Purple Heart awards highlight need for continued focus on invisible wounds

It was recently announced that 29 service members would be awarded Purple Heart medals for the injuries they suffered, mainly traumatic brain injuries (TBI), during a January missile strike by Iran on Iraq’s Al Asad Air Base.

Despite the fact that President Donald Trump initially dismissed these injuries as “headaches” that “weren’t very serious,” the award of the Purple Heart to 29 of these service members significantly helps the public perception regarding the severity of “invisible wounds” such as TBI. 

Nonetheless, ambiguity about TBI, and how to treat it both medically and philosophically in relation to other types of war wounds remain.

Even though TBIs cannot be seen, they are oftentimes just as detrimental to the health and well-being of those who are afflicted with them than are more obvious physical injuries such as limb amputations.

The Purple Heart is the oldest and most recognized of American military medals. It is awarded to service members who were killed or wounded by enemy action. In the aftermath of the conflicts entered into as a result of 9/11, debates have ensued regarding its eligibility criteria, including for service members with TBI.

Although TBI and concussive injuries have long qualified for the Purple Heart, for many years, the criteria was overly restrictive, reflecting attitudes similar to the one recently expressed by Trump, i.e., that invisible wounds simply aren’t that serious.  

Thankfully, this started to change after 9/11; however, as evidenced by the President’s recent comments, we still have a long way to go. 

In 2011, each branch of the military issued directives that, although varying slightly, removed the previously existing requirement that, in order to eligible, a loss of consciousness was required. To qualify, the branches clarified that servicemembers must have required treatment from a medical office — or if one was not available, a medical officer verified that treatment should have been received after the fact — for concussion, lack of consciousness, memory loss or other symptoms typical of mild to moderate TBI. This also included types of treatment such as limitation of duty or administration of medication. 

Despite this clarification, after the recent awards were issued, CENTCOM spokesman Commander Zachary Harrell issued a statement reminding the public “that a [TBI] diagnosis does not automatically qualify a service member for Purple Heart eligibility or awarding.” 

To this end, it is of note that a total of 109 US service members were diagnosed with TBI after the January airstrike, meaning that only about 27 percent of those injured were ultimately awarded the Purple Heart. It is unclear why so few qualified, other than perhaps differing levels of severity, in that some did not require medical treatment. Without more information provided from the service branches, this also highlights that there is likely still some ambiguity regarding how to treat TBI, particularly when it comes to referral for the Purple Heart. 

Because medical technology has continued to advance rapidly regarding brain health, this also serves as an indication that the various service branches may want to further clarify the 2011 mandates to ensure equity and consistency in awarding the military’s most prestigious medal, as well as to ensure that we continue to take invisible wounds seriously.

When the criteria were amended in 2011 to make more types of TBIs eligible for the award, some critics feared that the new criteria did not meet the historical standard of severity applied to other types of wounds, which would take away some of the prestige associated with the reward.

However, not only has the eligibility criteria consistently been amended over time, but in fact the opposite is true. Recognizing the severity of TBIs as on par with visible wounds actually enhances the prestige of the award because it encourages medical professionals and service members alike to be proactive in their treatment of brain injuries, thus preventing greater health and wellness complications later on.

Harrell’s remarks, as well as the previous remarks by Trump, are an important reminder that TBI and its effects are still largely misunderstood, and this misunderstanding is detrimental to our service members. 

Although the symbolism associated with the award of The Purple Heart is one way to convey the recognition of the severity of TBI in our society, more importantly, an immediate diagnosis can also prevent future complications for service members and can impact their ability to subsequently receive VA benefits.

According to Major Edward Dice, an airman who has since been awarded a Purple Heart for TBI, when he was first injured in an IED, “[t]he information and awareness of TBI and concussion and blast injuries wasn’t very prevalent. . . . It was just relax, and see how you feel the next day.”

As Dice explained, even mild TBI, if untreated, can linger and cause problems in the future such as anxiety, depression, post-traumatic stress, and even suicide. 

“One of the key things that I’ve learned is … TBI is certainly one of those things that if treated immediately and properly, the lingering issues that a lot of guys go through later in life can be analyzed or completely eliminated,” he said.

This week’s announcement of the 29 Purple Heart awards to service members who suffered from TBI is a step in the right direction toward reminding the general public that, despite their invisibility, TBIs must be taken seriously, but that we must also continue to further enhance our understanding of these complicated injuries. 

To this end, remarks dismissing TBIs as merely headaches, or overlooking these injuries in the awarding of prestigious medals, are a reminder that we still have work to do as a society toward understanding and appreciating the impact of invisible wounds.

As summarized by former Navy Secretary Ray Mabus when the 2011 criteria for the Purple Heart were revised, “[w]ounds suffered while defending our nation, whether seen or unseen, deserve our utmost gratitude and respect.”

Certainly, there is no better way to show our utmost gratitude and respect than by treating TBIs on par with visible injuries.

Rory E. Riley-Topping served as a litigation staff attorney for the National Veterans Legal Services Program (NVLSP), where she represented veterans and their survivors before the U.S. Court of Appeals for Veterans Claims. She also served as the staff director and counsel for the House Committee on Veterans’ Affairs, Subcommittee on Disability Assistance and Memorial Affairs for former Chairman Jeff Miller (R-Fla.). You can find her on Twitter: @RileyTopping.