WASHINGTON — The National Guard and Reserve have played a critically important role in the wars in Afghanistan and Iraq, deploying in unprecedented numbers and enduring repeat tours of duty to combat zones where they fight alongside active duty troops.
But this unforeseen surge has been hampered by significant problems from the start.
Many stem from the fact that most of the more than 665,000 who deployed were working men and women who were part of a civilian “strategic reserve” that trained one weekend a month and two weeks a year.
“When you’re a strategic reserve… you think that you’re not going to be a day one player, you’re going to be used later on and that you’ll have time” to get ready, said Gen. Craig R. McKinley, the chief of the National Guard Bureau, which oversees and coordinates operations among the 54 state and territorial Guard units.
“What Sept. 11 taught me is that you may not have time, you may need to be ready today and you have to do today what you might not have been prepared to do, but you’ve got to get in the game anyway,” said McKinley, who assumed the Guard post in November 2008.
In the immediate aftermath of the Sept. 11 attacks, most reserve component soldiers — the National Guard and the Reserves for each military branch — were medically unready to deploy. In response, the Pentagon turned to a private company for help in creating a massive pre-deployment pipeline to quickly assess the medical status of the reserves and shore up readiness rates.
From the start, many units went through the mobilization process so quickly that there wasn’t enough lead time to fix some health problems, holding up deployments despite the military’s critical need for additional troops to support its growing combat effort. More than 2,400 Army Reserve soldiers were held back, at least temporarily, because of inaccurate assessments by the contractor, according to data provided by the Army Reserve Medical Command.
The number could be even higher as the command looks closely at the records of medically non-deployable soldiers, according to Maj. Gen. Richard Stone, the Army’s deputy surgeon general for mobilization, readiness and reserve affairs.
And an unknown number of other reserve soldiers were sent overseas who should not have been, including some with behavioral problems that could become aggravated by the stress of combat and lead to depression, post-traumatic stress disorder and even suicide, according to interviews with current and former officials, troops and experts, and a review of government documents and studies.
“In a time of crisis when they needed so much manpower, nobody wanted to identify problems,” said Dr. Remington Nevin, who worked with the military’s main health surveillance wing. “If we had a robust screening process, we wouldn’t have had enough people to fight the surge.”
In recent years, the military has taken steps to more thoroughly prepare and assess the reserves before deployment. In response, readiness rates among the reserves are at a little over 60 percent and at over 70 percent for the Guard, the highest numbers ever, according to Stone.
The Pentagon has also placed a greater focus on behavioral issues in an effort to weed out those unfit to serve due to potentially debilitating mental health problems.
But reservists have reported suffering from mental health problems, including post-traumatic stress disorder, at a higher rate than their active duty counterparts, based on data maintained by the Armed Forces Health Surveillance Center. “We were deploying sick soldiers who got broken [more] when something happened to them, and we end up picking the costs for decades to follow,” said Nevin, who said he was not speaking in his official capacity as an epidemiologist at Fort Polk in Louisiana.
The extent of the problem is still becoming known as many of their injuries go undiagnosed because the reserves lack the same access to care and support as their active-duty counterparts, according to Nevin and others.
As a result, military officials still do not know whether they are fully vetting the reserves before sending them to war, especially those who have already deployed, experts say.
Responding to urgent need
The massive mobilization began three days after the Sept. 11, 2001 attacks, when President George W. Bush declared a state of emergency that authorized the Defense Department to issue a mandatory call-up of the reserve component for duty related to terrorism.
After the first Gulf war, the Government Accountability Office had said the medical readiness process needed improvement if the reserve components were to meet the nation’s security needs.
To ramp up deployment of the reserves, the government expanded a joint venture known as FEDS-HEAL, in which the departments of defense, health and veterans affairs had been paying a private contractor to provide medical services since 1999.
FEDS-HEAL required reservists to undergo a series of tests and screenings when called up to active duty. The contractor, LHI of La Crosse, Wis., evaluated reservists on their physical and mental health, using a combination of doctor examinations and self-administered questionnaires designed to catch medical problems.
The new program was getting underway just as 75,000 reserve members were activated during the first major combat operations in Afghanistan. And soon, reservists were being sidelined for minor and easily correctable problems by LHI’s rapidly expanding network of contract health-care workers, said Lt. Col. Ross Waltemath, director of civil military affairs at the Indiana National Guard.
“We had a bad problem in the beginning with the contract company,” Waltemath said. “No one wanted to talk anymore. Every single screening you went through, ‘I am perfect’ was all you heard.”
Stone agrees that there were problems, but said LHI was only trying to err on the side of caution.
“The profiling was done in a very liberal manner to protect the service member,” Stone said.
LHI, also known as Logistics Health Inc., declined repeated requests for an interview and for a response to the specific criticism, citing the “sensitive nature” of their business. But a statement released by the company’s official spokeswoman, Tracey Armstrong, said, “We regularly exceed the requirements and regulations of individual service components and of our contractual obligations.”
Tackling mental health concerns
Gaps in the screening process caused other serious repercussions, in part because identifying physical problems was much easier than behavioral ones, especially those starting to surface among those on their second or third deployments.
The Pentagon relies on reserve members to report their own health problems because they have no way of tracking their medical care when the reserves are not called up for active duty.
“Study after study has shown self-administered surveys are the best way to get information,” Stone said. But the military lacks a central record-keeping system capable of maintaining complete health records of those in the reserves, undermining its ability to spot and manage medical conditions, according to Waltemath and other experts.
Medical documents of guardsmen at an Evansville, Ind., readiness screening event. Self assessment surveys play a crucial role in evaluating the health of reservists. (Bob Spoerl/Medill)
Some of the reserve members missed the initial warning signs that they were suffering from depression and post-traumatic stress disorder. Others reported not seeking care due to concerns that getting mental health treatment would hurt their career, according to Terri Tanielian, director of RAND Corporation’s Center for Military Health Policy Research.
“The soldier can seek civilian care for mental problems and his unit may never come to know,” Nevin said. Because of confidentiality, the reserve members’ commanding officers also can’t get access to their medical records, depriving the military of another avenue for identifying problems.
And the pre-deployment screenings administered by LHI did not have adequate controls in place to catch potential behavioral problems, according to some military officials and experts.
Those deploying between 2001 and 2006 only had to answer one question related to mental health on their pre-deployment surveys: “During the past year, have you sought counseling or care for your mental health?”
“For me to find out someone has a problem, the soldier has to come to me with the problem or I have to find out by accident,” Waltemath said. “That’s a challenge the active-duty soldiers don’t face.”
Since 2003, when the Armed Forces Health Surveillance Center began keeping statistics, the reservists reported mental health problems at significantly higher rates than their active duty counterparts.
After media reports asserted that the military was sending mentally unfit service members into combat zones, the Pentagon in 2006 developed minimum mental health standards for those deploying. That included a special pre-deployment questionnaire focusing exclusively on potential behavioral problems.
Waltemath said that helped, but only so much.
“How much time do you get with those clinicians–five minutes?” he said. “I don’t want someone dictating if I have a behavioral health issue with a five minute talk.”
In September 2007, the Pentagon awarded LHI a new $790 million, five-year contract to run what was now called the Reserve Health Readiness Program.
That year, Ryan Kohlheim’s brother Spencer had just returned home after spending six months in Afghanistan, his sixth deployment with the military. He said his problems coping with civilian life were getting worse.
“He was involved in an incident where he freaked out on some people,” Kohlheim said. After his brother spent a night in jail, he took him to a Veterans Affairs facility for counseling sessions and treatment for substance abuse and mental health problems.
Less than a year later, Spencer again deployed to Iraq. Two weeks after returning home in December 2008, he hanged himself in their grandmother’s house.
Kohlheim said he didn’t know what kind of screening process his brother went through. But, he said, “I don’t think he was in any shape or form to deal with everything going on there. I absolutely think they should have stopped him from going.”
"I just needed to get away from all of that," said Shannon Cousin, an Indiana National Guardsman, who hoped his deployment to Afghanistan would keep him away from family problems. Officials say a lot of the behavioral health problems might be because of family problems pre-deployment but get aggravated during the deployment. (Bob Spoerl/Medill)
Looking to the future
Nevin and others remain concerned that the screening process is inadequate, especially for the reserves.
Annual statistics from October 2010 showed that only one in 300 reservists had been identified for mental health referrals based on the pre-deployment health assessment forms they filled out — significantly fewer than the one in 100 among full-time soldiers, according to the Armed Forces Health Surveillance Center.
Some states have put in place additional measures designed to improve the pre-deployment process.
Waltemath’s Indiana National Guard, for instance, ensures that its members spend a significant amount of time, face to face, with a specialist to discuss mental health issues before deployment and at a VA facility after deployment something that is not required on the federal level.
Even though the two wars are winding down, officials in the National Guard and Reserve say they need to continue to improve the screening system because the reserves have now become fully integrated into the active duty military’s operational plans for the future, and they will need to be ready.
Next year, the Pentagon is expected to issue a new RHRP contract, and estimates it to be worth more than $1 billion.
