Shock and Awe HITS HOME U. S. HealtH CoStS of tHe War in iraq EVaN KaNtER M.D., Ph.D. NOVEMBER 2007 aCKNOWLEDGMENtS PSR and the author wish to thank the following individuals who made contributions to or provided critical review of this report: Michael McCally, M.D., Ph.D. Robert Gould, M.D. Tim Takaro, M.D., MPH Karin Ringler, Ph.D. Will Callaway, M.S. Linda Bilmes Lachlan Forrow, M.D. The author expresses deep gratitude to his veteran patients for their inspiration. aBOut thE authOR Dr. Kanter is a psychiatrist and neuroscientist who specializes in the treatment of Posttraumatic Stress Disorder. He is a Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a Staff Physician in the VA Puget Sound Health Care System. He is a member of the National Board of Directors of Physicians for Social Responsibility. Shock and Awe HITS HOME U. S. HealtH CoStS of tHe War in iraq NOVEMBER 2007 PHYSICIANS FOR SOCIAL RESPONSIBILITY 1875 Connecticut Avenue, NW, Suite 1012 Washington, DC 20009 Telephone: (202) 667-4260 Fax: (202) 667- 4201 E-mail: [email protected] Web www.psr.org US Affiliate of International Physicians for the Prevention of Nuclear War he military operational costs of the war in Iraq, now greater than $500 billion1, have surpassed those for the entire Vietnam conflict. These escalating operational costs are alarming, yet the Tlong-term public health costs will be much greater. Providing medical care and disability ben- efits to veterans will cost far more than is generally being acknowledged. These costs have been estimated at as much as $660 billion.2 As physicians and health care professionals we are acutely aware of the actual price we are paying in human terms and we are compelled to bring this to the attention of the Congress and the American people. thousands dead. The number of fatalities of Blast INjuRIEs aNd POlytRauMa U.S. military personnel serving in Iraq is ap- As U.S. forces have deployed advanced body armor proaching 4,000. This does not include journal- and armored vehicles, insurgents have utilized pow- ists and more than 1,000 civilian contractors erful car bombs and have increased the power and who have been killed.3,4 radius of improvised explosive devices (IEDs). The tens of thousands wounded. The total num- unexpected consequence of protective body armor ber of U.S. service members wounded, injured, paired with increasing explosive force are injuries or medically ill in Iraq now exceeds 60,000.5 that leave the torso intact, but produce horrific Because of advances in body armor and battle- wounds of arms, legs, face, and head. Currently, field medicine, many individuals who would 80 percent of combat injuries are caused by IEDs have died in previous conflicts are surviving and roadside bombs. These explosive devices com- with grievous injuries. The ratio of wounded in monly produce what is referred to as polytrauma combat to killed is 8:1, compared with 3:1 for — multiple, severe traumatic injuries. These may the Vietnam War, and 2:1 for World War II. The include brain and spinal column injuries, amputa- percentage of injured requiring amputations is tion of one or more limbs, blindness, hearing loss, the highest seen since the U.S. Civil War.6 burns, and fractures. Advances in battlefield emergency medicine are Hundreds of thousands of psychiatric casual- another reason for the high survival rates. The ex- ties. It is expected that up to 30 percent of all traordinary efficiency of Forward Surgical Teams veterans returning from Iraq will meet criteria (FSTs) deploying Rapid Assembly Tents has kept for serious mental health disorders.7,8 These may many individuals alive who would have died in pre- take the form of anxiety disorders including vious wars. posttraumatic stress disorder (PTSD), mood The goal of FSTs is damage control; wounds are disorders, and substance abuse disorders. A packed and left open and evacuation to Landstuhl significant fraction of these will be lifelong, Air Force Base in Germany averages 24 hours. This chronic afflictions. SHoCk and aWe HitS Home contrasts with Vietnam where surgical treatment memory, panic-level anxiety, and depression with was done in theater and weeks would elapse before suicidal ideation. These symptoms severely impact evacuation out of country. social and occupational functioning and may be Delayed deaths from polytrauma are not includ- profoundly disabling. ed in Department of Defense figures as “primary The National Center for PTSD uses the battlefield deaths.” Reasons for delayed deaths conservative figures 12–20 percent for the rate include sepsis from multiresistant microorganisms of PTSD expected in veterans returning from caused by blast wounds heavily contaminated by Iraq.9 Since 1,500,000 service members have been dirt and debris, deep vein thromboses, and pulmo- deployed to date, the number of expected cases nary emboli. is therefore in the hundreds of thousands. More Currently, there are four specialized polytrauma than 50,000 returnees already have been treated treatment centers in the Department of Veterans for PTSD. This represents only a fraction of Affairs (VA) system and new resources are being current incidence, however, since many cases of developed throughout the country to care for these PTSD have a delayed onset and many individuals patients, including over 250 cases of spinal column with PTSD do not seek care. injury, most of whom are tetraplegic and ventilator- A study of more than 100,000 veterans seen at dependent. These multidisciplinary rehabilitation VA health care facilities after returning from Iraq programs are labor-intensive and costly. and Afghanistan revealed that 25 percent received mental health diagnoses with the most common di- agnosis being PTSD.10 Of these, 56 percent had two POsttRauMatIc stREss dIsORdER or more mental health diagnoses. The youngest Posttraumatic Stress Disorder (PTSD) is the veterans (18–24 years) were more likely to receive most common mental health disorder diagnosed a PTSD or mental health diagnosis compared to among returning veterans of the conflicts in Iraq veterans aged 40 years or older. and Afghanistan. PTSD is an injury to the ner- The most important factor determining the vous system characterized by alterations in brain likelihood of developing PTSD and the severity function and stress hormone systems. The often of PTSD symptoms is the intensity and duration bewildering array of symptoms may include night- of the trauma. Multiple deployments greatly in- mares, flashbacks, intrusive memories, avoidance crease the risk of PTSD and are a cause for grave of reminders of the trauma, emotional numbing, psychiatric concern. More than 500,000 service social isolation, irritability and anger outbursts, members have been deployed multiple times. hypervigilance, difficulty with concentration and Many individuals are redeployed who already dem- onstrate significant symptoms of PTSD. Some are redeployed after they have been prescribed psychi- “this is a particularly brutal and violent atric medications by the military for various condi- fight and that ferocity needed a new tions. These individuals are at markedly increased more violent name. ‘Polytrauma,’ in its risk for PTSD. Following their initial deployment it is com- straightforwardness and simplicity, is mon in clinical practice to see patients after their precisely that word. today’s survivors are initial deployment who have clinically significant more damaged — and damaged in more symptoms that are subthreshhold for a diagnosis of PTSD or who meet criteria for PTSD but still and different ways than anyone had are able to manage fairly well in social and occupa- expected — nor had ever seen before.” tional settings. After subsequent deployments they often return with symptoms of far greater sever- 5 ronald Glasser, md ity and concomitant severe impairment in social and occupational functioning. From a psychiatric U.S. Health Costs of the Wr in iraq 5 standpoint, after redeployment they may never be report cited failed personal relationships, legal able to come home again. and financial problems, and the stress of their jobs Many of those affected are not getting care. as precipitating factors. There was a significant Waiting periods of months to see a PTSD spe- relationship between suicide attempts and length cialist are common in some geographic areas. of deployment. Considerable expertise in PTSD is present within A recent prospective study used data from the the VA system, but more funding and increased 1986–1994 National Health Interview Survey to staffing are needed desperately to ensure all veter- assess the risk of suicide among veterans in the ans receive the care and treatment they deserve. general U.S. population.14 The study tracked 320,890 men, of whom 104,026 had served in the U.S. military between 1917 and 1994. Veterans OtHER MENtal HEaltH dIsORdERs, were twice as likely to die of suicide compared with suBstaNcE aBusE, aNd suIcIdE non-veterans in the general population. Depressive disorders and anxiety disorders other than PTSD also are highly associated with combat exposure. Substance-use disorders are seen fre- tRauMatIc BRaIN INjuRy quently in returning veterans and are present in 50 Traumatic brain injury (TBI) is receiving increas- to 85 percent of those with PTSD.12 This associa- ing attention as a “signature wound” of this con- tion is thought to represent self-medication in at- flict.15 TBI may be penetrating or closed. Closed tempt to control highly distressing symptoms. head injuries are more common in the current Chronic pain syndromes are highly prevalent conflict, as helmets may protect the head from in veteran populations. Musculoskeletal injuries projectiles, but not from a blast wave. TBI is clas- are among the most common service-connected sified as mild, moderate, or severe depending on disabilities.