Transcript Traumatic brain injury - the signature wound of the United

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
[email protected]
The First International Conference on Law Enforcement and Public
Health - Melbourne, Australia. 11-14 November, 2012
Outline
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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
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Beyond battle deaths: accounting for the costs of war
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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.
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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
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“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
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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
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Origins
• 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 - )
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Original legal foundation for international
intervention:
Security Council Resolution 1386 (2001), 20
December 2001
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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 SecretaryGeneral;
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.
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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/
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Coalition IED incidents and casualties, Afghanistan 20042010 (DoD data)
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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
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(DoD in Cernak and Noble Haeusslein, 2010:256)
• 5,500 soldiers with traumatic brain injuries (to Jan. 2008)
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(DoD in Cernak and Noble Haeusslein, 2010:256)
• Improvised Explosive Devices (IED)
• body armour effects
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greater survival rates
diminution of thoracic injuries
injury types: ‘mangled extremities’ and closed head injuries
higher rate of severe, debilitating long-term consequences
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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
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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.
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Immediate effects of
blast and explosions
Source: Ralph De Palma et al, Blast Injuries, New England Journal of Medicine, 352:13 (31 March 2005)
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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)
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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
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• 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)]
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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
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Sociotechnical systems (a) weapons systems
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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)
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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
Penetrator
• B-52H bomber
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Coalition bombing practices
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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
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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
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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
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• 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
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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)
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Security and Development]
• Role of coalition military hospitals and staff re Afghan wounded
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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;
“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.
• added community health workers
(CHW in each to level of 7
professionals per 10,000 people
Source: The Dutch Engagement in Uruzgan:
2006 to 2010, A TLO socio-political
assessment, The Liaison Office, August 2010.
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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
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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
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What is to be done?
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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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