Porter and Repatriation Commission
[2005] AATA 537
•8 June 2005
Administrative
Appeals
Tribunal
DECISION AND REASONS FOR DECISION [2005] AATA 537
ADMINISTRATIVE APPEALS TRIBUNAL )
) No Q2003/1065
VETERANS' APPEALS DIVISION )
Re PATRICIA PORTER Applicant
And
REPATRIATION COMMISSION
Respondent
DECISION
Tribunal Mr RG Kenny, Member Date8 June 2005
PlaceBrisbane
Decision The Tribunal affirms the decision under review. .........[Sgd].........
RG Kenny
Member
CATCHWORDS
VETERANS’ AFFAIRS – determination of cause of death – proof to standard of reasonable satisfaction – death from ischaemic heart disease - application of Statements of Principles - no reasonable hypothesis of relevant relationship of anxiety disorder or hypertension to eligible war service - death not war-caused
Administrative Appeals Tribunal Act 1975 s 37
Veterans’ Entitlements Act 1986 ss 6A, 7, 8, 11, 14, 120(1), 120(3), 120(4), 120A
Buckham and Repatriation Commission [2000] AATA 174
Repatriation Commission v Hancock [2003] FCA 711
Fogarty v Repatriation Commission [2003] FCAFC 136
Benjamin v Repatriation Commission (2001) 70 ALD 622
Repatriation Commission v Smith (1987) 15 FLR 327; 12 ALD 798
Nicolia v Commissioner for Railways (1972) ALR 185
Repatriation Commission v Deledio (1998) 83 FCR 82; 49 ALD 193
Keeley v Repatriation Commission (2001) 60 ALD 401REASONS FOR DECISION
8 June 2005 Mr RG Kenny, Member Background
1. Leslie William Porter (the veteran) served in the Royal Australian Air Force (RAAF) from 5 February 1951 until 4 February 1957. During that period he was allotted, in accordance with sections 6A and 7, respectively, of the Veterans’ Entitlements Act 1986 (the Act), for war-service in Malaya from 30 October 1951 until 23 October 1952. He died on 21 July 2002 and, on 7 October 2002, Patricia Porter, his widow and a dependant as defined in section 11 of the Act, lodged a claim, under section 14 of the Act, for a pension on the basis that the veteran’s death was war-caused in accordance with section 8 of the Act. That claim was rejected by the Repatriation Commission (the respondent) on 15 January 2003 and, in turn, by the Veterans’ Review Board, on 22 August 2003. On 19 December 2003, the applicant sought review of that decision by the Administrative Appeals Tribunal (the Tribunal) and an extension of time for lodgement was granted by the Tribunal on 12 January 2004.
Hearing
2. At the hearing, Mrs Porter was represented by Mr A Harding of counsel. The respondent was represented by Mr B Williams.
3. Material available to the Tribunal comprised:
exhibit 1:the documents prepared in accordance with section 37 of the Administrative Appeals Tribunal Act 1975 (the Act) (T1 – T6);
exhibits 2,3 and 4: statements, dated 25 June 2004, 12 January 2005 and 19 May 2005, respectively, by the applicant;
exhibits 5, 6 and 7: medical reports, dated 24 September 2004, 17 January 2005 and 22 July 2004, respectively, by Dr Valters Zolte;
exhibit 8:extracts, dated 24 January 1951, 25 October 1951 and 25 January 1957, respectively, from the veteran’s service medical records;
exhibit 9: a medical report, dated 24 August 2004, by Dr P Grant;
exhibit 10:an extract from Buckham and Repatriation Commission [2000] AATA 174 (paras 35 and 36 thereof comprising a summary of the evidence given by Associate Professor John Mc Carthy, of the Australian Defence Force Academy, in that matter).
Issues and Legislation
4. In order for the death of a veteran to be accepted as being war-caused, one of the requirements in section 8 of the Act must be met and, insofar as it is relevant in this matter, paragraph 8(1)(b) of the Act reads:
“(1)Subject to this section, for the purposes of this Act, the death of a veteran shall be taken to have been war-caused if:
(a) …..
(b)the death of the veteran arose out of, or was attributable to, any eligible war service rendered by the veteran;”
5. Where, as in this case, the veteran rendered eligible war service in the form of operational service, the standard of proof applicable to the determination of the causation matter is set out in subsection 120(1) of the Act which reads:
“120 Standard of proof
(1) Where a claim under Part II for a pension in respect of the incapacity from injury or disease of a veteran, or of the death of a veteran, relates to the operational service rendered by the veteran, the Commission shall determine that the injury was a war-caused injury, that the disease was a war-caused disease or that the death of the veteran was war-caused, as the case may be, unless it is satisfied, beyond reasonable doubt, that there is no sufficient ground for making that determination.”
6. The operation of that provision is affected by the terms of subsection 120(3) of the Act and 120A of the Act. Those provisions read:
“120 (3) In applying subsection (1) or (2) in respect of the incapacity of a person from injury or disease, or in respect of the death of a person, related to service rendered by the person, the Commission shall be satisfied, beyond reasonable doubt, that there is no sufficient ground for determining:
(a) that the injury was a war-caused injury or a defence-caused injury;
(b)that the disease was a war-caused disease or a defence-caused disease; or
(c) that the death was war-caused or defence-caused;
as the case may be, if the Commission, after consideration of the whole of the material before it, is of the opinion that the material before it does not raise a reasonable hypothesis connecting the injury, disease or death with the circumstances of the particular service rendered by the person.”
“120A Reasonableness of hypothesis to be assessed by reference to Statement of Principles
(1)This section applies to any of the following claims made on or after 1 June 1994:
(a)a claim under Part II that relates to the operational service rendered by a veteran;
(b) ……...
(2)……..
(3)For the purposes of subsection 120(3), a hypothesis connecting an injury suffered by a person, a disease contracted by a person or the death of a person with the circumstances of any particular service rendered by the person is reasonable only if there is in force:
(a)a Statement of Principles determined under subsection 196B(2) or (11); or
(b)a determination of the Commission under subsection 180A(2); that upholds the hypothesis.”
7. The provisions noted above relate to matters of causation and require an application of the Statements of Principles which have been published by the Repatriation Medical Authority. However, before applying the provisions of the Act relating to causation, it is necessary to determine the “kind of death” as that term appears in subsection 120A(1) of the Act applicable to the veteran: see Repatriation Commission v Hancock [2003] FCA 711. Such matters are to be determined in accordance with the terms of subsection 120(4) of the Act: see Fogarty v Repatriation Commission [2003] FCAFC 136 at [34] and Benjamin v Repatriation Commission (2001) 70 ALD 622 at [53] – [54]. Thus, the matter must be determined to the decision maker’s reasonable satisfaction. This imports the civil standard of proof so that matters must be determined on the balance of probabilities: Repatriation Commission v Smith (1987) 15 FLR 327 at 335.
8. The first issue for the Tribunal to determine is the underlying cause of Mr Porter’s death. The second issue to be determined is whether the death of Mr Porter arose out of, or was attributable to, any eligible war service rendered by the veteran.
Cause of Death
9. The delegate in this matter decided that the cause of death was ischaemic heart disease. Mr Harding submitted that this was correct while Mr Williams submitted that there was no specific evidence that this was the cause of death in this case.
10. Mr Porter died during a walk with his wife at the Kandanga National Park which was part of a stopover that they made during a driving tour of Queensland. He died immediately, falling to the ground after stating that he “felt giddy”. The death certificate was completed by Dr Valters Zolte who was his treating practitioner in Brisbane where Mr and Mrs Porter had their home. Dr Zolte certified as to the cause of death and did so after discussing the matter with the medical practitioner who saw Mr Porter’s body in Gympie. The certified causes of death were:
(a)Myocardial infarction
(b)Hypertension
(c)Hypercholesterolaemia
11. The first condition was noted to be present for minutes and the hypertension to be present for 18 years.
12. Mr Williams referred to the absence of a post-mortem examination and the lack of personal witnessing of Mr Porter’s body by Dr Zolte as reasons for casting doubt on the correctness of the diagnosis of myocardial infarction.
13. A medical report was prepared by Dr Peter Grant, the Senior Medical Officer Compensation, on 24 August 2004 (exhibit 9). There, the causes of death as described on the death certificate were repeated and Dr Grant commented upon the prospect of their having a causal relationship between Mr Porter’s death and his service. However, the report provides no guidance on what was the ultimate cause of death in Mr Porter’s case.
14. In his evidence, Dr Zolte said that he had been treating the veteran from at least 1984 and had documented records of his being hypertensive from that time onwards. He said that, when a person suffers a heart attack, they usually make complaint of chest pain. He noted the only complaint of the veteran was that he “felt giddy” and he said this could be attributable to heart attack or to some form of cerebral ischaemia. Nevertheless, because of his history of treatment of the veteran, he said that he was almost certain that he had suffered a heart attack. He said it was for this reason that he had certified myocardial infarction as the cause of death.
15. Clearly, the evidence of Dr Zolte is based on his inferences from what he knows to be the health and treatment history of Mr Porter. No post-mortem examination was conducted and, in that situation the entry on the certificate is no more than prima facie evidence of the cause of death: see Nicolia v Commissioner for Railways (1972) ALR 185 at 186 and 187. However, given the long history of involvement by Dr Zolte with the treatment of Mr Porter, I am satisfied that his evidence should be accepted. At one stage in his evidence he said he was 95% certain that the cause of death was the myocardial infarction and, on another occasion in his evidence, he said he was 99% certain that this was the cause.
16. On the evidence of Dr Zolte, and in the absence of any evidence to the contrary, I am satisfied, on the balance of probabilities, that the veteran died from a myocardial infarction and that the underlying disease process related to that condition was ischaemic heart disease.
Relationship to Service
17. The procedure to be adopted in determining whether or not a particular condition, in this case ischaemic heart disease with associated myocardial infarction, arose out of, or was attributable to, any eligible war service that Mr Porter rendered, was set out by the Federal Court in Repatriation Commission v Deledio (1998) 83 FCR 82 at 92 in the following terms:
"1. The tribunal must consider all the material which is before it and determine whether that material points to a hypothesis connecting the injury, disease or death with the circumstances of the particular service rendered by the person. No question of fact finding arises at this stage. If no such hypothesis arises, the application must fail.
2. If the material does raise such hypothesis, the tribunal must then ascertain whether there is in force an SoP determined by the Authority under s 196B(2) or (11). ...
3. If an SoP is in force, the tribunal must then form the opinion whether the hypothesis raised is a reasonable one. It will do so if the hypothesis fits, that is to say, is consistent with the `template' to be found in the SoP. The hypothesis raised before it must thus contain one or more of the factors which the Authority has determined to be the minimum which must exist, and be related to the person's service (as required by ss 196B(2)(d) and (e)). If the hypothesis does contain these factors, it could neither be said to be contrary to proved or known scientific facts, nor otherwise fanciful. If the hypothesis fails to fit within the template, it will be deemed not to be `reasonable' and the claim will fail.
4. The tribunal must then proceed to consider under 120(1) whether it is satisfied beyond reasonable doubt that the death was not war-caused, ... If not so satisfied, the claim must succeed. If the Tribunal is so satisfied, the claim must fail. It is only at this stage of the process that the tribunal will be required to find facts from the material before it. In so doing, no question of onus of proof or the application of any presumption will be involved." (Emphasis added)
Deledio Step 1
18. This step requires that there be material which points to an hypothesis connecting a claimed condition with service. Mr Harding advanced two contentions:
first hypothesis:
19. Mr Harding contended that the development of ischaemic heart disease in Mr Porter was brought about by his hypertension which he suffered for many years. He referred to stressful aspects of Mr Porter’s service and contended that this resulted in an anxiety state which, in turn, contributed to the development of hypertension and, subsequently, ischaemic heart disease.
second hypothesis:
20. A second contention by Mr Harding also involved hypertension and the subsequent development of ischaemic heart disease. He contended that hypertension was either caused or aggravated by the ingestion of salt that Mr Porter took while serving in Malaya and which was taken to counteract the effects of excessive perspiration and loss of body salt because of the tropical climate. He referred to a 1951 measure, taken on enlistment, of the veteran’s blood pressure at 150/80 and a further reading at the time of his discharge of 180/90 in 1957.
21. I accept that those submissions constitute separate hypotheses of a relationship to operational service.
Deledio Step 2
22. The second step requires identification of the relevant Statement of Principles. Where a Statement of Principles, which was in force at the date of Mrs Porter’s initial claim, has been amended or replaced by a subsequent Statement of Principles, the matter is to be determined in accordance with whichever of the Instruments is more favourable to the applicant: see Keeley v Repatriation Commission (2001) 60 ALD 401 at 415, 422.
23. In this case, the Statement of Principles for ischaemic heart disease at the time of the claim was Instrument No 38 of 1999. This has now been replaced and further amended, respectively, by Instrument No 53 of 2003 and Instrument No 9 of 2004. For hypertension, the Statement of Principles as at the date of claim was Instrument No. 31 of 2001 and this has been replaced and amended, respectively, by Instrument No 35 of 2003 and Instrument No 3 of 2004. The Statement of Principles for generalised anxiety disorder is Instrument No 1 of 2000.
Deledio Step 3
24. The third step requires consideration of whether either of the hypotheses raised is a reasonable one. This requirement will be met if an hypothesis fits the template provided by a relevant factor and associated definition in the Statement of Principles.
25. For ischaemic heart disease, the relevant factor reads:
“the presence of hypertension before the clinical onset of ischaemic heart disease”.
26. For hypertension, the relevant factors and definitions, taken from the later Statement of Principles, read:
“ingesting at least 12 grams (200 mmol) of salt supplements per day on average for a continuous period of at least 6 months immediately before the clinical onset of hypertension; or
ingesting at least 12 grams (200 mmol) of salt supplements per day on average for a continuous period of at least 6 months immediately before the clinical worsening of hypertension; or
suffering from a clinically significant anxiety disorder for the six months immediately before the clinical onset of hypertension; or
suffering from a clinically significant anxiety disorder for the six months immediately before the clinical worsening of hypertension”.
clinically significant anxiety disorder means any anxiety disorder attracting a diagnosis under DSM-IV sufficient to warrant ongoing management by a psychiatrist, counsellor or general practitioner; and
salt supplements means salt added to food when cooking or eating or salt contained in salt tablets
27. For the purposes of the Statements of Principles, hypertension means:
“Permanently elevated blood pressure, evidenced by:
(i)a usual blood pressure reading where the systolic reading is greater than or equal to 140mmHg or where the diastolic reading is greater than or equal to 90mmHg; or
(ii)the regular administration of antihypertensive therapy to reduce blood pressure.”
28. The relevant factors in respect of generalised anxiety disorder read:
“experiencing a severe psycho-social stressor within the two years immediately before the clinical onset of anxiety disorder.
clinically significant means sufficient to warrant ongoing management by a psychiatrist, clinical psychologist or general practitioner; and
severe psycho-social stressor means an identifiable occurrence that evokes feelings of substantial distress in an individual, for example, being shot at, death or serious injury of a close friend or relative, assault (including sexual assault), major illness or injury, experiencing a loss such as divorce or separation, loss of employment, major financial problems or legal problems.”
29. If either of the hypotheses under consideration is reasonable, it will then be necessary to consider the fourth of the Deledio steps. This will require a finding that the relevant condition is war-caused unless the Tribunal is satisfied beyond reasonable doubt that such is not the case.
evidence
30. Oral evidence in this case was taken from Mrs Porter and from Dr Zolte.
31. Mrs Porter met the veteran in 1958 and they were married in 1960. During his service, Mr Porter was a photographer. Mrs Porter said that he rarely spoke about his experiences during the war except that he told her that he attended scenes where skirmishes between Australian troops and enemy soldiers had taken place and he would record, photographically, what he saw. She said that he advised her that he had often seen dead bodies and that he felt vulnerable in the sense that he was not sure whether or not someone would take a “pot-shot” at him whilst carrying out his photography duties.
32. Mrs Porter described her husband as a man who was not able to cope with stressful things. She said he left matters such as financial arrangements, the purchasing of items and disciplining of children to her as he would become upset if he was required to undertake those kinds of activities. She said that he would often become angry over quite simple things such as confusing travelling directions whilst driving in their car. She said he left to her matters relating to the education of their children including consultation sessions with school teachers. She said that Mr Porter had a well equipped tool room and would often lend tools to neighbours and, when they were not returned promptly, he would engage her to liaise with the neighbour for their return. Mrs Porter said he did not enjoy mixing with a lot of other people and that he left all social arrangements up to her. She said he would attend events such as the ballet, opera or concerts but did not like going to parties or hotels because he was not able to stand the noise and did not like the smoky atmosphere or the effects of alcohol consumption on people. Mrs Porter said that he was always quick to blame her if anything went wrong with the arrangements that she made. Mrs Porter said that, when they got married, he left all of the arrangements to her and he was not prepared to speak separately to the marriage celebrant. She recalled that, during the period before they were married, Mr Porter’s mother had died and, while this had been a stressful time for him, he left all of the arrangements concerning her funeral to his brothers.
33. Mrs Porter described Mr Porter’s sleeping habits as being characterised by restlessness and, though he was able to get to sleep easily, she said that he would often wake up in the middle of the night and not be able to get back to sleep.
34. Mrs Porter was unable to recall when Mr Porter was first diagnosed as having elevated blood pressure. In his post-service life, he worked for many years from the mid 1970s as a civilian employee at the army camp at Bulimba in Brisbane and she recalled that, at that time, he had a medical examination. She believed he was recorded as having elevated blood pressure readings then. Dr Zolte, who was his treating practitioner at that time, was unable to confirm this because he had no treatment records prior to 1984.
35. Mrs Porter said that her husband was not a man who saw doctors on a regular or frequent basis. She said she was not aware that he had ever been treated for anxiety. She could recall going to the chemist to obtain hypertension medication and she said this was another matter the veteran would not attend to for himself. She said that he took no medication apart from that related to his hypertension.
36. Mrs Porter was unaware of the level of salt intake that the veteran had taken during his Army service. She said that she always added salt to his meals in the cooking process and that he was not in the habit of adding additional salt at the table.
37. Dr Zolte said he only had records relating to the veteran from 1984 onwards. At that time, he changed the system of recording clinical notes and records and was unable to locate any records prior to that time. He was uncertain as to whether the veteran had been a patient prior to 1984 or whether he had demonstrated high blood pressure readings before then. His earliest record in 1984 demonstrated a blood pressure reading of 160/105. On examination of his clinical notes in relation to that consultation, he described Mr Porter as regularly attending for consultation and said that he was “one of his best customers”. He described him as being somewhat aloof and said that he did not describe any problems in the household except that, on one occasion, he came to see him because of sleeplessness. He said that he could not recall any references to an anxiety state and recalled Mr Porter as always looking cool and calm rather than anxious. When the various behavioural characteristics attributed by Mrs Porter to the veteran, as noted above, were described to Dr Zolte, he said that, by today’s standards, he may well have had an anxiety state.
38. Dr Zolte said that the 1951 measure of the veteran’s blood pressure at 150/80 would, by modern standards, be considered deserving of further investigation. He also said that it could well be that, at the time when that reading was taken, he was uncertain and anxious in a new situation and this may have attributed to the elevated reading. He said that it would need to have been followed up to ascertain whether it remained elevated. In relation to the discharge reading of 180/90 in 1957, Dr Zolte said this was a reading which really required follow-up analysis or investigation.
39. Dr Zolte said that, if the veteran had consumed 12 grams of salt per day during the period of the 12 months of his service in Malaya, this may well have contributed to the increase in his blood pressure during his service years. He said that, if the salt intake had fallen when he had returned to Australia at the end of 1952, he would have expected that any effects of the salt on the blood pressure reading would be overtaken. He said he was not aware of any analyses which demonstrated that, by lowering salt intake, blood pressure would fall. However, in all the circumstances, he considered that it was plausible that, even though he reduced his salt intake after 1952, an elevated blood pressure reading in 1957 could be due to the salt that he ingested for the 12 month period ending in 1952.
40. In his report, dated 24 August 2004, Dr Grant made the following observations:
…In relation to hypertension, the reading on 24 January 1951 would now be considered as suspicious of isolated systolic hypertension but would need a second elevated systolic reading for such a diagnosis to be confirmed (preferably within a few months).”
The reading on 28 January 1957 read in conjunction with the 1951 figure is consistent with hypertension pre-dating operational service. The significance of these readings remains unclear however – Mrs Porter states that high blood pressure was first tested in the late 1970s when her late husband was working at Bulimba as a civilian with the Department of Defence.
41. In the result, Dr Grant said that he was unable to find a relationship between the veteran’s death and his operational service.
submission on anxiety hypothesis
42. In relation to anxiety disorder, Mr Harding submitted that the witnessing of dead bodies and the sense of insecurity that the veteran related to his wife concerning being exposed to possible sniper fire constituted a severe psycho-social stressor for the purposes of the Statement of Principles on anxiety disorder.
reasonableness of anxiety hypothesis
43. The definition of psycho-social stressor is set out above. The photographic duties of Mr Porter would have involved him in situations where he would have encountered situations which would have been confronting to him. However, there is no material before the Tribunal which points to his having experienced substantial distress as that term is defined in the Statement of Principles, on those occasions. In that case, his circumstances do not point to satisfying the factor in the Statement of Principles on generalised anxiety disorder.
44. Even if there were such material, it would also be necessary for the requirement of the Statement of Principles on hypertension to be met. This requires that the anxiety disorder be “clinically significant” and that it be suffered in the period six months immediately before the clinical onset of hypertension. Dr Zolte, in his evidence, was prepared to accept that the veteran may have been suffering from some anxiety state. However, he also said that at no stage during his treatment of the veteran was this ever demonstrated apart from an occasion when he made reference to a period of sleeplessness. While Mrs Porter said that her husband was not one to frequent doctors, that was not the evidence of Dr Zolte. He said that he saw the veteran regularly and, perhaps, on a monthly basis and described him as “one of his best customers”. Whilst, in order to satisfy the definition of a clinically significant disorder, I accept the submission by Mr Harding that it is not necessary to have actual treatment, it is still the case that the condition must be sufficient in severity to warrant ongoing management by a psychiatrist, counsellor or general practitioner. Given the frequency of contact that the veteran had with Dr Zolte over a long period of time and his non-recognition of an anxiety state, the material before the Tribunal does not point to the presence of such a condition sufficient to meet that definition. Even if it were, there is no material which would point to the presence of anxiety disorder of that clinically significant degree for the six months immediately before the clinical onset of hypertension. Although there were isolated readings of elevated blood pressure in 1951 and 1957, there is no material which would point to the condition being diagnosed until 1984.
45. I am satisfied that that the hypothesis advanced in respect of anxiety disorder and hypertension does not meet the template of the Statement of Principles on hypertension and that, therefore, it is not a reasonable one.
submission on salt hypothesis
46. Mr Harding referred to the evidence of Associate Professor McCarthy which was reproduced in the reasons of the Tribunal in Buckham and Repatriation Commission [2000] AATA 174 (exhibit 10). In that case, the veteran served with the RAAF for periods totalling some nine months between 1963 and 1965 in the Far east Strategic Reserve and in Ubon. Professor McCarthy summarised the usage of salt supplements by military personnel to compensate for the excessive loss of sodium chloride from the human body as a result of excessive sweating. His evidence was directed to the research that he undertook in respect of the ingestion of salt by RAAF personnel in the early 1960s. His evidence is recorded as stating:
“The consumption of salt tablets was one way by which lost sodium chloride could be replaced.
You ask firstly how many salt tablets would have been recommended or directed for RAAF personnel to consume on a daily basis? Much clearly would depend on the locality of the RAAF personnel. The Veteran was serving at Penang and Butterworth, both in Malaysia at at (sic) Ubon in Thailand. Malaysia has a climate with a range of average daily temperatures of 21-32 degrees in coastal regions and 12-25 degrees in the mountains. In the north there is an average annual rainfall of 800mm. The result is very high humidity. Penang Island lies a short distance from the mainland – its climate is hot, humid and might be described as exotic. In Malaysia, therefore, the Veteran was serving in such a climate which according to second world war calculations, a salt supplement would be necessary.
It is impossible to say, however, how many salt tablets a day would have been recommended or directed by RAAF authorities. In the nineteen-forties and nineteen-fifties the average individual consumption of salt has been estimated to have reached 10 grammes per day. [Walker, Medical Services of the RAN and RAAF, p.100] According to information from the Defence Food Science Centre, this figure remains the average consumption today. In 1943 it was calculated that salt requirements in hot climates were: 2 grammes per hour for a man working; 0.5 grammes per hour for a man at rest; 12 grammes per day for sedentary occupations; 24 grammes per day for a man doing hard physical work. [Walker, Clinical Problems, p368].
It is noted that the Veteran was mustered as a Radio Technician Air. While this may not have entailed hard physical work it is reasonable to speculate that he would have been often on the tarmac servicing aircraft radio equipment in extremely hot conditions and without the benefit of shade. In such conditions it may be reasonable to argue that the Veteran’s salt requirements would have been at the upper end of the above scale.
…
You ask: How many grams of salt was contained in each salt tablet? This raises the question of the composition of the tablets themselves. The literature of some twenty years previously makes it clear that that (sic) no one standard sized tablet was made available. In the Royal Australian Navy, engine room staff working in tropical conditions were issued with salt tablets each containing 15 grammes of salt. A common issue was an 8 gramme tablet for RAN personnel working in adverse conditions. [Walker, Medical Services of the RAN and RAAF, p. 101]. Walker also mentions ‘…a convenient salt tablet [which contained] ½ gramme [of salt] with an additional equivalent amount of dextrose taken in one to three does (sic) daily. [Medical Services, p. 101]. A further combination largely used in the South West Pacific was ‘…a magnesium salt’. [Walker, Clinical Problems, p. 319], The modern salt tablet available from pharmacies contains 600mg of sodium chloride and the recommended intake is between 12 and 15 tablets each day if doing physical work in a hot climate. Thus if 15 tablets were taken the intake would be 9grms per day.”
47. Associate Professor McCarthy”s conclusions were:
“It is impossible to know how many salt tablets would have been recommended or directed for RAAF personnel to consume on a daily basis. Even is (sic) this question could be answered it would have no meaning because all would depend on the amount of sodium chloride contained in each tablet. As argued above, there appears to have been no standard tablet and each tablet contained variables of composition. It has been argued that the consumption of salt tablets would have possessed a self-monitoring aspect as the effects of salt depletion would have become quickly apparent. Thus it could be argued that the consumption of salt tablets was discretionary and discretion must have been applied otherwise there would have been a large number of heat and sodium chloride depletion casualties. There is no evidence available which shows that there were.
It is regretted that the lack of primary evidence makes this report more speculative than is desirable. There may be in existence an indent for salt tablets. I suspect, however, that such material would not have been deemed worth preserving by either the National Archives of Australia nor by the Australian War Memorial. There is also a possibility that salt tablets were prepared by the pharmacist on any given unit and thus formulated to meet the conditions of a specific locality. It remains true, however, that given the conditions in which the Veteran worked in Malaysia and Thailand, a salt supplement would have been required to avoid medical problems.” (Exhibit 5, pages 3-6)”
Mr Harding submitted that the evidence of Associate Professor McCarthy would point to an ingestion by Mr Porter of salt supplements in the order of 12 grams per day during his service in Malaya. He submitted that this would have had an impact on the already elevated blood pressure reading that the veteran had in 1951 and would have contributed to the higher reading which was found to be present in 1957. He referred to the service records of Mr Porter and to the fact that, after his return to Australia, he served in Victoria and, therefore, was in an area where he would not have continued to take any form of salt supplements. He noted the evidence of Dr Zolte and Dr Grant to the effect that the elevated readings would have warranted investigation on the application of today’s standards. Whilst he conceded that there may have been a natural progression of a pre-existing condition, he also submitted that, on the basis of Dr Zolte’s evidence, it could have been the continuing effect of the ingestion of salt during operational service. He referred to the diagnosis of hypertension in 1984 by Dr Zolte and submitted that it was probable that hypertension had been present for some years earlier than that because of the evidence of Mrs Porter who understood that a medical examination in 1977, when he began to work as a civilian for the Army at Bulimba, showed that he had elevated readings.
reasonableness of salt hypothesis
48. Dr Zolte accepted that it was plausible that the elevated blood pressure reading in 1957 might have been related to salt ingestion in 1952. However, he also said that he would expect that a return to lower salt dosages from 1952 onwards, when much of Mr Porter’s service was in southerly parts of Australia, would have resulted in a lowering of blood pressure. His evidence also was that the veteran may have been a person who was prone to hypertension and in whom there was no more than a natural progression of a condition which pre-existed his eligible service. Of course, any aggravation of such a condition by salt ingestion on service may also lead to attribution to service.
49. The definition of hypertension in the Statement of Principles is noted above. It requires threshold systolic and diastolic readings of 144 mmHg and 90 mmHg, respectively, as a “usual” reading. In this case, there are readings in 1951, 1957 and then 1984. In order to satisfy the requirement of the Statement of Principles, the definition would need to be met no more than six months after the veteran completed his operational service in October 1952. There is no material which points to his being hypertensive by April 1953. An alternative means of establishing that hypertension was present, for the purposes of the Statement of Principles definition, is through the regular administration of hypertensive therapy. In this case, there is no record of such treatment until 1984.
50. In either case of causation or aggravation of the condition, there must be material which points to the salt levels required by the Statement of Principles. I have noted the conclusion reached by Associate Professor McCarthy that it was impossible to know what levels of salt ingestion were recommended or directed by RAAF personnel in the 1960s. There is no material before me to advance that analysis in relation to the period when Mr Porter was serving. I have also noted that, in Buckham’s case, the veteran was able to give evidence of the level of his salt ingestion. In Mr Porter’s case, there is no evidence from the veteran himself as to the level of salt supplements that he took during his service. There is no material which points to ingestion of the threshold quantity of salt required by the Statement of Principles i.e. 12mmHg per day.
51. I am satisfied that that the hypothesis advanced in respect of salt ingestion and hypertension does not meet the template of the Statement of Principles on hypertension and that, therefore, it is not a reasonable one.
Decision
52. In the submissions of Mr Harding, hypertension was an essential link in each of the chains of causation advanced by him for ischaemic heart disease to be related to Mr Porter’s service. As the hypotheses for hypertension are not reasonable, it follows that the overall hypothesis for ischaemic heart disease and service is not a reasonable one. It follows that ischaemic heart disease and the death of Mr Porter from that disease process is not war-caused in accordance with section 8 of the Act.
53. The Tribunal affirms the decision under review.
I certify that the preceding 53 paragraphs are a true copy of the reasons for the decision herein of Mr RG Kenny, Member .
Signed: Camille Banks
AssociateDate of Hearing 19 May 2005
Date of Decision 8 June 2005
Counsel for the Applicant Mr A Harding
Solicitor for the Applicant Woods Prince
For the Respondent Mr B Williams, Departmental Advocate
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