By Lt. Gen. Patricia Horoho
Army Surgeon General/Commanding General Army Medical Command
50 years ago, U.S. Medicine began covering military medicine. Since then, much has changed. Most recently, with wars in Iraq and Afghanistan, advances have been made in blood plasma products, use of tourniquets, regenerative medicine, prosthetics, medical evacuation procedures and enhanced training for combat medics. All of which have been covered by this magazine.
This article focuses on improvements in Behavioral Health (BH), women’s health and preventive health implemented during the past 50 years, in times of peace as well as war, while the Army has both expanded and contracted in response to the needs of the nation.
Historically, mental health focused far more on long-term management in the inpatient setting, as there were far fewer therapeutic drugs available. During the Vietnam War there were more psychiatric patients than in previous conflicts, but more of those cases involved trainees adapting to the Army than soldiers coping with what was then called “combat fatigue.” The Army Medical Department (AMEDD) worked on preventive psychiatry, something now categorized as resiliency, and studied psychiatric patients who returned to duty. Test programs were developed to improve continuity of care between outpatient and inpatient Behavioral Health and some programs were expanded to help children whose fathers were deployed to Vietnam.
As the fighting in Vietnam subsided, Behavioral Health care was further extended to returning American POWs. Rather than simply discharging psychiatric patients, they were now sent to a transition program for rehabilitation care.
Efforts also continued to focus on early intervention. In 1974, a psychologist was added to each combat division to work alongside the divisional psychiatrist and social workers. During Operation Desert Shield, when about 3 percent of patients had Behavioral Health problems, there was a strong emphasis on psychiatric care for soldiers. After Desert Storm however, the Army realized the stresses of reunions on families, and soldiers required enhanced care for both themselves and their families.
Throughout the 1990s, efforts continued to optimize the Behavioral Health (BH) force structure, with Behavioral Healthcare organized in small teams that could be forward deployed on the battlefield to provide more timely support. In July 2003, only four months after Operation Iraqi Freedom started, a Mental Health Assessment Team was deployed to Iraq to examine the effectiveness of mental-health care provided in real time. Among many changes instituted as a result of these assessments were shorter deployments and longer dwell time (time spent at home contributed to less stress and more resiliency during and after deployment), and stigma-reduction efforts to encourage servicemembers to seek Behavioral Healthcare.
More recent Behavioral Health advances include providing resiliency training, improving the treatment of concussions and blast injuries and increasing access to Behavioral Healthcare through enhanced screenings, tele-Behavioral Health services and Child and Family Assistance Centers. In addition, Patient-Centered Medical Homes (PCMHs) colocated Behavioral Health and primary-care providers within medical service facilities, improving access and helping to alleviate stigma associated with seeking Behavioral Health services. In FY12, the Army began expanding Behavioral Health capabilities by assigning embedded Behavioral Health teams to all its brigade size operational units.
In 1964, women made up less than 1 percent of the Army and could only be assigned to administrative, medical and some communications positions. They could be discharged if they became pregnant, and enlisted females could be discharged if they married. Although women’s health was a low priority, care was certainly provided for servicewomen and dependents. After the end of the draft in 1973, the military actively sought female recruits, and by the end of the decade, over 9 percent of soldiers were women.
As more positions in the Army opened to women, especially in nontraditional jobs, their injury rates increased sharply. The Army responded with more physical training to strengthen women, while reevaluating both positions and processes. These moves reduced female hospitalization rates. In the late 1970s, the Army further recognized the expanded roles of women by adding gynecological items to field medical kits. There also were moves to improve access to care so female soldiers would not lose duty time; women’s health clinics were established outside hospitals; and female soldiers also were seen as a special target audience for health educational efforts to include sexually transmitted diseases, tobacco cessation and fitness regimens.
Operation Desert Shield drew more attention to women’s health issues, since they now made up more than 10 percent of the Army, many of whom were deployed. In the early 1990s, women’s health was intensively studied: shortages in OB/GYN physicians were identified, procedures — such as epidurals — became routine, and commanders were regularly briefed on women’s health issues. In addition, the Department of Defense set up a task force on women’s health, and a formal research program was established. The emphasis on prevention continued, both through health advice and through safety studies as even more military career fields were opened to women.
Women’s health topics also shifted as the generation of women who had volunteered in the 1970s and 80s aged and faced different health concerns. In 1995, Madigan Army Medical Center started a Women’s Health Initiative (focused specially on prevention), which later became a women’s health research center. Establishment of longitudinal databases allowed assessment of readiness, health promotion and health outcomes in all service personnel and, specifically, women’s health issues.
In 2011, AMEDD created a Women’s Health Task Force to address health issues specific to females during deployment. Task force members met with more than 150 women in Afghanistan. Their report highlighted several key findings and recommendations that already are being implemented — the need for greater women’s health awareness, a female urinary assist device, female body armor and a self-test kit for urinary and vaginal infections.
Preventive Medicine and Health Promotion
Army Medicine has long focused on preventive medicine to maintain readiness and conserve the fighting force. While prevention efforts have continued, the focus is now shifting to proactive engagement in healthy behavior. For instance, 50 years ago the US Surgeon General published the landmark report “Smoking and Health” that started the decadeslong reduction in tobacco use. At the time, the Army was focused on other topics, such as health education in Department of Defense schools and Army communities.
In 1971, the Army Surgeon General further emphasized prevention through education by establishing a Directorate of Health and Environment in The Surgeon General’s Office. The early focus was on nutrition, not just for soldiers, but for their families, as well. Fort Lee was selected for a post-wide study on improved nutrition through dining facilities, and all basic training soldiers were taught about nutrition. In 1976, the Army Physical Fitness and Weight Control Program was applied to all soldiers.
In 1982, the Army opened Health Fitness Centers (later the Army Physical Fitness Research Institute) to encourage fitness programs. In 1986, the Army Health Promotion Program began in what then-Surgeon General Quinn Becker called “the real beginning of the turning of our medical care system away from disease only and toward health promotion.”
In 2012, continuing that effort, we initiated the Performance Triad program, designed to inculcate healthy lifestyle behaviors into the DNA of the Army. By increasing awareness in the areas of sleep, activity, nutrition, we hope to improve performance and resilience in our Soldiers, family members, retirees and civilian workforce. Performance Triad Pilot programs have already kicked off at Joint Base Lewis McChord, Fort Bliss and Fort Bragg. The Performance Triad program, nested within the Army’s Ready and Resilient Campaign, is part of Army Medicine’s effort to transition from a healthcare system that treats disease, to a System for Health that serves to maintain, restore, and improve health through healthy choices made in the “life space.”
Army Medicine is a learning organization that continues to evolve under the demands of supporting an Army concurrently at war in two theaters of operation. While the wounds of war are and will continue to be ours to mend and heal, Army Medicine now looks forward to charting a new course for the health and readiness of the Force. We will set an example for the nation in quality healthcare, wellness, prevention and collective health for all those entrusted to our care. This complements the noble mission we execute today — world-class healthcare at home and abroad for soldiers, families and retirees.