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Mark C. Russell, Ph.D., ABPP

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End Mental Health Stigma and Disparity by Awarding the Purple Heart for War Stress Injury

Posted: 04/12/2013 10:43 am

On 17 April 2013, a diverse group of veteran's advocate organizations, military service agencies, and national mental health alliances will meet to discuss re-opening a controversial national campaign to award the Purple Heart, one of the oldest and most recognized American military medals, to service members who were killed or wounded by enemy action, for war stress injury (WSI) like post-traumatic stress disorder (PTSD) earned honorably in engagement with the enemy.

Overview of the Controversy

The current petition rekindles an impassioned debate started in 2008, when Secretary of Defense Robert Gates initiated a formal review. However, in 2009, Dr. David Chu, Undersecretary of Personnel and Readiness, decided that PTSD did not meet the requirements for the Purple Heart in that "Historically, the Purple Heart has never been awarded for mental disorders or psychological conditions resulting from witnessing or experiencing traumatic combat events (e.g., combat stress reaction, shell-shock, or PTSD)." However, during the First World War British "shell-shocked" soldiers were initially awarded the "Red Wound Stripe"-a Purple Heart equivalent.

Dr. Chu's circular reasoning is problematic-just because the Purple Heart hasn't been awarded for WSI doesn't mean that it shouldn't be. For instance, the original Badge of Military Merit designed as a purple heart of cloth, was introduced by George Washington in 1782 to encourage gallantry and fidelity among soldiers, and not specifically given to the physically wounded. In fact, prior to 1932, wounded American soldiers were only awarded "wound chevrons" according to Army Regulation 600-15. It wasn't until General Douglas MacArthur renamed the "Purple Heart Medal" in 1932 that it became focused on soldiers killed and wounded in combat.

Another frequent argument against extending eligibility to WSI is concerns about maintaining the integrity of the Purple Heart tradition. However, eligibility criteria for the Purple Heart have changed no less than six times since its inception. For example, President Reagan expanded criteria in 1973 to military personnel and government civilians killed or wounded in international terrorist attacks or peacekeeping operations, and President Clinton extended it to Prisoners-of-War in 1996-neither meeting traditional definitions of direct combat. Regardless, the level of vitriol from debates on equating mental and physical war wounds is shockingly self-centered.

In short, some believe WSI like PTSD should not be eligible for the Purple Heart because it "dishonors" those with Purple Hearts for physical injuries. For instance, a representative of The Military Order of the Purple Heart opined "Moreover, PTSD is a treatable disease -- loss of a limb, or any combat wound for that matter, is permanent. And, what about those who feign the illness just to receive VA medical treatment? The national spokesman for the Veterans of Foreign Wars, Joseph E. Davis, adds "Medals aren't awarded for illness or disease, but for 'achievement and valor."

Arguments in support

  • Overwhelming evidence that war stress causes authentic injury. Institute of Medicine conducted a national comprehensive study on the effects of military deployments, concluding that "In the brain, there is evidence of structural and functional changes resulting directly from chronic or severe stress. The changes are associated with alterations of the most profound functions of the brain: memory and decision-making" (p. 60) and "profound effects on multiple organ systems...the continuation of altered physiologic states over months and years contribute to the accumulation of adverse long-term health consequences" (p. 66) [2].
    • Since 2001, the Canadian military awards their Purple Heart equivalent "The Sacrifice Medal" for operational stress injuries like PTSD.
  • Some TBIs are now eligible for the Purple Heart, as many of those injuries can be diagnosed using brain scans and other objective medical tests.
  • The Purple Heart will confer long overdue honor to those suffering silently with shame, help eliminate stigma, and reduce gross disparity between mental and physical health that perpetuate mental health crises.
  • 60-80% of combatants with PTSD develop co-morbid psychiatric and medically unexplained conditions compounding the suffering and chronicity of the injury/sacrifice, including risk of suicide and premature death.
  • Given historical injustice to veterans and family members burdened by WSI, only a bold equivalent statement is sufficient to communicate parity.
  • The notion that receiving a Purple Heart for WSI "cheapens" or dishonors those with physical wounds, is valid only for those embracing outdated dualistic beliefs-placing greater value of physical over mental health.
  • It is unjust to arbitrarily assign greater recognition of minor shrapnel or other transient physical wounds over severe, potentially life-altering, chronic WSI, just because the former involves external bleeding.

Conclusions

Unresolved questions about the legitimacy of WSI and consequent mental health stigma and disparity, constitute the unspoken root causes for cyclical mental health crises due to ignoring lessons of war trauma. In order to truly transform mental healthcare, and end the cycle, there is far greater societal good accomplished by awarding the Purple Heart for WSI than accepting harmful dualistic stereotypes.

References

[1] Institute of Medicine (2008). Gulf War and health volume 6: Physiologic, psychologic, and psychosocial effects of deployment-related stress. National Academies Press: Washington, DC.

 
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