Costs of War in 2035 : Long-Term Care Challenges for Veterans of Iraq and Afghanistan

War-related medical costs for U.S. veterans of Iraq and Afghanistan may be enormous because of differences between these wars and previous conflicts: (1) Many veterans survive injuries that would have killed them in past wars, and (2) improvised explosive device attacks have caused “polytraumatic” injuries (multiple amputations; brain injury; severe facial trauma or blindness) that require decades of costly rehabilitation. In 2035, today’s veterans will be middle-aged, with health issues like those seen in aging Vietnam veterans, complicated by comorbidities of posttraumatic stress disorder, traumatic brain injury, and polytrauma. This article cites emerging knowledge about best practices that have demonstrated cost-effectiveness in mitigating the medical costs of war. We propose that clinicians employ early interventions (trauma care, physical therapy, early post-traumatic stress disorder diagnosis) and preventive health programs (smoking cessation, alcohol-abuse counseling, weight control, stress reduction) to treat primary medical conditions now so that we can avoid treating costly secondary and tertiary complications in 2035. (We should help an amputee reduce his cholesterol and maintain his weight at age 30, rather than treating his heart disease or diabetes at age 50.) Appropriate early interventions for primary illness should preserve veterans’ functional status, ensure quality clinical care, and reduce the potentially enormous cost burden of their future health care. INTRODUCTION In 2010, the United States conflict in Afghanistan surpassed Vietnam as the longest American war in history with approximately 2 million U.S. service members deployed to Iraq or Afghanistan. Operation Enduring Freedom (OEF) in Afghanistan has resulted in 1,903 service deaths with 15,516 fighters wounded in action. Operations Iraqi Freedom (OIF) and New Dawn (OND), which ended on December 18, 2011, have resulted in 4,475 deaths and 32,224 service members wounded in action. Through September 2009, the Veterans Health Administration had treated about 510,000 unique veterans from either conflict, and that number is probably closer to 800,000 today. Following the conclusion of the war in Iraq and the reduction of operations in Afghanistan, war-related medical costs for these veterans are likely to grow exponentially over time because of several major differences in these wars compared with previous conflicts. Specifically: (1) Many warriors now survive injuries that would have killed them in past wars (Table I). (2) Current improvised explosive device (IED) attacks have caused “polytraumatic” injuries—multiple limb loss; brain injury; severe facial trauma or blindness—that may require decades of costly rehabilitation. (3) In 2009, the average OEF/OIF service member was 25 to 29 years old and might be expected to live 50 more years. Today’s focus of medical, political, and economic attention has been the primary wounds impacting our veterans, such as IED explosive injuries. The strategic theme of this article is that society is not yet considering the medical costs of caring for today’s *Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover,