Veterans for Common Sense

Abuses Endangered Veterans in Cancer Drug Experiments

ALBANY – Carl M. Steubing, a decorated Battle of the Bulge veteran whose experience of war made him a pacifist but also instilled in him a zest for living life at full tilt, took his diagnosis of gastroesophageal cancer in 2001 as a challenge.

With a thatch of white hair and a rich baritone voice, Mr. Steubing, at 78, was not ready to succumb to illness. A retired music educator and wedding photographer, he remained active as a church choir director, expert cook, painter, golfer and fisherman. He was married to a woman 24 years his junior, and they had seven children and three grandchildren between them.

Mr. Steubing jumped at the chance to participate in an experimental drug study at the Stratton Veterans Affairs Medical Center in Albany, believing it offered him the hope of surviving longer. The research coordinator, Paul H. Kornak, told Mr. Steubing that he was “just a perfect specimen,” with the body of a man half his age, according to Jayne Steubing, Mr. Steubing’s widow.

He was not, though. Because of a previous cancer and poor kidney function, Mr. Steubing was not even eligible to participate in the experiment, according to government documents. Mr. Kornak, however, brushed that obstacle aside. He altered Mr. Steubing’s medical records, according to prosecutors, and enrolled him in the study. He also posed as a doctor.

In 2001, Mr. Steubing endured about six periodic treatments with an aggressive three-drug chemotherapy combination. Each infusion made him violently ill and forced his hospitalization. He died in March 2002.

Last month, at the federal courthouse in Albany, Mrs. Steubing glared at Mr. Kornak, 53, as he pleaded guilty to fraud, making false statements and criminally negligent homicide in the death of an Air Force veteran, James DiGeorgio. When Mr. Kornak admitted to falsifying the medical data of “subject initials CMS” – Carl M. Steubing – Mrs. Steubing’s face crumpled.

Mr. Kornak, who is scheduled to be sentenced in May, also agreed to cooperate in a widening investigation of the hospital’s cancer research program. From 1999 to 2003, when he worked there, scores of veterans were, at the least, put at risk. But allegations of carelessness, fraud and patient abuse in the hospital’s cancer research program predated Mr. Kornak, and employees say that administrators not only dismissed their concerns, but harassed them for standing up for the veterans.

“Research violations were a way of life at Stratton for 10 years,” said Jeffrey Fudin, a pharmacist at the hospital. “Stratton officials turned a blind eye to unethical cancer research practices and punished those who spoke out against them. The whole Kornak episode could have been prevented.”

According to Mr. Kornak’s lawyer, E. Stewart Jones, there was a “clear systems failure,” permitting a research culture where “rules weren’t followed, protocols weren’t applied and supervision was nonexistent.”

It was also a culture whose descent into criminality forced the Department of Veterans Affairs nationwide to reckon with what an internal memorandum in 2003 described as “systemic weaknesses in the human research protections program, especially in studies funded by industry.”

Excluding simple chart reviews, about 80 percent of the department’s human research is financed by industry. The private sector pumps considerable cash into the system. In Albany, it accounted for $500,000 of the $1.15 million in research funding in 2004.

Mr. Kornak, who declined to be interviewed, does not appear to have derived financial gain from his fraud. The Albany hospital’s research program, however, stood to benefit from the enrollment of patients, pulling in $5,000 from the drug company Aventis for Mr. Steubing’s participation.

Although veterans knew him as “Dr. Kornak,” Mr. Kornak was not licensed to practice medicine. Mrs. Steubing first learned this a year after her husband’s death when she read an article in The Times Union of Albany.

By 1993, Mr. Kornak had obtained and lost medical licenses in several states by forging his credentials and had pleaded guilty in Pennsylvania to felony fraud charges. The Albany hospital hired Mr. Kornak, who did attend some medical school, as a research coordinator, not as a physician. Nonetheless, he performed physical examinations, and his Veterans Affairs business card identified him as an M.D.

James A. Holland, Mr. Kornak’s supervisor, was the real M.D. and the principal oncology researcher. Federal prosecutors said in court papers last year that Dr. Holland, too, was possibly facing criminal charges.

Dr. Holland, who now works at Archbold Memorial Hospital in Thomasville, Ga., declined to comment. Archbold, in a statement, said Georgia’s medical board had investigated Dr. Holland’s actions in Albany and found no evidence of misconduct.

In September, however, the Food and Drug Administration started proceedings to disqualify Dr. Holland from conducting further clinical research because he had “failed to protect” subjects under his care in Albany.

According to the F.D.A., patients’ medical records were altered in at least five experimental drug studies, enabling veterans like Mr. Steubing to be enrolled in studies for which they were either too sick or too healthy to qualify. A patient with coronary disease, for instance, was enrolled in a study that excluded heart patients because of a risk of hemorrhages. A patient with impaired renal function was administered a drug toxic to kidneys that probably contributed to his death, the agency said.

“It kills me to think that the V.A. system deceived us,” said Mrs. Steubing, the director of an upstate school for emotionally troubled children. “You see these youngsters at Walter Reed now and everybody’s raving about the care they get. Well, Carl was one of those kids once, with a Bronze Star, a Purple Heart. And at the end of his life, his treatment was the antithesis of what you see on TV. It was such a betrayal.”

It can be hard to determine whether an experimental treatment is the cause of a cancer patient’s death. Mrs. Steubing will never know if her husband might have survived longer if he had undergone standard chemotherapy treatment or if he might have been spared the suffering he endured after each experimental infusion. The questions will always plague her, she said.

But, as Mr. Kornak’s homicide conviction indicates, the authorities have attributed one death directly to his fraud. In 2001, Mr. DiGeorgio, 71, declined precipitously and died within two weeks of being infused with experimental drugs that he should not have been given.

“My husband trusted and confided in the V.A. in Albany, and he wouldn’t go nowhere else,” Judith DiGeorgio, his widow, said. “It’s a disgrace what they did to him.”

Jon A. Wooditch, a deputy inspector general for Veterans Affairs, said department employees were forbidden to answer questions for this article because of the continuing investigations. Officials from the inspector general’s office have been questioning hospital employees in the last several weeks.

After Mr. Kornak’s guilty plea, the hospital director, Mary-Ellen Piché, circulated a letter to the staff noting “many improvements in research since the events,” among them that “credentials of researchers have been checked and confirmed” and that researchers have undergone ethics training.

Mr. Kornak, as it turns out, was so trained. As a certified clinical research professional, he had passed an examination covering such ethical topics as informed consent and clinical fraud.

Both Mrs. Steubing and Mrs. DiGeorgio have sued Mr. Kornak, Dr. Holland and the Department of Veterans Affairs. Mrs. Steubing’s complaint, in a class-action suit, says that veterans were treated like “guinea pigs.”

Overwhelmed Watchdogs

In the 1990’s, because of a marathon of new drug development, the field of clinical research grew into a multibillion-dollar industry, overwhelming the systems developed to protect human research subjects.

The ethical model for those systems was born in 1947 after German physicians were convicted for performing crippling and deadly medical experiments on concentration camp prisoners. But the Nuremberg Code did not stop unethical research.

Well into the 1970’s, the federal government sponsored human radiation experiments and the Tuskegee experiments, in which black men with syphilis were studied but not treated or told they had the disease.

Outrage over the Tuskegee experiments led to the gradual development of federal regulations governing clinical research. These regulations established the cornerstone protections for human subjects: a voluntary, informed consent process and oversight by an institutional review board, which would evaluate and monitor the scientific validity and ethical standards of studies.

In the 1990’s, however, the surge in drug research strained the institutional review boards and raised new questions about conflicts of interest and government oversight.

Veterans Affairs doctors have done pioneering research on spinal cord injuries and schizophrenia and helped develop the cardiac pacemaker. But like universities and private research companies, the department has grappled with allegations of exploiting its human research subjects.

The veterans department’s situation, though, was singular. Veterans, many unable to afford private health care, are a particularly captive and altruistic pool of subjects, “easy marks,” said Alan Milstein, a lawyer for Mrs. Steubing.

And the department’s huge, taxpayer-financed health care system, despite reports of significant improvements in quality of care, has struggled with issues of mismanagement. These problems include persistent complaints about abuse of power, cronyism and reprisals against whistle-blowers.

Speaking Up, to No Avail

Years before Mr. Kornak arrived at the Albany hospital in 1999, Mr. Fudin, a clinical pharmacist there, started expressing his concerns about the treatment of cancer patients.

Beginning in 1993, Mr. Fudin variously alleged that patients were placed in experimental studies without their consent, that patients who were ineligible for studies were nonetheless enrolled, and that patients were given “alternative therapies” that should have been classified as research. Veterans, he said, may have died as a result.

The former pharmacy manager, Anthony Mariano, shared his subordinate’s concerns.

“Every violation, I hand-delivered packets of information to the chief of research, threw them down on his desk and demanded he do something to stop the research,” Mr. Mariano said.

Instead, Mr. Fudin and Mr. Mariano found themselves under internal investigation. In 1996, Mr. Fudin was accused of patient abuse for refusing to dispense a certain cancer therapy. Mr. Fudin said he thought the therapy amounted to unsafe experimentation on patients. He was cleared of the charge, faced a second charge and again was cleared.

Claiming harassment and reprisal for whistle-blowing, Mr. Fudin filed a complaint with the Office of Special Counsel, a federal agency intended to protect federal employees. In late 1996, Veterans Affairs and Mr. Fudin reached a settlement. The department agreed to sponsor him for a doctorate in pharmacy by paying his tuition ($21,986) and giving him a flexible work schedule.

“It is regretful that these investigations of your clinical practices took place,” a senior Veterans Affairs official wrote to Mr. Fudin.

Still, Mr. Fudin said he was frustrated that his concerns about the cancer research program had not been addressed. His allegations were investigated in the mid-1990’s, but the doctor who conducted the inquiry, Thomas Ferro, said it was cursory and, ultimately, thwarted.

“There is always a hidden agenda either to exonerate or convict in these internal investigations,” said Dr. Ferro, who is now at the Veterans Affairs hospital in Richmond. “In this case it was to exonerate. I was buddies with the doctor I was deputized to investigate.”

Dr. Ferro said he did “a fairly superficial investigation only oriented toward uncovering egregious errors, of which none were found.” He reviewed about 10 patient charts, he said. He found a consent form missing in one and “consent form discrepancies” in others.

Dr. Ferro said he also found “creative science” in the use of “alternative chemotherapeutic regimens.” He said he was convinced that the oncologist was genuinely trying to help patients survive longer. “But,” Dr. Ferro said, “it didn’t strike me as prudent to be using alternative regimens when there was no clear-cut evidence they were helpful and the possibility that they might be harmful.”

Dr. Ferro said he “watered down” his findings in his final report, stating that no major violations were found, but that “minor discrepancies” were. His superiors, however, did not like any mention of problems, and they whited out “minor discrepancies” and other negative phrases, Dr. Ferro said.

They asked Dr. Ferro to initial the deletions, and he protested, but eventually did so, he said, “so as not to be a troublemaker.”

Dr. Ferro said he also recommended strict monitoring of cancer drug studies, and his ideas included having a chemotherapy expert “review the consent forms and review the documentation to make sure the patients were eligible for the studies.”

But the recommendations were shelved, he said. “The solution to the Kornak problem yet to come was in that document,” he said.

Both Mr. Fudin and Mr. Mariano faced additional internal investigations. Mr. Fudin was dismissed in 2001, and an administrative law judge ordered him reinstated in 2002.

Mr. Mariano, meanwhile, was criticizing a cost-saving drug substitution policy involving hypertension medication that he contended was harming patients who suffered from congestive heart failure. In 1999, after he published an article in a federal medical journal questioning the department’s drug policies, he was, at one point, reassigned from the pharmacy to a locked psychiatric ward and given no duties.

Eventually, after a complicated legal process, Mr. Mariano said, he resigned under pressure in 2001, and he now works as a pharmacist for Wal-Mart.

Mr. Fudin and Mr. Mariano served as grand marshals for Albany’s Memorial Day Parade in 2003, selected by local veterans honoring what they described as the men’s courage in blowing the whistle. Some veterans wore T-shirts emblazoned with whistles and, on a rainy May day, blew whistles as they marched.

Convicted, Then Hired

In 1993 in Harrisburg, Pa., Judge William W. Caldwell of United States District Court sentenced Mr. Kornak to a $2,500 fine and three years of probation for forging his credentials to obtain a medical license. Apparently, Mr. Kornak’s history of fraud began with the falsification of a college transcript, and lie followed lie until he lost a medical license in Iowa, was denied one in New Jersey and was arrested in Pennsylvania.

“As we all know, a house built on sand will eventually fall, and a career whose foundation is built on deception likewise has fallen,” Judge Caldwell said. “I think the conviction for this offense is going to make it extremely difficult, if not impossible, for Mr. Kornak to pursue a medical career.”

Six years after Judge Caldwell’s pronouncement, Mr. Kornak answered an advertisement for a research assistant position at the Albany veterans hospital’s research institute.

It was 1999. Dr. William Hrushesky, then the chief oncologist, interviewed Mr. Kornak, according to The Medical Research Law and Policy Report, a trade publication. (Dr. Hrushesky did not respond to inquiries from The New York Times.)

Mr. Kornak told Dr. Hrushesky that he had lost his medical license because he could not document a year of medical school in Poland, according to the journal. Mr. Kornak “gave us a résumé with an M.D. on it and a lot of gaps,” Dr. Hrushesky told the journal. “We decided to give him a chance.”

Dr. Hrushesky also said he assumed that the research institute, a foundation that oversees industry grants for research, checked Mr. Kornak’s credentials before hiring him. (Eventually, Mr. Kornak was hired away from the foundation by the veterans department itself.)

But at that point, the Veterans Affairs system did not require much background or credential checking for health professionals other than for physicians and dentists, and the system did not double-check to make sure that its hospitals actually did the required screening of doctors, according to a General Accounting Office report issued last year.

At the Albany veterans hospital, Dr. Holland inherited Mr. Kornak as a research associate. Mr. Fudin, the pharmacist, and other employees said Dr. Holland was swamped by the cancer patient load. According to an F.D.A. letter to Dr. Holland, he delegated far too much responsibility to unqualified subordinates in numerous drug studies.

Mr. Steubing was not a regular patient of the Albany hospital and, because he had private insurance, he was not a typical Veterans Affairs patient. He sometimes went to the veterans’ hospital in Castle Point, N.Y., for checkups, but he used private physicians for important health issues.

In early 2001, when Mr. Steubing’s gastroesophageal cancer was diagnosed, doctors at the Memorial Sloan-Kettering Cancer Center in Manhattan recommended a widely used two-drug chemotherapy regimen, which was available at Castle Point, closer to their home in Hopewell Junction.

At Castle Point, an oncologist suggested that Mr. Steubing see if he qualified for an experimental drug program, which added a third drug, Taxotere, to the mix. The study, sponsored by the drug company Aventis, involved both Sloan-Kettering and Veterans Affairs in Albany. Sloan-Kettering had a waiting period, Mrs. Steubing said she was told. Albany did not.

The Steubings met with Mr. Kornak.

“Kornak was your classic good-time Charlie,” Mrs. Steubing said. “Carl thought he could pick out a phony a mile away, but he really loved this guy.”

Mr. Kornak never gave them any indication that Mr. Steubing did not qualify for the study, Mrs. Steubing said. Instead, he encouraged Mr. Steubing to continue with the regimen even though it was devastating him.

“Kornak would say: ‘You’re going to beat this. The odds are in your favor,’ ” Mrs. Steubing said. “Little did we know that what they were doing to Carl was probably hastening his death rather than extending his life.”

Routine Visit Leads to an Inquiry

In December 2001, a clinical research associate for Ilex Oncology made a routine visit to the Albany veterans’ hospital, where Ilex was sponsoring a bladder cancer study.

Ilex, a cancer drug company, was offering the Albany research program $2,500 for each study subject. Such payments are a standard practice, and many researchers say that they barely cover the cost of conducting the studies. Critics of drug-testing practices, however, consider the payments a threat to scientific integrity.

Ilex’s research associate discovered some paperwork that raised suspicions, according to Caren Arnstein, a spokeswoman for the Genzyme Corporation, which bought Ilex at the end of last year.

“Things about the dates didn’t look right,” Ms. Arnstein said. “If the results of a pathology report for a biopsy are dated prior to the biopsy being taken – something seemed off.”

The discrepancies led to an audit by Ilex. In the spring of 2002, the Albany hospital began an internal review of the cancer research program, eventually referring the matter to the inspector general, according to The Times Union.

Ilex shut down the Albany study and alerted the F.D.A. The agency had also received another complaint, an F.D.A. official said.

In November 2002, the F.D.A. sent an investigative team to Albany. On average, it takes about a week to investigate a complaint. That team spent more than 50 days at the hospital. It studied the files of more than 50 research subjects and found problems in almost every one, according to its investigation report.

In January 2003, Mr. Kornak and Dr. Holland were dismissed. Mrs. Steubing got an unnerving call from a hospital official, telling her that her husband’s care might have been “compromised.”

“I said, ‘Well, Dr. Kornak and Dr. Holland were so wonderful to us,’ ” Mrs. Steubing said. “There was dead silence on the line and I thought, ‘Oh, it’s them.’ ”

Shaking Up the System, Twice

The year that the Albany veterans research program hired Mr. Kornak, 1999, was supposed to be a year of reckoning for the $1.2 billion research program at Veterans Affairs.

Federal regulators shook the system by suspending all human research at the West Los Angeles Veteran Affairs Medical Center, saying that it had been lax for years in obtaining informed consent and overseeing research.

News media reports about abuses of human subjects in West Los Angeles unleashed the fury of Congressional watchdogs, who asked the General Accounting Office to assess the safeguards for veterans who serve as research subjects. The office examined eight Veterans Affairs medical centers and reported “a disturbing pattern of noncompliance with regulations for the protection of human subjects.”

Dr. Stephan Fihn, the acting director of research and development for Veterans Affairs, said in an interview: “Historically, we relied on the integrity of investigators. In the vast majority of cases, that worked. We did discover, well, the tendency is to say, bad apples. There were some pretty egregious violations.

“What Congress basically said was that the V.A. has to take a very active role. What was lacking in human subjects protection was a strong oversight and enforcement effort.”

But the department did not change overnight, as the General Accounting Office said in a follow-up report four years later. It apparently needed a second shock to its system, and that came in 2003 when the problems in Albany – and the accidental fatal overdosing of a Veterans Affairs research subject in Detroit – came to light.

A new director of research for the department, Dr. Nelda Wray, ordered a nationwide review of research at Veterans Affairs medical centers and halted clinical research in Fargo, N.D., because the institutional review board there had all but ceased to function. She also ordered credential checks on researchers and ethics training for them.

By early 2004, the department’s inspector general had accused Dr. Wray herself of ethical problems and improprieties, including the mishandling of funds provided to Veterans Affairs by drug companies. Her lawyers called the investigation “an easy and convenient tool to stop sorely needed reforms.” She eventually left the department.

But there does appear to have been a sea change in the department’s approach toward protecting the subjects of human research. An external nonprofit agency, the National Committee for Quality Assurance, was hired in 2001 to accredit the agency’s programs to protect human subjects. The accreditation process, which requires medical centers to open up their research programs to full scrutiny, is rigorous.

At first, the committee met hostility.

“We just showed up and started telling them what was wrong, and it was way too abrupt,” said Brian Shilling, a spokesman for the committee. “But there’s been a lot of education and culture change in the V.A. since then.”

Just under a third of the veterans department’s 118 research centers have been accredited so far. Some centers did not pass their initial reviews, and research was curtailed until they showed improvement. One medical center, in Northampton, Mass., failed to earn accreditation.

Albany has not yet applied.

Gay vets’ benefits at risk?

As many as a million gay and lesbian veterans depend on the U.S. Department of Veterans Affairs for health care—including many who can’t get HIV/AIDS care anywhere else. It’s reason enough for GLBT activists to keep an eye on the Bush administration’s coming cutbacks

On January 6 veterans across the country were shocked to learn that Republican congressman Chris Smith of New Jersey, the chair of the House Veterans Affairs Committee, had been ousted from his position in favor of the much more right-wing Republican Steve Buyer of Indiana. 

Smith was widely regarded as a staunch defender of veterans’ benefits, and it is widely believed that the GOP removed him in order to replace him with someone who would be much more amenable than Smith had been to implementing severe cutbacks at the U.S. Department of Veterans Affairs. 

Does this matter at all to the GLBT community? You wouldn’t think so, from the reaction of GLBT rights organizations, which was silence. In fact, you’d be hard pressed to find a press release or public statement from any GLBT organization on any matter related to VA. I cannot find a single GLBT lobbyist who has contacts on either of the Veterans Affairs Committees, nor a single HIV/AIDS organization that will so much as provide a link from its Web site to VA’s HIV/AIDS information page. 

But VA does matter to us a great deal. The Urban Institute estimates that there are well over a million GLBT veterans in the United States. We don’t know how many of them depend upon VA for health care, but we do know that VA is the nation’s single largest health care provider of HIV/AIDS-related services, with over 20,000 HIV-positive vets in the VA system, and that many other, primarily low-income GLBT vets depend on VA for treatment of other chronic conditions. 

Many of those veterans may not be in the VA health care system for much longer. 

In 1996, Congress changed VA’s eligibility criteria, allowing most honorably discharged veterans with income under about $30,000 a year to receive care at VA medical centers, regardless of whether they are disabled or ever served in a war zone. Elderly veterans without prescription coverage quickly learned that they could receive prescription drugs from VA and began crowding into VA hospitals, tripling VA’s patient caseload in just a few short years. 

Rather than respond by either increasing the VA’s funding or, better yet, solving the national prescription drug crisis, the Bush administration, with the assistance of people like Buyer, is expected to propose a return to the pre-1996 eligibility criteria, possibly in the next term. The effect would be to throw several million veterans, many of whom are uninsured, out on the street. A gay friend of mine who is receiving treatment from VA for his stage 4 cancer says, if that happens, “I guess I’ll just go out on the White House lawn and die there in protest.” And forget about adding HIV to the VA’s list of “catastrophic disabilities,” which entitles veterans to health care regardless of their income level, a proposal that will almost certainly fall by the wayside now. 

What can you do about this? 

You can start by getting involved with a veterans’ organization—if not my own organization, American Veterans for Equal Rights, then one of the mainstream organizations. Don’t assume that these groups will be hostile or homophobic. Vietnam Veterans of America, for example, sent its head lobbyist to speak at AVER’s recent convention. Most of these organizations, like The American Legion, Veterans of Foreign Wars, and AMVETS, are hungry for new members, especially younger veterans. Getting involved with them is a great way to build bridges between the GLBT and straight communities, and there are few nobler causes than helping out our nation’s veterans in their hour of need. 

Lara Ballard is a regional vice president of American Veterans for Equal Rights, a nationwide grassroots network of GLBT veterans and allies. She can be reached at ballardla@aver.us

Wounded in Action

The first symptom was sleeplessness. It was July 2003 and Lance Corporal David McGough of the Royal Army Medical Corps was just back from a five-month tour of duty in Basra, Iraq. Lots of the lads from his unit had trouble settling back to a normal routine at first, but most were OK within a fortnight or so. David, however, did not sleep for an entire month.

“My body just wouldn’t switch off,” he tells me, fidgeting with his hands. “All the time this tension was building, this incredibly tense restlessness. I was going for weeks without any sleep at all and then collapsing, sleeping for maybe six hours, and then starting all over again.” At night, on leave, he walked around his small maisonette in a suburb of Preston, Lancashire, folding and re-folding his clothes, checking and double-checking the locks, looking over his shoulder repeatedly for imagined intruders.

McGough was vomiting every day, often bloodily. The odour of cooking or burned meat made him sick, though “the worst thing is the smell of public toilets”. “That brings the PoW camps back. The stench of those places was horrendous.”

Mostly it was the insomnia that started to drive him mad, that made him crash his car and almost beat his then-fiancee, that both masked and exacerbated his chronic underlying depression. The army doctor at the camp in Preston prescribed him Prozac and more or less told him to pull himself together. When Prozac failed to work, McGough was given a stronger antidepressant, citalopram, “but no sleeping tablets, and by then – Christmas – I wasn’t really sleeping at all”.

McGough’s two attempts at suicide, both at Christmas in 2003, were more cries for help than committed bids to kill himself. On the first occasion he held a knife across his throat until his sister begged him to put it down, and on the second he put a 9mm pistol to his head but did not pull the trigger fully. Horrified by what was happening, McGough’s father, a civil servant based in Northern Ireland, called Dr Alun Jones, a civilian psychiatrist who specialises in diagnosing and treating psychological problems in servicemen and women. “It was immediately clear,” says Jones, “that McGough was suffering a severe case of post-traumatic stress disorder.”

So far, PTSD experts have seen a mere handful of British sufferers from this latest war in Iraq – but as the violence goes on, the trickle is expected to become a flood. Late last year, the independent inquiry into Gulf war illnesses chaired by Lord Lloyd of Berwick came to the conclusion that there was “every reason” to accept the existence of a Gulf war syndrome, and that post-traumatic stress was one of several contributing factors. Though the Ministry of Defence does not publish statistical predictions, military psychiatrists in America have been warned to expect psychiatric disorder to occur in a remarkable 20{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of servicemen and women returning from Iraq.

“What we’ve got now is a situation starting to approximate to Northern Ireland or Bosnia, to civil insurrection rather than a straight shooting war,” says Jones, who runs PTSD clinics around the country and at a residential centre in north Wales.”In those kinds of circumstances, where you’re experiencing hatred and violence from an unpredictable civilian population, we tend to get a lot of very disturbed and damaged soldiers.” In the field of trauma studies, this atmosphere of constant and random danger is known by the shorthand “no safe place”.

Other surveys suggest that roughly half the servicemen who suffer psychiatric illness as a result of traumatic events do not seek medical help, or do so years later, when the psychological afterburn has irreparably damaged marriages, careers and mental wellbeing. “And there’s still a stigma attached,” says Leigh Skelton, director of clinical services at Combat Stress, the ex-services mental welfare charity. “PTSD is seen as a career-stopper within the army. Generally, the first line of action servicemen and women take is to bottle it up. Then they’ll self-medicate, usually with alcohol, sometimes with other substances. Cries for help often come from relatives rather than from the affected person.”

Symptoms range from insomnia, nausea and extreme fatigue to the classic “flashback”; aggression, feelings of alienation and irrational anger. Sometimes the disorder centres on one particular memory. A 30-year-old female ambulance driver in the Territorial Army, for example, constantly replays the moment her vehicle was blown up last year by a hand-made bomb tied to a lamp-post in Basra. One marine in his early 20s now suffering chronic PTSD remembers “the fear in the eyes of an Iraqi soldier in the window” of a building mortared by the British; and seeing that fear again when British soldiers mistakenly opened fire on a civilian vehicle.

McGough, however, identified no single trigger. Skinny and pale, when I met him in late November he was a shadow of the strong young man he was pre-Iraq – the high-flyer who studied psychology at Queen’s College, Belfast, who loved to sky-dive and socialise, who was promoted within a year of joining the RAMC. For him, the pressure began the moment he and his medical unit moved into Iraq, at 2.30am on the first night of the war, four hours after the Americans began their aerial bombardment of Baghdad.

McGough was 21 years old and effectively in charge of 80 rookie soldiers fresh out of training, most of them still teenagers. As medics, they travelled in canvas-roofed trucks and were not equipped with body armour. “There was gunfire everywhere. Some of them were literally crapping themselves in the back of those trucks.” That first night, there wasn’t even time to pitch camp. “The worst casualty I saw was an Iraqi guy hit about 13 times, big chunks of his stomach, face and legs just gone. We intubated him and opened him up by the side of a truck. You do it on autopilot at the time because your training kicks in. It’s only afterwards you start to think about what you’ve seen and done.”

The mobile field unit, the first line of medical services, was initially established just south of Basra, but was twice relocated to escape attack. Its job was to mop up trauma cases, stabilise them and send them to field hospitals nearer the southern border. According to McGough, the medical unit received up to 1,000 wounded Iraqis during his five-and-a-half-month tour of duty, of whom perhaps 60{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} died and were buried in mass graves.

A large proportion of the medics’ work, however, took place in the PoW camps set up on each site. “Usually we had about 150 prisoners coming in a day,” says McGough, “both soldiers and civilians who’d been picked up with guns. Some had clearly been tortured by the Iraqi regime. There was one man who had thick black stuff, like goo, coming out of his penis, and said he’d been injected with something when he was a prisoner before. Others had quite infected lash wounds on their backs, or broken jaw bones.” The unit also saw a number of raped women, who were treated and counselled by a female army gynaecologist.

Seemingly futile or absurd situations are known to compound wartime trauma. The unit’s first location at Basra was regularly attacked by Iraqis defending a nearby ammunition dump from a maze-like system of trenches. “There was no adherence to any kind of convention on their part. Sometimes it was ridiculous. Every time we hit and wounded someone, a white flag would go up on their side and the others would bring the man we’d wounded over to the base for treatment. Then they’d go back up and start shooting at us again.”

Most harrowing of all was the discovery of the corpse of a 12-year-old girl who’d been hanged in a backstreet alley in Basra. McGough was sent to confirm the death and recognised her as the child to whom he and his comrades had chatted the week before. “We heard later that she was probably hanged by the crowd because she’d been talking to our crew … That was one of the worst things. You expect to see some nasty stuff, but seeing a little girl hanging in the street because she once spoke to you … ”

PTSD has been a recognised injury of war for more than 30 years, yet treatment in Britain is still very patchy. It took complete break-down (“my girlfriend found me one night huddled on the floor, shaking and crying”) and several emergency trips to hospital in Preston before McGough was finally prescribed sleeping tablets. While a member of the British army, he was unable to access the civilian care system – and had been informed of a decision to discharge him without a pension.

“The army is not a branch of the social services,” says Jones, “but I do think there is a certain duty of care, knowing what we now know about the effects of trauma. It would be reasonable to expect the army to check these lads over for psychological injury when they come back from combat, but in fact there is no obligation whatsoever to do this.”

“No one rings or visits in the mornings because I’m just a horrible, nasty person before the drugs have kicked in,” says McGough. He was increasingly convinced that his physical symptoms – the vomiting and chronic weight loss – are related to anthrax injections and to the Naps tablets taken to counter the potential use of enemy nerve agents. On bad days he does not get out of bed at all.

“I loved being in the army,” he says. “It was supposed to be my long-term career, and I was prepared to give everything to it … I just wish I could shake this and get on with my life again.”

Troops unable to be treated for skin disease in Iraq will be seen by doctors in U.S.

ARLINGTON, Virginia — U.S.-based military doctors are bracing for a wave of servicemembers returning from Iraq this spring whose treatment for a skin disease has been delayed by the dangerous security situation there.

The soldiers who may be infected with cutaneous leishmaniasis are mostly from the 1st Brigade of the 25th Infantry Division, the Army’s “Stryker Brigade,” according to Dr. Alan McGill, infectious disease specialist at Walter Reed Army Institute of Research in Silver Spring, Md.

“We’ve heard rumors of a couple hundred cases in the Stryker Brigade,” McGill said Friday.

But travel in Iraq is so perilous for U.S. troops that health care staff there are choosing to let suspected cases of the disease go, rather than risk a trip to the large medical facilities for diagnosis, said McGill, the U.S. military’s leading leishmaniasis expert.

“Doctors in the field are making some hard choices, because any movement in Iraq places your life in jeopardy,” he said.

McGill said he agrees with that decision, because the sores caused by cutaneous leishmaniasis eventually go away without treatment.

“If I were over there, I wouldn’t take the risk of sending [a soldier] to [a large medical facility] to treat a skin lesion that’s going to get better anyway,” McGill said.

Although treatment for some may have been delayed, troops whose skin lesions are serious will be accommodated once their deployments are over, McGill promised.

“The security situation may have prevented a timely evaluation by stateside standards, but as soon as these guys get home, we are going to take care of them,” McGill said.

Leishmaniasis takes hold when infected sand flies bite humans who sleep on the ground or work in very dirty, sandy environments.

Human cases of leishmaniasis mostly fall into one of two categories: cutaneous, which causes skin lesions that vary from the size of a pencil head to larger than the bottom of a soda can; and visceral, a far more serious variation which leaves no external marks, instead attacking the internal organs.

Untreated visceral leishmaniasis can be fatal, according to the Centers for Disease Control and Prevention in Atlanta.

But sores from cutaneous leishmaniasis “heal on their own, [although] this can take months or even years … and leave ugly scars,” according to CDC spokesman Llelwyn Grant.

U.S. military doctors diagnosed about 750 cases of leishmaniasis among troops who participated in the first rotations of Operations Iraqi Freedom or Enduring Freedom in Afghanistan, McGill said.

Of those, only four cases of visceral leishmaniasis have been diagnosed, two from Iraq, and two from Afghanistan, he said.

Military physicians are expecting fewer cases among troops deployed in the second rotations of OIF and OEF, because most troops now stay in screened, air-conditioned facilities — one of the CDC’s primary recommendations for avoiding infection.

To date, WRAIR has received confirmed reports of about 20 cases of leishmaniasis from OIF2 and OEF2 troops, all of which are cutaneous, McGill said.

Nevertheless, “we think that we’ll see a delayed bubble of cases in March and April,” when second rotation troops begin coming home in large numbers, McGill said. “If we see 100 cases that need [treatment], I would not be surprised.”

Dear America,

I am a soldier, and I served in Iraq.

I spent the last year riding in an unarmored humvee with no doors, open to the whims of the enemy and the splashes of sewage from the wheels. I have cursed the generals in their plush palaces and air conditioned SUV’s. I have shivered with Dengue Fever, sweated in the 130 degree heat, and gotten violently ill an average of twice a week courtesy of the mess hall. I have cursed when an RPG was fired at me, only to laugh when it failed to explode because Hadji forgot to pull the pin. I am all too familiar with the buzz a bullet makes as it passes.

If you are an Iraqi, I will shake your hand, kiss the side of your face, drink your tea, share a meal together, and play with your children. I will count you as a friend. I do not care if you are Sunni, Shia, or Christian. I will fix your sewer. I will make sure you have food and clean water. I will give you the freedom to speak your mind without the threat of summary execution. I will shake my head in frustration when you ask, “What have you done for me lately?” I will not hesitate to put you down for good when I see you planting an improvised bomb on the sidewalk.

I will never be the same, and I want to scrub my mind with steel wool to remove the memories. I have watched the light fade from the eyes of another human being and known that I could not save him. I have seen animals carrying body parts. I have been told the words that cut directly to the center of an officer’s heart: “Sergeant G’s been hit, and it’s bad.” I have had to choose whether to kill a teenager for pointing a weapon at me. I have pulled the trigger when he turned his weapon toward one of my soldiers. I have drifted off to a fitful sleep with the smell of dead humans on my uniform.

The media will try to jolt you with narratives and images of increasing violence. In reply, pundits and talking heads will trumpet our successes, progress, and the enemy corpse count. Does it matter which side is right? Not really. The only thing that matters is that, right now, over one hundred and thirty thousand men and women in our armed forces are sweating, bleeding, and dying in the desert. They deserve the attention and respect that they have earned with their courage and purchased with their lives.

Jason N. Thelen

Dallas, Texas

Jason Thelen served as a Captain in the US Army Reserve during Operation Iraqi Freedom. This is the first in a series of columns he will be writing for Veterans for Common Sense. He can be reached at jthelen294@yahoo.com

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Returning veterans paint grim picture of war’s toll

Soldiers recently returned from Iraq gave an unfiltered and unflattering assessment of the war’s human toll as they detailed their war experiences to a crowd of Oakton Community College students and faculty Wednesday in Des Plaines.

One officer lost more than 38 pounds in the Iraqi desert when his unit ran low on food and water. Another was sent to the front lines without body armor. They witnessed soldiers blown to bits and mourned the loss of others who killed themselves when they returned home — often excluded from the government’s official body count.

And they’ve been frustrated with buddies who have had to wait months for medical services or for their claims to be decided by the Veterans Affairs Department.

‘People are unaware’

“There’s a tremendous human cost of this war, and America isn’t prepared for it,” said Paul Rieckhoff, a former Army infantry platoon leader from New York and founder of Operation Truth, a national soldier organization that is touring college campuses to present an alternative view of the war.

Rieckhoff criticized the military for not releasing the entire number of those killed or injured in Iraq, a figure he said is far greater than the 1,416 listed as killed and 10,622 listed as wounded by the Defense Department.

“It takes guys like us to embarrass [Defense Secretary Donald] Rumsfeld before things get changed,” he said. “The military is being run into the ground, and the American people are unaware of what’s really going on.”

The group showed a documentary in which former soldiers from Iraq — many of them amputees — were angry about how the government treated them once they returned, complaining they were met with a “nightmare of paperwork” to get medical and disability benefits.

“Once you’ve served your purpose,” one young soldier told the camera, “you’re no longer of use to the U.S. government.”

The soldiers’ group is advocating legislation that would provide the VA with more funding and stop a proposed budget cut, give better counseling and treatment for the estimated thousands of troops returning with psychological problems and train and equip National Guard and reservists on par with their active duty counterparts. It also wants the military to end its stop-loss policy, which prevents many soldiers from leaving the military when their term ends.

‘It’s very scary’

“We need the support of the American people to do more than put a bumper sticker on their car,” said Chris Lawrence of Chicago, who served in the Army for 12 years and received a Bronze Star for his service in Iraq. He encouraged members of the audience to write their congressmen in support of pending legislation.

Several students said they were outraged by what they heard.

“How is it that soldiers can be fighting in Iraq with no body armor, and Bush is having a $40 million inauguration party?” one student asked the panel of soldiers.

The soldiers sidestepped political issues, insisting they were not anti-war but wanted to get the word out about the needs of soldiers and their families.

“We’re not foreign policy experts. We’re just soldiers,” Rieckhoff said.

Freshman A. J. Lebeau, 19, of Park Ridge said the film and talk opened his mind.

“I was rather shocked,” he said. “I had no idea all that — the lack of supplies — was going on over there. It’s been kind of an enlightenment.”

Another student, sophomore Colleen Morse, 20, called the soldiers’ accounts “sad and appalling. Apparently we haven’t learned from Vietnam. It’s very scary.”

Insult to Injury: You Know They Treat Us Like Shit Says Iraq War Veteran

WASHINGTON — Most patients at the Walter Reed Army Medical Center in Washington have a lot on their minds: the war they just fought, the injuries they came home with, the future that lies ahead. The last thing a wounded soldier needs to worry about is where the next meal is coming from. But for hundreds of Walter Reed patients, that’s a real concern. Starting this month, the Army has started making some wounded soldiers pay for the food they eat at the hospital.

Paying out of pocket for hospital meals can impose a serious financial burden, costing hundreds of dollars every month. That can be a lot of money to a military family. But perhaps worse, the meal charge feels like an ungrateful slap in the face to some soldiers. “I think it sucks,” said a soldier from West Virginia who broke his neck in Iraq after falling off a roof. “I think that people should be able to eat. They get us over there, get us wounded and shot up and then tell us: Fend for yourself. You are all heroes, but here you go.”

Whether it is the lack of protective armor for troopsin the field or, now, wounded troops paying for food, complaints from soldiers have shed an unflattering light on how the military bureaucracy takes care of its troops. And they have prompted accusations that the Pentagon is fighting the Iraq war on the cheap, no matter what the cost to soldiers. The meal charge policy “is an example of a much larger problem relating to the overall cost of the war. It is all an indication of extreme costs they are trying to make up on the backs of these men and women,” said Steve Robinson, a retired Army Ranger and the executive director of the National Gulf War Resource Center. “If the war is costing too much, the one place you don’t skimp is on soldier and veteran programs. The administration has no problem deficit-spending on the needs of conducting war, and we see no reason not to apply the same methodology to veterans’ benefits and soldier care.”

A veterans’ advocate who lost the use of his legs fighting in Vietnam said the meal charges constitute a personal affront to soldiers. “I don’t care what bureaucratic bullshit they come up with, this is an insult,” said Bobby Muller, chairman of the Vietnam Veterans of America Foundation and director of the foundation’s Alliance for Security. “I cannot believe that people are being charged for their meals. This is a showstopper.”

For its part, the Army explains — and defends — the food charges at Walter Reed by saying they apply only to some outpatients, not inpatients confined to hospital beds. “I have been absolutely assured … that no inpatient has been charged for meals,” Walter Reed spokesman Don Vandrey told Salon. But until Jan. 3, outpatient soldiers who served in Iraq or Afghanistan ate for free in the chow hall. Now outpatient soldiers there longer than 90 days pay for meals in cash. Although Walter Reed did not disclose the exact number of soldiers affected, the policy is most likely to affect at least the estimated 600 soldiers getting long-term outpatient care at the hospital in what the Army calls “medical hold.”

Soldiers in medical hold are considered outpatients, but they usually live on hospital grounds — some are put up in nearby hotels if housing on the grounds is full — and have little choice but to buy food at the Walter Reed chow hall. Even as outpatients, soldiers in medical hold often have serious injuries. Some have been blown up by roadside bombs or crumpled in Humvee wrecks. They have serious head wounds and amputations. Others are struggling with post-traumatic stress disorder after being flown out of Iraq with shellshock. Some soldiers in medical hold are waiting to get processed out of the Army because their wounds are so serious that they will never return to duty. But processing at Walter Reed can take over a year, much to the frustration of the soldiers who would prefer to get outpatient treatment near their homes and families. Soldiers in medical hold also complain they are still expected to line up for daily formations and buy new uniforms even as they struggle with debilitating physical and mental trauma from their service in Iraq. They say being charged for food while they’re recovering is one more indignity.

From the Army’s perspective, the meal charges follow Army rules that are supposed to prohibit soldiers from getting free food as well as a separate food budget. But the only soldiers prohibited from getting both, under the new rules, are the long-term outpatients. “If they get [the cash each month] they would be expected to pay for their meals,” said Vandrey, the Walter Reed spokesman. He said the hospital was “really cracking down on soldiers who are getting both.”

But here’s how the new rules drain hundreds of dollars a month from the pockets of soldiers: Enlisted soldiers get an extra $267.18 every month in their paychecks for food. So before this month, all soldiers at Walter Reed got free food at the chow hall and extra cash. Soldiers say they received that extra food money while they were serving in Iraq, too, and they just let their families spend it on groceries. Now, though, the outpatient soldiers forced to buy meals at Walter Reed say they could spend around $15 a day if they eat three square meals at the dining hall — about $3 for breakfast and around $6 each for lunch and dinner. That adds up to $450 a month, $183 more than soldiers’ food allowance from the military. (The situation is even worse for officers, who get only $183.99 extra each month for a food allowance.) The soldiers at Walter Reed point out that that they don’t have the option of eating at home to save money because they are stuck at the hospital. Vandrey said spending $6 for lunch and dinner sounds excessive. “I eat breakfast and lunch there every day and I never spend more than $5 a meal,” he said.

Most soldiers in medical hold eat at Walter Reed every day, too. But for those well enough to leave the hospital grounds, a favorite spot — and a rare treat – is the local Red Lobster, particularly if the press is paying. At a recent meal there, three soldiers from Walter Reed told Salon the new meal charges were putting a serious strain on already tight pocketbooks. (All three ate hefty-size meals.) “I don’t starve, [but] it might be beans and weenies or a cup of noodles,” said the soldier from West Virginia who was treated for the broken neck; he can now walk, but does so with an awkward, bowlegged gait. “I’m not going to starve to death, but it is an issue that really sucks.” A soldier from Pennsylvania said, “They want to charge us for uniforms, for food, everything.”

Notwithstanding the charges for food, it should be said, Walter Reed has gained recognition for its excellent medical treatment of acute battlefield injuries, including those sustained by amputees. Soldiers seem to agree that while the hospital has its problems, that particular credit is well deserved.

The soldiers interviewed for this story asked for anonymity because they feared getting into trouble with their chain of command for speaking out. Many soldiers from Walter Reed attended the Heroes Red, White and Blue Inaugural Ball last week, attended by Secretary of Defense Donald Rumsfeld, Deputy Secretary Paul Wolfowitz and others. Soldiers told Salon they were lectured on the bus on the way to the ball that they would face consequences if any untoward comments about the military appeared in the press. One soldier said he and others were told that they should not feel compelled to speak with reporters, but if they did, they would be in their commander’s office in the morning if they said anything negative.

Beyond the creeping food bill, perhaps what’s most bothersome to soldiers about the meal charge rule is the principle of the thing: Paying for food at an Army hospital after fighting in a war doesn’t seem right. “You know they treat us like shit up here,” said the soldier from Pennsylvania. One officer from the Army Reserve who served in Iraq told Salon he was “highly disgusted” at being asked to pay for food after being stuck at Walter Reed. “It affects me to a point, but it has a tremendous impact financially on the junior enlisted soldiers,” he said. “After these kids get physically or mentally injured in combat, and then you expect them to take away from their personal finances to feed themselves? That is what disturbs me the most.”

Two live grenades found in luggage of soldier returning from Iraq

ATLANTA (AP) Two live hand grenades were found in the luggage of a soldier returning from Iraq on Thursday, halting operations at the international terminal of Atlanta’s airport for about a half-hour, a spokeswoman said.

The soldier was aware of the grenades and tried to alert the Transportation Security Agency, “but it was too late. The bags were already being screened,” spokeswoman Felicia Browder said.

She said there was no evacuation of the terminal, but people were kept back a safe distance until a bomb unit removed the grenades.

Passengers on a handful of international flights were not able to leave their planes for more than a half-hour during the incident, Browder said.

The soldier, who was not identified, was released to the military, she said.