July 22, 2012: While combat casualties in Iraq and Afghanistan got most of the headlines, the NATO medical personnel in the combat zone spent most of their time dealing with non-combat injuries and some nasty diseases. Accidents, disease, and stress (physical and mental) problems have, over the last decade, accounted for about 80 percent of those troops flown out so they could get more advanced care. There are more than ten of these evacuations for every soldier killed (combat or non-combat). Only 19 percent of those "medical evacuations" were for combat injuries. Thus, in the military hospitals (both in Iraq and Afghanistan, as well as back in the United States), the vast majority of combat zone casualties are not there because of combat injuries.

Britain saw most of its combat in Afghanistan. Compared to the Americans, a larger proportion of British personnel were combat troops. The Americans took care of most of the NATO logistics and support functions. The Brits had fewer troops who saw little combat but were still exposed to accidents and diseases. Thus 67 percent of British hospital admissions in Afghanistan were for non-combat causes (accidents and diseases). But nearly 80 percent of troops flown out for medical reasons were for non-combat injuries. So far, 422 British troops have died in Afghanistan, most from combat. About ten percent of combat casualties are fatal while most of the others are lightly wounded and usually treated in Afghanistan. But about 30 percent of wounds are very serious and have to be flown out, after they are stabilized, for more specialized treatment.

Once the fighting died down in Iraq (2009) U.S. troops there had more to fear from accidents, disease, and stress than enemy action. Less than half the troops who died in Iraq were combat casualties. This was a trend that has been growing for several years. As a result of this few of those in need of hospital care were combat casualties.

While not caused by combat, a lot of the "non-combat" injuries were the result of combat operations. For example, ten percent of those evacuated had musculoskeletal system problems. The infantry have to carry more weight (sometimes 50 kg/110 pounds or more), more often, than anyone else. Back and muscle problems are common. The combat troops are also out and about more frequently and more likely to catch exotic local diseases. Thus it's not surprising that in places like Iraq and Afghanistan, ten percent of the medical evacuations are for "ill-defined conditions." This was first discovered when thousands of American troops were stationed in the Persian Gulf during World War II. Before that the British warned, from their World War I experience, that Iraq was a nasty place (from a disease standpoint) to hang out in. Afghanistan has proved to have its own extensive collection of exotic and often unrecognized (by Western medicine) afflictions.

While most of the deaths in Iraq and Afghanistan were from combat, many were not. Of the 6,500 U.S. troops that have died in Iraq and Afghanistan, 19 percent of those fatalities were from non-combat causes. Most of the non-combat deaths were from accidents and disease. One of the major categories of non-combat death is vehicle accidents. In 2007, 20 percent of the non-combat deaths were from vehicle accidents. But in 2008, overall deaths declined by two thirds (from 904 in 2007, to 312 in 2008), but vehicle accident deaths went from 37 to 19.

The U.S. Army expected vehicle accidents to decline even more in 2008, because the number of terrorist incidents went down by 80 percent. Many vehicle accidents were the result of the fast driving tactics troops were encouraged to use to get away from roadside bombs and ambushes. Ask the NCOs and they will often complain that the sharp reduction in combat has removed the incentive to stay sharp and pay attention. Not a unique situation in a combat zone, and despite the energetic exhortations of the NCOs, too many troops do not stay alert enough to avoid accidents. Ask the troops and they complain about the heavier traffic. With peace breaking out all over central Iraq, and the economy continuing to boom, more Iraqis have cars. Iraqis drive like they're from Boston, with abandon and indifference.

Meanwhile, military experts around the world are still trying to make sense of how the United States (and Britain) kept its casualties so low in Iraq and Afghanistan. To put it in simple terms, you were three times more likely to be killed or wounded in Vietnam (or World War II), compared to U.S. troops serving in Iraq. And then there is the mystery of higher non-combat deaths in Afghanistan. In Vietnam, and Iraq, 19 percent of the deaths were from non-combat causes (accidents, disease, for the most part). During World War II, 25 percent of the dead were non-combat. In Afghanistan, 29 percent of the deaths were non-combat, although that is rapidly changing as combat deaths increase. Afghanistan does have a greater variety of diseases and nasty terrain (including the atrocious roads).

What the U.S. did was put in well trained, led, armed, and motivated troops and then supported them lavishly. Civilians were hired to do a lot of the menial jobs. Much effort was put into getting to know the local culture and avoiding civilian casualties. That eventually won over enough Iraqis to undercut support for Islamic radicals (mostly Sunni Arabs angry at no longer being in charge and minority Shia groups keen on setting up a Shia religious dictatorship).

But while the diseases and safety situation in Iraq is improving, there's still a way to go in Afghanistan. The many diseases, bad roads, hills, and mountains will remain for some time to come. Afghanistan will remain a dangerous place, even if no one is shooting at you.