“I got out of the Marines and within a few years, 15 of my buddies had killed themselves,” one veteran rifleman who served two tours in both Afghanistan and Iraq between 2003 and 2011 said to me recently. “One minute they belonged and the next, they were out, and they couldn’t fit in. They had nowhere to work, no one who related to them. And they had these PTSD symptoms that made them react in ways other Americans didn’t.”

This veteran’s remark may seem striking to many Americans who watched this country’s post-9/11 wars in Afghanistan, Iraq, and elsewhere unfold in an early display of pyrotechnic air raids and lines of troops and tanks moving through desert landscapes, and then essentially stopped paying attention. As a co-founder of Brown University’s Costs of War Project, as well as a military spouse who has written about and lived in a reasonably up-close-and-personal way through the costs of almost two decades of war in the Greater Middle East and Africa, my Marine acquaintance’s comments didn’t surprise me.

Quite the opposite. In the sort of bitter terms I’m used to, they only confirmed what I already knew: that most of war’s suffering doesn’t happen in the moment of combat amid the bullets, bombs, and ever-more-sophisticated IEDs on America’s foreign battlefields. Most of it, whether for soldiers or civilians, happens indirectly, thanks to the way war destroys people’s minds, its wear and tear on their bodies, and what it does to the delicate systems that uphold society’s functioning like hospitals, roads, schools, and most of all, families and communities that must survive amid so much loss.

Combat deaths: The tip of the iceberg

A major task of the Costs of War Project has been to document the death toll among uniformed American troops from our post-9/11 wars, especially in Afghanistan and Iraq. Compared to the 400,000 American deaths (and still climbing) from Covid-19 in less than a year, the approximately 7,000 American military deaths from those wars over almost two decades seem, if anything, small indeed (though, of course, that total doesn’t include thousands of military contractors who also fought and died on the American side). Even for me, as an activist and also a psychotherapist who bears witness to human suffering on a fairly regular basis, it’s easy enough to grow desensitized to the words “more than 7,000,” since my life hasn’t been threatened by combat daily.

Indeed, 7,000 is a small number compared not just to Covid-19 deaths here but to the 335,000-plus deaths of civilians in our war zones since 2001. It doesn’t even measure up to the 110,000 (and counting) Iraqi, Afghan, and other allied soldiers and police killed in our wars. However, 7,000 isn’t so small when you think about what the loss of one life in combat means to the larger circle of people in that person’s community.

To focus only on the numbers of American combat deaths ignores two key issues. First, every single combat death in Iraq and Afghanistan has ripple effects here at home. As the wife of a submarine officer who has completed four sea tours and who, as a Pentagon staffer, has had to deal with war’s carnage in detail, I’ve been intimately involved in numerous communities grieving over military deaths and sustaining wounds years after the bodies have been buried. Parents, spouses, children, siblings, and friends of soldiers who have been killed in action live with survivor’s guilt, depression, anxiety, and sometimes addiction to alcohol or drugs.

Families, many with young children, struggle to pay the rent, purchase food, or cover healthcare premiums and copays after losing the person who was often the sole source of family income. Communities have lost workers, volunteers, and neighbors at a time of mass illness and unrest just when we need those who can sustain intense pressure, problem solve, and work across class, party, and racial lines – in other words, our soldiers. (And yes, while the storming of the Capitol earlier this month included military veterans, I have no doubt that the majority of U.S. troops and veterans would prefer to be shot before getting involved in such a nightmare.)

Second, as the testimony of the former Marine I interviewed suggests, many people suffer and die long after the battles they fought in are over. Social scientists still know very little about the magnitude of deaths because of — but not in — war’s battles. Still, a 2008 study by the Geneva Declaration Secretariat estimated that indirect deaths from war are at least four times as high as deaths sustained in combat.

At the Costs of War Project, we’ve started to examine the effects of war on human health and mortality, particularly in America’s war zones. There, people die in childbirth because hospitals or clinics have been destroyed. They die because there are no longer the doctors or the necessary equipment to detect cancer early enough or even more common problems like infections. They die because roads have been bombed or are unsafe to travel on. They die from malnutrition because farms, factories, and the infrastructure to transport food have all been reduced to rubble. They die because the only things available and affordable to anesthetize them from emotional and physical pain may be opioids, alcohol, or other dangerous substances. They die because the healthcare workers who might have treated them for, or immunized them against, once obsolete illnesses like polio have been intimidated from doing their work. And of course, as is evident from our own skyrocketing military suicide rates, they die by their own hands.

It’s very hard to count up such deaths, but as a therapist who works with U.S. military families and people who have emigrated from dozens of often war-torn countries around the world, the mechanisms by which war creates indirect death seem all too clear to me: you find that, in the post-war moment, you can’t sleep, let alone get through your day, without debris on the highway, a strange look from someone, or an unexpected loud noise outside sparking terror.

If the stress hormones coursing through your body don’t wreak their own havoc in the form of painful chronic illnesses like fibromyalgia or mental illnesses like depression and anxiety, then the methods you use to cope like overeating, reckless driving, or substance abuse, very well might. If you are a child or the spouse of someone who has lived through repeated deployments to America’s twenty-first-century wars, then there’s a significant chance you’ll be on the receiving end of physical violence from someone who lacks the tools and self-control to deal peacefully. We aren’t counting or even describing such injuries and the deaths that can sometimes result from them, but we do need to find a way.

A gaping hole in our knowledge

My colleagues and I have started to examine the indirect costs of war through interviews with people who have born witness to war or lived through it, as has the U.S. government through its own limited collection of statistics. For example, in 2018, some 18 American active-duty military personnel or veterans died by suicide each day. (Yes, daily.) But all we really know so far is this: self-inflicted deaths from violence, car accidents, substance abuse, and chronic stress that can be traced back to this country’s post-9/11 wars are problems that plague military communities, and they didn’t exist at this magnitude before Washington decided to respond to the 9/11 attacks by invading Afghanistan and then Iraq.

Still, we have remarkably little information about the scope and nature of such problems. I’ll tell you what I do know with certainty, though: the only consistent and cohesive institutions sustaining troops home from America’s battle zones are the “families,” formal and informal, of servicemembers and the communities in which they live — not just their spouses and children, but also extended families, neighbors, and friends. When it comes to the more formal support structures — Veterans Affairs hospitals and outpatient clinics, providers that accept military insurance, small nonprofits that provide recreational and other forms of support and the like — there just aren’t enough of them.

It’s common knowledge in my community that referral processes and wait times for such aid are often long and stressful. If you’re a veteran seeking help, it’s likely that you’ll find yourself having to switch doctors more than once a year, rather than getting the continuity of care you might need to treat complex physical and emotional trauma. Meanwhile, childcare and other kinds of supportive caregiving that might help control neglect and abuse are laughably sparse.

As the upper-middle-class wife of an officer in a family that enjoys the benefit of dual incomes, I can still offer examples from my own life and community that should raise questions about how someone with fewer resources and already under the stress that accompanies multiple “tours” of America’s battle zones can survive. My husband and I had to pull years’ worth of retirement savings from our bank account to afford a lifesaving prenatal treatment for me that military insurance would not then fund (though it would indeed be covered later) — a problem that could have been avoided had the customer service representatives of the Department of Defense’s health and medical program, Tricare, been appropriately funded and trained.

The wife of an officer we know whose son has autism had to go through months of letter-writing and advocacy to receive care both for that boy and her other young child so she could apply for jobs and travel to her own medical appointments during her husband’s multiple deployments. (Tricare would only fund care for one child, leaving her watching the other.) Active-duty and veteran servicemembers I know regularly drink and use drugs heavily each night to calm their anxieties and post-traumatic stress symptoms sufficiently to sit through family dinners, watch our ever-more-distressing news, or get a few hours of sleep.

Many fear seeking mental-health treatment because of the real threat that, in the military, exposure for doing so will result in professional demotion. We live in an era where so much depends on competent, trustworthy security to shield us from the dual threats of a deadly pandemic and domestic terrorism and yet our security forces often lead lives that are problematic indeed.  The toll in such lives — what might be thought of as indirect deaths from combat — that we’ve endorsed by failing to welcome home and provide adequately for the some two million servicemembers who have fought in “our” wars should be a focus of our attention and yet is largely unnoticed.

A defense bill that defends little

With such human costs of war in mind, it’s a wonder to me that the only bipartisan bill passed by Congress over a presidential veto in the Trump years was the recent monumentally funded $740 billion “defense” bill. It included spending for yet more weapons production, as well as salary raises, among other measures that were meant to shore up the fighting power of our active-duty troops (after 19-plus years of unsuccessful wars abroad). 

Most striking to me, however, amid its massive support for the military-industrial complex, is how little that bill does to expand social support for military families. There is indeed a modest increase in daycare assistance for troops’ family members with disabilities, as well as limits to increased copays for those who use their military insurance in their communities. Missing totally, however, are key structural changes like protections for soldiers who seek mental healthcare, more robust job-training programs for those desiring to transition into the civilian workforce, greater accountability for Tricare when it comes to providing accurate information on services available in the community, and expanded childcare support for military families.

Indeed, what’s most notable about that bill’s very existence is how the leaders of both political parties keep funding war spending above all else, especially given that our foreign wars of this century have accomplished little of discernible value beyond making a mess that may never be cleaned up. To me, what that bill truly represented was the massive and unseen costs of America’s post-9/11 wars at home and abroad.

It seems that we Americans still care more about waging war in distant lands than about protecting our own people right here at home. Indirect deaths from our conflicts are a reality, however little noticed they may be.  Isn’t it time to begin weaving a genuine safety net, allowing vulnerable Americans who fought in those very wars to be better supported so that, no longer committing senseless violence against others, they don’t commit it on themselves?

This article has been republished with permission from TomDispatch.