This story was produced by NPR and ProPublica and versions of the story appeared on Frontline and in Stars and Stripes.
The US Army honors soldiers wounded or killed in combat with the Purple Heart, a powerful symbol designed to recognize their sacrifice and service.
Yet Army commanders have routinely denied Purple Hearts to soldiers who have sustained concussions in Iraq, despite regulations that make such wounds eligible for the medal, an investigation by NPR and ProPublica has found.
Soldiers have had to battle for months and sometimes years to prove that these wounds, also called mild traumatic brain injuries, merit the honor, our reporting showed. Commanders turned down some soldiers despite well-documented blast wounds that wrenched their minds, altered their lives and wracked their families.
The Army twice denied a Purple Heart for Sgt. Nathan Scheller, though the aftereffects from two roadside explosions in Iraq have left him with lasting cognitive problems, according to the Army's own records.
The 29-year-old former tank commander navigated an M1A1 Abrams through Baghdad's urban battlefield of bomb strewn highways and sniper filled alleys. Now he gets lost driving familiar routes around his home. An honor student in high school, he can no longer concentrate enough to read the adventure novels he once loved.
"I don't see how somebody else can tell me that I don't deserve one," Scheller said of the Purple Heart. "I may not have wounds on the outside. But I have wounds on the inside."
The denials of Purple Hearts reflect a broader skepticism within the military over the severity of mild traumatic brain injury, often described as one of the signature wounds of the conflicts, according to interviews, documents and internal e-mails obtained by NPR and ProPublica.
High level medical officials in the Army debated whether head traumas that are difficult to detect, often leaving no visible signs of damage, warrant the award, the e-mails show. Most people who sustain such blows, also known as concussions, recover on their own, but studies show 5 percent to 15 percent may have long-term impairments.
In 2008, Brig. Gen. Joseph Caravalho, then the top medical commander in Iraq, issued a policy(PDF) blocking medical providers from even discussing the Purple Heart with soldiers who suffered mild traumatic brain injuries.
"In many cases," Caravalho wrote that concussions with "minimum medical intervention will not warrant this award."
His policy appears to contradict Army rules governing the Purple Heart.
Army regulations say that a soldier is entitled to the Purple Heart if injured by hostile action. The soldier must require treatment—no matter how minimal—by a medical officer, and the injury must be documented. Medical officers can offer advice on whether an injury merits recognition. The soldiers' commanding general typically makes the final decision to award or deny a Purple Heart.
The Army's official list of wounds (PDF) that "clearly justify" the award includes, "Concussion injuries caused as a result of enemy generated explosions."
In an e-mailed response, Caravalho, who now commands one of the Army's top hospitals, said he was trying to help medical personnel understand some of the complexities involved in the diagnosis and treatment of mild traumatic brain injuries. He did not specifically address whether his order created new restrictions on the award of the medal.
"I was trying to make the point that medical providers in the field needed to ensure they documented the event, the findings and the treatment rendered," wrote Caravalho. "Without this corroborating documentation, I felt it would be increasingly difficult to support a Purple Heart request based solely on subjective, and potentially temporary symptoms."
Gen. Peter Chiarelli, the Army's second in command, said it is "very, very clear" that soldiers who have sustained documented concussions from enemy action should receive the Purple Heart. He said he was not aware of Caravalho's order until NPR and ProPublica brought it to his attention.
"This is a good catch," he said, saying he had asked Army lawyers to review the policy to see whether it should be changed. A Chiarelli spokesman said Wednesday that, as of last week, the review was continuing.
Chiarelli, the Army's point man on the treatment of traumatic brain injury and post traumatic stress, acknowledged there is ongoing resistance to awarding the Purple Heart for so-called "invisible" wounds.
He saw it firsthand when he served as commander in Baghdad from 2004 to 2005 and said he overturned many denials for the medal stemming from concussion injuries. There has been progress since then, he said, but more work remains.
"There still are some commanders, okay, who—and there may be some doctors, too—who don't feel that a concussion should entitle somebody for a Purple Heart," Chiarelli said. "But we have far more commanders that understand that the concussion is a real injury today than we had in 2004 and 2005."
"We are moving in the right direction to fix this."
A Certain Level of Tough
Created by George Washington in 1782 and revived 150 years later by Gen. Douglas MacArthur, the Purple Heart carries extraordinary significance.
Unique among military honors, it is an entitlement earned by all soldiers who meet the basic criteria. It does not depend upon a recommendation from a superior officer.
The Purple Heart confers practical benefits, gaining recipients a higher priority in obtaining medical service from Veterans Affairs medical facilities.
But for many soldiers, the Purple Heart is, first and foremost, a badge of courage: A tangible recognition of service, honor, and bravery.
Nearly 25,000 soldiers have been awarded Purple Hearts for all types of wounds suffered in Iraq and Afghanistan, according to the Army's Human Resources Command. A spokesman said the military does not know how many soldiers have received the Purple Heart for mild traumatic brain injuries, or how many have been denied. He said the Army doesn't keep track.
The number of Purple Hearts awarded is dwarfed by the number of soldiers who have suffered concussions. Official figures show about 90,000 Army soldiers have sustained mild traumatic brain injuries since 2002—though all those soldiers likely do not meet the criteria for the award. Tens of thousands of additional troops have gone undiagnosed, NPR and ProPublica reported in June, based on unpublished military studies, internal e-mails and interviews.
Some soldiers who have suffered mild traumatic brain injuries have received Purple Hearts. Sgt. Victor Medina, who was profiled in a previous story by NPR and ProPublica, received his award after his wife wrote to his commander insisting that he deserved the recognition.
"It would have been easier to get one if I had lost an arm or a leg. Then they could have seen it," Medina said.
The military's regulations to document the wound and treatment can make it difficult for someone with a mild traumatic brain injury to prove that the award criteria are met. Treatment for a head injury in the immediate aftermath of combat can be as little as bed rest, or pain medications which are not always noted in medical records.
Once they return home, some soldiers don't realize they have problems until months or years after the injury—making it difficult to prove a link between the blast and their symptoms.
Sgts. James Hopkins and Derrick Junge are among those who have been diagnosed with concussions, but were passed over for the Purple Heart.
Hopkins and Junge suffered their injuries in January 2009 when a rocket slammed into a wall near their trailer at Camp Liberty in Baghdad. At the time, a senior Army neuropsychologist, Lt. Col. Mike Russell, was conducting a study on concussions. He diagnosed the men and three fellow soldiers as having suffered mild traumatic brain injuries during the attack, according to medical records.
Yet only one soldier in the trailer, who suffered shrapnel wounds in the attack, received the medal. The other men have been turned down by senior commanders.
Hopkins received a form letter telling him that his documentation was not sufficient. The letter did not tell him what documents he was missing or exactly why he was denied.
"I'm over there. I'm doing what I'm supposed to do. I'm giving everything that I'm supposed to," said Hopkins. "But I feel I'm not getting that same thing in return." Hopkins had splitting headaches and trouble walking for days after the explosion. He still forgets details today. He repeats himself in conversation, forgetting what he told his wife moments ago. Not getting a Purple Heart, he said, "That's a big slap in the face."
Like many soldiers who suffered a concussion, Junge has trouble remembering details of what happened after the explosion. He believes a medic might have given him headache medication, but has no documentation of the treatment.
Nor has Junge received rehabilitation or other treatment for ongoing mental difficulties. A former B-2 bomber mechanic, he sometimes struggles with simple tasks, such as building a tree house for his kids. He gets irritated easily. He forgets details and the names of common household items.
Junge said he didn't see a doctor because he wanted to keep leading his unit.
"As a soldier, you're expected to be a certain level of tough. It's across the board from top to bottom. If it's not a visible injury, it's kind of looked as a non-injury," he said. "For soldiers, it's like, are you a puss?"
For the families of soldiers with mild traumatic brain injuries, the Purple Heart is sometimes the only outward sign of the serious internal trauma endured by their loved ones.
"He thinks nothing is wrong. And it's like, I'm married to a totally different person," said Holly Junge, Derrick's wife, breaking down in tears as she spoke. "That's scary."
Junge is scheduled to deploy back to Afghanistan later this month.