For a few days last month it looked like a war between the US and Iran was likely. First, on 3 January, General Qasem Soleimani, the highest ranking military figure in the Iranian Revolutionary Guard Corps, was assassinated by a US drone strike. This caused deep anger in Iran, prompting a retaliatory missile attack on an Iraqi base known to house many US troops.

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The fear was of a rapid further escalation with a forceful military response from Donald Trump, but it came to nothing as he tweeted that no US troops had been affected so no further action was required. The implication was that the Iranian attack had been little more than a pinprick designed to assuage domestic public opinion. As far as Trump was concerned, the matter was over. 

That was how it seemed, at least at first. Indeed, other reports from Washington spoke of the Iranians even warning the Iraqis about the impending attack and that the missiles were aimed at remote parts of the sprawling Ain al-Asad air base, itself out in the desert and a hundred miles west of Baghdad.    

Both sides could thus claim success. For the US, the killing of Soleimani was both militarily and politically significant as he was not only a key military leader, but also the closest ally of Supreme Leader Ayatollah Khamenei. His assassination demonstrated that no-one is safe from American power, no matter how important they are – reinforced by the superficial nature of the Iranian response. They simply would not dare provoke the Americans more.

For the Iranians, though, their domestic media could hold up the missile attack as proof that the country had the means to embarrass the US. Government sources claimed many US troops were killed and injured but for the wider world the easing of tensions was greeted with relief. 

A rather different picture is now emerging, centred on the actual impact of the missile attacks and much of it revolving around reports of US soldiers being struck by traumatic brain injury (TBI). Immediately after the attack the Pentagon said there had not been any injuries, corroborating Trump’s tweet, but eight days later it reported 11 personnel affected, some of them being taken to a medical facility in Kuwait. Within a few days there were reports of some troops even being airlifted to the Landstuhl Regional Medical Center in Germany.

It was at this point that the warning signs went up among some security analysts, since Landstuhl has been the key receiving centre for serious injuries from Afghanistan and Iraq for nearly two decades, with an extraordinary concentration of medical expertise available for almost any eventuality. The significance of the transfers was quickly downplayed by the Pentagon who maintained that soldiers were moved there just for observation.

Since then the number of soldiers affected has risen rapidly. By 30 January it was up to 64 and it is now at 109, about 1 in 10 of all the US troops based at al-Asad. As of early this week, 76 of the 109 have returned to duty with 33 still off sick. The symptoms are described as mild but even now the numbers are termed a “snapshot in time” so they may well rise and using the term “mild” hardly explains transferring some of those affected to a specialist centre.   

After the attack, Trump’s Defense Secretary, Mark Esper, said 10 ballistic missiles hit the base damaging tents, a parking lot and other equipment, characterising the attack as nothing major at the time. This contrasted with the view of General Mark Miller, the chair of the US Joint Chiefs of Staff who had said that the Iranian attack was intended to kill Americans and involved ballistic missiles with 1,000 to 2,000-lb warheads. Two days after the attack he said that:

Traumatic brain injury has been a common problem for US, British and other troops in Afghanistan and Iraq, and may be due to direct blast overpressures, shrapnel or other items striking the head, or soldiers being knocked down. Many thousands of troops have experienced TBI due to mortars, improvised explosive devices and other ordnance over the past two decades. 

What distinguishes the Ain al-Asad attack is that this was not down to the actions of irregular soldiers or insurgents but due to ballistic missiles fired by a state from its own territory against the soldiers of the United States. In spite of this, Trump has not retaliated and does not appear in any way ready to do so.

The stated position is still that this was a small problem with no long-term implications but it is probable that the attack is being analysed in considerable detail, especially in the context of the ability of the Iranians to use proxies to mine ships, blow-up pipelines and even attack large oil-processing plants. Irregular war is how Tehran utilises military power and the Ain al-Asad attack was just at one end of the spectrum.   

The impact of the al-Asad attack will open up two choices for the more thoughtful war planners in the bowels of the Pentagon, both stemming from an increased recognition of the range of options now available to Tehran. One is that a war would be thoroughly unpredictable, especially if missiles are factored in, so it is perhaps best avoided. The other is that if there is to be a war, then the United States should plan to use every means available right from the start in order to minimise the potential of Iran’s missiles.