Between Flesh and Steel

by Richard A. Gabriel

  162. Neel, Medical Support, 70.

  163. Ibid., 74.

  164. Ibid., 75.

  165. Heaton et al., “Military Surgical Practices,” 8.

  166. Ben Eiseman, “Combat Casualty Management in Vietnam,” Journal of Trauma 7, no. 1 (January 1967): 58.

  167. Neel, Medical Support, 122.

  168. Ibid., 127.

  169. Ibid., 32.

  170. Ibid.

  7

  THE TWENTY-FIRST CENTURY

  Unconventional Warfare

  The Soviet Union’s dissolution in 1991 and the empire’s transformation into a number of independent national states marked the end of the forty-three-year-long Cold War between the United States and the Soviet Union. Although these events greatly diminished the possibility of a major ground war in Europe, the superpowers’ competition was replaced by a series of colonial-style military interventions carried out in pursuit of their respective political and economic interests. The Soviet Union intervened militarily in Afghanistan (1979–1989) and the new Russian state in Armenia, Georgia, Moldova, and Tajikistan. The United States sent military forces into Somalia, Iraq, Afghanistan, Grenada, El Salvador, Panama, and Bosnia-Herzegovina, among others. The military medical establishments of the Soviet and American armies were still configured for large-scale conventional wars when these interventions occurred. Both quickly discovered that the old methods of rescuing, transporting, and treating casualties were ill suited to the difficulties that the terrain, weapons, and wounds that insurgency warfare in unfamiliar bacteriological environments presented. Their attempts to adjust to these difficulties led to changes in how military medicine was delivered on the battlefield.

  THE SOVIET-AFGHAN WAR

  The Soviet Union had been the first state to recognize the newly created Afghan state in 1919 and, in return, the Afghans were the first country to recognize Vladimir Lenin’s new Bolshevik regime. From 1920 to 1979, the Soviets were the Afghans’ main suppliers of economic and military aid, investing heavily in dams, roads, railroads, schools, and irrigation systems. By 1978, the Soviets had trained almost the entire Afghan officer corps and had strong sympathies with the People’s Democratic Party of Afghanistan, the country’s Communist Party.1 In October 1978, with the Afghan military’s support, the party carried out a coup in Kabul. A widespread tribal revolt broke out in response to the communist reforms, which included equal rights and education for women, credit reform, and land redistribution. After more than a year of internal turmoil, the regime began to weaken as the popular revolt gained strength. On Christmas Day 1979, the Soviet Union sent military forces into Afghanistan to rescue the regime. Moscow expected its troops would encounter little resistance and planned to stay less than three years. They were there for nine years, one month, and eighteen days.

  Within a month, the Soviets had deployed 750 tanks, 2,100 combat vehicles, and 80,000 troops to Afghanistan.2 By the end of the year, the Soviets had deployed 300 combat helicopters, 130 fighter aircraft, and a few squadrons of heavy bombers in Turkmenistan, and from there they launched carpet-bombing strikes into Afghanistan.3 The Soviets deployed their troops in a skeleton-like base network from which they launched “destroy and search” missions. They made no attempt to win the support of the mostly rural and illiterate population. Instead, the Soviets reprised the methods they had used in the collectivization operation in the Ukraine in 1937 and attempted to rip up Afghanistan by the roots as a prelude to reconstructing a new society.

  The Soviets began to depopulate the countryside with airpower. Waves of Mi-24 Hind helicopter gunships attacked villages, then troops landed to probe the ruins for weapons and insurgents. Survivors were routinely shot. Fixed-wing aircraft laid mines in the narrow valleys, and gunships doused crops and orchards with napalm. The Soviets gunned down herds of goats and sheep from the air and sowed farmland with mines to prevent further cultivation. They dropped hundreds of thousands of “butterfly mines,” essentially plastic bags filled with explosives, from aircraft over the country. Unable to be disarmed, the mine’s explosive charge is specifically designed to be nonlethal but sufficient to cause traumatic amputation. The Soviets painted many of these mines in bright colors to attract and injure children.

  By mid-1984, 3.5 million Afghanis had become refugees in Pakistan, another 1.5 million were displaced to Iran, and 2 million Afghanis became displaced persons in their own country. One analyst called the Soviet policy “migratory genocide.”4 The advantage of Soviet tactics from a medical perspective was that they minimized their ground forces’ exposure to attack and kept their casualties low. The Soviets’ brutal treatment of the Afghan population, however, angered the Muslim and Pashtun population in Pakistan. In short order, the Pakistani government formed an alliance of resistance groups, recruited fighters from the many Afghans living in refugee camps in Pakistan, provided arms and military training, and created a national insurgency movement to fight the Soviets. The Soviets found themselves mired in a guerrilla war that lasted nine years.

  Over the course of almost a decade, 620,000 Soviet soldiers served in Afghanistan. Of these troops, 14,453 were killed or died from wounds, accidents, or disease, or 2.33 percent of the total force. Another 53,753, or 8.67 percent, were wounded or injured, the later mostly in vehicle accidents on poor-quality roads.5 In the early days of the war, the mujahideen insurgents were armed mostly with rifles; however, as the war wore on, they acquired mortars, land mines, and high-velocity weapons, like rocket-propelled grenades and machine guns, from their Pakistani allies. These weapons changed the type of wounds that the Soviet soldiers suffered. Early in the war, soldiers suffered twice as many bullets wounds as shrapnel wounds. By the end of the war, however, the pattern had reversed, with 2.5 times as many Soviet soldiers wounded or killed by shrapnel than by bullets. The proportion of multiple and combination wounds also quadrupled over the course of the war.6 The Soviets adjusted relatively well to these new medical circumstances. Their ratio of dead to wounded improved over the course of the war, going from one dead for every three wounded who survived to one for every five. Enforced wearing of flak jackets and the introduction of improved body armor changed the medical profile of wounds. Wounds to the chest, stomach, and pelvis declined while wounds to arms and legs increased. Despite the increased severity of their wounds from mines and homemade explosive devices, more wounded survived at the end of the war than they did in the beginning.

  The Soviet war in Afghanistan was a conventional military operation, and its medical support structure was organized along conventional lines. Medical personnel were assigned at the maneuver company level and higher. A medic and assistant medic provided medical care in each company. A medical section consisting of a physician and physician’s assistant provided initial medical treatment at the battalion level. Their task was to provide advanced first aid, stabilization, and preparation for evacuation. The first serious medical intervention for the wounded was available at the regimental medical post staffed by a medical platoon, which consisted of two or three doctors, a dentist, two physician assistants, a technician, a pharmacist, nurses, a cook, a radio operator, and some enlisted orderlies and drivers.7 The post’s mission was to serve as a dressing station and provide immediate surgery, transfusions, treatment for the lightly wounded, and preparation for evacuation of the more seriously wounded to the division medical battalion.

  The division’s medical battalion was the basic medical service unit. The battalion staffed and operated a field hospital with a capacity to deal with four hundred patients every twenty-four hours, conduct surgery, and run a sixty-bed recovery facility. The medical battalion had three or more surgeons, a therapist, a doctor of internal medicine, an epidemiologist, and a toxicologist.8 Each Soviet division deployed to Afghanistan was accompanied by a medical battalion, and each of the separate motorized rifle brigades, air assault brigades, and motorized rifle regiments had a medical company attached to it to provide medical care. In addition, the Soviets deployed
eight hospitals in Afghanistan and two others on the Soviet-Afghan border to handle the wounded and patients suffering from disease. Two of these hospitals—a five-hundred-bed central military hospital and a five-hundred-bed infectious disease hospital—were located in Kabul. Another five-hundred-bed infectious disease hospital was in Bagram, with a small facility located in Kunduz. Field hospitals of two-hundred-bed capacities were located in Puli-Khumri, Kandahar, and Shindand.9

  The Soviet medical system was designed to treat the sick and wounded at the lowest possible combat echelon (platoon/company) and evacuate the most serious cases through the various echelons of treatment, holding the least wounded at the lowest level for their possible return to duty. The Soviets established a greater number of major hospitals than would have been expected for the size of their force because the number of wounded requiring intensive care was significantly higher than anticipated. This situation developed not only because of the changed nature of the insurgents’ weapons but also because more wounded survived to reach medical treatment. The wounded owed their initial survival rate to the medical teams’ ability to reach and transport them more quickly than they had in previous Soviet wars.

  The Soviet medical establishment moved into Afghanistan planning to evacuate the majority of its sick and wounded by ground transport, as it had in its previous military expeditions. Afghanistan’s harsh terrain and inadequate road network, the ambushing of medical convoys, and the frequent long distances between regimental staging areas and medical facilities forced the Soviets to turn to air evacuation as an alternative. From 1980 to 1988, the Soviet Army moved 68 percent of its wounded by air transport. It evacuated more than 25,000 casualties by helicopter during combat and moved more than 152,000 sick and wounded by air during some stage of medical treatment.10 Soviet aircraft also transferred 40,000 patients between the military hospitals in-country, and another 78,000, or more than 40 percent, went to hospitals in the Soviet Union for treatment and recovery.11

  The air evacuation system remained a work in progress until the end of the war. The primary Soviet medical evacuation helicopter, the Mi-8MB (Bisector), was too small and underpowered to carry more than a few patients at a time. It often could not reach the altitudes where troops were fighting, and seriously wounded soldiers in the high mountains could not often be evacuated and died where they fell. Troops carried the slightly wounded soldiers down the mountains to a location where the helicopters could reach them. Because the carrying party required security while transporting the wounded soldier, frequently fifteen men were occupied evacuating one wounded solider. The unit’s only doctor or medic usually accompanied the wounded soldier, leaving the rest of the unit without medical support.

  Official Soviet statistics state that 98 percent of the wounded received first aid during the first thirty minutes of being wounded, 90 percent were seen by a doctor within six hours, and 88 percent were in surgery within twelve hours.12 These figures seem optimistic in light of the usual difficulties associated with locating the wounded at Afghan battle sites and with getting airborne transport to them. Without enough medical evacuation helicopters, the wounded often had to wait for attack or cargo helicopters, which did not carry medical teams, to become available and transport them to medical facilities. Many wounded soldiers died either waiting for medical transport or en route aboard attack and cargo helicopters because they were not stabilized before or during transport. Moreover, it seems likely that the Soviet medics did not always render the best quality first aid. One study revealed that 10 percent of the fatalities examined stemmed from errors in pre-hospital care, with 10.6 percent of these errors attributed to poor first aid treatment.13

  Soviet authorities eventually realized that they had to reform the medical system, and prior to major military operations, they established special surgical and medical treatment teams to augment existing medical assets. These special surgical teams were integrated into the medical battalions that were then moved closer to the combat zone. The teams consisted of three thoracic-abdominal surgeons, a neurosurgeon, a rheumatologist, a heart surgeon, three anesthesiologists, five nurse anesthetists, two surgical nurses, five assistant surgical nurses, and two blood transfusion specialists. The division’s senior medical officer formed the reinforced medical battalion into a triage group and a specialty surgical group that performed thoracic, abdominal, neurosurgical, trauma, vascular, and general surgery.14 Casualties evacuated by air usually bypassed the company and battalion medical stations and were carried directly to the special surgical teams at the division.

  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.15 Using special surgical teams reduced fatalities among the moderately wounded from 4.3 percent to 2 percent over the course of two years.16 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.17

  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.18 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.19 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.20 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.21

  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-or
al 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.22 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.