Casualties

Daedalus

Volumn 140, Issue 3, 2011, Pages 179-188

  Shay, Jonathan ^a  

^a Boston Department   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ECONOMICS; EDUCATION; ETHNOLOGY; HISTORY; INJURY; LEGAL ASPECT; MENTAL DISEASE; MILITARY MEDICINE; POSTTRAUMATIC STRESS DISORDER; PSYCHOLOGICAL ASPECT; PUBLIC HOSPITAL; SOCIAL STIGMA; SOLDIER; VETERAN;

HISTORY, 20TH CENTURY; HISTORY, 21ST CENTURY; HOSPITALS, MILITARY; MENTAL DISORDERS; MILITARY MEDICINE; MILITARY PERSONNEL; MILITARY PSYCHIATRY; SOCIAL STIGMA; STRESS DISORDERS, POST-TRAUMATIC; VETERANS; WOUNDS AND INJURIES;

EID: 79960518614     PISSN: 00115266     EISSN: 15486192     Source Type: Journal    
DOI: 10.1162/DAED_a_00107     Document Type: Article

References (12)

1. In addition to my experience working as a psychiatrist for veterans, I have served in various capacities for the U.S. military, including Commandant of the Marine Corps Trust Study (1999-2000)
2. Chair of Ethics, Leadership, and Personnel Policy in the Of1/2ce of the U.S. Army Deputy Chief of Staff for Personnel (2004-2005); and 2009 Omar Bradley Chair of Strategic Leadership, U.S. Army War College (2010). I have also worked with Canadian Forces, U.K. Royal Marines, U.K. Royal Navy, Bundeswehr, other nato, and Israel Defense Force personnel.
3. The Textbook of Military Medicine is a vast multivolume, periodically updated work published by the Army Surgeon General. I commend the reader to the whole U.S. Army Medical Department Borden Institute website, http://www.bordeninstitute.army.mil/, where the following are available in their entirety as free downloads: all the massive current volumes of the Textbook of Military Medicine; various monographs, such as Water Requirements and Soldier Hydration and War Surgery in Afghanistan and Iraq, A Series of Cases, 2003-2007; and Emergency War Surgery, 3rd rev. ed. (2004).
4. The data in this paragraph were current as of January 5, 2008. The number wounded in action (that is, by enemy action) in Operation Iraqi Freedom (oif) and Operation Enduring Freedom (oef) was 9,801. This number represents only those injured severely enough to require medical air transport out of theater, which I take as a proxy for the severity of injury. (The number is 2.3 times higher when taking into account those wounded by hostile action, but whose wounds could be treated within theater without evacuation. However, this latter proportion applies only to oif; the "more austere" medical facilities of oef have meant that the wounded there are, proportionally, evacuated more frequently.) Adding roughly an equal number of nonhostile injuries severe enough to require medical air transport brings the number of those injured in oif and oef, as of January 5, 2008, to a combined total of 19,522. Adding "diseases/other medical" requiring medical air transport roughly doubles the combined total, as of January 5, 2008, from oif and oef to 46,751 (that is, the total of all who have been medically air transported out of theater for medical/surgical reasons).
5. Lest the reader speculate that the number of "diseases/other medical" has been inflated by mental health evacuations, note two facts: First, current military medical doctrine calls for treating combat stress reactions as close as possible to the service member's unit, using brief and simple interventions such as "Three Hots and a Cot": that is, physiological replenishment of food and water (three hots) and sleep (the cot). The doctrine discourages evacuation from theater because evacuation is believed to freeze the psychological injury in place, at a time when it is still reversible. This view has some empirical foundation. Second, a January 30, 2005, report from mhat ii (oif-11 Mental Health Advisory Team) estimated that all mental health diagnoses together accounted for 6 percent of evacuations, and of these 11.7 percent were Post-Traumatic Stress Disorder (ptsd) and Acute Stress Disorder (asd), narrowly and strictly diagnosed. 46,751 x 0.06 x 0.117 = 499. A narrow de1/2nition of ptsd used by the Department of Defense Task Force on Mental Health produced an estimate that 10 percent of those deployed in oif and oef had ptsd
6. Department of Defense Task Force on Mental Health, An Achievable Vision: Report of the Department of Defense Task Force on Mental Health (Falls Church, Va.: Defense Health Board, 2007). Using the Dole-Shalala Commission's round number of 1.5 million of service members deployed (the number is now larger), this yielded 150,000 with narrow ptsd. The broad de1/2nition, encompassing all signi1/2cant psychological injuries, produced an estimate by the dod Task Force on Mental Health of 38 percent, or 570,000. If the above number of those evacuated for "diseases/other medical" is inflated at all, it is more likely that it is from the policy of evacuating service members for diagnosis and treatment of conditions for which no appropriate specialist or sub-specialist had been deployed in the theater.
7. Jonathan Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (New York: Scribner, 2002), 240.
8. Within military circles, the tag "toxic leadership" is commonly used.
9. I still get goose bumps when I recall that during the break at a Commanders' Conference at the 101st Airborne, where I spoke, several battalion commanders came up to me and told me that they had required their troopers to read my book Achilles in Vietnam: Combat Trauma and the Undoing of Character (New York: Atheneum, 1994) prior to deployment, and that they could overhear admonishments among them, "Don't betray what's right!"
10. Rivers of ink have been spilled on the Of1/2cer Personnel Management System and related practices and culture. My most important teachers have been Faris Kirkland, Carl Bernard,Bruce Gudmundsson, Donald Vandergriff, Franklin "Chuck" Spinney, James N. Mattis, Donn Starry, Walter Ulmer, Richard Trefry, Greg Pickell, John Tillson, Dan Moore, Chet Richards, Mick Trainor, Chris Yunker, and John Poole.
11. Brett T. Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, and Shira Maguen, "Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy," Clinical Psychology Review 29 (8) (December 2009): 695-706.
12. Martha C. Nussbaum, The Fragility of Goodness: Luck and Ethics in Greek Tragedy and Philosophy (New York: Cambridge University Press, 1986), 417.