The Most Pervasive Combat Injury Among U.S. Soldiers is Invisible -- and the Pentagon Has Tried to Keep it That Way
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March is Brain Injury Awareness Month and to observe it, the Pentagon did something special: it told the truth.
In a news conference on March 4th, Brig. Gen. Loree Sutton estimated that as many as 360,000 veterans of Iraq and Afghanistan may have suffered service-related brain injuries. Until now the Pentagon estimated that some 10,000 veterans of the Afghanistan and Iraq war had suffered brain traumas.
It's about time they got it right. Almost a year ago, in April 2008, an independent report by the RAND Corporation estimated that some 320,000 troops -- 20 percent of the deployed troops -- had suffered traumatic brain injury (TBI). Included in the RAND figure were blast-induced neurotraumas (BINT) from new weaponry like improvised explosive devices, during which the head remains closed and, more often than not, the victim remains conscious. These closed-brain blast injuries are the most common injury -- brain or otherwise -- of the current wars, but until now, for the DoD, they didn't count.
"Just a Concussion"
Admitting to the incidence of the injury is a start, but the DoD has yet to admit its potential gravity. The DoD did not count closed-head blast injuries because they deemed them mild traumatic brain injuries, commonly referred to as concussions. In December 2008, another independent report, prepared for the VA by the Institute of Medicine, warned that the blast-induced neurotrauma might be something distinctive and far more serious than the mild TBI or concussions associated with closed-head injury. According to George R. Rutherford, of the Department of Epidimiology and Biostatistics at UC Medical School, San Francisco, the chair of the OIM committee that wrote the report, these blast-induced neurotraumas, seem unlike injuries we've seen before: "We're all worried that the blast neurotrauma hasn't really made it into the human literature."
Unfortunately, in the same news conference in which Brig. Gen Sutton offered new numbers, Lt. Col. Lynne Lowe, TBI Program Director in the Office of the Army Surgeon General, assured that blast injuries are just a concussion -- "the same as we see in a football game on TV." "Providers can give medication for headaches or dizziness, and reassure them that they will be OK … " Not true. Many veterans have long-lasting and serious symptoms.
An IED explosion produces high-pressured air waves that move at 1,600 feet a second, spreading hundreds of yards. The blast then strikes again: high-pressured air displaced by the first blast flies back to the site of the explosion in a "secondary wind." Even without penetration, the brain and other organs can sustain profound injury. According to Keith Young, vice-chair of research at Texas A&M and the VA Center for Excellence for Research on Returning War Veterans, "The blast is so close and so large, it seems to be shaking the brain. My guess is that this causes micro-bleeds." Others speak of diffuse axonal damage.
Yet the "It's Just a Concussion" theory pervades the DoD. The Walter Reed Army Institute for Research (WRAIR) website offers "General Questions an Answers" about blast injuries that deem them "no different" from concussions on a "football field," which "usually resolve … within a few days." The Q & A discourages screening, lest soldiers with simple concussions think they have a brain injury.
"It's Just in Your Head"
Complementing the "It's Just a Concussion Theory" is the "It's Just in Your Head" theory that the DoD and VA developed after the first Gulf War to explain Gulf War illness. A much touted 2008 Army study led by Charles W, Hoge, Director of the Division of Psychiatry and Neuroscience at the Walter Reed Army Institute of Research, and published in the New England Journal of Medicine, reported that while soldiers with mild brain traumas were found to have more health problems, it was due to their "PTSD and depression" not their TBI. But as researchers like Johns Hopkins' Ibolja Cernak, MD, PhD, have demonstrated, soldiers with blast injuries have a high incidence of PTSD and depression in addition to problems with attention, concentration, memory, headaches, dizziness, seizures, gait, nausea, mood, and vision, among others.
The Pentagon is a vast beast, as uncoordinated and incoherent as it is rigid and rule-ridden. Thus while WRAIR informational material minimizes the BINT, WRAIR's own Blast Neurotrauma Research Program seeks "to characterize potential biomechanical and biological mechanisms of injury, and the pathophysiological, neuropathological and neurologic impairments that resulted from exposure to explosive blast." And new initiatives like the Center for Neuroscience and Regenerative Medicine and the National Intrepid Center of Excellence as well renewed activity in older organizations like the Defense and Brain Injury Center are undertaking research into the nature and viable treatment of this new brain injury. This, like Brig. Gen. Sutton's disclosure, is encouraging.
The Truth Is Beginning to Come Out
The OIM remarks and recommendations on injuries in the current wars appeared in "Gulf War and Health: Long-term Consequences of Traumatic Brain Injury," the seventh of a series of OIM reports on the health outcomes of the 1991 war. Eighteen years after Desert Storm, the truth about the devastating illness that followed a third of our troops home, is only now emerging. In November, the Research Advisory Committee, a congressionally-mandated committee of high-level scientists, reported that Gulf War illness was "without a doubt" "caused" by neurotoxins the government had exposed troops to, including experimental anti-nerve gas pretreatment pills, insecticides and insect repellants, and sarin pluming from munitions facilities the U.S. had bombed. The committee criticized the "skewed" and "unscientific" research directed by VA and other bureaucracies, which suppressed evidence of the chemical causes and organic nature of Gulf War illness, in favor of bogus claims that wartime stress had caused an essentially psychological ailment. The report lamented that after 18 years there is still no treatment for the more than 200,000 troops suffering from Gulf War illness, a disease caused by profound neurological damage.
Eight years is better than eighteen for telling the truth. But there's much more truth to learn and tell. The blast injuries of Americans -- and Iraqis -- will remain when Brain Injury Awareness Month passes. Robert Gates's reformulated Pentagon has agreed to show us our dead soldiers. Now we need a thorough coherent approach to diagnosing, healing, and compensating the living afflicted by the current wars. Pre- and post-deployment neuropsychological testing and imaging studies would be an important step as would silencing the misinformation of Army spokespeople eager to discount the hidden wounds distinctive to this tragic war.