Govt struggles to care for wounded GIs
Sun, 24 Jun 2007 06:29:33 GMTBy MARILYNN MARCHIONE, AP Medical Writer
More than 800 of them have lost an arm, a leg, fingers or toes. More than 100 are blind. Dozens need tubes and machines to keep them alive. Hundreds are disfigured by burns, and thousands have brain injuries and mangled minds.
These are America's war wounded, a toll that has received less attention than the 3,500 troops killed in Iraq. Depending on how you count them, they number between 35,000 and 53,000.
More of them are coming home, with injuries of a scope and magnitude the government did not predict and is now struggling to treat.
"If we left Iraq tomorrow, we would have the legacy of all these people for many years to come," said Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine and an adviser to the U.S. Department of Veterans Affairs. "The military simply wasn't prepared for its own success" at keeping severely wounded soldiers alive, he said.
Survival rates today are even higher than the record levels set early in the war, thanks to body armor and better care. For every American soldier or Marine killed in Iraq, 15 others have survived illness or injury there.
Unlike previous wars, few of them have been shot. The signature weapon of this war — the improvised explosive device, or IED — has left a signature wound: traumatic brain injury.
Soldiers hit in the head or knocked out by blasts — "getting your bell rung" is the military euphemism — sometimes have no visible wounds but a fog of war in their minds. They can be addled, irritable, depressed and unaware they are impaired.
Only an estimated 2,000 cases of brain injury have been treated, but doctors think many less obvious cases have gone undetected. One small study found that more than half of one group of wounded troops arriving at Walter Reed Army Medical Center had brain injuries. Around the nation, a new effort is under way to check every returning man and woman for this possibility.
Some of those on active duty may have subtle brain damage that was missed when they were treated for more visible wounds. Half of those wounded in action returned to duty within 72 hours — before some brain injuries may have been apparent. The military just adopted new procedures to spot these cases, too.
Back home, concerns grow about care. The Walter Reed hospital scandal and problems with some VA nursing homes have led Republicans and Democrats to call for better care for this new crop of veterans.
A lucky few get Cadillac care at one of the VA's four polytrauma centers, where the most complex wounds are treated with state-of-the-art techniques and whiz-bang devices like "power knee" or "smart ankle" prosthetics. Others battle bureaucracy to see doctors or get basic benefits in less ideal settings.
Mental health problems loom large. More than a third of troops received psychological counseling shortly after returning from Iraq, and a third of those were diagnosed with a problem, a recent Pentagon study found. The government plans to add 200 psychologists and social workers to help treat post-traumatic stress disorder and other issues.
No one knows what the ultimate cost will be. Harvard University economist Linda Bilmes estimates the lifetime health-care tab for these troops will be $250 billion to $650 billion — a wide range but a huge sum no matter how you slice it.
Who are the wounded?
Lee Jones, 24, of Lumberton, N.C., was severely burned on the face, hands, feet and legs when his Humvee was hit with an IED two years ago. A partial amputee with speech and other problems from a severe brain injury, he now does work therapy delivering mail at a VA hospital and tries to re-establish life in a nearby apartment with a wife and baby daughter.
Marine Cpl. Joshua Pitcher, 22, from upstate New York, is a Purple Heart recipient who returned to Iraq after he was shot in 2005. Half of his skull was removed to allow his brain to swell as he now recovers from a brain injury and shrapnel wounds from a grenade blast in February.
Maj. Thomas Deierlein, 39, is a New York City marketing executive who served five years after graduating from West Point. Twelve years later, called up as a reservist, he nearly died of bullet wounds that shattered his pelvis, leaving him with a colostomy and learning to walk again.
Joseph "Jay" Briseno, 24, of Manassas Park, Va., was shot in the back of the neck by an Iraqi in the early months of the war. One of the most severely wounded, he is now a quadriplegic, on a breathing machine, blind and unable to speak, but aware of what has happened to him.
"The mistake in Vietnam was, we hid the injured away from folks so they didn't get to tell their stories. Now it's important that we let them tell their stories to the public," said Dr. Steven Scott, director of the Polytrauma Rehabilitation Center at the Tampa VA Medical Center in Florida.
Counting the wounded can be contentious. Earlier this year, the Department of Defense changed how it tallies war-related injuries and illness, dropping those not needing air transport to a military hospital from the bottom-line total.
Bilmes, the economist, thinks this is disingenuous.
"An accident that happens while they're there is a cost of war, particularly when you factor in the length of deployment" and injury-inducing conditions like very hot weather, carrying heavy packs, and more vehicle accidents because it is not safe to walk anywhere, she said.
As of June 2, 25,830 troops had been wounded in action. Of these, 7,675 needed airlifts to military hospitals and the rest were treated and remained in Iraq.
There were another 27,103 non-battle-related air transports. Of those, 7,188 had injuries. Most occurred from vehicle accidents, training or work-related accidents. Ten percent were sports injuries, said Dr. Michael Kilpatrick, who tracks this information for the Defense Department.
Nearly 20,000 of these "non-hostile" airlifts were for illnesses or medical issues: general symptoms like fever or pain needing tests or evaluation; back problems; psychological problems adjusting to being in a war zone; "affective psychoses" ; neuroses; respiratory or chest symptoms; depression; head and neck problems ; epilepsy; infections, and muscle pulls and strains.
"I don't want to try to say these are not war-related. Being in the military is a very physically demanding job," Kilpatrick said.
For stress-related problems, the military tries "three hots and a cot" — warm meals and a chance to sleep. Most of the time it works and troops return to their unit, Kilpatrick said.
Of the troops air evacuated to the military hospital in Landstuhl, Germany, 20 percent return to Iraq and 80 percent go back to the United States for more care or disability discharge.
Of the half-million troops who have left active duty and are eligible for VA health care, about one-third have sought it. The most complicated cases end up at one of the four polytrauma centers, in Tampa, Fla.; Richmond, Va.; Palo Alto, Calif.; and Minneapolis.
These were formed after doctors realized they were missing problems — amputees who were confused and unable to put on their prosthetics because of undiagnosed brain injuries, and guys who could remember their therapy dog's name but not their doctor's, or who could carry on a conversation but not recall what they had for breakfast.
Troops at these hospitals have an average of six major impairments and 10 specialists treating them.
"The important thing to realize is you could have all of them at once" — trouble speaking, seeing, walking, hearing, etc., Scott said.
Most of these injuries are caused by IED blasts, which send a pressurized air wave through delicate tissues like the brain, sometimes send it smacking against the inside of the skull and shearing fragile nerve connections that control speech, vision, reasoning, memory and other functions. Lungs, eardrums, spinal cords — virtually anything — can be damaged by the pressure wave. Injuries also come from collapsing buildings, flying debris, heat, burns or inhaled gases and vapors.
"Many of these you can't see on an X-ray," such as glass shards that can cause internal bleeding, Scott said.
In prior wars, one of every five to seven troops surviving a war-related wound had a traumatic brain injury, the military estimates. It's much higher in this war.
A pilot project at Walter Reed in 2003 to screen 155 patients returning from Iraq found that 62 percent had a brain injury.
"This is a very rapidly evolving area as a disease," with no screening test, agreed-upon set of symptoms for diagnosis, or even a billing code, said Kilpatrick, the military doctor.
Much needs to be learned about how to treat these injuries, he said, but credited the military medical staff for having the chance.
"It's just amazing to me every day when I look at these numbers," he said. "The good news is that the majority of these people who become ill or injured ... are going to survive and are going to be able to return either to the military or to civilian life and be productive."
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On the Net:
Government casualty data: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/castop.htm
State breakdowns: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/STATE_OEF_OIF.pdf
Defense and Veterans Brain Injury Center: http://www.dvbic.org
Harvard economist report: http://www.va.gov/
Department of Defense: http://www.defenselink.mil/
Rays of hope for Africas AIDS children
Sat, 23 Jun 2007 18:13:34 GMTBy CLARE NULLIS, Associated Press Writer
CAPE TOWN, South Africa - Little Natasha is a giggling, wriggling bundle of mischief. She adores Barney the Dinosaur, claps along to her favorite songs, and throws a typical 3-year-old's temper tantrums.
Natasha, who picked up the AIDS virus in her mother's womb, also suffers from hearing problems, rashes and stomach upsets, and can't play outdoors too often because she easily catches cold.
But she is alive. So very alive.
Natasha's health represents a small but significant victory over an epidemic gripping South Africa and neighboring countries. AIDS drugs are turning what was a certain death sentence for infants and young children into a manageable disease, providing a glimmer of hope on a continent of gloom.
But a long, hard road lies ahead. In Sub-Saharan Africa, fewer than 10 percent of infected children are receiving the medication they need. Even in South Africa, which has a relatively advanced AIDS-fighting network, an estimated 5.5 million people are estimated to have the virus, including about 240,000 children, only some 25,000 of whom have had the treatment that saved Natasha.
Last year, an estimated 950 South Africans died each day from AIDS-related diseases and a further 1,400 were infected each day, according to the Medical Research Council. UNAIDS head Peter Piot warned a conference in the coastal city of Durban this month that for every person in the country who started taking AIDS drugs, another five contracted the virus.
And despite the grim statistics and never-ending funerals, many South African men continue to have unprotected sex with multiple partners despite government pleas to change their behavior.
On a continent where poverty, war and lack of education rob children of their futures, AIDS attacks on many fronts. Even children who survive are often orphaned and vulnerable to abuse and exploitation.
Natasha clung to life against the odds. She stood little chance of survival at birth. Doctors referred her to Bowy House, a love-filled home with room for about 15 children.
"She was so thin you could see through her," Lalie Lombaard said with a shudder. Lombaard has cared for dozens of children at the home in Paarl, a town about one hour's drive from Cape Town.
Given the stigma that still surrounds AIDS in Africa, the identities of children are fiercely guarded and their surnames are rarely released. Under the U.N. Convention on the Rights of the Child, Natasha has the right to privacy.
She also has the right to life.
The South African government, long criticized for doing too little, now has the world's biggest treatment program, and children are a focal point of a five-year AIDS program unveiled in May. Authorities have also vowed to step up prevention programs to stop fetuses being infected. Other governments such as Zambia, Malawi and Botswana are also giving more priority to children.
UNAIDS and the U.N. Children's Fund say 2.3 million children in sub-Saharan Africa are HIV-positive, most of them infected by their mothers because they did not receive drugs taken for granted in wealthy countries to prevent transmission of the virus.
Globally, an estimated 530,000 children were newly infected last year and 380,000 died of AIDS, the vast majority in Africa. Without treatment, half of infected infants die before age 2.
Throughout southern Africa, child mortality rates have soared because of AIDS, reversing health gains from better sanitation and immunization even in relatively prosperous countries such as Botswana and South Africa.
When Natasha arrived at Bowy House, aged nine months, she had twig-thin limbs, protruding ribs and a balding head. Photographs taken only three months later show her restored to health, celebrating her first birthday with her parents and a pink-and-green cake decorated with fairies.
Her photo album gives snapshots of the many small signs of progress across southern Africa. Lower drug prices, easier diagnosis, and better training of health workers augur a dramatic increase in the numbers of lives that will be saved. And government efforts are being boosted by the Clinton Foundation, the Bill and Melinda Gates Foundation, U.N. money and President Bush's Emergency Plan for AIDS Relief.
There are a whole host of other programs. For instance, backed by funding from drug companies, the Texas-based Baylor College of Medicine has an acclaimed pediatric AIDS initiative with children's clinics in some of the most ravaged countries.
In Botswana, more than 3,800 children are receiving care and treatment at clinics affiliated with the Baylor initiative, including its flagship hospital in the capital, Gaborone. The aim is also to assign foreign physicians and nurses to ease debilitating staff shortages and train local health workers.
Other poor African countries are taking heart. For instance, the Zambian government has shifted its priority from purely high-risk adults to getting treatment to more children.
"The most significant success we have now is that we have a recognition that this is a priority area," said Albert Mwango, AIDS medical coordinator at Zambia's health ministry.
Eric Goemaere, the head of Medecins Sans Frontieres in South Africa, blames lack of political will for past inaction, because child AIDS wasn't a problem in North America and Europe and drug companies had little financial incentive to develop a child-friendly therapy.
In 2005, 57 children in the U.S. were infected by their mothers. In the impoverished Cape Town slum of Khayelitsha alone — home to some 500,000 people — it was three times as high, according to Goemaere.
Khayelitsha, where one in four pregnant women is infected, is now home to one of South Africa's busiest anti-AIDS programs, with about 500 children on medication. Wednesdays are dedicated pediatric days and the no-frills clinic set up by MSF reverberates with children's shouts.
Children have remarkably few side-effects, partly because their systems cope better, says Goemaere. But there are other problems; older children battle with rejection by family and friends and often lapse into depression, he says.
The very young can't swallow tablets and have to take multiple doses of syrup, according to a body weight formula that can baffle caregivers — often illiterate grandmothers. The medicine needs to be refrigerated, difficult in poor areas with no electricity. And cash-strapped caregivers often can't afford the cost of driving kids to clinics.
But there is progress. Prices of ARV drugs for children have come down dramatically over the past 12-18 months. The Clinton Foundation HIV/AIDS Initiative negotiated a reduction in the cost of pediatric drugs — often taken in combination — to $60 per year. Pharmaceutical companies previously accused of being greedy are now lining up to fund children's projects in a complex network of public-private partnerships.
The local government provides drugs free of charge to Bowy House, where Natasha has spent most of her life and has come to regard its care-givers and children as her family. Staff there recently drove her on a seven-hour journey over mountains and dirt roads to spend time with her mother, who is dying of AIDS. Natasha has an extended family in her dusty village, but her father is unable to care for her. There is no electricity and no schools.
The girl's favorite activity is to "go tata" — out for a drive. She adores weekends at the beach, being pushed in a stroller and feeding the ducks. In summer she and her friends chase through the garden sprinklers, despite the risk of catching cold.
"In general we forget that they are ill children. They are naughty and full of mischief but when we see how quickly they can have a setback it reminds us that they aren't normal," says Lombaard.
Natasha's day begins with breakfast and then her first drink of medication at 8 a.m. — she'll have another at 8 p.m. She doesn't complain about the foul taste because she knows it makes her feel better.
There are morning songs and dance. Natasha, who wears a hearing aid, is partial to "If You're Happy and You Know It, Clap Your Hands."
At lunch, she opens her mouth full of cottage pie and laughs hilariously.
Children at Bowy House are assigned a color to give them "ownership" of something — Natasha has an orange teddy bear in her cot.
She knows how to defend herself against Luvo, a boisterous 3-year-old boy who also looked like a famine victim when he arrived at Bowy House and now revels in annoying the girls. And she thrashes in fury when Lombaard, her surrogate mother, has no time to pick her up.
The home is an example of the localized care that many experts say should be Africa's model. The government pays for the medication, but its founder, Hester Veldsman, who founded Bowy House, relies entirely on private donations and struggles to meet monthly expenses of $9,500 and is always grateful even for donations of diapers and groceries.
And what happens when communities don't care or can't cope?
In Zimbabwe, about 1.3 million children — or one in five — are classed as orphans and 100,000 live in child-headed households, according to UNICEF estimates. Zimbabwean President Robert Mugabe's confrontation with the West has caused humanitarian aid to plummet and families are collapsing under an inflation rate heading toward 4,000 percent.
Zimbabwe's official media regularly report on children being raped by HIV-infected men who believe sex with a virgin will cure them.
Similar abuse has been reported in impoverished Lesotho and Swaziland, where AIDS has slashed life expectancy to the mid-30s and left an army of orphans vulnerable to exploitation. School enrollment rates for girls have dropped as they quit to care for younger siblings and sick parents or simply can't afford the fees.
In Zambia, the AIDS-related death of parents and grandparents coupled with migration to cities has left many rural children with nobody to care for them. Faith-based organizations are struggling to fill the gap.
In Cape Town, a church-based charity called Act of Grace plans to use some 150 shipping containers as emergency shelters for AIDS orphans.
Veldsman even now is overcome by tears when she thinks of Bowy, the 5-year-old boy for whom it was named, and who died months before AIDS drugs became available.
She counts Natasha as one of her victories.
"The doctors gave up on her, and I said, No, we can't give up," said Veldsman.
Aside from the medicine, there was one other vital ingredient in Natasha's survival, Veldsman said: "Tender loving care."
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AP correspondent Joseph Schatz in Zambia contributed to this report.
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On the Net:
Veldsman's organization: http://www.miqlat.org.za.
