This article, written by DefenseWeb Board Member Dr. Harold Koenig, examines Traumatic Brain Injury (TBI), an emerging military health challenge. In the article, Dr. Koenig discusses what we know about TBI in the context of Iraq and urges the military community to take action on the issue for the benefit of service members and families.

With Each New Conflict, a New Health Challenge
The Iraq War and Traumatic Brain Injury (TBI)

By Harold M. Koenig, M.D., Vice Admiral US Navy, Retired

Each war brings a new medical puzzle to solve.  War is brutal for both civilians and combatants, but the evolving nature of conflict, particularly in an age dominated by advanced technology and asymmetric weaponry, leads to new challenges.  The Iraq War, featuring guerilla-style combat in tense, crowded urban areas against hard-to-identify enemies, is no different.  The current conflict’s health challenge that is perplexing medical professionals and researchers alike is traumatic brain injury, or TBI.

To understand the complexity of researching and understanding how to treat TBI, it is worth remembering how military health issues have evolved, and been understood, in recent history.  Following the war in Vietnam, the issue was Post Traumatic Stress Disorder (PTSD), which was not formally recognized as a “real” disease by the medical establishment until 1980, nearly five years after Vietnam’s end.     

In 1991, the US launched Desert Shield/Desert Storm.  The combat phase of the operation lasted only four days and there were few casualties.  However, many soldiers spent almost a year deployed in the extreme conditions of the Arabian Peninsula.  When they returned to the US, some started experiencing vague and ill defined maladies.  Eventually, this was labeled “Persian Gulf Illness” or “Gulf War Syndrome.” 
 
Now, we have traumatic brain injury.  According to the National Institute of Health, TBI is defined as the effects to the brain from a head injury, and resulting disabilities can include problems with cognition, sensory processing, communication, and behavior or mental health.  The Veterans Administration estimates that more than half of our wounded soldiers have been injured by IEDs¹.  According to recent research, 10% of all troops in Iraq, and 20% of front line troops² , experience some degree of TBI, ranging from concussion to permanent brain damage. 

With advances in body armor protecting soldiers from wounds that would have been fatal in past wars, and the enemy’s preference for explosives, TBI is occurring much more frequently in Iraq and Afghanistan.  Body armor has been highly effective in protecting against injury from bullets and projectiles, but it is not effective against a blast injury from an improvised explosive device, or IED.

TBI has recently garnered wider attention by the public and from the media, for example former NFL players who experienced multiple concussions show TBI symptoms years later, including depression and brain damage³.  But until we can better define these issues, they will continue to be misunderstood. 

The increasing number of soldiers with TBI is a challenge for the military health system, the VA, and for our nation’s healthcare system.  The symptoms of traumatic brain injury can be sometimes misdiagnosed as PTSD (although a number of soldiers with TBI may also have PTSD).  Consequently, the appropriate treatment for these service members may also be missed or late in coming.

Some of the affected are going to recover; others will remain in a permanent vegetative state.  In between are many soldiers who, though able to function, will never be the same person as they were before their injury.  They may function mentally at a lower level.  They may be frustrated due to their inability to function as they did before and turn to liquor, the only “legal” sedative available to them, or other illicit substances.

TBI is becoming the “signature wound” of Operation Iraqi Freedom and Operation Enduring Freedom.  We need to sustain and increase funding for institutions like the Defense and Veterans Brain Injury Center which invest in research that helps us diagnose it earlier.  This will also help us better monitor those diagnosed with TBI, and understand what treatments work most effectively. 

We are going to hear a lot more about TBI in the future, and we have a responsibility to those who have served to bring the best scientific minds in our nation to address the consequences.  Confronting this challenge early and with the facts is what we owe our service members and their families.  As many as 75 percent of people with TBI may suffer depression, and their suicide rate is as high as four times that of the general population⁴.  The time to act is now.  
 

¹ http://www.csmonitor.com/2007/0102/p01s03-usmi.html

² Zoroya, Gregg. “Center for war-related brain injuries faces budget cuts,” USA Today, August 8, 2006.

³ http://www.nytimes.com/2007/01/18/sports/football/18waters.html?ref=sports

⁴ Rudavsky, Shari. “Initiative warns of depression risk after brain injuries,” Indianapolis Star, February 12, 2007.

 

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