THE UNIFIL STUDY - POSITIVE AND NEGATIVE CONSEQUENCES OF SERVICE
IN UNIFIL:   THE NORWEGIAN EXPERIENCE

Lars Weisaeth, M.D.,  Lars Mehlunn, M.D., and Mauritz S. Mortensen, M.A.
Division of Disaster Psychiatry
University of Oslo/The Norwegian Armed Forces Joint Medical Service
Olso, Norway

     Since its foundation after WWII, the United Nations has organized and implemented 34 peace-keeping/making missions in 40 countries on four continents. Norway -- a sub-arctic country with a population of four million -- has sent military troops (a total of about 50,000 over a period of nearly 50 years) to participate in 15 of these operations, from Kashmir via Congo to Bosnia-Herzegovina. Thirty-seven Norwegians have been killed while in service. By far the largest operation is the United Nations Interim Force in Lebanon (UNIFIL), initiated 1978, in which more than 25,000 Norwegian men and women have served so far.

     Clinical impressions (1) had made it clear that serving as a UN-peace-keeper might have serious personal consequences for health and well-being in the after time. The need for more systematic empirical data led to the initiation of the UNIFIL Study. (2). Started in 1990, it was the first comprehensive scientific investigation of its kind. The work has been carried out by the Division for Disaster Psychiatry, Joint Medical Services, Norwegian Defense Headquarters in Oslo.

	DESIGN 

     Between 1978 and 1991, a total of 15,931 men and women had served in the Norwegian units, mainly NORBATT, and HQ Staff Officer positions, adding up to 20,878 six-month terms. The study is a follow-up survey conducted 6.6 years on the average, after each soldier=s conclusion of the first service term in UNIFIL. The sample consists of three sub-groups. In order to attain representativeness of the entire population (all contingents and units within the contingents), a stratified sample of 1,062 individuals was drawn from the total of 15,931. Of these, 724 agreed to be interviewed, yielding a response rate of 68.2% in this sub-group, to be called the Cross-sectional Group. A sub-group of particular interest is made up of soldiers who had their service interrupted before the end of the term (SIBT), due to medical (29.5%), social (40.0%) or disciplinary (29.5%) problems, and were repatriated. In this group 59.7% agreed to be interviewed. A third group was a sample of matched controls for each of the SIBT subjects (equal in age, rank, contingent and position), but not repatriated.

	METHODS

     Data for the UNIFIL Study has been gathered by means of survey questionnaires, personal interviews and national demographic registers. A 67-page questionnaire was mailed to every individual in the samples, presenting a wide range of questions covering 20 main areas. Some results from the study will be presented below, focusing on characteristic UNIFIL-variables such as motivation for the service, self-evaluation of individual experiences, including positive vs. negative after-effects. A special section focused on stressful experiences possibly of a traumatic nature.

	RESULTS

     The majority (89.9%) of the Norwegian UN soldiers (Cross-sectional sample) were reservists on time-limited (3-6 months) contracts. As a small nation with limited manpower resources, Norway practices a system with 12 to 18 months compulsory military service for all males, voluntary for females, followed by 25 years of reservist status with refresher training and maneuvers, a total of 575 days of compulsory military service for men. Peace-keeping service is voluntary, and included in the total compulsory.

     The UNIFIL sample consisted mainly of young (mean age 26.5 years) men. More than half of the sample served for two or more six-month terms. It should be kept in mind that Norwegian men have always been used to serve for long periods outside the national borders, especially in the Merchant Navy which for many years had up to 60,000 men on 3,000 ships plowing all oceans. For young men to leave home and serve in foreign environments has been customary for 150 years. With number of jobs in the Merchant Navy somewhat declining, peace-keeping could be looked upon as a substitute.

	MOTIVES FOR VOLUNTEERING

     Various motives were given for seeking UNIFIL-service. To seek new experiences, excitement and danger were common, as was a financial motive, especially as this type of service well paid compared to work in the home environment. Half of the interviewed objects reported that the felt attracted to a military life-style, familiar to them from their compulsory service. Some wanted to qualify for a later military or civilian career through the experience acquired in the UNIFIL service. A considerable proportion said they wanted to contribute to peace, and obtain insight into the Middle-East conflict pattern, by going there and seeing for themselves. Relatively few entered the service in order to flee from domestic problems or merely to get a job. The majority of the motives reported -- from sensation-seeking, through practically-oriented motives to the rather idealistic and altruistic motives -- can be considered generally approvable. One view has been that adventure- and sensation-seekers might be less desirable. So far, however, there has been no significant relationship between these types of motives and possible harmful affects or experiences.

	SELF-PERCEPTION

     How then, did the UNIFIL personnel perceive their own mission and evaluate their roles as peace-keepers? The answers were elucidated through a series of semantic differential scales. The majority felt that they had managed to maintain a neutral position in face of the conflicting parties.  Most believed their personal contributions as part of the UN force to be important for securing peace in southern Lebanon. Some doubt was voiced, however, as to whether the UN interim forced really had made a contribution to solving the conflicts in the area. Nearly all felt that to be able to communicate well with the local population and building up mutual confidence to the conflicting parties was very important to for international peace-keeper. Opinions were more divided over the question of whether UN personnel should use more military force, and whether the role as professional soldier ought to be emphasized more strongly.

	DILEMMAS

     Although a peace-keeping soldier is different from a traditional soldier in that he and his unit are not supposed to take sides and try to solve problems by using fire-power against one or more of the conflicting parties, the interview objects reported that they frequently experienced hostility from various armed parties. In this respect the peace-keepers really served as a buffer. The uneasy feeling of being used as a punching ball might be strong especially among combat-trained infantrymen who had their very role model put to test.

     Well aware of the peace-keeper=s limited opportunity to retaliate, conflicting parties sometimes submit the peace-keepers to various forms of harassment, thereby compromising their mission. More cruel forms of provocations include captivity, isolation from soldier=s unit, arousal to take side in a local, conflict, thereby compromising the force, etc. Forcing peace-keepers to witness atrocities against children, women and elderly represents still another form of traumatic experience to the peace-keepers. One Norwegian soldier was taken hostage and equipped with a necklace of unsecured hand-grenades. Over several days he was threatened and made to believe that he was going to be killed. Among soldiers who have had these kinds of experiences, quite a few developed serious mental problems in the aftermath.

	ATROCITIES

     Witnessing atrocities against civilians without the opportunity to help, and being subjected to Aduring close@ incidents without permission to return fire, seem to represent especially severe traumas typical for the peace-keeper in contrast to the traditional combat soldier.

     As the saying goes, the traditional soldier expects war and gets peace, whereas the UN peace-keeper expects peace and gets war. Obviously, many of the Norwegian peace-keepers in southern Lebanon had not expected to face what they actually did. Despite the stressful events and traumatic experiences many had to face, however, the vast majority of the soldiers carried away a positive main impression of the service and the environment. Quite a few reportedly felt that their experiences had expanded their horizon with regard to the problems tormenting the population in the region. Many believed that their stress-tolerance and self-reliance had been enhanced, important elements in processing stressful experiences. Having acquire new military skills, the majority said they would recommend similar types of UN service to a friend or even to their son or daughter.

	HEALTH  PROBLEMS

     What consequences did the service have for the personnel in the follow-up with regard to health and well-being? Special attention was paid to the soldiers who had been repatriated before the end of their term, the SIBT group. As 96.7% of all servicemen completed their term as planned, this group consisted of a mere 3.3%, or 530 individuals. Repatriation varied somewhat over the 26 contingents. They were rather frequent at the start of the missing, and have almost disappeared as a problem in more recent years.

	PTSD

      The Post-traumatic System Scale (PTSS-10) was used to gauge the prevalence and intensity of core symptoms in the PTSD syndrome (3). In the cross-sectional sample, five percent were found to be PTSD cases (defined as a total score above six). The SIBT group, however, showed 15% prevalence of this case. In fact, if the borderline-group, those with scores 4-6, is included in the case-group, there is a case prevalence of 25.6% in the SIBT-group. The relative risks of PTSS-10 case in the SIBT group compared to the control group was found to be 3.5.

     A considerable proportion of the SIBT-group (48.8%) as well as the cross-sectional sample (44.6%) increased the consumption of alcoholic beverages during the service term. The explanation seems to be closer linked with increased availability and low prices than to need due to nervous tension or work overload. One sub-group, well represented in the SIBT-group, did not manage to adjust the alcohol intakes upon return home, but continued to consume more alcohol than before entering UN-service.

	ACCIDENT RISK

     Further problems following the UN-service included unemployment, deteriorating financial status, prosecution, major accident and divorce. Whereas there was no significant difference between the SIBT-group and the control group before the service with regard to unemployment, prosecution and accidents, the differences had increased considerably on these variables at the follow-up. For financial problems and divorce there was a certain over-representation in the SIBT-group already before the service commenced. At the follow-up, however, one third of the SIBT-group, twice as many as in the control group, had experienced longer periods of unemployment. Financial problems seem to follow in the wake of unemployment. Twelve percent of the SIBTs, two to three times more than in the control group, answered in the affirmative when asked whether they had been exposed to one or more serious accidents during the following period. Divorce was twice as common in the SIBT-group as for the controls. Even legal prosecution turned out to be clearly more common in the SIBT-group.

	SUICIDE

     The question of mortality may serve as an ultimate measure of possible noxious effects of the UN-experience. The most severe short- and long-term consequences in the UN peace-keeping forces is suicide and suicidal behavior. Earlier studies have shown that although suicide rates tend to decline during war-time, it may increase in the aftermath. Some Vietnam War-related studies (4) have pointed at this development. Although the conditions prevailing in the UNIFIL service cannot be compared with the dramatic Vietnam War situations, some health professionals and particularly the mass media have claimed that numerous suicides may have occurred in the UNIFIL personnel during service and in the years. In order to clarify this question, a study on the national registers in order to establish the number of deaths, time of death and causes of death. A 100% trace rate was obtained.

     Result showed that a total of 172 individuals (of the 15,931 who served on UNIFIL) had died in the relevant period of time. This cases were distributed in three categories and the figures were compared with expected figures in the same cohort in the total population, gathered from the Census Bureau. The comparison rendered these figures, UNIFIL veterans vs. expected: Natural, illness, etc., death 68/113, violent, incl. accidental deaths: 104/77.4, suicide: 45/32.1 = total N=172/190.

	EXPLANATIONS

     The total number of deaths in the UNIFIL veteran group was lower than the expectancy, due to the lower number of natural deaths. After all this personnel had been selected on the basis of fitness for service. The number of violent deaths was clearly higher, however, and the suicide figure was somewhat higher. The explanation may be two-fold. Either the UNIFIL experience was so stressful that it would explain the results, or there might have been a pre-selection of accident-prone individuals, some of whom suicidal. The solution to this problem would have to sought in psychology autopsy of each case.

     Early military studies (5) found that soldiers may be accident-prone for a period after having survived combat. Findings in the SIBT-group and the relative high numbers of accidental deaths would seem to support this hypothesis. On the other hand, accidental deaths might be entirely or at least in part a result of the selection process, in that sensation-seeking--risk-taking--individuals might be attracted to UNIFIL service, and thus become over-represented in this population. This would be in accordance with the most common motive for enlisting, namely to seek danger and excitement.

	OTHER STUDIES

     In recent years, a number of studies have addressed problem related to peace-keeping service. Segal et al. (6) found that combat-trained US infantry were not optimally suited for peace-keeping operations in the Sinai. Action-oriented soldiers forced into passive role-performance tended to develop frustrations. Similar problems may have been at work in Somalia. A Dutch follow-up study (7) found that five % of their former UNIFIL soldiers suffered from psychosocial problems several years after the Netherlands withdrew their contingent, a finding corresponding well with the Norwegian UNIFIL study. Swedish studies of medical and logistics personnel in UNIFIL (8) found that stress reactions were not prominent. During service in UNFICYP in Cyprus, only 0.5% of the Swedish personnel suffered from nervous breakdown (9). Among Danish personnel in ex-Yugoslavia 30 % showed some level of post-traumatic stress response, while seven % had severe symptoms (10). Also among Canadian soldiers serving in UNPROFOR is ex-Yugoslavia,  relatively high rates of post-traumatic stress symptoms have been reported (11). French studies (12) of 40 psychiatric cases, of which 38 were ex-Yugoslavia and two from Somalia, recorded anxiety disorders related to the experience of sniper-fire with the insecurity of being a living target. After their service in Somalia, 25.7% of US combat-trained soldiers qualified for the PTSD criterion of traumatic re-experience symptoms (13). A total of 11.4% fulfilled the PTSD criteria according to present US diagnostic categories. The best predictors of PTSD were high magnitude stressor events such as <<rocks thrown at unit>> (75%), <<unit fired upon>> (65%), and <<rejected by Somalis when trying to help>> (56%), and frustration with peace-keeping. Highly motivated German medical soldiers serving in three contingents in UNTAC in Cambodia 1992-93, were found to have low prevalence of psychological after-effects (14). A pre- and post-study of 56 Norwegian UN observers mostly serving  in ex-Yugoslavia (15) identified several stressors. Among the more severe stressors were lack of military structure, multi-national teams, disparity between age and military rank, the task of investigating civilian casualties including search for bullets in dead bodies, the experience of being shot at when unarmed, etc.

	CONCLUSION

     Although the main impression from the UNIFIL Study is that the vast majority of personnel cope relatively well with the challenges presented by the service in southern Lebanon, some individuals have problems. It is an important task to analyse the data in order to be able to develop selection procedures which may serve to minimize the number of risk-cases. Based upon the results of the present study, a number of initiatives have already been taken to reduce the risk of personnel developing post-traumatic stress disorders and other health hazards during and after peace-keeping service, and to prevent suicide. These initiatives include improved selection procedures, education and training, and psycho-social support measures, offered to personnel pre-deployment, during the operations and after completion of the term.

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