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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict Appendixes

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict This page in the original is blank.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict A VA Circulars This appendix includes the text of the first two VA Circulars published for this study. The first VA Circular, 10-87-138, was published in December 1987 and dealt with the examination of only POWs. It is here included without the Structured Clinical Interview for DSM-III-R (SCID) form. The second VA Circular, 10-88-117, was published in October 1988 and dealt only with the examination of non-POW veteran controls. A later VA Circular, 10-90-070, published in June 1990, superseded these earlier two circulars, but it is essentially a compilation of the earlier two and thus is not included here. Single copies of the SCID and the psychological forms (VA Forms 10-20844-a through 10-20844-d) are available from the author.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict Veterans Administration                                                                                                                      CIRCULAR 10-87-138 Department of Medicine and Surgery   Washington, DC 20420                                                                                                                      November 20, 1987 TO: Regional Directors; Medical District Directors; Directors, VA Medical Center Activities, Domiciliary, Outpatient Clinics and Regional Offices with Outpatient Clinics SUBJ: Research Study of Former Prisoners of War 1. PURPOSE: The purpose of this Circular is to outline the methodology necessary to conduct a research study involving former POWs (prisoners of war). 2. POLICY: The Veterans Administration Office of Research and Development has contracted with the NAS-NRC (National Academy of Sciences-National Research Council) to conduct a research study focused on the long-term health effects of imprisonment as a POW. While Circular 10-85-48 outlines a standard evaluation of these veterans, additional steps are necessary to conduct the research study. 3. DISCUSSION: a. It has been estimated that approximately 80,000 former Prisoners of War (POWs) from World War II and the Korean conflict are still living. Studies in this country and abroad have shown that the physical deprivation and psychological stress endured as a captive have lifelong effects on subsequent health and social adjustment. For example, specific residual health effects are known to be caused by prior malnutrition. In general, former POWs have significantly higher incidence rates for illnesses in many body systems, more frequent periods of hospitalization, and longer hospital stays. Vulnerability to psychological stress is also markedly increased. b. The NAS-NRC is currently conducting, under VA contract, a morbidity survey of former prisoners of war of WW II and the Korean conflict, continuing an ongoing longitudinal study begun in the early 1950's. Their current study is designed to collect information from the existing DM&S POW protocol examination (including history, physical examination, mental status examination, and social work survey) and add it to other existing data. The general outline of the study is simple. The NAS-NRC will invite the veterans in their national sample who have not already been examined to undergo the DM&S POW protocol examination. When the examination is completed, a copy of the results will be sent to VA Central Office for coding and abstracting by the NAS-NRC. These new POW protocol examination data will be added to earlier NAS-NRC data to be analyzed together, and the results will be published. c. The DM&S POW protocol examination program was begun in response to Pub. L. 97–37, the "Former Prisoners of War Benefits Act of 1981", when it was anticipated that many former POWs would contact the Veterans Administration to determine their eligibility under this law. Accordingly, DM&S developed a standard medical evaluation protocol. In order to adapt this program for research purposes, it is necessary to collect protocol examination data on representative groups of former POWs rather than to analyze data for only men who have presented themselves for examination. A later circular will address the examination of a control group of non-POW veterans to which comparisons can be made. d. The NAS-NRC study group contains a sample of former POWs who have been carefully selected to be representative of all WW II and Korean conflict POWs. Because of this design, sound inferences can be made from these samples to

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict the group of all POWs. There are approximately 2,000 POWs in the NAS-NRC study, and most medical centers should expect to examine not more than 10–15 of them. 4. ACTION: a. General Outline of the Research Study: (1) The NAS-NRC will contact their research veterans and invite them to participate in the VA's protocol examination program, which has OMB approval number 29-0389. If a veteran agrees to be examined, a copy of the veteran's reply form will be sent to the nearest VA medical center. This reply form will contain the veteran's name, address, and telephone number(s) which can be used to contact the veteran for examination scheduling. The individual reply forms for each VAMC will be accompanied by a list (NAS-NRC POW Examination Schedule List.) This list will contain the veteran's name, Social Security number, and the NAS-NRC case number (study identification number), and POW status (POW in all cases), as well as room for entering a "status code" (described below) and the date the examination has been scheduled. The list will serve as a control list so that each VAMC knows which veterans are to be scheduled for examination and which have already been scheduled. It is possible that a VAMC will be sent more than one list as more veterans decide to come in for examination. Each of these lists should be processed independently. (2) When the veteran is contacted for examination, one of the following codes (status codes) should be entered on the NAS-NRC Schedule List: Code Interpretation 1 Exam scheduled (also enter date of exam on list) 2 Exam previously done (do not repeat unless previous exam was incomplete) 3 Unable to contact (e.g., wrong telephone number) 4 Veteran refused examination (changed mind) 5 Veteran physically unable to come for exam 6 Veteran deceased 7 Able to contact, but veteran moved out of area or at another VAMC (specify) (a sample NAS-NRC schedule list is in Attachment A) (3) After the examination is scheduled, a copy of VA form 10-0048 should be sent to the veteran along with a study consent form (Attachment B), the standard VA research consent form (VA form 10-1086), and the usual cover letter (Attachment C). If in contacting the veteran, you find that the veteran has already been examined under the POW protocol and the previous examination was complete, do not bring the veteran in for a repeat examination. Instead, use code 2 above and send in a copy of the already completed exam, if it is available. If the previous exam was at a different VAMC, use code 7 and write the name of that VAMC in the schedule list margin. (4) When the scheduling for all the veterans on a particular list has been completed, that list should be returned to VA Central Office. When the examinations themselves are completed, copies of the complete examination packages, including VA forms 10-0048, should be sent to the VA Central Office

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict addressee given on page 4 of this circular within 30 days after completion of the examination. Examinations should be sent in individually as they are completed, rather than being held and mailed in a group. (5) The designated VA medical center POW physician coordinator will serve as principal investigator at VA Medical Center. The physician coordinator will be the contact person regarding this research project, and will assist the VA medical center's Research and Development Committee in obtaining the Subcommittee on Human Studies approval. (6) The designated VA medical center POW administrative coordinator will coordinate the scheduling of examinations for the study participants and all other administrative aspects of the local study, such as ensuring that the Schedule List (paragraphs 4a.(1), (2), and (3)) is properly filled out and returned. (7) Once the examinations are scheduled and the Schedule List returned, the POWs should be added to the DM&S POW Tracking System. This will allow the NAS-NRC to use the DM&S POW tracking system to follow the course of the examinations. Thus, it should not normally be necessary for the NAS-NRC to contact the VA medical center for status reports. b. Conduct of Former POW Protocol Examination: (1) When the veteran appears for examination, the POW administrative coordinator will explain the study. The short write-up in Attachment D ("What to Expect") should be copied and given to the veteran. At this time, the Informed Consent form (Attachment B) should be reviewed by the administrative coordinator, if it has not been mailed in beforehand, and the VA Form 10-0048 should be collected. The Informed Consent form should also be signed by the physician coordinator and witnessed, and a physician's progress note should accompany the Informed Consent form. (2) The examination for NAS-NRC research veterans will be identical to the customary examination as set forth in DM&S Circular 10-85-48, with the following special emphases. Duodenal ulcer has been documented as a medical condition with higher prevalence among Australian former POWs; thus, a careful and detailed history of gastrointestinal problems must be taken. Of additional interest is the fact that these findings were substantiated by a higher prevalence of the use of cimetidine among former Australian POWs. Therefore, a careful medication history should also be included in the POW protocol examination. Data from the same Australian study further suggest that arthritis and the medications associated with arthritis may also appear at a higher rate in former POWs, and this should thus receive special emphasis in the examination. (3) Psychological after-effects of military captivity may also persist among former POWs. For this reason, the required psychiatric consultation must be as thorough as possible and will include the structured clinical interview found in Attachment E. (5) The NAS-NRC has agreed to reimburse examinees for their travel. When the examination has been completed the examinee should be given a copy of the "NAS-NRC Travel Reimbursement Request" (Attachment F) to be filled out while at

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict the VA medical center and mailed to the NAS-NRC. The NAS-NRC will handle all details of reimbursement after the travel requests have been received. Mail these requests to: Mrs. Martha Bohman Medical Follow-up Agency National Research Council 2101 Constitution Ave., N.W. Washington, DC 20418. (6) Each VA medical center will need to secure the approval of its local Research and Development Committee and Subcommittee on Human Studies. The VAMC physician coordinator will act as principal investigator for this purpose and will use the material in Attachment G in this process. Appendix G contains a protocol to be submitted, and Attachment B contains the Informed Consent form to be included in the package. The forms attached to this circular (10-20839a-d) may be reproduced locally as needed. (7) A conference call will be held to discuss this circular. Remaining general questions regarding this research study and the completed examination may be addressed to the following: QUESTIONS TO: FORMS TO: Dr. William Page Mr. David Thomas (151J) Medical Follow-up Agency Medical Research Service National Research Council VA Central Office 2101 Constitution Avenue, N.W. 810 Vermont Avenue, N.W. Washington, DC 20418 Washington, DC 20420 FTS 737-2825 FTS 373-3939 Commercial 202-334-2825   5. REFERENCES: None 6. RESCISSIONS: This DM&S Circular will be rescinded on November 18, 1988. 7. FOLLOW-UP RESPONSIBILITY: Assistant Chief Medical Director for Research and Development (151). (signed) ARTHUR J. LEWIS, M.D. Deputy Chief Medical Director Attachments Distribution: SS (151F) COA: (10) only FLD: RD, MDD, MA, DO, OC & OCRO-1 plus 200-2 EX: Boxes 44–6 & 88–2, Boxes 104, 60, 54, 52–1 each & 63–5

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT A                                                                                                                      CIRCULAR 10-87-138   November 20, 1987 SAMPLE NAS-NRC POW EXAMINATION SCHEDULE LIST FACILITY NAME AND NUMBER VAMC Anywhere, 100 NAS-NRC CASE NUMBER POW? NAME SSN STATUS DATE SCHEDULED 123456 Yes veteran #1 123-45-6789 1 2/22/87 123457 Yes veteran #2 123-45-6780 4 refusal 132456 Yes veteran #3 231-54-9876 3 can't contact

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT B                                                                                                                      CIRCULAR 10-87-138   November 20, 1987 INFORMED CONSENT I ________________________________ a former prisoner of war or combat soldier, have been asked by Dr.__________________________________________ of __________________________________________ VA Medical Center to participate in an approved research project entitled "Medical Examination of Former Prisoners of War and Combat Soldiers." This study is being conducted by the Medical Follow-up Agency of the National Academy of Sciences-National Research Council under contract to the Veterans Administration. 1. I understand that this study will compare the physical health of former prisoners of war and combat soldiers, and that my physical health will be determined by medical examination. 2. The medical examination I will undergo will include a complete history and physical examination. There will also be a mental status evaluation, a social work survey, and psychological testing which will involve filling out forms with paper and pencil. There may be laboratory tests, as required, as a part of this examination. All medical results will be kept confidential. Information may be disclosed outside the VA only as permitted by the Privacy Act and other Federal laws. 3. I understand that my participation in this study might benefit me by providing a thorough medical examination, and that the study itself may benefit former prisoners of war and combat soldiers by helping to understand the effects of military service on health. 4. If I would prefer not to participate in this study or if I choose at any time to pull out of the study, I understand that I will continue to get the medical care I am eligible for under the rules of the VA. I understand that the results of this examination will be included in my VA medical record and that a copy of these results will be sent to the Medical Follow-up Agency of the National Academy of Sciences-National Research Council for their use in this scientific study. The Follow-up Agency is bound by the provisions of the Federal Privacy Act, and will not release any personal information about me to anyone. If I have any questions during or after this examination, I may call my VA doctor at ______________________________. 5. I have read or have had read to me all of the above and have received satisfactory explanation of the nature and purpose of the study. Any questions I have asked concerning this study have been answered to my satisfaction. I have also examined and signed VA Form 10-1086, Agreement to Participate in Research By or Under the Direction of the VA, which deals with further information I may need as a research volunteer. I hereby consent to participate in this study. _______________________________ PATIENT                                 DATE _______________________________ PHYSICIAN                             DATE _______________________________ WITNESS                                DATE   B-1

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT C CIRCULAR 10-87-138   November 20, 1987 COVER LETTER TO ACCOMPANY VA FORM 10-0048, FORMER POW MEDICAL HISTORY Thank you for agreeing to participate in the National Academy of Sciences-National Research Council's research study of former POW (prisoners of war) and combat soldiers. Attached to this letter is a former POW Medical History form which will be made a permanent part of your record. Please complete this form to the best of your ability, paying special attention to completeness of responses. However, if you find it difficult to answer any part of the questionnaire, you may leave it blank. Non-POWs should complete only items 1 through 12,14,25,29,30 through 37,39,40, and 54 through 62, replacing ''captivity'' with "combat" and "repatriation" with "release from active duty." If you have any questions about these changes, your administrative coordinator can help you with the form. For your convenience, we have mailed this form to your home where you have access to military and other documents which may prove helpful in filling it out. Also, included is a copy of the Informed Consent form for you to read. You should bring this form with you when you come for examination. Please bring the completed forms to this facility on the day scheduled for your medical examination, which is on ________________________________ at __________A.M./P.M. in room __________. Your administrative coordinator for this evaluation is __________, who may be contacted by calling __________. Please call your coordinator for any assistance needed in completing the history form and to confirm the appointment for your examination. Attachments c-1

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT D CIRCULAR 10-87-138   November 20, 1987 WHAT TO EXPECT The medical examination you will undergo today is provided by this VA medical center as part of a National Academy of Sciences-National Research Council study of the health of former prisoners of war and combat soldiers. The examination will include a complete physical examination, by one or more doctors, including medical history and appropriate laboratory tests. The examining physician will explain the need for and use of these tests to you. You will also be seeing a social worker for an interview and a psychiatrist for a consultation. These examinations are an important part of the research study. Because there are several parts to this examination, it may be necessary for you to wait before proceeding to the next part. If you have any questions about the examination, you should talk to your administrative coordinator, _____________________________.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT G CIRCULAR 10-87-138   November 20, 1987 NAS-NRC Research Protocol Medical Examination Survey of Former Prisoners of War of World War II and the Korean Conflict Background The Medical Follow-up Agency of the NAS-NRC (National Academy of Sciences-National Research Council) is presently conducting a morbidity survey of former POWs (prisoners of war) of WW II (World War II) and the Korean conflict. This survey continues earlier NAS-NRC research begun in the 1950's, and its purpose is the collection of medical examination data on former POWs and controls. In this regard, it is the first NAS-NRC study to collect medical examination data simultaneously on all participants. Purpose The goal of the research proposed here is to gather and analyze medical examination information from former POWs and comparable controls. The study design links the NAS-NRC's ongoing POW research and the Veterans Administration's POW medical evaluation program in order to secure information most efficiently. In brief, (details will be discussed in the methodology section), the VA medical evaluation protocol includes complete physical and psychiatric examinations by qualified VA medical personnel. Of special interest is the face-to-face psychiatric interview, which will gather information complementary to the current NAS-NRC questionnaire. The following specific issues are among those to be addressed by this research proposal: (1) Will psychiatric morbidity, as ascertained by interview and psychological evaluation, be higher among former WW II PWP (Prisoners of War Pacific) than among their comparable nonprisoner controls? Will this also hold true for WW II PWE (Prisoners of War European) and PWK (Prisoners of War Korean conflict) when compared to their respective controls? Will psychiatric morbidity be higher among PWP and PWK than PWE, as observed in earlier studies? (2) What differences, if any, will there be between psychiatric morbidity assessed by interviewer versus questionnaire? Will these differences help us better understand the results from (1)? (3) How have illness levels changed over time? In particular, has the earlier differential between the PWP and PWK groups, on the one hand, and the PWE group, on the other, decreased with time? (4) How do the physician-reported physical examination findings compare to the self-reported diagnoses, symptoms, and complaints from the 1984 questionnaire? Are some physical findings under-reported or overreported, and do nonmedical factors influence this reporting? (5) Can any signs of distinctive abnormal physical findings be seen in the PWE veterans who were seriously malnourished at repatriation? Methodology Since March, 1983, the VA Department of Medicine and Surgery has been conducting medical evaluations under a protocol set in DM&S circular 10-85-48. This protocol provides both a standardized format for medical evaluation and a standardized format for collecting POW medical history, the latter including a detailed history of captivity, repatriation, and postwar adjustment. The present proposal is designed to make use of this existing data collection mechanism. It is

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict important to note here that the VA Advisory Committee on Former POWs has previously recommended that the information contained in the medical history and examinations noted above be collected and made available for research use. To date, approximately 22,000 examinations have been performed under this protocol. Given a universe of roughly 80,000 former POWs, one can estimate that 500–600 men in the current NAS-NRC study group have already received this examination at some VA Medical Center. These 500–600 examinations will be sent to NAS-NRC for coding, abstracting, and tabulating, and the remaining portion of the NAS-NRC cohort will be examined and those results similarly processed. The advantage of this proposal lies in its use of the current NAS-NRC cohort, which has two notable properties: it was statistically sampled to be representative of WW II and Korean conflict POWs, and it includes comparable control groups. These two characteristics distinguish the NAS-NRC cohort from any self-selected sample of men who have presented themselves for examination and allow sound inferences and generalizations to be made from the study cohort to the whole population of former POWs. The following paragraphs outline the methodological process in more detail. The NAS-NRC cohort has been matched against the VA's file of completed examinations, using SSN (Social Security number) and claim number. This matching produced a file of NAS-NRC study veterans who have already been examined by the VA, and this file was then used to produce a separate list of examined POWs for each VA medical center. These lists have been sent to the VA medical centers, and because the POWs on these lists have already been examined, each VA medical center has only to send copies of their completed examination forms to NAS-NRC. NAS-NRC has already begun to abstract, code, and computerize the completed examinations it has received. While the already completed examinations are being processed, work will begin on the remainder of the cohort. All three POW groups (WW II Pacific, WW II European, and Korean conflict) were traced for the earlier survey, and mailing addresses have been obtained for approximately 90 percent of them. Letters of invitation will be mailed to these veterans, urging participation in the VA medical evaluation protocol, and requesting the veteran's permission to forward their name to the closest VA medical center for scheduling of the actual examination. Table 1 shows the number of POWs and controls by theater and by examination status. Because the examination of controls necessitates additional clearance from the Office of Management and Budget (OMB), this examination will be addressed in a separate circular. For completeness, however, the process of non-POW control examinations is briefly outlined here. When clearance to examine is obtained, NAS-NRC will begin tracing the WW II and Korean conflict controls. This tracing includes matching against the VA BIRLS file to ascertain mortality and to obtain SSN. With SSN the living controls can then be forwarded to IRS through NIOSH for address finding. Veterans who are not traced through IRS will be given to commercial tracing firms to locate. Located control veterans will then be mailed the same invitation as the earlier POWs. The progress of examinations in both groups will be tracked so that copies of examinations can be requested as soon as they have been completed; some site visits will be made to monitor examination processes. As part of the medical evaluation process, both POWs and controls will be invited to undergo further psychological testing; when clearance form OMB is obtained, these psychological tests will be mailed to individuals and returned directly to the NAS-NRC. The psychological test battery will consist of the following: (1) the 21-item Beck Depression Inventory; (2) the 20-item Center for Epidemiologic Studies Depression Scale; (3) the 90-item Hopkins Symptom Checklist ; and (4) a posttraumatic stress disorder checklist.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict The psychiatric consultation, part of the usual medical evaluation, has traditionally been unstructured, thus permitting great differences in the documentation and recording of clinical findings. For research purposes, a structured and more standardized clinical psychiatric assessment will be incorporated into the psychiatric consultation. This will be accomplished by including the posttraumatic stress disorder portion of the SCID-NP-V (Structured Clinical Interview for DSM-III-R, Non-patient Version), which is currently also being employed in a national study of Vietnam veterans and PTSD. Moreover, the SCID-NP-V is fully compatible with DSM-II-R, assuring a common framework for diagnosing and reporting psychiatric disorders. The incorporation of this portion of the SCID-NP-V into the customary psychiatric consultation thus provides an opportunity to "calibrate" the psychiatric examination, facilitating the comparison of results to ongoing and future studies. Copies of all completed medical evaluations will be abstracted, coded, and computerized. All medical examination, psychological testing, and disability data will be matched to the NAS-NRC master file to create a study file containing medical examinations, psychological tests, VA hospitalization experience, VA disability history, military service history, and POW captivity history. The study file will be analyzed to address the questions posed earlier, and a report will be prepared and submitted for publication. Discussion In this section, we address some of the practical issues in the study as outlined. Based on current data, it appears that roughly one-quarter of the NAS-NRC POW cohort has already presented itself to the VA for the medical examination protocol; this is approximately the same percentage as in the universe of all POWs. Thus, there are already approximately 600 NAS-NRC study veterans examined. Because protocol examination rates appear to be declining with time it is not reasonable to simply wait for more study veterans to present themselves to the VA for examination. Confounding factors play an important part in the analysis of the data from this epidemiological study. An advantage of the longitudinal data base provided by the NAS-NRC cohort is that many possible confounders of health and disability have been recorded: demographic data, such as age, race, marital status; military data, such as duration of service, rank, theater of service; and data from other sources, such as smoking and drinking behavior from the current questionnaire. These factors can be controlled in analysis when outcome measures are compared and when associations with other risk variables are calculated.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict Table 1 Estimated Sample Sizes for POW Medical Examination Study   POWs   War period and theater Already examined To be examined Total CONTROLS WW II, Pacific 175 475 650 700 WW II, European 95 280 375 385 WW II, European (malnourished) 60 190 250 - Korean conflict 220 620 840 850 Total 550 1,565 2,115 1,935

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict Veterans Administration CIRCULAR 10-88-117 Department of Medicine and Surgery   Washington, DC 20420 October 7, 1988 TO: Regional Directors; Medical District Directors; Directors, VA Medical Center Activities, Domiciliary, Outpatient Clinics and Regional Offices with Outpatient Clinics SUBJ: Examination of Controls in the Research Study of Former Prisoners of War (OMB 2900-0427) 1. PURPOSE: The purpose of this Circular is to outline the methodology necessary to conduct examinations of nonprisoner of war veteran controls who are part of the research study of former POWs (prisoners of war). Because the research study is only a one-time study, this Circular will not be incorporated into the Research Manual (M-3). 2. POLICY: The Veterans Administration Office of Research and Development has contracted with the NAS-NRC (National Academy of Sciences-National Research Council) to conduct a research study focused on the long-term health effects of imprisonment as a POW. Circular 10-87-138 contained the methodology for examining POWs; this Circular discusses the examination of non-POW veteran controls. 3. DISCUSSION: a. As noted in Circular 10-87-138, studies of former prisoners of war have shown that the physical deprivation and psychological stress endured as a captive have lifelong effects on subsequent health and social adjustment. A crucial part of the scientific design of such studies is the comparison of the health of former POWs to that of veterans of comparable service who were not POWs, that is, non-POW veteran controls. b. The NAS-NRC is currently conducting, under VA contract, a morbidity survey of former prisoners of war of WW II and the Korean conflict, continuing an ongoing longitudinal study began in the early 1950's. The design of the study was outlined in Circular 10-87-138, and this Circular adds the examination of non-POW veteran controls to the study. 4. ACTION: a. General Outline of the Research Study: The NAS-NRC has already invited the POWs in their research study to participate in the DM&S POW protocol examination program, and they soon will also invite non-POW veteran controls to participate. Once these non-POW controls agree to participate, their reply form will be sent to the nearest VA medical center for examination scheduling, just as the reply forms for POWs were sent. All reply forms will be accompanied by the NAS-NRC POW Examination Schedule List, as described in Circular 10-87-138. All of the steps outlined in Circular 10-87-138, paragraph 44.,(1)-(6) will apply to the examination of non-POW controls. Non-POW veteran controls should not, however, be added to the DM&S POW Tracking System. b. Conduct of the Examination of Non-POW Veteran Controls (1) The conduct of the examination of non-POW veteran controls will be identical, as much as possible, to the conduct of the examination of former POWs as outlined in Circular 10-87-138. The same examination processes should be

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict undertaken for non-POW controls, namely: physical examination, mental health evaluation (including the structured clinical interview for DSM-III-R in Attachment E of Circular 10-87-138), social work interview, and psychological testing (using VA Form 10-20844-a through d). (2) The POW Medical History form, VA Form 10-0048, will be filled out only partially, as follows: items 1–12 and 14, leaving out references to time of capture and time of repatriation; items 29, 30–37, using experiences during combat rather than captivity; items 39–42, again with combat replacing captivity; and items 54–60 and 62, with release from active military duty replacing repatriation. Copies of the completed examination package should be sent to the address listed below in paragraph (5). (3) The NAS-NRC has agreed to reimburse examinees for their travel. When the examination has been completed the examinee should be given a copy of the "NAS-NRC Travel Reimbursement Request" (Attachment A) to be filled out while at the VA medical center and mailed to the NAS-NRC. The NAS-NRC will handle all details of reimbursement after the travel requests have been received. Mail these requests to Medical Follow-up Agency National Research Council 2101 Constitution Avenue, N.W. Washington, DC 20418 (4) Each VA medical center will need to secure the approval of its local Research and Development Committee and Subcommittee on Human Studies. The material attached to VA Circular 10-87-138 may be used for this purpose, and it is permissible to combine the application for approval for examination of non-POW controls with the earlier application for examination of POWs. (5) Questions concerning this Circular and completed examinations may be addressed to the following: QUESTIONS TO: FORMS TO: Dr. William Page Mr. David Thomas (151J) Medical Follow-up Agency Medical Research Service National Research Council VA Central Office 2101 Constitution Avenue, N.W. 810 Vermont Avenue, N.W. Washington, DC 20418 Washington, DC 20420 FTS 737-2825 FTS 373-3939 Commercial 202-334-2825   5 REFERENCES: VA Circular 10-87-138. 6 RESCISSIONS: This DM&S Circular will be rescinded on October 9, 1989.

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict 7. FOLLOW-UP RESPONSIBILITY: Assistant Chief Medical Director for Research and Development (151). (signed) ARTHUR J. LEWIS, M.D. Deputy Chief Medical Director Attachments DISTRIBUTION: SS (151F) COA: (10) only (101B2)-5 FLD: RD, MDD, MA, DO, OC & OCRO-1 plus 200-2 EX: Boxes 44-6 & 88-2, Boxes 104, 60, 54, 52-1 each & 63-5

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The Health of Former Prisoners of War: Results from the Medical Examination Survey of Former POWs of World War II and the Korean Conflict ATTACHMENT A CIRCULAR 10-88-117   October 7, 1988 NAS-NRC TRAVEL REIMBURSEMENT REQUEST DATE:__________ NAME:______________________________ ADDRESS:______________________________ ______________________________ NAS-NRC Case number:____________________ VA medical center name:____________________ Number of trips made:__________ Number of miles traveled per round trip:__________ Under 5 __________ 5–10 __________ 11–20 __________ 21–50 __________ 51–100 __________ More than 100 Mileage rate: 21 cents per mile up to $75.00 maximum per trip. Minimum payment $5.00 per trip.  _______________________________________________________ Traveler's signature (must be signed to receive reimbursement) VA FORM 10-20877                                                                                                                       A-1 AUG 1988  

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