[acb-hsp] The Wars Come Home

[peter altschul]

The Wars Come Home: The Traumatic Brain Injury Epidemic
  By Conn Hallinan
  Dispatches From The Edge
  June 18, 2011
  "We are facing a massive mental health problem as a result of 
our wars in Iraq and Afghanistan.  As a country we have not 
responded adequately to the problem.  Unless we act urgently and 
wisely, we will be dealing with an epidemic of service related 
psychological wounds for years to come."
  Bobby Muller, President Veterans for America
  "The multiple nature of it [multiple tours and longer 
deployments] is unprecedented.  People just get blasted and 
blasted and blasted."
  Maj.  Connie Johnmeyer, 332nd Medical Group
  According to official Defense Department (DOD) figures, 332,000 
soldiers have suffered brain injuries since 2000, although most 
independent experts estimate that the number is over 400,000.  
Many of these are mild traumatic brain injuries (mTBI), a term 
that is profoundly misleading.
  As David Hovda, director of the Brain Injury Research Center at 
the University of California at Los Angeles, points out, "I don't 
know what makes it `mild,` because it can evolve into anxiety 
disorders, personality changes, and depression." It can also set 
off a constellation of physical disabilities from chronic pain to 
sexual dysfunction and insomnia.
  MTBI is defined as any incident that produces unconsciousness 
lasting for up to a half hour or creates an altered state 
consciousness.  It is the signature wound for the wars in Iraq 
and Afghanistan, where roadside bombs are the principal weapon 
for insurgents.
  Most soldiers recover from mTBI, but between five and 15 
percent do not.  According to Dr.  Elaine Peskind of the 
University of Washington Medical School, "The estimate of the 
number who returned with symptomatic mild traumatic brain injury 
due to blast exposure has varied from the official VA [Veterans 
Administration] number of 9 percent officially diagnosed with 
mTBI to over 20 percent, and, I think, ultimately it will be 
higher than that."
  Serious consequences from mTBI are increased when troops are 
subjected to multiple explosions and "just get blasted and 
blasted and blasted," in the words of Maj.  Connie Johnmeyer.  
Out of two million troops who have served in Iraq and 
Afghanistan, over 800,000 have had multiple deployments, many up 
to five times or more.
  But mTBI is difficult to diagnose because it does not show up 
on standard CAT scans and MRI's.  "Our scans show nothing," says 
Dr.  Michael Weiner, professor of radiology, psychiatry and 
neurology at the University of California at San Francisco and 
director of the Center for Imaging Neurodegenerative Disease at 
the Veteranbs Administration Medical Center.  They do now.
  An MRI set to track the flow of water through the brainbs 
neurons, has turned up anomalies that indicate the presence of 
mTBI.  However, the military has blocked informing patients of 
results of the research, and if history is any guide, the 
Pentagon will do its best to shelve or ignore the results.
  The DOD has long resisted the diagnosis of mTBI, as it has 
avoided paying for a successful -- but expensive -- way to treat 
it.  The price of that resistance is escalating suicide rates and 
domestic violence incidents among returning soldiers.  In 2010, 
almost as many soldiers committed suicide as fell in battle.
  MTBI is hardly new.  Some 5.3 million people in the U.S.  are 
currently hospitalized or in residential facilities because of 
it, and its social consequences are severe.  A Mt.  Sinai 
Hospital study of 100 homeless men in New York found that 80 
percent of them had suffered brain trauma, much of it from child 
abuse.  A study of 5,000 homeless people in New Haven discovered 
that those who had suffered a blow that knocked them unconscious 
or into an altered state were twice as likely to have alcohol and 
drug problems and to be depressed.  It also found mTBI injuries 
were correlated with suicide attempts, panic attacks, and 
obsessive-compulsive disorders.  And a recent study by Dr.  
Elaine Peskind of the University of Washington School of Medicine 
found that mTBI is a risk factor for developing Alzheimerbs 
disease.
  In spite of the documented consequences of mTBI, the military 
has been extremely tardy in dealing with it.  Part of the problem 
is military culture itself.  The Pentagon found that 60 percent 
of the soldiers who suffered from the symptoms of mTBI refused 
help because they feared their unit leaders would treat them 
differently.  Many were also afraid that if they reported their 
condition it would prevent them from getting jobs as police and 
fire fighters after they got out of the service.
  Even if soldiers wanted treatment, there are few resources 
available to them.  "There are two things going on regarding 
vets," says Col.  (ret) Will Wilson, chair of the American 
Psychological Associationbs Division 19 (Military Psychology).  
"One, there are not enough care providers available, and, two, 
there are not enough people focusing on the problem outside the 
military."
  Indeed, there are not enough military psychologists to treat 
the problem, and since the military pays below-market rates for 
civilian psychologists, up to 30 percent of private psychologists 
are unwilling to take on soldiers as patients.  The cheapest and 
easiest solution is to shoot up the vets with drugs.  A study by 
Veterans for America found that some soldiers were taking up to 
20 different medications, many of which canceled out the effect 
of others.
  The situation appears to be even worse for National Guard and 
Reserve units, who make up almost 50 percent of the troops 
deployed in Iraq and Afghanistan.  The Veterans for America found 
that such troops "are experiencing rates of mental health 
problems 44 percent higher than their active duty counterparts" 
and that their health care is generally inferior.
  A Harvard study found that 1.8 million vets under 65 have no 
health care or access to the Veterans Administration.  "Most 
uninsured veterans are low-to-middle income workers who are too 
poor to afford private coverage but are not poor enough to 
qualify for Medicaid or free VA care," the study found.
  Treating mTBI injuries is difficult, but by no means 
impossible.  Dr.  Alisa Gean, chief of Neuroradiology at San 
Francisco General Hospital, who has worked with wounded soldiers 
at U.S.  Armybs Regional Medical Center at Landstuhl, Germany 
says the old conventional wisdom that brain damage was 
untreatable is wrong.  "We now know that the brain can heal.  It 
has an intrinsic plasticity that allows it to recover, and this 
is particularly true for the young brain." A recent study by the 
Massachusetts Institute of Technology found that "neurons in the 
adult brain can remodel their connections," thus "overturning a 
century of prevailing thought."
  One method that has worked effectively is cognitive 
rehabilitation therapy (CRT) that retrains patients for tasks 
like counting, cooking, and memory.  But CRT takes time and it 
can be expensive, ranging from $15,000 to $50,000 per patient.  
However, the DOD-BS health program -- Tricare -- refuses to 
endorse CRT, because it says there is no scientific evidence that 
justifies the expense involved.
  However, an investigation by T.  Christian Miller of ProPublica 
and Daniel Zwerdling of National Public Radio found that the vast 
majority of researchers, even those associated with the DOD, 
sharply disagreed with Tricarebs evaluation of CRT.  According to 
the two reporters, "A panel of 50 civilian and military brain 
specialists convened by the Pentagon unanimously concluded that 
cognitive therapy was an effective treatment and would help many 
brain damaged troops." The therapy is also endorsed by the 
National Institutes of Health, the National Academy of 
Neurophysiology and the British Society of Rehabilitative 
Medicine.
  Instead of accepting the advice of its own researchers, 
however, Tricare hired ECRI- a company which had already done a 
study concluding that CRT was ineffective-to examine the therapy.  
But critics charge that the study was so narrow, and the 
assumptions behind it so loaded, that it was almost a given that 
the study would conclude the benefits of cognitive therapy were 
"inconclusive." Outside researchers blasted the ECRI study, one 
of them describing it as "hooey" and "baloney." In spite of the 
criticism, then Deputy Secretary of Defense Gordon England 
concluded, "The rigor of the researchbandhas not met the required 
standard."
  However, Miller and Zwerdling concluded that Tricare's 
resistance to CRT was not about science, but the bottom dollar.  
According to the reporters, a Tricare-sponsored study found "that 
comprehensive rehabilitative therapy could cost as much as 
$51,480 per patient.  By contrast, sending patients home from the 
hospital to get a weekly phone call from a therapist amounted to 
only $504 a patient."
  Defense Secretary Robert Gates has already made it clear that 
he intends to cut the military's $50 billion annual health 
budget.  No matter how effective CRT is, it's not likely to get 
past the brass, who would rather spend the money on weapon 
systems than on healing the men and women who they so casually 
put in harmbs way.
  So far, the military has put the clamps on the new MRI 
technique.  Dr.  David L.  Brody, an author of the study, told 
the New York Times that researchers were blocked from giving the 
MRI results to patientsdd"We were specifically directed by the 
Department of Defense not to so," adding, "It was anguishing for 
us, because as a doctor I would like to be able to help them in 
any way.  But that was not the protocol we agreed to."
  Given that mTBI is so difficult to diagnose, and sufferers are 
many times told there is nothing wrong with them, that seems an 
especially cruel protocol.  "Many of them [the doctors] were 
hoping we could give results to their care providers to document 
or validate their concerns."
  In the end it will come down to treatment, and whether the 
wounded vets will get the care they need, or sit by a phone and 
wait for their once a week call from a therapist.