Volume 5  Number 4  June 30, 2008
Second Opinions

Casualties of War: Iraq and Afghanistan

Grim Totals

According to the Department of Defense, more than 1.6 million U.S. military members have served in Iraq and Afghanistan in over five years of combat. Of those troops, almost 30,000 have been wounded in action, including over 8,000 severe limb injuries and estimated 423-1,000 amputations. An additional 28,000 or more have been injured or become so ill that they had to be evacuated from the war theater... Casualty deaths of U.S. since the war began in March, 2003 and as of June 27, 2008, in Iraq were 4113; in Afghanistan 342 killed. Iraqi and Afghanistan civilian deaths due to the invasion secondary to violence have been estimated at up to 833,000 with over 1.5 million seriously injured and over 600,000 Iraqi deaths in the areas studied in the Lancet report.

According to internal Army documents reported in previous years and recently by CNN, the number of attempted suicides or self-inflicted injuries in U.S active duty soldiers is rising at an alarming rate. These figures principally from those serving in or returning from Iraq and Afghanistan have gone from approximately 350 in 2002 to more than 2,100 last year. The number of suicides among active military service members, reached their highest level since the Army began keeping such records in 1980, 121 suicides in 2007, 20% higher than in the previous year. The UPI reports that as many as 1 of every 10 soldiers from the war on terror evacuated to the Army's biggest hospital in Europe was sent there for mental problems. Between 8 and 10 percent of nearly 12,000 soldiers from the war on terror, mostly from Iraq, treated at the Landstuhl Regional Medical Center in Germany had "psychiatric or behavioral health issues," according to the commander of the hospital, Col. Rhonda Cornum. The hospital has treated 11,754 soldiers from the war on terror, with 9,651 from Iraq and the rest from Afghanistan.

IED's and Head Injuries in Iraq

The roadside bomb or improvised explosive device (IED) is the signature enemy weapon in Iraq, and the number one killer of troops. When any high explosive charge is detonated, very hot, expanding gases are formed in millionths of a second. These gases can exert pressures up to or beyond 700 tons per square inch surrounding the explosion, and rush away from the point of detonation at velocities of up to 7,000 miles per hour, thus compressing the surrounding air. The entire blast pressure wave, because of its two distinct phases, a positive and negative or suction wave as the air rushes back, delivers a one-two punch to any object in its path. Depending on the size of the charge and surrounding conditions, these blast effects, whether from an IED, a car bomb, surface mine, or suicide bomber, may cause serious brain injury hundreds of feet or more from the detonation.

When troops are wounded in the field they are evacuated immediately if they have any obvious wounds. But though thousands of troops in Iraq have felt the blast of an IED, and those knocked unconscious are evacuated to a field hospital for evaluation, those who appear uninjured or do not complain of a problem remain on duty.

As specialists in brain injury know all too well, the human brain is the consistency of gelatin and any external force from an explosion shakes it violently; people can suffer brain problems without losing consciousness. Troops with closed head injuries may show no external signs of injury, and appear to be normal. One of the most frightening aspects of brain injury is that brain-injured people often lose the ability to know something is wrong.

More Long-Term Consequences of the Wars

Dr. Harriet Zeiner, a brain injury specialist at the VA recently commented on Iraq casualties: "One of the things commanders are trying to determine," she says, "is that after someone has been exposed to five and six concussive blasts are they still battle ready? Frankly, that floored us. You could have very significant effects from one exposure, and now they're trying to figure out if people who've been exposed five and six times should be going back into battle."

Compared to previous wars in Korea, Viet Nam, World War II, the toll of brain injuries in this war, thanks to roadside and car bombs, is astounding. According the Department of Defense, almost 18,000 troops have suffered such injuries, but the toll may well be higher. VA doctors say that two-thirds of them have been injured by IED blasts and two-thirds of those exposed to blasts, suffer some brain injury, ranging from a mild concussion to permanent damage. Thousands of unsuspected as well as suspected brain injuries will be one of the major legacies of this war.

Subtle personality changes that may occur as a result of such injuries would only be noticed by relatives or close friends who know the patient well, and other symptoms could take years to develop. "The effects of such injuries may therefore go unnoticed for years or even decades. The difficulty in diagnosis is further compounded by the fact that many of the symptoms of closed head injuries overlap or sound similar to those of post-traumatic stress disorder (PTSD)."

A recent JAMA article study by physicians in the Division of Psychiatry, Walter Reed and Army Institute of Research reports results of combined screening for PTSD, mental impairment, alcoholism, major depression, and other mental disorders of more than 88,000 soldiers returning from Iraq. The RAND Corporation, the well-known nonprofit research organization in their recent report stated that nearly 20 percent of military service members who have returned from Iraq and Afghanistan - 300,000 in all - report symptoms of post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment, according to the report. Many service members said they do not seek treatment for psychological illnesses because they fear it will harm their careers. But even among those who do seek help for PTSD or major depression, only about half receive treatment that researchers consider "minimally adequate" for their illnesses.

In the first analysis of its kind, researchers estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment - an amount that includes both direct medical care and costs for lost productivity and suicide. "There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan," said Terri Tanielian, Co-director, RAND Center for Military Health Policy Research and a researcher at RAND, "Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation."

Delayed Economic Costs

It could cost the VA at least $350 billion to provide disability compensation and health care to Afghanistan and Iraq veterans, according to a Harvard University researcher's conservative estimate. Those costs could climb as high as $663 billion, if many troops remain at war much longer and health care costs inflate.

The ultimate social and further economic costs to our society are unimaginable.

Martin F. Sturman, MD, FACP

Copyright 2008, Mathemedics, Inc.

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