March 14, 2024: The armed forces in the United States are paying more attention to the long term impact of combat on their soldiers. The primary tool for this study is STARRS (Study to Assess Risk and Resilience in Servicemembers). STARRS began with a random selection of 55,000 soldiers, who were interviewed to obtain additional data on their experiences in the military. That will be periodically updated over the lives of the study subjects. Over the decades the army will learn more and more about military and combat stress and be better able to develop policies to avoid it and create treatments for harmful aftereffects.

STARRS is one of a growing number of efforts to deal with an unprecedented number of troops who have spent a lot, more than any other war of time, in a combat zone. Over the last decade more and more of the combat NCOs and junior officers have been found to be suffering from debilitating PTSD or Post Traumatic Stress Disorder. Studies so far have found that at least 20 percent of troops sent into a combat zone suffer some form of mental distress. That's over 400,000 troops out of two million who have served in Iraq or Afghanistan. Adding in the many Vietnam veterans who have been treated for PTSD and studied, the army has already found some useful data. For example, troops are more prone to serious PTSD effects, including suicide, if there are genetic factors which are often, but not always, revealed by a family history of psychiatric problems, traumatic childhood events, and insufficient support and treatment after traumatic battlefield events. For centuries it's been accepted that some men are prone to break under the stress of combat. It was understood, even without any knowledge of genetics, that a soldier with a family history of mental instability would be less able to handle combat. Now the army can more precisely measure the risk and more accurately screen out those who will be most at risk.

Another big problem is that the United States has never had such a long period of combat with so many troops involved. Moreover, casualties, especially combat deaths, are much lower than in the past. As a result, more troops are surviving to spend a lot more time in combat. This is producing an unprecedented number of NCOs who are very stressed out. If the NCOs are having stress-related problems, that usually makes their subordinates uneasy as well.

The U.S. Army has, over the years, developed a set of guidelines for how to recognize the symptoms of PTSD level combat fatigue. With all the attention PTSD has gotten in the media during the decade after September 2001, troops were more willing to seek treatment, or at least admit there was a problem. While extreme cases of PTSD are pretty obvious, it's the more subtle ones that the army eventually concentrated on. These were easier to cure if caught early. But this caused problems with troops who are tagged as a subtle case and disagreed with the diagnoses. Most soldiers still believe that, once you are tagged, you won't be left alone by all those new specialists who only want to help you.

Worse yet, the army found itself facing several sources of PTSD. First, there was the discovery that many troops, because of exposure to roadside bombs and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. The VA, or U.S. Veterans Administration, which cares for injured veterans was particularly interested in knowing about a soldier's prior exposure to roadside bombs. The troops pointed out that PTSD is made worse by having too little time back home between combat tours, and this part of the problem has been addressed. But the subtle long-term effects are still only partially understood.

A major problem is that most people eventually get PTSD if they are in combat long enough. This has been confirmed by nearly a century of energetic efforts to diagnose and treat PTSD. This included much recent attention to civilian victims, via accidents or criminal assault. During World War II it was found that, on average, 200 days of combat would bring on a case of PTSD. After World War II methods were found to delay the onset of PTSD. These included more breaks from combat, better living conditions in the combat zone and prompt treatment when PTSD was detected. Military historians note that successful, and often popular, commanders throughout history have paid attention to the physical well-being of the troops, all in the name of maintaining morale. These measures also delayed the onset of combat fatigue.

That's why combat troops in Iraq and Afghanistan often slept in air conditioned quarters, had Internet access, lots of amenities, and a two week vacation to anywhere in the middle of their combat tour. This extended their useful time in combat before PTSD, also known as bad morale, set in. No one is yet sure what the new combat days average for PTSD to appear is, and new screening methods are an attempt to find out. The army and marines are now confronting the fact that, for a large number of their combat NCOs, the limits are being reached. It's a lot more than 200 days in combat but the army and marines have the majority of their most able and experienced NCOs approaching that limit.

This was not unexpected. The army knew that they had a large, and growing, percentage of its combat troops with over 200 days of combat. Some have three or four times that. For a while, treatments, most of them consisting of counseling and medications, worked. But these were not cures. A major reason for army generals talking about the army needing a break from combat was the looming loss of many combat experienced NCOs to PTSD. The army would not give out exact figures, partly because they don't have much in the way of exact numbers. After a few more years the army got a clearer picture of how well they coped with PTSD among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea, or World War II.

The problem was mainly among combat NCOs. Most of the troops are in for one enlistment, usually four years, and then leave. Junior officers get promoted out of jobs involving close combat, and officers in general are rotated between leadership and staff jobs. NCOs spend all their time with the troops, except those few who get promoted to Sergeant Major, which is a largely staff job as advisor to senior commanders. The Sergeants Major were among the first to note the stress problems with career NCOs, especially squad and platoon leaders, as well as company 1st Sergeants.

The only acceptable solution for the problem is to transfer the worst hit combat NCOs to non-combat jobs, particularly training combat troops. This is normal in the army and marines, where it's long been common for NCOs with physical conditions and injuries resulting from the rigors of peace or wartime infantry service to be offered transfers and retraining. Severe cases may also be offered a medical discharge and disability pay. The loss of these skilled and experienced NCOs from combat units results in more troops getting killed or wounded in combat. But that can happen anyway if you leave a stressed out NCO in action for too long.

Then there's the problem of what to call this new situation. Many troops wish everyone would revert to the older term, Combat Fatigue. What's in a word? For the troops PTSD is just another injury and not a disorder. It's something you deal with. Debilitating physical injuries such as bad backs or knee/foot problems and trying to cope often leads to sinking morale and a lot of people leaving the military. Often the economy is in bad shape and quitting your job was not a good option.

The army and marines are dealing with PTSD head on, believing that what happened in Iraq and Afghanistan will happen again, and now is the time to get ready. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it PTSD can often be treated, and its effects reversed. But not always. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD and trained in how to recognize and deal with it. In the civilian community there are far more people who can acquire PTSD after exposure to much less stress. What many troops wish the brass would understand is that, as recruits, they learned that stress was a major part of the job and understood it more than the mental health mafia is willing to admit.

Over a decade ago it became obvious that 21st century warfare was different. By 2011 the war on terror had caused 51,600 American military casualties comprising 6,200 dead and 45,400 wounded. This included a small number of CIA, State Department, and other agency personnel. Over 99 percent were military personnel working for the Department of Defense. Not all the casualties were from combat, with 21 percent of the deaths from non-combat causes. In World War II that was 25 percent. The fighting in Iraq accounted for 71 percent of the deaths and 70 percent of the wounded. Outside of Afghanistan and Iraq, operations in dozens of other countries represented 2.5 percent of deaths, but about 71 percent of these were from non-combat causes.

The first 21st century war was quite different from the 20th century conflicts. For one thing, far fewer Americans are being killed or wounded in combat. And fewer and fewer of those who are wounded die. It’s a continuing trend. In 2010, eight percent of the wounded died, compared to eleven percent in 2009. There are several reasons for more troops surviving battle wounds and injuries from accidents. An obvious cause is body armor. Improvements over the past decade, in terms of design and bullet resistance, account for about 20 percent of the decline in casualties. There's a downside to this, as the body armor is heavier and cumbersome. This reduces a soldier's mobility, increases friendly casualties a bit and saves some enemy lives as well.

Another major factor is medical care, which has gotten much better, quicker, and faster. Not only are procedures more effective, but badly wounded soldiers get to the operating table more quickly. Medics now have capabilities that, during Vietnam, only surgeons possessed. Movement of casualties to an operating room is much faster now, partly because of better transportation, but also because of more efficient methods, and operating rooms that are placed closer to the battlefield.

Another major factor is the change in what caused casualties. There were few casualties from artillery and mortars. Explosions, especially from roadside bombs, were less likely to cause fatal wounds. For example, 12.9 percent of bullet wounds were fatal, compared to 7.3 percent for bombs and 3.5 percent for RPGs and grenades in general. The enemy in Afghanistan preferred to use roadside bombs. U.S. troops were much more effective in a gun battle because they were taught effective combat maneuvers and practiced those as part of their training. All this contributed to the changing the ratio of wounded-to-killed, that was 6-to-1 in 1970s Vietnam, to 10-1 in 2011.

In Iraq and Afghanistan, there has also been a dramatic reduction in combat deaths compared to Vietnam, and previous 20th century wars. The death rate, adjusting for the smaller number of troops involved in Iraq and Afghanistan, revealed a massive reduction in combat deaths and the percentage of deaths that were from non-combat causes actually went up. For example, there were 47,359 combat deaths in Vietnam, which represented 81.4 percent of the military deaths in Vietnam. The remaining 10,797 deaths were from non-combat causes and comprised 18.6 percent of all deaths. In Iraq it is 80 percent and 20 percent. In Afghanistan it was 70 percent and 30 percent. The ratio of dead to wounded is also different in Iraq, where for each dead soldier there were 7.2 wounded. In Afghanistan it was 1 dead soldier for 8.1 wounded

There are also differences in the types of casualties. For example, in Vietnam, bullets caused 38 percent of the deaths. In Iraq, it was only 19 percent, and 27 percent in Afghanistan. The Iraqis were notoriously inaccurate riflemen, even though the urban battlespace in Iraq was very similar to Vietnam. There is more of a tradition of marksmanship in Afghanistan, despite or probably because of, the frequently longer distances involved. The superior protective vests, often called body armor, worn by American troops has made it more difficult for enemy marksmen, as chest shots are now frequently useless and fatal head shots are very difficult. The new helmet worn by American troops proved capable of stopping a rifle bullet, something combat helmets had been unable to do during a century of use. The helmets were originally designed to minimize injuries from high-speed metal or non-metal fragments created by exploding artillery shells, hand grenades or explosions in general.

In Vietnam, 15.7 percent of American combat deaths were caused by IEDs, or Improvised Explosive Devices, while in Iraq and Afghanistan IED deaths were initially 60 percent, and then declined. Casualties were avoided or made less severe with the development of MRAP armored trucks. Heavy use of these vehicles reduced the impact of the explosives. The roadside bomb was a much less effective weapon, a loser's weapon, because it killed more civilians than enemy troops riding in their MRAPs and other armored vehicles. This played a major role in turning local civilians against the Iraqi terrorists and Afghan Taliban.

Aircraft related deaths from crashes were 14.6 percent of the combat fatalities in Vietnam, while it was only a few percent in Iraq and Afghanistan. The current helicopters were built with Vietnam experience in mind, and are more resistant to damage and safer to crash land in. Ground vehicle related deaths were two percent in Vietnam, but more than double that in Iraq and Afghanistan. Most of the ground vehicle deaths were non-combat related. That's because from World War II to the present, the U.S. armed forces put huge numbers of trucks and other vehicles on roads, many of them poorly maintained, or shot up, at all hours, in all weather and with drivers fighting fatigue. There being a war on, the vehicles often proceeded at unsafe speeds.

What made the experience so different in the 21st century, versus 20th century wars? It was a combination of things. The most important difference is that the troops in Iraq and Afghanistan were fighting smarter. While the Vietnam era troops were representative of the general population, the post-Vietnam era army was all-volunteer and highly selective. The troops were smarter, healthier, and better educated than the general population. In the 1970s the United States eliminated peacetime conscription and all recruits after that were volunteers. During the first three decades of all-volunteer soldiers, new attitudes developed throughout the army, which always got most of the conscripts. The army, so to speak, became more like the marines, which were always all-volunteer, and more innovative as a result. This ability to quickly analyze and adapt gets recognized by military historians, and other armies, but not by the media. It also saves lives in combat.

This innovation has led to better training, tactics, and leadership. Smarter troops means smarter and more capable leaders, from the junior sergeants leading fire terms of five soldiers all the way up to the generals running the whole show. Smarter troops lead to tactics constantly adapting to changes on the battlefield. The better tactics, and smarter fighting, has been the biggest reason for the lower death rate.

Better weapons and equipment have made U.S. troops less vulnerable to attack. GPS guided weapons made the biggest difference. There were now GPS guided bombs, shells, and rockets. This enabled troops to hit a target with the first shot and be closer to the explosion and better able to move right in after the bomb or artillery shells explode and deal with armed enemy survivors. Another benefit is much fewer civilian casualties. In both Iraq and Vietnam, the enemy frequently used civilians as human shields, and the better trained American troops were able to cope with this in Iraq and Afghanistan.

And then there was night vision gear. This first appeared during Vietnam, but in four decades, the devices got better, lighter, and cheaper. Every soldier has night vision now, as do most combat vehicles. There are also better radios, better uniforms, and even better field rations. It all made a difference.

Then there was the Internet, which enabled the troops to get in touch with each other. This made a big difference. Not just for the combat troops, but also for the NCOs and officers. Each community had different problems and solutions. With the Internet, they could easily discuss problems, and quickly share successful solutions. The troops did this by themselves, and it was up to the military to play catch up. Life-saving tips are passed around with unprecedented speed. This made a major difference in combat, where better tactics and techniques save lives.

Computers and video games had an impact as well. There have been three decades of troops who grew up with PCs and video games. It was the troops who led the effort to computerize many military activities, and video games evolved into highly realistic training simulators. The automation eliminated a lot of drudge work, while the simulators got troops up to speed before they hit the combat zone. Computers also made it possible to do things with information, especially about the enemy, that were not possible before. A lot of troops instinctively understand operations research and statistical analysis, and they use it to good effect. Research has also shown that heavy use of video games trains the user to make decisions faster. That's a lifesaver in combat.

UAVs and own force trackers took a lot of uncertainty out of combat. For nearly a century, the troops on the ground depended on someone in an airplane or helicopter to help them sort out who was where. Early in the 21st century the observer overhead was replaced by robots. UAVs, especially the handheld UAVs ones every infantry company has, gave the ground commander his own recon aircraft. He controls it, and it works only for him. Combat commanders now have a top-down view of their troops, and the enemy. This has made a huge difference, creating some fundamental changes in the way captains and colonels command their troops. For higher commanders, the GPS transponders carried by most combat vehicles provide a tracking system that shows a real-time picture, on a laptop screen, of where all your troops are. This takes a lot of uncertainty out of command, but it will be suicidal in any near-peer war where vehicular GPS transponders will also tell the enemy where American vehicles are.

Living conditions enabled troops in combat to be more alert and effective. Some civilians thought air-conditioned sleeping quarters for combat troops, and lots of other amenities in base camps, was simply indulgent. It is anything but. Getting a good night's sleep can be a lifesaver for combat soldiers, and AC makes that possible. Showers, internet links to home and good food do wonders for morale, especially for soldiers getting shot at every day. Good morale means a more alert, and capable, soldier. The combat units often go weeks, or months, without these amenities, but the knowledge that these goodies are there, and eventually to be enjoyed, takes some of the sting out of all the combat stress. The rate of combat fatigue in Iraq has been much lower than in Vietnam, or any previous war.

The enemy in Iraq and Afghanistan was not as effective as the Vietnamese were. The Taliban are more effective than the Iraqis, but not by much. All this is partly due to cultural factors, partly because in Vietnam, the North Vietnamese were sending trained and educated soldiers south. The North Vietnamese also had commandos called sappers, who, while small in number, caused a lot of anxiety and casualties among U.S. troops. The irregular Viet Cong fighters in South Vietnam, were largely gone after 1968 as a result of the failed Tet Offensive, but even these fighters tended to be more deadly than the average Iraqi gunman or Afghan warrior. Iraqi troops have had a dismal reputation for a long time but they can still be deadly. Just not as deadly as their Vietnamese counterparts. The lower fighting capability of the Iraqis saved lots of American lives, but got far more Iraqis, including civilians killed. The Afghans have a more fearsome reputation, but in practice they are no match for professional infantry. And conventional wisdom to the contrary, they have been beaten many times in the past. They are blessed, after a fashion, to live in a place that was not worth conquering. So, whoever defeated them soon left.

Finally, there is the data advantage. The military, especially the army, has since Vietnam collected massive amounts of information on how each soldier died. There were detailed records of soldier and marine casualties. The army, in particular, collected and analyzed this data, and then passed on to the troops new tactics and techniques derived from this analysis. The army restricted access to the data, as it could provide the enemy with useful information on how effective they were. Some basic data was made public, but the details were locked up for over a decade. Studying this data was a full time job for many people in the military, and there was a constant stream of suggestions resulting from this analysis, and those suggestions often turned into yet another small decline in combat deaths.