The New Wartime Body
Amputee Vets Return from Iraq
By Socket

What happens when one’s body becomes the war zone, the setting for patriotic pride, and the argument for technological advances that alter scientific and economic landscapes? It often means returning with a different sense of self and relationship to one’s body for U.S. soldiers back from Iraq. Re-entry varies from the conceptual to the physical, and amputee veterans are returning from the Iraq war faced with transitioning back to civilian life without straightforward support to navigate the military health care system or job opportunities.

The Homecoming

Jody Casey, formerly a 19 Delta Cavalry Scout sniper now organizing with Iraq Vets Against the War (IVAW), set the tone of our conversation, “I wasn’t ready for re-entry. I wasn’t briefed about anything regarding re-entry. So, on top of dealing with the anger and isolation of being back, I also had to be my own advocate.” Casey advocated for work, securing mental and physical health care in a society that does not understand the realities of war. Counseling programs “were pushing all these pills my way without even hearing what I was going through, then they set me up with a counselor who has never known combat.” He faced similar frustrations when looking for employment. “The job on the top of the list was to be a teller at Wal-Mart. No offense to anyone who works there it’s just that I felt unseen, insulted, and under-valued . . . . They trained us only to re-enlist or work for Black Water Security or KBR.” [Kellogg, Brown and Root is a former subsidiary of Halliburton] Both are mercenary war-profiteer subcontractor companies currently patrolling, fighting, and “providing security” at a much higher pay rate than U.S. soldiers receive in Iraq. Casey stressed the enormous need for worker retraining programs and a modified GI bill that includes part-time and vocational students. “I only got trained to kill and be a solider.”

Casey matter-of-factly shared some ideas about how a worker re-training program could look. He suggested vocational training, something akin to “helmets to hardhats,” utilizing an apprenticeship model, but provided by the Army. “Such a program could help you retrain from war on many levels because right now they are unleashing unstable people back into society.”

The Body

Sources from Walter Reed Army Medical Center in Washington, D.C., estimate that since the onset of the Iraq invasion and occupation upwards of 400 U.S. soldiers have come back needing amputations and prosthetics (30 percent have multiple amputations). According to icasualties.org, since April 2003, between 18,000 and 20,000 U.S. soldiers’ injuries include second- and third- degree burns, bone breaks, shrapnel wounds, brain injuries, paralysis, and eye damage. In addition, 9,744 U.S soldiers wounded in action returned to duty between 2003 and 2004, while

8,239 soldiers did not return to war.

“The rocket went through my leg like a knife through butter. It was a terrible scene ... there was just blood and muscle everywhere,” Tristan Wyatt, 21, reported in a November 9, 2003, LA Times article entitled “Hospital Front.” A rocket had cut off his leg and those of the two other soldiers with him four months earlier in Fallujah, a type of injury treated frequently at Walter Reed. Doctors Dennis Clarke and Jim Kaiser both reported (upper extremity) amputations from the elbow down, (lower extremity) above the knee or through the hip resulting from roadside bombs, bullets, and IEDs (Improvised Explosive Devices). Kaiser concluded that “explosion injuries are vicious; they affect multiple body parts; for example, if one gets hit on the right side, part of the right leg, arm, and oftentimes their face gets exploded and pocked-up.”

“We were always working with a base of 100 patients at any point in time,” began Dennis Clarke, a visiting Orthoist-Prosthetist who specializes with lower extremity amputees. “On any given day, Walter Reed’s orthopedic wing has about 50 inpatients and another 180 outpatients,” says Jim Kaiser, who spent one week as a guest prosthetist at Walter Reed’s Occupational Therapy Department in 2004. Working consistently, with hardly a break for lunch, they made fittings for new prosthetics and adjustments on old ones, and cleanings of amputation sites were constant. “There was always something to do and someone to see to. We were very, very busy,” Kaiser continued. “Some prosthetics we made were arms; most were leg/lower extremity from explosions and many of the same people had multiple amputations.” Two factors – the war’s urban setting and quick response time – have vastly increased the survival rate for the wounded compared to Vietnam. However, since Vietnam, the number of those wounded in action has risen from 3 percent to 6 percent, according to Wendy Y. Lawton in the George Street Journal, December 10, 2004. Dennis Clarke continues, “When one third of your patients have more than one limb missing, the work and stress and attention is different and accelerated.”

The Technology

“Vets are provided with a training leg with the most high-tech components (mechanical parts) and myoelectric hands and elbows. Civilians do not get offered such things. These vets motivate research for new technology . . . being tested on vets by such companies as Ossur and Otto Bock,” remarked Chicago orthoist-prosthetist John Angelico of Scheck and Siress.

In the field of orthotics and prosthetics (O and P), an orthoist specializes in planning, making, and fitting orthopedic braces, and a prosthetist makes artificial body parts (limbs and joints) called prosthetics, prosthetic devices, or singularly, a prosthesis. Hip disarticulation is an amputation through the hip joint removing the entire lower extremity. What was once a rare surgery has become more commonplace in the field since the Iraq war. Myoelectrics utilizes the electrical properties of muscle tissue from which impulses may be amplified, a technology that adapts and compensates for the wearer’s natural gait and any irregular terrain, slopes, or steps. The most commonly used device on vets coming from Iraq is the C-Leg, a myoelectric leg developed by the companies Ossur and Otto Bock.

“I was surprised the veterans were receiving [myoelectric technology]. We had to struggle with the VA (Veterans Administration) to authorize knee technology. It took a year to get authorization. And then years later Walter Reed was giving that away to anyone.” Jim Kaiser shared his insights on how the army has improved treatment of amputee vets. “Then, a vet could get one knee prosthesis, a carbon flex foot mechanism and a spare prosthesis. Their goal was to make sure a vet has a prosthesis to wear and one spare.” While the standards apply today, the technology and care are so vastly different that it seems that the army is more willing to support vets from Iraq than their predecessors from Vietnam. Greater research and development of upper extremity technology has triggered a $4 million grant from the federal government for Dr. Kuiken at the Rehabilitation Institute of Chicago. According to Kaiser, “It was the most money spent on prosthetics since Vietnam.”

Dennis Clarke explained that the Department of Defense has created a “dream team” of experts brought in on a contractual basis since early on in the war. The volume and complexity of these injuries make it essential to bring in outside specialists. “Now there are three people permanently on staff at Walter Reed in the Prosthetics Department as well as the additional civilian folks brought in.”

When wounded on the battlefield, soldiers are flown to the Landstuhl airbase in Germany. Marines are sent to Bethesda while the Army is sent to Walter Reed, with all surgical procedures performed stateside. Innovations in sanitation, swelling control, and the use of digital cameras and scanners complement the plaster molds taken for every patient needing a prosthesis.

They send the records to Iowa for the Socket Interface, creating a personalized socket or suction system and joining it to the actual prosthetic device. The Socket Interface is done entirely on CADCAM – computer designed, computer manufactured technology – in approximately 48 hours with minor adjustments and alignments in person, but largely done on the computer. The success rate is high.

According to Clarke, the rehabilitative process is comprehensive, “Daily therapy of walking on parallel bars, transferring from one position to the next, and ultimately using crutches, to using one crutch, to using a cane. This process can take from 2 weeks to 2 months. Some patients were there eight weeks total, some were there 18 months.”

The future may hold a very different series of events, technologically speaking, for U.S. vets needing prosthetic devices. According to Lawton’s George Street Journal article, “$7.2 million from the Department of Veterans Affairs was earmarked in 2005 for a team of researchers working to restore natural movement to amputees - particularly Iraq veterans. Within five years, scientists based at Brown [University] and the Massachusetts Institute of Technology hope to have created ‘bio-hybrid’ limbs that will use regenerated tissue, lengthened bone, titanium prosthetics and implantable sensors that allow an amputee to use nerves and brain signals to move an arm or leg. Work through the Providence VA Medical Center falls into six research programs.”

“The prosthetic industry is moving forward because of war,” Dennis Clarke observed. “War is the single driver of technology in our profession. The net effect of these young and vibrant amputees is that they are pressing forward and doing well; that makes us look good. Technology does not lead change. Need leads change, and war is good for business because it necessitates need. One could argue that as earnest an anti-war statement could be made regarding the same issues.” When people talk about war being good for business and good for technology, it’s important to recognize who ultimately benefits and who pays with their lives. Recruiters are enticing people into war with promises of making money, but soldiers are not coming back wealthy. Soldiers are coming back in body bags or with serious injuries. With their lives and bodies changed, vets come back owing more money in the face of increased medical expenses and often in worse situations than they were in upon leaving.

The Figures

According to Corey Flintoff on the NPR program Day to Day, the cost of the invasion of Iraq could top $2 trillion – much greater than any Bush administration estimate – when estimates include long-term costs such as replacing worn out or destroyed military equipment, debt incurred to finance the war, and providing lifetime care for disabled veterans.

The most commonly needed device by Iraq vets is the myoelectric arm that ranges in price from $25,000 to $35,000 (according to Dr. Kaiser). The C-Leg microprocessor knee costs $50,000 with additional costs of components. Expensive technologies, yet these figures fail to consider vets’ other healthcare costs such as surgeries, medications, doctor’s appointments, and physical therapy.

Insurance programs sponsored by the Veterans Administration include the Service-members Group Life Insurance (SGLI), with the supplements of the Traumatic Service-members Group Life Insurance (TSGLI), Veterans Group Life Insurance (VGLI), Family Service-members Group Life Insurance (FSGLI), and Service Disabled Veterans Insurance (S-DVI). Each consists of its own rules and regulations, claims processes, fiscal calendars, and terms of eligibility. The TSGLI took effect on December 1, 2005, as a new program for service members who suffer from severe trauma: total or partial blindness, total or partial deafness, hand or foot amputation, thumb and index finger amputation, quadriplegia, paraplegia, hemoplegia, third degree or worse burns, traumatic brain injury, and coma. Yet, the myriad regulations dictate that beneficiaries had to file claims with the SGLI prior to December 1 in order to apply for TSGLI.

The De-partment of Veterans Affairs (VA) benefits booklet is a confusing description of programs, muddling the options available to vets. Examples of the poor wording include terms like “severely disabled” or “otherwise in good health” as requisites for coverage. This represents a bureaucratic nightmare considering that a soldier may need multiple insurances to meet their medical and life expenses. Yet, who judges good health and on what basis? Such are the obstacles encountering returning veterans who frequently are incapacitated, possibly not conscious, and focused elsewhere upon arrival from combat. The booklet makes no mention that vets can get a liaison or advocate to help mediate their medical needs. Taking initiative is vital to accessing any of these benefits.

The rate of injury is steady with no end in sight. Private individuals are pooling resources for research projects and individual vet support projects alike (with others listed at www.fallenheroesfund.org). The Intrepid Project has contributed over $14 million to military families, yet many more families will need help so long as operations in Iraq and Afghanistan continue. Elizabeth Bernstein wrote in “The Gift Shift,” a November 25, 2005, Wall Street Journal article, describing that “the president of the Intrepid Fallen Heroes Fund had collected well over half of the $35 million the fund needed to realize its big goal to build a center in Texas where U.S. troops can recover from war wounds and be a research facility for prosthetic protocol technologies.”

The high caliber technology provided to Iraq amputee vets has had a side effect on the access to care for non-vet amputees. Jim Kaiser states that “The climate in the sector of health insurance is that of [suppressing] technological costs.” According to Kaiser, “Blue Cross considers a C-Leg experimental; the technology has been available in the U.S. for five years and in Europe for nine. The insurance companies use terms like ‘situational, experimental and lack of medical necessity’ in order to deny people access to technology that is becoming the norm in its field. Myoelectric arm technology is 30-years [old], which insurance companies continue to dismiss as experimental. If one does not have bills covered by the VA, how does one pay to keep up with the expanding field? One possibility is that non-vets just don’t get to participate in this new technological landscape unless independently wealthy or have very committed and convincing doctors on their side. Perhaps non-vets may just have to wait for the insurance companies to catch up.”

Dennis Clarke elaborated that one hope for The Fallen Heroes Fund facility is to collect enough data to lobby mainstream non-military insurance companies. “It’s a fact that the industry has not proven its case yet. We need to prove to the insurance companies what the real benefit of these technologies are, how much better are these than the old ways. Our next step is to change the standard practice of insurance companies.” How many more soldiers must demonstrate such necessity in order to raise the bar for all amputees?

The Adjustment

The IVAW website quotes Douglas Barber, later found dead by his own hand, “All is not okay or right for those of us who return home alive and supposedly well. What looks like normalcy and readjustment is only an illusion to be revealed by time and torment. Some soldiers come home missing limbs and other parts of their bodies. Still others will live with permanent scars from horrific events that no one other than those who served will ever understand.”

Soldiers face a range of realities upon return. Some re-enter with a broad support network, adequate medical coverage, and stellar care. Others return feeling like absolutely nothing is intact and any possible resources are inaccessible and inadequate. Jim Kaiser stresses, “It is essential to provide constant quality follow-up care [to the veteran] once [he or she is] released from the VA system.” However, he worries that what is offered post-release pales and is lacking compared to what is offered immediately post-injury. In his practice of 120 people, 16 percent are disabled. “It is important to hire disabled people in the business of improving prosthetic care and not to shut people out.” These needs for support, recognition, and employment may seem obvious to some, but they do not go without saying.

Returning to active duty may seem like the lone option to some vets. Jody Casey had few prospects upon arrival home from Iraq. After being part of the U.S. military industrial complex, staying in can be easier than extricating oneself. “A significant percentage (10-20 percent) of amputee soldiers remains in active duty,” Dennis Clarke explains. “With prosthetic technology, one can do more than ever after sustaining these types of injuries and recover faster . . . these soldiers are specialists in their field, and it is better to bring back experienced solders with good training and combat experience.”

Throughout the VA literature and my conversation with Dennis Clarke, much emphasis was put on remaining in active duty. The push – after being injured, healing, receiving state of the art medical care – is to get back in the game. Those soldiers on active duty are rewarded with medical care coverage and accolades. Soldiers who choose not to return have far fewer options. The war practically creates a “super-soldier” archetype with bionic limbs and a taste for combat with vengeance running through them. The focus on active duty inhibits considering alternatives, divesting money and lives from this war. The creation of the invincible wounded warrior serves as propaganda for the war machine.

Jody Casey addressed the concept of support. “They don’t want you to know what your rights are . . . I had no idea where my local VA was or what my medical coverage was.” He discovered that his coverage was “two years of full medical and six months of dental.” The IVAW and a veterans’ support group are his community now and have become integral to his life. Having served in Iraq, working with IVAW and Vets for Vets has provided Casey with a different viewpoint of what the Iraq war is about – war profiteering happening at every level. “This is not about liberation” he concludes, “it’s about a few people making a lot of money on the back of the poor and now people like me have to pay for it with their whole selves.”