The War Inside

This story is published in partnership with CityView.

It’s hard to explain the sound standing behind artillery when it fires, a roar no movie can ever match that will temporarily render you deaf without proper ear protection. 

Then there’s the sight: the gun jerks violently, smoke billows from the tube, dust fills your battle position and blocks your eyes, turning the people around you into ghostly figures scrambling to load the next round. 

Finally, there’s the way an explosion feels, one capable of launching a 100-pound shell from Raleigh to Chapel Hill.

It knocks the breath out of you and makes your bones shudder. There’s a noticeable pressure at the front of your head, a dull aching sensation. Maybe the best way to explain it is that it feels like getting punched all over your body at the same time. It’s worse if you’re inside or under a structure. I can remember one particular blast during my time as a journalist in Iraq in 2016 covering artillery units for the U.S. Army that left me dazed for a couple of moments, the world spinning before me. 

Blast overpressure, or BoP, as it’s called—a “near-instantaneous pressure rise” in the area around an explosion. 

Artillery personnel, combat engineers, tankers, special forces troops, and mortar personnel make up the military occupations most at risk to exposure to what are known as low-level blasts. U.S. Army Sgt 1st Class. Joshua James, 35, one of the soldiers I reported on, experienced nearly 1,000 such blasts when he was deployed to Iraq for nine months in 2016 during the war against ISIL. The deployment was already exhausting, with soldiers forced to live in often squalid conditions under constant threat from enemy fighters. 

But then strange health and mental effects started occurring, even while the unit was still in Iraq. One of the soldiers in James’ sections described having dark and frightful nightmares. Others in the unit started having concussion-like symptoms: headaches, dizziness, forgetfulness.

They were the first signs of a much deeper issue.

After he came home, James became an Army recruiter in Hickory, bringing his wife and two children with him. But something had changed, those who knew him observed. Very rapidly, he’d turned from an easygoing guy to someone plagued by doubts and anxieties. Concerned about his own health, James had an MRI scan in 2021 that detected unexplainable abnormalities in his brain.

I kept in contact with members of James’ unit after I reported on and served with them in Iraq. Within five years of coming back to the U.S., two members of his artillery platoon were dead by their own hands, and at least two others had attempted suicide, out of about 30. Half the men in his eight-man gun section were suffering from mental health conditions such as depression and PTSD, or had been kicked out of the Army over behavioral issues and performance changes, symptoms associated with concussion injuries.

On November 15, 2022, James died by suicide. Just a few days before, he had posted on Facebook saying how proud he was on Veterans Day, tagging dozens of the artillery personnel he served with in Iraq. 

A growing body of research suggests that blast waves from his own weapon may have played a major role in not just his death but in the health issues that thousands of service members have reported in recent years. Each blast, whether it’s in training or battle, causes microscopic damage to their brains and is why traumatic brain injuries are the “signature wound” of the Global War on Terror. 

Repeated exposure has the potential to cause what the Centers for Disease Control and Prevention now call “primary blast injury of the brain.” Like other types of mild traumatic brain injuries, symptoms can include headaches, irritability, cognitive deficits, and even death. Research published in April found that “higher blast exposure was associated with alterations in brain structure, function, and neuroimmune markers, as well as lower quality of life.”

With almost 90,000 active-duty service members stationed in Fayetteville at Fort Liberty and Jacksonville at Camp Lejeune, and over 640,000 veterans statewide, North Carolina is at the center of this burgeoning health crisis. 

Low-level but Deadly

As an Army mortarman, Todd Strader’s job was to fire high-explosive projectiles at the enemy.

“I cannot calculate how many low-level blasts I had been exposed to,” said Strader, 54, who now resides in Apex. After leaving the Army in the early 1990s, he found himself suffering from intestinal issues and mental fogginess that left him concerned. 

Research that suggested potential negative effects of using these weapons led him to start a Facebook group and organization called the Cohort of Chronically Concussed Mortarmen, focused on spreading awareness of the issue. Veterans often describe their symptoms on his page: migraines, forgetfulness, mood swings. And they talk about their attempts to get treatment for an issue that very few knew anything about until recently.

Strader remembers one incident during live-fire exercises, which often require shooting dozens of shells. “I had such a bad headache, I fell to my hands and knees and puked my guts out … all the while grabbing my head in pain,” he said. “I had to be attended to by the medics.” 

He said he had obvious symptoms of a concussion, but the Army’s antiquated assessment protocols didn’t take that into consideration. Research and statements from service members indicate that much of the exposure occurs before a service member deploys. 

“They told us we can’t shoot more than six in a day, or we’d be concussed,” said a former Army combat engineer officer who served at Fort Liberty. He still works with the military in North Carolina and requested anonymity due to concern of professional retaliation. “I shot five total rounds on a range as a gunner and loader and I felt very woozy and wobbly.”

“During combat operations it was similar,” he said. “The perspective with blasts was ‘let’s get as close to it as possible without dying,’ so [the Army] did their research back in the day to make the regulations. They probably need to update it, knowing what we know now.”

There is still debate within the military and research communities over the health effects attributable to blast exposure. But a March Army Times report on suicide based on the military’s own records showed that from 2019 to 2021, mortarmen experienced a suicide rate 40 percent higher than those who did not use high-explosive weapons. 

The same report showed that artillerymen like James had the second-highest rate of suicide, behind soldiers who operate battle tanks and other armored vehicles. Jobs regularly exposed to blasts made up three of the top five highest suicide rates among all occupations in the Army.

“The perspective with blasts was ‘let’s get as close to it as possible without dying.’”

former Army combat engineer officer

Last year, Congress requested a report from the Department of Defense breaking down suicide risk by occupational specialty between 2001 and 2022. So far, the DoD has not produced the data, even though it was due December 2023. In a letter to Congress, the department said it “requires more intricate statistical approaches to make appropriate and reliable comparisons.”

The military did release a version of this data in 2010, without the advanced statistical approaches they say it now requires. That data shows some noticeable differences between the suicide rates of different military occupations. 

In 2009, the military’s overall suicide rate was 18 per 100,000, which had doubled to 36 by 2021. The Assembly and CityView’s comparison of the 2001–’09 and ‘19–’21 data indicates that military jobs occupationally exposed to blasts such as artillery personnel and mortar operators saw their suicide rates increase at a higher rate than the Army at large. The rate for mortar soldiers quadrupled, and the rate for tank crewmen tripled.

The 2010 report also showed that among infantry Marines, those with the highest suicide rates used explosive weapons: assaultmen, mortarmen, and anti-tank gunners had an average suicide rate 30 percent higher than that of riflemen and machine-gunners. Among combat jobs in the Army, in the 2010 data, combat engineers, who train with explosives and breaching equipment, had the highest average suicide rate at 36 per 100,000. 

North Carolina has thousands of troops in these occupations stationed at Fort Liberty and Camp Lejeune, both of which have some of the some of the highest rates of suicide among all military installations. Based on data provided to USA Today in 2021 and reports from other outlets, Fort Liberty had a suicide rate at about 42 per 100,000 in 2020, over three times higher than the statewide average in that time period. Camp Lejeune had a suicide rate of rate of 55 per 100,000. Veterans in N.C. have a suicide rate twice as high as the civilian rate. 

Data from 2002 to 2018 from a team of researchers writing in the Journal of Head Trauma Rehabilitation shows that among service members diagnosed with mild TBIs, suicide rates are almost three times as high as the national civilian average. 

Strader says he lives with the effects of blast exposure every day. He is currently rated as 100 percent permanently and totally disabled by the Department of Veterans Affairs, and feels that the quality of life he could have once had is gone. 

“I will never be the same,” he said. “The chronic headaches that have a hair trigger, the constant ringing and pain in my ears, the balance issues, the neuro-cognitive deficits, the daily mental battles within, the anxiety and depression, the price paid by family and loved ones.”

An Unknown Condition

Various tools to monitor blast overpressure have been in use for more than 15 years, including hand-held and wearable devices like gauges that can calculate exposure. Though a program using gauges was in place in the early 2010s, James and his unit were not issued them during the deployment to Iraq in 2016, based on my conversations and my observations during the time period. 

The military has started and stopped blast-monitoring programs for a variety of reasons, hindering attempts to gather long-term data. Early data from gauges used in Iraq and Afghanistan showed that the majority of blast exposure among service members was coming from their own weapons. 

There is still no official military guidance on which jobs and specialties are at the highest risk, beyond a fact sheet published in July 2023. The military also has no system in place to note exposure in a soldier’s medical records—something that Congress requested in 2020. 

In a letter to Congress this April, the DoD indicated that there are still multiple competing safety standards and procedures among the military’s branches, as well as a gap between the safety recommendations and the actual operations on the ground.

The first suicide in James’ unit came only a few months after they returned home, in April 2017. Sgt. 1st Class Tyler Chatfield, originally from Pittsboro, killed himself in the garage of his home near Fort Campbell, Kentucky. 

The unit underwent a pre-Iraq assessment that included neurological health, using the Automated Neuropsychological Assessment Metrics (ANAM) battery of tests to establish baselines for neurocognitive function. The tests are supposed to be conducted again once they return. However, there was no follow-up testing and evaluation even though Pentagon policy requires it for all returning deployed service members. 

Soldiers in James’ unit told me that they were rebuffed or ignored when they asked their superiors about the post-deployment assessment or care. The ANAM has been available for at least 16 years, but has not always been used to track blast exposure brain injuries and identify those who have suffered TBI or TBI-like symptoms.

By 2017, the DoD had known for a few years about the potential risks of blast exposure. But many veterans say they were never informed. After prodding from Congress, the DoD established the Warfighter Brain Health Initiative in 2020 to better coordinate research efforts, but progress has been slow on informing troops about the results, educating service members and their leaders on the risks, and implementing change in policies and practices. 

The military also doubled down on the warfighting strategy that exposed James and his unit as it transitioned from combat operations in Iraq and Syria in 2021. In 2017, a Marine Battery from Camp Lejeune deployed to Syria, where they fired tens of thousands of rounds—more than had been fired during the entire invasion of Iraq in 2003. The unit soon began reporting injuries and concussion symptoms, such as bleeding in the ears and stumbling around in dazes. 

In 2019, DoD released startling findings from their research on the unit: Its estimates found that an artillery crew firing at the same rate would suffer degraded combat abilities within three weeks and be almost totally ineffective in two months. Replacements could not be trained fast enough to make up for the losses.

That report wasn’t widely released, and service members like James had little idea how the findings might affect them. With the stigma in the military around seeking mental health treatment, and once they’d all been reassigned, there was no way to track their health outcomes. 

Matthew Harrison spent four years in the 82nd Airborne Division at Fort Liberty as a staff sergeant and mortar squad leader, where his unit fired thousands of rounds before they even deployed to Iraq in 2020. 

He started noticing symptoms soon after arrival, where he and his squad was asked to provide mortar support during operations against the Islamic State. Sometimes their fire missions would consist of dozens of rounds at a time. Their weapons protected them from direct enemy fire, but left a noticeable effect on Harrison and his crew. 

“I thought it was just normal at first; we would shoot and I noticed killer headaches that could only be slept off,” he said. “Once I came back home, I started having other issues, but for a while I didn’t realize they might be connected.”

For Harrison, now 26, it started with some minor memory loss. Then he couldn’t remember things like whether he’d driven to work. He started having to write down notes for himself, and felt a constant level of confusion, making it hard to to think and to find work. He left active duty in 2023, and continues to suffer from cognitive symptoms such as delayed reaction times. 

“Most of us, even as leaders, didn’t realize what was going on,” he said. “We weren’t educated on the risks.” 

The Army announced in April that the ANAM tests will soon be given when a recruit enters service, to provide a baseline for annual tests—akin to those sometimes given to high school football players. 

A Byzantine System 

Service members concerned about potential brain injuries have to navigate an often Byzantine-like military health care system. 

The DoD estimates that more than 410,000 per­sonnel have suffered mild traumatic brain injuries since 2001. But it does not currently count if a service member has suffered multiple TBIs, instead counting the first occurrence rather than repeated ones. 

It is still difficult to get blast-related injuries diagnosed in the first place, and even those who are formally diagnosed within the military medical system have issues getting care. A report released by the DoD’s Inspector General in 2023 found that the department and the Veterans Administration did not consistently identify and assess TBIs, implement processes for managing care, or conduct the proper return-to-duty process.

“Most of us, even as leaders, didn’t realize what was going on. We weren’t educated on the risks.” 

Matthew Harrison, who spent four years in the 82nd Airborne Division at Fort Liberty

The military has established treatment centers specifically for brain injuries, including Defense Intrepid Network facilities at Fort Liberty and Camp Lejeune. In a response provided to The Assembly and CityView for this article, the Defense Health Agency and Womack Army Medical Center at Fort Liberty said that there are no special or separate treatment options for low-level blast injuries compared to other types of concussions. Treatment protocols are aimed to alleviate symptoms and “are like the treatments given to alleviate commonly reported symptoms from concussion.” 

The response also pointed to the Warfighter Brain Health Initiative safety guidance, which notes that service members should recognize the potential for increased exposure in specific occupations or when using certain weapons systems. The guidance also recommends that service members implement safety precautions like firing limits, understanding the symptoms of blast exposure, and informing their command and a medical provider if they have long-lasting symptoms.

But the issue for many is actually accessing these facilities. Some said they had to seek treatment for other related medical issues first, or find specialized doctors—a process that can take years. 

Harrison started his own journey in 2021. It was hard to get the VA to take his symptoms seriously, he said. 

“Eventually I went to the ER once I started throwing up and they said I had severe headaches and gave me meds,” Harrison said. “I went to a doctor who was a Special Forces guy who knew what was up; he told me that he had seen similar symptoms and conditions among mortarmen exposed to thousands of low-level blasts.”

He was prescribed beta blockers that addressed his immediate symptoms, but couldn’t reverse the damage.

Strader began a disability claim with the VA in 2018 for his chronic migraines. Even though he had sought treatment while still active duty, his claim was denied: the VA could not find his medical records regarding his condition. 

He tried again the next year. “I began asking my doctors to consider a diagnosis of ‘chronic post-concussion syndrome’ and link it to at least a 50 percent likelihood it was caused by firing mortars in the Army.” He was able to convince the doctors, which then allowed him to access neurological and TBI care from Veterans Administration. 

The anonymous former engineer is also concerned about future care. “It’s going suck later on when I have a degenerative brain disease and they link it back to my time in service and micro-concussions,” he said. “The VA has already said ‘fuck you,’ basically, to the people like me and dismissed it as not their problem.”

Responses to the issue have picked up steam in the last few years amid growing media and public attention, and the U.S. Special Operations Command, headquartered at Fort Liberty, has been a leader on that front. A spokesperson for the Army’s program said that has included establishing neurocognitive evaluation programs that tie into medical records and a blast-exposure monitoring program for every member that includes downloading data into a centralized system for analysis.

The effort has also included redesigning training areas to be more blast-overpressure safe, using blast sensors to map out training areas, and 3-D printing new types of detonation equipment to reduce exposure in training up to 50 percent.

In an April testimony to the Senate Armed Services Committee, Army Secretary Christine Wormuth said they are interested in investing in similar programs for other branches. Some veterans, like Strader, are also developing their own solutions. After he learned through a CT scan that his cerebellum was herniating from the base of his skull, he began researching brain health.

“I learned that the cerebellum and other structures of the hindbrain play immensely important yet under-recognized roles in brain function,” Strader said. “And how those roles can be interrupted by the deleterious effects of low-level blast in big ways.”

Mortar personnel are trained to turn and face away when they fire, exposing the cerebellum to unimpeded blast waves. Strader developed protective equipment that could be worn on the back of helmets to protect the cerebellum. Strader’s tool protects the back of their heads with a piece of Kevlar-like equipment to diffuse the force. 

Strader was recently able to test the equipment with an Army unit during a mortar training exercise. The data he collected indicated that his creation reduced blast overpressure exposure by an average of 35 to 40 percent. 

“We are very excited about these initial results and much more testing is forthcoming to confirm its validity,” he said. 

In April, Sens. Warren (D-Mass) and Ernst (R-Iowa) introduced the “Blast Overpressure Safety Act,” which North Carolina Sen. Thom Tillis co-sponsored.

The bill would require the DoD to begin including a baseline neurocognitive test such as ANAM for each new recruit before training and improve data on concussive and subconcussive brain injuries. The military would also be required to create blast overpressure exposure and TBI logs for all service members, and increase transparency on the safety of new weapons. 

It also calls for training and partnerships for medical providers on how to identify brain injuries from blast exposure.

The bill has strong bipartisan support, and portions of it have been adopted into the National Defense Authorization Act—one of the few “must pass” annual bills. 

“We owe it to our veterans and service members to remove barriers to brain health treatment and ensure preventive measures are taken to protect them from TBIs and other harmful brain injuries,” said Tillis in a statement. “TBIs resulting from blast overpressure and exposure to explosive weapons are a far too common occurrence for service members, especially those who served in Iraq and Afghanistan.” Still, the veterans and service members say there’s more to be done.

There are indications that the bill could be the beginning of a focus on the issue of blast exposure, and not just in North Carolina. Future legislation could tackle other systemic issues that servicemembers and veterans face. 

“I hope to see a better use of advanced analytics, improved modeling, and a more holistic and multidisciplinary approach to treatment,” said Rep. Ro Khanna (D-Calif.) who sponsored the House bill and worked on getting an amendment added to the Defense budget. 

For Strader, low-level blast exposures dashed his dreams of traveling the world and goals for a post-military career. But he remains hopeful he can help protect the next generation of service members. 

“What happens when an unstoppable force meets an immovable object?” said Strader. “Ironically, that’s almost exactly what a blast is, but which is more affected by the impact? The force is no more but the object will never be the same.”

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Daniel Johnson is a Roy H. Park doctoral fellow at the Hussman School of Journalism and Media at the University of North Carolina at Chapel Hill. He was a journalist for the U.S. Army in 2016 in Iraq, and has reported for The New York Times and The Washington Post. Work he contributed to on blast overpressure injuries was finalist for the Pulitzer Prize in national reporting in 2024.