Is the Army deploying medically unfit troops?

As I mentioned earlier, both Mike the Mad Biologist and Josh Rosenau of Thoughts from Kansas have commented on a recent Salon article that features accusations that medically unfit troops are being deployed. The situation, if true, is unacceptable. However, judging from my wife's experiences as a brigade surgeon prior to deployment, the situation is likely to be a bit more complex than the article would make it appear.

Before I get into the specifics of the article, it might be good to start off with some basic facts about the operational medicine side of health care in the Army. For most people, knowledge of Army medical care probably begins and ends with two things: M*A*S*H* and the recent problems at Walter Reed. Both the old sitcom and the new example of how troops are really supported share one thing in common: they focus on the health care given to the wounded. Operational medicine focuses on something else - the health of (non-wounded) troops prior to, during, and after a deployment.

The US Army, like most military organizations, has a hierarchical structure. Individual soldiers are grouped into squads, squads into platoons, platoons into companies, companies into battalions, battalions into brigades, and brigades into divisions. As the size of the unit increases, so does the responsibility of the commanders. To help them deal with the increased responsibility, commanders get staff officers. Starting at battalion level, every unit has (at least in theory) a doctor assigned to the unit headquarters.

These physicians - the battalion, brigade, and division surgeons - have a number of different sets of responsibilities. They are responsible for making sure that the medical personnel assigned to the unit are appropriately trained and equipped. They are responsible for ensuring that everyone assigned to the unit receives appropriate medical care. And they are staff officers, responsible for ensuring that the unit commander receives appropriate medical advice, and that the soldiers assigned to the unit are medically fit for their jobs.

The allegations in the Salon article involve two specific physicians: 3rd Division surgeon LTC George Appenzeller and 3rd Brigade surgeon CPT Aaron Starbuck, who have been accused by soldiers of unilaterally changing physical profiles in a way that makes more soldiers deployable. (A physical profile is a medical document that is given to any soldier who has any medical restrictions on what they can and can't do.)

Based only on the article, this is a case where there is no outside verification of the claims made by either the doctors or the soldiers. Under the circumstances, the most that I can do to weigh the competing versions of reality is to take a pragmatic look at the motivations for each side.

The unit surgeons:

Army units today are often short of personnel, and there is some evidence that this is the case with the 3rd brigade. Brigade surgeons are typically majors, not captains. If CPT Starbuck has the job, it probably indicates that they were unable to locate a major with the appropriate credentials for the position.

Brigade commanders are not usually under pressure to deploy an exact number of warm bodies, or to put an exact number of boots on the ground. The pressure that they are under is focused on accomplishing their mission. This does, naturally, require fielding enough people to do the mission, but it also requires fielding people who are capable of doing their jobs.

The effect of these pressures when it comes to operational medicine is to create a pressure to make sure that everyone who is actually medically capable of doing a needed job during the deployment deploys, and that everyone who is not medically able to do their job stays home (and hopefully gets replaced by someone who can).

The troops:

The nature of the army personnel system also places a certain degree of pressure on soldiers with injuries - particularly when the soldier has spent a lot of time in uniform. Essentially, they need to be in one of two places medically: healthy enough to stay in the Army, or sick enough to get at least a 30% disability rating from the Army. That's because 30% is the magic number for medical retirement - 30% and up, you are retired, you get a pension, and you keep medical benefits and exchange privileges. Under 30%, and you get severance pay, and lose all the benefits - unless you have 20 years in uniform, in which case you can retire.

At the same time, there is pressure within units to get people who are medically unable to deploy medically boarded out of the military, particularly if they will not be medically fit before the unit returns. This occurs, in part, because it's the only way that a unit commander is going to get a replacement for that person who will be able to deploy. This means that a soldier who feels that he or she has reason to be medically barred from deployment has good reason to fight to be medically exempted from deployment, but that the same soldier also has good reason to fight to look healthier if they are threatened with a medical board. This particular issue will only be resolved if the military retirement system is modified so that medically discharged soldiers don't lose the pension that they've been working toward for the past ten or fifteen years.

What's credible:

According to the troops, here's what happened:

Eight soldiers who were at the Feb. 15 meeting say they were summoned to the troop medical clinic at 6:30 in the morning and lined up to meet with division surgeon Lt. Col. George Appenzeller, who had arrived from Fort Stewart, Ga., and Capt. Aaron K. Starbuck, brigade surgeon at Fort Benning. The soldiers described having a cursory discussion of their profiles, with no physical exam or extensive review of medical files. They say Appenzeller and Starbuck seemed focused on downplaying their physical problems. "This guy was changing people's profiles left and right," said a captain who injured his back during his last tour in Iraq and was ordered to Iraq after the Feb. 15 review.

According to the division surgeon, the story is different:

Appenzeller said the review of 75 soldiers with profiles was an effort to make sure they were as accurate as possible prior to deployment. "As the division surgeon and the senior medical officer in the division, I wanted to ensure that all the patients with profiles were fully evaluated with clear limitations that commanders could use to make the decision whether they could deploy, and if they did deploy, what their limitations would be while there," he said in a telephone interview from Fort Stewart. He said he changed less than one-third of those profiles -- even making some more restrictive -- in order to "bring them into accordance with regulations."

In direct contradiction to the account given by the soldiers, Appenzeller said physical examinations were conducted and that he had a robust medical team there working with him, which is how they managed to complete 75 reviews in one day. Appenzeller denied that the plan was to find more warm bodies for the surge into Baghdad, as did Col. Wayne W. Grigsby Jr., the brigade commander. Grigsby said he is under "no pressure" to find soldiers, regardless of health, to make his unit look fit. The health and welfare of his soldiers are a top priority, said Grigsby, because [the soldiers] are "our most important resource, perhaps the most important resource we have in this country."

Appenzeller's description of the reasons for doing the profile review is not only credible, it is exactly what the person in his job is supposed to do. It's also entirely possible that a number of the profiles were, in fact, more restrictive than the medical condition would actually call for. Any doctor in the military system can write a physical profile for a condition, but not every doctor has as good an understanding of exactly what conditions warrant what type of profile as the unit physicians do. (It's their job to know those things.)

At the same time, the contradiction between the division surgeon's account and the soldiers accounts is disturbing. An investigation might help clear that particular issue up. In the absence of one, though, I'd hesitate before jumping to conclusions about who is right and who is wrong in this particular case.