1 15 22 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2069 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-04-01 Title A name given to the resource Australian and American Newspaper Clippings on attitudes towards veterans and ten year anniversary of war's end, April 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2070 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-05-01 Title A name given to the resource Australian and American Newspaper Clippings on attitudes towards veterans and ten year anniversary of war's end, May 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2071 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-05-01 Title A name given to the resource Australian and American Newspaper Clippings on veteran lifestyle and ten year anniversary of war's end, May 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 079 Folder The folder containing the original item. 2054 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1984 Title A name given to the resource Australian Newspaper Clippings on Australian Royal Commission Hearings, February, March, and September 1984. Subject The topic of the resource Australian Royal Commission Hearings popular press veteran psychological health veteran health and hygiene ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 070 Folder The folder containing the original item. 1888 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Kameron, A. J. Description An account of the resource Corporate Author: W. D. Scott and Company Date A point or period of time associated with an event in the lifecycle of the resource 1981-04-01 Title A name given to the resource Australian Veterans Herbicide Studies: Overview of the Proposed Studies on the Effects of Exposure to Herbicides on the Health of Australian Vietnam War Veterans Subject The topic of the resource AVHS study protocol congenital birth defects veteran psychological health ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 072 Folder The folder containing the original item. 1912 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Lindley, Forrest, Jr. Source A related resource from which the described resource is derived The Stars and Stripes - The National Tribune Date A point or period of time associated with an event in the lifecycle of the resource May 6 1982 Title A name given to the resource Australian Vets Visit States Subject The topic of the resource veteran health and hygiene veteran psychological health ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1800 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clippings: USA Today - The Nation's Newspaper - Gives Its Op-Ed Page to Vietnam Trauma, September 1, 1983 Subject The topic of the resource veteran psychological health public opinion popular press ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 038 Folder The folder containing the original item. 0834 Series The series number of the original item. Series III Subseries I Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Korgeski, Gregory P. Gloria R. Leon Source A related resource from which the described resource is derived American Journal of Psychiatry Date A point or period of time associated with an event in the lifecycle of the resource 1983-11-01 Title A name given to the resource Correlates of Self-Reported and Objectively Determined Exposure to Agent Orange Subject The topic of the resource dioxin human exposure veteran psychological health veteran health and hygiene ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 054 Folder The folder containing the original item. 1418 Series The series number of the original item. Series III Subseries II Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Hearst, Norman Thomas B. Newman Stephen B. Hulley Source A related resource from which the described resource is derived The New England Journal of Medicine Date A point or period of time associated with an event in the lifecycle of the resource March 6 1986 Title A name given to the resource Delayed Effects of the Military Draft on Mortality: A Randomized Natural Experiment Subject The topic of the resource veteran health and hygiene veteran psychological health ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/c846a4bf774c356f6f5a1fe329c688c6.pdf ff42ea3db1e2d641de5746de90cdded7 PDF Text Text Item ID Number 01747 Author Corporate Author Center for Environmental Health and Injury Control, CD Roport/Articlo TltlO Health Status of Vietnam Veterans, I. Pyschological Characteristics, The Center for Disease Control Vietnam Experience Study Journal/Book Title JAMA Year 1988 Month/Day Ma 13 Color ^ Numboronmagos 7 v Descrmtoii Notes Monday, June 11, 2001 Page 1748 of 1793 �Reprinted from JAMA *• The Journal of the American Medical Association May 13, 1988, Volume 259 Copyright 1988, American Medical Association Original Contributions Health Status of Vietnam Veterans I. Psychosocial Characteristics The Centers for Disease Control Vietnam Experience Study The Vietnam Experience Study was a multidimensional assessment of the health of Vietnam veterans. From a random sample of enlisted men who entered the US Army from 1965 to 1971,7924 Vietnam and 7364 non-Vietnam veterans participated in a telephone interview; a random subsample of 2490 Vietnam and 1972 non-Vietnam veterans also underwent a comprehensive health examination, including a psychological evaluation. At the time of the study, the two groups of veterans were similar in terms of level of education, employment, income, marital status, and satisfaction with personal relationships. Certain psychological problems, however, were significantly more prevalent among Vietnam veterans than among non-Vietnam veterans. These included depression (4.5% of Vietnam veterans vs 2.3% of non-Vietnam veterans), anxiety (4.9% vs 3.2%), and alcohol abuse or dependence (13.7% vs 9.2%). About 15% of Vietnam veterans experienced combat-related posttraumatic stress disorder at some time during or after military service, and 2.2% had the disorder during the month before the examination. (JAMA 1988;259:2701-2707) MANY veterans are concerned that military service in Vietnam may have adversely affected their health and, perhaps, that of their children. Little objective evidence has been available, See also pp 2708 and 2715. as yet, regarding Vietnam veterans' health compared with that of other veterans of similar age and background. To address these concerns, Congress directed that appropriate epidemiologic studies be conducted (Veterans Health Programs Extension and Improvement From the Center for Environmental Health and Injury Control, Centers for Disease Control, Public Health Service, Department of Health and Human Services, Atlanta. Reprint requests to Centers for Disease Control, 1600 Clifton Rd (F-16), Atlanta, GA 30333 (Frank DeStefano, MD). JAMA, May 13, 1988—Vol 259, No. 18 Act of 1979, Public Law 96-151 [HR 3892], 93 STAT 1092-1098; and Veterans' Health Care, Training, and Small Business Loan Act of 1981, Public Law 97-72 [HR 34997], 95 STAT 1047-1063). One study, conducted by the Centers for Disease Control in response to this congressional mandate, was the Vietnam Experience Study (VES). The VES assessed health effects related to the general Vietnam military experience; it did not focus on exposure to herbicides such as Agent Orange. The health of a sample of male US Army Vietnam veterans was compared with the health of a similar group of US Army veterans who did not serve in Vietnam. The study included an analysis of postservice mortality, which has been published previously,1'2 a telephone interview, medical examination and psychological testing, and an evaluation of reproductive outcomes and child health. Comprehensive accounts of the latter three components can be found in a five-volume monograph.8"7 Information in these five volumes is summarized in a series of three reports in this issue of THE JOURNAL. In this first report, we focus on current psychosocial characteristics; in the second,8 on physical health; and in the third,9 on reproductive outcomes. SUBJECTS AND METHODS Participant Selection Study participants were selected from a random sample of male US Army veterans who served during the Vietnam era (Fig 1). To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who (1) entered military service for the first time between January 1965 and December 1971, (2) served only one term of enlistment, (3) had at least 16 weeks of active service, (4) earned a military occupational specialty other than "trainee" or "duty soldier," and (5) had a pay grade no higher than E-5 (sergeant) when discharged from active duty. Tracing and Interviewing All veterans not known to have died were eligible for the telephone interview (Fig 1). With the assistance of a private contractor, all eligible veterans were traced using mailings, telephone directory assistance, credit bureau searches, driver's license and motor vehicle registration records, city directories, local records, and personal field visits. Overall, 87% of Vietnam veterans (7924) and 84% of non-Vietnam veterans (7364) were successfully located CDC Vietnam Experience Study—Psychosocial Characteristics 2701 �Vietnam-Era US Army Personnel Records Filed at NPRC ~4.9 Million Vietnam 9558 Died on Active Duty 234 •H Died on Active Duty 34 4 Studv Cohort Died Between Discharge and Dec 31,1983 Mortality Study Died Between Discharge and Dec 31,1983 246 Vietnam 200 Non-Vietnam that is designed to assess the prevalence of certain psychiatric conditions according to the DSM-HI11 criteria of the American Psychiatric Association. The DIS was administered by specially trained psychology technicians under the supervision of licensed clinical psychologists. Technicians generally did not know whether a veteran had served in Vietnam until the end of the interview, when questions about posttraumatic stress disorder (PTSD) were asked. Since we focused on current status, veterans were considered to have a condition of interest (generalized anxiety, depression, alcohol abuse or dependence, drug abuse or dependence, and PTSD) if they reported a pattern of symptoms in the past month that met the full DSM-HI criteria for that condition. When we analyzed the occurrence of conditions over a veteran's lifetime, the prevalences of all conditions increased but the relative differences between Vietnam and non-Vietnam veterans generally remained the same.6 The MMPI is a self-administered questionnaire that provides a quantitative evaluation of personality, emotional status, and level of psychopathology.12 Elevations on the standard MMPI clinical scales were defined as T scores of 70 or higher, which represents 2 SDs above the mean for the population on which the scales were developed. Data Analysis Multivariate analyses were performed by using logistic regression13 to compute odds ratios and 95% confidence intervals. As a general approximation, if a 95% confidence interval excludes 1.0, the odds ratio estimate can be considered to be statistically significant (ie, Fig 1.—Number of veterans in each component of Vietnam Experience Study. NPRC indicates National Personnel Records Center. P<.05). In the results presented herein, all odds ratios have been adjusted for six characteristics that were considered a priori to be potential confounders or modifiers of associations between place and interviewed by telephone. Among Examination and Testing of service and current health. These Vietnam veterans located but not interA random subsample of veterans was "entry characteristics" were age at viewed, 31 were incarcerated and nine were physically or mentally handi- selected to participate in a comprehen- entry into the army, race, score on the capped; the corresponding figures for sive medical and psychological examina- enlistment general technical test (a non-Vietnam veterans were 32 and 11, tion in addition to the telephone inter- measure of mental aptitude), enlistview (Fig 1). Of those invited, 75% of ment status (drafted or volunteered), respectively. A structured questionnaire was the Vietnam veterans (2490) and 63% of year of entry into the army, and priadministered by trained interviewers the non-Vietnam veterans (1972) partic- mary military occupational specialty using a computer-assisted telephone ipated. All examinations and tests were (tactical or nontactical). For nearly all interview system. Before the telephone performed at one medical facility. Par- conditions, unadjusted estimates were interview and all other components 'of ticipants' expenses—including travel, similar to estimates that were adjusted the VES, participants were given a spe- meals, lodging, and a nominal stipend— for the six entry characteristics as well as to estimates that were adjusted for cial assurance of confidentiality. Inter- were paid from study funds. Psychological health was assessed by additional characteristics, such as eduviewers could not distinguish Vietnam veterans from other veterans until late using the Diagnostic Interview Sched- cation and marital status." We also evalin the interview when Vietnam veter- ule (DIS) and the Minnesota Multipha- uated interactions between entry charans were asked about various experi- sic Personality Inventory (MMPI). The acteristics and place of service. When DIS10 is a standardized questionnaire final models included significant interences unique to Vietnam. I. Psychological Characteristics II. Physical Health III. Reproductive Outcomes 2702 JAMA, May 13, 1988—Vol 259, No. 18 CDC Vietnam Experience Study—Psychosocial Characteristics �action terms, odds ratios were standardized to the distribution of the interaction variable in both cohorts combined.14'15 In the VES we had no objective measure of the amount of combat experienced by individual veterans. We did, however, use tactical military occupational specialty as an indirect indicator of which men were likely to have participated in direct combat. We realize, however, that some men with nontactical military occupational specialties would have experienced heavy combat and vice versa. As part of the psychological testing, we administered a combat exposure questionnaire16 that relied on men's recollections of events that occurred 15 to 20 years earlier. Both of these indicators of combat exposure are thus imperfect, although they probably are related to some extent to actual combat experienced. Vietnam veterans with tactical military occupational specialties did have higher self-reported combat exposure scores (mean, 34 [of a possible 72]) than those with nontactical military occupational specialties (mean, 18). Since we tried to use objective information as much as possible, we relied on military occupational specialty category as the indicator of leVel of combat for the present analysis. A summary analysis was performed to determine which of the entry characteristics, including place of service, were associated with current "poor psychological status." A veteran was considered to have a poor psychological status if he met full DIS criteria for generalized anxiety, depression, or substance abuse in the past month and if he had elevations on at least two of eight clinical scales (scales 1 through 4 and 6 through 9) from the MMPI. In a clinical setting, such findings would typically lead to further psychological or psychiatric evaluation and, perhaps, treatment. RESULTS Participant Characteristics Among those who were interviewed, the age and racial distributions of the Vietnam and non-Vietnam groups were similar (Table 1). The two groups also were similar with respect to age at entry into the army, enlistment status, and having had any absent without leave or confinement time while in the army. Non-Vietnam veterans tended to have higher entry general technical test scores while more Vietnam veterans entered the army before 1969, were assigned tactical military occupational specialties, and served in units associated with direct combat activity. Smaller proportions of Vietnam than JAMA, May 13, 1988—Vol 259, No. 18 Table 1.—Comparison of Selected Demographic and Military Characteristics Among Vietnam and NonVietnam Veterans Veterans Interviewed Characteristic* Mean age at interview, y Race, % white (not Hispanic) Mean age at enlistment, y Year of enlistment, % before 1969 Enlistment status, % volunteers Mean score on enlistment GT test Primary MOS.t % tactical operations Type of unit,:): % combat unit AWOL or confinement time, % with some Type of discharge,! % nonhonorable Pay grade at discharge, %E1-E3|| Examined Vietnam (N=7924) Non- Vietnam (N = 7364) Vietnam (N = 2490) Non-Vietnam (N = 1972) 37.5 37.4 37.4 37.4 83.2 82.0 82.5 81.1 19.8 20.1 19.8 20.1 72.0 60.6 70.5 60.5 35.6 32.8 38.3 35.1 103.9 106.6 104.6 107.6 34.2 26.9 34.0 25.3 57.0 44.8 55.9 45.0 10.0 10.5 9.4 10.8 1.8 6.2 1.9 6.5 9.3 15.9 9.4 16.4 "Unknown values are excluded from the results shown here. GT indicates general technical; and AWOL, absent without leave. tMOS indicates primary military occupational specialty—the job for which the man was trained in the army. Tactical operations includes jobs such as infantryman, armored vehicle crewman, artillery crewman, and combat engineer. ^Refers to the principal unit recorded in the military record for the man's foreign assignment (or US assignment if no foreign service was performed). Combat units include infantry, artillery, armor, cavalry, and engineer. §Also called character of service. Nonhonorable includes underhonorable, other than honorable, undesirable, general-underhonorable, bad conduct, and dishonorable. IIGrades E1 through E3 correspond to the various ranks of private. non-Vietnam veterans were discharged nonhonorably or at lower pay grades. The characteristics of the subsample of veterans examined were similar to those of the telephone interview participants (Table 1). Additional information that was available only for the examination participants indicated that childhood (younger than age 15 years) behavioral problems, as reported by the veterans, were not different in the two groups. In each group, about 12% had been expelled or suspended from school, 3% had run away from home, and 6% had been arrested. At the time of the study, the socioeconomic characteristics of Vietnam and non-Vietnam veterans were generally similar among the telephone interview participants and those examined (Table 2). Marital status was similar in the two cohorts: about 60% of ever-married veterans were currently married to their first wives. Non-Vietnam veterans tended to have more education and higher household incomes, but these differences almost disappeared after adjusting for differences in the six entry characteristics. More than 90% of the veterans in both groups were currently employed. The types of jobs the veterans held also were similar, although more non-Vietnam veterans were in executive, managerial, and professional specialty occupations. Information from those examined indicated that more than 90% of Vietnam and non-Vietnam veterans felt satisfied with their current personal relationships. Psychological Evaluation Vietnam veterans were more likely than non-Vietnam veterans to meet DIS criteria for alcohol abuse or dependence, generalized anxiety, and depression (Table 3). Few men in either group met DIS criteria for drug abuse or dependence. Vietnam veterans were significantly more likely to meet criteria for at least one of the conditions or for two or more of the conditions. Analyses of combat-related PTSD were restricted to Vietnam veterans since non-Vietnam veterans had little opportunity to experience combat. About half of Vietnam veterans reported experiencing one or more symptoms related to a traumatic combat event, and 15% met DIS diagnostic criteria for combat-related PTSD at CDC Vietnam Experience Study—Psyohosocial Characteristics 2703 �Table 2.—Comparison of Selected Socioeconomic Characteristics Among Vietnam and Non-Vietnam Veterans Veterans, % Examined Interviewed Characteristic* Marital status at interview Married Divorced, separated, or widowed Never married Education! Less than high school High school graduate Some college College graduate Usual occupation Executive and managerial Professional specialties Office, clerical, and sales Service and transportation Precision work, craft, and repair Operator and laborer Farmer, forester, and fisherman Unemployed at interview Income, $i <10000 10000-29999 30000-49999 >50000 Vietnam (N=7924) Non- Vietnam (N=7364) Vietnam (N=2490) Non-Vietnam (N = 1972) 74.2 74.5 73.2 73.8 17.1 16.6 18.1 17.7 8.7 8.9 8.7 8.5 14.1 11.6 13.7 10.1 39.6 37.9 37.2 35.8 28.5 28.9 30.3 29.1 17.8 21.7 18.9 25.0 18.5 20.5 19.6 21.8 11.0 14.0 11.3 15.0 7.8 7.7 8.0 6.8 13.5 12.4 15.3 13.7 25.7 24.5 24.0 24.4 20.6 18.1 18.9 16.3 2.9 2.8 2.8 2.4 9.5 8.5 9.6 9.1 9.7 9.4 10.0 10.0 46.6 45.0 47.1 45.1 33.4 33.3 32.9 32.5 10.3 12.4 10.0 12.4 *Men with unknown values for a particular variable were excluded from the analysis of that variable. fHighest grade or year of regular schooling attained as of interview. ^Combined family (gross) income for the calendar year immediately preceding the year of interview. some time during or after service (Table 4). In the month before examination, 79% of Vietnam veterans had no symptoms and 21% had one or more symptoms, with 2% meeting full diagnostic criteria for combat-related PTSD. Meeting DIS diagnostic criteria for combat-related PTSD was associated with having a tactical military occupational specialty. The odds ratio for tactical vs nontactical military occupational specialties was 2.0 (95% confidence interval, 1.5 to 2.5) for "ever" meeting DIS diagnostic criteria and 1.7 (95% confidence interval, 1.0 to 3.0) for meeting diagnostic criteria in the month before examination. Veterans who met criteria for PTSD were also more likely to meet DIS criteria for other psychiatric conditions. Among those who met DIS criteria for combat-related PTSD during the month before examination, 66% also met DIS criteria for anxiety or depression and 39% met criteria for alcohol abuse or dependence. 2704 JAMA, May 13, 1988—Vol 259, No. 18 The MMPI provided further information about the veterans' current psychological status. The reliability of each veteran's responses was evaluated by using the standard MMPI validity scales (L, F, and K) and two additional scales (Carelessness and Test-Retest). The same proportion of veterans in the two cohorts (11%) showed questionable or invalid profiles on the basis of elevations on these scales (T scores 5*70 on the L scale; 5*80 on the F scale; or >70 on the K, Carelessness, or Test-Retest scales). Analyses conducted with and without exclusions of questionable profiles yielded essentially the same results; questionable profiles have been excluded from the results presented herein. A larger proportion of Vietnam than non-Vietnam veterans showed MMPI indications of psychological problems (Table 5). Significantly more Vietnam veterans had elevations on scales 1,2,3, and 7 (which provide the MMPI's best indication of anxiety, somatization, and depression) as well as on scale 8 (which indicates unusual thoughts or behaviors, usually related to distress or psychopathology). Other clinical scales, including 4 and 9 (which are commonly associated with characteristics of addictive or antisocial personality) and 5 and 0 (both of which are of little clinical relevance), did not differ between Vietnam and non-Vietnam veterans. Overall, about half the participants in each group showed no elevation on any clinical scales, but elevations on two or more clinically relevant scales (scales 1 through 4 and 6 through 9) were significantly more frequent among Vietnam veterans. Current poor psychological status was also more prevalent among Vietnam veterans (Table 6). The increased prevalence of current poor psychological status, however, was more prominent among those veterans who entered the army before 1968. Regardless of whether a veteran had served in Vietnam, current poor psychological status was more prevalent in veterans who were not white, who had been young (younger than age 19 years) at enlistment, or who had lower general technical test scores at enlistment. The other entry characteristics, including military occupational specialty category, were not associated with current poor psychological status. The prevalence of current poor psychological status among Vietnam veterans was 13% for those with tactical military occupational specialties and 12% for those with nontactical military occupational specialties. The same proportional increase in current poor psychological status associated with service in Vietnam was found within different subgroups defined by race, age at enlistment, and enlistment general technical test score (Fig 2). Although proportional differences remained the same, absolute differences in risk of current poor psychological status between Vietnam and non-Vietnam veterans necessarily varied as the underlying risk changed. Thus, the absolute differences in risk between Vietnam and non-Vietnam veterans diminish as the risk moves downward from nonwhite veterans who had been young and had had low general technical test scores at enlistment to white veterans who had been older and had had high general technical test scores at enlistment. COMMENT Since the time of the conflict to the present, veterans and others have been concerned about the psychological health of American military personnel who served in Vietnam and about their CDC Vietnam Experience Study—Psychosocial Characteristics �Table 3.—Vietnam and Non-Vietnam Veterans Who Met DIS Criteria for Selected Psychiatric Conditions* Veterans, % Condition Alcohol abuse or dependence Drug abuse or dependence Generalized anxiety§ (with or without depression) Depression (with or without generalized anxiety) Total No. of above conditions >1 >2 Vietnam (N=2490) Non-Vietnam (N = 1972) Odds Ratlof 95% Confidence Interval 13.7 9.2 1.5 1.2-1.8 0.4 0.5 0.9$ 0.4-2.0 4.9 3.2 1.5 1.1-2.1 4.5 2.3 2.0 1.4-2.9 19.2 13.1 1.5 3.5 1.8 1.9 1.3-1.8 1 .2-2.8 *DIS indicates Diagnostic Interview Schedule. Veterans must have met DIS criteria in the month before examination. t Adjusted for the six entry characteristics. fCrude odds ratio presented because the number of cases is not sufficient for an adjusted estimate. §For clinical purposes, depression is considered the primary diagnosis for individuals with both depression and anxiety Of Vietnam veterans, 2.8% had generalized anxiety alone and 2.1% had generalized anxiety and depression; of non-Vietnam veterans, 2.2% had generalized anxiety alone and 1.0% had generalized anxiety and depression. Table 5.—Vietnam and Non-Vietnam Veterans With Elevated MMPI Clinical Scales (T score >70)* Veterans, % MMPI Scale Vietnam (N=2221)f Non- Vietnam (N = 1754)f Odds Ratio* 1.7 95% Confidence Interval 1.4-2.1 1.3-1.8 1.2-2.0 0.9-1.2 0.9-1.3 1.0-1.7 1 15.6 9.1 2 25.1 17.3 1.6 3 8.9 5.9 1.5 4 15.7 14.7 1.0 5 12.7 12.9 1.1 6 9.1 7.2 1.3 7 16.5 10.9 1.6 1 .3-1 .9 8 16.3 9.2 2.0 9 13.7 13.5 1.1 0 11.0 8.3 1.3 1.6-2.4 0.9-1.3 1.0-1.6 51.5 59.6 0.7 48.5 40.4 1.3 28.2 20.8 1.5 No scales elevated§ 21 scales elevated§ 2:2 scales elevated§ Table 4.—Vietnam Veterans Who Ever Met DIS Criteria for Combat-Related PTSD and Those Who Met Full Criteria in the Month Before Examination* 0.7-0.8 1.2-1.5 1.2-1.7 *MMPI indicates Minnesota Multiphasic Personality Inventory; a T score of 70 or higher represents 2 SDs above the standardization sample mean. fVeterans with questionable profiles are not included in this analysis. ^Adjusted for the six entry characteristics. §Excluding scales 5 and 0. adaptation to civilian life after their return home.17'20 In this study, 15 to 20 years after army service, Vietnam veterans seem to be functioning socially and economically in a manner similar to army veterans who did not serve in Vietnam. At the time of the study, few men in either group of veterans were in jail, institutionalized, or mentally or physically incapacitated. In both groups, three fourths of the men were married at the time of interview, with similar proportions married to their first wives. In addition, more than 90% expressed satisfaction with their family JAMA, May 13, 1988—Vol 259, No. 18 and other personal relationships. More than 90% were also currently employed. After differences that were present at induction into the army (such as general technical test score) had been accounted for, the educational levels, types of occupations, and household incomes of the two groups were similar. Although the outward indications are that the two groups of veterans have made similar adaptations to civilian life, the study results also indicate that more Vietnam veterans than non-Vietnam veterans currently are experiencing psychological problems. The current Vietnam Veterans, % (N=2490) Type of Symptoms Combat-related PTSDf Criterion B Recurrent thoughts or dreams Felt as if event recurring Criterion C Lost ability to care about others or lost interest in usual activities Criterion D Jumpy or easily startled Trouble sleeping Ashamed of being alive Forgetful or trouble concentrating Avoids situations that remind Symptoms get worse in situations that remind No symptoms Month Before Ever Examination 14.7 2.2 32.4 7.6 1.9 9.4 17.1 5.1 45.1 34.6 8.1 10.6 3.4 1.9 13.6 0.4 28.8 7.9 17.3 49.9 3.9 79.2 *DIS indicates Diagnostic Interview Schedule; and PTSD, posttraumatic stress disorder. fTo meet DIS criteria for combat-related PTSD, a veteran had to report a combat-related traumatic event (criterion A), at least one reexperiencing symptom (criterion B), a numbing symptom (criterion C), and at least two symptoms of autonomic arousal (criterion D). All symptoms were related specifically to the traumatic event. psychological problems of Vietnam veterans, as determined by the DIS, mainly involve (1) alcohol abuse or dependence, affecting about 14% of Vietnam veterans compared with 9% of nonVietnam veterans; (2) anxiety, 5% vs 3%; and (3) depression, 5% vs 2%. The MMPI results, although they do not provide information on discrete diagnostic categories, were generally in accord with the DIS results. Also, according to DIS criteria, about 15% of Vietnam veterans have ever experienced combat-related PTSD, and about 2% experienced the disorder during the month before the examination. Fewer than 1% in either cohort met DIS criteria for current drug abuse or dependence. The mortality analysis of the VES cohorts suggested that drugrelated deaths were higher among Vietnam veterans throughout the approximately 13 years of follow-up.1'2 The VES telephone interviews and examinations, however, indicate that current regular use of illicit drugs was similar among Vietnam and non-Vietnam veterans. Drug use, typically involving only marijuana, was reported by about 10% of Vietnam and 8% of non-Vietnam veterans.1 Use of illicit drugs other than marijuana was reported by about 2% to 3% in each group." To identify the participants who could be considered to have the poorest current psychological status, we combined CDC Vietnam Experience Study—Psychosocial Characteristics 2705 �Table 6.—Risk Factors Associated With Current Poor Psychological Status Prevalence of Poor Psychological Status Factor Year of entry and place of service 1965-1967 Non- Vietnam Vietnam 1968-1971 Non- Vietnam Vietnam Other risk factors Race White Nonwhitef Age at enlistment, y <19 % Odds Ratio* No. 5.6 51 163 Referent 1.6-3.2 1.0 13.0 2.3 8.8 93 134 1.3 8.8 322 1.0 14.7 119 Referent 0.8-2.0 1.0 10.9 1.4 16.3 105 8.7 326 12.7 10 1.4 <88 16.0 142 1.9 88-101 102-113 114-124 12.4 110 1.3 9.5 88 1.0 8.1 70 0.8 3.4 29 1.5-2.4 Referent 0.7-2.8 1.0 >24 Referent 1.1-1.8 1.9 19-24 95% Confidence Interval 0.6 Enlistment GT test secret >124 1.6-2.2 1.2-1.4 Referent 0.7-0.8 0.5-0.7 * Adjusted for all other risk factors in table. tNonwhite includes blacks, Hispanics, American Indians, Asians, and Pacific Island Americans. tGT indicates general technical. 40 40 o 30 o 30 £20 20 10 10 70 80 90 100 110 120 130 140 Enlistment GT Score 70 80 90 100 110 120 130 140 Enlistment GT Score Fig 2.—Predicted probability of poor psychological status by place of service, age at enlistment, race, general technical (GT) test score, and year of entry into military service. Left, Veterans who entered service between 1965 and 1967. Right, Veterans who entered service between 1968 and 1971. V indicates Vietnam; N, non-Vietnam; solid lines, nonwhite and younger than 19 years old; and dotted lines, white and between 19 and 24 years old. findings from the DIS and the MMPI. Among veterans who entered the army from 1965 to 1967, the prevalence of current poor psychological status for Vietnam veterans was about double the prevalence for veterans who did not serve in Vietnam; among those who entered later, the prevalences were similar. This suggests that some change occurred around 1968, but we cannot specify what the change may have been. The range of possibilities includes not 2706 JAMA, May 13, 1988—Vol 259, No. 18 only changes in the nature of the Vietnam conflict, but also changes in American societal attitudes and perceptions about the conflict and changes in the attitudes or expectations of men entering the army. Compared with veterans who entered the army before 1968, the prevalence of current poor psychological status decreased among Vietnam veterans but increased among nonVietnam veterans who entered in 1968 or later. When military occupational specialty category was used as an indicator of the extent of direct combat likely to have been experienced, the only psychological condition that showed a strong association with level of combat was combatrelated PTSD. Vietnam veterans with tactical military occupational specialties were nearly twice as likely as those with nontactical military occupational specialties to have ever experienced combat-related PTSD. For all the other psychological conditions, the increased relative risk associated with service in Vietnam was evident in both military occupational specialty categories. This suggests that those Vietnam veterans who had tactical military occupational specialties were not at any greater relative risk of having these subsequent psychological problems than those who had nontactical military occupational specialties. For most psychological conditions, the relative effect of service in Vietnam was the same regardless of such characteristics as race, age at entry into the army, enlistment status, and induction general technical test score, as well as military occupational specialty category. This suggests that the effect of Vietnam service, at least for those who entered the Army between 1965 and 1967, was a general one for which most veterans who served in Vietnam may have been at risk. The increased prevalence of current psychological problems among Vietnam veterans does not seem to have been due to the characteristics of the men who were sent to Vietnam. From all available information, the characteristics of the two groups seemed to be similar. In particular, the racial distributions and the prevalences of reported childhood behavioral problems were nearly identical. Also, preservice prevalences of psychiatric symptoms, including anxiety, depression, and substance abuse, were similar in the two groups.6 The only difference in known entry characteristics was that those with higher entry general technical test scores seemed less likely to serve in Vietnam. This difference, however, was small and did not account for the differences in psychological findings between Vietnam and non-Vietnam veterans. A potential concern with the study is the possibility of participation bias. Examination participation rates for Vietnam veterans were higher than those for non-Vietnam veterans. Detailed analyses of the factors that influenced participation showed that those examined were similar to those interviewed by telephone.5 Thus, participa- CDC Vietnam Experience Study—Psychosocial Characteristics �tion bias is not likely to have had a large influence on the study results. The higher prevalence of psychological problems among Vietnam veterans does not seem to be related to their being in worse current physical health. In the medical examination component of the VES, few differences were found between Vietnam and non-Vietnam veterans in terms of neuropsychological performance, neurological findings, or other objective measures of current physical health.5'8 Military service in Vietnam was, undoubtedly, an emotionally and psychologically difficult experience for many US servicemen. Fifteen to 20 years afterward, more Vietnam veterans have psychological and emotional problems compared with veterans who did not serve in Vietnam. These psychological problems, however, are not of a magnitude that has resulted in Vietnam veterans' having, as a group, lower social and economic attainment. This report was prepared by the following: Drue H. Barrett, MA; Coleen A. Boyle, PhD; Pierre Decoufle, ScD; Frank DeStefano, MD, MPII; Owen J. Devinc, MS; Robin D. Morris, PhD (Centers for Disease Control and Georgia State University, Atlanta); Mark J. Scally, MPA; Nancy E. Stroup, PhD; Scott F. Wetterhall, MD; and Robert M. Worth, MD, PhD. Other VES staff members include the following: Charles L. Adams, MPH; Joseph L. Annest, PhD; Andrew L. Baughman, MPH; Edward A. Brann, MD, MPH; Eugenia E. Calle, PhD; Elizabeth A. Cochran; Karen S. Colberg; Robert C. Diefcnbach; Barbara Dougherty; Sandra S. Emrich; W. Dana Flanders, MD, DSc; Anthony S. Fowler; Robert R. German; Patricia Holmgreen, MS; Martha I. Hunter; M. Riduan Joesoef, MD, PhD; John M. Karon, PhD; Muin J. Khoury, MD, PhD; Marcie-jo Kresnow, MS; Heather D. McAdoo; Brcnda R. Mitchell; Linda A. Moyer; Thomas R. O'Brien, MD, MPH; and Joseph B. Smith. Current and former Centers for Disease Control staff members who also made important contributions include the following: Robert J. Delaney; John J. Drescher; J. David Erickson, DOS, PhD; Melin- JAMA, May 13, 1988—Vol 259, No. 18 da L. Flock, MSPH; John J. Gallagher; Jerry G. Gentry, MSPH; Michael E. Kafrissen, MD, MSPH; Marilyn L. Kirk; Peter M. Layde, MD, MSc; Maurice E. LeVois, PhD; Peter J. McCumiskey; Daniel L. McGee, PhD; Terryl J. Meranda, MS; Daniel A. Pollock, MD; Melvin W. Ralston; Philip H. Rhodes, MS; Richard K. Rudy, MD; Paul D. Simpson, MS; and Dennis M. Smith, MD. Consultants who made important contributions to this study component include the following: Lee N. Robins, PhD (Washington University, St Louis), and Marjorie A. Speers, PhD (Division of Chronic Disease Control, Center for Environmental Health and Injury Control, Centers for Disease Control). Many other individuals and organizations have provided invaluable support to the study. These include the following: the Agent Orange Working Group and its Science Panel; the Congressional Office of Technology Assessment; the Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; Equifax Inc; the General Services Administration; the Internal Revenue Service; Lovelace Medical Foundation; the National Personnel Records Center, National Archives and Records Administration; the National Center for Health Statistics; the Institute of Medicine, National Academy of Sciences; Research Triangle Institute; the Social Security Administration; the Veterans Administration; and other staff members of the Centers for Disease Control and outside consultants. Leaders of Veterans Service Organizations provided important input and support to the study, and participation by Vietnam-era veterans made the study possible. References 1. Boyle CA, Decoufle P, Delaney RJ, et al: Poatservice Mortality Among Vietnam Veterans. Atlanta, Centers for Disease Control, 1987. 2. Centers for Disease Control Vietnam Experience Study: Postservice mortality among Vietnam veterans. JAMA 1987;257:790-795. 3. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: I. Synopsis. Atlanta, Centers for Disease Control, in press. 4. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: II. Telephone Interview. Atlanta, Centers for Disease Control, in press. 5. Centers for Disease Control Vietnam Experience Study: Health Stains of Vietnam Veterans: III. Medical Examination. Atlanta, Centers for Disease Control, in press. 6. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: IV. Psychological and Neuropsychological Evaluation. Atlanta, Centers for Disease Control, in press. 7. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: V. Reproductive Outcomes and Child Health. Atlanta, Centers for Disease Control, in press. 8. Centers for Disease Control Vietnam Experience Study: Health status of Vietnam veterans: II. Physical health. JAMA 1988;259:2708-2714. 9. Centers for Disease Control Vietnam Experience Study: Health status of Vietnam veterans: III. Reproductive outcomes and child health. JAMA 1988;259:2715-2719. 10. Robins LN, Helzer JE, Cottier LB, et al: The Diagnostic Interview Schedule, Version III-A, Training Manual. St Louis, Veterans Administration, 1987. 11. Diagnostic and Statistical Manual, ed 3. Washington, DC, American Psychiatric Association, 1980. 12. Dahlstrom WG, Welsh GS, Dahlstrom LE: An MMPI Handbook: Clinical Interpretation, revised edition. Minneapolis, University of Minnesota Press, 1972, vol 1. 13. Engelman L: Stepwise logistic regression, in Dixon WJ, Brown MB, Engelman L, et al (eds): BMDP Statistical Software. Berkeley, University of California Press, 1983, pp 330-344. 14. Wilcosky TC, Chambles LE: A comparison of direct adjustment and regression adjustment of epidemiologic measures. J Chronic Dis 1985;38:849-856. 15. Flanders WD, Rhodes PH: Large sample confidence limits for regression standardized risks, risk ratios, and risk differences. / Chronic Dis 1987;40:697-704. 16. Egendorf A, Kadushin C, Laufer RS, et al: Legacies of Vietnam: Comparative Adjustment of Veterans and Their Peers, publication V101. Washington, DC, Center for Policy Research Inc, 1981, pp 134-630. 17. Helzer JE, Robins LN, Wish E, et al: Depression in Vietnam veterans and civilian controls. Am J Psychiatry 1979;136:526-529. 18. Blank AS: Stresses of war: The example of Vietnam, in Goldberg L, Breznitz S (eds): Handbook of Stress: Theoretical and Clinical Aspects. New York, Free Press, 1982, pp 631-643. 19. Laufer RS, Gallops MS, Frey-Wouters E: War stress and trauma: The Vietnam veteran experience. J Health Soc Behav 1984;25:65-85. 20. Robins LN, Davis DH, Goodwin DW: Drug use by U.S. Army enlisted men in Vietnam: A follow-up on their return home. AmJEpidemiol 1974;99:235249. CDC Vietnam Experience Study—Psycho-social Characteristics Printed and Published in the United States of America 2707 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 065 Folder The folder containing the original item. 1747 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Description An account of the resource Corporate Author: Center for Environmental Health and Injury Control, CDC, Public Health Service, DDHS, Atlanta, Georgia Source A related resource from which the described resource is derived JAMA Date A point or period of time associated with an event in the lifecycle of the resource May 13 1988 Title A name given to the resource Health Status of Vietnam Veterans, I. Psychological Characteristics, The Center for Disease Control Vietnam Experience Study Subject The topic of the resource Vietnam Experience Study veteran psychological health PTSD study protocol ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 073 Folder The folder containing the original item. 1923 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Bloemen, Anne Source A related resource from which the described resource is derived World Environment Report Date A point or period of time associated with an event in the lifecycle of the resource July 15 1982 Title A name given to the resource Herbicides Linked to Vets' Brain Damage Subject The topic of the resource veteran health and hygiene veteran psychological health Australia ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 055 Folder The folder containing the original item. 1468 Series The series number of the original item. Series III Subseries II Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Description An account of the resource Corporate Author: Vietnam Veterans of America Title A name given to the resource Includes itinerary for Vietnam Veterans of America's Second Delegation to Vietnam, May 28, 1982 through June 3, 1982; listing and short biographies for members of the delegation; three articles related to delegation, "Hanoi Trip: Gains Seen By Ex-G.I.'s" Subject The topic of the resource Southeast Asia veteran psychological health Agent Orange Controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 079 Folder The folder containing the original item. 2042 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Coombs, J. S. Title A name given to the resource Letter: to Alvin L. Young from J. S. Coombs, 7 August 1984 Subject The topic of the resource veteran psychological health AVHS international cooperation ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. 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Description An account of the resource Corporate Author: Parliament of the Commonwealth of Australia, Senate Standing Committee on Science and the Environment, Canberra, Australia Date A point or period of time associated with an event in the lifecycle of the resource 1982-11-01 Title A name given to the resource Pesticides and the Health of Australian Vietnam Veterans: First Report, November 1982 Subject The topic of the resource Australian Parliamentary hearings mortality trends morbidity trends veteran psychological health ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/eda1ab0ba8cd79035b18e79b26b04f62.pdf cd6d46a606e7b3f8913bfe99ef4a1cbc PDF Text Text Item ID Number 01742 Author Corporate Author RopOrt/ArtiClB TitlO Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Journal/Book Titlo JAMA Year 1987 Month/Day February 13 Color n Number of ImaDBS 28 DOSCTiptOn NOtOS Includes an undated, pre-publication typescript of the article. Monday, June 11, 2001 Page 1743 of 1793 �Reprinted from the JAMA" Journal of the American Medical Association February 13, 1987, Volume 257 Copyright 1987, American Medical Associatbn Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study The postservice mortality (through December 1983) of a cohort of 9324 US Army veterans who served in Vietnam was compared with that of 8989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio, 1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. (JAMA 1987;257:790-795) MANY Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'2 The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).3 The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: (1) an assessment of postservice mortality, (2} a detailed health interview, and (3) a comprehensive medical, psychological, and laboratory evaluation. Although Agent Orange is among the many factors that could have From the Center for Environmental Health. Centers for Disease Control, Atlanta. Reprint requests to Centers for Disease Control, 1600 Cliflon Rd (C-25), Atlanta, GA 30333 (Coloon A. Boyle, PhD). 790 JAMA, Feb 13,1987—Vol 257, No. 6 adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere.4 SUBJECTS AND METHODS Study Participants Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who (1) entered military service for the first time between January 1965 and December 1971, (2) served only one term of enlistment, (3) had at least 16 weeks of active service time, (4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and (5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with ser- vice in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components.3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in allcause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are rare.'1 Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (NPRC) between September 1964 and June 1977. Personnel of the NPRC believe that this group includes the vast majority of US Army Vietnamera veterans who fulfill the study criterion of a single term of enlistment. The Figure outlines the process of participant selection. To achieve the desired sample size of 18 000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48 513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam and 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded. Vital Status Ascertainment Follow-up began the day the veteran was discharged alive from active duty CDC Vietnam Experience Study—Postservice Mortality �Vietnam-Era Army Personnel Records Filed at NPRC, Sept 1964-June 1977 (About 4.9 Million) I I Random Sample (48 513) [Records Not Found'(1355)j [ Qualified for Study (18581)] Vietnam (9558) I Not Qualified (28577) [Non-Vietnam (9023)[ I Died on Active Duty (34) Died on Active Dutyt (234) I 34)] Vietnam Cohort (9324) [ I Non-Vietnam Cohort (8989) Selection of study group. NPRC indicates National Personnel Records Center; asterisk, excluded from study; and dagger, 83% (N = 194) of active-duty deaths among Vietnam veterans were due to war-related activities. ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non-Vietnam veterans. The 95% confidence intervals (CIs) for the RRs were computed using procedures described by Laird and Oliver.7 The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), and adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, and combat engineers) and "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses," included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Monson's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. RESULTS and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate and contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans and 91.9% of those who served elsewhere. Entry and military service characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the eighth and ninth revisions6'6 of the International Classification of DisJAMA, Feb 13,1987—Vol 257, No. 6 eases (ICD) by an experienced nosologist at the National Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. Medical Review Panel To address limitations of death certificate-based diagnoses, a review panel of two physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the ICD. To estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate There were some differences in both preinduction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small. Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications and infantry unit assignments, reflect war-related military requirements in Vietnam. All-Cause Mortality Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among nonVietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow-up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time-specific results will be presented when appropriate. To determine whether the association between Vietnam service and mortality was uniform or varied across different CDC Vietnam Experience Study—Postservice Mortality 791 �Table 1.—Differences in Selected Characteristics Between Vietnam and Non-Vietnam Veterans at Entry Into Service and During Military Service Table 3.—Number of Deaths Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge From Active Duty, 1965 Through 1983 Vietnam (N=9324) At entry into service Race,* % white Age at entry (mean) Enlistment status,* % draftee Year of entry into service, % before 1969 Non-Vietnam (N=8989) 86.8 86.5 20.3 Characteristic 20.5 Characteristic* 65.6 Race White 63.7 Years Since Discharge From Active Duty s5 Nonwhite 72.1 Army General Technical Test score (mean, scaled to 100) During military service Primary military occupational specialty, t % tactical operations 60.6 105.5 Type of discharge, % honorable 34.3 27.4 26.6 Type of unit, % infantry 97.2 91.0 88.5 79.8 Year of discharge, % before 1970 48.1 44.6 *Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups. tThe job specialty for which the man was trained in the Army. No. RR No. RR 79 1.09 111 0.91 190 0.98 104 1.80 152 1.06 256 1.31 GT test scoref 97 1.42 141 0.90 238 1.08 <100 100 + 83 1.43 119 1.07 202 1.20 Duty MOSt 63 1.19 Tactical 89 1.04 152 1.10 Other 120 1.58 174 0.97 294 1.18 Age at discharge <21 47 1.83 42 0.67 89 1.14 14.6 Pay grade at discharge, % E4 or E5 RR All Years 146 1.50 193 0.99 339 1.18 37 1.30 70 1.07 107 1.14 Enlistment status Volunteer Draftee 103.1 No. 6+ 21 + 136 1.41 221 1.10 357 1.21 Pay grade at discharge E4-E5 125 1.50 183 1.10 308 1.24 E1-E3 58 1.95 80 1.16 138 1.44 Year of discharge 79 2.05 122 0.96 201 1.27 <1970 104 1.16 141 1.06 245 1.10 1970 + "There was no evidence of statistically significant effect modification for any of these characteristics (P>.OS). tArmy General Technical Test (GT) scores were missing for six veterans. ^Determined from principal military occupational specialty (MOS) held while on tour of duty. Table 2.—Number of Deaths, Person-Years, and Death Rates Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965-1983* Non-Vietnam Vietnam ==5 No. of Deaths PersonYears Ratef No. Of Deaths PersonYears 95% Cl 46350 2.4 73 44747 Ratef 1.6 RR 110 Years Since Discharge 1.45 1.08-1.96 6+ 136 81547 1.7 127 76582 1.7 1.01 0.79-1.28 All years 246 127897 1.9 200 121 329 1.7 1.17 0.97-1.41 *RR indicates rate ratio; Cl, confidence interval. tCrude death rate per 1000 person-years. subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 (95% Cl, 1.16 to 2.14). In the later 792 JAMA, Feb 13,1987—Vol 257, No. 6 follow-up period, adjustment changed the RR to 1.04 (95% Cl, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 21 years than those discharged at age 21 years or older (P = .02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P = . 05). Cause-Specific Mortality Death Certificates.—Only four major cause-of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circu- latory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P = .03) than nonVietnam veterans. The excess was most pronounced in the first five years after discharge from active duty (RR, 1.93; P = .01). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow-up period (RR, 2.47; P = .08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did not materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% Cl, 1.09 to 6.17). Medical Review Panel.—The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non-Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3.7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; K = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICD-9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% Cl, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1.21 (95% Cl, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was CDC Vietnam Experience Study—Postservice Mortality �Table 4.—Number of Deaths by Cause (From Death Certificate), Death Rates Among Vietnam and NonVietnam Veterans, and Unadjusted RRs, 1965 Through 1983* Vietnam Underyllng Cause of Death (/CD-9)t Non-Vietnam No. Rate* Infectious and parasitic diseases (001 -139) No. 95% Cl RR§ Rate* 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1 .76 Mental disorders (290-31 9) 7 5.5 7 5.8 0.95 0.33-2.70 Diseases of nervous system (320-389) 0.49 0.25-0.99 Neoplasms (140-239) 2 1.6 1 0.8 Diseases of circulatory system (390-459) 12 9.4 23 19.0 Diseases of respiratory system (460-51 9) 5 3.9 4 3.3 Diseases of digestive system (520-579) 5 3.9 3 2.5 Diseases of genitourinary system (580-611) 4 3.1 0 Congenital anomalies (740-759) 1 0.8 1 0.8 Symptoms, signs, and ill-defined conditions (780-799) 2 1.6 1 0.8 188 147.0 143 117.9 External causes (E800-E999) General Population Comparison 1 .25 1 .00-1 .55 2 7 No death certificate *RR indicates rate ratio; Cl, confidence interval. f/CD-9 indicates International Classification of Diseases, ninth revision. No deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the musculoskeletal system. Therefore, these categories are not shown. tCrude death rate per 100000 person-years. §lf the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. Table 5.—Number of Deaths From Specific External Causes (From Death Certificate) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Dutyt All Years 64- External Cause of Death (/CD-9) No. RR 95% Cl Motor vehicle accident (E810-E825, E929.0) 66 1.93 1.16-3.22 further refinement of the later follow-up period suggests the upward trend in drug-related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. Again, as in the death certificate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% Cl, 1.11 to 5.87). No other RR presented in the medical review results was materially altered by adjustment. No. RR 95% Cl No. RR 95% Cl 67 1.16 0.72-1.87 133 1.48 1.04-2.09 Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire followup period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0.48; 95% Cl, 0.25 to 0.85), whereas non-Vietnam veterans had only a slight deficit (SMR, 0.87; 95% Cl, 0.54 to 1.34). Accidental poisoning (E850-E869, E929.2) 11 1.69 0.49-5.77 7 ... ... 18 2.47 0.88-6.92 COMMENT Other accidents* 23 1.05 0.46-2.37 39 0.89 0.48-1.67 62 0.95 0.58-1 .56 Suicide (E950-E959) 25 1.72 0.76-3.88 32 0.64 0.32-1.30 57 0.98 0.58-1.65 Homicide (E960-E969) 18 1.52 0.59-3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 10 3.79 0.81-17.87 The intent of this study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide variety of possible health-influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam, and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group. External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particular factor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel Undetermined intentlonality (E980-E989) 4 6 *RR indicates rate ratio; Cl, confidence interval; /CD-9, International Classification of Diseases, ninth revision. tTime-specific RRs are not presented for categories with less than ten deaths in both Vietnam and non-Vietnam groups combined. ^Includes /CD-9 categories E800 to E807, E826 to E849, E870 to E928, E929.1, E929.3 to E929.9, E930 to E949, E970 to E978, and E990 to E999. primarily the result of two deaths from neoplasms among non-Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of alcohol-related MVA deaths JAMA, Feb 13,1987—Vol 257, No. 6 during this period (RR, 1.35; 95% Cl, 0.60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow-up period. Although the number of deaths is too small for formal analysis, CDC Vietnam Experience Study—Postservice Mortality 793 �Table 6.—Number of Deaths From Alcohol and Drug-Related Causes (From Medical Review) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Duty s5 Cause of Death Alcohol-related natural causesf Alcohol-related traumatic causes:): Drug-related causes§ No. All Years 6+ RR 95% Cl No. 95% Cl No. RR 95% Cl 25 5 RR 0.87 0.40-1.90 30 1.08 0.53-2.22 42 1.29 0.70-2.37 61 1.04 0.63-1.71 103 1.13 0.77-1 .67 18 1.21 0.48-3.06 22 2.01 0.82-4.94 40 1.58 0.83-3.00 'RR indicates rate ratio; Cl, confidence interval. tincludes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291.9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (425.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). ^Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800 to E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. §Deaths for which one of the following drug-specific diagnoses is the underlying or contributing cause of death: drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E850.5, E850.8, E851-E854, E855.1 to E855.2, E866.6, and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). Table 7.—Observed and Expected Numbers of Deaths by Cause Among Vietnam and Non-Vietnam Veterans and SMRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge -~5 Cause of Deathf (ICDA-8) All natural causes (000-796) External causes (E800-E999) 6+ All natural causes (000-796) External causes (E800-E999) All years All natural causes (000-796) External causes (E800-E999) Observed Expected^ SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Vietnam 13 Non- Vietnam 24.2 23.4 0.54 0.29-0.92 16 0.68 0.39-1.11 92 55 72.5 69.4 1.27 1.02-1.56 0.79 0.60-1.03 38 39 65.8 63.4 0.58 0.41-0.79 96 102.7 0.93 0.76-1.14 0.62 0.44-0.84 88 96.6 0.91 0.73-1.12 51 55 90.0 86.8 0.57 0.42-0.75 0.63 0.48-0.82 188 143 175.2 166.0 1.07 0.93-1.24 0.86 0.73-1.01 *SMR indicates standardized mortality ratio; Cl, confidence interval; and ICDA-8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. •(•Excludes nine deaths (seven Vietnam, two non-Vietnam) for which death certificates were not recovered. ^Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, 794 JAMA, Feb 13,1987—Vol 257, No. 6 both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized dif- ferences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10'13 are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method.14 The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.16 The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external-cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.16 Although the Australian investigators did not examine external cause mortality by time since discharge, there was a suggestion of a decline in relative mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occurred more frequently among their Vietnam veterans. Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.12 The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes." Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.11 Australian Vietnam veterans had an excess of deaths from alcohol-related CDC Vietnam Experience Study—Postservice Mortality �natural causes, but no increases in deaths from alcohol-related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American and Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam,17'18 drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.15 Our finding of increased mortality from drug-related causes in the later followup period was not consistent with surveys indicating little or no influence of Vietnam service or combat exposure on postdischarge drug use.18'19 The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.15 Various indexes, of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.15 This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservicc externalcause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. Alternatively, our findings may reflect consequences of the unique environment and experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included.21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20'21 as did non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide additional insights. The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefono, MD, Melinda L. Flock, MSPH, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RN, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; NPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC; and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC. Copies can be obtained from the CDC, Atlanta, GA 30333. References 1. Veterans Health Programs Extension and Improvement Act of 1979, Public Law 96-151 (HR 3892), Dec 20, 1979, 93 STAT 1092-1098. 2. Veterans' Health Care, Training, and Small Business Loan Act of 1981, Public Law 97-72 (HR 3499), Nov 3, 1981, 95 STAT 1047-1063. 3. Protocol for Epidemiologic Studies of the Health of Vietnam Veterans. Atlanta, Centers for Disease Control, November 1983. 4. Post-service Mortality Among Vietnam Veterans. Atlanta, Centers for Disease Control, 1987. 5. International Classification of Diseases, Adapted for Use in the United States, rev 8, PHS publication 1693. US Dept of Health, Education, and Welfare, 1967. 6. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, rev 9. Geneva, World Health Organization, 1977. 7. Laird N, Oliver D: Covariance analysis of censored survival data using log-linear analysis techniques. JAmStatAssoc 1981;76:231-241. 8. Cox DR, Oakes D: Analysis of Survival Data. London, Chapman & Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. Comp Biomed Res 1974;7: JAMA, Feb 13,1987—Vol 257, No. 6 325-332. 10. Anderson IIA, Hanrahan LP, Jensen M, et al: Wisconsin Vietnam Veteran Mortality Study. Madison, Wis, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of New York State Vietnam veterans. Am J Public Health 1985;75:277-279. 12. Kogan MI), Clapp RW: Mortality Among Vietnam Veterans in Massachusetts, 1972-1983. Boston, Massachusetts Dept of Public Health, 1985. 13. Holmes AP: West Virginia Vietnam-Era Veterans Mortality Study. Charleston, WVa, West Virginia Health Dept, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. J Occup Med 1982;24:299-304. 15. Fott MJ, Dunn M, Adena MA, et al: Australian Veterans Health Studies: The Mortality Report: Part I. A Retrospective Cohort Study of Mortality Among Australian National Servicemen of the Vietnam Conflict Era, and an Executive Summary of the Mortality Report. Canberra, Australia, Australian Government Publishing Service, 1984. 16. Lathrop GD, Moynahan PM, Albanese RA, et al: Project Ranch Hand II. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides: Baseline Mortality Study Results. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss HL: Vietnam military service and marijuana use. Am J Drug Alcohol Abuse 1985;11:119-130. 18. Robins LN, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward. Arch Gen Psychiatry 1975;32:955-961. 19. Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. Arch Gen Psychiatry 1984; 41:327-333. 20. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epidemiol 1974;100:367-372. 21. Nefzger MD: Follow-up studies of World War II and Korean War prisoners: I. Study plan and mortality findings. Am J Epidemiol 1970;91: 123-138. CDC Vietnam Experience Sludy— Postsorvice Mortality Printed and Published in the United States of America 795 �Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study Published in February 13, 1987 issue of The Journal of the American Medical Association. �ABSTRACT The postservice mortality (through December 1.983) of a cohort of 932.4 US Army veterans who served in Vietnam was compared with that of 0989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio,.1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. �INTRODUCTION Many Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'^ The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).^ The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: 1) an assessment of postservice mortality, 2) a detailed health interview, and 3) a comprehensive medical, psychological, arid laboratory evaluation. Although Agent Orange is among the many factors that could have adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere"./l �SUBJECTS AMD METHODS Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who 1) entered military service for the first time between January 1965 and December 1971, 2) served only one term of enlistment, 3) had at least 16 weeks of active service time, 4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and 5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with service in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components. 3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in all-cause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (IMPRC) between September 1964 and June 1977. Personnel of the WPRC believe that this group includes the vast majority of US Army Vietnam-era veterans who fulfill the study criterion of a single term of enlistment. The figure outlines the process of participant selection. To achieve the desired sample size of 18000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam arid 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded . Follow-up began the day the veteran was discharged alive from active duty and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate arid contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans arid 91.9% of those who served elsewhere. Entry and military service �characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the Eighth and Ninth Revisions'1"-1' ^ of the I.nJ;£mat_i_onal Q.3^As..ific.ati_qn......of.....Diseases ....ID1 by an experienced nosologist at the National ...(C. Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. To address limitations of death certificate-based diagnoses, a review panel of two -physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the I.QQ' T° estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non.....Vietnam veterans. The 95% confidence intervals (CIs) for each RRs were computed usiricj the procedures described by Laird and Oliver.''' The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), arid adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, arid combat engineers) arid "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses, ^ included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Morisori's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. �RESULTS There were some differences in both pre induction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small, Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications arid infantry unit assignments, reflect wai— related military requirements in Vietnam. Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among non-Vietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow.....up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time— specif ic results will be presented when appropriate . To determine whether the association between Vietnam service and mortality was uniform or varied across different subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 ( . % CI, 1.16 to 2.14). In the later follow-up period, adjustment 95 changed the RR to 1.04 (95% CI, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 2.1. years than to those discharged at age 21 years or older (P=.02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P=.05). Death Certificates. -• Only four major cause— of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circulatory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P=.03) than non-Vietnam veterans. The excess was most pronounced in the first five years after discharge from active duty �(RR, 1,93; P-.Ol). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow up period (RR, 2.47; P-.08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did riot materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% CI, 1.09 to 6.17). Medical Review Panel, ••••• The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3,7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; kappa = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICID 9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% CI, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1,21 (95% CI, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was primarily the result of two deaths from neoplasms among non Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of which were alcohol-related MVA deaths during this period (RR, 1.35; 95% CI, 0,60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow up period. Although the number of deaths is too small for formal analysis, further refinement of the later follow-up period suggests the upward trend in drug related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. �Again, as in the death certi Ficate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% CI, 1.11 to 5,87), No other RR presented in the medical review results was materially altered by adjustment. Gener.aJ Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general, population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire follow.....up period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0,48; 95% CI, 0.25 to 0.85), whereas non.....Vietnam veterans had only a slight deficit (SMR, 0.87; 95% CI, 0.54 to 1.34). �COMMENT The intent of our study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide range of possible health influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group, External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particularfactor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized differences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10""1^ are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method. 1 ^ The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.^ The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.^ Although the Australian investigators did riot examine external cause mortality by time since discharge, there was a suggestion of a decline in relative �mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occur more frequently among their Vietnam veterans, Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.^ The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes .•*••'• Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.^ Australian Vietnam veterans had an excess of deaths from al.cohol--reJ.ated natural causes, but no increases in deaths from alcohol related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American arid Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam, I'7'-'-^ drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.^ Our finding of increased mortality from drug-related causes in the later follow-up period was not consistent with surveys indicating little or no influence of Vietnam service on postdischarge drug use. ^ ^ ' The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.^ Various indexes of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.^ This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservice external-cause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. �10 Alternatively, our findings may reflect consequences of the unique environment arid experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included. 21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20,21 as (-j-jd non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide ad d i t i o na1 i n s i g h t s . �11 ACKNOWLEDGEMENTS The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefano, MD, Melinda L. Flock, MSPII, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RIM, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; MPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC, and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC, Copies can be obtained from the CDC, Atlanta, GA 30333. �12. REFERENCES H e . a lt-h !^t.99.ra!M .il^Grision and Improvement Act of 1979, Law96-~15'l.......( M R......3li?2)"......6e"c~20"........1979",.......93......STAT ...... ~ 2. Public Veterans' Health _......___......_^ , and . _ Business _ _ Act of 1981, „ . . _.....— —.......Care,, Tra i n i rig....._......._Small ......„_....... Loan . .......... _.. „ . _ _ 3 , [r°.t..9I t°L iEMi!M£l9<3.ic Studies of the Health of Vinetnam yc|tejrans . !...-9£.. Atlanta, Centers for Disease Control, November i.983. . ... .. c3 r Disease Control, 1987, States, rev 8, Welfare, 1967. PUS publication .1.693. i.ec! for Use in_..the Unitecl US Dept of Health, Education, and ..9f ..i...l0t r n a t i o n a 1 S t a t i s ti. c a 1 C la s s if i c a t i o n o f D i s e as e s , ... ..be,...e _.a!.ldjl§.y.?..§A...9f P.?a.th, rev 9. Geneva, World Health Organization, 97..................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 7. Laird l\l, Oliver D; Covariance analysis of censored survival data using log-linear analysis techniques . .J_Am Stat Ass_oc 1981; 76 : 231.....2.41 . 8. Cox DR, Oakes D: Ajlollisi.s_.....9.f. itlC.y,i.V..al Q.a.t.a.- London, Chapman and Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. s. 1974; 7: 325-3 32. Qomg 10. Anderson HA, l-lanrahan LP, Jensen M, et al: W..ij.conj_ij;i^V]i^^nami Veteran Mortality/ S.ty_dy . Madison, Wise, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of l\lew York State Vietnam veterans, Am_J.....PubllS.......Health 1985; 75 : 277-2.79 . 12. Kogan MD, Clapp RW: Mortality Amoj'ig Vietnam yeterans; in..Massiacjui]Sj3t1;;_si, l Z 2 i 9 3 . Bos ton , M ! a h s ! t l.r.8 a7TVe:^ ....... •——••- 1 3 . HO ime s AP : Charleston, W VA, West Virginia Health Department, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. 1 9 8 2. ; 2 4 : 2, 9 9.....3 04 , 15. Fett MJ, Dunn M, Aderia MA, et al: .CL^ ...^ Ay.st;ra_l.ian_ Vete_ra_ri_3......Health......S_tyd_i_e_sj:......The . . . . . ^ St_u_(iy_ of Q9b9C a a a e - 6 L t b ? ! ! . . £ s . . t Re po r; t . Canberra, A u s t ra 1 i a , . . . . !!9L<.i.l Australian Government Publishing Service, 1984. �13 16. Lathrop GD, Moynahan PM, Alfoanese RA, et al: £roj.ectRanch Hand II. An ! [ i i . 5 i . 9 i I D 5 ! ^ l : i . i £ °f...ii?!.l?.i.tb...JLffl;i!.£i5 illD...LCQiCS.® E§lisonnej. iE^!!.9l£c ..i..l.3^iD Foil owing Ex.J2£l^ureto..JJ..Ii-^rM.9..M£.?....;. !3<as£l.ine.!J£!r.^£il.tl......S..t.y..dj/ !l§..s.y.lt_s. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss ML: Vietnam military service and marijuana use, Am J D.ru_g_Alcoh£ 1__Abuse 1985; 11: 119•-130. 18. Robins l...l\l, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward . .Arch .Gen Psychiatry 1975; 32 : 955 961. 19. Yager "I", Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. A.r_cJ;i__Gen Psjf£hia_t_r\f 1984; 41:327-333 . 2.0. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epjidemio1 1974;!00:36 7-372. 21. Wefzger MD: Follow up studies of World War II and Korean War prisoners. I. Study plan and mortality findings. Am J_.E£_ideipi_o_l 1970; 91: 123-138 . �VIETNAM-ERA ARMY PERSONNEL R E C O R D S FILED AT NPRC BETWEEN SEPT 1964 AND JUNE 1977 Approx. 4,900,000 RANDOM SAMPLE 48,513 QUALIFIED FOR STUDY 18,581 RECORDS NOT FOUND 1,355 Ll NOT Q U A L I F I E D 28,577 NON-VIETNAM 9,023 DIED ON ACTIVE OUT 234 DIED ON ACTIVE DUTY 34 VIETNAM COHORT 9,324 NON-VIETNAM COHORT 8,989 Selection of s t u d y g r o u p , NPRC indicates N a t i o n a l Personnel Records Center; a s t e r i s k , excluded f r o m s t u d y ; and dagger, eighty-three percent (N=194) of a c t i v e d u t y deaths among V i e t n a m veterans were due to war-related activities. �fable 1. Differences in Selected Characteristics Between Vietnam and Won Vietnam Veterans at Entry Into Service and During Military Service Character:!, stic Vietnam (N=9324) Won-Vietnam (N=8989) _Ate_ntry_...into service Race/' (% white) 86.8 86.5 Age at entry, (mean) 20.3 20.5 Enlistment status/' ( draftee) % 63.7 65.6 Year of entry into service, (% before 1969) 72.1 60.6 103.1 105.5 Army General Technical Test score (mean, scaled to 100) During military service Primary mi 1 itary occupational specialty"1" % tactical operations 34 .3 27, ,4 Type of unit, % infantry 26..6 14,.6 Type of discharge, % honorable 97, 2 , 91, 0 Pay grade at discharge, % E4 or E5 88,,5 79, ,8 Year of discharge, % before 1970 ,1 48, 44. 6 Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups, + The job specialty for which the man was trained in the Army. �Table 2, Years Since Discharge Number of Deaths, Person-Years, and Death Rates Among Vietnam and Won Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965--1983'x' 6-1- All years V i §t na m Person-years 110 <5 l\lo. of deaths _ 46,350 2.4 73 44,747 1.6 1.45 1.08 1.96 136 81,547 1.7 127 76,582 1.7 1.01 0.79-1.28 246 127,897 1.9 200 121,32.9 1.7 1.17 0.97-1.41 Rate'1" l\lo. deaths _N o n;-V let n am. Person-years Rate4' RR indicates rate ratio; CI, conPidence interval. "'" Crude death rate per 1000 person years. RR 95% CI �Table 3, Number of Deaths Among Vietnam and Won Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge from Active Duty, 1965-1903 Y e a r s S i nee D i s c h a r < From Active Duty 30 <5 All years 6-1- Characteristic 'K' No. RR No. RR No. RR Race White Won white 146 37 1 .50 1 .30 193 70 0.99 1 .07 339 107 1 .18 1 .14 Enlistment status Volunteer Draftee 79 104 1 .09 1 .80 11 1 152 0 .91 1 .06 190 256 0 .98 1 .31 97 83 1 .42 l .43 141 1:1.9 0.90 1 .07 238 202 1 .08 1 ,2.0 63 120 l .'19 l ,58 89 174 1 .04 0,97 152 294 1 . 10 1. 1 8 47 136 l .83 l ,41 42 221 0.67 1 , 10 89 357 1 .14 1 .2.1 125 58 l .50 l . 95 183 80 1 .10 1 .16 308 138 1 .24 1 .44 79 2.05 122 0.96 201 1.27 104 1.16 141 1 .06 2.45 1. 10 GT test score"'" < .1.00 100+ Duty MOS + Tactical Other Age at discharge 21+ Pay grade at discharge E4 - E5 El - E3 Year of discharge <1970 1970-1- There was no evidence of statistically significant effect modification for any of these characteristics (P>0.05). Army General Technical Test (GT) scores were missing for six veterans. + Determined from principal military occupational specialty (MOS) held while on tour of duty. �Table 4. Number oP Deaths by Cause (from Death Cerlif'icato), Death Rates Among Vietnam and Won Vietnam Veterans, and Unadjusted RRs, 1965 190;i'K Underlying cause of death (ICD 9)+ Infectious and parasitic diseases (001 139) Vietnam No. Won Vietnam Rate? No. Rate + RR§ 95% CI 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1.76 Mental disorders (290-319) 7 5.5 7 5.8 0.95 0.3 3 --2. 70 Diseases of nervous system (320 389) 2 1.6 J. Diseases of circulatory sy s tern (390 459) 12 9,4 23 19.0 0.49 0.25--0.99 Diseases of respiratory system ' (460 519) 5 3.9 4 3.3 Neoplasms (140 239) Diseases of digestive system (520-579) 3.9 Diseases of genitourinary system (580-611) 0.8 ri ft \J , O 3.1 Congenital anomalies (740-759) ! 2.5 0.8 �Table 4. Number of Deaths by Cause (From Death Certificate), Death Rates ftrnong Vietnam and Won.....Vietnam Veterans, and Unadjusted R R s , 1965.....1903* (continued) Symptoms, signs, and :i. 1 !-•d e f i ne d c o n d i t i o n s (780.....799) External causes (E800-E999) 0.8 1.6 188 147.0 143 117.9 1.25 1.00.....1.55 l\lo death certificate \f. RR indicates rate ratio; CI, confidence interval, + ICD 9 indicates International Classification of Diseases, ninth revision. l\lo deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the rnusculoskeletal system. Therefore, these categories are not shown. T Crude death rate per 100,000 person-years. § If the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. �Table 5. Number of Deaths From Specific External Cause:; (K'rom Death Certificate) Among Vietnam and Won Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, .1.96.5-1983*' External cause of d e <5 a t Years Since Q_i_3charge From Acti ye Duty+ 6+ h ~ ~ Motor vehicle accident (E810--E825, E929.0) 66 1.93 1.16--3.22 67 Accidental poisoning (E8SO-E869, E92.9.2) 11 1.69 0.49 5.77 Other , accidents+ 23 1.05 Suicide (E950 E959) 25 Homicide (E960 E969) 18 Undetermined intentional:!, ty (E980 E989) 4 All Years 1.16 0.72-1.87 133 1.48 1.04 2.09 7 - - 18 2.47 0.88 6.92 0.46 2.37 39 0.89 0.48 1.67 62 0.95 0.58 1.56 1.72 0.76-3.88 32 0.64 0.32 1.30 57 0.98 0.58 1.65 1.52 0.59 3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 - 6 - 10 3.79 0.81-17.87 *' RR indicates rate ratio; CI, confidence interval; ICO-9, International Classification of Diseases, ninth revision. "'" Time-specific RRs are not presented for categories with less than 10 deaths in both Vietnam and non-Vietnam groups combined. £ Includes ICD-9 categories E800 to E807, E826 to E849, E870 to E928, E92.9.1, E929.3 to E929.9, E930 to E949, E970 to £978, and E990 to E999. �"fable 6. Number of Deaths From Alcohol and .Drug-Related Causes (From Medical Review) Among Vietnam and Mori-Vie tnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965.....1983* ............... Years_ S.ln£g_P_i^_chair3_e From Active Duty <5 6-1fill Years Cause of death o Alcohol.....related natural causes"1" 5 ..... Alcohol.....related traumatic causes t 42 1,29 Drug related causes§ 18 1.2.1. * + ~ ••••• " 25 0.87 0.40.....1.90 30 0.70-2.37 61 1.04 0.63-1.71 103 0.48 3.06 22 2.01 0.82-4.94 40 1.08 0.53-2.22 1.13 0.77.....1.67 1.58 0.83-3.00 RR indicates rate ratio; C.I, confidence interval. Includes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291,9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (42.5.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). + Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800--E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. § Deaths for which one of the following drug-specific diagnoses is the, underlying or contributing cause of death; drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E8S0.5, E850.8, E851-E8S4, E855.1 to E855.2, E866.6 and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). �Table 7. Years since discharge Observed and Expected Numbers of Deaths by Cause Among Vietnam and Mori Vietnam Veterans and SMRs, y by Years Since Discharge From Active Duty, 1965--1983 Cause of De ath+ (ICOA--8) Vietnam Won Vietnam 16 23 . 4 0.68 0.39-1. 11 13 24 . 2 0 . 54 0.29 0.92 Observed Expected SMR 95% CI 92 72.5 1 . 2.7 1.02-1.56 55 69.4 0.79 0.60 1.03 All natural causes (000 796) Observed Expected SMR 95% CI 38 65.8 0.58 0.41-0.79 39 63.4 0.62 0.44-0.84 Observed Expected SMR 95% CI 96 .1.02 . 7 0.93 0.76-1.14 88 96.6 0,91 0.73-1.12 All natural causes (000 796) Observed Expected SMR 95% CI 51 90.0 0,57 0.42 0.75 55 86.8 0.63 0.48 0.82 External causes (E800-E999) All years Observed Expected IJI SMR 95% CI External causes (E800--E999) 6+ All natural causes (000 796) External causes (E800 E999) <5 Observed Expected SMR 95% CI 188 175.2 1 . 07 0,93-1.24 143 166.0 0.86 0.73-1.01 SMR indicates standardized mortality ratio; CI, confidence interval; and ICDA 8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. "'" Excludes nine deaths (seven Vietnam, two non Vietnam) for which death certificates were not recovered. T Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young. For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 064 Folder The folder containing the original item. 1742 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived JAMA Date A point or period of time associated with an event in the lifecycle of the resource February 13 1987 Title A name given to the resource Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Subject The topic of the resource Vietnam Experience Study mortality trends veteran psychological health ao_seriesIII