Objective: The purpose of this analysis was to identify and document significant differences in the self-reported health problems and reproductive outcomes of American women in three study cohorts: military women who served in the theater of operations in Vietnam during the war (THR), military women who served during the Vietnam era and were not stationed in Vietnam (ERA), and a cohort of civilians who practiced nursing during the Vietnam war but never served in the military (CIV).
Design: This investigation was a secondary analysis of data collected for the National Vietnam Veterans Readjustment Study (NVVRS), which was the first government study of Vietnam veterans that included women. The NVVRS used a retrospective cross-sectional design of six cohorts, as previously defined, and stratified by gender. Data consisted of information gathered in five-hour face-to-face interviews.
Population, Sample, Setting, and Years: The NVVRS investigators identified subjects for the study by a hands-on review of the individual military personnel records of more than 90 US Army units stationed in Vietnam as well as official records provided by the US Air Force and the Department of the Navy. This procedure resulted in a pool of names large enough to provide sufficient numbers for both veteran cohorts. Civilian counterparts were selected using a combination of a household sample and names of nurses drawn from the US National Registry of Nurses. Over sampling of women and nurses was accomplished to better approximate the actual proportions of nurses (89%) and include enough subjects to achieve adequate statistical power. The cohorts used in this analysis were: 434 THR 301 ERA and 220 CIV women subjects. NVVRS data were collected from November 23,1986 to February 15, 1988. Secondary analysis was conducted in 1999-2001.
Concepts or Variables Studied Together: Agent Orange is a powerful defoliant that reacts quickly to decimate vegetation. It was used in Vietnam to hinder enemy operations, destroy crops and protect perimeters of field outposts. Agent Orange was also sprayed in areas to clear grass and foliation around hospitals, living quarters, and base facilities. The most toxic by-product contaminant of Agent is 2,3,7,8 -tetrachlorodibezo-para-dioxin (TCDD), a known carcinogen commonly referred to as dioxin. Exposure was determined by cross referencing the reported dates of assignment and locations of 25 duty stations with information from the U.S. Army Joint Services Environmental Support Group and US Air Force mission spray data. In this analysis, a woman was considered to have been exposed if she was stationed in provinces of South Vietnam while spraying activities were actually being conducted.
Methods: Although the NVVRS was not planned as a health study, 49 questions about health problems, with date of onset, and six reproductive outcomes presented an opportunity to investigate these outcomes. To accommodate the complex design and weighted strategy, variances were estimated by Taylor Series Linearization using the Survey Data Analysis software (SUDAAN). Logistic regression was used to test dichotomous dependent variables. In the case of continuous variables, multiple regression was the method of choice. The primary measure of association of disease was the Odds Ratio. Outcomes with a date of onset prior to military service or reproductive outcomes prior to service in Vietnam were dropped from the analysis.
Findings: While THR women reported more breast cancer, illnesses, and injuries than other women in the study, there was persuasive evidence that women in the Agent Orange exposed group were significantly more likely to be at risk. These findings included the total number of health problems reported by individual subjects and disabilities that prevented them from working. Other findings indicated that exposed women were significantly more at risk for developing anemia, cancer, autoimmune diseases and multiple sclerosis than the other women in the study. This analysis found 46 cases of cancer in 434 women who served in Vietnam. THR women reported more miscarriages, stillborns, and induced abortions than the CIV women in the study. Women in the exposed group reported more miscarriages, tubal pregnancies, induced abortions, and total negative reproductive outcomes than unexposed subjects.
Conclusions: War, like any other human catastrophe, must be acknowledged as an important occupational and epidemiological event that deserves a full and complete exploration and scientific review.
Implications: The investigation reported here presented an unique first opportunity to assess the relationship of the health problems and reproductive outcomes of American military women exposed to Agent Orange in Vietnam. The findings are preliminary in nature and indicate the need for a more definitive investigation of the health problems of these veterans.
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