Dispatches From The Edge—Purple Hearts: A Cold-Blooded Decision

By Conn Hallinan
Wednesday February 11, 2009 - 07:13:00 PM

Behind the recent decision by the U.S. Department of Defense (DOD) to deny Purple Heart medals to soldiers suffering from Post Traumatic Stress Disorder (PTSD) is a cold-blooded calculation: it saves money. 

The official rationale for refusing to honor what is widely considered the “signature wound” of the wars in Iraq and Afghanistan is that PTSD, according to Pentagon spokeswoman Eileen Lainez, is “an anxiety disorder caused by experiencing or witnessing a traumatic event,” not “a wound intentionally caused by the enemy.” 

But a recent study by the Rand Corporation found that up to 320,000 vets returning from the two conflicts suffer from Mild Traumatic Brain Injury (MTBI), a condition whose symptoms are almost indistinguishable from PTSD. Virtually all MTBI injuries are the result of roadside bombs, or improvised explosive devices (IED). 

Because the two wars have seriously stretched the U.S. military, it is not uncommon for soldiers to do multiple tours. Out of the 1.6 million troops who have served in both theaters, 525,000 have done more than two combat tours, 70,000 have served three, and 20,000 have done five or more. During their deployments they are constantly exposed to IEDs. 

“The multiple nature of it is unprecedented,” says Maj. Connie Johnmyer of the 332ed Medical group, a unit that deals with psychological problems. “People just get blasted, and blasted, and blasted.” 

According to a study by the U.S. Department of Defense and Veterans Brain Injury Center, 31 percent of Veterans returning from Afghanistan and Iraq to Walter Reed Hospital have MTBI. 

MTBI is a slippery beast, one that Dr. Michael Weiner, Director of the Center for Imaging of Neurodegenerative Disease at the Veteran’s Administration Medical Center, calls “murky.” Its symptoms range from depression and uncontrolled rages to digestive problems, emotional disengagement, blinding headaches, memory loss, and sexual dysfunction, and is associated with higher suicide rates. 

It also has long-term effects. A Geisinger Health System study found that Vietnam vets suffering from PTSD were twice as likely to die from heart disease as vets without PTSD. 

“It is a complicated injury to the most complicated part of the body,” says Dr, Alisa Glean, chief of Neuroradiology at San Francisco General Hospital, and author of the standard text for imaging MTBI, and who works with wounded soldiers at the Army’s Regional Medical Center at Landstuhl, Germany. 

It doesn’t show up on CAT scans, and its symptoms may not manifest themselves for several months, or even years. There is not even full agreement on exactly what causes it. Some researchers think it is just a concussion on steroids, but others point to injured tissue deep in the brain, which can’t be explained by a simple concussion hypothesis.  

Whatever its origins, the consequences for sufferers can be catastrophic. 

One of the major effects of MTBI is what Dr. Judith Landau, a psychiatrist and president of Linking Human Systems in Boulder, Colorado, who works with veterans’ families, calls “identity ambiguity: people who were decisive become indecisive. People who were charming become withdrawn.” She says she sees soldiers who “left as a good son, a good father, and a good husband” suddenly “start hitting their children, can’t have sex, start drinking too much, talking too loud.” 

Like a stone thrown into a pond, this behavior ripples out to family, friends and co-workers. “There is a 70 percent chance that relationships will break down” after a person suffers from MTBI, says Landau.  

It is possible to recover from MTBI, but the process may be long—sometimes from five to 10 years, according to Landau—and expensive. Estimates are that the costs will reach at least $14 billion over the next 20 years. 

Which is where the Purple Heart comes in. 

Purple Heart awardees are entitled to enhanced benefits, including exemptions from co-payments for hospital and out patient care, and they are fast tracked for getting appointments for medical care and psychological services. 

Soldiers returning home find there are few psychological services and virtually no individual therapy. It is not uncommon to wait several months to see a therapist, and then only once a month. And MTBI sufferers may see as many as seven different therapists. 

The military has made little effort to deal with MTBI and PTSD. Soldiers suffering from PTSD outnumber amputees at Walter Reed Hospital 43 to 1, but there is no PTSD center. Sufferers are generally sent to the hospital’s psych division, where they are housed with bipolar and schizophrenic patients and tanked up with drugs. A study by Veterans For America (VFA) found that some soldiers were taking up to 20 different medications at once, some of which canceled out others. 

The military has lost 22 percent of its psychologists over the past several years, mostly to burn out. Soldiers have difficulty finding private therapists because the Veteran’s Administration (VA) pays below market rates and has even cut those reimbursements in 2007. Upwards of 30 percent of private psychologists won’t take on military patients because they can’t afford to. 

The situation is worse for the National Guard and Reserves, who make up almost 50 percent of the troops deployed in both wars, and who, according to VFA, “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts.” Health care for such troops is generally inferior—and more expensive—than that offered full-time regulars. 

Many soldiers are also reluctant to report their symptoms because they are afraid if they do so it will keep them from getting a promotion or landing a job once they leave the military. Only 53 percent of those diagnosed with MTBI sought help and, according to the Rand Study, “roughly one-half got minimally adequate care.”  

Worse, solders who report they are having behavioral difficulties may find themselves discharged from the service, with the consequent loss of medical care. They may even be billed for their recruitment bonus. 

PTSD and MTBI are both caused by being deployed into combat zones. Large numbers of these soldiers are exposed to IEDs—the number one cause of death and injury in both wars—but many do not suffer visible injuries. To make “shedding blood” the only criterion for being awarded a Purple Heart (and the benefits that go with it) is to deny the nature of the wars in Afghanistan and Iraq. 

In contrast, the Canadian Military awards a “Sacrifice Medal” that includes “mental disorders that are, based on a review by a qualified mental health care practitioner, directly attributable to a hostile or perceived hostile action.” 

A recent editorial in the Globe and Mail charged that the Pentagon’s decision applies “19th century medical standards to what constitutes injury,” and that the ruling “will further stigmatize mental illness and fails a group of veterans whose sacrifices can be every bit as great as those with physical injuries.”  

In his recent testimony before the Senate Committee on Veterans’ Affairs, the new Veterans’ Administration Director, Gen. Eric Shinseki (ret) said he promised to care for wounded veterans, “bearing scars of battle, some visible and many others invisible” and to “treat our veterans with dignity and respect.” 

They are fine words, but so far the military has stubbornly resisted treating these so-called “unseen damage” injuries that Iraq and Afghanistan is inflicting on U.S. soldiers. “Many soldiers and veterans are waiting months, often years, for mental healthcare and disability benefits,” says Veterans for Common Sense Director Paul Sullivan.  

Fewer than half of those Iraq and Afghanistan vets diagnosed with PTSD or MTBI have received disability benefits. One Veterans Affairs psychologist in Texas even urged VA staff to “refrain from giving a PTSD diagnosis” and consider instead “a diagnosis of maladjustment disorder.” PTSD sufferers receive up to $2527 a month, maladjustment disorders significantly less.  

Terri Tanielian, the co-leader of the Rand Corporation study, says, “There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan. Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation. Unfortunately, we found there are many barriers preventing them from getting the high-quality treatment they need.” 

The major barrier is pentagon shaped, and the bottom line is that, given a choice between buying fancy weapons systems and taking care of soldiers damaged by war, the military will always choose the former over the latter.