On March 20, 2003, a US-led military coalition invaded Iraq and toppled Saddam Hussein’s government before a violent uprising against Western forces erupted. As fighting dragged on for eight years, more than a million US troops have been deployed to the region, and many have returned with complex physical and psychological wounds that no single treatment can heal. To mark the 20th anniversary of the invasion, the Gazette spoke to Ron Hirschberg, an assistant professor of physical medicine and rehabilitation at Harvard Medical School and an expert in traumatic brain injury at Massachusetts General Hospital and Spaulding Rehabilitation Hospital. Hirschberg is also Senior Director of Health and Wellness for the veteran-focused nonprofit Home Base, where he hosts a podcast on military service and mental health. The interview has been edited for clarity and length.
GAZETTE: Is there still great pain among veterans who served in Iraq who are struggling with traumatic brain injuries, post-traumatic stress, depression and other conditions?
HIRSCHBERG: When the war stops and the coverage of Iraq and Afghanistan stops, the people who served there — whether it was one deployment or ten, whether they were there 20 years ago or two years ago before the fall of Kabul – these wounds are not like bones break and heal in 12 weeks. They can reappear months to years later, and then it’s a matter of controlling the symptoms and providing the right care so they can go about their lives. In fact, we can expect even more needs over time – as soldiers attempt to return to civilian life and those who struggle to do so become isolated. Part of what triggers post-traumatic stress and aggravates these wounds is no longer feeling connected to a group.
GAZETTE: We’re celebrating the anniversary of the start of the Iraq War. Is it possible and/or necessary to separate the Iraq service from the Afghanistan service when talking about these violations?
HIRSCHBERG: More than 1.8 million Iraq and Afghanistan veterans returned home with a permanent disability, of which nearly 1 million have been linked to mental illness and traumatic brain injuries, not to mention the moral wounds and complicated guilt of the Survivors who challenge their own uniqueness and complexity. When it comes to Afghanistan, there is a feeling that you left loose ends and guilt without the ability to help. Many of our veterans developed strong bonds with families and translators, and many of these people continued to face serious threats after we left Kabul.
“Part of what triggers post-traumatic stress and aggravates these wounds is no longer feeling connected to a group.”
GAZETTE: You mentioned that these conditions can last forever. What is the proportion of those who have recovered?
HIRSCHBERG: Recovery is a process. My role at MGH is to treat people with moderate to severe traumatic brain injuries. If you see someone coming after a car crash, they will be stabilized from day two to day four. Over the next week they will begin to heal. You recover not only days to weeks, but really months to years. You’ll see a lot of that recovery in six months to a year. People can heal in ways that allow them to live their lives and have good family relationships. You could go back to work, travel and live a functional life. I would use an analogy to chronic diseases like diabetes or cancer in remission. You won’t fix them, but you can guide people with more diagnostic understanding and treatment.
When we look at Vietnam, at the veterans who are now 50 years post-deployment, we see people who have had post-traumatic stress and other symptoms for decades. A classic situation is retirement or the start of the next phase of life. Then there is a loss of purpose and perhaps isolation that produces these symptoms. Even watching what’s going on in Ukraine can be a trigger.
GAZETTE: So there are people who may not have suffered initially and now have symptoms many years later?
HIRSCHBERG: It’s possible that some have been treated and have been fine for many years and one day they get into trouble. We know that among all veterans there are 20 suicides every day, and between 2015 and 2020 there was an approximately 40 percent increase in suicides among active duty members. In the Operation Iraqi Freedom and Operation Enduring Freedom conflicts alone, 30,000 veterans have died by suicide in the last 20 years. Since 9/11, more than 125,000 veterans of all eras have died by suicide.
GAZETTE: When we talk about these invisible war wounds, do they depend on the specific type of injury or do they depend heavily on individual factors?
HIRSCHBERG: Who you are — your medical history, social factors, psychiatric factors — is important. Then there is the injury itself and after the injury. Rehab and recovery are heavily influenced by society and can be affected by affiliation or lack of affiliation. It’s really like a tribe of people who not only have a sense of belonging, but also a real sense of purpose. Part of treating these invisible wounds is finding new connections and a new purpose.
“There are 20 suicides every day among all veterans, and between 2015 and 2020 there was an approximately 40 percent increase in suicides among active-duty members.”
GAZETTE: Have there been advances in science to understand and treat these disorders?
HIRSCHBERG: At its core, Home Base has a standard of care, like insulin for diabetes or chemotherapy for cancer. The standard includes long-term therapy, cognitive processing therapy, and cognitive behavioral therapy. For traumatic brain injuries, it is cognitive rehab therapy and vestibular/physical therapy. The data show that these therapies work. But colleagues at Spaulding, Mass General Brigham and Home Base are trying to improve on them by trying to find biomarkers for post-traumatic stress and traumatic brain injury and how they may affect treatment. We work in the field of psychedelics and have a partnership with MGH’s Center for the Neuroscience of Psychedelics and we’ve done some work in Virtual Reality for PTS. We pride ourselves on our wellness efforts, connecting people in the kitchen with nutritionists and in the gym with strength and conditioning coaches. We also integrate art therapy and music which opens up more creative spaces and has been shown to help with stress and depression.
GAZETTE: Why are you doing this work?
HIRSCHBERG: I haven’t served in the military, and every day I’m there I’m reminded that it’s our job to take care of the people who have reached out to take care of us. Julian Kitching, a Green Beret, and his brother, an Army Ranger, came through our program. Julian said at Run to Home Base last year that service members are signing up to go into battle to protect us. The last thing anyone wants is to go to war, but if they have to, they’re there. The other end of the equation is simple: we’ll take care of them when they get back.