Why Inconclusive Science Is Complicating the Treatment of Wounded Warriors

If there's a member of the brass who's taken mental-health issues in the military head on, it's four-star Gen. Peter Chiarelli. On his second deployment to Iraq, he served as commander of all coalition ground forces. Since then, he's gone before Congress to explain the Army's work on the invisible wounds of war and created a suicide-prevention task force. When word got out that NEWSWEEK was investigating the science of battlefield concussions, his office lined up an interview with articles editor Andrew Bast. Excerpts:

How well do we understand the short- and long-term effects of mild traumatic brain injury (MTBI), or battlefield concussions?
I don't think we do. The vast body of medical understanding of these wounds will show you that we just don't understand. It's science that's just not that well developed. I use the example of open-heart surgery. You can go to two doctors for the same problem, and one may use different antirejection drugs and different postoperative requirements, but it is all a very well-developed science. The science of the brain, however, is not. That's what causes the huge issues we've got here.

What are the issues, exactly?
The comorbidity issue between posttraumatic stress [PTS] and TBI are huge. One of the biggest problems we have is that every soldier who is in a blast, and has some kind of a behavioral-health issue after the fact, thinks they have TBI. Some of them do, but some don't. They may have PTS or some other behavioral-health issue. And the drug regimen for the two is very different. So if a doctor makes a mistake and diagnoses someone with PTS who has TBI, the drug regimen would be different.

Can you explain that term, comorbidity?
Comorbidity is the sharing of symptoms. The symptoms are much the same for PTS and TBI. So when you have similar symptoms, it's very difficult to make a diagnosis. We're not being criticized for the way we're working with soldiers who've lost arms or legs. If you were at the Army 10-miler the other day, there were hundreds of wounded warriors on prostheses. These are mechanical injuries, and we're very good at treating those. But [on brain injuries] what has been hard is that people really feel we are letting them down. The problem is that we just don't know. You'll find a lot of people who will come to you with the answers, but I think if you were to talk to the specialists, they will tell you that very little that's come to their attention that they have researched has proven to be effective.

So where are we in treating wounded warriors and where does it go from here?
What I'm most excited about are these proteins we've found that we believe are biomarkers that will allow us at the point of injury to take a simple prick of the finger with an instrument—we think we'll have three years from now—that would be much the same as what's used by a diabetic to check blood sugar. It would give a combat medic certainty that these proteins associated with concussion or TBI are present in a body. This research is looking extremely positive. It would allow us to ascertain almost immediately whether the individual has or doesn't have a concussion on the battlefield.

The Army reported about 80,000 cases of MTBI from 2000 to 2010; do you think that's accurate?
The numbers I talk about are 60,000, but I don't think we totally know. It's very difficult for us to be able to tell you with any certainty because the stigma associated with these things has been so great that soldiers don't want to admit that they've got that problem. In January I was at the All-American Bowl and I had the opportunity to present a Purple Heart as part of the awards banquet to a young soldier who was in two explosions four days apart. He was an E-6 filling in for a platoon sergeant, and after the first blast the medic tried to evaluate him. He said, "No, I am the acting platoon sergeant, I have to stay with my soldiers." Four days later he gets into another explosion and the next time he remembers anything he's waking up in a bed in Landstuhl, [Germany]. He has TBI and is now working his way out of the Army. These are sad, sad cases. Many are also preventable. That's why I'm excited about the protocols we've put in downrange so when an individual like that sergeant suffers a blast, we evaluate him immediately after the combat action, but then we hold him out of the fight for 24 hours to evaluate him a second time.

If battlefield concussions and PTS are invisible wounds of war, as the definition of wounds widen, do you run the risk of service members gaming the system?
Sure you do. And you just have to forget that. You have to let the science progress. I'll forget 99 of them if there's one who I can help. That's how I feel about it. I feel it's absolutely essential, and I think the number that might game the system is a small group of individuals. And because we have immature science, it's always going to be difficult. We'll get better and better; however, until we get there, we've got to treat every single one of them that displays themselves with those symptoms as having the problem.

In the long term, there's a responsibility in treating these service members that goes on for decades. What does the future look like to you?
That's exactly why we're working so much research with the Department of Veterans Affairs, at the Cincinnati veterans' hospital, at UCLA, at Emory. If you talk to the experts, you see that no one's trying to not help these soldiers. The fact of the matter is, the science is such that we can't help them in every case because we don't know what to do.
** Read more about the new generation of warriors coming home in our Fighting for Themselves package.