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3 DEPLOYMENT-RELATED STRESSORS The U.S. military has participated in numerous wars on both U.S. and foreign soil and, regardless of the conflict, many of the deployment-related stressors to which military personnel can be exposed are the same: possible death or injury to oneself, killing or injuring others, poor living conditions, and harsh physical environment. Military personnel may be exposed to multiple deployment-related stressors and have multiple exposures to a single stressor, all of which may adversely affect their physical and mental health. The psychiatric sequelae of war are well documented (Hotopf et al. 2006), and a recent Institute of Medicine (IOM) report notes that depression, substance abuse or dependence, and anxiety disorders, especially posttraumatic stress disorder (PTSD), were increased in Gulf War veterans after deployment, and that symptom severity was associated with the level of war stress (IOM 2006). The 1980s saw the beginning of studies on the psychologic effects of combat on veterans. Numerous studies (Goldberg et al. 1990; Kang et al. 2003; Kulka et al. 1990; O’Toole et al. 1998) found that the feature of combat that was uniformly traumatic in three wars—the Vietnam War, the Korean War, and World War II—was being an “agent” of killing the enemy (rather than just being a “target”). Some researchers interpreted that finding as signifying that responsibility for killing someone may be the “most pervasive” trauma of war (Fontana and Rosenheck 1994). A 2002 Department of Defense (DoD) (Bray 2003) survey of mental-health issues among all branches of the military found that in the 12,756 active-duty personnel who responded to the questionnaire the most frequently reported sources of stress were being away from family and deployment. DoD has periodically surveyed soldiers and Marines deployed to Iraq during Operation Iraqi Freedom (OIF) to assess their need for behavioral-health care and to determine what effect, if any, multiple deployments have had on their mental health (MHAT 2006a,b). Four such surveys have been conducted: September-October 2003 (OIF I), September-October 2004 (OIF II), October-November 2005 (OIF 04-06), and August-October 2006 (OIF 05-07). In the last two surveys, both active-duty troops and reservists reported that the most important noncombat stressors were deployment length and family separation; deployment length was of even greater concern for soldiers who had been deployed more than once. Increased deployment length was also related to increased mental-health problems and marital problems (MHAT 2006a,b). Those findings are particularly important because in April 2007, the length of active- duty U.S. Army deployments to Iraq and Afghanistan was extended from 12 to 15 months (Tyson and White 2007). The 2006 survey found that the level of combat experienced by a soldier or Marine was the most important determinant of their mental health (MHAT 2006b). Specific deployment-related stressors include all those experienced during actual combat, the anticipation of deployment to a war zone, noncombat stressors, military sexual harassment 31

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32 GULF WAR AND HEALTH and assault, poor living conditions, and exposure to environmental and chemical stressors. Some stressors are specific to reserve and National Guard troops, peacekeepers, and women. STRESSORS DURING COMBAT Exposure to combat has been described as one of the most intense stressors that a person can experience (Grinker and Spiegel 1945), and for many people who experience combat, it is the most traumatic experience of their life (Kulka et al. 1990). Combat may encompass many threatening situations. Among those reported most frequently by all U.S. combat veterans are killing or attempting to kill the enemy; being shot at by others; exposure to dead and wounded comrades, enemy combatants, and civilians; and being injured. Deployment stressors in the Persian Gulf War included being in the vicinity of a Scud missile explosion, contact with prisoners of war or dead animals, direct combat duty, witnessing the death of a person, forced sexual relations or a sexual assault, being exposed to dismembered bodies or maimed soldiers, coming under small-arms fire, having artillery close by, and having a combat-related injury (Kang et al. 2000; Unwin et al. 1999). Hobfoll et al. (1991) noted that military personnel in the Gulf War were at greatest risk for stress when their work was hazardous and they anticipated exposure to chemical warfare; the risk increased with more time spent in the field and more exposure to the dead and wounded. Another stressor was the feeling that they were deserting their families at a time of need. Sutker et al. (1993) asked 215 Gulf War veterans about their perception of injury and death, preparedness for deployment and combat, unit cohesiveness, harshness of the physical environment, perceived level of national support for the war, and stress attributable to nonmilitary events. Respondents were also asked to describe the three most stressful events they had experienced during their deployment. The stressful events cited most frequently were hardships associated with separation of home and family (18%), fear of Scud missile and other military attacks (15%), and discomfort with the physical environment (13%). Other stressors included loss of control, uncertainty, and fear of the unknown (8%); lack of leadership (7%); protracted delays in returning home after cessation of hostilities (5%); inadequacy of supplies and equipment (5%); prolonged truck transport through the desert (4%); lack of information (4%); and financial difficulties (3%). In one of the few studies to determine not only stressful exposures but the level of stress experienced by the veterans, Stretch et al. (1996a) conducted a survey of 1524 veterans deployed to the Persian Gulf during Operation Desert Shield and Operation Desert Storm. The veterans, about half of whom were reservists, were asked to indicate what stressors they had experienced and how stressful each was. Of the stressors associated with combat exposures, 80% of the veterans indicated that threats of Scud missile, terrorist, or chemical attacks were stressful; 59- 69% of the veterans rated the stress as moderate or greater. Such events as being in danger of being killed or wounded or being fired on by the enemy were stressors for almost half the veterans. Almost 83% of the veterans reported lack of contact with their families to be stressful; 68% of those surveyed found it to be moderately stressful or worse. In a study of Pennsylvania and Hawaii active-duty and reserve or National Guard soldiers who had been deployed to the Gulf War (Stretch et al. 1996b), the stressors that were most closely associated with PTSD were those related to combat, such as exposure to the killing or wounding of American soldiers by friendly fire, having a buddy killed or wounded in action, and exposure to dead or dying people. Other significant stressors for PTSD included concern about exposure to oil-well fires in Kuwait,

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DEPLOYMENT-RELATED STRESSORS 33 crowding in base camps, long duty days, being fired on by the enemy, and noise from guns and artillery. Kulka et al. (1990) asked Vietnam veterans about both war-zone stressors and traumatic events for the National Vietnam Veterans Readjustment Study (NVVRS). They distinguished between the two with the understanding that exposure to war-zone stress, such as being on frequent long-range patrols in hostile enemy territory, could increase the risk of exposure to a traumatic event, such as being in an ambush in which their colleagues were killed or wounded. Male veterans were asked 94 questions about war-zone stress exposures: 48 items about exposure to combat, 24 items about exposure to abusive violence and related conflicts, 12 items about deprivation, 9 items about loss of meaning and control, and 1 item about ever having been a prisoner of war in Vietnam. They found that 75% of veterans with high levels of war-zone stress also had exposure to at least one traumatic event during the war, and one-third of theater veterans with low war-zone stress described at least one traumatic experience. When war-zone combat exposure based on military records was compared with self-reports of combat exposure, Dohrenwend et al. (2006) found that 96.5% of Vietnam veterans who were classified as having low combat exposure on the basis of their military records reported having low or moderate exposure, and 72.1% of those classified as having very high combat exposure reported high exposure. Fontana and Rosenheck (1999) used NVVRS data to identify important war-zone stressors. Primary stressors are killing or injuring others and insufficiency (inadequate food, inadequate water, inadequate weapons or munitions, inadequate equipment or supplies, loss of freedom of movement, and lack of privacy)—part of what King et al. (1995) called a malevolent environment. Other studies of Vietnam veterans indicate that participating in or witnessing atrocities against the enemy or civilians, both dead and alive, can be an important stressor (Fontana and Rosenheck 1999; King et al. 1995). Schlenger et al. (1992) sought to develop a comprehensive exposure measure that would capture the array of war-zone stressors. They used principal-component analysis of the 100 interview items on the National Survey of the Vietnam Generation (part of the NVVRS) to develop a list of major stressors for men and women. For men, the stressors were exposure to combat (such as frequency of receiving enemy small-arms fire), abusive violence and related conflict (such as involvement in mutilation of bodies), deprivation (such as lack of shelter from weather), and loss of meaning and control (such as a sense of purposelessness). For women, the stressors were exposure to dead and wounded (such as frequency of giving care to people who later died), exposure to enemy fire (such as frequency of being under enemy fire), direct combat involvement (such as frequency of firing a weapon in a combat situation), exposure to abusive violence (such as seeing or hearing of Americans who had been tortured), deprivation (such as frequency of fatigue or exhaustion), and loss of meaning and control (such as feeling out of touch with the world). In Operation Enduring Freedom (OEF) and OIF, many of the stressors are more reminiscent of the Vietnam War than of the 1991 Gulf War or World War II. With the defeat of the Iraqi Army and later sectarian violence, U.S. troops have been subjected to guerilla warfare and terrorist actions from civilian insurgents and militias; soldiers must be constantly on guard against snipers, improvised explosive devices (IEDs), and suicide bombers; and all civilians must be viewed with caution. In 2003, Hoge et al. (2004) surveyed 2856 Army and 815 Marine combat infantry troops before and several months after their deployment to Iraq and Afghanistan for the Army units and

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34 GULF WAR AND HEALTH to Iraq only for the Marines. The postdeployment surveys indicated that during deployment in Iraq, on the average, 92% of the soldiers and Marines were attacked or ambushed; 95% were shot at or received small-arms fire; 94% saw dead bodies or human remains; 89% received incoming artillery, rocket, or mortar fire; and 86% reported knowing someone who was seriously injured or killed. Over 81% of the soldiers and Marines reported shooting or directing fire at the enemy, 57% reported being responsible for the death of an enemy combatant, and 21% reported being responsible for the death of a noncombatant. Soldiers deployed to Afghanistan reported far fewer combat experiences than those deployed to Iraq (see Table 3-1). TABLE 3-1 Combat Experiences Reported by Members of the U.S. Army and Marine Corps After Deployment to Iraq or Afghanistan Army Groups Marine Group % in Afghanistan % in Iraq % in Iraq Experience (n = 1962) (n = 894) (n = 815) Being attacked or ambushed 58 89 95 Receiving incoming artillery, rocket, or mortar fire 84 86 92 Being shot at or receiving small-arms fire 66 93 97 Shooting or directing fire at the enemy 27 77 87 Being responsible for the death of an enemy combatant 12 48 65 Being responsible for the death of a noncombatant 1 14 28 Seeing dead bodies or human remains 39 95 94 Handling or uncovering human remains 12 50 57 Seeing dead or seriously injured Americans 30 65 75 Knowing someone who was seriously injured or killed 43 86 87 Participating in demining operations 16 38 34 Seeing ill or injured women or children and being 46 69 83 unable to help them Being wounded or injured 5 14 9 Having a close call, being shot or hit, but being saved Not asked 8 10 by protective gear Having a buddy shot or hit nearby Not asked 22 26 Clearing or searching homes or buildings 57 80 86 Engaging in hand-to-hand combat 3 22 9 Saving the life of a soldier or civilian 6 21 19 SOURCE: Adapted with permission from Hoge et al. (2004). In the 2006 DoD Soldier and Marine Well-Being Survey of 1767 active-duty personnel stationed in Iraq, the troops reported being unable to respond to threats from Iraqis, such as having concrete blocks dropped on their vehicles from overpasses, by the rules of engagement. An important combat stressor that has increased during OIF is sniper attacks. Almost two-thirds of the soldiers and Marines reported having a member of their unit killed or injured (MHAT 2006b).

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DEPLOYMENT-RELATED STRESSORS 35 Graves registration, the handling and retrieving of dead bodies or body parts, can also be stressful for military personnel. McCarroll and colleagues found that regardless of age, sex, previous experience with handling remains, or volunteer status, veterans who handled remains or even saw body transfers had more PTSD symptoms than veterans with other military occupations (McCarroll et al. 2001) and a higher rate of diagnosis of PTSD (Sutker et al. 1994). Mere anticipation of working in the mortuary with exposure to mass deaths was stressful to many of the military personnel, although those who had more mortuary experience and those who had volunteered for the duty found it less stressful than those who did not (McCarroll et al. 1993, 1995). Stressors associated with mortuary work included handling bodies, working with x- rays, handling personal effects, and observing bodies being moved from transfer cases. NONCOMBAT STRESSORS Uncertainty about the duration of deployment was a continuing concern for U.S. troops during the Gulf War, particularly during the early phases of the buildup (Wright et al. 1996). A large epidemiologic study of Gulf War veterans (Fiedler et al. 2006) found that veterans who had had other deployments, such as in Vietnam or Bosnia, in addition to their deployment to the gulf did not have an increased risk of major depression or generalized anxiety disorder or any anxiety disorder, including PTSD. However, additional deployments were associated with a two-fold increase in substance dependence. A study of nearly 60,000 military and civilian peacekeepers deployed on a NATO mission to Bosnia (Huffman et al. 1999) found that prior deployment was associated with lower rates of depression symptoms (measured with the Self-Rating Depression Scale) and PTSD (determined with the PTSD Checklist). Neither study queried veterans regarding the length of their deployment. DoD Mental Health Advisory Team surveys of both active-duty troops and reserve and National Guard soldiers deployed to Iraq during OIF in 2005 and 2006 found that the most important noncombat stressors were deployment length and family separation; deployment length was of even higher concern to soldiers who had been deployed more than once (MHAT 2006a,b). Furthermore, the number of soldiers who were anxious about uncertain redeployment dates rose from 35% in 2005 to 40% in 2006. DoD noted that the 5% increase may have been due to the survey’s inclusion of soldiers from a brigade combat team that had had its tour extended beyond 12 months and had learned of the extension only from their spouses, who, in turn, had learned of the extension from the garrison leadership. Morale was particularly low among enlisted men who had had multiple deployments to Iraq. The committee notes that in April 2007 the length of deployment of active-duty Army personnel in Iraq was extended from 12 to 15 months and that 13,000 National Guard troops were expecting to be called up for second tours to Iraq. Marines have shorter deployments than Army soldiers, generally 9 months compared with 12 months. About one-third of the soldiers in the 2006 DoD survey reported finding their work boring and repetitive. Of particular concern to many soldiers and Marines was a perceived inequity in access to base amenities, such as recreational equipment and communication equipment, for personnel who had missions outside the base camp (MHAT 2006b). Those concerns contributed to the low morale of the troops.

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36 GULF WAR AND HEALTH ANTICIPATION OF DEPLOYMENT TO A WAR ZONE Human and animal studies show that the anticipation or perception of exposure to a severe stressor in the absence of actual exposure can be as powerful as the actual exposure in eliciting the stress response (see Chapter 4). Several of the questionnaires developed after the Gulf War (for example, Sutker et al. 1995; Ikin et al. 2004, 2005) to identify war-zone stressors include anticipated or perceived exposure to chemical weapons in addition to actual combat exposure. Before deployment, most stressors are associated with fear of unknown or expected enemy tactics. In a survey of 1400 U.S. troops just before the January 15, 1991, deadline for the withdrawal of Iraqi troops from Kuwait, researchers found that the fear of Iraqi use of chemical or biologic weapons was the greatest stressor (Norwood et al. 1996). Kang et al. (2003) defined veterans as having been “combat-exposed” if they were “wearing chemical protective gear” or “hearing chemical alarms sounding.” Stretch et al. (1996a), in a survey of over 1500 Gulf War veterans, found that waiting for deployment to the gulf was moderately to extremely stressful for 67% of them. Predeployment anticipation of an event might be more stressful than its occurrence during deployment. Before the January 1991 gulf air war, Gifford et al. (2006) conducted interviews of Gulf War troops in Saudi Arabia to identify potential stressors and then followed up 6-9 months after the troops returned to the United States. They found that the stressors changed as the soldiers adapted to the new environment in the gulf, the infrastructure was modified with new equipment and facilities, and communication to and from families, the public, and top military and political figures improved (see Table 3-2). However, some stressors persisted throughout the war; for example, soldiers had been told by senior military personnel to expect large numbers of casualties, and this anticipation existed until virtually the end of the war. Australian Navy Gulf War veterans were surveyed to identify stressors in military units that were not actively engaged in combat or that had little direct combat exposure—those troops served in blockade efforts or provided transport, supplies, or medical support (Ikin et al. 2004, 2005; McKenzie et al. 2004). Of the 1232 respondents, 81% indicated that they had been on a ship or aircraft passing through hostile water or airspace; 71% had been in fear of artillery, missile, Scud rocket, or bomb attack; 71% had been on formal alert or in fear of nuclear, biologic, or chemical attack; 67% felt cut off from family or significant others; and 54% felt that while on board a ship they feared death, injury, or being trapped as a result of a missile attack or hitting a sea mine. For Australian Gulf War-era veterans who had been deployed to areas other than the gulf and for veterans who had not been deployed, the greatest stressor was feeling cut off from family members and significant others. Similarly, a study of the entire cohort of 3000 Gulf War veterans from Canada found that although the vast majority served at sea, they frequently saw Scud missiles overhead, and that resulted in stress because they feared that the missiles contained chemical-warfare agents (Goss Gilroy Inc. 1998). When United Kingdom (UK) Gulf War-deployed troops were compared with UK troops deployed to Bosnia or not deployed, the Gulf War-deployed troops reported more exposure to all stressors except dead animals and exhaust from heaters or generators (Unwin et al. 1999). Anticipation of attack with chemical or biologic agents was the most common predeployment fear among the UK troops.

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DEPLOYMENT-RELATED STRESSORS 37 TABLE 3-2 Stressors Experienced by U.S. Forces in the Gulf War Deployment Phase Stressors Early Uncertainty of tour length, no projected date of return Lack of communication (slow mail and poor telephone availability) Information deprivation and resulting rumors Ambiguous demands (precombat vs garrison environment) Austere, crowded living conditions Harsh desert conditions (heat and sand) Lack of respite—always in chain of command Lack of recreational or entertainment opportunities Lack of amenities, such as hot meals Cultural isolation, restriction of behavior, and ambivalent perceptions of rules Uncertainty about public support Buildup Lack of companionship of opposite sex Lack of contact with family Lack of private time Leaders around too much of the time Not being allowed to “act like Americans” Lack of adequate morale, welfare, and recreation equipment Lack of alcoholic drinks Fatigue and lack of sleep Flies Anticipation of combat Threat of attack with chemical or biological weapons Expectation of massive casualties Possibility of friend getting killed or wounded Possibility of self getting killed or wounded Fear of not getting adequate medical care if hit Possibility of losing a leader SOURCE: Adapted with permission from Gifford et al. (2006). MILITARY SEXUAL ASSAULT AND HARASSMENT Sexual assault and harassment1 are widely acknowledged stressors in the general population and are severe stressors when incurred in a war zone. In the military environment with its overwhelmingly male population, sexual victimization is more likely to be experienced 1 The U.S. Army defines sexual assault as “intentional sexual contact, characterized by use of force, physical threat or abuse of authority or when the victim does not or cannot consent. Sexual assault includes rape, nonconsensual sodomy, indecent assault (unwanted, inappropriate sexual contact or fondling), or attempts to commit these acts.” The Army defines sexual harassment as “a form of gender discrimination that involves unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” (U.S. Army 2005).

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38 GULF WAR AND HEALTH by women, regardless of their military occupation and background (Wolfe et al. 1993a). The rate of reported sexual assault was about 70 per 100,000 uniformed service members in 2002-2003 for all duty stations; 9% of the victims were men (DoD 2004). Reported rates of sexual harassment of women in the military were about 46% and 24% in 1995 and 2002, respectively, and of men 8% and 3%. The female-to-male ratio for being a victim of sexual assault in the Gulf War was 16.5:1 and for sexual harassment 25:1 (Kang et al. 2005). The 1995 National Health Survey of Gulf War Era Veterans and Their Families, conducted by the Department of Veterans Affairs (VA), found that of the 11,441 Gulf War veterans who responded (4202 women and 7239 men), 24% of the women reported having been subject to sexual harassment, and 3.3% reported sexual assault; only 0.6% of the men reported experiencing sexual harassment, and even fewer (0.2%) reported a sexual assault (Kang et al. 2005). Wolfe et al. (1998) interviewed 160 Army women on their return from the Gulf War and 18-24 months later; the women reported rates of sexual assault of 7.3%, physical sexual harassment 33.1%, and verbal sexual harassment 66.2%—all higher rates than those found in peacetime military and civilian population. Goldzweig et al. (2006) reported rates of sexual harassment in veterans and active-duty military that ranged from 55% to 79%, with sexual assault ranging from 4.2 to 7.3% in active-duty women and 11 to 48% in female veterans. LIVING CONDITIONS During the buildup to the 1991 Gulf War, combat troops were crowded into warehouses and tents on arrival in the Persian Gulf region and then often moved to isolated desert locations. Most troops lived in tents and slept on cots lined up side-by-side, affording virtually no privacy or quiet. Sanitation was often primitive, with communal washing facilities and shortages of latrines. Hot showers were infrequent, the interval between launderings of uniforms was sometimes long, and desert flies, scorpions, and snakes were a constant nuisance. Military personnel worked long hours and had narrowly restricted outlets for relaxation. Troops were ordered not to fraternize with local people, and alcoholic drinks were prohibited in deference to religious beliefs in the host countries. The diet of most of the military units consisted mostly of packaged foods and bottled water. In a 2006 survey of 1767 soldiers and Marines stationed in Iraq for OIF, over one-third reported the lack of privacy and personal space to be a stressor (MHAT 2006b). Temperature extremes are also a source of stress. In the first 2 months of troop deployment (August and September 1990) to the Persian Gulf region, the weather was extremely hot and humid, with air temperatures as high as 115°F and sand temperatures reaching 150°F. Troops had to drink large quantities of water to prevent dehydration. In some of the areas of Iraq that U.S. troops patrol in OIF, the temperature can reach 140°F. Although the summers in the Middle East are hot and dry, temperatures in winter (December-March) are low, and wind-chill temperatures at night can drop to well below freezing. Wind and blowing sand make protection of skin and eyes imperative. Goggles and sunglasses help somewhat, but visibility is often poor, and contact lenses were prohibited in the Gulf War (Ursano and Norwood 1996). In a survey of 1576 Gulf War veterans, 62-85% experienced the chronic stressors associated with living and working in the gulf, including crowding, lack of privacy, working in the desert, long hours, and boredom; 35-61% of the veterans found the conditions to be at least moderately stressful (Stretch et al. 1996a).

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DEPLOYMENT-RELATED STRESSORS 39 ENVIRONMENTAL AND CHEMICAL STRESSORS The exposure of Gulf War troops to numerous environmental and chemical agents has been addressed in previous volumes of the Gulf War and Health series, and such exposures will not be considered here except to note that many troops may have found such exposures— anticipated, known, or suspected—to be psychologically stressful and physiologically challenging. Troops in the 1991 Gulf War were exposed to environmental and chemical agents, possibly including chemical-warfare agents. Some exposures were the result of living and working conditions at camp or in the field, such as exposures to petroleum-based combustion products, including those of kerosene, diesel, and leaded gasoline used in unventilated tent heaters, cooking stoves, and portable generators. Some troops were exposed to the smoke from more than 750 oil-well fires. Pesticides, including dog flea collars, were widely used by troops in the Persian Gulf to combat the region’s ubiquitous insect and rodent populations. Exposure of U.S. personnel to depleted uranium occurred as the result of “friendly-fire” incidents, cleanup operations, and accidents (including accidental fires). U.S. troops in the gulf had been warned that they might be exposed to biologic and chemical weapons. Iraq previously had used such weapons in fighting Iran and in attacks on the Kurdish minority in Iraq. U.S. military leaders feared that the use of such weapons in the gulf could result in the deaths of tens of thousands of Americans. Therefore, in addition to the standard predeployment immunizations, the anthrax and botulinum toxoid vaccine were also provided to some military personnel. Troops were also given blister packs of 21 tablets of pyridostigmine bromide (PB) to protect against nerve gas. Troops were to take PB on the orders of a commanding officer when a chemical-warfare attack was believed to be imminent. Alarms sounded often, and troops responded by donning the confining protective gear and ingesting PB as an antidote to nerve gas. DoD has estimated that about 250,000 personnel took PB at some time during the Gulf War (IOM 2006). The sounding of the alarms, the reports of dead animals, and rumors that other units had been hit by chemical-warfare agents caused the troops to be concerned that they would be or had been exposed to such agents. Despite the relatively small numbers of U.S. personnel injured or killed during combat in the Gulf War, the troops, as in any war, faced the fear of death, injury, capture by the enemy, and, in the case of the demolition of a munitions-storage complex at Khamisiyah, Iraq, possible exposure to the nerve agents sarin and cyclosarin. RESERVE AND NATIONAL GUARD TROOPS The Gulf War was the first since World War II in which reserve and National Guard units were activated and deployed. The greater participation of reserve and National Guard troops in the Gulf War has now been surpassed by OEF and OIF (Table 3-3). As of February 14, 2007, almost 85,000 reserve and National Guard personnel have been mobilized to serve in OEF and OIF. Reservists and National Guard troops may encounter more stressors going to a war zone than those faced by active-duty military personnel; many of the additional stressors were unanticipated at the time the reservists and National Guard troops signed up for service. The stressors experienced by reservists and National Guard troops might include financial concerns, such as significant loss of income due to leaving more lucrative civilian jobs for lower military

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40 GULF WAR AND HEALTH TABLE 3-3 Percentage of Active-Duty vs Reserve and National Guard Troops, by War Military Status War Percentage of Troops Active duty Vietnam War > 99% Gulf War 83% OEF and OIF 80% < 1% Reserves and National Guard Vietnam War 17% Gulf War 20% OEF and OIF SOURCE: DoD (2007); Joseph (1997); Kapp (2006). wages; logistic issues, such as having to make arrangements for the care of children, elderly parents, or other family members; and arranging legal and financial matters. Over 13,000 of the 265,322 reservists mobilized for the 1991 Gulf War were single parents (Ursano and Norwood 1996). Employment was also a concern; although some employers kept the reservists’ jobs open until their return, this was not always the case. For business owners and self-employed people, there were issues associated with delegating work responsibilities, ensuring continuity, or handling obligations to clients or others. Uncertainty about the length of the deployment, the destination of the unit if and when deployed, and the short notice given before deployment (generally 2-9 days) contributed to the stress of activation and deployment on the reservists and their families (Ursano and Norwood 1996). Gulf War reservists also experienced stress resulting from rapid, unexpected activation and deployment to a combat zone and then rapid demobilization from the combat zone, perceived and actual threats to their safety, lack of confidence about equipment and training, poor communication and leadership, and loss of prestige and income when disbanded (Malone et al. 1996). PEACEKEEPERS U.S. troops are often deployed around the world as part of United Nations (UN) peacekeeping forces and have performed this function in Lebanon, Sinai, Bosnia, and Somalia. The inherent conflict between being trained for active combat duty and acting in a peacekeeping capacity can lead to stress in military peacekeepers particularly if they are involved in maintaining an established peace as opposed to a more traditional combat role of establishing peace among warring parties (Litz et al. 1997). Researchers at VA interviewed 3461 U.S. troops deployed to Somalia after their return from the peacekeeping mission. They found that the psychologic stressors faced by U.S. peacekeepers on dangerous missions like that in Somalia included frustration with the rules of engagement, such as exercising restraint in dangerous situations; demoralization; hostility and anger; and witnessing death and violence. Potentially traumatic events included sniper attacks, contact with land mines, witnessing starvation, and violence. Maguen et al. (2004) surveyed 203 U.S. military peacekeepers before and after deployment to Kosovo about possible stressors. The most frustrating stressors were being overseas during special events (74%), being separated from family and friends (71%), being bored (54%), knowing that many of the war criminals were not arrested (73%), seeing children who were victims of war (67%), and seeing civilians in despair (58%). About 88% of the soldiers also reported fear of having their unit fired on (of whom 28% found this fear moderately to

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DEPLOYMENT-RELATED STRESSORS 41 extremely negative), 85% had gone on patrols or performed other dangerous duties (22% found this to be moderately to extremely negative), 83% had patrolled in areas where there were mines (33%), and 76% reported potential for being ambushed or attacked (21%). Other significant stressors experienced by the soldiers included risk of being taken hostage (67%), needing to manage civilians in chaotic conditions (62%), witnessing violence (61%), and patrolling through the zone of separation (61%). Similarly stressful conditions have been described in other peacekeeping populations and missions, for example, in the Norwegian UN peacekeepers in Lebanon (Mehlum and Weisaeth 2002). Bartone et al. (1998) described similar findings among a group of 300 U.S. Army personnel deployed from Germany to serve as medical support to the UN peacekeeping mission in Croatia in 1993. Personnel identified stressors at predeployment and at three times during the 6-month deployment. Stressors changed during the deployment phases; in the predeployment phase, the major stressors were uncertainty about who was going to be deployed, when and for how long deployment would last, the introduction of new unit members with disparate field experiences, the amount of time required for unit training and preparation that conflicted with family preparations, and uncertainty about possible base closures during deployment. Other stressors associated with getting ready to deploy were changes in unit leadership and having to move families back to the United States (units were stationed in Germany with families). During the middle deployment phase, the primary stressors were associated with missing a spouse and not knowing where the unit would be based at the end of deployment; Army base closures, uncertainty about where the family would live, and boredom associated with lack of meaningful work were also stressors. In the late phase of deployment, the primary stressor continued to be missing a spouse, followed by Army drawdown, lack of ready access to transportation, and boredom. Research on Danish military units sent to northern Iraq as peacekeepers after the 1991 Gulf War also indicated the stressful nature of this duty. Self-reported exposures included witnessing direct war actions such as shootings, grenade attacks, and bomb explosions; witnessing assaults on civilians; seeing severely wounded or dead people; being threatened with arms; watching colleagues or friends being threatened with arms or shot at; being shot at; pointing a gun at or shooting someone; and being exposed to threats from the local population (Suadicani et al. 1999). WOMEN The role of women in the military has changed over the last century. In World War II, almost 350,000 women served in the armed forces in a variety of health-related, clerical, and other noncombat roles. In the Korean War, 48,700 women served in support roles; and during the Vietnam War, over 7000 women served in the Vietnam Theater, most as nurses. In 1973, at the end of the Vietnam War, 55,000 women were in the active-duty military, making up 2.5% of the armed forces. But it was only with the Gulf War that the number and responsibilities of military women dramatically increased. By late February 1991, 37,000 military women were in the Persian Gulf, making up 6.8% of the U.S. military forces. Women served in all the services, although they were excluded from some combat specialties; they were administrators, air-traffic controllers, logisticians, engineering-equipment mechanics, ammunition technicians, ordnance specialists, communicators, radio operators, drivers, law-enforcement specialists, and guards. Many female truck drivers hauled supplies and equipment into Kuwait. Some took enemy

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42 GULF WAR AND HEALTH prisoners of war to holding facilities, and others flew helicopters and reconnaissance aircraft. Still others served on hospital, supply, oiler, and ammunition ships or served as public-affairs officers and chaplains. Several women commanded units the size of brigades, battalions, companies, and platoons in the combat service-support areas (DoD 2004). By September 30, 2004, the number of women on active duty in all branches of the military was more than 212,000—nearly 15% of the active-duty armed forces. As the number of women in the military has grown, so has the number of female veterans. In 1990, female veterans numbered an estimated 1.2 million; that number had increased to 1.6 million by 2000 and to 1.7 million by the end of 2004. The number is expected to rise to about 1.9 million in 2020 (Klein 2005). As greater numbers of women serve in more combat-support occupations, they are exposed to many of the same war-zone stressors as are men. Schlenger et al. (1992) found that for female Vietnam veterans, the primary stressors were exposure to dead and wounded (for example, giving care to people who later died), exposure to enemy fire, direct combat involvement (for example, firing a weapon in a combat situation), exposure to abusive violence (for example, seeing or hearing of Americans tortured), deprivation (for example, being fatigued or exhausted), and loss of meaning and control (for example, feeling out of touch with the world). Vogt et al. (2005) queried 317 Gulf War veterans (including 83 females) about combat experiences, the aftermath of battle (such as handling human remains and dealing with prisoners of war), perceived threats, difficult living and working environments, concerns about family and relationship disruptions, lack of deployment social support, and sexual harassment. There were no sex differences for most of the stressor measures; however, women reported more exposure to interpersonal stressors, such as incidents of sexual harassment, and reported that they received less postdeployment social support than men. In contrast, men reported more mission-related stressors, such as combat experiences. These findings were supported by Wolfe et al. (1993b), who also found that immediately after their Gulf War deployment, men (n = 2136) and women (n = 208) reported similar deployment experiences, that is, 74% of men and 78% of women had been on alert for chemical and biologic attack, 74% of men and 70% of women received incoming fire from large arms, and 50% of men and 45% of women had seen death or disfigurement of enemy troops. However, when the participants generated and ranked their own lists of stressors, there were significant differences between the men and the women. Almost half of the women (48%) reported combat exposure as their most significant stressor compared with 38% of men. Almost equal percentages of women (24%) and men (28%) reported a war-zone but noncombat event (such as a unit member’s being injured or killed in nonmission activities or nearness to a prisoner-of-war riot) as their most significant stressor, and 20% of women and 25% of men reported that a personal or domestic stressor was the most stressful event during deployment. Only 7% of women and 9% of the men did not report a stressful event. In a similar study of the Iowa Gulf War cohort, Carney et al. (2003) asked men and women who were deployed to the Gulf War theater (Saudi Arabia, Bahrain, Persian Gulf, Iraq, Kuwait, or other country) about exposure to nine combat-related stressors. Among 129 women and 1767 men in the study, the most frequently reported stressors for both sexes were seeing dead bodies or severely maimed or injured people, having a Scud missile explode within 1 mile, and having explosions other than Scuds within 1 mile; the men, however, had significantly more exposure to combat. In all, with the exception of combat exposure and sexual threat, women and men had similar deployment exposures.

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DEPLOYMENT-RELATED STRESSORS 43 Although men and women may experience many of the same deployment-related stressors, women may have different reactions to those stressors. Just being female may put some women veterans at greater risk for adverse mental-health effects when exposed to a deployment- related stressor. One study attempted to distinguish between men’s and women’s reactions to combat stressors. Fontana et al. (2000) found that men and women had similar responses to many of the stressors experienced while on a peacekeeping mission in Somalia. Both men and women became more frightened as their exposure to combat and to witnessing Somalis dying increased. For men, being frightened, being sexually harassed as a result of showing fear in a combat situation, and witnessing Somalis dying were all associated with PTSD. The same stressors were associated with PTSD in women; however, just being female was sufficient for a woman to be subjected to sexual harassment, regardless of whether or not she had shown fear in a combat situation. In another study of Navy health-care providers deployed to the Persian Gulf on a hospital ship days before the Gulf War, there was anticipation of large numbers of casualties and concerns for safety. Women were more likely to report having depression; however, when training and experience were factored into the analysis with fear of injury and the stress of work demands, the sex difference for depression disappeared (Slusarcick et al. 2001). CONCLUSIONS The many stressors associated with being deployed to a war zone are not limited to the actual period of deployment, but extend into the pre- and postdeployment periods. Among the most serious are combat stressors which include killing someone, seeing comrades killed or injured, being threatened or fired on, and seeing and handling dead bodies. In OEF and OIF, stressors inherent in guerilla warfare are also present, such as not recognizing the enemy, being constantly on guard for the presence of IEDs, and balancing military activities with humanitarian services. Others stressors are associated with being deployed to an unfamiliar location, concern about financial obligations, and being away from family and loved ones. The committee notes that most of the studies discussed in this chapter queried veterans about a prescribed list of stressors or exposures that the investigators thought the veterans would find stressful. With the exception of Sutker et al. (1993), the studies did not ask open-ended questions about what stressors, exposures, or conditions the veterans found most stressful. Furthermore, many studies asked veterans to indicate only whether they had experienced a particular situation and not the degree to which the veterans found the exposure to be stressful. Therefore, the findings must be interpreted with the knowledge that, by and large, veterans could respond only to what they were asked and that their responses may not reflect the whole spectrum of stressors to which they were exposed and the level of stress that such exposures elicited. An understanding of deployment- related stressors, their frequency, and their magnitude is critical for interpreting the epidemiologic studies that are evaluated in Chapters 6 and 7. REFERENCES Bartone PT, Adler AB, Vaitkus MA. 1998. Dimensions of psychological stress in peacekeeping operations. Military Medicine 163(9):587-593. Bray RM. 2003. 2002 Department of Defense Survey of Health Related Behaviors Among Military Personnel. Research Triangle Park, NC: RTI International.

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