No, that is why I used the term "sufficient condition." It is certainly not a necessary condition.

This means that something -- alcohol abuse -- might explain the outburst of violence by a soldier in an isolated part of Afghanistan. I've offered revenge as a possible motive, but that alone might not change an angry soldier into a murderous soldier. What alcohol does is remove inhibitions. It is disputable whether it reveals what was already there or simply enables a whole different personality.

It would be very interesting to know if a physician were on Bales' base or came to the base after he turned himself in. Medical observation might illuminate a great deal of this tragic case.
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Is it possible to translate dollars spent to purchase mefloquine into doses purchased?

Army Times Nov. 19, 2011 Army limiting use of anti-malaria drug by Thomas Watkins (Associated Press) quotes Dr. Remington Nevin, an epidemiologist and Army major who has done research on mefloquine.

Navy Cmdr. Bill Manofsky compared his criticism of mefloquine, which he believes caused him permanent damage, to screaming into a hurricane. Veterans and veterans' groups have been screaming for two decades.

Lariam is bought by the government through the medical supply system. It can track were every tablet was issued to an authorized medical outlet. The outlet will have prescriptions to show who received the meds. Prescriptions are normally destroyed after 5 years.

It is a closed system. The Govt can track basically where every tab went with a quick computer audit.

According to the article, the $1.8 million translated into about 10,000 yearlong courses. That would be, I assume, about 520,000 individual pills, which would amount to abut $3/pill. I don't know the civilian price, but it doesn't seem unreasonable at first glance.

As far as the overall medical issues go, let's do this: I'm going to go take a nice long hike and de-stress some more. When I get back, I'll write a fairly detailed post that covers the basics of the medical situation, particularly as it relates to primary care and preventative medicine. That should explain why I find the idea of medics administering Lariam without physician approval to border on the ludicrous.

Thanks. That would be helpful.

I also find the that medics dispensing Larium without a physician's oversight not in the cards. It is a prescription drug. About the only prescription drug a medic has in his aid bag are iv's and morphine (for obvious reasons).

Way back in the days of Usenet user groups there were veterans claiming that they had been given Lariam but that their medical records did not show this. This 2004 article is from UPI and was reprinted in Military Times; it may be by the same suspect authors. It makes essentially the same claims of inadequate medical records.


This 1997 site at Indiana University may be of interest.

This has mattered to some veterans for several decades.

I figure I'll hit this first, then do the longer explanatory post.

I have no doubt that there are significant risks associated with mefloquine. I don't think anyone has any doubt about that. The question is how extensive the risks are, particularly when compared with the risk from malaria, and the risks associated with other antimalarials.

Remember, the law of large numbers is involved here. If mefloquine caries a 1 in 10,000 risk of significant adverse side effects, we can expect that there are (at least) dozens of soldiers who have wound up with adverse reactions over the past two decades simply based on the numbers involved. Most of these people are otherwise healthy, young, and not traveling to destinations of their own choosing. I do not want to understate in any way the scale of the individual tragedy involved in any of these cases.

I also don't want to understate the problems caused by inadequate, sloppy, or downright negligent medical care. Again, it's a statistical certainty that there's been some of that involved - lots of doctors treating lots of patients over lots of time. There's no way that major mistakes have been completely avoided.

In my mind, the big questions here do not involve whether these bad things happen. They do. But are they happening far more than we would expect, are the steps being taken to reduce or prevent them insufficient, and what more can and should be done.

The overall picture:
The Army's medical system is enormous. There are a couple of dozen inpatient treatment facilities, most of which have one or more residency programs. There are a couple of dozen more clinics - each of which is basically a hospital minus the inpatient beds (in other words they have primary care and multiple specialty clinics under the same roof). There are a half dozen or so research institutes, a bunch of training programs, and the army, navy, and air force share a full-fledged medical school. The overall annual budget is in the vicinity of $10 billion, and that doesn't include the medical units that are "owned" by the combatant commands instead of being directly run by the medical department. The Army Surgeon General (the current one is actually a nurse) oversees this health care system.

I mention all of this because I think the sense of scale is important. When we are talking about an organization of this size and complexity, mistakes are going to happen, bureaucratic inertia is going to come into play, and so on. That does not excuse those things when they do happen, but I think it does make it important to try to figure out how much of any particular problem is related to individual errors and how much is systemic shortcomings - and, of course, what steps are being taken to minimize both to the greatest extent possible.

The overall picture can be broken into three basic divisions - research, clinical care, and operational medicine. The first two are more or less self-explanatory (and we won't be dealing with research). The third is less so. Operational medicine, in a nutshell, refers to the medical support given to the individual combatant units. Generally speaking, every battalion sized unit or larger has a slot for a unit physician. These physicians are called "surgeons" for reasons of tradition, but most are not actually trained in surgery. They're more likely to be primary care or emergency medicine trained. A battalion has a battalion surgeon; a brigade has a brigade surgeon; and so on. These doctors are expected to provide care to the soldiers in the unit and advice to the unit commander.

Pre-deployment clinical care:
All (or virtually all) of the permanent bases have some sort of medical treatment facility - a clinic, hospital, or medical center. Some of the staff will be assigned to the treatment facility full-time. Some will be dual-hatted as unit physicians and as part of the treatment facility staff. (For example, a doctor might be both the head of aviation medicine at the clinic and the brigade surgeon for the local aviation brigade.) Every soldier will have a primary care manager (a doctor, nurse practitioner, or PA) assigned. The PCM takes care of the primary care stuff, coordinates specialist care as needed, etc. Continuity of care is taken seriously. It's expected that a patient will see their own PCM or another provider on the same team 90% or more of the time, including acute care visits. The statistics are monitored, and if a particular clinic is not meeting that goal, questions will be asked. These permanent treatment facilities are JCAHO-accredited, and subject to both JCAHO and military inspection.

When a deployment is on the horizon, every soldier is assessed for their medical fitness to deploy. If the soldier does not meet the basic standards, decisions have to be made. They may be transferred, they may be medically boarded to determine if they need to be retrained for a different military specialty, or (depending on the specific condition) a waiver may be granted and they may deploy anyway. The decisions are made on an individual basis, and the soldier involved may have some input on the decision, but the unit surgeon and unit commander will have a lot of input on the decision to seek a waiver. (In other words, a soldier might want to stay home, but the commander might decide they are needed downrange and have the waiver process started.) Decisions about malaria treatment are made prior to deployment, since the medications need to be started prior to departure.

Downrange:
I'm going to use MASH analogies here. They're not perfect, but they are familiar to most of us.

There are both clinical and operational medical resources deployed in theatre.

On the clinical side, there are combat support hospitals and forward surgical teams. These are purely medical units that exist to treat illnesses and injuries. In MASH terms, these are the equivalent of Tokyo General, the Evac Hospital in Seoul, and (of course) the MASH units themselves. The staff assigned to these units treat and/or stabilize patients and determine whether they should be returned to their units or evacuated to Germany or the USA. They also have resources - specialists, lab facilities, etc - to assist the medical personnel on the operational medicine side of the house.

On the operational side, things are more complicated. MASH-watchers are familiar with battalion aid, which is where the battalion surgeon works, and with Dr. Sydney Freedman, who was identified as the divisional psychiatrist. There's a lot more to it than that.

An army battalion has (depending on the type of battalion) anywhere from 300-1200 soldiers assigned. Each deploying battalion should have 1 physician, 1 PA, and a number of medics. The battalion surgeon is responsible for the battalion aid station, provides (along with the PA) primary care to the soldiers in the battalion, has some oversight responsibility for the medics, and is the staff officer responsible for advising the battalion commander on medical issues. An army brigade is made up of 3-6 battalions. In addition to the medical staff at the battalion level, the brigade also has a brigade surgeon, brigade PA, and medics. In addition to that, one of the battalions in the brigade is a support battalion that has a medical company with ambulances, pharmacy resources, some lab resources, maybe some radiology support, a physical therapy tech or two, preventative medicine techs, etc.

There are additional operational medical resources at higher levels - for example, all divisions (and some brigades) have a behavioral health officer assigned - but we don't need to be as concerned with those at this point. The key thing is that all these medical resources are in addition to and separate from the deployed hospitals and full-scale treatment facilities.

As I alluded to earlier, the quality level of battalion surgeons can vary quite a bit. All of them have medical licenses, but not all of them are specialty-trained. They also are usually relatively inexperienced (most are 2-6 years out of medical school). Quite a few are doing their payback time for their scholarships, and intend to get out of the military as soon as possible. I suspect, for example, that Connie Rhodes was not the world's most enthusiastic battalion surgeon when she deployed after firing Orly. Terry Lakin, on the other hand, was by all reports an outstanding battalion surgeon during his 2004-2005 Afghanistan deployment. (I should probably note that Lakin was on flight status, and therefore would not have been taking mefloquine.) Many of the PAs, on the other hand, are former enlisted medics who have gone to PA school while on active duty.

The brigade surgeons are generally speaking more experienced than the battalion surgeons. In addition to their brigade staff responsibilities, they provide medical oversight to the battalion surgeons.

All this and mefloquine:
Here's how all of this impacts the "medics are giving out mefloquine without the knowledge of the doctors" hypothesis:

For this to happen, a medic would need to get mefloquine. As SueDB pointed out - and he has extensive experience with this part of military health care - this would require the medic to obtain the mefloquine without the necessary prescriptions, and would require bypassing the pharmacy accountability systems. The medic would then need to distribute the mefloquine without attracting the attention of the battalion or brigade surgeons or PAs - not to mention the company commanders, who will typically have attended many staff meetings where the battalion surgeon was present, and will have some idea about what is supposed to happen. Medics generally work at the company level, but there are usually only 2-6 companies in a battalion.

Medical records issues:
There were clearly major issues in the past. Steps have been taken to minimize those. Computerization has helped a lot. There are probably still going to be some issues, and those are probably more likely to happen when troops are forward deployed, particularly to isolated bases. These mistakes should not be a major problem or intentional at this point. Efforts are made to check records on return from deployment, doctors in the military have the same duty to maintain records as civilian doctors, and doctors that fail to do so may both be subject to military discipline and to action by their civilian licensing authority (as Lakin recently learned).

Newest Army Project is to establish a medical record when the soldier is wounded that follows him/her all the way through to the hospital in the US - electronically. Also project to place med records on ID tag.

mikedunford's post is thorough and helpful. It is difficult for me to imagine managing such a large operation as the health care system of the military, much less managing the variety of records generated by that system. OTOH, the scale of the military itself dwarfs the health component, and I really cannot imagine how that system works.

I was under the impression that the possibility that Sgt. Bales used Lariam had been raised by his attorney. Although I may find something after more searching, that seems not to be the case. The suggestion seems first to have been made by Dr. Elspeth Cameron Ritchie in a March 20 article in the Battleland section of Time: Military Mental Health: Afghan Massacre: Potentially Toxic Exposures?. Dr. Ritchie is said to have been "the top advocate for mental health inside of the Office of the Army Surgeon General" before retiring after 24 years of service. This statement may have been the root of the suspicions about Lariam in Sgt. Bales' acts of terrible violence:

She did not limit the possibilities to Lariam; she raised the possibility of steroids, TBI, use of exotic and dangerous varieties of alcohol, and amphetamines, which she claimed are mailed to soldiers from home. She explicitly said that she has no idea if any of these substances were a factor in Sgt. Bales' actions.

At no point did she raise the possibility of a medic administering Lariam to Bales without a prescription. That was probably my conjecture after learning how little Lariam is now being prescribed in Afghanistan. However, she says that if she were on the medical board, she would raise questions about Bales' possible use of all of the above drugs.

A great deal of the contemporary and archived material about the use of Lariam in the military and its side effects for some people is by Mark Benjamin and/or Dan Olmsted, usually writing for UPI. They are taken as authorities on some of the many sites run by veterans about Gulf War syndrome and other illnesses. Were it not for the anti-vaccination campaign of both reporters, I might give them the possibility of being truth-tellers crying into the night. As it stands, I think they are probably sensationalists.

I understand why the military cannot say whether Sgt. Bales took Lariam, even though the odds are that he did not do so. I'm glad to see that the military takes seriously the privacy of soldiers' medical records.

Today's truthout article reveals a lot about the story spread by Benjamin: UPDATED: Why the Huffington Post Needs to Immediately Retract Mark Benjamin's Afghanistan Massacre Report by Jeffrey Kaye. An important fact in this article belies Benjamin's claim that the military issued an emergency order for an investigation of the use of Lariam in Afghanistan nine days after the massacre. The original order was issued on January 17, 2012, in a memo from Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson. What was issued on March 20 was a reminder that the results of the investigation were coming due. Several news media accepted the original Benjamin story, as did I, and I cannot find corrections on the Web (Benjamin did make changes to his article; e.g., he changed "emergency" to "urgent").

What it looks like we have here is a complex institution and one man's complex story. That story is naturally being over-simplified for the public, including by two people with suspect credibility. What I have been looking for is an explanation of why a man (with an admittedly somewhat spotty record) went off on a mission to kill children, women, and men, apparently in two separate missions. That still makes no sense to me. It would make no sense regarding any of the American veterans of the two recent wars that I have known.

Not to be a smart ass, but Toll - humans no matter how "civilized" still DO these things to each other. One man's freedom fighter is another man's terrorist/traitor.

As it has been and shall ever be. That is sad but true.

What Sgt. Bales did still does not make sense to me, even though such acts probably occurred well before Homo sapiens sapiens came along and have regularly occurred ever since. This is an extreme form of child abuse, among other things. What could drive a man to do that?

It is easier for me to understand the Japanese bombing Pearl Harbor than to understand Sgt. Bales' murders. Disproportionate revenge would make some sense in both cases.

Tollie: IMO I believe he was damaged before he enlisted. He fleeced investors, got into a scrape here and there without giving any thought to the consequences and suffering his victims or family would experience. And he escaped the brunt of the consequences by hiding in the army. Reminds me of a classic sociopath. Now he tries to claim an insanity defense. It took careful planning to leave camp unnoticed TWICE to repeat the deed. I'm sorry but I can't buy it.

He almost certainly has psychological issues and they're probably clinical. However, the nature of the offense makes it highly unlikely that an insanity defense will succeed. The offenses are also fairly unique in that they manage to hit almost all the aggravating factors that make an offense capital (which are quite similar to those in civilian capital cases).

Thanks Loh. That's truly interesting. I realize I have a grossly oversimplified opinion, but doesn't a true insanity defense utilize the idea the person didn't realize or was incapable of knowing he was committing a capital offense at the time? That way, murder couldn't be committed with premeditation? For a solitary soldier to leave a heavily guarded barracks unnoticed, not once but twice, would crush an insanity defense wouldn't it?

As the story of Robert Bales has trickled out, "our Bobbie" does seem to have been a damaged personality before he enlisted. In my first post on this, I expressed the hope that the UCMJ would not allow an insanity defense on this. I then went on to speculate about this being an act of revenge and the motive for that revenge.

He does sound like a classic sociopath, in which case I would simply give up trying to understand his behavior. I guess that I was looking around for something that would explain it, and the former Army psychiatrist offered some possible explanations. I agree that leaving camp twice runs against the explanations that she offered; this was not a spur-of-the-moment act induced by a psychiatric breakdown. It was two planned acts.

We have made some many errors in these wars and messed up or destroyed so many lives, on all sides, that I would like to see this all end now.

That is more or less the federal insanity defense, based on old English common law (the M'Naghten test). A more reasonable test is that by whatever mechanism, the mental illness rendered the defendant incapable to control the criminal conduct, that is, that the crime was a product of insanity. However, in the hysteria surrounding the Hinckley case, Congress decided to revert to the ancient rule. This rule is often called the "wild beast" rule, that is, the defendant is no more capable of reason than a wild beast. Such a defendant would be incapable of complex planning and would not tend to conceal the crime.

Bales may avoid the death penalty because either the prosecutor does not seek it or on something less than a full insanity defense, that is, a diminished capacity defense. Exactly how well competent and well planned the crimes were also factors into that. I think it is likely he has at least a partial defense, but juries are often reluctant to find even diminished capacity in particularly heinous crimes.

I'll note that even if Bales gets a death sentence, the likelihood of it being carried out is slim. The last person executed by the military was in 1961. That was for the rape and attempted murder of an 11 year old girl, a crime which would not now be death-eligible.

PBS News Hour April 2, 2012 Lawyer to Examine Bales' Medications at Time of Afghan Killings

The suspicion has shifted from Lariam to Ambien, with a side helping of alcohol involved.

The article states that "the Ambien defense" has been "ineffective" if the accused did not follow the instructions for taking the drug. It is treated then as more like voluntary intoxication.

Others warn of the dangers of alcohol in a combat zone while advocating that the military lift the current ban in which "Grown men are reduced to the status of underage teenagers when it comes to alcohol, and as a result, when they do get their hands on it, many drink the same way teenagers do: they go hog wild." Robert Bales and the Case for a Measured Approach to Alcohol in Combat

The problem with no alcohol in combat zones, is alcoholics or dry drunks. They go through a personality change that no one is prepared for, nor are there support services that emphasize this facet of deployments.

Military.com April 14, 2012 On advice of counsel, Staff Sgt. Robert Bales has refused to participate in a

Bales had asked to have his attorney present for the examination and to have a neuropsychologist on the board.

NYTimes has a post about a pair of brothers who returned from war.




Go read the rest here:
http://www.nytimes.com/2012/04/15/opini ... me.html?hp

Now the wife says He Didn't Do It:
"Kari Bales, the wife of a U.S. Army staff sergeant charged with killing 16 villagers in Afghanistan in March, said on Monday she continues to believe her husband is innocent and that "I don't think that anyone really knows what happened"

But she also said she has not asked Robert Bales, her husband of seven years who is charged by the U.S. military with 16 counts of murder in the March 11 mass shooting, what happened on that day. "I just don't need to ask him. I know my husband and it's not a question I really need to ask. I know him," she told the "CBS This Morning" program"

"Innocent" he didn't kill the villagers, or "innocent" Sgt.Bales didn't know what he was doing when he shot them. Sounds like the wife can't accept the event ever happened.

I think we everyone have a tremendous capacity for denying reality and that it is a necessary survival mechanism. We will go to great lengths to deny unbearable truths. How can she accept that the father of her children did such a horrible thing?

She lives in a house on the river Denial next to Mrs. Sandusky.