No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Long-term Costs of Conflict: The Case of the Iraq War
Objective:
To examine global disability trajectories in US military with and without traumatic brain injury (TBI) over the first decade following deployment to identify risk profiles for better intervention stratification, hopefully reducing long-term cost.
Setting:
Patients and participants were enrolled in combat or directly following medical evacuation at the time of injury and followed up every 6 months for 10 years.
Participants:
There are 4 main groups (n = 475), 2 primary and 2 exploratory: (1) combat-deployed controls without a history of blast exposure "non-blast- control" (n = 143), (2) concussive blast TBI "'blast-TBI" (n = 236) (primary), (3) combat-deployed controls with a history of blast exposure "blast-control" (n = 54), and (4) patients sustaining a combat concussion not from blast "non-blast-TBI" (n = 42) (exploratory).
Design:
Prospective, observational, longitudinal study.
Main measures:
Combat concussion, blast exposure, and subsequent head injury exposure over the first decade post-deployment. Global disability measured by the Glasgow Outcome Scale Extended (GOSE).
Results:
Latent class growth analysis identified 4 main trajectories of global outcome, with service members sustaining combat concussion 37 to 49 times more likely to be in the worse disability trajectories than non-blast-controls (blast-TBI: odds ratio [OR] = 49.33; CI, 19.77-123.11; P < .001; non-blast-TBI: OR = 37.50; CI, 10.01-140.50; P < .001). Even blast-exposed-controls were 5 times more likely to be in these worse disability categories compared with non-blast-controls (OR = 5.00; CI, 1.59-15.99; P = .007). Adjustment for demographic factors and subsequent head injury exposure did not substantially alter these odds ratios.
Conclusions:
Very high odds of poor long-term outcome trajectory were identified for those who sustained a concussion in combat, were younger at the time of injury, had lower education, and enlisted in the Army above the risk of deployment alone. These findings help identify a risk profile that could be used to target early intervention and screen for poor long-term outcome to aid in reducing the high public health cost and enhance the long-term quality of life for these service members following deployment.
“Mission Accomplished” said the banner on the aircraft carrier Abraham Lincoln from which in May 2003 the then US President, George Bush, declared the conclusion of the military operations against Iraq. Nothing could have been further from the truth, which was highlighted when, in the fall of 2006, the security deterioration in Iraq peaked.
In game theory, a player enjoys a first-mover advantage if he achieves a higher payoff by turning the game into a sequential one with him being the first mover, provided of course that the game can be changed in the first place. Leaving the proviso aside, once we are talking about tactics such a statement might sound obvious rather than revealing, though. Jensen (2015) argues that, if in a battle what can be seen can be hit, military actors should be primed for the offense, i.e. trying to make the first move by striking first. It holds true in particular in naval engagements and aerial dogfights, and obviously it is the lore told by countless Wild West movies: he who draws first wins.
Importance
The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden.
Objectives
To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability.
Design, Setting, and Participants
This prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One- and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016.
Main Outcomes and Measures
Changes in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1- to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability.
Results
Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34 [8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1- to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1- to 5-year outcomes.
Conclusions and Relevance
Considerable decline was observed in military service members with concussive blast TBI when comparing 1- and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-term and extremely costly effect of these wartime injuries.
Wars have important economic dimensions. They involve costs requiring resources that have alternative uses such as new hospitals, schools, and roads. Economists can contribute to the understanding of wars by identifying their costs. Case studies make a valuable contribution by providing estimates of the costs of conflict. Much has been written about the costs to the USA of the conflicts in Afghanistan and Iraq. Similar studies for the UK have been lacking. This chapter provides UK estimates of the costs of both conflicts.
ResearchGate has not been able to resolve any references for this publication.