Monday, 26 August 2013

2008 - An Approach for the Malvinas War Veterans´ issue : The Peer Support.



- Eduardo C. Gerding  -


International Review of the Armed Forces Medical Services Vol 81/2- June 2008, pp 115-127







"The extreme and terrible nature of war touches something essential about being human. For those who survive, the victors and the defeated, the battle lives in their memories and nightmares ... It survives as hundreds of searing private memories, memories of loss and triumph, shame and pride, struggles each veteran must fight each day of his life."

- Mark Bowden, Black Hawk Down: A Story of Modern Warfare.


The Operational Stress Injury

Operational stress injury (OSI) is a non-medical term used to describe any persistent psychological difficulty including anxiety, depression and Post Traumatic Stress Disorder ( PTSD ) resulting from operational duties performed by the men and women of the Armed Forces. The OSIs (or Combat Stress Reactions) are not mental weakness nor are they signs of cowardice. OSIs have no preferences and can strike anyone of any gender, of any personality type, rank, trade or classification. The OSIs don´t prefer one operational tour to another.

The symptoms and the injuries themselves vary according to the nature of the warfare and, equally important, the reception given to the injured soldier. Single traumatic events - including events far away from combat - can generate vivid, ever more frequent nightmares. In many case the symptoms do not appear for some time after the event a veteran can return home healthy with years passing before the condition develops. US Army General George Patton whose views on this subject are thought to be extreme, stated that ‘any man who says he has battle fatigue is avoiding danger’. This traditional equating of OSI with cowardice is still sometimes encountered even in modern armies (89). However we should remember that courage is not absence of fear, but the mastery of, and ability to overcome fear. (60,61,94). Efforts to predict which combatants might be more vulnerable have broadly failed. It has been suggested that female soldiers are "more resilient" in some unexplored way.  Washingtonpost.Newsweek Interactive. Notwithstanding, female may require too assistance to avoid marginalization.(7)


The soldier´s experience in the battlefield
 

What is a soldier exposed to ? We should remember the traumatic experience of the conscripts aboard the cruiser ARA General Belgrano. Mount Longdon, Mount Tumbledown and Goose Green were no doubt bloody ground battles which ended with fixed bayonets and hand-to-hand fighting (28). The Welsh Guards were bombed aboard the RFA Sir Galahad and Sir Tristam at Bluff Cove/Fitzroy more than 55 were killed and many were terribly burned and injured.(2).The 1982 conflict took 746 Argentine lives, 255 British and 3 inhabitants of the island. It was certainly no picnic. The campaign cost the British 255 men killed (113 of the Royal Navy) and 777 wounded (436 of the Army).(38,39). Robert Fox, BBC radio´s man in the front line, wrote on the 1982 conflict that ¨more British servicemen died than the total number killed on operations in Afghanistan since 2001 and Iraq since 2003. Such attrition is unlikely to be tolerated today (2).

A most accurate report on this type of dreadful experience was published in The New England Journal of Medicine showing that during the Iraq war 56 percent of soldiers and Marines have killed another human being, 20 percent admit being responsible for noncombatant deaths, and 94 percent had seen bodies and human remains. (11). Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.(46). The majority of soldiers probably won’t want to discuss what they did and the horrific things they encountered at all. And again, they might well like to isolate. If they elect to be with others, they will probably want to be around those who are war veterans like themselves. They want to be with people can understand what they went through, plus the resulting emotionally painful aftermath.(29)

Note:
In the case of the 1982 conflict intellectuals still argue about the war and its consequences (43,77,81).In the meantime, Great Britain maintains a heavy military presence at the Mount Pleasant complex on Isla Soledad. The cost is some $150 million a year, or about one quarter of 1 percent of Britain's defense budget, and includes about 1,200 soldiers, sailors and airmen, plus weaponry ranging from Tornado jet fighters to howitzers and naval patrol craft. (79)
The soldier´s self image
 
Is there a stigma so strong that a soldier is unwilling to admit, even to himself, that he's injured? Does the world regard him as a legitimate casualty, or as merely a weak individual (58,67). And is this soldier returning to a place that accepts him gratefully as a veteran, or will he be scorned as promoting an unjustified war? Does the war veteran describes his own experience (Gallo) or has incorporated what he has read in books about the war? (36). Injuries sustained sometimes get buried deeply within, where they can fester and poison other parts of the veteran's life to the point of total breakdown. (76) . Tony McNally was a gunner in the British Royal Artillery during the 1982 Conflict. He has battled mental health problems for years, triggered by guilt over the moment his missile system  malfunctioned being unable to prevent the death of his comrades on bombed and blazing ships.

At his home in Dalton, Cumbria , Mr McNally recalled the moment when four Argentine jets, two A4 Skyhawks and two supersonic Mirages, came roaring in to attack the Royal Fleet Auxiliaries Sir Galahad and Sir Tristram as they landed Scots Guards and Welsh Guards at Bluff Cove on the western side of the  Falklands, the launchpad for an attack on Argentine forces occupying Port Stanley, 80 miles away. "The British  Army's way of telling you to deal with war immediately after is to get drunk and that will sort you out," said Mr McNally. "On the ship home, it was chaos. People started fighting; one guy stabbed another guy in the belly with a bayonet. For a military environment, it was pretty illdisciplined.
When Mr McNally returned to Britain, he felt flat and depressed. "When I got off, my parents weren't there to greet me. I felt so alone. I made my own way home. When I got there my mam hugged me and my dad shook my hand, but that was it, it seemed like a massive anticlimax, like I'd just been out for a packet of fags." He was 19 years old. (87)
The moral edge
 
Psychologist and former US Army Ranger, Lieutenant Colonel Dave Grossman and others have written extensively and insightfully regarding the profound debilitating effects of killing in war combat behavior. He emphasized the importance of appreciating the relevancy of moral values and norms to defining themselves as personas, structuring their world, and rendering their relationship to it, and to other human beings, comprehensible. Those values and norms provide the parameters of our being called ¨moral identity¨ by Grossman. I term our Combat behavior often violates the moral identity and negatively impacts on the self-esteem, self-image, ands integrity causing debilitating remorse, guilt, shame, disorientation and alienation from the remainder of the moral communitymoral injury. (11). Dr Nigel Hunt´s research has examined the universal and the cultural effects of war trauma.
The universal elements of the condition include the traumatic event, and the memory of that event, which triggers an emotional response. Also universal are the two basic elements of coping with the condition — either addressing it or choosing to ignore it. The cultural elements of war trauma cover the acknowledgement, treatment and support networks for the condition, as well as the way it manifests itself. This can vary broadly depending on the nationality, social background and religion of those suffering from the symptoms. In Finland veterans are the focus of a great deal of respect from their government and population. They are also offered annual 'respite care' sessions at specially-built camps across the country. Here they can spend two weeks a year with other veterans, in a relaxing environment, with access to expert advice and help. As a result, Finland sees a very limited incidence of war trauma among its veterans. But for veterans coming home to the UK find no such support network in place. Often, the only place for them to turn is oversubscribed charities such as Combat Stress and the Royal British Legion. 
In Iran, there's a very strong religious support network in place,” said Dr Hunt. “The existence of war trauma is recognized, particularly in relation to the Iran-Iraq War, and people are supported by their religious belief and their relationship to their imam and mosque. Their reasons for going to war were just, because they were fighting for God, and their memories and injuries are justified by their devotion.”. ¨Here in the UK we don't have such a strong belief system. Those fighting in Iraq and Afghanistan are more likely to ask what they are fighting for. When they see horrific incidents, they might struggle to justify it in the context of the wider conflict. Unlike Iranian soldiers, they know they don't have the full support of the people back home. And when they do return home, a system isn't in place to deal with the resulting psychological problems. All of these factors will mean that war trauma amongst UK veterans will increase over the coming months and years unless significant extra funding and effort is dedicated to supporting them.
 
The PTSD
 
That combat stress reactions could be a consequence of a mental conflict arising from a sense of duty being matched by an unconscious wish to survive, was first adapted to battle psychiatry by the psychoanalyst David Eder (1916) whilst working with soldiers evacuated from Gallipoli (94). It is estimated that twenty-five to thirty-nine percent of Argentine war veterans suffered PTSD and eighty-eight percent of them have never attended a health centre (10,13). More than half of all male Vietnam War veterans and almost half of all female Vietnam War veterans have experienced PTSD. In the USA. the rigorous evaluation of war-related psychiatric disorders begun with the National Vietnam Veterans Readjustment Study. This national epidemiologic survey of male and female veterans of Vietnam was conducted in the mid-1980s. The veterans were therefore assessed 10 to 20 years after their service in Vietnam. The prevalence of current PTSD was 15 percent among men and 8 percent among women. The lifetime prevalence of PTSD was higher 30 percent among male veterans and 25 percent among female veterans. (14,34). Prior research has revealed heightened aggressive behavior among veterans with PTSD.(86). New research into PTSD is leading to a better understanding of its underlying neurobiology, risk factors and long-term implications. 
The findings were published in a recent issue of Annals of the New York Academy of Sciences and were revealed at a conference jointly sponsored by the New York Academy of Sciences and the Mount Sinai School of Medicine.(64,97,98). According to Colonel Charles Engel MD, MPH, director of the deployment health clinical center at Walter Reed Army Medical Center, between 15 and 29 percent of soldiers returning from Iraq and Afghanistan will suffer from PTSD (11). Table 1 shows the results observed among the Argentine War Veterans. There were no Royal Army Medical Corps psychiatrists in the Malvinas war (73). US Army researchers evaluated health assessment forms completed by 88,000 soldiers and an attending clinician immediately on their return from Iraq and then again a median of 6 months later. 
Immediately upon return, reservists and active duty soldiers showed similar rates of overall mental health concerns — about 17% in each group. During follow-up reevaluations, however, reservists reported "substantially higher rates of interpersonal conflict, PTSD, depression, and overall mental health risk" than active duty soldiers.(62). Dr Nigel Hunt, Associate Professor in the Institute of Work, Health and Organizations (University of Nottingham, UK ) points that. “If you start showing symptoms of war trauma during service you are the responsibility of the Ministry of Defense and you have access to a strong network of support and treatment,” he said. “But many people do not develop the condition until they have left the services, once they have lost the supportive network, spending time day to day with people who understand what they have been through and how they feel. Once out of the services, they are the responsibility of the NHS, where many practitioners don't have the experience and specialist knowledge to deal with people suffering from war trauma. And once they have been diagnosed, they can spend up to two years on a waiting list waiting to be treated.”(93)

Who are the professionals who deal first with the PTSD? As a general rule the GPs are the first ones. In the USA, war veterans are supposed to fill a previous formulary made by the National Center for PTSD (NCPTSD) ( Screening for PTSD in a Primary Care Setting in the medical office ) which not only allows to detect such cases but instruct the GP what to do if the war veteran refuses the health mental assistance. Who treat the PTSD? Psychiatrists are the physicians who have specific training in the assessment, diagnosis, treatment, and prevention of mental illnesses. Psychiatrists attend medical school and receive an M.D. After completing medical training, they complete an additional four years of residency training in mental health. In addition to this, some receive additional training in a specific area of interest such as geriatric psychiatry, child and adolescent psychiatry, addictions and other areas. A second important distinction between a psychologist and a psychiatrist is that the last can prescribe medication, while psychologists cannot. There has been a recent push to grant prescribing powers to psychologists, with states such as New Mexico and Louisiana (USA) now allowing psychologists to write prescriptions after consulting with a psychiatrist.(Kendra Van Wagner- How Do Psychologists Differ from Psychiatrists ?-About.com: Psychology )
The legal consequences
 
A group of 280 British ex-servicemen are suing the Ministry of Defense in the largest group action of its kind to seek compensation for post-traumatic stress disorder. The veterans, who between them have served in almost every recent military action involving British forces - including Bosnia, the Gulf, the Falklands and in Northern Ireland - claim the MoD failed to diagnose and treat those suffering from PTSD.(42,45,91)
 
Note:
Veterans with PTSD did not differ from those without PTSD in hippocampal volume, but they did show significantly lower urinary cortisol levels, and poorer memory performance on the Wechsler Logical Memory test and Digit Span test. Smaller left hippocampal volumes were observed in veterans who developed PTSD in response to their first reported traumatic exposure, compared to veterans who had first experienced a traumatic event to which they did not develop PTSD, prior to experiencing a subsequent event that led to PTSD. In contrast, the two neuroendocrine measures were associated with risk factors related to early trauma exposure. (97,98)

 
The war veteran´s family
 
The total amount of deaths produced by the sinking of the cruiser ARA ‘General Belgrano’ represents 50 per cent of all the Argentine casualties in the conflict. Thirty per cent were 18 years old conscripts which had an obvious impact in many families. The 1995 research of the INSSJP over 145 war veterans showed that 36.6%
had disintegrated families with abandon of one or two parents. A great amount (35%) of their fathers died immediately after the Malvinas war thus increasing the veteran’s sense of guilt. About 64% belonged to a low
income class. 74 % suffered discrimination when searching a job. Only 12 % owned a property and 35% lived in precarious situations. (13). The Australian Gulf War Veteran´s Health Study(2003) revealed that veterans
were more likely to report fertility problems. (18).The Vietnam Veterans Health Study (partners and  children) (1998) of 40,030 Vietnam veterans reported on their partners and children health showed that 36% of the partners were affected by the veteran´s experience, 40% suffered stress, 34% anxiety and 30% depression.21% had problems conceiving a child and 22% had a miscarriage. They had a child with a major illness (27%), psychiatric problem(11%), anxiety disorder (16%), congenital abnormality (16%), cancer (2%), fatal accident (2%) and suicide (1%).(18). The risk of a Vietnam veteran fathering a child with an anomaly was similar to that of other fathers (29).The partners and children of Australian Vietnam veterans study(1999)revealed that children of veterans presented more family conflicts (95).

The war veteran might be inclined to disregard the family; he or she might isolate and not want to participate in important events meaningful to others. And, because the war veteran might appear unwilling to assume certain responsibilities, he or she might come across as lacking concern for others, or self centered. However, again, these responses likely don’t stem from narcissism, but could easily be symptoms of PTSD.(29). This same concepts were issued by Mike Seear and Professor Lars Weisaeth in Buenos Aires at the Women´s Forum on March 28,2007 (52). The long term consequences of an OSI for family members and also for personnel dealing with war veterans affairs may include compassion fatigue and in some cases vicarious trauma. (South Carolina Law Enforcement Assistance Program)
 
Domestic violence
 
Regarding domestic violence, the partners of women at greatest risk were those who abused drugs or alcohol, were intermittently employed or unemployed, had less than a high-school education, and were former husbands, estranged husbands, or former boyfriends of the women. What is never stated, however, is that what carries the lowest risk of domestic violence for women is marriage. Stated another way, among women in relationships that are less stable than marriage, the risk is three times as high.(99). The use of illicit drugs and a history of physical fights in the home are important risk factors for homicide in the home. Rather than
confer protection, guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance (56)

What the Veteran Says - What his Family Says

In 1995,according to an Argentine Legal Information Center (Centro de Informática Judicial de la Cámara Civil) , there were 1009 accusations of domestic violence which increased to 1601 in 1996 and skyrocketed to 1820 the following year. The Woman´s Municipal Center of Vicente Lopez (Province of Buenos Aires) had 3500 average annual cases of domestic violence. In Cordoba the Assistance Center to Victims gave support as well to 5000 victims. In 1995 and 1996 there were 25,000 average emergency telephone calls for domestic violence in the city of Buenos Aires.

 About 1700 victims were assisted in 1998 at the Hospital Alvear´s Violence Center, 1200 of which were due to marital violence.500 victims were assisted in 1978 at the Argentine Association for the Prevention of Domestic Violence. It´s estimated that there are 5000 to 7000 rapes per year in Argentina.(PNUD) (71)
 
Suicides as the 1982 Conflict´s aftermath
 
The Korean War Veterans´ Mortality Study (2003) among more than 17.000 male military veterans revealed a higher mortality from suicide (up by 31%) and alcoholic liver disease (up by 36%).(18). There are no official data on war veterans´ suicides neither of the Argentine nor the British. (69). In the case of the British this applies to the government, the Ministry of Defense, the army, navy, RAF and even the individual regiments themselves. According to The Pan American Health Organization in 1995 accidents were the most prevalent external cause of death among Argentines 30 years and younger followed by suicide (574 deaths in 1995). From age 30 on, the leading cause of deaths shifted toward cardiovascular disease and malignant tumors. Information on the prevalence of mental illness in Argentina is very scant.

Data from public-sector establishments are incomplete, but indicate that 2,5% of all hospitalizations were related to this category of disease. (88). In 2002 a shocking little known toll of the Malvinas War was revealed: More veterans have taken their own lives since the South Atlantic conflict ended than the number of Servicemen killed in action. (31,37,63). According to the Argentine Health Minister in 2004 the annual suicide rate in Argentina was 8.2 cases per 100,000 inhabitants. If we take as certain the number of Argentine war veterans who committed suicide that rate would be 108.7
that is 14 times higher than the rest of the population(35) According to the WHO in 1999 the UK the annual suicide rate for males was 11.8 and 3.3 for women. It has been stated that 4 of every 10 Argentine war veterans have tried to commit suicide sometime (16). Argentina’s veterans believe 460 of their men have died by their own hand.

The South Atlantic Medal Association say they are "almost certain" the suicide toll is greater than 255 - the number of men killed in the war (almost the equivalent of half a battalion of fighting men). The association estimates the total could be 264, according to a report in the Mail on. Cofounder Denzil Connick blamed the suicide rate on the "stiff upper lip brigade" and a lack of resources to tackle PTSD. They were policemen, teachers, lorry drivers and care workers or simply unemployed. But they had one thing in common.

They were all Malvinas war veterans, they had all suffered post-traumatic disorders, and they were all failed by the system. It’s hardly surprising that some soldiers and sailors who experience the full horrors of war fail to readjust to civilian life.

Haunted by their experiences, terrorized by flashbacks, they develop psychiatric disorders and, in spite of the support of family or friends, succumb to suicide. Among the Argentine and British forces the same question arises: Why him ? why my comrade? Why not me? Argentine cases Corporal Gunner Eduardo Adrian (Tachi)Paz who served in the Argentine Navy since he was 17 years old (aboard the destroyer ARA Segui) left his home in Rosario on November 22, 1999 and went to the 70 m high Flag Monument from where he jumped. Paz who worked as a painter had six children (3 to 16 years old). (5,31). Former conscript Juan Loncopán from Comodoro Rivadavia who was an employee at the local municipality had 5 children. One night 37 years old Loncopan hanged himself in a soccer stadium leaving note stating he couldn´t cope with the 1982 conflict.(5)

Another war veteran called Ramon Antonio Acevedo (Pucará) was a fisherman from Puerto Vilelas (Province of Chaco) who had 5 sons. He was admitted to a hospital and killed himself with a shotgun. Navy Petty Officer (ret) Julio Cesar Araoz was a maquinista aboard a corvette. When he returned from the war shot himself with a .38 revolver.(69). Romualdo Ignacio Bazan from the province of Catamarca was a sailor aboard the Monsunen. When this last was attacked by the British the Corporal Javier Rivero fell in the cold waters. Then Bazan without knowing how to swim plunged into the sea and rescued his comrade. He received the Medal for Courage. When the war ended Bazan joined the Federal Police where he became a Sargeant. Then in 2006 he hanged himself in his house in Lanus leaving a young former wife and two children (65)


War veterans´sons commit suicide just like their parents

 
In 2006 the society was shocked when three young lads committed suicide just like their fathers did (69)
 
British cases
 
Charles 'Nish' Bruce, an SAS hero of the Falklands and one of the world's top freefall experts, who leapt to his death from a light aircraft last week (Mr Nish plunged 5,000ft from a plane without a parachute). A former 2 Para Lance Corporal said: "I know that around 37 former Paras who served
in the Falklands have killed themselves
". Connecting a vacuum-cleaner hose to his car, Ian Cubbold, 60, switched on the engine, took sleeping tablets and lay down to inhale the lethal exhaust fumes and die at his home near Yeovil, Somerset, in 1993. There were no such preparations made by Colin Dreary, aged 31. He simply picked up a knife and stabbed himself to death at his home in Sunderland in 1994. Mark Crown, 39, died in June 1995.  He handcuffed one hand to his car steering wheel, doused himself with petrol and set himself ablaze. He left a wife and two children. Jim Laker was 37 in September 1997 when he launched himself off the roof of a building in Aldershot.

Note:
According to his wife Ann Laker, Jim Laker did not throw himself off a building in Aldershot as referred by The Sunday Times June 10, 2007 (Times On Line) http://www.timesonline.co.uk/tol/news/uk/article1899458.ece. Jim Laker did die in 1997 (September 27th his daughter´s 11th birthday), he hanged himself in the attic of their house in Sandhurst, Berkshire. (The Falklands, Friday 2, May 2008)

Stephen Rawlins, a guardsman aged 38, hanged himself at his father’s home in south Wales on Remembrance Day, 2000.  Martin Harbert, 44, hanged himself, leaving three children, in May 2001. Charles Bruce, 46, threw himself out of a plane without a parachute in January 2002.  John Hunt, 39, took an overdose of pills in June 2002, at his home in Calne, Wiltshire. That same year, Godfrey Williams, 40, died in Llandeilo, south Wales, after stabbing himself in the heart with a bayonet. (25,27,32)

The American experience
 
The US military is experiencing a "suicide epidemic" with veterans killing themselves at the rate of 120 a week (1), according to an investigation by US television network CBS. At least 6256 US veterans committed suicide in 2005 - an average of 17 a day - the network reported, with veterans overall more than twice as likely to take their own lives as the rest of the general population. While the suicide rate among the general population was 8.9 per 100,000, the level among veterans was between 18.7 and 20.8 per 100,000.

A study which tracked 320,890 US men, about a third of whom served in the US military between 1917 and 1994 showed that male veterans are twice as likely to die by suicide than people with no military service, and
are more likely to kill themselves with a gun than others who commit suicide.(Reuters, June 11,2007).Which ages represent the higher risk ? A study by the University of Michigan and the Department of Veteran Affairs revealed that although veterans diagnosed with depression are not more likely to commit suicide than other civilian patients, there is a significant difference in the suicide rate for younger war veterans. The study concluded that, despite speculations of older veterans being more susceptible to suicide, those within the 18-44 age range showed the greatest suicide risks. The findings were backed up by associate psychiatry professor Dr. Paul Ragan of the Vanderbilt University Medical Center. Dr. Ragan explained that the results have been confirmed in the past by other members of the scientific community. He also said that suicide risks rise for people in general who are within the ages of 15-24, and those aged 40 and up, explained ABC News.

The cause of unreliable data

In the case of the 1982 conflict just like Vietnam there have been probably a variety of reasons by which actual suicide numbers have been difficult to collect. The following may have interfere with data collection (99)
  • Intentionally vague coroner reports
  • Coroner's sincere inability to exact cause of death
  • Professional's falsifying documents
  • Religious factors
  • Body not recovered
  • Refusal by family members to acknowledge suicide
  • Job security of surviving family members
  • Inconclusion the person served in Vietnam
The Vietnam myths on suicide
 
It is interesting to note that in Vietnam many statements were quoted which were lately repeated in other conflicts. Those myths state that the Vietnam veterans were driven, or encouraged, to end their lives by something or someone.

Common among groups of surviving Vietnam veterans are comments like,

  • "(the spouse) drove (him/her) to commit suicide."
  • "(he/she) couldn't keep a job. Employers are against Vietnam vets."
  • "(he/she) knew Agent Orange (cancer) would get (him/her)"
  • "Too much stress"
  • "The (VA or Federal government) refused to help (him/her)"
Drugs
 
Can drug addiction be rightly linked to wartime service? Is the problem worse than the Armed Forces are willing to admit?. (ABC ) There are no reliable papers on Malvinas war veterans and drug abuse. However, there have been some researches on the general population which may be fully applied to the war veterans.

Argentina is the Latin American country which consumes more marihuana (21,22). In the province of Buenos Aires, the amount of drug addicts assisted increased from 15,000 in 2002 to 30,000 in 2003. About 300,000 to 500,000 use illegal drugs in such province. According to the WHO the use of the paco (a drug composed by very toxic cocaine residues) has increased 200 % in the last four years thus being at the top of the rest of the Latin American countries. (6,83). Notwithstanding, there are no war veterans registered at the SEDRONAR (Secretary of Prevention and Assistance) ( Note 29-9-06). Scientists at the University of South Florida and James A Haley VA Medical Centre in Tampa state that they have definitively linked a common genetic trait to drug and alcohol abuse. The discovery elaborates on earlier suspicions about a gene called mu-opioid. It might eventually help people measure their own risk for addiction, and help scientists design more effective drugs for treating substance abuse. The researchers found that 95% of study participants who abused alcohol, smoke and used illicit drugs shared a specific variation of the mu-opioid gene (3,4).
 
Alcohol
 
Beer sales in Argentina increased from 240 million litres in 1980 to 1300 million litres in 2003 (a 400 per cent increase).(22).  In Argentina the driver who is a heavy drinker as well has an average age of 45 years old
which is very much the age our Malvinas war veterans have (9). Diane England, Ph.D. worked overseas with military families in Italy for five years, including during the first year of the Iraq War. She says that as they did not know about PTSD at the time and had no treatments for it, veterans were left to deal with the symptoms of PTSD on their one.  And indeed, to deal with the painful memories and the flashbacks, for example, many turned to alcohol and drugs to self medicate. Then, over time, they became alcoholics and drug addicts. Some of these same veterans who developed PTSD engaged in emotional abuse and verbal abuse, using it against their wives and their children. (29). According to the US National Center for PTSD, 25-75% of survivors of abusive or violent trauma report problematic alcohol use, this is associated with a chaotic lifestyle, which reduces family emotional closeness, increases family conflict and reduces parenting abilities.

The importance of epidemiological analysis
 
The only way to ascertain the true prevalence of organic and psychiatric casualties of the war among serving soldiers and their relatives is by epidemiological studies. (53). When the British faced subjective complaints
among their forces which couldn´t be effectively investigated objectively they compared prevalences with a cohort sample.  At the King´s Centre for Military Health Research a study was made in which they compared the health of male regular UK armed forces personnel deployed to Iraq during the 2003 war with that of their colleagues who were not deployed, and compared these findings with those from previous survey after the 1991 war. The statistical analyses was done in the Stata Corporation, College Station, TX, USA). (47,48,51).A similar research was postulated in by the author and Mike Seears between Argentine forces deployed (Mount Tumbledown) and non deployed and a comparison with their British counterparts .(82)
 
Note:
A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design and should be compared with a cross-sectional study. A cohort is a group of people who share a common characteristic or experience within a defined time period (e.g., are born, leave school, lose their job, are exposed to a drug or a vaccine, etc.). A bias is a prejudice in a general or specific sense, usually in the sense
for having a preference to one particular point of view or ideological perspective. However, one is generally only said to be biased if one's powers of judgment are influenced by the biases one holds, to the extent that one's views could not be taken as being neutral or objective, but instead as subjective.

Organic diseases
 
The Veterans´ Cancer Incidence Study (2003)among more than 15,000 male military Korean War veterans alive in 1982 revealed a higher cancer incidence overall (up by 13%)and for selected sites. (18)

Resilience
 

The Vietnam Australian Veterans´Sons and Daughters Project has been focusing on resilience and was part of the Australian Government to reduce the higher rate of suicide among sons and daughters of veterans than the Australian norm. It aimed to reduce suicide by increasing personal strengths, coping skills, resilience and access to care. (12,17,59). Unfortunately only 2% of children use the service. Dr Polusny and her research team have developed a program of longitudinal risk and resiliency research focused on National Guard soldiers and their families. Currently, over 2,600 Minnesota National Guard soldiers are deployed to OIF(Operation Iraqi Freedom) (Iraq and Afghanistan) with the 1st Brigade Combat Team of the 34th Infantry Division (1/34 BCT). The study and two year follow up will evaluate the effectiveness of reintegration interventions for resilience in OIF/OEF veterans, measure the health economics of deployment and describe gene-environment predictors of resilience in combat veterans. (72)

The war veterans´s centers
 

In addition to the primary tasks of fostering pride and friendship among combat veterans, veteran organizations have an important role to play in securing preventive, curative and rehabilitation health services for its members. Combat veterans and veteran organizations can also, because of their experience of the true reality of war, contribute in a unique way towards reconciliation between former enemies and provide support to those who have been exposed to war’s traumatic stresses and suffer from its consequences. (94)

The Peer Support Approach

Healing can be accelerated by the support of peers, health professionals and resources within the community. The Peer Support approach assumes that individuals who have experienced a mental illness can better understand and relate to individuals trying to deal with their mental illness. Additionally it promotes a wellness model which considers clients to be normal as opposed to a medical model which considers clients to be sick. The concept of peer support had its beginnings in 1935 with the establishment of Alcoholics Anonymous which operated under the principle that persons who had experienced and overcome alcoholism would be more effective in assisting others who were trying to do the same. Self help is founded upon the principle that people who share a disability have something to offer each other which cannot be provided by professionals (Clarke Institute 1997). Peer Support do not replace traditional services but offer an alternative to individuals who feel alienated from the mental health system. Peer Support Groups have been available to Canadian Forces personnel and veterans since September  2004. (44). As a result of different motives there might be doubts regarding the possibility of having Peer Support Reunions with different ranks attending the same meetings (19,33). In such regard Commodore Toby Elliot says : ¨With regard to the officer class as a whole, however, are those who have entered the services as officers in the first place who feel the stigma of mental ill health and the effect of "the military ethos" very strongly. They see themselves at great risk of career limitation if they admit they have a problem whilst serving, and so this mindset creates barriers to help seeking and treatment both in service and then when they leave the service. I am quite convinced that the only way to tackle this problem is to set up a separate system for officers where they can seek help, treatment and as a spin off set up peer group support where this is achievable (needs the individual to realize the benefit to be gained by participating in such a program.) Better still, however, in both groups, is to encourage them to join their regimental association and find old friends and comrades they have served with, and discover what a powerful difference can be made by taking such a positive step ¨

Goals and objectives of the Peer Support Programs
 
Most Peer Support Programs emphasize the need for a sound structure of the program. A documentation describing work on goals and objectives offers proof of the task that workers are performing. The participation by consumers is associated with: 
  1. Reduced hospitalization,
  2. Reduced use of other services,
  3. Increased knowledge, information and coping skills, 
  4. Increased self-esteem, confidence, sense of well being and being in control and 
  5. Stronger social networks and supports.

Types of Peer Support

  1. A paraprofessional approach whose workers are supervised by a professionally trained counselor,
  2. Volunteer workers who conduct peer support on an outreach basis,
  3. Former clients of vocational rehabilitation agencies ,
  4. Peer tutors who provide independent living skills instructions,
  5. Workers who provide pertinent information on topics such as housing social services etc. and
  6. Workers who provide community networks and activities.
Methods of service delivery
 
a. One to one basis : The one to one provides greater privacy and is
easier to develop trust .
b. A group basis: The group method put more demands on the person to
share and be active. It requires more skill from the facilitator but they
bring about a powerful feeling of unity.
 
The Peer Support Counselor
 
The Peer Support Counselors should have a special training. It´s not just a war veteran giving advice to another or transferring the nuisances to others or generating conflicts with the health officers but a man who may solve problems through the proper channels.The Washington State Peer Support Counselor Training Program has now trained and certified consumers for the past two years. The Mental Health Division conducted eight separate 40-hour trainings in Tacoma, Washington. Approximately 25 consumers attended each 1-week training. Peer Support Counselors become certified by successfully completing the program and passing the certification exam and completing the Department of Health Registered Registered Counselor Program. Health Promotor Agents courses given by the University of Buenos Aires (Agente Promotor de Salud) had a similar training to the Peer Support Counselor although there were certain differences. A promotor is an advocate who promotes health in her/his community and is a bridge between the community and systems of care. The first risk for a war veteran acting as a Peer Support Counselor World be to incur in Existential Authority. This last implies the lack of respect and the withering look the war veteran shows towards anyone who has not participated of his same conflict thus creating a bad attitude among his work-mates being at loggerheads with his employer who may sack him (sometimes in a improper way).Another could be the political risk like the one described in the USA in which a new Tucson based national group offering emotional support for Iraq veterans had another unstated purpose which was to recruit the troubled vets into anti-war activism. ( Vet support group has anti-war affiliations-Arizona Daily Star-Jan 16,2007) .

Functions of the Peer Support Counselor
 
  1. Provides a role model, 
  2. 2. Becomes a link between the client and the services which are provided through the Center etc.,
  3. The Peer Support worker drawing on personal experiences provides training in a wide variety of independent living skills.
  4. Peer Support workers may more readily recognize and address the psychological needs of their counterparts (Varenhorst 1984).
Programs to reduce the suicide rates
 
The Members Assistance Program of the New York City Police Unions (MAP) have reduced the rate of police officer suicide and increased the level of acceptance for mental health services. In 2001 MAP became POPPA Police Organization Providing Peer Assistance.

Seminar held at the Hyatt Hotel in Baku (13-14 February 2007)
Mark Sandman Psychologist and Infantry sniper of the 101 Airborne Division during
the Vietnam war (fifth man standing from the left ) has been encouraging the Peer
Support Program
for the Argentine Malvinas war veterans. Sandman gave lectures on
PTSD at the Universidad de Flores (Buenos Aires). The photograph shows him during a
seminar held at the Hyatt Hotel in Baku (13-14 February 2007) with participation of
Members of the Azerbaijani Parliament, the Supreme Court and officers serving the
Ministry of Defense and Internal Affairs.


The actual Argentine program
 
The INSSJP (National Institute of Social Service for Pensioners) (very much like the British NHS) has a Resolution 191/05/DE which is known as the National Program for the Assistance of the War Veteran and his family. It allows the war veteran to freely choose his GP or specialist , it pays for every medical assistance, it has an open registry for professional services, pays for any transfer to a high complexity medical center which includes lodging and an attendant. As a result of Resolution 622/05 War Veterans Areas were created in every delegation (called UGL) of the INSSJP. In the delegations there are war veterans who inform their peers about the different services provided and the administrative procedures.

The War Veteran´s Submanagement Area situated in Buenos Aires provides local, regional and national programs. The UGL and the Submanagement area work in close contact with War Veteran´s centers.(70). The Argentine Military Hospitals have been registered by the MoD in the INSSJP´s Special Health Providers List for War Veterans so the veteran and his family will be able to be assisted in any of those military centers regardless of their original force. ( Argentine MoD-Press Information Nº078/76, April 12. 2007). Recently, a War Veterans´ Nationwide Surveillance has been started the data being analyzed by the
CONICET ( Consejo Nacional de Investigaciones Científicas y Técnicas).

The first province to be researched was Corrientes. In certain cases this meant getting into far away zones like the paraje Vizcaíno (45 Km from the island main harbour). Although it is an Argentine territory is surrounded by Paraguayan waters. This is the homeland of war veteran Marcelino Fernández, who, although situated in front of the Yaciretá dam, lacks of energy supply. (100). In the province of Chaco, medicine students and residents and members of the War Veterans´ Center took part in the city of Resistencia of a screening research which comprised 220 war veterans ( from a 1000 war veteran population); 5 per cent were considered as a high risk group (26). The INSSJP is giving some training courses on PTSD to mental health professionals (54). One of the main targets of the War Veterans´ Submanagement Area is the prevention and treatment of drug abuse.

The future challenge
 
Given the actual average age of the Argentine war veterans there are other problems, besides the mental derangements, which will become of an utmost importance. We may observe closely this issue by analyzing the first ten causes of mortality in Argentina in 2006 (96)

Top Ten Causes of Death, all ages Argentina, 2002

An agreement (Resolution 947/04) between the INSSJP and the John Fitzgerald
Kennedy University in Buenos Aires allows free psychological assistance of the
Malvinas War Veterans. From left to right: the author, Mike Seear ( Operations and
Training Officer,1st Bn, 7th Ghurka Rifles in the 1982 conflict ), Lars Weisaeth
( Research Director for the Norwegian National Study Center for Violence and
Traumatic Stress ) and Dr. Hector Fischer Dean of Psychology .

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