has complete coverage of the halls of congress on the house and senate floors to congressional hearings, briefings and committee meetings. c-span gives you a front row seat to how issues are debated and decided with no commentary, no interruptions and completely unfiltered. c-span, your unfiltered view of government. >> defense department officials and others testified on traumatic brain injury and blast exposure care before a subcommittee. they discuss the need for more health monitoring of service members and other policy changes that the military can emblem it to address the problem. this runs just over two hours.

>> this hearing will come to order. i'm pleased to welcome you all to today to close hearing to receive testimony on the department of defense's efforts to protect service members. service members put their lives and health on the line. in return, we have a profound responsibility to make sure that the nation is doing all they can to prevent battlefield and training casualties.

. >> to we have the other on the record? service members put their lives and their health on the line when they put on their uniforms. and in return, we have a profound responsibility to make sure that the nation is doing all that it can to keep them safe, to prevent battlefield's and training casualties and to provide the best possible care for those who are injured. we are holding this hearing because dod is not meeting its responsibilities when it comes to traumatic brain injuries another injuries that result from firing weapons injuries

from blast overpressure, the pressure caused by a shockwave that exceeds normal atmospheric values have been the signature wounds of the war in iraq and afghanistan. but there are also injuries incurred in training here at home. they are invisible but they affect thousands of service members causing headaches, seizures, hallucinations and ultimately significantly increased risk of depression and suicide. over the course of just three months, in 2023, dod provided tbi treatment to service members nearly 50,000 times. the more we learn, the more we come to understand that blast exposure is an ongoing threat to the health of individuals service members and to the well- being, the morale and the readiness of our entire force.

i appreciate the support i have had on this issue for ranking member scott, from senator ernst, senator tillis and other members of the community. i secured a long-term study of blast overpressure injuries in the 2018 act and i worked with senator and to work with legislation blast overpressure and secure additional requirements to track blast overpressure injuries in the fy2020ndaa. dod is working to implement the legislation but we still have significant problems. last year, the new york times reported on heightened brain injury risk for u.s. troops in syria fighting isis. four artillery batteries assigned to the region fired more weapons than any military

american artillery since the vietnam war. the result was that each of these units had members with serious blast overpressure injuries and each had at least one member that committed suicide. these deaths are a tragedy. ryan, a navy seal deployed to iraq and afghanistan was subject to a significant blast from his own weapons over the course of his career and later died by suicide. his father, mr. frank larkin, is here today to discuss the harm that blast overpressure has caused to service members and their families. the times also revealed that even when dod had made policy changes to address risk, those changes were not evident on the ground. weapons known to deliver shockwave as well above safety thresholds were still widely

used. training did not involve basic safety measures and special operations forces were not issued blast exposure gauges, the gauges needed to track the threats they face. so dod and congress both have a lot to do. here is my agenda to address the problem. first, we need to establish mitigation strategies specific to the service member roles that are most at risk for blast overpressure. second, we must require dod to create blast exposure and traumatic brain injury logs for all service members and integrate these logs into the va and dod healthcare records. the department of defense should partner with innovative evidence-based programs like homebase to help service members get the care they need. i'm going to have to brag here for a minute. homebase is a nonprofit organization founded by the

massachusetts general hospital and the boston red sox to take care of the invisible wounds of veterans, service members, military families and families of the fallen. homebase has clinics in massachusetts and in florida. ranking member scott's state. homebase has a comprehensive brain health and trauma program specifically designed for special operations veterans and service members where it has been leading innovative treatments for veterans with cooccur -- co- occurring substance abuse and mental health conditions. as we work through this year's ndaa, i want to support this program's work and i appreciate dr.'s offense from homebase joining us today. one more item, we need to make sure that dod sets a threshold on the maximum number of rounds that service members can safely fire and that this includes consideration of exposure

limits over an extended period of time. dod must do its part and congress must you our part. to our witnesses, welcome and thank you for appearing. we will have two panels today. the first panel will consist of outside witnesses to provide their perspective on where dod and the services are falling short on protecting service members from blast overpressure. dr. samantha berni, at the party were in granite school, dr. ross, chief of traumatic brain injury and help and wellness programs at homebase and frank larkin, chief operating officer of troops first foundation and lead of the national warrior called the initiative. the second panel will consist of officials from the department of defense and walter reed to hear how dod is tackling the issue. we will have dr. martinez

lopez, assistant secretary of defense for health affairs, kathy lee, director of war fighter brain health policy at dod and captain carlos williams, director of the national intrepid center of excellence at walter reed national military medical center. i will now turn to ranking members scott for his comments to open hearing. >> first, i want to thank senator warren, chairwoman of the committee and the subcommittee and thank you for caring about the issue and taking this job so seriously. chairwoman warren, want to thank you for holding the hearing on such an important topic. traumatic brain injury or tbi is one of the most common injuries sustained by american service members. in 2022, more than 20,000 military personnel were diagnosed with tbi. stop and think about that for a second.

in 2022, there were more than 20,000 members of the military were diagnosed with a traumatic brain injury. that is pretty bad pick the best majority, over 84% were classified as mild which is more commonly known as a concussion. but if any of us have raised kids and have had a concussion, it scares the living daylights out of you. missing, service members feel exposed to low-level blasts that do not typically result in a clinically diagnosable concussion. this is concerned because repeated exposure to low-level blasts may cause similar symptoms is more severe cases of tbi. we know low-level blast exposure from firing heavily well-being systems or exposes may cause a variety of symptoms including concentration, memory problems, ability, headaches and decreased hand eye coordination. each of the issues alone can be serious and disrupt somebody patients life. unfortunately, there remains a great deal about exposure to these blasts that we do not yet know.

more research and better data require military and healthcare providers can mitigate the frequency of blast exposure where possible and treat those exposed to blasts where necessary. we have taken action to do that in the 2018 national defense authorization act. congress required the department of defense to conduct a medical study on blast pressure exposure. two months ago, the committee received the final report on the study. the hearing presents an opportunity to assess the quality of the department eye work. legislation require the study which followed specific individuals over an extended period of time to include three specific elements. first, the department was to monitor, record and analyze data on blast pressure exposure for any service member likely to be exposed to a blast in training or combat. second, to assess the feasibility and advisability of a blast exposure and history of a medical record. last, the part was to review the safety precautions of heavy weapons training in light of

emerging research on blast exposure. reviewing the final report submitted this last december, it is clear the department still has more work to do. particularly in its ability to monitor and record blast exposure for military personnel. only a few hundred soldiers or marines were fitted with wearable devices that unfortunately seem to suffer from quality-control issues it well the department eye report does say that it may be feasible to record blast exposure information, and a service member medical record, a business case analysis is required to determine the way forward in this area. i would like to learn more about how the department plans to conduct this business case analysis. is an important issue that i believe the department is getting to -- committed to getting this right in the tbi center of excellence and i hope they will provide the military with information needed to better understand the effects of repetitive blast exposure. we muster member that the

exposure to low-level blasts will continue to be a necessary risk for many front-line combat troops. but if we can better quantify the type and number of blasts that have the potential to cause significant or perhaps permanent injuries, then we can use that information to make better decisions about how best to accomplish a particular mission. i would like to hear from the witness on what congress can do to ensure the department of defense has resources it needs to conduct its plan and where we can help. this is about the well-being of the individuals that put on the uniform who were closest to the front line of combat and every service and were diagnosed with tbi. we owe it to them to ensure that when they going to harm's way, they are well trained and have the right equipment and are utilizing a manner that achieves an objective with the understanding of the risk involved you want to thank all the witnesses for being here today. i look forward to your testimony and i want to thank senator warren for putting this together. >> thank you.

>> chairwoman warren, ranking member scott and members of the committee, good afternoon and thank you for the opportunity to testify today. my name is dr. samantha mcburney and i'm a biomedical engineer at the nonprofit nonpartisan rand corporation. my research for the last 15 years not only at rand but at the university california berkeley and the university of southern california has focused on traumatic brain injury or tbi who both as a result of blunt impact and blast overpressure. today, i would like to see with the above repeated exposure to low-level military occupational blasts which are low-level blast exposures experienced while fulfilling military occupational duties. evidence suggests that service members are exposed to these blasts in the form of blasts overpressure where the pressure wave that emanates from the source of an explosion take the pressure wave can cause sub concussive

injuries that are not immediately detectable and would not qualify as a tbi. exposure to blasts overpressure can occur both in combat and in training as is already been mentioned. during training, exposure can be due to reaching exercises in the firing of increasingly powerful weapon systems such as the coral goose quill rifle and the at4. to provide perspective on the level of exposure that some service members have, one study found up to 32% of blasts experienced by breaching instructors exceeded the recommended exposure limit. studies have shown that the cumulative effect of repeated low-level blast exposure can cause symptoms similar to tbi. well a ready effects have been linked to low-level blast exposure as senator warren and senator scott have mentioned, there remains a lack of scientific evidence linking repeated exposure to injury. one reason for this is the difficulty of diagnosis.

the very nature of low-level blast exposure and the fact that it is not one single event that causes an issue but rather the cumulative effect of repeated exposure over time complicates injury recognition. symptoms typically do not manifest immediately which makes it unlikely that repeated exposure to low-level blasts are identified as the cause. additionally, injury is vastly underreported among service members and only obfuscating the issue of proper diagnosis further. there is also a lack of research about the military occupational specialties at greatest risk of exposure to low-level blasts. while there is no doubt certain occupational specialties are more frequently exposed then others, there is little research to support these hypotheses. so there remains a lack of understanding of the direct impact that repeated exposure to low-level blasts have on the health of service members in different occupational specialties. if the primitive intervention

is perfectly effective but cannot be delivered in time, it is not useful. this quote from a 2019 rand report perfectly describes the state and the reason many of us are here today. as a research community, we see the additional research needs to be done. however, there are steps the dod can take now to better protect service members against blast induced injury. i highlight four recommendations in my written testimony and i would like to bring your attention to one of them here. the creation and maintenance of blast exposure records. these records should include the number of exposures, the context of each exposure and any physical, mental or emotional effects resulting from said exposure. this would allow the dod to better track exposure frequency, assess high-risk occupational specialties, determine the connection between exposure and health outcomes and develop strategies to mitigate exposure and training environments. ultimately, these records can be used to develop an index score and engage in individual

combat readiness and potential health risks. as a weapon systems continue to become more advanced and increasingly powerful, low- level military occupational blasts will remain an enduring challenge for service members addressing the issue of repeated exposure to these blasts necessitate action and collaboration between the dod and the research community. by implementing the recommendations as outlined in my written testimony alongside continued research efforts to close substantial knowledge gaps, the dod can take significant strides toward better protecting the health and well-being of the service members. thank you and i look forward to your questions. >> good afternoon chairwoman warren, ranking member scott and members of the subcommittee. i am honored to provide testimony today on traumatic brain injury care and blast

exposure. my career is centered around improving the lives of people with traumatic brain injury. i currently serve as the president of spalding, chair of the physical medicine rehabilitation department at harvard medical center, chief of the department of physical medicine rehabilitation at mass general hospital in brigham and women's hospital and for the fast last 15 years, i have served at the home base program directing the brain injury program. actually see the patients as well as do the research. blast overpressure as we heard is a sudden onset of a pressure wave from explosions occurring with shoulder carried artillery and training deployment or breaching buildings and improvised explosive devices. generally, the bigger the explosion, the more damaging the pressure. tbi can have a wide range of physical and physiological effects. some signs appear mutely. others take days or weeks to

occur and may result in physical sensory cognitive behavioral or mental impact. according to the department of defense, since 2000, over 400,000 u.s. service members experienced at least one brain injury and 40% of those leaders screened positive for comorbid psychological health conditions. our own research has noted an elevated 10 year risk of hypertension, cardiac disease, endocrine or hormonal dysfunction and behavioral concerns such as depression even among the youngest of patients. home bases located in charlestown, massachusetts which i'm proud to say is a native floridian, satellite locations in florida and arizona and operates one of the oldest and most impactful private sector programs in the nation. for 15 years, we have served as

an incubator for clinical care models and research and the program is nestled near mass general hospital allowing us to leverage the faculty at the brigham healthcare system. home-based bridges the gap between medical care. in 2010, home base was approached by the navy special warfare with a complex set of problems facing navy seals. we quickly developed a comprehensive brain program named combat or the comprehensive brain health and treatment program. it is modeled after existing programs we developed for elite athletes and provides integrated multidisciplinary specialist treatment, evaluation and care coordination for veteran and an active-duty operator. home-based has treated nearly 1000 special operators to the intensive programs. 71.9% of combat participants

are active-duty and the overwhelming majority returned to duty. we are keeping the fighting force active. we currently have 178 active- duty special operators waiting to be screened and scheduled for combat and combat has care for operators in 47 states, the district of columbia, guam and puerto rico and 53 patients from massachusetts, 60, from florida. six from connecticut. 22 from hawaii. 278 from virginia. four from illinois, one from alaska and 54, from north carolina. the pot -- the combat program is highly efficient, agile and and compressed into five day care. patients see a minimum of nine providers and this may expand grossly related to pertinent diagnostic imaging or other studies. in summary, we are very grateful for the support

of congress, especially chairwoman warren who has shown this program. for the partnership and financial support provided by (indiscernible) the program is successful in the demand for care is growing at a steady pace. based on my experience in the field and treating patients at home base, i would recommend the department of defense consider the following options. invest in a develop -- to measure for partnership with academic -- . ensure all service members with traumatic brain injury (indiscernible) and has been said that the data needs to be lifted. develop treatment interventions . i also recommend the tot partner with home-based to

develop a long-term longitudinal health span study on the multi- system traumatic brain injury. and evaluating for repeated brain injury from blast exposure. thank you for the opportunity to testify on this very important topic and for your commitment to supporting members of the military. i'm happy to answer questions. >> thank you. mr. larkin, would you like to make an opening statement? >> thank you to the committee for the opportunity to speak. as a former navy seal, i'm here today to be a voice for all of those who are currently struggling every day holding wounds. ones that transcend out of mental, physical and spiritual domains. ones that have influenced with levels of suicide among active- duty force and veteran

populations. the department of defense -- to help them succeed. the u.s. navy seals operator first class. my son would be 36 years old today if he had not taken his life on the morning of april 23rd, 2017. he had been suffering from what we can only characterize as wounds of posttraumatic stress disorder and substance use disorder. the signature injuries of the last 20 plus years following the war on terror. and accomplish navy seal trained as a medic, and sniper. he loved being a seal. following four heavy combat tours in iraq and afghanistan,

began experiencing uncharacteristic changes that manifested in nightmares, anxiety, hypervigilance, loss of memory and declining functions. he stopped smiling. when his condition became more complicated and solutions didn't work, the system recognized and pushed him out of the seal teams and out of the navy. the separation created another deep wound. he felt he had let his teammates down, abandoning them. this under the assessments of actions. brain repeatedly said, something is wrong with my head. nobody is listening. this is reinforced by the endless stream of medications

prescribed and to address his behavioral systems symptoms and not the root causes. there is very little mention of tbi. despite the profile and repeated exposures. over the course of two years, he was described over 40 different medications. everything from stabilizing drugs for mood. he never received a clinical diagnosis. he was a walking concern. one night prior to his death, he said he wasn't going to live very long. and made me promise that if anything happened to him, he would want his body for research. and then said, it takes guys killing themselves before the system wakes up to the fact

that it has a problem and guys are hurt. two months later, we learned brian had a severe case of undiagnosed microscopic brain injury related to repeated blast exposure. unfortunately, the medical enterprises could not and still cannot see this level of microscopic injury in the living war fighter or veteran. my son died from his injuries suffered both in training for combat and combat operations. he didn't just die right away. these warriors with invisible wounds are hurt. they are not broken. they break when they are cut away from their teammates, tribes and arbitrated by the institutions where they have given their all. it has been 23 years since 9/11. the dod has spent almost $3 billion in mental health, substance abuse, suicide

prevention, ptsd, tbi and other war fighter assistance programs. i give them a d+, c minus at best for the lack of measurable impact for those that need answers. those at the deck plate dirt level, war fighters we promised to take care of and not leave behind. blast exposure is a key threat to where your brain health and potentially represents a significant national security threat to the force readiness and resiliency. however, whatever solutions we come up with, it can impact the operational effectiveness or lethality on the battlefield. we need to do this smarter and bring down the risk on the front end. thank you for being -- allowing me to be the voice. subject to your questions. >> thank you mr. larkin for being here and i'm sorry for your loss and i'm sorry for the treatment your son received. i think you said it right. traumatic brain injuries are considered the signature wound of our wars in iraq and

afghanistan well improvised explosive devices, ied's, may have caused some of these medical injuries, a military medical research study found that for troops with mild traumatic brain injury, "the most important cause of brain injury was a long-term exposure to explosive weapons." in 2011, the defense advanced research projects agency determined that 75% of the troops blast exposure and afghanistan was coming from their own weapons. the effects of blasts overpressure are terrible including memory loss, increased risk of dementia and substance abuse problems. but despite the severity of these impacts on service member patients help, when these problems are diagnosed, blast exposure is rarely identified as a potential cause. dr. mick barry, you have studied this issue for 15 years

now. why is it so difficult to detect when blast overpressure is causing the types of symptoms that we are talking about here and our service members? >> that is a great question, senator warren at a question so many people in the research committee are committed to answering. it really comes back to the nature of the injury itself. we are not looking at an injury that is caused by one isolated event. the fact that it is caused by repeated exposure to vary low level blasts, perhaps might happen throughout the course of an entire military career and complicates injury recognition. add to that the fact that symptoms typically don't manifest immediately as was mentioned and it becomes increasingly difficult to link symptoms to repeated exposure. >> i just want to say that i want to pick up on this because i think it is a really important point about the

challenge in trying to diagnose, because of the nature with the injury looks like. it is not a single moment in time where this happens. i just want to pick up and see if we can take this forward. we need to know how often we take it from your testimony, how often the service member has been exposed to blasts overpressure to give medical personnel the information they need to identify and treat the underlying cause of the symptoms. so far, the dod only has blast exposure data for a total of 500 service members. we are missing data obviously for a lot more. tracking this information through blast exposure and traumatic brain injury logs for all service members would be a good start but we also need to pay special attention to service members that are in especially high risk

blast exposure. some military occupational specialties such as training instructors, are significantly more likely to be exposed to blasts during training or operations. the marine corps found that the artillery community is also at particularly high risk and that high rates of exposure could lead them "to suffering injuries faster than combat replacements can be trained to replace them." sold doctor, i wanted to give you another chance as we are trying to push this forward. does dod currently have the strategies it needs to mitigate the risks from blast overpressure that are specific to each of the military occupational specialties that are most likely to be exposed? >> i cannot say i'm aware of the strategies.

in addition to that, a lot of the folks with whom i interact on a very regular basis with boots on the ground in these communities that are at risk of significant -- of significant exposure are unaware of such strategies. >> anything more you want to say about what dod should be doing in this space? i want to make sure i have given you a chance here no, thank you senator. mr. larkin and i were discussing prior to this, if i could choose the key take away for today, it would be to not let perfection interfere with progress. i think everyone here is looking for the right solution and what we really want to be sure of is that we don't wait too long to implement what we think is a perfect solution. there is a lot of research that still needs to be done coming from the research community. i'm always a supporter of more research. with that being said, we are looking to implement solutions and study said solutions while they are being implemented. >> let's focus on that for a

second just a little bit more. about the idea of collecting the data as we go along so that at least it is a first step in getting the information we need. i understand this is a gap that dod needs to fill. and i understand it is more challenging to limit service member blast exposure during, it combat. but there is no excuse for dod to continue to expose service members to unnecessary levels of blast overpressure during training. this is obviously an area where we could make change. it is clear there is a lot we need to do to protect each other from blast exposure. but dod, it goes to your point, dod constantly says we need more research. i'm a data nerd. i always want more research. but i'm very concerned about the idea that we will put off treatment. let me put the question more specifically to you.

that is, do you think we know enough now about the risks of blasts overpressure to service member patients health and to start taking action now. ? >> absolutely, yes. >> so we do know enough. doorsteps dod can take to get more data to understand this over time but more importantly, the steps they can take now in terms of treatment. i have talked long enough so i will come back to you later on this. senator scott. >> first, mr. larkin, i have kids and grandkids. i cannot imagine losing one of them. thank you for your service and your son percent service and i hope as a result, something good happens out of it, somebody prevents something else from happening.

can you explain what the blast does to the brain? let's say that i go shoot a shotgun or any of this stuff, what does it do -- each of them, how does it impact my brain? >> to my colleague's good point, perfection is the enemy of the good. you can criticize all the models but we know that these sub concussive injuries to a number of different things. they probably disproportionately impact areas of the brain, the great matter or white matter interfaces. they probably have a vascular effect. more likely long term. possibly a premature aging affect to the brain itself with multiple repetitive blasts, exposures or certainly with traumatic brain injury. lifelong exposure, getting that quantification that senator warren talked about is critically important.

we need to know one thing. we need to know, in who, how much, what were they doing and what was the actual phenotype or what happened to the symptoms of the person and track that very carefully. >> so right now you can get a glucose monitor and put all your data in there. and pretty fast, you can get a correlation, right? so have you had any opportunity -- we know that if you join the service, what blast you will have in boot camp and is their anybody doing anything that you would say, you just put all this data in something and you look at the model over a period of time? >> i think there are a number of groups including our own looking at blood based biomarkers for people, neuroimaging and all of those are critical as we understand the exposure and the diagnosis. but we also want to know, how

those things and specific lifelong exposures impact the symptoms of the person. there is not a 1-1 relationship. there is a relative relationship. >> if every service member, if you had the data, just start today. anybody knew that joins boot camp and goes to training, if you have the data and you had that in front of you, over time, you could do a productive analysis of where the problems are. >> to the point just raised, i think there action steps now and we are compelled very much so to make this a living and learning environment and continue to collect data and perhaps change policy and change programs and change how we treat people as we understand more over time. >> so you don't have enough information today of what

happens, as all these blasts happen. and you see the result. you see over time that this is what happens. this is what you have so far, right? >> i think that is right. i think senator what we have, and thank you for the excellent question, is a series of smaller studies that show changes in neuroimaging and changes in blood based biomarkers and representative of injury of the brain but how it will behave in a large population of people is one thing and how it will behave in bobby or sue is a different thing. >> right. so doctor, how hard would it be to just put up a program? it wouldn't be that hard, would it? >> that is a great question. unfortunately, one that i find myself unqualified to answer. >> we do it with bunch of other stuff like with glucose monitors. if you gave service members

just to say here, they all have cell phones. if you have an app and it says, every time you have exposure, you put this in. you put exactly in what you did. and people are not going to do well dislike they don't take their medicine. that wouldn't be that hard to do. we have all the stuff of sugar levels. why don't we not -- that would be the simplest thing to start doing. then you could start seeing like -- if you had all that data, you could pretty quickly do a productive analysis, even of short-term problems. like say what is my twenty-year problem, right? >> i think following people over a decade would be valuable. i think that we will see certain markers on certain things change early on. but we have to remember that

it's not an uncomplicated story. even the blood based biomarkers or other entities, have a lot of variation within. the brain i think, my colleagues would support me that it is an incredible structure. it is also a bit of a black box still within science and understanding how different networks relationships and how these nodes connect in an injury and one space affecting an entry and another. >> you would know the results. even though you don't exactly know why, you could over time predict what is going to happen. >> if you are looking for symptomatic prediction, senator, i think with a large enough dataset, you could certainly draw some strong relationships. >> and quickly come back and say, we know this. the odds are, you could go get a blood test for cancer now and it is very predictable whether

you will end up with cancer. is a perfect? no. it depends on the cancer. it seems like this would be pretty easy to do and it shouldn't be that hard. >> senator, i would agree with you. i would bring up the issue that we are all individual, different people. these kinds of injuries affect individuals in a different way. so a series of years worth of exposure is affected by who you were beforehand, the kinds of exposures and the treatment you had afterwards. that produces the results that is not so easy to put in a box. >> there are a lot of service members that are exposed to ied's during the tenure in afghanistan and iraq. are you tracking these service

members? most of them are probably in veteran status. are you tracking them for exposure to blasts and what is happening to them? anybody? >> i used to be a senior leader in the department of defense running the joint ied feed organizations. and i can tell you that it was a concern as far back as 20 -- 2008, 2009, that these blast exposures were creating a unique health risk to our warriors. we got into a point where we created new armored vehicles that were surviving the blasts but what got in the vehicle and what came out of the vehicle were two different states. and it alerted us to the fact that there were things, that the blast effect was having an effect on the human body and needed to be studied and researched. as far as having a handle on

-- unless there was a catastrophic injury and usually one that was visible, at the time, if a lot of these folks came out of the vehicles and looked fairly normal, and it wasn't until time evolved that we started to see the behavioral changes, cognitive dysfunction and so forth. i have no knowledge of whether anybody attempted to formally connect on the data and do anything with it. >> i think that is an important kind of follow-up as we try to understand what the impact of these blasts are long- term. also, i would think that -- it is bad enough that there are traumatic brain injury that needs to be followed up on but i would think a lot of them may develop conditions such as ringing in the ears. >> thank you very much, senator for that excellent point. i think we have long-term for

people such as ringing in the ear, chronic headaches or pain is a big driver that drives not only a headache or one's immediate perception but it invades behavior. if they are in pain, they don't behave the same way and don't cognitively perform the same way. what i'm saying is that the blast has a multi- system affect. of course, the brain is our principal and driving concern. but it has effects in things that are linked to tendinitis a that doesn't cause pain, but it is severely annoying and can be debilitating. i don't know whether you are -- it sounds like you are tracking the incidence of these kinds of issues and, it's something i'm very familiar with and there is no cure for these conditions, and so, i'm very interested to know what kind of breakthroughs

there are in treatment. i know tinnitus is a disease and tinnitus is a ringing not related to any problem with the ears. is that something you are studying? tracking? >> all i can tell you is i have it. it doesn't go away. i have to live with it. >> me, too. it's very annoying. sometimes it's so loud that it interferes with sleeping. so, i think there are a lot more of our service members who have endured or are enduring those conditions that we have to pay attention to. one more question, 2023 report noted that there is a critical gap in effective ppp in that most models represent the average human male, so there is that. this is for dr. mcburney, is

there any -- it's important we provide protective moment for our service members. how can we make sure that this protective equipment is also appropriate for women. is that happening? >> that's a great question and an important topic. it is happening. those findings were from the last state of the science meeting we had on blast -induced injury, and we were happy to learn that there is quite a bit of research being done in the community to make sure that the average male, specifically caucasian male, is not the only subject being used to test equipment. >> that's very important. thank you. thank you, madam chair. >> senator ernst? >> thank you very much. good afternoon. i would like to thank you, chairwoman, for the invitation to participate in this subcommittee today. it is a very important discussion that we are having.

traumatic brain injuries can arise not only from the combat deployments but also from those routine training exercises that our men and women go through every single day, even when they are adhering to safety standards and establish safety guidelines, the act of firing heavy weapons, just as you stated, mr. lichen, can create those long-term effects. other types of training sessions in preparation for combat plemons, many of these can lead to cognitive impairments affecting our function. mr. larkin, and understand you share the story about your son ryan, and i want to thank you so much for your service as a navy seal and your son's service as a navy seal. it was through mr. larkin, through frank sharing his sons story with me many years ago

that i finally understood the need to be involved with traumatic brain injuries. so, thank you so much for sharing what is a very difficult story to tell, but one that is incredibly important for every young man and woman that what's on the uniform of our nation. thank you for that. mr. larkin, did you share with the subcommittee how it was discovered that your son ryan had traumatic brain injury? >> thank you for the question, senator. thank you for your comments. ryan had expressed his desire that if anything ever happened to him, he wanted his body and his brain donated for traumatic injury, breach or syndrome research. that was done and his brain was donated to an activity at bethesda walter reed that

postmortem analysis revealed that he had an undiagnosed microscopic level brain injury that was uniquely aligned with blessed exposure. they only see this pattern of injury with blessed exposure. if we had not gotten that winding, the narrative that the navy had built around ryan and his struggle, and his subsequent passing would have continued on, continued to have damaged his reputation, but this finding was indisputable that he was injured. he was not, in his terms, crazy. >> exactly. i just want everyone to understand that so many of these injuries go undetected did through c.a.t. scans, through mris, pet scans.

as a follow-up to that, and i'm very grateful that ryan had chosen to do that because you would not have known about those injuries otherwise. but then, for you, and dr. zafonte, is the automated neuropsychological assessment metrics, the test used by the dod an accurate method of detecting those changes in cognition that can lead to a tbi diagnosis? >> thank you for the excellent question. i think we are searching for a gold standard. a number of those measures including the anam have significant flaws in them. everything from the way they are administered to challenges on their consistency and internal behavior within an individual and external to

other individuals, so while it is an interesting screening tomb, it is far from perfect. >> i hope we continue to work toward alternatives or ways that we find that gold standard . that is something that this subcommittee is working on. you have spoken a little bit about wearable devices as well that might be able to diagnose tbi or blessed exposure. all of these things require research, development, recommendations. are you confident that we can get to a point where you are able to make recommendations to congress, to dod, that will provide us a path forward in protecting these men and women? >> thank you, senator, for your excellent question. i would say, -- and i think my good colleague said this before

-- perfection is the enemy of the good. there are things we know to do now, and as we learn more, we should do better. if we act and make this a dynamic learning a positive environment for our service members, we can do things now while evaluating data and really make a positive change. i think we will learn that there is a lot more of that microscopic injury than we had ever believed, and in certain people, that will have some significant --. >> thank you. i believe you are absolutely correct. i think there are a lot more servicemembers out there that have sustained various micro tears or injuries to their brain. i was reminded of this quote not too long ago, and it is an old one. if the human brain were so simple, we could understand it,

we would be so simple we couldn't. and let that sink in. i think we are always going to be striving to find the answer that we need when it comes to traumatic brain injury. we may never reach that 100% solution just because of the dynamics of this incredible organ. but it doesn't mean we should just let it go. there are absolute disruptions to families, just as we have heard from mr. larkin. it is incredibly important that we pursue not only ways to prevent traumatic brain injury, but that we also find ways, if it does occur, and we won't be able to prevent it in 100% of cases, but if it does occur, we need to find ways to treat it and mitigate the impact to our families. thank you again, chairwoman. i really appreciate the ability to be here today.

>> i want to give a special thank you to senator ernst. they are not on this subcommittee. she has an absolutely packed schedule, but she has been engaged for years now on the issues around traumatic brain injury and working toward changes in the lot both in the documentation that will lead us to better diagnoses and also for the resources to begin treatment now for those who need it. she wanted to be here with us today, and i appreciate your coming and doing this. thank you. senator kaine? >> thank you. thank you for having this hearing. it is really important. i will ask the same question of both panels. i would love to get your take. we are not the only country that employs weapons that can have these effects on servicemember brain health. what have we learned or what

can we learn from the experience of other nations and their militaries, either about strategies to prevent or strategies to treat? >> senator, in my roll as a senior leader, back during the height of iraq and afghanistan, this was not a u.s. only problem. we were very much in the trenches with our nato allies, and were all experiencing the same challenges with maneuvering on the battlefield because the ied had paralyzed our movement and the ied was the weapon system the enemy used against us that literally brought home all the casualties and fatalities of those two conflicts and africa. if we don't bridge communications with those countries as we try to solve

this problem, we are missing a big part of it. they have a great data. they are as concerned about what we are talking about as we are. i think that we need a task force to bring together the government industry, academia, and foreign partners for a unity of effort to mask the data to solve this. we can solve it. it's just that, we have different ad hoc efforts going on right now. they are not coordinated. we are handicapped by a lack of data sharing and like i said, we have to get everybody in the same --. >> even within our own family, i noticed pennell two has -- not be a. this is a very high

priority. sharing within our family, certainly, but with our allies who have the same experiences, it's really important. do you want to edit that at all? >> it is an excellent one. one consideration i know some of our allies are considering at this time, and it was published in a report in 2018 by the center for new american security, is reviewing and updating firing limits for a lot of these weapon systems. those firing limits haven't necessarily been revisited in sometime and in my written testimony, there is a direct quotation from that report in 2018 that details exactly what information to revisit in these weapon systems manuals. perhaps consider updating to really get at mitigating exposure that our service members experience in training in particular. >> senator, thank you for the

great question. i agree with the comments of my esteemed colleagues. i would add one other thing. you are completely right. there is power in numbers. there is power in togetherness. there is power in the opportunity to discover and serve our allies throughout the world. and so, i would advocate for a common data element. a common data set that goes across our allies as we think about these kinds of exposures and the kind of long-term sequelae both immediate. what does somebody feel now and what are they experiencing years later? those kinds of things would be incredibly important and doable and many other health systems. >> thank you very much, i yield back. >> thank you, madam chair and senator scott, for holding this hearing. it's a really important one and i thank the witnesses for their attention to these really important issues for our military.

i got here a little bit late. if this has already been discussed, bear with me. i want to dig into this new york times article from november of 2023 entitled, the secret strange -- secret war strange new wounds in silence from the pentagon. this was about the marines in syria deployed in syrian 2016 and 2017 and they returned and really struggled with ptsd issues and health issues and it wasn't from direct combat. they were in combat but it was primarily from their -- it appears really significant amount of firing. kinda to

senator kaine's point, we have military members in different wars, vietnam, korea, world war ii, of course, fire thousands of rounds, but we have seen this before, but these marines seem to really have struggled have either of you read this report or this story. senators warren and ernst and tillis and january 18th two secretary austin asked him a lot of specific questions relating to this and other issues that relate to tbi, but this is a different tbi. so, sometimes i worry.

i just retired from the marine corps myself and i love the marine corps, but like all big organizations, they can be bureaucratic and i'm not sure these marines are treated very well. i'm wondering, from your experience, maybe we will start with you dr. zafonte, what is your assessment of that report from the new york times? and what do you think the next step should be? obviously, we will ask government witnesses and the next panel on this topic. but i would like to get your assessment from this particular episode. a lot of my constituents in alaska read this article and were quite disturbed by. we don't even have a big marine corps presence in my state but

a big armor and air force presence. i would like all of you to comment on what your thoughts were and what we can do. if the marines haven't seen this, you can see how they could overlook it, but i think this needs a much deeper dive than the military has given it and do chairman's credit, some other senators, they are already pressing secretary austin on it. what are your thoughts on it? >> senator, thank you for the excellent point and question. from my per spec live, i think that the piece brought up a series of issues. it really took the cover off of some things and made them more public in some ways. it talked about many of the long-term sequelae that are being seen clinically in this population of people. now, these are extreme

individuals, many of them, they are the 1% of the 1%. they are the fittest, the swiftest, and yet they are seeing clinically apparent problems. they are also the most resilient. they are selected many times. so, that raises for me some real concerns. it may be related to the density of the exposure. it may be related to the lifelong exposure. it may be related to a global element of the life and that stress for significant . >> of time. i think we need to learn more about the long-term issues here and the short-term ones, and i think part of the way we do that is better quantifying the exposure and the person over time. >> great. dr. mcbirney ? >> thank you for raising this.

i thought that new york times article was well written and investigated and reported. >> by the way, i don't believe everything the new york times writes, for the record. and so -- senator warren might -- i'm just getting. but, i'm sure the marines had some points in there that probably weren't reported and i'm not saying it was a perfect peace, but it raised an important issue, and these young men, to dr. zafonte's point, these are my view, the best of what we have in america and we certainly need to take care of them. >> absolutely agree. i think one of the main takeaways for me when i read that article was the fact that there is a culture that is pervasive across the dod. unfortunately, it really contributes to this underreporting that we see of injuries. i think the way that

these men were treated is indicative of this culture and the fear that a lot of servicemembers have when it comes to reporting injuries. there have been many studies done on the underreporting of traumatic injury. there are a variety of reasons that servicemembers that report injuries. but fear of negative repercussions on their military career certainly is a huge one. i think when i read that new york times article and the series of articles, that's really what came to my mind, a culture that needs changing, if we hope to improve this. >> mr. larkin, really quick, sorry, madam chair. i don't know if you love you on this, we have had many wars with many thousands and thousands of artillery rounds, fired. i had an 81 millimeter platoon on active duty. we fired all kinds of 81 millimeter mortar.

that that is because these howitzers, but it's a big mortar and you feel it when you are firing those. your ears hurt when you don't have your protection on because it is so loud. what is your sense on how we need to look at this? comparing it to other wears wars where we have shot thousands of rounds? >> if i'm going to put my money , it's want to be on the preventative end as much as we can to die down these injuries. a completely a dream -- agree with dr. mcbirney. the issue is trust. you won't get reporting unless there is trust built between that operator or warrior and the system. we have collected blast data on a variety of different efforts. >> on artillery, too? >> a variety of different settings where blast gauges and so forth have been worn by our

warriors. we have no idea where that data has gone. again, it never comes back to the war fighter like that to submit or what for radiation. they say, we were these things that we don't hear anything back. when we your and acquire weapon systems and munitions, why do we ask those manufacturers to provide us with blast overpressure data according to strict criteria that they all have to follow, that ultimately will allow us to craft training protocols and potentially surveillance programs for the more high risk occupation? >> -- >> we have been calling this my different name coming off the battlefield since world war i, and it all has rested in psychiatric mental health diagnosis and we are now starting to realize this is a biological injury caused by

blast overpressure. >> thank you. thank you, madam chair. >> thank you. i have another round of questions. we are glad to do it. i want to pick up on what mr. larkin was just talking about and that is trust. servicemembers who have been affected by blast overpressure aren't getting the help they need, and the question is not why not? i will go back to the new york times article. it does give us some on the ground anecdotes that people are experiencing. a marine corps officer who is leading an artillery unit was quoted in the story saying that he was experiencing severe headaches and small seizures, but was worried his injuries

would not be acknowledged because there was no documentation that he was exposed to anything serious. now, we talk about the importance of record-keeping and how that could fundamentally change what happens in this area, but i want to talk about where we are right now and the consequences of the failure to diagnose early and what that means. mr. larkin, you are the one focused on this more than anyone. i think you said in your written testimony that you estimate that about 80% of your sons exposure occurred during training. is that right? that's what i understood. >> yes, senator. be talk to other veterans that have trained for combat, but in combat, they will pretty much confirm that the majority of their exposures is in the training environment. and environment we can control. >> if i can ask you, we know about what happened to ryan

because he donated his brain postmortem, and they were able to do an analysis. can you speak to what happened when ryan was still alive and whether you and your family got the appropriate support that ryan needed as he clearly demonstrated that he was in increasing trouble? >> one thing i didn't share about ryan is that after he passed, we found on his computer were --. he downloaded numerous study on blast exposure and tbi and also is researching the medications he got. he was locked on this. i didn't like what he did. i didn't support what he did, but i have grown to understand why he did it. it was for his teammates. he was going to prove that something was wrong. when he went to get help, he did it more for his teammates and then himself. but again, you know, we did not

know what we did not know. i think a lot of people were trying to do their best for him , the best that they could, but maybe all the wrong way. we lacked the science and knowledge. tbi was not mentioned. it was not taken seriously because they could not see it. we still cannot see this level of injury in a living operator or war fighter, which is, within the medical enterprise, if you don't have a blood marker that alerts you, just like a heart attack. we look at heart enzymes and so forth that alert us that there is muscle damage and we see an ekg that tells us things are going wrong within the heart, we don't have that right now, and it handicaps our ability to triage these folks early on in

the evolution to your point. i don't know if my colleagues would agree with me, but the opportunity we have here is to get it this early, not wait till it gets to a catastrophic point in the disease and injury process where things have gone too far. >> let me pick up on this. i understand that this is hard to diagnose and we collect data that will be one way to make it easier to diagnose. i understand we would like to start as early in the process as we can, but there is another feature of this that we have some control over right now. when someone has any concern, who is the advocate to make sure they get the help they need? my sense of this is, it is just a patchwork. you get here, you get sent there and then you end up someplace else. the patient is put in the position of having to advocate for a diagnosis that it is not

the patient's responsibility or expertise to have to make. i am grateful that ryan did what he did in order to help his teammates, but ultimately, we have a bigger responsibility here. i just want to know if you can speak a little bit to the notion that starting now, before we have perfect information, we need a way for people to go into this system to be able to raise a hand and say, i have problems. like the marine quoted in the new york times piece. i have problems and i know there will be one person there who will advocate. and at least get them to the best possible treatment that we can. can you speak to that, mr. larkin? >> yes. the number one word i would pick out is listen. the system needs to listen to these folks as they step forward. and we need to understand this is a leadership problem, and we need to educate leadership as

to what is going on here so that they can properly usher these folks down the right paths so that we can stop there injury process and we can start a level of treatment that one size fits one, not one-size- fits-all. which is precision medicine. as the science develops, as our medical capabilities develop, we will get better and better at doing that, but again, ryan became disenfranchised he became adversarial because the system turned on him. the system he depended on. the system i depended on. this was my community too. so, this is why i am here today. i realize this is not a perfect world, but the ultimate greater of what we do or not do are the veterans, war fighters and their families. are we doing the right thing

for them? >> i very much appreciate that and i appreciate your comments. if i can't, i want to go to the treatment part of this. dr. zafonte, you work at home base, and homebase tries to be the one place that brings people in and gives a response. it is on-site of our service member, not hostile to our service member. you are on the front lines. you see people with tbi every day. can you talk a little bit about how homebase has organized itself and what you are seeing and what kind of needs you have? >> senator, thank you for the excellent question. i think we see ourselves as a partner with dod. we are auxiliary and in an important and differential way. we take a look at the whole person and what we try to

understand is that, i think mr. larkin captured it brilliantly. somebody is not just the psychologic illness, but we bring multiple specialists to bear on this person for a very intense evaluation that might take, as i said, months or years in a standard environment and try to merge them in a team- based behavior where we listen to the patient's and we develop a programmatic plan to treat, if we can't treat the microscopic injury right away, let's treat their symptoms and get them relatively well. >> i'm so proud of the work that homebase does. i really want to underscore the importance. there is help. there are things we can do and i take it, if i can have he underscored again, dr. zafonte, you actually return people to active duty military service. can you say a little more about that? >> i'm happy to.

thank you, senator. one of the most extraordinary things, especially for our special operators is the very high degree of return to duty, return to the force and fighting. as a person, that's what they want to do. they want to be well and go back to their teammates and contribute at a very high level. indeed, that is the goal. the goal is being able to get people agency over their own health again, and that's what we do. very high rates of return, large numbers of people still waiting for service, which we hope to provide. and i think that we see this as a means of enhancing programmatic excellence and serving as that bridge for midcareer, early career people who really need a bolus of health. >> early and accurate intervention, which i think is the point you make as well, mr. larkin and dr. mcbirney, i appreciative the work you do. thank you.

senator scott? >> thank you, chairwoman. dr. zafonte, nfl players are wearing the q caller? can you tell me how it works and what you think of it? >> thank you very much, senator. thank you for the excellent question. is an area of debate that is certainly of interest in the field of traumatic brain injury . the theory behind the q caller is that compression here at the neck, slight compression would result in less for shaking within the brain. its roll in blast related injury , i believe, unless dr. mcbirney has more data , is unclear. and sport related injury, it is received preliminary approval although the enthusiasm is modest. >> okay. knowing what you know now,

knowing the services, if you had a child or grandchild that was 18 years old, wants to be a war fighter and enlist in the -- whatever is what would your advice be to him? >> is not enlisting an option? i mean that as a serious question. traumatic brain injury is -- there is such a huge risk of getting this injury. as we have heard today, detection of this injury, treatment of this injury is not guaranteed. i would, in sitting here, i now have a 14-month-old daughter, so this question is very relevant. i would strongly urge her to reconsider her decision, and unfortunately, that's a decision that i know many veterans that i personally know

have asked their children to reconsider as well. >> mr. larkin? >> ryan is with me here today in spirit him and much of what i am saying is him talking to me. he would tell you he loved being a seal and he wouldn't trade anything. it's just that we got to do it better. i will say that my own naval special warfare community, the seal community, ryan's story has deeply affected them and they have moved aggressively to try to make a difference along with the parent command he was so calm up to the commanding general. they are leading the way in my opinion within the department of defense and very often, what special operations does, the conventional forces follow. thanks, ryan. >> dr. zafonte?

>> certainly i think this is a point of great debate, but i guess what i was say, and we see this in contact sports. we sit in the military. the first we can do is know what we know to do now, which is eliminate unnecessary exposure. rules changes in sports have made a big difference. i believe we can eliminate unnecessary exposure in this population of people where there isn't a lot of return on investment, either to their training, or for their long- term health, or for their team members, and that would be an awfully good place to start in enhancing force health. >> i thank all of you. if we care about our freedoms, we don't have a choice. we don't have a choice. we have to thank god every day someone is willing to put on the uniform because if we go to

the point where people say, there's too much risk, say goodbye to all of our liberties. i hope we get to the point where nobody would say, you shouldn't go in because of the risk. thank you. >> senator kaine? >> just to close it, senator scott, thinking about what you was a tear could pick one of my three kids is a marine who was eight-year infantry commander and now a marine reservist. thinking about him and how he might answer that question, let me just recount an amazing story i heard not long ago from doug wilder, the former governor of virginia and first african-american elected governor. he was drafted into the military in the korean war, and the military, like society at the time had a lot of racial prejudice. he was in a unit where there were many african-americans, many caucasians and others and doug is a guy who will stand up for himself. he had a commanding officer that said, i want everybody here to be treated fairly and

he believed, as did others in his unit, in the middle of some difficult battle circumstances, the african americans were not being treated well. they all agreed they were going to talk to you there co and pass it on and when they all stood up to do it, they said, doug, you do it. and so he laid out his concerns about the way they were being treated. his commanding officer said, you have done what i asked you to do, now go back to work and let me do what i need to do. and things didn't change for about three or four weeks and all of a sudden one day, everything changed. he did what he was supposed to do and he stood up and he said, this isn't right and we are a unit. if we make some changes, things can be better. i would hope that people grappling with the decision, maybe your daughter might be in this position, but people grappling with the decision will realize, things don't just get better by themselves. things don't just change by

osmosis. it takes people at all levels, from the private first class, all the way to a four-star standing up and saying, we will be better if we make these changes. and i think a lawful -- an awful lot of our young people have a lot of wisdom to offer. i would hope they might still say i'm doing this and i'm also going to be committed to speaking up if i see areas where we can be better. thank you. >> thank you, senator kaine. i will be calling on you as we are doing the nda, both to tighten up the rules on reporting and get more resources into treatment. that shirley has to come out of a hearing like this. thank you. thank you all for being with us today. i would like to call on the second panel. thank you.

[ indiscernible ] if you are we ready? secretary, martinez lopez, if you can give us an opening statement, please? >> distinguish member committee,

we are pleased to represent the officer secretary of defense to discuss the department of defense's commitment to address war fighter brain health issues and initiatives. we are honored to represent the dedicated military and civilian medical professionals in a military health system providing direct support to our combat and commanders and delivering healthcare for our 9.6 million beneficiaries. we will inform the committee about departments initiatives to understand the causes and impact of brain injuries and blessed exposures, support ongoing training of medical professional, inform treatment protocols and improve the cognitive and physical performance of our service members. the department of defense primary mission is to defend the nation. fulfilling this mission means war fighters me to the ability to make expedient and effective

decisions on the battlefield, promoting brain health enables our effectiveness as a fighting force operationally and mitigating the impact of traumatic brain injury in all of its form as a top priority of dod. we focus on near and long-term healthcare of our service members. in support of this priority, the dod established and joint efforts between the operational and medical forces called the war fighter brain health initiative. this initiative was finalized in 2022 two qualified policy and direction in support of unified efforts across the military to address tbi and blessed overpressure. the war fighter brain health initiative focuses on cognitive and physical performance, identification of known and emerging brain threats in military environments and

methods to immediately detect and treat brain injury. that wb hi initiative is a imported organizing function for our departmentwide efforts to address brain injury and related diagnosis such as ptsd and suicide. between 2000 and 2023, 485,553 service members were diagnosed with tbi. the numbers of tbi group just above 10,000 per year in 2000 to a peak of 33,000 per year in 2011. the dod responded to this increasing rate of tbi in combat during operation iraqi freedom and operation enduring freedom through rapid expansion of to get clinical care and research to support military forces around the globe. will recognize

, however, more research and insight is needed in both care and research dimensions to better understand the risk, how to protect war fighters, and how to treat brain injuries more effectively. our strategic approach to this issue is an authority of one involving policy to coordinate clinical changes and gap driven research investment. policies work, we look at how to refine for broader effectiveness. when they do not work, as expected, review why and modify them to invest in research to advance solutions. whether that overarching policy mind-set, we hope to discuss that we see pivotal actions, research findings under impact on our approaches implement it within the wbhi. we communicate this insight,

not because we believe they are foolproof solutions, rather, enable collective action through shared knowledge. we know there is still much to learn about the brain and not everybody response in the same way to similar exposures or injuries. we seek to integrate solutions for the future as we provide recommendations to inform and affect change to safety, doctoring and policy. this mission is both personal and professional. as providers, researchers, military leaders, we are committed to mitigating the risk of and improving the treatment for exposures and tbi. we appreciate your continued support of military medicine and for inviting us to be here with you today to discuss the important issues surrounding the brain health of our war fighters. we thank senator warren senator

scott, and members of the subcommittee for leading continued attention on blast exposures and brain injuries. we look forward to your questions. >> thank you very much. i appreciate it, dr. martinez. i appreciate that dod has begun to take steps toward mitigating the risks associated with traumatic injury. starting this year, new troops will be given regular cognitive assessments to help monitor potential impacts from blast exposure on their brain health. this will help medical providers recognize brain injuries and changes in cognitive function more quickly and it will help service members get the clinical help that they need. i am glad that dod is taking this critical step, but it is important we do this right. captain williams, your organization, the national intrepid center of excellence, works with servicemembers with tbi's and other invisible

wounds of war. as you know, -- and we have discussed you repeatedly today, one of the most significant ways that troops are exposed to blast overpressure is through training. to ensure that we are accurately monitoring the impact of blast exposure on servicemembers brain health, would be helpful to give a cognitive test before the service member begins training and firing weapons? >> thanks, senator, for the question. thank you for the opportunity to talk about this issue. absolutely, yes. it is critically important. baselining is something that we utilize in all aspects of medicine for surveillance. we utilize it prior to treatment, hard to modalities that we know cause risk. so, we have moved to know, this year, we hope to move to all members.

once they join the military and before they start, they get cognitive testing. they get the cognitive testing because we know that the risk of tbi in the military are in the training environment. it would be valuable to use the same precision medicine we have been using in the past for other modalities and we do with tbi. >> if baseline assessment is not starting until after training, it is not an accurate measure of the servicemembers brain health changes over time. we are going to miss the front end of this, and as we have talked about the importance of isolating the problem early, it is absolutely critical. make sure we are able to detect signs of cognitive decline due to blast exposure. we have to do this assessment before the training starts. second thing, we also need to do regular tests of servicemembers cognitive health after the baseline assessment.

while special operations command will conduct these tests every three years, dod is currently planning to retest troops only every five years. dr. martinez, you are responsible for assessing the effects of, and improvement, how dod tracts blast pressure exposure. would annual cognitive testing for servicemembers help increase the chance that we detect changes in cognitive function and detected them earlier when intervention would be more effective? >> as a department, we are looking into this. if there is value into doing it every year, we don't know. maybe three years, maybe five years, there is more data and more science we need to look into. i'm not looking in 10 years. i'm looking short-term research to figure out what would be the best frequency of doing the test.

not only that, but what kind of other testing we should add to the battery to assess the condition of our soldiers. servicemembers. >> i feel a little frustrated here that special operations command already clearly says five years is not enough. they are at three. and frankly, until we have better data, i don't know why we wouldn't be sent, let's do an annual test and see what we can detect. if the data shows us that three years is often enough interval to be able to detect changes, that's fine. but, it seems to be given what else we know and given how catastrophic the implications of untreated tbi can be, we ought to be erring on the side of collecting these data annually. i really want to push on this, waiting five years to test is just not often enough. another

way that dod needs to show it is serious about protecting servicemembers from blast overpressure is by establishing affect whipping -- weapon safety limit. we had conversation about this earlier. in 2022, dod directed the services to establish a maximum allowable number of rounds for servicemembers to fire to mitigate blast overpressure injury risk . now, good start, but i see two problems with this. first, the limit don't include brain injury risk. blast pressure experts have raised concerns this means that our current safety thresholds are built on things like whether or not it is likely to cause your eardrum to burst. they are very old guidelines and they are not about traumatic brain injury. miss lee, you are in charge of overseeing dod's war fighter brain health policy. why is it

important that dod establishes a maximum allowable number of rounds for servicemembers the fire that takes into account brain injury as well as injury just to the ears? >> senator warren, thank you for the question. thanks for having us here today to be able to talk about war fighter brain health blast overpressure and traumatic brain injury. this is an excellent question. it is imperative that we have allowable number of rounds for all the weapons systems that are commonly used so that we can avoid unnecessary blast exposure in our servicemembers. we believe that this also gives us an opportunity to be able to ensure the usage is correct, the position, crew position, proximity, and all those pieces can come together. our policies are moving in that direction to be able to look at the brain. as he mentioned, historically, it has been through your and lung, however, we are looking

at what the brain affects are and we will follow suit with our policies as such. >> again, i want to say, i feel a little bit of frustration here . i appreciate that you are working on establishing these limits, but we have to get this off the ground now. we know enough to start moving in the right direction. my office has heard stories of servicemembers having to take their own initiative in setting limitations for their troops. we have training instructors who just say, i have decided that is enough. and that's not enough to get this job done. again, i urge you, better to make your best estimate and get started on forcing these weapons manufacturers to start collecting these data so that they will be able to give us limits on how they can be used. one more concern here. it is how we measure these weapons safety limits.

dod's own studies found it took 72 to 96 hours to resolve servicemembers cognitive deficits after firing heavy weapons. that's about how long it appears before people are back to their original steady-state, but dod guidelines say, they are only going to test for the first 24 hours. miss lee, could servicemembers benefit from establishing weapons used safety limits for longer periods of time like 72 hours? >> yes, ma'am. we are looking to expand the timeframe so we allow for those differences that are coming up with blast overpressure. that is where our policies, the direction our policies are headed so that we can cover that time period. we are firmly committed to early detection. it provides the opportunity to treat, and that maximizes our outcomes.

>> i hope you do this soon. the department of defense inspector general has raised concern that military health system providers are not consistently providing a 72 hour follow-up appointment for patients with mild tbi's. clearly, a longer timeframe is something that dod itself recognizes and is important and that we need to get done. i get it, this is hard, and i am grateful you are doing the work you are doing. i want to be a partner, but a partner that urges you to move faster and deliver more for our servicemembers as quickly as possible. we need to do better for our troops and we need to do it right now. senator scott? >> thank you, chair. i will ask the same question. what would you tell your son or daughter who was going to go in and be a war fighter and enlist . what would you tell them

today? >> sir, i have three boys pick two of them serve in the military and one is in the reserves. i'm very proud of their service , and i will tell my grandkids, i have eight of them, there is a great opportunity in the services and i think there is some value, as a human being, as we develop, that service to country is very important. even if you do it for a short time, it makes a big difference. i don't care where you serve or how you serve, it's critical. now, they need to understand this is a risky business and they need to come out with her eyes wide open. so, my kids knew that. i made it very clear, but i'm still very proud of them. if they really think about that

and something triggers them,. >> thank you for the question. i have no children at this point. but i have many nephews, nieces and friends and family who i have encouraged to join the military. is has been the greatest honor in my lifetime to serve in uniform. i wouldn't change that requirement for anyone or request to anyone. i would tell them to follow their heart and i would encourage them to know that there are inherent risks to the job and our job is to make sure that the people who you are entrusting your life to, then the responsibility to care for you. the reason i'm here today is to say we want to make sure our men and women in uniform know that we are caring for them in every possible way. >> thank you. >> i have five children and one grandchild and i would absolutely say to support and

defend our homeland to join the military and join the armed services, one of them is a marine. through that service, it's about the trust and i have seen working in this environment for the last 20 years, especially around the traumatic brain injury realm, you really do need to be credible and have integrity based on that trust and ensuring that we are going to do right by you. we are going to take care of you. mr. larkin is part of our team. we are all in this together to take care of our people and take care of service numbers and make the sacrifice. >> the department last to conduct a business case analysis and review lessons learned to form his weight forward with blast monitoring. who is conducting the business case analysis and when you expect the analysis to be completed? what factors is the department including in its analysis? >> sir, do you mind if i defer

to --? >> the meeting was the 14th of february. it has been conducted by a contract service. we are expecting the results in september of 2024. we looked at this we have extensively involved military departments in this so that the outcome that comes and recommendations will be able to be implemented by the military departments both the service communities and the operational communities are heavily invested in this business case analysis service communities and the operational communities are heavily invested in this analysis so that we can review the necessary resources and look at how to establish a standardized monitoring program throughout the force. >> when you think you will be completed? >> the best cases to be completed in september. >> september. the fiscal year 2023 nda also didn't require the director to

conduct a censored. do you have any sensors in mind that you think are working? >> we are awaiting the bca results in december to make a decision on whether that pilot, which could be the segway from the section 34 work into a full- blown standard monitoring last program throughout the department. those are decisions we will make in the december 2024 time period. in terms of blast sensors, with communities including operations command that has been looking at three commercially available products. they are living in the acquisition world as they are doing suitability exercises come and based on the requirements of each individual community.

>> also, the fiscal year 23 report -- i guess this was due at the end of last year. is that different than the others? >> that is the strategy and action plan. i believe that is headed over your weight right now. >> is it? okay. thank you. >> can ask one more question? this is seven months before the business case analysis. what are you going to do over the next seven months? >> so in the original memo that was proposed before we finished section 734, the secretary put out this memo. before we

completed all the information, we thought it was imperative to try to get brain health guidance out at that time. so we sent the memo out. and that memo are six actions to try to avoid unnecessary blast exposures. what we are doing in the meantime is updating that memo with more data that we have from our research studies and from the bus community of researchers so we can provide more guidance to the military departments on how they can have safer environment. >> i appreciate that. [ indiscernible - low volume ] >> there anecdotes that we make policy changes. we talk appear in the abstract and on the ground, nothing has changed. >> the first issue is this is a joint effort between the operational forces and we on the medical side. it is the medical leadership in the operational leadership.

if we don't work together, this is not going to pan out. the way we exercise it at dod is through the side cancel. we lay out the guidance. we rely on the service to push it down. it is an issue of training in the services. it is an issue of equipment in the services. we will give you the best medical knowledge we have, but you have to figure out where you're going to fire the weapon and where. those kinds of things need to be exercised by the line. i went over to ft. campbell and i talked to him and i told him, it's simple. less is better. less often is better. pay attention to it. >> captain williams, did he want to add anything on that? good. senator scott. >> have you ever had a glucose monitor? do you know how they work?

so i can use a glucose monitor. i can put in my exercise and my food. i can do it myself. i can track to see how i feel, when my glucose goes up, and so, why don't we have something simple that people can do on their own? if i knew -- i get headaches nor i have -- or i have sleeping problems or any of these issues. i say, i can't do any more. that technology is so simple. there are two companies that do the glucose now that i know of. what you say, will you give us the technology and we can implement this and give it to everybody and let them monitor it themselves? >> [ indiscernible - low volume ]

>> anything below that -- on this issue, i don't know what the threshold is. >> i will decide for myself. the way i would look at it is, i'll put the information there, and i would say, hey, here's what i noticed. if i do this number of blasts, i get a headache. if i do this number of blasts, i can't sleep. i say, okay. i'm not going to do that. i'm not doing that to myself anymore. you know, this happened to me. i'm not an expert on this. you would think -- we are all going to be better if we self monitor ourselves, rather than some top-down program that tries to tell us everything. even glucose, i mean, your body is going to be different than my

body. my high-level is going to be different than yours. i'm just saying, but the information in their. it is a simple model. give it everybody. let them follow it on their own. you can connect. you can say, you can allow this person to connect. there is a company that allows people to do that now. levels. i think they have 50,000 people or so on a study where they do it on their own as private sector, with everybody voluntarily putting their date of their. >> sir, if i may, what you are speaking about is really and truly precision medicine pick and targeted therapy to the individual. it is very variable for each individual that has had a tbi, the symptoms they have. one of the things they said is that the dod needed to partner with private organizations to improve research. what type of modalities are out there that

can be developed to allow patients to focus on their individual symptoms? feedback is something we do in the network. we help patients understand their symptoms. if everyone is different, that is going to be a challenging -- monitoring to create that peer gets possible. as we continue to do research, i think we can get there soon. >> so i just gave you my answer. that is a big government answer. you might be right. i'm not saying you're wrong. i just actually believe that i will do a better job of monitoring my health than anyone else will on my health. i don't care what the study is. personally, if i eat something and i don't feel good, i'm never touching it again.. .. these are smart kids going in.

all of these people are getting smarter. i'm not doing this to my brain. and so i just think we ought to do exactly all the things you're doing, but it is pretty simple to set up a program to let a person monitor themselves. their body will be different than everyone else's. your blood glucose level is different than mine. >> with you. and i always listen to the patient. i was listen to the parents as a pediatrician. i do want to say -- i agree with you. i think as a medical professional and as a researcher, we want to come up with a pathway forward for the patients to monitor their own. that means we need to come up with baselines, which we just don't have at this time for tbi in general. when we move toward blood bowel

markers, much more concrete evidence, i think we can come up with the tool you are talking about. >> thank you. >> so i want to thank you all for being here. absolutely. absolutely. >> thank you all for being here. >> so north carolina university is including east carolina university, ecu, and healthcare providers like interim health have prioritized research care and support for service members and veterans diagnosed with tbis . i was able to see that when i was in the state last week. i am -- appreciate this hearing. it can improve the care they offer. i look forward to supporting their ongoing efforts. dr. martinez, in the longitudinal study on blast

pressure exposure that you published in december, one of the key findings was a greater likelihood of tbi . can you explain what you mean by greater likelihood and quantify the increase -- increased likelihood of tbi? what percentage of people were exposed to what level of blast are likely to develop tbis? >> so that section 734 longitudinal study that you are referencing where we looked at monitoring and documenting blast exposure and offering a review of weapon systems, which we codified as 15 weapon systems that were most commonly used, and we went deep to figure out, what are all the safety regulations about those -- and under the safety rubric, as well, we look at what the health and performance effects are, from this blast pressure

stuff. in the report, wereviewed 40 studies. 26 of those studies were funded by department of defense. we looked at what type of effects happen when you do blast overpressure. and then where do you have concerns about traumatic brain injury? in most of the areas, we found correlations in the narrow cognitive thinking areas, also in some healthcare utilization areas. we looked at blood biomarkers and proteins to see if there was any correlations, and we believe that would bear fruit, but right now, there is no clear trend in that regard. so we are relying on the symptom reporting as being the most indicative of someone that would've had a traumatic brain injury. and again, early detection of that through evaluation of multiple domains like their balance, and their eye movements, and their thinking skills, and symptom reporting. >> thank you for that. >> dr. williams, what recommendations would you make

to improve the ability to treat military personnel that were repeatedly exposed to low-level blasts? >> thank you for the caution, senator. as we spoke earlier, terms of baselining early. when you know better, you better. one of the most impertinent things we can do is baseline, from the moment they come into the military -- before they start military training -- that allows us to follow them over time. i admit, we have to find the right baselining tool. we can do more. we can do better. our goal is to start early so we can continue to monitor. >> so school at ft. liberty. research suggests that special operation forces are exposed to more blast exposure. there at risk for repeated blast exposure and related

brain injury. does that track with your research? >> absolutely. speckled review? >> yes or. >> while we certainly need to conduct more research come we have to do a better job protecting our service members with what we know today that lines of, dr. williams, with what you are sharing. i'm concerned that the department is not moving quickly enough to address these tbi risks. there are proven devices that can limit tbis, like neck collars , currently being used by operators, just that you see in the nfl. there are still years of dod testing that need to take place before they can be fielded. why aren't we expensing the field of wearable devices to keep our fighters safe from tbi trauma and head protection, rather than waiting for testing to be completed within the department, and how can we expedite the use of those devices? >> i will start with a simple

area. -- answer. we have to do no harm. >> even if they are already fda approved devices. >> i totally understand. fda approval doesn't mean it is tested. there is research being done that is not inclusive of operators, especially high- level operators that we are caring for. our goal is to make sure we do no harm to the general population. >> thank you. secretary. >> we may have to look at the data. in our setting, we will adopt it. if it will make a difference, we will. but we will put it through internal processes. that is true for every intervention we do with our patients. >> thank you.

ms. lee >> those had been mainly studied for head impact in the sports community. going to blast pressure, it is worth a look. it is worth more than a look, to do more research to make sure that it is safe and effective in both of the military population and --. >> thank you. >> thank you, senator bud. i want to thank all of our witnesses for being here today. i want to thank you for the work you do every day. my takeaways from this are that the department of defense needs to do better. we need to identify those who are most at risk because of the work they do, and we need to collect better data. we need to do all of this on a

much faster timetable. congress also needs to do better. we need to make sure that you have the resources to do your work, and we also need to make sure that those who are treating tbi like homebase have the resources they need. it is shameful that there are active-duty military who have what appears to be tbi and they cannot be treated because the resources simply are not there. a waiting list at a place like homebase is our failure. we need those resources, and we need the capacity to be able to treat those who have suffered brain injuries because of their service to our nation. we owe that to our service members. again, thank you all for being here. i want to thank the senators who are here. i want to thank my partner, senator scott, on this. this will be an issue that we take up during the next round of nda negotiations. thank you.

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