Traumatic Brain Injury: The Signature Wound of the Iraq War

Traumatic Brain Injury, or TBI, is the signature wound of the Iraq War. It can be caused by bullets or shrapnel hitting the head or neck, but also by the blast injuries that often result from mortar attacks or roadside bombs. It is this second kind of injury that is especially prevalent in Iraq; about 65% of Iraq and Afghanistan veterans wounded in action were injured by explosive devices. Overall, between 10 and 20% of Iraq veterans, or 150,000 and 300,000 people, have suffered a TBI during the war.TBI does not always cause an external wound; the pressure of a blast can overstretch or bruise the brain without leaving a visible trace. Moreover, the symptoms of TBI can be difficult to distinguish from combat stress and other related psychological injuries. Telltale signs of TBI include memory and emotional problems; vision, hearing, or speech problems; and sleep disorders. In addition, multiple mild TBIs can accumulate over time, leading to serious neurological problems that are not readily linked to one injury. As a result, TBI can often remain undiagnosed and untreated.About 90% of TBIs are mild or moderate. But severe TBIs require a lifetime of care and rehabilitation. For the several thousand Iraq and Afghanistan veterans who have suffered this level of injury, the Pentagon and Department of Veterans Affairs have developed a nationwide network of hospitals and clinics. There are four major Polytrauma Rehabilitation Centers, in Tampa, FL, Richmond, VA, Minneapolis, MN, and Palo Alto, CA. These centers are supported by dozens of regional sites across the country.Although treatment is improving for veterans with severe TBI, TBI screening continues to lag. The Army has improved education for soldiers to help identify the symptoms of a mild TBI, and has begun to test troops' brain activity before their deployments to record baseline data. In spring 2007, the VA began to offer TBI evaluation to all Iraq and Afghanistan veterans seen at a VA hospital or clinic. Until a universal screening program is in place in the military, however, thousands of combat veterans will continue to struggle with the effects of an undiagnosed brain injury

Mental Health Injuries: The Invisible Wounds of War

As early as the Civil War, terms like "soldier's heart" and "nostalgia" were used to describe the psychological injuries incurred by combat veterans. In later wars, "shell shock" and "battle fatigue" described a similar array of symptoms. It was only in the aftermath of the Vietnam War, however, that veterans' mental health injuries were examined scientifically. A 1988 Congressionally mandated study estimated that 15 percent of Vietnam veterans suffered from Post-Traumatic Stress Disorder (PTSD) at the time of the conflict.During the Iraq and Afghanistan wars, American troops' mental health injuries have been documented as they occur, and rates are already comparable to Vietnam. Thanks to today's understanding of mental health screening and treatment, the battle for mental health care fought by the Vietnam veterans need not be repeated. We have an unprecedented opportunity to respond immediately and effectively to the veterans' mental health crisis.Rates of mental health problems among new veterans are high and rising. The best evidence to date suggests that about one in three Iraq veterans will face a serious psychological injury, such as depression, anxiety, or PTSD.1 About 1.5 million people have served in Iraq and Afghanistan, so approximately half a million troops are returning with combat-related psychological wounds. And problems are likely to worsen. Multiple tours and inadequate time between deployments increase rates of combat stress by 50 percent.These psychological injuries exact a severe toll on military families. Rates of marital stress, substance abuse, and suicide have all increased. Twenty percent of married troops in Iraq say they are planning a divorce. Tens of thousands of Iraq and Afghanistan veterans have been treated for drug or alcohol abuse. And the current Army suicide rate is the highest it has been in 26 years.According to the American Psychological Association, there are "significant barriers to receiving mental health care in the Department of Defense (DOD) and Veterans Affairs (VA) system."Instead of screening returning troops through a face-toface interview with a mental health professional, the DOD relies on an ineffective system of paperwork to conduct mental health evaluations. There are significant disincentives for troops to fill out the forms accurately, and those who indicate they need care do not consistently get referrals. In addition, access to mental health care is in short supply. According to the Pentagon's Task Force on Mental Health, the military's "current complement of mental health professionals is woefully inadequate." Moreover, 90 percent of military psychiatrists, psychologists and social workers reported no formal training or supervision in the recommended PTSD therapies.Effective treatment is also scarce for veterans who have left the military. As of May 2007, the VA has given preliminary mental health diagnoses to over 100,000 Iraq and Afghanistan veterans. The veterans' mental health system is simply overwhelmed by the influx; waiting lists now render mental health and substance abuse care "virtually inaccessible" at some clinics, according to the VA's own experts. The VA has exacerbated the shortage by consistently underestimating the number of new veterans who would need care, and by failing to spend millions earmarked by Congress for mental health treatment.No one comes home from war unchanged. But with early screening and ready access to counseling, the mental health effects of combat are treatable. In the military and in the veterans' community, however, psychologically wounded troops are falling through the cracks. Decisive action must be taken to fix the gaps in the mental health system if we are to reach this generation of combat veterans in time

A Breaking Military: Overextension Threatens Readiness

In December 2004, Specialist Thomas Wilson, a scout on his way to Iraq with the Tennessee National Guard, caused a media firestorm by asking then-Defense Secretary Donald Rumsfeld about Humvee armor shortages: "Why do we soldiers have to dig through local landfills for pieces of scrap metal and compromised ballistic glass to up-armor our vehicles and why don't we have those resources readily available to us?" Others in his unit agreed that they were undermanned and underequipped. Spc. Blaze Crook, a truck driver, said, "I don't think we have enough troops going in to do the job."Most military experts now agree that years of war and the spring 2007 "surge" have pushed our military to the breaking point. According to General George Casey, the Chief of Staff of the United States Army, "The demand for our forces exceeds the sustainable supply." Admiral Michael G. Mullen, the Chairman of the Joint Chiefs of Staff, has agreed, acknowledging that the current policy of an increased U.S. force presence in Iraq cannot continue past April 2008.The consequences of our overextension are dire. General Peter Pace, former Chairman of the Joint Chiefs of Staff, believes that there is a significant risk that the U.S. military will not be able to respond effectively if confronted with another crisis. By spring 2008, all four brigades of the 82nd Airborne, the Army's rapid response division, will be deployed to Iraq or Afghanistan, leaving the Army without "a rapid response capability for other crises around the globe." Army Lieutenant General Douglas Lute, President Bush's new war adviser, has gone so far as to say that a military draft is worth considering.Forced to fill the ranks without a draft, the military has faced serious problems with recruitment. The Pentagon has responded by lowering age, education, and aptitude standards for new recruits, as well as increasing enlistment bonuses. In March 2007, the National Guard actually ran out of funds for marketing and advertising. The costs of retention have sky-rocketed to over $1 billion, six times the amount spent in 2003. The military has also held 70,000 troops on active-duty beyond their expected contract enddates -- a controversial policy known as "Stop Loss" -- and has called up 15,000 veterans, many of whom have not put on a uniform in years.The military now regularly requires troops to serve multiple, extended combat tours. Over 449,000 troops have served more than one combat tour, and many have returned to war after only a few months rest. Active-duty Army combat tours are now 15 months long, with only half the recommended "dwell time" at home between tours. The increased tempo is expected to have a major impact on service members' health. According to a military survey, soldiers serving multiple tours are 50 percent more likely to suffer from a mental health problem.Equipment shortages have contributed to the plummeting readiness ratings of Army and Marine units, threatening our ability to cope with foreign threats and domestic emergencies. By September 2006, "Roughly one-half of all Army units (deployed and non-deployed, active and reserves) received the lowest readiness rating any fully formed unit can receive." About four-fifths of Army Guard and Reserve units not mobilized received the lowest possible readiness rating. State officials in California, Kansas and Oregon have publicly expressed grave concerns about the damage done to our domestic security. According to the Government Accountability Office, 20 states and territories now have "inadequate capability" to fulfill key domestic security missions. This situation is so dire that, in 2006, all 50 governors signed a letter calling on President Bush to ensure the National Guard is re-equipped.According to Dr. Andrew Krepinevich, President of the Center for Strategic and Budgetary Assessments, "[T]he Army and Marine Corps equipment is in such a state of disrepair that it will take years and tens of billions of dollars to repair or replace." The Army has already received over$38 billion dollars to repair or replace equipment used in Iraq and Afghanistan, and it is estimated that reset costs will be $13 billion a year for the duration of combat

A New GI Bill: Rewarding our Troops, Rebuilding our Military

In 1944, President Franklin Delano Roosevelt signed the original GI Bill, ensuring that eight million combat veterans coming home from Germany and Japan would be able to afford an education. Called the "Servicemen's Readjustment Act," the World War II GI Bill covered tuition, fees, and books, and gave veterans a living stipend while they were in school. Presidents Gerald Ford and George H.W. Bush, Senators Bob Dole and Patrick Moynihan, and authors Norman Mailer and Frank McCourt all relied on the GI Bill.Experts have argued that the GI Bill "reinvented America" after a half-decade of war. Indeed, a 1988 Congressional study showed that every dollar spent on educational benefits under the original GI Bill added seven dollars to the national economy in terms of productivity, consumer spending and tax revenue. But in his signing statement, President Roosevelt spoke more simply:"[The GI Bill] gives emphatic notice to the men and women in our armed forces that the American people do not intend to let them down."Today, 1.5 million troops are returning from Iraq and Afghanistan to a very different future than the one FDR made possible for the Greatest Generation. The current educational benefits offered to veterans are far lower than the original GI Bill. Today, after paying a nonrefundable contribution from their first military paychecks, troops can receive a total of up to $39,600 towards their education. Unfortunately, this covers only 60-70$1,200 contribution do not end up using the GI Bill at all. These veterans have paid the government $230 million, but received nothing in return.Today's veterans deserve a real reintegration program to help adjust to the civilian world. At the same time, a renewed GI Bill is a practical answer to the military's troop shortage. Despite investing$4 billion dollars in recruiting annually, the military has had serious problems recruiting high-caliber personnel. The Pentagon has responded by lowering age, education, and aptitude standards for new recruits, as well as upping the number of recruiters and increasing enlistment bonuses. These stop-gap measures will not address long-term problems with recruiting, especially as the overall size of the Armed Forces is expanded.Rather than continuing to spend billions in bonuses for lower-standard enlistees, increasing GI Bill benefits would encourage high-aptitude young people to join the military. The GI Bill is the military's single most effective recruitment tool; the number one reason civilians join the military is to get money for college. As our military recovers and resets in the coming years, an expanded GI Bill will play a crucial role in ensuring that our military remains the strongest and most advanced in the world

Battling Red Tape: Veterans Struggle for Care and Benefits

More than 1.5 million troops have served in Iraq and Afghanistan. 30,000 troops are counted among those wounded in action. But hundreds of thousands of others have suffered injuries not recorded in the official tally, including the many veterans with serious mental health problems. These veterans are overwhelming the military and veterans' health care and disability systems.As a result, hundreds of thousands of wounded troops and veterans are being forced to wait months and even years for medical appointments and disability compensation. Some veterans with serious mental health problems have committed suicide while waiting for counseling, and others have fallen into debt awaiting compensation from the military or Department of Veterans Affairs (VA).A major cause of the delays is the maze of paperwork that troops and veterans must navigate to get care or benefits. The military and the VA have separate health care systems and separate disability benefits systems, each with an exceptionally complicated and confusing bureaucracy.The medical care offered through the Department of Defense (DOD) is some of the most advanced in the world. But some wounded troops are suffering delays in treatment because the military does not use a consistent digital medical records system. Moreover, troops too wounded to continue their service must chaperone complicated paperwork through an arduous and confusing process of medical evaluation. Some veterans' advocates believe the Army is taking advantage of troops' confusion to lower disability ratings and save money. According to the Dole-Shalala Commission tasked with addressing the problems faced by troops at Walter Reed, less than 40% of wounded troops say they are satisfied with the disability evaluation system.For those who have left military service, the Veterans Affairs system can provide health care and benefits. Unfortunately, the transition from the DOD to the VA is far from seamless. Crucial DOD paperwork, including medical records and military service records, regularly gets lost in the shuffle from DOD to VA. Moreover, the transition from top-echelon military hospitals to a local VA facility can mean a reduced standard of care.Changes to VA eligibility rules have restricted access to VA health care and contributed to the 1.8 million veterans who lack health insurance. But even for those veterans with access to the VA system, delays and bureaucratic hurdles are commonplace. High demand has created a huge backlog for mental health treatment, making care "virtually inaccessible" at some clinics, according to at least one high-ranking VA official.The VA disability benefits system is also massively backlogged. There are about 400,000 pending disability claims, including 83,000 that have been waiting six months or more. The average wait-time for a disability claim is 183 days, or about six months. For claims that are appealed, the wait-time skyrockets to 657 days, or almost two years. Despite the backlog, the VA's claims processing staff has not substantially increased. In the meantime, veterans too wounded to work are often unable to support themselves or their families.The public outrage over bureaucratic neglect and shoddy conditions at Walter Reed Army Medical Center shined a light on the many problems facing wounded troops and veterans. A wide array of recommendations has been made, but whether these solutions will be effectively implemented remains to be seen

Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans

As early as 1919, doctors began to track a psychological condition among combat veterans of World War I known as "shell shock." Veterans were suffering from symptoms such as fatigue and anxiety, but science could offer little in the way of effective treatment. Although there remains much more to learn, our understanding of war's invisible wounds has dramatically improved. Thanks to modern screening and treatment, we have an unprecedented opportunity to respond immediately and effectively to the veterans' mental health crisis. Among Iraq and Afghanistan veterans, rates of psychological and neurological injuries are high and rising. According to a landmark 2008 RAND study, nearly 20 percent of Iraq and Afghanistan veterans screen positive for Post Traumatic Stress Disorder or depression. Troops in Iraq and Afghanistan are also facing neurological damage,. Traumatic Brain Injury, or TBI, has become the signature wound of the Iraq War. The Department of Defense is tracking about 5,500 troops with TBIs, but many veterans are not being diagnosed. No one comes home from war unchanged, but with early screening and adequate access to counseling, the psychological and neurological effects of combat are treatable. In the military and in the veterans' community, however, those suffering from the invisible wounds of war are still falling through the cracks. We must take action now to protect this generation of combat veterans from the struggles faced by those returning from the Vietnam War

From the bargaining table to the ballot box: political effects of right to work laws

Labor unions play a central role in the Democratic party coalition, providing candidates with voters, volunteers, and contributions, as well as lobbying policymakers. Has the sustained decline of organized labor hurt Democrats in elections and shifted public policy? We use the enactment of right-to-work laws—which weaken unions by removing agency shop protections—to estimate the effect of unions on politics from 1980 to 2016. Comparing counties on either side of a state and right-to-work border to causally identify the effects of the state laws, we find that right-towork laws reduce Democratic Presidential vote shares by 3.5 percentage points. We find similar effects in US Senate, US House, and Gubernatorial races, as well as on state legislative control. Turnout is also 2 to 3 percentage points lower in right-to-work counties after those laws pass. We next explore the mechanisms behind these effects, finding that right-to-work laws dampen organized labor campaign contributions to Democrats and that potential Democratic voters are less likely to be contacted to vote in right-to-work states. The weakening of unions also has large downstream effects both on who runs for office and on state legislative policy. Fewer working class candidates serve in state legislatures and Congress, and state policy moves in a more conservative direction following the passage of right-to-work laws

Supporting Our Troops, Veterans and Their Families: Lessons Learned and Future Opportunities for Philanthropy

Reviews the highlights, impact, and lessons of the foundation's Iraq Afghanistan Deployment Impact Fund grants to raise awareness of and help meet the needs of veterans and families. Makes recommendations for policy makers, grantmakers and nonprofits

Liver Transplant Dilemma: The Alcoholic, Medicaid Patient

A case scenario on Ivan Bradford. Ivan is a fifty-five year old, white male in need of a liver transplant. Ivan has been an alcoholic since he was thirty-two years old, and has developed an irreversible advanced liver disease, cirrhosis. In essence, the disease is the end result in scarring of the liver due to prolonged alcohol abuse. This scarring prevents the liver from performing many of its vital functions. Without a liver transplant Ivan will die

Liver Transplant Dilemma: The Alcoholic, Medicaid Patient

A case scenario on Ivan Bradford. Ivan is a fifty-five year old, white male in need of a liver transplant. Ivan has been an alcoholic since he was thirty-two years old, and has developed an irreversible advanced liver disease, cirrhosis. In essence, the disease is the end result in scarring of the liver due to prolonged alcohol abuse. This scarring prevents the liver from performing many of its vital functions. Without a liver transplant Ivan will die