TBI Could Be the Next Agent Orange
Paul Rieckhoff is the Executive Director and Founder of Iraq and Afghanistan Veterans of America (IAVA), a non-partisan non-profit group with over 100,000 members around the world. Since founding IAVA in 2004, it has become America’s first and largest Iraq and Afghanistan Veterans organization. Rieckhoff is now a nationally recognized authority on the war in Iraq and issues affecting troops, military families and veterans.
After graduating from Amherst College in 1998 with a degree in Political Science, Rieckhoff coached high school football, worked on Wall Street, participated in the rescue efforts at Ground Zero on 9/11, and served as an infantry platoon leader in Iraq from 2003-2004. In the spring of 2004, Rieckhoff became one of the first Iraq veterans to publicly criticize the war, call for better care for Iraq and Afghanistan veterans, and demand accountability from elected officials. In 2006 Rieckhoff also published Chasing Ghosts, a critically acclaimed account of his experiences in Iraq and activism on behalf of veterans.
Question: What is TBI, and is it really the “signature wound of this war”?
Paul Reickhoff: Traumatic brain injury, TBI, is a signature wound of the war. It may have impacted hundreds of thousands of people who have cycled through Iraq and Afghanistan. And for the most part, it's experienced when a roadside bomb, sometimes called an IED (improvised explosive device), blows up near or in the vicinity of a service member. So, that concussive blast literally rattles your head and causes your brain to smack against the inside of your skull kind of like a super-concussion. Sometimes it's an open head wound, often it's not.
And over time, there have been a number of veterans, thousands of veterans literally, who haven't been diagnosed. They think, “Well, maybe I'm just a little slow today, or I'm having some minor vision problems,” and they don't necessarily make the connection to the fact that they were around five, six, 50 blasts over the course of a deployment. So the screening at the outset has been woefully inadequate. The VA only started doing mandatory screenings for traumatic brain injury—I think it was in 2006.
But keep in mind, only half of Iraq and Afghanistan vets are going to the VA, so that means half of our population isn't being screened; half of our population may not be aware of the long-term symptoms of traumatic brain injury, so we have a lot of work to do around public education. We have a lot of work to improve the screening and treatment.
This is still very much a groundbreaking area. For the most part, the research around traumatic brain injury has come from car accidents and professional football. So we need more research, we need more treatment development. And there are folks like Bob Woodruff from ABC who has also started a traumatic brain injury foundation called ReMIND who have been incredibly powerful public advocates for us while at the same time are supporting the research we need.
But this could be like our generation's Agent Orange. Over the next decades, these symptoms and problems associated with traumatic brain injury will start to reveal themselves and start to emerge, and we need to understand that traumatic brain injury is just one example of how our commitment to veterans needs to be a life-long one. This may be 20 years before people start to really show signs or problems associated with their service, and as a public... as a group of leaders in Washington, our country has a commitment to honor that service all the way through their entire life.
Question: Does the VA do a good enough job of serving our veterans?
Paul Rieckhoff: Yeah, I would start by re-framing it. So this is Big Think, right? So, here's the big idea, is that the government can't handle Veterans Affairs alone. And that's a message that I have been trying to communicate and others who are really inside this have been trying to communicate for years now. The VA is gonna be a key component in supporting veterans over the next generation—but it's a component.
Less than half the folks are going to the VA, so what about that other half of the folks? They're gonna go to church groups, they're gonna go into the YMCA, they're gonna go into private community-based nonprofits, they're gonna come to veterans groups like ours. But it needs to be a coordinated effort that involves the federal government, the VA, and all these other groups working in concert together to tackle the problem.
We didn't just send the Federal government down to deal with Katrina. Yeah, they were a huge part of it, but there were local community groups. There were a lot of other spokes in the wheel that were critical to a response, whether it was effective or not. That's how we need to think about Veterans Affairs. When the President stands up and says, “I am doing this for veterans, and our VA is doing this,” that's great. But that's only impacting half of Iraq and Afghanistan veterans coming home. Why?
The quality of care at the VA is generally good. Most of our members and most folks say the quality of care at the VA is very good. Outreach stinks. They are not getting out into rural areas, they're not using the Internet, they're not using earned and paid media in any way to reach new veterans. They are just not present where my generation of veterans lives. If you're on Facebook, you're not gonna see the VA very often. If you go to VA.gov right now—if you're watching this on the internet, pop up the VA's Web site and compare and contrast that to a lot of other websites. You see, for the most part, it looks like a Web site that was built in the Gulf War, not Iraq and Afghanistan.
So there's a long way to go in empowering the VA to be more effective in their outreach, but at the same time there has to be a reality here—a ground truthing—that the VA is not gonna reach everybody. It might be a local church group, it might be a veterans group like ours, and those groups need to be empowered, they need to be supported, and there also needs to be a marketplace for them.
There hasn't been a history of philanthropy supporting Veterans Affairs. Almost every corporation and philanthropic organization in the nation has a list of things they work with every year: poverty, AIDS, homelessness... We need to put veterans on the national consciousness forever so they understand when you send folks to war there's a moral obligation to care for them coming home, and the federal government and the President do not have it under control. They cannot do it alone, and they need to ask the American people, and all of our resources as a nation, to get involved to help.
Recorded August 2, 2010
Interviewed By Max Miller
Traumatic Brain Injury (TBI) is a signature wound of our current wars. It may have impacted hundreds of thousands of people who have cycled through Iraq and Afghanistan.
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The COVID-19 pandemic is making health disparities in the United States crystal clear. It is a clarion call for health care systems to double their efforts in vulnerable communities.
- The COVID-19 pandemic has exacerbated America's health disparities, widening the divide between the haves and have nots.
- Studies show disparities in wealth, race, and online access have disproportionately harmed underserved U.S. communities during the pandemic.
- To begin curing this social aliment, health systems like Northwell Health are establishing relationships of trust in these communities so that the post-COVID world looks different than the pre-COVID one.
COVID-19 deepens U.S. health disparities<p>Communities on the pernicious side of America's health disparities have their unique histories, environments, and social structures. They are spread across the United States, but they all have one thing in common.</p><p>"There is one common divide in American communities, and that is poverty," said <a href="https://www.northwell.edu/about/leadership/debbie-salas-lopez" target="_blank">Debbie Salas-Lopez, MD, MPH</a>, senior vice president of community and population health at Northwell Health. "That is the undercurrent that manifests poor health, poor health outcomes, or poor health prognoses for future wellbeing."</p><p>Social determinants have far-reaching effects on health, and poor communities have unfavorable social determinants. To pick one of many examples, <a href="https://www.npr.org/2020/09/27/913612554/a-crisis-within-a-crisis-food-insecurity-and-covid-19" target="_blank" rel="noopener noreferrer">food insecurity</a> reduces access to quality food, leading to poor health and communal endemics of chronic medical conditions. The U.S. Centers for Disease Control and Prevention has identified some of these conditions, such as obesity and Type 2 diabetes, as increasing the risk of developing a severe case of coronavirus.</p><p>The pandemic didn't create poverty or food insecurity, but it exacerbated both, and the results have been catastrophic. A study published this summer in the <em><a href="https://link.springer.com/article/10.1007/s11606-020-05971-3" target="_blank">Journal of General Internal Medicine</a></em> suggested that "social factors such as income inequality may explain why some parts of the USA are hit harder by the COVID-19 pandemic than others."</p><p>That's not to say better-off families in the U.S. weren't harmed. A <a href="https://voxeu.org/article/poverty-inequality-and-covid-19-us" target="_blank" rel="noopener noreferrer">paper from the Centre for Economic Policy Research</a> noted that families in counties with a higher median income experienced adjustment costs associated with the pandemic—for example, lowering income-earning interactions to align with social distancing policies. However, the paper found that the costs of social distancing were much greater for poorer families, who cannot easily alter their living circumstances, which often include more individuals living in one home and a reliance on mass transit to reach work and grocery stores. They are also disproportionately represented in essential jobs, such as retail, transportation, and health care, where maintaining physical distance can be all but impossible.</p><p>The paper also cited a positive correlation between higher income inequality and higher rates of coronavirus infection. "Our interpretation is that poorer people are less able to protect themselves, which leads them to different choices—they face a steeper trade-off between their health and their economic welfare in the context of the threats posed by COVID-19," the authors wrote.</p><p>"There are so many pandemics that this pandemic has exacerbated," Dr. Salas-Lopez noted.</p><p>One example is the health-wealth gap. The mental stressors of maintaining a low socioeconomic status, especially in the face of extreme affluence, can have a physically degrading impact on health. <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">Writing on this gap</a>, Robert Sapolsky, professor of biology and neurology at Stanford University, notes that socioeconomic stressors can increase blood pressure, reduce insulin response, increase chronic inflammation, and impair the prefrontal cortex and other brain functions through anxiety, depression, and cognitive load. </p><p>"Thus, from the macro level of entire body systems to the micro level of individual chromosomes, poverty finds a way to produce wear and tear," Sapolsky writes. "It is outrageous that if children are born into the wrong family, they will be predisposed toward poor health by the time they start to learn the alphabet."</p>Research on the economic and mental health fallout of COVID-19 is showing two things: That unemployment is hitting <a href="https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/" target="_blank" rel="noopener noreferrer">low-income and young Americans</a> most during the pandemic, potentially widening the health-wealth gap further; and that the pandemic not only exacerbates mental health stressors, but is doing so at clinically relevant levels. As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413844/" target="_blank" rel="noopener noreferrer">the authors of one review</a> wrote, the pandemic's effects on mental health is itself an international public health priority.
Working to close the health gap<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDc5MDk1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTYyMzQzMn0.KSFpXH7yHYrfVPtfgcxZqAHHYzCnC2bFxwSrJqBbH4I/img.jpg?width=980" id="b40e2" class="rm-shortcode" data-rm-shortcode-id="1b9035370ab7b02a0dc00758e494412b" data-rm-shortcode-name="rebelmouse-image" />
Northwell Health coronavirus testing center at Greater Springfield Community Church.
Credit: Northwell Health<p>Novel coronavirus may spread and infect indiscriminately, but pre-existing conditions, environmental stressors, and a lack of access to care and resources increase the risk of infection. These social determinants make the pandemic more dangerous, and erode communities' and families' abilities to heal from health crises that pre-date the pandemic.</p><p>How do we eliminate these divides? Dr. Salas-Lopez says the first step is recognition. "We have to open our eyes to see the suffering around us," she said. "Northwell has not shied away from that."</p><p>"We are steadfast in improving health outcomes for our vulnerable and underrepresented communities that have suffered because of the prevalence of chronic disease, a problem that led to the disproportionately higher death rate among African-Americans and Latinos during the COVID-19 pandemic," said Michael Dowling, Northwell's president and CEO. "We are committed to using every tool at our disposal—as a provider of health care, employer, purchaser and investor—to combat disparities and ensure the <a href="https://www.northwell.edu/education-and-resources/community-engagement/center-for-equity-of-care" target="_blank" rel="noopener noreferrer">equity of care</a> that everyone deserves." </p><p>With the need recognized, Dr. Salas-Lopez calls for health care systems to travel upstream and be proactive in those hard-hit communities. This requires health care systems to play a strong role, but not a unilateral one. They must build <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank" rel="noopener noreferrer">partnerships with leaders in those communities</a> and utilize those to ensure relationships last beyond the current crisis. </p><p>"We must meet with community leaders and talk to them to get their perspective on what they believe the community needs are and should be for the future. Together, we can co-create a plan to measurably improve [community] health and also to be ready for whatever comes next," she said.</p><p>Northwell has built relationships with local faith-based and community organizations in underserved communities of color. Those partnerships enabled Northwell to test more than 65,000 people across the metro New York region. The health system also offered education on coronavirus and precautions to curb its spread.</p><p>These initiatives began the process of building trust—trust that Northwell has counted on to return to these communities to administer flu vaccines to prepare for what experts fear may be a difficult flu season.</p><p>While Northwell has begun building bridges across the divides of the New York area, much will still need to be done to cure U.S. health care overall. There is hope that the COVID pandemic will awaken us to the deep disparities in the US.</p><p>"COVID has changed our world. We have to seize this opportunity, this pandemic, this crisis to do better," Dr. Salas-Lopez said. "Provide better care. Provide better health. Be better partners. Be better community citizens. And treat each other with respect and dignity.</p><p>"We need to find ways to unify this country because we're all human beings. We're all created equal, and we believe that health is one of those important rights."</p>
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Shannon Lee shares lessons from her father in her new book, "Be Water, My Friend: The Teachings of Bruce Lee."
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