Between Flesh and Steel (47 page)

The Soviets' effort in increasing the surgical and treatment capabilities of the medical facilities and moving them closer to the combat zone was successful. Soviet data note that in the specially supported combat operations, 90 percent of the wounded received first aid within thirty minutes of being wounded, and 88.3 percent were evacuated by helicopter to the reinforced medical battalion. Thirty-one percent of the wounded were in surgery within an hour and another 38.7 percent within two hours. Taken together, 92.4 percent of the wounded were in surgery within six hours of being wounded.
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Using special surgical teams reduced fatalities among the moderately wounded from 4.3 percent to 2 percent over the course of two years.
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Over the course of the war, the Soviet medical system in Afghanistan proved only slightly less effective in saving lives than the American system had been in Vietnam. The overall death-to-wounded ratio for the Soviets in Afghanistan was 1 to 3.6 compared to 1 to 5 for the American efforts in Vietnam.
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The one area where the Soviet military medical system failed miserably was in preventing infectious disease. Of the 620,000 soldiers who served in Afghanistan, 469,685 were hospitalized for wounds or disease. This is an astonishing figure. Fully 75.76 percent of the Soviet force was hospitalized, with 11.4 percent for wounds and an amazing 415,932 soldiers, or 88.56 percent, for serious diseases. The latter included 115,308 cases of infectious hepatitis and 31,080 cases of typhoid fever.
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Another 233,554 cases were distributed among those who contracted plague, malaria, cholera, diphtheria, meningitis, heart disease, shigellosis (infectious dysentery), amoebic dysentery, rheumatism, heat stroke, pneumonia, typhus, and paratyphus.
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A substantial number of hospitalizations reflected a high incidence of combined infections, such as typhoid and infectious hepatitis, typhoid and amebiasis, and infectious hepatitis A and acute dysentery.
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The Soviet experience with disease in Afghanistan was nothing short of a medical disaster.

The effect of disease on Soviet combat power was substantial. At any given time, more than a quarter of the total force (the Fortieth Army) was unavailable for combat due to disease. From October through December 1981, the entire Fifth Motorized Rifle Division was rendered combat ineffective when more than three thousand of its troops were stricken with hepatitis. The sick included the division commander, four regimental commanders, and most of the division's staff. Every year a third of the entire Fortieth Army was stricken with some form of infectious disease.
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The Soviet Army was fully equipped with preventive medicine teams, vector control teams, and water purification units, but they were never able to control the spread of infectious disease. The causes of disease infection were the lack of sufficient supplies of clean drinking water, the failure to enforce basic field sanitation practices, the failure of unit cooks to wash their hands after defecation, an infestation of lice and rodents, a nutritionally insufficient diet, and the failure to provide soldiers with regular changes of underwear and uniforms. In short, the Soviets suffered from the same causes that had plagued armies throughout history and had previously afflicted Russian armies in the Crimean War, the 1905 Russo-Japanese War, World War I, and World War II. It wasn't so much Soviet military medicine that failed in Afghanistan as it was the traditional Russian disregard for basic field hygiene.

The most prevalent disease among Soviet troops was infectious hepatitis, accounting for almost half of all disease hospitalizations. The disease is highly infectious and spread through the fecal-oral route, usually because an infected person failed to wash his hands. The incubation period in Afghanistan was thirty-seven days, and recovery took six to eight weeks with relapses. Most significant was that almost three-quarters (74 percent) of the cases were contracted in Soviet base camps, where one would expect that the best sanitation practices would have been enforced. Instead, the disease proliferated where it could have been best prevented.

Soviet field hygiene was terrible. Garbage dumps were often collocated within the base camps, and garbage collection was poor. Field latrines and flush toilets were installed in some base camps, but Soviet soldiers often did not use them and relieved themselves close to the camps' living and dining areas. Troops often did not wash their hands after relieving themselves and paid little attention to washing their mess kits. A soldier was entitled to one bath or shower a week in the base camp, but he seldom washed in the field. A major source of infection was the unit cooks. Because of their poor personal hygiene, they became a primary cause of disease infection for the troops. A Soviet study of unit cooks found a considerable number infected with shigellosis, typhus,
E. coli
, and salmonella.
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Only a few sick cooks could contaminate an entire unit.

The Soviet soldier's field rations proved nutritionally inadequate. Units in field outposts often had nothing more to eat than “dry” rations, which were similar to the old U.S. Army C ration and held a can of meat with some crackers, jam, and a tea bag or two cans of meat mixed with oatmeal and a can of vegetables or fruit. The lack of nutritionally balanced meals coupled with the harsh climate, high altitudes, and
an average combat load of seventy pounds quickly reduced the resistance of many Soviet soldiers to illness, especially when they sought to supplement their meager rations with local meat and vegetables, which carried a range of pathogens. The Soviet logistics system was unable to provide its troops with adequate supplies of clean water, so soldiers often drank from the local springs and wells. Water in Afghanistan has a high bacteriological content to which the locals are mostly immune. The local water often carried typhus and amoebic dysentery that infected Soviet troops.

Soviet positions were often marked by an accumulation of refuse that were rife with rats and disease. Stagnant pools of water in discarded ration cans served as breeding grounds for malaria-carrying mosquitos. The Soviet soldier was entitled to three sets of underwear that were supposed to be changed weekly; however, in practice, the soldier often received only one set that he wore for months at a time. This unhygienic practice and the failure to wash bedding regularly led to an infestation of lice. The resulting epidemics of typhus crippled the combat units' ability to fight.

The lack of a professional career noncommissioned officer (NCO) corps also contributed to the Soviets' failure to control infectious diseases. The Soviet NCO was a conscript who first attended a six-month training course to serve as an NCO; however, these conscript NCOs had no effective practical or moral authority over their fellow conscripts with whom they identified and sympathized. As with the average Soviet conscript, the NCO looked forward to being released from service as soon as possible. Soviet NCOs were little help to their platoon leaders in enforcing discipline and military standards, and complete responsibility fell upon the young lieutenant commanding the unit. Thus, in addition to his primary responsibilities for training, maintenance, and combat duty, the platoon leader personally had to ensure that his troops were free of lice, washed their hands, drank clean water, disposed of their trash properly, and dug and used latrines. Without professional NCOs to help him, the Soviet platoon leader often failed to perform all of his duties adequately. One result was a breakdown in field sanitation.

The Soviet military medical system in Afghanistan functioned relatively well when it came to dealing with the wounded, but it became overwhelmed when handling large numbers of diseased and sick soldiers. Apparently the Soviets grossly underestimated the amount of medical support their army would require to treat casualties and disease simultaneously. The Soviet solution was to evacuate large numbers of sick and wounded to military hospitals in the Soviet Union and Warsaw Pact countries
to relieve overcrowded hospitals in-country. In Afghanistan, meanwhile, the Soviets' infectious disease hospitals and rehabilitation center for recovering disease patients were constantly filled with patients, and evacuating the sick out of the country became the norm.
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The army constantly shipped replacements into the theater of operations to compensate for the large amount of manpower lost to disease. After the war, media reports indicated that significant numbers of Soviet troops who had fought in Afghanistan also had acquired an addiction to the cheap opiates available there. Soviet officials, however, have not released any statistics on drug abuse by Soviet troops, and no evidence suggests that it affected the fighting ability of the Soviet Army as a whole.

An analysis of Soviet military operations since the Afghanistan war suggests that the Russian ground forces made few reforms to their medical support system after their experience in Afghanistan. In 1988, the Soviet Army was sent to Armenia to provide earthquake relief. Their lack of a good diet, field sanitation, and clean clothing resulted in high rates of disease and illness; consequently, the rescuers had to be rescued themselves. In 1989, a Soviet air assault regiment, an airborne regiment, and a motorized rifle regiment were sent to Tbilisi, Georgia, to put down rioting. The troops deployed with only a single change of underwear.

In 1992, the Russian Fourteenth Army engaged in combat in Tiraspol, Moldova. The lack of clean water and an abundance of disease-contaminated cooks once again led to an outbreak of disease. Only the brevity of the deployment kept events from getting medically out of hand. In 1992, the Russian 201st Motorized Rifle Division deployed to the border region between Afghanistan and Tajikistan to help guard the newly independent republic's border against mujahideen infiltration. Once again the Russian medical establishment failed to provide sanitary mess halls, field messes, and adequate clean water for drinking. Within weeks, viral hepatitis, intestinal infections, and malaria had rendered the division combat ineffective as hospital wards filled with sick soldiers.
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The Russian medical experience in Chechnya (1994–1996) was not much different than it had been in Afghanistan or in its other post-Afghanistan military operations. In two years, the Russians suffered 4,739 dead and 13,108 wounded.
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The Chechnya war was primarily a conflict fought in urban zones and produced different types of casualties than those suffered in Afghanistan. The majority of Soviets killed
in Chechnya were victims of sniper fire and had been hit in the head or upper chest. While the normal ratio of wounded to dead is roughly three or four to one, this ratio was reversed in the Chechnya fighting, which saw three killed for every one wounded.
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This type of combat confronted the Soviet medical system with new challenges. Snipers and the willingness of Chechnya insurgents to shoot down medical evacuation helicopters forced the Russians to rely on armored personnel carriers (BTR-80) as ambulances and other ground transport to reach and transport their casualties. The Russians seem to have anticipated the unique nature of the urban combat they would face in Chechnya, and weeks before the invasion they established and trained special emergency medical treatment detachments that deployed with the army.
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In addition, each maneuver company was reinforced with a physician's assistant, and each maneuver battalion received an additional doctor and ambulance section. On balance, the Russian medical system performed about as well as it had in Afghanistan when dealing with combat casualties.

The Russians' medical performance in dealing with infectious disease, however, was as dismal as it had been in Afghanistan.
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The same causes that had plagued the Russians in Afghanistan—a nutritionally inadequate diet; a lack of clean drinking water, clean clothing, and bathing facilities; poor hygiene among unit cooks; and generally poor field hygiene by the troops—plagued them again in Chechnya. Acute viral hepatitis and cholera were epidemic among Russian troops, and units were frequently rendered combat ineffective during outbreaks of disease. Throughout the war, the Russian Ministry of Defense could barely maintain its combat field units in Chechnya at 60 percent because of disease.
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The American military has been engaged almost continually in combat operations from 1990 to 2012. During this period, the United States conducted combat operations in Iraq (1990–1991), Somalia (1992–1993), Iraq again (2003–2012), and Afghanistan (2001–2012). American casualties in all of these conflicts were light by historical standards. In the Gulf War (1990–1991), 382 soldiers died, but only 147 of them, or 38.5 percent, were killed in combat. In Somalia, 31 American soldiers were killed and less than 200 wounded. Nine years of insurgency warfare in Iraq has cost 3,480 deaths by hostile fire and 31,931 wounded; 928 soldiers died in accidents or by disease. During ten years of war in Afghanistan, U.S. forces have suffered 1,227 dead, 11,411 wounded, and 253 dead due to disease and nonhostile causes.
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Of the
5,684 soldiers in Iraq and Afghanistan who suffered major limb injuries, 862 underwent amputation. The injured-to-amputation rate for both wars was 7.4 percent, or approximately the same as in Vietnam (8.3 percent).
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The traumatic limb injuries that casualties in Iraq and Afghanistan have suffered often were far worse than those seen in Vietnam, however, as they combine penetrating, blunt, and burn injuries with contamination by shrapnel, dirt, clothing, and even bone.
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From a medical perspective, U.S. casualties have been generally light, and in only a few battles, such as Mogadishu (1993) and Fallujah (2003), was the immediate casualty stream even moderately heavy. Field medical facilities have never been overwhelmed by the volume of casualties similar to those that occurred occasionally during Vietnam and commonly in Korea and World War II. In World War II, 22.8 percent of the wounded died; in Vietnam the figure was 16.5 percent. Taking the Iraq and Afghanistan Wars together, 8.8 percent of the wounded died.
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The performance of the medical disease control teams and the troops' general field hygiene were excellent in all wars. In Somalia, for example, where the endemic disease and contagion profiles are high, the health of American troops remained excellent. The weekly disease and non-battle injury rate was approximately 11.5 percent, with only 0.5 percent requiring hospitalization.
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Only seventy-two cases of malaria were recorded, and problems with diarrhea and heat stroke were minimal.
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Excellent diet, field hygiene, clean water, mosquito and rat control, and a program of disease surveillance were responsible for these outcomes.