Invisible casualties : Twenty-eight percent of Marines had killed a civilian

The experience is horrifying. Among soldiers and Marines from combat units involved in the early stages of the war in Iraq:

Nine in 10 had been attacked or ambushed and had been fired upon.

More than half had killed an enemy fighter.

Eighty-six percent knew someone who had been killed or seriously injured.

Almost all had seen death, and half had handled the dead.

Most saw ill or injured women or children they could not help.

Twenty-eight percent of Marines had killed a civilian.

The combat experience is defined by gore and fear as much as it can be by honor and bravery. For many of its casualties, the wounds are hidden in their minds and emotions and spirits, not obvious on their bodies. Indeed, the study that documented the experiences listed above is a sobering prediction that the war in Iraq will return to our shores many thousands of soldiers and Marines with significant psychological problems. The study of the effect of combat on troops’ mental health, conducted by Army doctors, appeared in the July 1 New England Journal of Medicine.

The conclusion: One in six combat veterans reported moderate or severe problems with depression, anxiety or post-traumatic stress disorder. One in six. Some experts expect that rate to rise as more troops come home and try to readjust to civilian life. And some worry that the growing numbers of citizen soldiers, members of the National Guard and Reserves, are at special risk.

The men and women studied had served in ground combat during the early phase of the invasion. But the problems may be as bad or worse for those exposed to combat during the occupation phase. Peacekeeping brings its own stress: extended tours of duty, lack of a defined front or enemy, the involvement of civilians as both combatants and innocent victims, and the reality that a lethal attack can come from any quarter at any time. After duty on Baghdad’s streets, a combat veteran can find that crossing even hometown streets triggers disturbing anxieties.

More grim indicators of problems ahead: As of January, more than 1,000 soldiers had been evacuated from Iraq for psychological problems. And another: The Pentagon is concerned about low morale among troops in Iraq and a spike in suicides. That’s unusual, because in times of war, the suicide rate among the military - normally lower than among the general population - usually drops even more, not climbs.

The most troubling telltale, though, is this: Among the soldiers and Marines who met psychiatrists’ criteria for major psychological problems, and who acknowledged they had a problem, fewer than half were interested in getting help, and only one in four had actually seen a mental health professional. The more severe the symptoms, the less likely the victim was to get help.

In an institution that values suck-it-up courage, the taboo remains. It has been a long time since Gen. George Patton reportedly waved his gun at a solder hospitalized for shell shock, taunting him as a coward who ought to be shot, but the stigma endures. Soldiers fear that admitting to psychological problems will be seen as a sign of weakness, one that could derail their careers and humiliate them in their comrades’ eyes. Perhaps the saddest fear the troubled soldiers expressed: that they would be blamed for their own problems.

This is not a failure of training, for those who are headed into battle are trained for combat. It is, instead, a failure to have an effective program to deal with the aftermath of combat.

The large number of these invisible casualties of war is something for which this nation must prepare, especially in areas such as Hampton Roads that will welcome back many service members who have come face to face with combat’s horrors.

The lingering symptoms - which can include anger and anxiety, depression, irritability and flashbacks - can complicate the transition to civilian life. The toll will likely include substance abuse and social and work-related problems. The suffering will spill over to the casualties’ families, friends, employers and communities.

Identification and intervention will be critical. Innovative programs are under way that try to get ahead of the problem by identifying and treating personnel in the field - but an Army team found its front-line efforts inadequate.

The overall success of the nation’s response will depend on how well the psychiatric resources of the Army and Marines in particular are geared up to reach out to and meet the enormous demand that lies ahead. And how well those resources prepare families and provide continuing support to help them through the transitions they, too, will face.

But the biggest impediment will be combat casualties’ unwillingness to get help. Getting past that will require a change in the military culture that neutralizes old taboos and openly acknowledges the toll of war on minds and emotions as well as bodies. It will require that the services are as compassionate and proactive in treating those wounds as in treating mangled limbs. That spirit must emanate from the top, but it must take root across the organization so it shapes the way an NCO interacts with subordinates, as well as what the brass mouths.

One of the distinctive characteristics of this war will make the problem worse: A large percentage of the force is made up of men and women drawn from the National Guard and Reserve. They are thrown abruptly from the familiarity and safety of civilian life into what is still a war zone, often without the preparation or mind-set of their active-duty counterparts. They will return not into the (potentially) supportive environment of a military community but to a civilian community that may lack the awareness, understanding and resources to deal with the emotional aftermath of what they’ve been through. They’re eligible for services through the Veterans Administration, but how accessible will they be?

Here, too, the military will have to play a big role. The job is to prepare Guard and Reserve combat veterans and their families for what they may experience and to provide - that’s right, provide, not foist off onto soldiers’ private health insurance - appropriate mental health services. And those services must, like the symptoms of post-traumatic stress disorder, extend over a long period. Civilian organizations devoted to mental health - in this area, community services boards - must be ready to reach out and take care of returning troops and their families.

It will take a concerted and sustained effort, on many fronts from family dinner tables to command board rooms, to heal the invisible wounds many of this war’s combatants will bring home and to minimize the destructive toll on themselves and their families.

Daily Press

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