New Report on Veterans Health Care Deficiencies

These reports need to be heeded. Sitting around and doing nothing is the wrong answer:

Many Iraq war veterans with traumatic brain injury are not getting adequate health care and job assistance for their long-term recovery despite years of government pledges to do so, Veterans Affairs Department investigators say.

"Significant needs remain unmet," according to the report released Thursday by the VA's inspector general. It is the first to examine the Bush administration's long-term efforts in supporting veterans with traumatic brain injury, a leading problem among soldiers struck by roadside bombs that often causes lasting emotional and behavioral difficulties.

The study tracked a group of 52 patients that received VA treatment after sustaining brain injury during a seven-month period in 2004. An initial review by the IG in 2006 found gaps in follow-up care and family counseling 16 months after the injury and urged the VA to improve long-term case management.

The VA pledged to coordinate the necessary follow-up care with the Pentagon, but the latest audit concludes that efforts are still falling short for roughly one in four patients.

In a perfect world, you would be able to help everyone. I realize that this is far from a perfect world, and there are always going to be people who, for whatever reason, either don't want or can't cope with receiving help. I get that. But there are too many stories about Veterans being turned away, or ignored, or told the wrong thing.

The report included a VA response in which the department acknowledged problems with case management but stated that with recent improvements it now had "systems in place to ensure that all veterans with TBI are being followed as their clinical needs require."

For example, the VA pointed to plans announced last week to start calling 570,000 recent combat veterans to make sure they know what services are available to them.

In the audit, investigators praised the new measures as "positive steps" but questioned whether the VA's latest promise to keep watch over veterans would prove to be a reality. They said that "at least 8 of 49 veterans we contacted had significant unmet needs and no evidence of VA case management in the previous year."

"We continue to be concerned that all veterans discharged after inpatient rehabilitation for TBI receive case management, unless this has been explicitly denied by the patient," investigators stated, adding that they will continue monitoring the VA to ensure Iraq war veterans are receiving the care they need.

When you read stories about what is going on with The Broken Soldier, and hundreds of other cases, you can't help but wonder why there isn't more outrage.

UPDATE I - PALE RIDER 3:07PM

Closing arguments in the VA trial we've been following were today:

In closing arguments in a federal lawsuit against the Department of Veterans Affairs (VA), plaintiff lawyers accusing the agency of failing to effectively take care of our nation’s military veterans said, “1,457 veterans died while their appeals were pending” in the last six months alone. “More of these veterans are dying in the United States than out in combat,” attorney Arturo Gonzalez said.

Two veterans rights groups - Veterans for Common Sense and Veterans United for Truth - sued the VA hoping a federal judge could order the government agency to overhaul and improve its system. The trial took place in San Francisco with seven days of court testimony. Closing remarks were held Wednesday.

Plaintiff lawyers claimed the agency has dropped the ball in a number of ways and as a result has not provided proper access to health care and benefits to veterans. For example, they said the VA has yet to fully implement the Mental Health Strategic Plan that was introduced back in 2004. Gonzalez said, “there is no plan for dealing with all of these veterans who are returning and who are in need of help.” The argument was also made that veterans are waiting too long to get medical appointments and the benefits they deserve.

Daniel Bensing, the Department of Justice lawyer representing the VA, told the judge that the VA has a “very well-regarded system for providing health care.” He insisted that 80 percent of the Mental Health Strategic Plan recommendations have been adopted and he said, “98 percent of Iraq/Afghanistan veterans are seen within 30 days.”

Human beings have limits

And those boundaries have been breached where about 20% of our defensive forces are concerned. A new study by the RAND Corporation, released just today, pegs the number of veterans suffering from PTSD and depression at about 300,000 and the number of veterans who sustained brain injuries at about 320,000. With only one direction for those numbers to go, we are facing an immediate future where we have somewhere in the neighborhood of a million veterans of the wars in Iraq and Afghanistan needing care that the VA is ill-equipped to handle - they are overstretched now, and only half of the soldiers struggling with depression, PTSD and TBI have sought treatment.

The new study gives us a glimpse at a cringe-worthy future if we don't get our collective act together and deal with the issues facing these good men and women who stepped up and served. It also compliments and confirms an Army study on mental health that was released by the Joint Chiefs earlier this month that pegged the number of soldiers suffering from PTSD after one deployment at 12%, after two deployments at 18.5% and after three deployments at 28%.

Here is the cold hard truth that these studies tell - if the US Army was a distance runner, it would be hitting the wall about now, unable to go on one more step.

The Rand study, completed in January, put the percentage of PTSD and depression at 18.5 percent, calculating that approximately 300,000 current and former service members were suffering from those problems at the time of its survey, which was completed in January.

The figure is based on Pentagon data showing over 1.6 million military personnel have deployed to the conflicts since the war in Afghanistan began in late 2001.

RAND researchers also found:

_About 19 percent — or some 320,000 services members — reported that they experienced a possible traumatic brain injury while deployed. In wars where blasts from roadside bombs are prevalent, the injuries can range from mild concussions to severe head wounds.

_About 7 percent reported both a probable brain injury and current PTSD or major depression.

_Only 43 percent reported ever being evaluated by a physician for their head injuries.

_Only 53 percent of service members with PTSD or depression sought help over the past year.

_They gave various reasons for not getting help, including that they worried about the side effects of medication; believe family and friends could help them with the problem, or that they feared seeking care might damage their careers.

_Rates of PTSD and major depression were highest among women and reservists.

The report is titled "Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery." It was sponsored by a grant from the California Community Foundation and done by 25 researchers from RAND Health and the RAND National Security Research Division, which also has done does work under contracts with the Pentagon and other defense agencies as well as allied foreign governments and foundations.

This war is going to end. It has to. We can't keep fighting it, no matter what the keyboard kommandos fighting the War of the Words™ in their jammies think (I'm using 'think' loosely here).

They aren't doing the hard work of service, and have no idea what it entails. But those soldiers they simultaneously lionize and abuse are human beings. They are sons, daughters, husbands, wives, fathers, mothers, brothers, sisters, friends, neighbors...human beings.

And they deserve to be treated as such. And that is going to require that society start stepping up now - because 'late' is at least a little bit better than 'never.'

From the L.A. Times:

Thousands more mental health professionals -- both in government hospitals and the civilian healthcare systems -- are needed to meet the need of troops and veterans, and new training is needed for current medical professionals, according to the report.

"Since the dramatic increase in the need for services exists now, the required expansion in trained providers is already several years overdue," the report said.

The study recommends finding ways to help Iraq and Afghanistan veterans get access to the civilian mental health providers.

Mental healthcare also needs to be standardized and improved, and only a little more than half of the service members being treated for stress disorders and depressions received adequate care, according to the survey.

"The prevalence of PTSD and major depression will likely remain high unless greater efforts are made to enhance systems of care for these individuals," the report said.

Stress disorders and other combat-related mental ailments can lead to suicide, homelessness and physical health problems. But more mundane problems caused by stress disorders and depression can have long-term social consequences.

"These conditions can impair relationships, disrupt marriages, aggravate the difficulties of parenting, and cause problems in children that may extend the consequences of combat trauma across generations," the study says.

The failure to adequately treat depression and stress disorders can cost the United States up to $6.2 billion, said Lisa H. Jaycox, another of the study's authors.

"While the existing therapies do not guarantee recovery in 100% of people," Jaycox said, "we make the case that investing in treatment early would prevent some of the negative consequences from unfolding and save money."

We are blessed as a nation to have a core of good, decent men and women who are willing to serve and sacrifice for this country. When we abuse them and violate the pact that America makes with her Soldiers, Sailors, Airmen and Marines we abdicate our honor as a nation. And I, for one, refuse to be a party to treason - which, as far as I am concerned, is what it boils down to when we shit on those who serve.

TBI: Worse than we thought

Research scientists at Johns Hopkins have discovered that the effects of Traumatic Brain Injury (TBI) from exposure to bomb blasts are even more devastating than previously believed. The newest research shows that even when there are no outward signs of injury, brain cells can be altered, the cellular metabolism changed. Metabolic changes lead to a cascading effect, cells experience premature aging, and the result is neuronal death. Neurons do not replicate. Once a neuron is lost, it is gone forever.

The effects of this cellular demise are symptoms that may not be evident for months, or even years. The symptoms can range from vertigo, memory deficits and headaches to disorders of affect, such as anxiety, lethargy, and apathetic demeanor. "These soldiers could have hidden injuries with long-term consequences," says Ibolja Cernak, a scientist with the Johns Hopkins University Applied Physics Laboratory.

This latest research underscores the suspicion that many have expressed, that the number of Soldiers and Marines who have experienced or will experience the “signature injury” of this war may have been vastly underestimated up to now. Now consider that exposure to violent percussive incidents is not isolated in occurrence, but instead happens almost routinely. Some Soldiers and Marines have been exposed to up to twenty five separate blasts.


The most recent findings are the result of percussive experiments conducted on animals, then the animals were sacrificed and the brain tissue examined microscopically. In the animal studies, scientists have discovered a fundamentally different injury than the “concussion” wound that has traditionally been ascribed to exposure to explosions. A concussion is essentially a bruise on the brain that generally heals with time.

Brain damage at the cellular level is likely permanent – and will almost certainly lead to further neurological degradation over time. Put bluntly, G.I.’s afflicted by TBI are not likely to get better, and in fact will almost certainly get worse.

Since the first wounded veterans began returning, clinicians treating the wounded have noticed a pattern of symptoms emerging over time. Patients have been screened and found to be healthy; only to return with emerging symptoms at a later date.

To complicate matters further, because the physiological damage that underlies the symptoms occurs at the cellular level, the damage is undetectable by any imaging technique. "This is a new beast," said one San Francisco-based traumatic brain injury specialist who treated soldiers this year at an Army hospital in Germany.

Vindication for a long-running hissy-fit

I have a long history of writing about mental health issues and repatriated soldiers. (More here, here, and here)

Sometimes it has felt like I was shouting down the well. Thank goodness these issues are finally getting some traction. Yesterday I got one more bit of vindication when the Institute of Medicine, which advises the federal government on issues of medical science, released their long awaited report on the treatment returning soldiers are not getting.

The report suggested changes to VA policies, but the panel could not say whether those changes would result in more or fewer PTSD diagnoses, or in greater or lesser expense for taxpayers. "PTSD has become a very serious public health problem for the veterans of current conflicts and past conflicts," said psychiatrist Nancy Andreasen of the University of Iowa, who chaired the panel. Noting the shortcomings of the VA system, Andreasen added that "a comprehensive revision of the disability determination criteria are needed."

She said the current VA system, in which PTSD compensation is limited to those who are unable to hold a job, places many veterans in a Catch-22.

"You can't get a disability payment if you get a job -- that's not a logical way to proceed in terms of providing an incentive to become healthier and a more productive member of society," she said.

The practice is especially wrong, she added, because it is at odds with VA policies for other kinds of injuries. To determine the compensation a wounded veteran should get, the government assigns one a disability score. Veterans who are quadriplegic, for example, can be assigned a disability level of 100 percent even if they hold a job, whereas veterans with PTSD must show they are unable to work to get compensation.

Andreasen said the policies are "problematic, in the sense that they require the person given compensation to be unemployed. This is a disincentive for full or even partial recovery."

I personally favor adopting the suggestions offered by Linda Bilmes of Harvard. She has offered the most troop-centric approach to offering services to those who need and deserve those services. Her notion is so simple it hurts: Give the troops who apply for benefits the benefit of the doubt!

The Institute of Medicine panel said the scale used to evaluate veterans is outdated and largely designed for people who suffer from other mental disorders. Andreasen and other members also said they had heard from veterans who had received wildly different kinds of evaluations -- some lasting 20 minutes while others took hours. The scientists said VA should standardize the evaluations using state-of-the-art diagnostic techniques.

While VA requires its experts to determine what proportion of a veteran's disabilities were caused by particular traumatic experiences, and to what extent overlapping symptoms are related to particular disorders, the IOM said there is no scientific way to classify symptoms in this manner.

Frankly, if you aren’t mad as hell about the way our troops are being treated – if you aren’t pissed off about the fact the VA is still not fully funded – don’t be mouthing platitudes about supporting the troops around me.

Gut-Check Time

Do you support the troops? I mean, do you really support the troops? Or is that just some words you say when the subject comes up? If you really do support the troops, you need to take stock of reality.

Our military is seriously compromised. These kids – and most of them are kids – are in the middle of an urban guerrilla war in an Arab country. Four years on, it has taken it’s toll, and the situation is unsustainable.

Here is reality – we are apace to create a couple of million people who have been repeatedly exposed to percussive trauma. It has an effect on the person after the frontal lobes bounce off the inside of the skull a few times. Couple the physical compromise with the constant anxiety. Now tell those same soldiers that they just had their out-date yanked and they have another three freakin’ months in this hellhole, and you have a recipe for atrocity. Especially when you are rotating people back in with inadequate dwell time, and things like War Ethics aren’t being taught.

Human beings can only take so much, god-damnit. What the fuck do you people want? How much more do you expect your Army to give? You have to knock this shit off and face the fact that you have asked too much. Not only has too much been asked, it was all predicated on lies. In a just world, the architects of the war would be charged with one count of murder for every “comma” out of Iraq.

Bullshit slogans like “Defeat is not an option” are a fucking insult. You got that? If defeat is not an option – don’t get in the pissing match in the first place, because you know what? Both sides always believe that, and one side always has to accept that they were wrong.

Reality trumps rhetoric every god-damned time. And the assholes who work at the think tanks need to get a new name for their various ventures if they can’t accept that.

A study released last week revealed some disturbing trends in the psyches of soldiers.

More than one-third of U.S. soldiers in Iraq surveyed by the Army said they believe torture should be allowed if it helps gather important information about insurgents, the Pentagon disclosed yesterday. Four in 10 said they approve of such illegal abuse if it would save the life of a fellow soldier.

In addition, about two-thirds of Marines and half the Army troops surveyed said they would not report a team member for mistreating a civilian or for destroying civilian property unnecessarily. "Less than half of Soldiers and Marines believed that non-combatants should be treated with dignity and respect," the Army report stated.

About 10 percent of the 1,767 troops in the official survey -- conducted in Iraq last fall -- reported that they had mistreated civilians in Iraq, such as kicking them or needlessly damaging their possessions.

Now think about this: These guys are going to come home and reintegrate into society. We are already failing returnees with TBI and PTSD on the mental health front. Society –it has the potential to get really ugly. We have vets becoming homeless waiting for benefits. First they get blown up, then they get blown off. What a fuckin’ deal.

If you really support the troops, if you realize they are beings with lives, loves, hopes, dreams and futures that are being denied them at your behest, and you have half assed it from the get-go, you need to suck it up, admit the error of your ways, apologize, and bring the troops home now.