Jonathan Foreman says that the focus upon the death toll in the Afghan conflict obscures the high numbers of soldiers who have suffered catastrophic wounds — and the scandalously inadequate compensation they have been offered once home in a land unfit for such heroes
It is not easy to measure success and failure in counter-insurgency warfare. Modern military establishments have all sorts of ‘metrics’, as they call statistics, but the politicians and the general public tend to focus on one measure alone: fatalities, and our fatalities at that. The deaths in Afghanistan of other Allied forces rarely make the headlines (though the loss of ten French troops in a single 2008 ambush did reach the front pages), and numbers of enemy dead are rarely mentioned at all.
The number of civilian casualties during the recent pre-election allied surge in southern Afghanistan has remained unclear. This is partly because the Nato-led Coalition doesn’t want to be in the business of Vietnam-style body counts, and perhaps because it is not easy to know who counts as a civilian in a conflict where one side eschews uniforms and in which a 14-year-old boy could easily be a combatant. This is frustrating because it makes it that much harder for the public to know ‘how we are doing’ and what, if anything, has been gained by all the sacrifices.
So — is it worth it? Much has been made of the 200th British military death in Afghanistan. However, those who are committed to the war in Afghanistan might point out that 200 fatalities over eight years works out at a lower death rate than the conflict in Northern Ireland between 1969 and 1977, and obviously at a much lower rate than in the Falklands war where 250 British servicemen died in three months. (We tend to forget that the IRA killed 146 members of British security forces in 1972 alone, about the same number that were killed by enemy forces during the entire Iraq war.) They point out that 200 fatalities is not a vast number in a country with a population of 61 million, and in which 200 young people were killed as a result of knife crime in the past year alone. The Danish contingent has suffered greater losses both in proportion to the size of its force in Afghanistan and in terms of Denmark’s population.
However, the true story is that the war in Afghanistan is taking a far, far greater toll than most people realise. A much more telling statistic than the number of dead is the number of wounded. Even more important than this is the number of severely wounded men and women and the startling ratio of wounded to dead. In the second world war the ratio of dead to wounded was 1:4. During the Vietnam war there were 15 wounded men for every American fatality in theatre. In Afghanistan and Iraq the ratio for British and American troops is between 1:30 and 1:40.
With all the focus on fatalities, not enough attention has been paid to the wounded. Why are so many wounded in Afghanistan? The first answer is to do with our improved technology. The body armour, plus dramatic advances in battlefield medical care (such as fast-clotting bandages and tourniquets that can be applied with one hand) mean that those who would have died in past conflicts are kept alive. And there have been great improvements in transporting critically ill patients by air. The other answer, perhaps the most significant one, is that Improvised Explosive Devices or IEDs —– military jargon for home-made bombs and land mines — wound many more than they kill.
Beginning in the first world war, Allied wounded were sorted into three categories of medical ‘triage’. If you had a level-one injury, it meant you could be patched up and sent back to the front. Someone with a level-two wound might be able to return to the front in a matter of weeks. A level-three wound required long-term medical treatment and if the patient survived, he would be unlikely to return to the front. Today, in Afghanistan, a significant proportion of our wounded soldiers are so-called ‘tier-four’ casualties. That essentially means they have suffered such a combination of catastrophic wounds, say loss of limbs and brain damage, that they would not have survived in any previous war. Many of these broken young men (and so far they are almost all men) will need 24-hour care for the rest of their lives and may never work again. This sort of care is unbelievably expensive and will place an intolerably heavy burden on veteran’s families for decades to come.
For every 30 wounded casualties there is an average of seven men with tier-four injuries. There may already be between 2,000 and 3,000 soldiers grievously wounded in Iraq or Afghanistan who are in this tier-four category. They have come back home to a country that is not prepared to look after them or their families. And their actual numbers, as a senior army officer recently admitted, are unknown. There is a compensation system in place but it is both overwhelmed — thanks to inadequate planning — and cruelly ungenerous. Indeed MoD bureaucrats and lawyers, driven presumably by the Treasury, have put remarkable energy into clawing back paltry sums paid to injured servicemen, including a soldier who suffered a tier-three wound in Iraq who has gone back to fight in Afghanistan.
It does not help matters that there are no longer any military hospitals in the UK. In the early 1990s John Major’s government decided to shut them down, war being a thing of the past. The Labour government completed this policy, closing the last hospital in Gosport in 2007, even though the nation’s single military-run ward at Selly Oak in Birmingham was already overwhelmed, and there is simply no question that military casualties recover better in military hospitals. Perhaps the most arresting statistic of all is an estimate by UK defence experts that puts the financial cost of long-term care for these 2,000-3,000 severely wounded men at between £2.5 billion and £4 billion — even based on a life expectancy of only 15 years after the original injury. Yet neither the Ministry of Defence nor the National Health Service has funds set aside for this purpose. Nor has either institution included the cost of looking after Britain’s severely wounded servicemen in its projected budgets for the years ahead. By contrast the government and MoD account in their operational ‘modelling’ only for the cost of fatalities. Conservative estimates suggest that, including pensions, and one-off grants, the state has paid out between £150 million and £200 million to the relatives of servicemen killed in action. This means that the lion’s share of looking after severely maimed veterans falls on soldiers’ families — people already devastated by the loss of an able-bodied husband, son or father. They are not equipped to bear such a burden and they should not have to.
If the bean-counters at the Ministry of Defence have thought about it all, they surely know that even the £570,000 maximum compensation allowed by the current system — a maximum that was not awarded to Paratrooper Ben Parkinson, the most severely injured British serviceman ever to survive a mine blast — is nowhere near enough to pay for necessities such as modern wheelchairs, lifts, widened doorways and long-term nursing care.
Eventually the state will likely be forced by public outrage to do the right thing by severely injured servicemen. But the fact that neither the MoD nor the NHS has thought to take into account the financial costs of looking after severely disabled servicemen — even after eight years of war — indicates that Britain’s political and military establishments do not understand the realities of modern counter-insurgency warfare. There is certainly something ludicrous about a defence establishment that is fiercely fighting over new procurement priorities but whose projected budgets do not even take into account the £2-4 bil lion that someone will have to pay if Britain is to maintain the covenant with men and women in uniform.
What military analysts call ‘health-security-economics’ is a key part of modern warfare. Along with ‘information warfare’, it is a field of which our enemies in Afghanistan and Iraq seem to have an instinctive grasp. They know that to make us leave they do not have to defeat us in the field: they merely have to persuade the public that the war is simply too costly in blood and treasure. In the IED they have found the perfect weapon to achieve this aim.
It is a weapon of strategic influence, as the jargon has it, one with the power to affect hearts and minds in the UK. This does not necessarily mean that we should pull out of Afghanistan, perhaps declaring victory in the classic post-colonial style, as the FCO did in Basra. Nor that we should continue fighting but in a more risk-averse way that would inevitably cede control of the country to the Taleban. It does unquestionably mean that all future deliberations about defence spending must take into account the real costs of looking after current and future casualties — in other words the ‘health-security-economics’ of war.
It also means that if the defence establishment wants to diminish the terrible financial as well as human costs imposed by the IED threat, and therefore avoid defeat in Afghanistan, it will have to re-examine its priorities, and think about the Afghan war as a campaign rather than a series of six month operations than can be managed with existing resources.
Among other possible shifts in direction, this could entail making an effort to counter the IED threat by developing the ability to monitor and control Afghanistan’s key highways from the air. You do not need fantastically costly and complex jet fighters flown by expensively trained air force commanders and colonels to perform this task. And you do not necessarily require expensive drones of the kind that have been employed against al-Qa’eda forces in Pakistan. You need relatively light and simple aircraft, with long loiter times, that can be piloted by corporals — and eventually by Afghans — and which can fly slowly enough to distinguish a man with a bomb or gun from a man carrying a scythe on his way to the fields.
Perhaps more radical change is needed, such as adding a large ‘nation-building’ civil affairs component to the military — as suggested by General Dannatt last week — so that it can effectively win hearts and minds in places like Helmand province where DfID, shackled by health and safety restrictions, has failed to have much impact.
Arguably the UK has tried to prosecute the Iraq and Afghan wars while making procurement and deployment decisions as if this were peacetime, with genuine military needs subordinated to industrial policy, gestures of EU solidarity, and some of the more irrational instincts of politicians and the services.
One requirement is certain. If the ‘covenant’ is not to be breached, leading to a collapse in the morale of our troops and their families, we are going to have to rebuild Britain’s military medical institutions.
We could do worse than to look to the United States for inspiration. Though the Department of Veterans Affairs (formerly known as the Veterans Administration) and the Walter Reed Military Hospital have been the target of valid criticism over the past few years, they do an excellent job of looking after America’s wounded GIs and Marines who are maimed in combat and come back to military hospitals where they are surrounded by their fellow servicemen (not civilian geriatric patients), where they are treated with respect and understanding, and attended by staff who are specialists in treating military casualties.
The VA, as it is called, draws its mission statement from Abraham Lincoln’s second inaugural address: ‘to care for him who shall have borne the battle, and for his widow and his orphan’. Its founders understood that in a democratic society if you are not serious about looking after your wounded troops then you are not serious about war. If you are not serious about war, then you have no business sending troops into battle. Moreover you are likely to lose.
Proceeds from this article will go to Help for Heroes and BLESMA.