Evidence of Greater Health Care Needs among Older Veterans of the Vietnam War

VOLUME 173 AUGUST 2008 NUMBER 8 ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required. MILITARY MEDICINE, 173, 8:715, 2008 Evidence of Greater Health Care Needs among Older Veterans of the Vietnam War LTC Matthew S. Brooks, MC USA*; Sarah B. Laditka, PhD ; James N. Laditka, PhD DA ABSTRACT This study examined self-rated health, impairments in activities of daily living, and treatment for eight health conditions among Vietnam War-era veterans, comparing those who served in Vietnam with those who served elsewhere. Data were from the nationally representative 2001 National Survey of Veterans (N 7,907; 3,923 veterans served in Vietnam). Age-stratified ( 60 years versus 60 years) analyses included multivariate logistic regression. In adjusted analyses, among those 60 years of age, those who served in Vietnam had notably poorer self-rated health and higher stroke risk (odds ratio, 1.51; 95% confidence interval, 1.48 1.53); odds of most other conditions were lower. Among those 60 years of age, those who served in Vietnam had poorer self-rated health, higher cancer risk (odds ratio, 1.33; 95% confidence interval, 1.32 1.35), and more treatment for hypertension, lung conditions, stroke, and hearing loss. Results suggest greater resource use among older veterans who served in Vietnam. Clinicians and the Department of Veterans Affairs should especially note their substantially higher cancer risk. INTRODUCTION Approximately 8.4 million veterans, representing nearly 32% of all veterans, served during the Vietnam War, making this the largest cohort of living U.S. veterans. 1 Of these, 2.6 million served in Vietnam. 1 As of 2007, approximately onehalf of Vietnam War veterans were approaching age 65. Given the aging of the Vietnam War-era cohort, it is useful to better understand the long-term effects of military service on health status. A better understanding of the health of Vietnam War veterans is useful from a budgetary perspective; in 2006, the Department of Veterans Affairs (VA) medical services expenditures totaled $31.7 billion, with $7.37 billion for acute hospital care and $11.6 billion for outpatient care. 2 In addition to these costs, 2006 Medicare and Medicaid longterm care expenditures for Vietnam War veterans were nearly $4 billion. 2 *U.S. Army-Baylor Graduate Program in Health and Business Administration, Fort Sam Houston, TX 78234. Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223. This manuscript was received for review in October 2007. The revised manuscript was accepted for publication in May 2008. Reprint & Copyright by Association of Military Surgeons of U.S., 2008. A number of studies of Vietnam War veterans found a strong relationship between post-traumatic stress disorder (PTSD) and poorer self-reported health. 3 10 Most of those studies used data from the National Vietnam Veterans Readjustment Study or the Centers for Disease Control and Prevention Vietnam Experience Study, both of which were conducted in the middle 1980s. A study of twins, in which one twin served in Vietnam and the other served elsewhere during the Vietnam War era, found higher odds of having hearing problems, skin conditions, and stomach conditions for the twin who served in Vietnam. 11 Vietnam War-era veterans reported more difficulty with activities of daily living (ADLs) than did any other veteran cohort, including the much older World War II veterans. 12 Use of dioxins in Vietnam has been implicated in longterm negative health effects for Vietnam War veterans. 13,14 In the 1990 report by ADM Elmo Russell Zumwalt to Congress on the effects of Agent Orange, the list of diseases associated with this mixture of chemicals included cancers, skin disorders, liver disorders, neurological defects, autoimmune diseases, gastrointestinal diseases, and other diseases and disorders. 13 Studies analyzed the population most at risk for dioxin exposure, that is, service members who were involved in the preparation and MILITARY MEDICINE, Vol. 173, August 2008 715

application of dioxins. 13 15 Many of those studies found links to physical health effects from exposure. The primary results showed links to melanoma, prostate cancer, diabetes mellitus, heart disease, hypertension, respiratory disease, and non- Hodgkin s lymphoma. 13 15 Studies using data from the National Vietnam Veterans Readjustment Study and the Vietnam Experience Study showed that Vietnam War veterans have poorer self-rated health 3,7,9,16 and more ADL impairments than do other cohorts 7,12 and they have many chronic health conditions associated with their service. 8,11,15 18 By using a nationally representative survey of noninstitutionalized U.S. Vietnam War-era veterans, that is, the National Survey of Veterans (NSV), which was conducted in 2001 (28 years after the end of the Vietnam War and 15 years after the National Vietnam Veterans Readjustment Study and Vietnam Experience Study), we examined a number of health status measures of veterans who served during the Vietnam War, comparing those who served in Vietnam and those who served elsewhere. To our knowledge, ours is the first study to use the 2001 NSV to examine the health status of Vietnam War-era veterans with respect to these measures. The timing of the 2001 NSV allowed us to examine health status among middle-aged and older veterans. The NSV included sociodemographic and other service-related measures that allowed us to examine health effects of Vietnam service other than those that might be directly attributable to service-related disability, service-related environmental exposure, or treatment for PTSD. Building on previous studies of long-term health effects of military service in the Vietnam War era, our objectives were to examine (1) self-reported perceived health, (2) limitations in ADLs, and (3) treatment for eight chronic health conditions. We examined long-term health effects of military service during the Vietnam War, comparing health outcomes for veterans who served in Vietnam and those who served elsewhere. Based on previous studies, we hypothesized that those who served in Vietnam would report poorer selfperceived health, greater impairment, and more treatment for chronic health conditions than those who served elsewhere. METHODS Study Sample Data were from the 2001 NSV, conducted by the VA. 19 The survey is nationally representative of noninstitutionalized veterans living in the continental United States. The analytic sample identified veterans in any service during the Vietnam War era, from August 1964 to May 1975. The sample included 3,923 veterans who served in Vietnam and 3,984 who served elsewhere. Service in Vietnam was used in lieu of actual combat experience because those in Vietnam who were not in combat often experienced combat-related trauma. 2,4,5,20,21 Furthermore, there is evidence of notable reporting error when individuals are interviewed about combat experiences. 6 To investigate age differences in health status, the sample was stratified into two age categories, namely, veterans 60 years of age at the time of the survey (n 6,141) and those 60 years of age (n 1,766). Among those who did not serve in Vietnam in the 60-year age group, 19% served in Germany, 35% in Asia, and 38% in the United States; among those 60 years of age, 17% served in Germany, 54% in Asia, and 25% in the United States. Dependent Variables: Health Measures Self-perceived health was a dummy variable indicating veterans who reported that their health was excellent, very good, or good, compared with fair or poor. Another dummy variable indicated those who had difficulty performing three or more ADLs. To obtain information about chronic health conditions, veterans were asked, In the past year, have you received medical treatment for high blood pressure, lung trouble, a hearing condition that requires a hearing aid, cancer, heart trouble, stroke, rheumatism or arthritis, or diabetes requiring insulin or diet treatment? For each of these eight conditions, we created a dummy variable indicating those with the condition. Exposure Variable The exposure variable identified whether each veteran served in Vietnam or elsewhere. Independent Variables A number of independent variables included in the multivariate models controlled for potential confounding. These variables represented factors that were associated with health status in previous research, 3 7,11,22 including respondents gender, age in years, and number of dependents. Separate dummy variables indicated respondents who identified themselves as African American; Hispanic; American Indian; Asian, Native Hawaiian, or Pacific Islander; or non-hispanic Caucasian. Another dummy variable indicated the small number of respondents who reported another race or ethnicity or two or more. Education was categorized to indicate high school education or less, some college or vocational training, or a master s or professional degree. Marital status was coded as married or not married; the latter category included those who were divorced, widowed, or separated and those who had never married. Income was categorized as less than $24,999, $25,000 to $49,999, $50,000 to $74,999, or $75,000 or more. The number of weeks worked in the previous year was categorized as full-time, part-time, or not working. Another variable indicated individuals covered by Medicare, Medicaid, TRICARE (health care insurance for active military personnel and veterans), or private insurance; all others were considered to be uninsured. Self-reports of serviceconnected disability were indicated by a dummy variable. Another variable indicated self-reports of having ever been exposed to environmental hazards, categorized as exposed, not exposed, or a response of do not know. A dummy variable indicated those who reported having received treatment for PTSD in the 12 months preceding the survey. 716 MILITARY MEDICINE, Vol. 173, August 2008

Covariates differed among the models in two instances. For the model predicting self-perceived health, self-perceived health was not included as a covariate. For the model predicting ADL impairment, the covariates representing arthritis/rheumatism, ADL impairment, and service-connected disability were not included. Statistical Analyses For bivariate analyses, the 2 test was used for categorical variables and the t test for continuous variables, to compare characteristics of those who served in Vietnam and those who served elsewhere. All analyses were weighted to be nationally representative of non-institutionalized U.S. Vietnam War veterans. For each dependent variable, first the unadjusted association with Vietnam service was estimated, and then we estimated separate adjusted logistic regression models. Variance tolerance tests suggested that multicolinearity did not affect the models notably. Analyses used SAS 9.1 software (SAS Institute, Cary, North Carolina). RESULTS Sociodemographic Characteristics Respondent characteristics are reported in Table I, stratified according to age at the time of the survey ( 60 or 60 years), for those who served in Vietnam and those who served elsewhere. The results are shown unweighted, with weighted percentages in parentheses. We focus on results that were both statistically and substantively significant. In both age groups, veterans who served in Vietnam, compared with those who served elsewhere, were substantially more likely to report being exposed to environmental hazards (for those 60 years of age, 49.5% versus 15.2%; for those 60 years of age, 50.4% versus 14.7%; both p 0.0001), being treated for PTSD (for those 60 years of age, 12.2% versus 3%; for those 60 years of age, 4.5% versus 1.6%; both p 0.0001), and having a service-related disability (for those 60 years of age, 21.6% versus 12.6%; for those 60 years of age, 37.6% versus 17.6%; both p 0.0001). Unadjusted Health Measures Table II reports the numbers and weighted percentages for the health measures, stratified for the two age groups, for those who served in Vietnam and those who served elsewhere. For those in the younger age group, veterans who served in Vietnam, compared with those who served elsewhere, were less likely to report excellent, very good, or good self-perceived health (p 0.0001), more likely to report ADL impairments (p 0.0001), and more likely to report receiving treatment for seven of the eight health conditions (all p 0.001). Among older veterans, veterans who served in Vietnam, compared with those who served elsewhere, were more likely to report ADL impairments (p 0.0056) and more likely to report receiving treatment for three of the eight health conditions (all p 0.01). Adjusted Health Measures Table III shows adjusted odds ratios (ORs) and 95% confidence intervals (CIs) associated with the exposure variable for each of the dependent variables, for veterans in the two age groups. Covariates representing almost all of the control variables (not shown in Table III) were statistically significant in all of the models, for both age groups. Among those 60 years of age, those who served in Vietnam were less likely to report excellent, very good, or good self-perceived health (OR, 0.85; 95% CI, 0.85 0.85) and were more likely to report receiving treatment for a stroke (OR, 1.51; 95% CI, 1.48 1.53). However, they were less likely to report ADL impairment or having received treatment for five of the health conditions (all p 0.0001). In the older age group, veterans who served in Vietnam, compared with veterans who served elsewhere, had lower odds of excellent, very good, or good self-perceived health (OR, 0.93; 95% CI, 0.92 0.94) and were more likely to report receiving treatment for high blood pressure, lung conditions, cancer, or stroke or having a hearing aid (all p 0.0001). Their greater risk for treatment for cancer was particularly notable (OR, 1.33; 95% CI, 1.32 1.35). They were also notably less likely to report receiving treatment for heart conditions (OR, 0.80; 95% CI, 0.80 0.81). DISCUSSION Ours is the first study to use the 2001 NSV to examine differences in health status between those who served in Vietnam and those who served elsewhere, using national data representing Vietnam War-era veterans 28 years after the end of the Vietnam War. Our first expectation, that those who served in Vietnam would report poorer self-perceived health than those who served elsewhere, was supported in both age groups. This result is consistent with previous studies of Vietnam War veterans and veterans of other wars. 3 5,7,9,10,22,23 Our second hypothesis, that veterans who served in Vietnam would be more likely to report substantial ADL impairments than those who served elsewhere, was not supported in the multivariate analyses. For veterans 60 years of age, there was little evidence to support our third expectation, that veterans who served in Vietnam would be more likely to be treated for chronic health conditions. One notable exception to that result was stroke; the odds that veterans who served in Vietnam would report having been treated for stroke were 51% greater than the corresponding odds for those who served elsewhere. Among veterans 60 years of age, those who served in Vietnam were more likely to report chronic conditions, with more reports for six of the eight conditions. Particularly notable for older veterans was the result for cancer, for which the adjusted odds for veterans who served in Vietnam exceeded the corresponding odds for those who served elsewhere by 33%. Collectively, the results provide evidence that, among veterans who served during the Vietnam War, health status may be worse for those who served in Vietnam, particularly among older veterans. This suggests MILITARY MEDICINE, Vol. 173, August 2008 717

that there may be substantially greater needs for health care and other services for the 2.6 million veterans who served in Vietnam as they age. Several factors should be considered when these results are evaluated. Consistent with many previous studies, the data were based on retrospective self-reports. 3,4,7,9 11,22 The data did not allow us to control for health risk factors that might have been present before military service. Because all respondents served in the military, however, we assume that most were in reasonably good health at the beginning of their service. This assumption is reasonable because military induction standards are rigorous and consistent, allowing control for a healthy worker effect. Recruits are extensively screened for health status. The presence of health conditions TABLE I. Veteran Characteristics Bivariate Comparisons of Vietnam War-Era Veterans Who and Veterans Who, According to Age Group (n 2,961) (n 3,180) p (n 962) (n 804) p Age, mean SD (years) 53.97 2.74 52.16 4.04 0.0001 66.99 5.57 67.10 6.83 0.0001 Gender, male/female, n 2,944/17 2,970/210 0.0001 952/10 783/21 0.0122 Educational attainment, n (%) High school or less 1,124 (36.04) 1,027 (33.08) 0.0001 272 (31.02) 280 (36.50) 0.0031 Bachelor s degree or 1,551 (54.85) 1,783 (56.87) 0.0037 521 (51.33) 401 (48.25) 0.0728 vocational training after high school Master s degree or 286 (9.10) 370 (10.05) 0.0122 169 (17.65) 123 (15.25) 0.2012 professional degree Family relationships, n (%) Married 2,222 (77.65) 2,418 (77.41) 0.3644 841 (87.87) 679 (85.77) 0.0727 Divorced, widowed, or 583 (17.91) 550 (17.23) 0.0157 95 (9.16) 90 (9.42) 0.3675 separated Never married 156 (4.44) 212 (5.36) 0.0211 26 (2.97) 35 (4.81) 0.0586 Racial background/ethnicity, n (%) Caucasian 2,476 (86.17) 2,663 (86.23) 0.8974 815 (87.14) 707 (88.60) 0.0511 African American 307 (8.62) 338 (9.60) 0.7391 100 (9.17) 67 (8.24) 0.1403 Alaskan/American Indian 185 (3.42) 152 (2.85) 0.0116 46 (2.91) 30 (2.01) 0.2787 Asian/Hawaiian/Pacific 32 (0.94) 35 (0.71) 0.9402 18 (1.72) 6 (0.55) 0.0420 Islander 2 or other 23 (0.54) 22 (0.44) 0.6966 10 (0.52) 3 (0.29) 0.1028 No race data provided 23 (0.88) 31 (0.64) 0.4061 8 (0.84) 11 (1.59) 0.2764 Hispanic ethnicity 97 (3.34) 86 (2.86) 0.1881 17 (1.35) 13 (1.15) 0.8078 Occupational status, n (%) Income of $0 to $24,999 511 (12.36) 484 (12.35) 0.0304 123 (11.29) 105 (10.79) 0.8643 Income of $25,000 to 735 (21.91) 693 (20.88) 0.0050 276 (27.05) 225 (26.46) 0.7934 $49,000 Income of $50,000 to 601 (23.89) 682 (23.67) 0.2683 179 (18.62) 148 (20.68) 0.9146 $74,999 Income of at least $75,000 594 (24.01) 733 (25.41) 0.0045 145 (18.80) 118 (17.44) 0.8159 Income data missing 520 (17.85) 588 (17.69) 0.3442 239 (24.24) 208 (25.64) 0.6212 Working full time 1,703 (66.94) 1,994 (68.45) 0.0001 238 (30.21) 258 (41.74) 0.0006 Working part time 550 (17.94) 612 (19.25) 0.5027 158 (16.66) 119 (16.47) 0.3503 Not working 708 (15.12) 574 (12.30) 0.0001 566 (53.13) 427 (41.79) 0.0157 Physical health status, n (%) Self-perceived health good, 1,762 (71.76) 2,328 (81.03) 0.0001 581 (66.99) 530 (74.39) 0.0167 very good, or excellent 3 ADL impairments 518 (11.05) 435 (8.60) 0.0001 161 (10.77) 97 (6.84) 0.0056 Service-connected 1,253 (21.55) 976 (12.64) 0.0001 608 (37.61) 342 (17.61) 0.0001 disability Environmental hazards, n (%) Exposed 1,804 (49.49) 576 (15.21) 0.0001 561 (50.41) 150 (14.65) 0.0001 Not exposed 691 (31.76) 2,347 (77.53) 0.0001 268 (35.31) 601 (79.03) 0.0001 Do not know 466 (18.74) 257 (7.26) 0.0001 133 (14.28) 53 (6.32) 0.0001 Has medical insurance, n (%) 2,320 (82.29) 2,652 (85.49) 0.0001 914 (95.40) 739 (92.42) 0.0081 Treated for PTSD, n (%) 638 (12.21) 166 (3.00) 0.0001 75 (4.50) 24 (1.64) 0.0001 Data are from the 2001 NSV. All percentages are weighted for national representativeness. 718 MILITARY MEDICINE, Vol. 173, August 2008

TABLE II. Unadjusted Results of Logistic Regression Analysis Predicting Physical Health Outcomes for Veterans Who Served in Vietnam, Compared with Veterans Who, According to Age Group (n 2,961) (n 3,180) p such as those included in this study, or a history of them, would be disqualifying. The disqualifying list is extensive. 23,24 Similar exclusion criteria applied to both enlisted personnel and draftees throughout the Vietnam War and are consistent with the standards used today. 23,24 Selective death and institutionalization of those in poorest health are challenges to all research on the long-term health effects of military service that is based on surveys of community-dwelling veterans. Previous research showed that Vietnam War-era veterans have PTSD at high rates, and this condition has been linked to early death 6 and poorer health No. (%) (n 962) (n 804) p Veteran Characteristics Physical health status Self-perceived health good, 1,762 (71.76) 2,328 (81.03) 0.0001 581 (66.99) 530 (74.39) 0.0167 very good, or excellent 3 ADL impairments 518 (11.05) 435 (8.60) 0.0001 161 (10.77) 97 (6.84) 0.0056 Treatment for High blood pressure 1,145 (33.66) 1,004 (28.03) 0.0001 546 (53.51) 403 (46.84) 0.0060 Lung conditions 344 (9.21) 288 (7.31) 0.0009 158 (13.46) 108 (8.55) 0.0785 Hearing loss 267 (6.27) 147 (3.44) 0.0001 218 (15.69) 134 (10.39) 0.0018 Cancer 168 (4.71) 139 (3.41) 0.0190 157 (13.53) 99 (8.86) 0.0188 Heart conditions 476 (11.90) 356 (8.65) 0.0001 277 (24.35) 207 (22.03) 0.1540 Stroke 90 (1.96) 54 (1.21) 0.0005 50 (4.84) 43 (4.16) 0.8958 Rheumatism/arthritis 1,040 (28.07) 880 (22.45) 0.0001 438 (35.28) 304 (29.70) 0.0013 Diabetes mellitus 401 (10.79) 305 (8.19) 0.0001 211 (20.21) 160 (15.14) 0.2911 Data are from the 2001 NSV. Percentages are weighted. TABLE III. Adjusted Results of Logistic Regression Analysis Predicting Physical Health Outcomes for Veterans Who Served in Vietnam, Compared with Veterans Who, According to Age Group OR (95% CI) Outcome Variables Physical health status Self-perceived health 0.85 (0.84 0.86) 0.93 (0.92 0.94) good, very good, or excellent 3 ADL impairments 0.77 (0.76 0.77) 0.87 (0.86 0.88) Treatment for High blood pressure 1.00 (0.99 1.00) 1.13 (1.12 1.14) Lung conditions 0.79 (0.79 0.80) 1.16 (1.14 1.17) Hearing loss 0.88 (0.88 0.89) 1.07 (1.05 1.08) Cancer 0.83 (0.83 0.84) 1.33 (1.32 1.35) Heart conditions 0.91 (0.91 0.92) 0.80 (0.80 0.81) Stroke 1.51 (1.48 1.53) 1.13 (1.11 1.15) Rheumatism/arthritis 0.92 (0.92 0.93) 0.95 (0.94 0.96) Diabetes mellitus 0.99 (0.99 1.00) 1.03 (1.02 1.04) Data are from the 2001 NSV. Results were adjusted for age, gender, race, ethnicity, education level, service-connected disability status, employment status, income level, marital status, insurance status, self-rated health, ADL impairments, environmental exposures, and PTSD treatment. outcomes. 15 17 It is likely that any bias introduced by these factors would attenuate the estimates toward zero, reducing the estimated difference between those who served in Vietnam and those who served elsewhere. In addition, the data were crosssectional and did not provide a basis for causal inferences. The data did not allow us to account for effects associated with respondents ranks or military specialties. This omission is a potential limitation. Research has found, however, that those who served in Vietnam are at greater risk of poor health than those who served elsewhere regardless of rank. 25 Furthermore, the military rank structure is fixed, based on unit authorizations, and the enlisted personnel/officer ratio tends to be constant over time. This ratio would be seen regardless of whether a unit served in Vietnam or elsewhere, as well as in most units rotated in for a tour of duty. 25 In addition, the mixture of occupational specialties in units serving in Vietnam would be nearly identical to that in units serving elsewhere. For example, an infantry battalion in Vietnam would have the same number of soldiers in various military occupational specialties as one stationed in Germany or elsewhere. 25 The findings of this study provide evidence that older veterans who served in Vietnam may be notably more likely to receive treatment for chronic health conditions and to report poorer self-perceived health than those who served elsewhere during the same period. Among younger veterans, those who served in Vietnam, compared with those who served elsewhere, had poorer self-perceived health and were notably more likely to be treated for stroke. As Vietnam War veterans experience retirement, declines in health associated with aging, and the deaths of spouses or other family members or friends, such events may exacerbate problems of poor health associated with military service. 26,27 Research has also shown that publicity about current military operations, such as the Iraq War, may trigger physical symptoms among Vietnam War-era veterans. 28 MILITARY MEDICINE, Vol. 173, August 2008 719

As these Vietnam War veterans become eligible for Medicare, which for average veterans occurred in 2007, they bring a large demand for services, requiring health care in both VA and non-va settings. From the perspective of clinicians, these findings highlight the importance of inquiring about military service as one means to screen for health problems and to provide treatment. The lessons learned from these veterans experiences may apply to veterans in the conflicts in Iraq and Afghanistan. There have been major advances in medical care, as well as in the speed of treatment for those severely injured in combat areas. The survival rate for those with serious injuries is markedly higher for those serving in Iraq and Afghanistan than for those in previous conflicts. 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