Howard Schultz is the chairman and chief executive of Starbucks Coffee. Excerpted from For Love of Country: What Our Veterans Can Teach Us About Citizenship, Heroism and Sacrifice by Howard Schultz and Rajiv Chandrasekaran (Alfred A. Knopf). Copyright 2014 Howard Schultz and Rajiv Chandrasekaran. Rajiv Chandrasekaran is an associate editor of The Washington Post.

Soon after Peter Chiarelli became vice chief of staff of the Army in 2008, a subordinate showed him a bar graph depicting the number of soldiers determined by the Department of Veterans Affairs to be at least 30 percent disabled. The tallest column was on the far left.

Those are amputations, Chiarelli thought. Or burns.


Then he examined the graph more carefully. Burns were off to the right, accounting for just 2 percent of disabled soldiers. Amputations were in the middle, at 10 percent. The big column, which represented 36 percent of seriously injured soldiers, was labeled “PTSD or TBI.”

Chiarelli was dumbfounded. PTSD, or post-traumatic stress disorder, is the catchall term to explain the anxiety, anger, and disorientation people can experience after exposure to physical harm or the threat of it. An insurgent attack would qualify, as would the threat of one, which most troops in Iraq faced every day. TBI, or traumatic brain injury, can happen when a soldier suffers a concussion from the blast of a roadside bomb. While some soldiers appeared to recover from concussions quickly, for others the effects lingered for months, or even indefinitely.

What stunned Chiarelli was not just the high percentage but the long-term persistence of PTSD and the aftereffects of concussions. He had been the operational commander of all American ground forces in Iraq. Before that, he’d led an Army division that was responsible for Baghdad. And yet the prevalence of debilitating post-traumatic stress and serious brain injuries was news to him. He had assumed that the stress of a near-miss would dissipate. So, too, would the effects of a concussion. He figured they were no big deal.

“If I had a platoon that lost folks, I had combat-stress teams, and I made sure they were flown to whatever base they needed to go to,” he said. “I knew what my football coach told me about traumatic brain injury: ‘Shake it off and get back in the game.’”

The graph sobered him. As vice-chief, his job wasn’t to focus on war strategy. He was responsible for “the force”—for training and equipping soldiers, modernizing weapons and overseeing the budget, and ensuring the well-being of the half-million men and women in the Army, the second-largest U.S. employer after Walmart. But it also was personal: he had put many of these soldiers in harm’s way in Iraq, and he believed he had a duty to those who returned harmed.

So Chiarelli set out to learn everything he could about PTSD and TBI. The task took on even greater urgency a month later, when the Army tallied that 115 soldiers had committed suicide in 2007. That was the most since the Army began counting in 1980 and nearly twice the national suicide rate. Chiarelli’s boss, General George Casey Jr., asked him to figure out why so many soldiers were taking their own lives.

Chiarelli could see that PTSD, TBI, and military suicide were overlapping circles. But by how much? Not every soldier with a concussion was going to experience post-traumatic stress. Many stressed-out soldiers had not been subjected to explosions. And when it came to suicides, TBI did not appear to be a main cause. But all of it fit under the rubric of mental health, an issue that had never really been on the front burner at the Pentagon.

Despite failures at Walter Reed and other Army hospitals early in the Afghanistan and Iraq wars, the military was providing extraordinary care to troops who had been burned, absorbed bullets or shrapnel, or lost limbs. (The Department of Veterans Affairs, which treats those who have left active service, was a deeply troubled institution that would be accused in 2014 of falsifying patient-care records.) The advancements in prosthetics and limb transplants since 2001 had been, in Chiarelli’s view, “nothing short of amazing.” But he soon discovered the same couldn’t be said for mental health and brain injuries. “What we were doing for their minds wasn’t a tenth of what we were doing for their arms and legs,” he said.

The broad-shouldered Chiarelli, whose face bore the worry lines of a general who had written too many condolence letters, summoned two military doctors, one an expert on PTSD, the other on TBI. He met with each for two hours. Then he went to Walter Reed and talked to physicians there. What they told him about the severity of the problem differed from what he had heard from the first two doctors. Frustrated, he contacted one of the few civilian doctors he knew, an accomplished plastic surgeon in Los Angeles who was providing advanced reconstruction treatment to soldiers disfigured by explosions. That doctor connected Chiarelli with David Hovda, the director of UCLA’s Brain Injury Research Center, who agreed to speak with a group of military doctors at the Pentagon.

Hovda began his presentation by projecting a slide of three brain scans. The one on the right, filled with splotches of yellow and red to indicate healthy activity, was of an uninjured person. On the other two slides, instead of yellow and red, there were large areas of dark blue and purple. The middle one, Hovda said, showed a comatose patient. The one on the left was the brain of a UCLA football player who had been injured in the first half of a game, went back to play the second half, and then walked into the emergency room the following day, complaining of a severe headache.

To Chiarelli, it was an epiphany.

“Those were the kids we were missing” in Iraq and Afghanistan, he said. “They’d go out and get concussed on a Tuesday, and they’d be out on patrol again on Thursday.”

The military doctors had been willing to listen to Hovda when Chiarelli, who had four stars on his collar, asked them to attend the session. But when Chiarelli brought Hovda back to Washington to help develop a new protocol for treating service members exposed to blasts, the doctors insisted the military didn’t need to change. Existing methods, they said, were fine.

Chiarelli was incensed. So, too, was General James Amos, then the second-in-command of the Marine Corps. He shared Chiarelli’s view that more needed to be done to address mental health issues. At the initial meeting of Hovda and the doctors, the two generals had jumped out of their chairs. “We’re going to bring some people in here who understand we’ve got a goddamned problem,” Chiarelli huffed, before walking out of the room.

It wasn’t going to be easy. And addressing battlefield concussions was only one of his challenges. He convened regular meetings to examine the case of every active-duty soldier who had committed suicide in the previous months. Were there warning signs? What should the Army have done differently? And he devoted hours each week to discussing post-traumatic stress. To dispel the stigma around it, he no longer referred to it as a disorder.

He learned that troops claiming post-traumatic stress—PTS, he insisted, not PTSD—were diagnosed with a twenty-question test. Are you feeling irritable or having angry outbursts? Have you lost interest in things you used to enjoy? There was no blood test or brain scan.

“Imagine going to your doctor because you think you have a broken leg and your doctor asks twenty questions, and then your doctor says, ‘You don’t have a broken leg. You can go home.’ You’d say, ‘Aren’t you going to X-ray my leg?’ That’s how we diagnose PTS,” he said. “This is like having a heart attack, and when you show up in a hospital, it’s 1945.”

Experts told him it would be years, if ever, before more advanced tests could be developed for PTS. So Chiarelli directed his energies toward expanding mental health treatment programs in war zones and on domestic bases, and he pushed military doctors to explore the efficacy of alternative therapies.

He achieved more headway in screening for traumatic brain injuries. In 2010, the Army and the Marine Corps developed a set of guidelines to follow after service members were exposed to a blast. If they were in a vehicle that was damaged by an explosion, or they were within fifty meters of a bomb detonation, or if they lost consciousness, they had to be given a thirty-question cognitive test. If they didn’t get at least twenty-six questions correct, they were to be sent to a doctor for an evaluation. And even if they passed the cognitive test the first time, they were supposed to be reevaluated the following day.

“We had to ram it through the bureaucracy,” Chiarelli said, but it was a rare victory in his fight with the doctors. They usually told him his ideas didn’t make sense—politely, of course—or that they couldn’t be implemented because of a lack of equipment or trained personnel. “It was a very frustrating experience,” he recalled. “The system was very resistant to change.”

Meanwhile, the number of suicides remained unacceptably high, and the PTS/TBI bar on the graph continued to grow taller.

In January 2012, Chiarelli’s term as vice-chief was over. That April, after nearly forty years in uniform, he retired.

He could have gone on to indulge his passion for golf or earn a hefty salary by working for a defense contractor, as many other retired generals have done. But Chiarelli couldn’t walk away from PTS and TBI. There was nobody to pass his work on to, because no other four-star general shared his zeal to address those ailments. When he had been leading troops in a war zone, he had repeatedly told them that the Army would take care of them if they were hurt. He hadn’t just been making speeches to prepare them for battle. He had been uttering a solemn promise, one that he was unwilling to walk away from, even in retirement.

Chiarelli moved back home to Seattle and assumed command of One Mind for Research, a nonprofit organization focused on advancing research and treatment of mental illness and brain injury. “I’m going to keep working this,” he told friends in the Army. “I’m not throwing in the towel.”

***

When Chiarelli retired, he thought he knew how to win the war against TBI and PTS. The problem, he assumed, was that research into those brain problems was underfunded. “I believed that if I used my good name, I could get money, and I could give it to researchers, and we’d be out of this in a few years,” he said.

He wanted One Mind for Research to raise a half-billion dollars by the end of 2014, money that would be used to fund research projects aimed at improving diagnoses and treatment. He began spending eight of every ten days on the road to meet with prospective donors—a far more grueling travel schedule than he had had as the Army’s vice-chief. Along the way, he called upon the academic experts whom he hoped to fund. Learning about their work, he believed, would help him make a more compelling pitch to those writing the checks.

It also infuriated him. At a session with brain injury experts in Boston, one doctor told him that he had completed a study showing that a drug commonly used to treat TBI was ineffective and might actually be harming patients. Holy shit, Chiarelli thought.

“What’s the drug?” he asked the doctor.

“I can’t tell you that,” the doctor replied.

“What do you mean?” Chiarelli responded.

The doctor told Chiarelli that a prestigious academic journal had agreed to publish his study in three months. He was prohibited from divulging the results until then.

“You mean we’ll be giving people the wrong drug for three months?” an incredulous Chiarelli asked.

“Sir,” the doctor said, “that’s the way the system works.”

The other physicians nodded understandingly at the doctor’s explanation. “They all looked at me as if I had a third eye growing out of my head,” Chiarelli said. “I was beside myself. When I was a general, if I had a defect on a helicopter and I waited three months to do anything—‘Hey, check the torque or the bolts’—and another helicopter crashed, I’d be the subject of countless investigations.”

Meetings with other academic researchers were less colorful but no less frustrating. Chiarelli discovered that they were collecting data on their subjects using different methods, making it difficult, if not impossible, to compare results. And he found that instead of collaborating, the smartest physicians and scientists were competing for the biggest share of a growing pot of federal research dollars. He had naively assumed that they would come together in the manner of the scientists who worked on the Manhattan Project to solve what he believed was a profound national challenge. Instead, they seemed to be acting as rainmakers for their universities. “They see data as their power to get more money,” he said.

We have a totally dysfunctional research system, Chiarelli thought. The problem isn’t money. The problem is the doctors. He tossed aside his fund-raising plan. “We’ve abdicated to the researchers,” he said. “We’re afraid to challenge them because they all went to school for twelve more years than we did.”

Instead of accepting their way of doing business, or simply complaining about it to his military buddies at the officers’ club, he decided to fight. He had been a four-star general, after all. He had run a war. He wasn’t going to let petty rivalries and self-interest get in the way of helping veterans with PTS and TBI. He resolved that his organization would not “spend another cent on research” until he could find folks willing to work together.

Chiarelli figured he could get the federal government, which was spending tens of millions of dollars to bankroll most of the research, to help him out by requiring recipients of grants to collaborate. He made his case to the National Institutes of Health, the Department of Veterans Affairs, and his former colleagues in the Pentagon. They were polite but noncommittal.

A few months later, the NIH issued a grant for TBI research. It “highly encouraged” the winners to assemble data in a shareable way, but it did not require it. That wasn’t good enough for Chiarelli. If the government wasn’t going to take on the researchers, he’d do it himself.

It was a battle that came to consume almost every waking hour of his retired life. He no longer had hundreds of staff officers at his disposal, ready to execute orders; if he wanted something done, he had to do it. When he had to crisscross the country for meetings, as he did almost every week, he traveled in economy class, often on red-eyes. Gone were the days when he could summon one of the Army’s executive jets.

Despite the relentless schedule, he carved out time to keep in touch with dozens of soldiers struggling with TBI and PTS whom he had met while he was in uniform. Among them was Major Ben Richards, who had suffered two concussions—one from a suicide bomb, the other from a roadside IED—while commanding an armored cavalry troop in Iraq. Upon his return, he had received his dream job in the Army—teaching history at West Point, his alma mater—but skull-splitting headaches, frequent insomnia, and flashes of anger rendered him unable to work. When doctors determined Richards’s injuries were too significant to allow him to return to the classroom, Chiarelli promised to keep tabs on his recovery.

A few months later, when the general called, Richards was apoplectic. Military doctors had prescribed four drugs to help him with his symptoms. All of them were off-label; they hadn’t been designed or tested for his ailments, but Army physicians determined they could nonetheless ease his suffering. And they did. His migraines subsided slightly. He was sleeping better. Then he went to the VA, which was responsible for his medical treatment once he retired from the Army.

The transition should have been a straightforward matter: transfer his files and continue his treatment. But the VA, as it does with all new veterans, insisted on conducting its own examinations and prescribing its own medicines. When Richards asked for refills of the four prescriptions that military doctors had so carefully calibrated for him, his VA doctor balked. The list of drugs VA physicians were authorized to prescribe, the doctor told him, was more limited than the military’s, and two of the four medicines Richards was on were not approved by the VA. When Richards warned that discontinuing one of them, a powerful drug intended to treat nerve pain, would subject him to severe withdrawal symptoms, the doctor still refused to budge. “We know this will put you in the emergency room,” Richards remembers the doctor telling him.

Richards explained his predicament to Chiarelli, who became equally incensed. If the military deemed the drugs effective, he believed the VA had an obligation to provide them. This wasn’t akin to substituting Advil for Tylenol. These medications, which were essential to helping severely injured veterans, couldn’t be replaced with another bunch of pills. In between his work for One Mind, Chiarelli tried to bend as many ears as he could in Washington on the issue. But the VA refused to change its protocol, citing cost concerns.

How many veterans, Chiarelli wondered, wind up killing themselves because the medications they need aren’t on the VA’s list? Richards dug into his savings and paid seventeen dollars a pill to slowly wean himself off the nerve-pain drug, but not every veteran can afford to do that.

***

On the Super Bowl Sunday after Chiarelli retired from the Army, the San Francisco 49ers squared off against the Baltimore Ravens. Instead of kicking back on his sofa with a cold beer and pretzels, Chiarelli spent the weekend at a meeting of brain specialists in Houston led by Geoffrey Manley, a neurosurgery professor at the University of California campus in San Francisco. Chiarelli regarded Manley, who had helped develop the new military concussion guidelines, as one of the smartest TBI specialists in the nation and a potential ally in promoting collaboration among researchers.

Manley had received a federal stimulus grant for a “shovel-ready project” to assess TBI patients as soon as they arrived in the emergency room and then track their recovery. The study collected patient information in an identical way at four different hospitals, allowing researchers to analyze and draw conclusions from a large pool of data. But the federal grant didn’t include money to process the data. When Chiarelli learned about the shortfall in Houston, he saw an opportunity: he offered to have One Mind pick up the bill. Once the data were curated, Manley was elated. “This is amazing,” he told Chiarelli.

As the two got to know each other, Chiarelli discovered that Manley shared many of his views about collaborative research. They discussed the unique national response to the AIDS crisis a generation earlier, when Congress funded public-private partnerships and top researchers agreed to work together to identify the virus and develop treatments. Those working on AIDS broke with protocol and shared their failures, not just successes, so others wouldn’t pursue fruitless paths. “This is so stupid. What organization has a success like they did with AIDS and then doesn’t change the way they do business?” Chiarelli said. “Why didn’t they step back and say, ‘This worked’? Instead, we went back to doing things the same old way.”

Chiarelli saw TBI as a medical crisis as complicated and important as AIDS and knew that the fruits of the research would benefit not just veterans but car-crash victims, athletes, and millions of other people. An estimated three million Americans suffer head injuries every year, and it’s the leading cause of death among adults between eighteen and forty-five. What was learned could also impact treatments for diseases such as Alzheimer’s, Parkinson’s, and amyotrophic lateral sclerosis. “You need the combined power of everyone working together,” Chiarelli said.

A few months after the Houston meeting, when the National Institutes of Health announced an eighteen-million-dollar grant to conduct a larger version of Manley’s initial study, Manley decided to give collaboration a shot. He assembled a team of ten other academic institutions to submit a joint application for the money. They offered to spread the work around the country, arguing that they would be able to assess a more diverse and representative sample of patients. Manley’s team, which won the grant, also agreed to make its database publicly available six months after the study. Even though the work was not focused on veterans, Chiarelli was certain the findings would have a direct benefit to the military. “Anything more we learn about TBI helps.”

As the study started, Chiarelli once again stepped in to finance what the government wouldn’t. One Mind donated $500,000 to underwrite travel costs and stipends for victims to return to the hospital every few months so they could be tested. Although the alliance among the researchers remained fragile—some of their superiors wanted them to bid for the whole project by themselves—Chiarelli was overjoyed. “They’re putting down their competitive instincts,” he said of the researchers, “and working together for the good of the country.”

But the fight was far from over. There still is not a reliable test to diagnose mild and moderate brain injuries, and treatment options remain woefully inadequate compared with advancements made over the past generation in cancer and heart-disease care. “We’re basically treating these great volunteers the same way we treated their dads after Vietnam and their grandfathers after World War II,” Chiarelli said. “We owe them more than that.”

***

On a misty spring morning, Chiarelli walked into the lobby of the University of Pittsburgh’s sports medicine center, past a row of autographed jerseys and helmets gifted by Steelers and Penguins players whose concussions had been treated within the modern, two-story building. He had come because he knew that professional football and ice hockey teams, whose trainers and coaches had once been as ignorant and inattentive to head injuries as the military, had begun to take these ailments more seriously. Among those at the vanguard of concussion research were specialists in Pittsburgh who cared for the city’s elite athletes. Chiarelli wanted to know what they had learned.

“So many other places that you go to, people with TBI and concussions are sent home. ‘Here’s some pain meds. Rest for a few weeks in a dark room,’” he told the university doctors who sat across a table from him in a conference room. The doctors explained a new approach they had pioneered to assess the severity of a concussion through a four-minute physical examination, as well as a therapy that involved getting patients to quickly reengage their brains through complex movements and mental exercises. “We’re convinced we can corner this injury,” said Micky Collins, a University of Pittsburgh professor who ran the sports medicine center.

Chiarelli jotted copious notes on three-by-five index cards and then jumped in with questions: What about using MRIs to assess the severity of concussions? Is your test simple enough that military medics could give it while in the field? What links do you see between brain injuries and degenerative diseases such as Alzheimer’s and Parkinson’s?

“Dr. Chiarelli—” Collins said.

“I’m not a doctor.”

“You sure sound like one.”

Chiarelli spent the morning listening, questioning, observing. He accompanied Collins as he examined patients. Chiarelli stood ramrod straight off to the side, hands clasped in front, staring straight ahead. He toured the facility and struck up conversations with nurses in the hallways. He learned that specialists at the university had authored more than twenty academic papers on concussion diagnosis and treatment.

An hour later, over lunch at a seafood restaurant, Chiarelli told the doctors that the Pentagon had spent $700 million on traumatic brain injury research since 2002. “But do they have anything like this? No. I had the program for four years. Did I know any of this? No. I was going around talking about this for four fricking years, and did anyone ever tell me to come here? Here you guys are with a proven model, and here we are, in the military, limping along.” He said their lessons needed to be shared with hospitals and rehabilitation centers across the country.

Collins said other experts were not yet willing to endorse their methods, which they were seeking to spread through articles in academic journals. “There’s a lot of politics in this,” he explained.

Chiarelli switched from listen mode to pitch mode. “Stop talking about twenty studies,” he said. “Break through that. Let’s move! We need action!”

As the day wore on, Chiarelli’s excitement—and frustration—grew still more acute. One of the university’s top neurosurgeons walked him through an ongoing, Pentagon-funded study to examine whether an expensive new brain-imaging tool, called high-definition fiber tracking, can more accurately diagnose TBI. Subjects in the study, most of whom were Iraq and Afghanistan veterans, spent three days receiving a comprehensive assessment. Before they went back home, they were given iPad tablets so they could take regular health surveys and video chat with doctors.

“Remarkable,” Chiarelli gushed. “This has great promise.”

Then he asked a neurosurgeon, David Okonkwo, whether he was collaborating with David Cifu in Richmond, the VA doctor who is leading the sixty-two-million-dollar longitudinal study.

“No,” replied Okonkwo, who said the Defense Department, which funded both studies, did not require cooperation with other research projects.

“As a taxpayer, shouldn’t I be pissed off as hell?” Chiarelli said. “What kind of system sets itself up like that?”

“I don’t have a comeback for that,” Okonkwo said.

Chiarelli slammed his hand on a stack of patient reports. “How long before this is ready for prime time?”

The surgeon warned Chiarelli not to expect immediate results. “I have a massive amount of respect for your impatience. But this isn’t about flipping a switch or having a turnkey solution. It’s about having people knowing what they’re doing.”

As Chiarelli rode to the airport in a taxi driven by a Vietnam veteran, the morning mist turned into the season’s final snowfall. Chiarelli stared out at the white-flecked highway median. Then he looked at his itinerary. Washington next. Then Boston. More meetings, more researchers, more urgency.