Normally we think of the costs of war in terms of dollars spent and body bags delivered to loved ones. However, this perspective overlooks the enormous financial and social burdens of veterans' long term disabilities such as those caused by traumatic brain injury (TBI), which is both under diagnosed and largely untreatable. As Dr. John Hart Jr., the President of the Society for Behavioral and Cognitive Neurology, notes: "A majority of the soldiers returning from the Iraq and Afghan wars are at risk of developing TBI."
Early estimates predicted that one tenth of veterans of the Iraq and Afghanistan wars would have TBI. More recently, this figure has been revised upward to 22%. However, the actual incidence of TBI among veterans is still unknown, and is likely to be much higher.
There are several reasons for these escalating estimates. They include the fact that body armor and helmets cannot fully protect against brain damage, the ubiquitous nature of improvised explosive devices (IEDs) in these conflicts, and systemic failures in medical treatment such as under diagnosis and misdiagnosis. Also, TBI victims may deliberately choose not to report their head injuries out of concern for their career prospects, or may simply be unaware of their condition. Repeated exposure to head injuries, even mild ones, can later result in permanent damage, which is one reason such injuries are so insidious.
The most common symptoms of TBI include memory problems, depression, irritability, slowed mental processing, difficulty finding words, and inability to concentrate. They can lead to job loss, social difficulties, strained family relationships, and plummeting self-esteem. Without correct diagnosis and help, TBI victims frequently find themselves unemployed, isolated, homeless or even suicidal, without ever knowing why.
Unfortunately, the symptoms of TBI are nearly indistinguishable from symptoms of other conditions such as post-traumatic stress disorder (PTSD) and depression, both of which also often co-occur with TBI among veterans. This diagnostic difficulty is compounded by lack of adequate training; as the 2007 Bradshaw Report to the Surgeon General noted, due to varying levels of knowledge, many cases of TBI escape detection by medical providers. Even when TBI is correctly identified, the sad fact is that there is no fully effective treatment or cure for this condition. Although several expensive, long-term treatment approaches helpTBI patients to some extent, no therapy can restore the kind of automatic, intuitive decision making that is essential for maintaining jobs and relationships.
The result of these systemic failures to diagnose and assist veterans with TBI can be found in homeless shelters, unemployment offices, drug and alcohol treatment programs, courtrooms, and ERs. Our already over-taxed social institutions and struggling families bear the burden of caring for these wounded veterans who are discharged from service without adequate support.
To understand the true costs of war, we need to know the long term consequences and expenses of TBI. The first step is accurately identifying the veterans and military personnel suffering from TBI. Congress has mandated this and allocated funds to do it; however, as Army Surgeon General Schoomaker recently told congress, the screening methods currently in use are "basically a coin flip." The military currently uses a short computerized test which is fast and cheap, but terribly ineffective. According to recent reports on NPR and propublica.org, these tests miss 40% of concussions. Even worse, these tests are typically given before deployment (if at all) and not repeated. Diagnosis of TBI now relies primarily on self-reporting by soldiers who may not know, or may not wish to disclose, that any injury has occurred.
Correcting this requires switching to comprehensive, baseline neuropsychological cognitive-function test batteries that take several hours, not 20 minutes. These should be given to all military personnel before deployment, with mandatory, rigorous follow-up screenings administered periodically. Every veteran who has suffered a head-injury or been near an explosion should also have an MRI scan. This combination of tests will detect the highest percentage of TBI victims, and would also facilitate the development of accurate, evidence-based diagnostic and treatment procedures for patients.
Once the true incidence of TBI is known, military budgets should include the costs of the long-term services and care needed to support these injured veterans -- a burden which is currently shouldered by suffering families and strained social service institutions and agencies. This care could be provided directly by VA facilities, or reimbursed to secondary service providers, as well as family members who spend untold hours caring for disabled veterans. Until the military takes true responsibility for its wounded, we overlook the real price of war and do a profound disservice to our veterans and their loved ones. The current high rates of undiagnosed, misdiagnosed, and incurable disabilities are going to haunt us all.