VA unlawfully turned away vulnerable veterans for decades, study says, with 400,000 more at risk

The Washington Post 

Democracy dies in Darkness

By Alex Horton

March 5, 2020

The Department of Veterans Affairs has for decades unlawfully turned away thousands of veterans with other-than-honorable discharges, rendering some of the most vulnerable veterans invisible and desperate for help, according to a study released Thursday

Systemic misunderstanding of the law within VA about which veterans it should care for — and which should be denied services — has triggered improper mass denial of care since 1980, the Veterans Legal Clinic at Harvard Law School said in the study, leaving an estimated 400,000 more at risk of never gaining access to health care they may have earned.

The discharges, given for misconduct that can range from drug use to insubordination but not proved in court, are colloquially known as “bad paper” for the lifetime of negative consequences they can have.

Experts and advocates have called for VA to properly assess eligibility shown to save lives. Veterans outside the VA system kill themselves at a higher rate than veterans who received recent VA care, the agency has said, and mental health care for veterans with bad paper can lower the risk of suicide, the American Journal of Preventive Medicine found last year. VA declined to say whether it unlawfully denied care to veterans.

Generally, other-than-honorable discharges make it less likely that veterans will qualify for VA services. But the agency is required by law to accept applications, look for mitigating circumstances that could grant them services, issue written decisions and provide appeal information to veterans.

It didn’t happen that way for Dwayne Smith, a Marine Corps veteran who served as an engineer equipment operator in Afghanistan’s volatile Helmand province in 2009. He returned with post-traumatic stress and traumatic brain injuries, and his best friend died in his sleep days after they came home.

“That was one thing that changed me,” Smith, 31, told The Washington Post.

His standing in his unit suffered, culminating in an unauthorized absence he used to go home to visit his mother, who was dying of cancer, he said.

Senior leaders offered him a way out as his enlistment neared its end: Take an other-than-honorable discharge or risk a dishonorable discharge later. He saw it as a plea bargain to be with his mother, and in 2012, he left the Marine Corps with bad paper.

Months later, unmoored and in need of care, Smith drifted to VA in search of help. A front-line worker at the Brockton VA outside of Boston looked over his discharge paperwork and sent him away without documenting his visit, he said. Multiple denials followed during the next two years.

“I was supposed to be able to turn to them,” Smith, now an athletic trainer for children, said of VA.

His experience is emblematic of the struggles of many of the half-million veterans issued other-than-honorable discharges since 1980, when certain eligibility requirements began to apply, said Dana Montalto, an attorney for the law clinic and co-author of the report.

Many veterans are simply given a verbal denial, while others are told incorrectly that the only solution is to go back to the Pentagon to try to get their discharge upgraded.

VA could not produce numbers for how many eligibility decisions it has made involving bad paper. The legal clinic estimated the number was around 100,000.

“VA has done more outreach to other-than-honorable former service members in the last few years than ever before,” VA press secretary Christina Mandreucci said Wednesday, which includes a call center launched in December to contact veterans who left the military in the past year, including those with bad paper.

VA also sent 444,487 letters sent to veterans with bad paper describing some mental-health benefits granted in 2017.

However, VA pulled their home addresses from Pentagon records — information that could be decades old for a Vietnam or Gulf War veteran, for instance, who may have used a parent or guardian’s address at the time of enlistment.

Veterans with 'bad paper' turned away from VA for decades, Harvard Law study finds - The result: 2,580 veterans with other-than-honorable discharges received care at VA in 2018, the agency said in a blog post last year, one day after a reporter in Seattle detailed the case of a veteran denied care.

“That is horrifically low by any measure,” said Kris Goldsmith, the associate director for policy and government affairs at Vietnam Veterans of America. “It shows how unserious VA’s leadership is in getting these guys and gals into the system.”

It is impossible to know how many veterans VA has turned away without evaluations, Montalto said.

In one case detailed in the study, a Vietnam veteran who left with bad paper suffered from untreated post-traumatic stress disorder for 50 years after he was incorrectly told he was ineligible for VA care. An attorney working on his case helped him win the benefits he earned, the report said.

Much of the confusion comes from inside VA, the report found, after records requests revealed guidance for staff that was wrong or incomplete at VA facilities across the country.

The Pittsburgh VA Medical Center used a clip art image of a thumbs-down to describe other-than-honorable discharges, implying they are a non-starter. VA’s hospital in El Paso incorrectly told a veteran that only honorable and general discharges lead to VA care, the study said.

Those cases contradict other guidance VA has provided. In 2017, VA allowed veterans with bad paper to use VA services in mental-health emergencies, and a law expanded that coverage a year later.

For tracking purposes, the legal clinic characterized bad paper as any discharge besides those considered honorable. Some of the categories — dishonorable and bad conduct — can be the result of serious crimes in uniform.

But others, like in Smith’s case, can be an arbitrary punitive action enforced by a commander, not a judge or jury in a military court.

Often, they are infractions that mushroom from physical or mental wounds, such as self-medicating with drugs or alcohol after combat or sexual assault. From 2011 to 2015, the drawdown period from the highest troop levels in Iraq and Afghanistan, more than half of the 91,764 troops separated for misconduct were diagnosed with post-traumatic stress disorder or traumatic brain injuries before discharge, the Government Accountability Office found.

They can also be the result of discrimination — the study found that more than 100,000 veterans in the LGBT community left the military with bad paper from the end of World War II until 2011, when the “don’t ask, don’t tell” policy was repealed.

After a five-year battle, Smith ultimately won his appeal and received VA care and compensation in 2018 for his traumatic brain injuries and post-traumatic stress disorder. And that was only after Montalto represented him pro bono.

“That was the biggest win,” he said, “to walk into VA with my head held high.”

Brain Injuries Are Common in Battle. The Military Has No Reliable Test for Them.

The New York Times

By Dave Philipps and Thomas Gibbons-Neff

Feb. 15 2020

Traumatic brain injury is a signature wound of the wars in Iraq and Afghanistan. But the military still has no objective way of diagnosing itin the field.

U.S. troops at Ayn al Asad Air Base in western Iraq hunkered down in concrete bunkers last month as Iranian missile strikes rocked the runway, destroying guard towers, hangars and buildings used to fly drones.

When the dust settled, President Trump and military officials declared that no one had been killed or wounded during the attack. That would soon change.

A week after the blast, Defense Department officials acknowledged that 11 service members had tested positive for traumatic brain injury, or TBI, and had been evacuated to Kuwait and Germany for more screening. Two weeks after the blast, the Pentagon announced that 34 service members were experiencing symptoms associated with brain injuries, and that an additional seven had been evacuated. By the end of January the number of potential brain injuries had climbed to 50. This week it grew to 109.

Brain Injuries Are Common in Battle. The Military Has No Reliable Test for Them.

The Defense Department says the numbers are driven by an abundance of caution. It noted that 70 percent of those who tested positive for a TBI had since returned to duty. But experts in the brain injury field said the delayed response and confusion were primarily caused by a problem both the military and civilian world have struggled with for more than a decade: There is noreliable way to determine who has a brain injury and who does not. Top military leaders have for years called traumatic brain injury one of the signature wounds of the wars in Iraq and Afghanistan; at the height of the Iraq war in 2008, they started pouring hundreds of millions of dollars into research on detection and treatment. But the military still has no objective tool for diagnosing brain injury in the field. Instead, medical personnel continue to use a paper questionnaire that relies on answers from patients — patients who may have reasons to hide or exaggerate symptoms, or who may be too shaken to answer questions accurately.

The military has long struggled with how to address so-called invisible war wounds, including traumatic brain injury and post-traumatic stress disorder.

Despite big investments in research that have yielded advances in the laboratory, troops on the ground are still being assessed with the same blunt tools that have been in use for generations.

The problem is not unique to the military. Civilian doctors struggle to accurately assess brain injuries, and still rely on a process that grades the severity of a head injury in part by asking patients a series of questions: Did they black out? Do they have memory problems or dizziness? Are they experiencing irritability or difficulty concentrating?

“It’s bad, bad, bad. You would never diagnose a heart attack or even a broken bone that way,” said Dr. Jeff Bazarian a professor of emergency medicine at the University of Rochester Medical Center. “And yet we are doing it for an injury to the most complex organ in the body. Here’s how crazy it gets: You are relying on people to report what happened. But the part of the brain most often affected by a traumatic brain injury is memory. We get a lot of false positives and false negatives.”

Without a good diagnosis, he said, doctors often don’t know whether a patient has a minor concussion that might require a day’s rest, or a life-threatening brain bleed, let alone potential long-term effects like depression and personality disorder.

At Ayn al Asad, personnel used the same paper questionnaires that field medics used in remote infantry platoons in 2010. Aaron Hepps, who was a Navy corpsman in a Marines infantry company in Afghanistan at that time, said it did not work well then for lesser cases, and the injuries of many Marines may have been missed. During and after his deployment, he counted brain injuries in roughly 350 Marines — about a third of the battalion.

After the January missile attack, Maj. Robert Hales, one of the top medical providers at the air base, said that the initial tests were “a good start,” but that it took numerous screenings and awareness among the troops to realize that repeated exposure to blast waves during the hourlong missile strikes had affected dozens.

Traumatic brain injuries are among the most common injuries of the wars in Iraq and Afghanistan, in part because armor to protect from bullet and shrapnel wounds has gotten better, but they offer little protection from the shock waves of explosions. More than 350,000 brain injuries have been reported in the military since 2001.

The concrete bunkers scattered around bases like Ain al Assad protect from flying shrapnel and debris, but the small quarters can amplify shock waves and lead to head trauma.

The blasts on Jan. 8, one military official said, were hundreds of times more powerful than the rocket and mortar attacks regularly aimed at U.S. bases, causing at least one concrete wall to collapse atop a bunker with people inside.

Capt. Geoff Hansen was in a Humvee at Ayn al Asad when the first missile hit, blowing open a door. Then a second missile hit.

“That kind of blew me back in,” he said. “Blew debris in my face so I went and sat back down a little confused.”

A tangle of factors make diagnosing head injuries in the military particularly tricky, experts say. Some troops try to hide symptoms so they can stay on duty, or avoid being perceived as weak. Others may play up or even invent symptoms that can make them eligible for the Purple Heart medal or valuable veteran’s education and medical benefits.

And sometimes commanders suspect troops with legitimate injuries of malingering and force them to return to duty. Pentagon officials said privately this week that some of the injuries from the Jan. 8 incident had probably been exaggerated. Mr. Trump seemed to dismiss the injuries at a news conference in Davos, Switzerland, last month. “I heard they had headaches,” he said. “I don’t consider them very serious injuries relative to other injuries I have seen.”

In the early years of the war in Iraq, troops with concussions were often given little medical treatment and were not eligible for the Purple Heart. It was only after clearly wounded troops began complaining of poor treatment that Congress got involved and military leaders began pressing for better diagnostic technology.

Damir Janigro, who directed cerebrovascular research at the Cleveland Clinic for more than a decade, said relying on the questionnaire makes accurate diagnosing extremely difficult.

“You have the problem of the cheaters, and the problem of the ones who don’t want to be counted,” he said. “But you have a third problem, which is that even if people are being completely honest, you still don’t know who is really injured.”

In civilian emergency rooms, the uncertainty leads doctors to approve unnecessary CT scans, which can detect bleeding and other damage to the brain, but are expensive and expose patients to radiation. At the same time doctors miss other patients who may need care. In a war zone, bad calls can endanger lives, as troops are either needlessly airlifted or kept in the field when they cannot think straight.

Mr. Janigro is at work on a possible solution. He and his team have developed a test that uses proteins found in a patient’s saliva to diagnose brain injuries. Other groups are developing a blood test.

Both tests work on a similar principle. When the brain is hit by a blast wave or a blow to the head, brain cells are stretched and damaged. Those cells then dispose of the damaged parts, which are composed of distinctive proteins.

Abnormal levels of those proteins are dumped into the bloodstream, where for several hours they can be detected in both the blood and saliva. Both tests, and another test being developed that measures electrical activity in the brain, were funded in part by federal grants, and have shown strong results in clinical trials. Researchers say they could be approved for use by the F.D.A. in the next few years.

The saliva test being developed by Mr. Janigro will look a bit like an over-thecounter pregnancy test. Patients with suspected brain injuries would put  Patients with suspected brain injuries would put sensors in their mouths, and within minutes get a message that says that their brain protein levels are normal, or that they should see a doctor.

But the new generation of testing tools may fall short, said Dr. Gerald Grant, a professor of neurosurgery at Stanford University and a former Air Force nlieutenant colonel who frequently treated head injuries while deployed to Iraq in 2005.

Even sophisticated devices had trouble picking up injuries from roadside bombs, he said.

“You’d get kids coming in with blast injuries,” he said, “and they clearly had symptoms, but the CT scans would be negative.”

He was part of an earlier effort to find a definitive blood test, which he said in an interview was “the holy grail.” But progress was slow. The grail was never found, he said, and the tests currently being developed are helpful for triaging cases, but too vague to be revolutionary.

“Battlefield injuries are complex,” he said. “We still haven’t found the magic biomarker.”

Alissa J. Rubin contributed reporting.

Fifty US troops left with brain injuries after Iranian rocket attack

The Sydney Morning Herald

January 29, 2020

Washington: The Pentagon says 50 US service members are now diagnosed with traumatic brain injury after missile strikes by Iran on a base in Iraq this month, 16 more than the military had previously announced.

President Donald Trump and other top officials initially said Iran's January 8th attack had not killed or injured any US service members.

"As of today, 50 US service members have been diagnosed" with traumatic brain injury, Pentagon spokesman Lieutenant Colonel Thomas Campbell said in a statement about injuries in the attack on the Ain Asad air base in western Iraq. Symptoms of concussive injuries include headaches, dizziness, sensitivity to light and nausea.

Thirty-one of the 50 were treated in Iraq and returned to duty, including 15 of those diagnosed most recently, Campbell said.

Eighteen of the total have been sent to Germany for further evaluation and treatment, and one was sent to Kuwait and has since returned to duty, he said.

"This is a snapshot in time and numbers can change," Campbell said. In its previous update on Friday, the Pentagon had put the number of thoseinjured at 34.

Trump last week appeared to play down the injuries, saying he "heard that they had headaches and a couple of other things".

That prompted criticism from a US war veterans' group. William Schmitz, national commander of the Veterans of Foreign Wars, said on Friday the group "expects an apology from the President to our service men and women for his misguided remarks."

According to Pentagon data, about 408,000 service members have been diagnosed with traumatic brain injury since 2000.

Iran fired missiles at the Ain Asad base in retaliation for the US killing of top Revolutionary Guard general Qassem Soleimani in a drone strike at Baghdad airport on January 3.

The missile attacks capped a spiral of violence that had started in late December, and both sides have refrained from further military escalation.


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