The Road to Walter Reed, Paved with Good Intentions - Part II

The Road to Walter Reed, Part I

During the 1990's, the problems facing Gulf War veterans had become a national issue. While no one has yet to medically identify the causality of the numerous illnesses suffered by these vets, it was still clear that the system had allowed the vets to be outprocessed from the military without proper identification and treatment of many illnesses that may have been managed to recovery if treated aggressively in the first few months or weeks of onset. Second, the survey of veterans' health returning from the Gulf was not begun until three years after their return and well after a good pattern and source could be identified clearly. That meant that the military medical corp would be hard pressed to identify the causality and recommend appropriate protections to the DoD. Finally, this had rapidly expanded the roles of disabled vets: those looking for treatment in VA centers and disability benefits.

Some of the issues that contributed to this problem were the rules and regulations that established points of separation from the military. In the case of the Reserve and National Guard components, those laws and regulations that activated the Reserve and Guard for emergent contingencies and then de-activated them again caused many to be seperated or returned to civilan life without appropriate oversight for potential medical issues (e.g. Gulf War Syndrome and other ailments). These points of separation and de-activation, strictly observed, had many servicemen and women stricken from the roles without consideration for other issues. This included medical issues as well as an appropriate transition period that provided for the continued care or time to transition back to civilian life (ie, obtaining a job, insurance, housing, etc).

In 1998, the National Defense Authorization Act (sections 501, 502, 513, and 522 among many) sought to address many of these problems by providing for voluntary extension by the service member. Most of these laws and regulations were set to become effective in the year 2000. These laws and regulations also strengthened the already existing ADME (Active Duty Medical Extension) program.

The ADME is designed to allow Reserve and Guard component servicemen and women to voluntarily extend their term of active duty while continuing to receive medical treatment until they are able to return to civilian life and work after demobilization. Those that do not volunteer for such an extension are REFRAD (removed from active duty) and, by not entering the voluntary program, have accepted responsibility for their own treatment and financial status. It would mean that the usual processes for de-activation or separation could be suspended in order to provide care, pay and benefits for the service men and women as well as their dependents.

In addition to these regulations, the 1998 NDAA also sets forth programs and incentives for attracting medical personnel, particularly doctors, dentists and nurses (section 517 and 534). According to the NDAA, the services were suffering a serious shortage. One of the improved incentives was to reduce the "pay back" scale for payment of education. Before 1998, the military required two years of service for every six months of education that was paid for by the government. The 1998 NDAA reduced this to 1 year per every six months paid. Further, nurses who graduated from civilian nursing programs were to be offered the Nurse Officer Candidate Accension Program. This would allow nurses to have their education paid for at schools that did not have Senior Reserve Officer Training Programs in place, in exchange for four years service.

These sections clearly indicate that another crisis was occuring at the same time the government was creating an additional burden on the Military Medical Corps.

Questions remain: now that the government has made good on its intentions to provide care and services for many more servicemen and women, how were they going to make good on it without the necessary human resources? You don't. The people you do have work longer and harder. The people needing to see those people wait longer and longer.

How do you build a system meant to maintain people longer than the original system intended complete with tracking of status, pay and benefits? You add paper and processes to an already onerous system, call it something else (Medical Retention Process), pretend everything is fine until a story breaks and congress calls you for a hearing, while men and women wait for pieces of paper and treatment in overcrowded facilities that were old, decrepit and never mentioned once in this NDAA or any succeeding NDAA or any other budgetary demands as a part of this entire process.

Just another pothole in the road to Walter Reed paved with good intentions.

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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

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Walter Reed: The Continuing Saga

February 27 Army Times -

The story ostensibly portrays many activities that the Walter Reed commander undertook as "CYA". However, I wanted to point out some things that did occur that are obviously not in keeping with the title and implications of the story.

Soldiers at Walter Reed Army Medical Center’s Medical Hold Unit say they have been told they will wake up at 6 a.m. every morning and have their rooms ready for inspection at 7 a.m., and that they must not speak to the media.

“Some soldiers believe this is a form of punishment for the trouble soldiers caused by talking to the media,” one Medical Hold Unit soldier said, speaking on the condition of anonymity.

It is unusual for soldiers to have daily inspections after Basic Training.

Technically, these soldiers are "active duty" which means the military can tell them what they can or cannot say to the media within certain parameters. Most units have a PAO or Public Affairs Office that handles inquiries and directs media. Thus, the command is not outside of what the military does in other units or outside of its pervue. However, the direction to stop talking to the media is very likely in direct reaction to the bad publicity the military medical command received from the Washington Post series of articles and the subsequent internet barrage.

What I find interesting is the comment regarding room inspections. In general, Building 18 has been rather informal. However, the recent Post articles pointed out that soldiers were drinking heavily in their rooms, possible death or injury of one or more from alcohol poisoning or narcotics, under age drinking (against the law even in the military), possible suicides or suicidal tendencies, PTSD events and, of course, the condition of the rooms from the walls, to ceilings to bathrooms and plumbing.

While it may seem harsh from a civilian perspective, particularly in light of the condition of some of the soldiers, it is a rather military response to the conditions. The only way to know is to inspect. That may, in fact, seem like "punishment", particularly to those who were not involved in the original complaint and interview or who do have issues.

Difficulties in this process will still arise because many of the patients are not fit enough or beyond pain meds in order to perform a military type cleaning of their own rooms. Still, there are others who are simply waiting to be processed for reasons only the military can sort out that are not beyond certain capabilities.

On a side note, it has been recommended by the VA and other top psychiatric professionals that getting back to "normal" routine after a traumatic event can be a stabilizing factor. On the other hand, I can't speak for the physical or psychiatric health of all the patients currently residing there. This may be helpful to some and detrimental to others. A more refined process for identifying the "cans" from the "can't" may need to be instigated or is already available. Finally, some are awaiting the completion of their treatment, a Medical Exam Board (MEB) indicating their condition and processing back to their active duty units as "fit". It may be appropriate to maintain "good military order" and not allow soldiers to slip into conditions or activities that would be detrimental to their ability to be deployed.

Like the military instigating across the board actions, the story is also rather broad in its brush strokes implying that these actions are above and beyond or that all those at Building 18 are beyond these capabilities.

Here is another piece of the "good and the bad":

Soldiers say their sergeant major gathered troops at 6 p.m. Monday to tell them they must follow their chain of command when asking for help with their medical evaluation paperwork, or when they spot mold, mice or other problems in their quarters.

"Follow the chain of command" has a lot of implications and purposes. First, this is the military's directive in almost all situations that is supposed to insure good discipline and order. It is also a nice cover to say the military wants "first crack" at fixing things. Obviously, they hadn't done such a good job previously, but the story looks like the first "casualties" of the investigation have already been "re-assigned" or "relieved".

The soldiers said they were also told their first sergeant has been relieved of duty, and that all of their platoon sergeants have been moved to other positions at Walter Reed. And 120 permanent-duty soldiers are expected to arrive by mid-March to take control of the Medical Hold Unit, the soldiers said.

I doubt these will be the last. Officers in the administration will be next, but the process will require a slightly different tact. Needless to say, this has probably ended the career of several administrative officers, some of which may not even know it yet.

Continuing on with the "chain of command" directive, I would like to point out that, even in the military, "follow the chain of command" doesn't mean that you are forever relegated to only speaking with the platoon leader or officer directly above you. It means to follow the process first in bringing issues to your immediate "supervisor", possibly doing so in writing a second time and then seeking out the next "command" element in line, ostensibly until you get results. Much like the civilian world of management, except that breaking that chain can be much more difficult in the military. Still, it doesn't exactly mean "shut up and get back in your place".

The best parts of the article were almost glossed over, probably with no help from the PAO (Public Affairs Office - who apparently declined to return calls). The report indicated:

120 permanent-duty soldiers are expected to arrive by mid-March to take control of the Medical Hold Unit

Without additional info from the PAO, my best guess would be that these are going to be people gathered from multiple units or from a specific MPU (Medical Processing Unit) that have performed very well at their previous stations and will be tasked with quickly sorting out and moving these soldiers either out to MTF (Medical Treatment Facilities = bases with specific clinics or specialists), through their MEB (medical exam board to determine fitness for active duty), to a CHBCO (Community Health Based Care Organization - treatment near home by Tricare networked civilian healthcare), REFRAD (released from active duty) or returned to their active duty or reserve units. There are a lot of places that these soldiers could be, including home, instead of at Walter Reed and building 18.

More "good and bad" news:

They were also told they would be moving out of Building 18 to Building 14 within the next couple of weeks. Building 14 is a barracks that houses the administrative offices for the Medical Hold Unit and was renovated in 2006. It’s also located on the Walter Reed Campus, where reporters must be escorted by public affairs personnel. Building 18 is located just off campus and is easy to access.

You should have read that to mean, who knows when building 18 that actually houses the wounded was renovated, but apparently the administrative building can be renovated to make sure certain officers and administrative personnel are comfortable. It's true that Walter Reed was scheduled to be shut down and renovated completely, which may have led to the allocation of funds to the "must be renovated or repaired" to maintain working order. But, it does seem interesting that funds could be obtained for the administrative area, ostensibly by some officer or manager creating a very convincing power point, budget and improved efficacy numbers, while nearly six years into the war, no one could do the same for a place that is housing a couple hundred wounded soldiers?

This may in fact have been noted by certain people in the command structure since the other "near miss" of the paragraph says:

Building 14 is a barracks that houses the administrative offices for the Medical Hold Unit

That could be a number of things including simply identifying the best and most recently updated building on the premises to house the wounded. It could be some administrative officer got a fire lit under his freshly pressed johdpurs and decided to make the "sacrifice" as a career saving move or an attempt to improve the public image of Walter Reed. Finally, not knowing how the decision was made, it might include a little "up yours" from the brass. The brass may have decided to toss out the administration folks as a little lesson on who they were supposed to be taking care of.

The final note at the end of the article is probably also true. The military medical command wants to salvage its image. Instead of giving a full tour of Malogne House, the good AND the bad, they clamp down like a venus fly trap on rotten meat, effectively shutting out the free flow press.

However, we still have people who have been there and done that, so information will not be stopped at Walter Reed Gate.

On a final note, they are hosting a contest to rename Building 18.

My suggestion, based on the hold overs and conditions? Stalag 18.

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