for WIZARD KIM: Review Paper—Topic Proposal & Reference Page

Why old soldiers cannot be allowed to simply fade away: life course epidemiology of war Rosalind J Wright

Ikin and colleagues’1 research findings published in this issue of JECH demon- strate all too clearly why old soldiers cannot be allowed to simply fade away (see page 359). As these authors sum- marise in their introduction, the public health literature has increasingly docu- mented both the short- and long-term effects of war on mental and physical disorders in military veterans. Their cur- rent work highlights how the impact of war may be even greater when health is not defined as merely the absence of disease. This is reflected through the World Health Organization (WHO) defi- nition of health as a state of complete physical, mental, social and spiritual well- being. These investigators studied a sam- ple of 6062 living veterans (aged 65 years and older) of the Korean War in Australia compared to 1506 similarly aged Australian men who did not serve in the conflict. Elderly Korean War veterans reported significantly lower life satisfac- tion and quality of life compared to their civilian counterparts some five decades after military service. Those with increas- ingly severe combat exposure were most greatly affected. Military service was associated with veterans’ adverse ratings on multiple domains of the quality of life scale (eg physical health, psychological health, social relationships and environ- ment domains).

The longer term influence of traumatic experiences, including war-related events, may best be understood through the lasting psychological sequelae that may result. Because war-related experiences are outside the range of usual human experi- ence and almost universally distressful, they are more likely to lead to persistent psychological co-morbidities including depression, anxiety, and post-traumatic stress disorder (PTSD). Although such emotional states may represent adaptive functioning in the face of trauma in the

shorter run, they may exact a toll on mental health and social functioning for years to come. Moreover, in addition to having significant psychological impact, war-related trauma may result in physio- logical alterations that lead to even broader health effects (eg cardiovascular and respiratory disorders, cognition), a notion grounded in traumatic stress the- ory.2 3 That is, stressors are thought to influence the pathogenesis of disease by causing negative affective states (eg anxi- ety, depression, and PTSD), which in turn exert effects on biological processes or behavioural patterns that influence dis- ease risk. Although an individual’s reac- tion to trauma is multifaceted and associated with a range of psychological and behavioural sequelae, in the context of extreme events (eg war) distress symp- toms associated with PTSD (eg chronic re- experiencing of the trauma) have been most widely studied. In turn, PTSD has been linked to disruption of stress path- ways even several years following the experienced trauma,4 as well as being linked prospectively to increased mortal- ity,5 chronic disease risk,6 and disruption of a broad range of life-functioning domains including family and other social relationships.7

The potential public health impact is extraordinary when one considers over- lapping research demonstrating how past military experiences shape not only the life course of aging veterans, but also their families.8–11 This includes transgenera- tional effects on their children who may never themselves experience war directly.12 Evidence demonstrates that war-related transgenerational influences may result indirectly through disruption of parental and family functioning12 and attachment disorders.13 Offspring of mothers who have experienced war may be even more directly impacted. Infants of mothers who have prenatally pro- grammed biobehavioural sequelae from even remote stress (ie war-related events) may inherit biological vulnerabilities that alter their own reactivity to subsequent challenges as they grow up,14 putting

them at increased risk for psychological, behavioural and physical sequelae from the time of birth. Likewise, non-optimal early childhood environments and care- giving experiences (eg parental psycho- pathology or substance abuse, parental insensitivity) may impact these processes. Specifically, perinatal maternal–child interactions may disrupt infant emotion regulation and neuroimmune develop- ment, setting the stage for altered reactiv- ity throughout their life course. As more women serve in the armed forces across the globe, these effects cannot be ignored.

The application of a life course approach to epidemiological research examining the health effects of war promises to more clearly delineate the full scope of the hazards of war.9 How past military experiences shape the life course of aging veterans and their families is of particular public health import given that future generations continue to be put at similar risk. To date, more than 1.4 million American serviceman and women have been deployed to operations in and around Iraq and Afghanistan. Projected medical costs for US veterans of the wars of Iraq and Afghanistan range from $350 billion to $600 billion over the next 40 years.15 The adverse health consequences are projected to be even more substantial given the significantly longer length of soldier’s deployments, repeat deploy- ments and heavier exposure to combat. Moreover, many more soldiers are surviv- ing high-level injuries given advances in trauma medicine (ie a ratio of 16 wounded servicemen for every fatality as compared to 2.6 and 2.8 for the Vietnam and Korean wars respectively).15 The implication for the ongoing health and wellbeing of their spouses and families is not even factored into the existing esti- mates but must be accounted for in public health research, healthcare delivery and interventions going forward.10 11 16 In addi- tion, contemporary warfare and political violence increasingly involves civilian populations, which expands the scope of public health concern beyond soldiers.3 17

The public health impact of war is daunting given documented impact on the perpetrators, victims, families, and the societies in which it is embedded lasting long beyond the actual events. While public health research always has as its goal to inform prevention and interven- tion strategies to protect the public’s health, we are even more obligated to heed these findings as a final salute to the aging veterans’ service to his/her country- men and fellow human beings. Perhaps

Correspondence to: Rosalind J Wright, Channing Laboratory, Harvard Medical School, 181 Longwood Avenue, Boston MA 02115, USA; rerjw@channing. harvard.edu

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338 J Epidemiol Community Health May 2009 Vol 63 No 5

most importantly, documentation of the costly, broad and long-lasting effects of war should highlight the need to prevent future armed combat.

Competing interests: None declared.

J Epidemiol Community Health 2009;63:338–339. doi:10.1136/jech.2008.083741

REFERENCES 1. Ikin JF, Sim MR, KcKenzie DP, et al. Life satisfaction

and quality in Korean War veterans five decades after the war. J Epidemiol Comm Health in press.

2. Christopher M. A broader view of trauma: a biopsychosocial-evolutionary view of the role of the traumatic stress response in the emergence of pathology and/or growth. Clin Psychol Rev 2004;4:75–98.

3. Pederson D. Political violence, ethnic conflict, and contemporary wars: Broad implications for health and social well-being. Soc Sci Med 2002;55:175–90.

4. Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull 2006;132:959–92.

5. Johnson DR, Fontana A, Lubin H, et al. Long-term course of treatment-seeking Vietnam veterans with

posttraumatic stress disorder: Mortality, clinical condition, and life satisfaction. J Nervous Mental Dis 2004;192:35–41.

6. Kubzansky L, Koenan KC, Spiro A, et al. Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study. Arch Gen Psych 2007;64:109–16.

7. Koenan KC, Stellman SD, Sommer JFJ, et al. Persisting posttraumatic stress disorder symptoms and their relationship to functioning in Vietnam veterans: a 14-year follow-up. J Traumatic Stress 2008;21:49–57.

8. Parker MW, Fuller GF, Koenig HG, et al. Soldier and family wellness across the life course: a developmental model of successful aging, spirituality, and health promotion, Part II. Military Med 2001;166:561–70.

9. Parker MW, Fuller GF, Koenig HG, et al. Soldier and family wellness across the life course: a developmental model of successful aging, spirituality, and health promotion. Part I. Military Med 2001;166:485–9.

10. Peach HG. Further support for the families of Australia’s war veterans requires a broad research strategy. Med J Australia 2005;183:147–50.

11. Weingarten K. Witnessing the effects of political violence in families: mechanisms of intergenerational

transmission and clinical interventions J Marital Fam Ther 2004;30:45–59.

12. Davidson AC, Mellor DJ. The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma? Aus New Zealand J Psych 2001;35:345–51.

13. Rusby JS, Tasker F. Childhood temporary separation: long-term effects of the British evacuation of children during World War 2 on older adults’ attachment styles. Attachment Human Dev 2008;10:207–21.

14. Yehuda R, Bierer LM. Transgenerational transmission of cortisol and PTSD risk. Prog Brain Res 2008;167:121–34.

15. Bilmes L. Soldiers returning from Iraq and Afghanistan: The long-term costs of providing veterans medical care and disability benefits. Faculty Research Working Papers. Boston John F. Kennedy School of Government, Harvard University 2007.

16. Jackonis MJ, Deyton L, Hess WJ. War, its aftermath, and U.S. health policy: Toward a comprehensive health program for America’s military personnel, veterans, and their families. J Law Med Ethics 2008;36:677–89.

17. Johnson H, Thompson A. The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Clinical Psychol Rev 2008;28:36–47.

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Editorial

J Epidemiol Community Health May 2009 Vol 63 No 5 339