Agent Orange De Ja Vu

Posted on Dec 2, 2014 in Articles

Agent Orange De Ja Vu

            BG (Ret) Stephen N. Xenakis, M.D.

 

The New England Journal published findings this week that confirm damage to the brain from IED blasts suffered by soldiers in combat. In a companion editorial, a Harvard neurologist exhorts that this problem deserves “the utmost attention.” On a Sunday talk show over Memorial Day, a senior Army leader placed his emphasis on more research into the conditions. The veterans who also appeared complained about the hurdles they must overcome to get treatment. Good research is vitally important, and billions of dollars have been spent looking at the problems over the past five years. But, frankly, not much has been done in providing new treatments or expanding current programs, which means that hundreds of thousands of soldiers and veterans are languishing across the country.

 

Blast concussions, and the associated conditions, have become the “Agent Orange” syndrome of these wars and a serious public health problem. For those of us who lived through the Vietnam era–the rhetoric, the politics, the funding, the bureaucracies- the public discussions remind us all too vividly of the failures to address the damage from Agent Orange early and aggressively. The faces have changed, but the bureaucracies have grown, and the soldiers exposed to thousands of blasts over 10 years of war will have to wait “until the science shows” the evidence for the pathology and treatments for their conditions. That is tragic and wrong.

 

Good treatment has been delayed, and lacking out of professional neglect. Medical personnel have known enough for many years how to treat the effects of the IED blasts. The soldiers that I saw at Walter Reed Army Medical Center in 2004, with amputations of arms and legs, also complained of the problems in thinking and controlling their emotions that are now commonly accepted as signs of mild traumatic brain injury. By 2007, many soldiers would complain of such problems and even remark that they knew “the difference between their PTSD and blast effects.” The newly appointed Chairman of the Joint Chiefs of Staff and I sat with Captains at Fort Sill in October who told us those stories. When sharing the information with the leadership of military medicine, they responded, “the evidence was lacking” of a direct effect of the blasts on the brain. A senior neurologist even remarked that it made little difference to know if the blasts caused injury because we had no treatments for the problems. That attitude is callous and disgraceful, but barely disguised the sentiment of the medical bureaucrats. Ironically, the “lack of evidence” reinforced the prevailing opinions that the soldiers’ complaints were really psychiatric or signs of personal weakness. Military researchers pumped out a series of articles correlating the effects of IED blasts to psychological stress and challenging the early findings of the injuries to the brain.

 

The accepted treatment for mild traumatic brain injury–cognitive rehabilitation–was not approved by the DoD also for “lack of evidence.” Furthermore, research on potential new diagnostic tests and treatments were delayed and only started in the last year because the “evidence was lacking” that such tools would help. Only now, after 10 years of war, the tests are being conducted. There are a few exceptional centers for treatment of blast concussions and associated medical/psychiatric problems across the Department of Defense and Veterans Affairs, but clearly not enough to treat the hundreds of thousands of men and women who have served in Iraq and Afghanistan.

 

The challenge is to promote and deliver current treatments as best as possible, and not just wait for the golden nuggets from new research to help the problems decades from now. Too many warfighters will be going back to their communities–trying to get an education and find a job in a tough economy–and struggle with injuries and symptoms of their repeated tours of duty. The strategic focus for the DoD and VA should be on developing and expanding community health programs leveraging current treatments for their beneficiaries. We hear some words about “doing a better job,” but not nearly enough hard-nosed thinking and planning on how to do it. The buzz goes research and new findings – the glitzy science. Those of us who’ve seen this before recognize that the needs of the veterans are being “slow- rolled and pushed to the out-years.” IED blasts cause “invisible wounds, which may “not be real,” like a mental health problem or Agent Orange. These conditions have been stigmatized, funding for diagnosis and treatment have been inadequate, and their legitimacy is repeatedly challenged.

 

Nations get called to fight wars. But, wars are followed by public health epidemics. What a shame that we may neglect another generation of heroes. Can we ever ask young people to fight for us again if we do that?