officers, senior officers and supporting staff from
DVA, its membership comprised a representative from the Return
and Services League of Australia (RSL), Vietnam Veterans
Association of Australia (VVAA) and the Australian Veterans and
Defence Services Council (AVADSC). Professionals in
statistical methodology and epidemiology were engaged to provide
data and professional advice to the Committee. ACNielsen
Research Pty Ltd were engaged to conduct the survey of veterans,
and representatives of ACNeilson also joined the Advisory
For the purposes of the study, the Advisory Committee accepted
the definition of Vietnam veterans contained in the Nominal Roll
of Vietnam Veterans:
All members of the Australian Defence Force (ADF) and
the Citizen Military Forces (CMF) who landed in Vietnam or
entered Vietnamese waters including those who were seconded to
the Army of the Republic of Vietnam (ARVN), the United States Air
Force (USAF), the United States Navy (USN) and any other allied
service, all members of Australian Army Training Teams Vietnam,
all members male and female, of civilian medical and surgical
teams, all members of philanthropic organisation, all members of
the Australian Forces Overseas Fund and all official entertainers
and war correspondents who saw service in Vietnam during the
period between 23 May 1962 and 1 July 1973
After consideration of all options, the Advisory Committee
decided that the study should survey all Vietnam veterans who
could be located. The Committee believed in important
for all veterans to have the opportunity to participate.
ESO advice was that this was the expectation of the veteran
community itself, and a full survey gave reasonable confidence of
detecting rare medical conditions. Once taken, the
decision to survey all locatable veterans meant that the survey
instrument would be a mailed-out, self-reporting
questionnaire. Three distinct questionnaires were developed
- male veteran; female veteran; and widow(er)s/divorced and
The Advisory Committee agreed that the study should be
conducted in three phases, with the need for Phases 2 and 3
dependant upon the outcome of Phase 1. The agreed Phases
Phase 1 - A mailed survey of all surviving Vietnam veterans
Phase 2 - Analysis of Phase 1, production of a report on the
outcome of Phase 1, and a decision on potential Phase 3 studies.
Phase 3 - Follow-on investigations if required, including the
possibility of interview of a representative sample of Vietnam
Study Strengths and Limitations
The design of the study engendered both strengths and
The limitations of the study design were:
- Self-reported data has been obtained and over-reporting,
under-reporting or mis-reporting is known to occur in
this type of data (for example, because of the use of
unfamiliar medical terminology).
- The size of the survey questionnaires encouraged
veterans to respond but limited the number and
specificity of questions.
- The survey lacked a comparable control group, that is, a
group of people of the same age and gender who did not
go to Vietnam, but who would have answered the same
questionnaire as the veterans surveyed. In its
place comparison was drawn by reference to community
data for those of comparable age, where such data was
- The effects of contributing life style factors and
experiences post-service could not be ascertained
without Phase 3 being implemented
- There was a lower return of completed questionnaires
from widow(er)s/divorced and separated partner(s), and
the data that was returned could not be merged with
that of the male veterans.
Nonetheless, the study design had considerable strengths:
- The survey was inclusive and afforded all veterans the
opportunity to participate
- The large number of participants gave the survey great
- The survey size allowed reasonable confidence of
detecting rare medical conditions.
- The study design was effective in that 79% of those who
received a questionnaire returned a completed
For ACNielsen Research Pty Ltd to conduct the mail-out survey,
the address of each veteran was sought by cross matching the
names on the Nominal Roll with the Electoral Rolls, and a copy of
the relevant questionnaire was posted to the address so
obtained. Cross matching was performed by the Australian
Institute of Health and Welfare (AIHW).
In total 51,753 questionnaires were posted, comprising 49,944
male Vietnam veterans, 278 female Vietnam veterans and 1,531
widows/divorced and separated partner(s) of Vietnam veterans.
Out of 49,944 male veterans to whom a questionnaire was
posted, 40,030 returned a completed questionnaire (80%).
Some 6,470 did not respond (13%), and 2,379 questionnaires were
returned to the sender (4.8%).
Widow(er)s/divorced and separated partner(s) questionnaires
could generally only be sent on request as limited address data
were held for this group. 1,531 questionnaires were posed,
691 completed questionnaires were returned (45.1%), 797
recipients did not respond (52.1%).
At the completion of the survey a telephone follow-up of
non-respondents was conducted. Having examined the data
obtained from non-respondents, ACNielsen concluded that the
results from the mail-out phase could be used with confidence,
and that non-respondents did not pose a significant bias problem.
Where practical, community data was obtained on the prevalence
of conditions surveyed in the questionnaires to allow comparison
of the veterans responses with the expected response from
Australians of a similar age.
The data obtained allowed comparisons to be made between the
reported prevalence of conditions (that is, number of veterans
reporting the condition) and the expected prevalence of the
condition in a community cohort of the same size as the veteran
cohort. Comparisons were presented only for those
conditions where reasonable comparable estimates of expected
community prevalence could be made.
The comparisons were not a complete literature review of all
material written about the conditions, nor did they provide
aetiological reasons for the findings. They were designed
to provide reasonable community comparisons, with brief
discussion as to why, methodologically, expected findings may
have differed from the reported findings. They were also
designed to allow conclusions to be drawn about what differences
were likely to be real and whether more detailed inquiry or
action was required.
Where possible, comparisons used Australian data.
However, Australian data is not available for all conditions
covered in the questionnaires and on occasions while available,
it was not collected in a fashion comparable to the veterans'
questionnaire. In these cases, data from international
sources has been used.
General Comment On Survey Findings
The findings from the male survey are summarised below.
This summary is the result of initial analysis. More
detailed analysis of the survey data to follow particular lines
of enquiry or to allow comparison of response between questions
of a like nature is feasible, but has not yet been undertaken
given the requirement to publish the initial data. Analysis
of this type, in selected areas, will form a part of the future
work on the study.
Self-Reported Medical History of the Veterans (Questionnaire
Parts A and E)
When asked to asses their health as excellent, very good,
good, fair or poor, (Question E1 of the survey), 5% of veterans
rated their health as excellent, 14% as very good, 29% as good,
34% as fair and 16% as poor. These ratings, when
compared to community expectations, show that veterans are three
times less likely to report their health as excellent. The
responses to this question are directly comparable with community
data. Data for this question and data from the community
were ascertained in a similar fashion.
The response to Question E1 reflects the higher than expected
reported prevalence for most of the conditions surveyed in Part A
of the questionnaire, which sought information on 43 specific
conditions. In particular in Part A, veterans indicated a
high and consistent (30% or greater) experience of mental health
conditions; panic attacks, anxiety disorder, depression and Post
Traumatic Stress Disorder. Further, 25% of veterans
reported that they had been diagnosed with a cancer of some
description since their first day of service in Vietnam.
The responses support the hypothesis that the general health
of Vietnam veterans is worse than that of Australians of a
comparable age. The responses are not inconsistent
with the hypothesis that the prevalence of cancer and some
specific disease conditions are are greater in Vietnam
veterans. Validation of the self-reported responses
to questions relating to cancers, multiple sclerosis and motor
neurone disease in recommended to establish unequivocal evidence
as to the prevalence these conditions. This evidence is
considered essential as the basis for further policy action and a
foundation of studies into causality.
While it would be advantageous to validate responses to other
conditions surveyed in Part A, as a general rule, such validation
is not recommended. Treatment, compensation and
counselling, if required, for the majority of the conditions
surveyed are readily available upon acceptance following
diagnosis. The survey results can thus be accepted as
indicative, and veterans reporting suffering these conditions
should be urged to seek entitlement to treatment and compensation
if they have not already done so.
Compensation in particular is governed by Statements of
Principles (SoPs) prepared for individual medical conditions by
the Repatriation Medical Authority (RMA). It is recommended
that the survey results be referred to the RMA, for particular
attention where SoPs may not exist or the factors within the SoP
are restrictive. Examples of the latter are noted in the
report and reflected in the recommendations stemming from the
survey. Likewise, it is recommended that the Department of
Veterans' Affairs uses the responses to Part A as a guide in
planning the coverage of treatment and counselling services, and
of preventive programs.
Current Marital Status (Questionnaire Part B)
Part B of the survey sought to ascertain the marital status of
veterans. Responses to this Part show that the current
marital status of male Vietnam veterans approximated that of the
Australian male population.
This finding refutes the hypothesis that the marital status of
these veterans is different to that of the general
population. The responses to Part B are reliable, in that
data from the survey and data from the community are considered
to be directly comparable.
Health of Partner(s) (Questionnaire Part C)
Part C of the questionnaire sought to ascertain the effect of
the health of veterans on the health of partners.
In Part C, 36% of veterans report that service in Vietnam, or
health problems arising as a consequence of their service in
Vietnam, have had a serious adverse effect on current or past
partners. Some 40% report physical or psychological health
problems in their partners that they feel may be related to the
veterans' Vietnam service. Stress (40%), anxiety (34%), and
depression in partners are the most commonly cited
conditions. Thirty nine percent (39%) of all veterans with
partners report that treatment has been required for these
conditions. Those with greater length of service in Vietnam
report higher levels of problems.
Community comparisons are not available for this data.
The responses themselves tend to support the hypothesis that the
health status of the veteran has an effect on the health status
of his immediate family. Responses to this Part should be
read alongside veterans' reports on themselves in Part
A. Here, relatively high general levels of problems,
particularly of psychological problems, are reported. These
could be expected to create stress on a partner. For
these reasons it is recommended that the level of resources
available for counselling on mental health conditions experienced
by veterans and their families be reviewed for adequacy.
Health of Children (Questionnaire Part D)
Part D of the survey sought responses in the areas of:
- Fertility and adverse pregnancy outcomes;
- Sight problems;
- Hearing/ear problems;
- Congenital abnormalities;
- Other major illnesses;
- Deaths; and
- Psychiatric disorders in the veterans' children.
Responses to these questions indicate a potentially serious
problem. The responses, particular the high reported rates
of suicide, congenital abnormalities and cancer in the children
of Vietnam veterans, suggest that the effects of Vietnam service
may extend to the children of Vietnam veterans.
Verification of the self-reported responses in these three areas
is recommended. The results, if confirmed, have
significant policy implications for veterans' welfare and that of
Congenital Abnormalities and Death of Children
Responses to these two Parts of the questionnaire potentially
constitute the most disturbing findings from the survey:
- Congenital Abnormalities. Depending
on the condition surveyed, congenital abnormalities
reported varied from three to eleven times the expected
- Deaths of Children. Deaths from suicide of
children were reported at three times the expected
rate, and deaths from accident or other causes were
reported at twice the expected rate.
The responses support the hypotheses that a greater level of
congenital abnormality and greater mortality rates are found in
the children of Vietnam veterans. The report notes
difficulties that may have affected the accuracy of reporting and
the accuracy of the comparison data.
Not withstanding these difficulties, the veterans' responses
raise major concerns about the health of veterans' children, and
thus the recommendation is made that the reported rates be
validated as a matter of urgency.
Responses were sought to three specific forms of cancer
(leukaemia, Wilms' tumour and cancer of the nervous system), in
veterans' children. An opportunity was also provided
to report other forms of cancer if suffered.
Incidence of 11, 7 and 18 per 10,000 children were reported for
leukaemia, Wilms' tumour and cancer of the nervous system
The reported incidence of cancers amongst the children of
veterans is higher than that expected. As previously
recognised, this is a worrying finding, one which lends support
to the hypothesis that greater rates of cancer are to be found in
the children of Vietnam veterans.
Because of the markedly higher rates reported, and the
possibility of mis-classification of specific forms of cancer,
the data should be validated. Validation would also be
useful as a foundation for future studies into causality.
Fertility and Adverse Pregnancy Outcomes
Responses to questions relating to fertility and adverse
pregnancy outcomes indicate that 21% of veterans had tried for
more than 12 months without success to conceive a child.
Some 22% of veterans' partners have had a miscarriage, 5% have
had a termination, and 5% of veterans had fathered a child that
A general lack of comparable data obtained in a similar
fashion to that in this survey means that firm conclusions from
the reported data cannot be drawn. From the comparative
data that is available, there is a suggestion of greater
difficulty of achieving conception in veterans and their
partners, but this is counterbalanced that the number of veterans
who had ever fathered children is not greatly different from that
expected by cross-reference to community data.
Other Specific Disease Conditions
8% of veterans report that at least one of their children has
suffered an eye condition not correctable by spectacle, and 10%
report long-term hearing or ear problems. Some 27% of
veterans indicate that a child has suffered a major
illness. In regard to mental health issues, 11% of children
are reported as having been diagnosed with a psychiatric problem
and 16% with an anxiety disorder.
The occurrence of sight and hearing problems in veterans'
children appears to be lower than the community expectation,
although the report notes difficulties with obtaining accurate
comparative data. For the other conditions, comparative
data is not available. Thus it is not possible to conclude
with any degree of certainly whether the prevalence of these
conditions in the children of Vietnam veterans is higher of lower
Several findings recommending validation or verification of
data that is currently self-reported are made in this
report. As noted, validation is seen as an essential tool
to remove the possibility of mis-classification of specific
conditions, to provide incontrovertible evidence as the basis for
future policy formulation and to provide a foundation for studies
It is recognised that validation may cause concern to veterans
and their families. There are sensitivities relating to
confidentiality, the possibility that families will be surveyed
more than once, and potential hostility to yet more
surveys. Because of these concerns, a single, integrated
validation exercise is recommended. Further, it is
recommended that appropriate levels of support are offered to
those undergoing validation. Such support could include a
needs assessment process, facilitating access to rehabilitation
services for affected veterans and their families, and
appropriate educational campaigns in the ex-service community
with the support of ESOs. A suggested protocol for
validation is being drawn up by the Advisory Committee and will
be forwarded separately to the Repatriation Commission and
Minister for Veterans' Affairs.
This survey was not designed to ascertain the causes of
medical conditions that Vietnam veterans or their families may be
experiencing. The proposed validation will not
identify causation. Validation is designed to confirm the
association between the identified condition and Vietnam
service. Confirmation would provide strong evidence
that there are causal agents arising from military service and in
particular Vietnam service that have had an adverse health effect
in Vietnam veterans and their families. A variety of
potential exposures could explain such health effects.
These include chemicals, stress, various infectious agents,
unknown agents, or such exposures in combination.
As a result of the outcomes of the male veteran survey the
following recommendations are made:
Male Vietnam Veterans
- It is recommended that the results obtained for the
following conditions reported by veterans be validated
as a matter of urgency:
- all cancers (with the exception of non-melanotic skin
- motor neurone disease; and
- multiple sclerosis.
- It is recommended that the Department of Veterans'
Affairs uses the responses to Part A and E of the
survey as a guide in planning the coverage of treatment
and counselling services, and of preventive programs.
- It is recommended that while recognising the importance
of PTSD, there be a broader diagnostic and treatment
focus on other common mental health conditions in
- It is recommended that the findings of the survey be
referred to the RMA for their consideration,
particularly in developing or amending SoPs relating
- panic attacks;
- anxiety disorders;
- high blood pressure;
- male breast cancer;
- cancer of the eye;
- psoriasis; and
- microtrauma in musculo-skeletal systems.
- It is recommended that DVA notify oncologists that
Vietnam veterans are an at risk group for strongyloides.
Children of Male Vietnam Veterans
- It is recommended that the responses which taken
together indicate an increased level on congenital
abnormalities in the children of veterans be validated
as a matter of urgency.
- It is recommended that the responses which taken
together indicate increased mortality rates in the
children of veterans be validated as a matter of
- It is recommended that the responses which indicate
increased rates of leukaemia, Wilms' tumour and cancer
of the nervous system in the children of veterans be
validated as a matter of urgency.
Male Vietnam Veterans and Families
- If validation confirms the survey findings, therapeutic
and preventive interventions to assist veterans and
their families are recommended as a matter of urgency.
- It is recommended that the level and type of treatment
resources available for counselling on mental health
conditions experienced by veterans and their families
be reviewed for adequacy.
- It is recommended that, if practical, a single
integrated validation exercise be undertaken and that
appropriate levels of support be offered to those
- It is recommended that the findings of the survey be
drawn to the attention of the Australian Defence Force
for use in the refinement of preventive measures.