In the days following an Iranian rocket attack on U.S. troops in Iraq, as reported injuries ballooned from zero casualties to 64 diagnosed traumatic brain injuries at last count, questions have arisen as to whether the military’s most senior leadership recognizes the concerns over TBI.

Though President Donald Trump last week dismissed the injuries as “headaches" and “not serious,” Defense Secretary Mark Esper told reporters Thursday that he had personally explained to the president the implications of the diagnosis.

“I’ve had the chance to speak with the president. He is very concerned about the health and welfare of all of our service members — particularly those who were involved in the operations in Iraq,” Esper said, though he did not elaborate on whether the talk came before or after Trump’s statements. “And he understands the nature of these injuries."

Asked about the casualties during a press conference at the World Economic Forum Jan. 22, Trump said that he heard the service members had “headaches,” adding that they were not very serious.

As of Thursday, 39 of the 64 diagnosed service members have returned to duty, according to a Pentagon statement. All told, 38 were treated for their symptoms in Iraq, 21 were treated in Germany, eight have returned to the U.S. and nine more are scheduled to return.

“No, I don’t consider them very serious relative to other injuries I’ve seen,” Trump said, adding that he’s seen the aftermath of Iranian road side bombs, including “people with no legs and no arms.”

In fact, per Pentagon nomenclature, the mild traumatic brain injuries those service members sustained are considered “not serious.” The injury reporting system has three levels, Gen. Mark Milley, the Joint Chiefs chairman, said Thursday: Very serious, serious and not serious. Mild TBI falls under the last category.

“That’s not to minimize or dismiss or anything, that’s just to say that’s how we categorize injuries,” Milley said, adding that while the TBIs themselves are considered “mild,” that could change in the future.

The early signs of TBI include headaches as well as dizziness, nausea, trouble sleeping and others, and a diagnosis is made once those symptoms persist beyond the first few days.

“The over-pressures and the injuries to the brain — the unseen wounds of war, for example — can be serious, or they can be not so serious,” he said. “Sometimes they can be lifelong, sometimes they resolve themselves within weeks or months.”

Milley said that given the size and the impact points of the missiles, he was not surprised to hear that many of those nearby had suffered concussive injuries. But from the Pentagon’s perspective, he added, the first priority after an attack is to stem any life-threatening injuries.

“When we say ‘reported casualties,’ we’re really talking about killed-in-action and serious injuries like loss of limbs,” Milley said.

He also acknowledged the long-term behavioral health effects that can accompany TBI, particularly when it happens repeatedly.

“These things are cumulative, too,” he said. “So if you get multiple concussions, that could manifest itself down the road.”

When asked whether it was a mistake to report “zero casualties” so early on, Esper defended his initial statements.

“I think the reporting, at that time, was accurate," he said, adding, “as we predicted when the first reports came in several days later, there would likely be more and more.”

Meghann Myers is the Pentagon bureau chief at Military Times. She covers operations, policy, personnel, leadership and other issues affecting service members.

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