WARTIME INJURIES AND THEIR EFFECTS ON SOLDIERS: A HUMANITARIAN PERSPECTIVE Wars are as old as civilization.

The nature of weapons has progressed from the Stone Age club to the modern day arsenal of Nuclear and biological weapons. What remains unchanged is the brutality of Man and his greed for resources, fame and glory. But this quest leads to devastating consequences for him and his family, affecting everyone on its trail. What is an armed conflict? The soldiers are sent to fight in wars or may be deployed in crushing certain armed conflicts in disturbed areas. The I.C.R.C.commentary to Common Article 2 of The Four Geneva Conventions 1949, which refers to the notion of armed conflict in international armed conflicts, states as follows: It remains to ascertain what is meant by armed conflict. The substitution of this much more general expression for the word war was deliberate. One may argue almost endlessly about the legal definition of war. A state can always pretend, when it commits a hostile act against another state that it is not making a war, but merely engaging in legitimate self-defence. The expression armed conflict makes such arguments less easy. Any difference arising between two states and leading to the intervention of armed forces is an armed conflict within the meaning of Article 2, even if one of the parties denies the existence of a state of war. It makes no difference how long the conflict lasts, or how much slaughter takes place. The respect due to human personality is not measured by the number of victims1. The armed conflict may be in the form of an international or non-international armed conflict. Common Article 3 covers armed conflict within the territory of a state and if the following criteria are met: Hostilities by force of arms; Deployment of armed forces by the government(instead of police only); Collective character of hostilities on the insurgents side, with at least a minimum degree of organization and a responsible command capable of discharging humanitarian obligations.

When the raging flames of the wars and armed conflicts grip the countries, the soldiers are sent to fight and restore peace. They sustain a lot of injuries as combatants. Normally these injuries suffered by the soldiers can be classified into two categories: (1) Physical injuries, and (2) Mental illnesses The physical injuries borne by the soldiers could be of many kinds. A report on vascular surgery, obtained from compiling and analyzing the database of injuries of all US military casualties from December 2001 through March 2004 in Iraq and Afghanistan, revealed that out of 3057 soldiers, 1524 (50%) sustained battle injuries. In those patients which comprised the study group the usual or suspected vascular injuries occurred in 107 (7%) patients. Sixty-eight (64%) patients were wounded by explosive devices, 27(25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injuries. The majority of these injuries (59/66 [88%]) occurred in the extremities. Twenty-eight (26%) required additional operative intervention on arrival in the United States. The vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts2. Besides, a study conducted by the American Back Society has revealed that the soldiers serving in Iraq and Afghanistan often complained of severe back pain and had dismal rates of returning to duty. In addition, the study revealed that the wartime illnesses and injuries often have nothing to do with bullets, grenades, or other explosive devices. On the other hand disease and non-battle related injuries continued to be the major source of service member attrition. The study pointed out that musculoskeletal and connective tissue disorders were the most common reason for leaving the war zones, accounting for 24% of evacuation. They were followed by combat injuries (14%), and neurologic disorders (10%). A similarly poor return to work rate applies to soldiers with other illnesses and injuries as well. In 2007 only 1 in 5 soldiers evacuated from war zones ever returned to active duty. While illnesses were associated with a particularly low return to duty rate including psychiatric disorders, musculoskeletal disorders, and spinal pain in particular along with combat injuries. The major risk factors for the persistence of back and neck

pain and disability related to these complaints are psychosocial, including anxiety, depression, poor coping skills, and low level of job satisfaction3. The emotional distress suffered by the soldiers was equally responsible for their doomed lives along with the physical injuries. A common wound of the Iraq war was the traumatic brain injury, also known as the signature wound of the Iraq war. Those who were diagnosed with it often received treatment when it was too late: TBI (traumatic brain injury) remains as one of the most frequent causes of death and disability in todays battlefield. According to the Defense and Veterans Brain Injury Center, a research and treatment agency run by the Pentagon and Veterans Affairs Department, 64 percent of injured troops have suffered brain injuries. Health Systems in war time and their effect on the soldiers deployed As per the W.H.O. (World Health Organization) definition, health can be defined as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. In other words the impact of war and violence (a general term covering conflict, economic violence such as sanctions, and experience of dictatorship) must be measured not only by death and injuries due to weaponry, but by the often greater longer-term suffering linked with damage to essential infrastructure, a poorly functioning health system and the failure of relief and reconstruction efforts. A health system has been defined as all activities whose primary purpose is to promote, restore or maintain health4. A breakdown of the essential infrastructure and an interacting range of other health determinants have lead to a hugely increased burden of death and mental and physical illness from all causes, directly and indirectly attributable to the effects of conflict. The impact of conflict on the health of both the civilians and the combatants generally arises both from the direct effects of combat battle deaths and injuries and from indirect consequences that continue to be felt years after the conflict ends. In Iraq for example the conflict has taken the shape of daily attacks on the lives of both civilians and combatants and attacks by occupying forces. The immediate effects of the conflict on physical and mental health were only a miniscule proportion of the suffering; the long term effects would lead to health being harmed by conflict-related damage to essential health-sustaining infrastructure and to the

health system, as well as the corrosive effects of conflict related factors such as poverty, unemployment, disrupted education and low morale.

A health system consists of resources in the form of food supplies, drugs, water etc. served at a minimal rate or for free by doctors, nurses and health workers in clinics to every person irrespective of their race, class, gender etc. When conflicts occur there is relatively no security as such: The clinics and hospitals may fall in the target zone of aerial attacks; curfew in certain areas and at certain times could lead to heavy traffic, and have fatal consequences for patients inside ambulances and wide scale looting and plundering meant acute shortage of medicines. Besides massive power cuts and blackouts could make medicines unfit for cold storage. In fragile countries like Afghanistan delivery and scaling up of health services is more difficult than other low-income settings due to poorer governance, and severe human resource and financial constraints. Resource constraints are further exacerbated both by a contested policy environment and a reliance on international aid, which results in extremely volatile funding and making harmonization and alignment more challenging to the detriment of aid effectiveness. Under such circumstances the soldiers who were lucky enough to get quick access to proper and timely health care had better chances of recovery than those who were injured in places where health care were unavailable. The Hurdles on the road to recovery There are many psychological effects of war that have been well documented over the last hundred years. Posttraumatic stress disorder (PTSD) has received much attention. Although not defined until after the end of the Vietnam War, we can now find examples throughout history. The symptoms of this disorder include intrusive thoughts, numbness and disconnected feelings, hyper-vigilance and impairment in social and occupational functioning. Feelings of isolation and difficulty reconnecting with family and former friends are often the most difficult issues for the loved ones of service members living with PTSD. Traumatic brain injury (TBI) is another major concern. TBI can present with many symptoms, some similar to PTSD, including irritability impulsiveness and personality changes. Feelings of unworthiness and stupidity often surfaced on their minds. Many soldiers are reluctant to engage in care for numerous other reasons, including

concerns about the effect it may have on their careers. Moreover military doctors accuse them of faking their symptoms and trying to bilk the Army for tax-free, combat related disability pay. David Cifu, who oversees the Traumatic Brain Injury program at the VA medical center in Richmond, Va., said treating the TBI patients as if theyre making up their injuries is about the worst way to take care of them. The longer diagnosis and treatment are delayed, the harder such care can be. When treating a veteran with a missing limb, for example, health professionals note how a TBI may make walking with a prosthetic device more difficult. Besides they display cognitive disabilities: problems with math, short-term memory loss, slowed reactions and other problems. The impact of wartime injuries in military families Since the the start of the wars in Afghanistan and Iraq almost a decade ago, more than two million U.S. service men and women have served overseas in wartime duties and nearly half of them have deployed more than once. More than one million children in the United States have experienced a parents departure to serve in combat, with a sacrifice to the country that often goes unacknowledged. For those children who were aged 10 years or younger, their parents military service may have meant an entire lifetime of anticipating or experiencing his or her departure to an uncertain and dangerous situation. Reuniting with a service member returning from war also presents unique challenges for military families as children and parents alike have to negotiate the transitions of reintegration. For some families, their service members deployment may result in more striking disruptions in family life if their service member returns home with psychological and physical injuries. For other families, the cost of wartime deployment has meant the loss of a loved one. The suicide rates within the military has increased rising as high as 20 per 100,000 service members. Other illnesses such as posttraumatic stress disorder (PTSD), appears to increase during the year following return from combat. In addition, service members who have been deployed more than once to war have increased rates of mental health problems. Children from military families may also experience a sense of loss when their parent misses important milestones, including learning to ride a bike, winning a championship game or graduating from high school. Children may also experience the wear and tear stress of persistent worry over their active duty parents safety as well as awareness of their caretaking parents stress level. When the active parent returns home from war with a combat-related

mental health problem, traumatic brain injury or disabling physical injury, the caretaking parent left at home and the children must often deal with these issues. A clinical research team from the UCLA Madigan Army Medical Center and the San Diego Naval Medical Center with funding from the National undertook a study of U.S. Army and Marine Corps families from two military installations with high rates of deployment. This study included 171 families with a parent either currently deployed or recently returned from service in Iraq or Afghanistan. In this group, the average number of deployments was more than two and the average length of time away due to combat deployments was 16 months. While previous studies on the impact of deployment on children have focused primarily on the period of deployment separation, this study looked at children during and after periods of deployment separation and concluded that children had more complex reactions to their parents deployment than previously recognized. The study revealed that about one-third of children affected by parental combat deployment undeniably had significant symptoms of anxiety. Increased anxiety was synonymous for children whose parents were away at war and for those whose parents had returned home in the prior year. This finding of persistent anxiety even after the active duty parent has returned is consistent with reports from military families that their child continues to worry about the possibility of his or her parent deploying again. Like their children, service members spouses also showed increased levels of distress compared to the general adult population. Approximately one-third of the athome parents and almost forty percent of the active duty parents showed increases in anxiety and depression. Notably, the two the key markers for emotional and behavioral distress in children are parental psychological stress and the number of months of combat deployments during their lifetime. Depression and disruptive behaviors in children increased the longer their parent was deployed5. This study helps us to understand more about the impact of parental combat deployments on school-aged children and their parents. Clinical experience with these children and their families supports the finding that there is persistent anxiety about parents possible departure, even after a parent has returned. Families often report that these children are sensitized to reminders of separation and can be highly reactive to cues that may indicate their parents potential departure, such as coming home late from work. In addition, children often report ongoing worries about

their parents safety and possible deathboth of the military and civilian parent. Stress thus reverberates throughout families. The changing scenario in the aftermath of war After receiving numerous reports of suicides and murders in military camps, the U.S.Army has swung into action and started various programmes for the soldiers. To reach all service members, new systems of evaluation and care have been added to the behavioral health services and supports received by the returning soldiers. The Post Deployment Health Assessment (PDHA), which screens the soldiers returning home, was implemented after the first Gulf War. However, soldiers often did not admit to symptoms since they just wanted to get home as fast as possible. Beginning in 2005, the PDHA was joined by the Post Deployment Health Re-Assessment, which is done at three to six months after return from combat. It is designed to connect with service members once they have begun to confront the stresses of civilian life. The investigations at Fort Bragg and other installations revealed continuing problems with access to care as well as the reluctance of career-minded soldiers to seek treatment. As a result, the U.S. Army has dramatically increased their number of mental health providers, which increased about70 percent between 2007 and 2010. Stigma, however, is a persistent problem. A tremendous amount of money has been poured into family programs. For example, Family Readiness Groups (FRGs) have been greatly enhanced with paid FRG assistants. FRGs provide mutual support and assistance to soldiers and their families to increase their resiliency and enhance the flow of information and resources to help families adjust to military deployments. Whether these programs reach the most vulnerable families is still an open question. A young mother with small children who lives off-post with limited transportation may not be able to make FRG meetings. Previously, the National Guard and Reserve had little access to family programs and FRGs. Now there is The Yellow Ribbon Program in most states and virtual FRGs for the National Guard and Reserve. The Yellow Ribbon Program (www.yellowribbon.mil) is a Department of Defense effort to help National Guard and Reserve service members and their families connect with local resources before, during and after deployments. Army-wide programs used to be aimed at the nuclear family (e.g., spouses and children of deployed service members). Now there are numerous educational resources available for every

family member. In addition there are specialized programs at Walter Reed Army Medical Center in Washington, D.C., and other facilities for the families of the wounded. These programs aim to prepare children for seeing their parent missing a limb or disfigured from a blast. Still, parents and siblings needing support may feel left out. Another difficult area to address has been supporting families of the deceased. In the past, spouses and children have had to leave their housing on base and consequently, their support system, relatively soon after their loved ones death. Again, this has improved over time, with families having longer access to housing and health care. Organizations such as the Tragedy Assistance Program for Survivors(www.taps.org) have been invaluable in providing support.

The rising suicide rate has also been a major concern for all in the Army. Risk factors for suicide include the high operations tempo, feelings of disconnectedness upon return home, problems at work or home, pain and disability, alcohol and easy access to weapons. The military leadership has consistently made attempts to reduce suicide with numerous trainings for service members that focus on buddy aid and gatekeepers. However, so far these efforts have only been partially successful. The prolonged effects of exposure to violence and death are not easy to change. Hence new efforts are being made to try to assist soldiers and their families in addressing these issues. The Defense Centers of Excellence(www.dcoe.health.mil) is focusing on best practices and stigma reduction regarding psychological health and TBI. Other efforts include the Comprehensive Behavioral Health Campaign Plan, the U.S. Department of Veterans Affairs Integrated Mental Health Plan and the National Intrepid Center of Excellence (www.fallenheroesfund.org). An ongoing concern is the long term effects of the Long War for the next twenty, thirty or fifty years. After Vietnam, too many veterans ended up on the streets unemployed, homeless and addicted to substances. It is hoped that the interventions described above will result in better outcomes for service members and their families . The application of the rapid strides in medical science on the battlefield

A Government Accountability Office (GAO) report released in 1998 stated that military medical personnel have little to no practice with battlefield trauma care skills during peacetime. An

additional report by the National Library of Medicines Institute of Medicine indicated that approximately 98,000 individuals in the U.S. die each year as a result of medical practice mistakes. Most current medical simulation training relies on plastic forms, computerized mannequins, animals, and cadavers. Each of these has significant drawbacks, such as incorrect anatomy (animals), lack of realism (plastic forms and mannequins), limited use (cadavers), and expense. In addition, they do not replicate the majority of injuries encountered on the battlefield.

Front line medics face major challenges created by severe medical trauma.

The military

currently invests millions of dollars to train its soldiers; however, there remains much room for improvement in current training methods for combat medics. Many existing scenarios employ some type of simulation, however, due to limited realism their ability to fully immerse the trainee into combat medical situations has been called into question. Fully experiencing the scenario is exactly the kind of experience that will properly prepare medics to deal appropriately with actual battlefield injuries including broken bones, lacerations, amputations, severe bleeding and tissue damage. In addition, many civilian-trained medical personnel and first responders do not receive sufficient psychological preparation to aptly handle severe wartime traumatic injuries. The Virtual Reality Medical Center (VRMC) conceptualized and developed a unique injury simulator to supply more realistic military medical training - The Injury Creation Science (ICS) technology which was developed to embody an injury simulation capability that includes the curriculum and prosthetics required to train medical professionals in procedures to include bypassing a compromised airway, inserting an intravenous port, preventing blood loss as a result of arterial and venous wounds, dressing burns, and expanding a collapsed lung. ICS acts as an adjunct to current combat medic training and does not seek to replace it. Initial ICS technology was found to very realistically simulate a number of battlefield injuries such as amputations, eviscerations, blast injuries, punctures, and burns. Since the initial prototypes were developed, VRMC has expanded this technology into wearable part-task trainers that simulate injuries as well as allow combat medics to realistically practice tangible medical procedures common to the battlefield. The progression of these trainers has been under the guidance and partnership with the U.S. Army Research and Engineering Command Simulation and Technology Training

Center (RDECOMSTTC).The procedures

currently developed include treatment

of

pneumothorax, hemoperitonium, and gunshot wounds to an artery. For over fifteen years, The Virtual Reality Medical Center (VRMC) has been developing training and assessment protocols based on both subjective and objective measures, particularly by pioneering the use of physiological measures while trainees perform exercises in VR and other simulation environments. Trauma care skills and experience are crucial in the successful resuscitation and operative care of injured patients. Both initial learning as well as maintenance of skills is problematic due to a lack of training opportunities. Studies have shown that VR trauma simulators are likely to provide the best long-term answer to this problem. As summed up by Satava and Jones (1999), The benefits of virtual reality to healthcare can be summarized in a single word: Revolutionary. An important part of the next generation injury creation science program is the ability to accurately quantitate the effectiveness of training. In general useful metrics allow for prediction of percentage of improved performance, reduction in the number of errors, and the overall efficiency of the training program. The ICS prosthetics have also proven to be useful and reliable and provide a realistic training experience for health care professionals. After evaluating data from the U.S. Army Institute for Surgical Research, it is clear that a need exists for part task trainers to prepare military trauma care professionals for life saving procedures necessary to preserve the life of wounded war fighters. Many of these same procedures are done in civilian hospitals. Identifying common needs between field medicine and civilian hospitals can help reduce the estimated 98,000 people that die each year as a result of medical errors. It is imperative that the training of medical personnel continues by employing the highest level of fidelity and realism and leveraging the lessons learned from military training to civilian medicine6. Thus while a millennium has passed and we march forward to another millennium, what remains unchanged is the toll of human suffering. In the past only small populations were affected, but today the war on terror has engulfed all nations. The American administration has drawn a lot of praise from the international community for the killing of Osama Bin Laden in a civilian area inside Pakistan. But the success behind Operation Geronimo is attributed to the soldiers deployed in risky operations and covert missions...Theres

more to a soldiers life than pay perks and military badges - the wars victimise not only the civilian population but the soldiers and their families as well. Its high time we realise that the soldiers are not dispensable cogs of a wheel; they too have their hopes and desires and the need to nurture their families. Their health during wartime and thereafter should be of concern not only for their families but for the community as well. Only then they could contribute to the society in the long run. References:1. 2. Hans Peter Gasser Contemporary Management of wartime vascular bin/GetTRDoc?Location=U2&doc= GetTRDoc.pdf&AD=ADA480663 trauma(www.dtic.mil/cgi-

3.

Back Pain in the larger spectrum of war injuries, American Back Society(www.bomconcepts.com/abs/index.php?option=com_zoo&task=item&item_id=56&category_id=6 &item=1 WHO definition2000(a) NAMI(National Alliance on Mental Illness) Beginnings 17(www.nami.org/Content/ContentGroups/CAAC/Beginnings-17-final.pdf) Winter 2010, Issue

4. 5.

6.

Using Advanced Prosthetics for Stress Inoculation Training and to Teach Life Saving Skills(www.ftp.rta.nato.int/public//PubFullText/RTO/MP/RTO-MP-HFM-182/ MP-HFM-182-12.doc) Lagarde M, Palmer N. (in press) The impact of user fees on utilization of health services in low and middle-income countries: how strong is the evidence? WHO Bulletin. McGillvray M (2005). Aid allocation and fragile states. Background paper for the senior level forum on Development Effectiveness in Fragile States, Lancaster House, London. 13-14 January 2005. Vergeer P, Canavan A and Bornemisza O (2008). The transitional funding gap in post-conflict health sectors. Health and Fragile States Network. London School of Hygiene and Tropical Medicine.

7.

8.

9.

10. Doull L, Campbell F (2008). Human resources for health in fragile states. Lancet 371:626-627. 11. Burkle F. and Noji E. (2004). Health and politics in the 2003 war with Iraq: lessons learned. The Lancet October 9 12. Oxford Research International (2004). National survey of Iraq. www.oxfordresearch.com/publications.html