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Investigation

Casualties of War: Undocumented Traumatic Brain Injuries

Doug Scott doesn’t remember the blast. But he can’t forget the aftermath. All he knew was that his Humvee was in a ditch, its hood crushed, his gunner slumped over in the back.

It was Spring 2004, a little more than a year into Operation Iraqi Freedom. Scott’s recon unit, Charlie Troop, 10th Calvary had been tasked with maintaining security on the main route through Baghdad’s Sadr City, an area wracked by violent attacks from insurgent militias. He’d been the sixth vehicle in a convoy racing to rescue the pilots of a downed helicopter. As his memory began to trickle back, he slowly realized that an improvised explosive device—a roadside bomb—must have exploded as the convoy sped by, the blast from the bomb strong enough to fling his 5,200-pound Humvee into the ditch.

“It shakes your guts and vibrates right through you,” he says. “Everything went black and white a couple times. It just shakes you to your core.” 

This was the first IED attack Scott survived, but it was far from the last. He survived nine others before the end of his third and last deployment to Iraq in 2009.

“We know that 80 percent of TBIs weren't being documented in the early years of deployments to Iraq and Afghanistan."

Rachel Chase, PhD ’14, Author of doctoral dissertation that uncovered more than 21,000 undocumented traumatic brain injuries among U.S. troops in the Iraq and Afghanistan wars.

When he returned home to Pittsburgh he began to realize something was wrong. Concentration was difficult. Severe migraines assaulted him with blinding pain. He had trouble remembering things that had just happened. He slept only a few hours a night. Worst of all, he frequently “zoned out,” moments when he just stood and stared, but could not remember later. 

He went to doctors for answers. He suspected he’d suffered a traumatic brain injury (TBI) from the multiple attacks he survived, but he had to fight to obtain an accurate diagnosis and appropriate health care in military and veterans’ health systems. He also wasn’t alone.

Before 2007, the Army had no routine screening protocols for traumatic brain injuries. With no record of trauma, it’s likely that thousands who had no outward physical injuries – but who had suffered brain trauma—were misdiagnosed like Scott.

“There’s an enormous gap of people who suffered concussions who were never assessed and diagnosed, and I’d like to be able to see them get treatment,” says Scott, 38. “We held up our end of the bargain. I’m pretty keen to make the military hold up their end as well.”

Scott eventually got the health benefits he deserved, but he knew many others like himself who hadn’t been so successful fighting the system. He wanted to help them but didn’t know how.

That’s when he met Rachel.

Rachel Chase is the sister of Scott’s army buddy Nate. She was at her home in Columbus, Ohio working on her PhD dissertation proposal toward her degree at the Bloomberg School of Public Health. On this day in December 2011 Nate convinced her to take a break and accompany him on a day trip to Pittsburgh to meet his friend Doug Scott whom he’d known since 2004 when assigned to Scott’s unit as a medic.

The two army buddies hadn’t seen each other in seven years and their conversations soon turned back to their days in the Army. Rachel listened, but over dinner Scott steered the conversation to the topic of TBIs in the military. He knew she was a public health graduate student and he was hoping she might look into the topic through the eyes of a researcher. It ate away at him that his buddies from Charlie Troop and thousands of other vets might be grappling with the effects of TBI. 

Rachel was intrigued and she wanted some way to record her thoughts, but they were out for a social dinner and she had nothing with her where she could record her thoughts. But then she noticed the child’s crayons the restaurant supplied to keep younger diners occupied. She picked one up and began to sketch out a study plan.

Within a week, she had scrapped her original dissertation proposal and decided to take on the issue of TBIs in the military.

“I was in the Department of International Health and wanted to be one of the jet-setting students working around the world,” she recalls. “But in the end, I took on the project that meant the most to me, working with a community that wanted me to do this research.” 

When Chase began to investigate TBI, she found little research on blast-induced TBIs in general and on the lives of veterans with undocumented injuries. Her initial efforts to quantify the undocumented brain injuries proved frustrating. Her first idea was to calculate TBIs based on IED counts, but the figures were classified. 

Everything changed when a friend introduced her to Remington Nevin, MD, MPH ’04. A fellow doctoral student at the Bloomberg School, Nevin is a former Army physician, who had served in Afghanistan and had been an epidemiologist with the Armed Forces Health Surveillance Center. He steered Chase toward two graphs produced by the Center—TBI and amputation counts from 2003 to 2012. 

Chase had been trained as a mathematician and dove into developing a statistical model with the assistance of Biostatistics professor Roger Peng, PhD, MS, using amputations as a proxy to estimate the number or traumatic brain injuries. Her reason for connecting two issues that seemed so different? Both were closely linked with injuries sustained from roadside bombs.

“We basically extended the graph backward in time and created the graph we would have seen had all TBI screening and documentation policies been in place since 2003,” she explains. 

The results are sobering. Because the military hadn’t been documenting TBIs in the early years of the Iraq and Afghanistan conflicts, their findings suggested that documentation existed for only one in five troops who sustained head trauma between 2003 and 2006. 

“TBI has been called the invisible wound of these wars, and our research shows for the first time how truly invisible it is,” said Nevin. 

They first published their study online in May 2014 in the Journal of Head Trauma Rehabilitation. In their paper they estimated that 21,257 troops sustained TBIs between 2003 and 2006, more than four times the 5,272 cases recorded by the Pentagon in the same period. Although the military enacted policies in late 2006 to identify TBIs—particularly mild injuries—upon return from deployment, the study estimates that there were still 11,565 undocumented TBIs between late 2006 and late 2010. Over the four-year period, Chase explains, the military made incremental improvements in counting TBIs, with more screenings in the field, for example, but cases still went unrecorded. Overall, they concluded that between 2003 and 2010, an estimated 32,822 combat personnel sustained undocumented TBIs.

To understand the true meaning behind the missing TBI counts, Chase turned to veterans and service members—several from Charlie Troop—who deployed to Iraq or Afghanistan before routine TBI screening. 

She conducted 38 in-depth interviews with 26 veterans and family members. The vets included gunners, medics, scouts and ordnance disposal technicians—all of whom were at high risk of blast exposure. Some had been diagnosed with TBI years after returning home; some never sought care or gave up in frustration. 

“It was extraordinarily touching in doing this work that these people placed their confidence in me,” Chase says. “It was painful for them to talk about, but they would say, ‘I want people to know.’”

For more than two and a half years, Chase immersed herself in the lives of veterans, compiling their stories of frustration, anger and determination, and counting their unseen battle wounds that often left deep and enduring scars. 

She distilled their collective narrative into her PhD thesis: “You Don’t Have Anything to Give but Your Word and a Faulty Memory,” which she defended on November 5, 2014.  During her defense, Chase recalled the words that she couldn’t forget after spending the day in Pittsburgh with two Iraq veterans—her brother Nate and Doug Scott. 

“‘We want people to know we aren’t crazy,’” Scott had told her, “‘or, if we are, there’s a good reason for it.’”