Health impacts of war: case studies of New Zealand veterans of the First World War

The study of the impacts of war remains a relevant topic given how warfare remains a tragic part of the modern world. As of early 2024, there were major conflicts relating to the Russian invasion of Ukraine, and also one involving Israel in Gaza. One monitoring agency has detailed over 110 armed conflicts around the world: throughout the Middle East and North Africa (over 45), the rest of Africa (over 35), in Asia (21), Europe (7) and Latin America (6).¹

Different settings and weapons used in various armed conflicts will produce a variety of patterns of harm to the health of the military personnel involved. But some of the health impacts from wars spanning the last 150 years have similarities—including such conditions as post-traumatic stress disorder (PTSD), albeit with variant manifestations.^2,3,4 The conflict in Ukraine even involves trench warfare,⁵ which has similarities to the situation in the First World War (WWI).

Recent work has studied the morbidity impacts of WWI on New Zealand veterans.⁶ This involved examining the archival military files of a random sample of 200 personnel drawn from all participating personnel. The results showed that these veterans experienced a very high morbidity burden, e.g., 94% had at least one new condition diagnosed during their military service. Furthermore, the relative severity of these conditions was reflected by the high level of hospitalisation (89% at least once, with a mean of 1.8 hospitalisations for new conditions per individual). Indeed, over half of all these personnel (59%) were at some stage deemed no longer fit for military service. The study concluded that “the overall morbidity burden of this military force in WWI was very high, and much higher than the previous official estimates”. This high burden of morbidity was also compatible with an earlier study of New Zealand soldiers from Central Otago,⁷ the burden of influenza in the New Zealand military in 1918,⁸ and as described in other work.⁹ Nevertheless, this previous study focussed on quantitative analyses and did not illustrate a range of qualitative issues. Therefore, in this current study, a more qualitative approach was taken with the consideration of 10 illustrative cases.

Further key background to New Zealand and WWI includes the estimate of 98,950 military personnel serving overseas and 7,036 serving on home territory in the New Zealand Expeditionary Force (NZEF).¹⁰ An estimated 18.2% of these personnel died during the war and up to the end of 1923. The official number of personnel wounded or suffering illness was 41,317 (equivalent to 39.0% of all NZEF personnel). As of 31 March 1921, a total of 40,227 veterans had lodged claims for war pensions for war-related disability and 17,612 dependents had also lodged war pension claims (for the period September 1915 to 1921).¹¹ Of all these claimants, 89% were granted war pensions.

Methods

Cases for this qualitative study were all drawn from previous work involving archival military files on 200 military personnel in the New Zealand military who were involved in WWI.⁶ These personnel were a random sample of all participating personnel (albeit with some exemptions⁶). We chose to select illustrative cases along the lines of the following three themes:

• Severity of health outcomes (i.e., overall outcome and for PTSD);
• High frequency of conditions (i.e., new diagnoses; hospitalisations for new conditions; non-fatal injury events; sexually transmitted infections [STIs]);
• Debility as a consequence of various conditions (i.e., after being gassed, having gastroenteritis, malaria or pandemic influenza).

Data collection

The individual-level data primarily came from a publicly available online archive of military files.¹² Key information had been abstracted by the authors for the previous study,⁶ but the files on the selected 10 cases were all re-examined for this study (all by at least the first author). Lifespan data were collected via additional genealogical research as previously detailed.⁶ War pension data were collected by examining the “War Pension Card Index” (code=6825) held by Archives New Zealand. Additional data that could potentially inform long-term outcomes were searched for using the names of the individuals, e.g., in online legal documents¹² and in online New Zealand electoral rolls.

Ethics statement

Ethical approval for this study was provided through the University of Otago Human Ethics Committee process (Category B Approval, D22/030).

Results

The 10 cases covering the three themes are detailed in the table below. The theme of severity of impacts was illustrated with two cases. One died from suicide after their return to New Zealand with a serious head wound (Case A). The second was a severe case of “shell shock”/PTSD (Case B). The theme of high frequency of conditions was illustrated with a case with multiple new diagnoses (n=8 new diagnoses; Case C), a case of repeated hospitalisations for new conditions (n=6; Case D), a case of repeated non-fatal injury events (n=3; Case E) and one with multiple sexually transmitted infections (n=3; Case F). The theme of chronic debility as a consequence of various conditions was illustrated with cases who had suffered from being gassed (Case G) and having gastroenteritis (Case H), malaria (Case I) and pandemic influenza (Case J).

View Table 1.

Discussion

This qualitative study of 10 cases has further illustrated how severe the morbidity burden for military personnel in WWI could be. At the extreme end of the spectrum was premature death from suicide in 1919 (Case A). The cause of this man suffering depression is not precisely known, but it could reflect the collective impact of: i) his permanent facial injuries (with this reason in the official record), ii) having been “left weak and depressed” from pandemic influenza (with these issues mentioned by the Coroner), iii) the deaths of his brothers in 1916 (killed in action) and in 1918 (pandemic influenza), and iv) other possible wider societal factors that were common at the time, e.g., difficulty for veterans obtaining work in the post-war period.

These cases also illustrate the potentially long-term nature of some of the impacts, e.g., from PTSD (Case B) and debility from poisonous gas, gastroenteritis, malaria and pandemic influenza (Cases G to J). Unfortunately, there was limited long-term outcome information on these individuals from the sources we examined, other than occupational/address data from archival sources and lifespan. To better understand these outcomes would probably require very in-depth genealogical research and might not even be feasible in some cases. Even so, we know from other information that some injuries and illnesses among veterans had impacts for many years (see this review¹³), and there is a pattern of premature death among these New Zealand veterans of WWI.^14,15 Similarly, an Australian study found higher mortality after 1921 for particular WWI veterans (e.g., those who were discharged as medically unfit),¹⁶ and research has also shown that exposure to mustard gas in WWI was associated with increased risk of lung cancer death.¹⁷

Case C had a total of eight new diagnoses, with these spanning injuries (two separate occasions of gunshot wounds), three different infections, poor dental health and two poorly defined conditions. This high tally reflects typical exposure to hazards on the battlefield and to unsanitary and crowded living conditions for many WWI personnel. Many of these health problems could have been prevented with knowledge available at the time and better planning and resourcing, e.g., in terms of injury prevention,¹⁸ food quality¹⁹ and preventing diseases associated with crowding.^20,21 The approach to preventing STIs by military authorities was also initially problematic, but it did improve over the course of the war.^22,23

This study drew its 10 cases from a relatively small (n=200) random sample out of the total of 105,986¹⁰ New Zealand military personnel serving in WWI. As such, it is likely that some cases in the total military force would have suffered even more severe morbidity or even more extensive multi-morbidity than the cases considered here.

The limitations of the data used in this type of study have been discussed elsewhere, along with an inter-observer reliability assessment of data from these military files.⁶ But these 10 cases also directly illustrate some of the limitations. For example, there were sometimes vague and unclear diagnoses (e.g., “myalgia” experienced by Case C or the lack of a diagnosis for two of the hospitalisations for Case D). Also, it is possible that with the different STI diagnoses for Case F, there could have been an incorrect provisional diagnosis that was not subsequently changed in the records before another diagnosis was obtained shortly afterwards. Furthermore, the “PUO” experienced by Case D in November 1918 and the “sick leave” experienced by Case C in December 1918 could well have been from pandemic influenza.

Conclusions

These 10 selected cases reiterate how severe and extensive the morbidity burden for military personnel in WWI could be. Also illustrated is how the morbidity could contribute to adverse impacts on some of their lives after returning to New Zealand.