In the wake of the recent reports over poor treatment of wounded soldiers at Walter Reed Army Medical Center (WRAMC), as described in the Washington Post, it would do well for us to consider the possibility that the outrage we are expressing may have been in fact intended to appear at this very moment in time. We may unleash fury at this “scandal,” and it is probably our fury at the war, but we may also be missing an important development. The existence of an underhanded attempt to revamp the military healthcare system according to administration and Pentagon geopolitical demands but with the emotional responses of Americans largely opposed to these demands as the justification for this revamping cannot be ruled out as impossible. Indeed, this situation is probable.
The popular response to the “scandal” at WRAMC and the subsequent Veterans Affairs “scandal” will be used to justify the modernization of a healthcare system that could not be modernized without such a popular mandate. Many people opposed to the war are currently advocating, by expressing admittedly justified outrage, the expansion of an important part of the very system they may be trying to contain. The unpopularity of the war would not allow this modernization to occur upon request and certainly not upon demand. Any attempt to revamp the system, without a popular mandate, would therefore be immediately recognized as an expansionary effort at a time when military expansion is unpopular. This mandate is our outrage, and the war itself cannot continue without such a mandate. With the numbers of wounded steadily growing, there is no choice but to stop the war or to refurbish the healthcare system. If we support this refurbishment as dictated by the war’s architects, we also support the war.
In response to a failing war, the people running this country have found opportunity to revamp the domestic military medical healthcare system according to their geopolitical ambitions. In the United States, Iraq is all but a dead duck, but the nature of the conflict has opened certain doors where windows have been closed. The high numbers of Operation Iraqi Freedom wounded and the government’s inability to treat these wounds has long been evident. American soldiers overseas enjoy the most modernized, efficient, battlefield medical treatment and evacuation system in history. On-site care, open roads and airways, globally established medical facilities, communications, and in-transit treatment capabilities contribute to the current influx of wounded. In a war where little else has been positive, where so many and so diverse wounds have been endured and sustained, the medical treatment and evacuation system has performed superbly, and has been widely lauded to boot. But until now the focus on the dead has drawn much attention away from the epidemic of the wounded. Indeed, wounded are known as a more accurate gauge of the costs of this war than the dead, and there is ample literature on this situation specifying the contexts, types, nature, and number of injuries.
A few examples of the efficiency of the combat medicine system will demonstrate the gravity of the situation. There are anywhere from 25,000 to 50,000 wounded, depending on definitions At least two-dozen arrive home every week (on Tuesday, Thursday, and Sunday, invariably at night), and are expected to remain in the Defense Department system for about 300 days. Soldiers injured on the battlefield invariably survive, with survival rates well above 95%. The ratio of wounded to dead is arguably 16 to 1, compared with less than 2 to 1during World War Two. Wounds to extremities, burns, blinding, and brain injury are widespread. Advanced armor protects the body’s vital organs against attacks but soldiers’ limbs are exposed, are taking hits, leaving them very mangled and in need of expensive long-term care. Multiple surgeries are common and a number of programs (costing millions) have been established to deal with burns and amputations. What would have killed soldiers in earlier wars is not killing them today, a situation that showcases the full capabilities of the overseas combat medicine system, but simultaneously exacerbates the problem of caring for soldiers at home. This war is clear evidence that as time has progressed, the American military has become better at saving lives but not at avoiding injuries.
Combat medical treatment itself is therefore very important to recognize. Perhaps serendipitously, but probably not, the moment Army Surgeon General Kevin Kiley began speaking of the medical system established between Iraq and the United States, in the wake of the recent reports, he was interrupted by Congress-members questioning him, who cited time constraints. The testimony aired on C-SPAN on March 5th was itself twice interrupted: first for an all but empty House chamber and second for House debate on Water and Sewage reform. In prepared statements regarding medical evacuation from Iraq, the elapsed time that the military said it was able to get wounded home was increased by twelve hours (from 36 to 48 hours) than actual capabilities, with the probable intent of downplaying the evacuation system to make it seem worse than it is. This tactic is focused on downplaying the system’s effectiveness. If it is seen as too good, the system’s effectiveness will be noticed as part of the problem, which is not simply the failure of the long-term healthcare system. The over-efficiency of the medical treatment and evacuation system and the disastrous overseas operations we are involved in contribute as much to this problem as the domestic failures do. Were we not in Iraq for so long, sustaining so many injuries, the system would not be overburdened and would therefore be in no need of remedy. Since we have been and possibly will be overseas for so long, the domestic system must be addressed or the war itself cannot go on.
When the Post story broke there was a passage that sheds light on our current situation. The Post reported what they feel it means to be a soldier at Walter Reed: “We did our duty. We fought in the war. We got wounded. Fine.” It is peculiar that in spite of all the criticism of the war, it is “fine” that people are being harmed. In the entire furor that followed these reports and the “swift action” that was immediately taken to remedy the situation, this one line stands out as an indication that the wounded are certainly not much of an official priority, even as so much negative emotion is being unleashed by officialdom at themselves and their system, and by citizens and soldiers on officialdom and its system. Indeed, the Post evidently intended to use the issue of large numbers of wounded and questionable capacity to treat them long-term as a unifying force where no other unification could exist. It seems that a unifying attempt by more tried methods was long ago abandoned, as tolerance of the conflict has progressively disappeared, making such attempts more costly. The relative absence of the wounded from war commentary provided a perfect avenue by which the war rhetoric could be bolstered. The absence led to an opportunity to manipulate the truth.
The Post reported: “The priority has to be that the soldiers at Walter Reed get the best possible care,” echoing the White House. They reported that the “outrage underscored that, while the war in Iraq is an enormously divisive issue, it remains a tenet of faith among the public that wounded troops deserve the best of care.” Military families and soldiers are among the last bastions of support for the war, and losing their support would certainly doom the project. This “scandal” may have dealt a blow to that support, but it was also an attempt to revitalize and recapture it. “With anger building among military families and veterans groups, representatives have seemed less reluctant to criticize the administration,” said the Post. A professor at Howard University noted that the events were a “potent reminder of past indignities and past traumas,” referring to the Vietnam era. In one article the Post described how the 25 million military veterans in this country were “united in their outrage, along with the nation.”
It is apparent that the war is a dreadfully failing cause, but with such popular support for troops, as frothed up by the outrage over the wounded, the people responsible see a chance to capitalize on their failures. Betting that the sentiments of frustrated and irate citizens, as embodied in the “support for the troops” mantra, would provide license to overhaul the healthcare system, the war’s architects played a very smart hand. This issue was a “rare unifier”, Congress showed “rare unanimity,” with Congressman Carl Levin stating, “The war in Iraq has divided our nation but the cause of supporting our troops unites us.” In defensive language but along the same lines, Congressman Larry Craig, Senate Veterans Affairs Committee chairman, recently said, “people now want to say that not only are they against the war, and the way the President has handled it, but now they want to take aim at the way the government takes care of veterans.” United as such, we have still allowed this overhaul to continue.
This “scandal” suggests the analogy that manufacturers of toxic waste will ignore their nefarious production as long as possible. The course of events following the Post reports follows this logic exactly, which was nicely laid out by Congressman John Tierney during recent Congressional hearings: “First deny, then try to cover up, then designate a fall guy.” President Bush, of course, knew nothing, with press secretary Tony Snow saying that it is imperative that we “find out what the problem is and fix it.” The military likewise knew nothing, with Defense Secretary Robert Gates saying, “We need to find out the scope of this problem.” Gates was going to review “all rehabilitative care and administrative procedures.” The second indicator is the cover up, which was amply provided by Assistant Secretary of Defense for Health Affairs William Winkenwerder, who said, “We get concerns all the time directed to us, but we never got a concern sent our way about this issue. I’m not sure why that is,” Army Chief of Staff Peter Schoomaker, “I couldn’t be madder, and I couldn’t be more embarrassed and ashamed at the kinds of things that have turned up, because clearly its not what my impression would have been based on the feedback that I’ve gotten as I’ve talked to soldiers and the families.” Kiley argued that the Walter Reed stories were factual but “one-sided.” Thus, stage two is complete. Finally, the third step, the fall guy, was adequately demonstrated with the firings of at least two top officials almost as soon as Gates issued his two-minute-long sound byte speech on March 2nd about failed leadership. General George Weightman was the biggest fall guy of all, losing his job less than eight months after assuming command of Walter Reed and publicly acknowledging his own failures as a leader. There have been numerous other changes to the hierarchy since, most recently with the appointment of Michael Tucker and Terrence J. McKenrick, who will together lead “a brigade focused on helping wounded outpatients navigate a treacherous bureaucracy.”
It is of course preposterous that the President and other top officials, including Congress, were unaware of the existence of and conditions facing wounded soldiers. If they were, they are woefully incompetent and unfit to carry out their own Global War on Terror. But the logic of ignorance serves the purpose of allowing the government a free hand in “reforming” the healthcare system at a time when its hands are clearly tied: the war could not go on as such, nor could the problem of wounded be ignored any longer, and so the obvious was revealed: “Top officials at Walter Reed Army Medical Center, including the Army's surgeon general, have heard complaints about outpatient neglect from family members, veterans groups and members of Congress for more than three years.” The Post said that, “Kenneth L. Farmer Jr., who commanded Walter Reed for two years until last August, said that he was aware of outpatient problems and that there were ‘ongoing reviews and discussions’ about how to fix them when he left. He said he shared many of those issues with Kiley, his immediate commander. Last summer when he turned over command to Major General George W. Weightman, Farmer said, ‘there were a variety of things we identified as opportunities for continued improvement’.” When it was revealed that, “Its Not Just Walter Reed,” the Post wrote that the conditions nationwide were an “open secret of substandard, under-funded care.”
Of course, “a swift investigation and repair” would be undertaken. There was “intense reaction” from a newly “critical” Democratic Congress, and the Pentagon was taking a “pounding” of questions, certain to respond quickly and decisively. Thus, reporting on the preliminary results of a supposedly months old Army inspector general’s investigation, the Post said, “The service needs to standardize its training of workers who assist patients, that its information-management databases are inadequate and that there are "policy disconnects" between Army regulations and Defense Department instructions.” Among other problems expected to be dealt with, as reported by Vice Chief of Staff Richard Cody in the Post: overworked and under-trained employees, cumbersome and lengthy administrative processes, improperly manned medical holding units, leaders who can ensure proper accountability, facilities not maintained to the standards set by the military. These problems have been amply discussed and fleshed out in the Post.
Reflecting the urgency of this problem, the Post quoted ousted Army Secretary Francis Harvey, the second fall guy, “‘this is too important and cannot wait for a report to be finished or a review to be completed. We'll fix as we go; we'll fix as we find things wrong’.” The language of the response was itself extremely militant. There would be a “surge plan,” akin to the troop “surge” so discussed of late, and it was said that soldiers “battled our enemies and shouldn’t have to battle bureaucracy.” A favorable Post write-up of Kiley described him as “utterly ruthless” in addressing problems and that watching his “dogged and aggressive” leadership would be watching a “thing of beauty.” The reform would “inject a battlefield perspective into what has traditionally been a solely medical operation.” Snow said the problem would be “attacked.” Militancy is, of course, the best way the military, and increasingly more civilian officials, know how to deal with their problems. By “attacking” the problem, the architects confronted the populace with a challenge most likely not to be accepted. They used failed rhetoric initially applied to Iraq to the problem of wounded soldiers.
It is important to note the role of stigma and stoicism in the military and the subsequent silence that we may expect from many soldiers who would otherwise express concern. Soldiers were granted permission by the military to voice concerns at predetermined times and places, but were ordered not to speak to the media thereafter. Also noteworthy is the so-called “culture of victimization” that has developed around the many wounded troops. The idea of this “culture” is that soldiers appreciate the sympathy and concern of civilian citizens and others, but are quite happy to weather their respective storms alone. The division between military and civilian life has never been greater than it is today, making this argument more durable. This position diminishes the potency of arguing an end to the war because we are sustaining too many casualties. If troops can take it, so can we, they did their duty and got wounded, fine, so can we. We should just keep quiet and let them feel however they want to.
The fact that the problems were known and not acted upon only exacerbates the outrage and lends further license to the “reform” cause. Attempting to crush any chance that there would be opposition to a “reform” of the system, Gates said, “I am disappointed that some in the Army have not adequately appreciated the seriousness of the situation…Some have shown too much defensiveness and have not shown enough focus on digging into and addressing the problems.” Vice-President Richard Cheney barked that, “Our administration’s priority is very clear to the Congress and to the country: there will be no excuses, only action, and the federal bureaucracy will not slow that action down. We’re going to fix the problems at Walter Reed, period.” One wonders what Cheney’s idea of “problems” is.
It should be said that there is important opposition to the attempted developments. Weightman was asked by Congressman Henry Waxman to justify “a memorandum from Garrison Commander Peter Garibaldi sent through you to Colonel Daryl Spencer, the Assistant Chief of Staff for Resource Management with the U.S. Army Medical Command.” The memo revealed intentions to privatize healthcare and employment at Walter Reed. The administration was accused of intentionally fomenting the problems at the hospital in an attempt to break the already faltering system, demonstrating the federal government’s incapability to deal with the problem and thereby cornering the healthcare services once their plans to revamp the system were realized. The plan was to diminish the ranks of federal personnel and eventually replace them with private employees. The contract obligations of the company charged with providing employees was not acted upon, resulting in a shortage of employees and an intended exacerbation of the problems. An estimated drop in employees from 300 to 60 has been suggested. Waxman said, “It would be reprehensible if the deplorable conditions were caused or aggravated by an ideological commitment to privatized government services regardless of the costs to taxpayers and the consequences for wounded soldier.”
The military initially said funding was not a source of the problem, but later the Post reported, “the hospital may lack adequate funding and staff for rehabilitative services. ‘That's my first impression, that there are personnel shortages and funding shortages,’” said John Marsh, the DOD investigator appointed by Gates immediately after the story broke. The Post went on, “Pentagon budget officials in recent years have required military medical services to cut costs by hundreds of millions of dollars, ‘This year, its $80 million in my core budget. Next year, its on the order of $142 million,’ Kiley said. ‘I can't find $142 million in efficiencies.’ Senator Ted Stevens said that the Pentagon's imposed cuts reach nearly $500 million this year and nearly $800 million next year for all branches of the armed forces. ‘It is shocking to see, at a time when the military medical facilities need more money, that we have budget people directing reductions,’ he said. ‘I'm really, really alarmed at that.’ In the interview yesterday, Marsh said his first impression was that Walter Reed did not have enough workers for rehabilitative services. ‘I think they're going to have to have more people,’ he said.” Funding was therefore certainly an issue, though it was arrived at in a roundabout way.
Testimony by Sergeant Michael Shannon, a patient at Walter Reed, reveals the complexity of this situation: “This system cannot be trusted and soldiers get less than they deserve from a system seemingly designed and run to cut the costs associated with fighting this war.” Shannon’s sentiments perfectly reflect the Post’s peculiar logic noted earlier. The remark implies that the war should be continued, but only if soldiers and citizens can trust that, given the high probability they would be wounded overseas, they will also be taken care of at home. Since we cannot not support the troops, the system must be able to be trusted, which requires a complete overhaul. The war is therefore more important than the system, and so the system must be justified to the demands of the war. In the context of this determined effort to expand the system, Schoomaker said, “I have concerns as we go through this long war about taking down capacity that may be needed.” Indeed, it is expected that the troop surge will produce more casualties, which is going to strain an obviously overburdened system. Of course, we could remove the possibility of having to deal with casualties, but the constraints of our war rhetoric forbid imagining such a thing. “‘There is a sense of distrust in the system,’ Schoomaker said. ‘They are going to help us reestablish that trust with the very people we are pledged to support.’”
Kiley cited that it was not just leadership breakdowns but bureaucratic failures that contributed to the problem. For its part, Congress was going to have to allow an overhaul of the whole operation, but to succeed in this, important legislative steps would have to be taken. The Base Realignment and Closure Act of 2005, which effectively doomed the now indispensable (and very old) Walter Reed to be closed, would have to be overturned: The Post said, “Problems in outpatient care have been exacerbated in part by the planned closure in 2011 of Walter Reed.” The closing plans were also going to cost people their jobs, as Norton noted: “What it does is send the signal to everybody, go look for another job because we think its going to close down.” The BRAC overturning process is still ongoing but the “Walter Reed National Military Medical Center”, a fusion of Walter Reed and the Navy hospital at Bethesda, “aimed at creating the nation’s premier military facility for treating soldiers wounded in Iraq and Afghanistan, research, and education,” is quite likely to be established, given that we are told the BRAC is simply untenable in the “long war” we find ourselves in. When the reports came out that “Its Not Just Walter Reed,” the next phase began, the important revelation being that the problem was systemic across the entire military healthcare system and could not be repaired without major changes, as many suspected. DC delegate Eleanor Holmes Norton noted a “completely dilapidated administrative system…The problem is much more serious than one building.”
Of course, the VA has traditionally been under-funded, and no guarantees that it will be reformed exist because of the situation at Walter Reed. The problems facing the Veteran’s Affairs Department have been no secret to observers and scarcely need mention. In 2004 former VA chief Anthony Principi said that the VA could not care for soldiers except those already in the system. Principi, a long time health official, was replaced by R. James Nicholson, an appointment seen as largely political (though such a thing is denied) given Nicholson’s relative inexperience in healthcare (he was a former foreign diplomat). Congress-members have regularly remarked on the prevalence of maimed soldiers, and last September a speech was delivered on VA inadequacies and suspicions of the administration misleading the Congress on VA’s ability to care for the wounded. The VA has regularly returned to Congress for billions in emergency funding despite its enjoying historically unprecedented budgets in the last two years. There have also been a number of other indications demonstrating the VA’s failures. Two years ago the VA temporarily reopened over 70,000 Post-Traumatic Stress Disorder cases for reevaluation, resulting in a powerful backlash among veterans and at least one suicide, which promptly quashed the attempt. Veterans in Texas have marched hundreds of miles to protest VA failures there. The data theft scandal of last year only adds to the list. The most recent development of interest regarding the potential of the VA and DOD to provide a “seamless transition” for returning veterans is the DOD attempt to end file sharing with the VA due to data sharing agreements. This action prompted uproar among VA doctors, who could not properly treat soldiers sent to the VA without information about their previous treatment, given the complexity of wounds. The decision was quickly reversed. The General Accounting Office has repeatedly issued reports on military healthcare, with no shortage of warnings about both healthcare systems’ problems. In 2003, Paul Sullivan of the Gulf War Resource Center noted that the military healthcare system was a “public disaster waiting to happen.”
The Post reported on March 8th, “Consider what the White House and the Pentagon have done after learning of substandard care for injured veterans at Walter Reed: They've created no fewer than eight overlapping investigations, commissions, task forces and study groups to respond. President Bush stood in the Oval Office yesterday morning with Bob Dole and Donna Shalala, the new co-chairs of the President's Commission on Care for America's Returning Wounded Warriors … Only days before Bush named the Dole-Shalala commission, he tapped Jim Nicholson, the Secretary of Veterans Affairs, to lead a Cabinet-level Task Force on Returning Global War on Terror Heroes. Then there's Defense Secretary Robert Gates's Independent Review Group (IRG), led by former Veterans Affairs chief Togo West and former Army secretary Jack Marsh. Rounding out the cornucopia of Commissions: a military "Tiger Team" to examine outpatient medical care… Two military probes called "15-6 investigations," something called a "Lean Six Sigma" examination, and a Criminal Investigation Command (CID) probe.” Nicholson noted that the Task Force would issue a report on April 19th regarding its findings and recommendations on systemic reforms. Dole and Shalala, co-chairs of the PCCRWW, noted that a “broad mandate” had been issued by the administration to review the military healthcare system. Shalala expected that the Commission’s recommendations would change the military healthcare system for the next thirty years. The Commission will review the entire system and make recommendations to conform to the new demands of the GWOT.
Iraq is a failing operation, but in the wake of potential triumph for those opposed, there must not be any mistake that the forces generating Iraq, sustaining it, and still playing a major part in deciding domestic and foreign politics are very much alive and kicking. The most recent act of the (hopefully) post-Iraq leadership has been to expand the healthcare system that it intentionally allowed to disintegrate during the course of the conflict. Now, with people angry and confused it is playing on their sentiments once again to further its own agenda. In the end, “broad mandates” have been anticipated; “systemic reforms” were desired but could not be undertaken without help from the popular outrage (by an already outraged populace) generated by the war and the Washington Post reports. This “scandal” was a timely, staged, public affairs disaster intended to elicit exactly the popular response that has been generated, in turn freeing the administration and the Pentagon to initiate sweeping “reforms” of a healthcare system that is not in step with current geopolitical and military ambitions. This disaster has given the administration license to attempt two things: first, to overhaul the healthcare system, thereby allowing the second development: that the system can continue to sustain the war’s casualties, and therefore the war itself. Of course, if we do not support the troops, the troops will not support the administration.
Joseph Szczekoski lives in Pennsylvania, and can be reached at: firstname.lastname@example.org.