Page 111 - JSOM Winter 2024

On Saving – The Psychosocial Benefit of
Saving Lives in War and Society

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Russ S. Kotwal, MD, MPH *; Robert L. Mabry, MD ; Jeffrey T. Howard, PhD 3

ABSTRACT
Posttraumatic stress can result from combat and noncombat- On Killing – The Psychological Cost of Learning to Kill in
related experiences. Conditioning military forces to be lethal War and Society, outlines potentially deleterious residual ef-
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or to save lives may influence responses to stress. Training fects on military personnel as a result of combining modern
to respond to casualties and to save lives should be a uni- warfare training methods with a dysfunctional rationalization
versal practice among medical and non-medical personnel and acceptance process following a killing or otherwise trau-
when preparing for combat operations and battlefield casu- matic combat-related experience. U.S. Military personnel on
alties. National security requires a strong military. A strong the frontlines have been trained and conditioned to kill more
military is reliant on a strong society that is cohesive as well effectively over the past century, increasing firing rates from
as economically and spiritually intact. Cohesion is vital to 15%–20% in World War II to greater than 95% during the
the overall health and development of a society. A lack of co- Vietnam conflict. The cost of killing, however, must also be
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hesion can result in excess mortality and a reduction in life realized by the society who sent these Military personnel to
expectancy. Cohesion expands social networks and increases fight on its behalf, as consequences can include the symptoms
social capital that provides support for its military and over- and prolonged sequelae of posttraumatic stress.
all population. Cohesion and leadership are needed to defend
our nation, preserve national security, improve societal health, In addition to combat-related traumatic events, military forces
and save lives. can also experience noncombat-related traumatic events be-
fore, during, and after military service, as well as concomitant
Keywords: cohesion; combat; posttraumatic stress; saving lives; moral injury. Recently, the lifetime prevalence of posttrau-
societal health matic stress disorder (PTSD) in U.S. Military Veterans was
estimated to be 9.4%, which is higher than the 6.1%–6.8%
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lifetime prevalence of PTSD estimated for the U.S. general
population. Given that roughly 5%, or 18 million of 340 mil-
War and Posttraumatic Stress
lion in the U.S. population, are military Veterans, as many
A major stage of psychosocial development occurs in young as 1.7 million existing Veterans may be affected by PTSD at
adulthood as individuals mature and advance their ability to some point in their lifetimes. Additionally, with a past-month
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form and maintain cohesive relationships with others in so- PTSD prevalence in U.S. Military Veterans of 5.0%, nearly a
ciety. The age of individuals undergoing this formative stage million Veterans are currently living with PTSD. Although
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overlaps with population recruitment goals for military ser- factors such as underdiagnosis, overdiagnosis, misdiagnosis,
vice. Although military service in itself can impact psychoso- stigma, or secondary gain may obscure the precise number
cial growth, deploying to combat and experiencing traumatic of those affected, it is still incumbent upon society to iden-
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events on the battlefield can potentially impact psychosocial tify and address the underlying issues that may contribute to
development even more. As some of these military Service- PTSD.
members and Veterans struggle to cope, they may feel isolated,
alone, and unable to develop or maintain close relationships Conditioning and Responses to Stress
based on mutual trust and respect.
Repetitive and realistic training under stress or duress can
In support of our national defense, we condition military per- promote an unconscious competence and mastery of skills re-
sonnel to overcome an innate resistance to an act that is es- quired for combat. On the battlefield, all personnel have the
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sentially inhumane if placed in a context external to warfare potential to inflict, incur, or treat an injury. Thus, conditioning
and self-defense. Posttraumatic stress resulting from modern methods have been used to create a more lethal fighting force
warfare has gained considerable notoriety during the two de- as well as to reduce morbidity and mortality on the battlefield.
cades of recent conflict in Afghanistan and Iraq. The book, Lives have been saved through optimized casualty response and
*Correspondence to russ.s.kotwal.ctr@health.mil
1 Dr. Russ S. Kotwal conducts strategic projects for the Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston,
TX, and is an Adjunct Professor for the Department of Military and Emergency Medicine, School of Medicine, Uniformed Services University,
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Bethesda, MD. Dr. Robert L. Mabry is an Adjunct Professor for the Department of Military Medicine, School of Medicine, Texas A&M Uni-
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versity, Bryan, TX. Dr. Jeffrey T. Howard is an Associate Professor for the Department of Public Health, College for Health, Community, and
Policy, University of Texas at San Antonio, TX.
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