Leading Senate Forum, Warren Calls on DoD to Strengthen Care for Servicemembers with Traumatic Brain Injuries from Blast Overpressure

September 06, 2024

Leading Senate Forum, Warren Calls on DoD to Strengthen Care for Servicemembers with Traumatic Brain Injuries from Blast Overpressure

"It is the minimum that we owe them - to understand what is happening when they are exposed and to give them the care, support, and treatment that they need if they have suffered from that exposure."

Video of Event (YouTube)

Washington, D.C. - Leading a Senate forum, U.S. Senator Elizabeth Warren (D-Mass.) questioned brain health experts from the Department of Defense (DoD) and Home Base, a national nonprofit organization dedicated to treating the invisible wounds of veterans, servicemembers, military families, and families of the fallen, about the importance of improving access to care for servicemembers, establishing a longitudinal study to better understand other health effects that may be connected to blast overpressure, and addressing the link between blast overpressure and suicide. Later this year, the Senate will consider the fiscal year (FY) 2025 National Defense Authorization Act (NDAA), which includes several provisions from Senator Warren's bipartisan, bicameral Blast Overpressure Safety Act. .

Senator Warren highlighted Home Base's work to promote early treatment and family involvement in the treatment process. Mr. Dennis Hernandez shared his story about how he sought help after realizing there were blocks of time in his day he couldn't remember - but the Department of Veterans Affairs told him that he did not meet the criteria for moderate traumatic brain injury (mTBI). He was then referred to Home Base, the care from which he described as "pivotal in my post-military life" and to which he credited his ability to start his own company and pursue higher education. Dr. Ross Zafonte, Chief of Traumatic Brain Injury and Health and Wellness Programs at Home Base, testified that servicemembers delaying care leads to worse health outcomes with broader implications on their life.

Dr. David J. Smith, Deputy Assistant Secretary of Defense for Health Readiness Policy and Oversight, agreed that ensuring service members have access to care is "directly related to our readiness and our ability to do the missions that we're called upon to do" and that Home Base is an example of organization doing "a great job" trying to get service members into treatment earlier in their career. He also highlighted the "incredible value" of Home Base's pilot with Special Operations Command.

Dr. Zafonte also discussed the link between blast exposure and long-term consequences, saying that servicemember blast overpressure exposure appears to have links to high rates of suicide, cancer, heart disease, and sleep apnea. Kathy Lee, Director of the Warfighter Brain Health Policy at DoD, shared that one of DoD's objectives is to develop partnerships with outside entities to better address exposure and "encourage people to come in and seek care."

Senator Warren highlighted that "the early evidence is flashing red" for a link between blast overpressure and risks of suicide. She pushed for DoD to address links to suicide in the strategies for military occupational specialties at high risk for blast overpressure it will be soon be required to establish under an FY 2025 NDAA provision she secured. Dr. Smith confirmed that "TBI does appear to have risk factors associated with suicide" and that more research needs to be done in this space. Senator Warren emphasized the importance of supporting families, who often can see that servicemembers need help but may struggle to know how to get it, and Ms. Lee agreed that "we need to treat the families…as part of the solution."

Senator Warren discussed how the Department will now conduct baseline cognitive assessments of servicemembers, a requirement she also secured in the FY 2025 NDAA. Dr. Zafonte confirmed there is a need to also conduct regularized cognitive assessments testing of all soldiers to keep those files on record and monitor for any possible issues, and Dr. Smith stated that "we wholeheartedly agree" on doing repetitive cognitive testing.

Transcript: Blast Overpressure Forum
Friday, September 6, 2024

Round 1 Questions: Expanding Access to Care

Senator Elizabeth Warren: New York Times reporting in December 2023 revealed stories of service members with exposure to high levels of blast overpressure experiencing hallucinations, seizures, depression, heart and digestive issues, and more.

Too often service members wait until the end of their careers to seek treatment for exposure to blast overpressure. They may worry that taking time off to seek treatment will interfere with their career progression. Or, the prospect of scheduling a patchwork of doctor appointments may feel daunting and time consuming.

Mr. Hernandez, if I can, I'd like to start with you. You spent most of your time in the Special Forces as a Green Beret, and, after 22 years of service, you participated in Home Base's two-week Intensive Clinical Program. So, can I just ask about the gap in there? And that is the challenges that you faced in receiving care. And then, why did you eventually come to Home Base?

Mr. Dennis Hernandez, former Green Beret in the Army Special Forces: I'd had some friends that had gone through the National Intrepid Center of Excellence, so NICO, mostly through the military and government programs. They were all active duty, though. I was already off active duty and retired at the time.

Senator Warren: So you're no longer eligible for the one program out there?

Mr. Hernandez: I actually wasn't sure how to reach out. I was talking about it with my Sergeant Major, as I was referring to before. And he actually helped refer me to this, because I'd tried going to the VA, and, as I stated, it was a less-than-stellar experience. It's a common story - a little too common. But this is just one experience out of many good ones I've had at the VA. But this one just sticks out because I was entering there looking for help with a problem, and the neuropsych that was interviewing me had walked in the room as if I was interrupting his day. I wasn't in there for more than 5 minutes, he told me I didn't meet the criteria and he moved me along.

Senator Warren: I don't want you to say anything you don't want to talk about, but can you say a little about the symptoms that were causing you to seek help?

Mr. Hernandez: I was forgetting a lot. And not just not remembering a specific detail - entire blocks of time. I was a penetration tester in my previous field, and I would actually test security for companies and corporations and ensure that their security worked. There was one test we had run in the morning that in the afternoon, when we were debriefing on it - with video - I don't remember. And that was one of the last straws for me to start seeking help with Home Base. Because it's just a really jarring, jolting feeling - there's video of you doing something that for all you know could be made up. There's evidence of people who were there, saying you were there and that you said this, and it doesn't exist in my memory. So, that feeling isn't great to say the least. That is how I ended up getting referred to Home Base and talking to the people here, and then eventually doing the two week intensive program.

Senator Warren: Dr. Zafonte, in your role as Chief of Traumatic Brain Injury at Home Base, you see firsthand the extensive damage that low-level and subconcussive blasts have on service members. What is the impact of a service member delaying assessment and treatment?

Dr. Ross Zafonte, Chief of Traumatic Brain Injury and Health and Wellness Programs at Home Base: First of all, thank you, Dennis, for your service, and your advocacy for other service members. Senator, thank you for that great question. I guess I would say I'm worried about this issue with delay - people delay because they believe they need to be tougher. This is already the toughest group that we possibly could find.

And then, as Dennis described, they delay sometimes, because care isn't seamless, isn't integrated, and these issues compound over time. Having more exposure, not getting treated, really leads to, as I referred to earlier, a maladaptive kind of spiral. You get negative on negative. You get pain, on top of headaches, on top of depression, on top of a cognitive clouding, that we just heard about. And it has family impacts. It leads to isolation and, we believe, multisystem effects.

So Home Base helps people get treatment, helps people get immediate access - and we want to help provide more to more people. And really, I think, helps restore the fighting forces' health.

Senator Warren: I just want to focus on this for a second. From the time, Mr. Hernandez, that you first started experiencing symptoms that had you worried, and that told you, "I need at least to be checked. I need to talk to someone," and the time you made it to Home Base, roughly about how long was that?

Mr. Hernandez: I would say from the first time I tried seeking assistance from the VA - I went in 2022 to Home Base, so 5-6 years.

Senator Warren: 5 or 6 years. And I'm hearing you say, Dr. Zafonte, that the more time that there's delay, that the symptoms can just continue to get worse. Is that right?

Dr. Zafonte: Absolutely, Senator. What we want to do is get to people early, to address their issues and try to mitigate what we can.

Senator Warren: So, if servicemembers don't get the care they need, when they need it, they have worse health outcomes?

Dr. Zafonte: We believe that their outcomes will be worse, and that those outcomes may have broad implications for their quality of life.

Senator Warren: I appreciate this because it matters in terms of some of the policies we think about in terms of access to care early on. But there's a second thing that Home Base does that I want to ask about, and that is not only providing incredible care for the servicemember or veteran, but also bringing the families in.

Why is it, Dr. Zafonte, that Home Base has focused on asking each servicemember or veteran who comes in to have a family member or close friend - a partner - with them in this treatment?

Dr. Zafonte: Senator, thank you for the question. It comes down to the whole person, the whole life. When we think about ourselves, our families are key to who we are. They are our very core. Families are critical to doing a few things, one of which is supporting the person - making sure that they actually follow up.

But also response validity. As someone who clinically treats people, if your family member is there with you on occasion, they may tell a little bit more of the story than you may tell yourself.

Senator Warren: Mr. Hernandez is smiling while this happens.

Dr. Zafonte: I think families have an important impact on behavioral health, on people's functional status, and linking to any therapeutic regime we develop. So, we are in part critically molded by the families we're a part of.

Senator Warren: I so appreciate that Home Base includes this, and I take it, Mr. Hernandez, that you're a supporter of this?

Mr. Hernandez: Absolutely.

Senator Warren: Good. Commanders agree that this care is critical. At a hearing earlier this year, the Commander of Special Operations Command said Home Base is, "a blessing for your special operators" and that they see results when there is more access to care.

This is the reason that I'm pushing to secure federal funds to establish an intensive four-year brain health and trauma demonstration program for service members to get treatment for blast overpressure, blast exposure, traumatic brain injury, and other common psychological or neurological conditions among service members.

Dr. Smith, you're in charge of health readiness and protection for our service members. Do programs like Home Base, that give service members access to efficient and effective treatment, help promote readiness?

Dr. David J. Smith, Deputy Assistant Secretary of Defense for Health Readiness Policy and Oversight: Thank you for that question, Senator. Clearly, protecting the health of our servicemembers is one of my priorities and the department's priorities. And ensuring the care to our servicemembers helps not only them and their families but also is directly related to our readiness and our ability to do the missions that we're called upon to do.

Senator Warren: I just want to underscore this. It is important that we honor our servicemembers. That is morally the right thing to do, but it also just makes good sense on readiness. And that's the part I just want to underscore. Do you agree with that, Dr. Smith?

Dr. Smith: Totally agree with you, Ma'am.

Senator Warren: Good. Good.

Dr. Smith: As you know, our primary mechanism for access is through either the direct care system, which is the group of military clinics, hospitals that we have around the world, and or TRICARE, where we partner with partners across the world to be able to try to promote access. I can't endorse any particular treatment of course, as you know, but I do want to point out some of the great things that Home Base is actually doing.

One, very important piece that Dr. Zafonte - and was evident from Mr. Hernandez's story - is trying to promote people to come in early to get treatment. And the reality is what we see is typically later on in career. Now, that may be when they're starting to point out the effects more, but it's also, I think, what you'd pointed out, that there's a stigma associated with doing that. So I think Home Base is an example, and a number of other organizations that are doing a great job of trying to promote that, specifically.

Also this partnership that I am talking about that SOCOM, our special operations command, has with Home Base. The pilot that they're doing in this space really has incredible value, and we're really looking forward to the data that they're capturing to be able to see the effect and what is working better than others, where do we need to expand emphasis, take away emphasis. And I think that this is exactly the kind of work that we need to be doing to be able to further this.

Senator Warren: Now, I appreciate the Department of Defense's approach and partnership with Home Base and other organizations in order to try to deliver the best possible case, but also always going back to how we've got to do the research and get more data about what's going on.

Round 2 Questions: Long-Term Impacts of Blast Overpressure

Senator Warren: I'd like to focus for a minute on the long-term impact of blast overpressure. The care that programs like Home Base provide are even more important given that service members may be dealing with symptoms for the rest of their lives.

Mr. Hernandez, you believe that in addition to exposure from standard training and IEDs, that much of your exposure to blast overpressure also occurred because you were a trainer. That's what I'm told. What types of long-term health challenges have you and your fellow service members faced after this kind of exposure?

Mr. Hernandez: With those specific challenges, I've already mentioned the gaps in memory. I've noticed a lot of self doubt, depression, anger. It doesn't always happen right away, but over time, when you spend enough time on teams with people, you notice the change in personalities. They'll start out as a happy, jovial person, and over time, will become much sourer, negative, depressive, and just generally angry. Unfortunately, in the military, most people turn to drinking to solve the problems. We've gotten a lot better over the decades in identifying that and taking care of it internally, referring externally as needed.

Senator Warren: I very much appreciate your highlighting these challenges. This helps add to the advocacy work you're doing.

Other service members, such as artillery crews and mortarmen, have reported anxiety, depression, irregular heartbeats, headaches, difficulty concentrating. So, there's kind of this constellation of responses that people talk about with this long term exposure.

Dr. Zafonte, when you work with your patients, they face a variety of debilitating symptoms. What other types of long-term health consequences are you seeing in service members? And what are you concerned about, about possible connections here - between blast exposure and long term consequences?

Dr. Zafonte: Well, first of all, thank you for the great question, Senator. I think we are very concerned because we are seeing a number of different linked, longer term health problems that we need to study over time. These include, as you just said, behavioral ones, anxiety, depression, but things like attention and memory. A number of our folks are notable for chronic pain, for muscular-skeletal issues. And pain doesn't exactly make suicidality better, it makes it worse. We know heart health issues may exist, and the rates of everything, from sleep apnea to hypertension to heart disease are elevated. And as we said before and you noted, we have this concerning element of a link to cancer that we have to explore more. So I think there are a lot of long-term health concerns. We are getting good at identifying which ones they are. We now have to understand the why and how to mitigate it.

Senator Warren: Let's talk a little bit about the why. What we've talked about now are observable symptoms. Self-reported symptoms, some that you can see, and we're starting to track song long-term consequences.

Do these results surprise you?

Dr. Zafonte: In some ways they do because of the broad and multisystem gravity of them. It's clear that we're concerned about links to long-term neurodegenerative disease. The ones that surprise people probably a little bit more are linkages that we, as I have described and others have shown, to heart disease or cancer or to other multi-system injuries.

As Dennis would probably share with us, carrying a ruck-sack, or parachuting, or jumping out of things, that's not so great on your back and shoulders and other entities. Pain produces more sleep dysfunction, which might produce more brain dysfunction. We're concerned with the multi-domain nature of this, and the need to really parse it out and understand it.

Senator Warren: Have you examined the brains themselves? Have you been doing MRI tests and other kinds of tests on the brains of Special Operators?

Dr. Zafonte: Yes, we have. We have serial MRIs being done on our combat operators. Our colleagues at MGH have done brilliant work looking at a multi-system approach to specific imaging techniques to find some of the abnormalities that appear linked to blast exposure.

Senator Warren: So, these are people who may not be symptomatic -

Dr. Zafonte: Yet.

Senator Warren: Yet, but who are united in their blast exposure, and you have seen at least evidence of brain malformations. What are you seeing?

Dr. Zafonte: We're seeing abnormalities in either network connections or specific areas of the brains. The why isn't as clear. I think what we really need to do is understand who these folks are, what the impact of the blast itself is, one side, what is the impact of all of the stress and the other parts of a life in special forces, on the other side, and how that affects brain health and overall health.

Senator Warren: That describes the study of how people are right now, but to better understand the impact of blast exposure, what kind of a study do you need?

Dr. Zafonte: That's a great question, Senator. I'm a believer that we learn the most from a longitudinal study. From a long-term study characterizing and following people. Long-term studies do something incredibly important, such as nurses' health or Framingham, that many of you may have heard of. They identify risk factors. They help us detect rare event things like head and neck tumors. They help us position the ideas to develop clinical interventions to help people. They allow us to predict health outcomes. They answer questions for the service members themselves about prognosis, and they strengthen evidence for care.

Senator Warren: If I'm understanding this, it appears that we have people who are exposed, blast exposure, and then we have at least some preliminary evidence of changes in the brain - tumors, other changes in the brain. Stop me if I don't have this right.

Dr. Zafonte: I wouldn't say brain tumors, although we haven't linked that, Senator. Colleagues from a large data set within another group have seen brain cancer.

Senator Warren: There is at least some early concerning evidence. Then a constellation of symptoms that start to show up, and over time may get worse, and then ultimately things that may not show up for years, like cancer, Parkinson's disease, other connections that may be related to blast overpressure exposure. And I take it, what you're saying is, you gotta have some studies that reach out over a long enough period of time to be able track the effects of blast overpressure. Is that a fair description?

Dr. Zafonte: Fair description, Senator. We need to follow people serially, keep them as part of a study group and understand how they behave, not in the first few years, because many of them are younger, but are they being robbed of early middle life? Are they aging quicker in some ways? Are they being exposed to diseases that they might see in their 80s and late 70s in middle life?

Senator Warren: Ms. Lee, the fourth line of effort in DoD's Warfighter Brain Health Initiative is to, quote, "reduce or eliminate long-term and late effects of brain exposures and injuries." What are the benefits to studying potential long-term health effects, like brain tumors or other long-term effects, in service members?

Ms. Kathy Lee, Director of the Warfighter Brain Health Policy at DoD: Senator Warren, thank you so much for your question. And thank you for highlighting the Warfighter Brain Health Initiative. And thirdly, thank you for your unrelenting efforts to secure funding in this space so that we can continue this very critical effort.

We developed the Warfighter Brain Health Strategy and Action Plan, the comprehensive strategy and action plan. we have five lines of effort, and we wanted to ensure that we did have, even before you had brain threats or brain exposures, blast exposure in this case, all the way to understanding - through traumatic brain injuries, exposures, injuries - all the way to a better understanding of the late and the long term effects.

People that suffer from comorbidities in conjunction with their traumatic brain injury, and then also later effects that have been found on brain tissue. So that's why we want to reduce and eliminate the late and long term effects looking at that. Some of the previous lines of effort support and contribute to this goal by better longitudinal monitoring and mitigation of both risk exposure and cognitive and physical performance impacts.

We have three major objectives in this line of effort number four. And that's really to have a better understanding, as Dr. Zafonte mentioned, looking longitudinally at what causal factors, how to better characterize, how to distinguish between long term effects versus the later effects that we've seen in some patients. Also to understand who does get those long term effects. Not everybody gets them, so what's the discernment between somebody that does experience those very challenging and complex sequelae.

Secondly, we want to inform proactive and evidence based treatment and rehabilitation strategies, and counter measures to improve those outcomes so that we can influence and maximize quality of life. The benefit of studying long term health effects is to support and improve service members long term functionality and quality of life. And we strive really to get to a point where there is no longer a line of effort four.

And finally, we have to do that, the third objective is, with partnerships with other federal agencies, including our VA partners, as well as private industry, and others that can help us really achieve these goals of better characterization and understanding between exposures, how to those threshold lead us to blast injuries, and then how can we mitigate this, all upfront, encourage people to come in and seek care, and eliminate, as I said, hopefully we're not talking about a line of effort four in years to come.

Senator Warren: I very much appreciate the work you're trying to do, and hope that through this partnership, we can do more of this kind of longitudinal study. Without more information, we will continue to provide good care here at Home Base, and I am grateful for that, but we need better information about what's happening overall. So, I'd like to turn to one more issue before we wrap up today.

Round 3 Questions: Suicide Risks and Cognitive Assessments

Senator Warren: For our final part of this discussion, I'd like to focus on understanding suicide risks related to blast overpressure.

In late June, the New York Times reported that a military lab examined the brains of Navy SEALs who died by suicide and found [quote] "distinctive damage from repeated blast exposure in every brain it tested." Let me say that again: physical, identifiable damage in every single brain it tested.

Data shows that the high risk is not limited to the special operations community. A congressionally mandated report found that suicide rates for troops repeatedly exposed to blasts were more than double the rates of the civilian population.

One of the provisions I secured in this year's NDAA requires DoD to establish individualized strategies for the military occupational specialties at the greatest risk.

Dr. Smith, DoD's current suicide strategy does not address what we know now to be true: blast overpressure exposure is a major risk factor for suicide. Would service members at high-risk for blast overpressure exposure benefit from strategies evaluating and addressing their higher risk for suicide?

Dr. Smith: I appreciate the question. It is clearly true we need a much better understanding on how blast exposure and associated brain injuries are connected to suicide risks.

You hear the tragic stories, and it clearly, particularly with service members taking their own lives, motivates us to act in the space. But I would say that the connection between blast overpressure and suicide risk remains a very understudied area, and we need to collect and examine more as we have been talking about longitudinal data to scientifically determine whether and how blast overpressure may contribute to suicide risk.

I think you are probably also aware that in January, the TBI Center of Excellence published a research review that looked at the state of science on TBI and other comorbidities, including suicide and attempted suicide. But I will also point out that all this research has been done typically and has not taken blast overpressure into account in these studies. Partially because it isn't easily measured and it's a fairly new understanding that's coming into awareness. So again, it's understudied. But in that, it was clearly shown that TBI does appear to have risk factors associated with suicide. It tends to have a higher correlation with moderate to severe TBI.

Now, the reality is the data is really messy, and it's hard to actually support firm, strong conclusions out of this. Also, as we talked about, when you have someone with TBI, they also have what doctors call other comorbidities, such as PTSD and depression, and those actually have a higher correlation in the studies than TBI itself. But there is clearly substantial overlap between these various issues, and that's what also makes it hard to study.

In June we did publish a report that looked at the various MOS, military occupational specialties, and we did see that clearly military occupational specialties have an elevated risk. We also saw ones that don't have elevated risk to blast overpressure but were high also. So that reinforces the need to look at this and continue to support or try and sort out what are the pieces associated with this.

While we're doing that, it goes back to making sure we're working on the prevention efforts, working on trying to get individuals in to be seen earlier because we know there are effective treatments if we do that, and also we instituted the cognitive monitoring that will help trigger that and help.

I hope that answered your question.

Senator Warren: You will never get pushback from me saying, "You want more to research and want to understand a problem better," particularly in this area. But the early evidence is flashing red, and I'm very disturbed that our current suicide strategy doesn't aggressively take into account the possible links between blast overpressure exposure and suicide risk.

And this is the part that I just want to make sure we keep pushing this out. We can't wait until we finish all our research and then say we're going to turn to this problem.

Let me ask you to weigh in on this, Mr. Hernandez. What is your sense? Do you think it would be helpful to bring more service members who have had blast overpressure exposure?

Mr. Hernandez: Oh, absolutely, ma'am.

Senator Warren: Go ahead.

Mr. Hernandez: It's kind of a loaded question too. We don't have enough time to talk about this. There's a short answer and a very long answer.

Senator Warren: Okay, alright.

Mr. Hernandez: The short answer is that there needs to be a lot more open ongoing dialogue between leaders and soldiers, free from repercussions, stigma, or anything like that. Additionally, it is equally important, as you stated already, that the government increase research in the links between TBI and suicidal ideations, in addition to the comorbidities that have been discussed. There is a lot more that could be looked into for the links between them.

The military has a long history of paying lip service. Now we're going into the semi-long answer. The military has a long history of paying lip service to its members, stating, "No career-ending, ruining actions could be taken if you seek mental health assistance. That's crap. Everyone knows this. Everyone in the military-most won't tell you, but they will tell you exactly what they see. We're seeing it time and time again. Soldiers seek mental health, and they immediately become stigmatized. We've done a lot better job over the years taking that stigma out, but it's a generational effect.

The military has done the right thing by starting this process and taking that stigma out; we initiated peer counselors, master resiliency training, and even some organizations have psychologists at the unit level. So we're doing a lot better about it, but there's still a lot more that could be done.

Because there is always a pervasive group of people in the military whose battle cry is always, "This isn't how we used to do it." Well, great. It's called progression. So, with them, I'm not saying they're bad people or bad soldiers or servicemembers. They're just stuck in that way. Sometimes you can't train an old dog with new tricks.

So, in one person's opinion, it's a generational defect. We need to allow those soldiers to retire, and as we're training the new generation, bring them up with the proper techniques and abilities to mitigate this and help.

I'm not saying, "Don't train the old soldiers," but no matter what we do, a lot of stuff in the military is "Check the box. We did this training, great. I saw that PowerPoint. Somebody talked to me for an hour that I didn't pay attention to. Box checked."

Senator Warren: Well, I appreciate your perspective on this. You know I am glad to see the military take a much more active role in suicide prevention and start to take this issue more seriously. I'm obviously concerned that the blast exposure risk factor does not seem to be weighted into the overall strategy yet. Even the Department of Defense's Suicide Prevention Office has said, quote, "Patients who have experienced a mild TBI have a twice as high risk of suicide than individuals without mild TBI. I cannot understand why DOD would delay even a day on working on plans to identify and reduce risks stemming from blast overpressure. That's my urgency at this moment.

Also, education is critical. Lieutenant David Metcalf, a Navy SEAL who died by suicide, left a suicide note that described, "Gaps in memory, failing recognition, mood swings, headaches, impulsiveness, fatigue, anxiety, and paranoia were not who I was, but have become who I am. Each is worsening."

The spouses of those who have died by suicide usually may know something is wrong, but it can be difficult for them to figure out what's wrong and how to fix it. In the wake of this tragedy, his wife, Jamie, launched a grass-roots effort by families for DoD's Brain Tissue Repository Lab to study the brains of others who have died.

Ms. Lee, why is it important for the Department of Defense to help educate families of service members about recognizing and understanding the symptoms of blast overpressure exposure?

Ms. Lee: First, ma'am, thank you so much for sharing David and Jaime's story. We too have learned and read of David's suicide note. It's very compelling. It's a motivator, I have it on my desk, I keep it with me every day because it's a motivator for us to push forward as rapidly as possible. It might not be the hundred percent solution but the eighty percent solution to get out the door so that we can help folks.

It is an important question about why we should be educating family members about this topic. Recent research has shown that social integration and support, including connectedness to your family, can be a protective factor against suicide. So we need to treat the families as a solution, as part of the solution. As we mentioned before, a core priority is getting families to come in for early detection. As soon as the symptoms arise or as soon as they believe that there could be an injury. As well as for mental health concerns. Families can help with both those dimensions. They can spot the symptoms when they happen and also encourage loved ones to come into care. So family and education are paramount. Even with high-quality care, support from loved ones is critical to help support as they're navigating the traumatic brain injury recovery schematic. Educating families can help them prepare and help them through that recovery and also enhance patient outcomes. We too believe that it is very crucial to make sure that we're educating.

The department, in December, stood up a Warfighter Brain Health Hub so all this information concerning cognitive performance, blast overpressure, head impact research, and traumatic brain injury in the late and long term effects. All that is collated on one site so we can keep the best up-to-date information. I encourage all to go check that out for best practices in what we're learning as soon as we know it. It's dot.mil.

Senator Warren: Yes, and I appreciate that. You know, I want to focus though on the work of the families. I so much appreciate the work that they have undertaken, but we can't leave this on the families. I want to come back to this question of research and how it is that we get the kind of research that we need. I think you mentioned, Dr. Smith, earlier in the answer to one of my questions about how we need-that it is very hard to study because we don't have the information on who has been exposed, how much they have been exposed, what the early impacts were, what your baseline was before there were problems.

Dr. Zafonte, I had gotten into an earlier NDAA, a blast Overpressure Safety Act. And now the DOD has issued a response. Components of the DOD will now be required to conduct cognitive baseline assessments for service members, which provides a starting point to compare and track changes in service member brain health over time. And just last week, the Army started conducting assessments at Fort Moore, where 60,000 soldiers are trained every year.

Dr. Zafonte, I was hoping you could explain a little bit about why this baseline assessment is a good start, but whether medical providers would benefit from seeing more frequent assessments of service members cognitive health, including perhaps a full evaluation before they leave the service.

Dr. Zafonte: Well, thank you, Senator, for your advocacy. I think learning of that news we all smiled. I can't emphasize enough that having a person's baseline-knowing where they are-is critical in knowing where they are going. Serial assessments allow us not only to identify factors for that person but, over time, to think about prognosis for others or who we might intervene on early on. So serial measures are critical to what we want to do.

The other thing to consider, and I believe Dr. Smith brought this up, as has others, is that we need to know who somebody is to understand their path, to understand their unique path, to understand their exposures and use various presently measured metrics of exposure, but also think about the design of getting better at measuring exposure.

Senator Warren: I appreciate that. You know I want to wrap this up, but I really do want to underscore here that the Department of Defense's new memo shows that it has the authority to mandate these assessments. Baseline assessments are crucial, but they are only a starting point. We need more assessments as people progress. Some may need even more assessments, and we need assessments before people leave active duty military. And this is essential both for the research and just to make sure we are actively treating those who need it most.

Dr. Smith, did you want to add something to that?

Dr. Smith: Yes, ma'am. I think we wholeheartedly agree. And as you know, we have set it up to where it is repetitive. We have been doing baseline testing for folks that deploy since 2008, so the good news is that we have that information, but now we are going to have it on everyone and we're going to do it. The plan right now depends on the organization, but at minimum five years because that's the stability that we've seen in the testing that we have.

But some are likely to go sooner. And then, of course, whenever there's an event, that would be another trigger where they would potentially have. And that's the whole point of having these-to be able to compare it to where they were before they had the event.

Senator Warren: I very much want to see this as a routine part of screening our active duty military when they come in the door at determined intervals in between if specific events have happened and when they leave active duty service. That has to be a part of what we do, and we need to keep those records, and we need to keep records on exposure, so I'm going to keep hammering on this. I appreciate that you're moving in the right direction, and I want us to move there faster and with shorter intervals on the testing.

Closing Statement

Senator Warren: I want to thank all of our panelists for coming to today's forum. I also want to thank Home Base for hosting our conversation and Spaulding Rehab for providing the space to hold this discussion.

I am proud to support the incredible work that you do here in Massachusetts for service members and veterans, and I will continue fighting for more resources for programs like Home Base that provide critical care, help get service members back into the field, and that engage families directly in care.

It is also important to examine other long-term consequences of blast exposure. I am concerned about the early evidence of specific brain abnormalities as a result of blast exposure. I am concerned that we have preliminary work here. That is all the more reason to put the resources in and do the larger studies that we need in order to determine clearer connections between blast exposure and possible medical consequences. We need more definitive studies to determine exactly what's going on. We owe it to our service members and their families to do this research so that we can better protect service members from risks.

DoD has a responsibility to do even better. To understand and address the links between blast overpressure exposure and suicide. We also need to do a better job of educating our families so that they can help support their loved ones, identify symptoms, and get the help they need. The DoD's memorandum is a big step in the right direction, but more is needed.

The work on blast exposure and traumatic brain injury is critical to upholding our responsibilities to those who volunteer to serve our nation. It is the minimum that we owe them - to understand what is happening when they are exposed and to give them the care, support, and treatment that they need if they have suffered from that exposure.

I am grateful to everyone at Spaulding. I am grateful to everyone at Home Base. I am grateful to our Department of Defense for all that you are doing every day to try to support our active duty military and our veterans. And I am particularly grateful to you, Mr. Hernandez, for getting out and advocating. Nothing has an impact like telling a personal story. Nothing has an impact like having been there and being able to say to others who may be suffering from some of the same symptoms, not just identifying that you have a problem, but the real hope of Home Base, and that is, there's treatment for these problems. We can help, but we can only help if we can get people in the door and we have enough knowledge about the most effective treatments over time.

So, thank you all for your work. Thank you to all of you who came. We make this a part of our public record, and believe me, it will be part of our next round of discussions in the Senate Armed Services Committee. So thank you all for being here today.

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