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DEPARTMENT OF DEFENSE EXECUTIVE LEADERSHIP DEVELOPMENT PROGRAM

MAKE THE CONNECTION

Recommendations for Helping Recovering Service Members Achieve Renewed Sense of Purpose, Independence, Dignity, Passion for Life, and Confidence for

Enhanced Long-term Quality of Life

Pamela L. Boteler ELDP Class of 2012

Submitted June 2012

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Introduction We – the Department of Defense (DoD)

and the Department of Veterans Affairs (VA) –

are at a major cross-roads, a critical juncture, as

we face an ever increasing number of wounded,

ill, or injured (WII) service members returning

from combat or injured in the line of duty. Too many have the painful visible physical wounds

that will be with them for life, but far too many more have painful non-visible wounds, which are

sometimes harder to help and impossible to capture in a photo. Of greatest concern is that, given

current practices for dealing with issues related to our WII service members, and also with

returning personnel in general who are struggling with sleep issues, anxiety, pain and depression

– our greatest challenges, the silent elephant(s) in the room, may be in our near future. We may

actually be on a path to a “perfect storm” in five plus years if we do not take thoughtful,

strategic, corrective action now.

Getting and keeping our WII service members on a positive road to recovery, and

enhancing their and their families’ life-long strength, resilience, independence, confidence, and

motivation is one of the highest priorities of the DoD. Facilitating their rehabilitation and

readiness for reintegration either back to active duty or to civilian life is a multi-faceted and

complex task that is recognized as a matter of national security, is mission essential, directly

impacts our communities, and impacts our ability to recruit and retain the best and brightest for

the future.

In this era of drastic cost reductions and an ever-increasing load on the military health-

care system, it is time for the DoD and the VA to move even more aggressively in a direction of

VISION: Through a whole-person, mind/body focus and whole-of-society approach,

recovering service members achieve renewed sense of purpose, independence, dignity,

passion for life, and confidence, for enhanced long-term quality of life.

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utilizing a holistic (whole-person) and whole-of-society approach for treating and helping

Service members, and their families, recover and rehabilitate from wounds, injuries or illnesses.

At the macro level, the vision for this framework leverages and capitalizes on a whole-of-society,

community/grass-roots, public/private approach with connections at the federal, state and local

levels of government. At the micro level – this framework must have, as a foundation, activities

to strengthen the body, mind and spirit.

This paper will look at the macro and micro levels as described above and assumes post-

deployment and post-military service. This paper will also address what can be done before and

during deployment to better prepare our service members for maximum fitness and readiness of

our units and Total Force.

Statement of the Problem

To describe the macro level, a report signed by the President and Cabinet Secretaries

entitled Strengthening our Military Families: Meeting America’s Commitment, states: “Less than

1 percent of Americans serve in uniform today, but they bear 100 percent of the burden of

defending our Nation. Currently, more than 2.2 million service members make up America’s all-

volunteer force in the active, National Guard, and Reserve components. Since September 11,

2001, more than two million troops have been deployed to Iraq and Afghanistan. Fifty five

“The willingness with which our young people are likely to serve…shall be directly proportional to how they perceive the veterans of earlier wars were treated and appreciated by their nation”

~ General George Washington, November 10, 1781

“And, of course, we must keep faith with our Military Family. Our active, guard and reserve service members, our wounded warriors, our families, and our veterans deserve the future they

have sacrificed to secure.” ~ General Martin E. Dempsey, October 1, 2011, in a letter to the Force

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percent of the force is married and 40 percent have

two children. Only 37 percent of our families live on

military installations; the remaining 63 percent live in

over 4,000 communities nationwide. Multiple

deployments, combat injuries, and the challenges of

reintegration can have far-reaching effects on not only

the troops and their families, but also upon America’s

communities as well. These challenges should be at

the forefront of our national discourse.”1

Additionally, from 2000-2011, over 230,000

service members have been diagnosed with various

levels of traumatic brain injury

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• There are approximately 47,740 wounded military from Iraq and Afghanistan conflicts;

. It has been reported

that 11 to 20 percent of veterans from Iraq and

Afghanistan (which could equate to as many as

400,000) and 30 percent of Vietnam-era veterans live

with Post-Traumatic Stress Disorder. These numbers go up exponentially if you include those

struggling with post-traumatic stress issues (i.e., not diagnosed with the full-fledged disorder)

and depression – an even larger issue. Other sobering statistics include:

1 Strengthening our Military Families: Meeting America’s Commitment. January 14, 2011. (Obama, 2011) 2 Source: Defense Medical Surveillance System (DMSS) and Theater Medical Data Store (TMDS) Prepared by Armed Forces Health Surveillance Center (AFHSC), via the Defense and Veterans Brain Injury Center. http://www.dvbic.org/pdf/dod-tbi-2000-2011Q4-as-of-120210.pdf. Includes TBIs from non-combat and combat related-causes. Common non-combat causes: crashes in privately owned and military vehicles, falls, sports and recreation activities, and military training.

WHAT WE NEED: • Whole-person focus for healing and

reintegration of wounded warriors. • Integrated, whole-of-society, approach

to care and support. • Independent, external review to

examine current/future needs, organizational structure and policy.

• Application of the same principles used to heal warriors as are used to create them.

• Cessation of drug over-prescription. • More rapid integration of physical,

cognitive, complementary and peer support modalities as soon as practicable in medical plans.

• Set and reset our human warriors as well as our critical equipment.

• Enhanced focus on strengthening the mind before, during and after deployment.

• More research on post-traumatic growth.

• Greater sharing of information/best practices across the DoD enterprise and inter-agency.

• Encouragement of maximum participation of all WII service members from funded/supported programs/activities.

• Match intentions with actions.

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• An estimated 18 veterans commit suicide every day; since 2001, 2,293 U.S. military have

committed suicide;

• Twenty-seven percent of troops returning from Iraq/Afghanistan abuse alcohol3

• The expense of caring for veterans of the Iraq and Afghanistan wars is an unfunded

budget liability for U.S. taxpayers that in years to come will rival the cost of entitlement

programs such as Social Security and Medicare. Estimates of the cost of lifetime medical

care and benefits for returning troops disabled by their service could reach a total of more

than $1.3 trillion.

4 Linda Bilmes, of the Kennedy School of Government at Harvard,

stated in 2007: “It’s like a miniature Medicare.”5

• About half of the more than a million veterans returning from those two wars (over a

million) are expected to receive medical care in the private sector rather than from the

VA – i.e., this is not just a VA (federal) problem.

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• Many service members still in theater, here in the States, or transitioning out of the

military are addicted to drugs and alcohol, overweight, sick from prescription

medications, or at times engaging in negative behaviors disruptive to themselves, their

families and society. These are the cases which fall outside of the official diagnoses of

“wounded, ill or injured,” but characterize the population making up the “perfect storm”

3 PR Newswire, United Business Media press release May 3, 2012: http://www.prnewswire.com/news-releases/health-latest-news/easter-seals-welcomes-colonel-david-w-sutherland-united-states-army-retired-to-its-team-150069065.html. It is unclear if the PTSD statistics are based on actual diagnoses or health assessments and/or surveys filled out by service members. 4 “War veterans’ care to cost $1.3 trillion: New entitlement an unfunded liability; will eclipse Social Security”, The Washington Times, September 29, 2010. http://www.washingtontimes.com/news/2010/sep/29/war-veterans-care-to-cost-13-trillion/ 5 “What $1.2 Trillion Can Buy, LA Times, January 17, 2007. http://www.nytimes.com/2007/01/17/business/17leonhardt.html 6 “Colonel's Request is Simple: Ask Patients if They Served in Military,” American Academy of Family Physicians (AAFP), June 6, 2012. http://blogs.aafp.org/cfr/leadervoices/entry/colonel_s_request_is_simple

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– a population which will be making demands on the military health system in the years

to come.

Lastly, with 1% of the population a veteran of Iraq and Afghanistan (one could call them

“the other 1%”7), the general public – and the very communities they return to – is still too often

unaware of the sacrifices made by our service members and their families and of the needs they

may have. According to Stanford University professor William Perry, barely one in five

members of Congress have ever served in the military. These statistics, he argues, suggest that

the American people and their elected representatives are less engaged with the U.S. military

than at any time this past century.8 Washington Post reporter Bob Woodward called this

phenomenon an "epidemic of disconnection."9

At the micro-level, most service members start their military careers with physical

activity as a foundation for building physical, mental, emotional and spiritual strength and

resiliency in preparation for combat – and they undertake this training in a highly structured,

disciplined, high-stress, close-knit, goal-oriented, team environment. Physical activity is,

essentially, their lifestyle, their battle rhythm – it becomes who they are. Most (but not all) are

trained to be combat athletes, within combat teams. At least two problems arise from this

practice, based on several interviews with those who help wounded warriors in some capacity or

who are wounded warriors themselves:

7 Typical references to “the 1%” refers to wealth, while the other 99% of Americans struggle . http://westandwiththe99percent.tumblr.com/aboutus; 88 Stanford Report, August 8, 2011, from the Summer 2011 edition of Daedalus, the Journal of the American Academy of Arts and Sciences. http://news.stanford.edu/news/2011/august/kennedy-sheehan-military-080811.html 9 January 27, 2011, interview on the Oprah Winfrey Show. http://www.oprah.com/showinfo/The-Bravest-Families-in-America

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1. When service members incur physical or mental wounds, injuries or illnesses, whether

or not combat related, it seems the foundation for treatment, rehabilitation, and

recovery is more often rooted too heavily in traditional Western medical treatment

modalities – e.g., pharmaceutical, technological, chemical, etc. One can easily make

the claim that our service members - WII and not - are dangerously over-drugged and

under-cared for. They are given powerful medications, many of which have barely

cleared proper testing protocols, and too often multiple medications where the

synergistic effects of multiple combinations are not known. The foundation for

treatment is also too often centered in traditional hospital environments or doctor’s

offices, where doctors and practitioners often fail to communicate with each other,

medical records are not synchronized, appointment waiting times commonly span

weeks or months, and, where feeling alone in a world while surrounded by people who

just do not understand feels like the norm.

This post-injury period (which could be as much as two years of direct medical care,

even in-patient care) involves an environment within which physical and

mental/cognitive activities are often not incorporated as priorities in treatment/recovery

plans. Too often, these easily learned, self-empowering, lifelong positive habits are

not even considered or discussed as viable options. Or the specialists (medical and

non-medical) who could best assist are not available. Regardless, the natural battle

rhythm – the lifestyle – which created these great warrior spirits is too often discarded,

creating more long-term negative side-effects and behaviors rather than instilling

disciplined long-term health-promoting habits for life. Our service members too often

end up mirroring the negative lifestyle habits, ill-health and idiosyncrasies of civilian

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society, but it is the position of this author that we can do much better to create an

environment in which these men and women can thrive, outside of the strict, traditional

environment and modalities of the Western medical system.

2. The second problem is that pre-deployment training focuses primarily on physical

fitness and readiness. More needs to be done to educate service members on

mental/cognitive fitness and readiness10 and to encourage and empower drill

instructors and drill sergeants to incorporate this aspect of fitness into their training

regimens.11

There are numerous success stories of service members who have overcome considerable

adversity, moving past the vileness of war, and forging ahead with their lives with a “new

normal”, a new found sense of purpose, even excelling at things they would have never tried if

not injured. And, they are giving back to their communities and to the military, helping others

overcome their own challenges and thrive. They have fostered a renewed spirit for thriving in

spite of their daily challenges – “post-traumatic growth”

While one can never fully prepare for the horrors of combat, nor

compensate for pre-existing (pre-military) weaknesses, we have an obligation to give

service members as much physical and mental armor as possible before we send them

into harm’s way.

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10 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Psychological Fitness – “Keeping Your Mind Fit”.

– and are imparting this positive spirit

upon everyone they meet. Many of them experienced these growth spurts through various

component Warrior Athlete Reconditioning Programs and perhaps even the Warrior Games. But

http://www.realwarriors.net/active/treatment/psychologicalhealth.php. 11 Based on conversations with top drill sargeants and drill instructors, this author can only conclude that they do not feel empowered to deal with mental coaching. Too much pressure to get service members physically ready – a task far more difficult with this new generation of sedentary kids/young adults. 12 Admiral Michael Mullen, opening statements the August 2010 Supplement to Military Medicine entitled “Total Force Fitness for the 21st Century: A New Paradigm.” Page 1. “It is, in fact, not at all uncommon for people to achieve a higher level of physical and emotional fitness following difficult events like battles and wars. This is what Richard Tedeshi and others have called “post-traumatic growth.” http://hprc-online.org/files/TotalForceFitness.pdf.

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many have done it on their own, in the privacy of their own home or community, not seeking the

limelight. Success leaves clues and given the ever-growing population in need of greater support

and assistance, it is even more apparent that we need to keep our arms wrapped around these

men and women as well as our wounded, ill and injured service members. They can be integral

connectors in helping lead others to greater health and quality of life – and to the health of our

communities.

Additionally, for every fantastic, cutting-edge “alternative” and/or “holistic” program or

newly integrated hospital or medical or community center, there are 10 stories of disjointed,

conflicting programs within DoD or the VA; too many medical programs and practices causing

more unintentional harm than good; and so-called charitable groups preying upon WII service

members with too few administrative controls regarding who has access.13

This is not just a military problem. This is a societal problem. But, DoD has an

extraordinary opportunity to be the model – the driver – for taking a whole-person focus and

leveraging a whole-of-society approach to treatment, rehabilitation, and recovery to help WII

service members reintegrate back into civilian life, and thrive. The military enterprise has been

and is a pioneer on so many fronts – clinical psychology, medical treatment in the war zone,

integration of women and blacks, etc. It is clear from the outpouring of generosity that DoD (and

the VA) has the desire to be cutting-edge in this area as well. We just need to match intentions

with actions, and recognize that neither the DoD nor the VA can do it all. A whole-of-society

approach is a force-multiplier to ensure our service members and their families get the care and

support they deserve.

13 Issues with so-called charitable organizations are mentioned in a DoD Office of Inspector General report entitled: “Assessment of DoD Wounded Warrior Matters – Camp Lejuene. Report number DODIG-2012-067, March 30, 2012. http://www.dodig.mil/spo/Reports/DODIG-2012-067.pdf

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The primary research questions are:

1. How can policy be leveraged to create or accentuate consistent programs across the services

which support holistic, whole-person practices to more quickly and positively impact the

long-term health and quality of life of our WII service members and their families?

2. Should policy ensure that physical and cognitive fitness activities are a foundation within the

holistic treatment, recovery, and reintegration model and that these activities are offered to

all WII service members as part of a holistic, long-term recovery plan?

3. Is policy needed for DoD (and the VA) to inspire and ensure an integrated model for care and

whole-of-society approach?

4. Should policy require measures and indicators of successful outcomes?

Scope and Limitations

• The population targeted in this paper is: WII active duty, National Guard and Reserves, Iraq

and Afghanistan (2000-present), but care for all military and veterans should be the same.

• Physical fitness includes nutritional education and fitness, but these will not be explored in

depth in this paper. Proper nutrition is a highly critical, must-have component to accelerate

healing, high-performance, long-term health and quality of life.14

• This paper will also not address other areas discussed in the Chairman’s Total Force Fitness

DoD Instruction (to be discussed).

In the world of elite and

Olympic level athletics, it is recognized that you do not put regular gasoline in high-

performance cars, and, that drugs have dangerous side effects. Food is becoming their new

drug of choice. It is no different for our warriors.

14 “The most important determinants of good health are what we eat and how active we are.” Harvard School of Public Health. http://www.hsph.harvard.edu/nutritionsource/. “The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition.” ~Thomas Edison

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• This paper will not address other critical issues such as employment and education, even

though the overall well-being and reigniting the spirit of our service members and their

families are linked to all of these factors.

1. Is policy needed to create or accentuate consistent programs across the services

which support holistic, whole-person practices to more quickly and positively impact the

long-term health and quality of life of our WII service members and their families?

The Department is already empowered through existing policy and guidance to take care

of its service members and families throughout their military careers and when they reintegrate

back into their home communities. And the various components and offices are empowered to

work with each other to share and offer best practices. The Chairman’s Total Force Fitness

Framework Instruction (TFF)15 is a lynchpin for all programs highlighting the need to take a

whole-person and whole-of-society approach.16

15 Total Force Fitness Framework, CJCSI3405.01, 1 September 2011.

(See Figure 1 below). Additionally, Colonel

(Retired) David Sutherland, former Special Assistant to the Chairman of the Joint Chiefs of Staff

http://hprc-online.org/files/cjcsi In September 2011, then Chairman of the Joint Chiefs of Staff, Admiral Michael Mullen signed the Chairman of the Joint Chiefs of Staff Instruction (CJCSI), entitled Chairman’s Total Force Fitness Framework. He charged scientists and staff to explore what fitness really means to warriors and families. He asked them to think holistically, apply science to their ideas, and to provide 21st century leaders with 21st century definitions of and solutions for fitness, health and resilience. The result was the August 2010 Supplement to Military Medicine entitled “Total Force Fitness for the 21st Century: A New Paradigm.” Total Force Fitness (TFF) is a framework for building and maintaining health, readiness and performance in the Department of Defense. It views health, wellness and resilience as a holistic concept where optimal performance requires a connection between mind, body, spirit and family relationships. Eight domains were identified that combine to make up TFF. See also Human Performance Resource Center – a DoD Initiative under the Force Health Readiness and Protection Program, which has been at the forefront of TFF. http://hprc-online.org/blog/the-latest-development-in-the-total-force-fitness-movement-the-chairmans-cjcsi 16 Same as above, page B-1.

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and Director of the JCS Office for Warrior and Family Support17 wrote extensively about the

“Sea of Good Will” and a whole of society/community based approach.18

Figure 1

It should not take additional policy to get all parts of DoD and the VA working together

toward this critical goal. However, it may be time to update policy and re-communicate it

throughout the enterprise, and interagency. While parts of the military health system are world-

class, we do need to raise the minimum standard of care and approach across the spectrum – with

emphasis on the TFF approach as the minimum – and hold all parties accountable for the best

care. “Accountability” may need added emphasis in existing policy.

The good news is there is growing recognition that the human dimension of healing and

moving on from combat and preparing for combat (pre-deployment) are of paramount

importance. All of the Services have their own efforts and ideologies related to overall fitness,

17 CJCS Warrior and Family Support Office http://www.jcs.mil/page.aspx?ID=57 18 "Sea of Goodwill: Matching the Donor to the Need", Major John W. Copeland and Colonel David W. Sutherland, Office of the Chairman of the Joint Chiefs of Staff ,Warrior and Family Support (OCJCS WFS), http://www.jcs.mil//content/files/2011-12/120711143735_SOGW_donor_to_need.pdf ; "Channeling the ‘Sea of Good Will’ to Sustain the ‘Groundswell of Support’: Transitioning from Concept to Application", Captain Chris Manglicmot, Major Ed Kennedy and Colonel David W. Sutherland, OCJCS WFS, September 2011, http://www.jcs.mil//content/files/2011-12/120711143813_SOGW_Groundswell_of_Support_8_SEP_2011.pdf; and "A Call to Action: Sustaining the Groundswell of Support", Major Chris Manglicmot, OCJCS WFS, November 2011, http://www.jcs.mil//content/files/2012-01/013012110958_A_Call_to_Action_Sustaining_the_Groundswell_of_Support_18_November_2011.pdf

“The willingness with which our young people are likely to serve…shall be directly proportional to how they perceive the veterans of earlier wars were treated and appreciated by their nation”

~ General George Washington, November 10, 1781

“And, of course, we must keep faith with our Military Family. Our active, guard and reserve service members, our wounded warriors, our families, and our veterans deserve the future they

have sacrificed to secure.” ~ General Martin E. Dempsey, October 1, 2011, in a letter to the Force

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and these component-specific efforts are outlined briefly in the TFF Instruction. (see page B-2).

Unfortunately, far too many leaders at varying levels of responsibility, military and civilian, do

not know the TFF exists and have forged ahead within their own swim lanes, with seemingly

different visions of desired outcomes.

These varying efforts may be both a part of the solution - i.e., no “one-size-fits-all”,

centralized approach will ever work, and specialization within specific component culture is

critical. And, it may also be part of the problem, meaning, this “Sea of Good Will”19

DoD Strategic Guidance, Joint Doctrine, and Force Health/Support Joint Capability

Areas

is far more

disconnected than it should be, including being disconnected from those in need. TFF is certainly

not communicated across and down into the enterprise (including interagency) as much as it

should be, and, there appears to be little communication, collaboration or cooperation between

the OSD and the Joint Staff, or between the DoD level and the Services, to share all of the great

information, ideas and best practices coming from within each swim lane.

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define the overall intent and empower action toward a holistic approach for helping

individual service members, and it inspires an integrated, interagency and intercommunity

approach (to be discussed later). The health of our service members has a direct link to the health

of our communities. Ensuring the best care and support for all of our service members and

veterans is a force multiplier and greatly enhances our ability to recruit the next generation of

warfighters.

19 Phrase coined by Admiral Michael Mullen, “Honoring life on Memorial Day” The Washington Times. May 26, 2008. Available from http://www.washingtontimes.com/news/2008/may/26/honoring-life-on-memorial-day : 20 CJCSI 3405.1, September 1, 2011, Appendix B-1.

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Furthermore, TFF guidance requires measurement of programs for accountability

purposes – i.e., organizations/programs/activities should be able to quantitatively and

qualitatively articulate return on investment and that desired outcomes related to the long-term

health and welfare of our service members and their families are being achieved. And, in theory,

if they cannot demonstrate desired outcomes, then they should be modified or terminated (i.e.,

“the kill switch”), with funding moved to other programs achieving desired results. There is little

evidence that this is happening across the board.

Based on research to date, there appear to be enough best practices within each of the

Services and at the DoD level, and enough DoD guidance, all of which indicates we are moving

in the right, albeit very scattered, direction. And leadership of each Service is recognizing the

need to focus on the human dimension – mind/body and the spirit. It is time to move beyond

rhetoric to more action, using current success stories and the JSC as the guide.

2. Should policy or guidance ensure that physical and cognitive fitness (mind/body) are

bedrocks within the holistic treatment, recovery, and reintegration framework and these

programs and practices are offered to all WII service members as part of a holistic, long-

term recovery plan?

Two-part response: Response Part A: Yes it should. DoD Guidance, notably TFF,

already includes physical and cognitive activities within its construct, however none of the

guidance found makes this a priority over other areas. The only known military Component to

require physical/cognitive activities as a priority within the recovery/rehabilitation process is the

Marine Corps, as part of their Warrior Athlete Reconditioning Program.21

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(the Wounded

http://www.woundedwarriorregiment.org/warsports/warp.cfm. Marines must pick one of eight identified activities to participate in at least three times a week for twelve weeks. Upon completion of meeting individualized

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Warrior Regiment (WWR) requires all activities

within the regiment – e.g., participation in the job

transition cell). According to the Marine Corps

WWR, however, it is difficult to get the medical

program to incorporate and understand the

importance of “non-medical” (also called non-

reimbursable) activities within its protocols.

It is recommended that these modalities

be connected and incorporated as soon as

possible, as these activities have a direct and in many cases, profound impact upon medical

outcomes, if not driving desired positive medical and lifestyle outcomes. These non-medical

programs include physical/cognitive activities, notably team sports or activities within a group

(peer) environment. They are consistently shown to reignite the spirit and fire within the

Marines, and, this recognition of the importance of the spirit, according to WWR Commanding

Officer Colonel John Mayer, is a vital component of a WII Marine’s path to recovery and

thriving in their new life.22

Successful post-trauma rehabilitation and recovery programs offering a holistic approach,

with physical, cognitive, emotional, spiritual fitness as systematic, integral and equal parts of the

medical treatment protocol are few and far between when looking at the entire military health

system. Acute trauma care is without a doubt the best it has ever been, with state-of-the-art

technology and world-class personnel that the civilian population probably will not see for

goals, Marines may switch to a different required activity with the approval of their commanding officer. In addition to participating in the Required Activities, Marines may elect to participate in a long list of other activities. 22 May 24, 2012 presentation to the DoD Executive Leadership Development Program.

“All these obstacles you put in front of yourself: I can’t…like I used to. You realize

through sport all those obstacles are just delusions. You can do anything if you can

adapt it. You can really achieve what you want to achieve. Once those light bulbs come on all

the other part of health care becomes a lot easier. You’re not as angry about the nerve

pain or chronic pain management. You are not as threatened by medical procedures. You can

have better conversations with your providers & doctors. Sport opens those windows up. When soldiers see that light bulb come on,

everything gets a lot easier. Things make more sense. And there is more acceptance of

whatever injury you have, whatever your new normal is.” ~Marine, 2012 Warrior Games.

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another ten years. But what happens after that acute phase when they are transferred away from

this first line of offense? Many talk about it and have good intentions regarding implementing

this holistic model, and it is included as a priority in the fiscal year 2013 Budget Request – but

fewer throughout the vast military

medical system understand it and/or

have the capacity and resources to

implement and sustain it, like the new

Walter Reed National Military Medical

Center (WRNMMC) and the National Intrepid Center of Excellence (NICoE) (Bethesda, MD).23

These two institutions of excellence are the models for the direction in which the entire military

and VA health system should be moving and are direct results of DoD’s focused efforts to

improve and overhaul the military health system.24

Specifically regarding physical/cognitive activities, however, many in senior leadership

are resistant to going to the “extreme” of mandating these activities, as the Marines do, as soon

as medically practicable, or mandating any of these non-medical modalities as part of the

medical treatment protocol. This seems to be more a symptom of each of the Services’ different

cultures, but each of the military services should look more closely to the Marine model.

This is not an attempt to expand the already over-burdened healthcare/financial system by

attempting to make even more activities reimbursable within military health system. This is, on

the contrary, a way to include evidence-based, self-empowered skill sets and lifestyle changes

23 WRMMC http://www.bethesda.med.navy.mil/MedicalHome/Default.aspx. And NICoE http://www.dcoe.health.mil/ComponentCenters/NICoE.aspx 24 FY 2013 DoD Budget Request, section 5-2. http://comptroller.defense.gov/defbudget/fy2013/FY2013_Budget_Request_Overview_Book.pdf

“I was on the couch for three years because I was in so much pain. I had to have brain

surgery….. This pushes me to go to the gym. It’s painful, it hurts, but it makes me happy. It helps me work through the injury… and sleep

better.” ~Marine, 2012 Warrior Games.

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that promote personal responsibility and accountability as part of official medical recovery plans;

to move more people off disability roles as soon as practicable; or at least less dependent upon

the medical system. This is a direct way to help the Department achieve its stated objective of

“moving from healthcare to health” and “reducing the generators of ill health encouraging

healthy behaviors and decreasing the likelihood of illness through focused prevention and the

development of increased resilience.”25

One area in which we are dangerously sabotaging our goal achievement efforts is with an

over-dependence and over-emphasis on pharmaceutical (prescription drug) solutions – for our

WII service members and those going into or preparing to go into combat areas. Combined with

heavy alcohol use,

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According to the Journal of the American Medical Association, prescription drugs taken

as prescribed in hospitals are the fourth leading cause of death in the U.S, after cancer, heart

disease and strokes, causing about 106,000 deaths a year (or 290/day) and over two million

serious injuries per year (almost 5,500/day) in the U.S.

this forms one of the military health system’s greatest Achilles’ heels. It is

setting DoD and the VA up for the “perfect storm” in the coming years if not addressed

immediately, and holistically. This perfect storm will negatively affect the health of the

individual, the health of the military health system and the economy.

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25 FY2013 DoD Budget Request, section 5-2.

Over-the-counter drugs also cause

http://comptroller.defense.gov/defbudget/fy2013/FY2013_Budget_Request_Overview_Book.pdf 26 According to the National Institute on Drug Abuse (NIDA), alcohol abuse is considered the most prevalent problem and one which poses a significant health risk. A study of Army soldiers screened 3 to 4 months after returning from deployment to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs). And although soldiers frequently report alcohol concerns, few are referred to alcohol treatment. Research findings highlight the need to improve screening and access to care for alcohol-related problems among service members returning from combat deployments. NIDA, “Topics in Brief: Substance Abuse among the Military, Veterans, and their Families”, April 2011. http://www.drugabuse.gov/publications/topics-in-brief/substance-abuse-among-military-veterans-their-families 27 “Facts on Prescription Drug Deaths and the Drug Industry,” August 2011. http://theconference.ca/facts-on-prescription-drug-deaths-and-the-drug-industry

18

many deaths, e.g., every year over 15,000 patients die in North America from ordinary aspirin

and Ibuprophen. Ordinary Tylenol is the cause of thousands of hospital admissions and hundreds

of deaths annually in North America.28 These statistics do not include drug overdoses. According

to the Centers for Disease Control and Prevention, in 2008, there were 20,044 overdose deaths

from prescription drugs. Of those, 14,800 were from narcotic painkillers29, (which are top of the

list prescriptions in the military health system along with sleep aids) and, in 2008, poisoning

became the leading cause of injury death in the United States and nearly 9 out of 10 poisoning

deaths were caused by drugs.30

It is recognized that there are drugs that have saved lives and have meant the difference

between life and death or disability for many. But the balance of benefits-to-costs is greatly

skewed on the side of costs, usually due to side effects. All drugs have side-effects: some relieve

the symptom targeted, but most cause second and third order negative side effects which then too

often get another drug solution. The only difference between a drug and a poison is dosage and

application. A reduction or elimination of symptoms (which is the goal of drugs) does not

necessarily equate to health and long-term well-being, which is the stated goal DoD and the VA).

It is much easier to prescribe a pill – the cheaper solution in the short term, but the most

expensive in the long term because of the negative side-effects and the, too often, health

damaging attributes. The upfront costs of time and energy dedicated to helping humans as

Why are we (DoD and the VA) playing this same dangerous

game with our service members and their families?

28 “Facts on Prescription Drug Deaths and the Drug Industry,” August 2011. http://theconference.ca/facts-on-prescription-drug-deaths-and-the-drug-industry. 29 Report: Prescription Drug Deaths Skyrocket, November 2011. http://www.foxnews.com/health/2011/11/01/prescription-drug-deaths-skyrocket/ and National Centers for Disease Control and Prevention, National Center for Health Statistics, Data Brief Number 81, December 2011. http://www.cdc.gov/nchs/data/databriefs/db81.pdf 30 National Centers for Disease Control and Prevention, National Center for Health Statistics, Data Brief Number 81, December 2011. http://www.cdc.gov/nchs/data/databriefs/db81.pdf

19

humans can be high, but the long-term pay-offs have been shown to reduce our debt and are

positive health force multipliers.

The medical profession, at the very least, needs to recognize and convey the importance

of synergies with these “non-medical” (non-reimbursable) practices and make them a priority

within the treatment/recovery plans of the patients. It is the position of the author that a mid-day

appointment with a military-personnel focused athletic group (combined peer-interaction/support

and exercise) will have greater and more long-lasting impact than lonely appointments with

psychiatrists or psychologists whom many service members feel cannot empathize with them or

their experiences.

Based on a limited review of hospitals and centers across the country, the only known

hospital to include physical/cognitive activities as part of the medical protocol, (in this case, as

actual medical appointments), is the Naval Medical Center San Diego (Balboa).31 The Balboa

Warrior Athlete Program is at the center of this and assumed as a critical partner in achieving

positive medical outcomes. Ninety-five percent of BWAP activities32

31 Based on interviews with Tricia Betts, US Paralympic Military Program Site Coordinator (Balboa), United States Olympic Committee, San Diego, CA, December 2011–February 2012.

are medical appointments;

however, physicians do not require them. Once a service member is medically cleared to

participate in their recreational/sports related programs, then physical fitness activity is

considered part of their medical treatment and integrated within their very hectic days. Because

the activities are medical appointments – with sports trainers, sports coaches/teams/clinics,

recreational therapists, strength and conditioning coaches, etc. – the activity is treated the same

as appointments with a medical doctor, with details and progress logged in the official medical

record. An advantage of this approach is that the physical activity occurs during the work day at

32 http://www.med.navy.mil/sites/nmcsd/Patients/Pages/BWAP.aspx

20

hours when energy, focus and alertness levels are usually higher, and that activity and progress

made are part of their permanent medical file and correlated with other desired medical/health

outcomes – e.g., a reduction in the use of/need for prescription drugs. And this protocol allows

them to more easily engage in activities which might be more family oriented, further

strengthening the family bonds so critical to long-term recovery.33

The Warrior Hope and Care Center at Camp Pendleton, a joint effort between the

Marines, the Navy and the private sector, is more than a medical facility: it is designed to offer

troops a one-stop shop for counseling, reconditioning and transitioning services. Marines and

sailors will no longer have to go to different locations on and off base for the “mind, body, spirit

and family services” they need. According to staff,

It is unclear, however, if any

related activity outside of the hospital setting (e.g., an equine therapy program) is acceptable.

34 it seeks to model many of its programs and

practices after Balboa; however, its business model is different and needs to be explored further

for more programs across the country, particularly as budget cuts become more severe. The

Center is partially funded with Appropriated Fund monies, but supported with mostly

Nonappropriated fund dollars35

33 Based on interviews with Tricia Betts, US Paralympic Military Program Site Coordinator (Balboa), United States Olympic Committee, San Diego, CA, December 2011–February 2012.

(e.g., staff salaries). This means the Center can more easily

accept donations and assistance from nonprofits and community organizations and operate more

like a Working Capital Fund, gaining financial support to cover costs of operations. This is a

business model to explore more closely, as we try to move away from the government bearing

the entire financial load. This approach directly connects military facilities with the communities

34 Based in interviews February 2012. 35 Nonappropriated Funds. are government monies that are not appropriated by Congress and are not held within the United States (U.S.) Treasury. Military Departments and Defense Agencies generate NAFs primarily through the sale of goods and services to the DoD military, civilian personnel and their family members in conjunction with authorized Morale, Welfare, and Recreation (MWR) programs. These funds are used for the collective benefit of military personnel, their family members, and authorized civilians. DoD Financial Management Regulation, volume 13, Chapter 1, page 1-5. http://comptroller.defense.gov/fmr/13/13_01.pdf

21

(nonprofits and private sector organizations), allowing those community-based organizations that

do this every day and do it well, to continue their work and help us better serve our Warriors.

DoD cannot sustain being the sole service provider and financier for this ever-increasing

community, nor can the VA. This economic model can be another lynchpin for leveraging a

whole-of-society approach.

One challenge of the Center’s approach is that, according to Center staff, the Center does

not fall under Navy Medicine. Among other things, this means that participants in its programs

do not get credit for participation in activities as a medical appointment; activities are not logged

and tracked in their official medical file, and therefore are not correlated with medical/health

outcomes. The hours available for service members to participate in activities are either very

early or very late and because of this, there is too often little incentive or energy to go the Center.

We need medical staff to encourage them to participate in Center activities and make them

official parts of their medical program. As of February 2012, Center staff report low turnout for

activities and stated that if activities were part of medical protocol (as Balboa), participation

would increase exponentially. This was also the sentiment of an activity provider at the Walter

Reed National Military Medical Center in Bethesda, MD; another Washington DC area nonprofit

running equine therapy programs approximately 50 miles from the WRNMMC; and a program

provider in Colorado.

Under the current system, “non-medical” seems to equal “non-important” – to both the

patient and the doctor. And that seems to be a message to community-based organizations

offering programs that have turned around – and saved – many lives. Based on interviews with

these nonprofits: if their activities were considered medical appointments – i.e., simply made to

be just as important as medical appointments – not only would WII service members and

22

veterans participate, and go more frequently, but the owners feel private donors would rise to the

challenge of ensuring that the non-profits had the resources needed to meet the demand. The

nonprofits feel participation would increase, partially because the times for most classes would

be during working hours (i.e., when energy levels are higher) and, they would feel an incentive

to go with support from the medical program. All of these service providers have stated:

“potential participants, even those recovering at home, would be more likely to get out of bed to

participate”.36

Response Part B - (Should policy or guidance ensure that physical and cognitive fitness

(mind/body focus) programs and practices are offered to all WII service members as part of a

holistic, long-term recovery plan?): Yes, and existing policy may need to be modified to ensure

this is a consistent practice and that all communications include an all-inclusive message, from

the top down. For example, successful, high visibility, DoD-funded programs such as the

Wounded Warrior Games (funded by the Wounded Warrior Care and Transition Policy Office,

Office of the Secretary of Defense)

Again this is not an attempt to increase the number of reimbursable activities.

This is about empowerment, not entitlement. We have to create a system where people are drawn

to getting better and making improvements, rather than being drawn to only that which gets

reimbursed. It is recommended that this protocol be tested further to determine how these

activities can be integrated into the overall medical treatment plan as soon as practicable.

37

36 Interview with service provider, January 2012.

, and activities related to preparation and qualification for

those Games, are typically focused on a small percentage of the population: primarily those with

visible physical wounds or injuries who want to take their physical skills and compete in

37 Warrior Athletic Reconditioning Program: http://warriorcare.dodlive.mil/wounded-warrior-resources/athletic-reconditioning/

23

higher-level sports competition. Additionally, too often, advertisements for sporting activities

seem to only invite those with visible physical wounds/injuries. (See Figure 2 below)

Figure 2

The concept of the Warrior Games is extraordinary and has done much to build inspiring

bridges of hope for so many, including bridges of hope with and for our Allies, who have begun

participating in our Warrior Games. Considerable monies are spent on professional coaches and

clinics, flying WII service members to various locations, and transporting specialized equipment

for centralized trials, competitions and clinics. But these are funds spent on a very small part of

the WII population. Because of this, many perceive that, once again, those with invisible wounds

are left on the sidelines and money will not be spent on them for the same opportunities for the

very therapies they need – fun, high level training and competition and peer camaraderie. The

perception is that the photo op is more important than serving those with invisible needs. This

perception should be addressed as programs like these are expanded.

The emphasis needs to be on engaging the entire WII population and engaging

community programs with the most expertise and ability to get maximum funding to ensure all

get a fair and equal chance for recovery and transformation. Because our military Service

24

members are, in some cases, viewed as celebrities, and typically command respect, we have an

opportunity to give all of them our very best – equally, and instill within them to take what they

have been given and what they have accomplished, and pay it forward to those in their

community. This “giving” is part of the holistic healing framework and in alignment with DoD’s

core values of making and sustaining not only great warriors, but great members of society.

Why the emphasis on physical/cognitive activities?

Most people will tell you they feel better after exercise. It is good for not only your

general health, but it is also good for your brain. Studies show that in response to exercise,

cerebral blood vessels can grow, and one can

experience significant improvements in the

higher mental processes of memory and in

executive functions that involve planning,

organization, and the ability to mentally juggle

different intellectual tasks at the same time.38 A

recent study indicates that exercise can change

your DNA. “Exercise is medicine, and it seems the means to alter our epi-genomes for better

health may be only a jog away.” The more intense the physical activity – the better.39 Regular

exercise can also regulate sleep.40

38 The Franklin Institute Online – The Human Brain.

This is critically important for those suffering from insomnia.

Recent research findings indicate that sleep disturbance was associated with time-to-suicide –

i.e., the findings showed a connection between the presence of sleep disturbance and near-term

http://www.fi.edu/learn/brain/exercise.html#physicalexercise 39 “How Exercise Can Change Your DNA” Scientists discover that physical activity leads to beneficial changes in gene activity, even after a single workout. Karolinska Institute, Stockholm, Sweden. In the journal Cell Metabolism http://healthland.time.com/2012/03/07/how-exercise-can-change-your-dna/#ixzz1t55xay1B 40 WebMD Health News Exercise Helps You Sleep. Sept. 17, 2010. http://www.webmd.com/sleep-disorders/news/20100917/exercise-helps-you-sleep

“It just feels good. It’s real motivating to be with other athletes and wounded warriors.

Sometimes you feel bad, you feel like you’re hurting and you look around see others with

much worse injuries and they are out there pushing. It’s definitely very motivating.”

“I still survived. So there is a purpose for me to be here. And I’m going to take every day as if it’s my last day and I’m going to do that for the rest of my life.” ~Marines, 2012 Warrior

Games.

25

risk for suicide. The study suggests that sleep disturbance might provide an important

intervention target for a subgroup of at-risk veterans.41 Sleep disturbances are associated with

PTSD and TBI42

Recreational and competitive physical activities have been used successfully for decades

both formally and informally to help WII service members recover and reintegrate back into

active duty or transition into civilian life. And, in many cases, these activities, particularly when

incorporated within a supportive network of others who struggle with similar issues, have proved

to be superior to the more traditional “western medical” modalities (drugs, physical therapy,

psychological/talk therapy, etc.). Additionally, an increasing number of studies suggest that

drugs are no better than placebos for treating depression

, which have also been linked with suicides, but it is unclear which issue is

causing which symptoms as there is usually a mix of all of the above, plus the use of prescription

medications and alcohol. Combined with a lack of skills for dealing with varying levels of stress

and poor nutritional habits, all of this makes these cases very complex, and understandably

frustrating.

43 (also linked to post traumatic stress)

and pain, and that appropriate physical and cognitive activities can cause real, positive, long-term

physiological, psychological and neurological changes in the brain and body, accelerating

healing and ultimately transforming overall quality of life.44

41 Am J Public Health. 2012 Mar;102 Suppl 1:S93-7. Epub 2012 Jan 25. Sleep disturbance preceding suicide among veterans. Center of Excellence for Suicide Prevention, Canandaigua Veteran Affairs Medical Center, Canandaigua, NY

http://www.militaryhealthmatters.org/2012/04/sleep-disturbance-preceding-suicide-among-veterans/?goback=%2Egde_100364_member_111185089 42 Defense Centers of Excellence – for Psychological Health and Traumatic Brain Injury, http://www.dcoe.health.mil/results.aspx?cx=018123205902545604646%3Ai5_dg9dzczc&cof=FORID%3A10&ie=UTF-8&q=sleep%20and%20TBI. 43 “The Depressing News About Antidepressants,” Newsweek Magazine, via The Daily Beast, January 28, 2010. http://www.thedailybeast.com/newsweek/2010/01/28/the-depressing-news-about-antidepressants.html 44 A commentary on ‘Exercise and Depression’ (Mead et al., 2008). James A. Blumenthal, Ph.D. and Lephuong Ong, Ph.D. and Dr. Madhukar H. Trivedi, professor of psychiatry at the University of Texas Southwestern Medical Center, Dallas, TX. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777706/. And these references: “Prescribing

26

According to WebMD45

There is a small but hopefully growing movement among some doctors to consider and

study exercise as formal medicine and to prescribe exercise over drugs. Notably, doctors in

Stockholm are increasingly prescribing exercise in place of medication, according to a review by

Stockholm’s county council health board, a trend which is likely to continue.

improved self-esteem is a key psychological benefit of regular

physical activity. When we exercise, our bodies release chemicals called endorphins. These

endorphins interact with the brain receptors that reduce perception of pain. Endorphins also

trigger a positive feeling in the body, similar to that of morphine; e.g., that feeling, known as a

“runner's high,” can be accompanied by a positive and energizing outlook on life. Endorphins act

as the body’s natural painkillers. They also act as tranquilizers, and with enough vigorous

activity, act almost like narcotics. The good news with endorphins: unlike morphine or

narcotics, the body's endorphins do not lead to addiction or dependence.

46

Exercise to Treat Depression”, The New York Times, August 31, 2011.

3,024

prescriptions for physical activity were given

by doctors in 2008, whereas last year the

number shot up to 12,075, according to a

statement from the health board. “There is no doubt that physical activity has clear medicinal

effects. It’s equally obvious to prescribe exercise as it is to prescribe drugs,” said Birgitta

Rydberg, Stockholm County Council Health Board. She further stated: “We’re going to need to

http://well.blogs.nytimes.com/2011/08/31/prescribing-exercise-to-treat-depression/ and, UW Researchers Study Yoga as Treatment for PTSD, Channel 3000.com, Apr 09 2012: http://www.channel3000.com/health/30512979/detail.html 45Depression and Health Center, http://www.webmd.com/depression/guide/exercise-depression. 46 “Stockholm doctors prefer to prescribe exercise,” The Local: Sweden’s News in English, June 5, 2012. http://www.thelocal.se/41266/20120605/.

“You can discover more about a person in an hour of play than in a year of conversation.”

~Plato

27

develop this much more over the coming years. We’ll not only see a minimized use of drugs, but

it will be cheaper too.”47

In the end, we need approaches that combine science with practical, common sense.

Sometimes what feels right and looks right should not need a full blown clinical trial and peer-

reviewed study to prove valid. The Wounded Warrior Regiment recently took another group of

WII Marines to Wyoming for a weekend of horseback riding, cattle herding, and camping. All of

the participants stated without reservation that they neither needed nor wanted any of their sleep

medications during those three days. This is a recurring theme – and a desired outcome the

medical system should be working toward.

3. Is policy needed for DoD (and the VA) to inspire and ensure an integrated model for

care and whole of society approach – rallying interagency and public/private/non-profit

paternerships?

Policy and guidance already exist which inspire a whole of society approach and these

are published within the August 2010 supplement to Military Medicine: “Total Force Fitness for

the 21st Century,” the Chairman’s TFF Instruction issued September 2011, and the overarching

policies under which this Instruction falls. Guidance is also clearly laid out in the JCS Warrior

and Family Support office documents on the “Sea of Good Will” cited earlier. These

publications paint a picture of what a whole-of-society, integrated approach or model looks like.

(see Figures 3 and 4 below48

).

47 “ “ Same as above. 48 Courtesy of Major Chris Manglicmot, Warrior and Family Support Office, Joint Chiefs of Staff. Also found in: "Channeling the ‘Sea of Good Will’ to Sustain the ‘Groundswell of Support’: Transitioning from Concept to Application", Captain Chris Manglicmot, Major Ed Kennedy and Colonel David W. Sutherland, OCJCS WFS, September 2011, page 27. http://www.jcs.mil//content/files/2011-12/120711143813_SOGW_Groundswell_of_Support_8_SEP_2011.pdf.

28

Figure 3

29

Figure 4

30

Figure 349

A fundamental critical problem currently is the lack of policy to enable the very

public/private and interagency partnerships crucial to success. There seem to be both real and

perceived legal and ethical barriers to forming these partnerships, however, DoD and the VA

have long found ways to engage in formal partnerships with non-profits such as the U.S.

Olympic Committee, the USO, Red Cross and others. While there is talk of the need for

collaboration, these real or perceived barriers are preventing actions from matching intentions

and, thus, achieving desired outcomes. Perhaps there can be some insight gleaned from the

Corporation for National and Community Service and how they, as a federal agency, have

49 “Total Force Fitness for the 21st Century: A New Paradigm.” August 2010 Supplement to Military Medicine. http://hprc-online.org/files/TotalForceFitness.pdf.

31

formed partnerships with nonprofit organizations, corporations, and foundations to meet needs in

our communities, including veterans and military families.50

These publications inspire and empower creativity from the ground up. This creativity

can already be seen at the Walter Reed National Military Medical Center and NICoE, which

feature a state of the art integrated Patient-Centered Medical Home (PCMH) model, but as the

Warrior and Family Support Office mission articulates, we can do better and go deeper, reaching

into our communities.

The Integrated Medical Home is a term that refers to a holistic – whole-person –

approach to health care delivery and your care is supported by an integrated team of

professionals – i.e., who actually talk to each other on a regular basis. Medical records are

electronic, with total team access. The model is based on the concept that you and your family

are at the center of every decision regarding your care and you partner with your health care

team to develop an individualized approach to meet your health and wellness goals and optimize

health and well-being.51

Using this integrated patient-centered medical home model as a foundation, which the

Department has already committed to expand in FY 2013,

52

50 Corporation for National and Community Service

this whole-of-society vision can be

further expanded to ensure that all PCMH’s (and all existing medical centers and care facilities)

have a connection to surrounding local non-profits, community/grass-roots organizations, and

even state level organizations, expanding the web of connection and support options. According

http://www.nationalservice.gov/about/role_impact/militarycommunities.asp. 51Walter Reed Naval Military Medical Center Medical Home – Patient and Family-Centered Care http://www.bethesda.med.navy.mil/MedicalHome/Default.aspx 52 FY 2013 DoD Budget Request, section 5-2. http://comptroller.defense.gov/defbudget/fy2013/FY2013_Budget_Request_Overview_Book.pdf

32

to the FY 2013 Budget Request, the future vision seems to be the conversion of as many military

(and VA) hospitals into PCMH based models as possible for maximum financial and customer

service efficiency and effectiveness. At the very least, every major urban center should have a

PCMH.

Because two-thirds of our military/veterans live away from military installations, it is

critical that these PCMHs and military care facilities have connectors within the facilities who

are knowledgeable and/or can help service members and veterans find health care resources and

veteran-focused support networks within their local communities, and who can facilitate those

connections. Many dispersed local organizations do not even know there are military personnel

or veterans within their community, nor do they know how to best serve them. This presents

another monumental education opportunity, and more organizations are beginning to actively

address this emerging need for our wounded, ill, and injured service members. One great

resource for finding local resources is the National Resources Directory (NRD), a website that

connects wounded warriors, service members, veterans, their families, and caregivers to

programs and services that support them via a partnership between DoD, the VA, and

Department of Labor. It provides access to services and resources at the national, state and local

levels to support recovery, rehabilitation and community reintegration.53

The JCS Warrior and Family Support has been working to bridge these gaps and educate

the public since 2009. The paper Channeling the “Sea of Goodwill” - To Sustain the

“Groundswell of Support”: Transitioning from Concept to Application, Sutherland, et al.

describe the nation-wide network of support for veterans and families”. The goal of the model is

to promote grassroots involvement through building public awareness, encouraging community

53 NRD https://www.nationalresourcedirectory.gov/home/about_us

33

involvement, and promoting community services.54 Additionally, in May 2012, Easter Seals,

Inc., the nation's leading disability services organization, announced a new collaboration with

Colonel (Ret.) Sutherland and Lieutenant Commander Kim Mitchell, formerly of the United

States Navy, to develop a nationwide network of collaborative, community-based services and

supports for military service members, veterans and their families.55

5. Should policy require measures and indicators of successful outcomes?

It is recommended that this

concept be embraced at the highest levels of the military system and be communicated across the

enterprise (including interagency). This can further expand and deepen our awareness of how to

best serve our wounded warriors and their families in particular, but also our service members,

veterans and their families in general.

Yes. Significant funds are being put toward this growing community. As we look even

just five years down the road, we know this community and the need will only get bigger, based

on data indicating delayed onset of symptoms related to TBI and PTSD alone, and based on

concerns related to service members serving using powerful prescription medications and

experiencing negative side effects. We must ensure baseline data is being collected now so we

can track programs over time to determine maximum effectiveness. Measurements can be both

quantitative and qualitative in nature, knowing that it is difficult to quantify a feeling, such as a

renewed sense of purpose and related commitment. Multiple data points can be utilized to

determine effectiveness of programs and practices. An example of a science-based approach to

measurement is a small study conducted by the Naval Medical Center San Diego entitled: “Surf 54 "Channeling the ‘Sea of Good Will’ to Sustain the ‘Groundswell of Support’: Transitioning from Concept to Application", page 27 chart, Captain Chris Manglicmot, Major Ed Kennedy and Colonel David W. Sutherland, OCJCS WFS, September 2011, http://www.jcs.mil//content/files/2011-12/120711143813_SOGW_Groundswell_of_Support_8_SEP_2011.pdf. 55 Easter Seals, Inc. press release, May 3, 2012. Easter Seals Welcomes Colonel David W. Sutherland, United States Army, Retired, to its Team. http://www.prnewswire.com/news-releases/health-latest-news/easter-seals-welcomes-colonel-david-w-sutherland-united-states-army-retired-to-its-team-150069065.html

34

Medicine: Surfing as a Means of Therapy for Combat-Related Poly-trauma.”56 This study looked

at a service member with a bilateral amputation, TBI, severe burn injuries, depression and severe

pain who was not responding to traditional care (pharmaceutical, physical and psychological

therapies) and after a year was showing signs of decline in well-being. The patient was not only

enrolled in the surf clinic, but also exposed to a supportive environment with other wounded

warriors with similar struggle and veteran mentors. After six-months in the NMCSD surf clinic:

his balance exceeded that of his peers who did not participate; was one of the few patients at the

facility able to walk with the prosthetics full-time; significantly reduced the use of prescription

narcotics for pain control; depression resolved; and he experienced temporal relief of TBI.57

While this study is limited it is a noteworthy attempt at documenting physical, mental,

emotional and spiritual changes as a result of specific activities. Other organizations are making

efforts to also become more evidence-based, like the Rivers of Recovery Program.58

These

studies illustrate the potential for greater use of non-medical approaches to promoting healing,

reintegration, and “post-traumatic growth” and a reduced need for traditional therapies and

dependence upon the disability system. Who can argue with outcomes such as: increased

motivation and self-esteem: renewed sense of purpose; increased physical, mental and emotional

strength and resilience; confidence, dignity, goal-setting, personal responsibility? This should be

researched further.

56 Surf Medicine: Surfing as a Means of Therapy for Combat-Related Poly-trauma. Published November 2011 in the Journal of Prosthetics and Orthotics (2011; 23(1): 27-29. The American Academy of Orthotists and Prosthetists. Copy of report courtesy of the Medical Library Suite, Naval Medical Center, San Diego. 57 Surf Medicine: Surfing as a Means of Therapy for Combat-Related Poly-trauma. Published November, 2011 in the Journal of Prosthetics and Orthotics (2011; 23(1): 27-29. The American Academy of Orthotists and Prosthetists. Copy of report courtesy of the Medical Library Suite, Navel Medical Center, San Diego. 58 http://www.riversofrecovery.org/what-we-do/medical-research/

35

Conclusions and Recommendations

Given current practices for dealing with issues related to our WII service members, and

also with military personnel in general - who are struggling with sleep issues, anxiety, pain and

depression - our greatest challenges (and greatest burdens on our service members, veterans and

families and our health care system) may be in our near future. This is a path to a “perfect

storm”, with fallout affecting the very people and communities we seek to connect with and help

thrive, if we do not take thoughtful, strategic, corrective action now. Here are a few final

thoughts for consideration, including a recap of recommendations stated previously:

1. It is recommended that a review be conducted as soon as practicable by the Congressional

Research Service to facilitate a more strategic look at current and future needs for the WII

population and military personnel across the enterprise. We need to look at the enterprise

organizationally, but also address some fundamental problems with current policies and

practices that are having significant impact on our military health system and our

communities. Specifically:

a. It is unclear where authority rests within the Department for policy, programs and

funding for WII service members; who is paying for what within the Department; and

how much money is being used and/or budgeted in support of WII service members

across the services and at the DoD level.

b. An independent review of existing policy could reveal whether there are real or

perceived legal and ethical barriers to forming public/private and interagency

partnerships crucial to the vision of a whole-of-society solution to care and support

for our warfighters and their families.

36

c. Additionally, programs are being cut that are directly related to the health and well-

being of our service members – notably, the Drug Demand Reduction Program’s

Drug Testing and Prevention Program – in all of the components. This program is one

of the Department’s key methods for determining the extent of not only illegal drug

use, but prescription drug use and abuse. These tests can provide independent data to

better track potential cases for multiple-drug toxicity – or interactions among too

many drugs, which have led to too many deaths.59 They can also provide a cross-

reference for records kept by each of the services’ respective pharmacies. Injuries

and illnesses from prescription drug use, often combined with alcohol, are widespread

outside of the community of wounded, ill or injured service members under care in

our respective military wounded warrior programs. According to a recent article in

the LA Times (April 2012)60

The current day Army psychiatrist's deployment kit is likely to include nine kinds of

, more than 110,000 active-duty Army troops last year

took antidepressants, sedatives and other prescription medications. Many see a link to

abnormal behavior.

antidepressants (some linked to increased risk of suicide), benzodiazepines for

anxiety, four antipsychotics, two kinds of sleep aids, and drugs for attention-deficit

hyperactivity disorder, according to a 2007 review in the journal Military Medicine.

Some troops in Afghanistan are prescribed mefloquine, an antimalarial drug that has

been increasingly associated with paranoia, thoughts of suicide and violent anger

spells that soldiers describe as “mefloquine rage.” The article cites Peter Breggin, a

59 “A Fog of Drugs and War”, LA Times, April 7, 2012, the case of Marine Chad Oligschlaeger, who took all of his medications as prescribed. http://articles.latimes.com/2012/apr/07/nation/la-na-army-medication-20120408/2 60 Same as above.

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New York psychiatrist who has written widely about psychiatric drugs and violence:

“Prior to the Iraq war, soldiers could not go into combat on psychiatric drugs, period.

Not very long ago, going back maybe 10 or 12 years, you couldn't even go into the

armed services if you used any of these drugs, in particular stimulants….But they've

changed that.... I'm getting a new kind of call right now, and that's people saying the

psychiatrist won't approve their deployment unless they take psychiatric drugs.”

According to Bart Billings, a former military psychologist, “We have never

medicated our troops to the extent we are doing now.... And I don't believe the current

increase in suicides and homicides in the military is a coincidence.”

DoD now requires drug testing for all service members, in recognition of the

explosion in numbers of personnel using prescription drugs; but across the board cuts

have severed the ability to implement these requirements, particularly for the National

Guard and Reserves, whose personnel are far more dispersed than the other military

services and are being called upon more and more to serve in high risk areas. It is

acknowledged that the Army received additional monies for increased prevention

efforts, but considering the magnitude of the “perfect storm” ahead, this is considered

too little to address too many gaps. The Department has an obligation to keep

programs in place which can detect problematic usage to better inform policy and

guidance for how to address it.

2. Treat our service members with the same due diligence and care as we do our pacing items.

We set and reset our equipment better than we do our warriors. Pacing items are major

weapon systems or equipment that are so important that they are continuously monitored and

managed, with repercussions if they are not. These are must-have items and reportable on the

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monthly unit status report.61

3. Expand efforts to focus pre-deployment on strengthening the mind and spirit. Recommend

the Army communicate results from “The STRONG Project,” led by Amishi P. Jha, PhD,

Associate Professor of Psychology, University of Miami and funded by the Army Medical

Research and Material Command. The project aims to track the impact of pre-deployment

resilience and mindfulness training over the deployment cycle. The U.S. Army realizes that

body armor and physical exercise are necessary to protect soldiers’ bodies and keep them

physically healthy. However, more recently, there has been great interest in understanding

how soldiers’ brains and minds might also be best protected and kept healthy over the

cycle(s) of military deployment. The main purpose of the STRONG Project is to understand

if and how resilience and mindfulness training might provide soldiers with ‘mental armor.’

Equipment is set by working directly with the equipment and

giving it thorough inspections. In the same way, the services can better leverage the plethora

of incredible resources promoted on their respective websites by accentuating training for all

personnel on how to spot warning signs of someone struggling (the most extreme case would

be struggling with thoughts of suicide) and how to have those difficult, confidential

conversations with comrades in arms.

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61 Survival Guide for Property Book Officer.

This study provides a unique opportunity to help the U.S. Army determine how to best help

soldiers set (prepare) for deployment, reset when needed during deployment, and reset when

they return home. According to Colonel Walter Piatt, Commandant of the Army Infantry

School, preliminary results are very strong, indicating that this type of training might one day

http://www.quartermaster.army.mil/oqmg/warrant_officer_proponency/survival_guides/property_book_officer_survival_guide.pdf 62 The Jha lab http://www.amishi.com/lab/strong/.

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be as integral to a soldier’s fitness routine as physical training is now.63

4. Recommend expanding the tenets of the Army’s Comprehensive Soldier Fitness (CSF)

Program, a comprehensive approach to equipping and training our soldiers, family members

and supporting civilians to maximize their potential and face the physical and psychological

challenges of sustained operations. This is a true prevention model, aimed at the entire force,

which will enhance resilience and coping skills (“learned optimism”) enabling them to grow

and thrive for life. And CSF-PREP (Performance and Resilience Enhancement Program),

which provides a systematic way to build mental and emotional strength for Warriors, family

members, and supporting Civilians

The lifestyle

necessary for combat readiness is not that much different from the lifestyle necessary to

handle everyday civilian life stresses. We owe it to our service members, their families and

our communities to ensure we are preparing them for service, but also live after service.

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5. Conduct more research on post-traumatic growth. Success leaves clues. We must balance

research on illness, trauma and disorders with research on health, high performance, vitality

and longevity. Additionally, while we focus so intensely on wounded, ill, or injured service

members and veterans, we must not forget to also pay attention to those who seem to be

thriving, despite their struggles. The greatest sports teams know that they must give care and

support to both healthy and sick, or high performing and low performing athletes. With our

current intense emphasis on our WII service members and veterans, we may well be

. This is the epitome of recognizing that we are experts

at setting our soldiers physically, but not necessarily mentally and emotionally. Senior

Leadership must empower front line leaders (including drill instructors and drill sergeants) to

make time for the mental aspects of readiness. Educate to empower action.

63 Interview with Colonel Walter Piatt, March 2012. 64 http://csf.army.mil/whatiscsf.html

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disenfranchising some of our greatest assets, who are still serving on active duty or who have

already reintegrated back into their communities. We must not lose sight of our “Total

Force”.

6. Develop a plan to aggressively expand the Patient Centered Medical Home Model,65 and

rename it the Patient-Centered Health Home Model. Our vocabulary should be about health

rather than medicine and our vision for the future should include every major urban area

having a health home/community health center and each being connected to and

knowledgeable about surrounding organizations within the community. This approach is

already being explored by several U.S. cities and major insurance companies. This business

model could very well, over time, reduce skyrocketing medical costs. This PCMH approach

was cited in GAO’s report: “Applying Key Management Practices Should Help Achieve

Efficiencies within the Military Health System.”66 DOD’s health care costs have risen

significantly, from $19 billion in fiscal year 2001 to $48.7 billion in its fiscal year 2013

budget request, and are projected to increase to $92 billion by 2030. Evidence demonstrates

that “care delivered by PC providers in a Patient Centered Medical Home is consistently

associated with better outcomes, reduced mortality, fewer preventable hospital admissions

for patients with chronic diseases, lower utilization, improved patient compliance with

recommended care, and lower Medicare spending.”67

While the Walter Reed National Military Medical Center and the National Intrepid Center of

Excellence might seem like expensive propositions up front, their cutting-edge thinking,

65 Military Health System Patient Centered Medical Home Guide, June 2011. Provides information and recommendations on the PCMH model. http://www.tricare.mil/tma/ocmo/download/MHSPCMHGuide.pdf 66 GAO-12-224, Apr 12, 2012 http://gao.gov/products/GAO-12-224 67 Uniformed Service Academy of Family Physicians. http://usafp.org/PCMH-Files/PCPCC-Files/Evidence_of_Quality_-_2008-10-30.pdf

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technology, research and standard of care or the direction that the entire military health

system should be moving to reduce costs and burden to society in the long-term. Their focus

is on empowerment. The current system mentality is about entitlement.

7. Establish a joint forum for sharing best practices and ideas regarding programs and research

for our wounded warriors and their families across the DoD enterprise, and interagency, This

can be leveraged with the national network envisioned by the JCS WFS.

8. Update policy to ensure current focus on TFF and re-communicate it throughout the

enterprise, and interagency.

9. Recommend physical/cognitive (non-medical) activities, with a peer-group emphasis, be

incorporated as soon as possible as part of medical treatment plans, as these activities have a

direct and in many cases, superior positive impact upon desired medical outcomes. And,

recommend further testing of implementing these non-medical modalities as medical

appointments to determine their impact on patient recovery.

10. Consider the business model of the Warrior Hope and Care Center – i.e., use of primarily

Nonappropriated funds – for other health-related Centers. This approach directly connects

military facilities with the communities (nonprofits and private sector organizations) as it

lives or dies with community based/private donor funding. It also allows greater connection

with community-based organizations which do their specialized work every day to continue

their work and help us better serve our Warfighters.

11. Ensure all WII programs and activities are all-inclusive and do not discriminate based on

visible and non-visible wounds. Existing policy may need to be modified to ensure this is a

consistent practice and that all communications include an all-inclusive message.

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In closing, the JCS Warrior and Family Support Office is pointing the Department (and the

VA) in the right direction and connecting organizations and people at all levels. It is doing work

– matching intentions with actions – that needs to be done on a much grander scale. The mission

of WFS is simple: “Through a grass roots focus and a community based methodology, the

Warrior and Family Support Office strengthens our relationship of trust with the Nation by

connecting and assisting with communities to support collaborative efforts that help our Service

members, returning Veterans, their Families, and the Families of the Fallen with transition and

reintegration.” Furthermore, the CJCSI on TFF is designed “to help Warfighters and their family

members remain or become resilient and foster optimal performance over their life spans.” It

describes in detail tenets within each domain, identifies strategies, and suggests potential metrics

which could measure desired outcomes. And, it lays the foundation for an integrated, connected,

whole-of-society approach. Encouraging participation in group-based/peer-support sporting

activity hits on almost all of these domains.

Our WII service members and their families, and all military and veterans deserve to have

the greatest opportunities to recover and move on to lead productive lives, away from the

medical establishment, but still connected with the military culture and ethos, even if they still

“live with” some of their traumas. We must make the connection that while having a job can

mean the difference between having a place to call home with food on the table and living on the

streets – digging through trash cans, it is vital that we create a culture that emphasizes taking care

of the greatest home we will ever own: our bodies, our minds, our spirits. Total Force Fitness

begins here.