A war of disabilities: Iraq's hidden costs are coming home

by Glasser, Ronald J.
We know our wars through numbers. They sway public opinion, they make a military conflict seem either winnable or too dangerous to continue. How many of ours killed? How many of theirs? With our current war in Iraq, the number of U.S. dead hovers around 1,600: and even as the Pentagon has proven particularly reticent to dwell on casualties whether in its refusal to allow photographs of caskets returning home or in its objections to TV programs in which the names of the dead are read it continues to cite the relatively small number of deaths compared with the total troops as a sign of both the war's success and the limited threat to our combat and support units.

Yet the story of this war cannot be told solely in the count of its dead.
Some 12,500 American G.I.s have been wounded in Iraq. Eight soldiers have been wounded for every one killed, about double the rate in Korea, Vietnam, and the Gulf War. The percentage of soldiers who have undergone amputations is twice that of any of our past military conflicts; nearly a quarter of all the wounded suffer from traumatic head injuries, far more than in our other recent wars. These are soldiers who have survived Improvised Explosive Devices (IEDs) and car bombs, who are living with mangled limbs, eye injuries, and brain damage. The true legacy of this war will be seen not in the memorials to those lost forever but in the cabinets of files in the neurosurgical and orthopedic wards at Washington's Walter Reed Army Medical Center, in the backlog of cases at Veterans Affairs.

In 1968, when I was stationed at the Army hospital in Camp Zama, Japan, taking care of the wounded flown in daily from South Vietnam, I had what I thought was an epiphany. In the wards where the hundreds of wounded lay, the beds all had small decals attached to their posts, insignias of the soldiers' different units; these insignias made me realize how vastly varied the experiences of this war were each unit seeing its own unique form of combat, each soldier unable to know what was happening elsewhere. Since I believed that the entire war would eventually come medevacked to me in Japan, it was from the vantage point of the hospital, I thought, that one could understand Vietnam, both in its particulars and in its entirety. And after practicing medicine for thirty-five years, I still believe that injuries and their treatment can reveal what's really happening in a war.

In Vietnam the explosive charges that blew off arms and legs usually killed soldiers on impact. Penetrating chest wounds, ruptured aortas, shattered livers and spleens, collapsed lungs, internal hemorrhaging these injuries, which typically accompanied severe extremity wounds, quickly proved fatal. Yet if an injured soldier was still breathing when he was put on a chopper, the odds were in his favor, as more than 97 percent of those soldiers survived. The combat medics, whose handiwork I would see when the wounded made it to Japan, saved lives on the battlefield through little more than emergency-room practices: maintaining airways, stopping bleeding, giving intravenous fluids to maintain vascular volumes and blood pressures, and calling in the medevac units, which rarely took longer than thirty minutes to reach a surgical facility.

Because of its success in Vietnam, medical care under fire changed little over the next twenty-five years. But as the way we fight military conflicts has evolved, so, too, has the type of medical care combat troops require. Military units have been reconfigured for maximum mobility and flexibility, enabling them to concentrate overwhelming force at a precise time and at an exact point of engagement. With increasingly smaller units fighting in difficult terrain all over the world, most likely behind enemy lines or along very long and sparsely defended supply routes, our wounded can seldom be medevacked in a timely fashion. Today's more agile and mobile medical teams need to be able to keep the wounded alive, without the possibility of evacuation, for up to seventy-two hours. They are trained in intensive care rather than triage and are ready to perform "damage control" surgeries of less than two hours anywhere troops travel. The military also has incorporated civilian advances in tourniquets, stints, and dressings that control hemorrhaging; high-tech starch concentrates have replaced bulky plasma bags and IV fluids. A recent New England Journal of Medicine article on the care of those wounded in Iraq and Afghanistan concluded that medical advances have decreased lethality even as weapons have become increasingly deadly. "Little recognized," writes the surgeon who authored the paper, "is how fundamentally important the medical system is--and not just the enemy's weaponry--in determining whether or not someone dies."

The protracted urban warfare we are experiencing in Iraq has led to an unexpected number of wounded, in no small part because ongoing advances in both combat medicine and protective armor have led to surprising survival rates for these wounded. Soldiers now wear flak jackets made of ceramic plates embedded in Kevlar that are lighter, more flexible, and vastly more protective than anything our soldiers have worn before. This body armor protects the chest, back, and upper abdomen, preventing damage to the torso and allowing many soldiers to survive other serious injuries. During a battle along the mountain ridges of Tora Bora, Afghanistan, in 2002, a Special Forces trooper was shot at close range by a Taliban fighter: three rounds from an AK-47 to the G.I.'s chest. The soldier dropped to the ground, and a few moments later stood up again to shoot and kill his attacker. According to those who were there, it was like seeing Lazarus rise from the dead. It was something that simply had never happened in Vietnam, or in any other war.

Saving more soldiers also means higher numbers of amputees and of those blinded and brain-damaged. Early in the war, during the race up from Kuwait through Nasiriya to Baghdad, the majority of wounds were from gunfire, mortars, and rocket-propelled grenades. Since then, insurgents have avoided direct confrontations, choosing to target support units and supply convoys rather than combat units. Almost 70 percent of injuries have been caused by roadside IEDs, rocket-propelled grenades, or car bombs. In April alone insurgents exploded 135 car bombs, more than half of which were suicide attacks. Unlike in our other wars, when soldiers were struck from ahead and above, soldiers in Iraq are hit from behind, below, and beside--often as they ride in vehicles that are not as well armored as their own chests. Nearly half of all U.S. troops wounded in Iraq since the fall of Saddam Hussein have been hit in the lower extremities; 25 percent have been injured in the hand or arm. Even for soldiers wearing Kevlar vests, the wounds from booby-trapped IEDs, which combine blunt, penetrating fragments and burn damage, are particularly difficult to treat long term. Body armor protects a soldier's "center mass," but the explosions shatter and shred arms and legs. A surgeon in the spina bifida clinic of the Minneapolis hospital where I now work recently returned from a tour of duty at a medical facility in Iraq. While there he had removed flak jackets from wounded soldiers whose legs and arms were barely attached but who were wholly unmarked from neck to groin.

The frequency of upper-extremity injuries points to another phenomenon new to this war. Large numbers of patients seen within the military-hospital system have lost hands or arms and are in need of upper-extremity prostheses, which are more complicated and expensive than lower-extremity prostheses. Not all limb injuries result in immediate amputation. Whenever possible, military surgeons practice "limb salvage" to save extremities.
But limb-salvage techniques--which involve skin and vascular grafts, placement of internal rods, and muscle-transfer procedures--are not always successful; they may take up to a dozen surgeries, and two years, before surgeons and patient give up and settle for amputation.

There has been an unprecedented incidence of facial and head injuries among survivors as well, another consequence of the particular physics of this war. IEDs, with their upward force, fire chunks of shrapnel and dirt up under military helmets, and those projectiles can cause severe facial and eye injuries, and penetrating head wounds, as well as damage to the central nervous system and muscle tissue.
Moreover, shock waves from the makeshift bombs can prove as dangerous as the gravel, nuts, bolts, and jelled gasoline packed inside them. Kevlar helmets may protect against some projectiles, but, in a blast, their weight can add to injuries. "It's like a pan on your head, held on by shoestring webbing," an Army combat engineer explained. "When you take a hit, it rings your head like a bell."

Indeed, soldiers walking away from blasts have later discovered that they suffer from memory loss, short attention spans, muddled reasoning, headaches, confusion, anxiety, depression, and irritability. The military has given a new term to these pervasive, nonpenetrating head injuries: traumatic brain injury (TBI). For soldiers with TBI who remain functional, most will experience some form of brain damage and significant disability. The Army's 31st Combat Support Hospital in Baghdad, the only U.S. medical facility in Iraq with CT-scan capability and neurosurgeons, regularly performs craniotomies--a procedure in which the skull is opened and the injured brain inside is examined. A combat surgeon there, viewing dead matter in the brain of a recently wounded soldier, said of his work, "We can save you. You might not be what you were."

Army neurologists fear that severe brain injuries are being under-diagnosed, that more subtle neurological problems are being missed in soldiers not injured enough to enter the evac chain but who have been exposed to the types of concussive injuries prevalent in today's form of urban warfare. In a March medical paper on casualties resulting from blasts, these injuries were said to be "notorious for their delayed onset." When I asked a pediatric neurologist at my hospital about the severity of these concussive injuries for soldiers, he told me he spends a great deal of time worrying about life-altering concussions from helmet-to-helmet contact at local high school football games. Yet troops are within five to ten meters of enormously powerful explosions. He said, "You bet it scrambles their brains."

The hidden economic costs of the war in Iraq will not be found in the immediate treatment of the wounded or in increases to military death benefits. As expensive or labor-intensive as these might be, the largest monetary costs will involve the long-term care of thousands of severely and irrevocably damaged veterans; and these costs will only increase as the years pass. We are going to have to care and pay for a very large number of patients with what are, in any honest prognosis, lifelong disabilities. The price tag will be staggering. An above-the-knee computerized limb prosthesis--made of graphite and titanium, and battery powered with a microprocessor built in to better control movement--costs $ 50,000. A below-the-knee prosthesis is priced at between $ 10,000 and $ 20,000, and then there's the constant attention and ongoing readjustments needed to keep the prosthesis operational. The three types of upper-extremity pros. theses offered by the military range in price from $ 5,000 to $ 100,000; patients are given one of each, in order to use them in different situations. In the past two years, there have been numerous multiple amputees who have needed double and triple prostheses.

Traumatic brain injuries also will create long-term economic problems. Not only are these injuries more likely to go undetected; they also leave veterans with lasting cognitive and emotional damage. Then there are the serious psychological problems, including post-traumatic stress disorder (PTSD), which are brought on by the unpredictable IED attacks, the protracted urban combat, and the high incidence of casualties. A New England Journal of Medicine study from July 2004 found that roughly one in six soldiers who had served in Iraq suffered from major depression, general anxiety, or PTSD; many expect the numbers to go much higher.

Right now the majority of casualties, including amputees, are kept within the Department of Defense's military-hospital system--embedding the costs inside a mammoth military budget of some $ 600 billion annually.
The DOD can and does pay for all the prostheses; it can order same-day MRIs and CT scans of the head and neck. It recently opened an amputee care center at Brooke Army Medical Center at Fort Sam Houston, Texas, that will provide state-of-the-art care for service members who have lost limbs in Iraq and Afghanistan. In addition, a new multimillion-dollar, 29,000-square-foot amputee training facility is being built at Walter Reed.

But the wounded stay within the DOD military health-care system only as long as they remain on active duty. Every wounded soldier will soon become a veteran and will--unless he or she is old enough for Medicare or miraculously lucky enough to find a managed-health-care company that will take on patients with extreme preexisting conditions--be forced to receive any ongoing care through Veterans Affairs. There is little to suggest that the VA--an overburdened and underfunded system--can handle the wounded from Iraq once they are released from Department of Defense care.

The VA now serves 7 million of the country's 25 million veterans; in the last year alone, the VA provided 6,000 new prostheses and performed more than 40,000 adjustments. The average wait for a VA decision on an initial claim for disability benefits is 165 days; to rule on an appeal of one of its decisions, the VA takes, on average, three years. (In the last ten years, some 13,700 veterans have died as they were waiting for their cases to be resolved.) In Minneapolis the waiting period for an orthopedic appointment at a VA hospital can be more than six months, and patients there have been told to expect a further decrease in services over the next budget period. The VA needs more money, and its claims and appeals process needs an overhaul. Yet this administration hasn't adequately increased funding to the VA to deal with the influx of new veterans from Iraq. Of the 290,000 veterans of Iraq and Afghanistan who had left active duty by January 2005, 22 percent have already sought treatment from the VA; more than a quarter of them were diagnosed with some form of mental disorder. At this time, more than 1 million have served in these wars. The GAO recently found that six of seven VA medical facilities it visited "may not be able to meet" increased demand for PTSD. Hundreds of billions have been given to the Pentagon to pay for this war; to pay for the war's aftermath, VA discretionary funding for 2006 is to be increased by only one third of 1 percent.

"Based on what we should be doing, the VA is simply underfunded," former Georgia senator Max Cleland, a triple amputee from the war in Vietnam and head of the Veterans Administration under President Carter, told me. "The budgetary constraints put into place by this administration's tax cuts have proved a disaster for the whole system. The VA can't handle what they have to do now; how are they going to handle the flood of physical and emotional casualties, many of whom will be the responsibility of the VA for the rest of their lives?"

Ultimately, if the Bush Administration continues its refusal to accept the realities of this conflict, the most enduring images of the Iraq war will be the sight of legless and addled beggars on our street corners holding cardboard signs that read: IRAQ VET. HUNGRY AND HOMELESS. PLEASE HELP.

Ronald J. Glasser, M.D., is a Minneapolis specialist in pediatric nephrology and rheumatology and the author of several books, among them 365 Days. His last essay for Harper's Magazine, "We Are Not Immune," appeared in the July 2004 issue.