130226-M-IX060-006The United States Marine Corps Wounded Warrior Regiment provides and facilitates assistance to wounded, ill and injured Marines, sailors attached to or in support of Marine units, and their family members in order to assist them as they return to duty or transition to civilian life. (Photo by Cpl. Tyler L. Main)

"I really don't like the term 'PTSD,’” Department of Veterans Affairs psychiatrist Dr. Jonathan Shay told PBS' "Religion & Ethics Newsweekly" in 2010. "He says the diagnostic definition of "post-traumatic stress disorder" is a fine description of certain instinctual survival skills that persist into everyday life after a person has been in mortal danger — but the definition doesn't address the entirety of a person's injury after the trauma of war. "I view the persistence into civilian life after battle," he says, "... as the simple or primary injury."

Dr. Shay has his own name for the thing the clinical definition of PTSD leaves out. He calls it "moral injury" — and the term is catching on with both the VA and the Department of Defense.

We're turning our attention to this idea of moral injury and the limits of the PTSD diagnosis to explore what happens to a person who has experienced combat.

There are no clean lines separating PTSD from moral injury (which is not a diagnosis) — there is no Venn Diagram, as with PTSD and traumatic brain injury but Dr. Shay explains a fundamental difference by using a shrapnel wound as an analogy.

"Whether it breaks the bone or not," he says, "that wound is the uncomplicated — or primary — injury. That doesn't kill the soldier; what kills him are the complications — infection or hemorrhage."

Post-traumatic stress disorder, Dr. Shay explains, is the primary injury, the "uncomplicated injury." Moral injury is the infection; it's the hemorrhaging.

PTSD in service members is often tied to being the target of an attack — or being close in relationship or proximity to that target.

Moral injury, Dr. Shay says, can happen when "there is a betrayal of what's right by someone who holds legitimate authority in a high-stakes situation."

That person who's betraying "what's right" could be a superior — or that person could be you. Maybe it's that you killed somebody or were ordered to kill. Or maybe it was something tragic that you could have stopped, but didn't. Guilt and shame are at the center of moral injury. And, as Dr. Shay describes it, so is a shrinking of what he calls "the moral and social horizon." When a person's moral horizon shrinks, he says, so do a person's ideals and attachments and ambitions.

I first came across Dr. Shay's name — and his concept of moral injury in combat veterans — in a heart-smashing profile of Noah Pierce published by the formidable Virginia Quarterly Review.

The Life and Lonely Death of Noah Pierce"The Life and Lonely Death of Noah Pierce" tells the story of an Iraq War veteran from Sparta, Minnesota, who shot himself in the head in 2007 at the age of 23.

From Ashley Gilbertson's profile of Pierce:

"When Noah went missing in July 2007, after a harrowing year adjusting to home following two tours in Iraq, police ordered a countywide search. His friend Ryan Nelson thought he might know where to look. When he pulled up to the spot, he immediately recognized Noah's truck. Inside, Ryan found his friend slumped over the bench seat, his head blown apart, the gun in his right hand. Half a bottle of Jack Daniel's Special Blend lay on the passenger seat, and beer cans were strewn about. On the dash lay his photo IDs; he had stabbed each photo through the face. And on the floorboard was the scrawled, rambling suicide note. It was his final attempt to explain the horrors he had seen — and committed."

Gilbertson told Noah's story to Jonathan Shay. Again, from the article:

"Shay, a psychiatrist who has worked with combat vets for twenty years and authored two books about PTSD — or psychological and moral injury, as he insists it should be known — told me by phone from his Newton, Mass., office, 'It's titanic pain that these men live with. They don't feel that they can get that across, in part because they feel they deserve it, and in part because they don't feel people will understand it.'

"'Despair, this word that's so hard to get our arms around,' he said. 'It's despair that rips people apart [who] feel they've become irredeemable.'

"I told Dr. Shay about Noah's experiences in Iraq, in particular the killing, the loss of comrades, the nightmares. He sounded saddened on the phone, but unsurprised. 'The flip side of this fellow's despair was the murderous rages he experienced on his second tour,' he said. 'In combat, soldiers become each other's mothers. The rage, need for revenge, and self-sacrificial commitment toward protecting each other when comrades are killed [are] akin to when a mother's offspring are put in danger or killed.'

"Dr. Shay explained the nightmares and sleeplessness were one of the major issues. 'The lack of sleep contributed directly to a loss of control of his own anger, a loss of control of things he felt morally responsible for.'"

Treating moral injury in combat veterans, Dr. Shay said in the PBS interview, happens not in the clinic, but in the community.

”Peers are the key to recovery — I can't emphasize that enough. Credentialed mental health professionals like me have no place in center stage. It's the veterans themselves, healing each other, that belong at center stage. We are stagehands — get the lights on, sweep out the gum wrappers, count the chairs, make sure it's a safe and warm enough place…”

He doesn't write off clinical care, though he does disparage "cookie-cutter treatments."

"We're certainly doing a lot of things," he says, "but whether we're actually preserving vets' capacity to have a flourishing life after war, I don't know. I just don't know."

Jeff Severns Guntzel is senior reporter for the Public Insight Network (PIN). He has reported from the Middle East and points all over the United States for a cadre of publications and news organizations that are not usually mentioned in the same sentence, including Punk Planet Magazine, National Catholic Reporter, Village Voice Media, MinnPost.com, and GOOD. He also did time as an editor at Utne Reader.

Read more of Jeff's reporting as part of the Public Insight Network's veterans health project on vets and all those working to help them navigate life after combat.

Share Your Reflection



Thank you for this. We may finally be on to the truth. The psyche cannot absorb the "dogs of war." And each person affected passes this one to at least 4 generations. War truly is H*ll.

The impact of war on human beings always opens the door to examine broader human experiences. Using wartime research on PTSD, it became clear that adversarial and predatory behaviors also cause complex PTSD in legal proceedings, corporate schemes to trick consumers and so it is with moral injury. In legal cases that have been filled with trickery and violations of all a person holds dear for years on end in wars of attrition also meet the criteria for moral injury. Human beings need some simple things and holding to a moral code is one of those critical staples of a civilized society.

I am so glad to see to expand this concept to address our worldin general. Thank you so much.

DR Shay has got it right. Shame and guilt are killers.............. and its not just killing or surviving behavior for which veterans feel shame or guilt....

I'm very moved by this piece for several reasons and will try to be brief and to the point. I am interested in this topic because I am a veteran, too Not a veteran of any foreign war, nor veteran of any national military branch; I am a veteran of the 'war at home,' and that war has left me with the diagnosis and effects of PTSD - just as devastating and debilitating as many of our military veterans. I do not wish to draw attention away from the plight discussed in this article - it is too real and too painful and too destructive to dismiss. I also do not want to disparage any further research, treatment progress, discoveries that have come from the veterans' diagnoses and ground-breaking work that has flourished amidst such pain because it is through the identification of the symptoms of PTSD by veterans that those of us were finally able to be recognized as suffering similarly

The 'war at home' I speak of is domestic violence - multi-generational, repetitive, unrelenting - and it is something that carries the primary injury past the first offense and collateralizes the damage to the very apt description of 'moral injury' as so eloquently stated by Dr. Shay, I know my own experience has been the identified result of two generations before me of domestic violence brought into both my parents homes and then brought into my home as a child The third generation of domestic violence came into my adult home with my three children in the guise of two men - one their father, and the second their stepfather - as well as the continued abuse from my parents and their grandparents.

When I read the descriptions of the 'mothering' that is often required of the soldiers in combat, I was reminded of how my brother and I 'mothered' each other through the years of abuse; how my children 'mothered' me and themselves during our years of abuse and how the last thing we know how to do even now is 'mother' ourselves. I watch the subtleties of these atrocities continue to visit myself and the lives of my children. I know we are the 'walking wounded' who are making it look pretty good on the outside and not doing very well at all on the inside. We can talk about it, but would prefer not to; our friends and family give us space and time, but also wonder when we'll 'get over it.' Hell, even we wonder when we'll 'get over it.' too.

I am seeing a wonderful therapist and we are making more progress than I have been able to do before and still, I am stunned to hear her describe the work that is still ahead of us to 'put me back together again,' I am still not completely aware of the damage that has been done. I'm so used to being damaged that I don't know there is damage visible to a trained eye. I want to be whole and integrated; I want to live a full, vibrant life; and I want that for my children and for their children

Dr. Shay diagnoses effective treatment as being done with peers. I wholeheartedly endorse that form of treatment. I was in a support group for battered women and children over 10 years ago. Sadly, the abuse had barely begun with the last perpetrator - I had not even identified it as abuse at the time. I was attending the group to become an advocate of support for other women and their children. Sadly also, the group as so many like it, were disbanded due to budget cutting by the hospital that supported the advocate who founded the group.

I am grateful that the veterans have the funding and available support for them and know how difficult it is for many of them to access the help they desperately need and want. Because of the shame and blame that is part and parcel of this diagnosis, those who want and need help rarely reach out for it. The same is true of us veterans of the war at home; perhaps, even more so. We are told by so many people -- family, friends, police, court personnel, lawmakers, even the law breakers - that we are making too much of this, that it's 'over' and we should just 'move on' with our lives. We are told to 'honor our fathers and mothers,' 'honor our husbands til death do us part;' we are crippled further by the short-sighted and short-handed judicial system; we are hobbled by a society that still frowns on a woman who leaves her husband, regardless of how legitimate her reasons may be, we are forced to advocate for ourselves when our self has been battered and bruised and humiliated into a place where we never believed love would send us and where we barely know how we survived much less how we will do it.

I tell people who want to fully understand what I would consider fair and equitable treatment of us veterans of the 'war at home' that justice will be when the perpetrators of domestic violence are treated as rightly by society and the justice system as if they were any other criminal who would invade our homes and our lives and cause us harm. A stranger is held to a higher standard of justice than our fathers, husbands, parents; somehow, because it is a 'domestic' issue, it counts for less than if it were not. The same can be said for military veterans - we other veterans get the fallout from their treatment and I am glad for it - I just wish neither of us had to go through what we have gone through and continue to go through because of the 'moral injury' that has taken place.

My last point is this - at best, moral injuries are difficult to treat. How do we know when we are 'well?' How does one know when the moral injury has been 'healed?' we are a society that attends to things we can measure, quantify, judge complete. This 'moral injury' premise will take a long and large leap of faith to be embraced - my hope is that it will be sooner rather than later. Keep me posted, please, I am interested. Rhonda @ onceagain2007@gmail.com

I'm a survivor of rape and I can tell that what you say is 100% truth. Thank you Rhonda

wow rhonda, you hit the nail on the head. as a victim of DV myself, i tried so many times to let my marine boyfriend (well ex now) know that i can relate to what he is going through. he never believed that, this i know. yeah, being in a warzone with guns and killing is certainly different, however, when you live in fear daily of beatings, verbally, mentally, as well as physically, it wears you down. i have done a lot of work myself to try to nip this in the bud. i just recently started talking to my mother, which i am still shaky about, because she has no recollection of what she put me through when i was growing up, and my younger sister would always tell me that i was bitter and i needed to get over it. its not how it works. she was safe from all of that abuse, she was actually the one that perpetrated a lot of it thru my parents. i was in a DV shelter for 4.5 months, and oh man, i never thought that i would EVER be in that situation, but there i was. i met a lot of ladies who were in there because of significant others, and i was the only one that was there because of my parents. but, the more talking i did, and the more people i tried to help (which was mostly the kids, because i knew exactly how they felt in their situation) the more i helped myself. the therapy was great as well. i went to as many groups as i could throughout the week, because i was there for a purpose, not just a free place to stay because i had no where else to go. it only helps if you think that it will, and i did. my gram keeps telling me that i need to mend fences with my parents, but i cannot give them chance after chance to repeat the same behaviors over and over again like i had in the past. i feel that i am a very moral person, considering what i have went thru in my life. i could very well be another statistic, but i choose to refuse to do so. it is a hard road, but anything worth doing isnt going to be easy...this i know. its a work in progress that i still encounter daily challenges with.

I was diagnosed with PTSD due to DV. Your words "being in a warzone with guns and killing is certainly different, however, when you live in fear daily of beatings, verbally, mentally, as well as physically, it wears you down." was a eureka moment for me. As I mentioned in a reply to Rhonda I grappled with guilt over how I could have experienced the same level of stress as a war veteran, but your words validate my pain. As to talking to, in this case, my mother about her actions, it was a challenge. My expectations of any regrets expressed by her was short lived when she responded to my why's by saying "you were a difficult child". I wanted to shout "Yes, I was a child...and you were supposed to be an adult!", but had to let the moment slip by. Whether time or denial was the cause she did not want to deal with it. While I am thankful that I was self aware enough to not repeat the actions of my mother on my children, I sadly wonder what inner demons made her lose control to that degree. I have learned to let go of my why's and move forward.

Thank you for your well written thoughts. When I was diagnosed with PTSD my first thought was "This is a condition of veterans of war" and I've grappled with guilt over how I could have experienced something as damaging as they had....surely I am making a mountain over a molehill. Your words struck a chord and it helps to know that there are others out there whose DV experiences caused PTSD. It helps lessen the guilt.

Thank you for writing this! I've been looking a perfect piece to share with students, to enable them to grasp 'the war at home', along with their PTSD studies related to veterans. If you'll allow me to use it, please e-mail me how you wish to be cited. My e-mail is 16thnote@bellsouth.net Again, thank you for your contribution to the literature regarding this epidemic syndrome. Terri

We believe Dr. Shay is onto something in raising awareness in Moral Injury, but we think he has the causal relationship backwards. In Dr. Shay's model, "something happens to you," and that makes you feel you or life is without worth, the universe is an immoral place, etc. Based on our research with US Marines (TECOM Resilience Research Project), and an agentic theory of human beings, we understand it to be the reverse. Marines can narrate how they make moral judgements about themselves as leaders, parents, spouses, etc. and then because of their decision, develop attendant complications. In the first model, military members are passive subjects, affected by forces/circumstances; in the second model members are agents, actively trying to navigate the complex contexts of their lives.

This is a meaningful difference. If self-judgments in the wider context of living (or which moral injury in response to the battlefield is a subset) is the star--if the members are the causal agents, how we help prepare--support and assist them as they make meaning of their lives, is very different than what we shoudl do if members are passive victims of events.

I like your agentic theory and wonder if you have a short research paper on it with proposals for what you briefly lay out here. I wrote a Masters thesis using virtue ethics to say something very similar. The passivity of injury and "stress" can be incapacitating and I am hopeful we can think about this subject more deeply together. My work is also funded my my own experience in OIF as an army artilleryman as well as theologian training as a Christian.

When I trained at the VA in chaplaincy I experienced this in my hospice veterans. Their moral injuries poured out as their normal life reflection process unraveled. As theirs did, my deceased dad, WWII secret of "friendly fire" where he mistakenly was told to kill his own soldier by his commander who did not like the soldier to be killed leaked out of my dad's memories in disconnected ways. I knew he would never link the truth for me because he was loyal to his military pledge as a sergeant Dad began electric shock treatments after the death of his mom. Each death of a family member as dad aged required more shock. In all he had over 150 shock treatments. His good psychiatrist told me towards the end of his life, "this good man is not getting relief from the shock treatments anymore. Something in his moral life wants to come up and out as he nears his death. For me and my brother we too had felt the effects of my dads moral injuries. My dad's brother recently told me that all his family on the farm were terrified as my dad dressed in his uniform at night and shot his gun off as he patrolled the yard, re enacting the event over and over. We have moral injuries from all of his untreated war experiences. Most Veterans never qualify for help because of their income. So as the chaplain at the VA helped me understand how these Vets go through their moral injuries he pointed out to me that my brother and I and the whole family carry PTSD and the moral injuries our dad inflicted on us by his rage, beatings, and fearful behaviors. Your moral injury explanation is on target and I will be using your description of it in my chaplaincy profession. Thank you

I have been blessed by a great counselor, Patsy F, with the VA. When the concept of moral injury was explained as above, it was as if a switch had been thrown. Finally, a clear understanding and explanation of what I had been going through. I deeply appreciate those who have researched and finally clearly explained what so many have been suffering.
I know now that I did the best that I could, but I failed to protect the innocent none the less. I have lived with guilt and severe anxiety. I have not yet come to grips with it fully, but just knowing and understanding the concept has allowed me to begin to heal. The best I can describe it is that the anxiety feels like the lash of an icy, satanic whip. I had no peace and guilt always pointed a finger at my soul. Moral injury is that bad. The aftermath was worse than the war. Being able to understand the concept of moral injury has allowed me to move forward and out of the pit. Thank you to all who to help vets. you are saving lives.

Thank you JIm for sharing hope for many Veterans and Caregivers that are reading this message.
I agree with you it is a process, one day at a time. Many Blessing to you.
God Bless America.

Oh, Dr. Shay has it right. Problem is, the power structure, be it, a military command or the VA Mental Health, still keep the veteran in his place when it comes to PTSD. Here in Pittsburgh I was being given 60-65 GAF scores while I was being charged with felony assault charges at work where I carried a gun. I was a federal police officer. My own private health care were gining me 35 GAF scores at the same time. I did beat the charges since there were no witnesses and the alleged attack was a week after I got out the hospital for bleeding in the head. At the time I had a 30% PTSD rating.
Since then I was awake in the middle of the night because I couldnt sleep. I had my Glock automatic on my lap and was watching TV. Finally around 4AM I fell asleep and then not long after that I was dreaming about VN. I dont know how it happened but I pulled the trigger and shot myself. Almost killed myself, broke the femur, hit the artery.
I am a survivor of Hill 875 and was at the CP when the Marine Corp F4 Phanton dropped two 500 pound bombs on it. Thank GOD one was a dud. The 173d and 4th Infantry command knew we were well outnumbered when they sent us (330 of the 2d Battalion 503d Infantry, 173d Airborne) up the Hill. The total was around 158 dead and a lot more wounded. A lot more the protected dont care about. They think giving 10% is being generous. More wounds back home. Your sacrifice doesnt matter. Im on the Hill every day. Have been since 1967. Its really a shit place.

Thank you for this clear description of what persons recovering from trauma suffer.

This puts so much into perspective for me. I just finished my Bachelor's degree in Psychology and was going to go on to my Masters but I am in enough debt. Anyway, as a child my best friend and his sister were murdered by their mother and then she committed suicide(long story) but I have come to realize that a little child (me) would assume that I better be good or my mother might do the same to me. It has taken years and the 12 step program(Al-Anon) for me to realized the connection. Community is the answer. I would like to work in this area but don't know how to go about it. Any advice?

My experience with our Injured Warriors and Families includes these moral values that connect with these inhabitants of guilt, anger, blame, fear, revenge, etc. However, the Trauma is a physical injury to the core or cellular level. It is for this reason the Injury is not only in the Mind or Emotions and must be treated Intensively and Extensively for years. The Disorder Labeling casts a shadow and psychic tattoo while the drug cocktails prevent recovery, restoration and resilience. They do the opposite than treat symptoms and with serious side effects. With drawl is also very dangerous for the patient. See our recommendations for serving our returning vets:

Thank you for your article and recommendations.

Yes, visit the WestCoast Podcast Trauma interviews with Guy McPherson. He is outstanding as are his guests.

Terrific article.
What struck me the most, and some of the other commenters also say this, is when Doctor Shay talked about the best treatment being in the community, and that "peers are key to recovery".
I work for a grief support organization and I see this so clearly. People walk in from all areas of life, circumstances, as different as they can be and come together in a room, talk and begin to heal. All the group leaders do is facilitate the discussions...these people support each other and work towards healing together. They have the bond, they know what it is like to have a dead parent, spouse, child or parent, and the knowledge that they are not alone, and the support of each other as they try and work their way through the maze that will now be their lives is invaluable.
Yes, the primary wound is the death, or the injury or the incident. But the primary place of healing, or of at least the beginning of it, is with others who intimately understand, and will LISTEN to and identify with the feelings that these survivors are going through, having been there themselves.

Shay is amazing. Thanks. From him I learned that war trauma must be communalized. I add that it is not just between comrades or helpers. Communalization: We must all be a part of the communalizing process. Am a clinician and an Iraq War Vet.

May i post this on my website. It is so relevant to our project: Women, War and What they fed the children. It will help so many readers...thank you.

Thoughtful article and reflections. I once lived in a town where I was part of a congregation in which a teen brought a gun to church one day and "showed it off" to some other kids. They rightly told our pastor who soon held a meeting with church officers to discuss the next right things to do. People were understandably concerned about safety and about the teen who made this poor decision. But what struck me (a psychologist) was how many people did not want the boy to return to the church until he had been treated by a mental health professional. They spoke of therapy as something mysteriously powerful and removed from the rest of life. They discounted the power of the community they had built. Meanwhile, therapists like me are often struck by how limited our powers are to help people if they are not supported by some kind of community. The gun-displaying teen needed the support, guidance, instruction, limits, love of church members (who had known him a long time) every bit as much as he needed therapy from a person who would start out as a stranger to him. I so agree with the comment about "the communalizing process" being at the center of healing and change.

Dr Shay's comments are very similar to material by Dr Chaim Shatan from the 60s and 70s, when he worked with vietnam vets against the war. i think he was one of the psychiatrists who created the PTSD diagnosis, and all of his work recognized the centrality of community as the core of recovery. this idea got lost somewhere along the line, and his earlier papers are worth reading for anyone interested in this issue.

While Dr. Shay writes off the participation of what he calls "mental health clinicians" like himself, he shouldn't write them ALL off. Maybe the psychiatrists who are quick to prescribe addictive drugs to dull the pain, but there are alternate therapies that utilize creativity and movement, conducted by credentialed clinicians, who do not prescribe. Maybe it is time for the psychiatrists to move over and let the creative arts therapies, yoga, movement, mindfulness and other modalities in.

I am currently writing my masters thesis on Moral Injury with Vets and would love to be able talk with you about this!! This was a great read, I love Dr. Shay's works.

I am currently working with a group who is developing a project to help veterans cope with PTSD. I am also have read the works of Dr. Shay and I am interested in talking with the person doing the masters work.

While in the Air Force, after Korea but six years before Vietnam war,I was on a loading crew which put "nukes" on SAC B-52s. The military had me brainwashed to think I was doing the right thing. I didn't stand up for myself to say this duty is morally reprehensible. As an adult ten years later, I knew that even with a gun pointed at my head I would refuse to do what I did as an Air Force twenty-one year old.

Dr. Jonathon's preference and usage of the term 'moral injury' and 'psychological injury' , in my experience, are more to the humanity of the person. PTSD seems more objective and a label that could be stigmatizing to others.

I expirenced the same kind of moral injury that is talked about in regards to veterans ,as a child growing up in a physically and emotionally abusive ,dysfunctional family in the1950's . There was no escape just surviving ,learning to live with the abuse and victimization of my brothers and sisters and myself . Desparitly trying to hold on to what primal sence of right and wrong and good and evil that was deep inside my soul. My life has been one of profound hope and despair exhausting trying to find meaning and purpose ans value in my life. Surviving as I have through the hope given by my wife ,daughter and now grandson. My younger brother and sisters did not fair as well.

moral injury happens to both sexes. straight up equal---ask me.

Thank you for your article. I am a veteran, and I am fortunate that I was diagnosed with PTSD and moral injury. The work is not easy around either issue. I do believe, though, that it is the work around the moral injury that has kept me alive.

There is a great deal of work on moral injury being done by the Soul Repair Center at Brite Divinity School, under the direction of Rita Nakashima Brock, PhD. For more information on their work, you can go here: https://www.brite.edu/academics/programs/soul-repair/

Tony Hillerman in his books about the Navajo depicts a scene in which a detective who has been involved in a deeply disturbing event (either he killed someone himself, or he was investigating a nasty murder) took advantage of the Navajo sweat bath healing tradition. Not all cultures have been blind to the damage done to a person's spiritual equanimity by such events - ritual healing apparently was something that warriors traditionally did upon returning from a battle. Surely even acknowledging that the damage exists, and that it affects something fundamental within the person, would be useful and a first step on the way to finding the right rituals for a given person to help resolve it.

Thank you for this piece--

I believe my uncle, who came back from the second world war with a mental disturbance, suffered from this type of moral injury. He believed that the government had placed a chip in his head and that radio signals sent by the government controlled some of his actions. I always thought that he did or experienced something during the war that violated his moral code and his mind dealt with it by attributing responsibility to the government. We never knew the source of his pain but he was hospitalized numerous times and given multiple medications in attempts to "cure" him of his delusions. He was another sad victim of war.

I am lost, dehumanized and institutionalized, not because of war, but in the name of peace. I was a Peace Corps volunteer (Lesotho '91-'93 and Malawi '93-'94. My first tour was amazing, though I did see some death in the villages. I left healthy, mentally and physically. My second tour was where things fell apart. AIDS was pandemic, in Malawi. The nationals were dying at a catastrophic rate, not of AIDS directly, but of pneumonia and tuberculosis. I was in the main hotbed of the disease, the Lower Shire Valley. My project, initially, was to educate the educators as to what I had done, in Lesotho. That plan didn't last. I was thrown into AIDS education and I had direct contact with the disease. The nationals wouldn't spend five seconds to slip a condom on for a few short minutes of sex. Their culture of promiscuity and infidelity was a fertile breeding ground for AIDS. HIV was no grace period, the killing strains of infections took over rapidly. The pneumonia was deadly. Not the simple, maybe-you'll-be- cured-with-some-pharms stuff. This stuff killed in short time. I hosted and attended groups from WHO. MSF, etc. and THEY were stymied by the virulence of the killing infections. Pneumonia did not respond to anything they threw at it. Tuberculosis was the same, and the typical months to years before death was reduced to days. Again, no pharms responded to the virility of the killing strains. One meeting had us discussing the impact of letting the strains die out. Clap the hands and the nationals got no help. AIDS was, thankfully, a short death sentence.

Discussed was what do you do with all the dead? When I arrived, in Malawi, I went to funerals. I, soon, developed funeral fatigue. There were several funerals a day in my village area, for staff and their extended families and throughout the district area that I covered. I want to mention funerals because I had experienced funerals where they needed to stack the dead on top of each other because nobody could dig fresh graves. The smells were horrible.

The mortuary, in Chikwawa, was cooled by an air conditioner, NOT A CHILLER, and could handle about 7 . Bodies weren't meant to be in there for more than a few days. When I was there the bodies were stack five deep on the floor. In 100 degree weather the lower bodies decomposed and generated heat to negate the a/c. The stuff of human decay was oozing from the door of the mortuary. The smell was horrible.

Rural clinics didn't have mortuaries. Families wuld bring the sick in and the families were expected to retrieve the dead and pay the hospital bill. When mom, dad, uncle, and the extended families died there was nobody to pay for all those bills. There was nobody to retrieve the dead. Clinics were forced to deal with the abandoned dead. When burials could no longer be done the dead would be left under a shade tree at the corner of the clinic property. The dead decomposed in the open. Villagers went about their business with the smell and possibility of infection. I saw this. I would ask my staff to scope out the village area before I arrived to avoid this sight and smell.

Kunyinda was a Mocambiquian refugee camp on the eastern border of Malawi. There was civil war in the Beak and refugees had come and stayed into Malawi. These people were dying as fast as their host nationals, BUT there was no space to bury the Beakins, in Malawi. Arable land was a premium in the area and it is taboo to plant a corpse where you plant your seeds. This taboo forced Malawi to repatriate the dead Beakins. I had driven by rows of refugee dead left at the border, in the sun for days. The dead are wrapped in cloth, but their faces are bare for identification. After a couple of days, there is no face. I remember projectile vomiting in my motorcycle helmet as I drove by.

Riding the bike was interesting. I saw a lot of country. One site I will never forget is the wheelbarrow man. This guy was an entrepenuer. Te local transportations systems frowned over transportation of the dead and unless private transport could be arranged the dead would stsy where they died. This guy used to take a 4x4 sized wheelbarrow with bicycle-spoked tired into Chikwawa to retrieve the dead for their families in the surrounding villages. I saw him once with four dead in his barrow. Other times there were fewer dead, but I saw him regularly.

So where am I know? I suffer from horrible nightmares and massive insomnia. When I catch a whiff of death I become a basket case. I used to self medicate, once to the point of a suicide attempt that I did not expect to survive. I cannot hold a job and I have become institutionalized. People think this is best for me.

I do receive therapy and, now, psychiatry. I am on sleep meds and Prazosin. I am jobless, broke and living in a halfway house. People say I should be lucky. I say cure me. Bring back the life I lost. Tell me PTSD is a label and that I have a moral injury instead of "he is a loser drunk." Take the nightmares away, let me sleep in peace. I want to live again.