"Beyond The Battlefield" is a 10-part series exploring the challenges that severely wounded veterans of Iraq and Afghanistan face after they return home, as well as what those struggles mean for those close to them. Learn how you can help here. Other stories in the series can be found here. Listen to reporter David Wood discuss "Beyond The Battlefield" with NPR's Terry Gross here. Wood and wounded veteran Bobby Henline will hold a live video chat this afternoon. See more details and send them questions.
In the dusty desert village of Jigjiga, in Ethiopia, I once watched a man die.
He'd been caught in fighting between Ethiopians and Somalis, in one of those senseless wars that go nowhere and settle nothing.
The Somalis had routed Ethiopian forces after a brief battle between their pre-World War II tanks. Now the Ethiopians were counterattacking. Airstrikes by a couple of aging American and British fighter-bombers, flown by Ethiopians, had us pinned down. Bombs tore into the village health clinic, a modest, green tin building. Rockets splintered crude shacks in the market, pulverized the mud wattle huts where most people lived. Strafing rounds of .50-cal bullets caught the unlucky who were trying to flee.
I didn't see the young man get hit, but he crawled toward me and collapsed where I was huddled against a low wall. His wound was horribly obvious: shrapnel had ripped open his chest and stomach. Blood soaked his clothes, matted his beard. His eyes were glazed.
Neither of us could move safely, but I managed to snag a gray wool blanket from a few yards away to try to stanch the blood. The air strikes seemed to go on forever, the concussive blasts, the sizzling sleet of shrapnel, the billowing smoke, the cries of the wounded. The man, in his late teens or early twenties, lay on his back beside me. The blanket became black with blood.
He moaned once and writhed. He mouthed the Swahili word for water, maji. Then flies began to settle on his open eyes. He was dead.
That's the fate of so many of those wounded in battle: they die. By design, battlefields are deadly places, and I've seen plenty of them in 35 years of covering conflict around the world. Sometimes the wounds are small but the injured person bleeds to death, quickly or slowly. Minor wounds left untreated can get infected and become mortal wounds. And in many wars, the wounded often are not reached by competent medical treatment promptly, or at all. These are preventable deaths, but deaths nonetheless.
That's why I leaped at the chance to explore and write about the American wounded of the wars in Iraq and Afghanistan. The numbers are heartening and astonishing, a sharp departure from the grim reality I have known.
Of the 2.3 million men and women who served in the current war zones, there are 53,000 U.S. casualties, of whom 46,747 were treated and saved, as of Oct. 17, 2011. Among them, there are perhaps 16,000 severely wounded, many rescued from the very edge of death.
In this decade of brutal combat, we are also seeing a historically low -- but still tragic -- number of battle dead: fewer than 5,000.
It may seem unremarkable that most Americans now come home from combat alive. It is not.
It is the gift of the heroic medics and corpsmen, battlefront surgeons and nurses, the reconstructive surgeons and rehabilitation therapists and ward nurses and technicians here at home. It is the gift of those who designed and fought to get the Pentagon to adopt advanced body armor, blast-resistant vehicles, personal tourniquets, flameproof gloves, and enhanced first aid training for the troops.
It is the legacy of medical researchers whose work, over the years, has given us on-board resuscitation and intensive care on helicopter and strategic airlift, and new medical techniques in emergency surgery, blood transfusion, skin and muscle grafting and organ transplants. It is the unending support and love of families of the wounded that is essential to recovery.
What their work means is this: If you were an American casualty in World War II, with pretty good medical care nearby, your chances of dying from your wounds were roughly one in three. You're with two guys in a foxhole, all of you wounded, one of you dies.
Today, if you are wounded in Afghanistan, you chances of dying are less than one in 10, statistically speaking. Ten Marines wounded on patrol by an IED, you all live.
Even so, the wounds of these survivors can be catastrophic, profoundly changing the lives of young men and women who have valued physical exertion, adventure, sports and the challenges of leadership. Small wonder that so many of the severely wounded struggle with anxiety, anger and depression even without a formal diagnosis of post traumatic stress disorder or traumatic brain injury. Small wonder that they often struggle with the temptations of drugs and alcohol.
Before I started to meet these severely wounded Americans and their families, the question did weigh on me: if they are so badly wounded -- if they will never regain the lives they once had -- is it a good thing that they were saved?
To speak plainly: Would they be better off dead?
It's a common question. A U.S. official once came back from the Walter Reed amputee center and told me that he'd been watching a quadruple amputee doing torso exercises on a floor mat. "No legs, no arms, he couldn't even kill himself!" he said with a tone of pity.
Certainly the young man who died beside me in Jigjiga was better off dead. With no medical care within a two-day walk, he faced a long and painful decline in his final hours or days, an agonizing postponement of the inevitable. At least, that was my judgment.
"Better off dead? Oh, I hear that all the time, always from people who don't have an injury," says Dr. Paul Pasquina, chief of Orthopedics and Rehabilitation at Walter Reed National Military Medical Center.
Working with the severely injured, he told me, "you clearly see the value of life. Nothing replaces life. How do you put a price on being able to see your child graduate from high school, or get married, or see your wife deliver your first baby? No matter whether you can or can't walk, or bathe yourself, or can't do all those functions, these are life-changing moments that you cannot replace."
That's easier to say in the sparkling, state-of-the-art medical facilities at Walter Reed, where no expense is spared to tend to the wounded. So I put the question to Beth Dameron, an RN and brain rehabilitation specialist at the VA Polytrauma Center in Richmond, Va. Many of her brain-injury patients are nearly helpless, and she bustles brightly among them with humor and tenderness.
During a pause in her rounds, I asked her, If it's pretty clear a severely wounded person is dying and has a minimal chance at a normal life -- if that person is always going to be in a vegetative state -- should you try to save that person anyway, right there on the battlefield when seconds count?
"In that moment, if you can, you do," says Dameron. "Because you don't know what the outcome will be. That person may not have the quality of life we have been used to, but he can be happy and, outside his injuries, healthy and able to be with and for his family."
Is that true of a triple or quadruple amputee with genital injury and brain trauma? Can that life be worth living? She chided me gently. "The quality of life is very personal," she says. "It's something that belongs to that person and his family."
Many of the severely wounded tend to be upbeat about their new status in life; their answer to the live-or-let die question is implicit. "I realized in Germany that I'm not gonna have any legs, but that's okay," Marine Sgt. Johnny Jones tells me. He's a 24-year-old from Dalton, Ga., who was blown up by an IED in Afghanistan and woke up in the U.S. military hospital in Landstuhl, Germany.
How did he feel about having no legs? He thought for a second as he practiced stepping up stairs with his two prosthetic legs, in the Walter Reed amputee center gym. He reached back to his school days to explain how it could have been a lot worse. "If you think you're gonna get a D, and you end up getting a C, that's okay," he says. "I was walking at six months after I got blown up. I know four quadriplegic amputees. Three years ago they wouldn't have been alive. Now they're walking."
Such buoyant optimism is infectious. We all love to hear stories of such success. Eric Shinseki, the retired Army four-star general who runs the VA and who lost a foot while fighting in Vietnam, likes to tell the story of an Army Ranger who was badly wounded, had a leg amputated, and eventually through unimaginable pain and hard work managed to return to active duty, and has completed several combat tours with the Rangers.
But the fact is that most of the severely wounded do not recover. Most do not go back on active duty with the Rangers.
Many are coping. Others are living lifetimes of difficulty and pain, struggling with shattered or missing limbs, badly scarred faces and traumatic brain injury or post-traumatic stress injuries, wounds that can be insurmountable barriers. In the course of six months of talking to the wounded and their families, I came across several who had considered suicide.
"It requires an incredible amount of strength and courage to get through this," says Steven Davis, a psychiatrist at Walter Reed. "Many of them are people with severe psychiatric issues, severe depression, anxiety disorders ..."
The severely wounded and their families celebrate each anniversary of their wounding as "Alive Day," the day they were lucky enough to go on living.
However we come to assess why the United States waged war in Iraq and Afghanistan, and the gains and losses from that fighting, we also might pause to acknowledge the service and sacrifice of all those who have kept our wounded warriors from suffering the same fate as the young man who died beside me, in a distant, dusty place.