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Grim account of the human cost of Iraq. Echoes of Ernest Hemingway's quote from 70 years ago when writing about the Spanish Civil War, "Never think that war, however necessary, is not a crime. Ask the dead; ask the infantry."
From The Times
April 20, 2007
Shell shock: the invisible scar from the trenches to the Gulf
US troops are fighting a high-tech war. Yet, as in the mud of the Somme, soldiers are suffering from the effects of fear and bombs
Roger Boyes in Landstuhl
The front line is only a few hours away and there is still sand stuck to their desert boots as the wounded are lowered on to the waiting trolleys. “OK, next one is coming out feet first,” shouts a nursing sister, as yet another American soldier is rolled out of a Blue Bird ambulance bus. The chaplain glances at his clipboard, leans forward and says: “You’re safe now Billy, you’re in Landstuhl.”
A liaison officer, wearing an armband that says “Caring for Heroes”, places a “wounded warrior’s pack” next to his feet, sees that one of the patient’s legs is missing and places it a bit higher. Tubes and electric cables form a mess of high-tech spaghetti around Billy’s naked torso.
Billy does not look well but then none of today’s deliveries from Iraq is in good shape, not even the infantryman who, according to the dispatch documents, has been removed from the battlefield because of acute diarrhoea. It has been a five-hour flight from Iraq to Ramstein airbase, then an ambulance drive to the biggest American military hospital in Europe. Many of the casualties were hit only 24 hours earlier, the C-17 transporter is the equivalent of the bumpy First World War field ambulance and they are drained and dazed.
The figures are contested but more than 3,300 American troops have been killed and almost 25,000 wounded in this war. Those wounded in Iraq (or just simply ill, since the American presence is now the equivalent of a medium-sized town) and Afghanistan have first to come through Landstuhl, a sprawling clinical compound close to the French border that was designed as a Hitler Youth campus. Landstuhl, nestled in a lush valley, is as verdant and as sleepy as Fallujah is dusty and noisy; the chokepoint of a controversial war.
Every day the wounded are wheeled in — 23 on the first day that we were there; 39 the next — and always there is the same nervous buzz among the waiting medical staff. Even the lowliest of orderlies has come to understand that the treatment of the wounded is the way in which a country measures its performance in war. When the standards of Walter Reed in Washington were criticised recently there was an immediate impact on frontline troops. It also stirred public distaste for the management of the war.
But what if the most lasting wounds are invisible and therefore immeasurable? All the signs are that the sustained war is creating a mental health problem in the American military — the modern equivalent of “shell shock”, a combination of post-traumatic stress disorder, which induces a continuing state of anxiety, and traumatic brain injury (TBI), that may have several physical symptoms.
“Six hundred of the soldiers that came here from Iraq last year had mental health conditions,” says Lieutenant-Colonel Gary Southwell, chief psychologist at Landstuhl, “and 20 per cent of them were suffering from post-traumatic stress syndrome — flashbacks, hypervigilance, memory loss. One of the major reasons people are being sent home is self-destructiveness, suicidal thoughts.”
Lance Corporal Yahiel Sanchez drove over a booby-trap bomb on Friday the 13th and the nurses are telling the 19-year-old Puerto Rican that he was a lucky man. “I was blown out of our gun-truck,” says the Marine. “I hit the ground and a friend dragged me to the cover of a cleared house.” While the battle with the insurgents raged on, Corporal Sanchez had his clothes ripped off, his broken leg was splinted and when a medical squad arrived they smashed down a door to make an improvised stretcher. It was an exemplary case of field medicine. Yet the young Marine’s answers are fuzzy, his eyes unfocused; his memory of the incident is precise but everything else around him seems to be in a fog.
“We can spot some TBI sufferers straight away,” says Lieutenant-Colonel Stephen Flaherty, the chief surgeon who has helped to pioneer a brain-screening system. “They can’t find their way to the dining facilities. Weeks on, they could be still reading maps upside down.”
Since last May the physically injured passing through Landstuhl have been given a brain scan: moderate and severe TBI can be spotted, but the mild variation does not show up. So a nurse waits patiently to see Corporal Sanchez and ask him to recite the months of the year backwards or to recall the first five words of their conversation. “We have developed a points system that has been tried out on contact sport athletes, football players mainly, who have suffered concussion,” says Colonel Flaherty. About 60 per cent of troops who survive bomb blasts — the top cause of death — could have brain injury.
Again and again in the wards and the corridors of the American hospital, we meet people whose injuries are little different from those suffered in the First World War. The face of Sergeant Derek Whittaker creases in pain as his physiotherapist persuades him to stand up for the first time since his vehicle was blown up. As he rises from the bed, he leaves a sheet that has turned magenta from lost blood. A big chunk of bone is missing from his leg.
“I can’t do it,” he gasps, blenched by the effort, and shamed by the admission of defeat. He is 28, nine months in Iraq with an army transport unit; an old man in a young man’s war. Conceding failure comes hard. Lying down again, he covers his face. “Headache?” asks his doctor, Lieutenant-Commander Kathy Vaydaghs. He grunts. A waiting nurse ticks her TBI question box.
There is no collective memory in the US, as there is in the British Army, of soldierly experience in previous wars: of trench warfare in 1915, of desert campaigning in the Second World War, of the long Northern Ireland operations. The American textbooks are written by Vietnam veterans. The mental health experts have, however, been mugging up on the First World War: the overlapping symptoms of TBI and post-traumatic stress disorder bear a remarkable resemblance to the shell shock suffered, sometimes for decades, by survivors of the Somme. The combination of noise, fear and pain overloads the brain.
“Above all, the problem is fatigue,” says Colonel Southwell. He has just returned from a year in Iraq and knows that 12 months’ service is a real psychological steam. “Six months would be optimal, but that is not possible in this war.” Now, as part of the Administration’s “surge”, combat service is to be extended to 15 months. Colonel Southwell hesitates before saying: “We do worry about this.”
So how modern is this war? Post-traumatic stress disorder was a condition diagnosed after returning Vietnam veterans went off the rails. Gulf War syndrome has been used to explain the extraordinary physical and mental symptoms of often distraught soldiers. But TBI has been defined actually in the midst of a counter- insurgent war and as a result it carries little of the stigma attached to the shell-shocked, locked away in British asylums in the 1920s.
“We have regular conferring — audio with Iraq and Afghanistan, video with Walter Reed — to track the development of a TBI case,” says Colonel Flaherty. The Congressional Research Service estimates that twice as many soldiers are being treated for brain injuries as for amputations.
“We really need the Government to step up,” says John Melia, executive director of the Wounded Warrior Project.
“If this country cannot serve severely injured men and women coming back from this conflict, we need to look at ourselves. Unfortunately, to this point we have failed.” That stamps the Iraq mission as a modern war, not a rehash of Vietnam or the Somme.
It can be measured in the number of soldiers who express a genuine desire to return to combat after being treated for sometimes horrific injuries.
Lance Corporal Kimani Boyea, 19, is an easygoing Marine from North Carolina, who had most of the left side of his face ripped out while serving as a gunner in a convoy protecting his commander. Now, with more than 100 stitches holding his face together, he is on his way back to his unit. “My mother cussed me out, she said, ‘like, why are you goin’ out there again?’,” says Corporal Boyea. “But this is my decision.” Hospital psychiatrists say that soldiers feel guilty about leaving their comrades behind.
The modern world has changed war not just in terms of firepower, intelligence and medication but also in the everyday lot of the soldier who can phone home regularly to discuss his daughter’s school report or the slow progress in renovating the kitchen. This could be a double-edged benefit, bringing home tensions “downrange” (as the US forces describe Iraq).
To be 19, to have been brought up on painless video game warfare and Tarantino films, to go to war in a strange land, be blown up and lose a bucket of blood, and want to return — that requires courage but also a suspension of normal fears and anxieties. It is the numbing down of war.
But stray a few corridors away from the hospital’s Burger King canteen and you end up in the intensive care unit and return to the gritty reality of war. “I saw 23 die in the ICU,” says a chaplain, Erik Harp. “Then I quit counting. One night a soldier called for me and said, ‘I’m going straight to Hell’.” The soldier told the chaplain he had killed 37 Iraqis. “They killed my buddies, I killed them and I found joy in it.” The chaplain told the dying man that God’s grace was infinite. The man continued to scream: “I’m going to Hell!”
“Is war ugly?” asks the Mormon minister. “It is.”
Casualties of war
3,312 US military personnel have died in Iraq since March 20, 2003
26,188 have been injured up to February 3 this year
19.1% of troops returning from Iraq report mental health problems, compared with 11.3% from Afghanistan and 8.5% from other theatres
27,886 of the 146,000 US troops serving in Iraq would eventually require psychological help if that rate continued
4% of troops suffer posttraumatic stress disorder after a month in Iraq, rising to 12% after seven months
4.4% are depressed after a month, rising to 9% at seven months
90% of casualties in Iraq survive, compared with 69.7% in the Second World War and 76.4% in Vietnam
20% of survivors have serious head or spinal injuries, and another 6% are amputees
Sources: healthday.com; Journal of American Medical Association; medscape.com; dodd.senate.gov; icasualties.org; US Department of Defence
Nightmares and flashbacks
- Shell shock was the term used in the First World War for the mental disorientation that resulted from the constant noise and fear of artillery barrages in the trenches
- About 1 in 20 Second World War veterans suffered from symptoms including flashbacks and nightmares
- More than half of all male Vietnam veterans, and almost half of all female Vietnam veterans — about 1,700,000 in total — experienced “clinically serious stress reaction symptoms”
- A third of male Vietnam veterans and a quarter of females are afflicted by of post-traumatic stress disorder for life
- The US Department of Defence reported 1,179 traumatic brain injuries sustained in Iraq up to March last year, of which 222 were classed “severe” or “penetrating”
Sources: US Department of Veterans Affairs; Federation of American Scientists
From The Times
April 20, 2007
Shell shock: the invisible scar from the trenches to the Gulf
US troops are fighting a high-tech war. Yet, as in the mud of the Somme, soldiers are suffering from the effects of fear and bombs
Roger Boyes in Landstuhl
The front line is only a few hours away and there is still sand stuck to their desert boots as the wounded are lowered on to the waiting trolleys. “OK, next one is coming out feet first,” shouts a nursing sister, as yet another American soldier is rolled out of a Blue Bird ambulance bus. The chaplain glances at his clipboard, leans forward and says: “You’re safe now Billy, you’re in Landstuhl.”
A liaison officer, wearing an armband that says “Caring for Heroes”, places a “wounded warrior’s pack” next to his feet, sees that one of the patient’s legs is missing and places it a bit higher. Tubes and electric cables form a mess of high-tech spaghetti around Billy’s naked torso.
Billy does not look well but then none of today’s deliveries from Iraq is in good shape, not even the infantryman who, according to the dispatch documents, has been removed from the battlefield because of acute diarrhoea. It has been a five-hour flight from Iraq to Ramstein airbase, then an ambulance drive to the biggest American military hospital in Europe. Many of the casualties were hit only 24 hours earlier, the C-17 transporter is the equivalent of the bumpy First World War field ambulance and they are drained and dazed.
The figures are contested but more than 3,300 American troops have been killed and almost 25,000 wounded in this war. Those wounded in Iraq (or just simply ill, since the American presence is now the equivalent of a medium-sized town) and Afghanistan have first to come through Landstuhl, a sprawling clinical compound close to the French border that was designed as a Hitler Youth campus. Landstuhl, nestled in a lush valley, is as verdant and as sleepy as Fallujah is dusty and noisy; the chokepoint of a controversial war.
Every day the wounded are wheeled in — 23 on the first day that we were there; 39 the next — and always there is the same nervous buzz among the waiting medical staff. Even the lowliest of orderlies has come to understand that the treatment of the wounded is the way in which a country measures its performance in war. When the standards of Walter Reed in Washington were criticised recently there was an immediate impact on frontline troops. It also stirred public distaste for the management of the war.
But what if the most lasting wounds are invisible and therefore immeasurable? All the signs are that the sustained war is creating a mental health problem in the American military — the modern equivalent of “shell shock”, a combination of post-traumatic stress disorder, which induces a continuing state of anxiety, and traumatic brain injury (TBI), that may have several physical symptoms.
“Six hundred of the soldiers that came here from Iraq last year had mental health conditions,” says Lieutenant-Colonel Gary Southwell, chief psychologist at Landstuhl, “and 20 per cent of them were suffering from post-traumatic stress syndrome — flashbacks, hypervigilance, memory loss. One of the major reasons people are being sent home is self-destructiveness, suicidal thoughts.”
Lance Corporal Yahiel Sanchez drove over a booby-trap bomb on Friday the 13th and the nurses are telling the 19-year-old Puerto Rican that he was a lucky man. “I was blown out of our gun-truck,” says the Marine. “I hit the ground and a friend dragged me to the cover of a cleared house.” While the battle with the insurgents raged on, Corporal Sanchez had his clothes ripped off, his broken leg was splinted and when a medical squad arrived they smashed down a door to make an improvised stretcher. It was an exemplary case of field medicine. Yet the young Marine’s answers are fuzzy, his eyes unfocused; his memory of the incident is precise but everything else around him seems to be in a fog.
“We can spot some TBI sufferers straight away,” says Lieutenant-Colonel Stephen Flaherty, the chief surgeon who has helped to pioneer a brain-screening system. “They can’t find their way to the dining facilities. Weeks on, they could be still reading maps upside down.”
Since last May the physically injured passing through Landstuhl have been given a brain scan: moderate and severe TBI can be spotted, but the mild variation does not show up. So a nurse waits patiently to see Corporal Sanchez and ask him to recite the months of the year backwards or to recall the first five words of their conversation. “We have developed a points system that has been tried out on contact sport athletes, football players mainly, who have suffered concussion,” says Colonel Flaherty. About 60 per cent of troops who survive bomb blasts — the top cause of death — could have brain injury.
Again and again in the wards and the corridors of the American hospital, we meet people whose injuries are little different from those suffered in the First World War. The face of Sergeant Derek Whittaker creases in pain as his physiotherapist persuades him to stand up for the first time since his vehicle was blown up. As he rises from the bed, he leaves a sheet that has turned magenta from lost blood. A big chunk of bone is missing from his leg.
“I can’t do it,” he gasps, blenched by the effort, and shamed by the admission of defeat. He is 28, nine months in Iraq with an army transport unit; an old man in a young man’s war. Conceding failure comes hard. Lying down again, he covers his face. “Headache?” asks his doctor, Lieutenant-Commander Kathy Vaydaghs. He grunts. A waiting nurse ticks her TBI question box.
There is no collective memory in the US, as there is in the British Army, of soldierly experience in previous wars: of trench warfare in 1915, of desert campaigning in the Second World War, of the long Northern Ireland operations. The American textbooks are written by Vietnam veterans. The mental health experts have, however, been mugging up on the First World War: the overlapping symptoms of TBI and post-traumatic stress disorder bear a remarkable resemblance to the shell shock suffered, sometimes for decades, by survivors of the Somme. The combination of noise, fear and pain overloads the brain.
“Above all, the problem is fatigue,” says Colonel Southwell. He has just returned from a year in Iraq and knows that 12 months’ service is a real psychological steam. “Six months would be optimal, but that is not possible in this war.” Now, as part of the Administration’s “surge”, combat service is to be extended to 15 months. Colonel Southwell hesitates before saying: “We do worry about this.”
So how modern is this war? Post-traumatic stress disorder was a condition diagnosed after returning Vietnam veterans went off the rails. Gulf War syndrome has been used to explain the extraordinary physical and mental symptoms of often distraught soldiers. But TBI has been defined actually in the midst of a counter- insurgent war and as a result it carries little of the stigma attached to the shell-shocked, locked away in British asylums in the 1920s.
“We have regular conferring — audio with Iraq and Afghanistan, video with Walter Reed — to track the development of a TBI case,” says Colonel Flaherty. The Congressional Research Service estimates that twice as many soldiers are being treated for brain injuries as for amputations.
“We really need the Government to step up,” says John Melia, executive director of the Wounded Warrior Project.
“If this country cannot serve severely injured men and women coming back from this conflict, we need to look at ourselves. Unfortunately, to this point we have failed.” That stamps the Iraq mission as a modern war, not a rehash of Vietnam or the Somme.
It can be measured in the number of soldiers who express a genuine desire to return to combat after being treated for sometimes horrific injuries.
Lance Corporal Kimani Boyea, 19, is an easygoing Marine from North Carolina, who had most of the left side of his face ripped out while serving as a gunner in a convoy protecting his commander. Now, with more than 100 stitches holding his face together, he is on his way back to his unit. “My mother cussed me out, she said, ‘like, why are you goin’ out there again?’,” says Corporal Boyea. “But this is my decision.” Hospital psychiatrists say that soldiers feel guilty about leaving their comrades behind.
The modern world has changed war not just in terms of firepower, intelligence and medication but also in the everyday lot of the soldier who can phone home regularly to discuss his daughter’s school report or the slow progress in renovating the kitchen. This could be a double-edged benefit, bringing home tensions “downrange” (as the US forces describe Iraq).
To be 19, to have been brought up on painless video game warfare and Tarantino films, to go to war in a strange land, be blown up and lose a bucket of blood, and want to return — that requires courage but also a suspension of normal fears and anxieties. It is the numbing down of war.
But stray a few corridors away from the hospital’s Burger King canteen and you end up in the intensive care unit and return to the gritty reality of war. “I saw 23 die in the ICU,” says a chaplain, Erik Harp. “Then I quit counting. One night a soldier called for me and said, ‘I’m going straight to Hell’.” The soldier told the chaplain he had killed 37 Iraqis. “They killed my buddies, I killed them and I found joy in it.” The chaplain told the dying man that God’s grace was infinite. The man continued to scream: “I’m going to Hell!”
“Is war ugly?” asks the Mormon minister. “It is.”
Casualties of war
3,312 US military personnel have died in Iraq since March 20, 2003
26,188 have been injured up to February 3 this year
19.1% of troops returning from Iraq report mental health problems, compared with 11.3% from Afghanistan and 8.5% from other theatres
27,886 of the 146,000 US troops serving in Iraq would eventually require psychological help if that rate continued
4% of troops suffer posttraumatic stress disorder after a month in Iraq, rising to 12% after seven months
4.4% are depressed after a month, rising to 9% at seven months
90% of casualties in Iraq survive, compared with 69.7% in the Second World War and 76.4% in Vietnam
20% of survivors have serious head or spinal injuries, and another 6% are amputees
Sources: healthday.com; Journal of American Medical Association; medscape.com; dodd.senate.gov; icasualties.org; US Department of Defence
Nightmares and flashbacks
- Shell shock was the term used in the First World War for the mental disorientation that resulted from the constant noise and fear of artillery barrages in the trenches
- About 1 in 20 Second World War veterans suffered from symptoms including flashbacks and nightmares
- More than half of all male Vietnam veterans, and almost half of all female Vietnam veterans — about 1,700,000 in total — experienced “clinically serious stress reaction symptoms”
- A third of male Vietnam veterans and a quarter of females are afflicted by of post-traumatic stress disorder for life
- The US Department of Defence reported 1,179 traumatic brain injuries sustained in Iraq up to March last year, of which 222 were classed “severe” or “penetrating”
Sources: US Department of Veterans Affairs; Federation of American Scientists
