#TBI

It costs HOW MUCH?

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The mind boggles. War is expensive to conduct. Once wars finish, the cost of looking after veterans is massive. In 2000, the Department of Veteran Affairs (VA) in America spent $43.6bn to look after returned servicemen and women. In 2020 it is expected to exceed $212bn (c. 5x), the equivalent of what the Chinese currently spends on its military.  Digging deeper into the data reveals that the cost of the aftermath of Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) on veteran treatment keeps growing in a straight line.

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Total obligations for OIF/OEF/OND patients has grown 19-fold in the last 14 years to over $7bn. Total veterans from those campaigns now totals 965,000 and is expected to hit 1.1mn by 2020. Cost per veteran patient over the 2006-2020 period will virtually treble.

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Expenditure on prosthetic devices (e.g. limbs, hearing aids) has near as makes no difference quadrupled in that period.

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Spending on pharmaceutical products is up 1.9x since 2006.

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Drugs such as Oxycontin which contain opioids have found their way to creating problems in the US armed forces. 15% of Army troops admitted to taking illicit drugs (cocaine, heroin, marijuana) and opioids back in 2008.

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Spending on programs to prevent substance abuse is up 1.8x since 2006.

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The VA notes key clinical metric trends from Quarter Four of 2012 to Quarter Four of 2017 show:

• 67% reduction in Veterans receiving opioid and benzodiazepine together;
• 44% reduction in Veterans on long-term opioid therapy (> to 90 days);
• 38% reduction in Veterans receiving opioids;• 56% reduction in Veterans receiving > 100 Morphine Equivalent Daily Dose;
• 51% increase in Veterans on long-term opioid therapy with a Urine Drug Screen
(UDS) completed within last year to help guide treatment decisions.

Spending on mental health programs is up almost 4x since 2006. The VA plans to promote the development of skills in VA providers to diagnose and assess PTSD
by developing a computer-based training using simulated virtual patient
technology that will allow clinicians to practice and receive customizable feedback
on giving CAPS-5 to a lifelike virtual patient.

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The 2019 VA Budget requests $8.6 billion for Veterans’ mental health services, an increase of 5.8% above the 2018 current estimate. It also includes $190 million for suicide
prevention outreach. VA recognizes that Veterans are at an increased risk for suicide and
implemented a national suicide prevention strategy to address this crisis. Veteran suicide in the US is at a 22/day clip.

The price of freedom. All said and told the US over the last 20 years will have spent the equivalent of $2.476 trillion with a “T” on veterans. That is the equivalent of one entire year of UK GDP.

Smart technologies are an absolute must for the VA. The cost of veteran health is the equivalent of 29% of what the US spends on defence, up from 14.8% two decades ago. Asking for yearly increases is a band aid solution.

How well do Americans know their Defense budget?

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The US spends more than the next 9 countries combined when it comes to defence. What is probably lost on many Americans is the spiraling cost of funding the veterans who served. The US is forecast in 2020 to spend almost as much on the Dept of Veterans Affairs (VA) as China does on military spending. The direct cost of wars in Iraq and Afghanistan has driven the indirect costs of treating those who served almost 5-fold since the war began. US politicians have passed increase after increase.  Have these increases been thought of in context of the trend? Or do annual increases just get signed off as a reflex action?

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If we put the VA budget next to the defence budget, the former has grown from 14.8% of the latter to around 29% between 2000 and 2020. The number of veterans receiving disability compensation has grown 2 million in 2000 to 4.3 million in 2016. A total of 7.2 million veterans are actively seeking services or payments from the VA, up from 5.5 million in 2000.

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Spending per veteran by priority group also reveals sharply higher costs. This is not an exhaustive list of priorities, but the main 7.

Priority 1

• Veterans with VA-rated service-connected disabilities 50% or more disabling
• Veterans determined by VA to be unemployable due to service-connected conditions.

Priority 2

• Veterans with VA-rated service-connected disabilities 30% or 40% disabling

Priority 3

• Veterans who are Former Prisoners of War (POWs)
• Veterans awarded a Purple Heart medal
• Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty
• Veterans with VA-rated service-connected disabilities 10% or 20% disabling
• Veterans awarded special eligibility classification under Title 38, U.S.C., § 1151, “benefits for individuals disabled by treatment or vocational rehabilitation
• Veterans awarded the Medal Of Honor (MOH)

Priority 4

• Veterans who are receiving aid and attendance or housebound benefits from VA
• Veterans who have been determined by VA to be catastrophically disabled

Priority 5

• Non service-connected Veterans and non-compensable service-connected Veterans rated 0% disabled by VA with annual income below the VA’s and geographically (based on your resident zip code) adjusted income limits
• Veterans receiving VA pension benefits
• Veterans eligible for Medicaid programs

Priority 6

• Compensable 0% service-connected Veterans.
• Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki.
• Project 112/SHAD participants.
• Veterans who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975.
• Veterans of the Persian Gulf War who served between August 2, 1990, and November 11, 1998.
• Veterans who served on active duty at Camp Lejeune for at least 30 days between August 1, 1953, and December 31, 1987.
• Currently enrolled Veterans and new enrollees who served in a theater of combat operations after November 11, 1998 and those who were discharged from active duty on or after January 28, 2003, are eligible for the enhanced benefits for five years post discharge.

Priority 7

• Veterans with gross household income below the geographically-adjusted income limits for their resident location and who agree to pay copays.

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Countries have an obligation to look after the troops that sustain injury, physical, mental or otherwise. The question is whether politicians are cottoning on to the mounting relative increase in healing the veteran community to the spending on weapons of war?

There are 19.6 million veterans in the US. By 2045 this is expected to dip below 12 million. With 2.1 million serving active duty military personnel and reserves, the overall costs of healing may not come down anytime soon.

What it does say is that there is a massive need to work out how to reduce the costs to the VA without impeding improving healthcare and benefits for veterans.

Banned documentary – Let There Be Light, 1946

In compiling the book of letters from the battlefields of WWII by Lt. Norman Peterson, researching PTSD in that era has unearthed some interesting facts. A documentary made by John Huston in 1946, which chronicled the treatment of troops suffering from neuro-psychiatric conditions, was banned by the Army from release to the public until 1981. The excuse made was that it was necessary to protect the identity of the patients, despite Huston having received signed waivers. It would seem the top brass did not want to have the extent of the problem acknowledged by the broader public.

The first published book related to what we now know as PTSD was the Diagnostic and Statistical Manual of Mental Disorders of 1952. It listed the condition as “gross stress reaction.” It wasn’t until 1980 that PTSD was properly recognized as a psychological issue. After WWII, veterans were told to just tough it out.

WWII British Army veteran, Victor Gregg, wrote the following in The Telegraph newspaper article on 9th November 2015 with respect to PTSD like conditions.

“I remember one day during the Battle of Alamein when my friend Frankie Batt, a man I had enlisted with in 1937, was blown to pieces. I recall trying in vain to put the bits together, to somehow bring Frankie back to life. As I picked up what was left of him I could feel the hate burning inside me. For the next three or four weeks our section never brought in a single prisoner, in spite of the fact that the battle was nearly over and the enemy were surrendering in droves. So long as no officer was there to witness, we shot as many as we could until our anger died its own death…by the time I got home I had witnessed things that I had not thought possible, and my brain was filled with images of suffering that were to haunt me for the next forty years…When I was demobbed, people didn’t talk about what was going on in their minds. It just was not the done thing; you straightened your shoulders and got on with life. The men who did try to raise the subject were treated with scorn…It was only after many years that I realised how much heartache and misery my anger caused to those I loved. 

The Cambridge History of the First World War contains an article by Jay Winter, Professor of History at Yale University, where he suggested that shell shock in WWI comprised around 20% of all troops, not the 5% often reported. His contention was that the truth was deliberately suppressed otherwise sufferers would not have received a disability pension if not accompanied by physical wounds.

In 1993, MA Kidson, JC & BJ Holwill wrote in the Medical Journal of Australia a piece titled, ‘Post-traumatic stress disorder in Australian World War II veterans attending a psychiatric outpatient clinic’. Out of 108 veterans who participated in the study 45% were shown to carry symptoms of PTSD – as defined by DSM-III – 48 years after it had ended. The study claimed, The presence of PTSD was significantly associated with the taking of casualties (an indicator of severity of war stress as reported by the veterans themselves) and with combat stress as rated by their treating doctors.”

A 2007-08 study at the University Michigan looked at 78 WWII veterans being treated for depression and discovered that 38% of them had significant PTSD symptoms.

Dr. Helen Kales, principal investigator of the geriatric psychiatry section at the University of Michigan wrote,

World War II veterans come from a generation in which expressing psychological symptoms or distress was pretty stigmatized. So these cases may have gone untreated as the vets did not seek treatment and were able to somehow suppress their symptoms and function.

Reading into Traumatic Brain Injury (TBI) reveals even more concerns about the problems we face dealing with returning soldiers.

While PTSD does not necessarily require physical damage to occur, TBI, in the military, tends to occur when exposed to blast-related injuries such as artillery, improvised explosive devices (IED), land mines and rock-propelled grenades (RPG).

TBI can be the result of occurrences where an object (bullet, bomb fragments) causes the scalp/skull to break or fracture. Sometimes it is a closed injury where the outside force impacts the head but no objects manage to penetrate. Even in the case of closed injuries, the brain can experience such considerable force that it can result in torn tissues, bleeding and other physical damage which can be irreversible in severe cases.

TBI was better recognized in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) where 1.64 million served. 60% of blast injuries in those conflicts resulted in TBI. According to the US Veteran Affairs (VA), 59,000 (c.10%) Iraq and Afghanistan veterans who used the Veterans Health Administration (VHA) from 2009 to 2011 were diagnosed with TBI.

VA now records that 4.3mn receive disability benefits, up 2mn from 2000. The total budget for the VA in 2019 will total $198.6bn, up from $97.7bn in 2009. It was $43.6bn in 2000. The VA is asking for $212bn for 2020. The VA budget relative to the defense spending budget was 14% in 2000. It is now 30%. The cost of war is obscene. The cost of looking after veterans is hot on defence spending heels.

One man’s path to cut the rate of veteran suicides

This video is a wonderful testament to the selfless sacrifice and idea of one man, Jason Zaideman, in order to help US military veterans avoid an all too common fate of suicide due to PTSD (Post Trauma Stress Disorder) and TBI (Traumatic Brain Injury). Jason has set up a charitable centre called Operation Combat Bikesaver (OCB) in Indiana (which has one of the highest veteran suicide rates among 50 states). OCB proclaims,

We believe that breathing new life into tarnished motorcycles by honing in on learned skill sets will relinquish the deafening grasp PTSD / TBI / Depression has on Veterans and First Responders. By creating distinctive works of art, those candidates can give back to others suffering in a brotherhood of unity, targeting relief to the chaos of one’s own mind…They will be introduced to building, fabricating, welding and painting to resurrect something that was once damaged and forgotten into something new and truly unique while rebuilding themselves at the same time…We have lost way too many to PTSD / TBI and Depression. All of us here at Operation Combat Bikesaver have lost someone to the after effects of defending their country and community. We would love nothing more than to help our Heroes return to feeling normal again.

Before we get into the sad details of veteran suicides in the US, OCB has raised a paltry $20,000 through crowd funding.  To put that in context we have all seen the viral photo-shopped Time magazine picture of a little girl crying at a defiant Trump. It was used with great effect by the Refugee and Immigrant Center for Education and Legal Services (RAICES) to raise $20mn via crowdfunding! $20 million!!

Even after it was revealed that the child – stolen from her father – was never separated from the mother (who left her other 3 kids behind) and paid a smuggler to get to the border, RAICES still shamelessly uses the picture to boost its funding target to $25mn. Despite poor veterans committing suicide at a rate of 20/day some citizens seemingly attain higher virtue by pouring 1,000x more into an organisation with highly questionable ethics. So much for thanking those that served one’s country.

The Department of Veterans Affairs (VA) writes it “has worked tirelessly to develop suicide prevention resources for every Veteran who is experiencing a mental health crisis, whether or not that Veteran is enrolled in the VA Health Care System. In fact, of about 21.6 million Veterans across the country —including almost 2 million women — just over 8.5 million are enrolled for care from a VA provider.  VA is committed to identifying and reaching all Veterans who may be at risk for suicide and continues to enhance programs designed to reduce risk among those who receive services from the Veterans Health Administration (VHA). As highlighted in a recent VA-led Call to Action to Prevent Veteran Suicide, eliminating the burden of suicide among Veterans will require participation from a broad group of federal government and community partners.”

Key findings from this year’s report include:

▪ In 2014, an average of 20 Veterans died by suicide each day. Six of the 20 were recent users of VHA services in 2013 or 2014.
▪ In 2014, Veterans accounted for 18% of all deaths by suicide among U.S. adults and constituted 8.5% of the U.S. adult population (ages 18 and older).
▪ The burden of suicide resulting from firearm injuries remains high. In 2014, about 67% of all Veteran deaths by suicide were the result of firearm injuries.
▪ There is continued evidence of a high burden of suicide among middle-aged and older Veterans. In 2014, about 65% of all Veterans who died by suicide were ages 50 and older.
▪ After adjusting for differences in age and sex, risk for suicide was 22% higher among Veterans compared with U.S. civilian adults. (2014)
▪ After adjusting for differences in age, risk for suicide was 19% higher among male Veterans compared with U.S. civilian adult men. (2014)
▪ After adjusting for differences in age, risk for suicide was 2.5 times higher among female Veterans compared with U.S. civilian adult women. (2014)
▪ In 2014, rates of suicide were highest among younger Veterans (ages 18–29) and lowest among older Veterans (ages 60 and older).

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Since 2001, the proportion of VHA users with mental health conditions or substance use disorders (SUD) has increased from 27% in 2001 to 41% in 2014.

Risk for suicide following separation from active duty service remains a concern among Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). 18-24yo suicides in those three categories has surged from 27/100,000 in 2003 to 124 per 100,000 in 2014.

OCB is a truly worthy cause. Sadly in today’s world, too many seek to signal their virtue on social media rather than get their hands dirty and properly do something productive like Zaideman to fix causes. Truly inspirational. $20 million to support a cause based on a fake photo or $20 million to support people who have lost limbs, buddies and in many cases hope? After reading about the gore of war from my own grandfather’s letters from WW2 it is not hard to see what a gross misallocation of money and morals this is.