Interview Lt. Gen. Eric B. Schoomaker
- The stigma attached to seeking care
- What they found at Fort Carson
- Why do suicide numbers keep rising?
- The suicides-fractured relationships link
- The concussion-PTSD link
As surgeon general of the U.S. Army, he is the Army's top doctor. This is the edited transcript of an interview conducted on March 15, 2010.
The RAND [Corp.] report in 2008 cited more than 300,000 soldiers from Iraq and Afghanistan either suffering from PTSD [post-traumatic stress disorder] or major depression. [Was] the military or the Army really ready for the mental health crisis that was going to come out of Iraq and Afghanistan?
I can't speak to whether we were ready or not. I think we knew from prior wars that combat and deployment is associated with post-traumatic stress reactions. I think the magnitude of those reactions -- that is, the number of soldiers that would experience them -- has only really been fully explicated by some of the studies that we've conducted over the last six years or so. We conduct on an annual basis now a study known as the Mental Health Advisory Team, or MHAT studies. They started early in the war, and they've continued on in part because they've given us such good information about the effects on the behavioral health and the mental health of our soldiers, and indirectly their families. And that has shown us that, in fact, anywhere from 15 to 30 percent of a unit returning, depending upon the intensity of combat and the degree of austerity of the deployment, may be associated with at least transient post-traumatic stress reactions.
In dealing with this, it's always good to separate the more long-lived or more resistant symptoms that may be a part of post-traumatic stress disorder from short-term symptoms that arise in a very large number of soldiers and any of us who are exposed to a potentially life-threatening circumstance like natural disaster, violent crime. I think the numbers are certainly high when you look at these transient symptoms. Our goal is to identify as many as possible as close as possible to the events and then try to get them their appropriate treatment and counseling and to prevent some of the untoward consequences of that.
Were you surprised that the numbers were as high as they are? ... Are those figures much higher than previous wars, Vietnam or World War II?
First of all, we know through anonymous surveys that as many as 30 or 40 percent of our soldiers -- and sailors, airmen, Marines for that matter, service members in general -- admit to having some degree of psychological or behavioral health challenges when they come into the service. So you've got to superimpose what's happening when they go on a difficult deployment with the background emotional baggage, for lack of a better term, that a soldier may bring into uniform in the first place.
Given the intensity of combat that many of our soldiers are exposed to and the duration of these deployments, especially during the surge, when we extended from 12 to 15 months for some units, the MHAT studies show this and surveys showed us that the stress resulting from that and the symptoms that solders suffered from afterward were commensurate with that length of deployment. As to whether I was surprised or not surprised, I can't say that.
What we have been very aggressive about doing is trying to identify the magnitude of the problem, the sources of those stressors, and to try, as promptly as possible, to treat people.
Let's talk about the Fort Carson EPICON (PDF) [epidemiological consultation report]. ... Why was there a study done, and what was the study?
The commanding general of the installation at the time, Maj. Gen. Mark Graham, who was very concerned about what was happening on his installation, asked me and Army Medicine if we wouldn't send a team that could conduct a study of this sort. We have, in the past, sent EPICON study team members to look at the potential causation of or constellation of factors that may have led to events on an installation or within a group. He requested it, and we promptly responded to him.
What was observed was over a period of about four to five years on Fort Carson, about 10 murders or attempted murders, very violent crimes, very tragic crimes were committed by soldiers assigned to units on Fort Carson, and there appeared to be a clustering of these horrific crimes in one particular brigade, a unit of about 3,000 to 4,000 soldiers. ...
What we found was that, in fact, about 14 soldiers were involved over this four-year period ending in 2008. ... And of the 14, 10 of them came from one single unit, a unit that had begun as the 2nd Brigade of the 2nd Infantry Division in Korea, had been deployed to Iraq, returned to Fort Carson -- not to Korea where it started but to Fort Carson, because it was restationed there. They then had a fairly short dwell, meaning that they remained at Fort Carson for a year or less before they were again deployed to Iraq. It was at that point that the surge took place, and their 12-month deployment was extended to 15 months before they returned to Fort Carson.
Ten of the 14 soldiers involved in these crimes on Fort Carson came from that one brigade, and six of the 10 soldiers came from one battalion of 600 or so soldiers within that brigade. And I believe that you are looking at one platoon, one smaller unit within a company, within that battalion, and that appeared to have a very close clustering of violent crimes committed by a few number of soldiers in this very large unit.
So the team of epidemiologists, led by an Army doctor, Col. Mike Bell, and Amy Millikan, another very experienced epidemiologist, went there and led a study that looked at this brigade and compared it to a sister brigade in the same division who also was involved in deployments and redeployments. [They] looked at characteristics of the two, followed all soldiers that had been members of that brigade from before they even entered the brigade through the time they were in the brigade and then their service after they left the brigade. [They] followed soldiers that numbered in the 20,000[s] or more just to see if there were characteristics that were featured within one or both of these brigades that may explain this.
What they found was that there was a clustering of problems at the individual level, at the small-unit level, and then perhaps even environmentally in the Fort Carson area that seemed to intersect and result in these horrific events.
What were the cluster of problems? What were the findings of the study?
This is the intersection of individual-level problems that tended to focus around unrecognized and untreated post-traumatic stress problems and depression and some other behavioral health problems; alcohol or drug use that was not addressed properly and treated successfully; and misconduct that began as nonviolent, non-serious crimes but weren't recognized and not dealt with aggressively by the leadership.
At the time we released the study last year, I called that a "toxic combination"; that, coupled with the small-unit dynamics, which tended to minimize or discourage soldiers from seeking behavioral health problems or to get prompt treatment for alcohol or to aggressively address misconduct when it was even at a much lower level of severity, those small-unit dynamics tended to exacerbate or multiply those effects.
And then we're examining what might be present in this community that may predispose to depression and problems with alcohol and drug use and the like. But those three intersecting with one another in a very complex, multifactorial way appears to have set the stage for these horrific crimes.
Part of that, you were talking about, is the leadership. What specifically was the problem with leadership, and what's been done to address that at this point?
One was the stigma associated with seeking care. There is already existing within each and every one of us a kind of individual stigma that tends to minimize or move us away from seeking care when we think we've got a mental health or behavioral problem. Probably my own personal experience with this is that none of us likes to look carefully at painful or difficult experiences that may lead to our behavior, especially when you're talking about someone who may have been witness to some horrific combat experiences or may have carried into his life in uniform some difficult family dynamics or exposure to violence or other things. ...
On top of that, there's a social stigma associated with fellow soldiers who may think of one another who have gone after care as being weak or somehow being less of a man or a woman because of that, or less of a soldier. And then there's the social stigma associated with leaders who may try to keep soldiers from seeking care because they feel [the soldiers] are trying to get over on the Army or trying to get out of duty or the like.
All those are dynamics that I think leaders can interact with and can ameliorate, or they can make it worse by minimizing it or actively discouraging soldiers from getting help. And that goes as well for problems with alcohol or drug use or misconduct that's not aggressively treated.
What happened in the study was that we saw soldiers who started in other units and then cycled through this unit [who] appeared to have normal health care-seeking behaviors and seeking care for behavioral problems before they came into the brigade, but once they got into the brigade and this battalion, that was somewhat suppressed, only to rebound again if they left the unit. ...
And was that because the leadership of this brigade was sending out messages saying seeking mental health treatment is -- what was the message they were getting?
I think the message was, either directly or indirectly from fellow soldiers as well as the small-unit leadership, that seeking care or promptly treating problems, like with alcohol, should be discouraged. And we saw, in comparison with a sister brigade, a marked difference in the command climate, as we call it, that led to this. ...
This command climate, has anyone been held accountable for that?
I'm not the person to answer that person. Quite candidly, I'm the medical adviser to the chief, but certainly the leadership of the Army has taken a very aggressive position toward reducing stigma in leadership by example. Our understanding, in follow-on studies not only at Fort Carson with the sister brigade but also in Fort Hood, [Texas,] following these tragic shootings that occurred last November, is that the unit leadership at the brigade and battalion level and higher understands the importance and understands the need to reduce stigma.
It still is difficult for us to penetrate at the level of the individual soldier in a small unit ... that this is an important element, and I don't think this is unique to the Army. One of our problems is that our culture is superimposed upon, or is a subordinate culture within, a larger American culture that needs to have a change in its attitude toward seeking care.
But it seems this whole question of accountability is pretty key in terms of changing that. Somebody we talked to compared it to sexual harassment. Years ago you could make jokes about women, sexual jokes, and nothing was done, but there was a change in the culture, so that now if a soldier is thought to be sexually harassing somebody, they're brought up on it. I guess the question is, has that ever happened with a leader who has belittled the need for mental health to a person who's seeking it?
I'm not personally aware of it. Maybe what you're suggesting is something that will come of the efforts that the Army has undertaken here and will change the way we deal with leaders who are not supportive of this. For now, I think the approach has been that we need to educate and train at every level possible. This, just like sexual harassment, needs to be a part of the enculturation of every soldier and every future leader, that this is part and parcel of taking care of your soldiers and your families.
Do you think it needs to [go] beyond education and training?
... I think the Army is looking at all ways that it can influence behavior. If nothing else, we are a community that places a lot of emphasis upon improving and changing behavior for the sake of good order, discipline and for the militia.
One of the things that was brought up also was the understaffing at Fort Carson. Soldiers that we've spoken to basically said they were quite aware of it because it meant that they would just have medicine thrown at them, or ... if they stopped going to a mental health provider, nobody would follow up on it; nobody would know. Do you think that this understaffing may have contributed to the crimes and the suicides in Colorado Springs in Fort Carson?
... I would be really reluctant to make that connection. I think one of the things that's been very hard for us to grapple with, is the multifactorial nature of this intersection of problems. We've not seen anywhere near the degree of criminality and violent crimes in the sister brigade. And quite frankly, one of the things we wanted to make clear from the beginning is that the vast majority of soldiers who deploy and redeploy on a recurrent basis, going back many, many wars, are not involved in criminal activity as a consequence of their service, especially service in combat. So to tie the criminal act of an individual soldier to a shortfall in behavioral health specialists I think is pretty extreme.
Nonetheless, have we suffered a shortage of behavioral health care providers? Yes. And I don't think, again, we're alone in this. The nation is facing a problem with its supply of and the availability of behavioral health specialists. The other thing that we are really trying to get our arms around is the synchronization and coordination of behavioral health care for a soldier, that this doesn't exist in an episodic or in a chaotic and in a noncontinuous way. And giving coherence to our programs is as important as having available care. ...
In the last several years we've added about 60 percent again of our behavioral health workforce to our camp's posting stations and units. We've become more aggressive about putting behavioral health science officers down into our individual brigades and then ensure that they have continuity of care. One of the most important features of the study at Fort Carson was the loss of continuity in several of those soldiers, including one of the soldiers that is now serving time for crimes. Soldiers who are returned from the deployment early, [who'd] come out of synch with their unit, were not adequately followed back into the rear detachments and to the home stations, and they kind of fell in a crack in the sidewalk, so to speak. ... I think the leadership is very sensitive about that.
And they were sent home specifically because they had problems?
Exactly. Some of them were sent home specifically because they were experiencing behavioral health problems or misconduct downrange, and the safety nets, so to speak, failed for us.
You'd think those would be the people that would get the most help if they've been sent away from combat because they are either getting in trouble or have behavioral health problems.
I totally agree with you, and I think one of the lessons that we've learned from this, and one of the approaches we are taking now, is to change the approach from one that looks at surveying our soldiers episodically and at these major events like deployment and redeployment to one that looks longitudinally across the life cycle of the solider and the family and ties care from one phase of their predeployment to what occurs downrange to what occurs when they return. We're trying very hard to get that kind of continuity in place just for the reasons that you've talked about.
You've got a big brigade combat team about to come back to Fort Carson this year, the 4-4. Are you still understaffed out there? Are you worried about what's going to happen? Are you prepared for them now?
Are we concerned about their transition? Absolutely. I think we're concerned about all the transitions that are occurring within our brigade combat teams [BCTs]. We're entering into our ninth year of war, and this has been a very tough time for the Army, an army that's under strain and families that are under strain. We have met personally with the brigade combat team commander. The team of medical and behavioral health leaders and specialists out at Fort Carson is leaning forward very aggressively to assist [with] a comprehensive behavioral health plan that has continuity and looks at the life cycle, if you will, of the soldier across these multiple phases.
In accordance with that, we're working very hard to make sure that this brigade combat team as it returns is well cared for. There's a much greater visibility of how we can help those soldiers and their families.
First of all, like society at large, we're really concerned about suicide and this loss of life. Whether a soldier or family member loses their life in combat or from suicide, the fact is we've lost a very valuable part of the formation and part of the Army, and it has a devastating effect on the unit and on the family, the community. Equally the worst thing I think to every one of us is that factors that lead a few of our soldiers to take their lives are probably resonant out there across the whole force, and this is just the tip of the iceberg, perhaps, [of] stresses that the force at large is feeling.
We're all working very hard to better understand and overcome those stresses. In fact, the vice chief of staff of the Army himself, Gen. [Peter] Chiarelli, has made this one of his most important areas of better understanding and study and action. We've initiated a five-year, $50 million study with the National Institute for Mental Health, the Uniformed Services University of the Health Sciences, University of Michigan and Johns Hopkins and some others that are looking at [this] in a comprehensive way. ...
What we know at this point is that suicide is an impulsive act. In most cases it's an act of desperation in people that are suffering from overwhelming psychological and psychic stress. We know from studies, for example, in San Francisco Bay and the Golden Gate Bridge, that people who survive suicide attempts or who are stopped from committing suicide almost uniformly don't try it again, reinforcing this notion that this is an act of desperation in people who are just under terrific pain.
What we're trying very hard to do is to sensitize other fellow soldiers and family members that if we have it in our midst, if a soldier whose behavior is changing, who's becoming withdrawn, who's beginning to act in such a way that we think may suggest that they're going to do harm to themselves, we need to take active steps. And that's occurring. ... But understanding better and trying to prevent the factors that lead to suicide I think is really ultimately what we're looking to do.
One thing that appears to be transcendent to all of these cases is fractured relationships: a rupture in a relationship that's very important to the individual, like a marriage or a girlfriend, boyfriend. Even the Army turns out to be, for some of our soldiers, a relationship that is so important to them, it gives them so much meaning, that if they commit misconduct or are punished under the Uniform Code of Military Justice, some of our soldiers have gone out and killed themselves as a consequence of that.
So being attentive to things that break these relationships and lead to problems in relationships with soldiers is important to us, not the least of which is our recurrent deployments and long deployments. ... When you look at the relative weight of frequency of deployment, length of deployment and length of time in between deployments, what we call ''dwell time,'' on the psychological state of our soldiers and the integrity of families, what we find is that the most important factor is the amount of time between deployments.
If dwell time back in home station is less than two years, optimally a little beyond that, then the baseline psychological state of the soldier can't be returned, and they can't reform and reforge these critical relationships. And then, of course, the length of time that one is deployed and the frequency of deployment becomes important as well. But our Special Operations units and Marines and other units that go for shorter lengths of time, with longer dwell between those deployments, are able to sustain those and move through the adversity of the deployment successfully.
So we think that if we can lower the length of deployment, and especially increase the dwell time between deployments, we will do something very positive for relationships and these very important, critical social contacts that our soldiers require.
As you outlined before, the particular unit that we're following had this pretty unusual situation. With their very short dwell time and a very quick turnaround, how much do you think that contributed to the criminal problems that ended up showing up in that unit?
I'm always reluctant, of course, to hang on any one factor what is a very complex decision on the part of a soldier to take another life or attempt to take life or to commit a violent crime. You yourself told me that of the platoon you're following, about half of them had gone through the initial deployment back to Fort Carson and then back out again. Only two of the 10 soldiers involved in the murders had done both of those deployments, sort of double pump. So clearly it wasn't an absolute cause of criminal behavior, because a large number of soldiers did that and did it successfully without problems -- either of an overwhelming psychological nature or alcohol problems -- and certainly without committing violent crimes.
But did it contribute? I think part of the small-unit dynamics that we described earlier ... was a sense that they had a black cloud over their head because they had been sent from Korea to Iraq and then back to Fort Carson and then back again, and then that had been extended. That appeared to color the attitudes within the unit dynamic. We talk about high-performing units and the positive environment within a high-performing unit, and I think the same can exist on the other extreme.
I want to talk a little bit about prescription drugs in the combat theater. One of the MHAT reports a couple of years ago, it looked like 10 to 20 percent, roughly in that range, were taking either antidepressants or sleeping pills to help them cope. Why are so many drugs being prescribed?
That's a little higher than I'm familiar with. I think the numbers are more in the range of 2 to 5 percent. I think the most recent figures are about 5 percent, and about half of those, I'm led to believe, are because of what you said, focal symptoms like sleep problems. We also use some of these combinations of antidepressants in lower doses to help with pain, like chronic arthritis and the like. They're being prescribed, ideally, by a licensed provider who has looked at the problems of the soldier and has concluded that this in their best interest. These drugs have been very useful in reducing the burden of psychological stress and symptoms in our soldiers, and I think, I trust, that it's being done responsibly.
One of the things that has come up, though, is the inability to have those providers out in the field where these guys are. They may be at the base, but when they get out to a combat outpost, they're not there. One of the guys that we've talked to said the drugs just stop because there wasn't anybody there to administer them, so suddenly he goes from taking medication that is there to help him to no medication at all.
I'm not aware of that. That's clearly something that needs to be addressed. ...
But you can't have a mental health person on every combat outpost, can you?
Not at every one. That's one of the challenges of working in a country like Afghanistan, where we talk about the "tyranny of terrain," and it's one of the reasons that we're trying to employ techniques like behavioral health counseling and support at distance through video teleconferences and the like. We've done that now successfully here in the United States. We started [at Tripler Army Medical Center] in Hawaii late last year with a pilot program in which we brought back a unit from combat and did one-on-one interviews in a parallel way using video teleconferencing and face-to-face behavioral health specialists and others. [We] found that the video teleconferencing worked very well, that soldiers accepted it very well. This generation of soldiers is very comfortable in a digital environment, either text messaging on their cell phones or working through a Skype camera.
We've now broadened that to a much larger group, and this will undoubtedly become a part of how we do focus counseling with our soldiers. We see the direct application to places like Afghanistan and other places where we can't have a behavioral health specialist at every combat outpost, but we might be able to reach out to them through these devices. ...
And some of these drugs, Celexa, Remeron, ... they're carrying black-box warnings talking about possible side effects with suicide, increased impulsiveness and aggressiveness. Why is the Army prescribing those kinds of medications in a war zone?
I think one of the problems with those black-box warnings is they apply to drugs like the so-called selective serotonin reuptake inhibitors, SSRIs, that are used for improving mood in depressed patients, are also for improving pain in chronic-pain patients, [one of the problems] is that the length between cause and effect has never really been very well outlined. There are many legitimate epidemiologists and experts in this field that would point out that depression is associated with impulsivity, is associated with irritability and anger issues, and frankly, people who take this because they are depressed are at higher risk to begin with for suicide. And so to associate that with people who are taking the drug for those problems may be reversing cause and effect here.
But whether it's reversing cause or effect, those are serious issues that I'm not sure being in a war zone is going to help.
We talked about this earlier when we started off, that the problems of separation, of being exposed to combat, of developing symptoms that may result from exposure, is something that happens in the combat zone. Frankly, we are aware of the fact that when soldiers are redeployed, are deployed another time after they have had an earlier experience, [they] may revisit memories and old experiences for which they may need some temporary relief. That's one of the initiatives that we're undertaking right now.
In the case of concussive brain injury, for example, being exposed to an IED [improvised explosive device] blast or the collapse of a building or something in which you get struck on the head and might either lose consciousness or have an interruption of consciousness, that physical injury to the brain ... may be associated in the combat setting with a much higher rate of the development of post-traumatic stress symptoms later. So we might be having soldiers who are recovering from the concussion -- because we're being much more aggressive about identifying when blasts occur and when a soldier may have suffered a concussion, putting them at rest -- but then later may develop post-traumatic stress reactions, hypervigilance, sleep problems, irritability, a sense that they're in constant danger, and short-term management of those with drugs is a very acceptable way of doing that.
The last thing I wanted to get to was the whole question of TBI [traumatic brain injury] and concussiveness. A lot of the guys in our unit were subject to blasts early on, five, six years ago. Most of them are now out of the Army, but an awful lot of them still talk about those symptoms. And what's there for them now? They feel like they've fallen through the cracks.
Many of those symptoms we think are attributable to this post-traumatic stress disorder may be closely aligned to the physical injury that they received in the form of a concussion. They have recovered completely from the concussion itself, which can cause headache and ringing in the ears and problems with gait and in walking and that sort of thing, but over time will recover as a football player would if well cared for and taken out of the game. But associated with that in the combat concussion might be this lingering post-traumatic stress, and that may not come on for months to years later.
One of the things we're undertaking right now is not only to better identify up close to the event as possible the blast when a concussion has occurred, but also to begin managing post-traumatic stress symptoms that may arise in combat. Specialists in this area who work with, for example, victims of rape, where there is a very close relationship between the violent crime and then the emergence or development of post-traumatic stress disorder symptoms, find that if you can begin to address these symptoms as close as possible to the event temporally, you relieve a lot of the burden of the symptoms for a long time afterward. In our community, the other part of this is if we can identify the concussion, treat the concussion and then watch for the emergence of any symptoms of lingering post-traumatic stress that may result, we might be able to prevent things like alcohol abuse, violent behaviors that lead to family discord or misconduct. We're trying to reduce the whole burden by shifting our attention more toward prevention of these.
Are you saying there's actually a physical correlation between a TBI and the emergence of post-traumatic stress?
I don't think we know exactly all the reasons for it. We're getting a better understanding of what concussive injury causes. A concussive injury is a physical event; we can time it to the event that led to the alteration in consciousness, or having your ''bell rung,'' or flat out being knocked out. We know that, depending on the force involved, whether it's a blow to the head from debris or whether it's this rapid acceleration/deceleration that can occur, ... that there's a disruption of normal brain cell activity that's caused by that physical injury. What we suspect is associated with that is what I call a chemical injury: It's a persistence of the release of stress hormones related to the circumstances or the context in which that concussion occurs, so that when Ben Roethlisberger, the quarterback of the Pittsburgh Steelers, woke up on the field in a game or was dazed on the sidelines, the context of his getting his bell rung or being knocked out is completely different than a combat situation in which, as you said, losing a friend or being under fire or just being in this state of life-threatening stress going into the event may set the brain up for this prolonged kind of chemical injury, as I call it. So our neuroscientists and the academic community in general is looking at both of these to better understand, one, how they're linked; and two, what are the neuroscientific causes of both of these forms of injury.
Studies that have been now published in journals like New England Journal of Medicine and the Journal of the American Medical Association by Charles Hoge and a number of other investigating teams have shown that many of the symptoms -- as you've described for these soldiers that five, six years ago may have suffered a concussion -- many of these lingering, long-term symptoms may in fact not be neurocognitive disruption because of the physical injury; they may be persistence of post-traumatic stress disorder symptoms, and they need to be addressed and treated by people who are skilled in treating PTSD.
A lot of the guys in our unit don't feel they're getting that help now.
I need to hear about that, as does the Veterans Administration. That's the group that we really need to address. We're working as hard as we can to prevent a repeat of that generation of Vietnam veterans who did not have timely attention given, and, quite frankly, probably victims of injuries from earlier wars for whom it wasn't recognized, that what we call ''battle fatigue'' or ''shell shock'' was this persistent what I call chemical injury from persistent stress hormone release that has led to long-term problems with their behavior.
Do you think there's a small generation of soldiers from the first part of the war in Iraq that fall into that same category now?
I don't know. I think the Veterans Administration, which has really learned an awful lot about both post-traumatic stress disorder and concussive brain injury and with whom we're partnered very closely, would probably have the best handle on that. I do know, just as we learned at Fort Carson with the study, that when that's compounded by alcohol, other drugs, family discord, that then leads to social disillusion. I think it compounds this astronomically, probably exponentially.
... [Is it acknowledged] that there was significant understaffing at Fort Carson and that more soldiers fell through the cracks than should have?
I think there's an acknowledgement that a comprehensive behavioral plan which emerged from the deployment experiences of these soldiers was a problem at the beginning of the war and has gotten much, much better since we've infused additional staff, since we've built coherence around the program, because it's not just a matter of more people to see soldiers and families, it's also how well coordinated the services are. And that includes coordination with the care that's going on outside and off post.
What we're finding -- and Carson is not alone, and Colorado Springs is not alone in this -- is that coordination with the mental health providers and assets that are out there in the community is just as important as coordination internally. And let me just mention, because it brings another level of complexity, we want to do everything we can to encourage soldiers and families to seek care, even if that is done confidentially or without our oversight and knowledge. ...
But do you think early on in the war, in Fort Carson at least, the fact that there was understaffing, there wasn't this sort of continuity?
Yeah, I think it was a problem, and Fort Carson's not alone in that.
A problem that led to undertreatment of a number of folks.