Those Who Have Borne the Battle (39 page)

 

 

The wars in Afghanistan and Iraq have gone on much longer than anyone predicted in 2001 or 2003. Many Americans grew skeptical of the wars with their shifting missions and ongoing costs. When the Iraq war began in March 2003, 75 percent of Americans polled supported the war.
The figure declined sharply, sometimes to less than half of the respondents, but did not consistently fall into less than half until 2005. In the fall of 2006, 40 percent approved of the war, and 58 percent disapproved.
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In December 2008, 56 percent of Americans thought the war in Iraq was a mistake and 30 percent believed the engagement in Afghanistan was a mistake. Support for the war in Afghanistan would sharply decline, beginning in 2009.

The Democrats won major victories in the off-year elections of 2006, and Barack Obama defeated John McCain in the 2008 presidential election. In each election, ending the war in Iraq was a major rallying cry for many. The increase in troops in Iraq in 2007, the “surge,” accompanied by significant tactical changes as provided for in the
Counterinsurgency Manual
, stabilized that situation militarily, at least to a level where the United States could draw down the military, which was the goal of the Obama administration. In Afghanistan, on the other hand, there was a renewal of insurgency, and the Taliban, often working out of Pakistan, proved to be a resilient foe and the Karzai regime proved to be an often weak ally. In December 2009, President Obama increased troop strength there but did set a deadline, of sorts, for a drawdown.

As these wars proved to be works in progress, it certainly has been the case that the resistance in these countries has proved more durable, effective, and deadly than nearly any official projections made at the outset. As a result of this, absent a major mobilization, our forces have been pressed with multiple tours in the hostile areas, with the length of tours being extended, and with American military personnel increasingly engaged in military actions where superior US firepower, training, and technology have not been determinative. Reserve and National Guard units have incurred multiple deployments, and some of them have suffered significant casualties as a result.

Paul Rieckhoff, who served as an army lieutenant with an infantry platoon in Iraq for nearly a year beginning in April 2003, expressed his frustration with the war upon his return from active duty. The Democratic Party featured him in their response to President George Bush's weekly radio address, sharing his perspective as a combat veteran. “With too little support and too little planning, Iraq had become our problem to
fix. We had nineteen-year-old kids from the heartland interpreting foreign policy, in Arabic. This is not what we were designed to do. Infantrymen are designed to close with and kill the enemy.” He would later describe the extended tours in Iraq as a “backdoor draft.”
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One of the true lessons of the Vietnam experience, one that was well learned and positively implemented, is for troops to rotate in units rather than individually to the war zones. Individuals deploy, work in theater, and return with their units. The shared training, personal relationships, and relatively stable leadership have clearly addressed one of the significant negative effects on performance and morale in Vietnam. This positive change does have some negative consequences, as quite frankly any rotation system does. There is a break in the relationships with local groups and a loss of immediate memory and experience.
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As the troops have been pressed to perform—and have done so remarkably well—and as their equipment has been pushed too hard and sometimes proved inadequate to the demands of the theater, so too have the support systems domestically been strained. Hospitals and medical-support facilities and VA transitional and ongoing services have faced unprecedented demands and numbers. No one in 2001 or 2003 predicted or even wished to consider wars of this length or casualties of this number—and no one predicted the types of casualties the medical system has experienced.

In addition to the duration of the wars, the taxing of medical support by wounded veterans has resulted from two other factors, both positive developments, but with ongoing consequences. One has to do with the efficiency and effectiveness of modern battlefield medicine, and the other has to do with the quality of combat protective gear and its proven effectiveness in preventing some fatal wounds.

Historically, immediate medical treatment of battlefield injuries or of accidents or disease in battle zones was a crucial factor in determining fatalities. This remains true. Obviously, the nature and severity of combat wounds and the seriousness of accidents or disease are always major variables. Equipment providing personal protection from many serious injuries as well as the speed and quality of medical attention have been major factors in saving lives. As weaponry has become more lethal, battlefield
medicine and combat protective equipment has struggled to keep up with and then improve upon the work of saving the wounded of war.

During the American Revolution, official records reveal that there were 1.4 nonmortal wounded for every immediate or delayed fatality. This likely understates the wounded. During the Civil War among the Union forces, there were 2.1 wounded for every death. In World War I the ratio of nonfatal wounds to battle deaths was 3.8 to 1. In World War II it was 2.3 to 1. In Korea it was 2.8 to 1, and in Vietnam it was 2.6 to 1. The lower the ratio, the greater the incidences of death among the wounded. The ratio of wounded to fatalities, in all of America's wars, prior to 9/11, including Operation Desert Storm, was 2.1 to 1.

Clearly, there has not been significant variation from the Civil War to Vietnam, with the First World War the only outlier from the general pattern. It is not clear why the ratio of nonmortal wounding to battle deaths was more favorable there. It may be due to the ways in which
wound
was defined, and it almost surely would relate to the use of gas warfare during this war, which could significantly cripple and debilitate but would not necessarily kill.

In Iraq, over the period from the invasion in March 2003 down through May 2, 2011, the ratio of wounded to killed was 7.24 to 1. In Afghanistan from October 2001 to May 2, 2011, the ratio was 7.18 to 1. Early in that war, Afghanistan had lagged behind Iraq largely as a result of the complexity of getting wounded troops from some of the mountain terrain quickly down to forward hospital bases. Speed is essential. In fact, in 2010 the ratio in Afghanistan had reached 10.48 to 1.
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This resulted largely from an expansion of medevac crews and the positioning of them and the field hospitals closer to the combat units.

A recent analysis of medical treatment in Afghanistan reported that in 2005, 19.8 percent of wounded Americans died, and in 2010 that figure was 7.9 percent. In 2010 those wounded by explosive devices were about 4.5 times those wounded by gunshot. Gunshot wounds remained the most lethal—12.9 percent of those wounded by firearms died, and 7.3 percent of the casualties from explosives died.
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Clearly, battlefield medicine has advanced significantly from the Vietnam era. Military medicine
is saving young men and women who would have died in previous wars. I have met some of these remarkable survivors. Theirs is quite an inspiring story.

Modern medicine has a companion piece in modern military technology. When the United States invaded Iraq in March 2003, the troops wore gear to protect them from potential biological and chemical warfare agents. This heavy equipment would prove to be unnecessary, but special protective vests and helmets have been critical innovations. The Kevlar helmets and body armor in use in the field protect vital organs from fatal damage.

There are new medical problems that result from the tactics and weapons used by the enemies in the field. Although there were no atomic, biological, or chemical warfare weapons in Iraq, neither were there many conventional firefights or battlefield engagements. US superiority in firepower and airpower is not always relevant in the type of action the US troops have faced in Iraq or Afghanistan.

As of September 2010, 80 percent of those killed in Afghanistan and 74.6 percent of those killed in Iraq were “white.”
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Representative of the more rural background of the modern armed forces personnel, the states with the highest deaths per capita were, in order starting with the highest, Vermont, Alaska, Montana, Nebraska, Wyoming, and South Dakota. The lowest per capita deaths, starting with the lowest, were from Connecticut, New Jersey, Delaware, New York, Rhode Island, and Utah.
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Studies of the war in Iraq confirm that the casualties of the war have increased the gap between rich and poor communities that had begun during the Korean War and increased during the Vietnam War; the casualty gap between richest and poorest areas has been the highest yet in Iraq.
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Let me add a brief personal observation, anecdotal and not empirical. Of the some three hundred men and a few women that I have spoken to in my visits to hospitals, I almost always ask what happened to them. They have described snipers, mines, mortars from the back of a pickup speeding away behind a berm, but most commonly they have recalled rocket-propelled grenades or an improvised explosive device—hidden under the
road or a bridge, sitting in road trash, perhaps a suicide bomber in a car or in a crowd.

When I first started going to visit the hospitals in 2005, the majority of the marines at Bethesda Naval Hospital who had been at Fallujah and elsewhere in al-Anbar Province suffered from gunshot wounds. Then for several years most Iraq casualties resulted from detonated explosive devices. These men and women had almost always been in vehicles. Over the past few years, with casualties increasingly from Afghanistan, there was at first an increase in patients with gunshot wounds, and this was followed more recently by a growth in injuries from explosions.

In the summer of 2011 when I visited Bethesda, there were forty-five patients in the hospital suffering from “battle injuries.” Of these, one had been injured by a mortar and three by gunshot wounds. Forty-one were injured by explosives. Those to whom I talked had largely been out of vehicles, on patrol or post, when they inadvertently tripped off or someone else detonated an explosive device. There were significant numbers of men with missing limbs.
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The troops deployed in these theaters are well trained to be observant for hidden explosives and booby traps, but this cautious, defensive approach, essentially trusting no one other than other American servicemen and -women, is not playing to their military strength. Of all of these accounts that I have heard over the years, at most a half-dozen have told me that they actually saw the person who attacked them. Even most gunshot wounds have been the result of sniper fire rather than firefights. There is often no “enemy” to fight. As one of the US soldiers in Ellen McLauglin's play
Ajax in Iraq
, observed, it was hard to know the enemy: “We're the only ones in uniform, you know.”
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Poet Brian Turner served in Iraq with the US Army's 3rd Stryker Brigade Combat Team. He wrote:
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Modern body armor and headgear have not protected troops from loss of limbs, from horrible burns, or from head injuries, often with significant traumatic brain injury. One young woman wrote after her brother came home with severe disabilities due to an explosion, “Giving one's life can come in more than one form.”
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Often enclosed in protective steel vehicles, they have experienced major explosions that at a minimum have caused significant concussions. Military medicine—as well as the National Football League—has lately discovered the possible consequences of concussion and of mild traumatic brain injury. Getting your “bell rung” is no longer something to be dismissed.

By March 2010 there were 178,876 diagnoses of traumatic brain injury from the current wars. These are not always designated as “wounded in action,” unless there are obviously physical or medical indicators of battlefield injury. In September 2010 one report indicated that there were 88,719 diagnosed cases of post-traumatic stress disorder. There was a growing recognition that some of these cases related to traumatic brain injury.

As of 2010, there were 1,407 veterans with amputations as a result of hostile action in Iraq and Afghanistan.
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A number of amputees have suffered multiple amputations, often with other significant medical conditions. These officially are “polytrauma.” These veterans have lengthy hospital stays with needs for sophisticated treatment, state-of-the-art prostheses, treatment for vision and hearing loss, counseling and surgery for major disfigurement, multiple surgeries, extensive treatment and plastic surgery for burn injuries, and extended physical and occupational therapy, all of which has been overwhelming the hospitals.
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