Rehabilitation Colloquium Reflecting on the Past

1
Rehabilitation ColloquiumReflecting on the Past

• 7 8 October 2008
• Dr Graeme Killer AO
• Principal Medical Adviser
• Department of Veterans Affairs

2
AIM

• My aim in this brief presentation is to revisit
  some of the health and rehabilitation challenges
  of World Wars 1 and 2 and Vietnam

3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7

• Ive come up with a definition which may not suit
  everyone but lets work through it. The word
  rehabilitation is derived from the medieval latin
  word rehabilitare, which means to restore. In
  the widest sense, the word rehabilitation, could
  be used in terms of restoration of confidence,
  self-esteem, reputation, physical, mental or
  social wellbeing, ability to work, or all these
  things. So it is important to understand the
  objectives of rehabilitation shouldnt be thought
  of only in terms of returning to paid employment.
  To the individual and his or her family these
  other objectives are probably more important

8
WORLD WAR 1
9

• With experience, doctors perspectives
• changed. They came to see that a mans
• capacity to endure in war was determined by
• many things heredity, upbringing,
• character, the society he came from,
• how he felt about the war, his relationship to
• his fellow soldiers, the length of time he had
• been fighting, whether his wife has been
• unfaithful quite apart from the military
• circumstances in which he found himself.
• They realised, too, that in the military context
• collective factors often mattered more than
• individual ones such as morale and unit
• leadership.

10
THE REPATRIATION COMMISSION MEETING THE
REHABILITATION NEEDS

• The newly formed Repatriation
• Department put in place a package of
• rehabilitation that included medical
• treatment after discharge, provision of
• artificial limbs (for which the Repatriation
• Department developed special expertise),
• education fees, tools of trade, professional
• instruments, blocks of land and livestock.

11

• The key issues in rehabilitation from WW1 were
• The Government through the Repatriation
  Department provided wide ranging rehabilitation
  measures for returning WW1 veterans
• There was strong community and political support
  for the veteran community
• There was little understanding of the mental
  health issues of returning veterans and mental
  health services for veterans and the wider
  community were primitive and not conducive to
  rehabilitation
• Some veterans with shell-shock self-managed their
  health problems through return to hard physical
  labour
• There was an understanding that unit morale and
  leadership were important features in prevention
  of shell-shock in a post-war environment

12
WORLD WAR 2

• There are some comparative statistics
• between WW1 and WW2 that are important
• in understanding different challenges and
• rehabilitation between the two wars. While
• the numbers who served in WW2 were
• considerably greater than in WW1 both the
• numbers who died of wounds and total
• battle casualties deaths were far less.
• However, in WW2 we had in excess of
• 20,000 prisoners of war (POWs), many
• prisoners of the Japanese with high
• mortality rates from those working on the
• Thai-Burma railway.

13
PRISONERS OF WAR (POWs)
14

• Dr Rowley Richards one of the 43
• Australian doctors on the Thai-Burma
• Railway said the POWs responded well to
• rehabilitation on their return and this was
• because
• They were a survivor population
• Mateship was paramount forged in hell and this
  continued after returning home
• Strong family support
• Many had been immunised for hard times because
  they came out of the depression
• A positive mental attitude
• Strong leadership in the camps

15
VIETNAM
16

• On review there have probably been a
• number of initiatives that have contributed
• to the rehabilitation of Vietnam veterans
• and their families
• Vietnam Veterans Counselling Service (VVCS)
  1981
• Australian Centre for Posttraumatic Mental Health
  (ACPMH) 1995
• The Heart Health Program 1997
• Access to new pharmaceuticals
• New education initiatives with the Australian
  General Practice Network (AGPN) (pathways to care
  study)

17
VIETNAM VETERANS COUNSELLING SERVICE (VVCS)

• The VVCS was not based on the medical
• model and allowed veterans and later their
• families to seek counselling in relation to
• their mental health problems and it has
• pioneered health promotion programs
• particularly in relation to the use of alcohol
• but outcomes would be improved if stronger
• links were developed with general
• practitioners and divisions of general
• practice.

18
AUSTRALIAN CENTRE FOR POSTTRAUMATIC MENTAL HEALTH
(ACPMH)

• ACPMH has had a significant role
• nationally and internationally in policy
• direction by educating both providers
• and veterans alike in mental health
• Problems associated with military
• service. It has also had a pivotal role in
• accrediting in and outpatient PTSD
• rehabilitation programs.

19
THE HEART HEALTH PROGRAM

• The Heart Health Program is about
• educating veterans in cardiovascular risk
• factors and encouraging lifestyle changes
• associated with regular exercise. It has been
• well accepted by the veteran community and
• many veterans have maintained ongoing
• participation after many years. The wife of a
• Vietnam veteran who had PTSD told me that
• her husbands involvement in Heart Health
• was the best thing he had done in married life.
• The strengths of this program relate to the
• wellbeing that comes from physical fitness,
• mateship and the fact that it is a voluntary
• program.

20
ACCESS TO NEW PHARMACEUTICALS

• New pharmaceuticals have indeed improved
• the management of some of the symptoms
• of PTSD, the SSRIs have reduced the
• hyperarousal symptoms and reduces
• irritability and anger and the atypical
• antipsychotics i.e. Olanzapine has improved
• the ability to sleep. The SSRIs have come
• into some criticism because of links to suicide
• in some individuals. The issue is primarily in
• this case about optimal patient management
• and careful monitoring of patients in the first
• two weeks of treatment because of the
• potential to develop agitated behaviour.

21
SUMMARY

• Keep rehabilitation program simple and dont over
  medicalise i.e. Heart Health, Men in Sheds
• Greater involvement of veterans in developing
  veteran
• self-help programs
• Early intervention is the key and there should be
  properly structured case management approach
• Rehabilitation programs need to be linked to
  preventive health programs and assessments
  particularly related to post discharge medical
  screening
• Building on the current links in rehabilitation
  between Defence and DVA
• Maximising rehabilitation outcomes within Defence
• Transition programs for all those leaving the ADF
• Inclusion of families in rehabilitation programs
• Rehabilitation packages should include medical
  treatment, education and vocational arrangements
• Improved education of health providers in terms
  of the impact of military service on health of
  serving members, veterans and their families
• Greater promotion of self-care and health
  literacy programs

22
(No Transcript)
23
(No Transcript)