Mike Lemke, a 45-year-old Army National Guard police sergeant from Colorado Springs, Colo., volunteered for active duty after seeing the twin towers fall on TV. "I wanted to, you know, kick some tail," he says. He was sent home from Iraq in August 2003 because of orthopedic and cardiovascular problems -- and with memories and feelings he couldn't shake. He'd seen what was left of one of Saddam's prisons, prowled by feral dogs with rotting limbs in their mouths; he'd mingled constantly with civilians, never knowing if one was armed. "You never feel completely safe," he says. "That stays with you."
Lemke could not sleep for his first 22 days in the medical barracks in Colorado's Fort Carson, where he remained for more than a year on "medical holdover" -- a period during which wounded soldiers await treatment and subsequently either return to duty or get a medical exit from the Army. He experienced flashbacks and temper surges and would hit the dirt at the sound of a jackhammer.
No one approached Lemke to inquire about his mental health. Only when a nurse practitioner happened to ask him how he was sleeping did the story come out -- and even then it took him two weeks to accept her suggestion that he seek counseling.
Why didn't Lemke ask for help? "There's a culture here of unless your legs have been torpedoed off or your arm's shot off, then it's not a combat injury," he says. "I did the same thing that everyone does in the military: You suck it up. You don't whine."
Lemke is still on medication and in therapy, and is not employed. He is angry at the Army for many reasons, including his treatment during the medical holdover. But the issue that will most directly affect his future is his dispute with the Army over his disability rating.
The Army Medical Evaluation Board (MEB) -- the body that works in concert with the Physical Evaluation Board (PEB) to determine wounded soldiers' medical retirement and disability status according to the detailed specifications in Army Regulation 635-40 -- gave Lemke a 10 percent disability rating for PTSD, which classifies it as "mild" and as allowing for "adequate" job and social functioning.
Whether a soldier is given a 30 percent rating or a rating less than that has major financial implications. A 30 percent rating grants a soldier lifetime disability benefits, along with the military's regular retirement benefits. Anything less than 30 percent results only in a one-time severance payment: two times the soldier's base pay times total years of active duty (up to a maximum of 12 years). Had Lemke received medical retirement, he estimates that he'd have gotten $1,200 to $1,600 every month for the rest of his life. His severance payment is far less. His 12 years of part-time duty convert to six years of active duty. Result, in his case: "For someone who was available to the government for 12 years, it's $26K and adios," he says.
The Army, citing privacy regulations, declined to discuss the particulars of Lemke's or any other soldier's case.
Lemke is one of a number of returning soldiers, mostly Army National Guard and Reserve, who say they are struggling not only to heal from physical and psychological wounds, but also to get proper mental health treatment while in the Army's care -- and adequate financial compensation when their medical condition forces them to leave the Army.
What was once poorly understood in WWI as "shell shock" (and, in the Civil War, as "soldier's heart") is now a much discussed, highly researched condition The Army is now acknowledging -- and devoting a great deal of resources to -- the ever growing incidence of PTSD and other mental health issues within its ranks.
According to a study performed at the Walter Reed Army Medical Center and published in the July New England Journal of Medicine, conservative estimates are that 17 percent of soldiers are coming home from Iraq and Afghanistan suffering from PTSD, along with anxiety and depression. For these soldiers (as opposed to Gulf War vets, whose PTSD rates hover at 9 percent), the strain and trauma of prolonged urban combat with a hard-to-identify enemy, and of constant exposure to violent death -- including that of fellow soldiers -- have left them with nightmares, flashbacks, and bouts of numbness and rage.
The study concludes that reducing "barriers to care among military personnel" -- barriers such as the stigma of seeking mental health care in the first place -- must be "a priority for research and a priority for the policymakers, clinicians, and leaders who are involved in providing care to those who have served in the armed forces."
However, numerous veterans of Operation Iraqi Freedom who have come home injured say that such "awareness" has yet to change a deeply engrained military culture in which the only "real" wounds are physical. Result: Soldiers -- especially National Guard and Army Reserve soldiers in " medical holdover" -- say they run into roadblocks to needed mental health care, severance arrangements that appear to downplay invisible injuries in particular, and even attempts to send mentally unfit soldiers back to Iraq.
"The DOD [Department of Defense] is taking great care of the acutely injured, the injuries you can see, the burns, the lost arms and legs that they're treating with state-of-the-art prosthetics," says Stephen Robinson, executive director of the National Gulf War Resource Center, a veterans' advocacy organization in Silver Spring, Md. "But they're doing a horrible job with the other injuries that aren't quite so evident." Robinson, who served in the Army Special Forces in the Gulf, testified in January before the House Armed Services Total Force Subcommittee that soldiers in medical holdover receive insufficient mental health screening and care. The Center for American Progress recently published his 11-page report criticizing the military's handling of mental health issues. "There are unseen costs of war that have dramatic national implications in terms of benefits and care and reintegration into society," he says. "It is a national disgrace that front-line and combat soldiers need to fight for medical care and benefits when they return home from war."
Robinson, who has spoken with thousands of Iraq war veterans, describes the typical cycle: "When soldiers come back they have to go through complicated workman's-comp-type paperwork to prove that something they did in the war is the reason they're sick," he says. "That can take from four to 16 months. So they come home injured, and rather than being integrated into society, they're stuck in medical limbo waiting for their disability rating and then being diagnosed with a preexisting condition" -- which, he adds, implies that they shouldn't have been sent over in the first place.
He claims, anecdotally, that the MEB is underevaluating soldiers by a fairly consistent 10 to 20 percent -- a key percentage if it leaves a disability rating under 30 percent. Robinson's hypothesis: The DOD simply does not want to foot these potentially substantial bills. That, or given the number of soldiers who will yet come home injured, it simply can't.
Lemke and many of his colleagues say such problems are particularly acute among National Guard and Reserve soldiers, who make up about 40 percent of deployed troops. (Of nearly 5,000 soldiers on medical hold, all but about 860 are Reserve component troops.) "I don't think they budgeted for the Reserve and Guard component," Lemke says. "And now they want to make the soldier eat it."
"Soldiers are soldiers," counters Jaime Cavazos, media relations officer for the U.S. Army Medical Command. "I doubt very seriously that an injured soldier would be thought less of because he was a guardsman or member of the Reserve."
The Army also disputes the charges of deliberately stingy severance. "There is no truth to any such opinions," says Col. Fred Schumaker, executive officer of the Army Physical Disability Agency at the Walter Reed Army Medical Center. "The Physical Evaluation Boards fully review the facts provided [by] the Medical Evaluation Board and then carefully match, as closely as possible, the compensation to the impairment in accordance with regulatory guidance. The PEBs don't just make up disability percentage rates or reduce them arbitrarily. They give each soldier exactly what he is supposed to be given." He adds: "It would be unusual if soldiers who are not compensated by the military disability system were happy about results."
Still, Guard and Reserve soldiers say that their low ratings are the final blow in a series of actions that lead them to question the Army's true commitment to caring for them, especially when their injuries are invisible.
"A lot of the people I've had contact with are not doing very well," says Kaye Baron, a clinical psychologist in private practice in Colorado Springs. Baron estimates that 60 to 70 percent of people she sees are in the military, and of that, roughly half have served in or been affected by the Iraq war. "For one thing, they're injured psychologically or physically, and on top of that they feel they're getting disposed of by the military -- like no one really cares."
Baron has also been puzzled by military diagnoses of, for example, personality disorder (which would be a preexisting condition, not qualifying a soldier for benefits) in soldiers whose symptoms are, in her estimation, fully explicable by PTSD. "I don't understand why military mental health is not doing more given that we know combat takes a toll on soldiers and PTSD is a widely recognized phenomenon. I don't know why they're not being more thoroughly examined and diagnosed."
Theoretically, based on the unprecedented efforts the Army has made recently to acknowledge, find and treat combat stress, soldiers should be getting more thorough examinations and diagnoses. Teams have traveled to Iraq to assess the mental health needs of the soldiers there. Partially in response to the 2002 murder-suicides at Fort Bragg by soldiers returning from Afghanistan, the Army has initiated a Deployment Cycle Support Program, designed to facilitate soldiers' transition to home life by addressing their health and personal needs. There's a 24-hour hotline called Military One Source for service members and their families. There are new PTSD guides for clinicians. Detailed protocols and procedures designed to screen for, track and treat soldiers arriving in medical holdover with mental health needs are in place. "Before a soldier is considered for retirement, we have ensured that we have given him the optimum healthcare possible," says Cavazos of the Army Medical Command.
But individual soldiers in medical holdover suggest that such improvements to the system have yet to trickle down to them.
One 47-year-old high-ranking military policeman -- who, fearing reprisal, requested anonymity -- was medevac'd out of Iraq late last September for a back injury, but came home with a host of other problems. He had been on active duty before, but this was different -- and not just because of the scorching heat and rampant dysentery in his unit's ill-equipped camp. "You're out in public all the time with people coming up to you and not knowing if they're armed until they fire at you," he says. This constant sense of threat meant sky-high stress levels and hyper-alertness. He only narrowly avoided shooting a kid who marched up to him saying "Fuck Americans," rock in hand. "I had a weapon on him and in my state of mind, sad to say, I really would have put that kid down," he recalls. (The kid, seeming to realize this, took off.)
When this soldier came back to the States, he figured that his flashbacks and nightmares were "the normal stress you go through when you come out of a war zone." But while his back was being treated, his wife informed him that he "was no longer the man she married" -- uncharacteristically withdrawn, prone to rage, hardly sleeping or eating -- and if he didn't get help she'd leave him.
Eventually, a physician at Kentucky's Fort Knox, where he was on medical holdover until being allowed to go home for temporary convalescent leave last week, diagnosed him with severe post-traumatic stress disorder. The medical report cited, among other symptoms: insomnia, nightmares, flashbacks, disassociation, easy startling, quick temper, and keeping to his room for fear of hurting others, all of which were said to cause significant impairment in his "occupational and social functioning." He has been able to manage his symptoms somewhat with quite a bit of therapy and medication, but he still can't tolerate groups of people, or much food.
Just two weeks ago the soldier received word that his PTSD had received a 10 percent disability rating from the MEB/PEB. (He counters that his remaining symptoms and resulting disability, as described in a second medical report, match those described for a 30 percent rating.) He was also informed that both the PTSD and his slipped disks (rated at 20 percent) were considered chronic, not directly related to combat in Iraq -- where he wore and carried 75 pounds of equipment every day.
"I lived in Iraq, and before I left I was mentally and physically healthy," he says. "I come back and my back's broken and my mind's broken. They say it's not combat related. The processes that are supposed to be in place to help us aren't working. They're just not taking care of us."
The Army notes that soldiers have ample opportunity to review their files both before they go to the board and after initial findings are returned; should they find anything amiss, they may request a reconsideration. Still, soldiers who have attempted this describe a maddeningly muddled, even misleading, bureaucratic process. Others say they accept insufficient ratings as a means of escaping the limbo -- and often unpleasant environment -- of medical holdover.
It has already been documented that the physical conditions in medical holdover can -- due in part to sheer overload by wounded soldiers returning from Iraq -- be less than conducive to healing. A story by United Press International last fall revealed that soldiers at Georgia's Fort Stewart were housed in concrete barracks with insufficient water and no air conditioning and that soldiers at Fort Knox waited months for medical attention. Sens. Kit Bond, R-Mo., and Patrick Leahy, D-Vt., were prompted to investigate and demand improvements. Many physical problems have since been addressed, and standards have been implemented to speed up soldiers' care.
Soldiers still say, however, that despite the Army's efforts, languishing in medical holdover only compounds one's psychological issues. "Everything is uncertain, you're denied care, and you know they don't give a damn whether you get well or not. It's getting to the point where soldiers will do anything to get out of here," says a 45-year-old non-commissioned officer in medical holdover at Fort Knox who was afraid to give his name. "The stress here is higher than in Iraq, and I was there."
Some soldiers say they spend as much time as possible in their rooms, as they fear both crowds and their own temper. The main picture they paint is one of heavy medication -- "You've got soldiers on so much meds all they do is sleep; they can't even make formation," says a 37-year-old reserve soldier in medical hold at Fort Knox -- and of maddening red tape, administrative runarounds, and, at best, indifference.
Also, Fort Knox, for one, is a training post. "They're firing all the time," says the military policeman now on convalescent leave, who, like many of his comrades, is startled by a mere footstep. "That's a trigger for me." (He has addressed this concern to the inspector general's office on post, who acknowledged the complaint, but so far no action has been taken.)
Soldiers do report positive individual experiences with physicians -- the 37-year-old reserve soldier, who didn't trust his own violent temper, says his psychiatrist saved not only his life, but likely someone else's as well. While each soldier in medical holdover is assigned a case manager to help him work with the medical system, some complain that not all case managers are as caring or as knowledgeable as they need to be. In fact, several of the more experienced soldiers in Fort Knox medical holdover have seen fit to become de facto experts on the Army's byzantine medical and benefits systems. The military policeman on convalescent leave is himself at work on designing a series of flow charts and writing a lengthy booklet about the disability evaluation system to serve as a guide for other soldiers.
Beneath the bureaucracy, the matter of military culture runs even deeper -- and is harder to transform. In his report to the Armed Services subcommittee, Stephen Robinson said extensive research and tours of medical posts by his organization showed that soldiers in medical holdover receive "little to no counseling regarding traumatic events experienced during war." Why not? More often than not, he says, they're not asking for it -- and they shouldn't have to in the first place.
According to the Army Medical Command, screening for mental health issues in medical holdover is done via self-reporting in questionnaires, or ad hoc by physicians treating soldiers for physical issues. "I'm sure that during the course of treatment a soldier will give off signs that will suggest that the individual needs some mental health counseling of some kind," says Cavazos of the Army Medical Command.
Robinson counters that it's essential for Army medical personnel to initiate intervention for mental health issues, even among soldiers coming home for physical injuries. "Questionnaires are not sufficient to establish physical and mental fitness," he says, especially given the stigma against seeking psychological help or admitting "weakness." Indeed, the Walter Reed study found that the fear of stigma was "disproportionately greatest among those most in need of help from mental health services." Says Robinson: "Fear of stigmatization will remain a problem until the military changes its culture."
By some soldiers' accounts, their commanding officers will not be at the vanguard of that change. Their job, after all, is to get soldiers back to duty.
"I was told [by higher-ups] to 'not worry about it,'" says the 45-year-old NCO in medical holdover at Fort Knox, of the insomnia, anxiety and panic attacks that eventually got him on Zoloft, BuSpar, Ambien, and trazodone. "These soldiers come here all wired," he said, referring to the hypervigilance that's typical of PTSD, "and they immediately start telling them that they're going to try to return them to Iraq." According to him, they're told by their chain of command: "Don't settle down because you're going to need that high intensity when you go back."
Spc. Laurence Kiefer, 30, a crane operator with the quartermaster combat support unit of the Montana National Guard, was brought home from Iraq to Fort Carson in May, in part because of injuries relating to a truck accident. He was suffering from combat trauma -- at one point he'd had to drive a 22-ton crane at its maximum speed of 10 to 20 mph, for a 17-hour, 350-mile trip, often under fire -- compounded by other stresses, including fear that he'd be sent back to serve in the same unit with hostile command. However, he didn't get summoned for his official "outprocessing" exam for nearly three months. In the meantime, after first "self-medicating" with alcohol, he eventually sought medication and psychological treatment.
Soon thereafter, he was told to pack up and re-deploy. He appealed to his psychologist, Jacqueline E. Delano, who felt that he wasn't ready, and who later asserted in writing that in a subsequent phone conversation, Kiefer's commanding officer "made statements indicating that he felt Spc. Kiefer was over-exaggerating his symptoms to get out of going back to Iraq" and "was not interested in this psychologist's professional opinion." Delano was able to delay Kiefer's departure by insisting on further evaluation; she then diagnosed him with a personality disorder, a preexisting condition that renders him both unfit to serve and ineligible for benefits. A civilian psychologist later asserted that Kiefer's condition was PTSD; Kiefer is currently fighting the "personality disorder" designation.
What recourse do these solders have? Says the 45-year-old NCO at Fort Knox: "The attitude here is: I don't trust these people. I'll wait till I get home and go to the V.A." Vets may apply for benefits through the V.A., which has a more generous ratings system. Five thousand veterans of Iraq and Afghanistan have gone to the V.A. with mental health diagnoses already. For those reasons and others, the V.A. is an appealing resource for soldiers in, and just out of, medical holdover. "The V.A. has no legal authority. They can't take what we say and turn it against us," says the NCO. "They can't hurt you like the Army can."
Now back at home and a civilian, Lemke is still doing his best, via word of mouth, to help soldiers who are confused or feeling mistreated by the system, or who are simply struggling with PTSD themselves. He even gets contacted by soldiers' wives who are desperate to find out "what's wrong" with their husbands. No matter what, he knows what his fellow soldiers have been through. "First I fought the war," Lemke says. "Then I had to fight a war for my treatment."
Editor's Note: This story has been modified since it was originally published.