Forgotten Casualties
By Lynn Harris
Salon.com
www.TRUTHOUT.org
Wednesday 22 September 2004
Mentally scarred by the horrors they've endured in Iraq, many
returning U.S. soldiers say the military isn't giving them the
help they deserve.
Mike Lemke, a 45-year-old Army National Guard police
sergeant from Grand Junction, Colo., volunteered for active duty
after seeing the twin towers fall on TV. "I wanted to, you know,
kick some tail," he says. He was sent home from Iraq in August
2003 because of orthopedic and cardiovascular problems - and
with memories and feelings he couldn't shake. He'd seen what was
left of one of Saddam's prisons, prowled by feral dogs with
rotting limbs in their mouths; he'd mingled constantly with
civilians, never knowing if one was armed. "You never feel
completely safe," he says. "That stays with you."
Lemke could not sleep for his first 22 days in the medical
barracks in Colorado's Fort Carson, where he remained for more
than a year on "medical holdover" - a period during which
wounded soldiers await treatment and subsequently either return
to duty or get a medical exit from the Army. He experienced
flashbacks and temper surges and would hit the dirt at the sound
of a jackhammer.
No one approached Lemke to inquire about his mental health.
Only when a nurse practitioner happened to ask him how he was
sleeping did the story come out - and even then it took him two
weeks to accept her suggestion that he seek counseling.
Why didn't Lemke ask for help? "There's a culture here of
unless your legs have been torpedoed off or your arm's shot off,
then it's not a combat injury," he says. "I did the same thing
that everyone does in the military: You suck it up. You don't
whine."
Lemke is still on medication and in therapy, and is not
employed. He is angry at the Army for many reasons, including
his treatment during the medical holdover. But the issue that
will most directly affect his future is his dispute with the
Army over his disability rating.
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The Army Medical Evaluation Board (MEB) - the body that
works in concert with the Physical Evaluation Board (PEB) to
determine wounded soldiers' medical retirement and disability
status according to the detailed specifications in Army
Regulation 635-40 - gave Lemke a 10 percent disability rating
for PTSD, which classifies it as "mild" and as allowing
for "adequate" job and social functioning.
Whether a soldier is given a 30 percent rating or a rating
less than that has major financial implications. A 30 percent
rating grants a soldier lifetime disability benefits, along with
the military's regular retirement benefits. Anything less than
30 percent results only in a one-time severance payment: two
times the soldier's base pay times total years of active duty
(up to a maximum of 12 years). Had Lemke received medical
retirement, he estimates that he'd have gotten $1,200 to $1,600
every month for the rest of his life. His severance payment is
far less. His 12 years of part-time duty convert to six years of
active duty. Result, in his case: "For someone who was available
to the government for 12 years, it's $26K and adios," he says.
The Army, citing privacy regulations, declined to discuss
the particulars of Lemke's or any other soldier's case.
Lemke is one of a number of returning soldiers, mostly Army
National Guard and Reserve, who say they are struggling not only
to heal from physical and psychological wounds, but also to get
proper mental health treatment while in the Army's care - and
adequate financial compensation when their medical condition
forces them to leave the Army.
What was once poorly understood in WWI as "shell shock"
(and, in the Civil War, as "soldier's heart") is now a much
discussed, highly researched condition The Army is now
acknowledging - and devoting a great deal of resources to - the
ever growing incidence of PTSD and other mental health issues
within its ranks.
According to a study performed at the Walter Reed Army
Medical Center and published in the July New England Journal of
Medicine, conservative estimates are that 17 percent of soldiers
are coming home from Iraq and Afghanistan suffering from PTSD,
along with anxiety and depression. For these soldiers (as
opposed to Gulf War vets, whose PTSD rates hover at 9 percent),
the strain and trauma of prolonged urban combat with a hard-to-
identify enemy, and of constant exposure to violent death -
including that of fellow soldiers - have left them with
nightmares, flashbacks, and bouts of numbness and rage.
The study concludes that reducing "barriers to care among
military personnel" - barriers such as the stigma of seeking
mental health care in the first place - must be "a priority for
research and a priority for the policymakers, clinicians, and
leaders who are involved in providing care to those who have
served in the armed forces."
However, numerous veterans of Operation Iraqi Freedom who
have come home injured say that such "awareness" has yet to
change a deeply engrained military culture in which the
only "real" wounds are physical. Result: Soldiers - especially
National Guard and Army Reserve soldiers in " medical holdover" -
say they run into roadblocks to needed mental health care,
severance arrangements that appear to downplay invisible
injuries in particular, and even attempts to send mentally unfit
soldiers back to Iraq.
"The DOD [Department of Defense] is taking great care of the
acutely injured, the injuries you can see, the burns, the lost
arms and legs that they're treating with state-of-the-art
prosthetics," says Stephen Robinson, executive director of the
National Gulf War Resource Center, a veterans' advocacy
organization in Silver Spring, Md. "But they're doing a horrible
job with the other injuries that aren't quite so evident."
Robinson, who served in the Army Special Forces in the Gulf,
testified in January before the House Armed Services Total Force
Subcommittee that soldiers in medical holdover receive
insufficient mental health screening and care. The Center for
American Progress recently published his 11-page report
criticizing the military's handling of mental health
issues. "There are unseen costs of war that have dramatic
national implications in terms of benefits and care and
reintegration into society," he says. "It is a national disgrace
that front-line and combat soldiers need to fight for medical
care and benefits when they return home from war."
Robinson, who has spoken with thousands of Iraq war
veterans, describes the typical cycle: "When soldiers come back
they have to go through complicated workman's-comp-type
paperwork to prove that something they did in the war is the
reason they're sick," he says. "That can take from four to 16
months. So they come home injured, and rather than being
integrated into society, they're stuck in medical limbo waiting
for their disability rating and then being diagnosed with a
preexisting condition" - which, he adds, implies that they
shouldn't have been sent over in the first place.
He claims, anecdotally, that the MEB is underevaluating
soldiers by a fairly consistent 10 to 20 percent - a key
percentage if it leaves a disability rating under 30 percent.
Robinson's hypothesis: The DOD simply does not want to foot
these potentially substantial bills. That, or given the number
of soldiers who will yet come home injured, it simply can't.
Lemke and many of his colleagues say such problems are
particularly acute among National Guard and Reserve soldiers,
who make up about 40 percent of deployed troops. (Of nearly
5,000 soldiers on medical hold, all but about 860 are Reserve
component troops.) "I don't think they budgeted for the Reserve
and Guard component," Lemke says. "And now they want to make the
soldier eat it."
"Soldiers are soldiers," counters Jaime Cavazos, media
relations officer for the U.S. Army Medical Command. "I doubt
very seriously that an injured soldier would be thought less of
because he was a guardsman or member of the Reserve."
The Army also disputes the charges of deliberately stingy
severance. "There is no truth to any such opinions," says Col.
Fred Schumaker, executive officer of the Army Physical
Disability Agency at the Walter Reed Army Medical Center. "The
Physical Evaluation Boards fully review the facts provided [by]
the Medical Evaluation Board and then carefully match, as
closely as possible, the compensation to the impairment in
accordance with regulatory guidance. The PEBs don't just make up
disability percentage rates or reduce them arbitrarily. They
give each soldier exactly what he is supposed to be given." He
adds: "It would be unusual if soldiers who are not compensated
by the military disability system were happy about results."
Still, Guard and Reserve soldiers say that their low ratings
are the final blow in a series of actions that lead them to
question the Army's true commitment to caring for them,
especially when their injuries are invisible.
"A lot of the people I've had contact with are not doing
very well," says Kaye Baron, a clinical psychologist in private
practice in Colorado Springs. Baron estimates that 60 to 70
percent of people she sees are in the military, and of that,
roughly half have served in or been affected by the Iraq
war. "For one thing, they're injured psychologically or
physically, and on top of that they feel they're getting
disposed of by the military - like no one really cares."
Baron has also been puzzled by military diagnoses of, for
example, personality disorder (which would be a preexisting
condition, not qualifying a soldier for benefits) in soldiers
whose symptoms are, in her estimation, fully explicable by
PTSD. "I don't understand why military mental health is not
doing more given that we know combat takes a toll on soldiers
and PTSD is a widely recognized phenomenon. I don't know why
they're not being more thoroughly examined and diagnosed."
Theoretically, based on the unprecedented efforts the Army
has made recently to acknowledge, find and treat combat stress,
soldiers should be getting more thorough examinations and
diagnoses. Teams have traveled to Iraq to assess the mental
health needs of the soldiers there. Partially in response to the
2002 murder-suicides at Fort Bragg by soldiers returning from
Afghanistan, the Army has initiated a Deployment Cycle Support
Program, designed to facilitate soldiers' transition to home
life by addressing their health and personal needs. There's a 24-
hour hotline called Military One Source for service members and
their families. There are new PTSD guides for clinicians.
Detailed protocols and procedures designed to screen for, track
and treat soldiers arriving in medical holdover with mental
health needs are in place. "Before a soldier is considered for
retirement, we have ensured that we have given him the optimum
healthcare possible," says Cavazos of the Army Medical Command.
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But individual soldiers in medical holdover suggest that
such improvements to the system have yet to trickle down to
them.
One 47-year-old high-ranking military policeman - who,
fearing reprisal, requested anonymity - was medevac'd out of
Iraq late last September for a back injury, but came home with a
host of other problems. He had been on active duty before, but
this was different - and not just because of the scorching heat
and rampant dysentery in his unit's ill-equipped camp. "You're
out in public all the time with people coming up to you and not
knowing if they're armed until they fire at you," he says. This
constant sense of threat meant sky-high stress levels and hyper-
alertness. He only narrowly avoided shooting a kid who marched
up to him saying "Fuck Americans," rock in hand. "I had a weapon
on him and in my state of mind, sad to say, I really would have
put that kid down," he recalls. (The kid, seeming to realize
this, took off.)
When this soldier came back to the States, he figured that
his flashbacks and nightmares were "the normal stress you go
through when you come out of a war zone." But while his back was
being treated, his wife informed him that he "was no longer the
man she married" - uncharacteristically withdrawn, prone to
rage, hardly sleeping or eating - and if he didn't get help
she'd leave him.
Eventually, a physician at Kentucky's Fort Knox, where he
was on medical holdover until being allowed to go home for
temporary convalescent leave last week, diagnosed him with
severe post-traumatic stress disorder. The medical report cited,
among other symptoms: insomnia, nightmares, flashbacks,
disassociation, easy startling, quick temper, and keeping to his
room for fear of hurting others, all of which were said to cause
significant impairment in his "occupational and social
functioning." He has been able to manage his symptoms somewhat
with quite a bit of therapy and medication, but he still can't
tolerate groups of people, or much food.
Just two weeks ago the soldier received word that his PTSD
had received a 10 percent disability rating from the MEB/PEB.
(He counters that his remaining symptoms and resulting
disability, as described in a second medical report, match those
described for a 30 percent rating.) He was also informed that
both the PTSD and his slipped disks (rated at 20 percent) were
considered chronic, not directly related to combat in Iraq -
where he wore and carried 75 pounds of equipment every day.
"I lived in Iraq, and before I left I was mentally and
physically healthy," he says. "I come back and my back's broken
and my mind's broken. They say it's not combat related. The
processes that are supposed to be in place to help us aren't
working. They're just not taking care of us."
The Army notes that soldiers have ample opportunity to
review their files both before they go to the board and after
initial findings are returned; should they find anything amiss,
they may request a reconsideration. Still, soldiers who have
attempted this describe a maddeningly muddled, even misleading,
bureaucratic process. Others say they accept insufficient
ratings as a means of escaping the limbo - and often unpleasant
environment - of medical holdover.
It has already been documented that the physical conditions
in medical holdover can - due in part to sheer overload by
wounded soldiers returning from Iraq - be less than conducive to
healing. A story by United Press International last fall
revealed that soldiers at Georgia's Fort Stewart were housed in
concrete barracks with insufficient water and no air
conditioning and that soldiers at Fort Knox waited months for
medical attention. Sens. Kit Bond, R-Mo., and Patrick Leahy, D-
Vt., were prompted to investigate and demand improvements. Many
physical problems have since been addressed, and standards have
been implemented to speed up soldiers' care.
Soldiers still say, however, that despite the Army's
efforts, languishing in medical holdover only compounds one's
psychological issues. "Everything is uncertain, you're denied
care, and you know they don't give a damn whether you get well
or not. It's getting to the point where soldiers will do
anything to get out of here," says a 45-year-old non-
commissioned officer in medical holdover at Fort Knox who was
afraid to give his name. "The stress here is higher than in
Iraq, and I was there."
Some soldiers say they spend as much time as possible in
their rooms, as they fear both crowds and their own temper. The
main picture they paint is one of heavy medication - "You've got
soldiers on so much meds all they do is sleep; they can't even
make formation," says a 37-year-old reserve soldier in medical
hold at Fort Knox - and of maddening red tape, administrative
runarounds, and, at best, indifference.
Also, Fort Knox, for one, is a training post. "They're
firing all the time," says the military policeman now on
convalescent leave, who, like many of his comrades, is startled
by a mere footstep. "That's a trigger for me." (He has addressed
this concern to the inspector general's office on post, who
acknowledged the complaint, but so far no action has been
taken.)
Soldiers do report positive individual experiences with
physicians - the 37-year-old reserve soldier, who didn't trust
his own violent temper, says his psychiatrist saved not only his
life, but likely someone else's as well. While each soldier in
medical holdover is assigned a case manager to help him work
with the medical system, some complain that not all case
managers are as caring or as knowledgeable as they need to be.
In fact, several of the more experienced soldiers in Fort Knox
medical holdover have seen fit to become de facto experts on the
Army's byzantine medical and benefits systems. The military
policeman on convalescent leave is himself at work on designing
a series of flow charts and writing a lengthy booklet about the
disability evaluation system to serve as a guide for other
soldiers.
Beneath the bureaucracy, the matter of military culture runs
even deeper - and is harder to transform. In his report to the
Armed Services subcommittee, Stephen Robinson said extensive
research and tours of medical posts by his organization showed
that soldiers in medical holdover receive "little to no
counseling regarding traumatic events experienced during war."
Why not? More often than not, he says, they're not asking for
it - and they shouldn't have to in the first place.
According to the Army Medical Command, screening for mental
health issues in medical holdover is done via self-reporting in
questionnaires, or ad hoc by physicians treating soldiers for
physical issues. "I'm sure that during the course of treatment a
soldier will give off signs that will suggest that the
individual needs some mental health counseling of some kind,"
says Cavazos of the Army Medical Command.
Robinson counters that it's essential for Army medical
personnel to initiate intervention for mental health issues,
even among soldiers coming home for physical
injuries. "Questionnaires are not sufficient to establish
physical and mental fitness," he says, especially given the
stigma against seeking psychological help or
admitting "weakness." Indeed, the Walter Reed study found that
the fear of stigma was "disproportionately greatest among those
most in need of help from mental health services." Says
Robinson: "Fear of stigmatization will remain a problem until
the military changes its culture."
By some soldiers' accounts, their commanding officers will
not be at the vanguard of that change. Their job, after all, is
to get soldiers back to duty.
"I was told [by higher-ups] to 'not worry about it,'" says
the 45-year-old NCO in medical holdover at Fort Knox, of the
insomnia, anxiety and panic attacks that eventually got him on
Zoloft, BuSpar, Ambien, and trazodone. "These soldiers come here
all wired," he said, referring to the hypervigilance that's
typical of PTSD, "and they immediately start telling them that
they're going to try to return them to Iraq." According to him,
they're told by their chain of command: "Don't settle down
because you're going to need that high intensity when you go
back."
Spc. Laurence Kiefer, 30, a crane operator with the
quartermaster combat support unit of the Montana National Guard,
was brought home from Iraq to Fort Carson in May for reasons
both medical and legal: injuries relating to a truck accident,
and charges that he'd stolen grenades. (The judge advocate
general, the prosecuting body of the military, has since found
no evidence to support the charges. Kiefer claims the accusation
came as retaliation for a dispute with his commander.)
He was suffering from combat trauma - at one point he'd had
to drive a 22-ton crane at its maximum speed of 10 to 20 mph,
for a 17-hour, 350-mile trip, often under fire - compounded by
stress over the charges, the shock of his wife's announcement
that she was leaving him, and the fear that he'd be sent back to
serve in the same unit with hostile command. However, he didn't
get summoned for his official "outprocessing" exam for nearly
three months. In the meantime, after first "self-medicating"
with alcohol, he eventually sought medication and psychological
treatment.
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Soon thereafter, he was told to pack up and re-deploy. He
appealed to his psychologist, Jacqueline E. Delano, who felt
that he wasn't ready, and who later asserted in writing that in
a subsequent phone conversation, Kiefer's commanding
officer "made statements indicating that he felt Spc. Kiefer was
over-exaggerating his symptoms to get out of going back to Iraq"
and "was not interested in this psychologist's professional
opinion." Delano was able to delay Kiefer's departure by
insisting on further evaluation; she then diagnosed him with a
personality disorder, a preexisting condition that renders him
both unfit to serve and ineligible for benefits. A civilian
psychologist later asserted that Kiefer's condition was PTSD;
Kiefer is currently fighting the "personality disorder"
designation.
What recourse do these solders have? Says the 45-year-old
NCO at Fort Knox: "The attitude here is: I don't trust these
people. I'll wait till I get home and go to the V.A." Vets may
apply for benefits through the V.A., which has a more generous
ratings system. Five thousand veterans of Iraq and Afghanistan
have gone to the V.A. with mental health diagnoses already. For
those reasons and others, the V.A. is an appealing resource for
soldiers in, and just out of, medical holdover. "The V.A. has no
legal authority. They can't take what we say and turn it against
us," says the NCO. "They can't hurt you like the Army can."
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Now back at home and a civilian, Lemke is still doing his
best, via word of mouth, to help soldiers who are confused or
feeling mistreated by the system, or who are simply struggling
with PTSD themselves. He even gets contacted by soldiers' wives
who are desperate to find out "what's wrong" with their
husbands. No matter what, he knows what his fellow soldiers have
been through. "First I fought the war," Lemke says. "Then I had
to fight a war for my treatment."
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