During the recent government shutdown, denial of the “death gratuity” to families of recently deceased veterans of the war in Afghanistan allowed people on both sides of a glaring political divide to condemn an unacceptable form of abandonment. Even in a climate of austerity, war deaths and injuries carry unquestioned obligations. It would seem that determining which fatalities fall into this category would be a simple matter. Killed by a roadside bomb near Khandahar province, the two Army Rangers, a military police investigator, and a nurse, all under age 26, are indisputable casualties of America’s 12 year long engagement in the region. Yet for all those whose ends can be explained by the sad, yet clear logic of organized violence, there are many whose deaths do not fold neatly into an apparent rubric of cause and effect.
After a death, an autopsy tells a story of biological failure within a single body. A wound bleeds out, a heart stops, a brain is deprived of oxygen. A different scientific process tells us about death in aggregate, or “rate of mortality,” as it’s called in epidemiological studies. Such morbid chronicles narrate deaths in terms of probabilities and likelihoods, drawing correlations between fatalities, illnesses, and attributes like gender and age, pack-a-day smokers, or those who run marathons. Studies like these offer speculative histories based on what can be known and what might be inferred into future patterns of fatality.
It is from epidemiology that the idea of the epidemic emerges, defined by the absence of proportion in the distribution of maladies. The term is primarily a descriptor of magnitude, but it also acts as an instrument of comparison, invoking ideas about acceptable patterns of mortality and conditions that give rise to “excess” deaths.
American military members are prime subjects for epidemiological research, both because their physical attributes are routinely recorded by military medical regimes and because the vitality of their bodies is thought to be a matter of national interest and responsibility. Long-term research endeavors like the Millennium Cohort Study and the Army Starrs program have amassed some of the largest cohorts of human subjects ever assembled for the purposes of long-term research. With hundreds of thousands of participants, access to a wide array of military administrative databases, medical records, and in the case of Army Starrs, blood samples, these studies are poised to offer unprecedented glimpses into patterns of illness and mortality using a vast assemblage of data unthinkable in civilian contexts.
In recent years, the combination of research readiness and moral demand unique to military populations has surfaced some discomforting correlations between military service and deaths. Suicide rates, in particular, have been an object of distress and scrutiny. Last year, former Defense Secretary Leon Panetta used the term “epidemic” to characterize reports that more soldiers had died as a result of suicide than from combat injuries in the fiscal year 2012.
The idea that military members may be more susceptible to death by self-harm than to enemy aggression challenges the quantitative coherence of the war’s official death tolls, archived and updated daily in digital monuments like the New York Times’ Faces of Death project or the Washington Post’s Faces of the Fallen. While these projects facilitate the remembrance of a settled past, epidemiology gestures toward an anxious future. The present is left as an indeterminate space pregnant with risk, yet couched in the promise of insight and order offered by modeling past patterns and revealing chains of causality.
The ideal typical scenario animating the logic of epidemiology is the case of infectious disease and the specific pathways carved out by its gradual spread in a vulnerable population. Yet where a biologist might study the organic components of the disease process in a single organism, epidemiology is an inherently social form of inquiry, studying how a particular contagion moves through groups, spreading slowly or quickly, affecting some but not others.
Existing data about suicide in the military has been subject to many attempts to isolate exactly what features of military life, soldierly identity, or other factors can account for the high incidence of self-harm. A report widely circulated this summer determined that elevated suicide rates should not be attributed to “deployment factors.” The study, funded by the Department of Defense and published in the Journal of the American Medical Association concluded that the 83 suicides captured in the Millennium Cohort Study (MCS) do not correlate with war-related factors such as combat exposure, length, or number of deployments. Rather, connections are more robust between factors that increase suicide likelihood in non-military populations such as gender, a history of seeking help for mental health disorders, substance abuse, relationship struggles, and financial issues. The study does not conclude, however, whether or not military life increases the chances of people encountering these stressors, raising a chicken or egg question that is less easy to answer with the data collected by the MCS.
Though epidemiological portraits do not always tell conclusive stories, other problems emerge when there are no attempts to track patterns of injury, or if those attempts are not subject to public scrutiny. A little over a week before Veteran’s day, an investigative report revealed that the Veteran’s Administration had stopped releasing data on the number of injuries sustained during the Iraq and Afghanistan wars. The realization of this absence occurred just as the number of war-related injuries was estimated to have reached 1 million, if past patterns have remained consistent. Though the VA had released monthly data about the number of new patients treated at its hospitals throughout the war, this practice was abruptly stopped last March without explanation, save a statement buried on a webpage that claimed “existing security arrangements” were at stake in their data collection systems. Though VA spokespeople have since promised that reporting will resume soon, the supposedly temporary absence has already created a dilemma for health policy makers, who use the data to request and allocate funds for specific Veterans’ health care programs.
Information is critical fuel for the administrative apparatuses that distribute care on a large scale. However, this process only works if there is a functional infrastructure in place to match needs with available remedies. A recent attempt to assess the “holistic damage” sustained in Iraq in the years since the 2003 invasion showed the extent of the war’s lethality over and above the deaths that can be attributed directly to violence. The study, published in the open access journal PLOS Medicine, was the first to be released since 2006. A concrete inventory of Iraqi war deaths was notoriously elusive throughout the war, and since the U.S. took its troops home, the situation has improved only slightly. Dangerous ground conditions, unreliable pre-war records, out-migration—not to mention fear and bias on behalf of available participants—have created an environment of ongoing uncertainty in questions of empirical assessment.
While acknowledging these limitations, the PLOS study offered a framing of war as a public health problem. Using population-based surveys targeting the years between 2003 and 2011, the researchers compared the estimated normal rate of mortality with the “excess deaths” caused by war, finding that “failures of health, sanitation, transportation, and communication” were responsible for a third of the nearly half million total deaths they connected to the invasion. Not due to obvious war injuries, like the gunshots, car bombs, air strikes, and other forms of violence that caused the majority of deaths, these deaths may be less likely to be reconciled and memorialized as war casualties. The study’s authors speculate that this lack of official recognition stands as a cultural barrier to the formation of a peaceful post-conflict society. One might also conclude that an even more significant barrier is the fact that regular violence is ongoing, and the frequency with which individual reports of deadly fighting appear in the media makes it almost certain that it is again on the rise.
As the Afghanistan drawdown grows near, it becomes easier to imagine a “post-war” reality in which the initial damage has been done, and all that remains is to attend to its effects as the event recedes into history. This may be accurate for many of those whose lives have intersected with the 12-year war. Even in the face of staggering damage, all existing accounts suggest that the majority of American veterans who have already ended their tenure in war zones have returned without reported injury. Challenges that may have attended their transitions have gone under the epidemiological radar, existing in personal biographies rather than the public record, itself an imperfect index. Yet, it is important to remember that the vast number of injuries sustained produce effects that are ongoing, and some that only take root in the aftermath. The information flows produced by war allude to this in the measured terms of statistical pasts and potential futures. The way that such allusions take shape in the bodies and lives of individuals, however, is an ever-unfolding story, less certain of its narrative arc and its recognition by those not directly affected.