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Missing in action: Afghan civilian victims of traumatic brain injury - the signature wound of the war in Afghanistan. Richard Tanter Nautilus Institute for Security and Sustainability rtanter@nautilus.org

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Missing in action: Afghan civilian victims of traumatic brain injury - the signature wound of the war in Afghanistan

Richard Tanter

Nautilus Institute for Security and Sustainability


The First International Conference on Law Enforcement and Public Health - Melbourne, Australia. 11-14 November, 2012


  • The war in Afghanistan - law enforcement and public health

  • The nature of the United Nations war in Afghanistan

  • Traumatic brain injury: the ‘signature wound of the war’

  • From ‘shell shock’ to TBI’: 100 years of arguments on the nature and uncertainties of diagnosis of brain blast injuries

  • Sociotechnical systems (a) weapons systems and TBI

  • Missing in action: Afghan civilian incidence of TBI

  • Sociotechnical systems (b) Afghan medical system response capacity

  • Sociotechnical systems (c) US medical system response

  • Cosmopolitan responsibilities for security and morality

Beyond battle deaths: accounting for the costs of war

  • non-fatal injuries

  • disability

  • reduced life expectancy

  • sexual violence

  • psychological trauma

  • displacement

  • loss of property and livelihood,

  • damage to social capital and infrastructure

  • environmental damage,

  • destruction of cultural treasures.

    See: Source: Monitoring Trends in Global Combat: A New Dataset of Battle Deaths, Bethany Ann Lacina and Nils Petter Gleditsch, European Journal of Population (2005) 21: 145–166.

Best study of Afghanistan war human costs to date

  • Neta C. Crawford, “Civilian Death and Injury in Afghanistan, 2011-2007”, Costs of War, Eisenhower Study Group, (September 2011)

    • http://costsofwar.org/article/afghan-civilians

    • http://costsofwar.org/sites/default/files/articles/14/attachments/Crawford%20Afghanistan%20Casualties.pdf

“There is no such thing as a nice war wound.”

“There is no such thing as a nice war wound. Even the simplest weapon has devastating consequences.

But the biggest danger is for Afghans travelling any distance to get here [Boost Hospital in Helmand Province].

The biggest problem is them arriving late in terms of their disease.

So a two-hour journey could take two or three days as they go around the checkpoints, with the result that the disease has progressed much more seriously to life threatening in some cases.”

Michiel Hoffman, Medecins Sans Frontiers (2010)

Source: Neta C. Crawford, Civilian Death and Injury in Afghanistan, 2011-2007, Costs of War, Eisenhower Study Group, (September 2011), p.14, at http://costsofwar.org/article/afghan-civilians

“The fact is that asymmetric warfare is inherently horrible, causes numerous civilian casualties, leads to inevitable abuses on both sides, and presents constant dilemmas in dealing with local allies that are not subject to US command and discipline.”

Anthony Cordesman, CSIS 2011

The nature of the United Nations war in Afghanistan

  • internationalised civil war

  • Government of Islamic Republic of Afghanistan

    • Afghan National Army and Afghan National Police

    • pro-government warload/clan-based groupings

  • United Nations Assistance Mission in Afghanistan (UNAMA)

  • United States ‘Operation Enduring Freedom’

  • United Nations-authorised multinational International Security Assistance Force (ISAF)

  • “Anti-Government Elements”

    • Taliban groupings

    • Non-Taliban warlord groupings

      • e.g. Haqqani network; Hezb-e Islami Gulbuddun (former PM Gulbuddin Hekmatyar

    • Al Qaeda rump


  • Afghanistan as a buffer state, and as a quasi nation-state

  • Soviet war (December 1979 - February 1989)

  • Civil war I: Democratic Republic of Afghanistan vs. the Mujahideen (Feb 1989 - April 1992)

  • Civil war II: Warlords vs Taliban (April 1992- late 1996)

  • Taliban government (1996 - late 2001)

  • UN-authorised and US-led intervention and establishment of Hamid Karzai headed government (late 2001 - )

Original legal foundation for international intervention: Security Council Resolution 1386 (2001), 20 December 2001

  • Authorizes, as envisaged in … the Bonn Agreement, the establishment … of an International Security Assistance Force[ISAF] to assist the Afghan Interim Authority in the maintenance of security in Kabul and its surrounding areas …;

  • Calls upon Member States to contribute personnel, equipment and other resources to the International Security Assistance Force, and invites those Member States to inform the leadership of the Force and the Secretary-General;

  • Authorizes the Member States participating in the International Security Assistance Force to take all necessary measures to fulfil its mandate.

    National ISAF participating states mandates derive from UNSC 1386 (2001) and annual successor motions, and bilateral requests for assistance from the Government of the Islamic Republic of Afghanistan.

US troops and private military contractors in Afghanistan

Source: Defense Contractors in Afghanistan, Overseas Civilian Contractors, December 21, 2009. http://civiliancontractors.wordpress.com/2009/12/22/defense-contractors-in-afghanistan/

Coalition IED incidents and casualties, Afghanistan 2004-2010 (DoD data)

Traumatic brain injury: the ‘signature wound of the war’ (for coalition military)

Blast injuries

  • 73% of all US casualties to 2008 in Iraq and Afghanistan caused by explosive weapons

    • (DoD in Cernak and Noble Haeusslein, 2010:256)

  • 5,500 soldiers with traumatic brain injuries (to Jan. 2008)

    • (DoD in Cernak and Noble Haeusslein, 2010:256)

  • Improvised Explosive Devices (IED)

  • body armour effects

    • greater survival rates

    • diminution of thoracic injuries

    • injury types: ‘mangled extremities’ and closed head injuries

    • higher rate of severe, debilitating long-term consequences

Physics of blast waves: simple (a) and complex (b) explosion pressure-time curves

Source: Blast injuries, Stephen J Wolf et al, Lancet 2009; 374: 405-15.

Exposure to blast wave and high-velocity wind behind shock front of blast wave.

Hurricane: 200 km/h, over-pressure of 1.72 kPa (0.25 psi)

Lethal blast-induced shock wave: 2,414 km/h; over-pressure 690 kPa (100 psi)

Source: Traumatic brain injury: an overview of pathobiology with emphasis on military populations, Ibolja Cernak and Linda J Noble-Haeusslein,

Journal of Cerebral Blood Flow & Metabolism (2010) 30, 255-266

Complex injurious environment because of blast

Source: Traumatic brain injury: an overview of pathobiology with emphasis on military populations, Ibolja Cernak and Linda J Noble-Haeusslein, Journal of Cerebral Blood Flow & Metabolism (2010) 30, 255-266.

Immediate effects of blast and explosions

Source: Ralph De Palma et al, Blast Injuries, New England Journal of Medicine, 352:13 (31 March 2005)

Mechanisms of injury of three types of battle-related traumatic brain injury

Source: J.L. Duckworth, et al., Pathophysiology of battlefield associated traumatic brain injury, Pathophysiology (2012)

Pathology of blast-related brain injury - contested pathways

  • Pathology of TBI multifaceted. May include:

    • Edema, hemorrage, diffuse axonal damage, gas emoli,

  • Controversy re barotrauma pathways:

  • blast overpressure transmitted through the skull >> tensile and sheer strains

  • damage to brain via elevations in cerebrospinal fluid (CSF)

  • venous pressure due to compression of the thorax and abdomen

  • shock wave through blood vessels or CSF

  • Quaternary: toxic gas injury

  • secondary and tertiary blast injuries common even without external sign

  • In building blast: crush syndrome complications

  • Few clinical studies of effects primary blast injuries

  • Animal studies

    • brains of minke whales after explosion suggest “pathological changes to the brain such as outer layer cortical neuronal and diffuse whiter-matter damage, including changes n myelin and axonal structure”. [Kocsis and Tessler (2009)]

From ‘shell shock’ to TBI’: 100 years of arguments on the nature and uncertainties of diagnosis of brain blast injuries

  • War in advanced countries triggers brain injury research and controversy

    • Russo-Japanese war >> studies of ocular

    • WW1 debate overphysical/brain pathology vs psychiatric explanations of shell-shock

      • “Counting is always for a reason.”

  • Gulf War, Afghanistan War, and Iraq War

    • Traumatic brain injury or post-traumatic stress syndrome

  • Conditions of combat: TBI and PTSD arise from similar linked - and are likely often interlinked

Sociotechnical systems (a) weapons systems

  • Explosive weapons used in Afghanistan:

    • AGE: “home-made/dispersed elementary factory-produced)

      • IEDs

      • self-killing bombs

      • mortars

    • Coalition: industrially-produced

      • mortars

      • ground-launched rockets

      • artillery

      • air-launched missiles

      • bombs

        • “dumb” gravity bombs

        • laser guided bombs

        • Guided Ballistic Units (GBU) - smart bombs

        • JDAMs: Joint Direct Attack Munition - $20,000 conversion kits

          • 2,000 lb, 500 lb, 250 lb.

    • thermobaric/enhanced blast weapons (e.g Hellfire missile)

Primary coalition weapons platforms: bombers and fighter-bombers

  • B-1 Lancer bomber

  • B-2 Spirit stealth bomber:

    • 80 x 500 lb GBU-38b JDAMs

    • 80 x 5,000 lb Bunker Buster

    • 2 x 30,000 lb Massive Ordnance


  • B-52H bomber

Coalition bombing practices

US/ISAF close air support sorties, Afghanistan, January-July 2009

Source: Department of Defense data, in U.S. Escalates Air War Over Afghanistan, Noah Shachtman, Wired (30 August 2010), at http://www.wired.com/dangerroom/2010/08/u-s-afghan-air-war/; http://www.wired.com/images_blogs/dangerroom/2010/08/Drilldown-2010.pdf

US DoD-promoted interpretive framing of conflict re civilian casualties in Afghanistan (Conetta)

“The new warfare” and “Damage limitation” frames

= focus attention on weapon performance parameters and targeting protocols as putative casualty indicators

“Casualty agnosticism” frame

= empirical evidence unreliable; sets unattainable data standards

- ignores empirically-based estimates qualified by uncertainty ranges

“Casualty irrelevance” frame

  • invoked memory of Vietnam body count practices (then used as proxy indices of progress to victory) to rationalize contemporary non-disclosure of existing data collected by DoD

    Source: Carl Conetta, Disappearing the Dead.Project on Defense Alternatives Research Monograph #9 (18 February 2004), http://www.comw.org/pda/0402rm9exsum.html

Missing in action: Afghan civilian incidence of TBI

Small number of studies and reporting of “mental health problems”

  • Minister of Health (2010, citing 2004 WHO data)

    • 60% suffer from mental health problems and war-, poverty- and gender-related stress.

  • WHO representative:

    • 60% suffer from mental illness and psycho-social problems

    • Two psychiatrists in the country

    • Almost none receive any help

  • “Dr Farid Anwari, a psychiatrist said that he feared the percentage of mental patients would be far more than what was announced.”

    (Source: ‘Over 60pc Afghans suffer from mental health problems’, Zarghona Salehi, Pahjwok Afghan News (10 October 2010), at http://www.pajhwok.com/en/2010/10/10/over-60pc-afghans-suffer-mental-health-problems

  • Closest to TBI is spotty reporting on post-traumatic stress disorder

  • No study of incidence of possible TBI among Afghan civilians

  • Very occasional mention in passing of Afghan civilian victims of Taliban bombings, but no inquiry

  • No reference found to date in medical and scientific literature of potential incidence of TBI among Afghan civilians resulting from Coalition bombing.

  • Anecdotal evidence : “crazy people in the villages”

  • Reasons for expecting substantial incidence

Sociotechnical systems (b) Afghan medical system response capacity

  • The poorest country in Asia with abysmal health and mortality rates

  • three decades of years of war

  • Kandahar example

    • Senlis Council report on Mirwais Hospital

    • War Zone Hospitals in Afghanistan: A Symbol of Wilful Neglect , Senlis Council (February 2007)

    • [note Senlis Council now renamed: International Council on Security and Development]

  • Role of coalition military hospitals and staff re Afghan wounded

The view from Uruzgan province: Impact of the Dutch PRT health push 2006-2010

Health care professionals, Uruzgan (total/female)

  • Netherlands provided Provincial Reconstruction Team leadership 2006-2010

  • focus on capacity building and access

  • 56 doctors and nurses in total there is one

  • qualified health care professional per 10,000 people

  • doubled no. of health posts to 200;

  • added community health workers (CHW in each to level of 7 professionals per 10,000 people

“The problem with these CHWs is the discrepancies between the expectations residents have of them and the services they are capable of providing. Residents treat them as qualified doctors when in reality they are more a referral service for health care facilities, with the ability to provide a cure for simple colds or the flu at most. Moreover, the CHWs are all volunteers. They are overwhelmed with requests while they have their own daily occupations to attend to as well.

Source: The Dutch Engagement in Uruzgan: 2006 to 2010, A TLO socio-political assessment, The Liaison Office, August 2010.

Sociotechnical systems (c) US medical system response

  • Coalition troops: treatment of wounded

    • On-site first response

    • Forward Surgical Teams moving directly behind troops

    • Local rapid evacuation to Combat Support Hospitals

    • Transfer to specialist military hospitals abroad (Kuwait, Spain, Germany)

    • If treatment expected to be more than 30 days, transfer to US

      [Source: Atul Gerwande, “Casualties of War: Military Care for the Wounded from Iraq and Afghanistan”, New England Journal of Medicine 351:224 (9 December 2004])

  • Queries about the adequacy of veterans’ support

  • Massive institutional research and treatment response from coalition countries’ medical and military establishment

    • the brightest and the best - and funding

Cosmopolitan responsibilities for security and morality

  • Law enforcement obligations

    • Geneva Conventions

    • UN Convention for the Amelioration of the Condition of Wounded and Sick in Armed Forces in the Field

      • Article 3, clause 2: “the wounded and sick shall be collected and cared for”

  • Emerging state-recognised normative commitments:

    • 60 government signatories to the Oslo Commitments on Armed Violence (2010), including to

      • “Measure and monitor the incidence and impact of armed violence at national and sub‐national levels in a transparent way”.

  • UN responsibility for consequences of UN-auspiced war

What is to be done?

  • Recognition of transnational moral responsibility for consequences of global authority-auspiced security practices

  • Serious and ongoing commitment of support for Afghan civilian medical capacity

  • ISAF-participating medical personnel recognise professional obligations to care for all battle-field sick and injured

  • Data collection on medical effects of all sources of violence in the Afghanistan war

  • ISAF countries’ accepting of responsibility for ongoing post-conflict detection and treatment

  • Require UN and ISAF-member countries publish transparent data and rules of practice on treatment of non-military Afghan war-injured

  • Recognition by western medical and research establishment of ethnocentrism and bias of existing TBI research and treatment regimes

  • Support the global movement to stigmatise and delegitimate use of explosive weapons in populated areas

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