Health impacts of war: case studies of New Zealand veterans of the First World War.

AIM: Armed conflict remains a tragic feature of the modern world and so it is necessary to continue to study its health impacts. Even the study of historical conflicts is relevant given that certain health impacts are common to most wars e.g., post-traumatic stress disorder (PTSD). METHODS: This study built on a previous quantitative analysis of a randomly selected group of 200 New Zealand veterans from the First World War (WWI). From this sample we selected 10 cases that illustrated particular themes around morbidity impacts. RESULTS: The theme of severity of impacts was illustrated with a case who was severely wounded and died from suicide when back in New Zealand, and another case with severe PTSD. The theme of the high frequency of non-fatal conditions was revealed with cases illustrating new diagnoses (a case with n=8 diagnoses), hospitalisations for new conditions (n=6), non-fatal injury events (n=3) and for sexually transmitted infections (n=3). The theme of chronic debility as a consequence of various conditions was illustrated with cases who had suffered from being gassed or having gastroenteritis, malaria or pandemic influenza. CONCLUSION: These 10 selected cases reiterate how severe and extensive the morbidity burden for military personnel in WWI could be. Also illustrated is how the morbidity could contribute to adverse impacts on some of their lives after returning to New Zealand.

Health impacts for New Zealand military personnel from the South African War of 1899-1902.

AIM: We aimed to update and provide more complete epidemiological information on the health impacts of the South African War on New Zealand military personnel. METHODS: Mortality datasets were identified and analysed. Systematic searches were conducted to identify additional war-attributable deaths in the post-war period. To estimate the morbidity burden, we analysed a random sample of archival military files of 100 military personnel. Lifespan analyses of veterans included those by level of combat exposure (eg, a non-combat sample came from a troopship that arrived at the time the war ended). RESULTS: We identified 10 additional war-attributable deaths (and removed three non-attributable deaths) to give a new New Zealand total of 239 war-attributable deaths. Given the average age of death of 26 years, this equates to the loss of 10,300 years of life. Most deaths (59%) were from disease rather than directly from the conflict (30%). Over a third (39%; 95%CI: 30%-49%) of personnel were estimated to have had some form of reported illness (26%) or injury (14%). The lifespan analysis of veterans suggested no substantive differences by exposure to combat (68.5 [combat] vs 69.1 years [non-combat]) and similarly when compared to a matched New Zealand male population. CONCLUSIONS: The mortality burden was larger and the morbidity impacts on the New Zealand military personnel in this war were much more substantive than revealed in the prior historical literature. There is a need to more fully describe historical conflicts so that their adverse health impacts are properly understood.

Descriptive Epidemiology of New Zealand's Highest Mortality Earthquake: Hawke's Bay in 1931.

In this study we aimed to produce the first detailed analysis of the epidemiology of the severe injury and mortality impacts of the 1931 Hawke's Bay earthquake in New Zealand (NZ). This involved the compilation and analysis of archival data (hospitalisations and deaths) including the examination of 324 death certificates. We found that there were 662 people for whom some hospitalisation data were available at four weeks post-earthquake: 54% were still in hospital, 4% were still classified as "serious", and 5% had died (n = 28). Our classification of death certificate data indicated 256 earthquake-attributable deaths and for another five deaths the earthquake was estimated to have played an indirect role. There were 15 buildings associated with three or more deaths each (accounting for 58% of deaths with a known location). Many of these buildings were multi-storey and involved unreinforced masonry - with some of this falling into the street and killing people there (19% of deaths). In contrast, deaths in homes, which were typically of wood construction and single stories, comprised only 3% of deaths. In conclusion, this earthquake had a relatively high injury impact that appears partly related to the lack of regulations for building construction that would mitigate earthquake-related risk. Such regulations continue to be of relevance for New Zealand and for other countries in earthquake zones.

The long history of health inequality in New Zealand: occupational class and lifespan in the late 1800s and early 1900s.

OBJECTIVE: As relatively little is known about how socioeconomic position might have affected health prior to the Second World War, we aimed to study lifespan by occupational class in two cohorts in New Zealand. METHODS: The first study included men on the electoral rolls in Dunedin in the period 1893 to 1902. The second study used an established cohort of male military personnel who were recruited for the First World War. Linear regression was used to estimate lifespan by occupational class. RESULTS: The first study of 259 men on the electoral rolls found no substantive lifespan differences between the high and low occupational class groups. But the second study of 2,406 military personnel found that men in the three highest occupational classes lived 3.5 years longer (95%CI: 0.3-6.8 years) than the three lowest classes (in the multivariable analysis adjusting for age in 1918 and rurality of occupation). CONCLUSIONS: We found no significant lifespan differences in one cohort, but a second cohort is the earliest demonstration to our knowledge of substantial differences in mortality by socioeconomic position in this country prior to the 1960s. Implications for public health: This study provides historical context to the long-term efforts to address health inequalities in society.

Remembering the 1918 influenza pandemic: national survey of memorials and scope for enhancing educational value around pandemic preparedness.

AIM: To systematically identify physical memorials to the 1918 influenza pandemic in an entire country. METHODS: Internet searches, contact with local historians and field expeditions were conducted. RESULTS: Despite the high impact of the 1918 influenza pandemic in New Zealand (~8,600 deaths), only seven publicly accessible local memorials which referred this pandemic were identified. Another 11 memorials were identified, but these were in private settings or did not refer to the pandemic. There is no national memorial and a marked contrast exists with the number of war memorials (260 times more per 1,000 deaths for one war), and for 20 smaller mass fatality events (one of which has eight memorials alone). The current educational value of these pandemic memorials is likely to be minimal since only three are in cities, there is a lack of supporting signage and there are no links to online resources. CONCLUSIONS: Despite the major impact of the 1918 influenza pandemic in New Zealand, publicly accessible memorials were found to be rare. This was in marked contrast to other disaster-related memorials and particularly to war memorials. There appears to be major scope for enhancing public education around the persisting threat of future pandemics via improved use of physical memorials and linkages to online resources.

Mortality of first world war military personnel: comparison of two military cohorts.

OBJECTIVE: To identify the impact of the first world war on the lifespan of participating military personnel (including in veterans who survived the war). DESIGN: Comparison of two cohorts of military personnel, followed to death. SETTING: Military personnel leaving New Zealand to participate in the first world war. PARTICIPANTS: From a dataset of the New Zealand Expeditionary Forces, we randomly selected participants who embarked on troopships in 1914 and a comparison non-combat cohort who departed on troopships in late 1918 (350 in each group). MAIN OUTCOME MEASURES: Lifespan based on dates of birth and death from a range of sources (such as individual military files and an official database of birth and death records). RESULTS: A quarter of the 1914 cohort died during the war, with deaths from injury predominating (94%) over deaths from disease (6%). This cohort had a significantly shorter lifespan than the late 1918 "non-combat" cohort, with median ages of death being 65.9 versus 74.2, respectively (a difference of 8.3 years shown also in Kaplan-Meier survival curves, log rank P<0.001). The difference for the lifespan of veterans in the postwar period was more modest, with median ages of death being 72.6 versus 74.3, respectively (a difference of 1.7 years, log rank P=0.043). There was no evidence for differences between the cohorts in terms of occupational class, based on occupation at enlistment. CONCLUSIONS: Military personnel going to the first world war in 1914 from New Zealand lost around eight years of life (relative to a comparable military cohort). In the postwar period they continued to have an increased risk of premature death.

Developing a physician engagement agreement at The Ottawa Hospital: a collaborative approach.

The Ottawa Hospital (TOH) is focused on providing safe, high-quality care to its patients. TOH has identified physician engagement as a critical factor for improving the quality of care they provide. The physician engagement strategy developed at TOH involved a qualitative inquiry into the impediments and facilitators of engagement. Using concurrent focus groups, researchers collected and analyzed the physicians' perspective regarding engagement. A systematic analysis of the verbal data was used to construct a statement of mutual understanding between the physicians and the hospital (physician engagement agreement). The process of developing this agreement is the focus of this article.

[Improved access and quality of palliative care: the Vaud cantonal programme and the Lausanne model]. / Vers un accès généralisé à des soins palliatifs de qualité: programme cantonal vaudois et modèle lausannois.

The Canton of Vaud introduced a development programme of palliative care in 2002. The goal of the programme was to ensure equal access to palliative care for anyone suffering from chronic progressive disease. One cornerstone of this programme is the desire to focus the intervention in the person's home, when desired by the patient and his family. Care networks are responsible for the implementation of this programme. The model presented here illustrates the means implemented and makes a preliminary assessment, which confirms the relevance of the main axes of the programme--training front-line teams, mobile second line teams specialized in palliative care and bed units.