Agent Orange déjà vu

The New England Journal of Medicine recently published findings that confirmed damage to the brain from improvised explosive device (IED) blasts suffered by soldiers. In a companion editorial, a Harvard neurologist forcefully concluded that the problem deserves “the utmost attention.” On Sunday of Memorial Day weekend, Candy Crowley of CNN interviewed the Vice Chief of Staff of the Army, Peter Chiarelli, who said that still “more research” was needed into the conditions plaguing soldiers. Veterans who also appeared on the show complained about the hurdles they must overcome to get even basic treatment. 

After many years and billions of dollars, the tragic story we have seen in past wars is repeating itself: a unique and debilitating disorder from combat is answered by delays and hand-wringing by military leadership while our wounded warriors suffer. 

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Why?

The simple answer is that not much has been done in providing new treatments or expanding current programs. 

Blast concussions, and the associated conditions, have become the “Agent Orange syndrome” of Iraq and Afghanistan and a serious public health problem. 

For those of us who lived through the Vietnam era, the complaints of soldiers and the recalcitrance of the military are reminiscent of the failures to address the damage from Agent Orange. Just like their Agent Orange predecessors, soldiers exposed to thousands of blasts over 10 years of combat still have to wait “until the science shows” the evidence for the pathology. 

Meanwhile, they receive inadequate treatment, endangering them further and making their reintegration as productive members of society even less likely. Not to mention the collateral damage of the suffering endured by their families and friends. 

That is tragic and wrong. 

Good treatment has been either delayed or denied because of professional neglect. Medical personnel have had available treatments for the effects of IED blasts, but failed to use them. These treatments may not always “cure” the conditions, but they have alleviated many of the worst symptoms. 

In 2004, I saw soldiers, some double amputees at Walter Reed Army Medical Center, who were obviously suffering with mild traumatic brain injury. 

By 2007, I accompanied the newly appointed chairman of the Joint Chiefs to Fort Sill in Oklahoma, and soldiers told us they knew “the difference between their PTSD and blast effects.” 

After I shared this information, the leadership of military medicine responded with depressing predictability: “evidence was lacking” of a direct effect on the brain from the blasts. A senior neurologist sniped that it made little difference because we had no treatments for the problems. That attitude is disgraceful; but most importantly, it is simply not true. 

Ironically, the “lack of evidence” has reinforced the prejudice that soldiers’ complaints are psychological or a question of character. Articles challenged early findings of brain injury by correlating the effects of IED blasts to psychological stress. The Department of Defense (DOD) refused to approve cognitive rehabilitation, diagnostic tests and other treatments because of a “lack of evidence.” Only now, after 10 years of war, have a few of these tests been started. Some DOD and Veterans Affairs centers are treating more TBI patients — but not nearly enough. 

The immediate challenge is help the warriors now, and not wait decades for the golden nuggets from new research to show results. Too many battle-scarred soldiers are returning to their communities — hoping to get an education and find a job in a tough economy — but sabotaged by invisible injuries from their repeated tours of duty.

The DOD and VA today must develop and expand health programs, leveraging current treatments with promising new therapies. We hear about “doing a better job,” but these are empty promises lacking funding and strategic planning. Those of us who’ve seen this before recognize that because IED blasts cause “invisible wounds, that could “not be real,” like post-traumatic stress disorder or Agent Orange, a combination of stigma and paralysis means tens of thousands of those who suffer will never receive help. 

Nations get called to fight wars. But wars are followed by public health epidemics. 

What a shame that we might neglect another generation of heroes. If we continue to do this, can we ever ask young people to fight for us again? 

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.


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