The Long-Term Costs of War

A new RAND Corporation study paints a disturbing picture of the mental-health issues facing combat veterans as they come home from Iraq and Afghanistan:

Nearly 20 percent of military service members who have returned from Iraq and Afghanistan -- 300,000 in all -- report symptoms of post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment....

In addition, researchers found about 19 percent of returning service members report that they experienced a possible traumatic brain injury while deployed, with 7 percent reporting both a probable brain injury and current PTSD or major depression.

Many service members said they do not seek treatment for psychological illnesses because they fear it will harm their careers. But even among those who do seek help for PTSD or major depression, only about half receive treatment that researchers consider "minimally adequate" for their illnesses.

In the first analysis of its kind, researchers estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment -- an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more high-quality treatment could save close to $2 billion within two years by substantially reducing those indirect costs, the 500-page study concludes.

I'm not surprised by the aggregate level of combat stress. These numbers are high, but they are consistent with what the Army's Mental Health Advisory Team reports have been telling us. Iraq and Afghanistan are difficult places to serve, and 12- to 15-month tours will take a toll on even the toughest troops. Everyone comes home changed in some way. Whether that evolves into PTSD, or resolves itself, seems to depend on a complex combination of factors, including age, family, personality, and specific combat experiences. I've seen two members of the same squad go to war and go through the same things, only to come home with completely different reactions. Everybody's war is different.

I'm particularly worried, however, about two sets of findings by RAND. First, that so few servicemembers are receiving the care they need. Many troops still fear the stigma of being labeled a PTSD case, and they avoid treatment out of fear it will harm their careers, their relationships, their pride, etc. Others do seek counseling and treatment -- but often it's inadequate, either because the right tools don't exist or because the particular base/location isn't resourced to help. The Pentagon and VA have made tremendous strides in these areas, but it's not enough. Six years into this war and we're still letting veterans fall through the cracks. That's not right.

Second, the RAND study suggests that we haven't begun to reckon with the full costs of these wars. The study estimates the annual societal costs for Iraq/Afghanistan-related PTSD at $2 billion to $3.1 billion and the annual societal costs for TBI at $591 million to $910 million. That's just one year! Project that out over the lifetime of these young troops and you're talking about a lot of money. Even the $3 trillion estimate by Linda Bilmes and Joseph Stiglitz may end up being low, once you factor in the long-term health care costs for Iraq and Afghanistan veterans.

But these costs will come due after the sound of the guns has faded, and long after the supplemental appropriations bills for the war have been passed. VA funding is discretionary funding; it is not an entitlement like Social Security. Which means that this generation will have to fight to ensure the VA has enough money to take care of these issues over the next 50-75 years.

By Phillip Carter |  April 18, 2008; 4:16 PM ET  | Category:  Veterans
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Oh no, thank god for Rand studies, people returning from Iraq and Afganistan are all screwed up and that is gonna cost money. I mean, where are we going to be able to send our kids when they leave home.

Posted by: dunnage | April 18, 2008 4:57 PM

Although we should respect those who serve, should we revere them, . make military service something desirable?

I don't know, but this Vietnam Vet wants to ask a sensitive set of questions we muat ask ourselves.

Here is a (numerically revised) letter to the editor that no paper in my area (Bay Area, Calif) would print:

They talk about "honor" and "pride" a lot. Their TV ads show young men slaying mythical dragons, climbing walls of fantasy, standing tall in multicolored uniforms. But is that the reality of our men and women in the services?

Few decisions are as important as those regarding life and death, yet we have come to idealize those who cede those decisions to others; people willing to perform draconian tasks automatically, without reflection. Is that what we want our young adults to become? Where is the pride in surrendering life's most important decisions to others? Where is the honor in killing on command?

The trials at Nuremburg have already shown us the answer. There will be an enormous price to pay for our self-righteous aggression - far worse than letting our sons and daughters be used for odious purpose, far more than the hunderds of thousands of physically, mentally, and morally wounded troops coming home in and out of boxes, more than the trillions (yes, trillions) of dollars wasted in the application of extreme violence.

We have lost our humanity.

Posted by: gkam | April 18, 2008 6:27 PM

My nephew came home very different than when he left, and I don't know how to talk to him about it. I'm a vet too, but the soldiers of this generation have spent more time in combat than any army we have ever fielded. We have more average combat time per soldier than the republic has ever had before - and THAT IS WRONG. They get tired, and they don't see the rest of the nation at war, just themselves.

I just keep saying to myself: 1 - 20 - 2009, 1 - 20 - 2009 - for that grand day will be, to coin an awkward phrase, the final beginning of the ending of this tragic mess.

Posted by: JD | April 19, 2008 2:32 AM

My nephew came home very different than when he left, and I don't know how to talk to him about it. I'm a vet too, but the soldiers of this generation have spent more time in combat than any army we have ever fielded. We have more average combat time per soldier than the republic has ever had before - and THAT IS WRONG. They get tired, and they don't see the rest of the nation at war, just themselves.

I just keep saying to myself: 1 - 20 - 2009, 1 - 20 - 2009 - for that grand day will be, to coin an awkward phrase, the final beginning of the ending of this tragic mess.

Posted by: JD | April 19, 2008 2:32 AM

My nephew came home very different than when he left, and I don't know how to talk to him about it. I'm a vet too, but the soldiers of this generation have spent more time in combat than any army we have ever fielded. We have more average combat time per soldier than the republic has ever had before - and THAT IS WRONG. They get tired, and they don't see the rest of the nation at war, just themselves.

I just keep saying to myself: 1 - 20 - 2009, 1 - 20 - 2009 - for that grand day will be, to coin an awkward phrase, the final beginning of the ending of this tragic mess.

Posted by: JD | April 19, 2008 2:33 AM

I'm leery of this study. I'm currently on my 2nd tour and here are a couple of thoughts: I would estimate that about 1 in 5 OIF vets have actually seen any "combat action" whatsoever. A higher percentage may have been subjected to rare or more-than-rare IDF, but only a relatively small percentage have shot or been shot at. What percentage of that 20% is reporting PTSD? Perhaps it's the majority. Speaking for myself, I know that all of my combat actions have been relived repeatedly in my mind (which probably fits the loosest definition of PTSD), but I would not call myself permanently impaired. Exposure to the horrors of war are certainly an occupational hazard, but today's Army is a professional force. Many of our troopers have spent their entire adult life preparing for war - and I think that makes a difference when compared to draftees of previous conflicts. There is much room for additional research on this and related subjects. I just hope that my generation of Soldiers doesn't automatically carry the "damaged goods" label just for having served. Most of the guys I serve with have every intention of eventually getting out and being productive, responsible members of civil society.

Posted by: TPL | April 19, 2008 3:51 AM

The Iraq war itself will be a prime cause of the deficit squeeze that will see VA funding ruthlessly attacked in years to come.

Crunch time is coming, the numbers prove it. It can be delayed, but not avoided. When the really deep cuts have to be made, VA healthcare will have fewer defenders than almost any other program.

Even the vets themselves will make far more fuss about cuts in their disability pay or whatever, than cuts to the medical system, especially the mental health component.

You watch. Nobody important has a vested interest in keeping discretionary funds flowing to veterans' mental healthcare.

If you think these vets are being neglected now, wait till the Iraq war is just a bad memory a la Vietnam. In 15 years, when the Vietnam vets have Alzheimers etc, there won't be two pennies to rub together for these guys.

But it's all peanuts compared to what has been done to the people of Iraq.

Posted by: B. Kaufmann | April 19, 2008 4:00 AM

I have PTSD, I don't like it much. I got it from a combination of abuse, bad luck, and job related trauma. It's no fun to say the least. It causes me problems to this very day with employers because of sleep difficulties.

I've found the military to be one of the few organizations in America willing to understand what it means to live with this condition. Government agencies are also decent about this too.

Everyone else though, well not so much. Insurance usually has limited coverage to say the least. Then there's the problem of finding a provider, it's damned hard to find professionals with experience treating PTSD in some areas of the country, much less just get help in general.

Look at the DC Metro area as an example. Critical mental health care has been such in the area that the VT shootings happened, the Sully Station Police shootings happened, and there have been numerous incidents of violently mental ill people being hurt or wounded in the area.

Those are the ones people hear about. They don't hear about the people who the police save. They don't hear about the guys who get locked up to save their lives & cause it's the only option there is.

Clearly, the one thing pretty much everyone in Virginia can agree on is that mental health resources are strained just dealing with emergencies alone. Non-emergency private practice can be pretty brutal too, and there are strains in the private sector over capacity in the Metro community.

DC has it's own set of issues, but they've gotten pretty good at dealing with mentally ill people with minimal violence. They have treatment capacity problems, but the cops there because they deal with whacky protesters all the time have some finesse that surrounding jurisdictions miss out on because they don't get the same otjt with masses of whacks. (Flocks of Flakes? Herds of Hysterics? Schools of Sillies?)

The rest of the country isn't in so much better shape community mental health wise either.

So how much is left over for PTSD treatment? Not so much really... Not until it gets acute, and someone's life is in ruins. It's not a good situation.

This needs to change badly. There need to be more treatment resources available.

There needs to be some serious _work_ done to club employers into greater tolerance and understanding of the problems associated with this. They need to understand that they are not being the people who they want to be when they treat someone with PTSD problems badly.

Part of the cost of freedom is this. When people do things for their country, or their state, or their county, or their buddies, or their families, and undergo trauma, PTSD is one of the costs. It is not fair or decent for American corporate and civil societies to shirk their debt.

I think the best news is that it's at least a problem that can get better. It's not without end, and while the time it takes varies, in most cases it's a problem that people who have can deal with.

When I look at the improvements in myself after getting treatment for this, often I am still surprised at the differences and improvements. So there is hope for people who've got it. The take away for everyone else is that it usually gets better and is worth the investment.

Posted by: Nym, at sea | April 19, 2008 5:11 AM

I'm also leery of these numbers. Something to remember is that the Army has a logistics tail of about 4-5 soldiers who keep things running for ever soldier on the front lines. I'm sure it is possible to suffer PTSD serving in one of the big logistical bases but its got to be much harder to do so.

I haven't seen a copy of the report but I suspect that what we have heard can be viewed as "painting with large brushstrokes."

On the other hand, I'm equally sure that the cost of treating the resultant mental health problems has been WAAAY underestimated. Its amazingly difficult and expensive to put people's souls back together again. And the carnage of not treating the problem is so great that ignoring it is NOT an option.

Posted by: Pluto | April 19, 2008 8:34 AM

TPL = Militaristic Stooge


Where do I begin? There have been forests worth of trees sacrificed to publish the literature we have on PTSD. Many of these studies (which you conveniently ignore) show that support personnel can and do demonstrate severe cases of PTSD given the unpredictability of indirect fire and a perception of that risk (more imagined than real but it can be devastating psychologically).

Second, your assertion that 80% of our servicemembers don't habitually serve in harms way is ridiculous. A quick survey of the casulaties killed thus far by MOS and grade refute this assumption. just last week, our Army lost a Colonel and Major to indirect fire IN THE GREEN ZONE WHILE THEY WERE EXERCISING ON TREADMILLS. Iraq is a dangerous place and unlike Vietnam, there is no where to "relax" ... no beer ... no women ... no "Saigon" to go out on the town in your Class Bs ... you get the idea. I think this adds to the tension.

Your jingoistic, kneejerk "warrior, professional, all-volunteer, hooah" claptrap reveals that you harbor the dangerously seductive narrative of this war - that an increasingly lower quality AVF are the "only" people in a nation of the 300 capable of getting the job done. What a crock! Keep it up young man and you'll get the isolated, politically-marginalized veteran population you seem to want. What constituency will be there to take care of YOU in 40 years if an increasingly isolated, politically-naive and self-selecting caste populates our armed forces? Think about it.

Your insult of previous generations of veterans enrages me. So our WWII, Korea and Vietnam draftees were subpar because they "didn't spend their entire adult life preparing for war." Amazing. Has today's Iraq-bound 11B10 4 months out of OSUT at Ft. Benning "spent his adulthood preparing for war?" How about the 22 year old 2LT? The 36 year old IRR recall who hasn't worn a uniform in 10 years? Is an increasingly lower quality AVF the reflexive answer here? Are single Moms, drop-outs, criminals and Cat-IV enlistees better equpped to handle the strains of combat. I don't think so.

Lastly, someone needs to look into the 24-7 "warrior posture" in CONUS and examine any correlation to contributing to stress symptoms. I think there may be some linkage and I've seen a growing "guilt trip" from Army leadership being placed on those in CONUS for "not doing their part" - even though many have served in OIF and OEF and are enjoying a well neeeded break.

Posted by: IRR Soldier... | April 19, 2008 9:22 AM

Wow. I really struck a nerve with IRR. Heh.

I don't even know where to begin in response. I think maybe the distance is too great to try to build a bridge. All I'm saying is that I believe there's still a lot of room for more research on PTSD. I don't deny that it's real - I don't deny that it can be debilitating. I stand firmly by the main point of my post. I hope that folks don't get labeled as "damaged goods" just because they served in combat. That wouldn't be fair.

IRR - you don't know me. I respectfully request you lay off the personal insults.

Posted by: TPL | April 19, 2008 11:34 AM

Don't blame TPL, and please stop the personal attacks on him and others. You may not know it yet, but you are in the que for the midnight follies that many of us go through - but it's no joke.

Although not a combatant, I came back a different persen, too, in November of 1968.

Does this guy think that we DIDN"T come home with the intent of restarting our lives, being productive. normal part of society? Instead, we found that nothing was the same anymore. Those used to stress and anxiety didn't understand that all that actually changed their brain chemistry. They needed the fix of adreneline, like the WWII vets who came home as Beatniks and Hell's Angels. The rest suffered privately. In my generation, many volunteered to go back. It wasn't for patriotism, it was the only place they belonged, felt right, by dint of body chemistry.

It took 20 years of job changes and the kind of irrational reactions we see in John McCain that sent me to get my first (surprising) diagnosis of PTSD.

But treatment was for combat troops, and I was in denial. It took another 20 for a seasoned vet to see me walking the streets and take me to the Vet Center.

TPL speaks because he doesn't know any better. It won't take 20-40 years like me, for him to find out otherwise. But he's different - his PTSD will be "professional".

Posted by: gkam | April 19, 2008 12:13 PM

If I conflated the responses of TPL and IRR, I apologize. To TPL, I suggest you read my first post, above.

I was an enlistee, too, and volunteered for that disgusting war. We were both suckers for the emotional pitches of duty and patriotism, as defined by the draft-dodging cowards whose dirty work we did.

John McCain will need all of you guys he can get for our next wars.

Posted by: gkam | April 19, 2008 12:23 PM

George W. Bush is a privileged character posing as a down home, plain folks cowboy. He spends three minutes deciding how to respond to a problem or threat. Then, his decision is chiseled in granite to demonstrate that he's no flip-flopper. Wrong yesterday. Wrong today. Wrong tomorrow. The tens of thousands of lives unalterably changed for the worse because of volunteer service in an ill-considered war have zero impact on Bush. He mouths the words, but feels nothing. Warriors exist because there are battles to be fought, at least in the abstract. In the case of Iraq, Saddam was a nuisance who threatened "our" oil and who attempted to kill Bush's father, the former POTUS. There were recriminations about how the Gulf War denouement was unsatisfactory because the opportunity to topple Saddam was not taken at the point of Victory in Kuwait. In a post-9/11 world, that was enough to concoct "evidence" and bamboozle Congress into authorizing what has become a perpetual war to establish a client state in the Middle East. Easier said than done. The sacrifices of the military men and women involved are unacceptably high in relation to the dividends received here at home. Promulgating policies for not doing everything possible to help those servicemembers who have been injured is easy for those desk jockeys who believe the injured should just suck it up or walk it off.

Posted by: BlueTwo1 | April 19, 2008 3:08 PM

Is every blog on the Post site run by a partisan liberal? The Post is far more interested in disseminating liberal propoganda than in educating its readers.

Posted by: Mike | April 19, 2008 3:54 PM

I'm surprised Halliburton/KBR haven't figured out how to make a fortune on this tragedy. Cheney could engineer a no bid contract per soldier and then you would see the profit motive take off as the more PTSD cases they can generate the higher the profits would flow to Halliburton in Dubai. Deferments showed Cheney was no fool, statements on the quagmire Iraq invasion would entail back when he was part of Bush 1 prove he was slick. It's just his lack of moral fiber selling out to enrich Halliburton/KBR with the blood and limbs of our precious youth on the alter of greed that sickens most Americans.

Posted by: REBCO | April 19, 2008 8:50 PM

TPL: One of the sad things about PTSD is that it is like a cancer, it grows over time. You say yourself that you are revisiting your own combats over and over again while on active duty: Now visualize it in ten years going on and on as you lie there and try to get to sleep. Every night. Every day. Combatflashes on civilian street, loud bangs making you take cover and get ready, etc. Every day, all day. I do not mean to alarm you, but thats how long a view must be kept on these things.

Posted by: Anonymous | April 20, 2008 6:34 AM

Help these Veterans! The VA is dysfunctional and does not work very well. Evaluate each Veteran by a competent authority and issue a medical debit card appropriate for their injury and let the Veteran get physical/psychological care within their home communities. If you do not have PTSD, you will have when you deal with the dysfunctional VA.

Posted by: ghostcommander | April 20, 2008 12:14 PM

As a U.S. Marine veteran and as the son of a career Vietnamese Air Force officer who served between 1954-75 then survived re-education/prison camps (1975-87), I have met many American Vietnam vets and countless ARVN vets without any VA benefits, pension, or recognition. Be glad that we American veterans at least have the VA!

Posted by: QuangXPham | April 22, 2008 4:08 PM

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