Military medicine’s toxic silence

WHAT went wrong at Walter Reed Army Medical Center? Congressional hearings and a new commission to study medical care for soldiers and veterans will yield some answers, but in the meantime, a past crisis may provide some clues.

Clinicians correct their mistakes by talking about them, a truth brought home in recent years by multiple studies of medical error in civilian settings. In healthcare, silence is deadly. Military doctors understand this. The culture of armed forces medicine has long encouraged open discussion of clinical and administrative difficulties. Rank has counted for less in such conversations than it typically does in the military. But since 9/11, there’s been slippage toward a different ethic -- one of denial and evasion. Fear has driven this shift -- fear of the consequences of speaking freely.

In 2004 and 2005, I and a colleague, Jonathan Marks, reported that some military doctors covered up detainee abuse -- and even helped to plan it -- at Abu Ghraib, Guantanamo Bay and secret sites elsewhere.

When these stories and others broke, many in military medicine were shocked and ashamed. They tried to talk about what had gone wrong -- and what the rules should be at such places as Abu Ghraib -- in the face of pressure to support the Bush administration’s few-holds-barred approach to detainees suspected of terrorism. But the Army’s top doctor, Lt. Gen. Kevin C. Kiley, and his politically appointed civilian overlord, William Winkenwerder, both of whom now face congressional fire for the squalid treatment of rehabbing soldiers at Walter Reed, made it plain to their troops that they couldn’t talk about what went on at Abu Ghraib or Guantanamo.

Shortly after the revelations of prisoner abuse at Abu Ghraib, I was asked by faculty at the military’s medical school, the Uniformed Services University of the Health Sciences, to speak at a forum on the ethics of clinical work with detainees. A tentative date in late summer of 2004 was set. I was then told by the event’s sponsors that then-Defense Secretary Donald H. Rumsfeld’s civilian staff had ordered the session canceled.

Later that year, Maj. Scott Uithol, an Army psychiatrist deployed to Abu Ghraib to help plan interrogations, was to speak at a forensic psychiatry conference on the ethical and other challenges this work posed. The Army Medical Command, headed then as now by Kiley, ordered him not to do so. Kiley ran Walter Reed from 2002 to 2004.

Many other Army doctors gave us similar accounts of being told to keep silent. Several junior officers spoke of threats from above to end their careers and bring criminal charges against anyone who broke with the brass’ “don’t-ask, don’t-tell” approach to mounting evidence of medical complicity in prisoner abuse. A reservist, Maj. David Auch, was scathingly criticized by Pentagon higher-ups when we quoted him in a New York Times article about nightmarish staff and equipment shortages at Abu Ghraib, to the point that a dentist did heart surgery and chest tubes were taken from the dead for reuse.

Kiley and Winkenwerder, who announced that he would resign as assistant secretary of Defense for health affairs a few days after the Washington Post broke the Walter Reed story, ordered reports on detainee healthcare from their subordinates rather than asking for inquiries from outsiders of equal or greater rank. The message was clear: Evidence of misconduct and neglect was to be cloaked demurely, not bared. Kiley’s deputy, Maj. Gen. Lester Martinez-Lopez, who wrote the only, even mildly critical, assessment of prisoner treatment, retired within weeks of submitting his findings.

Army doctors have performed heroically in the Iraq war. But many have become disillusioned about supply and personnel shortages -- and about the silencing of their concerns by higher-ups. There is some anecdotal evidence that recruitment and retention have become problems, aggravated by a sense that those who go along to get along are promoted over more able officers who are more inclined to speak freely.

At Walter Reed, news reports and congressional hearings have made it clear that lower-ranking and noncommissioned officers knew about the conditions under which hundreds of wounded and recovering U.S. soldiers lived until last month. It appears that those near the bottom of the chain of command found the squalor unspeakable, but word of it didn’t move upward along the usual channels, and those at the top never “walked the barracks” to preempt trouble.

“There’s a need for anyone in a leadership post to walk around, to talk to people, to not rely on subordinates only,” a predecessor of Kiley as Army surgeon general, retired Lt. Gen. Ronald Blanck, told me last week. Blanck did not criticize Kiley directly, but he spoke proudly of military medicine’s tradition of outspokenness from below.

For efforts by clinicians and administrators to improve the quality of medical care, evasion and denial of mistakes is toxic. The National Academies of Sciences and other bodies have embraced approaches to healthcare quality that stress sharing and vigorous discussion of clinical, bureaucratic and ethical problems. Within military medicine, the climate of fear created from above since 9/11 has made such discussion difficult, if not impossible.

It’s urgent that the Walter Reed investigations getting underway address the causes for this climate of fear. Fixing responsibility on a few generals won’t be enough (though surely it’s time for Kiley to go). We owe America’s military health professionals more protection for their independence and willingness to speak out -- because they deserve it and because their professional judgment is a potent safeguard against clinical, administrative and moral error.

Military medicine will always pose awkward administrative and ethical challenges, arising from tensions between the ideals of professional autonomy and obedience to command -- and between patient well-being and protecting the nation. Silence, enforced by fear, can submerge these tensions for a time. But when they’re not talked about, they can emerge explosively, as they did at Guantanamo, Abu Ghraib and now Walter Reed.