Sandra Day O’Connor and Maria Shriver have called for a 10 year plan to defeat Alzheimer’s disease–“our generations defining challenge.” Invoking the visionary leadership of both John F. Kennedy & Ronald Reagan, they spotlight the National Alzheimer’s Project Act as the greatest public and financial health issue of our time. No doubt our country needs the push as millions of baby boomers age into their retirement years and Alzheimer’s “must be considered a full blown epidemic.”
But, the country faces another epidemic, more immediate and a direct threat to national security, a disease of the brain like Alzheimer’s and a direct consequence of nearly 10 years of fighting in Southeast Asia – the disabling legacy of IED blasts and PTSD. The IED (improvised explosive device) has changed the wars in Iraq and Afghanistan and created harrowing suffering among hundreds of thousands of battlefield casualties. Over 2 million Americans have seen combat. At least half of all killed in combat have fallen to IED attacks. A quarter of the combatants – 500,000 men and women – have been victims of multiple blasts. All the surviving amputees from IEDs suffered “blows” to the head as well. For every soldier killed or seriously wounded, ten more live with the long-term effects. A common case - a senior NCO who had endured over 40 blasts, was working every day enthusiastically with all the commitment that can be imagined, despite having daily headaches, difficulty sleeping, and worrying that he couldn’t think as well as he did before. No one has checked his performance. He is a casualty, like thousands of other men and women who struggle each day to patch up their lives.
Blast concussions from IEDs contribute to homelessness, suicide, unemployment, fractured families, and weaken the fighting force- the early signs of a growing and tragic epidemic. The aftershock of hundreds of thousands of combat blasts ripples through the society with immediate and heavy impact. Over a thousand veterans have committed suicide, one quarter the number that has been killed in combat. The ratio of homeless veterans of these wars far exceeds those from Vietnam.
This epidemic will haunt our society, as has the medical fallout from previous wars. Vietnam was followed by the stubborn “signature injuries” of PTSD and Agent Orange, and the Gulf War Syndrome still afflicts many veterans of Desert Shield/Storm. Hundreds of thousands of men and women suffer the crippling aftershocks of their military service and continue to linger and impose billions in healthcare costs. If this history is pertinent, then we are just seeing the bow wave of a great epidemic in brain disease in the injuries from IED blasts.
By invoking the legacies of JFK’s expedition to the moon and Ronald Reagan’s defeat of communism, the campaign plan for defeating brain disease assumes the look and feel of a military operation grafted on to a medical science endeavor. In fact, defeating the devastating effects of IED blasts requires the strategic planning and organization of a Manhattan Project or moon shoot - projects that succeeded with strong leadership and action plans in pursuit of clear, tangible objectives. Such leadership is needed to treat mild traumatic brain injury, and guide the scientific enterprise, and balance the culture of medical science, anchored in academic institutions that are inherently open-ended and exploratory. It is not likely that the problem of brain diseases – either IED induced or Alzheimer’s – can be solved with the discovery a vaccine (as developed for polio) or even multiple drugs (as for HIV) – diseases caused by identifiable infectious agents. The brain disease of blast concussions is more complex, and links to many more biological, psychological, environmental, and social factors. Any campaign to defeat or mitigate these illnesses extends beyond medical science and requires the planning and programming of a Manhattan Project.
My experience over the past several years has shown that institutional processes and regulations have encumbered advances in brain science and developments of treatments. Despite nearly $2 billion that has been allocated to the problems of psychological health and blast concussion, few, if any, new treatments have been delivered to the troops and families. The current portfolio of research and development, which should be applauded, will take many years to show productive results. The Defense Centers of Excellence for Psychological Health/mTBI, established by the Congress, has not been able to achieve its intended goals and objectives. But, the demand for treatments is urgent, in the face of the probable continuing aggravation of symptoms and deterioration secondary to the blasts that affect the casualties. The planning and programming of a military campaign is vital.
In short, an ideal veterans/military medical campaign starts with drafting multiple courses of action targeting the diverse dimensions of the brain disease, and top-flight coordination of efforts – early identification of injury, expedited trials of potential diagnostic tools and treatments, quick development of promising cures. It looks like a counterinsurgency plan, a “surge” of initiatives with the sophistication and imprimatur that succeeded in Iraq and is being carried out in Afghanistan (with all the complexity). Rhetoric aside, customary medical science programs are driven by the scientific questions and individual interests of the respective researchers. No matter how well intentioned, the fundamental focus on the target problem or patient often becomes obscured by the culture of the researchers. And, the convoluted politics of the regulatory agencies interfere. In this way, potential and promising new treatments have been stymied and not pursued. Instead, really promising treatments – inexpensive and low risk - are being promoted independently and in “creative” fashion by their developers relying on good will and charitable donations if they can get them. This is good initiative, but inefficient and hurtful to the mission – ultimately helping the combat casualty. If a fundamental element of an effective surge campaign (counterinsurgency) has been partnering with local and influential agencies, then formalized academic, private, and clinical partnerships are needed to attack this epidemic.
It may be time for the White House to engage in the Surge Against Brain Disease. Its leadership is needed to empower the National Alzheimer’s Project Act and broaden the appeal to unlock the mysteries of the brain. The veterans rely on a common sense approach to recovering their individual health and not just good science. The nation must act to reduce the epidemic burden on society of the medical consequences of this war, mitigate the projected cost, and minimize the lost years of potential productivity.
Stephen N. Xenakis is a child and adolescent psychiatrist and a retired Army brigadier general. He is in clinical practice and the founder of a nonprofit conducting research on brain-related diseases. He discusses this topic further on NPR's All Things Considered.