April 13, 2019: After 2001 the United States entered its first period of sustained combat since the 1960s and began to realize that the costs of war lasted far longer than the fighting and overseas deployments. Many of the hastily recruited troops developed long-term medical disabilities that would require treatment for decades. In cases were the subject was given a medical discharge and suffering from more than 30 percent disabled a monthly payment was made for life. The amount of that payment depended on degree of disability plus the rank and years of service of an injured veteran. Those with less than 30 percent disability got a bonus payment when discharged and medical benefits for life or until medically certified as no longer disabled.

In an effort to reduce these long term injuries, and the number of disabled veterans (and thus save billions in medical costs), analysts have been examining the experience since 2001 when millions of personnel were sent overseas to fight or provide combat zone support. There were many changes made to recruiting standards after 2001 and all that data since 2001 provided an opportunity to see which screening decisions did, or could have, kept volunteers out of the military or at least out of jobs that would lead to long-term disability and early discharge. Much insight was gained from research done on employees of commercial firms doing work similar to what many military support personnel do (like equipment maintenance, logistics and medical care).

Some military jobs are unique, like the 15 percent of personnel who actually engage in combat. Their working conditions have changed considerably with fewer troops killed but more of them disabled by the additional physical stress of carrying more weight (much of it protective gear that reduces casualties enormously). But most of the disabled are not combat troops. One recent study of 1.7 million recruits found that four percent were medically retired and two percent were medically discharged during their first eight years of service. Many of these medical retirements and discharges could have been avoided if those involved had not been recruited in the first place or had been given a different job. Thus the physical exam for new recruits now pays more attention to the physical capabilities of volunteers and their demonstrated susceptibility to some diseases (a new capability based on recent developments in medical sciences.).

The provision of organized and government supported lifetime care of disabled veterans was a largely 20th-century development and the United States had established the Veterans Administration in 1930. That bureaucracy was much needed by 1945 and the end of World War II, because while there were four million World War I veterans (none of whom served more than 18 months in wartime), there were 16 million World War II vets. During World War II many served for years in exotic and disease ridden parts of the world and developed long-term disabilities. The medical experience with all those World War II vets provided the first insights into establishing recruiting standards for volunteers joining a peacetime force. The American military was usually all-volunteer in peacetime but that changed for the first time with the revival of conscription in 1950. The high demand for troops during the Vietnam War (1965-72) led to lowering of standards and, when conscription ended in 1972, the army found itself with a lot of troops who wanted to stay in but were later found to be unfit for peacetime service in general and an all-volunteer service in particular.

Since the 1980s the U.S. Department of Defense in general, and the army in particular, has sought to screen those seeking to join to obtain those easiest to train and most worth retaining (allowing to reenlist). The end of conscription in 1972 meant that all future troops would be volunteers who would be paid a lot more than the conscription era (1950-72) personnel. Technically conscription continued after World War II ended in 1945 but there were so many men in uniform who wanted to remain in the military that conscription was not needed again until the Korean War (1950-53) broke out. After that, the military, particularly the army, was dependent on conscription. So were the other services because many men eligible for the draft knew that if they served another year or two they could join the navy, air force or marines and get more useful technical training or serve with an elite combat unit like the marines. These other services rarely had to take conscripts. But, with the end of conscription, everyone was now faced with more volunteers than before and given the greater expense (payroll) and term of service (four years became the norm for first enlistment), better screening of volunteers became crucial. By the end of the century, it was clear that there were serious long-term implications for recruitment decisions.

The post 2001 combat peaked and wound down by 2011. At that point, the army was ordered to reduce its strength over seven percent. This was bad news for a lot of good soldiers who have been diagnosed with physical or mental stress problems. That's because there's a growing shortage of troops fit for combat zone duty. Currently, 15 percent of the troops cannot be sent overseas because they have medical problems that render them incapable of handling the stress of a combat zone. Until 2010, this was much less of a problem, because the army could keep people in service up to twelve more months. This "stop loss" rule enabled units to go overseas with all the troops it needed to get the job done. But after 2010, with stop loss gone and a growing number of combat troops unfit for deployment, the army was having a hard time manning combat units fit for overseas duty. One solution proposed was to medically retire many of those unfit to deploy, and recruit new troops who are more fit. The reduction in strength makes this easier to do.

New recruits present another problem. Bad diet and lack of exercise have become a major problem with American children since 1990. Thus the army was getting recruits who were chubbier and less fit (low bone density and iron levels) than ever before. This resulted in more injuries during training and combat. These troops were more prone to suffer physical injuries that will make them unfit for overseas service.

There's more to all this, because of many new technologies and tactics. Some of the new tech has resulted in the discovery of injuries that eluded earlier generations of medical personnel. And there has also been a new pattern of combat losses. These days, most of the serious casualties (about half) are for physical (31 percent) or mental (19 percent) stress. Only 14 percent of the casualties have been from the direct effects of combat. This decade of fighting has killed 6,000 American troops and wounded 45,000. But over 100,000 have been badly hurt by accidents, mental stress and disease. While most of the sick and wounded have been treated, and often discharged, there are now a growing number of active duty troops who cannot be sent to a combat zone because of injuries, illness or PTSD (post-traumatic stress disorder).

Even in peacetime, there are some troops who have a “profile” that makes them ineligible for certain types of duty. Because of the large number of casualties in the combat zone (including injury and disease), and the need to retain experienced NCOs and troops with technical skills, the number of those with a profile was much higher than it normally is in peacetime.

For the U.S. Army, this is not unexpected. Over a million American military personnel have gone to Afghanistan and Iraq since 2001, most of them for the army, and as more of them came back wounded, sick or injured, the number of people with a profile increased. This was particularly true with PTSD, which has become the most common reason for a profile that keeps troops out of combat.

While the risk of getting killed in combat is now a third of what it was in Vietnam and World War II, the incidence of physical and mental strain appears to have more than doubled. This is largely because troops are in combat for so much longer than in past wars. This makes it much more likely for troops to eventually develop PTSD, and the kinds of stress injuries (often accompanied by chronic pain) amateur and professional athletes suffer from as they get older. The lower death rate came about partly because of much more effective, and heavier body armor. Then there was all the weight of additional equipment (medical, combat and so on) that made combat safer, but at a cost, and the cost will be paid for by the troops for decades to come.

Despite all these changes, fewer young men and women want to join the military. This is more about social, cultural and political changes and the military is seeking ways to adapt without lowering their standards. That is another problem and one more difficult to deal with than staying alive on the battlefield.