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The Real Cost of the War

Why is the U.S. ignoring battle-scarred Soldiers? A special report.
By Mark Boal

Looking back, Adam Koroll was not surprised when he heard the news that Jacob Burgoyne had stabbed a fellow Soldier to death. Private Burgoyne predicted he would do something like that during their very first meeting at the Army hospital in Kuwait. Koroll, a medic, listened intently as Burgoyne, his patient, explained himself: After what he had seen and done in Iraq, he had little to lose and even less control over his reactions. He already felt, he said, like "a murderer in his heart." Why not kill again?

Koroll, 23, a National Guardsman in the sixth month of his first tour, was working as a mental health nurse. He recalls the young desert-tanned Soldier, fresh from the fighting on the other side of the border, slumped on a rickety bed in a drab room at the 865th Combat Support Hospital. At first glance Burgoyne appeared to be in outstanding physical shape, a six-foot blond warrior with a muscular build and a buzz cut -- he was what the Army calls a trigger puller. But Private Burgoyne was hunched over, holding his head in his hands; tears were streaming down his lean, hollow cheeks as he spoke.

"I'm going to do a quick check of your vitals," Koroll told him. He ran his stethoscope over Burgoyne's chest and back, listening for abnormalities in his heart rate. The medic tried to make small talk as he worked, but his patient's behavior disturbs him to this day. Burgoyne would crack a joke and laugh, and an instant later his face would tighten into a snarl. He'd rant about killing women and children. Tears of remorse would pool in his eyes. Then he'd come back to another nasty joke.

But no matter what shocking act of violence Burgoyne described, his eyes remained flat -- "dull and vacant," Koroll recalls -- even when they were wet from crying.

“ Post-traumatic stress disorder is the most common psychological injury of war. ”

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

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

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

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

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

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

That was nearly four years ago. Adam Koroll is home now, a civilian again, living on a tree-lined street in a Chicago suburb, the town where he grew up. It's a quiet place near the Wisconsin border, and Koroll has no plans to leave. He likes the quiet. "I was what they call a rear-echelon motherfucker," he says, sitting on a couch in the living room of a brand-new house he recently bought. "And I'm not ashamed to admit it," he adds.

“ Basically they told him to go out and have a few beers and he’d feel better.
Well, that’s what he did. But he didn’t feel better, apparently, because he stabbed someone to death. ”

In his three-bedroom home Koroll has everything he needs: a roomful of toys for his little girl (who stays with him every other week), a giant flat-screen TV, a PlayStation, a wickedly comfortable leather couch and a fridge full of Diet Coke. A late-model Subaru sits in the garage. Now 26, Koroll may not be living the American dream, but he's on his way. "I'm doing all right" is the way he puts it. There are few mementos of his military service here, apart from a small photograph on the mantel and an American flag salt-and-pepper set on the table.

Jacob Burgoyne, meanwhile, is sitting in the mental wing of a Georgia prison, serving a 20-year sentence for murder.

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

"Basically they told him to go out and have a few beers and he'd feel better," says Koroll. "Well, that's what he did. But he didn't feel better, apparently, because he stabbed someone to death." Standing up as he makes his point, he adds, "It's just a disgrace. The military failed."

Koroll is a big guy, six-foot-four, easily over 250 pounds, with a large head and a strong, jutting jaw. He was a linebacker in high school on a championship team, and with the weight he's put on since then, he looks as if he'd be even harder to push around now.

"That guy Burgoyne had a textbook case of PTSD, and he was supposed to go to the hospital," he says over his shoulder. "I signed the evac order with my own hand. What the hell happened?"

Koroll couldn't have known it at the time, but while he was in Kuwait, PTSD had become a political football, a surrogate in the larger debate over the Iraqi conflict. The powers that be in the Department of Defense were waging a quiet war against the very concept of PTSD.

The Army psychiatrist in Georgia who released Burgoyne in July 2003 would not comment for this story. That's fair. There is enough grief to go around for the tragedy that followed in the wake of Burgoyne's release, and to trace it to one decision on one day is probably pointless. It is accurate to say, however, that this doctor's decision was made under the influence of higher-ups who were mandating policy changes dictated by the DOD and the Department of Veterans Affairs that were designed to impact the way the government handles PTSD patients from the war.

“PTSD is the most common psychological injury of war. Military studies show that more Soldiers from both Iraq and Afghanistan exhibit symptoms of PTSD than of clinical depression or anxiety.”

PTSD is the most common psychological injury of war. Military studies show that more Soldiers from both Iraq and Afghanistan exhibit symptoms of PTSD than of clinical depression or anxiety. This is not surprising. Experts have found evidence of PTSD in troops from every major American war on record -- from World War I, when it was called combat fatigue, and World War II, when it was dubbed shell shock, to as far back as the Civil War, when it was called Soldier's heart. Even in the 17th century, German doctors noticed psychological scarring among combat Veterans, and they named the condition heimweh, meaning homesickness; centuries before that it was called nostalgia. In any given war, historians conclude, an average of 10 to 20 percent of fighting Soldiers are afflicted.

"It strikes the brave," according to Dr. Thomas Horvath, chief of staff at the Houston Veterans Administration Medical Center. "The more combat you see, the more intense is your PTSD." Because nearly all U.S. military active duty and reserves personnel, about 1.4 million Soldiers, have been exposed to battle conditions in Iraq and Afghanistan, an awful lot of brave people are at risk for PTSD.

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

“ PTSD is being underdiagnosed on a fairly wholesale level. ”

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

At the same time, politics may play a part in the underallocation of resources to PTSD patients. The Soldier has tremendous symbolic power in American politics. Healthy, happy Soldiers bespeak a just war. Look at how the Greatest Generation exemplifies the nobility of World War II. The converse is also true: A ruined Soldier bespeaks a ruinous war. In the mid-1970s the image of the shell-shocked vet wandering the streets like a character out of The Deer Hunter or Taxi Driver had a lot to do with discrediting the Vietnam war as a failed enterprise. This lesson has not been lost on a loose alliance of neoconservative psychiatrists and fiscal conservatives who are lobbying behind the scenes to limit the number of PTSD cases the government diagnoses, treats and compensates.

To this group it's essential that Iraq not be seen as Vietnam redux. Soldiers like Burgoyne who have been scorched by their combat experiences are therefore an embarrassment. Like the amputees and flag-draped coffins the administration hides from public view, such Soldiers are antithetical to the hawkish goal of mitigating the costs of the conflict. The critical difference, of course, is that mental illness isn't always obvious and is therefore easier to sweep under the rug. As one congressional staffer put it, "It's much easier to deny the reality of mental illness than it is to deny the spinal cord injury of some guy sitting in a wheelchair."

“PTSD rates for Soldiers in Iraq and Afghanistan are running between 10 and 15 percent. This means that, all other things being equal, one would expect to see the military diagnosing 13,000 to 20,000 cases of PTSD.”

The anti-PTSD movement was gathering strength when Koroll first examined Burgoyne, and it has now, almost four years later, grown into a juggernaut that has achieved many of its aims. A little math tells the story: According to figures made available to Playboy, the DOD now diagnoses about 2,000 cases of PTSD a year. Yet according to a landmark study conducted by Army researchers and published in The New England Journal of Medicine, PTSD rates for Soldiers in Iraq and Afghanistan are running between 10 and 15 percent. This means that, all other things being equal, one would expect to see the military diagnosing 13,000 to 20,000 cases of PTSD. Other figures obtained by Playboy after repeated requests show that evacuation rates for Soldiers with PTSD are also far below what statistical models predict they ought to be. From January to July 2006, only 716 Soldiers were evacuated from Iraq for PTSD. If the military diagnosed even half the cases in Iraq and Afghanistan that are thought to exist, the evacuation figures would be closer to 5,000 a year.

Additionally, this past May, a General Accounting Office inquiry found that only one out of every five Soldiers identified as being at risk for PTSD by military questionnaires given when troops come home are referred to doctors for follow-up and monitoring. The DOD, the report states, "cannot provide reasonable assurance that all service members who need referrals for further mental health or combat-stress evaluations receive them."

The wide gap between what medical experts say is the prevalence of PTSD and the actual diagnosis of the condition has outside observers of the Pentagon deeply worried. Dr. Robert Roswell, a former undersecretary at the VA, tells me bluntly, "PTSD is being underdiagnosed on a fairly wholesale level."

Joe Violante, national legislative director of Disabled American Veterans, one of the largest and most powerful Veterans' lobbies in the country, has been trying to force the administration to be more forthcoming in its approach to PTSD but has so far had little success. "People involved in running the war want to keep it under wraps," Violante says. "They don't want the story to be, 'Fight in this war and you'll come home messed up and unable to drive on the right side of the road.'"

In 2005 David Chu, an undersecretary at the DOD, shocked reporters when he said Veterans' health care costs had reached such heights that they were "taking away from the nation's ability to defend itself." Apart from that lone comment, which Chu declined to elaborate on, no senior administration official has spoken on the record about the costs of PTSD. And publicly, neither the DOD nor the VA has responded to any of the criticism leveled against it. The DOD, though it is struggling with manpower shortages and is underequipped to deal with the number of Soldiers coming out of Iraq with mental health problems, projects an image of business as usual. The Department of Veterans Affairs also continues to issue rosy estimates of its PTSD resources, even though every significant oversight agency has denounced the VA, claiming it's as unprepared as FEMA was to handle the aftermath of Hurricane Katrina. Here's the VA's own national advisory board on PTSD in a report released in February 2006: "The VA cannot meet the ongoing needs of Veterans of past deployments while also reaching out to new combat Veterans of [Iraq and Afghanistan] and their families within current resources and current models of treatment."

Pentagon and VA officials vigorously deny there is a policy to underdiagnose PTSD. "That would be immoral and unethical," says Dr. Michael Kilpatrick, the assistant secretary of defense for troop readiness. They attribute the low rates of diagnosis to a reluctance on the part of military doctors to "stigmatize the person or bring harm to their careers" by labeling them with PTSD, according to Lieutenant Colonel Dr. Charles Engel, the director of the deployment health clinical center at Walter Reed Medical Center. "It's out of respect for the patient that they don't make the diagnosis."

In the early stages of the war, long before U.S. forces slid their tent stakes into the Kuwaiti desert, the corridors of Washington, D.C. were buzzing with preparations. The Department of Defense submitted a war budget to Congress, a several-thousand-page document estimating in great detail all the expenses of the coming conflict, from tank divisions to the number of bullets the infantry would need. But no money was allocated for mental health casualties. The line item for that expense was simply left blank.

"DOD never prepared for a long war; it never prepared for an occupation," one senior congressional staffer tells me. "Now we're seeing the third thing it didn't anticipate: what to do with the Soldiers when they come home. Now they really don't have the money."

Though he was unaware of the budgetary machinations in Washington at the time he was deployed in Kuwait, Koroll noticed almost as soon as he landed in the sand that scant resources were being directed to the mental health of Soldiers.

He was stationed at the 865th Combat Support Hospital, a plum posting because it is the Army's largest and most important medical facility in the region. Safely tucked away in a remote corner of the desert, on the outskirts of Kuwait City, it is a concrete-block building with thick mortar-resistant walls. Though well manned by surgeons and critical-care nurses expert in gunshot and fragmentation wounds, the 865th hospital had no psychiatric ward, at least not when Koroll was stationed there. There was no wing devoted to psychological trauma, just a few offices at the end of a hall, where stressed-out Soldiers were counseled in rooms containing no sharp objects. At the time Koroll served in Kuwait, there was only one psychiatrist for all the armed forces in that entire country, and the doctor's responsibilities also included a large swath of southern Iraq. "I don't want to downplay the amputees or the gunshot wounds, but the military does a pretty good job with that type of injury," Koroll says. "The attitude toward combat stress was like, 'Oh, by the way, you might deal with this.' It was an afterthought."

A few weeks after Koroll landed in the Mideast, President Bush declared "Mission accomplished" from the deck of the USS Abraham Lincoln. After that the military recalled the handful of mental health teams that were in Iraq and Kuwait. "Can you believe that?" Koroll asks now. "I guess they really thought the war was over before it began."

With the psychiatrists trained to treat combat stress called back to the U.S., Koroll was theoretically in charge of any mental health cases that came to the hospital. Not that any did in those early days of the war.

Koroll worked the night shift, starting at six p.m. Most evenings were spent waiting for something to happen. As this was the beginning of the invasion, when there were few casualties, he often waited in vain. Many of the patients who did come in for care suffered from noncombat injuries and ordinary medical complaints such as sore throats and earaches.

“ The M2, known as the Ma Deuce, is the most coveted weapon in Iraq for its killing power and reliability. ”

But after a few weeks, the ground troops started their bloody crossing into Iraq. Helicopters lit up the night sky with their bright white landing lights, carrying wounded from the Iraqi front. Koroll would jump aboard and pull out the wounded, sometimes slipping on blood clotted to the consistency of Jell-O. Once, he cradled in his arms a Special Forces Soldier who'd had both his legs blown off to the hip sockets. Koroll cared for hundreds of patients. But the one he remembers most vividly is Burgoyne. "He's the one I can't seem to forget," he says.

Burgoyne's unit was called down to Camp Wolf, Kuwait, about 10 minutes from the hospital. The men were told to decompress and rest for a few weeks before returning to the comfort of the U.S. The rest of his platoon enjoyed the R&R, but Burgoyne found he was having a hard time relaxing. The fighting still felt too fresh in his mind -- the thump of his weapon, the blood, the bodies.

An athletic Southern boy, born and raised in Tallahassee, Burgoyne had enlisted in the Army at the age of 18. He became a career Soldier and ended up in Iraq wielding an M2, a .50-caliber machine gun mounted on the turret of his Bradley. By his own estimate Burgoyne shot to death more than 100 Iraqis as his convoy stormed into Baghdad. Some of the people he killed were Soldiers; some weren't. He knew that. He'd shot at women, children, old men. It wasn't indiscriminate slaughter exactly, but it wasn't easy to justify, either.

The M2, known as the Ma Deuce, is the most coveted weapon in Iraq for its killing power and reliability. A .50-caliber round is as thick as a prescription bottle and six inches long. Fired at close range, it will obliterate a living person instantly. "Puts their dicks in the dirt every time," as one observer has written. Burgoyne told Koroll he would like to forget most of what he did with that weapon during Operation Iraqi Freedom, his first combat experience. The whole thing seemed, at least to him, more like a turkey shoot than a proper campaign.

He told Koroll he'd been having trouble sleeping. In the twilight between sleeping and waking he watched blood darkening the creases of his hands, as if he had somehow forgotten to wash. It was a daily struggle to contain his troubling memories, and in the midst of a mundane chore he lost the fight.

He was told to drive his Humvee over to the Camp Wolf wash rack and clean it up. Every inch of the vehicle was coated with Iraqi desert dust; it hadn't been cleaned since it arrived in the country. Burgoyne was a good Soldier, and he took his Soldiering seriously, even this kind of housekeeping duty. He sprayed away the first layer of grime with a power hose, then dropped to a crouch to apply a little elbow grease with a big sponge. Scrubbing down a wheel well, he saw a small flash of white in the corner of his vision. Once embedded in the metal grille beside a tuft of human hair, a small white tooth had come unstuck and fallen to the wet concrete floor. Burgoyne watched it disappear in a swirl of soap and water. Then he doubled over and fell to the ground, unable to catch his breath.

"Evidently one of the tricks they used was to put children in the road to slow you down so you could be ambushed," Koroll recalls Burgoyne explaining. "Well, in Iraq you don't stop, and you don't slow down."

Soon after seeing that small tooth clatter to the floor of the wash rack, Burgoyne stalked back to his tent and chugged down a bottle of antidepressants.

“... a Harvard professor and psychiatrist who identified the syndrome in the early 1970s, PTSD is brought on by a "death encounter," an existentially profound brush with mortality, in which death is perceived as a real possibility rather than an abstraction. ”

To Koroll, Burgoyne's story made him a perfect candidate to receive a PTSD diagnosis. According to Dr. Robert Jay Lifton, a Harvard professor and psychiatrist who identified the syndrome in the early 1970s, PTSD is brought on by a "death encounter," an existentially profound brush with mortality, in which death is perceived as a real possibility rather than an abstraction.

All men do not respond equally to these death encounters. Highly intelligent people seem better equipped to survive a trauma unscathed, while those who score low on IQ tests seem to suffer the most, according to several studies. But if a death encounter is sufficiently intense, it can upend anyone's belief system in such a violent way that it can't easily be put back together, resulting in the onset of PTSD symptoms -- or so the theory goes. The trauma "explodes the cohesion of consciousness," in the words of Jonathan Shay, a PTSD expert at Boston University.

The illness evolves over time. It begins with painful reexperiencing of the traumatic encounter in flashbacks or harsh memories, proceeds to defensive maneuvers against the pain, then to avoidance, then to "psychic numbing" to dodge the painful recollections and finally to hyperarousal. The body behaves as if it's in fight-or-flight mode. The Soldier tenses up, develops insomnia and becomes jumpy and anxious. He feels under attack and easily threatened.

This altered state, which is caused by an overabundance of stress hormones and a shortage of serotonin, is an echo of the terror felt during the actual event. But rather than dissipating as it normally would, the fear grabs hold of the Soldier's mind and slowly colonizes his thoughts -- the gestation period can range from 30 days to 30 years -- until fear becomes a prominent feature of his personality. Not everyone who gets PTSD is disabled to this degree, of course. The majority of those with enough symptoms to be clinically diagnosed with the disease can still manage to lead productive lives. But for some, a full-blown case of PTSD is a horrible burden, entailing a life lived in perpetual terror, emotionally and biochemically stuck in the past, floundering in the present.

The early signs were already there, Koroll felt, as he listened to Burgoyne. Double-checking that no sharp objects or anything that could be converted into a weapon had been left in the room -- just a hospital bed and a bedside chair -- Koroll said good night and told Burgoyne he would check in with him the following morning.

PTSD wasn't recognized as a distinct syndrome until the 1970s. Before then psychologists believed that only weak men, those with hereditary or genetic flaws, suffered from combat stress. War was seen as a kind of crucible of masculinity that made strong men stronger. Still, by the early 1940s, more than half the patients in American VA hospitals were in psychiatric wards. The remedy for weakness was harsh: During World War I and World War II stressed-out Soldiers were given heavy courses of electroshock until, as one historian puts it, "the horror of the therapy was greater than the horror of the front."

“ For all but a small group of conservative thinkers, PTSD has outgrown its early links to the antiwar movement... ”

Medical opinions began to change in the 1960s with what was then called post-Vietnam syndrome, a condition marked by rage at being "duped and manipulated by society." The doctors who worked on defining the diagnosis were often outspoken critics of Vietnam, and they encouraged their patients to take up antiwar activism as part of working through their trauma and transforming it into productive feelings. Rather than blame the character of the Soldier, doctors blamed the war itself.

For all but a small group of conservative thinkers, PTSD has outgrown its early links to the antiwar movement to become an objective psychiatric category, as above the fray of politics as anxiety or depression. Still, an influential group of culture warriors and military commanders believes PTSD was an invention of liberals seeking to justify their politics with science. "For some in the military and for some of these conservatives, PTSD is still basically an anti-war concept," explains Dr. Ray Scurfield, a psychiatrist and pioneer in PTSD study.

With the election of George W. Bush, these fairly radical views were suddenly given a much more receptive hearing. B.G. Burkett, a retired Texas stockbroker, has spent the past 20 years waging a one-man crusade against deceitful American Soldiers. He calls them "phony Veterans" and believes PTSD has become a tool of antiwar liberals. Ask him about Lifton, the psychiatrist who helped define PTSD, and Burkett's voice rises with anger. "Lifton was an antiwar activist, for Christ's sake! If it were up to him, we'd have no war at all!" Then, more calmly, "Look, death encounters are a part of life. I watched my mother die. Do I have PTSD? It wasn't easy, but I'm still here. Whatever happened to resilience as a virtue?"

Burkett is one of the administration's talking heads on mental health as it deals with the fallout of the Iraq war. Burkett cheerfully and forcibly presents the notion that PTSD has become a scam used by antiwar liberals and that thousands of Vietnam Veterans are faking illnesses in order to cash in on federal disability payments. Burkett co-authored the book Stolen Valor (for which he received a thank-you note from Bush), which documents several cases of brazen fraud perpetrated by Vietnam Veterans.

Considering that this anti-PTSD movement represents a minority position well outside mainstream psychiatry, it has achieved impressive gains in the past few years. Another spokesperson for the movement, Dr. Sally Satel, a psychiatrist and an advisor to President Bush on mental health issues, argues that mainstream psychiatry is pathologizing everyday life, turning normal states of consciousness into medical problems in a kind of therapy creep. She shares offices at the American Enterprise Institute with Newt Gingrich and says PTSD disability payments encourage people to stay sick. Satel's name may sound familiar, as she is frequently published in the popular press and has offered expert testimony on PTSD even though she has not authored any noteworthy peer-reviewed papers on the disease.

"We had it more or less right in World War II," she says. "We should go back to the hereditary model. I'm not saying PTSD doesn't exist, but it's gotten out of hand. I mean, if you see a lot of action and then when you come home you have a hard time walking the dog by the bushes at night, maybe you just avoid the bushes. Does that entitle you to a lifetime of payments? And I don't think those payments even help you get well."

Clearly her position is supported politically by Republican conservatives. "Sally says exactly what they want to hear," one congressional staffer tells me. "Literally nobody else in the world of any stature will say that PTSD is nonsense, and she does. They love her for it."

“ Watchful waiting, which sounds to some like ‘don’t treat, don’t tell,’ is not part of the accepted psychiatric treatment protocol for PTSD... ”

Whether because of pressure from the anti-PTSD group or under his own philosophical steam, William Winkenwerder, the assistant secretary of defense for health affairs, who is responsible for the health and well-being of all troops, in early 2006 had already formulated a new protocol for dealing with PTSD. Essentially this new tack held that when handling returning troops, it was medically appropriate not to diagnose PTSD. Instead, troops with PTSD symptoms would not be told of the suspected diagnosis but would be closely monitored to see if their symptoms worsened or improved. In a letter to the General Accounting Office, Winkenwerder, the highest-ranking official with day-to-day control of mental health policy, called this new approach watchful waiting.

The familiar term watchful waiting derives from the language of cancer treatment but is usually a course of therapy undertaken with the full consent of a patient after a diagnosis has been made. Watchful waiting, which sounds to some like "don't treat, don't tell," is not part of the accepted psychiatric treatment protocol for PTSD, nor is the term mentioned in the military's own field handbook for in-theater doctors treating trauma cases. I contact Paula Schnurr, the editor of that handbook and a nationally recognized PTSD expert at Dartmouth, and ask if watchful waiting has an entry. There is a long pause on the other end of the line. "Let me see," she says. "I'm looking. Well, I guess it's not in here." She is not familiar with the concept, she says. "No, that's wrong. If someone presents with the symptoms, you give them the diagnosis. I find, in fact, in a lot of cases it is a relief to know the name. They're not stigmatized by it. They're relieved to know they're not crazy."

The American Psychiatric Association insists that PTSD is marked by clear biological changes as well as emotional symptoms. "PTSD is an illness that is related to structural and chemical changes in the brain," according to the APA, the most respected association of its kind. Scurfield is slightly less diplomatic about this administration's offhand approach to Soldiers' mental illness. "It's just bullshit," he says. "If spontaneous remission were a reality, why have 30 percent of Vietnam vets had a lifetime of PTSD?"

"Iraq is Vietnam without the water." Hang around Soldiers long enough and you will hear one of them say this. Actually the statistics suggest Iraq is a lot scarier than Vietnam. An exhaustive study of 303,905 Veterans of Iraq and Afghanistan done by a team of military doctors from the Walter Reed Army Institute of Research showed that combat exposure is near universal and 24/7 in Iraq. The likelihood of a Soldier having to face live fire is higher than in any previous American war. Ninety-three percent of Operation Iraqi Freedom Veterans report having been shot at, according to data from DOD surveys. Some 77 percent have pulled the trigger in an attempt to kill, which is roughly three times the trigger rate of World War II; 95 percent have seen dead bodies, and 89 percent reported having been ambushed or attacked. The urban warfare in Iraq has no clearly delineated front and no safe zone in the rear where Soldiers can go to decompress. The insurgency is spread across the country and moves freely through the same areas American troops have to traverse just to get around. No place, not even a guarded base, is safe, and the conflict has become the ultimate petri dish for PTSD.

By late 2004 military doctors working closely with troops had finally recognized the growing problem of PTSD among the ranks. Determined to stem the tide, even at the risk of displeasing the politically appointed higher-ups in the military, they pressured the DOD to return combat-stress teams to Iraq. In December 2004 that duty fell to the 55th Medical Company, an 80-person-strong unit that was "tasked," in military speak, with providing psychological care for the entire in-country force, roughly 130,000 troops. The patient-caregiver ratio was 1,625 to one. (Since then the Army has increased combat-stress personnel in Iraq to 200.)

The deputy commander for clinical services of the 55th was Lieutenant Colonel Kathy Platoni, one of the Army's top field psychologists and a hyperkinetic 54-year-old with a blunt, assertive manner that does not fit the mold of the ivory-tower academic. "I know how to handle an M16," she says.

Platoni spent the better part of two years traveling around Iraq. She found that underneath the bustle and swagger of life on a military base was a lot of unspoken pain and psychological suffering. "There's tremendous unpredictability in that theater," she says. "You are being regularly attacked by an unseen enemy who doesn't wear a uniform. I was seeing people who were dealing with a tremendous amount of combat stress and seeing their buddies just burned to death, incinerated or blown to smithereens. People will be jittery, shaky; they will cry. They can't sleep; they can't eat. They drop into a rage very quickly. They try to hide it, but you can see the signs."

Every company also had a significant number of Soldiers severely stressed out simply from living in cramped, dusty conditions in searing 110-degree heat, enduring ambushes in the morning and lethal mortar attacks at night for months on end. Adding to the strain are the tight restrictions on American Soldiers on Iraq bases -- no alcohol, no porn allowed.

Platoni concluded PTSD was rife among the troops she saw, running at a rate of between 15 and 20 percent. But she could do little to help. Her contact with Soldiers in the field amounted to barely more than brief hellos between mortar attacks. "Sometimes it's just talk therapy, just being there, listening, validating, trying to understand their experience," says Platoni. "It's pretty basic stuff."

In the eyes of the military, she says, the duty of the psychiatrist is "to keep the Soldier in the fight and the fight in the Soldier. We're force multipliers. Very few people get evacuated out of theater because there are so many shortfalls with people getting killed or injured. So there's that implicit message that you don't want to take anybody out of the action."

Platoni herself is no stranger to PTSD. Home now in Ohio, with just a few years left on her Army Reserves contract, she finds that on the short drive to her office she often scans the country roads for improvised explosive devices. When she goes out to dinner she always sits facing the door. She startles easily at loud noises. "I wouldn't say I have full-blown PTSD, but these are normal responses to extraordinarily abnormal circumstances."

Platoni was recently promoted to colonel. She says her thoughts always return to the Soldiers she saw in the field. "There are probably some people who should have been medevaced out of the theater who weren't," she says. "Not with all the manpower shortages." Then she pauses and adds, "The more combat you see, the more likely you are to be traumatized. I don't think we have a good way to resolve that. We just don't."

The government's attitude seems to be having the desired effect of keeping PTSD patients out of the DOD health care system and transferring the caseload burden to Veterans Affairs when the Soldiers return home. Since the wars in Iraq and Afghanistan started, 631,000 people have been discharged from the military, including National Guard and Reserve Soldiers who are now deactivated. Of those, 73,000 have sought mental health treatment at the VA.

“ Soon after Nicholson moved into his new offices, the VA, like the DOD, began to aggressively roll back its support for PTSD. ”

Critics say the VA, like the DOD, is falling short. A rumor going around the Veterans community claims that, even in cases of existing injuries, military doctors are underdiagnosing PTSD at military hospitals, preferring instead to use labels that do not entitle the Soldier to combat-related compensation. "We've been hearing it all the time from our guys in the field who are working with these Iraq vets," says Joe Violante of Disabled American Veterans. Military doctors "are being told not to diagnose PTSD."

In 2004 leadership changed at the VA. The head of the agency, Anthony Principi, a longtime favorite of Veterans groups, resigned. The timing of his resignation was suspect, as it came shortly after he told Congress the agency lacked funds to take care of Veterans, and the move was widely interpreted as a firing. Bush replaced Principi with a high-level party operative named James Nicholson. A Republican power broker and a party heavyweight, he chaired the Republican National Committee during the 2000 presidential campaign, when he called Dick Cheney "one of the most qualified, beloved people in America."

Soon after Nicholson moved into his new offices, the VA, like the DOD, began to aggressively roll back its support for PTSD. First, in a move that echoed Burkett's charges, Nicholson ordered an investigation into the files of 72,000 Veterans who had received PTSD compensation. Senate Democrats managed to undercut the review. In response, Nicholson commissioned a study at the Institute of Medicine to craft a new definition of PTSD, one more restrictive than that used by the American Psychiatric Association. That too fizzled. Finally, a second study was commissioned to "assess how PTSD compensation might influence beneficiaries' attitudes and behaviors in ways that might serve as barriers to recovery."

Veterans advocates interpreted these moves as an attempt to lay the groundwork for dismantling the VA's financial support of PTSD patients. Under the current guidelines, the VA considers PTSD a "compensable injury," which entitles sufferers to disability payments similar in spirit to workers' compensation. This is indeed an expensive proposition. A Soldier diagnosed with war-related PTSD is entitled to disability payments that can reach a total of $1.3 million over a lifetime; the cost of treatment drives the bill higher.

The VA currently spends between $3 billion and $4.5 billion a year on treating the condition, and the scope of the problem grows larger every day. This is partly due to a new population of Vietnam Veterans just now coming into the system, many of whom are unemployed and have discovered that the VA pharmacy is cheaper than Medicare. Veterans of Iraq and Afghanistan represent a second source of new patients, and these former Soldiers are even more likely than their predecessors to seek care, if only because, as members of the Oprah generation, they possess a greater degree of psychological fluency. A Republican official notes, "There's a lot of concern with the number of folks who are coming back reporting symptoms of PTSD. It does not minimize the situation to say that a lot of this is cultural, insofar as my dad's generation in World War II did not report pain. They did not talk about shell shock. They went quietly back to their life, and either they made their life work or it tore them up. Whereas this generation has learned to express its problems and to ask for and expect help." In every quarter of 2005, according to internal VA figures, the agency added 8,000 new PTSD cases to its claims rolls. "It's very worrisome," says Renée Szybala, head of the VA's compensation and pension division. "These numbers just keep going up and up, and frankly, I don't know if we can sustain them."

Harvard professor Lifton has been watching the attack on PTSD with growing concern. He believes there is now "a public assault on the diagnostic concept from neoconservatives, including neoconservative psychiatrists, and their message is that war isn't so bad for you -- or this war isn't hurting people too much," he says. "But I don't think the attack on PTSD will ultimately succeed. There is something to be said for reality, including the reality of suffering being acknowledged."

“ What’s going to happen? It’s a perfect storm. ”

But Veterans advocates fear the attack has already succeeded. They describe the unfolding situation as a train wreck, a catastrophe and a scandal. "You have large numbers of needy people coming back from the war, looking for help, and you have a government attempting to reduce expenditures, as well as conservatives who want to raise the bar and make it harder for vets to get the diagnoses," says Dr. Charles Figley, editor of Traumatology, who has written numerous books on PTSD and has been studying combat-related PTSD in Veteran populations for 20 years. He is not an antimilitary person, and he recently spent a year on a Fulbright scholarship at Kuwait University. Figley adds, "What's going to happen? It's a perfect storm."

When Adam Koroll heard Jacob Burgoyne's commander had overruled his evac order, he couldn't believe it. Normally a disagreement of this sort between a reservist specialist and an active-duty commander would be a no-contest fight in favor of the commander. But Koroll wasn't a typical reservist; he came from a military family and had followed in the footsteps of his father, brother, mother and even his ex-wife. He wasn't going to be treated like a weekend warrior.

"'All due respect, sir, that's not the right thing for this Soldier,'" Koroll says he told the commander. But Koroll was outranked. "The commander made a big stink about it. He said Burgoyne was a hero of the Third Infantry. He should stay with his unit," Koroll says. Finally a compromise was reached. Burgoyne would stay with his unit but be checked into a hospital as soon as he landed on American soil.

Not much is in the public record about Burgoyne's visit to a military hospital in Georgia. It is established that he checked in and checked out soon afterward. Burgoyne's mother, Billy Urbane, accompanied him to the hospital, but she says he never saw a psychiatrist. He spoke to one on the phone from the waiting room; the interview lasted five minutes. The psychiatrist released Burgoyne and told him to come back in a few days if he felt worse.

Burgoyne spent the next few days with his mother in a visitors' cabin she'd rented near the base. He was sullen and uncommunicative and spent his time on the couch, drinking beer and watching TV as she hovered around him, trying to draw him into conversation. "He was changed from the war," she says. "He said to me, 'Mom, there's things I've done you don't want to know about.' I could tell he wasn't the same Jake. The life had gone out of him."

The following night, a Sunday, Burgoyne went out drinking with his Army buddies. Then, for reasons he still can't explain, he turned on Specialist Richard Davis, a fellow Soldier, and began a vicious attack that ended with knives being drawn. Davis was murdered, his death the result of 32 stab wounds.

For three months Davis's remains lay undiscovered in the Georgia woods until Burgoyne finally confessed to the crime. In his defense he raised his PTSD diagnosis. "I don't know why it happened," he later said in court. "I actually liked Davis."

For his part, after his battle with Burgoyne's commander, Koroll lost track of Burgoyne as new cases came flooding into the hospital and Koroll had his hands full dealing with them. One morning he opened a copy of Stars and Stripes and saw a story about a Soldier who had been murdered by his platoon mate. Koroll nearly spat out his coffee when he saw the mug shot next to the headline. "I recognized those eyes," he says. "I didn't remember the name, but the second I saw the photo and the eyes with that really far-out stare, I said to myself, Hey, I treated this guy. Why isn't he in a hospital?" Koroll showed the newspaper to his colleagues at the hospital. "'I told you so,'" he recalls saying. "It wasn't anything more noble than that. Just, 'Hey, I was right.'"

On April 24, 2004, Koroll returned home. He was immensely glad to be back in Illinois and felt good overall about his time "in the sandbox." After all, he went to the desert and didn't get shot or otherwise wounded, didn't fall ill from some desert pathogen and didn't come home with a lingering case of PTSD or depression. Two days later, however, he got a letter from the Army informing him he was going to be discharged "in conditions other than honorable." The letter explained that after careful consideration the Army had decided his actions were unbecoming, noting specifically that he had missed two formations.

"I couldn't believe it," Koroll recalls, "because they've got guys over there with two, three Article 15s" -- a violation just short of a court-martial -- "who don't get discharged other than honorably, and here they were giving it to me because I missed a formation? Please. They didn't like me speaking up about Burgoyne."

The discharge hit Koroll especially hard because of his family's history with the military. If you grew up in the Koroll family, two things were more or less certain: the military and medicine. Koroll had been the first in a large family circle to leave the military under less than perfect conditions. "My discharge is not something we discuss at the dinner table," he says. "It's an unspoken thing."

Soon after, he and his wife divorced and were granted shared custody of their two-year-old daughter. Koroll landed a job running a mental health clinic for indigent patients.

Now he says he is getting out of the mental health field altogether to take a managerial job with a Fortune 500 company that has no psychiatric-medicine business. "It's just too hard," he says. "Things like PTSD, these mental illnesses, they are chemical, but I don't think America is ready to hear that. People always want them to be about something you did to yourself. They just don't want to believe these illnesses could happen to anyone, and until people do believe, we're going to have big problems with the guys coming home."

But the episode with Burgoyne still stings. Here is a man whose fate has become strangely intertwined with Koroll's even though he knew him for only two days. "There isn't anything more I could have done," Koroll says, looking down at his shoes. "I'm just a specialist, and I said, 'Hey, this is kind of crap,' and they said, 'Don't worry, Specialist.' I did my duty. I can honestly say that. The follow-up was flawed. Somebody told Burgoyne to suck it up and go have a couple of beers with his buddies, and that was his remedy, to have a couple of beers." He pauses. "The Army failed him, and they failed the family of the Soldier he killed."

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