Invisible wounds of war

Since October 2001, approximately 1.64 million U.S. troops have deployed as part of Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF; Iraq). The pace of the deployments in these current conflicts is unprecedented in the history of the all-volunteer force. Not only is a higher proportion of the armed forces being deployed, but deployments have been longer, redeployment to combat has been common, and breaks between deployments have been infrequent.

At the same time, episodes of intense combat notwithstanding, these operations have employed smaller forces and have produced casualty rates of killed or wounded that are historically lower than in earlier prolonged wars, such as Vietnam and Korea. Advances in both medical technology and body armor mean that more servicemembers are surviving experiences that would have led to death in prior wars.

However, casualties of a different kind are beginning to emerge — invisible wounds, such as mental health conditions and cognitive impairments resulting from deployment experiences.

• Territa Nielian & Lisa H. Jaycox (eds.), Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, RAND Corporation (Center for Military Health Policy Research), 2008

Thus is sketched the broad context of a study on psychological and cognitive injuries suffered by US service personnel as a result of deployment to Afghanistan and Iraq since 2001.

The study focuses on three broad types of those ‘invisible wounds’ — post-traumatic stress disorder, major depressive disorder and depressive symptoms, and traumatic brain injury.

It seeks to explore the dimensions of prevalence of these injuries among returned personnel; the costs attendant upon these conditions “stemming from lost productivity and other consequences”; and provision — and, more to the point, gaps in provision — of the care system intended to meet the health-related needs of service personnel and veterans.

The authors also seek to make recommendations to address what they recognize will be a significant ongoing concern with continued mass-deployment of personnel to combat zones.

The work is constrained in its aims by a recognised paucity of “available data”. As a reviewer in The Lancet observed:

The lack of such data illustrates their point more clearly than any calculations could do — these are battle injuries that are underdiagnosed, poorly understood, and under-resourced.

• Piers Page, The Lancet, Vol 372, 15/11/2008, p. 1724 (subscription reqd.)

One troubling aspect identified in the study is that veterans are hampered in seeking and accessing care by institutional factors, such that it is perceived accessing services “will negatively affect employment and constrain military career prospects, thus deterring many of those who need or want help from seeking it.” The stigma of mental illness apparently yet persists in the “never explain, never complain” military culture of machismo.

The study, however, seems almost at pains to avoid being a controversial or polemical document. Indeed, the authors write almost glowingly of efforts at all levels of the US government “to study the issues ... quantify the problems, and formulate policy solutions.”

And they have acted swiftly to begin implementing the hundreds of recommendations that have emerged from various task forces and commissions. Policy changes and funding shifts are already occurring for military and veterans’ health care in general and for mental health care in particular.

Nor does this study essay into any broader questions about the conduct of US foreign policy and the “global war on terror”; on the contrary, it studiously avoids such matters.

Rather, the authors merely assert the US’s national “responsibility not only to recruit, prepare, and sustain a military force but also to address Service-connected injuries and disabilities.” Essentially, this is a commendable work of advocacy for and on behalf of US service personnel and veterans.