Tuesday, March 06, 2007

Walter Reed: The Road To Hell, Paved With Good Intentions - Part I

No one that reads history or follows veterans affairs should imagine that anything that is occuring at Walter Reed (and any number of places) is a product of the last seven years under the current administration. It is, and always has been, an ongoing struggle between the need to provide care for soldiers and veterans, the capabilities of Department of Defense and other government agencies, the conglomeration of add ons either developed by DoD or written into law by a well meaning (or not) congress and, the always present, fiscal balancing act where Peter beats Paul to a bloody pulp and then Paul hijacks Peter at gunpoint.

The US Sanitary Commission was first organized as a "women's relief" program. Women wanted to do their part to support the war and looked for ways to participate.

Accompanied by several other gentlemen deeply interested in the problem, he went to Washington to study the situation. The idea of the Sanitary Commission was a natural outgrowth of what they saw, but the plan at first met with little favor. The medical corps was indifferent if not actually hostile; the War Department was in opposition; President Lincoln feared that it would be a " fifth wheel to the coach." But finally the acting surgeon-general was won over and recommended the appointment of " a commission of inquiry and advice in respect to the sanitary interests of the United States forces," to act with the medical bureau

The problems that beset veterans and wounded alike were present over 140 years ago:

A " home " was established in Washington to give food and lodging and proper care to discharged soldiers. Those in charge were always ready to help soldiers to correct defective papers, to act as agents for those too feeble to present their claims at the pension office or to the paymaster, and to protect them from sharpers and the like. Lodges were established near the railway stations to give temporary shelter. Two nurses' homes were established, but these were largely used as temporary shelter for mothers or wives seeking their wounded sons or husbands.

In the West, a home was established by the Chicago branch at Cairo, Illinois, which was one of the main gateways through which soldiers passed, going toward or returning from the army. Rations were issued by the Government, and the building was furnished for the most part by the commission which assumed the management. It was, in effect, a free hotel for soldiers, and thousands were looked after and kept from harmful associations. Later it was much enlarged by order of General Grant, who instructed the officer commanding the post to construct suitable buildings. Much of the money raised by the Sanitary Commission was by means of fairs, some of which became national events, and lasted for weeks. During its existence the Sanitary Commission received $4,924,480.99 in money and the value of $15,000,000 in supplies.

Most people should be aware of Clara Barton, Angel of the Battelfield and founder of the American Red Cross. A brief story that illustrates additional difficulties in military medicine over the last two centuries.

Arriving at the northern edge of the infamous "Cornfield" at about noon, Clara Barton watched as harried surgeons dressed the soldiers' wounds with cornhusks. Army medical supplies were far behind the fast-moving troops at Antietam Battlefield. Miss Barton handed over to grateful surgeons a wagonload of bandages and other medical supplies that she had personally collected over the past year. [snip]

With the outbreak of war and the cascade of wounded Union soldiers into Washington, Miss Barton quickly recognized the unpreparedness of the Army Medical Department. For nearly a year, she lobbied the army bureaucracy in vain to bring her own medical supplies to the battlefields. Finally, with the help of sympathetic U.S. Senator Henry Wilson of Massachusetts, Miss Barton was permitted to bring her supplies to the battlefield

The question may be why we see similar problems today regardless of technology?

The answer was in a little sentence in the paragraphs above:

Those in charge were always ready to help soldiers to correct defective papers, to act as agents for those too feeble to present their claims at the pension office or to the paymaster, and to protect them from sharpers and the like

The short answer is: buearacracy. Established armies and governments are always trying to account for supplies, weapons, money and men. Whether the Romans to the Continental Army, from Napoleon to the modern day American military, such efforts are originally built around the concept of maintaining and supplying the military, allocating needs to keep the army in the field and evaluate available human and material resources. In Democracies, it also tends towards "accountability" to the civilians who pay the taxes and through whose grace the government serves.

In so doing, every nation and established military end up with convoluted processes and immense paperwork that ends up bottle necked or missing somewhere in the vast black hole filled with clerks and managers. Even the Sumarians, somehwere in the historical confines of Iraq, kept track on clay tablets. It is doubtful that they felt their technological advance in clay tablets, stylets and cuniform were inefficient. Yet, for all their efficiency, it's likely they suffered from the same procedural and clerical morass that aflicts any nation with a bueacratic government intent on managing its resources.

A Road Paved With Good Intentions and Filled With Potholes

The road to hell is paved with good intentions. Our own road, bringing us to our current destination at Building 18, Walter Reed Hospital, begins somewhere a little closer in history: 1991 Gulf War.

Approximately 500k American troops were stationed in the deserts of Saudi Arabia, arrayed to expel Saddam from Kuwait. Of these deployed overseas, 100k were National Guard and Reserve forces. Chemical weapons were greatly feared, trained against and vaccinated against. Our own weapons, such as Depleted Uranium anti-armor rounds, may or may not be dangerous to those handling them. But, they are the best weapon on the field for such a task and they are deployed. In the desert, new insects (and old) along with necrotizing fasciitis (flesh eating) bacteria, spread disease despite the best sanitary attempts. Many of which are resistant to anti-biotics and still plague soldiers today.

The war ended in 100 days and saw 148 dead. Approximately 1k coalition forces, mainly American, were wounded. Both the front line and the rear medical treatment programs and facilities were capable of handling these injured, though, many suffered through the bueacratic out processing and medical relays with barely a blip on the radar. That is, until 1994.

Gulf War Syndrome and Political Fall Out Changes the Rules

Shortly after the end of Desert Storm (Gulf War I), veterans began to present with a wide aray of illnesses. Cancer, malaise, fibromyalgia like symptoms, nausea, vomiting, muscle cramps, infertility and a significant number of birth defects began to appear in this population. Veterans who were previously healthy prior to deployment began to believe that their illnesses were connected to their time in the desert and petitioned for benefits. Because the epidemiology (history) and etiology (disease relation) were difficult to establish, these veterans were often first treated as if their medical complaints were part of either a pre-existing, previously undiagnosed condition or as a condition developed post-service. Many were denied benefits just like their Vietnam brethern before them who had to struggle with the problem of "Agent Orange" and obtaining "service connected" benefits. Many of these Gulf War veterans were discharged for medical cause without being provided post service medical treatment or disability payments.

The news and out cry was slow in developing. Because of the lack of epidemiology and etiology, the DoD and government first maintained that these illnesses were unrelated. But, by 1996, the reported numbers had become so glaring that they had become impossible to ignore.

Figure 2. Probability of hospitalization for unexplained illness, deployed and nondeployed veterans. Adjusted for recruitment effort on 1 June, 1994, from Knoke JD and Gray GC (1998) "Hospitalizations for Unexplained Illnesses among U.S. Veterans of the Persian Gulf War" The slightly lower hospitalization risk for the deployed than for the nondeployed (Figure 2) is consistent with a healthy service member effect; that is, those selected for deployment are, on average, slightly healthier than those not selected." (San Diego, California: Naval Health Research Center).

As of the year 2000, 183,000 US Service Members who served in the Gulf (approximately 30% of the 700,000 deployed throughout Desert Shield/Desert Storm and post conflict maintenance) have been declared permanently disabled.

In 1994, the run on the VA by Gulf War I vets, combined with an aging Vietnam Vet population and the existing World War II vets began to take a toll on the VA budget and was rapidly expanding disability payouts from a war that was, for all intents and purposes, the lowest casualty war in history. To top that off, the resulting outcry from the civilian population and congress, was becoming a public relations nightmare. People were angry about the treatment of these vets (or lack thereof) by the military and subsequent discharges that left many without pay, without benefits for the Vets and their families and often without the ability to take a job or receive benefits in the civilian sector (due to "pre-existing" clauses).

Enter the Gulf War Health Center and the CCEP (Comprehensive Clinical Evaluation Program).

The Department of Defense's evaluation program was established June 7, 1994 with the goal of providing in-depth evaluations of Gulf War veterans who are serving in one of the active or Reserve components, or are retired. Walter Reed's Specialized Care Program was initiated in January 1995 by then Major General Ronald R. Blanck, hospital commander. The SCP's mission is to deliver a coordinated multidisciplinary treatment program designed to address persistent, disabling symptoms among Gulf War veterans or family members that remain undiagnosed after appropriate medical evaluation; and/or are unlikely to respond to specific biomedical treatments.

This eventually became the DHCC (Deployment Health Clinical Center) and the PDH-CPG (Post Deployment Health Clinical Practical Guidelines)

And the discharge of military personnel for inexplicable conditions or without appropriate medical care by the military was translated into the ADME (Active Duty Medical Extension).

Which brings us to our modern problem: what happens when you design giant, insensitive, buearacratic processes meant to protect service members from already existing, giant, insensitive buearacratic processes during peacetime?

A road to process hell, paved with good intentions and full of sink holes and paperwork IEDs.

Cross referenced at the Castle


Superdestroyer said...

Thanks for posting this. This is so much more reasonsed that the activist propoganda that is filling up the blogosphere.

Shimmy said...

Walter Reed Army Hospital is the Dick Cheney Memorial Slum.