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[H.A.S.C. No. 108–25]



FOR FISCAL YEAR 2005—H.R. 4200






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FEBRUARY 25, 2004




JOHN M. McHUGH, New York, Chairman
TOM COLE, Oklahoma
JIM SAXTON, New Jersey
JIM RYUN, Kansas
ROBIN HAYES, North Carolina
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VIC SNYDER, Arkansas
MARTY MEEHAN, Massachusetts
JIM COOPER, Tennessee

Lynn W. Henselman, Professional Staff Member
Elizabeth McAlpine, Staff Assistant
Jennifer Ruddock, Staff Assistant



    Wednesday, February 25, 2004, Fiscal Year 2005 National Defense Authorization Act—Budget Request on Force Health Protection and Surveillance
in the Global War on Terrorism

    Wednesday, February 25, 2004

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    McHugh, Hon. John M., a Representative from New York, Chairman, Total Force Subcommittee

    Snyder, Hon. Vic, a Representative from Arkansas, Ranking Member, Total Force Subcommittee


    Thibeault, Corp. Victor, United States Army, 10th Mountain Division, Fort Drum, NY; Michael Duggan, Deputy Director, National Security and Foreign Relations Division, American Legion; Sue Schwartz, DBA, RN, Co-Chair, The Military Coalition's Health Care Committee; and Robert Washington, Washington, Robert, Sr., Co-Chair, The Military Coalition's Health Care Committee

    Winkenwerder, Dr. William, Jr., Assistant Secretary of Defense for Health Affairs; Dr. Michael J., Kussman, Deputy Chief Patient Care Officer, Co-Chair of the Department of Veterans' Affairs Taskforce for the Seamless Transition of Returning Service Members, Veterans' Health Administration, Department of Veterans' Affairs; accompanied by Dr. Laurent Lehmann, Chief, Mental Health Strategic Health Care Group, Department of Veterans' Affairs; Lt. Gen. James B., Peake, Md, Surgeon General, Department of the Army and Sgt. Maj. Kenneth O. Preston, Sgt. Maj. of the Army
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[The Prepared Statements can be viewed in the hard copy.]

Duggan, Dennis Michael

Kussman, Michael J., joint with Susan H. Mather, and Laurent S. Lehman

McHugh, Hon. John M.

Preston, Maj. Kenneth O.

Snyder, Hon. Vic

Washington, Robert joint with Sue Schwartz

Winkenwerder, Dr. William joint with General James B. Peake

[The Documents submitted can be viewed in the hard copy.]

Statement of Reserve Officers Association of the United States, Pre- and Post-Deployment Health Care of RC members
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[The Questions and Answers can be viewed in the hard copy.]

Mr. McHugh
Dr. Snyder


House of Representatives,
Committee on Armed Services,
Total Force Subcommittee,
Washington, DC, Wednesday, February 25, 2004.

    The committee met, pursuant to call, at 2:06 p.m., in room 2118, Rayburn House Office Building, Hon. John McHugh (chairman of the subcommittee) presiding.


    Mr. MCHUGH. The hearing will come to order. There is much more authority that way with the microphone up, down. These concepts are befuddling to me.

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    First of all, welcome, everyone. I appreciate your being here. The Subcommittee on Total Force meets this afternoon to assess the force health protection and surveillance efforts for servicemembers that have been ongoing with respect to the global war on terrorism. And I certainly want to welcome our witnesses here today. And I know we all look forward to their testimony.

    After the Gulf War, some veterans began to experience debilitating illnesses that could not be explained. With increasing concern about health problems in the ranks of former military personnel, numerous activities were initiated to investigate veteran illnesses. When attempts were made to compile information on health status, medical care, troop locations, and environmental hazard during deployments, the Department of Defense, simply put and frankly put, came up short.

    We cannot let this happen again. It is our responsibility and duty to ensure the health and well-being of our forces as they now deploy to what by any measure are fairly described as extremely dangerous locations. Our service men and women and their loved ones must be confident that they are receiving the best opportunities for good health.

    Since the events of September 11, 2001, this country has seen hundreds of thousands of servicemen and women deploy in support of Operation Enduring Freedom and Operation Iraqi Freedom. In light of the number of recent and upcoming deployments and redeployments, it certainly is appropriate that we take stock of the effectiveness of the various force health protection laws, policies, and programs to ensure health risks are being identified and servicemembers are receiving the care they need.

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    In November 1997, Congress adopted legislation, Public Health Law 105–85, that established a system for assessing health status before and after deployments and centralized retention of information related to those deployments. To provide better oversight for force health protection efforts, Congress also requested that the GAO, the General Accounting Office, examine Department of Defense (DOD)'s compliance with the requirements of the law.

    And the findings of the GAO report were—I think it is fair to say—abysmal and were addressed by this subcommittee in a hearing held last March as well as by other congressional committees over the past year. Today we will have the opportunity to examine DOD's progress in providing compliance with the law and how it is implementing effective force health protection programs.

    In addition to this objective, the subcommittee seeks to understand the present and emerging health concerns for those deployed in support of the war on terrorism.

    We will have the opportunity again this afternoon to review the status of the smallpox and anthrax vaccine programs; the challenges associated with caring for combat casualties; and how servicemembers are being protected from environmental hazards and infectious diseases.

    The nature of warfare that we are seeing in OEF and OIF brings new challenges to force health protection. The traumatic events and stressors associated with fighting terrorism are ever present in this war. Vigilance in the effective management of a full range of post-traumatic stress reactions must be a top priority and the subcommittee looks forward to both the DOD and Department of Veteran's Affairs (VA) perspectives.
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    This subcommittee is also interested in understanding the factors that led to the increase in servicemember suicides in July 2003 in Iraq and how DOD is currently positioned to prevent suicides not only in theater but back at home stations. In October 2003, an Army Mental Health Advisory Team went to Iraq and Kuwait to assess the events that led to the suicides and to examine behavioral health care in theater.

    And again, we in the subcommittee are interested in what the team learned during its review and how many of its recommendations have been implemented thus far.

    Finally, as veterans move into the VA health care system, the transition must be seamless to ensure the highest quality of care. The DOD and VA have met many challenges in this respect over the last year and we look forward to the testimony today regarding that progress as it is occurring as we speak.

    Before I turn to the committee's ranking Democrat, Dr. Snyder, I want to, as I opened with, thank all our witnesses for the commitment they have shown as they do their part to support that war on terrorism. But I especially want to acknowledge the presence of two soldiers, two heros, who are with us today from Walter Reed Army Medical Center, Corporal Victor Thibeault—did I pronounce that correctly, Corporal?

    Corporal THIBEAULT. Yes, sir.

    Mr. MCHUGH. Good.

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    A witness on our first panel who is a 10th Mountain Division soldier from Fort Drum, New York in the shadows of where I was born, climb to glory. And also a soldier who fought in the war in Afghanistan and made great sacrifices for this country. Also seated in the audience is Staff Sergeant Maurice Craft in the 82nd Airborne Air Defense Artillery soldier who served in Iraq and was severely injured by an explosive device while on patrol.

    I had the opportunity—where is the Sergeant? There he is. Sergeant, good to see you.

    I had the opportunity to meet with these two heroes a little bit earlier in the afternoon in my office. They are incredible examples of the heroism, the courage that is displayed amongst the ranks of our military each and every day. Their stories are extraordinary, but at the same time, they are indeed reflective of the men and women that have volunteered for this service.

    They volunteered for the actions in which they incurred their injuries. They also, even perhaps more incredibly, volunteered to be here today. And that shows particular courage. And I thank you both and express my appreciation for your sacrifices, your courage and for your service.

    You and your comrades in arms have the highest respect and appreciation of this subcommittee and indeed the entire Congress and the people of the United States. I just returned on Friday from Afghanistan, visiting the 10th Mountain Division, more to the point, visiting our military forces in that theater. And I, as always, was impressed with their devotion, their dedication, their effectiveness. And we are thrilled you are with us here today.
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    With that, I would be honored, as always, to yield to my partner and to a leader on health care issues and someone who brings a particular professional perspective to it, Dr. Vic Snyder, the gentleman from Arkansas, the ranking member.

    Vic, the floor is yours.

    [The prepared statement of Mr. McHugh can be viewed in the hard copy.]


    Dr. SNYDER. Thank you, Mr. Chairman. I appreciate your holding this hearing. And I also appreciate the comments you made. And I will just be brief here.

    I appreciate you all being here. On Monday, I was down at Fort Polk. We have several thousand Arkansans getting ready, who have been activated for the guard unit; they are getting ready to go over as part of the 39th Brigade. And, of course, that always brings home when you see friends of yours who are about to go over.

    But I think what even brings it more home to me was the fact that we have had—I think the number now is about 11,000—medical evacuations from Iraq since the action started. And obviously those are not all wounded. There are medical reasons, accidents, whatever it is. But that is a significant number of people who are coming back, serious enough to come back and to be medevaced. And, of course, they have all the injuries and illnesses that are taken care of in theater. So health care is a huge issue.
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    And those of us that are in the profession like Ms. Schwartz and myself and General Peake, of course, we think health care is about the most important thing out there anyway. But this is a huge issue. And it is a much more complicated issue because of the system that the military is. It is always moving. It is always changing. It always has responsibilities, even greater than providing health care. And that makes it particularly challenging.

    So thank you. And I look forward to your testimony.

    [The prepared statement of Dr. Snyder can be viewed in the hard copy.]

    Mr. MCHUGH. I thank the gentleman, as always. I would be happy to yield to any other member.

    The gentleman from Virginia.

    Mr. SCHROCK. Thank you, Mr. Chairman. I had it on, but I didn't have it in front of me. Thank you, Mr. Chairman.

    And thank you all for being here, especially the two of you who have served over there. I have been privileged to be in Afghanistan once and Iraq twice, so I know what you were enduring over there. I lived in Vietnam for two years, so I have some appreciation for what you might have gone through.

    There is a fundamental trust between those who serve our nation in uniform, whether they are active or reserve or National Guard that not only will an acceptable level of medical care be provided for them and their families, but that this level of care will be as high as possible.
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    There is also a fundamental expectation that the choices that our military commanders make in assuring the medical readiness of our armed forces personnel will be made in the most professional manner with respect to the highest and most stringent principles of both military and civilian medical professionals. I believe that as a nation we do everything possible to honor this trust our men and women in uniform place in us for their health and well-being.

    I also believe that the process of internal self-regulation in this arena must continue and that the scrutiny of outside organizations such as the General Accounting Office and others represented here today should be welcomed as a healthy, fresh look at how well we are doing. Our military health systems provide a very high level of health care to both our servicemembers and their families.

    I would urge all the witnesses present to continue to devote yourselves to this end, whether you provide that care directly or monitor and seek to improve that system. In the end, the health of our men and women in uniform drives the health of our military. And I thank you for what you do. And I thank you all for being here today.

    Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the gentleman for his leadership and presence.

    The gentlelady from California has indicated by turning on her light she is going to make a statement.
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    Ms. SANCHEZ. That is correct. No, no, no, Mr. Chairman. Hopefully you will give me more time on my questions, though.

    Mr. MCHUGH. I envy the gentlelady's choice. I thank her for that.

    As I have noted, I would say to our first panelists and to the others we do have two panels today, and we want to hear extensively on a discourse between the members in attendance and all of you in your responses. So we do have your written statements, those of you who are here to render them. I would ask that all of those, without objection, be entered in their entirety in the record—without objection, so ordered—and encourage you to the extent possible that you summarize those written statements, those of you who have them.

    Corporal, I know that you are going to speak from the heart, and I couldn't agree more. But for those who have written statements to try to summarize those to the extent you can.

    With that, let me welcome and introduce our first panel. And I am going to start, kind of, with the reverse of where we normally do. The first is Robert Washington, Sr., who is Co-Chair of the Military Coalition's Health Care Committee. Thank you for being here, sir.

    And he is accompanied by Sue Schwartz who is a DBA, an RN, who is Co-Chair of the Military Coalition's Health Committee.

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    And, Mr. Washington, she is going to handle the tough questions, is that it? Okay.

    Also Michael Duggan, Deputy Director of the National Security and Foreign Relations Division of the American Legion. Mr. Duggan, welcome.

    And as I commented earlier, Corporal Victor Thibeault, United States Army, 10th Mountain Division, Fort Drum.

    I am not sure if that is a vote or calling us back in. I think it is calling us back in.

    Mr. Washington, welcome, sir. We are going to start with you, if we might. And we look forward to your comments. And our attention is yours.


    Mr. WASHINGTON. Thank you. Good afternoon, Mr. Chairman and distinguished members of the subcommittee. Thank you for allowing Dr. Schwartz and I to appear before the subcommittee to present the coalition's views. The coalition would like to thank you again for sponsoring legislation that is helping servicemembers, veterans, family members and survivors. We deeply appreciate the subcommittee's continued leadership and commitment to those who are in uniform today and those who have served our nation in the past.
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    Force health protection includes fitness in health, protection and prevention and treatment. The coalition agrees with the General Accounting Office that there are significant improvements in compliance with DOD's guidance. Unfortunately, the war against terrorism was well underway before this guidance was finally enforced. The pre and post-assessment forms are self-administered, and medical personnel review the forms with servicemembers.

    The coalition has reviewed these documents and has concerns about subjectivity and the human dimension of the evaluation process. We urge the subcommittee to direct a study of the effectiveness of the self-administered pre and post-deployment assessment and continue providing oversight to ensure compliance with pre and post-deployment policies and procedures.

    The Military Coalition is most appreciative to Congress for including the Temporary Reserve Health Care Program in the fiscal year 2004 National Defense Authorization Act. This program will provide temporary coverage until December 2004 for National Guard and reserve members who are uninsured or who do not have employer-sponsored health care coverage.

    The coalition is also grateful to the subcommittee for Sections 703 and 704 of the fiscal year 2004 NDAA. Section 703, Earlier Eligibility Date for TRICARE Benefits, for Members of Reserve Components, provides TRICARE health care coverage for reservists and their family members starting on the date a delayed-effective-date order for activation is issued and the Temporary Extension of Transitional Health Care Benefits which changes the period for receipt of transitional health care benefits from 60 or 120 days to 180 days for eligible beneficiaries.

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    Respectively, Congress recognized the extraordinary sacrifices of our citizen-soldiers by extending this pre and post-mobilization coverage. Now it is time to recognize the changed nature of 21st century service in our nation's reserve forces by making these pilot programs permanent. We urge the subcommittee to endorse permanent authorization of all provisions of the Temporary Reserve Health Care Program to support readiness, family morale, the deployment health preparedness for guard and reserve servicemembers.

    Congress authorized all other Federal departments and agencies to provide occupational payment of premiums for employer or personal health insurance. If this benefit is good for the roughly 10 percent of the selected reserve who are Federal workers, it ought to be provided in kind to the rest of the guard and reserve as an option. We urge the subcommittee to authorize payment of part or all of civilian health care premiums up to the TRICARE limit as an option for mobilized servicemembers.

    Congress responded by passing legislation that allows DOD to provide medical and dental screening for selected reserve members who are assigned to a unit that has not been alerted for mobilization in support of operational missions, contingency operations, national emergencies or war. Unfortunately, waiting for an alert to begin screening is too late.

    The coalition recommends expansion of the TRICARE dental plan for guard and reserve servicemembers. This would allow these personnel to maintain dental readiness and enable reservists to meet readiness and deployment standards. The coalition believes that a root cause of medical holds is a lack of effective screening protocols and the resources necessary to support them.

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    A reserve component member must often complete their physical exam in the private sector. For those who do not have insurance, there is a reluctance to incur this expense. Even for those with employer-sponsored insurance or other insurance coverage, a routine physical is often not covered in the benefit. Providing services with adequate resources to ensure that reserve component members receive required medical screening and treatment necessary to ensure medical readiness must be a high priority.

    The coalition is also concerned that the effects of war that can't be seen or easily evaluated like the psychological conditions that arise from war such as Post Traumatic Stress Disorder (PTSD) and escalated domestic violence. Reserve component members and their families, many of whom live far from the support service provided on military installations, may also experience additional stresses.

    Unfortunately, many of the medical health issues may not emerge until some time in the future after eligibility for TRICARE has ended. Where will these families be helped? How will deployment-related mental health issues that emerge amongst reserve component servicemembers and their families be identified and tracked in the health care statistics?

    The coalition notes that all servicemembers and reserve component personnel and their families can access the One Source information referral service. We hope that these programs help relieve the strain of counseling that traditionally has fallen on the family service centers and the chaplains. The coalition recommends that the subcommittee endorse the resources necessary to support these services for our nation's servicemembers and veterans so that they do not become the next generation of our nation's homeless.

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    In conclusion, the Military Coalition reiterates its profound gratitude for the extraordinary progress this subcommittee has made in the area of deployment health policy, practice and procedures as well as securing a wide range of personnel health care initiatives for all uniformed service personnel and their families and survivors. The coalition is eager to work with the subcommittee in pursuit of these goals outlined in our testimony.

    Thank you very much for the opportunity to present the coalition's views on these critical and important topics. Dr. Schwartz and I stand ready to answer any questions that the distinguished subcommittee may have.

    [The joint prepared statement of Mr. Washington and Dr. Schwartz can be viewed in the hard copy.]

    Mr. MCHUGH. Thank you very much, Mr. Washington. For the record, before we go to the next presenter, do you know off the top of your head how many—I have the list here, but I can't count past 25. How many organizations does the coalition——

    Mr. WASHINGTON. Are in the Military Coalition?

    Mr. MCHUGH. Yes.

    Mr. WASHINGTON. Thirty-five, sir.

    Mr. MCHUGH. Thirty-five. You are right, it is for the record. So your reach is substantial, and we appreciate that. Thank you for your testimony.
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    Next Mr. Michael Duggan, Deputy Director, National Security and Foreign Relations Division, American Legion. Welcome, sir. We are honored to have you and representation from the American Legion here today. And we are anxiously awaiting your testimony.

    Mr. DUGGAN. Thank you, sir. Mr. Chairman, distinguished members of the subcommittee, the American Legion is extremely pleased to appear before this particular subcommittee to express its concerns with regard to DOD force health protection and surveillance efforts for our servicemembers deployed in Operations Iraqi Freedom and Enduring Freedom. Like you, Mr. Chairman, we take our hats off to all service men and women, and particularly those who are engaged in combat.

    The health and health care of our armed services are major concerns to the American Legion. We participate, I might add, in monthly meetings hosted by the Deployment Health Support Directorate in Office of the Assistant Secretary of Defense for Health Affairs (OASD) on a monthly basis and are extremely informative. Our American Legion national commanders have also had the opportunities to visit the troops in Europe as well as the Far East. We visited, of course, the troops in Walter Reed on a number of occasions there.

    And finally, I would add that the American Legion with its 14,000 posts across the country extends not only an open door, but actually a formalized family support network in which to work with families who have activated reservists who are either deployed or returned from deployment.

    And we are just now beginning to work with the Army, in particular in being able to refer particularly severely disabled servicemembers such as the gentleman we have here from Walter Reed to, hopefully, a hometown American Legion Post kind of thing, where they can provide some kind of help, not only to the individual, but to the family as well, too, because this is some pretty traumatic stuff.
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    Chemical and biological weapons have not been used against American troops, thank God, in Afghanistan or Iraq. Still the Legion is concerned about the ability of American troops to operate in a nuclear, biological and chemical environment. During the 1991 Gulf War, thousands of chemical detections turned out to be false alarms. The ability to properly detect the presence of Nuclear, Biological and Chemical (NBC) agents still remains a grave concern.

    In October of 2002, the GAO reported that the DOD was unable to account for some 250,000 defective suits and has reported that the defective suits were either destroyed or have been used in training activities. Last year, as mentioned, the GAO found non-compliance with force health protection and surveillance policies for many active duty servicemembers. This included, as mentioned, required pre and post-deployment health assessments, required immunizations and failure to maintain health-related documentation in centralized locations.

    Of the records reviewed, some 38 to 98 percent were missing two or more required shots. GAO concluded that an effective quality assurance program at OASD Health Affairs was required. This focus would be ensuring compliance with Force Health Protection (FHP) policies on pre and post-deployment health assessments, shot records and blood drawing for HIV and post-deployment assessments.

    We in the Legion appreciate the Department of Defense's increased efforts actually to ensure its policies and programs are fully and consistently implemented by the services. And the non-compliance with required policies could result in personnel deploying with possible health problems and/or encountering delays and other problems in obtaining health care and VA benefits, not unlike problems experienced by the veterans of the first Gulf War.
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    The anthrax vaccine continues to be an important part of the military's force health protection program. The American Legion, of course, agrees with DOD's position to adequately protect military personnel against the threat of biological attack such as anthrax or small pox.

    However, serious concerns with past problems associated with BioPort, the sole manufacturer of the vaccine, in the way adverse reactions are tracked and followed continue to worry us. The American Legion has long advocated a second manufacturer of the vaccine as well as a newer vaccine proven for its efficacy and safety and an inoculation period shorter than the current six-shot regiment.

    The anthrax vaccine controversy has existed since the first Gulf War. A similar controversy seems to be brewing regarding the case of the anti-malaria drug Lariam. There have been media articles about military personnel experiencing severe side effects, including depression and other psychological symptoms after being prescribed Lariam. If a servicemember suffers a chronic disability as a result of taking Lariam which is not documented in health records, it makes it only that much more difficult to prove service connection which impacts on veterans accessing VA health care and health care facilities.

    Title 38 of the United States code requires a burden of proof in establishing service connection on the veteran which depends to a large extent on DOD's efforts to maintain and complete proper health records and health insurance as well as, for example, the documentation of troop locations, environmental hazard exposures data and the timely sharing of this data with the Veterans Administration (VA). The sharing of information with VA appears to be going pretty well right now in the briefings, at least, that we received.
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    Due to the duration and extent of sustained combat in Operations Iraqi Freedom and Enduring Freedom, the psychological impact and stress on deployed personnel is of utmost concern to the American Legion. The military has counseling available, as PTSD often manifests itself months or years after individuals are removed from traumatic combat or experiences. This is especially important for the reservists and Guardsmen who may be rapidly demobilized after returning from deployment and may not have the same medical support system as their active duty counterparts.

    Frankly we are surprised at the number of Guardsmen and reservists who are called to active duty and not deployed due to existing medical and dental conditions. Undoubtedly these soldiers, we believe, need permanent and affordable TRICARE health care and dental plans for them and their families to use for pre-mobilization and pre-deployment purposes and for post-deployment as well.

    Last, American Legion urges that the Congress mandate separation or discharge physicals be mandatory for all servicemembers and not optional as they are now, particularly for those who have served in combat zones and have sustained numerous deployments. This is necessary because of the oftentimes inadequate medical record keeping and to ease, as I mentioned, accessing VA health care and applying for a disability compensation and other veterans' programs. We are told by DOD in their force health protection briefings and in the seamless DOD, VA briefings that only about 20 percent of discharging servicemembers opt to have separation physical exams.

    Mr. Chairman, we feel that should be substantially increased. Again, we thank you for this opportunity, Mr. Chairman. And that concludes my statement.
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    [The prepared statement of Mr. Duggan can be viewed in the hard copy.]

    Mr. MCHUGH. Thank you very much, Dr. Duggan. And we appreciate all you do, not just in being here today, but at all times for both the veteran and the active service community and do thank you for being here today.

    Last, certainly not leastly, we hear from Corporal Victor Thibeault. The corporal does not have a written statement, as I understand.

    Corporal THIBEAULT. I have some things written down, Mr. Chairman.

    Mr. MCHUGH. But he wishes to share his experience, which, as far as I am concerned, is really the most important words we may hear today from the subcommittee's perspective. So Corporal and the sergeant who has accompanied you, again, we are honored by your presence. And we welcome your testimony.

    Corporal THIBEAULT. Thank you, and good afternoon, Mr. Chairman and members of the subcommittee. I am Corporal Victor Thibeault from the 110th Military Intelligence Battalion, 10th Mountain Division, Fort Drum, New York. Climb to glory.

    Mr. MCHUGH. Climb to glory.

    Corporal THIBEAULT. I was stationed in Afghanistan when I was ambushed by a Taliban insurgent in the Martyr's Circle area. A grenade landed in my vehicle under my squad leader's chair inside the vehicle. I grabbed the grenade and tucked it underneath myself to protect him and to protect the civilians outside in the surrounding area. I wanted to stop any propaganda that may be caused because of hitting any innocent civilians. I wanted to save my buddy also.
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    Treatment at Walter Reed was excellent. I have never been anywhere where people are more professional. And I thank them all for being there for us when we come back. Some of the programs there are excellent also, stress management and dealing with the pain. They offer a lot of programs like therapy and things of that nature.

    But I also agree with this Lariam statement. I believe that the Lariam pill has a lot of problems. I had a lot of side effects from it, so I stopped taking it. There is also a problem with transitioning from Walter Reed into whatever you decide to do afterwards. There are a lot of soldiers that want to get out and proceed onto college or whatever they may.

    And there are also a lot of soldiers that feel like they have to stay in because they are dependent on the funding of the pay because of their families and housing. I think that a lot of these soldiers, they want to get out and do better, but they can't transition because they don't have the proper funding with the percentages that you get from the military afterwards with the disabilities. And I just think that needs to be improved also.

    And I think that the medics out there in the field were trained excellently. They did everything that I thought they would do after I was injured. And I am proud of all of our soldiers over there. And I support the war. Thank you.

    Mr. MCHUGH. Thank you. Thank you all.

    Corporal, if I may, I am going to start with you. You mentioned Lariam, the malaria pills. You said you had problems. Could you share those problems to the extent you are comfortable with the subcommittee?
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    Corporal THIBEAULT. Yes. There is a lot of diarrhea, a lot of sickness. I went through a period of two, three weeks of sickness, constant nightmares. It is mostly a lot of physical things like people get sick a lot over there because of it.

    Mr. MCHUGH. Now you answered, kind of, my second question. But I am going to ask it anyway because I am a politician. You have comrades, other folks, who were experiencing similar or some kind of problem from the Lariam or at least thought they were?

    Corporal THIBEAULT. Every soldier I know has problems with it.

    Mr. MCHUGH. Every soldier?

    Corporal THIBEAULT. Every soldier I know.

    Mr. MCHUGH. You never met a soldier who said, ''A day at the beach.''?

    Corporal THIBEAULT. Never.

    Mr. MCHUGH. Okay. Thank you very much. When you were in my office an hour and-a-half or so ago, you mentioned—and this is my word, not yours because you didn't say this. I sensed the frustration that—how long have you been in treatment now stateside?

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    Corporal THIBEAULT. About two and-a-half months now, sir.

    Mr. MCHUGH. Two and-a-half months? And where are you vis-a-vis a prosthesis for your injury on your hand?

    Corporal THIBEAULT. I haven't received a prosthesis yet, sir, at all. No.

    Mr. MCHUGH. Any word of it?

    Corporal THIBEAULT. There is word, but no show.

    Mr. MCHUGH. Bad choice of words on my part. All right. I think we can leave it at that.

    Corporal THIBEAULT. Some prostheses are easier to get a hold of because the injury is more frequent than others.

    Mr. MCHUGH. Yes. And I want the audience to hear this, not because I think it was a misjudgment on the part of your medical providers, because I don't, but because I was stunned by it. And I can only assume when they came to you you were somewhat surprised. What was the choice they gave you about prosthesis and your operation and the condition of your hand?

    Corporal THIBEAULT. They told me I had a choice to cut my arm up further to receive a different type of prosthesis. I refused that. But they also offered to take my toe off and put it on as a thumb. And I didn't want to do that either. I don't want to lose any more of my body parts. I just wanted to——
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    Mr. MCHUGH. And I want everybody in the audience to understand. I am not saying that as a criticism of DOD health care. I am saying this is what these people do for this country and what this sergeant over here has done for his country. And we ought to go to bed at night remembering that and thanking God that there are people like these two people who serve.

    And thank you so much for your sacrifice and for the honor you provide to all of us. I appreciate it.

    One more question, then I want to yield to my colleagues.

    To Mr. Duggan or to Mr. Washington or to Ms. Schwartz, I heard a lot about, understandably, suicides, troubling situation. What suggestions, observations, criticisms, what can you share with this subcommittee as to what we need and the department needs, the services need to do particularly better to follow up? I think if you are a member of the so-called active component, you are at least in an environment where care is available. Whether or not it is available sufficiently or you access it is another issue.

    But in this seamless force, total force military, where, as was noted in Mr. Washington's comments, you are so reliant upon those folks who, after the fact, go home where that environment of support may not be there, what can we do in the mental health care arena to better accommodate and hopefully, if not eliminate, lessen the likelihood of those circumstances?

    Any thoughts on that?
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    Dr. SCHWARTZ. That is the concern of the Military Coalition as well, Mr. Chairman. Because the active duty force, obviously the families are on the installations, there is the family service center there, there is the outreach there. As Mr. Washington mentioned in his testimony, there is the One Source, but once the family loses the Transition Assistance Management Program (TAMP), the additional TRICARE benefit, where do our Guard and reservist families turn? And I am sorry, sir, we don't have the answer. But we are very concerned.

    And as we look at the VA benefit, when the VA benefit was created, it was created for the single servicemember. And they provide PTSD services for the servicemember. But where is the outreach for the family members?

    And we are most appreciative of what the Legion does, but as we say, the family has to go home and live with the servicemember. And the families get post traumatic stress disorder as well. They are traumatized by what happened. And we would ask the subcommittee to look into it to find a way to help these reserve families long after their service has been extended.

    Now you have given them the ability to buy into TRICARE. And hopefully Section 702 some day will be implemented and those families will get that support. So we look to that as one possible solution. But I don't have an answer, sir. But we appreciate that at least we are looking at it.

    Mr. MCHUGH. Thank you.

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    Mr. Washington, any comments?

    Mr. WASHINGTON. I have to agree with Dr. Schwartz. I don't have any recommendation at this time as to how we would fix this problem. I would think that maybe some type of study to look into the feasibility of prolonged distance, a tracking system or something, to kind of monitor these folks after they leave the service and go back into the communities.

    Mr. MCHUGH. Yes. Mr. Duggan?

    Mr. DUGGAN. Sir, I would only comment to the effect that I think I read—and that is all I really know about the suicide thing. I don't know if there are any patterns for that which have been established. If there have been, I am certainly not aware of them.

    But I think what I have read, though, what has really affected a number of the troops is when they change the go home date, when the tour got extended kind of thing. And I think to preclude that kind of thing—because I know the two years that I served in combat units in Vietnam, that was the most important day in my life, was the day I was going home. That is when life started.

    And when you change that, without my knowledge or without my input, then all of a sudden, you have just changed my life tremendously because for one thing, you have increased the odds that I might not be going home. I could get killed at this kind of thing.

    And the stress, the stress is—and again, just talking from my own experience, I have PTSD—unabashedly, I have PTSD. And it didn't pop up for 20 years after it. And I went through the stuff when I was retiring and all, no problem, ''Good to go.'' kind of thing. But whamo! One day it just came back and hit me hard.
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    So the more that is, kind of done in that regard is more follow up, perhaps mental health counseling or screening, for example, if they are still on active duty. And hopefully something like that could be called for in any TRICARE plans which might get approved, say, for the National Guard.

    Mr. MCHUGH. Let me ask you. You said 20 years later in your own case. And that is an impressive amount of time. What avenues were available to you?

    Mr. DUGGAN. VA

    Mr. MCHUGH. Were they receptive? Were they understanding?

    Mr. DUGGAN. Absolutely.

    Mr. MCHUGH. They were?

    Mr. DUGGAN. The VA really was. And what they all are required to look at—at least for service connection and therefore, counseling and so forth—was a time in Vietnam and wearing a purple heart and Combat Infantryman's Badge (CIB) and a few things like this. So that got you in.

    Mr. MCHUGH. Good. Thank you.

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    Corporal THIBEAULT. Mr. Chairman, this depression when you come back from combat is too great to be—when you transition from the hospital to being on your own again, it is hard to deal with the depression. That is why a lot of guys are committing suicide because they have had no one to go to when they get out. And they transition, say, to the Malogne House where you stay at in transition from the hospital to being on your own or back into the Army.

    The depression is too great, and you don't have anyone there supporting you to help you get through that depression unless you go find it yourself. And that is a big problem. I think that we need more counselors to help us get through this transition phase and that would take down that—that percentage will decrease over time, I am pretty sure.

    Mr. MCHUGH. Let me get this straight. You had the grenade in your hand you could have thrown it out the window but recognized that you would cause significant casualties in the civilian population so you held onto it?

    Corporal THIBEAULT. Yes, sir.

    Mr. MCHUGH. You all hear that?

    Dr. Snyder?

    Dr. SNYDER. Thank you, Mr. Chairman.

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    Mr. Washington, you had a series of formal recommendations and Dr. Schwartz, too, in your statement. The one about insurance; we haven't solved the problem at all in this country about health insurance. And so, I always get sensitive to the fact that if we are messing up somebody who already has insurance—and you are suggesting that we do—by giving the option of going on TRICARE but not really taking care of the fact that they are going to have trouble paying for their premium with their coverage they already have.

    It seems like there are two options there in terms of dealing with that problem. One would be as you suggest that the government would pay the premium during the period of activation. The immediate problem I would see with that would be you would essentially then start paying people unequal amounts. One person would have a Cadillac policy. One person may have a real streamlined policy.

    And it could be a significant amount of money compared to what they are actually getting in salary from being in the reserve forces. And so, you then have different people being paid different amounts. And you can have premium increases during time of service. And it seems like it could be some inequality there or not equity.

    It seems like another way to go is you could have a set amount that people could be given the choice of going into TRICARE or you can draw this much per month, but it would be the same amount for everyone. Then people would have to make a choice. And it would not be an amount that would cover probably all the premium. But it may be enough that it made it worthwhile. Is that the kind of solutions you all were thinking about?

    Dr. SCHWARTZ. Yes, Dr. Snyder. If I may elaborate—and with my apologies—that which was not clear in our testimony. What we would want is that the costs of TRICARE be established as a stipend, X amount of dollars. And those dollars would be contributed toward the servicemember's TRICARE benefit or they could elect and take the chip, so to speak, of the same amount and put it toward their other health insurance.
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    In other words, say the benefits were $500. Then you get 500, take TRICARE as your $500 benefit, or you may take that in kind to purchase the other health insurance.

    Dr. SNYDER. I don't know if we have that. I am going to ask you, General Peake, if we know what that amount is about if we add on a person. Do you all know?

    Dr. SCHWARTZ. Well, sir, under Section 702 of last year's National Defense Authorization Act, a financial cost is to be put toward TRICARE, and then the servicemember will have a 28 percent cost share of the cost of the TRICARE benefit.

    Dr. SNYDER. But that will have to be determined?

    Dr. SCHWARTZ. Yes.

    Dr. SNYDER. Yes.

    Dr. SCHWARTZ. So we are anxiously awaiting that figure.

    Dr. SNYDER. I am just going to go down the line here. Dr. Schwartz, I wanted to ask you specifically. And I acknowledge that I am asking this question because you are a woman. But do you have any thoughts about how our health care system is working when people come back? This has happened to me personally multiple times as a family physician. Women come to see me with some problem and then they acknowledge in confidence that they have been sexually assaulted but hadn't told anyone about it. How do you think our military system works when that situation occurs?
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    Dr. SCHWARTZ. With all due respect, Dr. Snyder, I can't comment on that.

    Dr. SNYDER. Okay. That is fine.

    And, Mr. Duggan, you made a comment, I think, at the end of your report. Because I think there are a whole lot of issues here that if we could just get a handle on—we have these two fine men here today. But you suggest that a series of field hearings out there to talk. I think your point is you have to throw that net out there real wide and talk to a lot of people to, kind of—there may be problems out there we are not aware of. Is that what your point is?

    Mr. DUGGAN. Yes, sir. We put that in there. And this really, kind of, falls in the category of good idea kind of thing more than anything else. I don't know how practical something like that could ever be done. But I believe one of the predecessors to the chairman here, I believe Congressman Buyer, if I am not mistaken, may have held field hearings. Well, they call them field hearings, but they were still on some of the bases like Norfolk and those kinds of places. And this was after the Gulf War.

    And so, they had both, not only military witnesses, but also civilian as well, too. And I think they were trying to really, kind of, assess that in the field kind of thing, the similar kinds of things we are looking at now.

    Dr. SNYDER. Yes. Trolling for problems is what you want to do just to see what is out there. I am always impressed when I go back home. I go back home every week.
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    And you walk into a grocery store or wherever it is and there will always be somebody saying, ''I don't want to bother you, but is it okay if I ask something?'' And a lot of times that is how we as members—somebody, a relative of a guard or a reserve person comes up to us and are having this problem. That happened to me at Fort Polk on Monday. And, in fact, I asked about it today at the hearing with General Shoomaker.

    Mr. DUGGAN. Yes. Yes. And Doctor, to just kind of take off on that, it might be, for example, a reservist or Guardsman to have those hearings either near or perhaps even in a National Guard armory if you really want to hear how it is coming, what it is really like, kind of, thing.

    Dr. SNYDER. And when I first read that, my first thought was, well, maybe you wouldn't want to do it as a hearing. Maybe what you would want to do is to set it up where as a member or a staff you would be in a private room where you would say I would like you to have 30 veterans of the war and/or their families come and see me for a brief 5-, 10-minute conversation.

    Mr. DUGGAN. Sure. Sure. Yes, that kind of thing.

    Dr. SNYDER. One-on-one where they would know that they would not be in a public hearing or they could just confide in you that things are going fine or everything is going fine except——

    Mr. DUGGAN. Yes. Sure. You could do it that way, too.
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    Dr. SNYDER. And see what turns out. Yes.

    Mr. DUGGAN. Yes, sir.

    Dr. SNYDER. And, Corporal, I wanted to ask you. I read a little—I guess it was a note from Lynn or something about the fact that your family got notification of your injury by hearing it on the news?

    Corporal THIBEAULT. Yes, sir.

    Dr. SNYDER. Is that so?

    Corporal THIBEAULT. The name wasn't released until after my family was notified. But my father didn't find out until he found out from my buddy's wife. She called him and told him. They called her, but they didn't call my father, which upset me.

    Dr. SNYDER. Sure.

    Corporal THIBEAULT. And so, he didn't know I was injured until after I was already back in the states.

    Dr. SNYDER. Yes. I think as members I think we are having a problem now, too, because of privacy. I think every member would like to be notified when somebody is wounded.
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    Corporal THIBEAULT. That is another issue, sir.

    Dr. SNYDER. At least, I don't think we are able to have——

    Corporal THIBEAULT. I have another issue regarding that. There is a big problem with names being released to the press but not to the Disposition and Adjustment Board (DAB) and the Veterans' Administration to help us. They want to help us but not hurt us like some of the press does.

    Dr. SNYDER. Okay.

    Corporal THIBEAULT. And I think a big issue that people need to talk about is having these guys come in to represent us or to help us out so that they don't need to pay for more counselors to help us because they are already here for that.

    Dr. SNYDER. Okay. That issue was brought up at our hearing, the public hearing we had this morning with General Schoomaker.

    Dr. Schwartz, did you have a comment on that issue?

    Dr. SCHWARTZ. No. I apologize.

    Dr. SNYDER. No, that is okay.
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    Dr. SCHWARTZ. There has been this problem with the families. And my husband's squadron was in a mishap. Okay? A Continental United States (CONUS) mishap. In fact, my husband has had mishaps all over the place in his squadron. And being a wife, you put on the news and it is like you wait for the call. And everybody calls everybody else's wife and says, ''Did you get a call, did you get a call?''

    And it is just a horrible thing waiting to hear, ''are you the one?'' And God forbid somebody in uniform comes to the front door. They might just be in a uniform. But that kind of thing happens. And in today's age of technology and communications, it is going to be a greater and greater challenge to protect these families. And sincerely, I am so sorry it happened to the corporal. I am so sorry.

    Corporal THIBEAULT. My name was released to the U.S. News & World Report without my permission. And they put my story in that magazine. And I had no—I didn't know about it. Somebody else told me about it, and I received a magazine later on.

    Dr. SNYDER. Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the distinguished ranking member.

    Next I am pleased to yield to both my friend, colleague and someone I admire very much: chairman of the Subcommittee on Terrorism and Unconventional Threats, the gentleman from New Jersey, Mr. Saxton.

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    Mr. SAXTON. Thank you very much, Mr. Chairman.

    And thank all of you for being here.

    Corporal Thibeault, you were how long in Afghanistan before your injury?

    Corporal THIBEAULT. About five and a half months, sir.

    Mr. SAXTON. And let me just ask you this. And maybe you have already given as complete an answer as there is to this, but while you were in the theater both before and after your injury, what were the aspects of health care in the way you were taken care of that you were most pleased about, that were the most positive?

    And second, what do you see as the weaknesses in the system that you observed? And maybe if you can comment for some of your friends that you have been spending time with during recuperation on those two points as well, it might be helpful to us.

    Corporal THIBEAULT. I didn't have any problems with treatment on the way back. I went about a half an hour without getting treatment prior to finding a medic. That is because of where I was and who I was with out in the field.

    But by the time I got back, I was walking out to get some Special Forces (SF) medics to work on me. And they got me up in the chopper. The one thing I was concerned with was security for that aircraft because there have been a few birds going down over there. And I was scared of that happening while I was already injured.
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    But the field hospital—I went in there, they put me out. They did the surgery. I woke up. I was fine from then on. The treatment was excellent.

    They are training these guys the best they can. And I wouldn't have had it any other way. The hospital is excellent. The staffing, the treatments—it is the transition period that really hurts the soldiers. And I think that needs to be a major focus in dealing with these issues.

    Mr. SAXTON. The transition period meaning from——

    Corporal THIBEAULT. Transitioning from the hospital back into the Army. I just reenlisted in September, so I had this as a career. This was going to be my career in life, but now it has changed. So I have to make a change in my life. It is a rapid change. So it is hard for me to make certain decisions. And I don't know everything about getting out of the military and going on to college or doing whatever.

    I need help doing that, and I don't have that help. I have been doing everything on my own and the same with some other soldiers. I think they have case workers and things like that, but they are not the ones there doing the work. We are. And I think that someone should be there to help us out and point us in the right direction.

    Mr. SAXTON. Thank you. And you have obviously spent a fair amount of time recuperating in the hospital and being around other people with injuries that may be similar in nature, at least that occurred in the theater. Have you heard any kind of general themes of comments that would shed light on those two questions?
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    Corporal THIBEAULT. Not really, sir.

    Mr. SAXTON. Okay. Thank you, Mr. Chairman.

    Mr. MCHUGH. I thank the gentleman.

    I just want to get a couple of points clear. The gentleman asked some excellent questions. And I don't want to ask the corporal something he is unable or precluded from answering. But when you say because of the unit you were with, you were with——

    Corporal THIBEAULT. I was working with counter intelligence surveillance. I am on a surveillance team.

    Mr. MCHUGH. Which makes——

    Corporal THIBEAULT. I was working——

    Mr. MCHUGH [continuing]. Medical deployment issues somewhat slower than they would be for field——

    Corporal THIBEAULT. Yes. I didn't have a line medic with me.

    Mr. MCHUGH. Thank you.

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    Corporal THIBEAULT. Well, we cross train, and we do Combat Life Saver (CLS) training. So everyone on my team is CLS qualified, which is combat life saver.

    Mr. MCHUGH. Right. The other thing is you mentioned transitioning. Can you share with us—I think of Rick Shinseki who is chief of staff of the Army, Vietnam amputee, chief of staff of the Army. What has been your experience with respect to your particular medical condition vis-a-vis your options of staying in or getting out? How has that been presented to you?

    Corporal THIBEAULT. It hasn't been presented.

    Mr. MCHUGH. At all?

    Corporal THIBEAULT. No. I would like to have a sit down meeting with the people that are working with me to get me——

    Mr. MCHUGH. Turn around. General Peake maybe will help you right there. Maybe he ought to be able to help you out here, Corporal. Please, I don't mean to make——

    Corporal THIBEAULT. As far as medically, I am doing the right thing: therapy and things like that.

    Mr. MCHUGH. Sure.

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    Corporal THIBEAULT. But I have no—I don't know anything about a medical board. I don't have any counsel on that at all.

    Mr. MCHUGH. Now I had no plans to ask this. You and I hadn't talked about it. As a human being and someone who, as you said, made a clear decision that obviously was at least effective, not interrupted, that the lack of information is probably more anxiety producing than if you knew what was going to happen one way or another. Am I probably right in that?

    Corporal THIBEAULT. Yes.

    Mr. MCHUGH. Yes. Okay. Thank you very much.

    And I thank the gentlelady from California.

    By the way, we are all volunteers, too. Nobody is on this subcommittee that didn't ask to be.

    And I admire that in my colleagues and certainly admire it in the gentlelady from California who has been a leader in concern of the welfare of the troops. Ms. Sanchez. Thank you for letting me preclude your time.

    Ms. SANCHEZ. Thank you, Mr. Chairman. Thank you for the time.

    I actually wanted to follow-up because one of the major questions I had was this whole issue of this seamless transition. And we have heard the DOD say that about DOD to VA and how they are committed to that. But my biggest worry has been because, believe it or not, I have gotten a lot of amputees back, in particular, to Southern California.
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    The problem that we have had is of their not knowing what is the next step: What job opportunities there are, how do they get out, when do they get out, who is going to help them to find a job, are they eligible for training in particular areas? Can I just have Dr. Schwartz and—I can't read any more. I am getting old.

    Mr. Duggan, I think it is—talk about what you have seen out there with respect to this whole transition. And I just want to say that because I believe it was Mr. Murtha who sent around a dear colleague letter talking about how he, being from Pennsylvania, had seen a lot of this happen also and how we have no jobs program or no retraining program. So I am just trying to get an idea about this.

    Dr. SCHWARTZ. Yes. Thank you, Ms. Sanchez. We share a concern as well because, as we said in our testimony, when you are acutely injured or even out in the field, our folks are getting world class care. There is bar none, and we are most appreciative for what is out there. But as the servicemembers do transition into the community, where is that gap? And we believe the VA would certainly be the organization to provide those services.

    And now we have increased demands upon the VA that weren't there before, and we would have to look to the VA to provide those services, once they transitioned out of DOD and are not, ''veterans.'' But that is obviously——

    Ms. SANCHEZ. But you are seeing nothing? In other words, there is no work by the DOD to come out to work with the veterans' organizations or with the VA or for the VA to work on this or for community colleges to get involved, for example, for retraining? There is really nothing out there?
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    Dr. SCHWARTZ. I can't comment on that. We haven't been involved in that. But maybe Mr. Duggan with the American Legion can address that.

    Mr. DUGGAN. First of all, there is what is called a DTAP Program, a Disabled Transition Assistance Program, (DTAP), which is what the VA and people from the Department of Labor do for the employment possibilities. DOD may be there as well, too, VA for sure, particularly for the severely disabled.

    But outside of that, what we have seen, of course, here at the major hospitals in the area here, Walter Reed and the Bethesda Navy, have the VA people right in there as well, too. And they are supposed to be providing information, hopefully on a name basis to the VA so that it will facilitate their getting treatment from, follow-up treatment, from the VA as well, too.

    Ms. SANCHEZ. When you talk about treatment, are you talking about physical and emotional therapy that is an ongoing requirement for a while, at least?

    Mr. DUGGAN. Yes, it is an ongoing requirement. And, yes, when you are in the hospital that is for sure. And, yes, they stay at Walter Reed for a while, too, or they are transferred to other military MTF, military treatment facilities, as well.

    Ms. SANCHEZ. But once the Army or the Marines or wherever decide, ''Thank you very much for serving your country, but we can't use you anymore, not for this job.''
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    Mr. DUGGAN. The services that I know of from my vantage point or to my knowledge are getting into that now, particularly the Army. The Army, I think, has got, kind of, a lead program. And I hope that it will be picked up by the other services as well. But it stands to reason because the Army has the greatest number.

    Ms. SANCHEZ. So when you talk about this lead program, what is it that you think this program is doing?

    Mr. DUGGAN. Well, what they do, what new order of change right now, Congresswoman, nucleus of the thing is just in its infancy is just starting off is that the idea is that the—and it is primarily transitioning off to, hopefully, to the veterans' service organizations and the VA And there are a number of veterans' service organizations that are going to be involved in that. What can be done? As mentioned, the only transition that we are kind of talking about is being able to help them, for example, the VA claims process.

    Ms. SANCHEZ. Right, their paper work.

    Mr. DUGGAN. That is the biggest trauma that they have, I think, outside of their own physical trauma and the trauma of getting out of the Army and getting back into civilian life. And that is traumatic. The idea of doing it with reduced paychecks is traumatic because even if you are 100 percent rated disabled by the military, by their physical evaluation, medical evaluation board—I don't know what the base pay of an E–4 is these days, $2,000 or so, whatever it is.

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    So, if they are 100 percent, they will get that, and tax-free kind of thing. But they can't keep that as well as any rating by the VA as well, too. And we think they should. They can accept one or the other, but they cannot receive both because the two different agencies for the same kind of thing, for disability. So they give up their military disability pay with the idea of perhaps they might get a better rating and perhaps more from the VA

    That is a money problem right there. And that is a crunch. And the job thing, that is another major crunch. Just what can they do now because they are disabled kind of thing?

    Ms. SANCHEZ. The concurrent issue is, obviously, one we have been working on for a while. But I am more interested that I have lost a limb. I don't know. I am considered 40 percent disabled or whatever. They are going to give me $300 a month for the rest of my life or what have you. I have no family or have nowhere to go. What am I going to do with my life? There is really nothing out there right now.

    Mr. DUGGAN. No, not that I am aware of. Frankly, not that I am aware of, outside of the veterans' service organizations; I think they are pretty much on their own. That is my view.

    Ms. SANCHEZ. Thank you, Mr. Chairman.

    Mr. MCHUGH. Thank the gentlelady.

    Next the vice chairman of the subcommittee, someone who has come to this Congress and taken these issues up and run with them. And we are deeply appreciative of his support and his contribution.
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    The gentleman from Oklahoma. Mr. Cole?

    Mr. COLE. Thank you very much, Mr. Chairman.

    Having missed most of the testimony because I was in another committee meeting, I just want to apologize for that, number one, to you and just express my appreciation to each of you individually for what you do for our country, what you have done and what you do for the people that defend and protect us every day. I am very grateful.

    And I look forward to the next panel, Mr. Chairman. Thank you.

    Mr. MCHUGH. Thank the gentleman, lady and gentleman.

    Again, as I tried to indicate in my opening comments, we deeply appreciate your being here today, the contributions that all of you make, particularly the corporal and your brother in arms, the Sergeant. We deeply appreciate your sacrifices, your contributions and what you have done for us here today in helping us to face up to the realities of these conflicts. So with our thanks and blessing and deepest appreciation, I would ask if you would please dismiss.

    I would also say perhaps other members may have written questions. If that is the case, we would appreciate your cooperation in submitting written responses for the record in return. But thank you for your leadership and your concern. Appreciate it.

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    Mr. MCHUGH. If I may introduce the second panel before we begin with their comments. First is William Winkenwerder, Jr., M.D., Assistant Secretary of Defense for Health Affairs, Department of Defense.

    Dr. Winkenwerder, welcome.

    Lieutenant General James B. Peake, Surgeon General of the Department of the Army. Our first two witnesses are hardly strangers to this Hill, to this conference room or to this subcommittee. And we are pleased to welcome them back here today.

    Sergeant Major Kenneth O. Preston, Sergeant Major of the Army.

    Sergeant Major, welcome, sir.

    Michael J. Kussman, M.D., Deputy Chief Patient Care Officer, Co-Chair of the Department of Veterans' Affairs Task Force for the seamless transition of returning servicemembers, Veterans' Health Administration, Department of Veterans' Affairs.

    Dr. Kussman, thank you so much for being here, sir.

    And Dr. Kussman is accompanied by Susan Mather, M.D., MPH, Chief Officer of the Public Health and Environmental Hazards Division of the Department of Veterans' Affairs and Laurent S. Lehmann, M.D., Chief of the Mental Health Strategic Health Care Group of the Department of Veterans' Affairs who will be here for response to questions. As I understand it, Dr. Kussman will be presenting the oral testimony.
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    Welcome to you all. Thank you so much. I think, to the first panel we have posed some questions and issues that we may indeed wish to pursue during the ensuing dialogue. But for the moment, we do have all of your written testimonies in their entirety. Without objection, we will enter those into the record in their entirety. And as I have advised certain members of the panel in past testimony, we would deeply appreciate your ability to summarize to the greatest extent possible those written comments.

    So with that, Mr. Secretary, thank you for being here.


    Dr. WINKENWERDER. Thank you.

    Mr. MCHUGH. Good to see you again. And we look forward to your comments today, sir.

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    Dr. WINKENWERDER. Thank you, Mr. Chairman. Mr. Chairman and members of the committee, thank you for the opportunity to appear before you today to discuss the department's force health protection program. Today we have more than 253,000 servicemembers, men and women, deployed in support of our nation's defense, including those serving in Afghanistan and Iraq. DOD is firmly committed to protecting their health, both before, during and after these deployments.

    And before I continue with my comments, I just want to salute the two young servicemembers here today and thank them for their service, for their courage and for their sacrifice for their country. I appreciate it.

    I have provided a more detailed written statement, as you have said. But let me just highlight some of our major force health protection efforts. Protecting our personnel who deploy in harm's way is a primary mission of the military health system. Our objective, obviously, is to recruit and maintain a healthy and fit force to prevent disease and injury among servicemembers throughout their military service careers, including deployments, and to provide medical and rehabilitative care to those who become ill or injured as part of this service.

    We maintain the health of our force through health promotion, wellness programs, routine medical and dental examinations and periodic preventative health assessments. When medical conditions are identified, we have a robust program under TRICARE to ensure appropriate care for servicemembers and, in fact, for all our beneficiaries.

    To ensure our forces are fit to deploy, we review key indicators necessary for deployment. Last year, we developed a new metric. It is called (IMR), Individual Medical Readiness. This is a new tool for us. And it captures the individual's readiness status from a health perspective.
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    We use indicators in the area of medical and dental health, deployment limiting conditions, required immunizations, required laboratory samples, required equipment items, things like protective masks and hearing protection, eyeglasses and all of that together to calculate an overall readiness score. And this is a tool for commanders, not just for medical people. It is now being used by the services.

    And it is a powerful tool that both protects forces and assists commanders in knowing what the readiness of their troops are. And it is used not just in the active, but also in the reserve community.

    The department protects deploying forces with appropriate vaccines against potential biological weapons. We have successfully immunized servicemembers from two deadly agents, both small pox and anthrax. More than 580,000 people have been vaccinated against small pox using a comprehensive program of education, screening and follow-up.

    We have achieved a safety performance, I am proud to say, similar or superior to that seen with small pox vaccine used in earlier decades. And we lead the nation, DOD does, at this point in time, in terms of collecting and sharing information about the small pox vaccination. We are really the largest source of vaccinated people in the world today.

    Because this vaccine does have inherent risks, we developed four specialty sites in the vaccine health care center network to provide good care and advice in the rare situations where there are serious adverse events after a vaccination. Over a million members have been vaccinated against anthrax. Despite our recent operations tempo, 82 percent of those were given on time. And we are working to improve that rate.
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    Let me just mention the issue of refusals on anthrax vaccinations. Those numbers are really very, very small, literally on a couple of hands, which is contrary to some of the media reports you may have seen that suggest that there are, in fact, hundreds of people who have refused. That is not our experience since 9–11.

    In all of our vaccination programs, the focus is on safety and protection. The Institute of Medicine concluded with respect to the anthrax vaccine that it is safe and effective against all forms of anthrax, including inhalational anthrax. And on December 30th recently of 2003, the Food and Drug Administration issued a final rule that supported that decision.

    To support our forces in the field, we deployed preventative medicine teams that conduct comprehensive surveillance and environmental and health surveillance. That collected data is centrally archived. If an environmental hazard is identified, we record the demographic and exposure data and conduct further testing and treatment as required.

    For operations in Iraq, we introduced for the first time this past year an electronic medical surveillance system called Joint Medical Work Station, or JMeWS, is our acronym for it. This system provided near real-time surveillance information for commanders related to patterns of illness and the medical availability of medical resources.

    During Operation Iraqi Freedom, we used far-forward surgical and medical teams and technologies to care for casualties within minutes of injury, as the example that the young servicemember just talked about. It took about 30 minutes. We don't like it to be any more than that. There is that golden hour that we try to get to people to take care of traumatic injuries.
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    Based on current analysis, more than 98 percent of those wounded who, in fact, reached medical treatment survived their injuries. And one-third of those returned to duty in 72 hours. That is a remarkable statistic, really the lowest we have ever seen in military history, that more than 98 percent of people survived those injuries.

    The rate of disease and non-battle injuries among our deployed forces is similarly low, in the area of four percent. We attribute these low values in part to improved health screening, pre-deployment and comprehensive preventative health management during operations.

    There was a mention about medical evacuations. Of the patients evacuated from Iraq since operations began—and I think the number was quoted earlier as around 11,000—approximately 87 percent of those were moved for routine, non-life threatening care. So I want to make clear that the vast majority of these are not urgent or critically ill patients. In fact, most are for rather routine causes.

    Let me touch on the issue of mental health. Our forces face threats to their mental health, let there be no doubt, from depression to acute stress disorders to suicidal ideation and thoughts. The services and specifically the Army have developed and deployed mental health teams to monitor and manage stress and provide care in the theater. And I am sure General Peake will be able to talk about that in just a moment.

    The Army also sent a team to assess risks and adequacy of our current interventions. One of the recommendations, I understand—and again, General Peake can go into this in further detail—was to adopt a more garrison-based suicide prevention program to be more outreaching to those people and not wait for them to come in, but to reach out to them.
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    While one death clearly from suicide is a tragic event, we are continuously monitoring suicide rates to determine what the specific reasons and causes are. And while the suicide rate for those who have been deployed in Iraq is higher than for Army personnel who have not deployed in the past year or so, it does remain lower—and I think this point is important—than the overall rate for the same group of young Americans when you adjust for their age and their gender. And so, that is an important point to note.

    We deploy troops to areas where malaria is a threat. In 2003, we did have 80 cases of malaria for the troops that went into Liberia, and that was a concern. I think what we learned from that effort is that there was need for better compliance with anti-malaria medications. And we will touch on that issue as well.

    One of the medications used to protect against malaria is mefloquine or otherwise known as Lariam. And while it is FDA approved, there are precautions associated with the use of mefloquine. The FDA cautions that mefloquine should not be prescribed to people with an active or recent history of a significant mental disorder such as depression or psychosis.

    Now we follow all the FDA guidelines for using this medication. Every servicemember is screened and receives information about possible side effects before taking the product. That is our policy, and that is what should be done.

    Additionally, I want everyone to note that I have directed a study to assess the rate of adverse events to include suicide and neuropsychiatric outcomes that may be associated with the use of Lariam or other antimalarials prescribed to deploying servicemembers. And that study has already been started. And hopefully we will get some answers to some of the concerns that have been expressed.
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    After deployment, all servicemembers complete a health questionnaire and they are screened by providers to assess any health concerns. Blood samples are taken and archived, and all deployment health records are maintained in the individual's permanent health records. These records are available to the VA.

    In January, we introduced a quality assurance program to track compliance with pre and post-deployment health programs. I receive regular reports on this data, including information on health status, health and mental and medical concerns and the number of referrals for specialty care that have occurred after deployment.

    Since January 2003, more than 90 percent of over 300,000 servicemembers who have returned have reported that their health status is either good, very good or excellent. And I think that is good news. And I was certainly pleased to get that report just recently.

    DOD partnered and we are working closely with the Department of Veterans' Affairs to develop clinical practice guidelines specifically for personnel returning from deployment. These guidelines are useful for clinicians when caring for servicemembers who have deployment-related concerns. And they help with managing complex illnesses and conditions.

    Let me talk for a minute about the issue of reservists and reserve benefits. The benefits, the temporary benefits that the Congress passed in 2003 are now being implemented. By extending TRICARE eligibility post-separation and by extending eligibility for care through the VA for up to two years, we are better positioned, we believe, to identify and track medical concerns. And to facilitate care for separating servicemembers, we have mandated pre-separation counseling through the Transition Assistance Management Program.
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    To better coordinate care between the DOD and the VA, health information such as tests and discharge summaries is being shared through the Federal Health Information Exchange.

    And finally, to enhance coordination of care, the VA has placed social workers in several of our hospitals to enroll wounded servicemembers with the VA before they are even discharged from our facilities. In my judgment, our relationship with the VA is working better than it has ever worked. That is not to say that there are not some problems and issues that we need to continue to work on and to improve, but the working relationship is very good.

    Let me just close by saying I am proud of the progress that has been made to improve force health protection for our servicemembers. It is certainly a distinct privilege to serve our servicemembers. We have accomplished much, but we have more that we can do and more that we will be doing in the year ahead.

    So thank you and I look forward to addressing any of your questions.

    [The joint prepared statement of Dr. Winkenwerder and General Peake can be viewed in the hard copy.]

    Mr. MCHUGH. Thank you very much, Mr. Secretary. As you have heard, we have a vote called. Actually we have two votes. If I may impose upon the goodwill of our presenters to stand at ease, we will try to get back as soon as we can. And we can then hear from our remaining witnesses. I would appreciate that. So we will stand at adjournment. Thank you.
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    Mr. MCHUGH. We will reconvene the hearing. The good news is that is the last vote of the night. And it is only good news.

    So again, Mr. Secretary, thank you for your testimony.

    To the rest of you and to Secretary Winkenwerder, thank you for your patience in sticking with us.

    And next we are honored and pleased to welcome no stranger, as I said in my opening comments, to this committee room, to this subcommittee certainly, the Surgeon General of the United States Army, General Peake.

    Welcome, sir.

    General PEAKE. Mr. Chairman, Congressman Snyder, members of the committee, it is really good to be with you again. Last week, I was in Iraq. I know you were in Afghanistan. I had a chance to visit with the senior Army leadership from General Sanchez to the 4th Infantry Division (ID) commander to the 1st Armored Division and with the medical leadership that is now in place for Operation Iraqi Freedom II (OIF).

    The issues of force health protection are clearly high on their priority lists. And as I had a chance to visit with the soldiers at the grass roots of the medical system, those on their way out to patrol the streets of Baghdad, those providing care at the confinement facilities, those in the combat support hospitals in Tikrit and in Baghdad, I can tell you the sense of commitment and mission focus on the full spectrum of health of the force is there in spades.
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    First, living conditions have improved significantly since I was there last in July. My Army secretary's strong emphasis on this has really given a cleaner environment with most areas providing climate controlled billets now, excellent dining facilities and overall improved living environment. And I do believe that will make a difference as we get back into the intense heat of the summer.

    In both divisions that I visited who are both looking to return home in the next few months, I found tremendous support from the top leadership on down for our organized and disciplined reintegration program that is part of our overall Army deployment cycle support plan. The commanders understand the importance of the post-deployment health surveys and are embracing the electronic capture of this data wherever possible.

    Nearly 50 percent of our electronic submissions come directly into the Defense Surveillance System electronically out of Iraq and nearly 100 percent are electronic out of Kuwait. As these are stored electronically in a central database, they are available to clinicians to review whenever and wherever they happen to be and will be likewise available to VA clinicians when the patients are seen in that system.

    We are working toward a seamless environment that I know you envision for us. As we get ready to field our Center for Health Care Strategies (CHCS) II across the military health system, this important post-deployment health survey really becomes virtually the first page of our computerized patient record.

    Another aspect of surveillance is our environmental surveillance. And that has produced more than 2,300 samples, both routine and targeted, of soil, water, air with more than 77,000 analytes to characterize the environments into which our soldiers have deployed. Further, this information is archived at the Center for Health Promotion and Preventive Medicine.
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    It is available to units themselves over a secure Web site all around the world on demand. We also share the common operating picture of unit locations through the blue force tracking that allows us to make the correlations should concerns arise.

    Let me give you an example. When the soldier is accompanying contractors who are reconstructing the water plant in Iraq it raised a concern about potential industrial chemical hazards, one of our Center for Health Promotion and Preventative Medicine (CHPPM) environmental teams went to the site, worked with the British coalition partners as well as our own folks, examined the unit, tested blood, tested pulmonary functions, found no effects, no blood levels and appropriate cleanup of the chemicals is done. The information was archived and clearly communicated to the unit all while the unit was deployed.

    Another example, at Karshi-Kanabad in Uzbekistan in 1991, we occupied an old Russian base. I think we talked about that in a previous testimony. Environmental hazards were identified and abated. But since then, we have received and archived weekly preventive medicine reports, including the results of routine water testing, received and archived sporadic reports of other topics of preventive medicine interest, like pesticides and dining facility inspections.

    And most importantly, our environmental experts at CHPPM maintain contact with the Combined Joint Task Force's (CJTF)'s 180 surgeon staff to assure that rotating personnel are aware of the history there at K2 and that the risk mitigation put in place early on is maintained and that the attendant need for health risk communication has been accomplished. Now that is longitudinal, institutional attention to force health protection.

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    I may have mentioned Tony Intripido, one of our majors at a previous testimony. He is one of our environmental scientists who spent a lot of the time at the Hart office building cleaning up after the anthrax. Since then, he has led teams to do environmental sampling at ports in Kuwait and in the oil fires that we had in Iraq. He represents the kind of great people who take this responsibility very seriously.

    We have had a number of teams all through this theater looking at various health issues. You are familiar with the teams we sent to investigate what we were concerned might be unusual pneumonia outbreaks and found a diverse set of causes without any epidemiologic evidence of a related outbreak, or the team of experts that we deployed into country to deal with the leishmaniasis related to sand fly bites and the centralized treatment we set up back at Walter Reed to ensure that we met all FDA requirements in the treatment protocols.

    Now we have expanded to another center at Brooke Army Medical Center in San Antonio and will soon make available a thermal treatment that can be used for appropriate cases at home station. We have provided extensive information to redeploying soldiers about this disease. This is also a part of force health protection.

    Another team was the mental health advisory team that has been alluded to earlier that was invited into the theater by the leadership to assess the mental health status of soldiers looking at care available in theater, care through the system and at suicides. It is unprecedented to have this kind of look at this point in a combat operation. And the theater leadership provided access around the theater and soldier available for surveys and interviews all at the peak of the heat of the Iraqi summer.

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    They found the stressors that you would expect, environmental, family separations. And then so soon post the rush to Baghdad, many had seen some severe wounding. The team reaffirmed that far forward care was effective and helped keep soldiers from becoming psychological casualties.

    Some of our mental health teams were doing this better than others. And the visit refocused everyone on the forward outreach approach to mental health. As they walked back through the system, there were opportunities to improve as issues of continuity of care as the soldiers moved through the system, and those have been tightened up.

    Surgeon evacuations in the summer were analyzed, and the percent of mental health evaluations really remained about the same, 8 to 10 percent of evacuations, as at other times and during this operation and in other operations. The team did find something that we have recognized in other studies of soldiers—the concern of stigma of assessing mental health assets. And getting the mental health assets forward and easily available cuts this down. But I know it doesn't eliminate it.

    On my visit last week to the 1st Armored Division (AD), the combat stress teams that were down in the units were specifically commented on as a real value add to the soldiers by the leadership as was the improved ability to communicate with family back home. Each of the young soldiers I spoke to had an opportunity to access e-mail on a regular basis and access to periodic Morale, Welfare, Recreation (MWR) phone calls.

    The rise in suicides last July was not sustained in subsequent months, although it was a real concern at the time that it might represent something aberrant. Clearly, even a single suicide is one too many in our Army family, but let me just review those statistics.
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    By the year 2003, there were 21 OIF in-theater suicides. This is a rate of 15.8 per 100,000. There are an additional five cases from 2003 that are still being investigated. But overall in the Army for 2003, there were 61 suicides, including those in-theater for a rate of 12.4 per 100,000. And there are still six total pending investigation.

    When one looks at the United States population, as Dr. Winkenwerder spoke about, 20-to 34-year-old aged males, the rate is 21.5 per 100,000. From 1995 to 2002, the Army rate has been between 9.1 and 14.8 per 100,000, so we are a bit higher in this combat period.

    The issue of Lariam does come up. Of the 21 confirmed suicides in-theater, only 4 soldiers were in units taking Lariam. We do know the documented side effects of this medicine that we use to protect soldiers from a deadly form of falciparum cerebral malaria. We do use alternate prophylaxis when indicated, but we do not believe that this represents the big causal factor in our suicide rates.

    What the team did note that failed intimate relationships, legal problems and financial problems, the same kind of issues that you see back home related to suicide, seemed to be the predominant triggers in-theater as well. The program to provide assistance to soldiers and their families as the troops rotate home is an important part of protecting the force and is the focus of our Army leadership.

    I have already commented on the post-deployment health assessments, and this further includes a serum sample that goes into our repository and a T.B. test. The focus is on reintegration with briefings in-theater first, a period of part-time with the family and part-time with the unit back home before going on block leave once the soldier returns and what we call the Army One Source that you have heard about earlier. It is actually a civilian model of an employee assistance program.
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    Our soldiers and their family members can access a 1–800 number or Web site 24 hours, seven days a week with any family, counseling, adjustment concerns at any time—I think we passed out one of the tri-folds for you to take a look at it. It de-medicinizes things as simple as family counseling, which, without a formal diagnosis, is not a TRICARE-covered benefit. This is another way to attack the perception of stigma around mental health access. We have placed so far 47 of 58 post-deployment care managers into our primary clinics to be immediately available so you don't have to go someplace else to access a mental health kind of assistance or counseling.

    Force health protection is so many things from vaccinations to vision protection to body armor to hand washing at the mess halls to increasing the number of combat life savers that Corporal Thibeault talked about within the units. And all of these things and many more are being done and emphasized by our superb line commanders, which is the key to it. I am proud to be on this team.

    And I look forward to answering your questions, sir.

    Mr. MCHUGH. Thank you very much, General. Again, we always deeply appreciate your being here.

    Next, as I introduced earlier, Sergeant Major Kenneth O. Preston, Sergeant Major of the Army. Sergeant Major, thank you for being here, and we look forward to your comments, sir.

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    Major PRESTON. Thank you, sir.

    Mr. Chairman, Dr. Snyder, distinguished members of the committee, now what I would like to do is start and introduce Command Sergeant Major Michelle Jones who is here with me also, the Command Sergeant Major for the Army Reserves.

    Mr. MCHUGH. Thank you for being here, Sergeant.

    Major PRESTON. It is a tremendous honor to sit before you today and represent 1.2 million members of our great Army. As we speak this afternoon, we have soldiers deployed to more than 120 different locations around the world. And, of course, the deployment and redeployment into and out of Iraq is currently ongoing.

    Over the past year, I have served as the 5th Corps and the combined joint task force 7th Command Sergeant Major in Baghdad, Iraq. And I served there with General Sanchez and before General Sanchez, General Wallace.

    I was very honored to serve alongside soldiers from all parts of our great nation. And many of you have visited these soldiers in the streets of Baghdad, the outposts of Afghanistan and the hospitals like Walter Reed Army Medical Center.

    As the senior enlisted soldier in Iraq, the safety, health and well-being of our troops was my principle focus. I traveled all over Iraq and Kuwait to ensure leaders were talking to their soldiers about the challenges and stresses of combat and keeping soldiers informed. I checked to ensure that leaders were enforcing standards and ensuring soldiers were properly equipped to accomplish their missions.
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    Soldiers are the centerpiece of all of our formations. We continue to make advances in weaponry and technology, but wars are fought and won by soldiers. After the fight, it is imperative that we care for these men and women physically and mentally. We must take care of the soldiers' families and ensure they receive the reintegration counseling following a long deployment.

    We have made great strides in my last 28 years of service. All the lessons from Desert Storm to the present were incorporated into our soldiers' transition returning from Afghanistan and Iraq. We aggressively screen and prepare soldiers for the health risks that they may face before deployment. We provide world-class treatment on the battlefield and rescreen and educate soldiers and their families when they return home.

    Our in-theater medical care has never been better. From our stress control teams to our emergency medical technician trained medics, on the battlefield, soldiers are getting better care in combat than they have before in history.

    Since 9–11, we have lost more than 545 and treated more than 2,600 soldiers, civilians and contractors during Operation Enduring Freedom and Operation Iraqi Freedom. Each of these men and women has demonstrated tremendous personal courage and sacrifice in the defense of our nation. We owe each of them a tremendous debt of gratitude. Without a doubt, many of these wounded soldiers would not have survived without the latest in force protection equipment and medical treatment.

    Our deployment cycle support program is improving every day. And we continue to capture lessons learned and apply them quickly to make operations better.
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    I thank you for your continued support both here and during your visits that you have taken into Iraq and Afghanistan. And thank you for this opportunity to appear before you today. And I look forward to your questions.

    [The prepared statement of Major Preston can be viewed in the hard copy.]

    Mr. MCHUGH. Sergeant Major, thank you. I mentioned earlier I just returned from Afghanistan. I had the honor of jogging—I jogged, they ran—with several of the sergeant majors. And obviously at all levels, the sergeant majors are the ones who care most about the men and women in uniform, the enlisted ranks. And they are the ones—you are the ones—to whom they look for support and guidance. And we appreciate your leadership in that area.

    Next we have Dr. Michael Kussman, deputy chief, patient care officer and co-chair of the Department of Veterans' Affairs Task Force for the Seamless Transition of Returning Servicemembers, Veterans' Health Administration, Department of Veterans' Affairs.

    Dr., your business card has to be, what, 5 foot by 8 foot?

    Dr. KUSSMAN. You are too kind, sir. It doesn't have all that on there.

    Mr. MCHUGH. We are honored that you are here, sir, today. We look forward to your comments. Thank you.
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    Dr. KUSSMAN. Thank you, Mr. Chairman and distinguished members of the subcommittee. I appreciate the opportunity to appear before you today to discuss our efforts toward a seamless transition for separating servicemembers from DOD's health care system to the VA's health care system.

    You were kind enough to recognize Dr. Mather, our chief officer for public health and environmental hazards, and Dr. Lehmann, chief consultant for mental health. I would like to recognize one other person, Mr. Ronald Henke, who is our director of compensation and pension services for the veterans' benefits. And he is here sitting behind me and so, would be available to answer any questions specifically about some of the questions that came up earlier.

    Working with DOD, the VA has put into place a number of strategies, policies and procedures to provide appropriate services to returning servicemembers. The VA has successfully adapted many preexisting programs and has improved outreach, clinical care and VA health provider access to DOD health records.

    I have submitted a full statement for the record and at this time would like to just summarize briefly some of the things that were in that full statement. Last August, the VA's under secretary for benefits and under secretary for health created a task force for the seamless transition of returning servicemembers. This task force focused initially on internal coordination between the Veteran's Benefits Association (VBA) and Veteran's Health Association (VHA) as we approached its mission in a comprehensive manner.

    This was rapidly expanded to incorporate representatives of the DOD, which has led to improved dialogue and collaboration between our two departments. Each VA facility and each regional office has identified a point of contact to ensure that the needs of returning servicemembers and veterans are met. The VA distributed guidance on case management services to its field staff to ensure that proper coordination and processes are followed.
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    We have placed full-time benefits personnel as well as VHA social workers in several military treatment facilities. They work closely with military medical providers and DOD social workers to assure that returning servicemembers receive information and counseling about VA benefits and programs. VA actively participates in the discharge planning process for servicemembers who, due to injuries or illness suffered in Operation Enduring Freedom (OEF) or OIF, are in the process of transitioning from DOD to the VA

    We have also expanded our collaboration with DOD to enhance outreach to returning members of the reserves and National Guard. I would refer you to a Web site that is on the VA home page that is specifically for OEF and OIF. It is a marvelous Web site that has gotten great raves from servicemembers and their families as they look for information related to this transition.

    A critical concern for veterans and their families is the potential for adverse health effects related to military deployments. The VA has produced brochures that address the main health concerns for military service in Afghanistan and Iraq and has recently distributed another on health care for women veterans returning from the Gulf region.

    Mr. Chairman, based on lists of separated veterans received from DOD, we have estimated that as of December of 2003, 9,753 Iraqi Freedom veterans and 1,798 Enduring Freedom veterans have received health care from the VA for a wide variety of health problems.

    For returning servicemembers who are experiencing emotional and behavioral problems, the VA has programs specifically developed to assess and address emotional and behavioral problems associated with military experience. Within its mental health programs, VA operates a comprehensive continuum of health care for PTSD in its medical centers and clinics.
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    Our mental health clinical activities are linked to and supportive of our vet center activities. Last year, vet centers began expanding readjustment counseling services to all Enduring Freedom and Iraqi Freedom veterans. As of December of last year, vet centers had served 4,300 of these veterans.

    In response to a question that was asked earlier, at the secretary's direction, Mr. Principi, the vet centers have opened up services for family members as well as the returning veterans. He has also developed a number of tools to assist the clinician when treating Iraqi Freedom and Enduring Freedom veterans. These include a computerized clinical reminder triggered by the veteran's separation date, the veteran's health initiative program and clinical practice guidelines.

    Two post-deployment clinical practice guidelines have been developed in collaboration with DOD, a general purpose post-deployment guideline and a guideline for unexplained fatigue and pain. The VA and DOD will also release a new clinical practice guideline on the management of traumatic stress by the end of this month.

    The VA and DOD are also collaborating to develop the ability to share medical information electronically. Patient data and laboratory results, radiologic reports, outpatient pharmacy information and patient demographics are now being sent from DOD to the VA via secure messaging.

    The VA and DOD are now developing prototype interoperable data repositories that will permit bi-directional data exchange with pharmacy information by October of this year. The departments will achieve health information interoperability hopefully by the end of 2005.
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    Mr. Chairman, servicemembers separating from military service and seeking VA health care today will have the benefit of our decade-long experience with Gulf War health issues as well as the president's commitment to improving collaboration between VA and DOD. As Secretary Principi has stated, we will have failed to meet our very reason to exist as a department if a veteran is poorly served.

    This concludes my statement. My colleagues and I are happy to respond to any questions that you or other members of the committee might have. Thank you.

    [The joint prepared statement of Dr. Kussman, Dr. Mather, and Dr. Lehman can be viewed in the hard copy.]

    Mr. MCHUGH. Thank you very much, sir. And thank you again for being here.

    And we appreciate those others who have joined us here today to possibly respond to our questions.

    The good news here, I think, as we have heard from our panelists also equally if not more important as we have heard from our military presenters, Corporal Thibeault and Sergeant Craft—and Sergeant Craft didn't address this subcommittee, but I had a chance to chat with him beforehand. And as Corporal Thibeault did indeed testify, Sergeant Craft felt the level of care, medical care that he received along with Corporal Thibeault was outstanding. And that is the good news.
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    And I commend all of you for playing an instrumental role. And I certainly agree with the assessment, I know, that General Peake and Secretary Winkenwerder made that indeed military health care assistance, particularly on the battlefield, is the best ever. The challenge of your success is we are having survivals today that result in devastating injuries that 10 years ago, perhaps less, would have been battlefield fatalities. We need to care for those. You understand that.

    But I would like to start with a couple of what I hope are quick questions with respect to some of the anecdotal things we heard from the first panel, particularly from Corporal Thibeault. His statement was kind of surprising to me. I had no idea he was going to say it. In his experience, every single servicemember who took Lariam had a demonstrable reaction. So the significance of the severity of that, I suppose, varies from member to member.

    I would be interested in, of course, General Peake and Secretary Winkenwerder's comments about that general anecdote. But also what is our experience with respect to the vaccination program, vis-a-vis small pox and others with respect to the civilian vaccination program? In other words, how do they compare with reaction, safety, et cetera?

    And what, if anything, are we doing to limit the adverse reactions of those? It is a highly controversial issue, particularly on the Lariam side; some ongoing studies. But just for the record, I would be interested in your comments, whichever of you would like to go first.

    Dr. WINKENWERDER. Why don't I make a comment? And then——
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    Mr. MCHUGH. Mr. Secretary.

    Dr. WINKENWERDER [continuing]. I would like General Peake to join in. The comments that the corporal made were of concern to me as well because it certainly reflects a perception, and certainly perceptions can become realities when they are widely held that this medication is widely problematic. The medication is an FDA approved and licensed medication that is used outside the military. I don't believe we are the only users of this medication.

    We have some efforts going on to try to track this down, this issue down, and better understand it. First is we have a study that is ongoing to look at perceptions and to survey our own servicemembers about their perceptions to better understand whether what the corporal had to say is just among the people he knows and talks with or whether it is really a broadly held view across all the services. How many people believe this, and why do they believe it and so forth? So we will learn something about that. That study is ongoing.

    Second, more to the point of a scientific study to look at whether there are, in fact, any adverse outcomes that are serious. I have directed that that be initiated. And we have just gotten started on that.

    Typically those—I want to caution for any quick answers on that. Typically those kinds of studies take many months to as much as a year even up to two years to really do a good scientific study to look at a controlled group, a case group and trace back to see if there is a relationship here between real adverse outcomes. So we have to do both of those things.
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    I would turn to General Peake as well in terms of anything else he would care to add on this issue. It is an important concern for us, obviously.

    General PEAKE. I will just say it is important in a couple of ways. One is we do use it to protect soldiers from something that could kill them. And we have had soldiers die of cerebral malaria, and the Marines have had that same kind of experience. So where we can have a non-chloroquine resistant kind of environment, we can go to chloroquine and these other prophylaxes, and we will.

    But where we have that risk and it is the appropriate thing to do is to use mefloquine because it will protect, we are very comfortable with that. But I think it is important for us to do this study. And I support that, sir. Because what we want is the confidence of the soldier to be able to take it. Because as you heard Corporal Thibeault say, he stopped taking it. And we have had those kinds of issues before, too.

    We did go through the full FDA approval process and so forth. And so, there is a Web full of people who have mystique about Lariam. We still feel it is—especially in a resistant environment—the appropriate treatment or the appropriate prophylaxis.

    It is also important to use this treatment in certain cases of malaria. So it is—I think the right thing to do is to take a good, hard look at it and to dispel what myths are there and find out what the facts are.

    Mr. MCHUGH. Appreciate your comments. The reason you study things is to discover new things. I understand that. And you both have just said you have a study going on.
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    But based on what you know right now, is your adverse reaction experience with respect to Lariam specifically, significantly different than what—and Secretary Winkenwerder mentioned, you mentioned, sir, there are others outside the military that have used this—is it significantly different, that is, higher? Or are they pretty much the same as far as you know?

    Dr. WINKENWERDER. I don't have the answer to that question.

    General Peake, do you?

    General PEAKE. My sense, sir, is that we don't think it is as big a problem as has been made out. When we look at a measurable event, and if the measurable event is suicide—we looked at the Fort Bragg stuff, as we spoke to you before—you couldn't nail that down. And we tried to see if there was any correlation there. And we couldn't make it.

    And the 21, as I mentioned in my testimony, of cases of suicide in-theater, only 4 of those soldiers were in units that took Lariam. Only one did we detect the Lariam in the post mortem sample. So we don't think that that was—we don't see that as a causal factor there.

    Mr. MCHUGH. Okay. But it is an issue under study?

    General PEAKE. Yes, sir.
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    Mr. MCHUGH. Let's talk about suicides for a moment. One of the concerns we have heard—and General Peake, you just mentioned 21 in-theater—one of the concerns we have heard is that statistically the services, in this case the Army, is not considering those who have been redeployed in suicides. And that is of particular concern, it seems to me, given our utilization of the reserve component, guard and reserve.

    General PEAKE. Sir, it is not an attempt to try to skew it. The problem is what is your denominator. So we can look in-theater and we can look at how many, what the number, 100,000 man-years, how many man-years you have. We have had six suicides. As of now, I think it is six who are folks who had deployed to OIF and then returned and committed suicide.

    I wouldn't necessarily say that is a direct correlation. It is just that that is the body. And you say, well, okay, what is the denominator to create? So it is not a matter of saying that there is not an issue and we are looking at it.

    But I can tell you if you look at those that have died in-theater, it is a rate of about 15.3 or 15.4, something like that. And with the potential now of what we are looking at of—I think there are five still potentially pending—some of them may not turn out to be suicides, some may. Even if you add all those together, it would be less than what the national average would be.

    But it is not to say—I can't tell you exactly what the denominator would be if you added in all the people that have come and gone.

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    Mr. MCHUGH. And I understand that.

    General PEAKE [continuing]. A matter of math.

    Mr. MCHUGH. Pardon me? I am sorry.

    General PEAKE. I am not trying to oppose——

    Mr. MCHUGH. No, and I am not accusing you of that. We are here to discuss the lay of the land and to learn. But what are you doing about either the ability to counsel or the ability to factor those who have redeployed after obviously having been deployed to those two theaters? I am speaking specifically Iraq and Afghanistan,—to either factor in those suicides are equally important to make sure that there is some sort of care for those who are—particularly in the guard and reserve.

    If you come back to a base and you are redeployed, at least you are in an environment where you can just walk across the compound and receive help. If you are redeployed from the reserve component, guard or reserve, you go home and you are in your community and you don't have that support network.

    General PEAKE. Yes. That is true.

    Dr. WINKENWERDER. Let me just make a comment on that.

    Mr. MCHUGH. Please.
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    Dr. WINKENWERDER. It is important. We are looking at it. We are going to continue to look at it and try to improve our surveillance.

    I just want to mention a task force that I recently appointed to look at the whole issue of post-deployment care and follow-up for reservists specifically following their deactivation. And I have asked Dr. Kilpatrick who is here with me today as well as our chief information officer—because some of this is a matter of tracking information and being able to communicate with the VA, with the local guard or reserve unit, with the DOD and bringing information together so that we can follow people.

    The sources of care, I believe, are available to people. As we have mentioned, people have six months of continued eligibility under TRICARE. And they also have eligibility through the VA assistance.

    So I am not as much concerned about the availability of care as I am someone following up on that member who looks like he or she might have an indicator that they might have a problem. And that is the kind of system we are looking to try to create.

    Mr. MCHUGH. We weren't aware of that, and I am thrilled to hear it because I agree. Utilization is a very important challenge here. It is not like if you redeploy from a guard and reserve unit you are going home to the plains. Or you may be. But, it is not deserted.

    There are means of care. But it is the utilization of that. And clearly, in this new seamless total force, we are utilizing guard and reserve units to an extent that I don't believe we have, if ever, certainly in some time. And we need to take that into consideration. So I am delighted to hear your response.
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    I don't know, General Peake, if you want to add anything.

    General PEAKE. I would just add just maybe the point that you made that there is—the guard and reserve leadership is becoming, because of this environment, more attuned to their responsibility as the soldier's commander. So they are really not just in the plains by themselves. They are with their unit and the support groups that the guard and reserve have been standing up. There is a camaraderie out there that I think is maybe different than what it was in the past.

    And I think they will be very instrumental in trying to identify the ones with problems. And then, as has been pointed out, there really is the availability for them to access care.

    Mr. MCHUGH. All right. Thank you. I have a couple more questions.

    I am going to yield to my colleagues, particularly the ranking member, Dr. Snyder.

    Dr. SNYDER. Thank you, Mr. Chairman.

    I am not sure who to address these questions to, Mr. Secretary or General Peake. So I will just throw them out there. You heard the issue—I think it was Mr. Duggan that brought it up—about the possibility of the guard and reserve forces keeping their private insurance and that maybe we can set up some kind of way of giving them a choice between going to the TRICARE program and activation. And you heard that discussion.
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    Do you have any thoughts? Or has that figure been determined about what it would cost, what it will cost, TRICARE would cost the Federal Government, how much money per person? And then if there is a way then of looking at giving that money as a voucher or something to help pay for private insurance. Does that idea appeal at all?

    Dr. WINKENWERDER. Let me say a few things about that subject. It is a very important topic. And we are working on that issue internally within DOD having discussions with the leadership of the joint chiefs and with the reserves.

    Dr. SNYDER. Excuse me. By working on it, do you mean exploring that possibility?

    Dr. WINKENWERDER. We are exploring what are the best ideas that we might work with you and work with Members of Congress on to address this issue. As you know, the Congress took action to extend the benefit earlier as people are activated up to 90 days prior to actual activation and then on what we call the backend after serving up to six months.

    And in addition, I wanted to note there was a comment in one of the earlier testimonies about the fact that health screenings or regular physicals were not available for the reservists. I would differ with that view.

    I don't think that is an accurate view, particularly in light of the 701 provision that was also part of all those provisions that passed that created the eligibility for screenings that the reserve communities themselves can do and pay for, screening health physicals every year periodically. So that shouldn't be a problem for people to get screened to ensure that they are medically ready.
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    Now to the question specifically about extending the insurance to people who are not activated or are inactive; we have concerns about that for several reasons. One, we are not sure that it would have an impact on either retention or recruitment or readiness. And that is an issue we think we ought to understand before we create a new entitlement, essentially.

    It could be very expensive, depending upon how such a benefit could be structured. It might cost into the many hundreds of millions, into the billions. I am not trying to overstate or understate this issue. But this could be a very expensive new benefit. And so, the costs, when we are facing some very serious and significant strains in our own existing defense health program, cost is a concern.

    Dr. SNYDER. Now, Mr. Secretary, my specific question, though, was about people who we are going to be paying their health care at the time of activation.


    Dr. SNYDER. They are going on TRICARE, but their preference may be to keep the current coverage they have because of availability of physicians.

    Dr. WINKENWERDER. That is an important issue, and we think we have an idea—I don't want to talk about it publicly—for how to deal with that issue.

    Dr. SNYDER. All right.

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    Dr. WINKENWERDER. We would like to ensure that there is as much continuity with the same physician as possible. And we have some thoughts about this. We will share those with you very soon.

    Dr. SNYDER. You are not ready to roll that out yet? Good.

    Dr. WINKENWERDER. And let me just note that, finally, in terms of the—again, going back to the inactive reservist community—that about 80 percent or maybe a little more than that have private insurance today. Those are the figures that we have.

    So we do have concerns about displacing perfectly good private insurance and solving a problem that may not exist. We don't say that there are not some problems and concerns, but we want to target our solutions to where we think the real concerns are.

    Dr. SNYDER. Good. I wanted to ask you, too, Mr. Secretary—because in your statement you talked about the 11,000 veteran medevacs. And you described that, I think, 87 percent of them you were considering routine. Now I guess I am not sure. It shouldn't be a routine thing to be flown a few thousand miles. What kinds of things do you consider to be routine to be medevaced for, because you were talking about significant numbers of people?

    Dr. WINKENWERDER. Let me touch on that, and then I will ask General Peake to get into that in more detail. Particularly early on in the first few months in the theater, that if we look at our month-to-month evacuations, it was much higher during the spring of last year and the summer. And it has come down with each month.
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    And part of that related to the types of services we had available or didn't have available in the theater. So we were evacuating, for example, women to do pelvic exams. So that was obviously not a critical, urgent kind of problem.

    Other types of conditions that it was believed that the care could be better made available either in Kuwait or in Landstuhl, Germany. And as I mentioned, a lot of those people were brought back into the theater. So they didn't have—they weren't serious conditions.

    Let me ask General Peake to further elaborate on some of those examples.

    General PEAKE. Things like lithotripsy. There were a number of stone cases. They can sit and wait until the next airevac comes, and it doesn't have to go urgently or with the critical care in the air team, I think is the point that he was making, sir. It is not just wounded in action that come through our medevac system.

    Dr. SNYDER. But I would consider—I will use that as your example, lithotripsy—that is not what I consider routine care.

    General PEAKE. No, sir.

    Dr. SNYDER. People are in agony. You are talking about kidney stones. Yes.

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    General PEAKE. That is right.

    Dr. SNYDER. Most of these were routine—that is not——

    General PEAKE. Diagnostic, somebody comes back with a rule out Myocardial Infarction (MI). And you rule that out, and then they need a cardiac cath or something, those kinds of things.

    Dr. SNYDER. Yes.

    General PEAKE. Or for diagnostics. It may even be a large piece of it.

    Dr. SNYDER. Dr. Winkenwerder mentioned pelvic exams. It is not the exam; it is what it is for. If it is an ectopic pregnancy, it is an emergency.

    Dr. WINKENWERDER. Most of them were not. We have some further detail on the exact reasons that people were——

    Dr. SNYDER. Maybe that is enough discussion.

    Dr. WINKENWERDER. And as a physician you would be able to look at it and say these are—the vast majority of them are for routine kinds of things.

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    Dr. SNYDER. Also in your statement, Dr. Winkenwerder, you mentioned over 90 percent of the 300,000 rated their health care or their health when they got back as good or excellent or very good or something. I guess I am a half empty kind of guy.

    But if I take the 90 percent, 10 percent of the 300,000, that means 30,000 of relatively young people that you think are the cream of our country are saying that their health is average or poor. Now that is a fair number of people, 30,000. Is that an accurate interpretation of the statistic you gave?

    Dr. WINKENWERDER. I don't know how if they didn't rate into those categories exactly what they did say. We can get that information for you. What we do know is that about 15 percent believe that they needed—or between their self-assessment and then having that reviewed by a medical provider, generally a physician or a nurse practitioner—that they needed to be referred for some other care.

    So that is not a small number. You are right. These are for a variety of reasons. But our system, we believe, is working because it is identifying people that need to get care.

    [The information referred to can be viewed in hard copy.]

    Dr. SNYDER. Right.

    Dr. WINKENWERDER. And that they are not just, sort of, rolling back to the base and somebody is really not looking at them. But you make a very good point about the numbers.
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    Dr. SNYDER. I wanted to ask about quality assurance issues. And the GAO has not really treated our system very well over the last few years in terms of percentage of people vaccinated and ready to go and having the health surveys done. And so, you all are undertaking that task now with your own quality assurance evaluations.

    So hopefully we will, at some point, not have to worry about GAO's doing it anymore, because you will have that information for us and you will be able to respond to it. But where are you at with regard to setting up—and let me have you both respond—to a quality assurance system that you have confidence in that will tell us where we are at with all the kind of assessments that we think are important in following with pre-deployment and post-deployment?

    Dr. WINKENWERDER. This is an important issue. Let me ask General Peake to talk about the Army program. And then I will make a comment about all of DOD.

    General PEAKE. We have teams that are going out looking at specific sites, taking the rosters of the soldiers that are deployed and then cross walking us, which is the central database, being able to cross walk it with what is available in the hard copy. We see that there is something of a disparity between the mega-lists out of Defense Management Data Center (DMDO) in terms of who is on that list so that when we go down to the individual post campus station, they get accurate lists of who is deployed.

    We are looking at those coming back to ensure that we have—and there is sometimes a lag. That is why we are so excited about the electronic entry because there is a lag when it is done on paper. And then it has to be sent to be scanned into the systems. I think we are getting well ahead of that power curve.
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    Just to make a point that this is a living thing, this screening. They get screened in theater now. That is done ahead of time. They come back, and then they have been seen by a clinician. It is not—the comment about being self-administered—it is self-administered. It is filled out, and then you sit down with a clinician and go over it. So I think just to be clear about what we were doing with that.

    And then we were giving them a chance when they come back too. Okay, you had a chance to think about this. Now is there anything else that is new? And in one case, 25 percent, they were saying, yes, let me add this or that.

    Dr. SNYDER. I was wondering in regard to the issues of vaccination compliance and all those kinds of things.

    General PEAKE. We are really pushing the electronic entry. We are looking to make sure that that is disciplined. I know that there are some discrepancies in the database of those in-theater because the troops are moving, some of those kinds of things.

    But compared to what we did in Desert Shield, Desert Storm where it was all stubby pencil and half of them were lost, I think we are miles ahead. We are able to show this data to commanders and to give them a sense of what the status of their troops are; their unit. And that is what starts to add credibility and discipline to the system.

    Dr. WINKENWERDER. Let me just add to that to say that our overall quality assurance program has several elements to it. One is each service has its quality assurance program that includes audits and checks and monitors and reports on a regular basis. Then at the DOD level, we come in and periodically are having scheduled visits, unannounced visits, to sites to look at compliance with the policy and with the reporting statistics.
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    And we get regular reports from the central electronic database and are able to match those from what the local command says its experience is. And then finally, we are going to produce an annual report to tell you about our performance. I share your vision that ultimately we don't want to count on the GAO to tell us how we are doing. We would like to be able to produce the data that allows you to say we have done a good or not so good or a great job.

    Mr. MCHUGH. Thank the gentleman.

    Next I am pleased and honored to yield to a gentleman who I have served with when he was ranking member of the then-independent MWR Panel and also as ranking member of the Personnel Subcommittee, the gentleman from Massachusetts, Mr. Meehan.

    Mr. MEEHAN. Thank you very much, Mr. Chairman.

    Dr. Winkenwerder, I would like to follow up on some of the chairman's questions. I am concerned, as I know you are, about the number of suicides that have occurred during Operation Iraqi Freedom as well as what appears to be an inability on the part of the military to deliver psychological counseling when it is needed most.

    The failure to provide mental health services to soldiers that seek them can lead to tragedy, as I think it did for Marine Corps Second Lieutenant Christopher Shay from my home state of Massachusetts. Lieutenant Shay was deployed in June of 2002 to conduct reconnaissance missions in preparation for Operation Iraqi Freedom. And he was an honor student out of Paris Island selected to difficult missions. He had a deep love for the Marine Corps.
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    And then on November 17th, 2002, Lieutenant Shay took his own life leaving his family with many unanswered questions. Just weeks before Lieutenant Shay's death, he was given the drug we have been talking about, the anti-malaria drug Lariam. And you got into a dialogue with the chairman about the extent that there are known psychotic behaviors associated with it and then the credibility.

    There have been stories done in newspapers all over the country; ''60 Minutes'' had a piece on it. In the case of Christopher, he soon began complaining about acute anxiety. And in the days leading up to his death, Lieutenant Shay requested assistance from the ship's physician, as I understand it, 12 times in 30 hours but was never placed on suicide watch. So it appears in this particular case that the medical services failed Lieutenant Shay.

    You said that you have since deployed—you have a task force and deployed mental health teams to monitor this sort of case. Lieutenant Shay's family is obviously looking for answers of their own. How do we prevent cases like this from happening again?

    Should he have been placed, for example, on suicide watch? And I want to, in addition to the chairman, voice my concerns about the drug. And I wonder why we are not using anti-malaria drugs that maybe are safer alternatives that are out there, that have been reported as out there, and why we are using a drug that has been known to cause some psychotic behaviors.

    And finally, you mentioned the study. I was wondering if you could expand on the scope of the study and maybe give some specifics in terms of how long that you think it will take.
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    Dr. WINKENWERDER. Where would you like me to start? You have asked a number of questions. Let me take——

    Mr. MEEHAN. Okay. How about in the order I asked them? The first one is in the case of Lieutenant Christopher Shay. When you have somebody who 12 times in 32 hours expresses concerns, are there mechanisms that are being put in place that would put someone on suicide watch who had taken a drug with the known side effects in some cases? And we can debate how many cases. Have there been any changes there?

    And second, why aren't we using alternative drugs that may be safer? And obviously I am not a doctor, but at least I have read some research that indicates there may be safer alternatives.

    Dr. WINKENWERDER. I am not familiar with the details of—what was his rank again? I am sorry. Mr. Shay.

    Mr. MEEHAN. Second Lieutenant.

    Dr. WINKENWERDER. Second Lieutenant Shay. But from your description of it, there were indicators that this young man unfortunately was stressed and anxious and others might have had or should have had reason to be concerned about him. You indicated that you are not a clinical person. And I think that is the position probably many of our line unit leaders find themselves in, not having all the knowledge and wherewithal to make those kinds of assessments about individuals.
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    I can say that we are certainly, through all the efforts that General Peake described, seeking to elevate awareness broadly, even beyond the medical community about the impact of stress and anxiety and all of these separations and losses, the impact of all of that on individuals and how it can lead to depression and anxiety and then things like suicide. So we are certainly——

    Mr. MEEHAN. Well, in this particular instance, just to point out—he takes the antimalaria drug, Lariam, and then he starts complaining of acute anxiety. And, as I said, he requested assistance from the ship's physician 12 times in a 32-hour period.

    And it just seems like perhaps, given the drug, given all of the circumstances, but specifically in this instance, the drug, and the fact that he contacted the physician 12 times in 32 hours that he should at least be placed on some kind of a watch, given the fact that there is some evidence to suggest——

    Dr. WINKENWERDER. Well, let me turn to General Peake because he certainly has the line experience to make a comment about how that might be handled, should be handled.

    General PEAKE. Well, we frequently will put somebody that we are concerned about into a suicide watch. That is a very common thing to do. And what happened in this particular case, I don't know. I don't know if the Navy has looked into that specifically to get more circumstances around it. But it is really hard to make the call from here to tell you what happened or didn't happen or why.
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    We do often take somebody we are concerned about, put them under suicide watch. We have a graduated program where we will bring them back through the system. And as I say, 8 to 10 percent of our overall evacuations were for mental, psychological reasons so that there is not a hesitancy if somebody really is of concern.

    For whatever reason, this was missed or not recognized. And I can't address exactly why.

    Mr. MEEHAN. Would it be a good idea if somebody takes this drug, given all that we have——

    General PEAKE. Sir, many, many people take this drug. And our impression is that it is a recognized side effect. There is no question. And if anybody has a history of emotional issues and so forth, we would choose to go to one of those other prophylaxes.

    The issue, as an example, with mefloquine, you take it once a week as opposed to doxycycline where it requires a daily dose that is more easy to miss. And then if you take—you can go to chloroquine, which is weekly. But there are chloroquine resistant strains of malaria. So it is a matter of balance and trying to protect the soldier or Marine and making the best clinical judgment about which medicine is best to do that and what the risk is.

    So I guess I would—we are looking at other antimalarials. That is one of the things that our medical research and material command does is explore those other antimalarials. So we would like to find something that really has no side effect.
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    Mr. MEEHAN. Well, let me ask you then. Given the cases—there have been cases of suicide. There have been cases where soldiers have killed other people, wives that have taken the drug. I would assume that there is something in place where in the future if somebody is taking the drug that there would be some kind of a special instance where that would show up.

    That, okay, this is not a case of he or she has taken Lariam and maybe we should take extra precautions, given the fact that—for example, the facts in this case happen to be that he got a hold of the physician 12 times in a 32-hour period. I guess I would feel better to hear that we are responding to these cases. But I guess I would like to ask about the scope of the study. Would this be included: some of the concerns that I am raising?

    Dr. WINKENWERDER. That is exactly why we are doing this study. And we need to be led by science and by facts and the best science and best facts and truly understand from looking at populations of people that were taking the drug and where there were adverse events and where there were not and doing comparisons to determine what in research they call relative risk. Is there a greater risk for such an event if you were taking the medicine? Is there greater risk of suicide or an adverse outcome?

    Mr. MEEHAN. So you don't even necessarily agree that——

    Dr. WINKENWERDER. Well, we don't have those facts. It is not a matter of whether I agree or disagree. The fact base is not there to draw a conclusion one way or another. I think it is very important that we obtain that fact base. And that is exactly why I believe a study is needed. And that is why we are going to be starting it right away and pursuing it aggressively.
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    Mr. MEEHAN. General Peake, would you say that it is a side effect?

    General PEAKE. Sir, it is a—in the FDA literature, it says that people can have these kinds of side effects. The issue is how often it happens. The sergeant major reminded me that you weren't here when I mentioned the fact that of the 21 cases of suicide in-theater that we have documented, only four of those soldiers were even in units that were taking Lariam. And actually there was only one of them that had the Lariam in the bloodstream when we measured it. So obviously, it wasn't responsible for all of those suicides.

    And when we talk about the Fort Bragg issue, we tried to pin that down, and there was just no evidence that Lariam was the causal factor in those murders and suicide.

    Mr. MEEHAN. Because of the lack of Lariam in the bloodstream?

    General PEAKE. And many of them hadn't taken it. I forget the number specifically, but there was absolutely no statistical correlation between Lariam use and those murder-suicides.

    Mr. MEEHAN. Well, in this study, will that all be taken into consideration, these specific cases, the case of——

    Dr. WINKENWERDER. We will gather as many cases as we can. That is the whole idea. And that is why——
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    Mr. MEEHAN. Well, I would feel a lot better if you told me that the cases that certainly had been reported where people have taken the drug and then there were suicides or murders or, for example, the case—I happen to be aware of it because it is a family from Massachusetts. But the facts in this case really concern me. And I would feel a lot better about the study and the analysis if I knew that these cases were going to be taken into consideration. I get a little concerned when—there aren't that many suicides, you testified.

    Dr. WINKENWERDER. Right.

    Mr. MEEHAN. So I would hope that we could get in this study and analysis a surety that we study all the cases where there were suicides and specifically the instances where Lariam was taken. And I would hope Lieutenant Christopher Shay—that case would be listed because the facts as I understand them are very concerning to me.

    Dr. WINKENWERDER. We appreciate your concern, and we will be doing everything we can to do the best possible study.

    Mr. MEEHAN. I would strongly urge you to look at those cases and make sure it is in the data. Otherwise I am not sure how the—the last part of my question was when will the study be concluded?

    Dr. WINKENWERDER. We have already tasked a group to begin to design it. That is one of the important, sort of, setup tasks as to how does one design such a study; how many people do you need to have statistical power; where do you get the cases from; who is going to do it——
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    Mr. MEEHAN. Is there someone I could send a letter to, to just outline my concerns of what should be, because if they are just designing it, it seems to me we all have an opportunity maybe to have some input.

    Dr. WINKENWERDER. Feel free to send it to me.

    Mr. MEEHAN. Thanks, Mr. Chairman.

    Mr. MCHUGH. Thank the gentleman.

    I thought the gentleman asked some excellent questions. He asked one that if the answer was given I apologize, I didn't hear it.

    There is obviously a great deal of controversy about Larium. Whether it is based in fact or science has yet to be seen. That is why you are doing the study. I understand that.

    But if you have alternative methods of prophylaxis that from my understanding do not demonstrate those same levels of concern, why are we sticking to Larium, why don't we go to the others? That is not a leading question; it is perhaps an ignorant question, but——

    Dr. WINKENWERDER. I have asked the same questions myself.

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    Mr. MCHUGH. Okay. What was the answer?

    Dr. WINKENWERDER. Well, the answer that General Peake gave is that the Larium pill is once a week and the other types of medicines are daily, with the exception of the chloroquine.

    General PEAKE. We are going to chloroquine in Iraq because we have determined that it is not chloroquine-resistant malaria that we are seeing there. And so we won't be using Larium there. In some ways it is obviated. But there are places where we will have chloroquine resistance, perhaps in Africa as an example. And then you would want to use Larium because the consequences of cerebral malaria are very——

    Mr. MCHUGH. So the bottom line, there are perhaps instances where Larium can be avoided entirely, whether it is——

    Dr. WINKENWERDER. Absolutely.

    Mr. MCHUGH [continuing]. Good, bad or indifferent.

    Dr. WINKENWERDER. And that is what we do. I think it is a misperception to suggest that that is somehow the first choice drug that we go to. It is a process of figuring out, depending upon the location in the world and whether there is chloroquine resistance or there is falciparum, that particular type of malaria, what type of medication is best.

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    And so, in many areas we can treat with other medications and that is just what we do.

    Mr. MCHUGH. Okay. Thank you.

    I am sure you all heard, because I commented that General Peake was seated behind him, you heard our previous testifier, the good corporal, talk about how he has not to date had any kind of counseling input conversations about the potential for his continued service in the military, if any. I am curious why that didn't happen.

    I mentioned Eric Shinseki, who is an amputee from Vietnam and rose to be chief of staff of the United States Army, and my humble opinion, having worked with him for a number of years, a great chief. What is the process on that? A lot of anxiety, I would think. Every amputee I have met, service amputee, have to a person said, ''I want to go back to my unit, I want to continue to serve.'' Now, I understand that is not always possible, but for those that it is, how do we go about evaluating that, how do we go about informing them of the at least availability of that?

    Dr. WINKENWERDER. Let me ask General Peake to address that.

    General PEAKE. Sir, these young men have a lot of decisions to make about their own lives. And Corporal Thibeault's struggling with that, and there are different decisions to be made about his hand, his arm, his prosthesis: what kind to give him? What he really wants? And sometimes it is a struggle for these young men.

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    I was talking to Sergeant Craft, I think was his name, was saying, ''Initially I wanted to stay. Now, as I think about what my options are, I don't think that is really what I want to do.''

    And so there is this ambiguous period which is difficult for them. And so they have to work.

    A couple of years ago, after the early days of Afghanistan, I showed a picture of one of our special operator guys who lost his right arm, Sergeant McIlheney—you may have met him—well, I tried to get hold of him the other day and he was out at National Training Center (NTC) with his unit.

    So it takes a while to work through what they can do. Can they be productive within the unit? And we are working to try to let them be all that they can be, but it takes a while. He is only two months post-injury, and it remains to be seen what he will do with his hand.

    We have a program that we—again, trying to make them all they can be—where we can help them with computers, teach them how to use them, getting them special prostheses. That actually is part of DOD, and we are doing it for the VA as well. I know that we have had two of our amputees assessed by those folks out there. They have two or three more coming in this week for assessment.

    There is a lot that is going on, as well as with the VA, that says, ''How do we help these disabled soldiers be all they can be?''
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    We have support for brokering job offers from outside agencies; people come and say, ''How can we help you? We can get them into our programs.''

    So there is training available. The VA has programs for training. And they have to work through this about what they want to do with their own lives.

    Mr. MCHUGH. I couldn't agree more. And then, Dr. Kussman, I want to hear from you.

    If I may respectfully, I don't think—I don't believe that Corporal Thibeault was questioning that challenge. And you have described it very adequately. And obviously, people's minds change.

    It is a tremendously traumatic experience and what you want and expect and hope to get out of life probably at first goes from one thing to the next, minute by minute.

    But what I thought I heard him say in the testimony here, and what I am awfully darned certain I heard him say in my office, nobody has even talked to him about the potential of being in the service, given certain circumstances. You can't make a guarantee, because there is the prosthetic work, are you able to contribute, all that I understand. But maybe I misinterpreted what he said, but nobody has even talked to him.

    And I just think, I can only imagine what goes through a young man or woman's mind in that situation, at the peak of your physical ability all of a sudden, you are an amputee, missing a limb or two or whatever. Just to have someone from, in this case the Army, but any branch, come in and say, ''Son or young lady, I know it is a terrible time, but understand, if this happens, that happens, that happens; perhaps there is a chance for a military career.''
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    Just some words to give them an idea of what their potentials are, because I don't think they have any and for two months, that is an awful long time. And I just think it is up here, and we could probably be somewhat more reassuring in that area.

    Thanks for listening to my—and, General, you have been listening to a lot of my sermons and you have always been very patient and understanding. And I appreciate that.

    Dr. Kussman, do you want to say something with respect to the VA? And I know you are intimately involved, particularly in the amputee area.

    Dr. KUSSMAN. Yes sir, and I was a little disturbed myself when I heard the corporal talking, because we have tried to put in place a program that would at least educate him or help him with some of the questions that he seemed to have raised and so that bothered me.

    We did have a chance to talk with him during the break, and he did acknowledge that he had seen the VA benefits people who did go over with him some of the things that needed to be—that potentially he was eligible for. But in questioning him a little bit further, I think that, as was mentioned, his big concern is that there really is an uncertainty there that perhaps wasn't in the past, because in the past, most people who suffered an amputation were generally discharged from the service.

    Because of the advances in capability and the techniques in prosthetics, I think the number is somewhere—please correct me if I am wrong-but it's somewhere close to 50 percent of the patients who are suffering amputation are being considered to stay on active duty. But whatever it is, it is a significant amount——
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    Mr. MCHUGH. Excuse me, 5–0 or 1–5? 50 percent or——

    Dr. KUSSMAN. 5–0. Now that may be—I may have the wrong number, and please, if I am wrong, I apologize—but whatever it is, it is a much larger number than in the past. And it takes awhile to get to the point to determine whether the person is capable of staying on active duty. And part of that is fitting the prostheses and working through, then getting an Medical Evaluation Board (MEB) which makes a statement of the physical condition and then potentially going through the Physical Evaluation Board (PEB) process to find if there is a fitness for duty, that decision made.

    So it is a process. And you are right, if he has no one to go to that could help him through that, then I guess we have failed some place, and we certainly need to be more aggressive on that—I don't what to put words into General Peake or Dr. Winkenwerder's mouth, but from a DOD and VA thing.

    So we will certainly re-energize ourselves to be sure that people that we have met with, we go back and re-emphasize some of the benefits that he and everybody else would be eligible for.

    But we certainly can't adjudicate the issue of the MEV, PED; that is something that takes awhile to work through.

    Mr. MCHUGH. I appreciate that. And let me just say, for the record, and I have been on Capitol Hill now for 12 years, and there are some committees, subcommittees, that play gotcha. They get witnesses in here and say ''Gotcha.''
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    That is not why we are here today. And it is why I hope we never convene a hearing. It is to learn. And to the extent that you find out things that you are unaware of and that can help you, that is what it is all about.

    Now, I have never had reason to question this concern of your department, the Department of Defense in this case, the Army, any of the branches, certainly the VA They want to do the right thing, as do we. So if we can learn something, by God, we have spent time well.

    Speaking of time, we do have a hearing—a full committee markup at six—and they have to rearrange the room, Dr. Snyder.

    So I am happy to yield to you, but seeing as it is only you and I, we can close this up soon, I know.

    Thank you.

    Dr. SNYDER. Thank you, Mr. Chairman.

    I am on the VA Committee and sometime ago we had a hearing on this whole issue of transition from people coming back. And one of the women that testified, her son had a very, very serious illness. And coincidently, her job in private life was she worked in intensive care and did a lot—I think she was a registered nurse (RN) who worked in discharge was my recollection.

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    But my take-home from her testimony was the care was excellent, excellent, excellent. The transition and the discharge planning just wasn't at all what it ought to be in a complicated system. So I think there are a lot of things there to work on.

    Do you have another comment, Dr. Kussman?

    Dr. KUSSMAN. Yes, sir. I was there, too. And I heard that. And I think that case is really one of the cases that energized the secretary to drive us to do some new innovative things, where we have put full-time people in the facilities at DOD to partner and help with that transition, to smooth the process, to the point where once the person has been identified as entering the disability process and will be medically separated or discharged.

    Our social workers are then partnering with, particularly the Army, but DOD social workers, to help that servicemember decide where they want to go, if they want to use the VA—and as you know, they don't have to use the VA if they are medically discharged. They have options of staying in the military health system or using TRICARE.

    But if they choose to use the VA, we get them enrolled before they are actually finished with the process. And so they are in our system. We get them appointments in the VA wherever they are going to go and work through our points of contact, both from the Disabled Veterans Association (DVA) and Veterans Health Administration (VHA) to assist them.

    And so while the disability process is still working the VA is wrapping their arms around these people to help them with that transition.

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    I think that this has been a major innovation of what we have not done in the past.

    So I would hope that the case that was illustrated, that happened before we did this. It was illustrative of a weakness. And that something like this wouldn't happen again.

    Dr. SNYDER. Good.

    The chairman wants to wind this hearing down, but I had a couple more questions, and just maybe some quick answers.

    Sergeant Major, you have been very patient sitting there, but one of the things I noticed in your written statement was your concern about vehicles, people coming back home that haven't driven. You don't say it, but I suspect there is some partying and drinking going on. We lose more than we want of our young men and women when they get back.

    Is that something that we have an aggressive program going on to try to prevent those kinds of injuries and deaths?

    Major PRESTON. Yes, sir. What we have is all the units right now coming back—and Monday, I was down at Fort Campbell visiting the 101st, taking a look at their reverse SRP Program Objective Memorandum (POM) process.

    And they had already transitioned about 14,500 soldiers back into Campbell. But one of the things that is part of the reintegration training. And for most units, whether it is in Europe and you serve over there at Fort Campbell, or the other units that come back, they go through a seven-day reintegration program, which is really tied to getting married couples back together and working through those relationships. But also it incorporates safety, to include Privately Owned Vehicles (POV).
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    So for soldiers that put their privately-owned vehicles into storage prior to deployment, they get those vehicles back out. The vehicles get reinspected because they have been sitting for a long time and then go through a safety program.

    Dr. SNYDER. Good. Good. Good.

    Dr. Winkenwerder, just a quick question, really just probably a yes or no answer. The young corporal made a comment about his dad being notified by the news program. Are you satisfied with our notification program that it is as good as it can be in terms of accuracy and the right people they notify of deaths and injuries?

    Dr. WINKENWERDER. I will give you an answer that some people within DOD probably won't like. And my answer is based on some anecdotal concerns like this. No, I am not satisfied. This is not a process that we in the health community manage. It is managed from a different place. We are working to try to improve that. But it is not ideal.

    I think someone else made the comment that with the speed of transmission of information around the world, these kinds of events unfortunately happen. That doesn't mean that we must not do more to do better than we have.

    Dr. SNYDER. And this is my last—more really a comment. As somebody who has worked overseas several times and I have treated a lot of malaria and it is, as you know General, a real problem. I did go out and visit with the Marines at Bethesda. And this was before the results came out.
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    But, I did my own study in five minutes of walking the halls. What about your medicines? We threw them overboard. Why did you throw them overboard? Because we were sitting out in those ships for several weeks to months and they kept saying we were ready to go, we were ready to go. And we didn't. We just got tired of taking the medicine.

    They were just all very candid, I think, that they just didn't take the medicine. So, you are walking. It is like baby bear's porridge. You have to get it just right. We have to be concerned about side effects and attending to side effects and try to get these people in who are having side effects and avoid the kind of disasters.

    But at the same time, we do not want to encourage more people in malaria zones not to take these medications because I have treated resistant malaria. And when I was out there, we almost lost some folks from their experience at the 80th. There were some very serious folks on ventilators out there from cerebral malaria. And it is not something that we should be cavalier about.

    I know you aren't, but I don't want our young men and women being cavalier about, ''let's just chuck that medicine. We are tough young men and women. We are Marines. We are soldiers.'' That isn't going to cut it. Malaria is a deadly, deadly disease, particularly for people who have not had any exposure to it in their lifetime.

    Thank you, Mr. Chairman. Thank you for your indulgence.

    Mr. MCHUGH. Thank you for, as always, your leadership.
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    I don't know if apology is the right word. Any time you come to a congressional hearing and nobody asks you any questions, some would consider that a good day. But we have ignored—not ignored, but we have not gotten to the areas with Dr. Mather and her good accomplice, Dr. Lehmann.

    And we appreciate your being here. I assure you—and this may not be good news, either. But it is the way it is going to happen. We are going to submit some questions for the record. Obviously both of you have areas of great interest to us. And we would be interested in your responses. I am sorry that this six o'clock markup of the full committee is kind of precluded us from going to the conclusion. I hope you understand, but it was very good of you to be here.

    And to the rest of our presenters: Dr. Kussman, General Peake and Mr. Secretary, Secretary Winkenwerder, thank you, as always, for your leadership.

    And I want to thank the Sergeant Major, as I said, for his leadership and important position in representing particularly the enlisted men and women in the United States Army. You do a great job. And thank you for that leadership.

    Also as a matter of housekeeping, we do have a statement that has been submitted, testimony on the record from the Reserve Officers Association. And without objection, that will be entered into the hearing record, as I noted. And it is not just limited to Dr. Mather and Dr. Lehmann. We may have some written questions certainly the surgeon general and the secretary are accustomed to this.
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    Sergeant Major, written questions that we may submit to you, if you could, if you receive those, issue us in return some written responses. It would be greatly appreciated.

    So with that and our great thanks, we will adjourn the subcommittee meeting. Thank you all very much.

    [Whereupon, at 5:20 p.m., the subcommittee was adjourned.]