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The Few Who Served Deserved to Be Cared For

John H. Shale, MD, JD

Published: December 27, 2017

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

See article by Solomon et al

The Few Who Served Deserved to Be Cared For

Solomon et al1 report on the association between combat-related posttraumatic stress disorder (PTSD) trajectories and early detection of health risk factors in trauma survivors. It is a prospective assessment over 23 years of 116 Israeli combat veterans of the 1973 Yom Kippur War, of whom 101 were prisoners of war and the other 15 were comparable combat veterans. This elegant study focuses on the association of psychological and physiologic stress in captivity with C-reactive protein levels and metabolic syndrome. Most previous studies have tended to focus primarily on psychological issues, particularly PTSD, substance abuse disorders, and mood disorders.2,3

The Israeli experience is not entirely analogous to that of the United States. After the Revolutionary War that established the country, our wars have arguably been elective, and, excluding the Civil War, have not been existential. However, we have been in combat in the Middle East for almost 15 years, although not technically "at war" for much of that time.

On the other hand, Israel is a small country surrounded by hostile neighbors that threaten the country’s very existence. Consequently, every war Israel has fought has been existential. The Yom Kippur War, also called the Third Arab-Israeli War, of October 6 to 25,, 1973, was 3 times longer than the Six-Day War of 1967 and resulted in many more casualties. This was truly an existential war.

After our first Iraq war (Operation Desert Shield/Desert Storm) came the peace dividend of the 1990s (with peace dividend defined as "a portion of funds made available for nondefense spending by a reduction in the defense budget [as after a war]4). This "dividend" was then available for other purposes.5 The result was a substantial reduction in force across all the Armed Forces.

When war came again in Iraq in 2003, there were far fewer troops available for combat. The result was inevitable. The same troops were sent back to the Middle East repeatedly, exposing those troops to the stress of combat again and again.

The stress of combat has become both a personal and a professional interest of mine. Having served with a forward deployed medical unit supporting the second Marine division in Desert Shield/Desert Storm, I have experienced some of that stress and written on the topic of combat exposure.4 Also, treating the many young veterans I see daily and having a son who served as a flight surgeon with a Marine squadron in Iraq have served to reinforce this interest.

For the United States as a whole, the wars in the Middle East have not been existential, but rather elective. However, American troops engaged in combat in Iraq and Afghanistan are engaged in an existential war. It is clear that the young veterans, who have made repeated deployments to the "sandboxes," are acutely aware that for them combat is existential.

The new administration in Washington has indicated that they will provide better treatment for veterans. A good place to start would be by doing the kind of research that is being done by Solomon et al in Israel. This is the sort of research that we ought to be doing to improve treatment and outcomes. The US Department of Defense and the Department of Veterans Affairs should make a concerted effort to expand this research with a goal of improving treatments for both psychiatric and physical disorders.

These troops are all volunteers. They may have joined for a variety of reasons, some perhaps purely patriotic. But they did take the oath that might result in their being sent to a combat zone, even repeatedly. They are the few who have served the many. It is not unreasonable that the nation should provide them with appropriate and adequate care. This care should be evidence based, and that will require scientifically sound research.

Dr Shale is a retired United States Navy Captain.

Potential conflicts of interest: None.

Funding/support: None.


1. Solomon Z, Levin Y, Assayag EB, et al. The implication of combat stress and PTSD trajectories in metabolic syndrome and C-reactive protein levels: a longitudinal study. J Clin Psychiatry. 2017;78(9):e1180-e1186.

2. Sargant W, Slater E. Acute war neuroses. Lancet. 1940;236(6097):1-2. doi:10.1016/S0140-6736(01)02672-1

3. Seal KH, Bertenthal D, Miner CR, et al. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482. PubMed doi:10.1001/archinte.167.5.476

4. "Peace dividend." 2017. Accessed August 16, 2017).

5. The peace dividend. Newsweek. January 25, 1998. Accessed August 16, 2017.

6. Shale JH, Shale CM, Shale JD. Denial often key to psychological adaptation to combat. Psychiatr Ann. 2003;33(11):725-729. doi:10.3928/0048-5713-20031101-08

aDepartment of Psychiatry, University of Utah, Ogden, Utah

*Corresponding author: John H. Shale, MD, JD, University of Utah, Department of Psychiatry, 4227 Fern Dr, Ogden, UT 84403 (

J Clin Psychiatry 2017;78(9):e1313

© Copyright 2017 Physicians Postgraduate Press, Inc.

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