Operation Recovery

The Fort Hood Testimony Report

Findings

Fort Hood and Beyond: Evaluating the Testimony

The testimonies herein concern Fort Hood—as the country’s largest Army installation; as a place that experienced high deployment and redeployment rates throughout the Iraq and Afghanistan wars; as a post with a notoriously under-resourced and over-taxed mental health care and service infrastructure; and as a community grappling with the effects of those shortfalls. But the Fort Hood testimonies also concern something much broader—the Army’s attempt to hold down combat and counterinsurgency operations in two theaters with volunteer forces over the course of a decade; the long legacy of multiple deployments; and the ongoing health care needs of a generation of veterans on whose labor and bodies these wars have depended.

Fort Hood is at once many things. It is a garrison, a temporary duty station, and a training ground. It is a base-town where families live and children go to school. It is a command structure and a set of policies that interlock with larger bureaucratic structures and institutions which regulate not only Fort Hood, Texas—but the path between Fort Hood and Iraq, Afghanistan, and other sites of US military action. If the wounds of war seem invisible to much of the country beyond its gates, Fort Hood is a place where the effects of thirteen years of war are self-evident. Life and work at Fort Hood are integral to the production of US warfare abroad.

Each soldier and veteran who tells their story here has served and lived at Fort Hood—some for months and others for many years. Many have deployed from it and returned home to it. Some have spent time in its inpatient psychiatric ward; raised children; gone AWOL; or become conscientious objectors. All have borne witness to the way life and military service change when soldiers deviate from the norm of ‘fit for duty.’

Each testifier also tells a story spanning beyond Fort Hood. The soldiers who testify here have served at many other bases—from Fort Riley in Kansas and Elmendorf-Richardson in Alaska, to Camp Zama, Japan. They have not only served in Iraq and Afghanistan, but in Bosnia, Kosovo, and Kuwait, as well as in Iraq during the first Gulf War. Some have served as many as four tours across these operations, while others have never deployed, yet have faced severe injuries at home. Twenty of the 31 testifiers served multiple deployments.

Many who testified chose to do so anonymously. In order to protect their identities, details, dates, locations, and other identifiers have been changed or omitted, and where applicable, testifier aliases are denoted by an asterisk (*) next to their names.

The findings and analysis presented here describe Fort Hood as a site of multiple functions and histories—all essential to contemporary US war-making. They also evidence patterns and themes emerging from a military system much broader than Fort Hood alone.

Testifiers discussed enduring concerns which were consistent over the course of their military service—over years and across duty stations—even as they marked acute and particular problems at Fort Hood. And although each story tells of unique struggles faced by each soldier—arising from their own unique experience in the military—we find a striking consistency in the ways these lives have been stressed, strained, and injured by the last decade of military service. Many of these abiding patterns are enshrined in policies determining how the military has responded to—and alternately ignored—the needs of its service-members and their families. In these ways, the testimonies and the analysis that follows from them can be read as being both about Fort Hood, as well as about a piece of US national history that we will be reckoning with for decades to come.

The following section outlines the key findings and analyses made possible by the 31 formal testimonies taken at Fort Hood between 2011-2013, and by outreach throughout the Operation Recovery campaign during the same period.

These findings concern: the high rates of traumatic injuries—including PTSD and TBI—that are the legacy of the era of multiple deployments; the policies and practices allowing—and even promoting—the redeployment of injured and traumatized soldiers; the disciplining and discharging of injured soldiers during the course of the drawdown; the abuse of the Medical Evaluation Board process; the routine violation of soldiers’ medically-verified work restrictions, i.e. ‘profiles’; the culture of stigma that discourages many soldiers from seeking care at all; a systemic lack of adequate health care and routine violations of medical ethics; the overuse of prescription medications and under-diagnosis of soldiers’ illnesses; the lack of remediation following exposure to toxics during military service; and the absence of accountability and survivor-support in sexual assault cases.

Multiple Deployments

High rates of traumatic injuries, suicide, and other violence at Fort Hood evidence the legacy of multiple deployments during the wars in Iraq and Afghanistan, which continue to reverberate through family and community life on and around the post at Fort Hood.

In addition to increasing length and frequency of deployments, along with the shortening of dwell times between deployments that occurred throughout the Iraq War, Fort Hood soldiers testified that officials regularly flouted deployment health regulations by redeploying injured and traumatized soldiers.

Soldiers testified that they, along with other soldiers they knew, had often been re-deployed by command discretion over their medical and mental health work restrictions. Most soldiers who testified had either been re-deployed from Fort Hood with conditions they felt should have rendered them medically non-deployable, or knew others who had been. Those who testified that they did not see this happen instead reported that they saw soldiers sent home from deployments early on, who “snapped” under the stress of being there, turning suicidal or homicidal. Soldiers generally testified that they felt the safety and morale of their units had been adversely affected by the presence of soldiers who should not have been deployed, or sent on missions, while suffering injury and trauma.

As the simultaneous labor needs of two combat theaters escalated, rapid re-deployment cycles and stop-lossed deployments amplified the strain on soldiers’ lives and psyches imparted by repeated deployments. With a year or less of dwell time between tours, soldiers testified that it was easier to completely postpone their re-integration into home and community life in the US— with the awareness of a near-future deployment. Indeed, soldiers testified they felt the need to simply get through the months until the next tour. And although this coping mechanism perhaps bolstered their immediate capacity to survive and complete further tours, in the long run it left a backlog of life-changing experiences and post-traumatic stress that soldiers struggled to find space to understand and address years later.

The inadequacies of Fort Hood’s mandatory pre- and post-deployment health screening processes were reportedly a site where injured and traumatized soldiers were pushed through and re-deployed against medical advice, and where their conditions often went unaccounted for upon return. Soldiers testified overwhelmingly that the pre-deployment Soldier Readiness Process (SRP) and post-deployment Reverse-SRP (R-SRP) screening processes were cursory, biased, and corrupt. Soldiers described SRP and R-SRP as sites where soldier health was de-prioritized under their commander’s mandates to meet deployment quotas. To soldiers, this was the scene of yet another “numbers game,” in which they were treated as the number, and their health conditions regarded as just another ‘box to check’ to bureaucratically facilitate their entry into war. As testifiers report, commanders who wanted to deploy medically non-deployable soldiers had to do little more than make a few calls to ensure the soldier avoided scrutiny during SRP. Testifiers spoke of instances where they and others were pushed through and deployed, or nearly deployed, despite needing a cane to walk or being unable to wear a flak vest.

Soldiers and veterans testified that over the years of their deployments, they usually did not receive a mental health screening or even see a mental health provider in SRP, nor in the run-up to deployments. Further, when soldiers were offered access to providers or screenings for mental health conditions prior to deployment, the lack of confidentiality imparted by the setting of SRP caused some soldiers to not report concerns. Without proper assurances of confidentiality in the gymnasium and open-air settings of SRP processing, the process was impacted by the same culture of stigma that pervades soldier life and work at the unit-level.

Testifiers emphasized the impact of stigma on R-SRP post-deployment health screenings, where they were keenly aware that fellow soldiers and leadership alike would either see them join a separate line for those reporting health issues, or receive notification that they needed further processing. Beyond its lack of confidentiality, testifiers repeatedly described R-SRP as an exceptionally poorly timed inquiry.

For one, soldiers often cited that upon the moment of return, they had no idea if their mental health had ‘changed’ since they were deployed, nor whether symptoms would later surface. Many post-deployment screenings simply asked if various measures had changed in the soldier’s own experience, such as sleeping and mood. Not only were such questions inadequate screening tools in themselves, but they were not administered at a time conducive to accurate reporting of developing post-traumatic stress or other symptoms.

Secondly, soldiers reported feeling multiple sources of pressure to simply rush through R-SRP and say ‘No’ to every question asked, both because they would be released to see family immediately after finishing the process, and because peers or leadership would encourage units to finish quickly.

Since at least August 2011, DoD and Army policies have mandated three repeated follow-up screenings after soldiers return from deployments. Soldiers who returned to Fort Hood from deployments as late as 2012 reported not having received further post-deployment screenings after their initial R-SRP. Others who disclosed physical and mental health symptoms during R- SRP received no subsequent follow-up from providers, leaving soldiers themselves to self- advocate through bogged-down primary care services if they chose to pursue further care.

By Any Means Necessary: The Drawdown ‘Numbers Game’

In January 2012, following the official end of the Iraq War, DOD officials signaled a change in strategy away from large-scale stability operations, instead envisioning “a smaller, leaner Army that is agile, flexible, rapidly deployable, and technologically advanced.” This proposal required a reduction in Army forces from 570,000 in 2010 to 490,000 in 2017, and was expanded and accelerated to 2015 due to federal sequestration.

Amidst the drawdown, soldiers are being disciplined, punished, and discharged for infractions that were previously ignored, including behavior resulting from traumatic injuries. As the drawdown has progressed, this sense of betrayal has been sharpened for many soldiers by de facto changes in discipline and discharge practices at Fort Hood and beyond. Soldiers and veterans testified that commands are determined “to get rid of soldiers by any means necessary.” As swiftly as soldiers were required to re-deploy to combat operations irrespective of their medical needs when forces required, the Army has drawn down its forces by strategically discharging soldiers irrespective of ongoing treatment needs and justified service benefits. The Army’s use of discharges to skirt its responsibility for providing health care and compensation to suffering soldiers is even more egregious considering many of these same soldiers who served multiple deployments experienced command-overrides of their needs for treatment at the time of re-deployment.

Fort Hood soldiers and veterans testified to commands handling the Army’s force-reduction requirements as a ‘numbers game’ in similar fashion to their previous handling of troop redeployments. The bureaucratic mandates of the Army and DoD’s force reductions are being prioritized beyond the needs of soldiers discharged without appropriate benefits. These soldiers—when their discharges still leave them eligible for VA care—are dismissed into an overwhelmed VA system, where they encounter long waits for care without adequate transitional support from the military.

The manipulation and mishandling of the Medical Evaluation Board (MEB) process is a primary means by which Fort Hood is discharging soldiers without appropriate benefits. Testifiers describe how access to MEB—and the possibility of medical retirement with associated benefits—is arbitrarily granted and revoked by commanders. Soldiers like Randal Terrell* were placed into MEB without their consent and at great cost to their ongoing treatment needs, while others like Cody DeSousa* were removed from MEB instantly by command discretion, in order to be re-deployed.

Soldiers who did gain access to MEB testified that the process seemed stacked against them. According to Army regulation, soldiers qualify to enter MEB if their mental or physical health imparts a significant, long-term disability from fitness for duty, or a need for greater ongoing treatment than military treatment facilities can provide. Yet, many soldiers in MEB at Fort Hood are mired in the same overwhelmed treatment facilities as the general service-member population, resulting in long wait times, inadequate access to care, and lengthy delays to the evaluations which move them through the retirement process.
Testimony from Fort Hood further evidences that some soldiers in MEB paradoxically faced less access to care than soldiers outside of MEB. Fort Hood service-member Randal Terrell* was repeatedly denied medical care due to his MEB status. He testified that he “was getting more help before” he was placed in MEB.

Randal was by no means alone in the experience of such denials. Several soldiers testified that they were disallowed access to vital treatments and surgeries that would have impacted their condition while in the long course of being medically evaluated. In general, soldiers and veterans testified that MEB was an overly long, drawn-out process in which military healthcare providers favored diagnoses and treatment recommendations which would place them as eligible for diminished disability ratings. This left soldiers struggling to self-advocate for proper diagnoses and better access to care—often with little if any patient advocacy assistance from within the system. Many of these conditions mirror the larger context of inadequate physical and mental health care at Fort Hood, while others are injustices specific to inadequacies in the MEB process.

Regardless of MEB status, soldiers face long wait-lists for medical and mental health care at Fort Hood, leading to lags in accessing initial treatment, as well as between appointments. Care provision is frequently pushed down to the lowest level of medical qualification—often onto Physicians Assistants and Medics—resulting in poor quality and continuity of care. The months, and sometimes years, soldiers spend in MEB processing at Fort Hood result in the worsening of their injuries and mental health, as well as frequent profile violation and stigmatizing and degrading encounters with peers and superiors. The long delay itself is yet another cause of inappropriate discharges. Facing interminable wait-times, soldiers are being offered alternative chapter discharges which release them sooner, and with lesser benefits than medical retirement would afford. With the medical and administrative system stacked against them in these ways, soldiers suffering injury or trauma are placed in no-win situations.

Soldiers in MEB are often on profile for medically necessary work restrictions, and as such face a context of stigma and punishment, along with other systemic factors blocking access to care. Testifiers frequently reported being denied time off to attend medical appointments. These instances included appointments for evaluations which were integral to the soldier’s progress through MEB. Frequently, supervisors claimed the soldier could not be spared from the kinds of banal work details injured soldiers were often placed on, such as picking up trash, pulling weeds, or mopping hallways on post for many hours at time. These details often pushed the limits or ambiguities of soldiers’ profiles, or violated them altogether, and in general were experienced as punitive and degrading by soldiers who were waiting to be acknowledged for having been injured in the course of their service, and medically retired from the Army. Soldiers often described these experiences as the Army adding insult to injury, as they were already struggling with a sense of loss because their profile restrictions kept them from doing the work they had been trained for, and which gave them a sense of worth, purpose, or pride. The barriers to evaluation and treatment in MEB amount to a denial of service-members’ right to medically retire with proper benefits once they are no longer fit for long-term duty.

Soldiers and veterans testified that they had seen and suffered Article 15’s and other disciplinary actions, such as extra duties, poor evaluations, blocks to promotion, and generally degrading and abusive treatment from supervisors and peers, because of the symptoms of their injuries. Throughout the drawdown, commanders at Fort Hood have heavily relied on the use of disciplinary measures rather than proper treatment to address behavior commonly understood to result from traumatic injuries—such as substance abuse. At other times, soldiers have been disciplined for issues directly resulting from their treatment—such as oversleeping while on heavy medications used to treat TBIs. In other instances, soldiers were discharged for being overweight —even when they had previously deployed at the same weight. These demonstrations of soldiers’ disposability, as well as a dire lack of effective pathways for redress, have contributed to a climate in which soldiers are afraid to even request care. This has resulted in immense pressure on soldiers—especially those supporting families—to not admit vulnerability or injury out of fear of retaliation or losing their job security. Many active duty soldiers who testified for this report indicated they chose to testify anonymously for fear of repercussions on their military status or benefit evaluations for pending discharges.

Fort Hood soldiers, veterans, and their family members testified that existing methods of redress for these and other grievances were often dead-ends. While some testifiers reported positive experiences of assistance from resources such as the Inspector General, and the Ombudsman’s office, as a whole, the testimonies evidence that soldiers and their families had to self- advocate—usually over extended periods of time and at risk to their military careers—before they were granted any redress. Many others reported that they either did not try to access methods of redress for fear of retaliation, or that they were discharged before having any opportunity to access redress. As a whole, the testimony evidences that health care protocols at Fort Hood are being conducted under a grave lack of appropriate oversight, accountability, and available recourse for those suffering such violations.

Testifiers acknowledged Fort Hood’s efforts to cope with and adapt to the widespread struggles of its soldiers and their families, yet they described these efforts as systematically lacking, and leaving soldiers open to scrutiny. One soldier described command’s efforts as “[putting] a band- aid over a gaping wound.” Another veteran testified that the military’s efforts were just an attempt to manage bad publicity and “get through each year” with the bare minimum of reform.47 Particular efforts—especially several of the military’s efforts to attend to health care—were described as provisions that allow Fort Hood to simply ‘check the box’ on paper. Soldiers described positions such as Equal Opportunity (EO) leadership as secondary or tertiary duties assigned to soldiers that do not have adequate time or training for them.

When Doctors’ Orders are Not Orders: Command Discretion Over Medical Care

Commanders and supervisors with no medical or mental health training maintain total discretion over soldiers’ medical and mental health care at Fort Hood. Commanders routinely disregard and override doctors’ orders for soldiers’ medically necessary work restrictions, as expressed in the soldier’s ‘profile.’ This practice is rampant at Fort Hood, despite its own command policy against profile violation, SURG-05, which states that doctor’s orders should be respected by commanders and supervisors, and not regarded as ‘recommendations.’ Despite its own policy, profile violations at Fort Hood are an everyday occurrence. The policy’s lack of specificity and the total absence of enforcement mechanisms render it ineffectual. Soldiers and veterans of Fort Hood testified that violations of their profiles were so common as to be ‘non-events,’ part of the expected, everyday fabric of life on post. Extensive profile violation at Fort Hood has caused medically non-deployable soldiers to be redeployed, and has exacerbated the medical and mental health conditions of countless soldiers and veterans, worsening their long-term prognosis.

While Fort Hood has had command policy against profile violation in effect since at least 2011, in reality, the chain of command remains systematically set up to allow for, and in certain ways promote, profile violation as an everyday norm. Throughout our interviews and outreach at Fort Hood during 2012 and 2013, most soldiers testified that they were unaware of these command policies against profile violation. This included many NCOs who were in charge of the daily activities of lower enlisted soldiers. Nearly all soldiers and veterans who testified reported that, regardless of policy, the sanctity of profiles depends entirely on the individual leadership of units, and varies widely between them.

The soldier profiling and communication system at Fort Hood seems engineered to fail the command’s promise to respect the medical needs documented in soldiers’ profiles. Army regulations in place since January 2011 mandate that all soldier profiles for conditions lasting for, or longer than, eight days are to be recorded by health care providers and communicated to the chain of command electronically through the MEDPROS e-Profile system. Army policy specifically dictates that with this electronic system in place, neither soldiers nor unit leadership should accept new paper profiles. In subsequent Compliance Report Clarifications on how units should implement e-Profile, the Army has directed leadership that “compliance is mandatory and overdue” for its instructions.

Fort Hood soldiers testified to a wide range of routine violations to these policies, which occur at the expense of soldiers’ physical and mental health. In practice, the systemic treatment of soldiers on profile at Fort Hood is in utter contradiction to the instructions of both Fort Hood’s own command policy and Army regulations.

Soldiers testified that in many units, profiles are simply disregarded, or soldiers are pressured to break them, on a day-to-day basis. Others reported that supervisors were always pushing the stated limits and unstated ambiguities of their profile’s restrictions—for example, a soldier whose profile stated they should not carry a rucksack over a certain weight was made to carry an alternate heavy object on a ruck march. Many testified that the common profiles for “Do not run” or “Run at own pace and distance” were treated as cause to push injured soldiers into more strenuous activity, often lengthening healing times for injuries, or causing re-injuries.

Soldiers also commonly reported that their supervisors and commanders only regarded profiled work restrictions as valid if the soldier could present the paper profile at the time a duty is requested of them. This held true at Fort Hood consistently, throughout our interviews, even while Army policy had long been on the books upholding the validity of electronic profiles, and indeed discouraging reliance on paper profiles. For soldiers on profile at Fort Hood, “If you don’t have it on you, it doesn’t exist according to our command.” In many units, the e-Profile system seems to be regarded as nonexistent. In other units, soldiers reported profile violations stemming from problems with the inconsistencies in the implementation of the e-Profile.

In those instances, provider compliance with e-Profile meant that they electronically entered but did not print the soldier’s profile, which left the soldier without the paper profile which was treated by their unit as the only valid release from work. When soldiers needed to log-in to e-Profile and print their profile for their supervisor, but had problems with access or printing services, their profiles were disregarded. These practices are in stark contrast to the Army’s e-Profile instructions to commanders and NCOs, who are mandated to actively monitor their soldiers’ work restrictions, communicated electronically by providers. Instead, multiple points of leadership are pushing the responsibility onto soldiers to self-report their profiles. Injured soldiers at Fort Hood are shouldering the burdens of this ill-implemented system.

In yet other ways, Fort Hood soldiers are pressured to disregard or violate their own profiles for a host of reasons. Even when not explicitly instructed to violate profiles, when consequences to their NCO Evaluation Reports (NCOERs), PT tests, promotions, or their ‘good grace’ with command were held over soldiers’ heads, they often felt pressured to engage in re-injuring work activities. Fort Hood veteran Ian Augusto* reported that the daily “extreme pressure” to violate his profile was paired with threats of punishment if he did not follow the dictates of his own profile ad nauseum. For example, Ian was threatened with punishment when he was five minutes early to work, while his profile required that he should only work from 9am to 5pm. Max Diaz* reported that a supervisor would threaten to “Article 15 you for malingering” if caught violating one’s own profile, even while his unit leadership pressured soldiers to violate profiles daily.

Widespread profile violation at Fort Hood exacerbates soldiers’ physical and mental health issues, stifles the potential benefits of any treatment and counseling they are receiving, and is itself is a source of chronic stress on soldiers. For many who testified, what may have been temporary injuries if proper treatment and work restrictions had been applied, instead became long-term, chronic health conditions. Profile violation by those in leadership positions also contributes to the stigmatization of medical and mental health concerns by perpetuating a culture of disregard for injury.

A Culture of Stigma with Concrete Consequences

Soldiers at Fort Hood fight a severe culture of stigma that discourages them from seeking treatment for physical as well as mental health issues. While Fort Hood has maintained command policy explicitly instructing leadership at every level to work against the stigmatization of mental health concerns since at least 2011, the culture of stigma continues unabated, and its pressures have become even more extreme amidst the drawdown. Military-wide, this stigma is partly evidenced by the fact that more than half of service-members with mental health issues forgo treatment.

Fort Hood soldiers and veterans describe stigma against physical and mental health issues as a pervasive aspect of their lives in the military, circulating by implicit, cultural means, as well as through explicit events which label, ostracize, and degrade soldiers for their health concerns, or for simply being on profile. These explicitly stigmatizing events were often accompanied by ridicule, humiliation, punishment, or ‘corrective training’ in front of peers applied by leaders to degrade and stigmatize soldiers with profiles or injuries. With the de-stigmatizing command policy SURG-01 in place, yet largely ignored, Fort Hood’s pervasive stigma operates in similar fashion to its empty prohibition of profile violation.

While SURG-01 instructs “leaders to do everything possible to eliminate any stigma or adverse consequences for soldiers associated with behavioral health assistance,” its prohibition lacks any definition of stigma, as well as any enforcement mechanisms. SURG-01 is thus largely ineffectual at its mission; non-specific prohibitions of stigma by both DoD and Fort Hood have not eased the extremely negative context endured by soldiers who suffer physical and mental health issues.

Meanwhile, the effects of stigma at Fort Hood continue to exert concrete and injurious effects on soldiers. Many testifiers reported that the extreme stigma often causes soldiers to wait to seek care until their injuries or mental health concerns are so severe that they have no other choice. For Jake Leighton,* this meant waiting to seek care until his drinking had become chronic and debilitating, while others such as Chaplain’s Assistant James Cleary* put off seeking care until he was hospitalized for suicidality. Under the pressure of stigma and the threat of punishment, soldiers’ injuries generally worsened while they avoided seeking care, usually over the course of several years of service. Mental health concerns which may have affected soldiers on a temporary basis were exacerbated without access to treatment and through the stressful and punitive events associated with the culture of stigma at Fort Hood. Many soldiers testified that after suffering for many years, they finally sought care when they were about to ETS, or that they waited until they were completely discharged to try to access care at the VA. However, soldiers like Curtis Sirmans, who waited to disclose his post-traumatic stress symptoms until entering the VA, face uphill battles in accessing care and proper disability ratings as veterans. Curtis, like many others, was denied acknowledgement by the VA for conditions which were not reflected in his Army medical records. Several veteran-testifiers described struggling with the culture of stigma and limited health care access at Fort Hood, followed by months and years of wait-lists at the VA.

Soldiers and veterans of Fort Hood testified that it did not seem to matter how “squared away” of a soldier you were before an injury or mental health concern emerged. Regardless, injured soldiers were “looked down upon,” and labeled with an array of derogatory terms, circulated by lower enlisted as well as those in leadership. Soldiers enduring this stigma felt doubly betrayed, for being stigmatized despite their service and sacrifice, as well as for being denied the care they were promised. And while the abiding stereotype against soldiers on profile is that they are ‘faking it’ or ‘riding their profiles’ to avoid work or deployment, many soldiers testified that they were already suffering the loss of their sense of worth that came with their work restrictions, and some continued to wish that they could still do their jobs.

For many soldiers, this stigma was synonymous with a culture of pressure on soldiers to simply override their own profiles or health needs to continue doing their assigned work no matter the consequence to their health. The possibility of being labeled a ‘shitbag’ loomed large, and was often reported as enough cause in itself for soldiers to avoid even being on profile or seeking treatment at all. Ridicule from supervisors and other soldiers for asking to go to sick call was frequently cited by soldiers as a deterrent for even pursuing that first step toward accessing care. There is no operational definition of stigma, nor means of enforcement.

Much like systemic profile violation at Fort Hood, soldiers report that the severity of stigma at the small unit level depends entirely on their leadership. Fort Hood soldiers testified that there were only a small minority of units in which leaders fostered respect for soldiers on profile or those in discharge processing—such as Warrior Transition Units (WTU). With access to WTUs extremely limited, this does not represent any significant headway at Fort Hood to de-stigmatize injury.

Fort Hood NCOs testified that their own efforts to de-stigmatize injury and advocate for soldiers’ care needs had put them at odds with their command. Several testified to the impossibility of complying with conflicting orders to complete jobs they were not staffed for and abide by their soldiers’ profiles and care needs. NCOs testified to their own dissonance as they sought to comply with the competing obligations of the NCO creed—“accomplishment of my mission and the welfare of my Soldiers.” Many NCOs faced direct pressure from the chain of command to cease their advocacy on behalf of lower-enlisted soldiers, but more often, NCOs were simply left alone to shoulder conflicting demands. As we spoke with soldiers, there emerged a distinct division of labor around maintaining the order and well-being of soldiers, wherein top leadership defer to un- enforceable policies concerning stigma and profiles while non-commissioned officers must attempt manage irreconcilable demands. Indeed, it was extremely difficult for testifiers to imagine forms of accountability that might implicate commissioned officers. When asked what types of actions would reduce stigma related to accessing health care, most testifiers responded that more punitive action should be taken against unsupportive NCOs—even in cases where the testifier themselves was an NCO who had faced pressure to violate profiles.

Soldiers repeatedly testified that stigma was even more extreme in certain MOSs, such as Combat Arms and Aviation. Those serving in Infantry units often reflected that they were particularly rife with stigma, remarking they were directly trained to “just rub some dirt on it and move on.”

Likewise, while commanders reportedly emphasized the value of seeking help, Apache Pilot Nicolas Addison* testified that anti-stigma edicts in Aviation brigades amount to empty rhetoric hiding the retaliatory context around disclosing mental health issues. Addison testified that, “You cannot have PTSD as a pilot. I mean, kiss your career goodbye. You’re done.” Yet he also reflected that he saw many peers continuing to endure symptoms of untreated post-traumatic stress. Addison himself resorted to seeking care through off-record appointments with providers and taking a Wellbutrin prescription for his self-diagnosed post- traumatic stress under the pretense of using it for smoking cessation.

Women soldiers and veterans at Fort Hood further testified that this stigma is intensified under the pressures faced by female service- members, who feel they have to be “more hoo- ah” and “prove themselves” due to a sexist workplace culture which regards them as less capable overall than male soldiers. Female soldiers testified that this intersection of sexism with the blanket stigma at Fort Hood made it even harder to decide to seek care, as they already faced the differential perception of being weak or inferior before suffering injury. The culture of sexism also combines harshly with Fort Hood’s generally lacking treatment of health concerns to place unrealistic expectations on women in service, for example, on pregnant active duty soldiers. As Anja Perry* testified, “Nobody expects you to fully recover in six months in the civilian world.” Yet, after her pregnancy, her command afforded no profile restrictions past that date and expected full physical performance and weight maintenance. Male soldiers confirmed that in historically all- male units where women are beginning to serve, women face a generally negative attitude from their peers, who believe they “cause trouble,” and that these sites can be rife with sexual violence against female soldiers and civilians alike. Nicolas Addison* testified that, for women entering Aviation units, “Nobody’s gonna be glad to see you, including myself.”

These testimonies reveal that the effects of this stigma are becoming more detrimental amidst the drawdown. Soldiers testified that commanders are more punitive and dismissive towards soldiers in need of care. Where soldiers once encountered rampant ridicule, they now fear the initiation of discharge proceedings likely to result in the fewest benefits that might be accorded. Supporting families, having accrued debt, or having one’s military experiences mediated by gender and race discrimination all compound the ways in which soldiers differently suffer under the drawdown’s implicit mandate to remain silent while suffering.

Betrayed Promises: Fort Hood’s Systemic Lack of Health Care

The aforementioned conditions are accompanied by many other structural barriers to health care access and quality which soldiers endure at Fort Hood. Their testimony provides evidence of a generally poor quality of care offered, and a poor-to-nonexistent continuity of care. The sense of betrayal as a result of these inadequacies runs strong amongst soldiers and veterans, as well as their family members who remain responsible for providing care and support where the military denies it.

Often when soldiers at Fort Hood can access treatment, they are forced to rely on Physician Assistants—or on Medics when they are in the field—who are, in turn, under structural pressure to practice beyond their scope of professional competence. With systemic lack of access to doctors and specialist providers, many soldiers only saw their assigned PAs over lengthy periods.59 In some cases, their treatment recommendations, diagnoses, and prescriptions would later be overridden by physicians once they finally saw them.60 Between a lack of communication between providers, and changes to her primary care doctor approximately every three to four months, Fort Hood veteran Anja Perry* reported she had to “start over” in seeking treatment at nearly every appointment.

Soldiers frequently reported that medical and mental health providers at Fort Hood used diagnostic practices which relied heavily on self- reporting, paper questionnaires, and very little time spent actually interviewing their soldier patients. Their testimony presents evidence that medical professionals serving in the military are not following consistent diagnostic and treatment protocols agreed upon as standard in the civilian medical sector, and prescribed in medical ethics codes of practice nationally. The perpetuation of command discretion over medical treatment likewise contributes structural pressures on providers to declare soldiers ‘fit for duty’ and send them back to work prematurely, in accord with command’s desires to meet readiness and deployment quotas.

This context of poor quality care has exacerbated injuries over the course of soldiers’ service. For some who testified, their physical injuries began during Basic Training, and the generally stigmatizing conditions and lack of longer-term care accessed since first enlisting resulted in chronic injury far beyond what was the natural result of the original incidents.

Perhaps the most chilling effect of these conditions combined is the high number of active duty soldiers and veterans who end their lives by suicide. Record high suicide rates—which far outpaced combat deaths and peaked in 2010 at Fort Hood with 22 active duty suicides—come as little surprise in light of the difficulty accessing care on post—and the increasingly high stakes of possible discharges for doing so. Painfully aware of the culture of stigma and scarcity of care, soldiers testified that they see through the Army’s suicide prevention efforts, which seem to amount to lip-service while the system at large is left in poverty.

Over-Medicated and Under-Documented

Over-medication for both physical and mental health symptoms is a primary means by which Fort Hood treatment facilities provide substandard care to soldiers on a routine basis. Nearly all soldiers and veterans who testified reported they were given prescription drugs for nearly anything which ailed them, often as a substitute for more thorough screening and non-pharmaceutical treatment. This is reflected in the daily averages reported by Fort Hood’s main medical facility, Darnall Army Medical Center: it reports a daily average of 4,258 patient encounters, and an average of 4,160 daily prescriptions.

For many, this heavy reliance on medication was accompanied by an alarming lack of medication management, both at home and on tour. In general, many Fort Hood soldiers’ impressions of medical and mental health treatment was that drugs were “thrown at them” indiscriminately to see if their problems would go away. Soldiers reported being prescribed medications instead of being given diagnoses, surgeries, and counseling.

Over-the-counter pain-killers and prescription opiates were some of those most commonly reported “indiscriminately” prescribed medications. Soldiers reported being on these prescriptions during deployments, and being assigned to duties and missions which they felt incapacitated to perform. Infantry soldiers such as Jake Leighton* felt they were thus unable to protect themselves and their fellow soldiers on missions, which was both a dangerous and stressful experience.

Along with frequently receiving psychotropic drugs as the only treatment offered for mental health concerns at Fort Hood, soldiers testified to being supplied with psychoactive drugs in large quantities in order to get them through their deployments. These soldiers, such as Allen Dunajs,* then received little to no medication management during their tours overseas—the nearest qualified provider to Dunajs while deployed to central Iraq was in Kuwait. At other times, soldiers would run out of their psychotropic medications while on tour and need to have a convoy assigned to retrieve supplies from another base in country. NCO Ian Augusto* testified that he struggled as a team leader to accommodate his soldiers’ prescription needs in Afghanistan, where miscommunication and base clinic’s supplies running out meant soldiers faced gaps in medication, and sometimes had other psychotropics substituted on the fly.

The general practice of over-medication for both physical and mental health conditions at Fort Hood often also took place without providers assigning soldiers accompanying diagnoses. With their conditions undocumented over long periods of service, soldiers struggled to make their case for a just disability rating ahead of discharge if they were able to enter MEB, and regardless often left the military with medical records which grossly underreported their disabilities and treatment needs to the VA.

Struggling Families

While the effects of multiple deployments on families at Fort Hood have been harsh, imparting long absences, fears of loss, secondary trauma, domestic violence, and uncertain futures amidst the changing context of the military, family members testified that the stakes felt even higher since the advent of the drawdown. The threat of pay cuts and risks to promotions following from the disclosure of injuries has become more severe, leading soldiers and families further into isolation and away from seeking help and treatment. Over the last decade, and throughout the drawdown, the spouses, partners, children, and community members surrounding soldiers at Fort Hood have shouldered soldiers’ needs for care where the military has discouraged and denied those needs. Families have remained soldiers’ de facto caregivers while often receiving little support from the military themselves.

What testifiers described as a dire lack of access to care for soldiers, is only more acute for their families. Family members testified that Fort Hood’s rhetoric of support for families lives on as yet another broken promise. Its standard family support programs, such as Family Readiness Groups (FRGs), frequently did not feel supportive to family members in need.

Meanwhile, financial support and health care was in even shorter supply than that available to soldiers. Amidst these conditions, soldiers expressed deep concerns for their family’s well-being, and family members described the isolation of life on and around Fort Hood as compounded by a lack of access to adequate health care and counseling resources.

Fort Hood Soldiers and veterans also cited the lack of support for their families as a source of stress they carried while on deployment—which intensified the host of other stresses they faced. The rigors of back-to-back deployments with inadequate dwell times meant that neither the soldier nor their family members could re-integrate and learn to cope with soldiers who reported feeling like “different people” after each deployment. For the children of soldiers, the fact of their long absences alone was difficult, and more so in combination with their parents’ emotional struggles or physical disabilities upon return.

Unfortunately, the struggles lived by soldiers’ families throughout a decade of deployments are now followed by drawdown practices that throw families into uncertain futures. The strains of the past decade have broken apart many marriages and parent-child bonds. And while families may have supported soldiers through years of service, even when their relationships paid the price, ex- spouses only maintain access to health care and military programs in extremely limited circumstances following a divorce.

Cynthia Thomas supported her husband, soldier Chris Thomas,* and their two children through three deployments over the course of almost two decades. They met upon his return from Desert Storm in 1991. Despite being severely injured in 2005 with multiple fractures and a Traumatic Brain Injury, after which he was declared medically non-deployable, Chris’s command re-deployed him to Iraq once more in 2007. Despite supporting Chris and their family for nearly two decades during his service, after their divorce Cynthia and her two daughters were left without benefits from the VA. As of January 2014, they testified that as a family, they continued to live without health insurance.

While family members’ access to military and VA benefits may be compromised, the emotional struggles continue. Parents testified that both they and their children suffered the effects of secondary trauma—though children seemed even more vulnerable. Testifiers who were separated from their children for years at a time continued to reckon with whether their tours abroad were worth the separation from their children’s lives and early development.66 Seeing the effects of the wars in Iraq and Afghanistan on Iraqi and Afghan children threw into relief questions of conscience for soldier-parents.

As a community, the greater Killeen and Fort Hood area continues to endure high rates of family violence and child abuse, as well as high divorce rates, evidencing a community whose resilience has been repeatedly tested by multiple deployments and inadequate resources. The Fort Hood area continues to cope with a high rate of traffic fatalities, as well as the long-term effects of the two mass shootings perpetrated on post in the last five years.

While each incident of violence is caused by unique factors in the lives of soldiers and their families, it is clear that the Fort Hood and Killeen community at large bears burdens of trauma, stress, and economic hardship that have uniquely accumulated over the last decade of U.S. wars.

The Decade’s Signature Traumatic Injuries

The counterinsurgency operations in Iraq and Afghanistan have been characterized by patrols of civilian populations, extension of the combat zone into civilian sectors, and the absence of a clearly defined ‘front line.’ These factors have served to compound service-members’ traumatic stress effects. Service-members’ risk of developing post-traumatic stress increase with each repeated deployment.69 PTSD diagnoses in the military increased by 650% between 2000 and 2011,which likely represents a gross underestimate of the prevalence of post-traumatic stress due to factors discussed below.

While many labels are applied to soldiers’ distress, many Fort Hood testifiers spoke less concretely or categorically about how they experienced their own struggles, as well as the collective mental health struggles of their fellow soldiers and veterans. Some of the words they used to reflect on the causes of soldier trauma are presented in the text boxes below.

Many testifiers spoke of how they felt “changed” in who they were as a person, with each deployment; that they were experienced as “a different person” afterward by loved ones. For many, this included being more “on edge,” irritable, or “ready to snap” than they had been before deploying. For others, alcohol or other drugs became a way to self-medicate. Many spoke of struggling with nightmares, night terrors, headaches, paranoia, memory loss, insomnia, hallucinations, flashbacks, despair, apathy, anger, guilt, feeling generally beaten down or betrayed by the military, and a profound questioning of the morality of their military service or conduct in theater.

While some soldiers testified to feeling lucky they did not develop what they saw around them as post-traumatic stress, PTSD, or TBI, they also reflected the great prevalence of “slight PTSD,” or soldiers generally not feeling like themselves, even if they did not feel they had ‘diagnosable’ mental health conditions. NCO Reese Stewart* testified to widespread mental health struggles amongst soldiers in his unit and others, and said that he himself simply felt that, after two tours in Iraq, “My give-a-fuck is busted.” Ian Augusto* reflected a similar sentiment, saying that amongst soldiers who had been on multiple deployments, “There’s a huge level of don’t-give-a-shitness, I guess you could call it.” Other soldiers instead felt a heightened sense of conscience, and questioned the morality of their own actions, as well as the wars they fought in. While many soldiers struggled for words to accurately describe the trauma or distress they continued to live with—especially when they did not feel the labels of ‘PTSD’ or other diagnoses fit those experiences—most testified that they were either diagnosed with PTSD or TBI, or that they would qualify for these diagnoses if properly evaluated.

Although the Department of Defense, the Army, and Fort Hood command alike maintain policies unequivocally upholding their priorities to respect and treat soldiers’ mental health concerns and traumatic injuries, testimony from Fort Hood shows a wide variation in how these are treated at the unit level, which has great bearing on soldiers’ mental health outcomes. The testimony also evidences an alarming tendency in military mental health treatment to avoid granting PTSD diagnoses in favor of other disorders less commonly linked to traumatic experiences—such as Adjustment Disorders, Personality Disorders, Bipolar Disorders, ADHD, Depression, and Anxiety Disorders.71 Soldiers who felt they had been wrongly diagnosed with these alternate disorders testified that it seemed like PTSD was the “last diagnosis” military providers wanted to give. Given this testimony, it is likely that the reported 5,000 soldiers diagnosed with PTSD at Darnall in Fiscal Year 2013 alone under-represents its true prevalence.

The application of alternative diagnoses to soldiers suffering post-traumatic stress also places diminished emphasis on their history of stressful or traumatic experiences during service, while implying their conditions are more characterologically rooted. This is greatly consequential to the service-connected benefits soldiers are offered at discharge, with alternative diagnoses often carrying less benefits. These diagnostic practices likewise may be miscommunicating veteran treatment needs to the VA in large numbers, and can result in soldiers unnecessarily struggling with their own mental health status or misattributing the causes of their symptoms to their own personal flaws instead of traumatic experiences.

Traumatic Brain Injuries have also become common during this decade of war. A primary effect of the technological advancement of warfighting since 2001 has been experienced by soldiers and veterans who have survived explosions and other injuries at rates never before possible. Higher survival rates have produced a generation of soldiers apt to be redeployed again after initial injuries. Unfortunately, the higher population of surviving soldiers has not been met by the military with sufficient resources to ensure their quality of life or psychological recovery. While enhanced physical survival has been enabled through advances in armoring and medical technologies, surviving soldiers have endured the absence of complementary breakthroughs in mental health treatment. Indeed, mental health treatment facilities at Fort Hood have been incredibly overwhelmed by the demand of soldier-patients seeking care.

The testimony reveals a general trend at Fort Hood from previously non-existent provider-training, screening, and treatment for TBI toward generally better provider-training and treatment options, along with better post-incident screening applications on tour. However, soldiers and veterans overwhelmingly testified that they still suffered untreated TBIs, and received inconsistent pre- and post-deployment evaluations after having been exposed to blasts. While the military did not begin to widely acknowledge the prevalence of TBI amongst soldiers until the Iraq War was well underway, the reasons for this neglect are poorly founded, as a body of scientific studies on concussive brain injuries was already well developed in the arenas of sports medicine and other international conflicts.

Once the DoD began to evaluate soldiers for TBI, it selected an evaluation tool, the Autonomic Neuropsychological Assessment Metrics (ANAM) test, which is not scientifically validated as a brain injury detection tool. The ANAM is a cognitive performance, or ‘aptitude,’ test. It was adopted by DoD and mandated as a pre- and post-screening for all deploying soldiers as a TBI screening tool.

A majority of Fort Hood soldiers and veterans who deployed after the ANAM was mandated testified that they had only received the pre-test, if they had been screened at all. This included veterans like Mark Simons,* who was exposed to multiple blasts on deployment, and reported chronic memory impairment and other TBI symptoms at the time of his interview, yet had never been screened for TBI by either the military or VA. The DoD’s lack of adequate TBI evaluation practices, including at Fort Hood, have caused uncounted soldiers to be redeployed and placed at risk of further aggravation to existing brain injuries, as well as allowed others to be discharged without benefits despite their symptoms.

When brain injury or other psychological distress results in memory loss or impairment, soldiers in need of care under the current health care system at Fort Hood are left at a systematic disadvantage due to the military’s over-reliance on self-reporting screening tools and lack of adequate record-keeping. Indeed, soldiers with memory impairments may be unable to recall or in 2008 report their medical histories. For some who testified, this was compounded by the effects of stigma, which meant they had generally not spoken about their struggles, or the precipitating events of their injuries, to even their friends or loved ones.

The decade’s signature wounds also include a devastating range of toxic health effects wrought by soldiers’ exposures to experimental vaccines, toxic munitions, and burn pits. Fort Hood soldier Dan Michael’s* wife, also a veteran, was repeatedly exposed to incinerated chemicals from burn pits in Iraq, leaving her with severe degenerative joint issues. Upon being initiated for medical treatment while on active duty, her supervising officers “treated her like she was the scum of the earth, especially when she had the nerve to speak up for soldiers’ rights.” Fort Hood veteran Devon Sawyer* continued to struggle with complex health issues on top of his TBI and post- traumatic stress, and at the time of his interview in 2012 was in the process of being diagnosed with either Crohn’s disease or ulcerative colitis. Devon continued to wonder whether his health condition was caused by his exposure to experimental botulinum toxin injections for his migraines, which were not permitted among civilians at the time, as well as vaccine exposures and environmental toxins in Iraq. While Congress has banned the future use of open air incineration by the armed forces, there remains a dire need to address the wide range of conditions veterans now suffer from following their exposure to burn pits. The DoD’s refusal to acknowledge the extent and locations of its use of toxic munitions in Iraq and Afghanistan likewise leaves in the dark veterans who are suffering complex effects from potential exposures, and leaves entire Iraqi and Afghan communities to suffer severe, intergenerational epidemics without remedy or reparation.81

Since beginning to recognize the extremely high prevalence of sexual assault and harassment in the military during the last decade, the DoD and VA have only begun to implement the reforms and programs needed by the tens of thousands of soldier and veteran sexual violence survivors. Based on an an anonymous survey, the Pentagon estimated that there were 26,000 incidents of “unwanted sexual contact” in FY2012, a large increase from the estimated 19,300 such incidents in the same survey for FY2010.

A stunning comment on the prevalence of sexual violence in the military, the difference in these numbers is a testament to the degree of underreporting likely taking place. The Pentagon released its FY2013 report on sexual assault earlier this month, which reports that the DoD received 5,061 sexual assault reports that year, a 50% increase over FY2012, in which 3,374 reports were received.83 In an Institute of Medicine study, only 33% of women and 10% of men who reported experiencing unwanted sexual contact reported the incident to a DoD authority.

Testimony from Fort Hood evidences that even where policies supporting survivors are in place, they are very inconsistently applied, and soldiers—men and women alike—face vicious stigmatization, with care and accommodation left at the total discretion of their chain of command. In the aftermath of Fort Hood veteran Rebekah Lampman’s sexual assault by a fellow service-member, “nothing was done according to regulation.” The report of her sexual assault was immediately spread amongst many service-members in her barracks; she was made to live in the same building with the same common facilities as her assailant for months on end; and her commanders repeatedly blamed her for the assault, telling her to “get up and move on.” The intense culture of stigma and victim-blaming for sexual assault in the military meant that Rebekah, like many other soldiers, was considered at fault for her assault far before any court martial could consider the evidence. Unlike most cases of sexual assault, Rebekah’s assailant was eventually court-martialed and found guilty, subsequently serving around nine months jail time.

Male survivors of sexual assault in the military face added stigma, as hypermasculine norms not only focus blame on all victims of sexual assault, but further silence the presence of male survivors. Many Fort Hood soldiers testified that the trainings they receive on sexual violence focus solely on scenarios with women victims. Fort Hood NCO Dan Michaels* was sexually assaulted early in his career, and when he asked for help, “was laughed at. When I called my first sergeant, he said he wished that happened to him.” Dan further testified that his sexual assault was not documented in his medical records or treated legally or medically; instead “they treated it as some sort of a joke.”

The military’s token attempts to address sexual violence and gender inequality continue to blame survivors and leave the behaviors of perpetrators unexamined and unaddressed.

This affects service-members of all genders and the relationships, families, and communities to which they belong. The out of hand acceptance of gender-based targeting and harassment is a key means by which the military evades responsibility for acknowledging and addressing the violence and trauma its members experience during service.

Read the full Findings and Analysis section, including footnotes

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