When Samuel Vaughan Wilson III speaks, he periodically stops midsentence to rub his jaw, still pained by the rocket-propelled grenade that ripped through his vehicle, grazing his face and singeing the nerves inside his mouth. It was one of several close calls during that year in Afghanistan: after one IED attack, he recalls with a medic’s precision how, under heavy gunfire, he cut open an Afghan police officer’s throat to clear an air passage, saving his life. He says with equal sobriety that his Army career is over.

“My father wants me to get screening [for Traumatic Brain Injury]. He thinks something is wrong,” said Wilson, who served as a combat medic in Afghanistan with the 508th Parachute Infantry, survived four IED incidents, numerous firefights, and that RPG near miss. According to the recommendation for his Army Commendation Medal, Wilson was credited, in one incident, with saving eight lives and maintaining his composure under “the most extreme circumstances in a combat environment.” But in September 2006, he left the military after 11 years under a rare medical discharge for post-traumatic stress disorder.

He now struggles to understand where his physical injuries leave off and the mental ones begin. His anger, restlessness, and sleepless nights are classic symptoms of both mild TBI and PTSD, which are provoked regularly during his day job as an emergency paramedic in Northern Virginia. “We’ve looked into it,” he said, of possible TBI screening, “but I’ve gotten nowhere in the VA system yet.”

Red-headed Wilson, 36, says he looks like Howdy Doody, but nothing about him is funny. The black ID bracelet of a platoonmate killed in action firmly around his wrist, he is at one turn intimidating and dark, at another vulnerable, self-deprecating, and visibly wracked with survivor’s guilt. He’s outrun death, but doesn’t quite feel alive.

“I love the Army—I was born and raised in it,” Wilson said, reflecting, not for the first time, on his lineage, which includes a grandfather, (Ret.) Lt. Gen. Samuel Vaughan Wilson Sr., who as one of “Merrill’s Marauders” fought behind enemy lines in Burma in World War II. The grandson isn’t the first in his family to bring home PTSD along with medals for valor. His haunted nocturnal pacing when he returned from Afghanistan forced his father, (Ret.) Army Lt. Col. Samuel Vaughan Wilson Jr., to face down a reappearance of his own demons, left over from the rice-paddy wars a generation ago.

“He and I walked in each other’s shoes if you will. His war was very similar to mine in that we both dealt with combat that was asymmetrical—at the least expected moments, [the fighting] would flare up,” said the elder Wilson, an infantry officer in Vietnam in the early 1970s.

But one major difference between his war in the Mekong Delta and his son’s in Kandahar is that, thanks to improvements in body armor and emergency medical response, today the military is bringing more soldiers and Marines home alive—battered, shattered, and transformed, but not in the body bags that drove a nation to disenchanted departure from Southeast Asia.

Yet by the thousands, they are also returning with horrifying injuries, the most pervasive being the IED’s especially vicious souvenir: traumatic brain injury. Symptoms range from memory loss, fatigue, irritability, mood swings, and a change in sleep patterns in milder cases to loss of co-ordination and balance, seizures, migraines, confusion, and agitation in more severe instances.

“TBI is going to be the worst story in terms of returning veterans,” said Paul Sullivan, an advocate with Veterans for America. He estimates that anywhere from 160,000 to 320,000 servicemembers and veterans are suffering from some degree of TBI today, “most of which are unscreened, undiagnosed, and untreated.”

Wilson’s story is hardly rare. Physically, soldiers like him look healthy, but they come home changed, confused about their circumstances and often too ashamed to seek help. If they are still on active duty, they worry that their brain injury or PTSD will be mistaken for a pre-existing personality disorder, which could result in a bad discharge. They are anxious about getting a good disability rating when they leave the military, as statistics show the Army is lowballing ratings for PTSD, TBI, and other injuries, meaning there is a good chance all they will get from Uncle Sam is a severance check.

Once out, they face a long waiting list at the Veterans’ Administration and a lack of mental healthcare access in rural areas. Many contemplate or commit suicide, get divorced, leave their jobs, and even walk the streets, homeless.

“The idea of okay, cheer them up, wave the flag, bring them home, and forget about them … we’re going to be paying for this for the rest of their lives. It’s going to be a horrible bill that we’re going to pay,” said Wilson’s dad, now a high-school teacher in quiet Farmville, Virginia.

“If we’ve got any moral virtue left, we’ve got to pay it,” he added. “We really didn’t anticipate, as a country, and as a nation, the tremendous stresses on our medical system. It’s a horrible thing.”

But some people did anticipate it, and veterans from previous and current wars—call them “warriors for the wounded”—have been working endlessly and aggressively to ensure today’s veteran isn’t betrayed.

Take Sullivan, a Gulf War veteran who left his job as a senior researcher at the VA in March 2006, frustrated his distress signals were being ignored. “They went on record with the Boston Globe that I was ‘alarmist,’” he said of a March feature on the perils of the VA system. “I had no other choice but to pull the alarm.” The VA does not refute Sullivan’s research but winces at his interpretation.

With an estimated 5.5 million veterans being treated at the nation’s 1,400 hospitals and clinics each year—230,000 of them from Afghanistan and Iraq—and an estimated 470,000 more yet to move into a system that is experiencing a backlog of 400,000 disability claims and a six-month average wait for a medical appointment, it is hard not see fire on the mountain.

“Everyone is giving lip service, but Walter Reed is just the tip of the iceberg,” Sullivan said, referring to the recent scandal at Walter Reed Army Medical Center, where soldiers were found languishing in moldy conditions, outflanked by a seemingly unsympathetic bureaucracy. Surveying the hundreds of thousands of new claims coming in, staff shortages, inefficiencies, and the increased needs of older veterans, he declares, “The VA is in a crisis right now.”

Enter TBI, which doesn’t always render a person physically disabled and fully dependent but if left untreated, can devastate lives. Thousands of times in this war soldiers close to a bomb blast have shaken themselves off and walked away to patrol another day. Months later, they return home and do not recognize the face in the mirror.

“It’s like slamming a laptop against the wall,” said Patrick Campbell, 29, a National Guardsman who served in the 256th Infantry Brigade as a medic in Iraq from November 2004 to October 2005. While the computer may seem functional afterwards, small quirks like a broken backspace key or a jagged line down one side of the screen soon become obvious and render use slow, frustrating, and intolerable for the long term.

“The concussive event—the wind and the pressure changes—it’s more damaging than the force of getting hit,” said Campbell.

He will tell you that in a single incident, an IED explosion causes an intense shockwave of pressure. When close enough, it can form tiny, destructive air bubbles in the brain and blow out precious wiring inside a soldier’s skull. Those not affected by the blast wave may be hurtled through the air, slammed around in a vehicle, or hit in the head with debris. Their Humvee might overturn. As described by some, any of this could throttle the brains like Jell-O.

In Vietnam, one soldier was killed for every 2.5 wounded; in Iraq the survival rate is one killed for every 16 wounded. But the effects of TBI may take hours, days—even weeks—to surface.

While at first glance Campbell looks as if he would be more comfortable in an armored Humvee than a downtown D.C. office space, but it’s soon clear his new posting is a good fit. Working fulltime for the Iraq and Afghanistan Veterans of America, which is steadily becoming the generational equivalent of such scrappy advocates as the National Gulf War Resource Center or Vietnam Veterans of America, his goal is to cast a floodlight on TBI’s effect on returning service members.

“There are a lot of people out there who have never been ‘right’ after an IED,” said Campbell, recalling one case in which a veteran had to carry around a notebook to write down everything he did, said, or had to accomplish because his short-term memory was shot. “Now they are at home and wondering why they are different.”

He recalls his own multiple “concussive events” in Iraq. One, an IED blast, left his ears bleeding and he and his buddy laughing over their luck. He went right back on patrol. Today, he plans to take advantage of the new mandatory TBI screening at the VA, wondering if those events contributed to his own diagnosis of PTSD.

“Not all people want to acknowledge that they have a problem. The symptoms are extremely close to PTSD,” which still carries a stigma, particularly among peers and the chain of command. It took Campbell a year and losing his best friend over his changed personality to finally seek help.

Thanks to lobbying efforts by groups like the IAVA, the VA announced in April that it will begin screening all incoming veterans from Iraq and Afghanistan for TBI. Now the pressure is on the Department of Defense, which only offers comprehensive TBI screening for the wounded coming into their hospitals, like Walter Reed.

If TBI is the silent affliction of this war, the casualty count should be the canary in the coal mine. As of mid-May, the military in Iraq suffered 14,804 injuries that required medical transport off the battlefield. This included 7,628 combat wounded and 7,176 non-hostile injuries, plus 19,589 “diseases,” which cover everything from a bacterial infection and mental disorder to cancer and pregnancy, that also required medical air transport. In Afghanistan, 6,213 injured soldiers were evacuated from the field, including 743 combat-related, 1,458 non-hostile, and 4,012 diseases.

Symptoms of TBI can turn up in any of the these categories. According to various reports, of the 1.4 million who have rotated through Iraq and Afghanistan, anywhere from 10 to 30 percent have been exposed to a bomb blast or other head trauma, leaving them with at least mild TBI. A recent study by doctors at Fort Carlson Army base in Colorado found that 18 percent of their returning soldiers had incurred a brain injury in Iraq.

Some 60 percent of the veterans in the VA’s Polytrauma Rehabilitation Center in Tampa, Florida, one of 21 centers handling vets with severe, multiple injuries, have a brain injury, according to ABC newsman Bob Woodruff in a February series he put together after his own year-long recovery from an IED blast. Meanwhile, officials at the Defense and Veterans Brain Injury Center, the military’s primary research and treatment facility for TBI, has treated 2,130 patients since 2003.

“That’s just a small percentage of the total number, and the fact is, nobody really knows how many have mild [TBI],” said Col. Jonathan Jaffin, Commander of U.S Army Medical Research and Materiel Command at Fort Detrick, Maryland and a spokesman for the DVBIC. He said 70 percent of their cases are mild and those affected may, with the right treatment, recover or at least adjust to their disabilities. But it is not clear, according to doctors, how soldiers with cumulative concussive injuries will fare long-term. All seem to agree the body of research on non-fatal blast injuries is thin.

“Mild head injury for years had been somewhat neglected,” Jaffin says, with standard testing for TBI often missing less severe cases. “So people would be suffering and being told they are normal.” As the pervasiveness of TBI among returning service members became clear, he said, the military and VA began developing better ways to detect it—though advocates will dispute their commitment.

VA officials say they are treating nearly 400 veterans diagnosed with moderate to severe TBI, while overall they have seen more than 1,600 potential cases since 2002. They acknowledge, however, that the system has yet to compile statistics for mild cases or outpatients.

Meanwhile, symptoms of mild to moderate TBI go unchecked, crowded out by the more obvious injuries. Furthermore, misdiagnosing TBI—most likely mistaken for PTSD—is commonplace.

“When it does occur, PTSD and TBI together can be especially difficult to spot. The problem lies in the overlapping symptoms—increased anxiety, short attention span, limited concentration, problems with memory. This overlap muddles things up,” points out Ilona Meagher, author of Moving a Nation to Care: Post-Traumatic Stress Disorder and America’s Returning Troops. “Once you have these kinds of errors on military records,” she added, “it creates a whole other level of problems down the road for the veteran after they’ve returned home.”

That road is paved with the stories of men and women who find that the system is no more compassionate than it was for their counterparts returning from Vietnam a generation ago. The PTSD label is not only stigmatizing, but its symptoms are often mistaken for personality disorders and are blamed for behavioral problems like insubordination and substance abuse, resulting in a one-way ticket out of the military with no retirement pay or benefits.

“This time it’s all about money—they just don’t want to pay,” insists Sullivan. But unlike previous wars, there is a small army of veterans’ advocates, many who cut their teeth on behalf of Persian Gulf soldiers in the 1990s.

Steve Robinson, also with Veterans for America, packed his experience and reputation along with his bags and spent most of May around Fort Carson, pulling together a massive case accusing the command of erroneously discharging 276 soldiers for personality disorders. These servicemembers all suffered from PTSD, and many had accompanying TBI diagnoses. His organization is also investigating more than 40 current cases on the base. They include bad discharges but also complaints from soldiers that their brain injuries and mental-health problems were mishandled or ignored by superiors.

Robinson, who has been working tirelessly as an advocate since his own stint in the Persian Gulf War, helped to attract a delegation of congressional staff who met in a closed-door briefing with spouses. His work also brought on a Government Accountability Office probe.

Spc. Paul Thurman, 24, is part of that investigation. After two head injuries incurred during training at Fort Bragg and in Kuwait, even under heavy medication he struggles daily with uncontrollable shaking, intense headaches, short-term memory loss, twitching, and the threat of seizures. His moment of terror came when he suffered a seizure and threw up during a meeting with an Army lawyer.

He was waiting for his medical evaluation and discharge at Fort Carson when he was given an Article 15—the non-judicial punishment meted out by a commander for minor disciplinary offenses—for cussing and walking off formation when he was told he couldn’t get his seizure medication at the onset of an episode.

Robinson and company took up Thurman’s case because they say he should not have been deployed after the first head injury. He had been diagnosed with lesions on the brain. “These guys came forward and said, look, you can’t push this dude around. They’ve been unbelievably helpful,” Thurman said of Robinson’s crew. “They know how to care for us.”

Thurman’s only mode of transportation before he joined the military at the age of 18 was a bicycle. He thought, cycling daily past the recruitment center, that the service would give him a job and his life direction. Now he can’t find a job because he can’t drive a car and the seizures aren’t a selling point with employers. He’s tired of the emergency room—particularly how he is made to feel that he’s done something wrong—and he’s scared that talking about it will put his final discharge status at risk.

Fort Carson says there is another side to these stories. While the base hasn’t denied struggling with TBI and PTSD—which according to reports has increased from 32 cases to 539 in the last year there—officials say none of the soldiers chaptered out for personality disorders were suffering from severe PTSD or TBI. Rather, their behavior, backed by a pre-existing condition found in their backgrounds, got them booted.

Robinson said his group chose Fort Carson as the first in five fact-finding missions because it had the most documentation to back up the soldiers’ claims. However, “these problems are system-wide.”

The disability ratings game has become a gauntlet for soldiers suffering from myriad physical and mental injuries. At the head is the Physical Evaluation Board, which assesses whether an active servicemember is still fit for duty and rates individual disabilities to determine the type of discharge and whether it warrants lifetime healthcare and retirement pay. A rating of 30 percent or more allows the soldier to be medically discharged with pay and healthcare. Anything beneath that buys a single severance check—and a U.S. News and World Report investigation found that nearly 93 percent of disabled troops were receiving low ratings.

The Veterans Disability Benefits Commission is reviewing these charges, and in April, it offered Congress some preliminary data that compared combined disability ratings from both the DoD and VA. The numbers showed that 81 percent of all disabilities between 2000 and 2006 were rated 0 to 20 percent by DoD. Out of 50,676 Army soldiers deemed unfit for duty, 27 percent received 0 percent ratings.

What is more striking are the differences between DoD and the VA, which uses its own ratings to assess healthcare and compensation. Focusing on comparative data for both institutions, the commission found that 59 percent of the time, DoD would give a soldier a combined rating of 0 to 30 percent, while the VA would take that same soldier and give him a rating of 30 to 100 percent. The disparity in specific mental health ratings were even more glaring.

VDBC chairman James Terry Scott told the Senate on April 12, “It is … apparent that DoD has strong incentive to assign less than 30 percent so that only separation pay is required and continuing family health care is not provided.”

“We’re very concerned,” said Ron Smith, deputy general counsel for the Disabled American Veterans. His job is to represent veterans appealing their disability ratings. He is not lacking for work. He said lowballing typically hits low-ranking servicemembers who get smaller severance payments and are likely to spend them more quickly. Then there is a lengthy gap before their new claims at the VA are processed.

“They are playing fast and loose with disability ratings,” charged Larry Scott, a staunch advocate who runs VAWatchdog.com, noting that victims of PTSD and mild to moderate TBI are more likely than others to get the bureaucratic boot out the door.

At the end of this bottleneck, there is the VA system, where Vaughan Wilson waits today. After nearly nine months, the medication for PTSD given to him following his discharge from the Army is nearly gone. His six months of free health coverage through the military has expired, and even when he had it, he had no luck in finding a PTSD counselor in rural Virginia, where he was staying with his dad for the first few months of civilian afterlife.

Beset by ongoing nightmares, bouts of panic and fury, Wilson is slowly getting his life on track—he and his fiancée Joy are expecting a baby in October—but he knows he needs treatment, including a much delayed screening for TBI. Built to carry a soldier’s legacy, he looks anything but weak or insecure, but his eyes are sad and he’s wound like a top. He’s no fool—he has collected affidavits concerning his many commendations, his medical evaluations, and photos of carnage if anyone tries to question the validity of his story.

“The most frustrating thing for me are the reasons my claim has been held up,” he said, noting one case in which he mistakenly provided the wrong Social Security number for his daughter on the forms. “The people I’ve encountered at the VA are doing the best they can … but there is too much of a paper trail” to manage and the bureaucracy is too massive, too tricky to navigate. “The disconnect was, there wasn’t a good handoff from the military to the VA,” he noted.

That disconnect is just one of the challenges facing the VA, which has treated nearly one in three returning veterans since the war on terror began. There is an average six-month wait for an initial appointment and four-month wait for disability claims. Appeals stretch over an additional year and a half, according to a March GAO report.

“I’m not a hate-the-VA guy,” said Scott. “I’ve been in the system for 26 years and have gotten nothing but great care. … [but] we’ve been fighting a war on the cheap and we are trying to care for our wounded on the cheap, too.”

VA officials say the new TBI screening is only a piece of an overall effort to improve diagnosis and treatment, reduce the backlogs, and close the VA-military gap. Paul Sullivan said advocates like himself will be there to make sure they make good, particularly on promises to respond to the challenges of TBI.

Ignoring brain injury while it destroys veterans won’t do, he said. “We will try to put people in jail this time if they try to go that route.”


Kelley Beaucar Vlahos is a Washington, D.C.-based freelance reporter.