It began with a trickle in the summer of '03, when Baathist guerrillas in Fallujah and Mosul mined the roads with improvised bombs. Soldiers lucky enough to survive those blasts reported a suite of symptoms not seen in other wars. Though the men often looked perfectly fine, they had migraines that lasted for days and eventually turned chronic and disabling, were easily addled by basic tasks or forgot how to do them altogether, erupted in violence over small frustrations, and went weeks without a full night's sleep. By the fall of '04, when Workman's national guard battalion deployed from its base in South Carolina, there were thousands of soldiers thus afflicted, and their syndrome had a name, if no known cure. It was called mild or moderate traumatic brain injury (TBI), a catchall term to distinguish its sufferers from those with penetrating head wounds.
Colonel Geoffrey Ling, an army neurologist, was working at a Baghdad combat hospital at the time. "The insurgency was going full tilt," he says, "and the number of TBIs was overwhelming. I'd treated brain injuries since I was a resident in Baltimore, but these were so much worse. The tissue swelled fast and the vessels burst, coating the brain with blood." Already doctors were calling it the signature wound of the war, but none really knew what they were treating. The damage done by blast waves was well beyond their triage expertise. "We were seeing all these cases, and the question arose: Is this a new disease?"
Though it shares key symptoms with post-traumatic stress disorder, with which it's often confused, mild TBI is a physical wound and will respond only to a personalized program of rehab techniques and drugs. Dimly understood at the cellular level even by the scientists hired to solve it, the syndrome is freakishly hard to treat and can bankrupt a family in short order. (Proper care, which starts in the tens of thousands of dollars, is flimsily covered by insurers.)
For the best possible outcome, early detection is crucial, because troops kept in combat often compound a mild case through exposure to subsequent blasts. But for the first four years of this bomb-driven war, the Department of Defense made little effort to diagnose and sequester these brain-injured soldiers, sending men past the wire to face dozens more explosions while they were symptomatic. Woeful, too, was the department's handling of TBI sufferers after they left the theater. They went largely unscreened when they stepped off the plane at home, received substandard care when they asked for help, and were left to rot in army hospitals, most notoriously at Walter Reed in Washington, D.C. In the past two years, the military has taken measures to redress this, spending millions on research, opening TBI clinics, and training everyone from medics to junior officers to identify injured troops. But for men like Kevin Workman, this is cold comfort. He wants no amends – just treatment and recognition for a wound that has cost him more than he can say.
To date, nearly 2 million soldiers have served combat tours in Iraq and Afghanistan, but no one in Washington has offered a definitive sense of how many brain-trauma victims have returned. In 2007 the Department of Defense created an agency called the Defense Centers of Excellence to count, treat, and study brain-blast victims. The centers identified about 48,000 cases dating back to 2003 and further asserted that the vast majority of the injuries were mild enough to have healed on their own. But in April 2008, the RAND Corporation ran roughshod over those figures, concluding after an exhaustive nine-month study that more than 300,000 troops had some form of TBI, and only half of them had improved over time.
"They call brain trauma 'the invisible wound'; well, there's nothing less visible than being uncounted," says Paul Rieckhoff, director of Iraq and Afghanistan Veterans of America, the largest and most impactful advocacy group to emerge from the concurrent wars. Rieckhoff, a veteran of the invasion of Baghdad, says his staff is swamped with calls and e-mails from TBI troops or their loved ones, most of them asking how to access care from a military that has largely ignored them. "The VA and DOD paid no attention to this problem the first four years of the war, and now there are all these guys in need of treatment with no clear way to get it. A lot don't even know they have head trauma, or are too afraid to admit it. They think if they raise their hand for help, it's the end of their service career."