The Coming Afghanistan Surge—and the Severely Wounded


Jan 15, 2010

This commentary originally appeared in Providence Journal,, and The San Diego Union-Tribune on January 15, 2010.

With the looming deployment of 30,000 more Soldiers and Marines to Afghanistan, the United States will soon have over 100,000 military personnel there until 2011—and likely longer. Like insurgents in Iraq, the Taliban make ample use of improvised explosive devices (IEDs). These munitions account for more than 70 percent of coalition casualties in Afghanistan, and any troop increase there is sure to be accompanied by an increase in the number of servicemembers who suffer the dreaded consequences of these weapons: limb loss, catastrophic wounds, severe burns, and traumatic brain injury—to say nothing of sudden death on the battlefield. More wounds from ground fire, rockets, and mortars too can be expected.

As America starts its ninth year at war, more than 32,000 U.S. service members have already been wounded in action in Iraq and about 3,500 in Afghanistan—where casualties are being suffered at an even higher rate than during the early stages of the 2007 Iraq surge. This does not include injury and disease, or latent post-traumatic stress syndrome.

Will U.S. resolve to strengthen care for wounded Americans be maintained? To be sure, some important steps have already been taken. But has the government fully implemented recommendations reached in 2007, after the disclosure of woefully inadequate conditions for wounded veterans at Walter Reed Army Medical Center?

What's clear is that the badly wounded from this war are coming home with injuries that would have killed their fathers and grandfathers, and they usually need extensive treatment and rehabilitation. Among those who survive IED explosions, head injuries from skull-penetrating fragments, shock waves, or severe blows to the head are commonplace, in addition to trauma to arms, legs or other parts of the body.

The military medical system classifies these types of wounds as "severe" if they involve amputation, severe burn, spinal cord damage, blindness, or traumatic brain injury. That may well mean severe enough to prevent performance of duties. Still, some who wish to remain on duty are permitted to do so, often with a job change. In either case, long-term treatment and rehabilitation have to follow.

In March, 2007, after the poor conditions for the wounded undergoing (or awaiting) such care and rehabilitation were exposed, President Bush authorized the creation of "The President's Commission on Care for America's Returning Wounded Warriors." The commission was headed by decorated (and severely wounded) World War II veteran and former Senator Robert Dole and former Health and Human Services Secretary Donna Shalala. The commission examined the continuum of health care experienced by wounded service members.

In July, 2007, the commission released its report, with six major recommendations:

  • Implement comprehensive individual recovery plans for the severely injured.
  • Restructure disability and compensation systems.
  • Improve care for post-traumatic stress disorder and traumatic brain injury.
  • Strengthen support for families.
  • Transfer patient information across systems.
  • Fully support Walter Reed Army Medical Center until its closure in 2011.

The commission identified more than 30 detailed steps that needed to be taken. President Bush ordered implementation of all steps except #6, which required an act of Congress.

To this point, strides have been taken toward this end. But the extent to which the government has fully implemented these recommendations is unclear, and, this is certainly the case in the view of many veterans of the war.

Both DoD and Veterans Affairs have developed a federal recovery coordinator program. New housing for the injured has been built. Oversight of evaluation of wounded service members has been enhanced, to help reintegrate them into the military or return them to civilian life. Support centers and transition units have been created, and more behavioral health providers have been hired.

That said, no systemic evaluation has been performed to determine the extent to which the system is working well—or, showing weaknesses that still remain.

Determinations on disability and compensation still lag, and progress on a common DoD and Veterans Affairs disability evaluation system is unclear. How much more do treatment protocols for brain-injured patients need to be improved? How will the critical shortage of trained mental health professionals be resolved, and when?

Family advocates too report that wounded service members and families lack information on pay and disability ratings that would help in deciding whether or not to stay in the military. Similar doubt remains about whether wounded reservists and their families are getting adequate support and access to services.

Now, with 30,000 more troops headed for the war zone, it's time to assess progress in the care of our wounded—and even more important, to correct deficiencies that remain.

Ralph Masi is a retired Army infantry officer. He conducts policy analysis at the RAND Corporation, a nonprofit think tank, where he studies the management of wounded servicemen and women.

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