PTSD: Treating The Numbers, Not The Soldiers

[litbrit speaking]

According to the United States Department of Veterans' Affairs--as its information page reads this morning, at least--Post Traumatic Stress Disorder (PTSD) is defined as:

An anxiety disorder   that can occur following the experience or witnessing of a   traumatic event. A traumatic event is a life-threatening   event such as military combat, natural disasters, terrorist   incidents, serious accidents, or physical or sexual assault in   adult or childhood. Most survivors of trauma return to   normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even   get worse over time.

Insofar as the government asserts, some   60% of men and 50% of women (overall, both military and civilian) experience a traumatic event at some point in their   lives.  Assuming, of course, that all traumatic events are reported or somehow noted--which of course they aren't--one can still be forgiven for being alarmed that such a staggeringly high number of human beings are at risk for developing PTSD.  And of course, many human beings do heal on their own, handling trauma in ways that don't threaten the safety and well-being of themselves and those around them; they work through the shock, terror, grief, flashbacks, and sense of needing to be on guard at all times, and with time and support, they return to a point where they can sleep a reasonably normal length of time without waking from re-enactment nightmares or go to a noisy, crowded place without feeling overcome by irrational waves of fear or violent urges.

For far too many who've witnessed war's indescribable tragedies firsthand, though, the notion of healing is itself a phantom concept, a dream.  From The Real Cost Of War (currently at Playboy Online):

 

Burgoyne had been brought into the hospital by one of the other soldiers in his unit after he had been found doubled over in his bunk, having tried to kill himself with an overdose of antidepressants. The attempted suicide, plus the lack of expression in his eyes and his "rapid cycling behavior" from rage to grief and back to rage, were the symptoms of a dangerously ill man. Koroll sensed he was looking at a severe case of post-traumatic stress disorder, the clinical term for someone who continues to experience trauma long after the event has passed. This reexperiencing of the original event can take the form of insomnia, flashbacks, paranoia, panic attacks, emotional numbness and violent outbursts.

These symptoms are treatable, Koroll knew. If he could transfer Burgoyne to a safe, comforting environment, the young man might be restored over time to full health and capacity. That meant getting the soldier out of the dusty chaos of the Kuwaiti Army base, where he was temporarily stationed after a bloody tour in Iraq, and sending him to a hospital in Germany where he could rest on clean white sheets in a quiet room in a first-class psychiatric facility.

It was Koroll's job as the on-duty nurse to make the decision about whether to evacuate Burgoyne. He was ready to do it based on what he'd seen. But he needed to ask one final question before he could order the evac in good conscience.

"So," Koroll said, "right now, at this moment, do you have thoughts of harming yourself or others?"

Burgoyne, he remembers, looked up through those flat, vacant eyes and said quite clearly, "Yeah. Yeah, I do."

Koroll picked up the soldier's chart and wrote in a clear hand, "Evac."

[...]

As it turns out, Burgoyne had not been evacuated to Germany as Koroll had ordered. According to Koroll, a colonel in Burgoyne's command pressured the hospital to allow Burgoyne to return to America with his unit, the Third Infantry Division, which was to be one of the first units lionized for its heroism in leading the fight north to Baghdad. "He's a hero. He should be with his men" is how Koroll remembers the explanation coming down to him. After he returned to Georgia, Burgoyne, according to his mother, spent a few minutes in an Army hospital, spoke briefly to an Army psychiatrist and then was released from medical supervision. Exactly two days later Burgoyne attacked a fellow soldier in the woods near Fort Benning, Georgia, killing him with 32 stab wounds from a three-inch blade and then burning his body with lighter fluid, because, as he explained at his subsequent murder trial, "that's how we disposed of bodies in Iraq."

Sadly, this story is not unique, but rather, is representative of the disturbingly underreported problem of PTSD.  More troubling than the fact that this serious anxiety disorder--and its devastating effects and costs--is shamefully underreported in the media is the reality that it is all too often underreported within the Unites States military.  Underreported, minimized, ignored, misdiagnosed, and, most frighteningly, untreated (my bolds).

Given the inevitability of psychological scarring in intense, prolonged conflicts, it is odd that the two bureaucracies most responsible for the mental health of American troops -- the Department of Veterans Affairs and the Department of Defense -- have taken steps to downplay the psychological toll of the war. According to sources I spoke to in the Pentagon and former officials in the VA, DOD and VA doctors are being pressured to limit diagnoses of PTSD in order to save the military money and manpower. The DOD's official medical policy toward PTSD was recently amended to include new criteria making it a virtual certainty that many soldiers who exhibit symptoms of the disease will not be diagnosed.  And the VA itself has been quietly working to arrive at new, stricter formulations of PTSD -- contradicting those of the American Psychiatric Association -- that would allow the agency to diagnose far fewer cases.

"Some people would argue that it's malicious and intentional, but to me it's a reflection of the military mind-set," says Steve Robinson, a 20-year veteran of the Special Forces who recently became a full-time policy advocate. "The Department of Defense is not a health care provider. It couldn't do the right thing if it wanted to because of how much money it would cost and how many doctors it would take. It's a matter of capacity. The number of people seeking care versus the number of doctors available to provide that care nationwide across the whole armed services is out of whack."

In the four years since Koroll's diagnosis of the young soldier was ignored, the anti-PTSD-diagnosis movement (for lack of a better phrase) within the military has grown, as evidenced by, among other things, the hard numbers.  The Department of Defense (DOD) reports diagnosing approximately 2,000 cases of PTSD a year, but according to a study by Army researchers that was published in The New England Journal of Medicine, PTSD rates are between 10 and 15 percent for soldiers in Iraq and Afghanistan; this translates to PTSD cases numbering between 13,000 and 20,000. (The study also notes, disturbingly, that only 23-40% of those veterans diagnosed with anxiety disorders and other psychological afflictions even seek treatement.) And according to figures obtained after repeated requests by Playboy, the evacuation rates for PTSD-afflicted soldiers--for example, those from January to July 2006, showing only 716 soldiers evacuated from Iraq for PTSD--fall well below the predictions of statistical models.  As reporter Mark Boal notes:

If the military diagnosed even half the cases in Iraq and Afghanistan that are thought to exist, the evacuation figures would be closer to 5,000 a year.

For their part, military officials deny any attempt to minimize or underplay the impact and magnitude of the situation.  This despite published forecasts that the cost of America's current involvement in the Middle East will soar beyond even the stratospherically high numbers around which most of us have just begun to wrap our heads; this despite officials having  gone on record with--and been roundly criticized for--statements like that of Pentagon undersecretary David Chu, in a January 25, 2005 article in the Wall Street Journal:

WASHINGTON—With the wars in Iraq and Afghanistan badly straining its forces, the Pentagon is facing an awkward problem: Military retirees and their families are absorbing billions of dollars that military leaders would rather use to help troops fighting today.

Congress, pressured by veterans groups, has in recent years boosted military pensions, health insurance and benefits for widows of retirees. Internal Pentagon documents forecast that the lawmakers' generosity since 1999 will force the federal government to find about $100 billion over the next six years to cover the new benefits.

"The amounts have gotten to the point where they are hurtful. They are taking away from the nation's ability to defend itself," says David Chu, the Pentagon's undersecretary for personnel and readiness.

As I read the profoundly upsetting Playboy article referenced throughout this post, I thought about my freshman economics class at Florida, which was taught by one very entertaining and sharp-witted professor named Dr. Denslow.  "Guns and butter," he said one day, actually plunking a box of unsalted butter sticks alongside a plastic toy grenade-launcher on his lecturn.  "Guns and butter.  The money stays the same, so how are you going to spend it--on guns, or on butter?"

Bombs or bodies?  Mines or minds?   Futilities or futures?

I'm Stumped

Posted by Nicholas Beaudrot of Electoral Math

Can someone explain this to me?

I'm not looking for hysterics. I'm looking for a calm, collected, calculated reason why it would be a bad idea for the American Red Cross shouldn't be allowed into New Orleans to deliver services. I'm even willing to accept an answer along the lines of "the government doesn't want the liability exposure if a Red Cross volunteer gets shot".

Starving the Beast

David Broder has a surprisingly good column on the reversed PBS cuts, arguing that the zeal to save Big Bird might have hurt the kids he teaches. The $100 million in restored cuts had to come from elsewhere, and so they did:

None of this suggests that the House was wrong to rescue Big Bird and his friends in public broadcasting. But it is a fact, as both Regula and Obey pointed out, that the broadcast stations and their audiences have far more influence on Congress than most low-income Americans possess. As Obey put it, "At least the people who pay attention to public broadcasting do have a megaphone of sorts, and they can get their message known."

Obey was also on sound ground in pointing out that "the press has focused 90 percent of its attention on public broadcasting," playing down or ignoring the trade-offs that were forced in other programs by the strictures of the budget plan pushed by President Bush and approved by party-line Republican majorities in Congress.
...
It's one more instance of the prevailing political culture -- controlled by a budgetary and tax system that puts the lowest value on the needs of those who are most vulnerable.

Just goes to show how rough financial meltdown is on Democratic priorities. Little seemed more obviously worthwhile than repelling a politically-motivated attack on PBS and NPR. Of course, if it had been presented in the context of health, labor, and education cuts, it would have been a harder choice. But this is their strategy: starve the beast. It's generally thought of as a way to halt the growth of government, but it's more than that. When a body starves, it tries to eat itself. At the beginning, the fat goes, but after a while, lean muscle mass and a variety of other vital substances get burned as well. And that's where we are now.

Fila-Bust-A-Bus

Bill Frist is setting up to use the nuclear option on Priscilla Owen, according to the Washington Times. The entire judicial nomination fight is an example of insider politics taking over real-world consideration - Democrats haven't paid for opposition to or obstruction of judicial nominees, largely because the nominees held back are in positions that have little to no direct relevance to most Americans' political understanding. They're not high-profile in a publicity sense, and after they're confirmed, they're about as likely to be seen on TV again as Cop Rock.

Frist, on the other hand, is playing really bad politics to attempt to score a much, much larger pragmatic victory - but this handful of judges isn't permanent, even if the appointments are lifelong, nor are they the sole determinant of federal interpretation of law. For what he gets, the seventh-grade-civics realization that Republicans just killed some old and not-really-understood portion of the government doesn't quite play well for them. Rather than highlight the dastardly deeds of the demonic Democrats, it's a great way to arouse the unfocused and uninformed ire of the body politic. To be blunt, the American people are never quite as dangerous as they are when they're angry about something that they don't really understand.

Choosing Priscilla Owen is, however, intelligent for two reasons. First, she's the only nominee that has the particular "well-qualified" rating from the ABA, and second, the fight's mainly over her abortion stance. Republicans love abortion battles, especially because there are so many ways to make up statistics about them, and it fundamentally alters the debate to her stance on abortion politics, rather than the "advise and consent" clause of the Constitution. If he can pull it off, the debate becomes about abortion law rather than Senate bylaws, and Owen likely gets through.

There is, of course, much, much more to this than the Post lays out, but it comes down to whether or not Democrats can not only block Owen, but articulate why she's being blocked.

In other words, we're likely fucked.

Poverty-Reduction

And this is why effective sex education and widespread access to birth control are overriding moral issue:

Nationally, the teenage birth rate fell 30 percent from 1991 to 2002, the most recent year for which such statistics are available.

If the rate had not dropped during the decade, 1.2 million more children would have been born to teenage mothers in the United States. Of those, 460,000 would have been living in poverty and 700,000 would have grown up in a single-parent household, according to the analysis.

460,000. Children. In. Poverty. That's a lot of misery and pain we've prevented, not to mention hundreds of millions of dollars saved in emergency room visits and social programs and, frankly, crime prevention. This impoverished children would be the ones on the public dole and, for many of them, the ones in the public jails. We know that. Keeping young women from getting pregnant is one of the most cost-effective approaches to poverty-reduction, so what a shame that we're moving more in the direction of "pregnancy can be transmitted through sweat and tears" than "speak to your pharmacist about the pill".

Forward-Looking

I'm not really sure what Garance Franke-Ruta is getting at in this post. She moves from saying that the task for Democrats is "finding the big story that explains our world and politics today in a way that sounds real and fresh" -- a true, if less than novel, assertion -- to arguing that conservative ideas aren't wrong just because they were thought up by conservatives. Well no, they're not. Indeed, conservative ideas are often quite right, which is why Democrats have adopted so many of them in recent times. Welfare reform was not identified with our side of the aisle, no matter how many times Moynihan is invoked. Deficit reduction was not thought to be a particularly Democratic thing to do, at least not until Bill Clinton did it. And James Galbraith not withstanding, we're not going back on it. We also pushed NAFTA through, passed a crime bill, and began adopting sensible, targeted tax cuts as a cornerstone of our economic policies. In fact, Democrats have been surprisingly willing to betray party dogma over the past 10 years, a trait attributable primarily, but not entirely, to Clinton.

But that shouldn't give us the idea that everything shiny, new, and advocated by Newt is worth adopting. Health Savings Accounts will destroy health care in this country. Seriously. As Matt says, and Arnold Relman argued in a TNR cover story a few weeks ago, HSA's might hasten the coming of a complete health care overhaul and, in that sense, be positive, but there'll be a lot of pain involved in that path. And if Garance is really just being sneaky and cunning and hoping to destroy so we can build, consider my comments moot. But know that HSA's will leave people like my girlfriend, who was born with hypophosphatemia, completely screwed, as the healthy opt into HSA's and those with chronic (though entirely manageable) conditions, like her, have no community on which to disperse costs. Under that scenario, health care becomes prohibitively expensive and many to most of those who need it worst will be unable to pay.

As for Flex accounts, they're fine, but they're really not forward-looking. They're an incremental step which makes things a touch better for folks. That's great -- hell, if the Prospect hires me, I'll be sure to take advantage of them. But this sort of small-bore proposal is only good for a sitting leader, not for a party that needs to prove itself visionary and in-touch. The way to assure voters that you see the future is to promise to radically upend the present. That means that health care can't be fixed by the tiny steps Garance is proposing, and certainly not by a simple willingness to trawl CATO and AEI for good proposals the right may have missed. Democrats need to find the courage put 1994 behind them and propose a radical restructuring of health care in this country. That's tough and dangerous to do, but it's also necessary, important, and the sole way to prove ourselves more than the party of tweaks. And that, in the end, is what forward-thinking means: able and willing to break out of the paradigm we're in and propose answers that the shackled politicians of the day are too scared to reach for. That's not, contra Garance, a call for compromise, but a recipe requiring vision.

A Progressive Idea for CAP

Regular readers know how much I appreciate the Center for American Progress's work -- the tax plan, Think Progress, the Progress Report, Campus Progress, etc, all are excellent examples of what a progressive think tank should be doing. But the one thing a progressive think tank should not be doing is calling itself a progressive think tank. Head on over to CAP's homepage -- once you get past the campaign boilerplate in the banner ("progressive ideas for a strong, just and free America"), you immediately see the topmost (right) sidebar button, a bright orange box direction you to "Progressive Priorities". If you don't click on that, your eyeballs are fairly destined to settle on the facsimile of a Social Security card that rests in the middle of the page promising a "Progressive Guide to the Social Security Debate". Jeez, I wonder which side of the aisle they're on?

One lesson Republicans quickly learned was that you get farthest by couching ideology in empiricism, which is to say you get farthest by hiding ideology and pretending you reach conclusions sympathetic to conservatism solely through dispassionate analysis of the facts. The Heritage Foundation bills itself as "Policy Research and Analysis", while AEI simply references their 60-year history and calls themselves "one of America's largest and most respected 'think tanks'". That both are hotbeds for partisan extremists who use facts the way most of us use fingerpaint never mattered, their simple refusal to trumpet an affiliation, combined with a pliant press corps, allowed them to become a serious force in American politics.

CAP's work is too good to be boxed in as progressive. Because the aim, really, isn't to make the center respect the left, but to make the center become the left. And you don't do that by labeling yourself as just one of the partisan fleas sucking blood from the debate, you do it by marking your opinions as Truth and thus letting your progressive solutions exist as if God himself etched them on tablets and sent them down from the sky. So CAP's banner should read "Ideas for a strong, free and just America", their sidebar should tout "America's Priorities", the site's central feature should be "Your Guide to the Social Security Debate". I understand what CAP's trying to do and I appreciate their attempts to popularize the progressive label, but it's more important that they popularize progressive ideas. Since the media's idea of a fact-checking is to marginalize their sources by listing whatever partisan affiliation they find on the homepage, the two goals are, to some extent, mutually exclusive.

Sidenote: A few months ago I put up a post complaining that the Heritage and AEI site were giving Social Security privatization prominent play and tons of resources, with unsuspecting visitors drowning in a sea of calculators and dishonest reports while CAP featured, well, nothing. It's a nice metaphor for the genesis of the debate that privatization is now marginalized on the conservative sites while the liberal think-tanks have made it central to theirs. Advantage: Us.

Thoughts on the Draft

The Moose is joining Phil Carter and Paul Glastris in calling for mandatory public service for all young Americans on national security grounds. I'm a bit conflicted on this -- I see the appeal of the plan, and I'm certainly not adverse to the idea of national service, in some ways, I think it'd be good for me and my peers. But seeing it proposed by folks who will never have to undergo it strikes a false note with me. Were we in some sort of perpetual national crisis that mandated an everlasting draft, as, say, Israel is, that'd be one thing. But this is being proposed simply as a way to make the American army bigger, more powerful, and more able to pursue expansionist policies (no matter what Andrew Sullivan says, Islamo-fascists aren't going to land on our shores and attempt to take South Beach). Considering my generation's weak support for our foreign policy expeditions, I think it's a pretty hard sell to force us into service in order to fuel more of them. Moreover, the modern operations our military carries out require a much more specialized force than will be found in a mass of two-year conscripts. Our real deficiencies are in the numbers of troops trained in languages, in peace-keeping, in nation-building, in communications technology. And sure, the influx of young grunts would allow for voluntary sign-ups to receive great training in those areas, but it seems like a massively inefficient way to achieve the goals.

More important than concerns over efficiency are concerns over fairness. First, there's no small portion of young Americans who would escape to and remain in foreign countries, particularly Europe, when faced with the option of conscription under a warlike Republican president. Were I coming of age in a draft system with Bush in power, I'd hightail it out of the country -- I can't imagine that serving this man's whims would be safe, moral, or smart. And while I realize that the civil options exist, I assume that universal conscription of this sort would have an override built-in, making it trivial to end the civil option in times of warfare or perceived threat.

Beyond that, the series of incentives in place to convince youth to enter the military, rather than the civil service areas, will not only continue the class stratification of America, but, I fear, actually make it worse. Considering the national security rationale of the proposal, the civil options are only being included so the whole plan isn't scuttled by middle-to-upper class kids and parents unwilling to enter harms way. But that secondary bit won't fool anybody, it'll simply be the option of choice for those who can justify passing up the increased economic benefits. The result, at least potentially, is that middle and upper-middle class kids will have one set of shared experiences, while those from lower socioeconomic rungs will share a wholly different memory. To some extent, that happens now. Increasing its prevalence strikes me as pretty problematic.

Lastly, I wouldn't want to be the politician who touches this. Whichever end of the spectrum decides to tell this generation that their post-high school freedom is effectively over will lose young voters for the foreseeable future. Worse, I can't shake the ugly images of future conservatives barnstorming the country and easily fitting the terrible, no-good, very bad draft into their critique of the nanny state. I'd much prefer if the right did not use this to achieve a lock on the young.

As I said at the beginning, I'm sure of nothing when it comes to proposals like this. Indeed, I'd probably be inclined to support one that focused solely on national service. But a plan whose sole purpose is to increase our ability for military projection by sucking all kids into a draft that'll only force the economically disadvantaged to fight strikes me as a troublesome plan. Perilous in the way it'll shape future class resentment and stratification, dangerous in the effect it might have on Democratic voting blocs, and scary in the implications a huge and ready force has for the foreign policy of trigger-happy leaders. Frankly, I'm glad that our military's size has constrained Bush. With a few more hundred thousand ready to deploy, I fear we'd be in Iran by now.

In any case, I'm very open to argument on this. So read the article -- it's a great piece -- and report back with your thoughts. I'm anxious to hear them.

How To Not Vote on the Count Every Vote Act in Three Easy Steps

Julie Saltman is wondering how Republicans will oppose the obviously-popular provisions of the Count Every Vote Act. The answer is through the magic of Congress! If every piece of introduced legislation had to face an up-or-down vote at polls, CEVA would pass in a landslide. But not only won't it find itself in front of voters, it's not going to find itself in front of congress critters either. With no Republicans jumping on board and the Democrats firmly in the minority, that bills never going to make it out of committee, and sure as hell won't find itself on the floor. Indeed, the bill is basically dead until its sponsors -- Kerry and Clinton -- run for president in 2008.

Why the bill hasn't attracted any Republican cosponsors is, however, an interesting question. Nothing so self-evidently popular can be ignored by politicians lest they find themselves similarly shunned by voters. So Republicans have created a counter-bill which, under the guise of tamping down on fraud, makes it harder for people to vote. Brilliant. Now the press can satisfy itself by reprinting quotes promoting the legislation of each side and belittling the proposals of the other side, Americans can assume that it's just more partisan food-fighting, and meaningful electoral reform can be totally ignored. So the answer, Julie, is through a manipulation of representative democracy, a mastery of congressional maneuvering, and a compliant press corps. Makes you proud to be an American, no?

Update: Seems Kevin Drum is puzzling over this as well. Guys -- Americans want health care reform way worse than electoral reform, but Republicans haven't had to give them that, either. Bills drafted by the minority and ignored by the majority enter a special hell where, along with lost socks and unwanted puppies, they cower in isolation forever. CEVA will be forgotten in a week or two.

Competing Discourses

In context of a post on post-war Japan, Steve Clemons writes:

Bush needs to be careful of trumpeting too much about our experience democratizing Japan -- as we were frequently on the side of the anti-democrats. To some degree, Japan democratized despite our promotion of a profound model of structural corruption there -- and the Japanese public and civil society institutions deserve credit. But Bush, as of late, has been warping this history.

Read that first line again -- "Bush needs to be careful of...". I've used it myself, Bush better watch for this or that, because he's flagrantly rewriting history/ignoring evidence/contradicting reality. I was wrong. Bush needn't be careful at all. Who in our press is going to stand up and correct the historical record? Is it you, Nedra Pickler? You, Ron Fournier? You, Dana Milbank? You, Judith Miller?

Of course not. As Digby is fond of saying, we've entered a full-fledged Foucaultian state of competing discourses, and Steve's -- ours -- takes much too long to explain. Journalistic objectivity has bred a mutant offspring of political speech completely unmoored from reality. Remember The Matrix? How the original Agents were powerful but bound by the laws of the realm? And how Agent Smith unfastened himself from those pesky constraints and his increased power was in danger of ripping the whole construct apart? It's that way now, and the result has been reality checks aren't nearly as useful as body checks. It might be that once this breed of hollow Republicans is plastered across the boards, the reality-based discourse that we miss can be restored to the political realm. Until then? Bush better be careful because Iraq is devolving into an Islamic Republic where women are oppressed and Shari'a law reigns, because he won't be careful to respect history.