Politicians and the press tend to tally the human costs of going to war by counting those killed. So far, that's 311 Americans in Iraq and 88 more as part of "Operation Enduring Freedom" in Afghanistan. If one dates this newly defined "war on terror" back to the 1983 car bomb attack on the US Marine barracks in Lebanon, another 300 or so American lives have been lost.
But the number of those wounded in action (or injured in combat-zone accidents) is far higher. And while combat deaths have been relatively low since the Vietnam War, the ratio of these nonfatal casualties to war fatalities is increasing - from 3 to 1 in World War II to more than 5 to 1 in Iraq (1,691 to date).
With no end in sight to a substantial US presence in Iraq, the number of nonfatal casualties (now averaging more than eight per day) is likely to keep increasing, experts say. And beyond the human dimension, the costs of such casualties, which tend to be overlooked as part of the cost of national security and foreign policy, will continue for decades as well. Among those costs: rehabilitation, retraining, postcombat counseling, long-term medical treatment, and assisted-living care.
Seen positively, the higher ratio of wounded to killed means more soldiers are surviving their battle injuries. Kevlar helmets, body armor with ceramic plates, and top-notch medical facilities nearby all help.
But what this also results in is "a large number of survivors with permanent physical and emotional scars, not to mention profound disabilities," says Loren Thompson, head of security studies at the Lexington Institute in Alexandria, Va. "Not only are some wartime wounds uncommonly complex to treat, but the range of treatments provided - including counseling, assisted living, disability benefits, and so on - can be quite extensive."
One reason: the nature of the attacks on US troops in Iraq these days - rocket- propelled grenades and roadside bombs instead of rifle fire - means that injuries often tend to be more traumatic, including loss of limbs.
The war in Iraq (and in the other theaters of the war on terrorism around the world) is likely to produce other longer-term costs as well. For example, the impact of this conflict in Iraq could mean more instances of Gulf War Syndrome than the 100-hour ground war of 1991, due to much longer periods of exposure to chemicals, depleted uranium, and other toxic substances. (It may already be showing up in the form of more than 100 recent instances of respiratory illness among US soldiers in Iraq.)
"This was by all accounts a vastly dirtier enterprise than the Gulf War was last time," says Larry Seaquist, retired US Navy warship commander and Pentagon strategist.
In addition, the impact of post-traumatic stress - tied to longer periods in the combat zone, more urban fighting, and the likelihood of double tours in Iraq - is expected to be greater as well. Several episodes of suicide and murder of spouses at Ft. Bragg last year by troops recently returned from Afghanistan have officials worried about - and expanding efforts to counter - the effects of post-traumatic stress disorder (PTSD).
"I wouldn't be surprised if we had a real bow wave of such problems still to come," says Captain Seaquist.
All of this puts the spotlight on the overall costs of national defense, in particular the Department of Veterans Affairs (VA), which is second only to the Defense Department in the size of its workforce. The VA expects to spend $59.6 billion this year, nearly all of that on health care and benefits for some 2.7 million veterans now receiving disability compensation or pensions.
As veterans of the wars in Iraq and Afghanistan join that group, says Seaquist, "we may see a freshly invigorated veterans' movement that is asking to make sure that ... veterans' rights are guarded."
[Editor's note: The original version of this story repeated a paragraph.]
This may be especially true because US forces in Iraq include an unusually high percentage of National Guard and Reserve soldiers, says military analyst Marcus Corbin at the Center for Defense Information in Washington. Many of these troops are older men with wives, families, and established positions in their professions and communities.
Lessons from Vietnam
"I think there is actually something different about reservists getting taken from their jobs and families and getting killed or shot up, compared to active duty troops, even though in theory there shouldn't be," says Mr. Corbin. "[It] cuts closer to home maybe."
One of the lessons of Vietnam, according to veterans and historians of that war, is to prepare for the emotional and psychological needs of returning soldiers - especially those who have seen heavy combat.
"In some ways, the wounded and injured present greater challenges for the nation," says retired Army Col. Dan Smith. "They suffer not just physical pain and sometimes long rehabilitation but all too often psychological scars and the loss of self respect."
Part of addressing this need is greater public understanding of what's being asked of men and women in the armed services.
"Folks [need to] understand the dangerous nature of the profession even when bad guys are not shooting at you in a hot war," says retired Army Col. Scott Snook, disabled in a friendly-fire incident during the 1983 US invasion of Grenada. For example, says Colonel Snook (who now teaches at the Harvard Business School), the Army alone experiences some 250 noncombat-related fatalities a year due to accidents, illnesses, and suicide.
It took Vietnam vet Lee Thorn more than 20 years after he returned home to California in 1966 to seek the help that led to his diagnosis of severe PTSD. He now receives free medical care and disability pay from the government.
Every few weeks, Mr. Thorn also takes part in a VA-facilitated "rap group" with similarly diagnosed Vietnam vets - most of whom have Purple Hearts for physical wounds.
"The first step was knowing that there were other guys like me," says Thorn, who was a bomb loader on an aircraft carrier. "I had 30 years of nightmares, and I haven't had any in the last five years."
This resulted in his ability to start and operate a nonprofit organization that works for reconciliation in heavily bombed Laos by providing health, education, technology, and economic development services there.
"Increasing health, increasing effectiveness in the world is what keeps me going back" to the group sessions with other vets, says Thorn.
Over the years, some have argued that the VA's functions should be part of the Defense Department. But that is very unlikely to happen for political reasons. Veterans' groups are only slightly less influential than the AARP.
"Many of the costs that fall under the VA never get much publicity or figure into debates on the costs of overseas military actions," says Ivan Eland, senior fellow at the Independence Institute in Oakland, Calif. "Certainly, the VA expenses should be part of the DoD budget. But even if this is not politically possible, we can at least add such costs in a government-wide estimate of the costs of the war."
Is there a political lesson in all of this?
"The public will put up with substantial casualties when there's a point to the action," says Mr. Corbin of the Center for Defense Information. "But when a war and occupation of a foreign country were started under false pretenses, are going badly, and there's no exit scheduled, look out."
Says Mr. Thompson of the Lexington Institute, who generally supports the US invasion of Iraq: "It's still a dirty business with horrendous human costs, costs that for some veterans will persist over many decades."