Brain Wars: How the Military is Failing its Wounded
Last month, the Pentagon sent a soothing letter to members of Congress worried about the treatment of soldiers who suffered brain injuries in Iraq and Afghanistan.
The letter, previously unreported, told House and Senate members that the military was studying the efficacy of a treatment known as cognitive rehabilitation therapy. Cognitive rehabilitation is a lengthy, often expensive program designed to retrain troops with brain injuries to do everyday tasks from remembering grocery lists to recalling words and names.
The letter includes contradictions of previous Pentagon statements. Notably, it makes no promise that brain-damaged soldiers will receive cognitive rehabilitation any time soon.
In the letter, George Peach Taylor Jr., the acting assistant defense secretary for health, acknowledged that the military health care's plan for troops and many veterans, called Tricare, does not cover cognitive rehabilitation therapy. One of the main reasons? A contractor hired by Tricare found limited evidence it works.
But as NPR and ProPublica reported Monday, Tricare's review came under fire in a series of confidential reviews by leading brain specialists. Scientists criticized the study as "deeply flawed" and "unacceptable." One even called it a "misuse" of science designed to hold down costs by depriving soldiers of care.
Cognitive rehabilitation has been used for decades to help civilians with brain injuries. Some major insurance companies, including Aetna and Humana, cover the treatment. Several major peer-reviewed studies support its efficacy. The Pentagon's own specialists and a panel convened more than a decade ago by the Institutes for Medicine have recommended its use.
Taylor's letter, which was written before the NPR and ProPublica stories appeared, did not mention the critiques of the Tricare study. But Taylor did make passing reference to another issue: money.
Comprehensive cognitive rehabilitation therapy can cost more than $50,000 per patient -- potentially adding enormous bills to the military's medical system at a time when hundreds of thousands of soldiers have suffered traumatic brain injuries on the battlefield. Tricare officials told us that money played no part in their considerations to deny coverage for the treatment. But Taylor told Congress that cost was a factor in figuring out which therapies to provide.
"Establishing the effectiveness of cognitive rehabilitation is an important issue for reimbursement of clinical services within the healthcare industry," he wrote to the chairs of the House and Senate Armed Services and Appropriations committees.
Taylor's letter also discussed a second set of studies, funded by $10 million set aside by the congressional committees in last year's defense bill. He wrote that the Pentagon's Defense and Veterans Brain Injury Center, known as DVBIC, had launched its own studies on how to treat mild traumatic brain injury. One of the signature wounds of the wars, mild traumatic brain injuries are often a result of blast waves from roadside bombs. Most soldiers recover quickly, but studies suggest as many as 15 percent go on to suffer lingering cognitive problems.
For careful readers of the military spending bills, this represents a significant change from what Congress had asked. The defense spending bill for 2010 asked the Pentagon to assess the value of cognitive rehabilitative in treating "traumatic brain injury in members and former members of the armed forces" (for those who want to read this passage in its full PDF context, you can check out the language on page 232 of the 1,236-page bill).
The difference is crucial. Why? Because cognitive rehabilitation therapy is actually a pretty well proven treatment for those suffering from moderate to severe brain injury. So by focusing only on mild traumatic brain injury, the Pentagon has avoided having to acknowledge the efficacy of the therapy for those with severe injuries, while tying up decisions on how to treat soldiers with mild traumatic brain injuries in a series of new studies.
In the letter, Taylor did say that cognitive therapy has proved promising: "Cognitive rehabilitation is a long-standing and significant component of comprehensive rehabilitation for individuals with moderate and severe TBI. There is an accelerating, but still small, body of scientific literature supporting cognitive rehabilitation in mTBI," he says, referring to mild traumatic brain injury.
Taylor said it will take years to complete the necessary studies. One should be finished in 2011, another in 2013. By then, many more troops will have suffered brain injuries. And many more who have already suffered blows to the head will have gone without cognitive rehabilitation therapy.
Why the delay? That's the question raised by soldiers, their families and brain injury advocates: if a treatment has some proof that it works, and no proof that it hurts, why not move faster to provide it?
"There should be a way to provide TRICARE coverage for cognitive therapy while further studies are ongoing," Sen. Mark Udall, D-Colo., who serves on the Senate Armed Services Committee, told us in a written statement. "We can't ignore the fact that many studies and experts have determined that cognitive therapy is effective for brain injured patients and the fact that the Department of Veterans Affairs already recognizes its value."
Rep. Bill Pascrell, D-N.J., co-chair of the Congressional Brain Injury Task Force, promised to send a letter to the Pentagon protesting its slow progress on cognitive rehabilitation therapy.
"It's unfortunate that this kind of foot-dragging has been what many have come to expect from the Pentagon when it comes to soldiers who have sustained traumatic brain injuries," Pascrell told us. "Brave Americans who risked everything for their country and sustained traumatic brain injuries -- the signature injury of the wars in Iraq and Afghanistan -- deserve cognitive rehabilitation therapy to help them secure the best futures possible. It is unacceptable that the United States has been at war for nearly a decade and there is still no plan to treat these soldiers."