The essence of war is killing or injuring the bodies of the enemy.[1] 6,767 US military personnel were killed and 52,142 injured in combat during Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom.[2] Survival rates of 90 percent and injuries from improvised explosive devices left many veterans severely disabled.[3] As the conflicts went on, Americans recognized that far more veterans were returning from deployments to Iraq and Afghanistan with symptoms of mental illness, including stress, depression, cognitive impairment, headaches, and substance abuse, ranging from temporary and mild to chronic and even fatal. As a result, the injuries associated with these conflicts in the popular imagination are the "invisible wounds" of major depression and suicide, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD).[4]

Historian David Kieran (Washington and Jefferson College)[5] traces how these mental injuries became the "signature wounds" of the post-9/11 wars. He clarifies how the often evolving perceptions of American civilians, journalists, members of Congress, activists, clinicians, and military leaders regarding war-related mental trauma infused larger debates over the legitimacy of the wars and US military policy and culture more generally. Besides canvassing journalistic media, memoirs and novels, reports of public meetings, congressional records, medical research, and military documents, Kieran has interviewed some three dozen Army leaders, clinicians, and researchers seeking effective screening tools. His inclusion of commanders worried about their troops, as well as parents of men and women forever changed by their military service makes this very scholarly volume accessible to an interested general audience.

Kieran begins his nuanced analysis with a history of mental health research from Vietnam to the Iraq War. He notes the growing awareness of the many veterans returning from Iraq and Afghanistan with symptoms of mental distress, often resulting in suicide. He shows how this helped spur public and political opposition to the wars.

The book's central chapters offer an institutional history of the Army's and Veterans Administration's response to soldiers' mental injuries—the "untold story" of the post-9/11 wars. Kieran demonstrates that the military was concerned about soldiers' mental well-being but unready for the sheer numbers of them returning with PTSD, depression, and TBI. Lacking scientific information on the less severe forms of TBI and hampered by inadequate PTSD screening, the Army and VA scrambled to respond. But factions within the Army, particularly its medical corps and operational leaders, quarreled over how best to care for soldiers' mental health.

The book is "a story of culture and cultural change" (10) in the military as a fighting force and in the larger society's views of mental distress, militarism, and the costs of war. Kieran's account of the dispute between Gen. Pete Chiarelli and Surgeon Gen. Eric Schoomaker is instructive.

Kieran's discussion of the emergent scientific concern with mild TBI from blasts synthesizes key scientific and clinical literature and translates it cogently for lay readers.

The author's arguments would have benefited from a conversance with work in medical anthropology. Kieran discusses the "broad concern in Congress, in the media, and in the Army that the difference between the two weren't being sufficiently parsed and that soldiers were being misdiagnosed," in part because they "signify differently in the culture" (186). But his discussion of the dissimilarities remains based in clinical and scientific definitions. PTSD may function as an "idiom of distress," a socially accepted diagnosis of symptoms vague enough to serve as a gloss for a range of disturbing phenomena. For soldiers, PTSD may express suffering related to military service that they cannot express more directly.[6]

Kieran's analysis of cultural change in the military is perceptive and complex, but he too often portrays public and political calls for the military to improve care for soldiers' mental health as motivated by opposition to the wars. One wishes he had drawn here on his previous work on the Vietnam War and its legacy which conflated criticism of soldiers with disapproval of the war. The result has been that opposition to the post-9/11 wars demanded simultaneous support for the troops and their mental health. But that does not mean civilians were without complex motives in advocating for the mental health of soldiers and veterans.

These criticisms do not detract from the significance of Kieran's work and the questions he raises about the role of the military in American society and the costs of intervention around the globe. It is only ten years since President Barack Obama announced the end of Operation Iraqi Freedom and just under five since he announced the end of Operation Enduring Freedom. We are just beginning to reckon with their effects on the mental health of thousands of veterans. Signature Wounds is a strong foundation for future research and a valuable resource here and now for both scholars and non-specialist readers.