SOLDIERS FACE NEGLECT, FRUSTRATION AT ARMY'S TOP MEDICAL FACILITY
Editor's Note: If you know of a boy or girl who is thinking of joining
the US Army or Marines, please show them this investigative report. It
documents the reality behind the US government's "support our troops
facade." The fact is "our troops" are being betrayed by a corrupt,
heartless, incompetent government bureaucracy.
SOLDIERS FACE NEGLECT, FRUSTRATION AT ARMY'S TOP MEDICAL FACILITY
By Dana Priest and Anne Hull
Washington Post | Sunday, February 18, 2007; p. A1
Behind the door of Army Spec. Jeremy Duncan's room, part of the wall is
torn and hangs in the air, weighted down with black mold. When the
wounded combat engineer stands in his shower and looks up, he can see
the bathtub on the floor above through a rotted hole. The entire
building, constructed between the world wars, often smells like greasy
carry-out. Signs of neglect are everywhere: mouse droppings, belly-up
cockroaches, stained carpets, cheap mattresses.
This is the world of Building 18, not the kind of place where Duncan
expected to recover when he was evacuated to Walter Reed Army Medical
Center from Iraq last February with a broken neck and a shredded left
ear, nearly dead from blood loss. But the old lodge, just outside the
gates of the hospital and five miles up the road from the White House,
has housed hundreds of maimed soldiers recuperating from injuries
suffered in the wars in Iraq and Afghanistan.
The common perception of Walter Reed is of a surgical hospital that
shines as the crown jewel of military medicine. But 5 1/2 years of
sustained combat have transformed the venerable 113-acre institution
into something else entirely -- a holding ground for physically and
psychologically damaged outpatients. Almost 700 of them -- the majority
soldiers, with some Marines -- have been released from hospital beds but
still need treatment or are awaiting bureaucratic decisions before being
discharged or returned to active duty.
They suffer from brain injuries, severed arms and legs, organ and back
damage, and various degrees of post-traumatic stress. Their legions have
grown so exponentially -- they outnumber hospital patients at Walter
Reed 17 to 1 -- that they take up every available bed on post and spill
into dozens of nearby hotels and apartments leased by the Army. The
average stay is 10 months, but some have been stuck there for as long as
Not all of the quarters are as bleak as Duncan's, but the despair of
Building 18 symbolizes a larger problem in Walter Reed's treatment of
the wounded, according to dozens of soldiers, family members, veterans
aid groups, and current and former Walter Reed staff members interviewed
by two Washington Post reporters, who spent more than four months
visiting the outpatient world without the knowledge or permission of
Walter Reed officials. Many agreed to be quoted by name; others said
they feared Army retribution if they complained publicly.
While the hospital is a place of scrubbed-down order and daily miracles,
with medical advances saving more soldiers than ever, the outpatients in
the Other Walter Reed encounter a messy bureaucratic battlefield nearly
as chaotic as the real battlefields they faced overseas.
On the worst days, soldiers say they feel like they are living a chapter
of "Catch-22." The wounded manage other wounded. Soldiers dealing with
psychological disorders of their own have been put in charge of others
at risk of suicide.
Disengaged clerks, unqualified platoon sergeants and overworked case
managers fumble with simple needs: feeding soldiers' families who are
close to poverty, replacing a uniform ripped off by medics in the desert
sand or helping a brain-damaged soldier remember his next appointment.
"We've done our duty. We fought the war. We came home wounded. Fine. But
whoever the people are back here who are supposed to give us the easy
transition should be doing it," said Marine Sgt. Ryan Groves, 26, an
amputee who lived at Walter Reed for 16 months. "We don't know what to
do. The people who are supposed to know don't have the answers. It's a
nonstop process of stalling."
Soldiers, family members, volunteers and caregivers who have tried to
fix the system say each mishap seems trivial by itself, but the
cumulative effect wears down the spirits of the wounded and can stall
"It creates resentment and disenfranchisement," said Joe Wilson, a
clinical social worker at Walter Reed. "These soldiers will withdraw and
stay in their rooms. They will actively avoid the very treatment and
services that are meant to be helpful."
Danny Soto, a national service officer for Disabled American Veterans
who helps dozens of wounded service members each week at Walter Reed,
said soldiers "get awesome medical care and their lives are being
saved," but, "Then they get into the administrative part of it and they
are like, 'You saved me for what?' The soldiers feel like they are not
getting proper respect. This leads to anger."
This world is invisible to outsiders. Walter Reed occasionally showcases
the heroism of these wounded soldiers and emphasizes that all is well
under the circumstances. President Bush, former defense secretary Donald
H. Rumsfeld and members of Congress have promised the best care during
their regular visits to the hospital's spit-polished amputee unit, Ward
"We owe them all we can give them," Bush said during his last visit, a
few days before Christmas. "Not only for when they're in harm's way, but
when they come home to help them adjust if they have wounds, or help
them adjust after their time in service."
Along with the government promises, the American public, determined not
to repeat the divisive Vietnam experience, has embraced the soldiers
even as the war grows more controversial at home. Walter Reed is awash
in the generosity of volunteers, businesses and celebrities who donate
money, plane tickets, telephone cards and steak dinners.
Yet at a deeper level, the soldiers say they feel alone and frustrated.
Seventy-five percent of the troops polled by Walter Reed last March said
their experience was "stressful." Suicide attempts and unintentional
overdoses from prescription drugs and alcohol, which is sold on post,
are part of the narrative here.
Vera Heron spent 15 frustrating months living on post to help care for
her son. "It just absolutely took forever to get anything done," Heron
said. "They do the paperwork, they lose the paperwork. Then they have to
redo the paperwork. You are talking about guys and girls whose lives are
disrupted for the rest of their lives, and they don't put any priority
Family members who speak only Spanish have had to rely on Salvadoran
housekeepers, a Cuban bus driver, the Panamanian bartender and a Mexican
floor cleaner for help. Walter Reed maintains a list of bilingual
staffers, but they are rarely called on, according to soldiers and
families and Walter Reed staff members.
Evis Morales's severely wounded son was transferred to the National
Naval Medical Center in Bethesda for surgery shortly after she arrived
at Walter Reed. She had checked into her government-paid room on post,
but she slept in the lobby of the Bethesda hospital for two weeks
because no one told her there is a free shuttle between the two
facilities. "They just let me off the bus and said 'Bye-bye,' " recalled
Morales, a Puerto Rico resident.
Morales found help after she ran out of money, when she called a hotline
number and a Spanish-speaking operator happened to answer.
"If they can have Spanish-speaking recruits to convince my son to go
into the Army, why can't they have Spanish-speaking translators when
he's injured?" Morales asked. "It's so confusing, so disorienting."
Soldiers, wives, mothers, social workers and the heads of volunteer
organizations have complained repeatedly to the military command about
what one called "The Handbook No One Gets" that would explain life as an
outpatient. Most soldiers polled in the March survey said they got their
information from friends. Only 12 percent said any Army literature had
"They've been behind from Day One," said Rep. Thomas M. Davis III
(R-Va.), who headed the House Government Reform Committee, which
investigated problems at Walter Reed and other Army facilities. "Even
the stuff they've fixed has only been patched."
Among the public, Davis said, "there's vast appreciation for soldiers,
but there's a lack of focus on what happens to them" when they return.
Maj. Gen. George W. Weightman, commander at Walter Reed, said in an
interview last week that a major reason outpatients stay so long, a
change from the days when injured soldiers were discharged as quickly as
possible, is that the Army wants to be able to hang on to as many
soldiers as it can, "because this is the first time this country has
fought a war for so long with an all-volunteer force since the
Acknowledging the problems with outpatient care, Weightman said Walter
Reed has taken steps over the past year to improve conditions for the
outpatient army, which at its peak in summer 2005 numbered nearly 900,
not to mention the hundreds of family members who come to care for them.
One platoon sergeant used to be in charge of 125 patients; now each one
manages 30. Platoon sergeants with psychological problems are more
carefully screened. And officials have increased the numbers of case
managers and patient advocates to help with the complex disability
benefit process, which Weightman called "one of the biggest sources of
And to help steer the wounded and their families through the complicated
bureaucracy, Weightman said, Walter Reed has recently begun holding
twice-weekly informational meetings. "We felt we were pushing
information out before, but the reality is, it was overwhelming," he
said. "Is it fail-proof? No. But we've put more resources on it."
He said a 21,500-troop increase in Iraq has Walter Reed bracing for
"potentially a lot more" casualties.
The best known of the Army's medical centers, Walter Reed opened in 1909
with 10 patients. It has treated the wounded from every war since, and
nearly one of every four service members injured in Iraq and
The outpatients are assigned to one of five buildings attached to the
post, including Building 18, just across from the front gates on Georgia
Avenue. To accommodate the overflow, some are sent to nearby hotels and
apartments. Living conditions range from the disrepair of Building 18 to
the relative elegance of Mologne House, a hotel that opened on the post
in 1998, when the typical guest was a visiting family member or a
retiree on vacation.
The Pentagon has announced plans to close Walter Reed by 2011, but that
hasn't stopped the flow of casualties. Three times a week, school buses
painted white and fitted with stretchers and blackened windows stream
down Georgia Avenue. Sirens blaring, they deliver soldiers groggy from a
pain-relief cocktail at the end of their long trip from Iraq via
Landstuhl Regional Medical Center in Germany and Andrews Air Force Base.
Staff Sgt. John Daniel Shannon, 43, came in on one of those buses in
November 2004 and spent several weeks on the fifth floor of Walter
Reed's hospital. His eye and skull were shattered by an AK-47 round. His
odyssey in the Other Walter Reed has lasted more than two years, but it
began when someone handed him a map of the grounds and told him to find
his room across post.
A reconnaissance and land-navigation expert, Shannon was so disoriented
that he couldn't even find north. Holding the map, he stumbled around
outside the hospital, sliding against walls and trying to keep himself
upright, he said. He asked anyone he found for directions.
Shannon had led the 2nd Infantry Division's Ghost Recon Platoon until he
was felled in a gun battle in Ramadi. He liked the solitary work of a
sniper; "Lone Wolf" was his call name. But he did not expect to be left
alone by the Army after such serious surgery and a diagnosis of
post-traumatic stress disorder. He had appointments during his first two
weeks as an outpatient, then nothing.
"I thought, 'Shouldn't they contact me?' " he said. "I didn't understand
the paperwork. I'd start calling phone numbers, asking if I had
appointments. I finally ran across someone who said: 'I'm your case
manager. Where have you been?'
"Well, I've been here! Jeez Louise, people, I'm your hospital patient!"
Like Shannon, many soldiers with impaired memory from brain injuries sat
for weeks with no appointments and no help from the staff to arrange
them. Many disappeared even longer. Some simply left for home.
One outpatient, a 57-year-old staff sergeant who had a heart attack in
Afghanistan, was given 200 rooms to supervise at the end of 2005. He
quickly discovered that some outpatients had left the post months
earlier and would check in by phone. "We called them 'call-in patients,'
" said Staff Sgt. Mike McCauley, whose dormant PTSD from Vietnam was
triggered by what he saw on the job: so many young and wounded, and
three bodies being carried from the hospital.
Life beyond the hospital bed is a frustrating mountain of paperwork. The
typical soldier is required to file 22 documents with eight different
commands -- most of them off-post -- to enter and exit the medical
processing world, according to government investigators. Sixteen
different information systems are used to process the forms, but few of
them can communicate with one another. The Army's three personnel
databases cannot read each other's files and can't interact with the
separate pay system or the medical recordkeeping databases.
The disappearance of necessary forms and records is the most common
reason soldiers languish at Walter Reed longer than they should,
according to soldiers, family members and staffers. Sometimes the Army
has no record that a soldier even served in Iraq. A combat medic who did
three tours had to bring in letters and photos of herself in Iraq to
show she that had been there, after a clerk couldn't find a record of
Shannon, who wears an eye patch and a visible skull implant, said he had
to prove he had served in Iraq when he tried to get a free uniform to
replace the bloody one left behind on a medic's stretcher. When he
finally tracked down the supply clerk, he discovered the problem: His
name was mistakenly left off the "GWOT list" -- the list of "Global War
on Terrorism" patients with priority funding from the Defense
He brought his Purple Heart to the clerk to prove he was in Iraq.
Lost paperwork for new uniforms has forced some soldiers to attend their
own Purple Heart ceremonies and the official birthday party for the Army
in gym clothes, only to be chewed out by superiors.
The Army has tried to re-create the organization of a typical military
unit at Walter Reed. Soldiers are assigned to one of two companies while
they are outpatients -- the Medical Holding Company (Medhold) for
active-duty soldiers and the Medical Holdover Company for Reserve and
National Guard soldiers. The companies are broken into platoons that are
led by platoon sergeants, the Army equivalent of a parent.
Under normal circumstances, good sergeants know everything about the
soldiers under their charge: vices and talents, moods and bad habits,
even family stresses.
At Walter Reed, however, outpatients have been drafted to serve as
platoon sergeants and have struggled with their responsibilities. Sgt.
David Thomas, a 42-year-old amputee with the Tennessee National Guard,
said his platoon sergeant couldn't remember his name. "We wondered if he
had mental problems," Thomas said. "Sometimes I'd wear my leg, other
times I'd take my wheelchair. He would think I was a different person.
We thought, 'My God, has this man lost it?' "
Civilian care coordinators and case managers are supposed to track
injured soldiers and help them with appointments, but government
investigators and soldiers complain that they are poorly trained and
often do not understand the system.
One amputee, a senior enlisted man who asked not to be identified
because he is back on active duty, said he received orders to report to
a base in Germany as he sat drooling in his wheelchair in a haze of
medication. "I went to Medhold many times in my wheelchair to fix it,
but no one there could help me," he said.
Finally, his wife met an aide to then-Deputy Defense Secretary Paul D.
Wolfowitz, who got the erroneous paperwork corrected with one phone
call. When the aide called with the news, he told the soldier, "They
don't even know you exist."
"They didn't know who I was or where I was," the soldier said. "And I
was in contact with my platoon sergeant every day."
The lack of accountability weighed on Shannon. He hated the isolation of
the younger troops. The Army's failure to account for them each day wore
on him. When a 19-year-old soldier down the hall died, Shannon knew he
had to take action.
The soldier, Cpl. Jeremy Harper, returned from Iraq with PTSD after
seeing three buddies die. He kept his room dark, refused his combat
medals and always seemed heavily medicated, said people who knew him.
According to his mother, Harper was drunkenly wandering the lobby of the
Mologne House on New Year's Eve 2004, looking for a ride home to West
Virginia. The next morning he was found dead in his room. An autopsy
showed alcohol poisoning, she said.
"I can't understand how they could have let kids under the age of 21
have liquor," said Victoria Harper, crying. "He was supposed to be right
there at Walter Reed hospital. . . . I feel that they didn't take care
of him or watch him as close as they should have."
The Army posthumously awarded Harper a Bronze Star for his actions in
Shannon viewed Harper's death as symptomatic of a larger tragedy -- the
Army had broken its covenant with its troops. "Somebody didn't take care
of him," he would later say. "It makes me want to cry. "
Shannon and another soldier decided to keep tabs on the brain injury
ward. "I'm a staff sergeant in the U.S. Army, and I take care of
people," he said. The two soldiers walked the ward every day with a list
of names. If a name dropped off the large white board at the nurses'
station, Shannon would hound the nurses to check their files and figure
out where the soldier had gone.
Sometimes the patients had been transferred to another hospital. If they
had been released to one of the residences on post, Shannon and his
buddy would pester the front desk managers to make sure the new charges
were indeed there. "But two out of 10, when I asked where they were,
they'd just say, 'They're gone,' " Shannon said.
Even after Weightman and his commanders instituted new measures to keep
better track of soldiers, two young men left post one night in November
and died in a high-speed car crash in Virginia. The driver was supposed
to be restricted to Walter Reed because he had tested positive for
illegal drugs, Weightman said.
Part of the tension at Walter Reed comes from a setting that is both
military and medical. Marine Sgt. Ryan Groves, the squad leader who lost
one leg and the use of his other in a grenade attack, said his recovery
was made more difficult by a Marine liaison officer who had never seen
combat but dogged him about having his mother in his room on post. The
rules allowed her to be there, but the officer said she was taking up
valuable bed space.
"When you join the Marine Corps, they tell you, you can forget about
your mama. 'You have no mama. We are your mama,' " Groves said. "That
training works in combat. It doesn't work when you are wounded."
Frustration at Every Turn
The frustrations of an outpatient's day begin before dawn. On a dark,
rain-soaked morning this winter, Sgt. Archie Benware, 53, hobbled over
to his National Guard platoon office at Walter Reed. Benware had done
two tours in Iraq. His head had been crushed between two 2,100-pound
concrete barriers in Ramadi, and now it was dented like a tin can. His
legs were stiff from knee surgery. But here he was, trying to take care
At the platoon office, he scanned the white board on the wall. Six
soldiers were listed as AWOL. The platoon sergeant was nowhere to be
found, leaving several soldiers stranded with their requests.
Benware walked around the corner to arrange a dental appointment -- his
teeth were knocked out in the accident. He was told by a case manager
that another case worker, not his doctor, would have to approve the
"Goddamn it, that's unbelievable!" snapped his wife, Barb, who
accompanied him because he can no longer remember all of his
Not as unbelievable as the time he received a manila envelope containing
the gynecological report of a young female soldier.
Next came 7 a.m. formation, one way Walter Reed tries to keep track of
hundreds of wounded. Formation is also held to maintain some discipline.
Soldiers limp to the old Red Cross building in rain, ice and snow. Army
regulations say they can't use umbrellas, even here. A triple amputee
has mastered the art of putting on his uniform by himself and rolling in
just in time. Others are so gorked out on pills that they seem on the
verge of nodding off.
"Fall in!" a platoon sergeant shouted at Friday formation. The noisy
room of soldiers turned silent.
An Army chaplain opened with a verse from the Bible. "Why are we here?"
she asked. She talked about heroes and service to country. "We were
injured in many ways."
Someone announced free tickets to hockey games, a Ravens game, a movie
screening, a dinner at McCormick and Schmick's, all compliments of local
Every formation includes a safety briefing. Usually it is a warning
about mixing alcohol with meds, or driving too fast, or domestic abuse.
"Do not beat your spouse or children. Do not let your spouse or children
beat you," a sergeant said, to laughter. This morning's briefing
included a warning about black ice, a particular menace to the amputees.
Dress warm, the sergeant said. "I see some guys rolling around in their
wheelchairs in 30 degrees in T-shirts."
Soldiers hate formation for its petty condescension. They gutted out a
year in the desert, and now they are being treated like children.
"I'm trying to think outside the box here, maybe moving formation to
Wagner Gym," the commander said, addressing concerns that formation was
too far from soldiers' quarters in the cold weather. "But guess what?
Those are nice wood floors. They have to be covered by a tarp. There's a
tarp that's got to be rolled out over the wooden floors. Then it has to
be cleaned, with 400 soldiers stepping all over it. Then it's got to be
"Now, who thinks Wagner Gym is a good idea?"
Explaining this strange world to family members is not easy. At an
orientation for new arrivals, a staff sergeant walked them through the
idiosyncrasies of Army financing. He said one relative could receive a
15-day advance on the $64 per diem either in cash or as an electronic
transfer: "I highly recommend that you take the cash," he said. "There's
no guarantee the transfer will get to your bank." The audience yawned.
Actually, he went on, relatives can collect only 80 percent of this
advance, which comes to $51.20 a day. "The cashier has no change, so we
drop to $50. We give you the rest" -- the $1.20 a day -- "when you
The crowd was anxious, exhausted. A child crawled on the floor. The
sergeant plowed on. "You need to figure out how long your loved one is
going to be an inpatient," he said, something even the doctors can't
accurately predict from day to day. "Because if you sign up for the
lodging advance," which is $150 a day, "and they get out the next day,
you owe the government the advance back of $150 a day."
A case manager took the floor to remind everyone that soldiers are
required to be in uniform most of the time, though some of the wounded
are amputees or their legs are pinned together by bulky braces. "We have
break-away clothing with Velcro!" she announced with a smile. "Welcome
to Walter Reed!"
A Bleak Life in Building 18
"Building 18! There is a rodent infestation issue!" bellowed the
commander to his troops one morning at formation. "It doesn't help when
you live like a rodent! I can't believe people live like that! I was
appalled by some of your rooms!"
Life in Building 18 is the bleakest homecoming for men and women whose
government promised them good care in return for their sacrifices.
One case manager was so disgusted, she bought roach bombs for the rooms.
Mouse traps are handed out. It doesn't help that soldiers there subsist
on carry-out food because the hospital cafeteria is such a hike on cold
nights. They make do with microwaves and hot plates.
Army officials say they "started an aggressive campaign to deal with the
mice infestation" last October and that the problem is now at a
"manageable level." They also say they will "review all outstanding work
orders" in the next 30 days.
Soldiers discharged from the psychiatric ward are often assigned to
Building 18. Buses and ambulances blare all night. While injured
soldiers pull guard duty in the foyer, a broken garage door allows
unmonitored entry from the rear. Struggling with schizophrenia, PTSD,
paranoid delusional disorder and traumatic brain injury, soldiers feel
especially vulnerable in that setting, just outside the post gates, on a
street where drug dealers work the corner at night.
"I've been close to mortars. I've held my own pretty good," said Spec.
George Romero, 25, who came back from Iraq with a psychological
disorder. "But here . . . I think it has affected my ability to get over
it . . . dealing with potential threats every day."
After Spec. Jeremy Duncan, 30, got out of the hospital and was assigned
to Building 18, he had to navigate across the traffic of Georgia Avenue
for appointments. Even after knee surgery, he had to limp back and forth
on crutches and in pain. Over time, black mold invaded his room.
But Duncan would rather suffer with the mold than move to another room
and share his convalescence in tight quarters with a wounded stranger.
"I have mold on the walls, a hole in the shower ceiling, but . . . I
don't want someone waking me up coming in."
Wilson, the clinical social worker at Walter Reed, was part of a staff
team that recognized Building 18's toll on the wounded. He mapped out a
plan and, in September, was given a $30,000 grant from the Commander's
Initiative Account for improvements. He ordered some equipment,
including a pool table and air hockey table, which have not yet arrived.
A Psychiatry Department functionary held up the rest of the money
because she feared that buying a lot of recreational equipment close to
Christmas would trigger an audit, Wilson said.
In January, Wilson was told that the funds were no longer available and
that he would have to submit a new request. "It's absurd," he said.
"Seven months of work down the drain. I have nothing to show for this
project. It's a great example of what we're up against."
A pool table and two flat-screen TVs were eventually donated from
But Wilson had had enough. Three weeks ago he turned in his resignation.
"It's too difficult to get anything done with this broken-down
bureaucracy," he said.
At town hall meetings, the soldiers of Building 18 keep pushing
commanders to improve conditions. But some things have gotten worse. In
December, a contracting dispute held up building repairs.
"I hate it," said Romero, who stays in his room all day. "There are
cockroaches. The elevator doesn't work. The garage door doesn't work.
Sometimes there's no heat, no water. . . . I told my platoon sergeant I
want to leave. I told the town hall meeting. I talked to the doctors and
medical staff. They just said you kind of got to get used to the outside
world. . . . My platoon sergeant said, 'Suck it up!' "
Staff researcher Julie Tate contributed to this report.
I hate it when they say, "He gave his life for his country." Nobody gives their life for anything. We steal the lives of these kids. We take it away from them. They don't die for the honor and glory of their country. We kill them."-- Admiral Gene LaRocque