From Draft NOtices, January—March 2008

Military Health Care in Crisis

— Kathleen Gilberd

The Iraq occupation and war in Afghanistan are taxing the military medical system beyond its limits. As the number of combat-related injuries and illnesses increases, many soldiers report that it is difficult to get medical care. Some are discouraged from going to sick call or flatly (and illegally) refused permission to see doctors, and others are sent away after inadequate examinations by overworked corpsmen or medics. In the field and at many medical facilities, service members may face misdiagnosis, poor treatment, long waits for specialists, inappropriate return to duty before injuries are healed, or months in holding companies awaiting medical discharge or retirement. Many with mental or physical problems receive imaginative administrative discharges instead of medical retirement.

It is difficult to focus on U.S. casualties and the failure of the military medical system when they are overshadowed by criminal occupation-related deaths, injuries, and illness among the population of Iraq. Casualties there are seldom reported in the U.S., and the nature of the occupation makes it difficult to gather accurate figures. Independent medical groups report huge numbers of permanent injuries and long-term mental disorders among children and adults. In addition, Iraq’s medical infrastructure has been devastated by U.S. attacks, after being weakened by years of embargo on medicines and medical equipment.

But the inadequacy of medical care for U.S. soldiers is also a crime, compounded by the fact that military leaders must have anticipated a significant part of the injuries, mental health problems, and combat-related illnesses inherent in these wars, and then failed to expand the medical system to handle them. It is a normal part of long-term military planning and budget projection to anticipate numbers of dead and injured -- and after Vietnam and the first Gulf war, to expect psychiatric problems and unknown illnesses. Yet the Pentagon did not shift sufficient funds, facilities and personnel to medical care and is simply not able to handle the numbers of patients. A recent report in USA Today gave Department of Defense figures of nearly 30,000 injuries among U.S. troops from the Iraq and Afghanistan wars. In 2006, 27,000 recent veterans were receiving treatment for PTSD from the Department of Veterans Affairs (VA). Critics believe these figures are much lower than the reality.

Military medical care has always been problematic, though it has seldom received public scrutiny. While some military hospitals have claimed excellence, other hospitals have much worse reputations, and every military family knows medical horror stories. The military medical field is traditionally understaffed. With too few doctors, corpsman and medics are often the only health care providers available to soldiers at remote bases or in the field. Although these personnel have far less training than licensed practical nurses, the system presses them to make diagnoses and treatment decisions beyond their training. (This is not meant as a criticism of corpsmen or medics, some of whom are among the finest medical personnel this writer has met, but rather of the system in which they work.)

It is widely believed that military physicians are worse, on the whole, than their civilian counterparts. Military credentialing is not rigorous and oversight is often inadequate. "Whistleblower" medical personnel are uncommon, since retaliation for complaints is a fact of military life. Some recent "patient rights" provisions must be posted at all medical facilities, but few service members are aware of them. And the rank system discourages questions and complaints by GIs -- physicians are all officers, and most patients are enlisted personnel used to taking their orders.

In the civilian world, litigation helps to counter the worst medical malpractice, hopefully weeding out the poorest doctors. For the military system, a strange set of legal cases called the Feres Doctrine prevents service members from suing for money damages for harm caused by medical malpractice or other wrongs which are "incident to military service." Courts have consistently held that the military’s disability system, with continuing medical care and small pensions for those who are medically retired, makes damages unnecessary, and ruled that litigation would interfere with necessary command discretion and prerogatives.

 This doctrine does not prevent suit for malpractice that injures military "dependent" spouses or children, but protects doctors and the military against damages suits by service members across the board. Critics feel that this creates a safe harbor for doctors who could not practice successfully outside the military and keeps public attention off of military medicine.

If you add to this a brutal war, with mobilization of reservists who are often under-prepared for active service, and rapid deployment and re-deployment of troops after rushed training, the situation gets much worse.

There have been complaints about poor medical care since early in the Iraq war. Counselors and attorneys assisting military personnel found that many were forced to deploy despite injuries and illness, including serious mental disorders. In late 2003, the military released figures showing an unexpected number of suicides in Iraq — 11 soldiers and two Marines succeeded in killing themselves in Iraq in the first seven months of the war. (These figures did not include suicides after return to the U.S. or after discharge from the service.) The Department of Defense sent a mental health advisory team to investigate the situation. It identified lack of mental health personnel and difficulty in obtaining anti-depressant and sleep medications in Iraq as significant parts of the problem. This means, of course, that the team accepted the continued use in combat of soldiers with mental disorders and in need of medication.

While the military reported fewer suicides in 2004, the figure shot up again in 2005. In May 2006, in a series of investigative reports, the Hartford Courant newspaper revealed that soldiers were deploying and re-deploying to Iraq with significant psychiatric problems, some shortly after beginning trials of anti-depressant medications. Reporters found that pre-deployment mental health assessments, mandated by Congress after the 2003 suicides, often amounted to one question on a health assessment form, and that little or nothing was done with the results. Among the soldiers who committed suicide in Iraq were a number who had been identified as ill and at risk before their deaths and had been kept on duty and in the field. These reports, and others that followed, created further congressional concern. Another round of studies ensued. The Courant staff can be credited with some improvements in mental health assessment and care, but the problems continued.

PTSD has been called one of two "signature" medical problems of the Iraq war. The other, which began receiving public attention two or three years ago, is traumatic brain injury (TBI). Even mild TBIs can cause long-term physical and mental impairment, and problems can be exacerbated if the injury is not quickly diagnosed. Yet neurological conditions of this sort are often missed without extensive and expensive testing — even CAT scans sometimes fail to show TBIs serious enough to cause memory and concentration problems, lack of physical coordination, and the like. While the military has some excellent neurological experts, it lacks the extensive facilities and personnel necessary for diagnosis, short-term treatment and long-term rehabilitation of these patients.

In early 2007, thanks largely to accounts from soldiers and veterans, the Washington Post reported abysmal conditions at Walter Reed Medical Center. In addition to problems in the hospital itself, reporters found that nearly 700 soldiers and Marines, released from the hospital but still suffering serious injuries, were housed for months in non-hygienic facilities on and off post while awaiting reassignment or, more commonly, medical retirement. The scandal led to a major shake-up, and a high-level firing and resignation. Ironically, the Army and some patients blamed many of the problems on outsourcing of supervision for these facilities to a civilian contractor who simply cut corners and costs.

Congressional hearings were held, and reports of problems at other military hospitals followed. In May, news reports of a separate scandal at Fort Carson pointed to another problem long recognized by military counselors and attorneys: soldiers returning from combat with PTSD were routinely misdiagnosed with personality disorders, often after a single 15-minute psychological examination. Personality disorders, considered lesser psychiatric conditions and thought to arise during adolescence, are presumed to have existed prior to enlistment, unlike PTSD, and so do not warrant military or VA medical care or pensions.

Soon similar reports came from Camp Pendleton, where failure to diagnose PTSD triggered another long-standing problem. Marines who showed symptoms of PTSD and other disorders were disciplined and discharged for misconduct — often for going UA (unauthorized absence, or AWOL), for "disrespect" to superiors, for angry behavior under stress, or for self-medication with drugs or alcohol. Since officers did not recognize the source of the problems, Marines were punished and then frequently discharged with other than honorable discharges. Misconduct discharges normally preclude processing for medical retirement and make it extremely difficult to obtain VA care or pensions.

Despite repeated exposés, reports, congressional hearings, and DoD promises of improved care, problems continue. On November 13, 2007, CBS reported an "epidemic" of suicides among recent veterans. And in early January of this year, USA Today carried a lengthy article on PTSD among women soldiers and veterans. Despite combat exclusions, women make up about 11% of troops deployed to Iraq, Afghanistan and the surrounding area. Many women not only see combat but engage in it as convoy drivers, as checkpoint guards, and in neighborhood searches. The article reported that combat PTSD was exacerbated for many of these women by PTSD from sexual assault — rapes and other sexual attacks by fellow U.S. soldiers. The VA found that 20% of women seeking help since 2002 showed symptoms of military sexual trauma. Reported incidents of sexual assault (recognized to be only a fraction of actual incidents) included 167 assaults in 2005 and 201 in 2006 within the U.S. Central Command, which includes both Iraq and Afghanistan.

These problems will continue as long as the U.S. carries out a "perpetual war." Military funds, resources and personnel are focused on warfare and not on the health of those facing or returning from combat. Soldiers are viewed, quite literally, as cannon fodder, as units in a machine to be discarded when they are injured or ill and can no longer fight. This is part and parcel of an imperialist policy of interventionist war, and cannot be solved until the underlying policy is changed. In the meantime, as military and VA facilities become more and more over-extended, veterans seek treatment in civilian hospitals, assistance from Medicare and Social Security Disability, and help from welfare and other social services. The cost to our society is much more than the direct cost of the war in lives and dollars, for we are looking at a whole new generation of wounded veterans neglected by the government.

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SIDEBAR: The Feres Doctrine and Hazards of Military Enlistment

— Miriam Clark

The Feres Doctrine, in regards to military personnel, means that the government cannot be sued for money damages for “incidents” of harm experienced due to military service. This creates hidden hazards of being in the military. Examples of government programs that have damaged military personnel but been protected under the Feres Doctrine include exposure to Agent Orange or depleted uranium and forced application of anthrax vaccines.

Agent Orange was a defoliant sprayed by plane over large areas of Vietnam during the war to kill vegetation and expose concealed jungle trails. It made huge areas of Vietnam’s soil unfit for cultivation. It was also a cancer-producing substance that affected hundreds of thousands of Vietnam citizens and U.S. personnel and eventually caused the deaths of thousands of these same people. Returning U.S. soldiers had many physical complaints that were dismissed as psychosomatic or imaginary by the Pentagon. Those complaints developed into cancer, congenital deformities in veterans’ children, and continuing death rates among the veterans. The Pentagon continues to deny Agent Orange was responsible.

Depleted uranium (DU) is a byproduct of energy-producing nuclear plants. Its high density makes it a superior armor-penetrating material. DU burns spontaneously on impact, creating tiny aerosolized particles less than five microns in diameter, small enough to be inhaled. At least 70% of the uranium in these weapons is released in this form on impact, and these tiny particles travel long distances when airborne. It has a half-life of more than four billion years. It is used to coat all types of missiles from bullets to tank shells, and 375 tons of it was used in the first Gulf war with devastating impact. U.S. military personnel were not warned that contact with these shells or the areas in which they had been deployed would be physically dangerous for them. DU was also used in Yugoslavia and more than 1,000 tons were deployed in the second Gulf war. 

According to the National Gulf War Resources Center, symptoms of Gulf War Syndrome include damage to organs, genetic manifestations, chronic fatigue, loss of endurance, frequent infections, sore throat, coughing, skin rashes, night sweats, nausea and vomiting, diarrhea, dizziness, headaches, memory loss, confusion, vision problems, muscle spasms and cramps, joint pain and loss of mobility, aching muscles, swollen glands, dental problems, and malformations of newborns. These problems have affected 50,000 to 80,000 U.S. veterans from the first Gulf war, and 39,000 have been dismissed from active service. As of 2002, 10,502 have died and 221,502 are on disability.

In 1999, 2.4 million U.S. Armed Forces personnel, including more than one million Reserve and National Guard members, were ordered to receive anthrax vaccine over a period of several years. This decision resulted in courts-martial and disciplinary hearings among U.S. Armed Forces personnel who refused the anthrax vaccine on safety grounds. In 2002 the U.S. military cited “a possible and as yet unproven link between anthrax vaccine and birth defects.”

For many decades, U.S. military personnel have been unknowingly used as test subjects for numerous weapons, including atomic exposure, Agent Orange, DU, and vaccines. That is one of the unknown hazards of service.

Sidebar Information Sources: Articles compiled in the book Medal of Dishonor, 1999; The National Gulf War Resources Center; “Anthrax Vaccine Controversy over Safety and Efficiency,” Institute for Molecular Medicine, 1999; and “U.S. Military Finds that Anthrax Shots May Cause Birth Defects,” Reuters, 1/18/02.

This article is from Draft NOtices, the newsletter of the Committee Opposed to Militarism and the Draft (http://www.comdsd.org)