By David Brown
Washington Post Staff Writer
Friday, May 23, 2008
Sen. John McCain's 5 1/2 years as a prisoner of war in North Vietnam undoubtedly changed the course of his life. But now that he is 71, that remote trauma seems unlikely to shorten his life span or to lead to mental or physical conditions that are not already apparent.
That is the implication of a body of research on the lifetime effects of captivity and war trauma and the anecdotal experience of the small group of naval aviators imprisoned with McCain at the notorious "Hanoi Hilton."
The Republican presidential candidate's medical records dating to 2000 will be opened for view by the media today in Phoenix. The Arizona senator's multiple cases of melanoma, a potentially lethal skin cancer, are likely to dominate the documents.
Although some experts have speculated that sun exposure during his imprisonment may have led to his cancer, the records are unlikely to speak directly to the effects of his years as a prisoner of war. Despite his painful and harrowing captivity, McCain has never received a diagnosis of post-traumatic stress disorder (PTSD), campaign spokeswoman Jill Hazelbaker said, and research suggests that the syndrome has been rare in American aviator POWs who served in the Vietnam War.
The records being released today contain "no psychological material because McCain has not been treated for anything related to that in the time frame of records we are releasing," she said.
Common sense suggests that any candidate who is campaigning vigorously is unlikely to have a serious disease that has not already declared itself, experts said.
"The demands of the modern campaign are so significant that if one can get through them, one can assume they are as fit as need be," said Mark S. Litwin, a surgeon and "survivorship expert" at UCLA's Jonsson Comprehensive Cancer Center in Los Angeles.
Nevertheless, McCain's years as a POW -- he was released in early 1973 -- constitute a distinctly unusual health variable among presidential aspirants.
There are no published studies of longevity among American POWs who served in Vietnam. Studies of Australian prisoners, however, found that they had slightly increased mortality in the years and decades immediately after the war, particularly from accidents, suicide and substance abuse.
Studies of U.S. troops captured during World War II and the Korean War also found higher death rates in the early decades after their release, mostly from tuberculosis and cirrhosis of the liver. Once past that period, however, former captives' longevity was scarcely different from that of other veterans.
The most obvious effect of McCain's captivity is in his arms. He broke both of them and a leg after ejecting from his bomber in 1967. Inadequate treatment of the injuries, as well as torture by his captors in Hanoi, left him with a decreased range of motion in his arms -- evident in the shrugging appearance of his shoulders.
At the prison, which received its sarcastic Hanoi Hilton nickname from the Americans held there, McCain was repeatedly beaten, bound and placed in prolonged solitary confinement.
Since his repatriation in 1973, he has occasionally been examined at the Robert E. Mitchell Center for Prisoner of War Studies, run by the Navy in Pensacola, Fla. However, Hazelbaker said this week that the senator "has not for many years participated in any POW follow-up."
The center saw 470 of 666 POWs who served in Vietnam and has also seen prisoners from World War II, Korea, the Iranian hostage crisis, the Persian Gulf War and the current wars in Iraq and Afghanistan.
Very little information about them has been published. For example, it is not known how their longevity compares with that of other veterans or non-veterans.
A 1996 paper, one of the few studies to appear in a scientific journal, reported that naval aviators imprisoned in Vietnam had eight times as much nerve and muscle damage as non-imprisoned fliers, probably a result of shackling and torture. They had slightly more joint and back disorders, as well.
Over a 14-year period, 4 percent of the aviator POWs, all of them officers, experienced PTSD. Research on World War II prisoners found that officers as a group had far less psychological trauma than enlisted men.
More recently, the Pensacola center helped identify something called "late-onset stress symptomatology" or LOSS, which came to light after 562 combat veterans -- about 300 of them POWs -- answered a long questionnaire. The syndrome involves the return of troubling memories late in life, along with emotional anguish and guilt, often triggered by retirement and friends' deaths.
LOSS shares with PTSD a re-experiencing of traumatic events and some of the physical "hyperarousal" that accompanies it. But it does not include "emotional numbing" and the avoidance of activities that trigger the intrusive thoughts -- two key features of PTSD.
"As the veterans reached their later years, they began to experience combat-related thoughts and feelings as they faced the changes and challenges of aging," said Lynda A. King, a researcher at Boston University and the local Veterans Affairs hospital, who has studied LOSS. "We saw it as something much broader than PTSD."
The idea that war trauma might return to haunt old age has been raised by other researchers, too. A 2001 study of 177 POWs in the Minneapolis area who served in World War II and Korea found that over a four-year period, the number of men reporting PTSD symptoms rose from 27 to 34 percent, and the severity of symptoms increased. Eleven percent said they had experienced symptoms, seen them disappear and then reemerge with advancing years.
The naval aviators who were imprisoned in Vietnam are in their 60s and 70s. Both now and in the years immediately after their release, they have seemed unusually resistant to psychological damage from the experience.
The lifetime prevalence of PTSD in all the Pensacola POW studies is 24 percent. In the naval aviators, however, it was 4 percent from 1979 to 1983, when the disorder was most likely to appear.
Prisoners in other wars suffered PTSD much more frequently.
A 1997 study of 262 POWs from World War II and the Korean conflict, both officers and enlisted men, found that 54 percent had PTSD sometime in their lives, and 30 percent still had it decades later.
The most severely traumatized group were prisoners held by the Japanese during World War II. Many were starved and worked nearly to death, were tortured and saw fellow soldiers executed, and were transported in the airless holds of "hell ships" that were unknowingly bombed and torpedoed by their countrymen.
Eighty-four percent experienced PTSD at some point, and 58 percent still had it in late middle age. For them, the researchers said, developing a mental illness was essentially normal.
Everett Alvarez Jr., a Vietnam POW who went on to serve as deputy administrator of veterans affairs in the Reagan administration, remembers attending meetings of those Pacific war veterans and thinking how different they were.
"They would say, 'We come to these meetings because we understand each other,' " he recalled this week. "They would say, 'We had marriages that have failed; we've lost jobs. We can't relate to others, but we can relate to each other.' "
For many reasons, including pre-captivity training and the cohesiveness of the group, Alvarez and his fellow officer POWs have managed to largely escape severe psychological damage.
Alvarez was the first pilot shot down over North Vietnam and was held the longest. He was released on Feb. 12, 1973, after 8 1/2 years. One of his compatriots at the Hanoi Hilton was McCain.
Alvarez sees his fellow captives fairly frequently and campaigned for McCain in 2000. He says he has seen no late-appearing PTSD and no LOSS in his contemporaries.
"There is no regression; it is all going forward, it is all business," he said last week. When they talk about their problems, the subjects are "regular geriatric issues."
Alvarez, 70, retired from the Navy in 1980 and now owns and runs a management services company. He spoke this week on his cellphone while walking to a meeting in downtown Washington. He was asked whether he thought anything about McCain's imprisonment might give voters pause.
"Hell, no," he said from the sidewalk. "John is one of the guys who did his job."