Collateral Damage
As the body count rises, so too do the unexpected costs of the Iraq war. Most of us know that we're currently hemorrhaging well over a billion dollars per week in Iraq. But even if we were to pull out today, there will be additional costs in the years ahead that no one seems to have anticipated. Medics have been performing miracles in the army hospitals of Iraq. The treatment chain is an order of magnitude better than what it was in Vietnam. Wounded personnel now receive expert care in a matter of hours as opposed to days. This has saved the lives of thousands of soldiers. The death toll in Iraq could easily be triple what it is. The February issue of Wired contained an article, " The Invisible Enemy," about antibiotic resistant bacteria which are infecting the wounded over in Iraq. The primary bug, Acinetobacter baumannii, is surviving the evacs out of Iraq into Landstuhl Regional Medical Center in Germany, the largest American military hospital in Europe, and even back to the States. While A. baumannii is easily thwarted by healthy people, it's an opportunistic bastard which enters the human body through breathing tubes, IV lines, catheters, skin grafts, and open wounds. Therefore, if it establishes a foothold in the American healthcare system, it could make any trip to the hospital a case of Russian Roulette. Until a few years ago, most strains could be dispatched with a wide variety of drugs. For the most tenacious infections, doctors could rely on a family of ultrabroad spectrum antibiotics called carbapenems. But strains of acinetobacter are emerging now that are immune to every known remedy. Multidrug - resistant pathogens are an epidemiologist's nightmare - reminders of the dark ages when millions of people died every year of runaway infections.
"We've been looking at acinetobacter in real time for years and years in our lab," says John Quinn, scientific director of the Chicago Infectious Disease Research Institute. "Then all of a sudden in 2005, we started seeing more bugs that were resistant to the carbapenems. First one out of 10 bugs, then four out of 10, and then almost all of the bugs. So there's a new sheriff in town. That's a clinical disaster."
To battle these new strains, clinicians are being forced to dust off a World War II-era relic called colistin, which is so toxic that it causes kidney damage in as many as one in four patients who take it. In 2004, the Infectious Diseases Society of America included acinetobacter on its "bad bugs, no drugs" short list of pathogens that are "raising significant public health concerns." According to a recent CDC study, the new multidrug-resistant organisms are almost four times more deadly than older strains.
And they're spreading fast. A major outbreak in Chicago two years ago infected 81 patients, killing at least 14. Arizona health officials tracked more than 200 infections in state hospitals early last year. Doctors at Vanderbilt University Medical Center in Tennessee used to see an infection or two every year; now it's one or more a month. "These bacteria are developing very, very quickly," says CDC epidemiologist Arjun Srinivasan, who has been consulting with the DOD about the military outbreak. "The bad news is that we're many years away from having new drugs to treat them. It should be a call to arms." Unfortunately, Big Pharma is more concerned with making sure men can still get it up. "The bugs are outpacing us, and these drugs are not the kind that bring in incredible profits," says Robert Guidos, director of public policy for the Infectious Diseases Society of America. "We're planning for bioterrorism and pandemic influenza, but what about the hundreds of thousands of people dying each year from nontheoretical situations? We need to think in longer terms." Another invisible enemy the American healthcare system will also have to worry about is traumatic brain injury (TBI). Not a day goes by when we don't hear about an IED taking out soldiers and civilians in Iraq. Those that survive the flames and the shrapnel still have to contend with the shock wave, which squishes the brain against the inside of the skull. Discover magazine highlighted the alarming rate of TBI's back in their March issue in article entitled " Dead Men Walking." In a matter of minutes, a surgeon will saw the skull in half and discard the damaged portion. There will be a plastic replacement waiting farther down the line. Shrapnel is excised, cerebral tissue swells, and the scalp is pulled taut and sewn back over a ballooning brain. Thanks to the wealth of surgical resources, a procedure that takes several hours in any general hospital in the United States might take Balad surgeons 30 minutes. The article documents the injuries, treatment, post-op care, and behavioral changes that two soldiers endured. Reyes's body sustained a range of trauma in the attack. The impact of the blast cleaved his tongue in two and tore open his abdomen from rib cage to navel. It slammed both his knees into a metal barrier and peppered his back with shrapnel. His left arm was blown open to the bone.
"I remember waking up, being on the street, being hot like I was on fire," Reyes recalls. "People were talking to me, asking questions I couldn't understand. Someone told me I got hit by an IED, and I got scared because I knew what it meant."
Blast-related brain injuries like those sustained by Reyes can deliver multiple TBIs. First there is barotrauma, in which the body suffers the same magnitude of pressure felt deep underwater. It's theorized that portions of the brain swell and decompress almost instantly during this stage, causing a host of cellular defects throughout the brain. Objects like shrapnel and gravel penetrate the skull, ping-ponging within the cranium walls. The force of the blast then blows an individual against an object, like a wall or a roof, causing blunt trauma to the head. Finally, in response to these injuries, the brain releases a metabolic cascade of neurochemicals that have a toxic effect on brain tissue. Reyes had no penetrating fragments; he experienced three of the four blast insults. The article goes on to explain the Reyes still suffers from memory loss. He has difficulty remembering family and friends, how to get around his hometown, and skills that he picked up with his military training. But as horrible as the wounds these guys have suffered, there's at least some sort of healthcare system in place that can rehabilitate them. I won't go into a debate about the quality of our healthcare system. All I'm saying is that we at least still have one. The people in Iraq don't have much of one at all. That's the subject of Discover magazine's article, " Iraq's Medical Meltdown." It leads off with: He has no face. There is a mashed pulp where his nose should be, a sticky, black suggestion of what may have been a mustache. A plastic tube runs into a hole once lined with lips. His entire head is a swollen, weeping burn. The blast disfigured him so badly that even relatives would have a hard time identifying him. The author, Michael Mason, who wrote the other article cited above, follows this poor man's treatment through the American military medical system in Iraq and reveals startling facts about the Iraqi system. "The Iraqi system was in bad shape before we got there," says Lt. Gen. (Dr.) James Roudebush, the Surgeon General of the Air Force. "Saddam spent about 50 cents a year for health care for each Iraqi his last year in power, while royal family members had entire hospitals devoted to their health."
In some cities, Iraqi patients have been murdered in their hospital beds for being on the wrong side of the local insurgency. Former intelligence officers in the Saddam regime are now allegedly in charge of security in at least one of Iraq's public hospitals. "I would see an average number of 75 patients a day," R. A. explains. “But sometimes we received an unbearable number, more than available beds. Many of the patients died in front of my eyes due to the lack of life-saving drugs and anti-ischemic drugs, and the lack of chest tubes."
"The medical-care system in Iraq is in shambles," says Gene Bolles, former chief of neurosurgery at Landstuhl Regional Medical Center (LRMC), Germany, where American soldiers are taken after leaving Iraq. "It's almost minimally functioning. There have been over 2,000 doctors killed and assassinated in Baghdad, with many more in Mosul." Iraq had 34,000 doctors prior to the invasion; 18,000 have since fled the country. Emphasis mine. Prior to entering the city, Burkle had predicted that Baghdad would be ravaged by looting, but he was surprised by the ingenuity of the actual strategy. “It centered on health care. The looters were able to destroy morale very quickly by looting the health-care system. It was highly organized, focused on hospitals, the public health-care system, pharmacies, and pharmaceutical warehouses, and it was unrelenting. Doctors and nurses had their homes looted if they left for work."
During Burkle's April 2003 visit to Yarmouk Hospital, a teaching hospital in Baghdad, he was shocked by what he saw.
"There was nothing in Yarmouk left after the looting. The only beds and stretchers were in the emergency department. They had only a handful of bed sheets. Everything had been torn off the walls: The cardiac monitors were gone, dialysis units were trashed, and the motherboard was stolen from the CAT scan. Patients were lying on the floors because their beds had been stolen." And the future looks bleak. Knowing his experience in rebuilding other health-care systems, I ask Burkle how long it would take to restore Iraqi health care to its revered pre–Gulf War days, assuming the effort would be conducted perfectly and without setbacks. "Oh, my God," he says. "I can tell you that in Africa the recovery rate of its countries takes about a decade. It is going to take a long time for Iraq to come back. Even if there is a will, there are no doctors or nurses. It's going to take a long time, just for medical and nursing education alone."
"They will never see the country they had before," Burkle explains. "People have split and divided along ethnic, tribal, and religious lines. I think the legacy is that we have given them a license to divide Iraq, and it will never be the same, for good or bad." This is truly a tragedy beyond words. \_/ DED Labels: Iraq
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