This is the second article in a three-part series on the epidemic of traumatic brain injury among those who served. Read part one here.
It was 2009 at the Pentagon, and a group of military doctors and civilian experts was having a fight in front of two of the top generals in the U.S. military.
Gathered in a conference room at the Pentagon, the civilian doctors were insisting that the traumatic brain injuries service members were suffering were far more serious than the military realized.
The military doctors wanted more evidence that the brain injuries, which were starting to mount as deployed troops were facing the near-constant threat of roadside bombs in Iraq and Afghanistan, were going to have the long-lasting effects the civilians predicted.
"The two groups had a frickin' food fight in front of [Marine Corps Commandant Gen. Jim] Amos and I, and we got up and said, 'We're out of here, this is ridiculous,'" then-Army Vice Chief of Staff Gen. Peter Chiarelli recalled in a recent interview with Military.com. "We knew we had a problem."
It was "three hours of hell," Chiarelli recalled. "Military doctors were basically poo-pooing traumatic brain injury, and the civilian experts were saying, 'Wait a second, you guys are way behind here.'"
Chiarelli had set out to learn all he could about the mental wounds of war after being shocked by statistics he saw shortly after becoming the Army's No. 2 officer. Those numbers showed 36% of the service's seriously wounded soldiers were suffering from TBI or post-traumatic stress disorder, far outpacing more visible war injuries such as burns and amputations. So, he organized the Pentagon briefing.
But while the debate was raging in Chiarelli's office, doctors had known for years that TBI was becoming a problem. As hundreds of thousands of service members suffered brain injuries, action was delayed and the military dithered over what to do, mired in flashpoints such as the 2009 Pentagon meeting.
That delay may well have cost lives, given an increasingly clear link between the brain injuries and suicide.
Six years earlier, physicians at Walter Reed National Military Medical Center in Washington, D.C., and the National Naval Medical Center in Bethesda, Maryland, began seeing service members from Afghanistan and, later, Iraq, with physical injuries from combat. They were also arriving with mental deficits, despite not appearing to have received any blows to their heads.
As they recovered, these men and women looked fine -- and said they felt great -- but they struggled with headaches, behavioral changes, memory loss and difficulties solving problems.
"It was always the moms who would tell us, 'Something's not right. This isn't how he usually is,'" said Maria Mouratidis, a psychologist who specializes in traumatic brain injury and psychological health who worked at Bethesda during the early days of the wars.
The year military physicians in D.C. and Maryland first noticed the issue, the Army diagnosed 437 soldiers with traumatic brain injury, more than half of whom had permanent brain damage. At Bethesda, roughly 83% of wounded Marines and sailors had either temporary or permanent brain damage as part of their combat injuries.
The numbers were so striking, doctors began calling TBI a signature wound of the wars, much like Agent Orange-related illnesses in Vietnam or mustard gas poisoning from World War I. But it would be more than seven years before the Defense Department established treatment protocols for these injuries or instituted guidance for commanders to address the problem in the field.
Early pushback from military leaders and lengthy debate in the military medical community about TBI and its often-concurrent diagnosis, PTSD, meant troops like Army Spc. Daniel Williams went years before they knew what was wrong with them.
Williams, who suffered from angry outbursts, sleeplessness, memory loss and migraine headaches, knew he had PTSD from a roadside bomb blast that killed a buddy, but he didn't learn he had a head injury until more than three years after the event.
"If you are not out there making millions of dollars for them playing football, they don't care," Williams said about what he sees as a lack of interest in veterans' injuries, including head trauma, mental health conditions and suicide. "Society right now, they don't care. They could give a crap less. People hate us."
A Growing Problem
Clinicians at Walter Reed, Bethesda and elsewhere may have been quick to recognize the issues with brain injuries, but DoD leaders took years to address the growing problem.
Needing troops to remain in battle to fight two wars -- going to combat with, in the words of then-Defense Secretary Donald Rumsfeld, "The army you have, not the army you might want or wish to have at a later time" -- the Pentagon was slow to implement measures and treatment that may have prevented some of these injuries, and subsequently some of the estimated 30,000 suicides by post-9/11 veterans.
Traumatic brain injuries have been diagnosed nearly 460,000 times among the almost 3.7 million Americans who have served in the U.S. military since Sept. 11, 2001. And despite years of efforts and assurances by leaders that they consider suicide prevention a priority, the suicide rate among service members and veterans remains stubbornly high.
While suicide is a complex issue with many contributing elements, TBI is emerging as one of the biggest factors, according to studies published in the past five years by the Centers for Disease Control and Prevention, the Department of Veterans Affairs and outside researchers.
One study published earlier this year found the suicide rate among veterans who experienced a mild TBI, also known as concussion, was three times higher than the general population, and that those with moderate to severe brain injuries were five times more likely to die by suicide.
What made Iraq and Afghanistan so different was that, in previous wars, troops close to any explosion or a blast would have died. And in the early days of both those wars, U.S. service members did -- in Humvees that lacked armor, trucks with canvas tops, on foot patrol wearing insufficient body armor, their medics and corpsmen ill-equipped to treat patients on the battlefield for a new style of warfare.
"[The services] thought it was going to be like the Gulf War and not even last a month," Mouratidis said.
As the death toll climbed, families began spending thousands of dollars on body armor to send to their deployed loved ones and pressing the Pentagon for better equipment -- blast-resistant up-armored vehicles, comprehensive armor with hardened "blast panties" to protect groins and genitalia, and better helmets. Some troops improvised armor, filling vehicles with sandbags to try to shield themselves.
The fight was slow. And in the meantime, head injuries mounted.
On the battlefield, one of the most common ways service members were suffering brain injuries was while they were in vehicles targeted by improvised explosive devices.
Flaubert Tchantchou, a researcher who led a study on brain injuries of service members in vehicles targeted by land mines published in 2018, said military vehicles weren't equipped to absorb the shock of a blast, so that even if those inside didn't suffer visible injuries, their brains were getting knocked around in the explosions.
"The injury might not sound that severe," Tchantchou said in an interview with Military.com. "The person lost consciousness, but seemed to recover. But over time because of the impact of this injury to the brain, it might have a long-term effect on this person, who will be suffering gradually over time. The symptoms vary from one person to another. One person might be feeling anxiety randomly. Some of them might be really, really very depressed."
Tchantchou studied the issue by putting lab rats in small-scale vehicles and exposing them to similar force as an under-vehicle blast.
The development of Mine-Resistant Ambush Protected vehicles, or MRAPs, with their V-shaped hull to deflect blasts, was meant to address the IED threat. But the first MRAPs didn't arrive until 2007.
Once the services' medical commands understood the battlefield, they improved the level of care at the front lines, placing advanced treatment centers near the forward operating bases. They perfected the extraction of the wounded to larger bases, where they were stabilized and then flown back to the U.S. -- sometimes within 48 hours of being hit.
In 2004, recognizing a growing problem in their patients, the physicians at Walter Reed, Bethesda and elsewhere started pressing for improved screening and diagnosis of traumatic brain injury.
That year, experts at the Defense and Veterans Brain Injury Center developed a screening tool for traumatic brain injury that could be used by medical personnel on the front lines. A year later, the center issued guidance to deployed providers on the diagnosis of traumatic brain injury following a blast, along with information on detection and treatment.
The Pentagon, knee-deep in executing two wars, balked.
Army Col. Tony Carter told USA Today at the time that the recommendations, which included screening questions and removing those who were concussed from combat, weren't supported yet by science.
"That would be very, very difficult to do. You don't know [how many blast exposures are too many]. Half a dozen? One? I mean, what's the tipping point?" Carter said.
The Fight at the Pentagon
The problem dragged on. In 2009, Chiarelli called in the 13 experts, including David Hovda, director of the University of California Los Angeles' Brain Injury Research Center, to brief Army officials and doctors at the Pentagon on TBI. When the outside experts argued that concussion was a serious injury that could cause psychological symptoms deserving of rest, Army medical leadership "basically said, 'There's nothing to this,'" Chiarelli recalled.
Hovda, a bald 69-year-old with a baritone voice who recalled every detail of the meeting like a grandparent sharing a war story, confirmed Chiarelli's account.
"Several of these doctors -- I promised that I wouldn't expose their names or anything -- said that this was false, and I was just dreaming this up," Hovda, who let out a knowing chuckle when asked whether the Army resisted his advice, told Military.com in an interview.
While both men declined to name who in the Army medical community pushed back, the top person in the room that day was Lt. Gen. Eric Schoomaker, the Army surgeon general at the time.
To that point in Schoomaker's career, he had spent "half a lifetime trying to keep people from forcing us to buy things that were of no value on the battlefield," he told Military.com
"Part of my responsibility is to build things, and to post protocols and policies that are based in good evidence and not do things that may potentially harm," Schoomaker said. "History is replete with examples in which we've done things for all the right reasons, thinking we were doing good, only to discover later that we weren't."
He cited medical treatments such as treating acne with radiation or using mercury to treat various ailments in the 19th century.
"I'm not saying that Gen. Chiarelli was advocating the use of mercury for anything, but what I felt I needed to align on was that a large number of people were coming forward -- were going a little too rapidly toward solutions -- when we didn't have evidence for them."
Dr. Robert Labutta, a former Army neurologist who later served as an adviser to the Defense and Veterans Brain Injury Center, remembered the debate well.
"Good medicine has skeptics. They want to see the proof," Labutta said during an interview. "There were publications talking about the epidemic, there was a parallel with sports and the NFL -- when do you take someone from the field? When do you take someone from the battlefield? How do you treat it? Healthy skepticism helps to refine the thinking so doctors are not overtreating or undertreating."
After that meeting, however, Hovda didn't just go away. He continued to consult, doing work that contributed to the creation of the military's National Intrepid Center of Excellence that researches and cares for brain injuries -- work that led to the creation of DoD Instruction 6490.11, DoD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting, published in 2012.
Members of Hovda's team visited Afghanistan shortly after the meeting with Chiarelli and others, and he recalled the resistance they encountered from staff noncommissioned officers after floating the idea that troops who experience concussion should be allowed more time to recover.
"If you're in combat, the last thing you want to be done is to be pulled away from your unit and be taken out of action," Hovda said. "They were never trained to recognize this problem. This was something brand new for them. And it was a little slow on the pickup, but they got it pretty quick."
The Search for a Solution
As more service members became injured, however, the services started coming around, and the public sector, private industry and academia began investing in research into the effects of blast on the human brain and mitigation efforts.
Among the thousands of projects, the Army's Program Executive Office Soldier in 2008 fielded a helmet accelerometer sensor with the 101st Airborne Division that measured the pressure wave from a blast.
At the same time, the Defense Advanced Research Projects Agency, the wing of the Defense Department meant to test far-out technology, was expressing interest in wearable technology that would measure the level of blast experienced by service members. If a soldier or Marine was injured or came in close proximity to a blast, a medic or corpsman could check the reading of DARPA's Blast Gauge and determine whether treatment was necessary.
The systems had drawbacks. The Army's gauges measured what happened to a soldier's helmet -- including any movements, bumps or strikes -- and used an algorithm to estimate the concussive impact and extent of injury, without actually measuring what was happening inside the head.
"It kind of makes sense to have an accelerometer on the helmet, but if I bump my head getting into the vehicle ... or I I take my helmet off and drop it on the ground, it's really easy to get [a] really high false positive rate," said David Borkholder, a professor at Rochester Institute of Technology who founded BlackBox Biometrics Inc., makers of the Blast Gauge System.
DARPA's project, which formally began in 2010, consisted of three different sensors on a service member's body armor that measured overpressure, or the amount of pressure above the normal amount in the atmosphere. But after it was tested in Afghanistan, developers discovered their Blast Gauge detected the most exposures in troops firing heavy weapons.
The data seemed to indicate repeated exposure to blasts that were much more common than just IED attacks could add up and cause brain injuries, and that weapons such as recoilless rifles, shoulder-fired rockets, artillery and mortars were likely harming troops' brains.
The results didn't exactly sit well with the DoD, according to Borkholder.
"I think there's a good corollary there to the NFL with concussions," said Borkholder, who has a slim build and tight haircut. "So the NFL wanted a bunch of research to look like they were doing something, but at the end of the day, they wanted their guys playing football, right?
"It completely changes the landscape when you say most of these exposures are happening in training and are preventable," he added.
In the end, neither program really gave the Pentagon what it wanted: a system that could determine whether a service member had a concussion. And in 2016, the projects were abandoned for the most part, although, according to Borkholder, U.S. Special Operations Command still remains interested.
Eventually, the military would take action, and nowadays, the Pentagon and VA have comprehensive brain health programs.
The Defense Department this year unveiled a new brain health strategy; both it and the VA updated clinical guidance for treatment of service members whose concussion symptoms linger; and nonprofits that help veterans with TBI say art, music and other nontraditional therapies are showing signs of success.
But despite the end of both wars, the problem still exists.
Service members venture into harm's way -- at least 110 service members suffered traumatic brain injuries in an Iranian missile strike on Iraq in 2020 -- and they train consistently with large-gauge weapons. The biggest offenders are the Carl Gustaf M4 and AT4, the M72 Light Anti-Armor Weapon, and the .50-cal sniper rifle, among others, according to a study done by Lauren Fish and Paul Scharre at the Center for a New American Security in 2018.
The continued training and combat exposures come at a price. Since 2003, veterans have filed 348,587 claims for traumatic brain injury, nearly 59% of which were approved. The VA could not provide a figure for the annual payout to veterans for TBI, given that awards are paid based on a combined degree of disability for all service-connected disabilities.
A VA spokesman added, however, that the average single disability rating for TBI-related conditions is 30%.
The costs extend beyond disability pay. Many veterans with traumatic brain injury require assistance on a daily basis, and some need around-the-clock care. And while it's not known how many suicides among post-9/11 veterans can be attributed to traumatic brain injury, the deaths leave behind devastated families and friends.
For Williams, who attempted suicide several times, life was never the same.
"I got separated and divorced. I lost my kids, lost the house," said Williams, who has since remarried. "I am never going to stop having a TBI."
Veterans and service members experiencing a mental health emergency can call the Veteran Crisis Line, 988 and press 1. Help also is available by text, 838255, and via chat at VeteransCrisisLine.net.
-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime.
-- Rebecca Kheel can be reached at firstname.lastname@example.org. Follow her on Twitter @reporterkheel.