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News Briefing with Dr. William Winkenwerder Jr.

Presenters: Assistant Secretary of Defense for Health Affairs Dr. William Winkenwerder Jr., Surgeon General of the Army Lt. Gen. Kevin Kiley, Surgeon General of the Navy Vice Adm. Donald Arthur, Deputy Surgeon General of the Air Force Maj. Gen. James Roudebush a
November 04, 2005 2:30 PM EDT
News Briefing with Dr. William Winkenwerder Jr.

            MR. BRYAN WHITMAN (Pentagon deputy spokesman):  Well, thank you for joining us this afternoon, and thank you for the presence that we have here from the department.  Let me tell you who we have here in a second.  But as I indicated earlier today, we've reached an important milestone here in our health programs for soldiers, sailors, Marines,  airmen that are returning from combat operations.  And today, Dr. Winkenwerder, the assistant secretary of defense for health affairs, is here joined by the uniformed health professionals to talk about this program and how we are incorporating the lessons learned from pilot assessments into a broader implementation of this program across the services beginning in January. 

 

            With Dr. Winkenwerder today is Lieutenant General Kiley, who is a surgeon general of the Army.  We also have Vice Admiral Arthur and Major General Roudebush who will also join him here and provide some comments and then take your questions. 

 

            So with that, Dr. Winkenwerder, let me turn it over to you. 

 

            Thank you. 

 

            DR. WINKENWERDER:  Thank you, Bryan

 

            Good afternoon, everyone.  I'd like to thank you for being here this afternoon as we discuss a really important part of the ongoing efforts of the Department of Defense and certainly the military health system and our armed services to support our soldiers, our sailors, our airmen and Marines and their families.  And I'd like to again thank all our representatives from the services, surgeon general offices and also include Rear Admiral Tom Cullison, who's here as well with us, who's the chief medical officer of the Marine Corps. 

 

            As the assistant secretary of defense for health affairs, safeguarding the health and well-being of our service members is my top priority.  My ongoing mission and the mission of every member of our military medical family is to provide dedicated service members with access to quality health care and help them with the peace of mind that they deserve, as well as their families. 

 

            We recognize that deployments may have an impact on the health and well-being of our service members, and we know from research that health concerns are identified even several months after returning from operational deployments. 

 

            So to better ensure early identification of these health concerns and to provide access to better treatment and services, I directed earlier this year [an] extension of our existing deployment health program, to include a post-deployment reassessment of the global health -- both the physical and mental status -- of all service members, every single returning or redeploying service member, at an interval three to six months after they return. 

 

            People sometimes ask -- and I know it may be occurring to you -- "Are you doing this because this war is different?"  I'm aware of no information that demonstrates that the current conflict is affecting our service members or their families in ways different from past wars.  What's different is the way we're responding.   

 

            Today we're here because we have reached an important milestone in our effort to understand and address the effects of deployments on our service members.  The post-deployment health reassessment is currently completing a pilot phase, as Bryan said.  We've evaluated approximately 3,000 service members among Army, Navy, Marines.  And the Air Force will just be beginning its effort in the very near future, and they'll describe in more detail these efforts. 

 

            These pilot programs were initiated at high deployment platforms, beginning in June 2005.  Lessons learned will maximize our success as we begin to implement this program more broadly and regularly across all services.  And we expect to begin doing that in January. 

 

            Key elements of the program include outreach, education and training, screening, assessment, evaluation and treatment, and then follow-up. 

 

            Leaders, service members and clinicians have been educated and are now being educated in this post-deployment health reassessment  process.  They're educated about commonly occurring signs or symptoms that people may exhibit upon return after their deployment.  They're also being brought up to speed about available health care benefits and support services and community services that might address the various needs. 

 

            Effective education to gain leadership support and service member participation and optimal clinical practice is critical to the success of this program. 

 

            Screening is conducted to identify current concerns, while education is important for issues that emerge outside the screening time frame. 

 

            Our effort is to make this outreach effort really a routine thing, a regular kind of activity that occurs after everybody comes back from deployment.  It is in part to destigmatize any -- the -- recede or -- active effort to receive any support that might be needed.   

 

            Importantly, as a commanders' program, support from service leaders is key to the success of this program.  While the department created this program with input from all the services, unit commanders are charged with ensuring that service members are provided this opportunity, and they're encouraged to fully participate in this program.  We've heard good feedback already from our commanders, and maybe our surgeons general will be able to talk about that. 

 

            The program is being implemented by the services in an iterative fashion, as service members return from deployment and reach the 90- to 180-day assessment period.   

 

            And now, with that brief introduction, I'd like to turn it over our representatives, beginning with General Kiley from the Army. 

 

            GEN. KILEY:  Thank you, Dr. Winkenwerder.  And, ladies and gentlemen, thanks for joining us this afternoon.  I think Dr. Winkenwerder really hit on the key aspects of this post-deployment reassessment.  I'd just like to comment that a lot of this is based on some great work that's been done out at Walter Reed Institute of Research and from the European Regional Medical Command looking at stress levels and the response to stress and the concerns that soldiers have about themselves -- everything from marital problems to relationship problems to anxiety and anger.   

 

            As we try to identify more easily these soldiers to help them, this post-deployment screen at the 90- to 120-day mark we think will move us ahead significantly in achieving those goals.  It's calibrated for the health of the soldier, not just the mental health of the soldier.  We're going to ask soldiers about their physical well-being, also.  And it will give commanders and our medical leadership an assessment of the overall medical readiness of our units.   

 

            As an aside, when our units return from operations around the world, one of the things -- the equipment is rechecked and reset. Even our soldiers, as they come back from deployments, undergo dental examinations -- part of the annual dental exam process.  And so we just see this as an expansion of the process that looks at resetting the fighting force so that they gain and maintain wellness throughout their tours. 

 

            Now, we have a couple of pilot projects going on.  I can tell you the numbers are still small, so we're a little bit reluctant to give hard data.  But the data we've seen -- about 1,900 soldiers in the Fort Hood area, about 250 soldiers out of Tripler -- the Schofield Barracks area, and then about 200 soldiers out of Fort Lewis have undergone some portion of this reassessment.  And the data is very consistent with our published data to date, which says that anywhere from 12 to 15 percent of soldiers at the 90- to 180-day mark are concerned that they may have some issues or some worries.  And I'm -- carefully use those terms because ofttimes those data points are characterized as mental illness, mental trouble, and they aren't.  I mean, when we're asking soldiers to be honest and to recognize that maybe they might need to be referred to a mental health counselor or maybe to a chaplain, we don't want them to feel like there's something wrong with them, it's more a function of having -- recognize that they're having concerns, worries and issues. 

 

            So our data is encouraging, one, that soldiers are answering the questionnaires; and two, that we haven't seen a spike, a significant jump in terms of soldiers that are articulating that they have real concerns. 

 

            Additionally, it's important to remember that this is an overall health assessment and not just a mental health assessment.  And so many of these soldiers that have been working very hard in combat operations throughout the world and come back, they get some time to rest and recover and they begin to realize that some of the things -- backaches, those kinds of issues, maybe even skin rashes, for example, that they thought were just part of being deployed haven't gone away. This gives them an opportunity to come back to us, instead of having to come to us voluntarily, we bring them all back, and as we start to ask them about these things, I think we see that --"Yeah, I am having an issue here; I'd like to talk to somebody about this.  My back still hurts.  Or I've got, you know, swelling in my joints, or a rash or something."   

 

            So I want to make sure that we're clear that this is a total health assessment and not just a mental health assessment. 

 

            And it is part of the continuum, not only the continuum of soldiers, sailors, airmen and Marines and their service to the nation from the day they sign up to enlist with us to the day that retire or separate, it's that kind of a continuum, but it's also a continuum of our evolving knowledge of combat stress, human response to combat stress, and our abilities as a healthcare system to not only react to the results of that stress, but if and when we can, to preempt abnormal stress.  On the battlefield we push combat stress consultation and support far forward.  And this is really part of that continuum to recognize that even after soldiers have come back, and even after they've been reunited with their families, and all seems well, sometimes it isn't all well.  And we want to continue that kind of a process. 

 

            So I'll stop for now and be happy to answer any other questions a little bit later in the conference here. 

 

            I'd like to turn the podium over now to Admiral Arthur. 

 

            Sir?    

 

            ADM. ARTHUR:  Thank you, General Kiley.  And thank you very much to all of you for coming and helping us to roll out this wonderful program. 

 

            I'm Admiral Arthur.  I represent the sea services of the Navy and Marine Corps.  And we are used to deploying, and whenever we come back from deployment, we're also used to making sure that family concerns are well-addressed for both the family members who have stayed home as well as for the active duty who have deployed.  

 

            This is a different program only in that the stresses of combat are much greater than the usual deployment stresses.  And I think it's incumbent on us to recognize those stresses of combat and to allow the active duty members and their families the opportunity to gain counseling or just to talk about some of the experiences that they've had. 

 

            It is, as General Kiley said, a total health reassessment.  And in that way, we get to see if the experience of combat has affected them both mentally and physically. 

 

            It's a different program than we had in Desert Storm or in any other conflict, and I think that's a good news story, because we've learned the lessons that we need to pay attention to our deployed service members and their potential needs.  It's a good opportunity for us to deal with their families as well, and we are -- we pride ourselves in giving family-centered care. 

 

            I think General Kiley and Dr. Winkenwerder have really laid out the program very, very well, and I'll wait for your questions.  Thank you very much. 

 

            GEN. ROUDEBUSH:  Well, good afternoon.  And again, thank you so much for being here with us.  My name is Major General Jim Roudebush. I'm the deputy surgeon of the United States Air Force.  And I'm really pleased to be part of this opportunity to share this program and what it means to us in the Air Force. 

 

            It's clear that our ability to successfully execute the Air Force's mission in this very challenging environment is absolutely dependent on the health of each and every airman, officer and enlisted. 

 

            In that regard, we pay close attention to that health in a continuum from accession to separation or retirement, with all activities that occur during that continuum -- most specifically, in this case, to focus on the deployed activities. 

 

            Our Air Force's health force protection program employs a population-based health approach that focuses on prevention.  In that regard, annually, each airman is required to perform fitness testing, as well as to undergo a preventive health assessment, which looks at all of those aspects of their health and their occupational exposures and activities that may in fact have an impact upon their health status. 

 

            These requirements and these activities allow for early identification and allow us to address any issues at an early stage, as opposed to a later stage. 

 

            The Post-Deployment Health Reassessment to us represents a targeted enhancement to our existing health care continuum and really  improves our ability to assure that each of our airmen is in fact fit to fight.   

 

            The Air Force Reserve instituted the PDHRA, the Post-Deployment Health Reassessment, in September of this year, and we are just beginning to gather data on that activity.  Our active duty units will deploy this program in December, and the Air National Guard will deploy the program in January. 

 

            Now, as noted, about 90 days post-deployment, all airmen will be instructed to access a website and will view both the PDHRA instructional and educational materials, as well as filling out the survey, which is, as was pointed out very rightfully so, a survey that addresses all aspects of health.  Those who require treatment or further attention will be seen at a military medical treatment facility or a VA facility, if that's more appropriate and more convenient for the individual, or a TRICARE provider.  

 

            We expect the Post-Deployment Health Reassessment to do three things for us.  We are confident that it will improve our ability to identify deployment-health-related issues by screening at a time when the symptoms are likely to emerge.  Secondly, it does reduce the stigma for those who experience post-deployment issues through the routine assessment of such concerns.  And thirdly, it actively decreases the barriers to care through the proactive approach that's being employed.   

 

            Now, we understand that mission requirements will remain challenging and are rarely, if ever, static.  Therefore, it's imperative that we increase and focus our efforts to identify healthcare problems as early as possible, and to address them appropriately.  We believe the Post-Deployment Health Reassessment program is a truly effective tool that will assist us in accomplishing this objective. 

 

            Thank you very much. 

 

            Dr. Winkenwerder. 

 

            DR. WINKENWERDER:  Okay, ready for questions.  

 

            Yes, sir? 

 

            Q     Can you tell us, either through this process or through other information-gathering, what kind of numbers and statistics you're seeing on post-traumatic stress syndrome and on post-deployment suicide? 

 

            DR. WINKENWERDER:  Let me begin by saying roughly how many people we've evaluated with our -- what is now a normal, routine post-deployment health assessment.  That's the assessment that's done immediately upon return.  What we're describing today is the additional three to six months beyond.   

 

            But we've evaluated just under 900,000 with the -- who have returned from deployments in the CENTCOM area of operations -- Iraq or Afghanistan.  And most of those people who have returned indicate that their health is good or very good.  In fact, the number ranges from 90 to 94 percent indicating their health is either good or very good. 

 

            About 10 to 15 to 20 percent, depending upon the unit and where they're coming from, indicate that they have some kind of health concern.  And actually, a slightly higher number are referred on, in the 20 to 25 percent range, for some sort of either mental, medical, health -- any kind of problem.  And as you might expect, sometimes people during their deployed operation would put off going for medical visits, they wait till they get back for a medical or dental follow- up. 

 

            So those are some broad overview statistics.  The rates for -- in the studies that have been performed that look at the specific -- again, screening criteria, not a diagnosis -- this is just sort of a screening positive or a screening indicating there's a possibility of PTSD are in the range of 12 to 13 percent at post-deployment -- that was from The New England Journal's study; and 16 to 17 percent for PTSD, depression, anxiety, sort of any of the mental health issues. And what we find a few months later is that the figures are roughly similar.  They may go up a few percentage points -- three, four, five percentage points, so people kind of become more generally aware that they've got an issue.  And that's, in part, why we're targeting this particular phase at that particular point in time, kind of after people have the chance to get back and make their own self-assessment about how they're doing.  They're often a little bit more reflective. And so we're -- that's what we've learned. 

 

            Q     So is suicide part of that? 

 

            DR. WINKENWERDER:  Yeah, suicide -- great news story on suicide -- obviously, any suicide, any death taken at one (sic/one's) own's (sic/own) hands is not good news.  But it is good news from the standpoint that the suicide rates that we experienced in 2003 have dropped by over 50 percent during 2004 and on into 2005.  So we believe that our support, our combat stress control teams, the heightened awareness -- all the things that we're doing, we believe, are having an impact.  And so the rate has dropped by more than 50 percent.  We hope that continues.  We'd like to drive it down to zero. That's certainly our objective. 

 

            Q     Do you have numbers on that, or could someone get us numbers on that? 

 

            DR. WINKENWERDER:  We'll try to get those for you and follow up. I don't have them handy just now. 

 

            Yes? 

 

            Q     Just to clarify, you said post-traumatic stress -- 12 to 13 percent, and then, several months later, you said it goes up 3 to 5 percent -- or those numbers go up?  Or are you talking about second number -- 16 to  17 percent, which you said also included anxiety. Could you verify those? 

 

            DR. WINKENWERDER:  Yeah.  The 12 to 13 percent was for PTSD. That was from the Hoge study.  And then if you broaden the category to  anxiety, depression, PTSD, all of those, it was around the 16 to 17 percent range.  And I think Colonel Hoge and others had found that -- and we'll have to get back to you on the precise percentages -- but my recollection was that it may -- in six months, that number may go up by four or five percentage points or more in terms of the positive screening for those various potential problems. 

 

            Q     In both categories? 

 

            DR. WINKENWERDER:  In both categories, that's right. 

 

            Q     So then can you compare that to, say, the earlier Gulf War, and how is that different -- 

 

            DR. WINKENWERDER:  Well, I want to go back to what General Kiley and maybe Admiral Arthur had indicated, that we know things -- we know more today than we've ever known.   We -- there are certainly studies that were done on Vietnam veterans, but those studies were done years after the deployments.   

 

            But we have no indication -- I'm aware, as I said earlier, of no information to indicate that this particular conflict is affecting people in any way differently than any prior conflict.  What's different is our knowledge -- precise knowledge about the effects, but more importantly is how we're responding to support people; that's what's different. 

 

            MR. WHITMAN:  Yes? 

 

            Q     Just to clarify, the numbers you gave the 12, 13 percent, this is from the roughly 900,000 personnel who were interviewed right after their return? 

 

            DR. WINKENWERDER:  No, not from -- that was not the survey sample.  The survey sample was actually much smaller than that.  I don't have the exact numbers, but this was from a New England Journal of Medicine study that was performed and published in 2004. 

 

            Q     But this was right after -- this was right after they returned? 

 

            DR. WINKENWERDER:  This was within the first six months after they returned. 

 

            Q     Can you say what you learned from -- I think, you said 3,000 people were used in the pilot program, what the results show, and what you learned? 

 

            DR. WINKENWERDER:  Let me turn to either Admiral Arthur or General Kiley on what we're learning about this additional step, the three-to-six month period.  But more importantly than the numbers, I think, is the fact that we're here to -- and that's the message we're providing -- we're here to respond; we're here to reach out; we're to help.  But let me ask if either of you want to say anything about what we've learned. 

 

            ADM. ARTHUR:  Yes, thank you.  I think we learned in practical terms that combat is stressful, that everyone who goes into combat is in some way psychologically affected.  I don't think you can get around that fact.  What is significant about what we're doing is we are addressing it up front with people who understand combat because they have also been there and can more readily talk with the soldiers, sailors, airmen and Marines who are coming back.  We have learned that we shouldn't let our combat veterans go out into society without any questions asked or without any contact, as we used to do.  I think we've learned that if we contact them early, that their stress is reduced, their family issues are taken care of, and that we're better shipmates for those who have gone into combat.  But we can't get around the fact that combat is inherently stressful. 

 

            I'd like to turn it over to General Kiley who does have some specifics to talk with you about. 

 

            GEN. KILEY:  Thank you. 

 

            I'd like to just set a couple things straight, so that we're clear on our terms, because I think sometimes we get a little bit confused about that. 

 

            The whole study looked at a cohort of soldiers anonymously and scanned them, screened them, asked them about symptoms, signs of how they were feeling.  And the numbers that Dr. Winkenwerder generated are what that finding showed, which is about 12 to 13 positive for post-traumatic stress disorder symptoms:  hypervigilance, anger, sleep disturbances, depression associated with those things. 

 

            The real diagnosis of PTSD that I think sometimes the general population fixes on is, as I understand, it much smaller in terms of the soldiers that we identify with those symptoms, and then we take them into counseling and we talk to them and work through what's really going on with them.  That number is much smaller -- it's in the 4 percent range -- that would really distill out to be a diagnosable PTS.  We don't want to be that severe in terms of demanding that -- meeting that criteria in order to offer soldiers opportunities to talk to somebody and gain some help if they need it. 

 

            So the data -- Dr. Winkenwerder is correct in that data, and then Dr. Hoge followed those soldiers, and the numbers of soldiers that had PTSD-like symptoms plus anxiety symptoms and depression symptoms, those rose over time.  Those rose up to what he said, about probably close to 20 percent.  Okay. 

 

            An additional study was done in Europe that was not published, but it showed almost exactly the same phenomenon.  That's my reference to the European Regional Medical Command, where they went to one of the units that was redeploying and had been there for a year.  They did the same kind of questionnaires; asked them how they were doing, what were their symptoms, and educated them about the kinds of things to look for in terms of how they were feeling, how they were interacting with their families and with their peers and with their superiors and subordinates.  And then went back at about six months -- in 120 days or so -- to the exact same soldiers and said, okay, now you've gotten through the honeymoon period of redeployment, you've been back, you've had block leave, you've done those things; again, referencing this reset concept I talked about before.  Now, are you -- have or have you had -- have you had -- any symptoms?  Have you had nightmares?  I mean, everybody has nightmares.  Everybody gets mad once in a while.  The issues are to what degree do they get mad, to what degree do they become hypervigilant, to what degree do they start having problems with alcohol or anger control or marital discords? And those numbers were creeping up very similar to what Dr. Winkenwerder and Dr. Hoge had found in their study with both active- duty Army and Marines, which is that over time -- and we like to think it's a couple of things -- the soldiers feel a little more comfortable about talking about these things and admitting them and saying, you know, maybe I ought to talk to somebody about these nightmares I've been having.  I'm waking up at night and startled, and my wife or my husband doesn't want to come near me.  Not many of those, but those kinds of things that would prompt them.  And we're looking to be as receptive, as open and as encouraging to those. 

 

            And I believe that's what drove us to say we probably ought to -- I don't mean to speak for Dr. Winkenwerder, but that's what drove us to say, look, let's formalize this process.  Let's not make it hit and miss at installation A or Navy base B or Marine base or air base, let's do this across the MHS because we can see some value in it -- not because we have to ferret out problems, but we want the message to be very clear to our soldiers and their families -- and their family members -- that we are not only interested, but we are excited about the opportunities of getting people to feel better and get back to work, to be reset and ready to go again, if they need to. 

 

            So, I don't know if that answers all your questions.  But the numbers have all tracked the same way with all of these studies as we've looked at them, and about the same numbers on some of our preliminary data on this more codified study. 

 

            DR. WINKENWERDER:  Yes, sir? 

 

            Q     I'm a bit confused about the 12 to 13 percent figure. You're saying these are figures obtained from a New England Journal of Medicine study? 

 

            DR. WINKENWERDER:  Yes. 

 

            Q     Are those figures that you take to be accurate?  Or do you have your own figures?  Are they are the same as those?  Different than those?  Or is that the figures that the military uses as being reflective of the actual case? 

 

            DR. WINKENWERDER:  The study was performed by Colonel Hoge from the Army Medical Department.  So he conducted, with others, the study. It was published in the New England Journal study.  It was our own effort, if you will, made public to the world. 

 

            Q     Okay. 

 

            DR. WINKENWERDER:  And -- but, yes, as General Kiley was saying that, obviously, you don't get published in the New England Journal of Medicine unless there's pretty rigorous scientific review.  So the methodology and the approach to the study was carefully reviewed.  And I'm sure that's why it was published there. 

 

            Yeah? 

 

            Q     Sir, just a -- is there a difference between the response from the -- between enlisted and officer?  In the past, the officers were more stigmatized by answering this sort of a deal.  And I guess the second part, is there medical conditions, not mental medical conditions, just regular medical conditions that people are reporting to you at 90 to 120 days in? 

 

            DR. WINKENWERDER:  With regard to any difference between enlisted and officer, I'm not aware of anything -- any data that indicates any different rates of responses, either in terms of identification of problems or not having problems.   

 

            And your second question related to any new kinds -- or identifying specific -- 

 

            Q     Sort of like Gulf War syndrome type thing? 

 

            DR. WINKENWERDER:  No.  No indication that new or previously undiagnosed diseases or medical problems are cropping up.  No.  And as a matter of fact, I would just take this opportunity to say our surveillance information today on what is happening in the theater and our collection of that information is far superior than it was, you know, roughly 15 years ago with the first Gulf War, or any prior conflict.  We have collected large amounts of information from each interaction with an individual.  Much of it now is in electronic databases.  And so we're now digitizing, if you will, our collection of information.  It will be an important source of research for years to come, I'm sure, as we follow people and their health through the continuum. 

 

            Yes? 

 

            Q     Can you be a little more specific about the methods that are actually employed to determine whether someone has PTSD?  I mean, all we've seen so far is there's a survey or a questionnaire that's going to -- 

 

            DR. WINKENWERDER:  Well, the tools that are used are, first, a survey.  And that's based on the science of what symptoms are common. But again, I want to emphasize, checking off boxes of a survey saying that, you know, I think I have this, this and this, does not equal a diagnosis.  And so, as General Kiley was saying, it's a screening tool that has been looked at, believed to be a valid way to screen and identify individuals who might fit the diagnostic criteria. 

 

            Q     So -- but after the survey, I mean, is there anything else? Couldn't someone theoretically just fill out the survey saying "Oh yeah, I'm fine."  I mean, is there a period where they're -- I don't want to say watched -- where they're monitored, or is there any kind of interaction with the family? 

 

            DR. WINKENWERDER:  Well, they could fill the survey out incorrectly or not be honest, and I'm sure some people do that.  We don't think that is a large number of people.  We think most people fill the forms out honestly.  Those surveys -- the initial surveys just after deployment are done with a medical provider, you know, checking.  After someone fills it out, they sit down and talk with a doctor or nurse or physician assistant, and so they kind of go through it and talk to them about their result.  And so it's a careful process, and you know -- 

 

            GEN. KILEY:  There might be a couple things I can add. 

 

            DR. WINKENWERDER:  Yeah. 

 

            GEN. KILEY:  To answer your question, at the first re-assessment, the individuals get to look at this questionnaire, and frankly they've seen some of these questionnaires before, so it's not new to them. After they've finished the questionnaire, then they have face-to-face, depending on whether they're active, Reserve or National Guard, and a provider, be it a social worker or primary care provider, will talk to them about all the positive answers.  And if they say, "I'm feeling great, and I'm doing great.  I'm good to go," we like to see in their eyes if they feel that way too and that there's not some kind of a disparity there.  Then, if there are issues, I am having trouble one way or the other.  Maybe I'm having current backaches or my leg is going numb or I'm having difficulty breathing, all of that's referred. 

 

            I mean, we -- and so that's the -- that's part of the message today with this press conference is that this is a very complex process.  It's going to be, you know, nationwide, and we're working through exactly those kinds of issues associated with what are the resources that are going to be required and how quickly can we do it; are there two or three different ways that we're going about getting out the soldiers to let them tell us how they're doing, which are going to be the most effective. 

 

            But there is a codified process that recognizes that you -- you know, and then the soldier that wants to not admit anything, frankly, there's nothing we're going to be able to do with that.  We just need to have the concerned commanders and leaders that keep an eye on troops in general. 

 

            Q     Is there anyone who takes -- who has an effort to actually do that, to monitor the troops when they come back?   

 

            DR. WINKENWERDER:  Well, their unit leaders are really the best, you know, that know the most about their soldiers, and certainly, we count on them to do that.  We count on one soldier to care about another -- you know, a buddy, and -- or friend.  And so there are different ways.  This is obviously a very important part of the overall way in which we reach out to people, identify people who may have problems or concerns and get them to the support and help they might need. 

 

            Yes? 

 

            Q     General Kiley, I just wanted to return to something that you mentioned.  You mentioned that 4 percent of returning service members had diagnosable PTSD.  Is that --  

 

            GEN. KILEY:  In the soldiers that we looked at, that we surveyed, it looks like about 4 percent of them got to the point where the were getting some routine health care assistance for PTSD, versus 12 to 15 percent, depending what number you're looking at, what time of the day, have PTSD-like symptoms. 

 

            Q     But are you comfortable saying that 4 percent of the returning service members have this? 

 

            GEN. KILEY:  Considering that there's a lot of other surveys out, there's a lot of -- there's the general public -- the incidence of PTSD in the general public associated with trauma in the community, I think I'm pretty comfortable that for right now, that's a pretty good number. 

 

            Q     Okay.  And how many -- if you take that 4 percent, is that 4 percent of 900,000, and so we're looking at what, 3,500? 

 

            DR. WINKENWERDER:  No. 

 

            GEN. KILEY:  No, no. 

 

            DR. WINKENWERDER: No. 

 

            GEN. KILEY:  No, no, no.  Remember, these are all the -- these are the people that have said yes to something now, okay?  I mean, you know, the vast majority -- 85 percent or more of the 900,000 are doing okay and feeling fine.  So we're down to a real small subset that are in that group. 

 

            Q     What I'm trying to get at is, how many people are we talking about when you say 4 -- 

 

            DR. WINKENWERDER:  We don't have that. 

 

            GEN. KILEY:  I don't have that. 

 

            DR. WINKENWERDER:  We don't have that.   

 

            GEN. KILEY:  I don't have that. 

 

            Q     Four percent of what, then? 

 

            GEN. KILEY:  The small subset that said positive to the 12 to 15 percent.  In other words, if I screen a hundred soldiers, 12 to 15 percent of them will say, "I have some symptoms," and of that, about 4 percent actually have, you know, significant PTSD, which is a very small number. 

 

            DR. WINKENWERDER:  And let me make one -- 

 

            Q     Four percent of the 12 (percent), or is it 4 percent of the original base number? 

 

            DR. WINKENWERDER:  Of the original base number.  But let me clarify one point, General Kiley. 

 

            GEN. KILEY:  Certainly. 

 

            DR. WINKENWERDER:  And that is that the Hoge study looked only at a service members who had been in combat operations.  So the 900,000 people I describe are all deployers who have returned. 

 

            The combat operations is a subset, and we also know from studies that the stress levels among those who have been involved in combat operations are higher than those who, you know, are in the rear, who were not involved in combat operations.   

 

            So the bottom line is, we don't have the figure that you're asking for. 

 

            Q     Right.  I'm still somewhat confused as to -- it's 4 percent of the returning soldiers who have been in combat operations? 

 

            GEN. KILEY:  No.  No, it's 4 percent of those that answer positive to the screen, which is a much smaller percentage, I think. 

 

            Q     And -- 

 

            MR.    :   Let us try -- 

 

            GEN. KILEY:  Let me come back -- I'll get you the information on that.  I can get you the data. 

 

            Q     But is it 4 percent of the 12 -- you're talking about -- 

 

            DR. WINKENWERDER:  It's a very small number.  It is -- it's a small number, it really is, that have a diagnosable condition of PTSD. 

 

            Yes? 

 

            Q     Just to clarify -- when you mentioned the Hoge study, this is not synonymous with the 3,000 people who responded to the pilot program? 

 

            DR. WINKENWERDER:  No. 

 

            Q     No? 

 

            DR. WINKENWERDER:  Correct. 

 

            Q     Can you say what you learned from that pilot program?  What did you learn about rates of PTSD and people who -- 

 

            DR. WINKENWERDER:  We don't have that data to share. 

 

            Q     Okay.  Can you say when service members will start responding to this new survey? 

 

            DR. WINKENWERDER:  Three thousand, roughly, have gone through the process.  It's being implemented broadly, starting in January. 

 

            Q     Starting in January? 

 

            DR. WINKENWERDER:  Right. 

 

            Q     Okay.  Thank you. 

 

            DR. WINKENWERDER:  Yes? 

 

            Q     The survey, is that anonymous, or do people identify themselves?  I'm not sure I understand whether -- you know, once they've done the post-deployment survey, right, whether they are then at that point counseled by somebody as to what they should be doing next -- or is it an anonymous survey, or whether it's just sort of --   

 

            DR. WINKENWERDER:  We want to make sure -- we want to make sure that you're real clear about this.  When every service member returns, there is a post-deployment health assessment.  That's immediately at the time of return.  Sometimes they're completed just before people actually get on the airplane or boat or whatever mode of transportation to bring them back to the United States, sometimes it's just after.   

 

            The new process that we've described -- 

 

            Q     Let me -- let me just interrupt you right there -- 

 

            DR. WINKENWERDER:  Well, let me finish, please.   

 

            The new process we've described today is something that happens three to six months after that.  The data that I quoted you on the 900,000 people, that's on those who've just come back.  The 3,000 is -- the pilot is the number of persons who've completed, on a pilot basis, this new process that we're implementing, the post-deployment health reassessment at six months. 

 

            Q     Yeah, but the first one -- I mean, is the first one -- are these assessments that are conducted individually, say -- 

 

            DR. WINKENWERDER:  Yes. 

 

            Q     -- by sort of medical personnel? 

 

            DR. WINKENWERDER:  Yes, that's correct. 

 

            Q     Okay.  Now, the reassessment -- however many months later -- from what I gather, that's just a survey? 

 

            DR. WINKENWERDER:  No, no.  There are two different processes, and we have might have made that clearer for you.  The Air Force is conducting something that will be done on the Web -- correct? -- as a way of reaching people. 

 

            Army, Navy, Marines are doing something that's face-to-face. Okay.  And it's just different approaches.  The Air Force, obviously, they're -- have decided to take on that approach, because of the way they think it will best fit with everything else that they do, and of course the face-to-face is what the Army and the Marines and the Navy believe works better for them. 

 

            Q     Will that secure the data and all -- 

 

            DR. WINKENWERDER:  Well, it'll be -- it will provide -- one thing we'll say, since the questionnaire is exactly the same, it'll provide an interesting opportunity to compare how people respond via the Internet, which would be -- it's not anonymous because you have to identify yourself as having completed it -- but it's different then obviously coming in and meeting with a person, a medical professional, a medical provider, and saying, you know, I've checked off this and here go over my survey with me.  So -- 

 

            ADM. ARTHUR:  May I say something? 

 

            DR. WINKENWERDER:  Yeah, go ahead, Don. 

 

            ADM. ARTHUR:  I'd just like to say that it's not about the data. The data that are collected will be used for statistical analysis. This is about getting to each soldier, sailor, airmen or Marine who has an issue and helping that person and his or her family.  So we don't want it to be anonymous.  We want to know who is having problems and to directly address those problems with them.  So the data will be collected, but our aim is to get to each of the people who are coming back from combat and address their personal issues. 

 

            Q     So in these reassessments, a person will sit down -- I mean, in the case of most of the services, not the Air Force, but -- they'll sit down with somebody; they'll go through this questionnaire; and at the end of that, if they see that that person's having certain problems, then they will be counseled as to -- 

 

            GEN. KILEY:  They'll be referred at that point. 

 

            ADM. ARTHUR:  Yes. 

 

            Q     They will be referred to? 

 

            ADM. ARTHUR:  A wide variety of places.  They can go --   

 

            Q     They're advised to go see a doctor or something? 

 

            ADM. ARTHUR:  Well, a doctor or a family social worker, or someone who can help with the specific problems that are identified. They're actually pinpointed.  If they're family problems, then they can go to a family counselor.  If they're more personal problems, more psychological problems, then they might go to a psychiatrist, a psychologist, or another mental health professional. 

 

            GEN. KILEY:  Or a chaplain. 

 

            ADM. ARTHUR:  Mm-hmm.  Exactly. 

 

            GEN. KILEY:  Dr. Winkenwereder, if I might -- there's just one point of clarity. 

 

            DR. WINKENWERDER:  Yeah.  Yeah.  Just -- yeah. 

 

            GEN. KILEY:  The survey is accomplished utilizing the web, but each survey is assessed by a provider to look at that survey, to see if there any indicators or issues that need to be addressed, then that is in addition to the annual face-to-face preventive health assessment that we do, in addition to our annual fitness testing.  And given that our deployment rotations are somewhat different than the other services, being 120 days, we have greater periodicity within our cycle that allows us to really keep a good track and awareness of an individual's health. 

 

            So the Web-based survey for us was the best tool in that continuum.   But there is a great deal of face to face that occurs. And certainly if there's any issues that are raised, that is very much a one-on-one assessment. 

 

            DR. WINKENWERDER:  Okay?  Yes?  Maybe one more. 

 

            Q     Just to clarify, the pilot program, you have no initial either results or indications from this initial pilot program?  Is that -- 

 

            DR. WINKENWERDER:  That's correct.  Our interest was far more in determining how it best worked to meet the need of the individual, how to best structure the process, the interface, engaging the command, educating people.  It really was -- the pilot was not about producing data to analyze, it was really about structuring the process to best engage the individuals. 

 

            Q     And just one other quick thing just on something a little off the subject here.  On the avian -- the bird flu -- 

 

            DR. WINKENWERDER:  Yes. 

 

            Q     -- are you -- obviously this is also something that people are concerned about.  Vaccines -- there has been a big issue about whether soldiers should, shouldn't take them, would they want to take them, whether they should be able to choose.  What are you doing in preparation for that eventuality? 

 

            DR. WINKENWERDER:  We're doing quite a lot.  And today's forum is probably not the best to go through all the things that we're doing. But we are working with the combatant commands, with the Joint Staff, my office, the assistant secretary for homeland defense, a variety -- many people, on developing, and finishing in some cases, plans that are nearly being -- that were already near finish -- preparedness and response plans.  We're stockpiling Tamiflu antiviral medication.  We expect delivery of the first lots of the new vaccine starting in February.  And we're working closely with the Department of Health and Human Services to make sure that everybody's educated.     

 

            There's a variety of things that we're doing.  And maybe there will be another time when we can go into more detail on that.  But we feel pretty good about what our progress is. 

 

            Let me take one last question. 

 

            Yes? 

 

            Q     Just to maybe a little more prosaic, is there any difference between the way you're administering this program for active duty and the reserve component? 

 

            DR. WINKENWERDER:  Good question.  We're reaching out to all, active, reserve, Guard.  And the way in which the service is received might differ slightly, but the survey tool, the instrument, the interaction will all be very similar for each component. 

 

            Yes? 

 

            Q     Will you also be trying to reach the people who have already separated from the service? 

 

            DR. WINKENWERDER:  Possibly, but that will not be the first priority.  Obviously, as we implement, we want to reach those, as we indicated, with the most recent deployments and work through all those that have deployed. 

 

            Q     Can I get a point of clarification? 

 

            DR. WINKENWERDER:  Yes. 

 

            Q     Who exactly is it that evaluates these surveys, these questionnaires?  Are they medical personnel? 

 

            DR. WINKENWERDER:  It would be a medical professional, yes. 

 

            Q     And then if it's determined that there's a problem with someone who's filled this questionnaire, it's referred, or do they go to the individual, the soldier, the service person, and tell them they're -- that they're going to refer them -- 

 

            DR. WINKENWERDER:  Well, it's a face-to-face interaction, and as General Roudebush said, even with the Air Force approach, there is a provider that's evaluating the survey tool and will personally interact with each individual.  It's a discussion to determine the best type of service, the best level of support, whether it's a referral to a mental health professional, referral for a medical problem or a referral of family support, or what have you.   

 

            Q     If it is a referral to a medical health professional, does the service person have the option of denying the referral?  I mean --  

 

            DR. WINKENWERDER:  Sure.  I mean, we -- you know, there's freedom for all of us.  But we know that the vast majority of people follow up with their appointments, as they're guided to do. 

 

            Thank you.  Thank you.   

 

            ADM. CULLISON:  Sir, could I walk through the Marine --   

 

            DR. WINKENWERDER:  Yeah.   

 

            ADM. CULLISON:  Just let me walk you through the Marine process, just to make it real clear that the individual Marine or sailor would fill out the questionnaire privately.  The hospital corpsman or general medical officer usually assigned to that unit would review that form separate from the individual, who'd then have a face-to- face, about a 15-minute conversation, about the responses.  If, as General Kiley said, all the responses were negative, "I'm feeling fine," we would make sure that that was the case, just by -- as I'm doing with you -- looking him in the eye. 

 

            If there were positive responses saying, "I need help," then that would be explored further.  If it's something that a general medical officer could take care of him- or herself, they would do that.  If not, they would refer them within the military health system to a provider or to someone else in the Marine Corps Community Services, or the chaplain or wherever that help would be best received. 

 

            DR. WINKENWERDER:  Yeah.  Let me just close by saying one thing, and that is, we appreciate your interest in this.  We really do.  We want to reach the broader medical -- the -- I'm sorry -- the broader military community, service members, their families.  And certainly you'll write your stories however you think you should write them, but this is a positive effort, we believe.  It's been received well so far, and it's being done to help support our service members and their families.  So -- 

 

            Q     Sir, could you say why suicides are down 50 percent in the military?  Do you attribute that to anything? 

 

            DR. WINKENWERDER:  I think I spoke to that.  Yeah. 

 

            Q     Thank you. 

 

            DR. WINKENWERDER:  Thank you.

 

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