The overall picture:
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.
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).