Don’t politicize traumatic brain injury

Traumatic brain injuries (TBI) are emerging as one of the most daunting medical issues of the 21^st century.  Addressing that challenge is not, however, advanced when it becomes mired in misinformation and politicization.

Unfortunately, that’s much of what’s happened in the controversy surrounding the aftermath of the January 8^th Iranian missile attack against Al-Asad airbase where about 2,500 U.S. military and civilian contractors work.  Let’s sort this out a bit so that you can make up your own mind about this important issue.

The context

Following the drone strike that killed General Qasem Soleimani, (the leader of Iran’s Quds force, a U.S.-designated terrorist organization), Iran vowed “vengeance”.  Despite a barrage of 16 missiles with warheads of up to 2,000 pounds, the Pentagon reported immediately after the attack that there were “no casualties to U.S. personnel, coalition personnel, contractors or Iraqis.”  Nine days later, however, U.S. Central Command said:

“While no U.S. service members were killed in the Jan. 8 Iranian attack on Al Asad Air base, several were treated for concussion symptoms from the blast and are still being assessed.”

“As a standard procedure, all personnel in the vicinity of a blast are screened for traumatic brain injury, and if deemed appropriate are transported to a higher level of care.” 

“In the days following the attack, out of an abundance of caution, some service members were transported from Al Asad Air Base, Iraq to Landstuhl Regional Medical Center in Germany, others were sent to Camp Arifjan, Kuwait, for follow-on screening.”

On January 22^nd, a reporter questioned the President while he was attending the World Economic Forum in Davos, Switzerland (emphasis added below.):

Q: Mr. President, a question on Iran: Initially, you said repeatedly to Americans that after Iran retaliated for the Soleimani strike, no Americans were injured. We now know at least 11 U.S. service men were airlifted from Iraq.  Can you explain the discrepancy?

THE PRESIDENT:  No, I heard that they had headaches, and a couple of other things.  But I would say, and I can report it is not very serious.  Not very serious.

Q: So you don’t consider a potential traumatic brain injury serious?

THE PRESIDENT:  They told me about it numerous days later.  You’d have to ask Department of Defense.  No, I don’t consider them very serious injuries, relative to other injuries that I’ve seen.

I’ve seen what Iran has done with their roadside bombs to our troops.  I’ve seen people with no legs and with no arms.  I’ve seen people that were horribly, horribly injured in that area, that war — in fact, many cases put — those bombs put there by Soleimani, who is no longer with us.  I consider them to be really bad injuries.

No, I do not consider that to be bad injuries.  No.

How does the military categorize “casualties”?

About a week later at Pentagon news conference General Mark Milley, the Chairman of the Joint Chiefs of Staff, noted that while it was too early to tell how serious the injuries might prove to be, the “diagnosis we have so far for all the — all of the folks that have been diagnosed to date is mild traumatic brain injury.”  (Emphasis added.)

In addition, Defense Secretary Mark Esper said:

SEC. ESPER:  I’ve had the chance to speak with the president.  He is very concerned about the health and welfare — welfare of all of our service members, particularly those who were involved in the operations in Iraq, and he understands the nature of these injuries. (Emphasis added.)  

Gen. Milley then explained how the military categorizes those injured (emphasis added below.):

GEN. MILLEY:  And I would say, there’s three categories of wounded in action that we’ve had for years.  One is VSI, very serious — and you’re probably all familiar with this — very serious injured; one is S.I., serious injured; and one is NSI, not serious injured.

And, in this case, the reporting to date indicates mild TBI, which would be in the category of not serious injured.  That doesn’t mean they’re not injured, and it doesn’t mean to the individual.  But in the categories that we categorize wounded in action, these individuals are in the NSI category at this time.

That’s not to minimize or dismiss or anything, that’s just to say that that’s how we categorize casualties. 

Later, a reporter returned to the issue (emphasis added below) :

Q:  If I could stick with TBI, actually.  When — when you saw the payload of the missiles and how close they came to some of the shelters, at that point, did you expect that there would be TBI, or is that something that surprised both of you?

GEN. MILLEY:  For me, it’s not a surprise.  This is — is — concussive injuries is a result of any explosive device that goes off.  You can get concussive injuries from hitting your head, from falling, from parachute jumps, et cetera.  So, no, it’s not necessarily a surprise.

What we do when — when we’re in contact with the enemy — we’re in a firefight, incoming mortars, rockets, theater ballistic missiles or anything, the very first thing you’re focusing on is life and limb.  So when we say “reported casualties,” we’re really talking about killed in action and — and serious injuries like loss of limbs.

The TBI manifests itself over time.  It’s not necessarily instantaneous.  So not a surprise, necessarily, but the focus immediately is loss of life and limb.

Q:  Just to go on, in retrospect, do you think it would have been better or more forthcoming if you had not initially said there were no injuries?  And — and do you think the president saying, “They’re just headaches,” minimizes, sort of, the injuries and TBI?

SEC. ESPER:  The chairman and I spent most the night going over casualties and understanding what happened on the ground with Gen. McKenzie and others.  I think the reporting was accurate.  At that time, as reported, there were no casualties, as…the chairman just defined it.

On February 10^th CNN said that the Pentagon reported over “100 US service members have been diagnosed with mild traumatic brain injuries.”  Of that number (actually, 109), medical treatment had already “enabled nearly 70 percent of those diagnosed to return to duty.”

How common are “mild” TBI cases in the military?  

As of November 2019, since 2000 there have been 413,858 TBI cases of “all severities.”  About 2.3% have been “severe” or “penetrating.”  82.8% have been “mild.”

Today, the New York Times reports that both military and civilian “doctors struggle to accurately assess brain injuries” adding that:

“A tangle of factors make diagnosing head injuries in the military particularly tricky, experts say. Some troops try to hide symptoms so they can stay on duty, or avoid being perceived as weak. Others may play up or even invent symptoms that can make them eligible for the Purple Heart medal or valuable veteran’s education and medical benefits.”

Thus, it would seem plausible that the evolving figures as to how many are being examined for TBI, as well as how many have been diagnosed with TBI, are not the product of nefariousness or incompetence by military or Administration officials, but rather a reflection of how intricate and difficult TBI is to assess and treat, even for medical professionals.

What about TBI in the civilian world?  

The Korey Stringer Institute at the University of Connecticut defines TBI as a “as a bump, blow, or jolt to the head or a penetrating head injury that leads to the disruption of normal brain function.”  It also points out how common these injuries are in the sports setting:

“It is estimated that approximately 1.6 to 3.8 million sports related traumatic brain injuries (TBI) occur every year, accounting for roughly 15% of all high school sport-related trauma reported. However, these numbers may be considered an underestimate due likely to failures in reporting of head injuries sustained or seeking medical attention. 

In fact, approximately 55% of pediatric athletes who sustained a concussion were not seen within a health care facility and approximately 42% of adults with a mild TBI (mTBI) did not seek medical care as well. The age group most vulnerable for sustaining a sports related concussion (SRC) is between ages 9-22 years old when team sports are most popular.  Additionally, females have been diagnosed at higher rates of concussion susceptibility than males during both competition (1.46x) and practices (1.75x).”  (Emphasis added)

While it is undoubtedly true that some TBIs are catastrophically or permanently debilitating, it seems many are not.  The Korey Stringer Institute outlines a sensible process for returning high-school athletes to practice and competition, as evidently millions do.

Importantly, Korey Stringer Institute notes this (red box added):Thus, it is not especially surprising that a significant majority of those servicemembers who suffered “mild” TBI in the Iranian missile attack have already returned to duty.  According to Military.com, “[w]ith mild TBI patients, full recovery can be within minutes to hours; a small percentage have symptoms that may persist months or years.”

Moreover, new treatments are being developed for those who suffer more serious forms of TBI.  New equipment (perhaps from old designs!) and revised procedures might help troops avoid suffering TBI in the first place.  And even more TBI research is forthcoming as the Department of Defense and the Vetrans’ Administration announced new funding last fall.  Still, it is wise to establish an ongoing monitoring protocol as the military has done in order to ensure proper treatment should symptoms re-emerge or worsen in the future.

Politicization? 

After the President’s remarks at Davos, politicians, pundits, and the media erupted in indignation.  Presidential candidate Joe Biden called the remarks “disgusting,” and other presidential hopefuls chimed in similarly (see e.g., here).

USA Today’s editorial board railed that TBI was the “the ‘signature wound’ of America’s 21st century wars, could lead to suicide [and Trump’s] comment is a cruel reflection of lingering ignorance on how to treat service members.”  Although what Trump had actually said was that he didn’t consider the TBI reported to him (i.e., mild TBI) as serious as the loss of a limb, the Veterans of Foreign Wars are nevertheless  “demanding that President Donald Trump apologize for downplaying traumatic brain injuries sustained by US service members.”

Given that the TBI injuries the Iranian strike caused have so far been diagnosed to fall onto the “mild” scale, and that (as General Milley put it) when the military reports “casualties” it is “talking about killed in action and…serious injuries like loss of limbs,” decide for yourself if you think that the President’s comments were, at the time they were made, really off-the-mark.  Though any comparison may be churlish, could not someone reasonably consider “mild” TBI to be less serious than the loss of limbs?  You decide.

Decide this as well: does the absence of any contextualization of TBI in the larger military and civilian settings by any of the pundits or the media critics suggest that perhaps their real interest is to simply undercut the success of the Soleimani strike?  Are we seeing a permutation of a phenomena I noted elsewhere in 2018? :

“[In 2017 New York Times columnist] Ross Douthat observed that the U.S. had won a great victory over the Islamic State but that “nobody seemed to notice.” Douthat cited several reasons for the lack of attention but most interesting is this: “this is also a press failure, a case where the media is not adequately reporting an important success because it does not fit into the narrative of Trumpian disaster in which our journalistic entities are all invested.”  (Emphasis added.)

Put another way, is the TBI issue being caught up in our hyper-polarized politics?  In the immediate aftermath of the Soleimani strike reaction mostly followed party lines, with Trump’s political opponents criticizing the strike (see e.g., “Democratic presidential candidates condemn killing of Iran general” and “Democratic Presidential Candidates Criticize Trump For Ordering Soleimani Strike” ).  However, that condemnation proved out-of-step with the views of most Americans as polls showed 53% approved of the killing of Soleimani.

Consequently, here’s something for you to decide: by inferring that Trump’s comments show indifference to injuries to U.S. troops, are his political rivals trying to recast themselves not as critics of a strike itself (as it now appears that most Americans approve of it), but rather into seeming defenders of the military, the institution in American society in which the public has the most confidence and respect?

Addtionally, are Trump’s political opponents trying to use his TBI comments chip away at his support among veterans?  (Indeed, a few days ago, the New Republic had an in-depth article grimly analyzing what it headlined as the “Democrats’ Veteran Problem.”)  There’s absolutely nothing wrong with politicians trying to chip away at political support for their opponent, but do we need to use TBI as the tool to do it?

Without doubt, everyone should be rightly concerned about the 109 servicemember cases we’ve seen thus far of “mild” TBI arising from the Iranian missile attack, but if the concern is geuinely about the very real perils of TBIs and the health and safety of people, shouldn’t the critics have also included some recognition of – and expression of concern for – the “1.6 to 3.8 million sports-related traumatic brain injuries (TBI) [that] occur every year”?  Again, you decide.

A foreign policy factor? 

Trump’s remarks may have another, more strategic purpose. Retired Air Force colonel C R Krieger, a former F-16 wing commander and National War College instructor, made this analysis of Trump’s comments (related here with his persmission):

“I think the President, as a matter of foreign policy, is trying to minimize the attack, so he can claim there is no need to escalate this tit-for-tat.  I expect he borrowed Admiral Nelson’s telescope for the purpose of observing the Iranian attack.  The British were probably happy to loan it to him for the observation.

This is not to minimize TBI.  It is a serious problem.  On the other hand, an increasing escalation, resulting in more American and Iranian deaths, would also be a serious problem.That said, and not being an area expert, I expect there will be continuing low level aggression.  But, because we didn’t respond, it will be lower, slower and further off.”

My friend Cliff Krieger has a real point.  It isn’t hard to imagine that the risk of creating public pressure for further escalation animated the President’s decision to comment in the first place, and then to describe the “mild” TBI reported to him as “not serious.”

Let’s also ask ourselves this: what might the Iranians have thought at the time had the President reacted differently than he did?  That another strike was forthcoming?  What might that kind of thinking have meant for a tense situation already fraught with suspicion, distrust, and hostility?   Nothing good in my book.

Concluding thoughts

A robust and even sometimes contentious political dialog can serve a democracy.  But if we genuinely want to find workable, bipartisan solutions to the challenge of TBI, it shouldn’t be used as a cudgel by any political group.

Of course, it’s beyond question that we must care for anyone affected by TBI, but as with other medical conditions, there are differing degrees of seriousness, and most who suffer “mild” TBI will likely go on to live very healthy and productive lives.  Addtionally, we need to be very careful to avoid doing anything that unnecessarily feeds the “damaged veteran” stereotype that hampers and even stigmatizes those who have served.

To be clear, none of this is to minimize TBI, but rather to add information to put a complicated issue in fuller context so that real, nonpartisan progress can be made towards addressing it not just in the military, but also in civilian society.  It’s just too important to be reduced to a politicized bumper sticker.

Still, as we like to say on Lawfire^®, gather the facts, examine the arguments, and decide for yourself!