The Departments of Veterans Affairs' Center for PTSD defines and describes PTSD:
... PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life.
PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.
At least 30% of Operation Enduring Freedom and Operation Iraqi Freedom soldiers have been diagnosed with stress-related mental health problems which impair social, occupational, and interpersonal functioning according to the Army Surgeon General Lt. Gen. Kevin C. Kiley, who estimates that 5% have developed PTSD, an estimate significantly lower than other leading experts have reported. In testimony before Congress in April 2005, Kiley testified that progress was being made into how the disorder was perceived:
We are embracing the diagnosis of PTSD... MHS [military health system] and VA [Department of Veterans Affairs] are embracing it rather than taking that diagnosis and excluding it and looking for some other diagnosis. That's a major cultural, medical shift.
However, in October 2005, he acknowledged, in reference to post-traumatic stress disorder in the Army, that "There’s no question there is still a stigma." Still, efforts such as including post-deployment screening, stress assessment, combat stress control teams joining troops in combat, and training leadership in addressing PTSD are all good beginnings. But are there domestic forces undermining the military’s attempts to combat PSTD? Are our soldiers receiving the very best treatment upon their return home? Behind the Bush Administration’s public face of "Support the Troops," political agendas compete with the needs of the veterans.
The escalating price tag on the Iraq war has been projected into the trillions. Nobel prize-winning economist Joseph Stiglitz and Harvard budget expert Linda Bilmes included projected healthcare and disability costs and the impact on the economy in their estimates. And, as Stiglitz and Bilmes noted, their estimates are conservative; the actual costs could run much higher. Thus, it’s no surprise that evidence suggests that budget pressure and ideology have motivated the Bush administration to enact cost cutting measures aimed at limiting combat damaged troops access to benefits. By its aggressive management of the public relations problems generated by the increasingly unpopular war, our government has sought to veil the death and destruction from public view. In what amounts to the Swift-boating of the American veteran, battlefield damage is minimized while operatives plant stories in the media to trumpet the view that the source of PTSD resides solely within the individual and not with the war itself. The soldiers hailed as heroic upon deployment find themselves, upon their return, portrayed as psychologically impaired before they went to war, morally weak, or untruthful, malingering veterans.
President Bush’s economic advisor Larry Lindsay was forced to resign in December 2002 when he suggested the war could cost as much as $200 billion; thus, presumably there are intense incentives to cut costs. Powerful ideologues carefully positioned within the administration are enacting measures that would do so, not through diligent budgetary oversight of all military expenditures which have been rife with massive financial irregularities, but instead by limiting veterans’ benefits. This agenda to ration care, to redefine disorders in such a way to deny the need for medical intervention, and to malign the victims unduly taxes and spends a national treasure: the wellbeing of our military personnel.
The kids coming back from Iraq and Afghanistan, all of them in harm’s way, deserve to come back to 21st century medical care. Whatever the cost, we need to incur that cost to provide world-class medical care to the extraordinary men and women who are in harm’s way.
August 25, 2005
Anthony J. Principi
Former Secretary of Veterans Affairs 2001-2005
Principi’s forceful support for veterans’ healthcare benefits was made as he announced the closing of the aged Walter Reed Army Hospital and the opening of a new billion dollar facility in Bethesda, Maryland. Principi, whose two sons served in Iraq and under whose advocacy the Veterans Affairs budget grew from $48 billion to $65 billion in three years, resigned from the VA on 11/16/04, shortly after the reelection of President Bush.
On 1/26/05 President Bush replaced Principi with Jim Nicholson, former Chairman of the Republican National Committee from 1997-2000 and Ambassador to the Vatican, a real estate lawyer and developer with no healthcare experience. The Department of Veterans Affairs has as its stated goal "…to provide excellence in patient care, veterans' benefits and customer satisfaction." In classic foreshadowing of the isolation veterans feel from the decision-making processes of the VA, on 2/16/05 Nicholson convened a meeting of the Advisory Committee on Homeless Veterans [.pdf] in the Tropical Room at San Juan Puerto Rico’s Caribe Hilton Hotel rather than in the arguably more appropriate (considering the concerns about finances), frugal confines of a room at 810 Vermont Avenue NW, Washington, D.C. And Nicholson stunned the veterans community in August 2005 when he asserted that most sufferers from Post Traumatic Stress Disorder (PTSD) can be cured, a contention unsupported by the scientific literature. In fact, the official VA site itself states that there is no cure.
In early 2005, House Republican leaders ousted a strong supporter of increased funding for veterans’ benefits, Rep. Chris Smith (R-NJ) as chair and as a member of the Veterans Affairs Committee, replacing him with a choice strongly opposed by veterans groups, Rep. Steve Buyer (R-IN), whose website boasts is a "…leader in the fight to reduce government spending." Senator Arlen Specter (R-PA) shifted from chair of the Senate Committee on Veterans Affairs to the Judiciary Committee and Larry Craig (R-ID) was appointed chair in his place. Craig was given a 0% rating by the American Public Health Association in 2003 for having an anti-public health voting record.
It is noteworthy that there is a direct link between Craig and the Cato Institute, a libertarian think tank which advocates reducing government funding of healthcare. The Cato Institute’s director of health policy is none other than Michael F. Cannon, who served under Larry Craig’s direction as health policy analyst in the Senate Republican Policy Committee. Remember Cannon’s name as his policy influence may be seen in proposals for PTSD treatment.
The parsimony agenda at the Veterans Health Administration has been marred by scandal, most notably by Bush appointee Dr. Nelda Wray, recruited from the Houston VA and the health-outcomes research unit at Baylor University School of Medicine. She created a stir in the research community when, newly installed in 2003 as Chief Research and Development officer, she moved VA research away from the hard science of basic research to outcomes research (which supports the cost cutting and limited utilization goals of managed care), and tried to put funding decisions in the hands of cherry picked experts instead of using the traditional peer review process. Wray was dismissed after misappropriating $1.7 million in funds provided by the pharmaceutical industry, taking inappropriate trips to Houston, using expensive lodging and transportation, creating an environment of fear in her agency, and funneling a $750,000 contract to her colleague in Houston in violation of VA regulations.
The official investigation [.pdf] revealed that she had extravagantly spent the pharmaceutical funds maintained by the Friends Research Institute, Inc. in an unofficial relationship and "…this spending constituted an illegal augmentation of the Department’s appropriations, and a misuse of position." The Research and Development Office CFO, John Bradley reported that "… Dr. Wray did not accept being questioned, and that 'bad things' happened to those who questioned her." Criminal charges were never filed.
While Army Surgeon General Lt. Gen. Kevin Kiley, acknowledges that 30% of returning troops have stress-related mental health problems, these problems are being redefined and minimized by "military medical officials" as "normal reactions to combat." These same unnamed military medical officials "cautioned against people reading their data as suggesting the war had driven so many soldiers over the edge." With Army suicide rates and heavy alcohol use increasing, barriers that prevent the majority of the afflicted from seeking treatment have been identified. In the comprehensive New England Journal of Medicine study "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care" (Hoge, et al.), these barriers are as diverse as the perceived stigma of being seen as weak and treated differently by unit leaders and members; skepticism that the use of mental health services is confidential; and inconsistent rulings and lengthy delays in obtaining disability and other benefits. Veterans’ advocate Kirt P. Love1 notes:
DOD/VA still use the old trick of patronizing a person into walking away. I’ve experienced it myself with VA in my own medical dealings. It is so easy with a soldier who is already irritable and excitable. The doctor says something demeaning, the soldier blows up, walks out, and the doctor writes on the computer hospital notes the soldier is violent and non-responsive. Afterwards, the soldier is haunted by that field note in his medical folder that grants VA the ability to keep him at bay or even restrain him. Forced psychiatric observation, which keeps the soldier from coming back. It’s a trap that most soldiers never see coming. These kids are driven to denial from almost every direction in the bad cases.
There has been recent speculation that the VA is under pressure to report low rates of PTSD for the public relations needs of Mr. Bush’s war agenda. Kirt Love¹ adds:
As we speak, DOD is rapid chaptering 100’s of medical cases out of Iraq. More than 10,000 injuries have taken place in Iraq alone, and yet it looks like that rather than medical chapters -- many are just being rushed out with nothing. The stories here at Fort Hood are quite disturbing, and yet because soldiers are taught "tough guy medicine"-they don’t want to complain because they look weak. Which is very much to DOD’s advantage. So it looks like the Pre/Post deployment medical screenings (PL 105-85) aren’t being done right to track these soldiers as they transition back to civilian life. About 23% look like they are slipping through the system. No doubt PTSD is being grossly under reported as these kids watch their bomb riddled buddies return home in body bags. You can imagine many are thinking "what right do I have to complain when the guys next to me died." We are seeing a small number of the physically injured in the media, but the traumatized are nearly invisble in many ways.
Particularly worrisome to veterans groups are the blue ribbon panels. The VA announced via a press release from Senator Larry Craig’s office that it has entered into an agreement with the Institute of Medicine (IOM), an arm of the National Academy of Sciences, who have convened a blue ribbon panel to conduct a review of the assessment and diagnosis of PTSD, followed by a review of treatment and compensation practices. The IOM is a private, nonprofit organization. Veterans groups may have valid reasons for concern as blue ribbon panels have been known to be "too close to private industry." Love adds:
After 7 years of working with the IOM’s many committees, I’m firmly convinced that they just want another paying contract-so they will write in favor of the contractor rather than genuine medical issues in favor of the veteran. When these studies were started in 2005, the IOM staff even tried to hide the fact of the public meetings even from the National Veteran Service Organizations. Only after I challenged them earlier last year did they circulate that these meetings were public. 2005 was no different than any other year with the IOM, and they even let the contractor (VA, Mark Brown) dress down the only veteran in the room. To try and run me off during the opening meeting. Granted the panel tried to give me false hope in the beginning as if they were interested in any external content. But as the year progressed the panel staff became adversarial until the November 15th 2005 Government Reform hearing where they became outright belligerent. That’s where they were called into question on their choice of review materials in Gulf War medical research. They are NOT the friend of the veterans, and have abused the letter of PL 105-368 that assigned them the Gulf War contracts-PTSD included. This is why even the Service groups have stopped attending these meetings, just about no one in Washington DC respects the IOM these days but the contractors. DOD, VA.
The PTSD review panel has likewise come under fire [.pdf] for not including even one member with experience with PTSD in combat populations. Two members of the panel, who had contributed to an exhaustive review of the literature [.pdf] on PTSD for the American Psychiatric Association (APA) on 11/04, resigned shortly after the start of the panel’s first meeting on 5/9/05. Betty Pfefferbaum, M.D. J.D, one of a nine-member work group that conducted the APA review, resigned 5/18/05. Carol North M.D., M.P.E, and a frequent research partner of Dr. Pfefferbaum, resigned her position 7/29/05 following the 7/11/05 meeting. When contacted for comment, Dr. Pfefferbaum replied, "I resigned before the IOM process actually began because my time commitments do not permit me to work on projects that are not directly applicable to my areas of interest (primarily disaster trauma, terrorism, and children) and because I did not feel I had sufficient expertise in the area to make meaningful contributions."2 That she had sufficient expertise to contribute to the literature review for the American Psychiatric Association would seem to contradict this reasoning.
Dr. North reported that "In what seems to be unfortunate timing for my work with the IOM committee, I took a full time position at the Dallas VA in conjunction with a new job I started at UT Southwestern Medical Center in Dallas this fall. Obviously, my new VA affiliation could provide the appearance of conflict or bias with the committee's agenda, and the IOM has a policy of not having members on their committees who receive their salary from the sponsor of the study."3 She resigned two and a half months after the start of the study. It is indeed unfortunate that it was required that she depart due to her unique position with the very population in scrutiny. That her VA affiliation is considered a "conflict of interest" no doubt adds to the skepticism of veterans’ organizations.
The APA literature review [.pdf] that Dr. Pfefferbaum and Dr. North contributed to recommends that PTSD treatment must have one person to coordinate a team approach and that "Because of the diversity and depth of medical knowledge and expertise required for this oversight function, a psychiatrist may be optimal for this role, although this staffing pattern may not be possible in some health care settings"(p.12, emphasis added by authors). The relationship between the Senate Committee on Veterans Affairs under the chairmanship of Larry Craig and the Cato Institute healthcare policy (a policy which advocates deregulating the provision of healthcare and allowing its allocation to non-MD and unlicensed providers in order to drive down costs) under the directorship of Michael F. Cannon may provide an additional layer of meaning to the two psychiatrists’ departures.
The competing agendas of budget, public relations and ideology overrun veterans’ needs. Those in positions of power whose ideology embraces limited utilization of healthcare benefits, the deregulation of healthcare providers, and the reduction in federal spending for healthcare contribute to the deterioration of the provision of healthcare to our returning veterans. And all those President’s men can’t put Johnny back together again with a yellow ribbon.
1. Private e-mail to D.E. Ford dated January 16, 2006
2. Private e-mail to D.E. Ford dated December 30, 2005
3. Private e-mail to D.E. Ford dated December 30, 2005
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Contributors: Zan, Cho, Standingup, Stoy, Vivian, JeninRI and lilnubber
Illustration by R. Stoy
Photo provided by Kirt Love
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