    [Senate Hearing 118-681]
    [From the U.S. Government Publishing Office]

                                                        S. Hrg. 118-681

                           TRAUMATIC BRAIN INJURY AND
                              BLAST EXPOSURE CARE

    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SUBCOMMITTEE ON PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES
                              UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               FEBRUARY 28, 2024

                                   __________

             Printed for the use of the Committee on Armed Services

     [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                     Available via http: //www.govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    60-824 PDF                  WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                          JACK REED, Rhode Island, Chairman

     JEANNE SHAHEEN, New Hampshire		ROGER F. WICKER, Mississippi
     KIRSTEN E. GILLIBRAND, New York	DEB FISCHER, Nebraska
     RICHARD BLUMENTHAL, Connecticut	TOM COTTON, Arkansas
     MAZIE K. HIRONO, Hawaii		MIKE ROUNDS, South Dakota
     TIM KAINE, Virginia			JONI ERNST, Iowa
     ANGUS S. KING, Jr., Maine		DAN SULLIVAN, Alaska
     ELIZABETH WARREN, Massachusetts	KEVIN CRAMER, North Dakota
     GARY C. PETERS, Michigan		RICK SCOTT, Florida
     JOE MANCHIN III, West Virginia		TOMMY TUBERVILLE, Alabama
     TAMMY DUCKWORTH, Illinois		MARKWAYNE MULLIN, Oklahoma
     JACKY ROSEN, Nevada			TED BUDD, North Carolina
     MARK KELLY, Arizona                  	ERIC SCHMITT, Missouri

     		    Elizabeth L. King, Staff Director
       		John P. Keast, Minority Staff Director

    _________________________________________________________________

                           Subcommittee on Personnel

                      ELIZABETH WARREN, Massachusetts,
                                   Chairman

     RICHARD BLUMENTHAL, Connecticut	RICK SCOTT, Florida
     MAZIE K. HIRONO, Hawaii		MIKE ROUNDS, South Dakota
     TIM KAINE, Virginia			DAN SULLIVAN, Alaska
     TAMMY DUCKWORTH, Illinois            	TED BUDD, North Carolina

                                      (ii)

                             C O N T E N T S

    _________________________________________________________________

                               February 28, 2024

                                                                       Page

    Traumatic Brain Injury and Blast Exposure Care...................     1

                               Member Statements

    Statement of Senator Elizabeth Warren............................     1

    Statement of Senator Rick Scott..................................     3

                               Witness Statements

    McBirney, Samantha, Professor of Policy Analysis, Pardee Rand         5
      Graduate School.

    Zafonte, Ross D., Chief of Traumatic Brain Injury and Health &       14
      Wellness Programs, Home Base.

    Larkin, Frank J., Chief Operating Officer, Troops First              23
      Foundation, Lead of National Warrior Call Day Initiative.

    Martinez-Lopez, Hon. Lester, Assistant Secretary of Defense for      44
      Health Affairs, Department of Defense; Kathy M. Lee, Director,
      Warfighter Brain Health Policy, Department of Defense; and
      Captain Carlos D. Williams, USN, Director, National Intrepid
      Center of Excellence.

    Questions for the Record.........................................    62

                                     (iii)

                             TRAUMATIC BRAIN INJURY
                            AND BLAST EXPOSURE CARE

                                  ----------

                          WEDNESDAY FEBRUARY 28, 2024

                          United States Senate,
                             Subcommittee on Personnel,
                                   Committee on Armed Services,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 2:59 p.m., in
    room 222, Russell Senate Office Building, Senator Elizabeth
    Warren (Chairman of the Subcommittee) presiding.
        Subcommittee Members present: Senators Warren, Blumenthal,
    Hirono, Kaine, Ernst, Sullivan, Scott, and Budd.

             OPENING STATEMENT OF SENATOR ELIZABETH WARREN

        Senator Warren.
        [Technical problems.] This hearing will come to order. I am
    pleased to welcome you all to today's hearing to receive
    testimony on the Department of Defense's efforts to protect
    servicemembers from blast overpressure.
        Servicemembers put their lives and their health on the line
    when they are--[technical problems]. In return, we have a
    profound responsibility to make sure the Nation is doing all we
    can to keep them safe, to prevent battlefield and training
    casualties--oops, thank you.
        [Technical problems.]
        Senator Warren. That could be trouble. All right. Good. Did
    we get the other on the record? Just so, I got started here.
    Servicemembers put their lives and their health on the line
    when they put on their uniforms.
        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 and training casualties, and to provide the
    best possible care for those who are injured. We are holding
    this hearing----
        [Technical problems.]
        Senator Warren. We are there? Good. We are holding this
    hearing because DOD is not meeting its responsibilities when it
    comes to traumatic brain injuries (TBI) and other injuries that
    result from firing weapons.
        Injuries from blast overpressure, the pressure that is
    caused by a shock wave that exceeds normal atmospheric values,
    have been the signature wounds of the wars in Iraq and
    Afghanistan.
        But there are also injuries incurred in training here at
    home. They are invisible, but they affect thousands of
    servicemembers, causing headaches, seizures, hallucinations,
    and ultimately significantly increased risks of depression and
    suicide.
        Over the course of just 3 months in 2023, DOD provided TBI
    treatment to servicemembers 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 individual servicemembers, and
    to the well-being, the morale, and the readiness of our entire
    force.
        I appreciate the support I have had on this issue from
    Ranking Member Scott, from Senator Ernst, from Senator Tillis,
    and from other Members of this Committee. I secured a long term
    study of blast overpressure injuries in the 2018 National
    Defense Authorization Act, and I have worked with Senator Ernst
    to introduce legislation on blast overpressure and to secure
    additional requirements to track blast overpressure injuries in
    the Fiscal Year 2020 NDAA.
        DOD is working to implement this legislation, but we still
    have significant problems. Last year, The New York Times
    reported on heightened brain injury risks for United States
    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 significant blasts 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 servicemembers and
    to their families. The Times also revealed that even when DOD
    had made policy changes to address risks, those changes were
    not evident on the ground. Weapons known to deliver shock waves
    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 that
    are needed to track the threats they faced.
        So, DOD and Congress both have a lot to do. Here is my
    agenda to address this problem. First, we need to establish
    mitigation strategies specific to the servicemember 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 servicemembers and to
    integrate these logs into their VA and DOD health care records.
    Third, the Department of Defense should partner with
    innovative, evidence based programs like Home Base to help
    servicemembers get the care they need. And I am going to have
    to brag here for just a minute.
        Home Base is a nonprofit organization founded by
    Massachusetts General Hospital and the Boston Red Sox to take
    care of the invisible wounds of veterans, servicemembers,
    military families, and families of the fallen. Home Base has
    clinics in Massachusetts and in Florida, Ranking Member Scott's
    State.
        Home Base has a comprehensive brain health and trauma
    program specifically designed for special operations veterans
    and servicemembers, where it has been leading innovative
    treatments for veterans with 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. Zafonte from Home Base
    joining us today. One more item.
        We need to make sure that DOD sets a threshold on the
    maximum number of rounds that is safe--that servicemembers 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 do our part.
        So, to our witnesses, welcome and thank you for appearing.
    We are going to 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
    servicemembers from blast overpressure.
        Dr. Samantha McBirney Professor of Policy Analysis at the
    Pardee RAND Graduate School, Dr. Ross Zafonte, Chief of
    Traumatic Brain Injury and Health and Wellness Programs at Home
    Base, and Frank Larkin, Chief Operating Officer of Troops First
    Foundation and lead of the National Warrior Call Day
    Initiative.
        The second panel will consist of officials from the
    Department of Defense and Walter Reed to hear how DOD is
    tackling this issue. We will have Dr. Lester Martinez Lopez,
    Assistant Secretary of Defense for Health Affairs, Kathy Lee,
    Director of Warfighter 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 Member Scott for his comments to
    open this hearing.

                    STATEMENT OF SENATOR RICK SCOTT

        Senator Scott. First, I want to thank Senator Warren, the
    Chairwoman of this Committee and--our Subcommittee and thank
    her for caring about this issue and for taking this job so
    seriously. Chairwoman Warren, I want to thank you for holding
    this hearing on such an important topic.
        Traumatic brain injury, or TBI, is one of the most common
    injuries sustained by American servicemembers. In 2022, more
    than 20,000 military personnel were diagnosed with TBI. Stop
    and think about that for a second. Just in 2022, there are more
    than 20,000, 20,000 members of military that were diagnosed
    with a traumatic brain injury.
        That is pretty bad. The vast majority, over 84 percent,
    were classified as mild, which is more commonly known as a
    concussion. But if any of us have--when you have raised kids
    and they have a concussion, it scares the living daylights out
    of you.
        Missing from this data are servicemembers who are
    frequently exposed to low level blasts that do not typically
    result in a clinically diagnosable concussion. This is
    concerning because repeated exposure to low level blast may
    cause similar symptoms as more severe cases of TBI.
        We know that low level blast exposure from fire and heavy
    weapons systems or explosives may cause a variety of symptoms
    including concentration, memory problems, irritability,
    headaches, and decreased hand-eye coordination. Each of these
    issues alone can be very serious and disrupt somebodies life.
        Unfortunately, there remains a great deal about exposure to
    these blasts that we yet do not know. More research and better
    data are required so that military and health care providers
    can mitigate the frequency of blast exposure where possible and
    treat those exposed to blast where necessary.
        We have actually 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 Department's
    final report on this study. This hearing presents an
    opportunity to assess the quality of the Department's work. The
    legislation required 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 servicemember
    ``likely to be exposed to a blast in training or combat.''
    Second, the study was to assess the feasibility and
    advisability of including blast exposure history into a
    servicemember's medical record.
        Last, the Department was to review the safety precautions
    of heavy weapons training in light of emerging research on
    blast exposure. In reviewing the final report submitted this
    past December, it is clear the Department still has more work
    to do, particularly in its ability to monitor and record blast
    exposures for military personnel.
        Only a few hundred soldiers and marines were fitted with
    wearable devices that unfortunately seem to suffer from quality
    control issues. And while the Department's report does say that
    it may be feasible to record blast exposure information in a
    servicemember's medical record, a business case analysis is
    required to determine the way forward in this area. In this
    hearing, I would like to learn more about how the Department
    plans to conduct this business case analysis.
        This is an important issue. I believe the Department is
    committed to getting this right and I believe the TBI Center of
    Excellence and Warfighter Brain Health Initiatives are
    excellent initiatives that I hope will provide the military
    with the information needed to better understand the effects of
    repetitive blast exposure.
        We all must remember the exposure to low level blast will
    continue to be a necessary risk for many of our frontline
    combat troops. But if we can do better--if we can better
    quantify the type and number of blasts that have the potential
    to cause significant, 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 witnesses what Congress can
    do to ensure the Department of Defense has the resources it
    needs to conduct its planned work and where we can help. Only
    this is about the well-being of the individuals that are
    willing to put on the uniform, who are closest to the front
    line of combat, and every servicemember that is diagnosed with
    TBI.
        We owe it to them to ensure--and their families to ensure
    that when they go into harm's way, they are well-trained, have
    the right protective equipment, and are utilized in a manner
    that achieves the objective with an understanding of the risk
    involved.
        I want to thank you to all the witnesses for being here
    today. I look forward to your testimony. And again, I want to
    thank Senator Warren for putting this together.
        Senator Warren. Thank you.
        [Technical problems.]

     STATEMENT OF SAMANTHA MCBIRNEY, PROFESSOR OF POLICY ANALYSIS,
                      PARDEE RAND GRADUATE SCHOOL

        Dr. McBirney. 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 McBirney,
    and I am a Biomedical Engineer at the nonprofit, nonpartisan
    RAND Corporation.
        My research for the last 15 years, not only at RAND, but
    also at the University of California, Berkeley and the
    University of Southern California, has focused on traumatic
    brain injury, or TBI, both as the result of blunt impact and
    blast overpressure.
        Today, I would like to speak with you about repeated
    exposure to low level military occupational blasts, which are
    low level blast exposures experienced while fulfilling military
    occupational duties.
        Evidence suggests that servicemembers are exposed to these
    blasts in the form of blast overpressure, or the pressure wave
    that emanates from the source of an explosion. This pressure
    wave can cause sub-concussive injuries which are not
    immediately detectable and would not qualify as a TBI.
        Exposure to blast overpressure can occur both in combat and
    in training, as has already been mentioned. During training,
    exposure can be due to breaching exercises and the firing of
    increasingly powerful weapon systems, such as the Carl Gustaf
    recoilless rifle and the AT4.
        To provide some perspective on the level of exposure some
    servicemembers have, one study found that up to 32 percent 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.
    While a variety of effects have been linked to low level blast
    exposure, as Senator Warren and Senator Scott have already
    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 blast is
    identified as the cause. Additionally, injury is vastly
    underreported among servicemembers, 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 blast. While there is no doubt that certain occupational
    specialties are more frequently exposed than 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 blast has on the
    health of servicemembers in different occupational specialties.
    If the preventive intervention is perfectly effective but
    cannot be delivered in time, it is not useful.
        This quote from a 2019 RAND report perfectly describes the
    current State and the reason many of us are here today, ``as a
    research community, we clearly see that additional research
    needs to be done. However, there are steps the DOD can take now
    to better protect servicemembers 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 number of exposures, the context of each
    exposure, and any physical, mental, or emotional effects
    resulting from that exposure.
        This would allow the DOD to better track exposure
    frequency, assess the occurrence among high risk occupational
    specialties, determine the connection between exposure and
    health outcomes, and develop strategies to mitigate exposure in
    training environments.
        Ultimately, these records could be used to develop an index
    score to gauge an individual's combat readiness and potential
    health risks. As our weapon systems continue to become more
    advanced and increasingly powerful, low level military
    occupational blasts will remain an enduring challenge for
    servicemembers.
        Addressing the issue of repeated exposure to these blasts
    necessitates 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 our servicemembers.
        Thank you, and I look forward to your questions.
        [The prepared statement of Dr. McBirney follows:]
       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Warren. Thank you.

     STATEMENT OF ROSS D. ZAFONTE, CHIEF OF TRAUMATIC BRAIN INJURY
               AND HEALTH & WELLNESS PROGRAMS, HOME BASE

        [Technical problems.]
        Dr. Zafonte. Good afternoon, Chairwoman Warren, Ranking
    Member Scott, Members of the Subcommittee. My name is Dr. Ross
    Zafonte. 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 President of Spalding, Chair of the
    Physical Medicine Rehabilitation Department at Harvard Medical
    School, Chief of the Department of Physical Medicine
    Rehabilitation at Mass General Hospital and Brigham and Women's
    Hospital, and for the past 15 years, I have served at the Home
    Base Program, directing its Brain Injury Program. I actually
    see the patients, as well as do the research.
        Blast overpressure, as we just heard, is a sudden onset of
    a pressure wave from explosions occurring with shoulder carried
    artillery in training or deployment, in breaching buildings,
    and from improvised explosive devices. Generally, the bigger
    the explosion, the more damaging the pressure width.
        TBI can have a wide range of physical and physiologic
    effects. Some signs appear immediately, others take days or
    weeks to occur, and they may result in physical, sensory,
    cognitive, behavioral, or mental impacts.
        According to the Department of Defense, since 2000, over
    400,000 U.S. servicemembers experienced at least one brain
    injury and 40 percent of those later screened positive for co-
    morbid 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 Base is located in Charlestown, Massachusetts, with, I
    am proud to say, as 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 innovative
    clinical care models and research, and the program is nested
    within Mass General Hospital, allowing us to leverage the
    faculty in Mass General Brigham Health System. Home Base
    bridges the gap between research and clinical care.
        Now, in 2018, Home Base was approached by the Navy Special
    Warfare with a complex set of problems facing Navy SEALs. We
    quickly developed a comprehensive brain injury and polytrauma
    program. This program is named COMBAT, or the Comprehensive
    Brain Health and Treatment Program.
        It is modeled after existing programs that we developed for
    elite athletes and provides integrated, multi-disciplinary,
    specialist treatments, evaluation and care coordination for
    veteran and Active Duty operators. Home Base has treated nearly
    1,000 special operators through our intensive programs, 71.9
    percent of combat participants are Active Duty and the
    overwhelming majority return to duty, so we are keeping the
    fighting force active. We currently have 178 Active Duty
    special operators waiting to be screened and scheduled for
    COMBAT Program, and COMBAT has cared for operators in 47
    States, the District of Columbia, Guam, Puerto Rico, including
    53 patients from Massachusetts, 60 from Florida, 6 from
    Connecticut, 22 from Hawaii, 278 from Virginia, 4 from
    Illinois, 1 from Alaska, and 54 from North Carolina.
        The COMBAT program is highly efficient, agile, and
    compressed into a 5-day model of care. Patients see a minimum
    of nine providers, and this may expand grossly related to
    pertinent diagnostic imaging or other studies.
        So, in summary, we are very grateful for the support of
    Congress, especially Chairwoman Warren, has shown this program,
    and for the partnership and financial support provided by
    SOCOM.
        The program is successful and the demand for care is
    growing at a steady pace. Based on my experience in this field
    and treating patients at Home Base, I would recommend the
    Department of Defense consider the following options. Invest in
    and develop tools to measure----
        [Technical problems.]
        Dr. Zafonte. Increase funding for partnerships with
    academic medical centers. Ensure all servicemembers with
    traumatic brain injury can easily access care. And as has been
    said, that data needs to be linked to blast exposure.
        Develop novel methods to define and understand the impacts
    of declining health spans and develop treatment interventions.
    I also recommend that DOD partner with Home Base to develop a
    long term, longitudinal health span study on the multi-system
    injury of blast and traumatic brain injury.
        And invest in research that evaluates and treats the long
    term sequalae of repeated brain injuries of 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 am happy to answer questions the Committee may
    have.
        [The prepared statement of Dr. Ross D. Zafonte follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Warren. Thank you, Dr. Zafonte. Mr. Larkin, would
    you like to make an opening statement?

     STATEMENT OF FRANK J. LARKIN, CHIEF OPERATING OFFICER, TROOPS
     FIRST FOUNDATION, LEAD OF NATIONAL WARRIOR CALL DAY INITIATIVE

        Mr. Larkin. Thank you to the Committee for the opportunity
    to speak. My formal testimony is submitted for the record.
        As a former Navy SEAL, I am here today to be a voice for
    all those that have worn our Nation's uniform and are currently
    struggling everyday with both visible and invisible wounds.
    Wounds that transcend mental, physical, and spiritual domains.
    Wounds that transcend--I am sorry, wounds that have influenced
    an epidemic level of suicides amongst our Active Duty force and
    veteran populations.
        My intent today is not to pounce on the Department of
    Defense or the Veterans Administration, but to help them
    succeed. I would not be here if it was not for my son Ryan,
    U.S. Navy SEAL Special Operator 1st Class Ryan F. Larkin. My
    son would be 36 years old today if he had not taken his life on
    the morning of April 23d, 2017.
        He had been suffering from what we have come to
    characterize as invisible wounds, a complex rubric of post-
    traumatic stress disorder, moral injury, and substance use
    disorder that was complicated by undiagnosed traumatic brain
    injury from blast exposure, the signature injury of the past 20
    plus years fighting the global War on Terror.
        Ryan was a highly decorated and accomplished Navy SEAL,
    trained as a special operations medic, sniper, and explosives
    breacher. He loved being a SEAL, furthered by the love and
    loyalty for his teammates that was cemented on the battlefield.
        Following four heavy combat tours in Iraq and Afghanistan,
    Ryan, like many others who have worn the uniform of our Nation
    in combat, began experiencing uncharacteristic changes that
    manifested in difficulty sleeping, nightmares, anxiety,
    hypervigilance, loss of memory and declining cognitive
    functions. He stopped smiling. He sought help, but the help
    that was offered was not aligned with what he needed.
        When his condition became more complicated, and their
    proposed solutions didn't work, the system weaponized his pleas
    for help against him and pushed him out of the SEAL team and
    out of the Navy.
        This abrupt separation created another deep weeping wound.
    He felt that he had let his teammates down, abandoning them.
    The system he trusted hung labels on him to justify their
    assessments and their actions. A year after he honorably
    separated from the Navy, Ryan ended his life. Ryan repeatedly
    said, something is wrong with my head, nobody is listening,
    they keep telling me I'm crazy.
        This was reinforced by the endless stream of medications
    prescribed by both defense health and VA clinicians to address
    his behavioral symptoms, not the root cause of his challenges.
    Everything defaulted to psychiatric and mental health illness,
    with very little mention of TBI, despite his operational
    profile and repeated exposures to blast overpressures from our
    weapons systems and enemy IEDs.
        Over the course of 2 years between defense health and the
    VA, he was prescribed over 40 different medications, everything
    from potions, lotions, and creams to high end psychotropic and
    mood stabilizing drugs. He never received a clinical diagnosis.
    He was a walking experiment.
        One night prior to his death, he said that he wasn't going
    to live very long, that he was broken up inside. He made me
    promise that if anything ever happened to him, that he wanted
    his body donated for TBI-Breacher's Syndrome research. Then he
    turned to me and said, you know dad, it is going to take guys
    killing themselves before the system wakes up to the fact that
    it has a problem.
        The guys are hurt. Ryan's brain was donated to a DOD
    research effort at Walter Reed National Military Medical
    Center. Two months later, we learned that Ryan had a severe
    case of undiagnosed microscopic brain injury uniquely related
    to repeated blast exposure. Ryan was hurt, not crazy.
        He was right all along. Unfortunately, our medical
    enterprises could not and still cannot see this level of
    microscopic injury in a living warfighter or veteran. My son
    died from his injuries suffered both in training for combat and
    combat operations.
        He just didn't die right away. These warriors with
    invisible wounds, they are hurt. They are not broken. They
    break when they are cut away from their teammates, their
    tribes, and are betrayed by the institutions where they have
    given their all. It has been 23 years since 9/11. DOD has spent
    almost $3 billion in mental--on mental health, substance abuse,
    suicide prevention, PTSD, TBI, and other warfighter assistance
    programs.
        I give them a D plus, C minus at best, for the lack of
    measurable impact for those who need answers. Those are the
    deck plate, dirt level warfighters we promised to take care of
    and not leave behind.
        Blast exposure is a key threat to warrior brain health and
    potentially represents a significant national security threat
    to our force, readiness, and resiliency. However, whatever
    solutions we come up with, it can't impact our operational
    effectiveness or lethality on the battlefield.
        We need to do this smarter and by down the risk on the
    front end. Thank you for the opportunity to be the voice for
    others like Ryan. Subject to your questions.
        [The prepared statement of Mr. Frank J. Larkin follows:]

                   Prepared Statement by Mr. Frank J. Larkin
                           introduction & background
         . . . We know that losing someone with traumatic brain injury
    (TBI) to suicide isn't the worst part. There are 500,000 other Ryan's
    currently out there with TBI trying to stay alive, despite being four
    times as likely to attempt suicide. Military TBI and suicide scientist
    Dr. Jayna Moceri-Brooks' husband, a career Armor officer with TBI, is
    just one of them. We know the worst parts are when you get the call
    about another. And another. And another.
        We know no one is immune, not even colleagues like Dr. Kate
    Rocklein, whose husband Michael Froede was Special Operations (SOF),
    had TBI, and died shortly after Ryan as she was conducting research on
    factors inducing suicide in SOF. Always canaries in the coal mine, we
    know Special Operations' projected incidence of TBI exceeds 52 percent,
    three times that of other combatant commands, with corresponding
    suicides in these elite units outpacing the larger military at
    estimated rates of 2.5 to 1.
        Ryan, Michael, nearly half of Michael's chalk from the Special
    Forces Q course, and countless others have died from TBI while
    inspectors general found last year the entire US Central Command failed
    to assess and treat brain injuries in its combat troops. Or DOD
    assigning no oversight authority for TBI initiatives force wide. Or DOD
    spending three billion taxpayer dollars on quote-unquote the best
    neurological care possible, like $3.7 million reading Greek classics to
    soldiers, or $2.7 million producing a Sesame Street vignette about
    death.
        Or DOD spending $76 million annually for Preservation of the Force
    and Family, an unsuccessful non-clinical fitness program posing as
    brain and mental healthcare for Special Operators still
    disproportionately dying from TBI-related suicide. Unfortunately, that
    human performance program is the foundation of the Warfighter Brain
    Health Initiative.
        Without this Committee exercising the considerable power endowed by
    its mandate to ensure our common defense, holding leadership
    accountable for treating TBI and preventing related suicides will
    remain aspirational, to the horror of families imagining more survivors
    bearing the costs of these wars, and to a generation of potential
    recruits again witnessing our military abandon the very troops it has
    unsuccessfully enticed them to become.
        We are elevating these threats to servicemembers (SM) lives to
    congressional levels based on alarms raised by impartial clinicians and
    scientists analyzing 20+ years of DOD's TBI initiatives. We are
    elevating these threats because DOD's reports to Congress now globally
    exclude mention of TBI and, on their face, are overtly disingenuous and
    have over-capitalized Congress' patience and goodwill.
        We know DOD hyperfocus on capturing blast overpressure data is a
    ruse because DOD has had exposure thresholds for a decade. Warfighter
    Brain is a 5-year-long exercise in regurgitative rebranding of
    previously ignored recommendations made by myself and others years ago.
    We know experts predict Warfighter Brain is more likely to induce TBI-
    related suicides than prevent them.
        We know the Longitudinal Blast Overpressure Study was neither
    longitudinal nor an actual research study. Despite unfettered access to
    DOD-created and approved sensors, investigators used untested, faulty
    sensors while exposing SMs to dangerous ex-urban blast overpressures
    without informed consent or right to refuse. Were it legitimate
    research, it never would have passed review by a qualified ethics
    board. And if it had produced any tangible results, those data would be
    dismissed as biased, problematic, and unacceptable.
        We know that pillars of Warfighter Brain have no basis in medical
    evidence, nor can such human performance programs treat brain trauma in
    any way advised by clinical medicine. We've known since 2006 that
    athletic training cannot improve TBI cellular pathologies. We know
    DOD's current plan is to treat TBI primarily by accelerating SMs'
    cognitive processing speeds--an infinitesimally small aspect of TBI--
    but not by providing cutting-edge TBI assessment and treatment
    available to civilian citizens.
        In the words of one Operator with TBI, ``HPO just means we're in
    the best shape of our lives when we kill ourselves.''
        We know DOD has weaponized science to avoid acting decisively on
    TBI: they will again try to convince you that nothing can be done
    without snipe hunting for more data. We know TBI from blasts with
    pressures as low as 30psi--about the force of a bicycle tire exploding-
    scrambles DNA signaling, causing hosts of chronic clinical syndromes
    and neurological disorders, from Parkinson's to mood disorders to
    suicide. Yet in November 2022, ASD guidance was that overpressures of
    4psi were plenty dangerous enough. Again: we know that DOD knows the
    overpressures and thresholds.
        We know that SOF's superior fitness and resilience does not repair
    anatomical damage from blast exposures and treating TBI with human
    performance optimization is like prescribing CrossFit for Alzheimer's.
    We know the past 10 years of DOD pushing athletic wellness programs for
    neurological injuries has done much to gaslight SMs with TBI into
    believing they could heal if they weren't so weak, further incenting
    their suicides.
        We know DOD is publicly moving toward force wide assessment of
    cognitive processing deficits from TBI to remove injured SMs and their
    families from career military service with immediacy--``med-boarding''
    them is far more economically appealing than expenditures toward
    healing and retaining our Nations' most experienced and sophisticated
    SMs during a time when we can recruit neither into our armed forces.
        We know from Dr. Moceri-Brooks' pioneering work that receiving the
    Purple Heart for brain injuries would reduce suicides, one of precious
    few tangible solutions available to us. We also know that without
    consent of Congress, DOD adjusted criteria for the Purple Heart and
    TBI. Awards branches now misapply regulations in denying multitudes of
    eligible SMs Purple Hearts for combat related TBI: officially denying
    this injury's existence and further incenting their suicides.
        We know from Dr. Rocklein's influential work that Special Operators
    have been stripped of tabs and tridents and separated from their teams
    en masse for exhibiting uncontrollable symptoms of TBI and suicidal
    behaviors. We know such institutional betrayals precede suicide in
    Special Operations more often than not. And tomorrow these unsanctioned
    practices can be easily reversed--with the stroke of a pen--at no cost
    to taxpayers.
        We know Warfighter Brain is another slick, opaque strategy full of
    battlefield buzzwords without clear paths to success. Since we also
    know DOD is only selling tickets to another circus, my second
    recommendation is to transfer TBI care to vetted, agile private
    industry and academic health sciences partnerships equipped to
    immediately assess and initiate approved emerging treatments with basis
    in evidence and efficacy.
        Last, and especially poignant given my presence here because of
    Ryan's death, and Dr. Rocklein's discoveries because of Michael's
    death: we know comprehensive reforms are the only viable path forward.
    Therefore, I recommend immediately implementing the Froede-Larkin
    Reform Act, also submitted prior to testifying, into this year's NDAA.
    It is evidence-based and signals sincere course correction to
    disenfranchised SMs with TBI, and their families suffering with them,
    reverses nearly 20 years of TBI mismanagement and confusion, and
    ensures upcoming generations of SMs never again experience such
    cruelties of bureaucratic inertia toward their health, welfare, and
    survivability.
        Acknowledgments: Testimony prepared collaboratively with Dr. Kate
    Rocklein and Dr. Jayna Moceri-Brooks.
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        Senator Warren. Thank you, Mr. Larkin. I appreciate your
    being here and sharing this story. I am sorry for your loss,
    and I am sorry for the treatment your son Ryan received. I
    think you said it right, traumatic brain injuries are
    considered ``the signature wound'' of our wars in Iraq and
    Afghanistan.
        While improvised explosive devices, IEDs, 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 the long term
    exposure to explosive weapons.''
        In 2011, the Defense Advanced Research Projects Agency
    determined that 75 percent of the troops' blast exposure in
    Afghanistan was coming from their own weapons. The effects of
    blast overpressure are terrible, including memory loss,
    increased risk of dementia, and substance abuse problems.
        But despite the severity of these impacts on
    servicemembers' health, when these problems are diagnosed,
    blast exposure is rarely identified as a potential cause. Dr.
    McBirney, 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 in our
    servicemembers?
        Dr. McBirney. That is a great question, Senator Warren, and
    a question that so many people within the research community
    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 very low level blasts that perhaps might happen throughout
    the course of an entire military career really 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.
        Senator Warren. So, yes, I just want to say, I want to pick
    up on this, because I think this is a really important point
    about the challenge in trying to diagnose because of the very
    nature of what the injury looks like. It is not a single moment
    in time where this happens. And so, I just want to pick up and
    let's see if we can take this forward.
        We need to know how often, I take it from your testimony--
    we need to know how often a servicemember has been exposed to
    blast overpressure, to give medical personnel the information
    that they need to identify and treat the underlying cause of
    their symptoms. Now, so far, the DOD only has blast exposure
    data for a total of 500 servicemembers.
        We are missing data, obviously, for a whole lot more.
    Tracking this information through blast exposure and traumatic
    brain injury logs for all servicemembers would be a good start,
    but we also need to pay special attention to servicemembers
    that are at especially high risk for blast exposure.
        Some military occupational specialties, MOSs, such as
    training instructors, are significantly more likely to be
    exposed to blast 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.''
        So, Dr. McBirney, I wanted to give you another chance in
    this is 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?
        Dr. McBirney. I can't say I am aware of any of those
    strategies. And 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
    exposure are additionally unaware of such strategies.
        Senator Warren. Okay. So, anything more do 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.
        Dr. McBirney. No. Thank you, Senator. I think really Mr.
    Larkin and I were discussing prior to this. I think if my--if I
    could choose the key takeaway 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 am always a supporter of
    more research. That being said, we can also be looking to
    implement solutions, study said solutions, while they are being
    implemented at the same time.
        Senator Warren. So, let's focus on that for just a second,
    just a little bit more, about the idea of collecting the data
    as we go along, so at least it is a first step in getting the
    information that we need.
        I understand this is a gap that DOD needs to fill, and I
    understand that it is more challenging to limit servicemember
    blast exposure during combat, but there is no excuse for DOD to
    continue to expose servicemembers to unnecessary levels of
    blast overpressure during training. This is obviously an area
    where we could make change, and it is clear that there is a lot
    we need to do to protect our servicemembers from blast
    exposure.
        But DOD, it goes to your point Dr. McBirney, DOD constantly
    says we need more research, we need more research. And I am a
    data nerd. I always want more research, but I am very concerned
    about the idea that we are going to put off treatment.
        So, let me put the question more specifically to you, and
    that is, do you think we know enough now about the risks of
    blast overpressure to servicemembers' health to start taking
    action now?
        Dr. McBirney. In short, absolutely. Yes.
        Senator Warren. All right. So, we do know enough. So, there
    are number of steps DOD could take to help us get more data so
    that we can understand this over time, but more importantly, a
    number of steps they could take right now in terms of
    treatment.
        I have talked long enough so I will come back to you later
    on this, Dr. Zafonte and Mr. Larkin. Senator Scott.
        Senator Scott. Yes. Well, first, Mr. Larkin, I can't
    imagine--having kids and grandkids, I can't imagine lose one.
    So, thank you for your service, your son service and just hope
    as a result, you know, something good happens out of it.
    Somebody--it prevents something else from happening.
        Dr. Zafonte, can you explain what the--the blast, what does
    it do to the brain like this? Like let's say, you know, I go
    shoot a shotgun or doing this stuff, what does it do--each one
    of them, how does it impact my brain?
        Dr. Zafonte. Well, I think, to my colleagues' good point,
    perfection is the enemy of the good. You can criticize all of
    the models, but we know that these sub-concussive injuries do a
    number of different things.
        They probably disproportionately impact areas of the brain
    at gray matter, white matter interfaces. They probably have a
    vascular effect. More likely long term, there is possibly a
    premature aging effect to the brain itself with multiple
    repetitive blast exposures or certainly with traumatic brain
    injury.
        So, lifelong exposure, getting that quantification that
    Senator Warren talked about is critically important because we
    need to know one thing. We need to know in who, how much, what
    were they doing, and then what was the actual phenotype or what
    actually happened to the symptoms of the person, and track that
    very carefully.
        Senator Scott. 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 to take--
    because we know, if you joined the service, we know what blast
    you are going to have in boot camp if you are enlisting--you
    know, enlisted. Is there anybody that is doing anything to just
    say that when you just put all this data on something and then
    just look at the model over a period of time?
        Dr. Zafonte. I think there are a number of groups,
    including our own, looking at blood based biomarkers for
    people, neuroimaging. 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. Because
    there is not a 1 to 1 relationship. There's a relative
    relationship.
        Senator Scott. If every servicemember, if you had the data
    of--you know, just start today. Just anybody new that joins
    boot camp and starts going through infantry training. If you
    just have the data and you had that in front of you, then over
    time you could do predictive analysis of, you know, where the
    problems are, right?
        Dr. Zafonte. Right, and I think that--but to the point that
    was just raised, I think there are action steps now and that we
    have--we are compelled very much so to make this a living
    learning environment and continue to collect data and perhaps
    change policy, change programs, change how we treat people as
    we understand more over time.
        Senator Scott. So, you don't have enough information today
    exactly what happens as all these blasts happen. What you have
    is, you know, you see the result. You see over a period of time
    that this is what happens. That is what you have so far, right?
        Dr. Zafonte. 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 your imaging, changes
    in blood based biomarkers, representative of injury of the
    brain. But how it is going to behave in a large population of
    people is one thing. How it is going to behave in Bobby or Sue
    is a very different thing.
        Senator Scott. Right. Okay, and how--so, Dr. McBirney, how
    hard it would be to just put up a program? It wouldn't be that
    hard, would it?
        Dr. McBirney. That is a great question. Unfortunately, one
    that I find myself unqualified to answer.
        Senator Scott. But we do it in a whole bunch of other
    stuff. We do it like with glucose monitors, right. And if you
    gave servicemembers just--you know, just say, here--they all
    have cell phones, right? You just had an app that said, okay,
    so every time you have exposure okay, you put this in. You put
    in exactly what you did and what you shot.
        Some people are not going to do it well, just like no one
    follows their health--you know, they didn't take their
    medicine. But that wouldn't be that hard to do, right? I mean,
    we have all this stuff from sugar levels.
        Why don't we do--I mean, why don't we--why wouldn't that be
    the simplest thing to start doing and then you could start
    seeing that, like--if you could--if you had all that data, you
    could pretty quickly do a predictive analysis of even short
    term problems. Not, you know, it take a long time to say what
    is my 20 year problem, right.
        Dr. Zafonte. Yes, I think following people over decade will
    be valuable. I think we will see certain markers and certain
    things change early on, but we have to remember that it is not
    an uncomplicated story.
        Even the blood based biomarkers or other entities such as
    imaging have a lot of variation within. You know, the brain, I
    think my colleagues would support me, is an incredible
    structure, but it is also a bit of a black box still within
    science, and understanding how different networks
    relationships, how these nodes connect, and an injury in one
    space affects an injury another, that is a challenge.
        Senator Scott. But you would actually know the result. I
    mean, you even though you don't know exactly why, you could
    over time predict what is going to happen.
        Dr. Zafonte. If you are looking for symptomatic, senator,
    prediction I think with a large enough data set, you certainly
    could draw some strong relationships.
        Senator Scott. Right, and then very quickly come back and
    say, okay, we know this. We know that if you have this much,
    you know--the, you know, the odds are like you can go get a
    blood test for cancer now and it is very predictive of whether
    you are going to end up with cancer. Is it perfect? No. I mean
    it depends on the cancer. So, it seems like this would be
    pretty easy to do and it shouldn't be that hard.
        Dr. Zafonte. So, Senator, I would agree with you, but I
    would bring up the issue that we are all individual and
    different people, and these types 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 then the
    treatment you had afterwards. That produces this result, and
    the fact that it is not so easy to put in a box.
        Senator Scott. Right. Okay. Senator Hirono.
        [Technical problems.]
        Senator Hirono. I call myself for 5 minutes--[technical
    problems]. There are a lot of our servicemembers who were
    exposed to IEDs during the tenure in Afghanistan and Iraq. So,
    are you tracking these servicemembers? Most of them probably
    are in veteran status. Are you tracking them for exposure to
    blasts and what is happening to them? Anybody?
        Mr. Larkin. So, I used to be a senior leader within the
    Department of Defense running the Joint IED Field Organization,
    JIEDO. I can tell you that it was a concern as far back as
    2008, 2009, that these blast exposures were creating a unique
    health risk to our warriors.
        We had gotten to the point where we had up armored and
    created new armored vehicles that were surviving the blast, but
    what got in that vehicle and what came out of that vehicle were
    two different states, and it alerted us to the fact that there
    were things--that blast effect was having an effect on the
    human body that needed to be studied and researched.
        So, as far as you know, having a handle on--unless there
    was a catastrophic injury and usually one that was visible, at
    the time, if they--a lot of these folks came out of these
    vehicles, and they looked fairly normal.
        Senator Hirono. Yes.
        Mr. Larkin. 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 collect on that data and do anything with it.
        Senator Hirono. I think that is an important kind of
    followup as we try to understand what the impact of these
    blasts are long term. Also, I would think that--I mean, it is
    bad enough that there is traumatic brain injury that needs to
    be followed up on, but I would think that a lot of them may
    develop conditions such as ringing in the ears. Yes, so, Dr.
    Zafonte.
        Mr. Larkin. Thank you very much, Senator, for the excellent
    point. I think we have long term sequelae for people such as
    tinnitus or ringing in the ear, chronic headaches.
        Senator Hirono. Yes.
        Dr. Zafonte. Pain is a big driver that drives not only a
    headache or one's immediate perception, but it also invades
    behavior. People who are in pain don't behave the same way, and
    they don't cognitively perform the same way.
        So, what I am saying is that blast has a multi-system
    effect. Of course, the brain is our principal and driving
    concern, but it has effects in things that are linked to the
    brain, linked to the behavior that we need to know more about.
        Senator Hirono. Well, for example, tinnitus--that doesn't
    cause pain, but it is severely annoying. It can be
    debilitating. I don't know whether you are--it sounds as though
    you are also tracking the incidence of these kinds of issues,
    and it is something I am very familiar with, and there seems to
    be no cure for these conditions.
        I am very interested to know what kind of breakthroughs
    there are in treatment--I know that tinnitus is the disease,
    and tinnitus is a ringing that's not related to any problem
    with the ears. So, is that something that you all are also
    studying, tracking?
        Mr. Larkin. Senator, all I can tell you is that I have it
    from the use of explosives and weapons.
        Senator Hirono. You have it?
        Mr. Larkin. It doesn't go away.
        Senator Hirono. I know.
        Mr. Larkin. It is just--I have to live with it.
        Senator Hirono. Me too. It is very annoying. Sometimes it
    is so loud that it interferes with sleeping. So that is--I
    think that there are a lot more of our servicemembers who have
    endured or are enduring those conditions that we have to pay
    attention to. One more question.
        A 2023 RAND report noted that there is a critical gap in
    effective PPE in that most models represent the average human
    male. So is that--and this is for Dr. McBirney. It is certainly
    important that we protect--provide protective equipment to all
    of our servicemembers.
        So how can we make sure that this kind of protective
    equipment is also--is appropriate for women. Is that happening?
        Dr. McBirney. That is a great question, a very important
    topic, and it is happening. So those findings were from the
    last State of the science meeting that 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, and specifically in many instances the average
    Caucasian male, is not the only subject that is being used to
    test equipment.
        Senator Hirono. Yes. That is very important. Thank you.
    Thank you, Madam Chair.
        Senator Warren. Thank you. Senator Ernst.
        Senator Ernst. Thank you very much, and 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 about the impact on our
    servicemembers and their families.
        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 established safety
    guidelines, the act of firing heavy weapons, just as you
    stated, Mr. Larkin, can create those long term effects.
        Other types of training sessions in preparation for combat
    deployments, many of these things can potentially lead to
    cognitive impairments affecting our function. Mr. Larkin, I
    understand that you shared the story about your son, Ryan.
        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 son's 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 puts on the uniform of our Nation. So,
    thank you for that. Mr. Larkin, did you share with the
    Subcommittee then how it was discovered that your son Ryan had
    traumatic brain injury?
        Mr. Larkin. Thank you for the question, Senator, and 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 brain injury breacher syndrome research.
        That subsequently 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 of brain
    injury that was uniquely aligned with blast exposure. They only
    see this pattern of injury with blast exposure.
        If we had not gotten that finding, the narrative that the
    Navy had built around Ryan and his struggle, and his subsequent
    passing would have continued on--would continue to have damaged
    his reputation. But this finding was indisputable that he was
    injured. He was not, in his terms, crazy.
        Senator Ernst. Exactly, Mr. Larkin, and I just want
    everyone to understand that so many of these injuries go
    undetected through CAT scans, through MRI's, PET scans.
        As a followup to that then, and I am 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 that right?
        I want to make sure I get it correct, Dr. Zafonte, is the
    automated neuropsychological assessment metrics, the ANAM test
    that is used by the DOD, an accurate method of detecting those
    changes in cognition that can lead to a TBI diagnosis?
        Dr. Zafonte. Senator, thank you for the excellent question.
    I think we are searching for a gold standard. A number of these
    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 tool, it is far from perfect.
        Senator Ernst. Yes, and that is why 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 a TBI or blast 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. Any thoughts--yes, Dr. Zafonte.
        Dr. Zafonte. 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.
        I think if we act and think our responsibilities to make
    this a dynamic, learning, positive environment for our
    servicemembers, we can do things now while evaluating data and
    really making positive change in the future.
        I think we are going to learn that there is a lot more of
    that microscopic injury than we had ever believed, and then in
    certain people, that is going to have some significant sequelae
    over time.
        Senator Ernst. Thank you, Dr. Zafonte, and 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's an old one, so forgive me, but if
    the human brain were so simple, we could understand it, we
    would be so simple we couldn't.
        Just let that sink in, because 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 percent
    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 percent
    of cases, but if it is to occur, we need to find ways to treat
    it and mitigate the impact to our families.
        So, thank you again, Chairwoman. I really appreciate the
    opportunity to be here today.
        Senator Warren. So, I just want to say a very special thank
    you to you. Senator Ernst, Senator Ernst is not on this
    Subcommittee.
        Like many in the Senate, 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
    law, both for 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. Thank you, Senator Kaine.
        Senator Kaine. Thank you, Chair Warren, and to the
    Subcommittee for having this hearing. It is really important,
    and I am just going to ask the same question of both panels.
    So, I just have one question and I would love to get your take,
    and I will ask the same question to the second panel.
        We are not the only country that employs weapons that can
    have these effects on servicemembers' brain health. So, 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?
        Mr. Larkin. Senator, again, in my role as a senior leader
    of the Joint IED Defeat Organization at DOD, back during the
    height of Iraq and Afghanistan, this was not a United States
    only problem.
        You know, we were very much in the trenches with our NATO
    allies, Five Eyes partners, who 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 really we need unsolicited--we need a gyro
    like task force to bring together the Government, industry,
    academia, and our foreign partners for a unity of effort to
    match the data, the intellectual capability, and our technology
    to solve this.
        We can solve it. It is 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 got
    to get everybody on--in the same----
        Senator Kaine. Even within our own family. I know this
    panel too has DOD, but not VA. I mean, I am I know in the
    Richmond, VA, this is a very high priority. So, sharing within
    our family certainly, but with our allies who have the same
    experience is really important. Dr. McBirney or Dr. Zafonte, do
    you want to add to that at all?
        Dr. McBirney. Sure. No, thank you for the question,
    Senator, and it is an excellent one. One consideration that I
    know some of our allies are considering at this time, and it
    was published in a report in 2018 by the Center for a 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
    some time. In my written testimony, there is a direct quotation
    from that CNS report in 2018 that details exactly what
    information to revisit in these weapon systems manuals, and
    perhaps consider updating to really get at mitigating exposure
    that our servicemembers experience in training in particular.
        Senator Kaine. Dr. Zafonte.
        Dr. Zafonte. Senator, thank you for the great question, and
    I agree with the comments of my esteemed colleagues. I would
    add just 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.
        I would advocate for common data elements, common data sets
    that go 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 then what do they experience
    years later. Those kinds of things would be incredibly
    important and doable in many other health systems.
        Senator Kaine. Thank you very much. I yield back.
        Senator Warren. Thank you. Very important. Senator
    Sullivan.
        Senator Sullivan. Thank you, Madam Chair, and thank you and
    Senator Scott for holding this hearing. I think it is a really
    important one, and I want to thank the witnesses for their
    attention to these really important issues for our military.
        So, I got here a little bit late, so if this has already
    been discussed, bear with me, but I want to dig into this New
    York Times article from November 2023 entitled, A Secret
    Strange--Secret War, Strange New Wounds, and Silence from the
    Pentagon. This was about the marines in Syria deployed in Syria
    in 2016 and 2017.
        They returned and really struggled with PTSD issues and
    health issues, and it wasn't from direct combat. I mean, they
    were in combat, but it was primarily from there, it appears,
    really significant amount of firing howitzer rounds.
        Kind of to Senator Kaine's point, we have had military
    members in different wars, Vietnam, Korea, WWII, of course,
    fire thousands and thousands of howitzer rounds. But so, we
    have seen this before, but these marines seem to really have
    struggled. Have you--either of you read this report or this
    story? Okay.
        Senators Warren, and Ernst, and Tillis on January 18th,
    letter to Secretary Austin asked him a lot of specific
    questions relating to this and other issues that relate to TBI.
    But this is a kind of a different TBI.
        So, sometimes I worry, you know, I just retired from the
    Marine Corps myself, and I love the Marine Corps. But, you
    know, like all big organizations, they can be bureaucratic, and
    I am not sure these marines are treated very well. I am
    wondering, from your experience, maybe we will start with you,
    Dr. Zafonte, what is your assessment of that report? Was well
    done reporting, in my view, from the New York Times.
        What do you think the next steps should be? Obviously, we
    will ask the Government witnesses in the next panel on this
    topic but would just like to get your assessment from this
    particular episode. A lot of my constituents in Alaska wrote--
    read this article and were quite disturbed by it.
        We don't even have a big Marine Corps presence in my State,
    but big Army and Air Force presence. So, can--I would like all
    of you to just comment on what your thoughts were and then what
    we can do--you know, if the marines haven't seen this, you can
    see how they could overlook it, but we--I think this needs a
    much deeper dive than the military has given it.
        To the Chairman's credit and some other senators are
    already pressing Secretary Austin on it. So, what are your
    thoughts on it?
        Dr. Zafonte. Senator, thank you for the excellent point and
    question. From my perspective, 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, near term
    and long term, that are being seen clinically in this
    population of people. Now, these are extreme individuals, many
    of them. They are the 1 percent of the 1 percent. They are the
    fittest, the swiftest, and yet they are seeing clinically
    apparent problems. There are also, in many ways, 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, and it may be related to a global elements
    of the life in that kind of stress for a significant period of
    time.
        So, I think we need to learn a lot 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.
        Senator Sullivan. Great. Doctor McBirney, do you have a
    view on this?
        Dr. McBirney. Absolutely. No, and thank you for raising
    this. I thought that New York Times article was very well
    written and well investigated and reported. I think----
        Senator Sullivan. By the way, just for the record, I don't
    believe everything at the New York Times writes.
        [Laughter.]
        Dr. McBirney. Certainly.
        Senator Sullivan. So, Senator Warren might--no, I am just
    kidding. But so, I am sure the marines had some points in there
    that probably weren't reported, or I am not saying it was a
    perfect piece, but it raised an important issue. These young
    men, to Dr. Zafonte's point, these are, my view, the best of
    what we have in America. We certainly, you know, we need to
    take care of them.
        Dr. McBirney. Absolutely, agreed. I think the 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, that 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 brain injury. There are a variety of reasons that
    servicemembers don't report injuries. But fear of negative
    repercussions on their military career is certainly a huge one.
    So, I think when I read that New York Times article in the
    series of articles, that is really what came to my mind, is a
    culture that needs changing if we hope to improve this.
        Senator Sullivan. Yes, and, Mr. Larkin, real quick. Sorry,
    Madam Chair. You know, there--and I don't know if you have a
    view on this, but we have had many wars with many thousands and
    thousands of artillery rounds fired. I had an 81 millimeter
    mortar platoon for 2 years on Active Duty, my marines.
        We fired, you know, all kinds of 81 millimeter mortar. That
    is not as big as these howitzers, but it is a big mortar, and,
    you know, you feel it when you are firing those, and your ears
    hurt when you don't have your ear protection on because it is
    so loud.
        But what is your sense on how we need to look at this, that
    article, but compare it to other wars where we have shot
    thousands and thousands and thousands of rounds.
        Mr. Larkin. So, you know, if I am going to put my money, it
    is going to be on the preventative end as much as we can to by
    down these injuries. But I completely agree with Dr. McBirney,
    the issue here is about trust.
        You know, you are not going to get in reporting unless
    there is trust that is built between that operator or that
    warrior and the system. We have collected blast data on--in a
    variety of different efforts----
        Senator Sullivan. On artillery too?
        Mr. Larkin. Just in, you know, 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. So again,
    it never comes back to the warfighter like a dosimeter would
    for radiation.
        So, they say, well, you know, we wear these things, but we
    don't hear anything back. One of the things, and it might be a
    novel idea I offer, is, you know, when we procure and acquire
    weapons systems and munitions, why don't 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.
        But again, we have been calling this by a different name
    coming off the battlefield since WWI, 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.
        Senator Sullivan. Thank you. Thank you, Madam Chair.
        Senator Warren. Thank you. I have another round of
    questions that I want to do. I know Senator Scott does. If
    anyone else does, we are glad to do it. But I want to pick up
    on what Mr. Larkin was just talking about, and that is trust.
    That servicemembers who have been affected by blast
    overpressure aren't getting the help they need.
        The question is, why not? I will go back to The New York
    Times article because it does give us some on the ground
    anecdotes that people are experiencing. So, a Marine Corps
    officer who is leading an artillery unit was quoted in this
    story saying that he was experiencing severe headaches and
    small seizures but, ``was worried that his injuries would not
    be acknowledged because there was no documentation that he was
    exposed to anything serious.''
        Now, we have talked some 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 who has focused on this more
    than anyone.
        I think you said in your written testimony that you
    estimate that about 80 percent of your son's exposure occurred
    during training. Is that right? That is what I understood.
        Mr. Larkin. Yes, Senator. If you talk to other veterans
    that have trained for combat, been in combat, they will pretty
    much confirm that the majority of their exposures is in the
    training environment, an environment that we can control.
        Senator Warren. So, 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. But 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?
        Mr. Larkin. So, one thing I didn't share about Ryan is that
    after he passed, what we found on his computer were--he
    downloaded numerous studies on blast exposure and TBI and also
    was researching the medications that he got. So, 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.
    Now, when he went to get help, he did it more for his teammates
    than himself.
        But again, you know, we didn't know what we didn't 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, and because
    we lacked the science, we lacked the knowledge. TBI was not
    mentioned--I mean, very little. It was not taken seriously
    because they couldn't see it.
        We still can't see this level of injury in a living
    operator or living warfighter, which is--again within the
    medical enterprise, if you don't have a blood marker that
    alerts you, you know, just like a, you know, heart attack, we
    look at heart, you know, enzymes and so forth, that alert us
    that, hey, there is muscle damage and we see an EKG that tells
    us that, you know, things are going wrong.
        But then when 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. The opportunity here, and I don't
    know if my colleagues would agree with me, but the opportunity
    that we have here is to get it at this early, not wait till it
    gets to a catastrophic, you know, point, you know, this disease
    process, the injury process where things have gone too far.
        Senator Warren. So let me just pick up on this. I
    understand that this is hard to diagnose and that it is--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, that 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 go here,
    you get sent there, then you end up someplace else, and 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.
        So, I just want to know if you can speak just a little bit
    to the notion that starting now, before we have perfect
    information, that we need a single way for people to go into
    this system, to be able to raise a hand, say, I have problems
    like the Marine that is quoted in The New York Times piece. I
    have problems and 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?
        Mr. Larkin. Yes, and I think the No. 1 word that I would
    pick out is listen. The system needs to listen to these folks
    as they step forward.
        You know, 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 their injury process and that
    we can start a level of treatment that one size fits one, not
    one size fits all, you know, which is precision medicine. I
    think as the science develops, as our medical capabilities
    develop, we are going to get better and better at doing that.
        But again, Ryan became disenfranchised. He became, you
    know, adversarial because the system turned on him, a system
    that he depended on, a system I depended on. This was my
    community, too, and so, this is why I am here today, and I
    realize this isn't in a perfect world, but you know, the
    ultimate grader of what we do or not do are the veterans, the
    warfighters, and their families. Are we doing the right thing
    for them?
        Senator Warren. Yes. Yes. I very much appreciate that and
    appreciate your comments here. If I can, I want to go to the
    treatment part of this. Dr. Zafonte, you work at Home Base, and
    Home Base tries to be the one place that brings people in and
    gives a response.
        That is on the side of our servicemember, not hostile to
    our servicemember. You are on the front lines. You see people
    with TBI every day. Can you talk just a little bit about how
    Home Base has organized itself, and what you are seeing, and
    what kind of needs you have?
        Dr. Zafonte. Well, Senator, thank you for the excellent
    question. I think we see ourselves as a partner with DOD, and
    that we are auxiliary in an important and differential way.
        That we take a look at the whole person, and what we try to
    understand is that, you know, I think Mr. Larkin captured it
    brilliantly, somebody is not just a psychological 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 emerge them in a team
    based behavior where we listen to the patients 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.
        Senator Warren. I am so proud of the work that Home Base
    does, and I really want to underscore the importance--there is
    help. There are things we can do, and I take it, if I can just
    have you underscore it again, Dr. Zafonte, you actually return
    people to Active Duty military service. Can you say just a
    little more about that?
        Dr. Zafonte. I am happy to. Thank you, Senator. I think one
    of the most extraordinary things, especially for our special
    operators, is the very high degree of return to duty, return to
    the force, return to fighting. Because if you think about it as
    a person, that is what they want to do.
        They want to be well and go back to their teammates and
    contribute at a very high level, and indeed, that is the goal.
    The goal is being able to give people agency over their own
    health again, and that is what we do.
        Very high rates of return. Large numbers of people still
    waiting for service, which we hope to provide. I think that we
    see this as a means of enhancing programmatic excellence and
    serving as that bridge for mid-career, early career people who
    really need a bolus of help.
        Senator Warren. Early and accurate intervention, which I
    think is the point you make as well, Mr. Larkin and Dr
    McBirney. I appreciate the work you do. Thank you. Senator
    Scott.
        Senator Scott. Thank you, Chairwoman. Dr. Zafonte, NFL
    players are wearing--some of them are wearing the Q collar.
        Dr. Zafonte. Yes, sir.
        Senator Scott. Okay, can you tell me how it works and what
    you think of it?
        Dr. Zafonte. Thank you very much, Senator, for that
    excellent question. It is an area of debate that is certainly
    of interest in the field of traumatic brain injury. The theory
    behind the Q collar is that a compression here at the neck,
    slight compression, would result in less force shaking within
    the brain.
        Its role in blast related injury, I believe, unless Dr.
    McBirney has more data, is unclear. In sport related injury, it
    has received preliminary approval, although the enthusiasm in
    many investigators is modest.
        Senator Scott. Okay. All right. Knowing what you all know
    now, knowing the service is the service--so if you had a child
    or grandchild that was 18 years old, wants to be a warfighter,
    enlist in the, whatever, what would your advice be to him? You
    want to start, Dr. McBirney?
        Dr. McBirney. Is not enlisting an option? I mean that as a
    serious question. Traumatic brain injury is such--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. Unfortunately, that is a
    decision that I know many veterans that I personally know have
    asked their children to reconsider as well.
        Senator Scott. Mr. Larkin.
        Mr. Larkin. So, Ryan is with me here today in spirit, and
    much of what I am saying is actually him talking through me. He
    would tell you he loved being a SEAL and he wouldn't trade
    anything. It is 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, USSOCOM, right up to the Commanding
    General. They are leading the way, in my opinion, within the
    Department of Defense.
        Very often, you know, what Special Operations does, the
    conventional forces follow. So, thanks, Ryan.
        Senator Scott. Dr. Zafonte.
        Dr. Zafonte. Certainly, I think this is a point of great
    debate. But I guess what I would say, and we see this in
    contact sport, we see it 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. That would be an awfully
    good place to start in enhancing force health.
        Senator Scott. Thank all of you. I mean, I don't think--if
    we care about our freedoms, we actually don't have a choice. We
    don't have a choice. We have to thank God every day somebody is
    willing to put on the uniform, because if we get to a point
    where people say there is too much risk, then say goodbye to
    all of our liberties.
        So, I hope we get to the point where, you know, nobody
    would say you shouldn't go in because of the risk. So, thank
    you.
        Senator Warren. Senator King.
        Senator King. Just a closing comment on that question,
    Senator Scott, you know, thinking about what you would say to
    your kid. One of my three kids is a Marine who was an 8-year
    infantry commander, now a Marine reservist, and keep thinking
    about him and how he might answer that question.
        But as I think about the question, let me just recount an
    amazing story that I heard not long ago from Doug Wilder, who
    is the former Governor of Virginia, first African American
    elected Governor.
        He was drafted into the military in the Korean War, and the
    military, like society at that time, was still dealing with an
    awful 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 is going to 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 really difficult battle
    circumstances--the African Americans in the unit were not being
    treated well and they all agreed they were going to talk to
    their CO and pass that on. When they all stood up to do it,
    they all just said to Doug, okay, now 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 you all go back to work and let me do what I need to
    do, and things didn't change for about 3 or 4 weeks, and then
    all of a sudden 1 day everything changed because he did what he
    was supposed to do. He stood up and he said, this isn't right,
    and we are a unit, and 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 17.5 years from now,
    but people grappling with the decision will realize things
    don't just get better, you know, by themselves. Things don't
    just change by osmosis. It takes people at all levels from the,
    you know, private first class all the way up to a four star
    standing up and saying, we will be better if we make these
    changes.
        I think an awful lot of our young people, or people at all
    ages, but I think a lot of our young people have a lot of
    wisdom to offer. I would hope that they might still say, yes, I
    am doing this, and I am also going to be committed to speaking
    up if I see areas where we can be better. Thank you.
        Senator Warren. Thank you, Senator Kaine. I will be calling
    on you, as we are doing the NDAA, both to tighten up the rules
    on reporting and get more resources into treatment. That surely
    has to come out of a hearing like this.
        So, thank you. Thank you all for being with us today. I
    would like to call up the second panel. Thank you. All right,
    are we ready? Secretary Martinez Lopez, if you can give us an
    opening statement, please.

       JOINT STATEMENT OF HON. LESTER MARTINEZ-LOPEZ, ASSISTANT
    SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE;
        KATHY M. LEE, DIRECTOR, WARFIGHTER BRAIN HEALTH POLICY,
      DEPARTMENT OF DEFENSE; AND CAPTAIN CARLOS D. WILLIAMS, USN,
            DIRECTOR, NATIONAL INTREPID CENTER OF EXCELLENCE

        Dr. Martinez Lopez. Chairwoman Warren, Ranking Member
    Scott, distinguished Members of the Senate Armed Services
    Committee, we are pleased to represent the Office of the
    Secretary of Defense to discuss the Department of Defense's
    commitment to address warfighter brain health issues and
    initiatives.
        We are honored to represent the dedicated military and
    civilian medical professionals and the military health system
    providing support to our combatant commanders and delivering or
    arranging health care for our 9.6 million beneficiaries.
        We will inform the Committee about the Department's
    initiatives to understand the causes and impact of brain
    injuries and blast exposures, support ongoing training of
    medical professionals, inform the development of treatment
    protocols, and improve the cognitive and physical performance
    of our servicemembers.
        The Department of Defense's primary mission is to defend
    the Nation. Fulfilling this mission means warfighters need 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 its form is a top priority of DOD
    as we focus on near and long term health care of our
    servicemembers.
        In support of these priorities, the DOD established a joint
    effort between the operational and medical forces called the
    Warfighter Brain Health Initiative. This initiative was
    finalized in 2022 to codify a policy and direction in support
    of unified efforts across the military to address TBI and blast
    overpressure.
        The Warfighter 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. The WBHI Initiative
    is an important organizing function for our Department wide
    efforts to address brain injury and related diagnosis, such as
    PTSD and suicide.
        Between 2000 and 2023, 485,553 servicemembers were
    diagnosed with TBI. The annual members of TBI grew from 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 TBI clinical care and
    research to support military forces around the globe.
        We recognize, however, that more research and insight is
    needed in both the care and research dimensions to better
    understand the risk, how to protect the warfighters, and how to
    treat brain injuries more effectively.
        Our strategic approach to this issue is an iterative one
    involving policy to coordinate clinical changes and gab driven
    research investment. When policies work, we look at how to
    refine for broader effectiveness. When they do not work as
    expected, we review why and modify them to invest in research
    to advance alternative solutions.
        With that overarching policy mindset, we hope to discuss
    that we see as pivotal actions, research findings and their
    impact on our current approach as implemented within the WBHI.
    We communicate these insights not because we believe they are
    foolproof solution. Rather, enable collective action through
    shared knowledge.
        We know there is still much to learn about the brain and
    not everybody responds 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,
    doctrine, and policy. This mission is more both personal and
    professional.
        As providers, researchers, and military leaders, we are
    committed to mitigating the risk of and improving the treatment
    for BOP 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 warfighters.
        We thank Senator Warren, Senator Scott, and the members of
    the Subcommittee for leading continued congressional attention
    on blast exposures and brain injuries, and we look forward to
    your questions.
        [The prepared joint statement of Dr. Martinez Lopez, Ms.
    Lee, and Mr. Williams follows:]

       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Warren. Thank you very much. I appreciate it, Dr.
    Martinez. So, I appreciate that DOD has begun to take steps
    toward mitigating the risks associated with traumatic brain
    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 servicemembers get the
    clinical help that they need. I am glad that DOD is taking this
    critical step, but it is important that we do this right.
        Captain Williams, your organization, the National Intrepid
    Center of Excellence, works with servicemembers with TBIs and
    other invisible wounds of war. As you know, one of the--and we
    have discussed here 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 it be
    helpful to give a cognitive test before the servicemember
    begins training and firing weapons?
        Captain Williams. Thanks, Senator, for the question, and
    thank you for the opportunity to talk about this important
    issue. Absolutely, yes. Let me start out by saying yes, it is
    critically important.
        Baselining is something that we utilize in all aspects of
    medicine for surveillance. We utilize it prior to treatment,
    utilize prior to modals that we know cause risk. So, we have
    moved to now--this year, we hope to move to, all members, once
    they join the military and before they start the initial
    military training, they get cognitive testing.
        They get cognitive testing, because we know that the
    highest risk of TBIs in the military are in the training
    environment, and so, it would be valuable. We wanted to use the
    same precision medicine we have been using in the past for
    other modalities, that we do with TBI.
        Senator Warren. Okay. So, if the baseline assessment is not
    starting until after training, that is not an accurate measure
    of the servicemember's 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 is
    absolutely critical.
        So, to make sure that we are able to detect signs of
    cognitive decline due to blast exposure, we have got 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 3 years, DOD is currently
    planning to retest troops only every 5 years.
        Dr. Martinez, you are responsible for assessing the effects
    of and improving how DOD tracks blast pressure exposure. Would
    annual cognitive testing for servicemembers help increase the
    chance that we detect changes in cognitive function and detect
    them earlier when intervention would be more effective?
        Dr. Martinez Lopez. Ma'am, the--as the Department, we are
    looking into this. I think if there is value into doing it
    every year, we don't know. So, maybe 3 years, maybe 5 years.
    There is more data and more science that we need to look into.
    I am not looking at 10 year research.
        I am looking at 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 the soldiers--the servicemembers.
        Senator Warren. So, I just want to say I feel a little bit
    frustrated here that Special Operations Command already clearly
    says 5 years is not enough. They are at three. Frankly, until
    we have better data, I don't know why we wouldn't be saying,
    let's do an annual test and see what we can detect.
        If the data show us that 3 years is often enough interval
    to be able to detect changes, that is fine. But it seems to me,
    given what else we know, and given how catastrophic the
    implications of untreated TBI can be, that we ought to be
    erring on the side at least of collecting these data annually.
    So, I really want to push on this, waiting 5 years to test is
    just not often enough.
        Another way that DOD needs to show that it is serious about
    protecting servicemembers from blast overpressure is by
    establishing effective weapon use safety limits. We had some
    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 limits don't include brain injury risk. Blast pressure
    experts have raised concerns that 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.
        Ms. Lee, you are in charge of overseeing DOD's warfighter
    brain health policy. Why is it important that DOD establish a
    maximum allowable number of rounds for servicemembers to fire
    that takes into account brain injury as well as injury just to
    the ears?
        Ms. Lee. Senator Warren, thank you so much for the
    question, and thanks for having us here today to be able to
    talk about warfighter brain health, blast overpressure, and
    traumatic brain injury.
        This is an excellent question. We absolutely--it is
    imperative that we have allowable number of rounds for all the
    weapon 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 you mentioned, historically, it has been
    through ear and lung. However, we are looking at what the brain
    effects are, and we will follow suit with our policies as such.
        Senator Warren. So 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 are going 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
    got training instructors who just say, I have decided that is
    enough, and that is not enough to get this job done.
        So 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
    use safety limits. DOD's own studies found that it took 70 to
    96 hours to resolve servicemembers cognitive deficits after
    firing heavy weapons. So that is 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.
        Ms. Lee, could servicemembers benefit from establishing
    weapons use safety limits for longer periods of time, like 72
    hours?
        Ms. Lee. Yes, ma'am. We are looking to expand that
    timeframe so that we allow for those differences that are
    coming up with blast overpressure. So that is again where our
    policies, the direction that our policies are headed so that we
    can cover that time period. We are firmly committed to early
    detection, provides the opportunity to treat, and that
    maximizes our outcome.
        Senator Warren. Well, I hope you do this soon. The
    Department of Defense's Inspector General has raised concerns
    that military health system providers are not consistently
    providing a 72 hour followup appointment for patients with mild
    TBIs, so clearly, a longer timeframe is something that DOD
    itself recognizes is important and that we need to get done.
        Look, I get it, this is hard, and I am grateful that 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.
        Senator Scott. Thank you, Chair. So, I will ask you the
    same question, what would you tell your son or daughter who was
    going to go in and be a warfighter, 18 years old, go enlist--
    what would you tell them today, based on what you know?
        Dr. Martinez-Lopez. Sir, I have three boys. Two of them
    served in the military. One is still in the reserves. So, I am
    very proud of their service just like, you know, and I will
    tell my grandkids, I have eight of them--so, that there is a
    great opportunity in the services.
        I think there is some value as a human being that we
    develop, that service to country is very important. Even if you
    do it for a short time, it makes a big difference as you as a
    person.
        I don't care how you--where you serve or how you serve, is
    it critical now? They need to understand that this is a risky
    business, and what--so they need to come out with their eyes
    wide open, right.
        So, my kids knew that .I very, very--I made it very clear
    and--but I am still very proud. I will tell my grandkids, if
    they really think about, there is something that triggers them
    to serve, go fetch.
        Senator Scott. Captain.
        Captain Williams. Thank you for the question, sir. I have
    no children at this point, but I have many--nephews, nieces,
    and friends of the family who I have encouraged to join the
    military. This 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, they have a responsibility--a
    responsibility to care for you. So, no different, and the
    reason why I am here today is saying we want to make sure that
    our men and women in uniform know that we are caring for them
    in every possible way.
        Senator Scott. Thank you. Ms. Lee.
        Ms. Lee. Yes. So, 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 is about the trust, and I have
    seen working in this environment for the last 20 years,
    especially around the traumatic brain injury realm, that 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 a family, and we are going to take care of you. Mr.
    Larkin is part of our team. We are all in this together with
    the same mission to take care of our people and take care of
    servicemembers that make the sacrifice.
        Senator Scott. Thanks. Secretary Martinez, the Department's
    report to Congress on the longitudinal blast study says the
    Department plans to conduct a business case analysis and review
    lessons learned to inform its way forward with blast
    monitoring.
        So, who is conducting the business case analysis? When do
    you expect the analysis to be completed? What factors is the
    Department including in its analysis?
        Dr. Martinez-Lopez. Sir, do you mind if I defer to Ms. Lee.
        Ms. Lee. So, the business case analysis kickoff meeting was
    the 14th of February. It is being conducted by a contract
    service. We are expecting the results in September 2024. We
    looked at--we are looking--we have extensively involved
    military departments in this so that the outcome that comes,
    the outcome 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
    so that we can review the necessary resources, the--and look at
    how to establish a standardized monitoring program throughout
    the force.
        Senator Scott. When do you think you will be completed?
        Ms. Lee. The business case analysis will be completed in
    September.
        Senator Scott. September? Okay. Right. The 2023, the Fiscal
    Year 2023 NDAA also authorized but didn't require the Director
    of the Defense Health Agency to conduct a pilot program to
    monitor blast exposure to the use of commercially available,
    off the shelf wearable sensors. Do you all plan to do it, and
    do you have any sensors in mind that you think are working?
        Ms. Lee. So, yes, sir. So, we are awaiting the BCA results,
    the business case analysis results in September, to make a
    decision on whether or not that pilot that could be the segue
    from our Section 734 work into a full blown standard monitoring
    blast program throughout the Department.
        So, again, those decisions, we will probably make in the in
    the September 2024 time period. In terms of blast sensors, we
    have various communities to include the Special Operations
    Command that have been looking at the--right now, the three
    available, commercially available products.
        Those decisions are, right now, living in the acquisition
    world as they are doing suitability and fielding exercises, and
    based on the requirements of each individual community.
        Senator Scott. Good. Also, the Fiscal Year 2023 NDAA
    required a report describing the strategy and implementation
    plan for the Warfighter Brain Health Initiative. I guess this
    was due at the end of last year or so. Is that different than
    the others?
        Ms. Lee. That is the strategy and action plan that has five
    lines of effort. I believe that is headed over your way right
    now.
        Senator Scott. Oh, okay. All right. Thank you.
        Senator Warren. So can I just ask one more question. It is
    7 months before the business case analysis. What are you going
    to do over the next 7 months?
        Ms. Lee. So, in the original memo that was produced before
    we had finished Section 734, the Assistant Secretary of Defense
    for Readiness put out this interim guidance memo. Before we had
    completed all of the information, all the data, we felt it was
    imperative to try to get brain health guidance out at that
    time.
        So, we sent the memo out. Included in that four PSA memo
    are six actions to try to avoid unnecessary blast exposures.
    So, what we are doing in the meantime is updating that memo
    with more data that we have from our research studies and from
    the blast community of researchers, so that we can provide more
    direction and guidance to the military departments on how they
    can have safer actions out in the operational environment, in
    the training environment.
        Senator Warren. Okay. I appreciate that, and how are you
    going to make sure that it makes it all the way down to the
    ground level? There are anecdotes that suggest that we make
    policy changes, we all talk to each other up here in the
    abstract, and then down at the ground nothing has changed. Dr.
    Martinez.
        Dr. Martinez-Lopez. Ma'am, the first issue is this is a
    joint effort between the operational forces and we in the
    medical sector. So, it is the medical leadership and the
    operational leadership.
        If we don't work it together, this is not going to pan out.
    So, the way we exercise that at DOD is through a safety
    oversight council. So, we are meeting with all the services and
    laid out the guidance, and we rely on the services then to push
    it down. It is an issue of policy internal to the services.
        It is an issue of training in the services. It is an issue
    of equipping in the services. We will give them the medical
    guidance, you know, the best knowledge we have, but the
    implementation itself, how are you going to fire your weapon,
    where, and those kind of things have to be exercised by the
    line.
        Now, I went over to Fort Campbell, and I talked to the CG
    of Fort Campbell. He was--and I told him, it is simple. Less is
    better, and less often and better. So really look at--pay
    attention to that.
        Senator Warren. Right. Right. Captain Williams, did you
    want to add anything on that? Okay, good. Senator Scott.
        Senator Scott. So, have you guys ever had a glucose
    monitor? Do you know how they work? Okay, so I can put on
    glucose monitor, I can put in my exercise, I can put in my
    food, and I can just do it myself. I can sort of track to see,
    you know, how I feel when my glucose goes up. So, why don't we
    have something just simple that people can do on their own?
        Because if I knew, gosh, I get headaches or I get, you
    know--I have sleeping problems or I have any of these issues,
    then I would say, I mean, I can't do this anymore. I mean, why
    don't we do something--I mean, the technology is so simple,
    right.
        I mean, it is basically you just go you go to--there is two
    companies that do the glucose one now that I know of. Why don't
    we just go there and say, will you give us the technology and
    we can implement this and just give it to everybody and let
    them monitor it themselves?
        [Technical problems.]
        Dr. Martinez-Lopez. I am going to State the first steps--
    [technical problems]. The problem with glucose is I know
    exactly where the thresholds are. So, I know that like at 126
    it is abnormal blood sugars, so anything above that or below
    that, and I can monitor it. On this issue, I don't know what
    the threshold is. So, we haven't determined that threshold yet,
    and even worse----
        Senator Scott. No, I will decide for myself. I will decide
    that--the way I would look at it is, I will put the information
    in there and then I would say, hey, here is what I noticed. If
    I do this number of blasts, I get a headache. I do this number
    of blast, I can't sleep.
        Then I start saying to myself, and I say, well, okay, I am
    not going to do that. I am not doing that to myself anymore
    because--you know what, this has happened to me so I am not an
    expert on this, but you would think, I mean, you know, we are
    all--we are all going to be better if we self-monitor
    ourselves, right? I mean, rather than some top down program
    that tries to tell us everything, and even glucose--I mean,
    your body is going to be different than my body.
        So, what my high level should be is going to be different
    than yours, right. So, I am just saying, put the information in
    there. It is a real simple mode. Give it to everybody. Let them
    start following it on their own, and then they can easy--you
    know, like on those--anybody can connect.
        You can say, oh, I am going to allow this person to
    connect. There is a company out there that allows people to do
    that now that--it is call levels and they are doing they are
    doing--I think they have 50,000 people or so on a study, where
    they are doing it on their own as a private sector, just with
    everybody voluntarily putting their data in there.
        Captain Williams. Sir, if I may, one of the most important
    things--and what you are speaking about is really and truly
    precision medicine and targeted therapy to the individual. It
    is very variable for each individual who has had a TBI, the
    symptoms that they have.
        One of the things that the past NDAA said was that the DOD
    needed to partner with private industry and private
    organizations to improve research and to improve treatment.
    That is one of the things that we want to look at, is look at
    what type of modalities are out there, or that can be developed
    to allow patient to focus on their individual symptoms.
        But we have to know what that baseline is first for that
    individual. Biofeedback is something that we do in the Defense
    Intrepid network, at NICO, we help patients understand how to
    control their own individual symptoms.
        But if each person is different, then that is going to be a
    challenging, should I say, monitoring to create, but it is
    possible. As we continue to do research, I think we can come--
    we can get there soon.
        Senator Scott. So, to me, I just gave you my answer, that
    is a big government answer. Okay, just my--you might be
    absolutely right. Just, I am not saying you are wrong. I am
    just--I just actually do believe that I will do a better job of
    monitoring my health than anybody else will ever do my health.
    I don't care what the study is, I will do a better job.
        I think--if I started--I can just say personally, if I eat
    something and I don't feel good, I am never touching it again,
    all right, period. I assume--I mean, it is smart--these are
    smart kids going in the service.
        I mean, just look at these sports. All these people are
    getting smarter about this and saying, I am not doing this to
    my brain. I just think we ought to do exactly all the things
    you are doing, but it is pretty simple to set up a program to
    give and, you know--let the person monitor themselves because
    their body is going to be totally different than everybody
    else's. Like your blood glucose level is different than mine, I
    guarantee you.
        Captain Williams. So, I totally agree with you, sir, and as
    an internist and a pediatrician, I always listen to the
    patient. I always listen to the parents, right. It is very
    important.
        [Technical problems.]
        Captain Williams. But I do want to say, though, I agree
    with you. I think as a medical professional though, and even 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, with normals,
    which we just don't have at this point in time for TBI in
    general. When we move toward blood biomarkers, when we move
    toward much more concrete evidence, I think we can come up with
    the tool that you are talking about, that can allow a patient
    to monitor themselves.
        Senator Scott. Thank you.
        Senator Warren. Good. So, I want to thank you all for being
    here--absolutely.
        Senator Budd. Thank you all for being here. So, North
    Carolina universities, including East Carolina University, ECU,
    UNC Chapel Hill, and health care providers like Atrium Health
    have prioritized research, care, and support for servicemembers
    and veterans diagnosed with TBIs.
        I was able to see that when I was in the State last week.
    So again, I appreciate this hearing. Further understanding the
    cause of TBI will significantly improve that care that they
    offer, and I look forward to supporting their ongoing efforts.
        Dr. Martinez, in the longitudinal study on blast pressure
    exposure of members of the armed services that you published in
    December, one of the key findings is a greater likelihood of
    TBI--can you explain what you mean by a greater likelihood and
    quantify the increased likelihood of TBI? So, what percentage
    of people were exposed to what level blaster, likely to develop
    TBI?
        Dr. Martinez-Lopez. Senator, I will defer to me Ms. Lee for
    the answer.
        Senator Budd. Certainly. Thank you.
        Ms. Lee. So, the Section 734 longitudinal study that you
    are referencing, where we looked at monitoring and documenting
    blast exposure and then also offerings 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 all the
    safety regulations were about those.
        Under the safety rubric as well, we looked at what the
    health and performance effects are, the brain health effects
    from all this blast overpressure stuff. In the report, we were
    able to--we reviewed 40 studies, 26 of those studies were
    funded by the Department of Defense.
        We looked at what type of effects happen when you are doing
    blast overpressure, and then where do you have concerns about
    traumatic brain injury. Most of the areas that we found
    correlations were in the neurocognitive and thinking areas.
        Also, in some health care utilization areas. We looked at
    blood biomarkers and proteins to try to see if there was any
    correlations, and we believe that that will bear fruit, but
    right now there is no clear trends in that regard.
        So, we are relying on the symptom reporting as being the
    most indicative of someone that would have 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 their symptom
    reporting.
        Senator Budd. Thank you for that. Dr. Williams, what
    recommendations would you make to improve the Department's
    ability to diagnose and treat military personnel who are
    repeatedly exposed to low level blast?
        Captain Williams. Thank you for the question, Senator. As
    we spoke earlier in terms of baselining early. So, it has been
    stated several times, and when you know better, you do better.
    One of the most important things we can do is baseline our
    members from the moment they come into the military.
        That means before they start the military training, and
    that allows us to follow them over time. I admit we have to
    find the right baselining tool. Right now, we use ANAM. ANAM
    focuses on cognition and that is an appropriate component, but
    we can do more. We can do better, and our goal is to, again,
    start early so we can continue to monitor.
        Senator Budd. Thank you. North Carolina is the proud home
    of the Kennedy Special Warfare Center and School at Fort
    Liberty, and research suggests that Special Operations forces
    experience higher rates of blast exposure in training and
    combat than other military personnel, and thus are at an
    elevated risk for repeated blast exposure related brain injury.
    So, does that track with your research?
        Ms. Lee. Absolutely.
        Senator Budd. All three of you?
        Captain Williams. Yes.
        Senator Budd. Thank you. While we certainly need to conduct
    more research, we have to also do a better job protecting our
    servicemembers with what we know today. That lines up with Dr.
    Williams, with what you were just sharing.
        So, I am concerned that the Department is not moving
    quickly enough to address these TBI risks. So, there is tested,
    FDA approved devices that can limit TBIs, including some like
    neck collars that are currently being used by Special Operators
    and just like you see in the NFL.
        Now, I am hearing, however, that there is still years of
    DOD testing that need to take place before they can be fielded
    for the broader force.
        So, for the panel, for each of you, why aren't we expanding
    the fielding, FDA approved wearable devices now to keep our
    warfighters safer from TBI inducing head trauma and
    overpressure protection, rather than waiting for duplicative
    testing to be completed within Department? How can we expedite
    those devices, the use of those devices?
        Captain Williams. You know, I would start with a simple
    answer, our goal is to do no harm. Right now we need more
    information for some of these devices to determine if they
    would do harm in the operational setting.
        Senator Budd. Even, doctor, if they are already FDA
    approved devices?
        Captain Williams. I totally understand. FDA approval,
    oftentimes, is not tested in our population, and that is a
    different story. So, we realize now that a lot of times this
    research is being done and is not inclusive of operators,
    especially high level operators that we are caring for. I think
    our goal is to make sure we do no harm to that general
    population.
        Senator Budd. Thank you. Secretary.
        Dr. Martinez-Lopez. We may have to look at the data and we
    look at the size, if it is sound. Even in our study, we will
    adopt it. If it is really going to make a difference, we will.
    But we will put them through our internal processes, and that
    is true for every intervention we do have with our patients.
        Senator Budd. Ms. Lee?
        Ms. Lee. Senator, the jugular vein compression devices that
    you are speaking about had mainly been studied in head impact
    in the sports community. So, pivoting to blast overpressure,
    which has a different mechanism of injury, is worth a look--
    definitely worth more than a look--to do more research to make
    sure that it is safe and effective in both the military
    population, as well as blast overpressure as the mechanism.
        Senator Budd. Understood. Thank you all. I yield.
        Senator Warren. Thank you, Senator Budd. I want to thank
    you all, 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 were most at risk for TBI
    because of the particular work they do. We need to collect
    better data, and 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 Home Base 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
    Home Base is our failure.
        We need those resources, and we need that capacity to be
    able to treat those who have suffered brain injuries because of
    their service to our Nation. We owe that to our servicemembers.
    So, again, thank you all for being here. I want to thank the
    senators who have been here.
        I want to thank my partner, Senator Scott, in this, and
    this will be an issue we will take up during the next round of
    NDAA negotiations. Thank you.
        [Whereupon, at 5:02 p.m., the Committee adjourned.]

        [Questions for the record with answers supplied follow:]

                 Questions Submitted by Senator Mazie K. Hirono
                 tbi treatment at military treatment facilities
        1. Senator Hirono. Dr. Zafonte, I applaud your dedication and
    efforts as a principal investigator on DOD clinical trials evaluating
    novel treatments for TBI and PTSD. Do you think there is enough
    training for military medical professionals at treatment facilities,
    such as Tripler Army Medical Center, to identify and treat TBI and the
    accompanying symptoms?
        Dr. Zafonte. As a non-profit academic medical center, outside DOD,
    I do not have personal knowledge of the extent of the TBI training
    programs at military medical centers.

        2. Senator Hirono. Dr. Zafonte, which novel treatments in your
    trials seem the most promising?
        Dr. Zafonte. Home Base is proud of our TBI space's history of
    innovation. Nestled within the world-renowned Massachusetts General
    Hospital (MGH), Home Base's National Center of Excellence utilizes the
    extensive resources and faculty of MGH, Harvard Medical School,
    Spaulding Rehabilitation Hospital, the Massachusetts Eye & Ear
    Hospital, and other components of the Mass General Brigham integrated
    healthcare system to provide evidence-based care. Furthermore, this
    incredible ecosystem within which we operate provides us with insight
    into the latest research and clinical care opportunities, as well as
    daily access to world-leading researchers and clinicians who work at
    the forefront of mental health and brain injury care. This guarantees
    the synchronization, not the siloing, of our efforts to treat these
    invisible wounds.
        Science is just beginning to understand the long-term impacts of
    mild and moderate TBIs. Home Base is actively investigating the short-
    term and long-term effects of these injuries, which encompass a
    spectrum of physical and psychological ailments ranging from
    neurodegenerative diseases to behavioral health disorders and even
    cancer. A critical issue is understanding the specific biopsychosocial
    injury patterns associated with repeated blasts. Through my research
    and collaboration with specialists, we are uncovering critical insights
    that continue to inform evidence-based interventions and elevate
    clinical care standards.
                             tbi and mental health
        3. Senator Hirono. Secretary Martinez-Lopez, Dr. McBirney, and Dr.
    Zafonte, traumatic brain injuries can range from mild to severe, and
    studies have shown notable correlations between TBI and mental health
    conditions such as anxiety, PTSD, depression, and suicidality among
    current and former servicemembers. Can you speak to this correlation
    and what steps are being taken to address treatment with this
    relationship in mind?
        Secretary Martinez-Lopez. DOD Response (Secretary Martinez-Lopez):
    Yes, DOD funded research has elucidated relationships between traumatic
    brain injury (TBI) and mental health conditions. During the acute
    evaluation of mild TBI using the Military Acute Concussion Evaluation
    (MACE) 2 screening tool, there are questions about a history of
    depression, anxiety, or other behavioral health concerns so that we can
    offer additional assistance and followup for servicemembers who report
    these concerns.
        The MACE 2 also approaches concussion from a symptom cluster
    perspective. Anxiety is covered under the concussion symptom clusters
    and we manage each symptom cluster uniquely, recognizing that the
    combination of symptoms changes recovery trajectory. We know
    Servicemembers may take longer to recover (similar to other combined
    injuries) and may require more followup medical encounters to
    facilitate recovery if a history of a mental health condition (or other
    non-mental health concussion symptomatology) is present.
        In addition, other DOD guidelines and tools incorporate
    psychological interventions as part of the multi-disciplinary approach
    to TBI treatment. There are standardized concussion tools, such as the
    Progressive Return to Activity (PRA) protocol, that outline state-of-
    the-art treatments as well as how to return Servicemembers to duty and
    full function. The PRA is meant to incorporate a range of symptoms
    post-concussion and direct an individualized recovery plan. The DOD
    also has specialty clinical and comprehensive interdisciplinary centers
    of excellence called the Defense Intrepid Network (DIN) for TBI and
    Brain Health. These programs have been developed to deliver a holistic
    patient centered interdisciplinary TBI model of care. Behavioral health
    services can include psychiatry, psychology, and social work.
    Additional services may include neurology, sleep medicine, pain
    management, and rehabilitation services, such as balance and vision
    therapy. These centers of excellence also offer innovative treatments
    such as creative arts therapies, animal-assisted therapies, and mind-
    body wellness services.
        Dr. McBirney. My research has remained focused on traumatic brain
    injury (TBI) and subconcussive injuries, so, while I do know that there
    is a correlation between TBI and some mental health conditions, such as
    anxiety, posttraumatic stress disorder (PTSD), depression, and
    suicidality,\1\ I do not feel qualified to speak to the correlation and
    any subsequent treatment efforts.
    ---------------------------------------------------------------------------
        \1\ Jennifer N. Belding, Claire A. Kolaja, Rudolph P. Rull, and
    Daniel W. Trone, ``Single and Repeated High-Level Blast, Low-Level
    Blast, and New-Onset Self-Reported Health Conditions in the U.S.
    Millennium Cohort Study: An Exploratory Investigation,'' Frontiers in
    Neurology, Vol. 14, March 2023; Michelle R. Dickerson, Susan F. Murphy,
    Michael J. Urban, Zakar White, and Pamela J. VandeVord, ``Chronic
    Anxiety-and Depression-Like Behaviors Are Associated with Glial-Driven
    Pathology Following Repeated Blast Induced Neurotrauma,'' Frontiers in
    Behavioral Neuroscience, Vol. 15, December 2021; Yueh-Chien Lu, Ming-
    Kung Wu, Li Zhang, Cong-Liang Zhang, Ying-Yi Lu, and Chieh-Hsin Wu,
    ``Association Between Suicide Risk and Traumatic Brain Injury in
    Adults: A Population Based Cohort Study,'' Postgraduate Medical
    Journal, Vol. 96, No. 1142, December 2020; Trine Madsen, Annette
    Erlangsen, Sonja Orlovska, Ramy Mofaddy, Merete Nordentoft, and Michael
    E. Benros, ``Association Between Traumatic Brain Injury and Risk of
    Suicide,'' JAMA, Vol. 320, No. 6, 2018; Sarah L. Martindale, Anna S.
    Ord, Lakeysha G. Rule, and Jared A. Rowland, ``Effects of Blast
    Exposure on Psychiatric and Health Symptoms in Combat Veterans,''
    Journal of Psychiatric Research, Vol. 143, November 2021.
    ---------------------------------------------------------------------------
        Dr. Zafonte.
    The Need
        My research with TBI has noted an elevated 10-year risk of
    behavioral concerns such as depression, anxiety, and even bipolar
    disorder. TBI can have wide-ranging psychological effects. Some signs
    or symptoms may appear immediately after the traumatic event, while
    others may appear days or weeks later. According to the Department of
    Defense, since 2000, over 413,000 US (United States) servicemembers
    have experienced at least one TBI, and 40 percent of those with in-
    theater TBIs later screened positive for comorbid psychological health
    conditions, including post-traumatic stress disorder (PTSD),
    depression, and anxiety.
    Innovative Treatment Models
        In 2015, Home Base launched a 2-week intensive clinical program
    (ICP) for veterans, servicemembers, and their families impacted by the
    invisible wounds, including a TBI-specific track. The ICP combines
    evidence-based therapy with complementary and alternative medicine.
    What sets the ICP apart from other programs is that it is staffed not
    only by Massachusetts General Hospital clinicians and fitness and
    nutrition experts--all trained in military culture and specializing in
    treating invisible wounds--but also by veterans, servicemembers, and
    military family members who are subject-matter experts and are able to
    provide high-level peer support through their shared life experiences.
    Veterans and servicemembers work with their treatment team to determine
    an individualized treatment plan. Our clinicians are experienced in
    delivering the most effective and innovative treatments to help heal
    the invisible wounds of war. We encourage family members and support
    people to participate in our program offerings as they are integral
    parts of the healing process. We also provide them with their own
    education and support options.
        Home Base recognizes that TBI treatment cannot exist in isolation.
    The overwhelming majority of the patients who we treat in our ICP for
    TBI also receive treatment for co-occurring mental and behavioral
    health concerns through individual and group therapy, emotional
    regulation training, mindfulness, and wellness classes. The TBI
    patients receive supplementary services to treat their TBI concerns,
    including daily cognitive rehab, physical medicine, and rehabilitation
    (PM&R), and physical therapy.
                           holistic treatment for tbi
        4. Senator Hirono. Secretary Martinez-Lopez, Dr. McBirney, and Dr.
    Zafonte, if current medical approaches to treating TBI and related
    outcomes in American servicemembers are lacking or require additional
    resources, what alternative pathways are being explored to treating TBI
    from a holistic perspective?
        Secretary Martinez-Lopez. The Department has a multipronged
    approach to care, allowing for each element to be enhanced as needed.
    The core elements are standardized assessment tools and protocols;
    specialty clinical sites networked for information sharing; and
    standardized policy to optimize documentation, screening, and care. The
    Defense Health Agency (DHA) established the Acute Concussion Care (ACC)
    Pathway as part of the Fiscal Year 2021 Quadruple Aim Performance Plan
    to standardize acute concussion assessment and care across the Military
    Health System (MHS). The goal of the ACC Pathway is to improve recovery
    times and outcomes by utilizing a multi-modal assessment tool at the
    time of injury (MACE 2) and to ensure timely access to repeat
    evaluations with personalized treatment protocols in alignment with a
    progressive return to activity process.
        Supporting the goal of the ACC Pathway, the DHA Procedural
    Instruction 6490.04, ``Required Clinical Tools and Procedures for
    Assessment and Clinical Management of Mild Traumatic Brain Injury/
    Concussion in Non-Deployed Setting,'' April 26, 2021, established the
    required clinical tools and procedures for management of mild TBI, or
    concussion, in a non-deployed setting. Specifically, the use of the
    MACE 2 and the PRA are the main tools used for the assessment,
    management, and rehabilitation of all patients with a mild TBI. Our
    current focus is on enhanced use of the existing mechanisms as well as
    documentation to enable continued refinement.
        The Defense Intrepid Network (DIN) for TBI and Brain Health, which
    includes the National Intrepid Center of Excellence (NICoE),
    collaborates with civilian healthcare facilities to enhance care for
    servicemembers with TBIs and psychological health (PH) conditions. The
    DIN provides state-of-the-art clinical care, best practices,
    translational research, and education and training for the DOD and U.S.
    Government. The DIN delivers a comprehensive, holistic,
    interdisciplinary care model for the continuum of brain injuries and
    associated behavior heath conditions. This interdisciplinary care model
    is noted to be the most successful treatment for cases that have not
    responded to traditional care. The DIN's model is the foundation on
    which the majority of other TBI programs across the country are based.
    The network includes 13 sites (located across the United States and one
    in Germany). NICoE serves as the DIN's headquarters and is home to some
    of the most advanced TBI and brain health research in the Nation. The
    DINs interdisciplinary care model combines traditional medicine
    services such as behavioral health, neurologic, and rehabilitative
    care, with a host of complementary services such as acupuncture,
    chiropractic, and meditation, along with integrative health services
    such as art, music, and dance movement therapies. NICoE has a broad
    armamentarium of technologies and techniques to diagnose, treat and
    rehabilitate servicemembers. The model is rooted in a wellness mindset.
    The DIN consistently shares its model of integrating care and research
    with civilian facilities and leverages civilian expertise and
    assistance through the referral service.
        Dr. McBirney. Given my lack of clinical experience, particularly
    compared with others on the panel, I do not consider myself to be well
    positioned to answer this question. I will defer to my colleagues.
        Dr. Zafonte. Home Base views all our patient care issues, from PTSD
    to TBI, through a holistic lens. At Home Base, our approach to holistic
    treatment for warriors is centered on addressing the complex interplay
    of biopsychosocial issues that they often face. Our comprehensive and
    integrative model focuses on treating the whole person, recognizing
    that mental, physical, and social health are deeply interconnected.
    Here is an outline of our approach:
    Mindfulness and Mental Health
          Mindfulness Practices: We incorporate mindfulness-based
    stress reduction (MBSR) techniques to help warriors manage stress,
    anxiety, and depression. Practices such as meditation, deep breathing
    exercises, and guided imagery are taught to enhance emotional
    regulation and promote a sense of calm.
          Cognitive Behavioral Therapy (CBT): CBT is employed to
    address negative thought patterns and behaviors, helping warriors
    develop healthier coping mechanisms.
          Trauma-Informed Care: Recognizing the impact of trauma on
    mental health, we provide therapies specifically designed to address
    PTSD and other trauma-related conditions. This includes Eye Movement
    Desensitization and Reprocessing (EMDR) and trauma-focused CBT.
    Addressing Physical Dysfunction and Pain Management
          Comprehensive Physical Therapy: We offer personalized
    physical therapy programs to address musculoskeletal issues, improve
    mobility, and reduce pain. These programs often include exercises
    tailored to individual needs, manual therapy, and strength training.
          Pain Management Strategies: Our approach to pain
    management is multifaceted, incorporating both traditional and
    complementary methods. This includes pharmacological treatments,
    acupuncture, chiropractic care, and massage therapy.
          Functional Movement Training: We focus on improving
    functional movement patterns to prevent injury and enhance physical
    performance. This includes education on proper biomechanics and
    posture.
    Facilitating Safe and Vigorous Evaluation of Novel Holistic Therapies
          Research and Evidence-Based Practice: We are committed to
    staying at the forefront of medical research to ensure our treatments
    are grounded in the latest scientific evidence. We conduct and
    participate in clinical trials to evaluate the efficacy and safety of
    novel holistic therapies.
          Integrative Medicine: Our integrative medicine approach
    combines conventional medical treatments with complementary therapies.
    This might include nutrition counseling, herbal medicine, and mind-body
    practices such as yoga and tai chi.
          Patient-Centered Care: Each warrior receives a
    personalized treatment plan based on their unique needs and
    preferences. We involve patients in the decisionmaking process,
    ensuring that their values and goals are respected.
    Social Support and Community Integration
          Family and Community Support Programs: Recognizing the
    importance of social connections, we offer support programs for
    families and facilitate community engagement activities. This helps
    warriors build a strong support network.
          Peer Support Groups: Peer support is a vital component of
    our approach. We provide opportunities for warriors to connect with
    others who have had similar experiences, fostering a sense of
    camaraderie and mutual support.
          Holistic Wellness Programs: Our holistic treatment
    approach at Homebase aims to empower warriors by addressing the full
    spectrum of their health needs, promoting resilience, and enhancing
    their quality of life.
          Nutrition and Lifestyle Counseling: Proper nutrition and
    a healthy lifestyle are crucial for overall well-being. We offer
    guidance on diet, exercise, and sleep hygiene to support warriors'
    holistic health.
          Recreational and Creative Therapies: Engaging in
    recreational activities and creative arts can be therapeutic. We
    provide opportunities for warriors to participate in art therapy, music
    therapy, and recreational sports.
                                   __________
                Questions Submitted by Senator Elizabeth Warren
                       weapons training and brain health
        5. Senator Warren. Secretary Martinez-Lopez, there is currently no
    uniform chart or scale for safe levels of blast exposures for the
    weapons that servicemembers routinely train on. When and what steps
    will DOD take to implement safety standards and guidance to
    servicemembers and military leaders that use, fire, and/or train on
    these weapon systems?
        Secretary Martinez-Lopez. DOD Response (Secretary Martinez-Lopez):
    The DOD is focused on safety and mitigation to avoid unnecessary blast
    exposures and will continue to issue weapon specific guidance in
    accordance with research developments. We have learned that each combat
    or training scenario modifies blast overpressure (BOP) in unique ways,
    which presents challenges in developing uniform guidance. Accordingly,
    while we continue to develop solutions to characterize BOP threats, the
    Department has implemented an `as low reasonably achievable (ALARA)'
    policy approach to maximize safety.
        In parallel to this policy guidance, the Department is reviewing
    and generating new data concerning blast exposures in training and
    combat to update safety protocols for the prevention of TBI. In
    November 2022, the Assistant Secretary of Defense for Readiness issued
    ``Interim Guidance for Managing Brain Health Risk from Blast
    Overpressure.'' This interim guidance provides that DOD Components will
    manage the risk of BOP exposures exceeding 4 pounds-force per square
    inch (psi) as a part of training, planning, and execution. This policy
    is currently being updated to expand on risk management actions based
    on the outcome of research and studies.

        6. Senator Warren. Secretary Martinez-Lopez, in order to get an
    accurate measure of servicemembers' brain health over time, we must
    have a starting point or baseline to serve as a point of reference and
    comparison through force-wide cognitive testing. Previously, DOD
    responded to a congressional inquiry that ``DOD will start with the 15
    initial military training (IMT) sites. Each Military Service has
    different lengths of IMT from 7 to 13 weeks. Cognitive baseline testing
    will occur during IMT and varies as to the actual week during IMT that
    this will occur based on current training cycles and new recruit
    throughput. DOD's regular cognitive testing program will cover all
    personnel in a phased approach, beginning with the Active Duty
    component and then the Reserve Component. At minimum, cognitive testing
    will be repeated every 5 years.'' How many IMT sites does this leave
    out and what actions will be taken at those remaining IMT locations?
        Secretary Martinez-Lopez. There are a total of 15 IMT sites across
    the Department that encompasses enlisted and officer servicemembers in
    both the Active Duty and Reserve components. Therefore, there are no
    IMT sites that are left out. All newly accessioned servicemembers will
    be tested at one of the 15 IMT sites. The Cognitive Monitoring Program
    baseline collection is anticipated to begin June 2024 and IMT sites
    will be phased in throughout the rest of calendar year (CY) 2024.

        7. Senator Warren. Secretary Martinez-Lopez, what cognitive test
    will you use for the baseline and periodic testing and will you
    implement it at Military Entry Processing Stations (MEPS)?
        Secretary Martinez-Lopez. The DOD currently uses the Automated
    Neuropsychological Assessment Metrics (ANAM) for baseline and periodic
    testing pursuant to DOD Instruction (DODI) 6490.13, ``Comprehensive
    Policy on Traumatic Brain Injury-Related Neurocognitive Assessments by
    the Military Services,'' September 11, 2015, as amended. DODI 6490.13
    states ``The [ANAM] is the DOD-designated neurocognitive assessment
    tool until such time as evolving science and medical best practices
    inform a change in policy.'' The DOD has approved testing to begin at
    various points at each IMT site (not at the Military Entry Processing
    Stations). The Cognitive Monitoring Program baseline collection is
    anticipated to begin June 2024 and installations will be phased in
    throughout the rest of calendar year 2024.

        8. Senator Warren. Secretary Martinez-Lopez, what is the
    Department's plan to rapidly expand testing capabilities and sites that
    can do them?
        Secretary Martinez-Lopez. In September 2023, the Executive Council
    on Recruit and Basic Training (CORBT) supported the establishment of a
    DOD CORBT Cognitive Monitoring Working Group for the implementation of
    cognitive assessments at the IMT sites. The cognitive monitoring
    office, in coordination with the CORBT, has identified 15 IMT sites to
    establish baseline testing. As discussed in question 6, baseline
    collection is anticipated to begin June 2024 and IMT sites will be
    phased in throughout the rest of calendar year 2024.

        9. Senator Warren. Secretary Martinez-Lopez, do you have an
    estimate of how much it would cost to expand testing capabilities and
    sites to all IMT locations?
        Secretary Martinez-Lopez. The Department has conducted a cost
    analysis plan (CAP) and, as a result, the Department has programmed
    resources for implementation of baseline testing at IMT. The current
    estimated cost is 4 million dollars to conduct initial assessments at
    all 15 IMT sites.

        10. Senator Warren. Secretary Martinez-Lopez, what support and
    resources will the Services need from DHA to meet increased demand for
    assessments?
        Secretary Martinez-Lopez. The DHA, in coordination with the Army,
    has evaluated the resources needed to conduct the Cognitive Monitoring
    Program, which involves obtaining baseline cognitive assessments and
    then repeating, at minimum, every 5 years. The Department has
    programmed resources for implementation of the Cognitive Monitoring
    Program, which includes the estimates to conduct cognitive monitoring
    at the IMT's.

        11. Senator Warren. Secretary Martinez-Lopez, what are the 15 sites
    where the DOD will implement cognitive testing during IMT?
        Secretary Martinez-Lopez. The 15 sites are below.
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        12. Senator Warren. Secretary Martinez-Lopez, when will cognitive
    testing be available and required for all IMTs within DOD?
        Secretary Martinez-Lopez. Cognitive baseline testing will begin at
    select IMT sites in June 2024 and will be phased in throughout the rest
    of calendar year 2024 until testing is available at all 15 IMT sites.
    All newly accessioned servicemembers will go to one of the 15 IMT sites
    and receive cognitive testing.

        13. Senator Warren. Secretary Martinez-Lopez, what process do each
    of the service branches follow to screen Active Duty servicemembers for
    symptoms of blast overpressure and when do they conduct these
    screenings?
        Secretary Martinez-Lopez. All Services follow the same approach to
    screen for symptoms associated with BOP, as outlined in standardized
    clinical tools.
        Historically, the focus in medical assessments after deployment has
    been exposures to potentially concussive events, including blast
    related exposures, and symptom based, with the latter typically driving
    the need for further assessments or treatment. Standardized medical
    assessments occur twice after deployment and are facilitated through
    the Post Deployment Health Assessment Form DD 2796 and the Post
    Deployment Health Re-Assessment Form DD 2900. All military medical
    treatment facilities (MTFs) have providers trained in TBI screening
    with the ability to refer patients to one of the TBI Specialty Care
    clinics or the Defense Intrepid Network for TBI and Brain Health for
    more comprehensive care. As a part of the continuum of care,
    servicemembers receive ongoing evaluation and treatment by a primary
    care provider during the annual Periodic Health Assessment, and those
    individuals reporting a history of TBI (or circumstances suggestive of
    the possibility) are further assessed for their Service or treatment
    needs.

        14. Senator Warren. Secretary Martinez-Lopez, what steps are each
    of the service branches taking to support servicemembers who are
    experiencing TBI and blast overpressure symptoms due to exposure during
    training?
        Secretary Martinez-Lopez. The Military Departments support
    servicemembers who are experiencing TBI and BOP through clinical
    treatments for symptoms, and by enhancing awareness, education, and
    training to enable early recognition and treatment. The DHA provides a
    robust compliment of evaluation and treatment services to address those
    servicemembers who present with symptoms secondary to exposure to BOP
    and TBIs. To help bring servicemembers into the healthcare system, in
    December 2023, the DHA established the new Warfighter Brian Health
    (WBH) hub (https://health.mil/Military-Health-Topics/Warfighter-Brain-
    Health) that provides a unified approach toward optimizing
    servicemember brain health. In addition, the WBH Strategy and Action
    Plan, Objective 3d, ``Optimize Medical Care to Return Warfighters to
    Full Duty Following TBI,'' aims to identify, develop, and deploy
    evidence-based assessment, diagnostic, treatment, and rehabilitation
    strategies for TBIs. In support, the DHA developed the July 2023,
    Provider Fact Sheet, that informs providers about low-level blast
    exposure and steps to take to ensure patient education, documentation,
    and treatment.

        15. Senator Warren. Secretary Martinez-Lopez, when will DOD start
    to conduct routine cognitive testing for servicemembers who are already
    in the service (not initial entry servicemembers)?
        Secretary Martinez-Lopez. The Department plans to begin conducting
    routine cognitive testing for servicemembers who are already in the
    Service in December 2025; 18 months after the start of cognitive
    testing in accessioned servicemembers at the IMTs.
                        tools for measuring brain health
        16. Senator Warren. Ms. Lee, what tools would the department need
    to equitably and accurately assess soldier brain health and the
    diagnosis and prevention of brain injuries in soldier fitness tests and
    operational performance?
        Ms. Lee. As discussed in question 7, the DOD uses the ANAM for
    baseline and periodic testing for brain health and as appropriate for
    diagnosed TBIs with cognitive deficits. The ANAM is a cognitive
    assessment tool designed to detect the speed and accuracy of attention,
    memory, and thinking ability. ANAM is useful as a complimentary tool to
    determine if there are cognitive changes in a servicemember. For this
    reason, ANAM testing is conducted prior to deployment and can be used
    to identify and monitor changes in function before and after an injury.
    The DOD also continues to explore other tools that can be used to
    assess WBH through conducting research analysis through in progress
    reviews and sending out requests for information from industry and
    academic communities. For concussions, injuries that are part of the
    spectrum of brain injuries, the DOD continues to use the MACE 2 and PRA
    tools in conjunction with networked specialty care.

        17. Senator Warren. Secretary Martinez-Lopez, what partnerships or
    collaborations does the Department of Defense have with private sector
    companies or universities and are these partnerships advancing
    solutions for traumatic brain injury prevention and recovery?
        Secretary Martinez-Lopez. The DOD collaborates with multiple
    universities and industry partners, such as the National Collegiate
    Athletic Association, University of California San Francisco through
    the Transforming Research and Clinical Knowledge in Traumatic Brain
    Injury (TRACK TBI) initiative, Abbott, and the National Academy of
    Science, Engineering, and Medicine, just to name a few.
        Yes, these partnerships are advancing solutions for prevention,
    diagnostics, treatments and recovery following TBI.
                    protecting most at-risk service members
        18. Senator Warren. Dr. McBirney, what would be the benefits of
    establishing strategies specific to the Military Occupational
    Specialties (MOS) most at risk for blast overpressure?
        Dr. McBirney. Establishing strategies specific to the MOSs most at
    risk would allow for targeted prevention and mitigation efforts, which
    would offer several benefits. One is improved occupational safety. MOS-
    specific strategies would enhance the overall safety and well-being of
    the servicemembers and reduce the likelihood of brain injury among
    personnel who are regularly exposed to blasts. Additionally, by
    safeguarding the health and well-being of servicemembers in roles with
    known blast exposure risk, the military can maintain higher levels of
    mission readiness and effectiveness. Moreover, MOS-specific strategies
    would better support post-service transition and veteran care for
    veterans who may have been exposed to blast overpressure during their
    military service. Lastly, establishing MOS-specific strategies would
    allow for limited resources to be focused where they are needed most.

        19. Senator Warren. Ms. Lee, when will DOD establish strategies
    specific to the Military Occupational Specialties most at risk for
    blast overpressure?
        Ms. Lee. Please see information provided in response to question 5.
    In addition, the Department has identified MOS's that are most
    vulnerable to BOP exposures and is implementing risk mitigation
    activities aimed at those high risk MOS's and the utilization of Tier 1
    weapon systems and munitions.

        20. Senator Warren. Secretary Martinez-Lopez, although DOD has
    identified the most at risk MOSs, it has grouped some broader groups
    together. For example, putting all combat arms in the high risk group
    combines heavy weapons troops with light infantry, which may risk
    missing subpopulations such as mortar soldiers who may be at higher
    risk than light infantry soldiers. Does DOD have plans to break down
    these subpopulations to ensure that they are not missing out on
    critical groups?
        Secretary Martinez-Lopez. The Department is in the process of re-
    evaluating munitions-related training and associated MOS's that put
    servicemembers at risk of BOP exposure. As discussed above, recently
    the Services have identified specific MOS's for the Department's WBH
    Initiative to focus blast exposure efforts, to include mitigation of
    activities and enhanced screening for servicemembers.

        21. Senator Warren. Secretary Martinez-Lopez, the New York Times
    reported at least one suicide in each of the artillery units they
    investigated that experienced significant effects of blast overpressure
    from fighting ISIS in Iraq and Syria in 2016 and 2017. Please provide a
    breakdown of the rates of deaths by suicide among artillery units sent
    to Syria and Iraq to fight against ISIS.
        Secretary Martinez-Lopez. Currently, the DOD does not have a means
    to longitudinally track each servicemember by MOS and their disposition
    based on possible BOP exposure. The DOD is working closely with the
    research community to develop a BOP dose response curve to update the
    occupational exposure tracking system, which would allow for tracking
    of those exposed to BOP.
                        tracking blast overpressure data
        22. Senator Warren. Secretary Martinez-Lopez, what is DOD's plan
    for a wide scale rollout for integrating blast overpressure data into
    servicemember's individual longitudinal exposure record (ILER)
    following the pilot study with 500 servicemembers?
        Secretary Martinez-Lopez. The next steps include the finalization
    of the common data elements to be captured for each servicemember
    exposure event. Long term storage capability is also important so that
    blast exposure data will be available for ongoing evaluation and
    research purposes.

        23. Senator Warren. Secretary Martinez-Lopez, when will DOD be able
    to stand up this program and how much funding is needed to establish a
    permanent module?
        Secretary Martinez-Lopez. The Department is conducting a business
    case analysis (BCA) to inform the development of a standardized
    monitoring program for blast exposures. The BCA will evaluate the
    resources necessary to monitor, record, and analyze BOP exposures. The
    BCA is projected to be completed by December.

        24. Senator Warren. Secretary Martinez-Lopez, will the information
    on blast
    exposure data added to the ILER records include retrospective data for
    servicemembers?
        Secretary Martinez-Lopez. All data in the ILER is retrospective and
    is inclusive of environmental data that could impact servicemember
    health. As blast exposure data becomes available, it will be evaluated
    for the optimal way to include it in ILER.

        25. Senator Warren. Secretary Martinez-Lopez, while the Defense
    Department is tracking servicemembers who have had traumatic brain
    injury, this misses out on important data regarding those who are
    impacted by blast overpressure in other ways, such as sleep problems,
    headaches, behavior health issues, irregular heartbeats, and vestibular
    injuries. What steps is DOD taking to track a broader swath of
    servicemembers impacted by blast overpressure and blast exposure,
    beyond just TBI?
        Secretary Martinez-Lopez. The Department's focus is connecting
    servicemember level exposure to the ILER, with the Electronic Health
    Record (EHR) being the primary means to link blast exposure and health
    effects. The first priority is to encourage servicemembers to seek
    treatment and to make them aware of the reasons they may want to seek
    treatment for possible BOP related symptoms. Policy, standardized
    screenings, and education all help enable that objective. Once in the
    system, the DOD is seeking to track BOP as an exposure in the health
    records if a servicemember presents for related symptoms. Currently if
    a servicemember was experiencing adverse health effects from BOP in the
    garrison environment, then they would seek care within the MHS. In the
    deployed setting, all servicemembers who are within 50 meters of a
    blast event are required to undergo a mandatory medical screening and
    evaluation. The documentation of servicemember blast exposure is
    critical.
        To achieve this in the EHR, the DOD, in partnership with the
    Department of Veterans Affairs (VA), developed a specific blast medical
    diagnosis code in the International Classification of Diseases, Tenth
    Revision (ICD-10) for primary blast injury to the brain. The Department
    is developing guidance to ensure clear instructions for use of this new
    blast medical record code to help provide additional insights to inform
    clinical or operational decisions. This effort is expected to be
    completed this year to enable better medical surveillance for BOP
    exposure and injury.

        26. Senator Warren. Secretary Martinez-Lopez, what updates does DOD
    provide to servicemembers after they participate in studies monitoring
    blast overpressure? Please provide a breakdown of the rates of deaths
    by suicide among artillery units sent to Syria and Iraq to fight
    against ISIS.
        Secretary Martinez-Lopez. The DOD does not routinely provide
    updates or information to servicemembers after they consent to be in a
    research study. For most of the studies, the data collected by
    individual servicemembers are aggregated and de-identified for purposes
    of data analysis. There are plans to provide the results from the
    anonymized studies that are summarized and made available on the WBH
    Portal.
        For the second part of this question, please refer to response to
    question 21.

        27. Senator Warren. Dr. McBirney, and Dr. Zafonte, what are the
    benefits of establishing blast exposure and traumatic brain injury logs
    for servicemembers?
        Dr. McBirney. These logs would allow the Department of Defense
    (DOD) to better track the frequency of low-level blast exposure, assess
    the occurrence among high-risk occupational specialties, determine the
    connection between exposure and health outcomes, and develop strategies
    to mitigate low-level blast exposure in training environments.
    Ultimately, in-depth exposure records could be used to develop an index
    score to gauge an individual's combat readiness and potential health
    risks. \2\
    ---------------------------------------------------------------------------
        \2\ Charles C. Engel, Emily Hoch, and Molly M. Simmons, The
    Neurological Effects of Repeated Exposure to Military Occupational
    Blast: Implications for Prevention and Health: Proceedings, Findings,
    and Expert Recommendations from the Seventh Annual Department of
    Defense State-of-the-Science Meeting, RAND Corporation, CF-380/1-A,
    2019, https://www.rand.org/pubs/conf--proceedings/CF380z1.html; Lauren
    Fish and Paul Scharre, Protecting Warfighters from Blast Injury, Center
    for a New American Security, May 2018.
    ---------------------------------------------------------------------------
        Dr. Zafonte. Logs would create a method by which patients could
    bring more data to bear in their evaluations for TBI and allow for more
    uniformity. Data would also give servicemembers greater control over
    their healthcare, as they could make informed choices when seeking
    treatment.
                          addressing cultural barriers
        28. Senator Warren. Secretary Martinez-Lopez, what efforts is DOD
    and all the services undertaking to inform, educate, and build a
    culture of safety in units to follow appropriate safety measures to
    protect from blast exposure, such as accurately wear personal
    protective equipment (PPE) or blast gauges, pausing the use of weapons
    once an unsafe threshold has been reached?
        Secretary Martinez-Lopez. The November 2022 the interim guidance
    memorandum, ``Managing Brain Health Risk from Blast Overpressure,''
    (discussed above) stated that until the relationship between BOP and
    brain health effects are more fully understood, DOD Components will
    manage the risk of exposures from weapon systems exceeding 4 pounds per
    square inch as part of training, planning, and execution. This
    memorandum specified risk management requirements for DOD Components,
    including minimizing the number of personnel in the vicinity of BOP
    events, increasing standoff distances from weapons; minimizing the
    duration of live-fire events; establishing a maximum allowable number
    of rounds fired during each training event; ensuring application of
    personal protective equipment; and training and educating on BOP
    hazards and risk management actions. This policy is currently being
    updated to expand on risk management actions based on the outcome of
    research and studies.
        The DHA, with all three Military Departments and the Assistant
    Secretary of Defense for Health Affairs, developed the ``DOD Service
    Member Fact Sheet, Information on Low-Level Blast Exposure,'' July
    2023, found at: https://www.health.mil/Military-Health-Topics/Centers-
    of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/Low-Level-
    Blast-Exposure. The fact sheet was designed for servicemembers, where
    their occupational specialties may involve working with or exposure to
    blasts generated from firing heavy weapon systems or explosives in
    combat or training environments. The last page gives examples of MOS's
    that can be exposed to low level blast.

        29. Senator Warren. Secretary Martinez-Lopez, what training is DOD
    and the services providing to unit leaders on protecting their units
    from the blast overpressure and blast exposure?
        Secretary Martinez-Lopez. As specified within the interim guidance
    memorandum, ``Managing Brain Health Risk from Blast Overpressure,''
    (mentioned above) DOD Components are required to train and educate on
    BOP hazards and risk mitigation actions. Additionally, Commanders are
    to implement actions to further reduce risk by training and educating
    personnel on BOP hazards and risk management actions. The Military
    Departments and unit commanders are responsible to determine how often
    and in what manner training is conducted and tracked to ensure
    proficiency while training safely in compliance with current safety and
    range regulations.

        30. Senator Warren. Secretary Martinez-Lopez, what steps is DOD and
    each of the services taking to destigmatize servicemembers who come
    forward with blast overpressure and TBI symptoms, both for those who
    have and have not engaged in direct combat?
        Secretary Martinez-Lopez. Our first priority is the health of our
    servicemembers which is why we make every effort to encourage anyone
    who has experienced symptoms related to blast overpressure (BOP)
    exposure or traumatic brain injury (TBI) to seek diagnosis and
    treatment. Policy, standardized screenings, and education all help
    enable that objective--and to ensure that servicemembers throughout the
    Department do not perceive any potential stigmatizing barriers to care.
    The Military Departments support servicemembers who are experiencing
    symptoms related to TBI or BOP exposure through clinical treatments for
    related symptoms, and by enhancing awareness, education, and training
    to enable early recognition and treatment.
        Currently, if a servicemember is experiencing adverse health
    effects from BOP exposure in the garrison environment, then they would
    seek care within the Military Health System (MHS) as outlined in the
    July 2023, Service Member Fact Sheet (Information on Low-Level Blast
    Exposure: Service Member Fact Sheet (health.mil)). In the deployed
    setting, all servicemembers who are within 50 meters of a blast event
    are required to undergo a mandatory medical screening and evaluation.
    Required screenings and evaluation further build awareness of possible
    risks and normalizes use of the MHS to receive care for these types of
    experiences, thus further reducing any possible stigma associated with
    seeking care. Incident based protocols do not require the servicemember
    to self-identify the need for a medical evaluation; it is mandatory
    based on the potentially concussive event (i.e., blast event).
    Furthermore, servicemembers receive training and education on how to
    recognize BOP symptoms, requirements to report exposures to their
    command, and seeking an evaluation from their medical provider if
    experiencing symptoms.
        Military medical training institutions emphasize TBI prevention,
    diagnosis, and treatment through both enlisted and officer courses as
    part of our efforts to encourage accessing care and, whenever
    applicable, reduce and eliminate any potential stigma associated with
    receiving help. Additionally, the Military Services require
    servicemembers to take the Joint Knowledge Online course US 1114
    ``Concussion Training for servicemembers,'' which describes actions and
    responsibilities to protect warfighter brain health. Topics covered
    include the definition and causes of concussion, signs and symptoms of
    concussion, its impact on physical performance and mission readiness,
    and the roles and responsibilities of servicemembers and leaders as
    they pertain to concussion.

        31. Senator Warren. Secretary Martinez-Lopez, what steps is DOD and
    each of the services taking to ensure that servicemembers who come
    forward due to traumatic brain injury or blast overpressure effects do
    not face retaliation for doing so?
        Secretary Martinez-Lopez. Our first priority is the health of our
    servicemembers which is why we make every effort to encourage anyone
    who has experience symptoms related to BOP exposure or TBI to seek
    diagnosis and treatment. Taking care of our people, which includes
    protecting them from retaliation or reprisal in any form at any level,
    is important for our servicemembers' wellness and the overall readiness
    of our force. The Military Departments support servicemembers who are
    experiencing symptoms related to TBI or BOP exposure through clinical
    treatments for related symptoms and education and training on early
    recognition and treatment, the Department is implementing policy to
    ensure they are afforded every opportunity to protect their ability to
    serve along the way.

        32. Senator Warren. Secretary Martinez-Lopez, the New York Times
    reporting revealed that there are many cases where policies are not
    being implemented on the ground, i.e. troops were not actually
    following safety measures on the ground. What steps are you taking to
    work with the services to ensure that policy changes are being
    implemented on the ground?
        Secretary Martinez-Lopez. The DOD's Deputy's Safety Oversight
    Committee (DSOC) governance structure has been and will continue to
    support oversight and compliance activities to ensure policy changes
    are being implemented on the ground.

        33. Senator Warren. Dr. McBirney, and Dr. Zofante, are you aware of
    cases where servicemembers were retaliated against for coming forward
    about their injuries from blast overpressure and exposure?
        Dr. McBirney. I am not aware of any specific cases in which
    servicemembers were retaliated against for coming forward about their
    injuries from blast overpressure and exposure. However, there is ample
    research on the underreporting of injuries among servicemembers \3\--
    specifically, the underreporting of TBIs--and the reasons
    servicemembers underreport, one of them frequently being concerns that
    reporting could have negative consequences. A 2020 study assessing
    unreported and untreated TBI among more than 5,000 soldiers concluded
    that, of those who reported a concussion, only 52 percent sought
    medical care. Of those who did not seek care, 18 percent were concerned
    that reporting might have negative repercussions on their careers.
    Additionally, 28 percent of soldiers who experienced a mild TBI (and 11
    percent of soldiers who did not) reported that there is a stigma
    associated with mild TBI. \4\ This stigma goes beyond TBI and speaks to
    the culture across DOD--one in which there is stigma associated with
    seeking medical services and/or mental health treatment. \5\
    ---------------------------------------------------------------------------
        \3\ Laurel Smith, Richard Westrick, Sarah Sauers, Adam Cooper,
    Dennis Scofield, Pedro Claro, and Bradley Warr, ``Underreporting of
    Musculoskeletal Injuries in the US Army: Findings from an Infantry
    Brigade Combat Team Survey Study,'' Sports Health, Vol. 8, No. 6,
    November/December 2016.
        \4\ Sandra M. Escolas, Margie Luton, Hamid Ferdosi, Bianca D.
    Chavez, and Scot D. Engel, ``Traumatic Brain Injuries: Unreported and
    Untreated in an Army Population,'' Military Medicine, Vol. 185, Supp.
    1, January-February 2020.
        \5\ Kyong Hyatt, Linda L. Davis, and Julie Barroso, ``Chasing the
    Care: Soldiers Experience Following Combat-Related Mild Traumatic Brain
    Injury,'' Military Medicine, Vol. 179, No. 8, August 2014.
    ---------------------------------------------------------------------------
        Dr. Zafonte. I am not personally aware of any retaliation.

        34. Senator Warren. Dr. McBirney, and Dr. Zofante, what steps
    should DOD and the services take to encourage servicemembers to seek
    treatment and help both during and after their career?
        Dr. McBirney. Research shows that two common reasons servicemembers
    do not seek treatment for TBIs relate to stigma and the belief that
    their injury did not require care, \6\ the latter of which stems from a
    lack of education and awareness. Additional barriers to seeking
    treatment include logistical barriers and structural factors related to
    the military medical system (as detailed in Question 7). \7\ Therefore,
    there are several options that DOD has to encourage servicemembers to
    seek treatment. These include destigmatizing [mental] health care,
    enhancing the accessibility of services, implementing routine mental
    health screenings, training servicemembers and leadership on the signs
    of [mental] health issues and potential brain injury, establishing
    clear, confidential channels for servicemembers to provide feedback on
    care received and any barriers they encountered, and developing further
    peer support programs. \8\
    ---------------------------------------------------------------------------
        \6\ Joie D. Acosta, Wenjing Huang, Maria Orlando Edelen, Jennifer
    L. Cerully, Sarah Soliman, and Anita Chandra, Measuring Barriers to
    Mental Health Care in the Military: The RAND Barriers and Facilitators
    to Care Item Banks, RAND Corporation, RR-1762-OSD, 2018, https://
    www.rand.org/pubs/research--reports/RR1762.html; Escolas et al., 2020;
    Hyatt, Davis, and Barroso, 2014; Marie-Louise Sharp, Nicola T. Fear,
    Roberto J. Rona, Simon Wessely, Neil Greenberg, Norman Jones, and Laura
    Goodwin, ``Stigma as a Barrier to Seeking Health Care Among Military
    Personnel with Mental Health Problems,'' Epidemiologic Reviews, Vol.
    37, January 2015; Terri Tanielian, Mahlet Woldetsadik, Lisa Jaycox,
    Caroline Batka, Shaela Moen, Carrie Farmer, and Charles C. Engel,
    ``Barriers to Engaging Service Members in Mental Health Care Within the
    U.S. Military Health System,'' Psychiatric Services, Vol. 67, No. 7,
    July 2016.
        \7\ Acosta et al., 2018; Tanielian et al., 2016.
        \8\ Donald Berwick, Katherine Bowman, and Chanel Matney, eds.,
    ``Traumatic Brain Injury Prevention and Awareness,'' in Traumatic Brain
    Injury: A Roadmap for Accelerating Progress, The National Academies
    Press, 2022; Kathryn E. Bouskill, Carrie M. Farmer, Irineo Cabreros,
    Jonathan H. Cantor, Natalie C. Ernecoff, Lynn Hu, Shira H. Fischer,
    Aaron Kofner, Lisa S. Meredith, Matthew L. Mizel, Aneesa Motala,
    Tepring Piquado, Zachary Predmore, and Rajeev Ramchand, Improving Care
    for Veterans with Traumatic Brain Injury Across the Lifespan, RAND
    Corporation, RR-A1205-1, 2022, https://www.rand.org/pubs/research--
    reports/RRA1205-1.html; Escolas et al., 2020; Michael S. Jaffee,
    ``Traumatic Brain Injury and the Military Health System,'' in David
    Butler, Jessica Buono, Frederick Erdtmann, and Proctor Reid, eds.,
    Systems Engineering to Improve Traumatic Brain Injury Care in the
    Military Health System: Workshop Summary, The National Academies Press,
    2009; School of Education and Human Development, Texas A&M University,
    ``Support for Family Caregivers After Military Traumatic Brain
    Injuries,'' November 27, 2018.
    ---------------------------------------------------------------------------
        Dr. Zafonte. As a non-profit academic medical center, outside the
    system, I do not have sufficient personal knowledge of the internal
    barriers servicemembers face to seeking TBI treatment to respond to
    this question in detail.

        35. Senator Warren. Dr. McBirney, and Dr. Zofante, what steps
    should DOD and the services take to encourage servicemembers to follow
    safety measures to protect themselves from blast overpressure?
        Dr. McBirney. Perhaps the most effective way to encourage
    servicemembers to follow safety measures is through education and
    awareness. Servicemembers and leadership need authoritative information
    about the dangers of blast overpressure, including its sources and the
    potential short-and long-term health consequences. Regular training and
    awareness campaigns can help personnel understand why protective
    measures are necessary and how they can effectively mitigate risks. \9\
    Additionally, the dissemination of safety equipment that is both
    validated and functional will encourage safety members to protect
    themselves from blast overpressure.
    ---------------------------------------------------------------------------
        \9\ Berwick, Bowman, and Matney, 2022.
    ---------------------------------------------------------------------------
        Dr. Zafonte. As a non-profit academic medical center, outside the
    system, I do not have sufficient personal knowledge on the internal
    incentives or barriers to servicemembers following safety measures.
                         providing service members care
        36. Senator Warren. Dr. Zofante and Captain Williams, how many
    servicemembers do you have on your waitlist and what is the average
    wait period for them to start your respective programs?
        Dr. Zafonte. Currently, there are 236 Special Operations personnel
    in the screening and review process. We have scheduled 241 Special
    Operations personnel for an upcoming cohort. From the start of the
    first engagement with a potential participant, the average wait time is
    12-15 months.
        Captain Williams. The National Intrepid Center of Excellence
    (NICoE) and the larger Defense Intrepid Network (DIN), 13 facilities
    total, have two outpatient program types, the traditional outpatient
    traumatic brain injury (TBI) clinic model and the interdisciplinary
    intensive outpatient program (IOP). The Defense Health Agency access to
    care standard for a specialty care program is 28 calendar days from
    date of referral. Servicemembers referred to the traditional outpatient
    clinic model consistently meet the access to care standard.
        Nine of the 13 DIN sites have the IOP, and the waitlist for these
    locations is approximately 640 servicemembers. Each site proactively
    schedules patients into the program as openings become available, with
    servicemembers typically booked within three to 6 months.
        It should be noted that, in pursuit of career goals, there are
    periods in the training and deployment rotation of servicemembers where
    they are more willing to commit to the 4-week IOP program. Many of
    these patients are still functioning at a high capacity (but not at
    their full potential). Therefore, time from referral to engagement in
    the IOP is not always considered to be an ``as soon as possible''
    appointment by the servicemembers.

        37. Senator Warren. Dr. Zofante and Captain Williams, how much
    additional funding would you need to address the servicemembers on your
    wait list for your respective programs?
        Dr. Zafonte. Home Base is funded almost entirely through
    philanthropy with some supplemental State and Federal appropriations.
    Every dollar that we bring in makes an impact on how many patients we
    can treat, the programs we can support, and the innovation that we can
    pilot. The primary obstacle to reducing the waitlist is the absence of
    adequate physical space for treatment and the need to expand our pool
    of qualified healthcare providers. Home Base launched a capitol
    campaign and was successful in raising funds to build a new floor for
    our headquarters in Charleston, MA. When we complete that space in mid-
    2024, we will have the capacity to see twice as many patients weekly as
    part of the ComBHaT program. Increased Federal support for Home Base
    would allow the organization to continue building out a world-class
    provider team, ensure continued investment in innovative treatment
    models and technology, and allow us to remain the gold standard for
    treating TBI and invisible wounds of war.
        Captain Williams. The additional resources necessary to address the
    wait list are associated with increased specialized clinical personnel
    and an exemption from standard healthcare productivity practices.
    Staffing models for practice guidelines of interdisciplinary care,
    including outpatient and IOP programs, are currently being established
    for further determination of manning requirements.

        38. Senator Warren. Dr. Zofante and Captain Williams, how much
    advance notice do servicemembers get before they are able to enter your
    program?
        Dr. Zafonte. Entering the ComBHaT program is a multi-step process.
    Prospective participants reach out over the phone, via email, or
    through an online ``connect to care'' platform. Once an interest form
    is submitted, a team member from Home Base reaches out to the
    prospective patient and begins the screening and intake process. That
    process is multi-faceted and may include a medical clearance process
    before the Special Operations personnel can participate. Once cleared
    for admission, the team works with the participant to find a time that
    can work with the up-tempo schedule of Active Duty Special Operations
    personnel. The entire process can take 12 to 18 months. Home Base also
    maintains a standby list of people who are interested in filling the
    spot for a last-minute cancellation.
        Captain Williams. Each DIN site varies on the advance notice
    provided to servicemembers. Typically, servicemembers often prefer
    dates that are optimal for their training and deployment rotations and
    can have upwards of 3 months' notice. However, due to the potential for
    quickly changing circumstances with each individual patient, positions
    in the IOP cohorts may open due to cancelations, sometimes with only
    days or a few weeks' notice. Unscheduled members on the waitlist are
    immediately offered the opportunity to attend if they are agreeable and
    available.
        See comment on question 36 above for additional clarification.

        39. Senator Warren. Dr. Zofante and Captain Williams, what onsite
    childcare options do you have for servicemembers when they attend your
    program?
        Dr. Zafonte. Home Base does not currently offer onsite childcare
    for our participants.
        Captain Williams. There are currently no onsite dedicated childcare
    services across the network. Some installations have Child Development
    Centers or Child and Youth Services that may be able to provide hourly
    care for those registered with each individual program.

        40. Senator Warren. Dr. Zofante and Captain Williams, what is the
    average number of servicemembers whose families are able to attend your
    respective programs as well?
        Dr. Zafonte. We invite all ComBHaT participants to bring family
    support. Approximately 50 to 60 percent of ComBHaT patients bring a
    family support member with them for the 5-day evaluation program.
        Captain Williams. The numbers of spouses/families that choose to
    participate varies across locations in the DIN, ranging from 5 to 25
    percent of spouses/families.

        41. Senator Warren. Dr. Zofante and Captain Williams, at what point
    in their career do most servicemembers attend your respective programs?
        Dr. Zafonte. We have a diverse range of participants in ComBHaT,
    from early careers to veterans. While we do not actively track our
    participants' career stages in our data set, anecdotally, the majority
    are in their final few years of service. Home Base has recently seen an
    uptick in senior leaders (E-8/E-9 and O-5 through O-9) participating in
    the ComBHaT program.
        Captain Williams. Most members attending the DIN intensive
    outpatient programs have greater than 15 years' time in service.
        This percentage is slightly impacted by the military occupation
    and/or community, severity of TBI and Service affiliation. It is common
    for servicemembers with TBI symptoms and associated conditions to not
    to seek care until they are nearing the end of their careers due to
    fears of stigma, non-deployability, or duty limiting profiles.
    Therefore, comprehensive medical and psychological evaluations near the
    end of their career, including diagnoses and treatment for TBI
    symptoms, continues to be highly sought after. Specific DIN locations
    reported the following:
        A.  ISC Fort Liberty (Army Special Operations) reported that about
    75 percent are within 2 years of retirement with the other 25 percent
    at mid-career (10-12 year).
        B.  ISC Camp Lejeune (Marine Special Operations) reported that the
    majority of IOP patients are at 815 to 18 years of service; the
    outpatient program varies from first acute concussions event to pending
    retirement (e.g., 18+ years).
        C.  ISC Eglin (Airforce Special Operations) reports for both IOP
    and OP the average is 16 years' time in service with an average patient
    age of 37 years old.
        D.  ISC Camp Pendleton (1st Marine Expeditionary Force) reported a
    majority of servicemembers have ten or more years of service.
        E.  ISC Ft. Cavazos reported there has been a diverse
    representation of mid and late career enlisted and officer
    participation at both levels of care (outpatient and IOP) over the last
    decade. In the last 2 years, there has been a spike in early career or
    junior soldiers who have not deployed but sustained concussions in
    while in garrison.

        42. Senator Warren. Dr. McBirney, and Dr. Zofante, what are the
    biggest gaps in information getting to servicemembers and their
    families about blast overpressure risks and symptoms, as well as
    options for treatment?
        Dr. McBirney. My research has not focused on this, so I will defer
    to my colleagues to answer this question.
        Dr. Zafonte. As a non-profit academic medical center outside the
    DOD system, I do not have sufficient personal knowledge on how DOD
    shares information with servicemembers and their families. However, to
    my knowledge, most servicemembers who come to Home Base learn about the
    program from their peers and self-refer to the program. I recommend
    that DOD ensure that high-quality evidence-based programs in the
    private sector are easily accessible to servicemembers and their
    families.

        43. Senator Warren. Dr. McBirney, and Dr. Zofante, what are the
    biggest barriers to servicemembers seeking and obtaining treatment for
    blast overpressure and exposure?
        Dr. McBirney. While there is little to no research on the barriers
    that prevent servicemembers from seeking and/or obtaining treatment
    specifically for blast overpressure and exposure, there is some
    research on barriers that prevent servicemembers from seeking treatment
    for TBI and further research on barriers related to the treatment of
    mental health and other health issues. Barriers include those that are
    purely logistical (e.g., difficulty scheduling an appointment \10\);
    structural factors associated with the military medical system (e.g.,
    limited capacity of the system, limited number of providers available
    to address needs); \11\ a lack of knowledge of the risks of exposure to
    lower-level blasts; \12\ and institutional attitudes and cultural
    issues, also known as public stigma \13\ (e.g., perceived attitudes
    held by leadership, \14\ concerns that seeking care could have negative
    career repercussions \15\).
    ---------------------------------------------------------------------------
        \10\ Acosta et al., 2018.
        \11\ Tanielian et al., 2016.
        \12\ Escolas et al., 2020.
        \13\ Tanielian et al., 2016.
        \14\ Acosta et al., 2018; Sharp et al., 2015; Tanielian et al.,
    2016.
        \15\ Escolas et al., 2020; Hyatt, Davis, and Barroso, 2014;
    Tanielian et al., 2016.
    ---------------------------------------------------------------------------
        Dr. Zafonte. Servicemembers often avoid seeking care for blast-
    related injuries due to several interrelated reasons:
        1. Stigma: There is a pervasive stigma associated with seeking
    medical or psychological help, often viewed as a sign of weakness. Many
    servicemembers fear that admitting to an injury, especially one
    involving mental health, could negatively impact their careers and how
    peers and superiors perceive them.
        2. Desire to Stay in the Fight: The strong sense of duty and
    commitment to their mission drives many servicemembers to downplay or
    ignore their injuries. They may fear being sidelined or removed from
    Active Duty, which could prevent them from fulfilling their
    responsibilities and supporting their comrades.
        3. Concern for Team Members: Servicemembers often prioritize the
    well-being of their team over their own health. They worry that seeking
    treatment could leave their team shorthanded, increasing the risk for
    their fellow soldiers and potentially compromising the mission.
        4. Lack of Recognition of Subtle Symptoms: Blast-related injuries,
    particularly traumatic brain injuries (TBI), can have subtle and
    delayed symptoms that are not immediately recognized. Servicemembers
    may attribute these symptoms to stress, fatigue, or other benign
    causes, leading to a delay in seeking appropriate care.
        Addressing these barriers requires a cultural shift within military
    organizations to normalize seeking help and recognize the importance of
    early intervention for blast-related injuries.
                                   __________
                 Questions Submitted by Senator Tammy Duckworth
                         blood tests for tbi screening
        44. Senator Duckworth. Secretary Martinez-Lopez and Ms. Lee, the
    Department of Defense (DOD) has recognized the need for an accurate
    blood test to assess concussions and screen military personnel for
    traumatic brain injuries. Due to DOD's leadership in this space and
    working with industry to bring such a test to market, there now exists
    an FDA-cleared blood test available to servicemembers and civilians
    alike. However, more research and clinical trials are needed to make
    this test available from the battlefield to the sports field, and to
    truly operationalize the point-of-care ability of a TBI test. How is
    DOD continuing to work with the stakeholder community to drive this
    research forward?
        Secretary Martinez-Lopez and Ms. Lee. The Department published the
    WBH Research Strategy in January 2024 which provides guidance for DOD
    medical and operational research and development (R&D) activities to
    coordinate, optimize, and advance WBH science. Specifically, focus area
    2.6 of the WBH Research Strategy, ``Assessing and Diagnosing Warfighter
    Brain Injuries,'' recognizes blood biomarkers as a priority. Select
    medical units within the DOD have fielded blood biomarker kits in their
    medical equipment sets. The WBH Vision outlines R&D efforts focused on
    brain health hazards, threats, and operational requirements, with the
    goal of rapidly transitioning products and practices to optimize WBH
    and performance. The Department also collaborates with multiple
    stakeholders to include industry partners, academic institutions, and
    other Federal agencies within the context of the National Academies of
    Science, Engineering and Medicine (NASEM) TBI Forum, specifically in
    the area of biomarkers for TBI. In April, the Director of the WBH
    Office presented at a National Academies of Science, Engineering, and
    Medicine (NASEM) workshop on `Innovation Trends in Technology for the
    Prevention, Treatment, and Management of TBI' to outline the DOD's
    challenges and barriers to using TBI FDA cleared devices as part of
    ongoing efforts to maximize implementation and to and drive research
    and innovation in this space.

        45. Senator Duckworth. Secretary Martinez-Lopez and Ms. Lee, are
    there other opportunities to work with Federal partners like VA, CDC,
    BARDA, and NIH to research, update, and disseminate best practices and
    evidence-based diagnosis for TBI?
        Secretary Martinez-Lopez and Ms. Lee. Yes, there are many
    opportunities to partner. The Department has a long history of
    successful partnerships with other Federal agencies and organizations
    in advancing clinical practice, conducting research, developing
    educational and prevention and awareness products and exploring
    technology solutions. For example, the DOD partnered with the VA to
    publish the ``VA/DOD Clinical Practice Guideline for the Management and
    Rehabilitation of Post Acute Mild Traumatic Brain Injury,'' in June
    2021. In 2023, the Department has partnered with the Department of
    Health and Human Services, the VA, and the Department of Transportation
    to lead and support recently published recommendations from the NASEM
    report, ``Traumatic Brain Injury: A Roadmap for Accelerating
    Progress.''
                                   __________
                   Questions Submitted by Senator Joni Ernst
                                early detection
        46. Senator Ernst. Dr. Zafonte and Captain Williams, what methods
    are there to diagnose TBI where the wounds are undetectable on MRI and
    PET scans?
        Dr. Zafonte. For servicemembers with negative standard anatomic MRI
    scans, more sophisticated diagnostic tools are essential to detect
    subtle or cumulative injuries that might not be visible on conventional
    imaging. Multimodality scanning, which employs advanced MRI paradigms
    potentially linked to PET-based markers, offers a more comprehensive
    assessment of brain function and structure. These advanced imaging
    techniques can reveal microstructural damage, metabolic changes, and
    other subtle abnormalities indicative of traumatic brain injury (TBI).
        Additionally, blood-based biomarkers, as well as physiological and
    reaction markers, hold promise for enhancing our understanding of both
    short-and long-term exposure effects. These biomarkers can provide
    critical information about the biological processes underlying injury
    and recovery, thereby supporting clinical diagnosis and monitoring.
        It is crucial to link these sub-markers and tools to clinical
    symptoms, resilience factors, and long-term maladaptation. This linkage
    ensures that diagnostic findings are relevant and actionable within a
    clinical context. By correlating biomarkers and advanced imaging
    results with clinical presentations and patient outcomes, we can
    develop more targeted and effective treatment plans. This holistic
    approach enhances our ability to identify those at risk, monitor their
    recovery, and ultimately improve the long-term health and resilience of
    our servicemembers.
        Captain Williams. The most reliable method to diagnosis continues
    to be history and physical examination of the patient. Blood based
    biomarkers are an important emerging tool in TBI diagnosis. Advanced
    technologies to further characterize TBI, including
    magnetoencephalography (MEG) and quantitative EEG methods that look at
    neural network disruptions, remain under research investigation.
        The most reliable mechanism for assessing the invisible wounds of
    war is still a sound medical history and neurological/
    neuropsychological and behavioral health evaluations. Interdisciplinary
    approaches leverage the expertise of each provider and enhances the
    understanding of the multifaceted disease State. Not only do
    neurological and behavioral health providers shed light on brain health
    and functioning, but assessments by internal medicine (endocrinological
    disturbances, nutritional deficiencies), physiatry, and rehabilitation
    providers identify important medical conditions that impact cognitive
    bandwidth, level of performance, and emotional regulation.
        Each interdisciplinary team member has objective and subjective
    screening tools and outcome measures. These approaches include not only
    diagnosis of TBI but treatment of symptoms and sequelae. Some examples
    include a servicemember's neurocognitive testing helps to understand
    disruption of cognitive domains, levels of functioning, and emotional
    regulation. Assessment of sleep disturbances is also a critical
    component in the assessment and treatment of TBI, sub concussive
    events, blast exposure, and psychological health conditions. In
    addition, utilization of the creative arts therapies has been
    advantageous in the externalization of otherwise compartmentalized and
    untreated symptoms for servicemembers.

        47. Senator Ernst. Dr. Zafonte, are there other alternatives
    available Automated Neuropsychological Assessment Metrics (A-NAM) test
    that is used by the DOD an accurate method of detecting changes in
    cognition that can lead to a TBI diagnosis?
        Dr. Zafonte. ANAM is used to assess for cognitive deficits acutely,
    usually within the first week, following a traumatic brain injury. It
    is typically used in the first few days following a mild traumatic
    brain injury. There has been a large amount of research published over
    the past 15 years relating to using ANAM and other neuropsychological
    test batteries for this purpose. Each battery carries known limitations
    and strengths. To address this question adequately, a working group
    would need to review the State of the science on this topic.

        48. Senator Ernst. Dr. Zafonte, would wearable devices assist in
    the diagnosis of these types of TBI? If so, what kind?
        Dr. Zafonte. Implementing wearable technology to detect blast
    exposure represents a significant advancement in identifying
    servicemembers at cumulative risk and refining exposure thresholds.
    These devices can continuously monitor environmental factors and
    physical responses, providing real-time data on blast intensity and
    frequency. This information is crucial in recognizing those who might
    be at increased risk due to repeated low-level exposures that could
    cumulatively result in significant harm.
        While wearable technology offers valuable insights, it is important
    to understand that it does not diagnose traumatic brain injuries (TBI)
    on its own. Instead, these devices serve as an early warning system,
    raising suspicion of potential injuries based on exposure patterns.
    They provide additional evidence that clinicians can use to make more
    informed decisions about further evaluation and potential intervention.
        By integrating data from wearable technology with clinical
    assessments, we can enhance our ability to identify at-risk individuals
    early, potentially before significant symptoms manifest. This proactive
    approach supports better outcomes by enabling timely and targeted care,
    ultimately improving the health and readiness of our servicemembers.

        49. Senator Ernst. Secretary Martinez-Lopez and Captain Williams,
    earlier, we heard from Mr. Larkin, whose son Ryan had microscopic tears
    on his brain that were not detectable on MRI and PET scans. What
    methods are there to diagnose TBIs like this?
        Secretary Martinez-Lopez and Captain Williams. There is no approved
    technology to radiographically diagnose microscopic tears. These
    injuries can be below the resolution of conventional and advanced
    imagery; therefore, a variety of assessment and treatment approaches
    are utilized to identify neurological network disruptions. This makes
    the interdisciplinary model critical for targeting treatment and
    recovery, as well as deploying investigatory technology such as MEG and
    Quantitative Electroencephalography (QEEG).
        See comment on question 46 above for additional information.

        50. Senator Ernst. Secretary Martinez-Lopez, when will the DOD
    transition from the pre-deployment neurocognitive testing to the
    broader screening program?
        Secretary Martinez-Lopez. The Department plans to expand the
    current cognitive assessment testing beginning June 2024 at 15 initial
    military training sites.

        51. Senator Ernst. Secretary Martinez-Lopez, what neurocognitive
    test are you using and why is this best suited for our servicemembers?
        Secretary Martinez-Lopez. For several years, the DOD has used the
    ANAM as the primary neurocognitive test to meet the requirements
    outlined in DOD Instruction 6490.13, ``Comprehensive Policy on
    Traumatic Brain Injury-Related Neurocognitive Assessments by the
    Military Services,'' September 11, 2015, as amended. The Army has been
    the lead agent in executing the Department's neurocognitive program and
    has collected over 3.7 million baseline tests (approximately 93-95
    percent are pre-deployment). A sample size of the data within the
    repository supported the publication of the ``Long-Term Test--Retest
    Stability of ANAM in a Large Military Sample \1\.'' The study results
    indicate that the use of the ANAM baseline for comparison can be done
    up to 5 years, thus the baseline results are stable. To date the
    Department continues to use the ANAM as the primary neurocognitive test
    as there has been no data to demonstrate superiority of another
    assessment tool, despite head-to-head comparison studies of
    computerized neurocognitive tests \2\.
    ---------------------------------------------------------------------------
        \1\ Meyers J. (2019). Long-Term Test-Retest of ANAM in a Large
    Military Sample. Archives of Clinical Neuropsychology 35 (2020) 70-74.
        \2\ Wesley C. (2017). A Comparison of Four Computerized
    Neurocognitive Assessment Tools to a Traditional Neuropsychological
    Test Battery in servicemembers with and without Mild Traumatic Brain
    Injury. Archives of Clinical Neuropsychology 33 (2018) 102-119.

        52. Senator Ernst. Ms. Lee, what information are you providing to
    servicemembers and their families about the Warfighter Brain Health
    Initiative?
        Ms. Lee. In additional to information provided to servicemembers
    seen in TBI clinics, we have education and awareness efforts tailored
    for military and family members. The WBH Hub, established in December
    2023 (at health.mil/brain), serves as the single source of information
    on brain health topics. Our goal is to make the latest brain health
    information easy to access for our servicemembers, providers, families,
    and the public and provide a bridge from our clinical community to the
    operational environment.

        53. Senator Ernst. Ms. Lee, what positive impacts has the
    Warfighter Brain Health Initiative made on the servicemembers and their
    families?
        Ms. Lee. The outreach activities that support the WBH Initiative
    (WBHI) have positively impacted the overall awareness of the importance
    of optimizing brain health. Due to multiple educational efforts,
    especially throughout March, which is Brain Injury Awareness Month,
    servicemembers and their families have increased knowledge and
    resources available to them. The WBHI offers extensive support in areas
    crucial to military relevance, including cognitive performance, brain
    health, BOP exposures, TBI evaluations, treatments, care, and long term
    or late effects of brain exposures and injuries. This broad scope
    provides numerous opportunities for positively impacting the readiness
    of the Force and enhancing the quality of life for servicemembers and
    their families.

        54. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, how is the
    Department screening servicemembers who may have developed TBI in a
    deployed location?
        Secretary Martinez-Lopez and Ms. Lee. DODI 6490.11, ``DOD Policy
    Guidance for Management of Mild Traumatic Brain Injury/Concussion in
    the Deployed Setting,'' September 18, 2012, as amended, directs a
    medical screening and evaluation of a servicemember that has been
    involved in a potentially concussive event, such as being 50 meters or
    closer to a blast incident. DOD policy dictates that the MACE 2
    screening tool and PRA are used nearest to time of injury and drive
    clinical decisionmaking for immediate care. Upon redeployment there are
    standardized medical assessments which occur twice and are facilitated
    through the Post Deployment Health Assessment Form DD 2796 and the Post
    Deployment Health Re Assessment Form DD 2900. All military health care
    facilities have providers trained in TBI screening with the ability to
    refer patients to one of the TBI clinics or to the Defense Intrepid
    Network for TBI and Brain Health for more comprehensive care. As a part
    of the continuum of care, servicemembers receive ongoing evaluation and
    treatment by a primary care provider during the annual Periodic Health
    Assessment, and those individuals reporting a history of TBI (or
    circumstances suggestive of the possibility) are further assessed for
    their Service or treatment needs.

        55. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, what can
    the DOD do to expedite developing a system to monitor blast exposure
    among servicemembers?
        Secretary Martinez-Lopez and Ms. Lee. The DOD has multiple efforts
    underway, the first major step was the Assistant Secretary of Defense
    for Readiness memorandum (discussed above), published November 4, 2022,
    ``Interim Guidance for Managing Brain Health Risk from Blast
    Overpressure.'' This memorandum provided guidance to implement the
    following mitigation strategies: (1) minimizing the number of personnel
    in the vicinity of BOP events; (2) increasing standoff distances from
    weapons; (3) minimizing the duration of live fire events; (4)
    establishing a maximum allowable number of rounds that may be fired
    during each event or time period; (5) ensuring application and
    appropriate use of personal protective gear and equipment (e.g.,
    hearing protection); and (6) training and educating on blast
    overpressure hazards and risk management actions.
        The Assistant Secretary of Defense for Health Affairs is working
    with the Military Departments the Assistant Secretary of Defense for
    Readiness, and DOD's Public Health and occupational health subject
    matter experts to develop a dose response curve for BOP (currently this
    does not exist in either the military or the civilian sector). In
    parallel, we are seeking supplementary data sources and ammunition
    distribution logs that might provide blast exposure by weapon system or
    round with both timing and unit level information. Last, the DHA is
    leading a BCA on BOP monitoring, with a projected completion of
    December 2024. The BCA will evaluate various methods for monitoring and
    documenting BOP exposures, such as recording shot counts, using MOS's
    as proxies for blast exposure, surveys and questionnaires through self-
    reporting, and wearable blast sensors.

        56. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
    Williams, can you detail the current State of brain-computer interface
    (BCI) technology and how it's being utilized within the Department of
    Defense (DOD) to detect, measure, or assist in recovery from traumatic
    brain injuries (TBIs) among servicemembers?''
        Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The DIN
    uses Bio and Neurofeedback (NFB) as a form of BCI. BCI represents a
    body of science focused on the acquisition of brain signals, signal
    analysis and translation into commands that control an external device
    to replace or restore useful function to people with neurological/
    neuromuscular disorders.
        In the DIN, utilization of BCI focuses on techniques designed to
    improve internal brain-body performance by acquiring brain wave
    information and augmenting brain wave band power through NFB. NFB
    converts neural signals into visual, auditory, and tactile information,
    and the subject can selectively enhance or inhibit certain components
    to promote learning and regulate brain function through real-time NFB
    training. Studies in the DIN network and in the academic community have
    demonstrated the ability to enhance performance in memory,
    concentration, and limb movement. A similar process is used in
    biofeedback to regulate internal brain-heart coherence, sweat response,
    respiration rate and skin temperature to modulate the bodies autonomic
    nervous system. Additionally, NICoE is leveraging MEG technology in
    research protocols to characterize the complex waveform harmonics of
    the brain in understanding distortion and patterns in posttraumatic
    stress disorder. These precision real-time characterizations may
    provide future strategies for improving treatment of posttraumatic
    stress and other behavioral health disorders in the setting of
    traumatic brain injury.

        57. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
    Williams, how is BCI technology being planned for and/or transitioned
    from various innovation and R&D portfolios across the Department and
    services to be integrated into operational routines to potentially
    monitor and measure overall brain health and TBI indicators from the
    time of entry into service until completion of service for our
    servicemembers?
        Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The DOD,
    to include the DIN, does not currently utilize BCI technology for
    monitoring of overall brain health and TBI indicators during service.
    We will continue to evaluate findings from our research investments for
    possible integration where appropriate.
        See comment on question 56 above for more information.

        58. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
    Williams, what are the projected priorities, investments, and key
    developments in the field of BCI technology over the current FYDP and
    future needs for the Department, specifically as it relates to improved
    monitoring, data, and improved detection to improve outcomes for
    servicemembers with TBI?
        Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. There are
    currently no set clinical priorities for BCI technology.
        See comment on question 56 above for more information.

        59. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
    Williams, what is the current protocol, cadence, and process for a
    servicemember to be identified as being at risk for TBI, evaluated, and
    subsequent followup? Please include associated timelines, general cost
    per servicemember, and confidence/accuracy of reliable TBI detection at
    scale.
        Secretary Martinez-Lopez, Ms. Lee, and Captain Williams.
    Comprehensive screening protocols to identify servicemembers being at
    risk for TBI include assessing for potential risk factors such as
    history of head injuries, behavioral health conditions, and combat
    exposure. Cadence of screenings varies depending on factors such as
    deployment cycles, mission requirements and changes in individual
    health status. Deployment cycle evaluations include the pre deployment
    health assessment, the post deployment health assessment and the post
    deployment health reassessment, which are all opportunities for
    servicemembers to be identified as being at risk for TBI and evaluated.
    Throughout all these standardized processes, if a servicemember is
    identified as being at risk for TBI, then they are referred for further
    evaluation. There is no monetary cost to the servicemember.

        60. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
    Williams, what congressional support and guidance needs to be provided
    in order for the Department of Defense to have the necessary
    authorities and resources to ensure that the personnel and healthcare
    leadership across each service are able to develop and employ programs
    that would use BCI technology to monitor, track and mitigate risks such
    as TBI, costly fatigue/focus mishaps, or other relevant brain health
    categories?
        Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The
    Department has the necessary authorities to employ BCI technology to
    monitor, track, and mitigate risks such as TBI, which would require a
    prospective longitudinally monitored program to establish a normative
    data set with neurocognitive testing, blood biomarkers, cerebral
    vasomotor reactivity measurements and quantitative
    electroencephalography matched against time in service, and the
    tracking of various Military Occupational Specialties with different
    levels of exposure to different weapons systems (including Explosive
    Ordinance Disposal, Special Warfare Combatant Crewmen personnel, and
    paratroopers).
        See comment on question 56, 57 and 58 above for more information.
                              treatment approaches
        61. Senator Ernst. Ms. Lee, during your tenure at the Warfighter
    Brain Health Policy Initiative, what non-conventional treatments have
    been seen to be effective in treating TBI?
        Ms. Lee. The Defense Intrepid Network for TBI and Brain Health
    utilizes many innovative and non-conventional treatments to help
    relieve symptoms and to optimize functioning and well-being. Many of
    these treatments are undergoing empirical validation of their
    effectiveness. Some examples of these treatments include biofeedback
    and mindfulness training, acupuncture, therapeutic arts, such as music,
    writing, art, dance and movement, and animal engagement, such as canine
    and equine therapy.

        62. Senator Ernst. Captain Williams, Intrepid Centers offer
    specialized treatments focused on treating TBI that are not widely
    available at other military treatment facilities. Can you describe some
    of these treatments and their effectiveness in treating TBI?
        Captain Williams. Repetitive TBI operational stressors can result
    in an overall disruption of brain health characterized by a wide
    variety of symptoms and conditions. The key to treatment is the
    establishment of a patient-centric interdisciplinary holistic program,
    to address the injuries of mind, body, brain, and spirit, to enhance
    return to duty, and improve interpersonal relationships, and overall
    functioning.
        The DIN uses an interdisciplinary model of care, where the
    treatment team specialties to treat TBI and associated psychological
    health conditions are co-located within one facility. The NICoE program
    leverages the co-localization of 18 disciplines and treatment
    modalities combine conventional neurological, behavioral health and
    rehabilitation therapies with integrative medicine interventions and
    educational modules to promote a culture of healing, self-efficacy, and
    self-advocacy. This includes creative arts therapies (art therapy,
    dance movement therapy and music therapy) that provide an essential
    integrated behavioral health approach, in conjunction with mind-body
    wellness services, biofeedback, and psychological health services.
    Integration of this ``high touch'' to the ``high tech'' paradigm,
    includes neuroimaging, neuro-optometry, audiology, vestibular testing,
    and augmented reality/virtual reality assessment and treatment. NICoE
    and other DIN sites also teach detailed cognitive strategy and
    assistive technology training, including the Brain Fitness Center,
    which uses personal cognitive training programs.
        The interdisciplinary team approach expedites diagnostic evaluation
    and helps achieve a collaborative comprehensive care plan. Studies have
    shown significant improvement using this model of care in recovery
    across multiple neurological and behavioral health domains. Since the
    onset, there are now 13 centers that use this interdisciplinary model
    for both intensive outpatient programs and extended outpatient
    programs.
        The NICoE intensive outpatient program includes the scheduling of
    105-130 separate encounters (varies with individual need) across 4
    weeks with the assessment and treatment across 18 disciplines. The
    clinical program is informed by research conducted at the NICoE and
    with academic and industry partners. Our research has demonstrated
    statistically significant and clinically meaningful recovery across
    seven major domains of functioning.

        63. Senator Ernst. Captain Williams, how do we make these
    treatments more accessible to servicemembers with TBIs?
        Captain Williams. The formalization of the DIN will accelerate the
    standardization of TBI specialty care across the DHA and increase
    programs that provide the same high-quality care for our beneficiaries.
    Our best practices can be utilized by all TBI providers across the
    military health system.
        The establishment of the DIN supports local and regional patient
    populations, as well as local and regional referring entities. It will
    allow expansion of services and sharing of resources within the DIN
    sites via telehealth services. The primary focus will be Active Duty
    servicemembers who have experienced a TBI, are at greatest risk of TBI
    injury and blast exposure, or those who may experience sub-concussive
    events. Formalization of the DIN will also allow for retirees and
    beneficiaries to access services. The DIN also strives to partner with
    other Centers of Excellence to continue expansion and accessibility of
    care.
        In addition, the Continuum of Caring, Healing and Thriving
    Initiative (the Continuum) is intended to facilitate a seamless
    transition of care by sharing resources for mental health treatment and
    peer networks at the Department of Veterans Affairs and non-
    governmental organizations, creating great opportunities for public-
    private partnerships and to work closer with operational units to
    prevent, educate and build resilience in the warfighter (aligning with
    lines of effort of the Warfighter Brain Health Initiative). The
    Continuum will allow the DIN the opportunity to support servicemembers
    in their journey long after they have completed treatment, with peer
    support and case management, and assist them as they transition into
    civilian life.

        64. Senator Ernst. Secretary Martinez-Lopez and Dr. Williams: The
    legislation responsible for the creation of the National Intrepid
    Center of Excellence is 15-years old, yet I understand that your
    program is not a ``program of record'' for the Department of Defense.
    Is that accurate, and if so, why is that the case? What are the
    implications of not being a program of record?
        Secretary Martinez-Lopez, and Captain Williams. Yes, the DIN, which
    includes the NICoE, is not a program of record. As the TBI facilities
    have become a network with centralized governance, establishing the DIN
    as a program of record is the next step.
        Activities that are not a program of record do not have a separate
    allocation of funds for that activity. That means the activity is
    included in the overall medical facility funding and must compete with
    other personnel and resource funding priorities. The impact to care can
    be more consequential at DIN sites where there is a model of care
    utilizing unique staffing patterns and there may be little capability
    in the private sector. Presently, the NICoE, and associated DIN TBI
    clinics are funded from Defense Health Program dollars for their
    respective military medical treatment facilities.

        65. Senator Ernst. Captain Williams, what recommendations would you
    make to improve the Department's ability to treat military personnel
    who, as part of the job, are repeatedly exposed to low-level blasts?
        Captain Williams. Start conducting baseline identification upon
    entering the military and/or engaging in high-risk Military
    Occupational Specialties, including neurocognitive testing, and
    monitoring over time and/or change in functioning. It is also crucial
    to support early career training on sleep hygiene, dietary/nutritional
    assessment, exercises that promote autonomic control, and emotional
    regulation. Behavioral health assessments and treatment following
    deployment are also important to introduce behavioral health as self-
    care and teach team member monitoring as part of the culture of peak
    combat performance. This will help minimize the stigma of prevention
    and increase resilience.
                       warfighter brain health initiative
        66. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, in order
    to assess the operation needs of the Services with regard to the
    Warfighter Brain Health Initiative, how does the DOD/DHA maintain
    awareness of the needs and concerns of the operational communities that
    they support?
        Secretary Martinez-Lopez and Ms. Lee. DOD governance structures are
    the primary means by which we maintain awareness of the needs and
    concerns of the operational community. I, as the Assistant Secretary of
    Defense for Health Affairs, coordinate through the Under Secretary of
    Defense for Personnel and Readiness, with the Assistant Secretary of
    Defense for Readiness and other senior officials within the Office of
    the Secretary of Defense, to execute requirements related to
    operational communities. To maintain awareness, DOD leverages the
    current MHS governance structure, which includes representatives from
    the Military Departments, and executes operational needs and
    requirements through the Joint Staff processes and initiatives.

        67. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, how are
    the military department's priorities communicated to the DHA Commander
    and staff and likewise, what is the mechanism for DHA to engage with
    senior operational leaders providing updates on the evolving science
    impacting the Military Department's personnel health and readiness?
        Secretary Martinez-Lopez and Ms. Lee. Refer to question 66 above
    for the same mechanism to communicate the Departments priorities.

        68. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, who in DHA
    has the responsibility for drafting the requirement/Capabilities
    Development Document for the blast dosimeter program? Has this process
    already started? What is the status of the program?
        Secretary Martinez-Lopez and Ms. Lee. A blast dosimeter program has
    not been developed. The DHA J5 (Strategy, Plans and Policy) is
    responsible for drafting requirements documents. Currently the MHS has
    published Initial Capabilities Documents addressing research solutions
    for WBH, combat casualty care and military operational medicine, which
    will support the development of Capabilities Development Documents for
    a blast dosimeter program.
                                   __________
                  Questions Submitted by Senator Dan Sullivan
                       marine artillerymen tbis in syria
        69. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, in
    large scale combat operations against a peer adversary, artillerymen
    are going to fire thousands of rounds. Can you tell me what the DOD is
    doing to ensure the experience of the marines who were deployed to
    Syria in 2016 and 2017, as reported in the New York Times article from
    November 5, 2023 titled ``A Secret War, Strange New Wounds, and Silence
    from the Pentagon,'' is not repeated?
        Secretary Martinez-Lopez and Ms. Lee. In response to recent
    casualty events in Syria, the Department reviewed its procedures in
    place for the reporting of potentially concussive events (PCE) and its
    management of TBI. It is important to acknowledge that our
    understanding and focus on brain injury and pivot to WBH is evolving.
    Before WBH our medical and policy practices included exposures to PCEs
    but remained focused on TBI by traditional definitions. In the standing
    up of the WBH program we are acknowledging the relationship between
    ``sub-concussive'' BOP and symptoms and seeking to expand our
    screening, treatment, and followup. Accordingly, the DOD's review
    included an in-depth look at TBI related documentation, screening,
    diagnosis, treatment, follow-on care, and reporting as prescribed in
    DOD policy. The review also provided insight into the mild TBI (mTBI)
    rates resultant from a drone attack on a forward operating base, which
    represents an emerging threat to the Joint Force. Early detection and
    treatment for mTBI remains essential to maximizing patient outcomes and
    ensuring the prompt and safe return of our warfighters to duty. The
    Department will continue to review our processes and procedures as part
    of policy oversight and compliance functions.
                           tbi prevention & treatment
        70. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, how is
    the DOD's approach to TBI prevention changing as new data is gathered?
        Secretary Martinez-Lopez and Ms. Lee. The biggest shift is one from
    a TBI centric approach to a more holistic approach to WBH. As insights
    grew from research investments and the experiences of military
    providers caring for servicemembers with TBI in combat and the home
    front, the DOD developed novel treatment paradigms and policy to
    maximize utilization across the force. By 2018, military leaders began
    to explore the hypothesis that BOP exposures could result in brain
    health changes similar to those seen with diagnosed concussions. Also
    in 2018, the Deputy Secretary of Defense directed the development of a
    comprehensive strategy and action plan to promote brain health and
    counter TBI. The DOD's WBHI is a joint effort between operational and
    medical forces. The focus is to optimize WBH, specifically cognitive
    and physical performance, identify known and emerging brain threats in
    military environments, and detect brain injury immediately when it
    occurs to combat its effects on warfighters, their families, first line
    leaders/commanders, and their communities at large. As part of our
    responsibility to our Nation and the troops defending it, DOD wants to
    reduce the risks of exposure to known and emerging brain threats, such
    as BOP, head impact, and directed energy. Our commitment is to
    understand, prevent, accurately diagnose, and promptly treat BOP and
    effects in all its forms in all operating environments. This means that
    we are committed to understanding, through our research investments and
    field experiences, the role that BOP exposures plays in sustaining
    TBI's. In support of these policy initiatives, we continue to focus on
    how to disseminate best practices, new research findings and resources
    about WBH. The WBH Hub, established in December 2023, at health.mil/
    brain, serves as the single source of information on brain health
    topics. Our goal is to make the latest brain health information easy to
    access for our servicemembers, providers, families, and the public and
    service as a bridge from our clinical community to the operational
    environment. These linkages are critical for TBI prevention efforts.

        71. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, how is
    the DOD's approach to TBI treatment changing as new data is gathered?
        Secretary Martinez-Lopez and Ms. Lee. Through the DHA's Acute
    Concussion Care Pathway, the Department has been able to direct the
    usage of State of the science tools that are improved and updated as
    new data is gathered. This care pathway, tailored to each
    servicemember, was established with the goal of improving recovery
    times and outcomes by utilizing the MACE 2 to ensure brain health
    deficits were identified even if only detectable in a subset of
    clinical domains. These tools also help ensure timely access to repeat
    evaluations with personalized treatment protocols that are demonstrated
    to accelerate injury recovery through individualized progressive return
    to activity processes. This pathway resulted in the clinical screening
    of approximately 20,000 first time TBI diagnosed servicemembers across
    the Military Services in fiscal year 2023.
        As discussed above, the MACE 2 is an acute assessment tool for all
    medically trained personnel who treat servicemembers involved in a
    potentially concussive event. This tool incorporates current state-of-
    the-science TBI assessment, including balance, eye movements and
    cognitive screening. This clinical advance was driven by the DOD, first
    though research to clarify what was needed, and then through early
    adoption. The DOD is currently preparing a shortened version of the
    MACE 2 based on feedback from medical staff utilization in combat that
    will enable more rapid screening. As noted, the MACE 2 supports the PRA
    protocol that has demonstrated accelerated recovery through
    individualized treatment. The tool was updated in January 2023 with new
    data that had been gathered. Additionally, the DHA also coordinates
    with our research community through formal review and analysis meetings
    to evaluate research findings that can be translated into practices and
    tools to help improve treatment options available to those with TBI.

        72. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, are DOD
    medical personnel appropriately trained and equipped to identify and
    diagnose TBIs?
        Secretary Martinez-Lopez and Ms. Lee. Yes, DOD medical personnel
    are trained to identify and diagnose TBIs. Training content and
    platforms are evolving as clinical translation opportunities arise from
    research findings. Additionally, the Department continues to provide
    opportunities for awareness and training for providers, most recently
    through the release of the WBH hub at www.health.mil/brain. Military
    Services issue TBI diagnostic equipment based on roles of care and
    individual Service mission requirements.

        73. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, can you
    describe the various echelons of care under which a servicemember is
    initially exposed to a blast (say like the many recently injured by
    drove and rocket attacks in Syria and Iraq), assessed, diagnosed with a
    TBI, and then treated?
        Secretary Martinez-Lopez and Ms. Lee. The military's medical system
    is organized into several echelons of care, often referred to as
    ``Roles of Care.'' These roles outline the different levels of medical
    support available to military personnel depending on their location,
    the severity of their injuries, and the resources available. While
    specific terminology and organization may vary between different
    Military Departments, a typical framework includes the following:
          Role 1 (Unit-Level Medical Care) medical personnel
    provide primary health care, tactical combat casualty care, triage,
    resuscitation, walking blood bank, and stabilization. Initial
    management of TBI care begins at point of injury, where medical
    personnel are trained in evaluation, treatment, management, and
    evacuation of patients diagnosed with mild, moderate, to severe TBIs.
          Role 2 (Forward Trauma Management and Emergency Medical
    Treatment). Role 2 medical personnel provide reassessments of TBI
    patients further trauma management and emergency medical treatment,
    including continuation of resuscitation started in Role 1.
          Role 3 (Theater Hospitalization). In Role 3, the patient
    is treated in a MTF staffed and equipped to provide care to all
    categories of patients, to include resuscitation, initial wound
    surgery, and postoperative treatment. TBI patients receive
    comprehensive care including advanced diagnostics, surgical
    interventions, critical care, medication management, and early
    rehabilitation services ensuring thorough treatment and stabilization.
    These facilities provide both immediate and ongoing medical support to
    manage brain injuries and associated complications.
          Role 4 Care (Definitive Care). Role 4 medical care is
    found in US-based hospitals and robust overseas MTFs. Role 4 represents
    the highest level of definitive medical care available within the MHS
    or the United States. These facilities provide specialized treatment
    for servicemembers who suffered a TBI, including advanced medical and
    surgical care, intensive rehabilitation services (physical,
    occupational, and speech therapy) long-term neurological and
    psychological support, and continuous monitoring to facilitate recovery
    and reintegration.
        The events in Syria triggered a medical screening for concussion
    using the MACE 2. Providers are trained to conduct this assessment at
    all Roles of care, although, based on operational requirements, this
    may be deferred to a higher role of care.
        As discussed above, the MACE 2 is multimodal in that it captures
    assessment information from many health care areas such as balance, eye
    movements, cognition, report of symptoms and key past medical history
    that can prolong the recovery from a concussion. Acute TBI care is
    provided throughout the Roles of care with checkups to ensure recovery.
    There are standardized tools, such as the PRA protocol, that outline
    state-of-the-art treatments as well as how to return servicemembers to
    duty and full function. The PRA specifically allows clinicians to
    follow recovery of symptoms identified in the MACE 2 and offer
    treatment tailored to a servicemember's specific deficits (e.g.,
    symptoms). There are also programs in place to screen for mild TBI and
    offer followup care during redeployment.
            If recovery does not occur as expected, the DOD has a wide
            range of clinical services to assist with more in-depth care.
            DOD has specialty clinical and comprehensive interdisciplinary
            centers of excellence for TBI and brain health. These programs
            have been developed to deliver a holistic patient centered
            interdisciplinary TBI model of care. Behavioral health services
            can include psychiatry, psychology, and social work. Additional
            services may include neurology, sleep medicine, pain
            management, and rehabilitation services such as balance and
            vision therapy. These centers of excellence also offer
            innovative treatments such as creative arts therapies, animal-
            assisted therapies, and mind-body wellness services.

        74. Senator Sullivan. Secretary Martinez-Lopez, are there
    standardized TBI screenings that are part of pre and post-deployment
    medical examinations?
        Secretary Martinez-Lopez. Yes. As a part of the continuum of care,
    servicemembers receive ongoing TBI screenings and evaluation by a
    primary care provider during the annual Periodic Health Assessment, and
    those individuals reporting a history of TBI (or circumstances
    suggestive of the possibility) are further assessed for treatment
    needs. Historically, the focus in medical assessments after deployment
    has been exposures, including blast related exposures, and symptom
    based, with the latter typically driving the need for further
    assessments or treatment. Standardized medical assessments occur twice
    after deployment and are facilitated through the Post Deployment Health
    Assessment Form DD 2796 and the Post Deployment Health Re Assessment
    Form DD 2900. All MTFs have providers trained in TBI screening with the
    ability to refer patients to one of the TBI clinics or the Defense
    Intrepid Network for TBI and Brain Health for more comprehensive care.

        75. Senator Sullivan. Secretary Martinez-Lopez and Captain
    Williams, since TBI injuries can present differently and at various
    times post-injury, at what time intervals post-deployment/post-exercise
    do servicemembers undergo TBI screening?
        Secretary Martinez-Lopez, and Captain Williams. Post deployment
    health assessments occur twice; 30 days before or after redeployment
    and then 90 to 180 days after redeployment. TBI screening occurs during
    those times.

        76. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
    Captain Williams, has DOD compiled blast data from its inventory of
    weapon systems to determine TBI risk based on system and duration of
    exposure?
        Secretary Martinez-Lopez, Captain Williams and Ms. Lee. The Office
    of the Under Secretary of Defense for Acquisition and Sustainment
    (OUSD(A&S)) is responsible for the acquisition policies. DOD Components
    are responsible to evaluate environment, safety and occupational health
    risks in the weapons systems acquisition processes in accordance with
    the guidance contained in Military Standard (MIL STD) 882E \3\.
    ---------------------------------------------------------------------------
        \3\ Department of Defense Standard Practice, System Safety, MIL-
    STD-882E, September 27, 2023

        77. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
    Captain Williams, which office in the DOD is responsible for assessing
    TBI risk from individual weapon system operation?
        Secretary Martinez-Lopez, Captain Williams and Ms. Lee. The Office
    of the Under Secretary of Defense for Acquisition and Sustainment
    (OUSD(A&S)) is responsible for the acquisition policies. DOD Components
    are responsible to evaluate environment, safety and occupational health
    risks in the weapons systems acquisition processes in accordance with
    the guidance contained in Military Standard (MIL STD) 882E3.

        78. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
    Captain Williams, are weapon manufacturers required to provide blast
    overpressure data to the DOD?
        Secretary Martinez-Lopez, Captain Williams and Ms. Lee. My office
    is not aware of any manufacturer requirements to provide BOP data to
    the Component capability developer or program managers (PMs) nor of any
    refusal to provide requested environmental, safety, or occupational
    health (ESOH) data.

        79. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
    Captain Williams, have any weapon manufacturers been asked to provide
    blast overpressure data to the DOD and refused?
        Secretary Martinez-Lopez, Captain Williams and Ms. Lee. My office
    is not aware of any manufacturer requirements to provide BOP data to
    the Component capability developer or program mangers, nor of any
    refusal to provide requested ESOH data.
                        tbi injury tracking & data bases
        80. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, do
    tracking mechanisms or medical data bases exist for TBI baselines and
    injury assessments, much like they do for hearing audiograms, which
    stay with servicemembers their full career and get transferred to the
    VA once they exit the military?
        Secretary Martinez-Lopez and Ms. Lee. Currently there is no tool
    used to establish a traumatic brain injury baseline and the current
    tracking mechanisms that exist for TBI baselines and injury assessments
    are not similar to hearing audiograms. However, there is a data
    repository for baseline neurocognitive assessments. Currently, the
    baseline neurocognitive assessments do not get automatically
    transferred to the VA when a military member separates or retires. The
    VA does have access to the neurocognitive assessments upon initiation
    by a VA clinician to request the results.

                                     [all]