On behalf of those who are suffering and will continue to suffer from the adverse consequences of the Department of Defense, Veterans Affairs, and command policies addressed within the report, we recommend these changes be implemented immediately.
Ensure Respect for Soldiers’ Profiles
Violations of soldiers’ medically necessary work restrictions violates their rights to health and well-being. Commander discretion over soldiers’ profiles and access to treatment not only interferes with soldier well-being by impeding the treatment plan, but also perpetuates stigma against injured soldiers, and promotes a culture of fear whereby soldiers avoid seeking care.
End commander discretion over medically necessary work restrictions expressed by soldiers’ medical and mental health care providers, to ensure doctor’s orders are upheld within the chain of command. Ensure that no member of any of the DoD’s forces is forced to work or deploy against medical advice.
- DoD, as well as all branches of the US military, must implement specific policy and enforcement mechanisms barring commander discretion over the professional advice of medical and mental health practitioners working in the military.
- Install enforcement mechanisms and reporting procedures to address commanders who fail to support the pursuit of health care.
Stop Improper Discharge Procedures
The consequences of the draw-down should not be shouldered by injured soldiers and their families. The Department of Defense must ensure that no service-member is discharged improperly, outside of DoD separation regulations. DoD must enact immediate evaluation and monitoring of discharge practices in all departments. This must be followed by DoD instruction to address how the departments should drawdown their forces in an ethical manner which is aligned not only with DoD separation policies, but with service-members’ rights to the health care they were promised upon enlistment. Fort Hood command must act simultaneously to implement these changes, using all available resources, to cease the violations of soldiers’ right to health under its watch. These changes should be monitored by an independent body partnering with the military to ensure accountability.
Prioritize the provision of adequate medical and mental health care for all service-members as a military-wide commitment to implementing an ethical drawdown of the forces.
Cease improper screening and diagnostic procedures used to justify involuntary, disciplinary discharges and administrative separations, as well as inaccurate MEB disability evaluations.
- Provide proper diagnostic assessment. When a diagnosis of PTSD or TBI is warranted, it should never be replaced by diagnoses such as Personality Disorders, Adjustment Disorders, Depressive Disorders, Bipolar Disorders, Attention Deficit Hyperactivity Disorder, nor any other diagnosis which would misrepresent the service-member’s condition by implying a pre-existing or characterological condition.
- Fort Hood must cease any pressure on or instruction to providers to avoid diagnosing soldiers with PTSD. Such practices allow the military to eschew its duty to provide due benefits to soldiers, and adversely affect soldiers’ navigation of longer-term care.
Institute automatic mandatory comprehensive physical and mental health evaluations in all pending misconduct discharges and other involuntary discharges, especially as many behavioral infractions at Fort Hood result from soldiers’ psychological distress and/or treatment protocols, such as substance abuse, tardiness, and brief AWOLs.
Protect Service-Members’ Right to Medically Retire
Given the evidence of improper diagnostic procedures and involuntary discharge proceedings at Fort Hood, command should implement special protections to ensure soldiers their right to medically retire.
The Department of Defense must work in partnership with the Department of Veterans Affairs in order to align disability ratings procedures and ensure consistent transfer of all medical and mental health records. The current disconnect between DoD medical retirement processing and access to VA health care results in extremely poor continuity of care.
Ensure compliance with regulations protecting service-members who acquire disabilities in the workplace, in accordance with international labor codes.
Create and expedite the implementation of cross-department medical and mental health disability ratings procedures and records-keeping systems in partnership with the Department of Veterans Affairs. The current disconnect between these systems blocks proper continuity of care, and exacerbates the treatment delays of service-members in MEB and veterans at the VA alike.
Stop Deploying Soldiers Against Medical Orders
Remove command discretion in the issuance of deployment waivers for medical and mental health conditions.
Develop transparent pre- and post-deployment screening processes that are aligned with civilian screening and treatment guidelines, for implementation in SRP and R-SRP, respectively. Ensure implementation of the pre- and post-deployment procedures across all military branches.
- Ensure that every soldier is screened for psychological trauma before and after deployment at key follow-up benchmarks.
- Ensure comprehensive screening for post-traumatic stress, traumatic brain injury, and military sexual trauma, before and after deployments.
- Initiate review of confidentiality practices in SRP and R-SRP. Implement changes to the processes where confidentiality protections can be increased, especially where soldiers’ mental health conditions may be subject to increased stigma if revealed during or after SRP/R-SRP.
- Ensure that protocols for in-theater post-incident screening for traumatic brain injury are consistently applied.
Stop Over-Medicating Soldiers and Unethically Prescribing Psychotropic Medications
Increase non-pharmaceutical treatment options for traumatic injuries and mental health concerns, as well as for medical conditions which would benefit from non-pharmaceutical treatment—such as referrals to specialist care and further testing.
Per the instruction of the DoD Inspector General, DoD must issue comprehensive policy to track and reconcile medication management in all departments and establish drug take-back programs.
Enhance medication management and oversight for any soldier prescribed multiple psychotropic medications. Provide easy access to civilian psychiatrist referrals where additional medication management is needed.
Discontinue the issuing of prescriptions without the assignment of diagnoses for complex medical conditions and mental health treatment.
Institute medication evaluations at an enforced standard of every three months, at minimum wherever psychotropic prescription drug treatment is necessary.
Install means for closely monitoring any soldier prescribed multiple or off-label psychoactive drugs for the treatment of PTSD and other mental health conditions. Severely restrict the prescription of benzodiazepines, atypical anti-psychotics, and other off-label drugs for the treatment of mental health conditions.
Provide Soldiers Adequate Physical and Mental Health Care
Increase the ratio of mental health professionals to soldiers both on base and in theater to ensure timely access to care and continuity of care, and expand referrals to civilian providers when necessary to meet soldiers’ needs for timely care and diagnosis.
- Reduce reliance on physicians assistants and medics instead of physicians for the diagnosis and treatment of conditions beyond their scope of practice.
- Ensure adequate civilian providers are covered under military insurance plans, emphasizing coverage for specialist providers.
Support service members in following through on treatment plans by providing child care during medical appointments and allowing passes to attend appointments during work hours, regardless of training schedules.
- Commanders and NCOs should not be permitted to disallow soldiers from attending health care appointments. DoD, DoA, and Fort Hood command should issue new policy clarifying command adherence to soldier appointments, and devoting resources to facilitate soldiers’ attendance.
Ensure that every soldier preparing to deploy is proactively contacted by a mental health provider who is assigned as their provider before and after deployment.
Improve tracking, record-keeping, and communications between health care providers.
Provide consistent medical records to the service-member at all times and to Veterans Affairs immediately upon discharge, to ensure continuity of care and diminish long transition times to access proper VA treatment.
Ensure Comprehensive Treatment for Traumatic Brain Injury
Establish consistent pre- and post-testing protocols to properly diagnose instances of TBI.
- The ANAM is not an adequate diagnostic tool—DoD should issue new policy specifying adequate diagnostic protocol for implementation in all departments.
- As the Army has itself recommended, unit leaders should “understand the requirements for concussive care” and be “trained to implement the policy” specified in the Military Acute Concussion Evaluation and Blast Exposure/Concussion Incident Report.
- Decrease reliance on service-member self-reporting in screenings for psychological trauma and traumatic brain injury. Increase reliance on proactive and periodic diagnostic inquiry.
- Discontinue screening procedures which rely solely on questionnaires and paper forms.
- Ensure that every screening and diagnostic tool used on US service-members meets established diagnostic guidelines and codes of practice published by the American Psychiatric Association and American Psychological Association.
Ensure Proper Command Response and Comprehensive Treatment for Military Sexual Violence
DoD and Fort Hood Command must work to ensure comprehensive physical and mental health treatment for survivors of sexual harassment and violence, and institute consistent command response with a focus on victim protection in cases of sexual violence. Training and leadership on sexual violence must turn away from victims and instead focus on perpetrators and leadership accountability for eradicating sexual violence, and must work to reduce the prevalence of sexual violence on both male and female service-members.
Ensure comprehensive physical and mental health treatment for survivors of sexual violence by instituting further protections and bolstering existing programs.
- Protect survivors of sexual violence from under-diagnosis of mental health conditions by instituting special treatment reviews for survivors within military treatment facilities, along with offering referrals to civilian mental health providers specializing in treating survivors of sexual violence.
- Honor records and diagnoses when they are voluntarily submitted by civilian providers treating victims of sexual violence.
Install means for consistent, comprehensive command response to instances of sexual violence, that focus on supporting and respecting the survivor.
- Implement protocols for victims to transfer units after reporting a sexual harassment or assault without approval from their direct chain of command.
- Institute mandatory evaluation criteria for NCOs on how well they address military sexual violence.
- Include commander and NCO evaluations on leadership climate for eradicating military sexual violence in regular performance and promotion reviews and make the results publicly available.
Ensure Confidentiality and Adherence to Principles of Medical Ethics
Ensure neither physicians assistants, nor any other medical or mental health personnel, are placed under any pressure or quotas for sending soldiers back to work when medically evaluating them.
Ensure soldiers have a right to confidentiality with their medical and behavioral health providers by requiring commanders and others privy to private health information to adhere to standard health care privacy regulations.[14
- Establish means of redress and accountability for breaches of confidentiality and improper release of private health information. If such breaches result in adverse effects on soldiers, e.g. in discharge proceedings, due compensation should be awarded.
Medical and mental health care providers serving in the US military should be governed by the same medical and mental health codes of ethics as civilian providers.
- DoD should allocate resources for regular, periodic review of adherence to these standards in all military treatment facilities and screening procedures, to be implemented by independent oversight bodies working in partnership with military leaders.
- Ensure that providers working in military treatment facilities adhere to ethical standards of care and diagnosis. Providers should never be placed under institutional duress or instruction to short-cut psychological evaluations or prescribe medication in any fashion otherwise than is standard in civilian medical practice.
Reinforce Soldier Care and Develop Leadership Accountability Mechanisms
Institute standards for soldier care a regular, binding, and enforceable component of the review and evaluation of leadership.
- Subject commanders and NCOs to regular, periodic review regarding their promotion of health care and well-being for soldiers in their charge, including their ability to foster a unit culture which works to destigmatize these issues.
- Include sections for adherence to profiles, promotion of health care, and destigmatization in NCO and Officer Evaluation Reports and make them integral criteria for promotion.
- Institute anonymous evaluations of NCOs and commanders by junior enlisted which are also considered on NCOERs and other leadership evaluations.
Begin Remediation for Toxic Health Effects
Fully disclose and publish the extent, locale, and practices of the US military’s use of burn pits and toxic munitions (to include depleted uranium, white phosphorus, and Mark-77) in Iraq and Afghanistan.
Fund comprehensive, unbiased, scientific study of the medical and mental health issues caused by the US military’s use of toxic munitions and burn pits to be conducted by non-military affiliated institutions. This must include health effects suffered by Iraqi and Afghan populations as well as US service-members and veterans.
Provide funding, assistance, and resources to all who suffer as a result of these toxic exposures, including funding for specialized treatment of toxic health effects, cancer treatment clinics, and reparations for the affected families of US service-members, Iraqis, and Afghans.
Re-allocate funding from military budgets to fund and support the comprehensive environmental clean-up of sites in Iraq and Afghanistan which remain contaminated by the US military’s use of toxic munitions and burn pits.
Ensure that all military operations in foreign territories dispose of wastes in manners which respect the health of civilians, US service-members, and the environment. DoD must enforce the ban on open pit incineration mandated in the National Defense Authorization Act for FY 2010.
Initiate Accountability and Reparations Processes
The US government must take full responsibility for the lasting effects of the wars in Iraq and Afghanistan on both its veterans and Iraqi and Afghan civilians by responding with full transparency on the conduct of its operations in both wars, and by paying appropriate reparations to all who have suffered their unjust consequences.
DoD must take responsibility for its neglect of service-member health and the lack of oversight under its jurisdiction which have adversely affected US service-members and veterans. DoD should pay reparations to the families of service-members and veterans whose long-term medical and mental health prognosis have been exacerbated due to neglect and abuse the service-member suffered under DoD-regulated healthcare systems, as well as for service-members who have suffered from PTSD, TBI, military sexual trauma, and the health effects of exposure to toxic munitions and burn pits.