Q&A: Pete Geren
Written by Ted McKenna
Helping the U.S. Army Achieve Its Health
Care Goals, in Treatment and Prevention
Secretary of the Army
As secretary of the Army, Geren has statutory responsibility for all matters relating to the U.S. Army: manpower, personnel, reserve affairs, installations, environmental issues, weapons systems and equipment acquisition, communications, and financial management.
Geren is responsible for the Department of the Army’s annual budget and supplemental of $170 billion. He leads a work force of over 1 million active duty Army National Guard and Army Reserve soldiers; 230,000 Department of the Army civilian employees; and 280,000 contracted service personnel. He has stewardship over 15 million acres of land.
Geren had been serving as the 28th under secretary of the Army, a post he held since February 21, 2006; Geren was named as the acting secretary of the Army March 9, 2007.
Geren joined the Department of Defense in September 2001 as special assistant to the secretary of defense, with responsibility for interagency initiatives, legislative affairs and special projects. Geren served as acting secretary of the Air Force from July to November 2005.
Prior to joining DoD, Geren was an attorney and businessman in Fort Worth, Texas. From 1989 until his retirement in 1997, Geren was a member of the U.S. Congress, representing the 12th Congressional District of Texas for four terms. He served on the Armed Services, Science and Technology, and the Public Works and Transportation committees during his tenure in the Congress.
Geren attended Georgia Tech from 1970-73 (no degree) and received his bachelor’s from the University of Texas in 1974 and his J.D. from University of Texas Law School in 1978.
Geren was interviewed by MMT Editor Ted McKenna.
Q: What are some of the challenges in running a medical system like the Army’s?
A: It’s huge relative to other health care systems. The Army and the VA are the two largest health care systems in the country.
Q: I can imagine being so spread out geographically creates logistical issues.
A: They’re huge—they’re spread out demographically, and they have a population that moves a lot. You have soldiers that are transferred from post to post to post, so that’s a much more mobile population than the population in general. When you think, too, about the medical responsibilities that the Army takes on, it’s everything from providing medical care in some remote cave in Afghanistan to providing traditional medical care to Army medical care to families here at home—delivering babies, giving mammograms and treating other types of diseases and providing what most Americans consider to be just traditional medical services.
When we look at the challenges that come with delivering health care in all those different situations and places and environments, we deliver it differently in every one of those places. Think about the soldier out in the middle of nowhere in combat. The first medical provider for a wounded soldier is his battle buddy. All of our soldiers are trained in combat lifesaver skills, to be able to stop the bleeding, apply tourniquets, start IVs. In fact, I was at Walter Reed [recently], talking to a soldier who had lost one leg and likely will end up losing another. One of his fellow soldiers walked up, and he said, “This is the guy that saved my life. He pulled me out of the truck, put the tourniquet on my leg, and he was able to stanch the bleeding on the other. Otherwise I would have bled to death.”
So the first line of delivery of medical care in the Army is a welltrained fellow soldier, and that has really increased our survival rate, because everybody in a unit knows how to provide the basic medical care to either stop the bleeding or unblock a blocked breathing passage, and knows how to deal with many of the wounds that are the most common in combat.
Q: That would be a challenge to know how to best provide training for that.
A: It is, and we continue to upgrade it. We just continue to improve the skill level of the soldiers, their ability to take care of themselves and each other. One of the innovations in taking care of yourself is a one-handed tourniquet. It sounds like a simple thing, but if you’re by yourself and you have a major wound in one of your arms, a twohanded tourniquet doesn’t help you much. So that’s been one of the innovations; just a little simple innovation but a lifesaver. We try to push as much knowledge as far forward as we can.
Then you have the medics, who obviously wouldn’t be as close by as your battle buddy, but medics are deployed forward as well. Our medics are either EMT or paramedic certified—they have the same kind of skill level you’d have in an ambulance that was responding to an emergency in a major urban area. The medics can put in chest tubes, intubate, splint bone fractures and know what to do to protect a wounded or injured soldier from additional injury.
So in the most remote places in the world, we’re delivering fairly sophisticated medical care on site. Then bringing the soldier on back, obviously the medevac is a very important part of the equation. That’s an area, too, where we work hard to have the right type of equipment and the right type of training to be able to start providing lifesaving medical care for the transportation back to the combat support hospitals. That is really trauma center level care—very close to the battlefield. Then from there you move more into the area most Americans traditionally expect at a hospital. You go to a tertiary care center. The soldiers I was talking to [recently], they went from combat to the combat support hospital to Landstuhl, which is a tertiary care center in Germany, and then in this case back to Walter Reed. Once you get to Walter Reed, the number of trauma patients we treat probably distinguishes us from many hospitals, but you’re starting to get to the traditional challenges of providing medical care in a regular hospital setting.
Another challenge we have is meeting the needs of some of the wounds that are not unique to war but more commonplace in war. We have a high number of blast injuries coming out of this war—traumatic brain injury that results from that, mostly concussions—and a large number of amputations. With the field medicine we have and the body armor we have, we have soldiers surviving wounds that they would not have survived previously. The battle armor protects their trunk and their core, and we have many amputations. At Walter Reed you can see the dramatic progress that we’re making in prosthetics, not only in developing them but in working with industry to develop the best rehab products.
Q: That gets into the long-term care for wounded soldiers, the ones that might not have previously survived these kinds of injuries.
A: Right. So our unique health care system goes literally from the most remote battlefields in the world to tertiary care hospitals that compare with the finest anywhere.
Q: Is it your general sense that the system is as efficient and effective as can be, considering all the logistics and training involved?
A: We always strive to get better. We’re never going to be satisfied. But look at our tertiary care centers, for example, that you could compare to the civilian medical system. Our medical command follows nine measures related to disease management and preventive medicine, and with four of these measures, we outperform 90 percent of America’s health plans. Our goal is to reach the top 10 percent of health plans in all nine measures. So we certainly rank among the best, and in certain areas we are the best, and we also generate a great deal of research and innovation that accrues to the benefit of the rest of the medical community, particularly in the area of trauma care.
Q: People associate health care with lots of paperwork. Electronic health records seem like a good way to deal with that, particularly given how much people in the Army move, as you were saying. How goes the Army’s effort to get into electronic health records?
A: I’m sure you’ve seen the emphasis that President Obama has placed on electronic health records. We are moving in the right direction there; we’re not where we want to be. But electronic health records are key when you have a mobile population such as we have, and we are becoming more and more successful in using electronic health records to move with the patient, not only post to post or city to city, but as you move from health care providers within specialties within our own systems. That’s an area that we have a great emphasis on and are making a significant investment in. But we’re also working with the VA. In fact, Secretary Gates and General Shinseki are co-chairing a partnership effort in the Pentagon to greatly improve the transparency of the move from the Department of Defense to Veterans Affairs. In some places we’ve got a great partnership, a great working relationship, and in some areas it’s [not as] good.
At Eisenhower [Army Medical Center, at Fort Gordon, Ga.], we’ve got a great partnership with the VA. We do at Madigan [Army Medical Center, at Fort Lewis, Wash.] and at Tripler [Army Medical Center] in Hawaii. So there are certain areas where we’ve got a very good communication. But we recognize that this is a critically important area, and Dr. Gates’ and General Shinseki’s vision is that from the moment you join the Army you’ll have a health record that will follow you until your last days. As you transition from the Army to the VA and then go on into civilian life and move into the autumn years of your life, you’ll have a health record that will be complete and follow you wherever you go.
Q: It’s not an easy problem to solve.
A: It’s a huge technical challenge. The sheer scale of it is daunting. But the commitment is there, and with the president strongly supporting it and Dr. Gates and General Shinseki personally leading the way, I’m confident this is an area where you’ll see significant progress over the coming years.
Q: Are there other priorities for improvement in the medical system that you’d point to?
A: There’s patient care. You’re familiar with what happened with us at Walter Reed back in late 2006 and early 2007. What we learned there was that we were not properly organized to meet the needs of our outpatient population.
Q: And that’s something that’s still being redressed?
A: It is. There were a number of issues that contributed to it. The excellence that we had come to expect in our tertiary care systems, we were not delivering in the outpatient area. In response to that, we’ve developed a completely new system focused on our outpatient population— our warrior transition units [WTUs], which you’re probably familiar with. We’ve got 36 of those now; we’re actually going to reduce that to 32 in the fall, in September or October. But that’s an innovative model where every soldier in the WTU is assigned to a primary care manager—a physician, a physician’s assistant or a nurse practitioner— plus a nurse case manager and a squad leader. So you have somebody in charge of their medical care, the nurse case manager that reaches across all the different needs and domains that are important to help that soldier heal, and a squad leader that helps the soldier maintain his life in the military.
Our goal of this is to meet the needs of the whole person, not only the medical needs and the rehab needs. We are committed to helping the soldier heal and at the same time develop life skills—coping skills or professional skills, to continue serving in the Army or to transition to the VA and civilian life.
Q: I can imagine it’s difficult making the transition to the civilian world sometimes, and if you have major injuries it would be even more difficult.
A: It is. It’s also a challenge for us, frankly, to properly meet the needs of this population. We didn’t have this type of a structure, this type of organization, and the training personnel, these squad leaders and the other cadre that all work in support of the patients in the WTUs; this was a new skill set for us. We’ve brought back people from the battlefield, people who have suffered serious wounds, injuries or illness to work as cadre there. But they are used to leading able-bodied men and women that don’t have these types of injuries, and getting this cadre of people to lead in this environment has been a challenge. But I think we’ve made great progress. We offer incentives to bring the best of our NCOs into these areas of responsibility and continue to hone this system so that it works for the patients. I know personally in what I do, and what [Chief of Staff] General George Casey and [Vice Chief of Staff Lieutenant] General Pete Chiarelli do, we travel all across the system and go to the WTUs. I tell the patients, “You got two jobs. One is to heal, and one is to help build this new system, because we didn’t have it before and you’re helping us make the system work, not just for you but for those that will come after you.”
So we’re constantly tweaking and fine tuning this system so that the soldier, while he or she is there, gets well but at the same time continues to advance professionally, continues to develop skills and talents that can either serve them in the Army or serve them in civilian life. And we also work with their families. That’s a big part of the program as well, making sure we have soldier families’ assistance centers at each of the WTUs. Many of these families must prepare to cope with the long-term needs of a soldier with a permanent medical condition of some sort.
Q: PTSD would certainly fall in that category, I would think. PTSD and suicide have been in the media a lot of late. Are you confident in the strategy the Army is taking to address these issues?
A: We won’t be satisfied as long as there’s a single suicide in the Army. We’ve seen our rate of suicide go up year over year for the last five years. This year we’re running ahead of where we were last year.
Q: What do you think is the cause of this? Is there a short answer to that?
A: I don’t think there is a short answer. In some cases, it’s people who have never deployed. Most people just assume that it’s the stress or rigors of combat, but our numbers break down fairly consistently—a third have never deployed, a third commit suicide while they are deployed, and a third have deployed but are not on deployment. One thing we have seen, though, is that soldiers who have deployed more tend to be more resilient and the rate of suicide is lower. One of the big steps we’ve made over the last year is that we have many parts of the Army working to address the suicide problem. It’s a high priority across the whole U.S. Army—with the chaplains, with the human resources command, with our medical command, with our psychiatrists, with our leaders of every sort. Everybody is working on this issue.
But we felt we could benefit from better coordination and more centralized leadership, so that we all learn from the many different efforts. We put Pete Chiarelli, the vice chief of staff of the Army, in charge of the suicide prevention efforts. To use an Army term, we’ve got a belly button when it comes to suicide prevention efforts. It’s a four-star general who literally has a reach across the entire Army. I feel that we’re starting to make progress in taking advantage of all these disparate bodies of knowledge that have been generated by all the many groups that are working to address this problem.
Q: It’s not as if there is a medical device you wave around to solve the problem. Is it fair to sum up the Army strategy as focusing on psychological counseling and making sure you do enough outreach that people know it’s OK to go for help and not feel stigmatized about it?
A: I’d say three things. One, you mentioned stigma. There is no doubt that the perception of stigma is a barrier to care. That’s true in the Army and it’s true in the private sector. Probably more true in the Army because of the premium on self-reliance. But we’re working very aggressively to try to reduce the stigma, and we’re doing this through different types of outreach programs. An advantage in the Army is we can make people attend things. You can’t do that on the outside. We have chain teach programs that are required for literally every soldier in the Army—active duty, Guard and Reserve. We’re requiring them to participate on a program on PTSD, which helps people identify the symptoms in themselves and others. Last February we had a stand-down across the entire Army and everyone had to participate in an interactive video training session called “Beyond the Front.” Then we have another chain teach program across the whole Army that we’re in the middle of now. We have the advantage of being able to reach everybody, and we’re working to do that.
Part of the benefit of that is it helps reduce the stigma because we just lay it right on the table—“Help us work to see what you can do to help yourself and others”—and just be very frank about dealing with the challenges of mental health issues. So reducing stigma is a big part of our effort.
The second is just overall building resiliency. We’ve got a program up at the University of Pennsylvania where we’re partnering with them and looking at different ways to build resiliency. But the Army is good at building resiliency. We’re trying to learn what we can do in that area that works the best, and help people not only be physically resilient, but emotionally and mentally resilient. So it’s a very comprehensive undertaking that involves our psychiatrists, our psychologists, chaplains, all of our leaders.
The third thing is to just get everybody engaged in addressing this. Any soldier in the Army can spot the symptoms of an onset of heat stroke and knows what to do about it. Our goal is to have every soldier in the Army to be sensitized to identify the warning signs of suicide and know what to do about it, and also feel duty bound to do something about it. We’ve got programs that train them to spot the symptoms and train them in how to intervene. Then we’re also working to try to get more soldiers to get not only mental health counseling but substance abuse counseling.
Q: I was reading that abuse of prescription medicine is a big problem in the Army right now.
A: Prescriptions, alcohol and illegal drugs as well. We’ve started a pilot program that allows confidential reporting. We’re doing that at three installations right now. There are some challenges associated with it, and we’re still working through the rules and the implementation of it. That’s a major change in the culture of the Army, that if you’ve got a substance abuse problem, some sort of dependency, we’re going to provide you the opportunity to seek counseling confidentially, and we are doing that at Fort Richardson in Alaska, Schofield Baracks in Hawaii and Fort Lewis in Washington.
Q: So it’s seeking counseling without getting in trouble, basically.
A: You’d be able to go to the substance abuse counselors, and unlike in the past when that would have been reported to your commanding officer, you’re able to do it confidentially. There are some that don’t support the initiative. In order to identify and address ahead of time the concerns before we expand it more broadly, we’ve put it at these three installations with heavy deployment burdens. We’re trying to figure out ways to encourage more soldiers to seek help.
Q: Our magazine also covers CBRN issues, so I wanted to get your take on how well you feel the Army has prepared for all the sorts of chemical, biological, radiological and nuclear threats out there.
A: It is an area that is a strong emphasis in the Army. We’re partners with some of the other services and other departments of government in the effort to address the threat of nuclear, chemical and biological agents. We have laboratories at Aberdeen Providing Ground and Fort Detrick, where we have the Army Medical Research Institute of Infectious Diseases. We study the defenses against chemical and biological attacks up there. For example, we’re working on a new anthrax vaccine now, something that works better for the patients—fewer shots and fewer side effects. We’re also part of the National Interagency Biodefense Campus at Fort Detrick, Md., where we’ll be working with the Department of Homeland Security, the National Institutes of Health and the Department of Health and Human Services on research to develop medical countermeasures against biological threats.
Q: That seems like a smart direction, to collaborate as much as possible. Science seems to work best when people work together and share information.
A: I think so. There’s nobody that has a corner on the market on knowledge in this area. You think about, too, how the Department of Homeland Security would see their mission a little differently than the Department of Defense and something that might work well against a chemical, biological or nuclear threat in a continental United States setting might not be effective in a different environment in a different country. So they work together to develop common responses, but then they’re able to address the individual needs that come with their mission.
Regarding nuclear threats, we provide staff to the Armed Forces Radiobiology Institute in Bethesda, [Md.,] and they’re one of the few labs in the world that does that type of research. For chemical, we have the U.S. Army Medical Research Institute for Chemical Defense at Edgewood Area, also close by Aberdeen Proving Grounds, and they’re working on better defenses against nerve and blister agents, and run a world-recognized training course for both civilian and military responders. In fact, in some of our training at installations around the country, we work with fire departments and other first responders to train them and help them to develop and export skills to the civilian sector that we develop inside the Army.
Q: Any final point you’d make or advice you’d offer to the new nominee who will take over for you as Army secretary?
A: I know [Rep. John McHugh, R-N.Y.] well. He brings great experience and demonstrated commitment to soldiers and Army families. He’s worked a great deal in the soldier and family support area in his time in Congress. You always have to be careful—you don’t want to presume that the Senate will confirm anybody. But I have every expectation and hope that he will be confirmed and that when he is, that the experience he has with his leadership in Congress and with these human resource types of areas, I think he will continue to help us advance the body of knowledge and the level of care in the Army.
Q: It’s interesting that medicine might seem to be all about technology and techniques, but then human resources is such an important aspect to it.
A: Absolutely. This is digressing from that a bit, but a strong area of emphasis in the Army, and also partly because we’re able to get people to do things whether they want to or not, is prevention and regular physicals and different types of medical care—medical, dental, vaccines, wellness. The Army has such a strong emphasis on living healthy lifestyles. So it’s a very comprehensive approach to wellness on the part of the soldiers and their families. I think you’d see that you actually have more patient visits per person in the Army than you see in the outside world, and it’s largely because of the emphasis on wellness and physical fitness and preventive care, and the types of tests that identify medical issues before they become serious. That’s a heavy emphasis in the Army, and we pride ourselves on that being a key part of our commitment to soldiers and their families, a commitment to their wellness. ♦