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Modern Warfare Destroys Brains Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

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Modern Warfare Destroys Brains Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury NATIONAL SECURITY FELLOWS PROGRAM Modern Warfare Destroys Brains Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury Warren Stewart Kevin M. Trujillo PAPER JULY 2020 National Security Fellowship Program Belfer Center for Science and International Affairs Harvard Kennedy School 79 JFK Street Cambridge, MA 02138 www.belfercenter.org/NSF Statements and views expressed in this report are solely those of the author and do not imply endorsement by Harvard University, Harvard Kennedy School, the Belfer Center for Science and International Affairs, the U.S. government, or the Department of Defense. Design and layout by Andrew Facini Copyright 2020, President and Fellows of Harvard College Printed in the United States of America NATIONAL SECURITY FELLOWS PROGRAM Modern Warfare Destroys Brains Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury Warren Stewart Kevin M. Trujillo PAPER JULY 2020 About the Authors Colonel Warren Stewart holds a doctorate in nursing practice (DNP) from Duke University. Warren is board certified as an Acute Care Nurse Practitioner and Critical Care Clinical Nurse Specialist with over 22 years of trauma experience to include multiple deployments in support of combat operations. Warren currently serves as the Assistant Deputy for Medical Affairs for the Assistant Secretary of the Army, Manpower & Reserve Affairs. Lieutenant Colonel Kevin Trujillo has over 20 years in the US Army and over 16 years serving in Special Forces and Ranger assignments holding key leadership positions from Detachment Commander through Joint Task Force Commander. He has extensive combat experience due to numerous deployments to Iraq and Afghanistan and was recently selected to com- mand a US Army Special Forces Group. Both authors pledged to donate their brains to the Center for Neuroscience and Regenerative Medicine Brain Donation Awareness Program. For information how to donate your brain for research: https://www.research- braininjury.org/registry/ Modern Warfare Destroys Brains: ii Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury Acknowledgements A special thanks to the following individuals who provided their guidance and insights with our research: Dr. Daniel P. Perl, Professor of Pathology, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, and Director, Neuropathology Core Center for Neurosciences and Regenerative Medicine; Ms. Stacey Gentile, Neuropathology Core Project Manager for the Henry F. Jackson Foundation; Ms. Jane Horton, Senior Advisor (USD P&R); Home Base BG Jack Hammond (USA-Ret.), Executive Director; CSM Bill Davidson (USA-Ret.) Director of Peer Outreach and Support; Dr. Alex Balbir, Director Independence Services, Wounded Warrior Project; Mr. Frank Larkin, former SEAL, father of Ryan Larkin, advocate for brain health awareness and for permission to include some of his policy recommendations; Dr. B Christopher Frueh, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center; Ms. Terri Tanielian, Senior Behavioral Scientist, Rand Corporation; COL Mark Mitchell (USA- Ret.), Former Principal Deputy Assistant Secretary of Defense for Special Operations/Low-Intensity Conflict; Dr. Chris Nowinski, co-founder and CEO, Concussion Legacy Foundation; Ms. Kathy M Lee, Special Assistant to Deputy Assistant Secretary of Defense for Health Readiness Policy & Oversight; VADM Szymanski, Deputy Commander US Special Operations Command; Ms. Kat Deary, USSOCOM Command Surgeon’s Office; MG William Rapp (USA- Ret.) Harvard Fellows Director and Military Lecturer Belfer Center, Harvard Kennedy School and the countless Gold Star Spouses who provided their personal stories and for those who gave their lives in defense of our country. Belfer Center for Science and International Affairs | Harvard Kennedy School iii Table of Contents Executive Summary ...........................................................................1 1. Introduction ....................................................................................................................2 2. “Operator Syndrome” .................................................................. 7 Post-Traumatic Stress Disorder ...................................................................10 Traumatic Brain Injury and the Scope of the Problem .............................. 14 Interrelated Conditions of “Operator Syndrome” .................................... 19 Endocrine Dysfunction ...................................................................................................... 19 Sleep Disturbance and Sleep Apnea ............................................................................... 20 Depression and Suicide ..................................................................................................... 21 Remaining Components of the “Operator Syndrome” ..............................22 National Security Implications ....................................................................23 3. Blast Related Traumatic Brain Injury ........................................25 Effects of Repeated Blast Exposures ..........................................................28 Differences Between CTE and IAS ............................................................. 30 Modern Warfare Destroys Brains: iv Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury 4. Humanizing the Impacts ............................................................32 The Costs .......................................................................................................35 5. Current USSOCOM and DOD Efforts to Address Warfighter Brain Health ................................................................................ 37 Department of Defense Efforts—USD for Personnel and Readiness ...... 38 6. Policy Recommendations .......................................................... 41 Technology ....................................................................................................41 Research ...................................................................................................... 42 Policy ............................................................................................................. 44 Education ...................................................................................................... 46 7. Conclusion ...................................................................................48 Bibliography .....................................................................................50 Belfer Center for Science and International Affairs | Harvard Kennedy School v Glossary bTBI Blast related traumatic brain injury/Blast wave traumatic brain injury CTE Chronic traumatic encephalopathy DOD Department of Defense IAS Interface Astroglial Scarring mTBI mild traumatic brain injury PTSD Post-Traumatic Stress Disorder SO Special Operator SOF Special Operations Forces TBI Traumatic Brain Injury USSOCOM United States Special Operations Command blast related traumatic brain injury: traumatic brain injury caused by an explosion or blast that can be more complex compared with a TBI from other causes blast wave: complex pressure wave generated by an explosion, an instantaneous rise in atmospheric pressure that is much higher than normal for humans to withstand. comorbidities: the simultaneous presence of 2+ morbid conditions or diseases in the same Pt, which may complicate a Pt’s overall health or treatment plan chronic traumatic encephalopathy: a neurodegenerative disease caused by repeated head injuries interface astroglial scarring: distinct and previously undescribed pattern of scarring at boundaries between brain parenchyma and fluids, and at junctions between grey and white matter. posttraumatic stress disorder: a psychological reaction occurring after experiencing a highly stressing event (such as wartime combat, physical violence, or a natural disaster) that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event. traumatic brain injury: A traumatically induced structural injury or physiological disruption of brain function, as the result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event: Any alteration in mental status (e.g., confusion, disorientation, slowed thinking, etc.). Any loss of memory for events immediately before or after the injury. Any period of loss of or a decreased level of consciousness, observed or self-reported. Belfer Center for Science and International Affairs | Harvard Kennedy School vii Rangers from 75th Ranger Regiment train on the 120mm Mortar System. US Army Photo / Spc. Garrett Shreffler Executive Summary “Operator Syndrome,” especially blast TBI (bTBI) and PTSD, are destroy- ing the lives of special operators at an alarming rate. For the purposes of this paper, operators are Green Berets, SEALs, MARSOC Raiders, Combat Controllers, Pararescue, Explosive Ordnance Disposal Technicians, Special Mission Units or those that may accompany special operations forces regu- larly in training or on missions. The USSOCOM must continue to aggressively address bTBI. The authors acknowledge that the Nation and the command have invested heavily in developing strategies to address this issue; however, thus far, the efforts seem disjointed and have failed
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