Stop the Killing

By David Ollier Weber

An epidemic of suicide among active-duty military personnel as well as veterans holds implications for civilian doctors and hospitals.

David Ollier Weber

In an average week last year, nine American GIs—soldiers, sailors, airmen or Marines—were killed while on active duty in Iraq or Afghanistan. Five more died that week not from enemy bullets, terrorist bombs or service-related accidents but by their own hand.

Every month last year at least 1,000 former GIs—many of them recently discharged soldiers, sailors, airmen or Marines—tried to commit suicide, a Veterans Affairs official reported. About 20 in 100,000 succeeded.

War exacts a terrible toll. It claims as victims not only those killed or wounded in combat and the hapless civilians caught in the crossfire, but also those who survive to come home. Suicide is the tip of an iceberg of war-related mental anguish.

Consider This Recent Letter

A civilian psychiatrist writes to military authorities to urge the discharge of a soldier who had remained absent without leave rather than return to his base after a devastating tour in Iraq:

"Mr. [NAME] … has experienced tremendously aversive experiences in combat…. Three episodes stood out as events that would lead to lasting psychological injury. First, during a battle in Ramadi, Iraq, Mr. [NAME] tried to rescue U.S. military personnel who had been severely injured after a large explosion. Injured personnel remained on top of a large truck. When he tried to remove a GI by the legs, he was shocked to discover that only the pelvis and legs remained from the waist down; the upper part of the body had been separated. During that episode, he encountered many other body parts in the process of trying to rescue the injured.

"On a second occasion, he was ordered to clean the top of a truck that was covered with blood and body parts. During a third episode, he held the hand of an Iraqi soldier, who was dying after the lower part of his body had been blown off in an explosion. Mr. [NAME] reports frequent flashbacks and nightmares about these experiences, as well as deep guilt and remorse for his own actions in combat; he started crying as he stated, ‘I wonder how many orphans over there that I've created by killing their dad.'"

This distraught soldier had tried four times to end his own life, the psychiatrist noted. "As his first suicide attempt, he tried wrecking his car while driving at 120-130 miles per hour. In a second attempt, he tried to hurt himself while driving a four-wheel drive vehicle; he hit a tree, and the vehicle burned up. Third, while intoxicated, he offered another person in a dune buggy $1,400 cash to run over him. Fourth, he drank a half gallon of vodka and a fifth of Jim Beam whisky and then took 12 Xanax tablets, in an attempt to kill himself. The next morning, when he woke up, he threatened to kill a ‘cop' who was present and everyone else in the room (including family members and his best friend, as well as himself)."

Should the military police attempt to arrest the soldier and forcibly return him to the base where he would pose a high risk of harming himself or others, the psychiatrist warned, "my legal and ethical responsibilities as a medical professional would lead me to seek his confinement in a civilian hospital, even if he does not consent to such confinement."

Four New Cases Each Week

The doctor who intervened so emphatically in this case is one of a group of about 70 primary care and mental health practitioners nationwide who make up the Civilian Medical Resources Network. Organized in 2006, the network's participants provide free or very-low-cost confidential assessments, acute clinical interventions and documentation for active-duty military personnel who are distrustful of the military medical system's willingness to treat them objectively when they seek reassignment or early discharge.

There's a growing need for such independent services, notes Howard Waitzkin, M.D., Ph.D., distinguished professor of sociology, family and community medicine and internal medicine at the University of New Mexico in Albuquerque. Waitzkin—a founder of the Civilian Medical Resources Network—takes referrals like his colleagues when appropriate from among the neediest of the more than 3,000 service members and their families who now call each month to the GI Rights Hotline ([877] 447-4487), a 24-hour national resource maintained by 25 religious and peace organizations. Currently, says Waitzkin, the network's providers are assisting four new clients each week.

In an article in the March 2009 issue of the journal Social Medicine, Waitzkin and Marylou Noble of Physicians for Social Responsibility and Amnesty International, in Portland, Ore., described those clients. Men predominate, although women also seek assistance in rough proportion to their representation among active-duty military personnel (15 percent). Almost all the clients are from low-income backgrounds. Many have experienced childhood abuse, neglect or sexual assault. More than two-thirds are diagnosed as suffering from post-traumatic stress disorder (PTSD), anxiety, depression and/or substance abuse. Half are AWOL. One in five has seriously considered or attempted suicide. A few admit to homicidal fantasies.

Waitzkin is a scholar and adherent of social medicine, a field pioneered in the 1840s by the "father of pathology," German physician Rudolf Virchow. Virchow and his heirs have focused on the characteristics of a society that can cause illness. Waitzkin and Noble list seven social, or "contextual," contributors to severe GI mental distress that network doctors have cited repeatedly:

The "economic draft." Today's volunteer military relies primarily on youths from low-income, minority and even foreign backgrounds. That means they often enter the service with emotional, financial and cultural scars that can be aggravated by the stressors of military discipline, low pay and unconventional warfare. Indeed, says Waitzkin, military psychologists routinely diagnose serious mental health problems like PTSD and depression as a "personality disorder," a pre-existing condition. Ironically, this diagnosis disqualifies the patient for financial and health benefits after discharge—notwithstanding the failure of military screeners to have detected any personality disorder during the GIs' pre-induction psychological evaluations.

Deceptive recruiting practices. GIs referred to the network frequently nurse a festering resentment that they were misled by recruiters. Reservists, for example, say they were assured they would not see combat duty. The length and frequency of tours in war zones, and a Defense Department stop-loss policy that unilaterally extends terms of service beyond the initial contract end date, have not matched the recruits' expectations.

Ethical dilemmas and violence without meaning. Terrorizing, wounding or killing civilians, especially children, in carrying out orders generates deep guilt and associated psychological manifestations—all the more so when the GI can discern no progress as a result in meeting military, political or social goals.

Suspicion of military health care. Service personnel assisted by Civilian Medical Resources Network providers overwhelmingly complain that military doctors played down the seriousness of their physical and mental problems. The GIs must go outside the system for an unbiased second opinion in support of their desire for discharge or reassignment to a noncombat role.

Isolation and intimidation. GIs on military bases say supervisors actively discourage them from seeking outside evaluations. Often they are in remote locations. Moreover, duty requirements make it difficult to schedule and keep appointments with civilian professionals. Those who are absent without leave enjoy freer access to the GI hot line and the physician network, observe Waitzkin and Noble, but they are haunted by fear of capture and forced return to their units.

Privatization of military mental health services. Many Civilian Medical Resources Network clients report that they or their families experienced great difficulty obtaining help from the civilian managed care organizations to which the Defense Department has outsourced mental health services in recent years. Indeed, note Waitzkin and Noble, the contractor whose chief executive officer has reaped the biggest financial boon from Operation Iraqi Freedom is not Boeing or Halliburton but HealthNet, whose ValueOptions staff have replaced military practitioners who formerly treated active-duty personnel in military facilities.

Torture and human rights abuses. Waitzkin and Noble emphasize that few of the GIs who turn to the network have personally engaged in conduct that violates the Geneva Convention, the historical rules of war or specific military regulations. Nevertheless, they say, all service members are keenly aware that some of their colleagues and superiors have at times tolerated and even encouraged such practices. This knowledge adds to their stress and creates stigma and shame, which further discourage them from seeking help.

The Problem of Double Agency

Perhaps the most troubling aspect of military health care, says Waitzkin, is that providers act under conflicting loyalties—"double agency."

According to the Hippocratic oath, he points out, "the patient's interest is [a physician's] first and only interest." But personnel shortages have meant that troops must be deployed and re-deployed rapidly to Iraq and Afghanistan. Thus military medics are asked to take into account the goals of the service in maintaining force numbers and readiness—as well as the economic ramifications to the system—when assessing GI mental and physical health complaints.

In the online magazine Salon, writers Michael de Yoanna and Mark Benjamin recently reported a conversation in which an Army psychologist was caught on tape telling a brain-injured soldier, "Confidentially … not only myself but all the clinicians up here [at a Colorado base] are being pressured [by the commanding officer, a psychiatrist] to not diagnose PTSD and diagnose anxiety disorder [instead]." The more grave condition, post-traumatic stress disorder, the writers explained, obligates the service to provide extensive treatment and possibly a lifetime of disability payments.

Waitzkin and Noble quote this case summary by a Civilian Medical Resources Network clinician:

"A GI with two fractured vertebrae experienced severe numbness in his legs. When he wore a flak jacket, he could not move his legs. He previously fractured an eye socket, after which surgeons inserted a metal plate; he still experienced double vision and could not focus. Other problems included rectal bleeding and renal insufficiency.

"When he contacted the GI rights hot line, he was scheduled to be deployed to Iraq in about two weeks. Seeking a medical discharge, he went to sick call. He stated that a medic told him that he was in bad shape but that the Army needed him and so would not discharge him. Instead, he was told that he could get physical therapy in Iraq. He had a hard time seeing a doctor because his sergeant kept telling him that he shouldn't go to sick call. The GI requested documentation in connection with his request for discharge and secondarily also sought care for his problems."

Waitzkin is highly skeptical of military physicians' ability to divorce the demands of the service from the needs of individual patients. "In my opinion," he says, "their double loyalties are a fundamental contradiction of the Hippocratic oath."

Complicating the situation is the fact that while in uniform, GIs and their families are covered by the military health plan known as TRICARE and in general are expected to use only its network of providers, authorized civilian subcontractors, 63 military hospitals and 413 medical clinics. Visits to doctors or psychologists outside the TRICARE program for a second opinion or treatment are seldom reimbursed unless they have been pre-authorized.

"Occasionally TRICARE coverage can apply, but it's very unpredictable," says Waitzkin. "One of my big problems is the lack of choice GIs have while on active duty."

As more and more soldiers, Marines, airmen and sailors return from deployment in Iraq and Afghanistan with troubling and sometimes crippling experiential baggage, asserts Waitzkin. "Military medicine, especially military mental health services, is in a state of tremendous crisis. We're seeing an epidemic of depression, suicide, substance abuse and PTSD caused by the specific types of warfare being conducted," he says.

"Things have gotten so horrible that awareness is growing," Waitzkin says. "I think policymakers and the Veterans Administration are getting the message. The evidence has been there for many years. But active-duty GIs are really the overlooked category."

Civilian doctors and hospitals, he warns, "will soon be seeing an influx of these patients."

David Ollier Weber is principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Weekly. He served as a U.S. Navy destroyer officer in the Western Pacific.

This article 1st appeared on July 27, 2009 in HHN Magazine online site.

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