Panel I Of A Hearing Of The Defense Subcommittee Of The Senate Committee On Appropriations - Department Of Defense Medical Programs

Statement

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SEN. INOUYE: I'd like to welcome all of the witnesses as we review the Department of Defense medical programs. There will be two panels this morning. First, we'll hear from the service surgeons general: General Eric Schoomaker, Admiral Adam Robinson Jr., and General James Roudebush. Then, we'll hear from our chiefs of the Nurse Corps: General Patricia Horoho, Admiral Christine M. Bruzek- Kohler, and General Kimberly Siniscalchi -- did I get it correct?

MR. : You did.

SEN. INOUYE: I'd like to welcome back all of the three surgeons general to our committee once again. I look forward to continuing our work together to ensure the future of our military medical programs and personnel.

As you may have noted, this is the first defense hearing that the committee will be holding this year. We deliberately selected the medical program as our inaugural topic to underscore the importance that this issue has to our committee. Our surgeons general and the nurses have been called upon to share their insight on what is working and what is not working.

Military medicine is a critical element in our defense strength. Our ability to care for our wounded soldiers on the modern battlefield is a testament both to the hard work and dedication of our men and women in uniform and to the application of the new technology, which is a hallmark of the U.S. armed forces.

So, too, our medical programs demonstrate a commitment to provide for our service members and their families which is unsurpassed in any other military. It is a vital component of our military compensation package, one that is necessary to sustain an all-volunteer force -- a force, I might add, which by all measurement is the finest in the world.

This is a unique medical hearing, because we have not received the details of FY 2010 DOD budget, nor have we received the remaining FY 2009 supplemental request. While we might not be able to discuss detailed budget issues, we'll focus on various medical personnel and medical technology issues facing the department, our service members and their families.

On a personal note, when I was in the Army some time ago, 4 percent of the men in my regiment were married -- just 4 percent. I think that was about the average in the United States Army. Now, 56 percent of the Army, 54 percent of the Navy and 45 percent of the Marine Corps and 59 percent of the Air Force are married. This completely alters the dynamic of the service I remember to the one you see today. Not only that, but the demographics of our service members have drastically changed. We also have more than a few dual-service parents and couples, most of which deploy to theater.

We've all read about the rising rates of suicide, divorce and substance abuse in our military. This is not something that can only be addressed with the service member. This must be approached with the service member, their family, their fellow soldiers, sailors, Marines and airmen. The solutions are not one size fits all or one service fits all. Instead, all ideas must be on the table for everyone to consider. What works for the Army may not necessarily work for the Navy.

In addition, we need to take a unified approach to medical research in areas directly tied to the warfighter that we are currently tackling and those that could be right around the corner. This coordinated approach should cross the entire federal government, utilizing the resources and the expertise of the Department of Veterans Affairs, the National Institute of Health, Department of Homeland Security and the Substance Abuse and Mental Health Services Administration, just to name a few.

The department stands at a very pivotal juncture in its efforts to modernize the medical technology enterprise architecture. I'm certain each one of you can share a story or two about the various versions of the department's medical health records and how challenging it can be, at the least. Now you are tasked to both modernize the system and make it interoperable with the VA to facilitate seamless transitions for our service members and to enable joint DOD/VA locations to care for both veterans and service members.

These are not simple tasks, and I know that there are many challenges ahead, and these are some of the issues that we'll face in years ahead. We continue to hold this valuable hearing with the service surgeons general and the chief of the Nurses Corps -- as an opportunity to raise and address these and many other issues. And I look forward to your statements and note that your full statements will be made part of the record.

Before we proceed with witnesses, may I call upon the vice chairman of the committee, Senator Cochran?

SEN. THAD COCHRAN (R-MS): Mr. Chairman, thank you very much. I'm pleased to join you in welcoming our two panels of witnesses today, the service surgeons general and the chiefs of the Nurse Corps.

We have an important duty to provide for the medical needs of our active, Guard and Reserve personnel. The joint approach in managing the military medical programs has been very important in supporting our soldiers, sailors, airmen and Marines, especially during wartime.

The men and women of the Medical Service Corps deserve our thanks for the services they've provided and continue to provide, and I'm pleased to join the chairman in being here to receive your testimony and working with you as we try to identify the priorities that need special attention in the funding cycle that we are approaching.

Thank you very much.

SEN. INOUYE: Thank you very much.

I'm especially pleased to have with us in the committee this morning Senator Bennett of Utah. He's our newest member.

And welcome, sir. Would you like to make a statement?

SEN. ROBERT F. BENNETT (R-UT): Your being pleased is only exceeded by my being pleased at the opportunity to be here. (Laughter.) Thank you for your welcome.

SEN. INOUYE: Thank you very much.

May I call upon the first witness, Lieutenant General Eric B. Schoomaker. He's a doctor, a Ph.D., and he's also the surgeon general of the U.S. Army.

GEN. SCHOOMAKER: Thank you, sir.

Chairman Inouye and Vice Chairman Cochran, Senator Bennett, thank you for providing all of us here a forum for discussing our service medial programs and to allow me to discuss Army medicine and the defense health program.

As you mentioned earlier, sir, I'm joined by our chief of the Army Nurse Corps, Major General Patty Horoho and commander of the Western Regional Medical Command and Madigan Army Medical Center at Fort Lewis, Washington.

Also, in recognition of the Army's having declared 2009 as the year of the NCO -- the noncommissioned officer -- I'm joined today by my senior -- the senior enlisted medic in the Army who is my command, Sergeant Major Althea Dixon. She is one of the finest soldiers and leaders with whom I've had the pleasure to serve and is an invaluable member of my command team.

Sergeant Major Dixon has been my battle buddy and my conscience and my unwavering standard bearer for the last three commands and through some of the most difficult challenges that Army medicine has faced. We've traveled together throughout the United States, especially throughout the Southeast United States when we worked together in the Southeast Regional Medical Command but also in Europe and in Kenya, Thailand, Korea, and most recently in Afghanistan and Iraq.

She embodies, really, the ethos of the noncommissioned officers. She's a person to whom I turn for unvarnished truth about my command and my effectiveness as a commander, and she's my constant reminder of what is one of the most distinguishing and powerful features of our Army, which is our noncommissioned officer corps.

For my oral statement today, I'd like to highlight just a handful of key points that I raised in my written testimony.

First, I'd like to thank the Congress and this subcommittee in particular for the very generous and much appreciated funding support that you have provided for the military health system and for Army medicine over the last year. Congress has been attentive to the needs we have in military medicine, particularly in our sustainment, restoration and modernization funding -- SRM funding -- for facilities and our research and development funds for research.

Our sustainment, restoration and modernization funding really gets put to great use by our facilities managers who keep our facilities operating safely and reliably. Some of our older hospitals are not ideal for practicing a 21st century form of medicine, but our SRM funding has really allowed us to keep them in good shape and running safely and smoothly.

Our research and development dollars are going toward some very promising research. I think Senator -- chairman alluded to that earlier. It's aimed at saving and improving the lives of soldiers on future battlefields. And frankly, although I use the term "soldiers" to describe the recipients of these efforts, increasingly we conduct our research programs really as a joint effort among my three colleagues here so that all warriors -- soldiers, sailors, airmen, Marine, Coast Guardsmen and our other federal agency partners as well as the public at large are beneficiaries of our work.

Examples are biomarkers for traumatic brain injury, tissue re- engineering, interventions to build resilience and prevent psychiatric casualties -- just a few examples of where innovative research initiatives that were funded through our FY '09 core medical research budget are working.

And I eagerly await the outcomes of these and other research efforts that can better the lives of our soldiers and other warriors.

Next I'd like to briefly mention the latest developments in our Warrior Care and Transition Program. This is probably one of the most important advances that we've made over the last several years.

In our first year of standing up the Warrior Care and Transition Program through the Army Medical Action Plan, we heavily invested in the structure of our units. We focused on proper ratios of care providers and cadre that oversee our warriors in transition. That's what we call our soldiers who are in these programs. They are transitioning into uniform, back into uniform, or into civilian life, or into continued care in the private sector or the VA.

Now in our second year, we're directing our efforts at optimizing the transition for our soldiers and families. In March of 2008 we launched a comprehensive transition plan initiative for our warriors in transition. Instead of focusing solely on their injury or illness, the comprehensive transition plan fosters an holistic approach to a warrior's rehabilitation and transition.

These are lessons which wounded, ill and injured soldiers from former wars, such as the chairman himself and Senator Dole, General retired, now Secretary Shinseki and General retired Fred Franks have told us were the most important lessons to be gained from their own experiences as -- in recovery and rehabilitation.

This is accomplished through a collaboration of a multidisciplinary team of physicians, of case managers, specialty care providers, occupational therapists, and others. And together with the soldier we develop -- and the family we develop an individually tailored set of goals, emphasize the transition phase to civilian life or return to duty.

And I'm confident that this is really where we need to be doing that and it's going to come up with the right outcomes for our folks.

An even newer Army program that I have high expectations for is our Comprehensive Soldier Fitness Program. The Army chief of staff, General George Casey, has established a vision of an Army comprised of balanced, healthy, self-confident soldiers and families and Army civilians whose resilience and total fitness enable them to thrive even in this area of high operational tempo and persistent conflict and engagement.

To achieve this ambitious vision, he's instituting a comprehensive soldier fitness program. The intent of this program is to increase the resiliency of soldiers and families by developing the five dimensions of strength: physical, emotional, social, spiritual, and family. It's currently in development. It's under the leadership of Brigadier General Rhonda Cornum, an Army Medical Department physician. I expect this program to have a positive effect and a profound effect upon our soldiers, their families and our Army civilians.

Last, I wanted to share with you a copy of our new combat medic handbook. Our combat medics, which we call 68 Whiskeys -- 68W's -- are the best trained battlefield medics in the world along side our Navy and Air Force colleagues, of course.

As the Army and the Joint Force have labored to provide better body armor and protection from ballistic and burn and blast injury and have altered the tactics, techniques, and procedures in a complex urban terrain to reduce combat casualties and improved on our killed- in-action rates -- that is, survival from the initial wounding incident -- our medics have enhanced these improvements and have further contributed to a historically low diet of wound rates despite more destructive weapons that are wielded by our enemies.

The medics of this 68 Whiskey generation are trained to perform advanced airway skills, hemorrhage control techniques, shock management and evacuation. Examples are Sergeant First Class Nadine Kahla and Sergeant First Class Jason Riesler (sp) who are 68 Whiskey NCOs assigned to the Army Medical Department Center and School in San Antonio, Texas. They are representatives of the other 17 68 Whisky NCO authors that contributed to this new "Advanced Field Craft: Combat Skills" (sic/Combat Medic Skills) textbook, a state of the art manual for combat medics.

This delineation of combat medic skills is newly published. It'll be issued to every graduating new combat medic beginning this month.

It's an incredible resource developed by some truly incredible NCOs.

In closing, I wanted to thank the committee for the terrific support that you have given to the defense health program and to Army medicine. I greatly value the insight of this committee and I look forward to working with you closely over the next year.

I also want to salute our noncommissioned officers for their professionalism, competence and leadership. They're truly the backbone of the Army and of Army medicine.

Thank you for holding this hearing. Thank you for your continued support of Army medicine and the warriors and families that we're most honored to serve. Thank you, sir.

SEN. INOUYE: Thank you very much, General Schoomaker.

May I now call upon Vice Admiral Robinson?

ADM. ROBINSON: Thank you much -- very much, Chairman Inouye, also Vice Chairman Cochran, Senator Murray and Senator Bennett and other distinguished members of the committee.

Since I last testified we have seen the emergence of impressive changes and unique challenges to this nation and the global community. A historic presidential election has made significant national and international political impact, a war effort sustained with military troops deploying into hostile areas, and an increasing military medicine presence playing a key role to support the humanitarian civil assistance mission.

We are seeing uncertainty, change and fluctuation in our economy that will impact all of us, including military medicine.

Navy Medicine continues on course because our focus has been and will always be providing the best health care to our sailors, Marines, and their family members, all while supporting our nation's maritime strategy.

In response to our most critical demand, to support the Marine Corps, we are realigning medical capabilities to emerging theaters of operation. As the Marine Corps forces shift their efforts to Afghanistan, Navy medicine will support them and sustain our efforts in medicine, in trauma medicine and surgery capabilities.

The Navy's maritime strategy calls for proactive humanitarian assistance and disaster response efforts, and these are now preplanned engagements. These missions deploy from sea-based, land-based or expeditionary platforms and aim to meet a great spectrum of medical needs.

Our nation's humanitarian efforts serve as a unique opportunity for medical diplomacy to positively impact the perception of the U.S. by other nations.

In addition, these missions have become another avenue for improved recruiting and retention of Navy medicine health care providers. Filling vacancies in our medical department corps is critical to meeting our mission of maintaining medical readiness of the warfighter and providing health care to all eligible beneficiaries.

The chief of naval personnel and I have worked together on this issue, making medical recruiting a continued priority for fiscal year 2009. In spite of successes in the Health Professions Scholarship Program medical and dental corps recruitment, meeting our direct accession mission still remains a challenge. I anticipate increased demand for Medical Service Corps personnel, in particular, to better meet our increasing requirements.

From individual augmentation requirements to planned humanitarian assistance missions and unexpected disaster relief missions, as well as to meet the growing needs of a Marine Corps that is in fact growing, these demands will impact Medical Service Corps specialties linked to mental, behavioral and rehabilitative health and operational support.

Consistent with increased operational demand signals as well as to compensate for prior shortfalls in recruiting, the overall recruiting goals for uniformed Medical Service Corps officers have nearly doubled since fiscal year 2007.

The Navy has been successful during the past year recruiting and retaining Nurse Corps officers using a combination of accession retention and long repayment incentives. For the first time in over five years, Navy Nurse Corps officers' gains in 2008 outpaced losses. The chief of the Navy Nurse Corps, Admiral Chris Bruzek-Kohler, is here and will follow up in her statements and testimony.

Our Graduate Medical Education is a critical part of the foundation for Navy medicine's ongoing success. Despite the demands on faculty and staff for operational support, our Navy GME programs continue to be highly rated by the Accreditation Council for Graduate Medical Education, and our program graduates continue to pass their board certification examinations at rates significantly higher than the national average in almost every specialty.

More importantly, Navy-trained physicians continue to prove themselves to be exceptionally well-prepared to provide care in austere settings ranging from the battlefield to humanitarian assistance and disaster relief efforts.

Over the last year Navy medicine expanded services so that wounded warriors would have access to timely, high-quality medical care. In 2008 we consolidated all wounded ill and injured warrior health care support with the goal of establishing global policy implementation guidance and oversight in order to deliver the highest quality customer-focused, comprehensive and compassionate care to service members and their families.

As of March 2009, 161 medical care case managers were assigned to 45 medical treatment facilities and ambulatory care clinics caring for approximately 1,500 OIF/OEF casualties. The medical care case managers collaborate with Navy Safe Harbor and Marine Corps Wounded Warrior Regiment, both line programs, in working directly with wounded warriors, their families, caregivers and multidisciplinary medical teams.

We work diligently to coordinate the complex services needed for improved health care outcomes and to ensure that service members return closer to home as soon as possible.

Navy and Marine Corps liaisons at medical treatment facilities aggressively ensure that orders and other administrative details, such as extending reservists, are completed.

Last year we established a centralized operational stress control program and coordinator who is working in conjunction with our line leadership to indoctrinate mental health stigma reduction into the broader Navy and Marine Corps culture.

Over 11,000 sailors have received operational stress control training to date, and formal curriculum will be introduced in the fall of 2009 at key points throughout the careers of sailors from accession to flag officer.

Also to anticipate emerging mental health threats, Navy medicine actively conducts real-time in-country surveillance and assessment of the mental health of our troops.

Chairman Inouye, Vice Chairman Cochran, I want to express my gratitude on behalf of all who work for Navy medicine, uniformed, civilian contractor and volunteer personnel who are committed to meeting and exceeding the health care needs of our beneficiaries.

I would also like to thank you and the members for your continued support of Navy medicine and of the military health system.

Thank you.

SEN. INOUYE: I thank you very much, Admiral Robinson.

May I now call upon Lieutenant General Roudebush?

GEN. ROUDEBUSH: (Off mike) -- thank you for this opportunity to both share our issues, our concerns but also our accomplishments with you this morning.

Is that better? Thank you, sir.

I believe your comments frame it very appropriately and very correctly in terms of the importance of what we bring, both individually and collaboratively to the care of the men and women who have raised their right hand and sworn to support and defend and go into harm's way for our nation.

It's important that we do care for them and it's important that we work with each one, one by one, as they transition, perhaps to care within the Veterans Administration, to assure that that transition is as smooth, effortless and user-friendly as it can be.

So I think your comments set this up very, very well. Thank you, sir.

And thank you and the committee for your unwavering support in our endeavors in this regard. We simply could not do it without you and we truly appreciate that.

This morning, sir, I'd like to talk a bit about Air Force medicine, understanding that Air Force medicine is part of a joint capability and we keep that issue very clearly in mind.

Air Force medicine contributes significant capability to the joint warfight in combat casualty care, wartime surgery and aeromedical evacuation.

On the ground at both the Air Force Theater Hospital at Balad and Craig Joint Theater Hospital in Bagram, we are leading numerous combat casualty care initiatives that will positively impact combat and peacetime medicine for years to come.

Air Force surgeons laid the foundation for a state-of-the-art endovascular operating room at Balad, the only DOD facility of its kind, and their use of innovative technology and surgical techniques has greatly advanced the care of our joint warfighter and coalition casualties, and their work within the joint theater trauma system -- collaborative joint work -- their work within this joint system has literally rewritten the book on the use of blood in trauma resuscitation

To bring our wounded warriors safely and rapidly home, our Critical Care Air-medical Transport Teams, or CCATTs, provide unique ICU care in the air within DOD's joint en route medical care system. We continue to improve the outcomes of CCATT wounded warrior care by incorporating lessons learned in the clinical practice guidelines and modernizing the equipment we use to support this important mission.

But it's important to note that this Air Force-unique expertise also pays huge dividends back home. When hurricanes Katrina and Rita struck in 2005, Air Force active duty, Guard and Reserve medical personnel were in place conducting life-saving operations.

Similarly, hundreds of millions of this total force team were in place September 1st, 2008 when Hurricane Gustav struck the Louisiana coast and when Hurricane Ike battered Galveston, Texas, less than two weeks later. During Hurricane Gustav, Air Mobility Command coordinated the movement of more than 8,000 evacuees, including 600 patients. Air crews transported post-surgical and intensive care unit patients from Texas-area hospitals to Dallas, principally. I'm extremely proud of this incredible team effort.

The success of our Air Force mission, however, directly correlates with our ability to build and maintain a healthy and fit force at home station and in theater. Always working to improve our care, our Family Health Initiative establishes an Air Force medical home. This medical home optimizes health care practice within our family health care clinics, positioning a primary care team to better accommodate the enrolled population and streamline the processes for care and disease management. The result is better access, better care and better health.

The psychological health of our airmen is critically important. To mitigate their risk for combat stress symptoms and possible mental health problems, our program known as Landing Gear takes a proactive approach with education and symptom recognition both pre- and post- deployment. We educate our airmen that recognizing risk factors in themselves and others, along with a willingness to seek help, is the key to effectively functioning across the deployment cycle and reuniting with their families.

Likewise we screen carefully for traumatic brain injury at home and at our forward-deployed medical facilities.

To respond to our airmen's needs, we have over 600 active duty and 200 civilian and contract mental health providers. This mental health work force has been sufficient to meet the demand signal that we have experienced to date, but that said, we do have challenges with respect to active-duty psychologists and psychiatrists recruiting and retention and we're pursuing special pays and other initiatives to try to bring us closer to 100 percent staffing in these two very important specialties.

For your awareness, over time we are seeing an increasing number of airmen with post-traumatic stress disorder; 1,758 airmen have been diagnosed with PTSD within 12 months of return from deployment from 2002 to 2008. As a result of our efforts at early post-traumatic stress identification and treatment, the majority of these airmen continue to serve with the benefit of treatment and support.

Also understanding that suicide prevention lies within and is integrated into the broader construct of psychological health and fitness, our suicide prevention program, a community-based program, provides the foundation for our efforts. Rapid recognition, active engagement at all levels, and reducing any stigma associated with help-seeking behavior are hallmarks of our program. One suicide is too many and we're working hard to prevent the next.

Sustaining the Air Force Medical Service requires the very best in education and training for our professionals. In today's military, that means providing high-quality programs within our system as well as strategically partnering with academia, private sector medicine and the Veterans Administration to assure that our students, residents and fellows have the best training opportunities possible.

While the Air Force continues to attract many of the finest health professionals in the world, we still have significant challenges in recruiting and retention. We're working closely with our personnel and recruiting communities using accession and retention bonus plans to ensure full and effective staffing with the right specialty mix to perform our mission.

At the center of our strategy is the Health Professions Scholarship Program. HPSP is our most successful recruiting tool but we're also seeing positive trends in retention from our other financial assistance programs and pay plans.

Thank you for your unwavering support in this critical endeavor.

In summary, Air Force medicine is making a difference in the lives of airmen, soldiers, sailors, Marines, family members, coalition partners and our nation's citizens. We are earning their trust every day. As we look forward to the way ahead, I see a great future for the Air Force Medical Service built on a solid foundation of absolutely top-notch people, outstanding training programs and strong partnerships. It's an exciting, challenging and rewarding time to be in Air Force and military medicine.

I couldn't be more proud of this joint team. We join our sister services in thanking you for your enduring support and I look forward to your questions.

SEN. INOUYE: I thank you very much, General Roudebush.

I'd like to begin questioning now.

Admiral Robinson, on October the first of this year the Great Lakes Naval Health Center and the North Chicago veterans center will be merging. It's not the first DOD-VA activity, but it is without question the largest.

And I'm certain you have, as we have learned, legislative and other problems -- problems with labor unions, problems on the co-mingling of funds and such. Can you tell this committee what is being done at this moment?

ADM. ROBINSON: The Federal Health Care Clinic at Great Lakes and the Department of the Navy, working in conjunction with the Department of Veterans Affairs, are coming together to try to make sure that we have a seamless health care operation in the North Chicago area that will take care of the health care needs of the uniformed service members in the Great Lakes area as well as the beneficiaries of the VA system. There are a number of significant obstacles that I think will be overcome, but that is not to say that they are not there.

The first and most notable among them is the IMIT system and that revolves around using Vista and using Alta. Which system is the best? They are incompatible in the sense that we can't use both of them together. They do different things for both systems. And yet we need to have one IT system that we can utilize in the clinic. There have been a number of workarounds. This is not an insoluble issue, but it is a major issue that we have to get resolution with. And, in fact, Navy medicine is pledged, along with VA, to make sure that we can come to some understanding of how we can use the best parts from both systems so that we don't destroy either Vista or Alta, but at the same time we can have one system at the VA.

There are also issues that revolve around recruitment or, I should say, the employee relationships at Great Lake. There are also issues that, from my perspective as surgeon general, are very large issues in terms of credentialing, particularly of our ancillary health care providers. The VA and how they credential is different than what we do in DOD because very few VA providers -- perhaps none, but very few VA providers are operationally oriented or deploy. But my providers I have to make sure maintain the operational medical skills so that when I tap them to deploy to an operational area, they are full up. And so I have to make sure that we have credentialing issues that are taken care of and that are going to solve problems that I may have in the Navy.

And then there are the -- you said the co-mingling of funds, but the funding streams for both DOD and DVA and how those funds matriculate through our services, the oversight of those funds -- all of those issues, and this is just a very small example, all of those issues have to be cared for and we have to maintain the equities of both DVA and DOD.

Again, these are -- there are also other issues that are involved. These are a few examples.

Mr. Chairman, I think that we are going to solve all of these issues but I will also say with openness that these are very difficult issues and we're working them hard. So they're not easy solutions, but I do think that we can get to a place where we can have an excellent health care facility at FHCC.

SEN. INOUYE: So you're telling us that on October the 1st, all of the issues will not be fully addressed?

ADM. ROBINSON: All of the issues are not going to be addressed on October the 1st. But I think that if we take an iterative approach to the issues of how we serve our beneficiary population, how we serve our patients, can the doors open and can we, in fact, be an effective health care institution for DVA and DOD patients, I think the answer is yes. I do not think that all of the issues that I have talked about will be fully resolved, and in fact, I think that that is absolutely essential in order to get to the quality care and the quality of service that we in DOD and DVA have to have in order to take care of patients.

SEN. INOUYE: There is a problem that is not in your jurisdiction, but, as a result of these joint facilities, we have a Veterans' Committee, we have an Armed Services Committee, and so the matter of who has control is becoming a bit sensitive now. But that's not your problem.

ADM. ROBINSON: Yes, sir.

SEN. INOUYE: Can I ask a question of General Schoomaker? Everywhere you turn, there seems to be a center for excellence. We have been creating one for traumatic brain injury. I support that. We have one for amputees, for hearing and vision. Do you believe that by creating centers we give the impression that only these centers are the ones that we are concerned with and other matters are not of interest to us?

GEN. SCHOOMAKER: Well, sir, I think -- I understand your question and I understand the concern. I think the efforts of those that have chartered those centers, as well as the execution of the centers, the leadership of the centers, are working very hard not to focus so much on brick-and-mortar solutions but to act as clearinghouses.

I think increasingly, with the generosity of the American public and the innovation that occurs within the academic community, with other federal research and treatment entities like the National Institutes of Health, we're seeing -- and the use of, that's already been alluded to by Admiral Robinson, of the use of information technology, we have an opportunity for these centers really to be the nexus of knowledge networks and to harvest best ideas, to find potential solutions while also monitoring where problems are arising and to move funding, to move energy, to move focus to those physical brick-and-mortar sites where that can be done.

And I think this is certainly the effort that's under way in the Defense Center of Excellence for traumatic brain injury and post- traumatic stress disorder or psychological health. I don't think anyone -- certainly I do not conceive of this new center of excellence as being the sole brick-and-mortar site and only repository of (good ?) research and clinical activity, but certainly is in a position to reach out to anyone who can offer solutions to the problems that are arising.

SEN. INOUYE: Admiral, or General Roudebush, as you've indicated, there's been a rise in suicides, substance abuse, spousal abuse, children abuse. Are we making a joint effort of all services, or just each service on its own?

GEN. ROUDEBUSH: Well, sir, in terms of approaching what are very complex problems that cross a variety of areas when you're caring for the active-duty soldiers, sailors, Marines and caring for their family members, we do approach that in a service-specific way which attends to the culture that those families both exist within and operate within, whether it's an Army post or a Navy station or an Air Force base. So we each have an approach that I think is adapted to the operational perspective of how we operate but also attends to that culture.

But we also work across services, in terms of sharing both successes and issues, sharing programs, sharing insight into what we're doing, and operate, I think, effectively across those areas.

Now, I will tell you that as we are able to reduce stigma, as we are able to increase visibility of issues, we are seeing more. Perhaps we're seeing more because there are more and we need to be very attentive to that. But I think we're also seeing more because we're able to see more and give us the opportunity to engage, hopefully intervene, to assure that proper care is provided at a time when it can make a difference and do it either within the service construct or within the joint construct, because we certainly care for Navy and Army families in our Air Force facilities, and likewise our Air Force families are very well cared for in Army and Navy facilities. So it's incumbent upon us to work jointly, but we also need to work separately to assure that we are getting at the issues within our operational platforms.

SEN. INOUYE: Thank you very much.

SEN. COCHRAN: Mr. Chairman, thank you.

Admiral Robinson, more Marines will be deployed to Afghanistan in coming months and I've been informed that the standard time required for medical evacuations in Afghanistan are considerably different from those in Iraq, for instance. Would you comment on the adequacy of the resources that will be available and the response time for medical evaluations as more Marines and corpsmen are involved in that theater of operation?

ADM. ROBINSON: Yes, sir, Mr. Vice Chairman.

The Afghanistan area of operation is substantially different than the area of operation in Iraq, both from a terrain and an infrastructure point of view. Afghanistan has desert terrain, which can reach upwards of 140 degrees Fahrenheit all the way to mountains which are very, very cold, very subzero weather. Additionally, infrastructure in terms of roads are completely -- not completely, but almost completely lacking in Afghanistan, as opposed to other areas, which makes the necessity for how we to operate there from a medical point of view a lot different in terms of mobility and in terms of air evacuation.

The golden hour, which I as a surgeon and as a former chief of surgery at Portsmouth Naval Hospital, having trained many general surgeons in trauma, is an age-old edict that we've used in surgery since it was first developed at the University of Maryland, shock trauma. It's based upon the work from the Vietnam War and also the fact that if we can utilize air evacuation of critically injured personnel and get them to immediate definitive medical facilities, we can save lives. And, in fact, that is absolutely true.

One of the things that we in Navy, Army and Air Force medicine also utilize is the effective resuscitative capability that the Army medic, the Navy corpsman and the Air Force medic utilize on the ground at the time of injury, such that we can start definitive or -- excuse me, we can start adequate resuscitation of injured personnel, stabilize them, control their airway until adequate evacuation capability is there.

So the 60 minutes and the air evacuation, which is more difficult in Afghanistan, is not something that is necessarily going to reduce either the capability or the success of trauma surgery or trauma capability that we've had in the past. And I only emphasis that from a medical and a surgical point of view because very often the golden hour appears to be truly a 60-minute evolution. It actually includes the ability to stanch bleeding, to make sure that we have ABC airway breathing and circulation re-established, to make sure that we have resuscitation re-established -- to make sure that we've done those definitive measures for the injured personnel who are going to in fact survive, such that we can get them to definitive care. And in fact, if we get them there two or three hours after injury, that is usually adequate as long as that resuscitation has occurred.

So the long answer to the short answer -- we, Navy medicine, Air Force and Army medicine, will be capable of making sure that we give the same care to our trauma victims in Afghanistan.

SEN. COCHRAN: Well, that's very impressive and, I think, deserves commendation for the excellent leadership you're providing in this area.

General Schoomaker, with the increase in personnel deployed to Afghanistan, do you believe that you will have sufficient medical personnel and medical supplies to support this troop increase?

GEN. SCHOOMAKER: Well, sir, I think medical supplies is probably the easier of the two to answer. I don't envision any rate-limiting element of medical supply or equipment there. We have, I think, evolved the medical logistics capability of the entire CENTCOM area of operation dramatically over the last six, seven years, focusing on the so-called theater-level medical material centers, one of which is in Europe, one of which is in Qatar and we have distribution sites within Afghanistan. So I don't have concern so much about that.

Medical personnel, I think, is a challenge to us. And this is one of those areas, quite frankly, that coordination among the three services is most important. The Army right now is very heavily engaged both in Afghanistan and in Iraq in providing medical support. As we draw down troop levels in Iraq, we're going to continue to have fairly robust medical support because, as we all know, you have to support the areas in which troops are operating. And so we're going to continue to see Army medics and, for that matter, Navy and Air Force as well maintained in Iraq.

So we're cooperating, I think, with the CENTCOM planners and with the joint medical planners within Afghanistan to provide the resources that we can. And the Navy and Air Force, I think -- as you heard earlier, the air base at Bagram now, and that Level 3 or Role 3 facility is now largely Air Force, after having been started by the Army and transitioned to the Air Force. The Navy is going to play a more important role in the south.

So yes, we're stretched, but we're working as closely as we can with our joint partners to cover those areas of responsibility.

SEN. COCHRAN: But will the increase in deployment affect rotation schedules and deployments of surgeons as well as medical specialists? What is your expectation?

GEN. SCHOOMAKER: Well, sir, everybody plays a role in this -- in Army medicine. It's not recognized by many people, but some of our most heavily deployed specialties are not surgeons at all. They're pediatricians who serve as general field surgeons, the physicians' assistants, our psychologists, psychiatrists, our mental health workers are very heavily engaged.

And do I think that's going to change the rotation length? No, sir. It's not going to change the rotation length. In fact, we're working to come closer to what our colleagues in the Air Force and Navy have, which are shorter rotations even if they're more frequent. We know from talking with our families and talking with our specialists that not only can they maintain the broad range of skills that they require in their specialties, if they're deployed for a shorter period of time, even if that turns into more frequent deployments, but their families are much more tolerant of shorter rotations, especially the six month or so rotations. So we're working very hard to do that and getting support from the line for that.

SEN. COCHRAN: Thank you very much.

General Roudebush, what role will the Air Force have in supporting the troop increase in Afghanistan?

GEN. ROUDEBUSH: Well, sir, the Air Force is in Afghanistan. As General Schoomaker pointed out, we have the Air Force Theater Hospital at Bagram, which is jointly manned with the Army, but, as General Schoomaker pointed out, primarily Air Force, as well as a number of other smaller facilities that are either Air Force or jointly manned. And we will certainly sustain those, and, over time, be increasing Air Force medical lay-down to support what you initially pointed out with Admiral Robinson in terms of working the medevac support time, which, I believe you know but I will note: Our line leadership has really leaned into supporting that with additional rotor capability. The Air Force is providing additional helicopter assets and other assets to assure that we can be as timely as we need to be, and I think Admiral Robinson laid that out very well. So we will be certainly supporting the increased troop lay-down.

However, I think there's two other points that I would note. The Air Force and Navy and Army are also deeply involved in rebuilding the nation. We have embedded training teams working with the Afghan military and police to rebuild their medical infrastructure, to mentor the Afghanis so that they can be ultimately self-sufficient, provincial reconstruction teams doing a great deal of work to bring that nation forward to the point where it can in fact operate on its own recognizance.

The second point I would make is that we have significant support from our NATO allies on the ground in Afghanistan from a medical perspective, which we also integrate and leverage to assure that we have not only a joint approach to this but we also have a coalition approach.

So as we look at the overall military lay-down in Afghanistan, there are a variety of perspectives that play into this that I think will assure that our forces are best positioned to do the mission that they are being sent there to do.

SEN. COCHRAN: Thank you, Mr. Chairman.

SEN. INOUYE: Thank you.

Senator Bennett?

SEN. BENNETT: Thank you very much, Mr. Chairman.

And gentlemen, let me thank you for your service and your expertise.

I come to this committee new, so I don't have as intelligent or well-informed questions, but the only way I'm going to learn is to ask some stupid ones, so bear with me.

General Schoomaker, you talked about general wellness, that is, physical, psychological, spiritual, et cetera, et cetera, and I think that ties into this whole question of mental health. The discussion about suicides and child abuse and other things has been an interesting one to listen to.

In this process of trying to make sure that the individuals who serve in the armed forces are well rounded and balanced in every area, is there any prescreening of people who might be more susceptible to some kind of mental trauma and preparation prior to their going into deployment so that they might, if something happens to them, have some previous training or preparation or expectation that could help them after the fact to deal with the problem more than if it just hit them for the first time?

GEN. SCHOOMAKER: Yes, sir. Let me talk first about the screening because I think that's fairly -- that I can deal with fairly quickly. And that is that aside from usual accession screening to include medical and psychological screening that occurs on any inductee, we don't have any specific screens that are used or selections that are used, because quite frankly, I don't know that we have any determinants right now for success or failure in terms of the whole fitness of an individual. I mean, we use physical fitness monitors and assessments of general health but other than that none.

I think one of the promises of the research that is now being conducted in traumatic brain injury and especially in psychological health potentially is finding early markers, if you will, and determinants of psychological injury. And there are emerging theories and I think there's some empiric evidence to support that post- traumatic stress reaction, for example, which occurs in a very large number of people subjected to trauma, whether that's in combat or the trauma of natural disaster or rape or violent crime or family violence, motor vehicle accidents, might be the persistence of a dysfunctional flight or fight reaction. And there may be markers that we can discover and alert people very early to that emergence.

In the meantime, what we're doing in the Army is through the use of a set of tools, a suite of training tools called battle mind training developed by the Walter Reed Army Institute of Research, we are building resilience in deploying soldiers before they deploy, during the deployment and then upon redeployment. And this suite of tools on battle mind, which has become sort of our branded name for that, is one of the cornerstones of the resiliency training. It's been one of the only instruments that we're aware of that has actually been shown to reduce during deployment the incidence of new post traumatic stress problems.

The chief of staff's initiative in comprehensive soldier fitness is that attempt writ large. The idea here is that we have spent a lot of our time as a corporation, as an institution looking only at the negative events -- suicides, family violence, you know, driving while intoxicated or drug-associated crimes and misconduct, and the emergence of post traumatic stress reactions and post-traumatic stress disorder if not addressed early enough and reversed. What the Army is trying to do is to find those determinants of resilience and growth and post-traumatic growth rather than to turn adversity into a trauma and into an irreversible psychological injury is to build the capacity of individuals through a multidisciplinary approach, which works on the positive. And so we're working with some of the leaders in positive psychology and other tools to promote that aspect rather than only measure us in terms of what negative events occur. And in so doing we hope to move the whole population of soldiers and families away from the threshold where they become dysfunctional.

SEN. BENNETT: Thank you. That's very helpful.

Now, I was interested in the comment that you get significant increases, to use the business language, significant increases in productivity out of the troops if you alter the length of their deployment. I'm guessing here, but are there any studies going towards the question of frequency of patrols, for example, during the deployment where you send Marines into a nasty neighborhood in Fallujah day after day after day as opposed to every other day or every third day or something of that kind? Is there any research in this regard or any attempt to find research in this regard that might have the same impact that you have found with respect to the overall length of deployment -- six months gives you better soldiers even if there are more deployments than if you put them there, say, for 18 months and kind of leave them alone? Is there any further research in the area I've talked about about their exposure to traumatic situations on deployment?

GEN. SCHOOMAKER: Well, sir, first of all, you may have inferred something that I did not intend to imply, that is, that productivity of a soldier in general is somehow linked to the length of deployment.

The chairman, I think, or the vice chairman earlier asked about the tolerance of recurrent deployments of medical specialists or surgical specialists as a function of the length of the deployment, and my comment there is that we observe that the skills of, for example, a general surgeon begin to deteriorate after a certain amount of time in theater because they're not exploring and not using the full spectrum of what a general would use. So -- but --

SEN. BENNETT: I did misunderstand you, then.

GEN. SCHOOMAKER: Yes, sir.

SEN. BENNETT: I got the impression that there were data that suggested the front-line troops would benefit from more frequent but shorter deployments, and you're saying that's not the case, that I misunderstood you.

GEN. SCHOOMAKER: Yes, sir. I think we have ample evidence through a series of annual iterative surveys called the Mental Health Advisory Teams, MHAT. We're in our sixth iteration of this, the sixth year. That team is right now in Iraq gathering data.

We do have ample evidence that the length of deployment is associated with increased problems of the development of post- traumatic stress and other problems of soldiers in theater, so don't -- I think you got that exactly right, sir. As we were in that period of the surge when we had 15-month-long deployments, there was no question that the longer that deployment went the more problems soldiers had.

We do find, as I mentioned earlier, that if those soldiers pre- deployment and during deployment are exposed to battle-mind training and sort of re-inoculation with this, it reduces the incidence of that. So, as I said before, it has been shown to be effective.

But as far as, so to speak, the productivity of a soldier, the effectiveness of a soldier, I would not ask you to infer from what I've been describing here that a soldier's effectiveness is improved by shortening the length of deployment. In fact, operational commanders would probably take exception with some of that as a grand statement.

SEN. BENNETT: Thank you. I appreciate that clarification, because as I've studied the Vietnam War, one of the things that was said was that you just got your unit cohesion going and then you'd pull them out and put a bunch of green troops in and that was one of the problems, so I'm glad to get that resolved.

Thank you, Mr. Chairman.

SEN. INOUYE: (Off mike.)

SEN. PATTY MURRAY (D-WA): Thank you very much, Mr. Chairman.

Thank you all for your testimony today.

General Schoomaker, let me start with you. How are things going with the DOD and the Department of Veterans Affairs' expansion of the pilot programs to expedite the processing of injured troops through the disability evaluation system?

GEN. SCHOOMAKER: Ma'am, I think that's going very well. As you know, or at least I've gone on record to say that the pilot, although a very, very good effort and one that we support very, very vigorously -- in fact, once the pilot was established in those few sites like Walter Reed, I've done everything in my power to implement it as widely as we can. I mean, once we learned that we can simplify bureaucratic morass and we can make it more user friendly for families and soldiers, I think we ought to be doing it as quickly as we can.

But I've also said that I'm concerned that it doesn't get at one of the most important and most disaffecting parts of our system of physical disability and evaluation, which is the dual adjudication of disability, one, by the Department of Defense for the unfitting condition for which the soldier, sailor, airman, Marine, Coast Guardsman is awarded a specific disability rating, the link to benefits -- not the least of which is benefits for TRICARE for him or herself and their families -- and then the Veterans Administration adjudicates a second comprehensive level of disability based upon the whole person.

SEN. MURRAY: I thought we were all going to go to the same system.

GEN. SCHOOMAKER: Ma'am, until we change law my understanding is that we cannot get away from the dual adjudication of disability for anyone in uniform. We still have the single (unfitting ?) condition for the service member and the whole-person concept for the VA, and what we need, in my understanding, is legislative relief to bring those two together.

But every other aspect of this highly bureaucratized system I think we're working very hard with the VA in doing and we're encouraging and supporting that in every way we can.

SEN. MURRAY: Admiral?

ADM. ROBINSON: I think that General Schoomaker has summed up well what the issues are.

I think that the Federal Health Clinic in Chicago actually underscores some of the difficulties of the DVA and DOD system in terms of trying to -- your question is specifically with the disability evaluation system, but what we have is we have two chains of command that work vastly differently with different sets of rules and regulations, and trying to bring them together has been the real challenge.

Additionally, the same issues that affect the FHCC, the Federal Health Care Clinic, in Chicago regarding IM IT, that is Vista and Alta, are the same sorts of things that affect the merger of the disability evaluation system. How does that relate -- if we have one system, we're going to have one medical IT way of dealing with those beneficiaries and whatever their medical needs may be. That's a very small example, but those come together.

In terms of my eyes on, surgeon general of the Navy at the Department of Defense for the oversight committees that very often General Roudebush, General Schoomaker attend with me, both DOD and DVA and all of the reps in between and the Marine Corps and all the other people involved have been working tirelessly to make this work, looking first at our patients and their needs and not at bureaucratic or other issues.

And I will say that across the board we have done that. We're looking at patients and what they need, not at the institutional obstacles. I only bring the institutional obstacles up because at the end of the day they exist and they make a difference.

SEN. MURRAY: General Roudebush?

GEN. ROUDEBUSH: Yes, ma'am. I think you raise a very interesting question. I'd like to offer perhaps an observation on your question but also give it perhaps a little different perspective.

The Department of Defense and Department of VA have different missions. And where we come together, the interface really most directly is as we transition an individual from Department of Defense -- Army, Navy, Marine Corps, Air Force -- to the Department of Veterans Affairs, we do need to assure that that transition is seamless.

Now, DOD -- in my instance, the Air Force -- needs to determine fitness for duty in terms is that individual fit to serve in the mission for which they're trained? The VA takes a rather broader look at how that individual is going to function back in the private sector. So these are two rather different determinations.

And I think to the extent that we simplify the transition to assure that these great men and women are cared for, only have to fill out paperwork once, have a smooth move from DOD activities to VA to include benefits, all benefits, is very important. Our pilot projects I think are helping in that regard. For us, we're going to be expanding to a variety of locations very small -- Vance in Oklahoma, for example -- to very large or larger -- Elmendorf in Alaska -- and I think that will continue to be instructive. The metrics show that we are in fact reducing the time but not to the time that we would consider to be appropriate.

But as we bring these two great institutions, DOD and VA, together, we also have other experiences, DOD joint ventures, for example. We've got a great example at Keesler where we use centers of excellence, what the VA brings very well within their operation, what the Air Force brings in our operation, and we leverage each others' capabilities, maintaining mission focus for the Air Force, for the VA, but really leveraging each others' capabilities. So I think those kinds of opportunities and experiences are important and also help instruct such things or inform such processes as how to best transition these men and women from DOD to VA.

So I think we're making progress. We are not where you want us to be. We are not where we want to be. But I think we are making progress in really identifying the issues that need to be attended to as we work this through.

SEN. MURRAY: No one said it was going to be easy.

GEN. ROUDEBUSH: Oh, no, ma'am.

SEN. MURRAY: But we're working. We need to get there. Okay.

GEN. ROUDEBUSH: Thank you.

SEN. MURRAY: Can you provide me with an update on the implementation of the comprehensive TBI registry that we started, I guess it was a year or so ago, including a singe point of responsibility to track incidents and recovery, General Schoomaker?

GEN. SCHOOMAKER: I will take that for the record, ma'am.

SEN. MURRAY: Could you?

GEN. SCHOOMAKER: Yes, ma'am.

And that is being -- I mean, the focus in Army medicine is to direct all of our energies and our talent toward the Defense Center of Excellence for Traumatic Brain Injury and Psychological Health under Brigadier General Loree Sutton.

SEN. MURRAY: Okay. If you could get back to me on that because that was one of our huge questions a year ago is making sure that people were registered and we were tracking them, so if you can get back to me on that.

GEN. SCHOOMAKER: Yes, ma'am.

SEN. MURRAY: Okay.

Let me ask all of you, the Reserves and particularly the National Guard have some real unique concerns when they're deployed.

We continue to hear from our folks out in our states, and obviously, as we transition from Iraq to Afghanistan, they're going to continue to be used.

So my question for each of you is: Have you budgeted properly to accommodate for the Reserve components as they are going to need DOD health care into the future?

General Roudebush, start with you.

GEN. ROUDEBUSH: Ma'am, in the Air Force and I believe in the other services, we have separate funding streams. The Guard comes from the states, the Reserve comes from the Reserve dollars, and DOD comes from the DHP. Now, to the extent that we merge our interests and our activities, we do cross-flow that very, very carefully.

For us, for example, we assure that our Guard members and our Reserve members and our active-duty members are tracked for completion of the PDHA/PDHRA. And in fact, our Guard and Reserve members are kept on active-duty status, mandate status, until issues are resolved, so they retain full benefits as we worth them through. But they do come from different streams of money.

However, the oversight and the application of that is very coordinated and very integrated for the Air Force.

SEN. MURRAY: Okay. Admiral?

ADM. ROBINSON: Your question is do we have adequate funds for the reserve forces and the answer is yes. Our reserve forces, we have adequate funds. We have methods of making sure that our reserve forces, once they come on active duty, are cared for just as any other active-component member would be.

As that reserve-component member goes off of active duty, he, she, family are covered by TRICARE for approximately a 180-day period. If there's some limiting mental or physical disease or condition that would make it better for them to stay on active duty, they will remain on active duty. As they transition to the Navy medical or the Navy mobilization platforms, the NMPS, to the reserve component, to the NOSCs, which are the local reserve units back in their hometowns or their home cities, they will go back into how we fund them from the reserve-component perspective.

But the key is that we have a number of medical, mental health and other areas that we track our reserve forces, that we integrate our reserve forces, and that we care for our reserve forces, and we are funded adequately to do that.

SEN. MURRAY: General?

GEN. SCHOOMAKER: Yes, ma'am. My comments would echo my colleagues here, that we're well funded. They are separate lines for the Army National Guard, Reserve and Army Reserve, and the active component.

As the admiral just commented, we're working very hard to ensure that any mobilized reservist or National Guardsman while on active duty is kept healthy, if they incur an injury, a combat wound or an illness, that that's fully treated and they're restored to health, including dental health. We made a major effort to restore dental health and hygiene before mobilized reservists and National Guardsmen are put back out into civilian life.

Our warrior transition units -- roughly 8,000 in total right now across 36 units in nine states -- are made up of all three elements, all three components, to include National Guard and Reserve. They have full access to those warrior transition units. In fact, about a third of our Warrior Transition Unit warriors in transition are soldiers who are returning from deployments or mobilizations who identify a problem that they have and they're brought in and they're retained on active duty until we can take care of the problem.

SEN. MURRAY: Okay. Thank you.

I appreciate a lot of the conversation that's already gone on regarding the increase in suicides, mental health. We have to stay focused on that and I appreciate all of your earlier comments, so I won't ask you that.

But I did want to ask you about another issue because yesterday DOD made public the FY '08 report on sexual assault in the military and it showed an 8 percent increase of reports of sexual assault. Now, some are arguing that that increase illustrates the fact that victims are now more likely to report those crimes, but I find the trend very disturbing because these crimes are happening at all.

I was part of the Women's Military History Month. A week ago I participated in the Army's panel on Sexual Harassment, Assault Prevention and Response (sic/Assault Response and Prevention) program. And clearly we all share the goal of eliminating sexual assaults from the military, but until that goal is achieved I am very interested to hear from all of you about how the medical community is supporting the efforts to care for these victims' both physical and psychological wounds.

And General Schoomaker, I want to start with you.

GEN. SCHOOMAKER: Yes, ma'am. First of all, I would say that the Army leadership and the Army as a whole shares your outrage with sexual assault and any increase in the incidence of these crimes. The Army has taken the approach that this is an assault not just on the individual woman but on the ethos of soldiers, the warrior ethos, that this is not to be tolerated, and has taken a very active, proactive role in education and prevention which is on the shoulders of commanders.

The medical side of this is that we are the response. We provide the examination. We help the woman through the stages of forensic evaluation. We have in all of our facilities to include -- as General Horoho can tell you, in our visit there last week, her review of what's taking place in the deployed setting in Iraq -- we have sexual assault response coordinators in each of these facilities either working with the assets we have in uniform and the uniformed facility or, in the case of when I was the installation commander at Fort Dietrich, Maryland, we leveraged the expertise of the community of Frederick, Maryland to assist us through Frederick Memorial Hospital.

So we do the counseling. We do the examination. We help the woman. We help her through the process that she has to go through in order to gather the necessary information about the assault and to investigate the crime, but we also do the follow-on counseling and help coordinate all those services that are necessary for her.

SEN. MURRAY: Admiral?

ADM. ROBINSON: Senator Murray, the Navy has the SAVI program, the Sexual Assault Victims Intervention program, which was established in 1994.

From that program has come an effort to not only educate people as to what is a sexual assault and to bring it to a level of visibility so that we are talking about it in our commands and it becomes a leadership issue on a daily basis, but we've also grown from that to develop a lot of the SARP, the sexual assault response and prevention, programs that you've seen and participated in some of the workings with the DOD in general.

From a medical point of view specifically, we not only help in the training of SAVI counselors -- and the SAVI program is also interesting because it takes the victim and puts the victim at the center of the activity, in other words, making sure that the victim understands, is affirmed, and actually has the counseling that he or she may need is a critical element in how we run the program.

The second one is to make sure that we then train the forensic experts that need to come along and do the investigations, which is what General Schoomaker was referring to, which is critically important. And I would suggest that if those folks are not trained in the military facility that we utilize our civilian police and forensic facilities to make sure that that's done properly.

And then the third point is the education and the prevention, which is something that needs to be done at the beginning of training in the military -- this is for men and women -- and it goes through some of the very didactic but very necessary thoughts regarding training, regarding definitions -- what is a sexual assault, what does "consent" mean, what does "yes" mean, what does "no" mean -- all of these types of things which men and women have to listen to.

And then the last part is to make sure that after we've done that that we have a program that's sensitive to the needs of those people who fall victim to sexual assault, so that means that the psychological, the mental health issues, and additionally we need to make sure that their families are cared for. Very often men and women are married or they have other family issues and we have to make sure that that's cared for.

We in the Navy have taken this full bore and very sensitive to what you've talked about, and we have been working this very hard for a long time.

SEN. MURRAY: I appreciate that answer. Thank you.

ADM. ROBINSON: Thank you.

SEN. MURRAY: General?

GEN. ROUDEBUSH: Ma'am, I think your approach is the one that I would echo.

We know that there are increased numbers. Now, whether it's increased reporting or increased incidents, we can certainly discuss the fact that there is one is too many.

SEN. MURRAY: That's correct.

GEN. ROUDEBUSH: So beginning with that as the going-in position is precisely where the Air Force leadership is attacking this issue.

It's a matter of respect. It's a matter of respecting each other. It's a matter of honoring each others' integrity and their person and treating each other as we would want to be treated.

It's an operational issue. It has direct mission impact. It's a cultural issue. It's a family issue because we strive individually, we execute as a team, but we take care of each other as a family, so this is a family issue.

We come at it in a very structured way. We learned important lessons as we assessed the issues at our Air Force Academy, which we have implemented across the board in terms of a sexual assault program that works to prevent sexual assault. But if it occurs, we respond in a very sensitive and coordinated way, to include restricted reporting if the individual prefers to perhaps help them come forward and get the help that they will need. We have a sexual assault response coordinator at every installation wired into the wing leadership. Medical is a part of that, is a key part of it. As General Schoomaker pointed out, we have important responsibilities and we are postured and do execute those responsibilities.

But really, it's a matter of taking care of each other, respecting each other, and that's precisely where our program is going in terms of training, education, sensitization and establishing the fact that it will not be tolerated any way, any shape, any form, anywhere, any time. It's a matter of respect.

SEN. MURRAY: Well, I appreciate your comprehensive answers on that, to all three of you, and I hope that's echoed throughout the forces. I think that the worst thing we can do is not talk about it, and this is an issue I'm going to continue to follow. I encourage all of you to as well to make sure those policies are implemented so that no one fears coming forward, but we start at the very beginning -- it's not tolerated -- and then if it does occur that people get the services and support and it doesn't become a crime that no one talks about.

So I appreciate all of your answers on that.

Thank you, Mr. Chairman.

SEN. INOUYE: Thank you very much.

I have many questions I'd like to submit to you, but one final one, if I may.

When I was wounded in World War II, from the battlefield to the hospital it took me nine hours to be evacuated. Most of the evacuation was carried out by stretcher bearers. Today if I were wounded with the same injury in Baghdad, I suppose I'd be in a hospital within 30 minutes because of helicopters and such.

As a result, a lot of things have happened. For example, in my regiment I don't believe we have one double amputee survivor; today, most double amputees survive. And you have many brain injuries and such, which in World War II very few ever survived.

But equally as important, I spent 22 months in a hospital. Today if I were at Walter Reed I'd be out in six months on the street. But when I left Percy Jones in Michigan, I knew a little about carpentry, electrical work, plumbing. I knew how to play basketball and swim. I knew how to drive. I knew how to go to a restaurant and order food, dine, dance. I knew how to defend myself. I knew what sex was all about.

My question is: Do you believe that the men and women who are being wounded in this war leave the service as I did, reassured, confident that I can tackle the world?

GEN. SCHOOMAKER: Sir, if I might start the answer from the standpoint of the Army, I think your eloquent description of what you went through and your sharing that with me personally and with my staff in office visits with you, I think it really captures the essence of what we're attempting in this comprehensive transition planning.

What we observed in, quite frankly, Senator Murray's question about physical disability evaluation system is really incomplete without addressing one aspect of this system. We have a system that its name alone telegraphs what it's about: physical disability. It's a system that is rooted in the Industrial Age. It's 50 years old. It's highly bureaucratic and it's contentious and adversarial. And we're trying to change the culture of disability and permanent dependency toward one of growth, of rehabilitation, of your experience without leaving any soldier or family without the necessary safety nets and transition support that they may require in the case of a very severe injury or illness.

So candidly we've turned away from -- the chief of staff of the Army engaged another former wounded soldier, General retired Fred Franks, a veteran of Vietnam, where he lost part of a leg, and went on to retire as a four-star general as the commander of the VII Corps in Desert Storm. General Franks has looked at the physical disability evaluation system and has concluded some of the same things or much of what I've said here today, which is that we need to move the culture away from one that focuses on disability and permanent dependency toward one that is aspirational, that's positive, that builds back capability and potential in every individual soldier, sailor, airman, Marine, Coast Guardsman and their family.

And we draw upon the experiences of soldiers such as yours. Today I would tell you that, with your injury, you very likely would remain in our hospitals the same length of time that you were there before only because it may take that long to fully recover from the wounds that you had and to be fully rehabilitated to do what you need to do to include remaining on active duty. We've turned away from looking at time as goal or an outcome measure for this system of transition. We look at the -- we're beginning to look and assess the goodness of the outcome for the individual soldier and family based upon what their comprehensive transition planning is.

So have we reached that point? At this point I would have to say no, sir, we have not. Does every soldier who's wounded grievously or is injured or ill to the degree that you suffered or others have have the confidence and realize their full potential? At this point I'd have to say no. But we won't be successful in this program of transitioning until we have all of our soldiers aspiring to what you achieved.

ADM. ROBINSON: Mr. Chairman, I think that your question is and your comments are very profound.

And it makes me think of a movie in 1947 or '48, "The Best Years of Our Life," in which a sailor is depicted -- Homer -- double amputee coming out of the war and spending approximately 24 to 30 months in a VA hospital. And I think he learned all of the things that you learned, but I don't think that they ever stated it as you did here. But he learned so much.

But one of the things that was lacking in that movie and in that whole scenario was the family because he was scared to death as to how he was going to be received by his mother, his father, his sister, and his girlfriend next door. The difference now is that we've brought families into the whole rehabilitation issue.

And the second part is that the length of time -- I absolutely agree with General Schoomaker -- it's not the time element, although it can be, but the length of time that one takes is not commensurate with the length of time that they stay in the hospital. It's the length of time that they have in that rehabilitative process with their families and in that re-engagement in the community and to be a full-up member economically, socially, spiritually in each community everywhere.

The Marine Corps and the Navy take a much different view than the Army, and we think that that needs to -- we need to get them out of that care facility environment and into that rehabilitative environment that's more community-based and that is run by the line element and the leaders that in fact have those men and women, take care of those men and women, and replace them back into those original slots that they've come from, if possible, or back into their communities so that they can learn many of the things that you learned at the VA Hospital in Michigan.

So I think that what I see as different is that we're no longer hiding people away or putting you in a position where you are -- I won't say warehoused, but you are at least put away and then you re- emerge into your communities and into societies, wondering if in fact you are going to be fully received back into those areas. We've merged those systems now. When you're wounded, not only are you off the battlefield quicker, not only are you back to a definitive care facility faster because of the great work that we do across Army, Navy, Air Force medicine, but we also make sure that as you get into the definitive care facilities we bring your families and we include them day one in that care, and that also extends as we transition to the Department of Veterans Affairs and the VA to make sure that your family and you also have an opportunity to do that.

So it's a completely different model, but I think it is trying to in fact do the same things and that is to make sure that when you go out, you're prepared to reintegrate into your communities and become productive citizens and re-establish yourself for the future.

One last comment: The only thing that you point out and underline dramatically is this: Wounds of war which are incurred during battle in a time sphere become the responsibility of the military health system and the Department of Veterans Affairs for the lifetime of the member and that member's family. And that means that the wounds of war of 2006, 2007 and 2008 will be the responsibility of all of us sitting here through the out years in 2040 and 2050. So we have to prepare for that and we have to take care of those individuals.

GEN. ROUDEBUSH: Sir, you frame both a compelling argument and a compelling challenge. To the extent that we are meeting that today, I offer two quick observations.

One, we do not even begin the disability evaluation process until we believe the individual has recuperated and recovered to the full extent, and there is time involved in that and we are willing to invest that time. As part of that time involved, the wounds that we're seeing are not singular in many cases; they're multiple. An amputee probably has some aspects of traumatic brain injury, some aspects perhaps of PTS or PTSD, so we have to approach each individual holistically and work those issues through.

Now, as we do that, my two observations: One, we have been, I believe, wonderfully assisted by our centers of excellence. Walter Reed has done a magnificent job of really centering the care of amputees, and the Fisher Foundation, in building the Center for the Intrepid in San Antonio, really begins to get at a number of those issues you talked about. How do you function within a living environment -- an apartment, a house? How do you ambulate? How do you interact? And they have done, I think, a wonderful service to our men and women in assisting with that -- and our centers of excellence at Bethesda in terms of head injuries. As we work through this, it really is a joint and collaborative issue.

But I would leave you with one observation. My wife's uncle -- a delightful gentleman who now resides in Phoenix -- was injured when a German 88 blew up in his bridging squad bridging a river in World War II. He was never the same after that injury in terms of his physical capabilities and had significant issues through life. But he has been a tremendous force in our family, just as you have been a tremendous force in our nation, perhaps based on some of those experiences and perhaps based on perspectives coming from a position that is different than others who might be walking up and down the street.

So I think we need to listen very carefully, we need to honor, we need to respect and we need to support. And I think Admiral Robinson has it just right: This is our challenge, but this is our duty.

Thank you, sir.

SEN. INOUYE: Gentlemen, I thank you.

Do you have any questions?

SEN. COCHRAN: Mr. Chairman, I have no questions. This has been an excellent hearing and I thank you.

SEN. INOUYE: I thank you very much, gentlemen.

And now the second panel, the important one. (Laughter.) (Applause.)

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