September 2007

VOL.80 NO.7 September 2007 $5.00

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Medicine in the Time of War

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CONTENTS Medicine in the Time of War September 2007 Volume 80, Number 7

Medicine in the Trenches of War

Monthly Columns

10 The Humanitarian Consequences of War Dahlia Wasfi, MD

4 On Your Behalf

11 Lending a Helping Hand Kantele Franko

7 President’s Message

12 Hurting and Healing in Gaza James S. Gordon, MD 14 Combat Medicine from Vietnam to Iraq Mike Cerre 16 Corpsmen in a Time of War Donald Barker, MD, and Shawn Nirdlinger

Stephen Follansbee, MD

9 Editorial

Mike Denney, MD, PhD

40 Hospital News

17 The UCSF Iraq Action Group Ashley Skabar Editorial and Advertising Offices

18 Doctors and Torture Robert Jay Lifton, MD

1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261

20 A Physician Holds Doctors Accountable Steve Heilig, MPH 21 Angels, Devils, and Heros Mike Denney, MD, PhD

Fax: 415.561.0833

Email: adenz@sfms.org Web: www.sfms.org/magazine Subscriptions: $45 per year; $5 per issue

Healing in the Aftermath of a Conflict 23 Walking Wounded: A Photo Essay Nathan Rapheld

Advertising information is available on our website, www.sfms.org/advertising, or can be sent upon request.

Printing:

27 Caring for Our Soldiers Shira Maguen, PhD

Sundance Press

29 Posttraumatic Stress Disorder Shira Maguen, PhD

Tuscon, AZ 85726-6605

P.O. Box 26605

30 Group Therapy at the V.A. Chad S. Peterson, LCSW 32 Couples Therapy for Veterans Keith Armstrong, LCSW 34 A Soldier’s Heart and Mind John A. Straznikas, MD 35 At Home without a Home Roberta Rosenthal, LCSW

To see San Francisco Medicine Magazine online, please visit our website:

www.sfms.org/magazine

43 For Hiroshima, the Healing Continues

San Francisco Medicine September 2007

www.sfms.org

ON YOUR BEHALF

September 2007 Volume 80, Number 7

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay

Notes From the Membership Department

Cover Photograph ©Getty Images 2007 Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman Editor Mike Denney Immediate Past-President Gordon L. Fung SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate

The Return of the SFMS Symphony Night!

Mark your calendars for Thursday, October 18! Enjoy a preconcert reception featuring hors d’oeuvres and beverages in the Davies Symphony Hall Green Room, followed by a dynamic and varied program of Liszt, Beethoven, and Prokofiev.

We have secured a block of tickets in the premier first tier, and tickets are $67 each, inclusive of the reception. Tickets are limited, so we must have your RSVP and payment no later than Tuesday, September 25.

To order tickets, or for more information, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Promoting Membership Just Got Easier!

We are pleased to announce that your physician peers can now join the San Francisco Medical Society online. Tell them to go to www.sfms.org and click “Join SFMS” on the top of the home page. It’s quick and easy, and new members get a 50 percent discount on their first year’s dues!

Remember: nonmembers are welcome at SFMS membership social/cultural events too. Attendance is a great way for them to get to know SFMS and its membership better.

Thank you to our members who have already referred their fellow physicians— physicians talking to physicians remains the strongest and best way for the Medical Society to grow its ranks and help shape the future of medicine.

All Medi-Cal Prescriptions Must Be Written on Tamper-Resistant Pads Effective October 1 A federal law that takes effect October 1, 2007, will require that all Medicaid prescriptions be written on tamper-resistant prescription pads. The new law, which was

San Francisco Medicine September 2007

buried in a supplemental Iraq war spending bill passed earlier this year, is designed to make it more difficult for patients to illegally obtain controlled substances. Federal budget estimates indicate it will save $510 million in Medicaid prescription fraud over a ten-year period.

California law currently requires the use of secure prescription pads for Schedule II to V drugs. This new law will require all physicians treating Medi-Cal and Healthy Families patients to use tamper-resistant pads for all outpatient prescription drugs, not just controlled substances. Phoned, faxed, or electronically transmitted prescriptions are not impacted by this new law.

CMA is very concerned that the short notice will lead to confusion among physicians and pharmacists, and negatively impact patient care and access to prescriptions.

CMA is also concerned that the additional hassle and cost involved will force physicians to leave the Medi-Cal program, where access to care is already a problem. The association is working on federal urgency legislation to reverse the law or at least make it consistent with current state law.

Physicians are reminded that CMA partner RxSecurity, www.rxsecurity.com/ cma.php, provides members with significant discounts on tamper-resistant prescription pads.

For more information, contact Elizabeth McNeil, (415) 882-3176 or emcneil@ cmanet.org.

Blue Shield Settlement Update Recently Blue Shield of California refused to settle a class-action lawsuit filed in 2003 that would have meant tens of millions of dollars to California physicians. This lawsuit alleged that Blue Shield’s payment practices defrauded physicians out of monies due for patient care. Blue Shield of California is one of the few Blue Shield companies out of nearly forty licensees in the nation that has refused to settle this case and pay doctors the money they are owed.

Even though Blue Shield of California www.sfms.org

chose not to participate in this settlement, all class members, including most California physicians, are eligible for one or more shares of the $130 million settlement. The class includes all physicians who billed any of the Blue Shield companies or their contracted intermediaries (capitated medical groups, IPAs, etc.) for services provided between May 22, 1999, and May 31, 2007.

The deadline to submit a claim is October 19. Physicians do not have to provide documentation for individual Blue Shield claims. To receive your share of the settlement, you need only calculate the aggregate payments received from the settling Blue Shield companies from 2004 to 2006. Claims submitted to Blue Shield of California should not be included in the calculations.

Because Blue Shield of California was unwilling to settle, most California physicians will only be entitled to one settlement share. Physicians who have treated a large number of out-of-state Blue Shield patients may be entitled to more.

Physicians with $5,000 or less in claims billed to the settling defendants are eligible for one pro rata share; those with $5,001 to $49,999 are entitled to five shares; and those with more than $50,000 will receive ten shares. The share value will be determined once all claims have been received.

For more information, contact CMA’s reimbursement helpline at (888) 401-5911 or e-mail gfonseca@cmanet.org.

CMA/UCSD Pain Management CME Program Available on DVD CMA and University of CaliforniaSan Diego have collaborated on a unique case-based CME program on DVD that physicians can use to receive their statemandated twelve hours of Category I CME in pain medicine and end-of-life care. The program, Pain Management: A Case-Based CME Program for Physicians, provides specific information on the most common pain syndromes.

The price, including CME testing and credits, is $150 for members and $200 for nonmembers. For more information, visit www.sfms.org

http://www.ab487.com.

2008 End-of-Life Care Practitioner Program Innovative certificate training features outstanding leaders such as Rachel Naomi Remen, MD; Frank Ostaseski; and others.

Six residential sessions in the San Francisco area will emphasize the psychosocial and spiritual dimensions of end-of-life care. For an application and more information, visit http://www.mettainstitute.org.

SFMS Delegation: Open for Policy Proposals SFMS’s delegation to the California Medical Association, with a strong track record of developing and advocating policy on a wide range of medical and public health issues, welcomes substantive ideas for new policy from any SFMS member. All relevant topics considered; please contact Steve Heilig at (415) 561-0850 extension 270 or heilig@sfms.org to discuss any potential areas of concern.

New Local Health Policy Discussion Paper Developed at the request of San Francisco Mayor Gavin Newsom, “Vision for a Healthy Francisco” was coauthored by former S.F. Health Director Sandra Hernandez, MD, and by SFMS staff member Steve Heilig, MPH. The proposals are not necessarily endorsed by Mayor Newsom’s reelection campaign, nor are they an endorsement of that campaign; but they are grist for discussion. The document may be viewed at http://actlocallysf.org/blog/ topic/2007/08/01/vision-for-a-healthy-sanfrancisco/.

SFMS Past-President to Receive Prestigious Award Edward Chow, MD, a former SFMS president, longtime S.F. Health Commissioner, and director of the Chinese Community Health Care Association, has just been selected to receive the California Medical Association Foundation’s Ethnic Physician Leadership Award. This annual award rec-

ognizes physicians who have been forerunners in addressing community healthcare needs and in mentoring other physicians.

The award will be presented at the CMA annual meeting in late October. Dr. Chow was nominated by the SFMS board of directors. For more information, visit www.calmedfoundation.org/whatnew/ AwardsPage2007b.aspx.

2007 SFMS Seminars!

Please contact Posi Lyon (plyon@sfms. org or (415) 561-0850 extension 260) to register for any of these seminars. Space is limited; advance registration is required.

October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training in handling phone calls and scheduling professionally and efficiently.

9:00 a.m.–12:30 p.m. (8:40 a.m. registration/ continental breakfast), $99 for SFMS/CMA members/$149 for nonmembers.

November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management.

9:00 a.m.–5:00 p.m. (8:40 a.m. registration/ continental breakfast), $250 for SFMS or CMA members/$225 for second attendee from same office/$325 for nonmembers.

Seminar: “Innovations in Palliative Care” October 3, 2007 6:30 p.m., UCSF Laurel Heights Cosponsored by the Sutter Health Institute for Research & Education and the SFMS. Featuring short presentations by palliative care experts from various local hospitals, plus dinner. Free.

For information, contact Steve Heilig at the SFMS at (415) 561-0850 extension 270 or heilig@sfms.org.

September 2007 San Francisco Medicine

Practicing Good Medicine Just Got More Rewarding

Announcing The Doctors Company’s 2007 member dividend.

Practicing good medicine has its rewards, but they don’t usually come in the form of a dividend from a medical malpractice insurance company. As a company owned and led by physicians, we take our commitment seriously: We relentlessly protect, defend, and reward our members.

We lead the industry with aggressive claims defense and with innovative patient safety tools and services that protect

our members, help them provide the highest quality care, and avoid claims. Our multi-year dividend plan is just one way we recognize and reward our members for their continued professional excellence and loyalty.

Beginning in July, members in California will receive a dividend credit between 5 and 7.5 percent as part of their policy renewal—proof that it pays to practice good medicine.

To fi nd out how we can help you make practicing medicine more rewarding, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293 or visit us online at www.thedoctors.com.

President’s Message Stephen Follansbee, MD

Medicine in the Time of War

A

s physicians, we frequently face the dilemma of dual loyalty.

Simply stated, dual loyalty refers to the conflict between our responsibility for the care and well-being of the individual patient and our nonclinical responsibility to another person, institution, or organization. How many of us have had to explain why we are late for dinner or must leave a social function early because of the needs of a patient? In these instances, the resolution of the conflict of dual loyalty is simple, although we may be unhappy to forgo the social obligation. Our medical ethics hold our responsibility to respond to the urgent medical needs of a patient in higher regard than our personal social obligations of the moment. We know this, and many of us try not to schedule many social events when we are on call, just to avoid this conflict.

The practice of medicine in a time of war brings the issue of dual loyalty to an important and much more far-reaching level.

How do we balance our responsibilities to our patients—to protect and advance their health, their well-being, and their confidentiality—with our responsibilities to the state? The state (in this case, the nation or a branch of the military or the Department of Homeland Security) may request that we use our medical knowledge, expertise, and training to aid their cause. There is no doubt that most military health care professionals provide important and excellent patientcentered care in time of war. That work is focused on achieving the traditional therapeutic outcomes for which we were trained, including better pain control, improved emotional well-being, and salvaging life and limb. There is no conflict of loyalty in carrying out these responsibilities.

However, we may also be asked to provide our expertise in nontherapeutic ways. We may be asked to help obtain information through means of severe interrogation that relies on our medical knowledge of the detainee, or administration of medications as part of interrogation. We may be asked, for a variety of reasons, to defer attention to the physical or emotional needs of detainees or enemy combatants. We may be asked to administer experimental medications or vaccines to our own personnel without informed consent. Any or all of these activities may be argued to be in the interest of our society or of a “greater good” in times of a “just war.”

The rationale offered is that, under these circumstances, military medical personnel have not established a doctor-patient relationwww.sfms.org

ship with the detainee or enemy soldier or even our own service personnel, and are simply functioning under these extraordinary circumstances as any other citizen called to war.

There are numerous examples over the centuries of medical personnel “crossing the line” in using their expertise in ways that have demonstrated more loyalty to the state than to the patient. The most glaring example in the twentieth century is undoubtedly the role of German physicians in experimentation on and participation in the murder of Jews, gypsies, the mentally retarded, and gay men and women in the Nazi concentration camps during the Second World War. However, more recent examples arise from the current “War on Terror,” which appears to be a war without end. I refer you to the 2005 article by Bloche and Marks in the New England Journal of Medicine. It is important to read the correspondence that followed. Are we ever truly “not physicians” and only “civilians” when we use our medical knowledge or training, particularly if our action causes pain, suffering, or loss of dignity or confidentiality, or if it abridges the human rights of another person? The question is put more clearly by M. H. Kottow in his 2006 article in the Journal of Medical Ethics, “Should Medical Ethics Justify Violence?”

Physicians have taken an important role in opposing the subversion of medical ethics to unethical, harmful ends. Physicians for Human Rights, a Nobel Prize–winning organization that has, for more than twenty years, been advocating for the advancement of health, dignity, and justice, has proposed guidelines for ethics in the time of conflict. Doctors without Borders, another Nobel Peace Prize recipient, has delivered health care around the world in times of famine, epidemic, and natural disaster since 1971. Moreover, the physicians and other health care personnel associated with Doctors without Borders continue to risk their own lives and well-being to enter areas of conflict or outright war and to offer medical treatment and support, all without political affiliation.

Physicians around the world show that they can and do heal in all situations. I suspect that, given the recent concerns over the actions of a few U.S. health care personnel, there are opportunities for organized medicine, including the California Medical Association and the American Medical Association, to take stronger positions opposing all nonhealing use of medical expertise and training by physicians that causes violence to another person.

September 2007 San Francisco Medicine

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Editorial Mike Denney, MD, PhD

What Ails Thee?

C

eltic legends about the Knights of the Round Table speak of a search for the “Grail,” an emblematic cup or bowl signifying wisdom, understanding, and love, a symbol that can heal the sick, relieve suffering, and offer spiritual grace. The first such tale is the story of Parsifal, who, as a youth, learned the art and science of knighthood. He learned well the skills of war, how to use his armamentarium of sword, lance, and shield to maintain order and to go to war against enemies of the kingdom. However, Parsifal did not learn well enough his final lesson in chivalry, which was always to be compassionate, to reach out to those who suffer.

When the youthful Parsifal first set out on his heroic adventures, he came across a run-down castle on a barren landscape. Inside he found the Fisher King, who was writhing in agony, suffering from a deep sword wound inflicted upon him in battle. In the castle, Parsifal actually got a glimpse of the Grail—but, distracted by his more warlike duties, he forgot to respond with compassion. With no apparent inclination to heal the king, he failed to ask even the simple question, “What ails thee?” Suddenly, the castle vanished in a great roar of thunder, and an ominous voice pronounced, “If you had asked the right questions, the king would have been healed and all the land would have been restored. Now you must wander in the wilderness for many years until you have learned compassion.”

In his book Beyond the Hero (Tarcher, 1995), San Francisco psychiatrist, scholar, and writer Allan Chinen, MD, observes that in its original version, written in the twelfth century by Chrétien de Troyes, the Parsifal story ended abruptly, right there. In an addendum, the poet promised that the story would be resolved in a sequel—which he apparently never wrote.

What was it about war that so distracted Parsifal from his compassion that he failed even to ask, “What ails thee?” In his soulsearching book, A Terrible Love of War (Penguin, 2005), renowned psychologist James Hillman states that because of its ubiquity and acceptability, war must be considered to be a “normal” part of human nature. Hillman points out that, “During the 5,600 years of recorded history, 14,600 wars have been recorded.” Millions upon millions of soldiers slaughtered on battlefields, 62 million civilians killed “collaterally” in the twentieth century alone, ethnic groups suffering genocide, populations living in fear of terrorist attacks, and through it all untold masses suffering unremitting physical and www.sfms.org

psychological wounds.

In this issue of San Francisco Medicine, we explore the theme of Medicine in the Time of War, and we notice that what is supposed to be “normal” for healers is the opposite of Hillman’s characterization of war—the ideal “normal” of medicine is not to kill but to heal all the sick indiscriminately, friend or foe, including those wounded in battles. Paradoxically, however, we cannot help but detect the malevolence of war subtly intruding upon the benevolence of healing. We speak of our “armamentarium” of medicine and surgery, the “fight” against cancer, an all-out “war” against disease, the “triumph” of vaccines, the “conquering” of the ravages of old age, and the “eradication” of smallpox and polio. We wince when we learn that, more ominously, some normal medical professionals actually engaged in research on prisoners of war, some normal physicians participated in the torture of captured soldiers, and a group of normal doctors recently planned and partially carried out terrorist attacks in England and Scotland.

What is it about war that so distracts some of us from compassion? Is the inherent “human nature” of war present in healers as well as warriors? Are we all sometimes like Parsifal, who was denied access to the Grail?

During the fifty years following the publication of the original, incomplete Parsifal legend, four poets wrote continuations of the story. In the final version, Parsifal, after wandering alone in the wilderness for years, returns to the old castle. Inside, the Fisher King still writhes in agony. This time, however, having suffered himself, Parsifal asks the loving, compassionate, and portentous question, “What ails thee?” The king is immediately healed, the castle is restored, the land blossoms anew, and Parsifal becomes the new king. Parsifal has gone “beyond the hero” to find the Grail that can heal the sick, relieve suffering, and offer spiritual grace.

And so it is that, as we ponder the art and science of medicine in the time of war, we might pause to consider our whole human nature, the healer and the warrior, so that we never fail to ask our patients, ourselves, and, indeed, humanity, “What ails thee?”

September 2007 San Francisco Medicine

Medicine in the time of war

The Humanitarian Consequences of War Dealing with Illness and Health Care in Iraq Dahlia Wasfi, MD

T

here is no respite for the Iraqi people from the suffering inflicted by war.

Destruction of Iraq’s electrical grids during the first Gulf War incapacitated the medical system—what had been a first-class range of facilities known as the “jewel of the Arab World.” After January 1991, primary health care and preventive services ceased to exist (CARE 2003), and with economic sanctions, there were critical shortages of food and lifesaving drugs and equipment (Garfield 1995).

Cholera became endemic in Iraq. Easily treatable diseases—such as respiratory infections and diarrhea—accounted for 70 percent of the deaths of children under the age of five (WHO 2003). By 1997, nearly one million Iraqi children, in a population of 26 million, were malnourished (UNICEF 1997). This calamity was the tragic state of Iraqi society when the invasion came—and with it, a vastly increased number of patients.

With the dissolution of law and order in March 2003 came the looting of Iraq’s hospitals, and a lack of security now delays the delivery of supplies. As one doctor explained, “Before the invasion, we had a much better supply situation—80 percent better than now” (Jamail 2005).

Epidural anesthesia for birthing labor or disc disease is simply not available. One of the main hospitals in Basrah could not perform operations for a week because they had no gauze. But at least that hospital was still standing. In Fallujah, 70 percent of the buildings—including hospitals—have been leveled by occupation bombing raids, and the remaining 30 percent have sustained damage.

The very nature of the situation in Iraq makes practicing medicine impossible. Am10

bulances are bombed, hospitals are often at the center of a battle zone, and chemical and biological weapons bring cancer to civilians and to soldiers (Hudson 1994).

“After January 1991, primary health care and preventive services ceased to exist, and with economic sanctions, there were critical shortages of food and lifesaving drugs and equipment.”

During the April 2004 siege of Fallujah, between 600 and 800 civilians were killed.

Then, in November 2004, the second major siege of Fallujah began (Lorimer 2004).

On November 6, the Nazzal Emergency Hospital was leveled; on November 8, the Fallujah General Hospital was seized by the U.S. military. Burhan Fasa’a—a cameraman with the Lebanese Broadcasting Company—reported, “There were snipers on top of the hospital … shooting everyone in sight.” The overall siege resulted in a death toll of 6,000 to 8,000 civilians. This means that the Iraqi death toll in Fallujah in November 2004 alone surpassed the entire Coalition’s death toll for all of Operation Enduring Freedom thus far.

As of October 2006, due to the desperate conditions in Iraq—no security, high crime, and targeted assassinations (Brussels Tribunal 2006)—an estimated 18,000 of Iraq’s 34,000 physicians have fled the country; 2,000 doctors and 164 nurses have been murdered; and another 250 medical

San Francisco Medicine September 2007

personnel have been kidnapped for high ransoms. It is further estimated that 68 percent of Iraqis lack access to safe drinking water, and 81 percent live in areas without sanitary sewage.

The segments of the population who suffer the most whenever there is no law and order are women and children. It is estimated that 270,000 children born since 2003 have had no immunizations. Due to the chaos, lack of security, and severe poverty, some 800,000 Iraqi children are not in school (Laurance 2006). According to the State of the World’s Mothers report released in May 2007 by Save the Children, the chance that an Iraqi child will live beyond age five has plummeted faster than anywhere else in the world since 1990. In 2005, one in eight Iraqi children died of disease or violence in the first five years of life.

Iraqi women have all but disappeared from their roles in the workforce. Once contributors to Iraqi society as teachers, judges, lawyers, doctors, engineers, traffic police, and more, the threats of violence and kidnapping now imprison many women in their homes. And even there they are not safe from the terrorism of daily house raids by U.S. soldiers and Iraqi police. As millions suffer, and hundreds continue to die every day, many Iraqis say that the lack of respect for their humanity makes their suffering under the last regime look like “the good old days.”

Since World War II, 90 percent of the casualties of war have been unarmed civilians—a third of them children (Emergency 2005). We must dare to speak out in support of the Iraqi people, who resist and endure the horrific circumstances of occupation.

We must dare to speak out in support of

Continued on Page 19... www.sfms.org

Medicine in the time of war

Lending a Helping Hand A San Francisco Physician Does His Part to Help Heal Afghanistan Kantele Franko

D

uring his last week of volunteering at a hospital in Kabul, Afghanistan, two of the youngest patients under Dr. Albert Chan’s care were newborn infants. They had similar rashes, but the first boy’s ailment was milder than that of the second, a five-day-old with a slowing heartbeat and shallow breathing who was near death and put on respiratory support.

The diagnosis was chicken pox—complicated by scarce resources, unstable security, and other effects of nearly two conflict-ridden decades since the SovietAfghan war.

“Ultimately, these babies suffer from a lack of primary care and infrastructure,” Chan said.

The UCSF pediatrician spent most of July working in the Afghan capital. He discovered firsthand that the aftermath of unrest causes more than medical problems for the country’s 29 million people, whose life expectancy is about 42 years.

A lack of clean water and sanitation, combined with an inconsistent education system and cultural taboos, makes preventive medicine all but a dream, Chan said.

The mountainous geography, a run-down transportation system, and widespread poverty prevent people from seeking medical help at the early signs of a disease, meaning even uncomplicated illnesses like chicken pox can get out of hand before they are treated.

When people do seek care, they face crowded facilities with shortages of medical supplies and doctors. There are 19 physicians for every 100,000 people in Afghanistan, compared with 256 in the United States and 198 in Mexico, according to World Health Organization data from 2000 and 2001, the most recent years available. www.sfms.org

Part of Chan’s job was training doctors in a recently developed residency program at the hospital, which is run by the Christian humanitarian agency CURE International.

“There are 19 physicians for every 100,000 people in Afghanistan, compared with 256 in the United States.”

At thirty-three, Chan was teaching his peers or those slightly younger, many of whom are aspiring doctors raised and educated in the shadow of conflict.

Beneath that shadow, their schooling and training have suffered, leaving a generation of young, intelligent doctors behind the medical curve, Chan said.

Security concerns, such as the threat of the Taliban in outlying areas, complicated things further. When Chan and his companions traveled outside Kabul for several days to an area once known for its tourism, they had to carefully plan a route back to avoid roads they knew to be unsafe.

Many of Chan’s Afghan colleagues had not been to their home provinces in years, and they don’t see many patients who are ethnically targeted by the Taliban, he said, because they try to stay hidden. Doctors Without Borders, a medical relief agency known for work in conflict areas, pulled out of Afghanistan in 2004, citing the slaying of five members and other security and policy concerns.

The lack of security darkens the country’s image in foreigners’ eyes, making most people disinclined to volunteer or work there, Chan said. He wants that picture put

into focus.

“I’m like, ‘Wait a second, people, there’s people with real lives there,’ “ he said.

David Dowall, director of the Institute of Urban and Regional Development, has garnered a similar perspective through his work across the border in Pakistan.

“When you’re on the ground, it’s not nearly as scary as it is when you’re reading about it in the Sunday paper,” said Dowall, quickly adding that security is still an important consideration and was a prime reason he turned down an offer to visit Afghanistan two years ago.

“The problems are really systemic,” said Dowall, who also teaches city and regional planning. “One person or one nongovernmental organization [is] going to do some good but not really get to the root of the problem.”

For Chan, the legacy of his summer stint abroad is as much about the evolution of the country’s health care system as saving the lives of newborns with chicken pox.

The real value of the trip is the trickle-down effect of passing on knowledge and new techniques and knowing that his trainees can train future doctors.

“I am not going to go in and [immediately] change things,” he said, “because Afghans have been making things work for them for years.”

This article originally appeared in the San Francisco Chronicle.

September 2007 San Francisco Medicine

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Medicine in the time of war

Hurting and Healing in Gaza Bringing Palestinian Physicians a New Method of Mind-Body Healing James S. Gordon, MD

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n Gaza at the beginning of this summer’s civil war between Hamas and Fatah, the Center for Mind-Body Medicine (CMBM)’s Palestinian trainees followed the firefights (the “clashes,” they all called them) as routinely as Americans attend to changes in weather or traffic patterns—but with a grim, sober sense of urgency. Knowing which faction was shooting at and killing whom, and where, was critical to their survival, as they traveled back and forth to our leadership training in Gaza City’s Commodore Hotel.

I first went to Gaza, which its inhabitants describe as “the world’s largest open-air prison,” five years ago. I wanted to see if the CMBM approach could be helpful in Gaza, as it has been in the U.S. for people with chronic illness, for medical school faculty and students, and for New York City firefighters post-9/11, and in Kosovo for people with populationwide psychological trauma.

In July 2005, we began to train ninety of Gaza’s most committed health and mental health professionals. We taught them the science that underlies our approach, which includes psychological self-care and selfexpression (through words, drawings, and movement), mind-body medicine (guided imagery, meditation, biofeedback, yoga), and small-group support. We helped them experience how this approach and these techniques could make a difference in their own lives as they dealt with the inevitable psychological trauma and ongoing stress of living in Gaza. (“We do not have posttraumatic stress disorder [PTSD],” more than one of our Palestinian colleagues informed me, with a smile. “We have ongoing and continuous traumatic stress disorder.”) Then we trained them to use our approach, in 12

small groups as well as individually and in classrooms, in a population that is exhausted from war and poverty, and psychologically as well as physically devastated.

“‘We do not have posttraumatic stress disorder,’ more than one of our Palestinian colleagues informed me, with a smile. ‘We have ongoing and continuous traumatic stress disorder.’”

Though we’ve traveled regularly to Israel, where we have a similar program, it had been eighteen months since we’d been in Gaza. Our Palestinian coordinator, Khalid (names of participants have been changed because this training is confidential and because becoming too visible is potentially dangerous in Gaza), and his colleagues hesitated each time we hoped to come. “Not now,” they said. “It’s too dangerous.” Early this spring, however, after the formation of the Palestinian Coalition Government and with only minor conflict with Israelis, Khalid said he felt “secure” about our coming back. It was the “safest” time. It turned out, much to his distress, that he was wrong about the safety. But it was absolutely the right time.

For the first time in my five years of visiting Gaza, we had to have protection.

Twenty-five heavily armed men from several of the government security forces and the police accompanied us from the Erez crossing to the hotel and lined the road at

San Francisco Medicine September 2007

popular, perhaps dangerous, crossroads. Half a dozen stood guard day and night during our training.

Each day, our five CMBM international faculty worked intensively with our leadership team, the thirty-seven clinicians who are the most active of our ninety original participants. Over the last eighteen months, they had collectively led more than 150 small groups, for eight to ten weeks each, and had taught our approach to thousands more traumatized children and adults in hospitals, clinics, homes, and classrooms for kids and university students. They had even, in the case of one trainee, taught a professor of psychology at Al Aqsa University, on a weekly “mind-body” radio show.

All thirty-seven of these trainees participated over the last eighteen months in weekly supervision groups, with a dozen of our most experienced and gifted Palestinian participants. And all the supervisors met every two weeks with Khalid. We have created, as one psychologist put it, “a network of expert practice and loving care.” Indeed, studies we did six months after we began our training showed continuing decreases in our trainees’ stress and anger, improvements in their mood, greater professional satisfaction, and more optimism about the future. “You have brought us hope,” they told us.

On the first day of this training, we began our small groups with a check-in.

“What’s been going on with you?” we ask our participants. “How are you doing right now?” The exercise promotes reflection and moment-to-moment awareness and enhances communication and connection among participants. Their responses revealed a delicate balance between enthusiasm for our training and the work they’d been doing and the increasing grimness www.sfms.org

of the situation. “I’m relieved to be here,” says Iman, a psychologist from Rafah in Gaza’s far south. “I’ve been using this approach with battered women and abused children—there are so many more of them these last months, during the conflict among ourselves—and they like it so much. But I had trouble preparing last night. The gunfire and the RPGs [rocket-propelled grenades] kept my children up and very disturbed.”

As the days go on, our Palestinian colleagues tell us about tragic times when they’ve invoked our work. After his brother was killed in a clash with Israel, Iman’s husband was “desperate” and wanted himself to become a “martyr”—a suicide bomber. “I sat for hours with him,” she told us, “and taught him ‘soft-belly breathing’ so he could relax.

We did some drawings to look at other possibilities than dying, to think about a future.”

When 17 civilians died in the shelling of the Beit Hanoun refugee camp, our trainees were there that day, assembling groups of family members, friends, and neighbors, providing opportunities to talk, teaching techniques for relaxation, offering ongoing human connection to survivors.

Noor, a nurse, tells us about a group she has formed of eight women, whose nursing infants are not gaining weight. At first, she says, the faces of the mothers and their babies were pinched and pallid. She taught them how to “breathe deeply into their soft bellies, as you taught us.” She invited them to share their present hardships and their fears for their own and their children’s futures. They drew pictures of their problems and, against initial incredulity, of solutions to them. “You can see the smiles grow with each week. The mothers relax and so do the babies,” Noor tells us. “They take to the breast and feed during the session and afterwards at home. I weighed them before we began and after each meeting and they’re all gaining weight again. And I used the Johns Hopkins scale to measure the mothers’ decreased anxiety and better mood.”

Over the last eighteen months, Ahmed, a psychiatrist, has led eight ten-week-long groups for patients and physicians in the psychiatric hospital where he works, and for older men with diabetes and hypertension in the neighborhood in which he lives. Now he has a new group, for children and parents www.sfms.org

whose seizures are caused not by abnormal brain activity but by sudden, traumatic loss and ongoing stress. “We shake and dance,” he says, “just as we did in our training, to begin each group. And they do it at home every morning to release tension, and every time they feel like they might have a seizure.

They are not all well, but they are all much better.”

In the breaks between sessions, our security guards line up in the lobby, sidearms at their waists, AK-47s over their shoulders, for impromptu individual consultations.

Most are in their early twenties and live at home. They have physical and emotional wounds, from firefights or prison time, that won’t heal: limps, chronic headaches, GI problems, painfully clenched jaws. Few sleep well. Many of the men have obvious tremors. “Every one of us,” an officer tells me, “is like this.”

On the third day of our training, we watch televised images of other security guards who have been killed at the Karni Crossing into Israel. “The Israelis did it,” someone shouts. “No, it was Hamas,” says a police commander who had just spoken with an official source.

The fracture lines from this pressure are everywhere visible and palpable, in the daily life and the reports of our trainees. In the weeks before we arrived, children had trouble concentrating in school. This week, because of the new fighting, they are unable to attend school at all. They wake at night, screaming at the sounds of gunfire and the muted thunder of the RPGs, peeing in their beds. They cling to parents who, they know all too well, can no longer can protect them or provide a predictable future.

Sometimes, especially recently, everyone feels overcome. “We’ve learned from you,” says Nadja, a psychologist, smiling a little sadly, “that exercise improves mood and decreases stress, but now we are afraid even to walk outside.” Ahmed, the psychiatrist, oscillates between grief for the enormity of the tragedy he sees each day (“I’ve treated four fathers who have killed their children”), rage at the indifference of the international community and the “blindness” of Palestinian leaders, and apocalyptic fantasy (“Perhaps a flood will come to wipe out all the old ugliness, as in the time of the

prophet Noah”).

On the last day of our workshops, with attacks on anyone in uniform and the death toll mounting, the streets are empty. As checkpoints manned by masked men proliferate and the fighting intensifies, several of our participants shave their beards, so as not to be mistaken for Hamas by Fatah forces. At morning check-in, half a dozen trainees report bullets and explosions coming perilously close the night before and on their way to the training. Blood covers the sidewalks.

On this last day, Iman begins by thanking the CMBM “for not forgetting.” She has created a ceremony with which we will close our small-group work. She tells us to put our hands on our shoulders and raise them, imagining we are lifting our burdens off us. Next, she shows us how to extend our arms upwards “to thank God for the life we have.” Then, she has us wave our hands over our heads, bringing them slowly down, rippling our fingers, to signify “rain washing away our pain and tears.” And indeed there are tears in many of our eyes.

Finally, as Iman leads, we dance to Arabic music, men and women together in a circle of celebration, of ourselves and our work, of bright and hopeful life in these dark times.

When we internationals leave Gaza, we do so without guards. Once protectors, they have now become targets. We wind our way, wide of checkpoints, in two inconspicuous cabs, back to the Erez Crossing.

James S. Gordon, MD, a psychiatrist, is the founder and director of the Center for Mind-Body Medicine in Washington, D.C., a professor at Georgetown Medical School, and former chair of the White House Commission on Complementary and Alternative Medicine Policy. Information about CMBM’s work overseas and its upcoming U.S. trainings is available on its website at www.cmbm.org.

September 2007 San Francisco Medicine

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Medicine in the time of war

Combat Medicine from Vietnam to Iraq An Embedded Reporter Reconnects Mike Cerre

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ears ago, as I was heading for Vietnam, a well-aimed shot of a Navy corpsman’s inoculation gun into my upper buttocks was a quick reminder of the axiom, “Military medicine is to medicine what military music is to music.” For my first three days in combat as a Marine officer, I walked with a not so inspiring hip-hop as the canteen suspended from my web belt kept impacting the fist-sized bruise he so skillfully imprinted on my posterior.

Over the course of my tour of duty in Vietnam in 1970 to 1971, and again with the Marines in Iraq as an embedded reporter for ABC News in 2003 to 2005, I discovered how much everything changes and at the same time nothing really changes in the military, especially as it relates to combat medicine.

Any marine of any generation will tell you endless stories of why the navy corpsmen and doctors assigned to the marines were some of the most capable, dedicated, and inspiring people they experienced in their careers. Regardless of their rank, they were universally referred to as “Doc” and commanded a level of respect that came with their legacy of being likely to be the first to get to a downed marine, no matter how deadly the situation. They were also the rare souls with whom a marine in a war zone would share how he really felt, physically and psychologically.

In training, we were always told that shock is one of the biggest killers on the battlefield, and that a serious casualty is always looking into the eyes of whoever is treating him to get the real prognosis on his condition. Somewhere along the training of a navy corpsmen, they still teach them how not to flinch, no matter how devastating the injury they are called on 14

to stabilize. They still know how to stop a sucking chest wound with one hand and rip open a compress with their teeth while nonchalantly asking to borrow the victim’s

“In training, we were always told that shock is one of the biggest killers on the battlefield, and that a serious casualty is always looking into the eyes of whoever is treating him to get the real prognosis on his condition.” favorite Rolling Stones tape cassette until he returns to duty. Substitute the Stones for Drowning Pool or 50 Cent, and I saw much the same routine carried out by corpsmen in Iraq, who would feverishly pull out all the medical and mental stops to make sure their marines wouldn’t “do something stupid like die on me” before the Medevac arrived.

Even more so than in Vietnam, time is one of the most critical arbiters in the life or death of casualties in combat. If a corpsman or an army medic can get their Iraq casualties on a helicopter alive, the chances of their dying are less than three percent, according to a New England Journal of Medicine report. The report goes on to illustrate how the increasing speed and mobility of evacuations has lowered the fatality rate among the wounded from 30 percent in World War II to 25 percent in Vietnam. Faster helicopters and more proximate field hospitals in Iraq have reduced the average Medevac to ten minutes (compared to an hour in Vietnam)

San Francisco Medicine September 2007

and the fatality rate to 9 percent.

Nothing has changed regarding a young marine’s false sense of immortality, and knowing they are on average only ten minutes from a hospital and thirty-six hours away from a major medical center in Europe or the U.S. emboldens them even more.

I remember discussing this on the flight over to the Middle East with a recent Stanford medical resident who was assigned to the same battalion as I. While the troops enjoyed a particularly violent in-flight movie, we were far more concerned and contemplative about the horrors we were likely to encounter in Iraq. He admitted that he was only given a four-week crash course in combat medicine, and that he was relying on his emergency room internship and his corpsmen to stabilize his causalities until they could get them to a surgical hospital.

He seemed to be banking on the element of time as much on as his own skills.

When the unit I was embedded with for its first two tours of duty was sent back for a third in March, the advance party was ambushed on the first day back in Iraq. One of the more seriously injured was Medevacked to a field hospital in minutes, underwent his first surgery at an Air Force hospital in Balad in an hour, and had his second surgery at a hospital in Landsthul, Germany, the next day. He was flown back to his home base hospital at Camp Pendleton, California, in time for the rest of the unit to pay him a visit on the night they were heading over to Iraq.

At any one time, the military has only thirty to fifty general and ten to fifteen orthopedic surgeons on duty in Iraq. The majority of the medical personnel I encountered in these facilities were from the reserve component, which reminded me of www.sfms.org

the reservist orthopedic surgeon from the University of Michigan’s medical school who treated me after I was Medevacked from Vietnam. The military still seems to rely on medical reservists more than on any other specialty in time of war. In a Nightline story about the activation of more than 70 percent of Vermont’s National Guard, the governor complained of losing a critical portion of his state’s first responders and EMTs with the call-ups.

While the medical profession seems most interested in surgical and technological advances that most grunts in the field hope they never have to see, the average marine is more interested in the new tools and training he’s received for saving his or his buddy’s life. The all-purpose sterile bandage, compress, and tourniquet we used in Vietnam has been replaced by ratchet-style tourniquets that can be loosened and tightened with one hand. Because we were never sure how long it would take to get a causality back to a hospital, we only used tourniquets as a last resort. The new bandages Army personnel carry are treated with chitosan, a compound made out crustacean shells that promotes blood clotting. Marines are using a powder called QuickClot that is suppose to do exactly what its name implies, simply by pouring it into a wound.

But it’s the nature of today’s wounds in Iraq that make the troops as vulnerable as ever to the crippling effects of war. The insurgency’s weapon of choice, the IED (improvised explosive device), has created an unprecedented rate of mangled extremities and fatal vascular injuries. Unlike the small, hand grenade-sized explosives the Vietcong used for their booby traps, IEDs get their explosive material from large artillery shells that can destroy lightly armored vehicles or level a building.

The Kevlar body armor used in Iraq is much better at stopping bullets and shrapnel than our flak jackets in Vietnam. But the explosive power of the IEDs can get under the vests and blast inward through the auxillary arm vents. As a result, the military continually has to modify them to provide better protection.

The fragmentation elements of nails, bolts, rock, dirt, and all matter of debris pepper a victim’s body, causing multiple www.sfms.org

points of bleeding that have to be contained simultaneously. They also severely increase the chances of serious infections. Iraq veterans being treated in stateside hospitals are responsible for “an epidemic of multidrug resistant Acinetobacter baumanii infection,” according to another report in the New England Journal of Medicine.

What struck me most while visiting a wounded marine in Walter Reed Hospital after my second embed was seeing the number of multiple amputees and those suffering from serious head and brain injuries. Not being a medical person and relying solely on my experiences with Medevacs in Vietnam, I’m fairly certain many of them would never have survived previous wars.

One of my embed colleagues, SSGT Merle Sigman, lost his right leg above the knee after taking a direct hit from an RPG, rocket-propelled grenade. Less than a month after his injury and before they could fit him for his prosthesis, he had already reconfigured his Harley Davidson motorcycle so he could ride again. While we visited, he was doing extensive upper body conditioning for his reenlistment physical exam. Eight months later, having adapted to his “C-leg,” a prosthesis with computer, he became the first above-the-knee amputee allowed to stay in the Marine Corps.

As critical as the reports on conditions at Walter Reed and other military hospitals are, they are still probably the best places to be if you have the types of injuries being sustained in Iraq. ABC News could have paid for and sent my colleague Bob Woodruff to any medical center in the world after the devastating brain injury he incurred while reporting in Iraq. They chose and reimbursed the military for his treatment at the Naval Medical Center in Bethesda, where I was treated after Vietnam.

In a recent Stanford Medicine magazine article, Lee Woodruff recounts the rationale for keeping her husband in a military hospital after consulting with civilian doctors and their Air Force surgeon friend, Bob Constantino. “That was so comforting,” she recalls. “Because my first thought was, ‘What are we going to do?’ You know, he’s in the military hospital—and the image in my mind was government incompetence, quite frankly. And Constantino, who had

been an Air Force surgeon for fifteen years, called and said, ‘I know what you’re thinking. And I want you to know that Bob could not be in better hands than he is in the military. Because with a brain injury, it’s about numbers. And these guys are seeing these blasts every single day, and they know exactly what to do and they do it without hesitating.”

Reconnecting with combat medicine and war after a gap of more than three decades has been as bittersweet as it has been enlightening. Somehow any discussions of medical advances are trumped by the grim realities of war and perhaps the worst of all conditions caused by humans.

Despite the fact that he lost a good portion of his skull, the marines I was embedded with were certain their beloved and seemingly invincible First Sergeant Ed Smith would somehow survive the wounds he sustained when we were caught next to an exploding ammo dump. “Doc Chavez was able to get his pulse back and he’s on the bird alive,” a young marine confidently told me as they hustled the First Sergeant’s litter into a helicopter. “He’s going to make it.”

He didn’t. Nothing really changes when it comes to the tragedy of war.

Mike Cerre, a Sausalito resident, is a journalist, former marine, former newscaster for KRON TV in San Francisco, the Executive Producer/Correspondent for GLOBE TV, and has served as an embedded reporter in Iraq.

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September 2007 San Francisco Medicine

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Medicine in the time of war

Corpsmen in a Time of War The Tales of Two Naval Hospital Corpsmen Donald Barker, MD, and Shawn Nirdlinger

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n September 1951, I found myself in Korea—a twenty-year-old Navy Hospital Corpsman serving alongside First Marine Division fighting against the North Korean Peoples’ Army in the mountains of North Korea, in what came to be known as the Battle of the Punch Bowl.

There were two Navy Hospital Corpsmen, and our marines called us both “Doc.” We were each assigned to a rifle platoon and were responsible for the medical care of the marines. When a marine goes down, it is the “Doc” who rushes to his side and is prepared to do whatever is necessary in rendering aid.

What will it be—perform a tracheotomy, tie off bleeders, start an IV? My first morning on line found me rushing to the aid of two of my marines who received multiple shrapnel wounds when a 76-mm recoilless rifle round zeroed in on their bunker. My fellow corpsman and I were able to isolate, clamp, and then tie off a severed femoral artery, thus stopping a major bleed. We then started an IV with serum albumin.

This was the beginning of a very eventful six-month tour of duty as a platoon corpsman, otherwise known as a “Devil Doc,” with I-3-1, an infantry company. When it ended, I was briefly assigned to the Third Battalion aid station and then to E Medical Company, a field hospital, where I worked in what we called “minor debridemont.”

We debrided all of the wounds involving extremities, packed them open with Vaseline gauze dressings, and later transported our patients to the hospital ship in Inchon harbor for secondary closure. The method of transport was by what was called a “rail bus.” This was a standard bus that had undergone the addition of train wheels. This allowed it to travel on the rails from Inchon 16

to the rail head at Munsan-ni, which was down the road from our field hospital. The bus was then removed from the rails and driven over to E Med, where the patients,

“When a marine goes down, it is the ‘Doc’ who rushes to his side and is prepared to do whatever is necessary in rendering aid. What will it be— perform a tracheotomy, tie off bleeders, start an IV?” on stretchers, were placed on racks inside the bus. The reverse procedure placed the bus back on the rails and onto the hospital ship, Consolation, in Inchon harbor.

Two corpsmen always accompanied the patients and spent the night on the ship, taking a hot shower and sleeping on bunks with mattresses and sheets. It was at E Med that Dr. Frank Spenser performed the first arterial grafts. These came from artery banks stocked from limbs so badly mangled that amputation had been essential.

During the Battle of Bunker Hill in August 1952, from a Friday afternoon to Monday morning, we triaged more than 1,000 wounded marines in 142 major operations under general anesthesia and 397 under local anesthesia in the minor tent.

We ran out of sterile gloves and ended up putting them on wet after soaking them in Zephiran chloride solution.

I returned to the United States after fourteen months in Korea and was flown to the Nevada Desert Atomic Test Site as

San Francisco Medicine September 2007

a member of the Third Marine Division Atomic Brigade out of Camp Pendleton.

It was here that we were taken out into the desert at midnight and placed in trenches.

The countdown began shortly before sunrise, and we were told to keep our eyes closed and look down at the bottom of the trench; there would be a flash of light, we would feel heat on the back of the neck, and it was then that we could look up. There it was: a perfectly shaped purple mushroom cloud.

The Joshua trees in front and behind the trench were smoldering. We walked toward ground zero and observed the desert floor swept clean. The sheep were singed and blinded and there were mannequins with burning clothing. We were then ordered back to the trucks and taken back to Camp Desert Rock—no radiation badges and no showers. Back at Camp Pendleton I was told I could now return to duty with the Navy or stay with the Marines and sail to Japan with the Third Marine Division. I chose to stay with the Marines.

I completed my tour of duty with the Third Marine Division in Japan, and it was there that I volunteered to work in the Air Force Hospital in Nagoya, where I was assigned to the obstetrics service. This was my best duty station, with open-gate liberty—out the front door of the hospital—whenever not on duty.

I completed my military service in 1954 and returned to civilian life. Following my retirement from my practice of podiatric medicine and foot surgery, I began volunteering as a chaplain’s assistant at the V.A. Hospital in Palo Alto, California. This is one of four polytrauma centers established by the V.A. to treat our injured veterans once they are released from the military hos-

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Medicine in the time of war

The UCSF Iraq Action Group Global Initiatives by Local Students Ashley Skabar

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hen discussing the political climate of the global community, there are few institutions as deeply discussed and heavily debated as those involving health care and education. The health and vitality of a nation is often reflected in its ability to provide its citizens with the physical health and knowledge The Iraq Action Group meets bi-weekly to pursue individual goals and on Thursdays at the UCSF campus contribute to the world community. When discussing health care and the meaning of public health, the In the early part of this year, Lowenimplications that come with acting as a self- stein and several of his colleagues formed and state-proclaimed health care provider what would become the UCSF Iraq Action are saturated with responsibility. I met with Group, a group of health care professionals Dan Lowenstein, noted neurology professor and students of medicine at the university and vice chairman of the department of dedicated to speaking out and taking action neurology at UCSF, to discuss his views on on the negative effects of the war with Iraq. the link between social responsibility and “The real focus of our work is to keep coming the health care system. back to what the health effects of the war “We feel that physicians and staff who are, so that other individuals can make their are involved in the provision of health care, own decisions as to whether or not the naas well as students who are learning about tion is going in the right direction. We just health care, have a responsibility to become want to make sure that people factor in what involved in larger societal issues that are the health impacts are of the war.” impacting the health of the people of the On May 9 of this year, the UCSF Iraq world,” Lowenstein told me in the nursing Action Group held a three-and-a-half-hour cafeteria at UCSF. He was speaking of the teach-in entitled “The Health Effects of the UCSF Iraq Action Group, an antiwar group Iraq War,” which brought a variety of worldon the health care campus. “We have a renown speakers, professors, physicians, and certain perspective when we see images on writers to the campus to discuss the negative the news, because we know what it’s like to consequences of the U.S. decision to invade face someone who is severely injured, who is Iraq. The topics spanned the breadth of the facing death. We know that story line first- definition of health and health care, from hand, so when we hear about the casualties the physical and psychological trauma of across the globe, we have a perspective on combatants to the economic strain in the the reality of the numbers. We understand U.S. and Iraq as a result of the war. the reality of illness and injury—it is part of Jed Wolpaw and Jeremy Jaquot, two what we do every day.” of the first student members of the UCSF www.sfms.org

Iraq Action Group, remarked that the attendance at the event more than surpassed the group’s expectations.

“We would have been happy if the auditorium was almost filled,” Jaquot told me in a phone interview, “but every seat was taken and then there were more people standing.”

With more than 600 people in attendance, the teach-in’s success, according to Lowenstein, was a political statement in itself. “There have never been so many people within the UCSF community brought together for an event on a global topic like this since the 1960s, and it really speaks to the depths of the feelings that people have about this war.”

Among the eleven speakers was William Schecter, a surgeon at San Francisco General, who delivered a lecture on the clinical descriptions of the physical wounds suffered during combat. Together, Jess Ghannam of the UCSF Department of Psychiatry and Charles Marmar from the Department of Psychiatry at the San Francisco V.A. Medical Center gave an overview of the psychological consequences of the war on combatants. Dahlia Wasfi, an Iraqi-American physician, spoke of the effects of the war from the perspective of a physician in America who has family in Iraq; she was given a standing ovation at the close of her poignant delivery.

Linda Bilmes, a visiting professor of economics from Harvard University, delivered a lecture specifically addressing the effects of the war on U.S. economics, stating that the most conservative estimate of the

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September 2007 San Francisco Medicine

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Medicine in the time of war

Doctors and Torture “Silence is Betrayal” Robert Jay Lifton, MD

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here is increasing evidence that U.S. doctors, nurses, and medics have been complicit in torture and other illegal procedures in Iraq, Afghanistan, and Guantanamo Bay. Such medical complicity suggests still another disturbing dimension of this broadening scandal.

We know that medical personnel have failed to report to higher authorities wounds that were clearly caused by torture, and that they have neglected to take steps to interrupt this torture. In addition, they have turned over prisoners’ medical records to interrogators who could use them to exploit the prisoners’ weaknesses or vulnerabilities.

We have not yet learned the extent of medical involvement in delaying and possibly falsifying the death certificates of prisoners who have been killed by torturers.

A May 22 article on Abu Ghraib in The New York Times states that “much of the evidence of abuse at the prison came from medical documents” and that records and statements “showed doctors and medics reporting to the area of the prison where the abuse occurred several times to stitch wounds, tend to collapsed prisoners, or see patients with bruised or reddened genitals” (Zernike 2004). According to the article, two doctors who gave a painkiller to a prisoner for a dislocated shoulder and sent him to an outside hospital recognized that the injury was caused by his arms being handcuffed and held over his head for “a long period,” but they did not report any suspicions of abuse. A staff sergeant-medic who had seen the prisoner in that position later told investigators that he had instructed a military policeman to free the man but that he did not do so. A nurse, when called to attend to a prisoner who was having a panic attack, saw naked Iraqis in a human 18

pyramid with sandbags over their heads but did not report it until an investigation was held several months later.

A June 10 article in the Washington

“The Hippocratic oath declares, ‘I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing.’”

Post tells of a long-standing policy at the Guantanamo Bay facility whereby military interrogators were given access to the medical records of individual prisoners (Slevin 2004). The policy was maintained despite complaints by the Red Cross that such records “are being used by interrogators to gain information in developing an interrogation plan.” A civilian psychiatrist who was part of a medical review team was “disturbed” about not having been told about the practice and said that it would give interrogators “tremendous power” over prisoners.

Other reports, though sketchier, suggest that the death certificates of prisoners who might have been killed by various forms of mistreatment have not only been delayed but may have camouflaged the fatal abuse by attributing deaths to conditions such as cardiovascular disease (Squitieri 2004).

Various medical protocols—notably, the World Medical Association Declaration of Tokyo in 1975—prohibit all three of these forms of medical complicity in torture.

Moreover, the Hippocratic oath declares, “I will use treatment to help the sick according

San Francisco Medicine September 2007

to my ability and judgment, but never with a view to injury and wrongdoing.”

To be a military physician is to be subject to potential moral conflict between commitment to the healing of individual people on the one hand, and responsibility to the military hierarchy and the command structure on the other. I experienced that conflict myself as an Air Force psychiatrist assigned to Japan and Korea some decades ago: I was required to decide whether to send psychologically disturbed men back to the United States, where they could best receive treatment; or to return them to their units, where they could best serve combat needs. There were, of course, other factors, such as a soldier’s pride in not letting his buddies down, but for physicians this basic conflict remained.

American doctors at Abu Ghraib and elsewhere have undoubtedly been aware of their medical responsibility to document injuries and raise questions about their possible source in abuse. But those doctors and other medical personnel were part of a command structure that permitted, encouraged, and sometimes orchestrated torture to a degree that it became the norm—with which they were expected to comply—in the immediate prison environment.

The doctors thus brought a medical component to what I call an “atrocityproducing situation”—one so structured, psychologically and militarily, that ordinary people can readily engage in atrocities. Even without directly participating in the abuse, doctors may have become socialized to an environment of torture and by virtue of their medical authority helped sustain it. In studying various forms of medical abuse, I have found that the participation of doctors can confer an aura of legitimacy and can even www.sfms.org

create an illusion of therapy and healing.

The Nazis provided the most extreme example of doctors’ becoming socialized to atrocity (Lifton 1986). In addition to cruel medical experiments, many Nazi doctors, as part of military units, were directly involved in killing. To reach that point, they underwent a sequence of socialization: first to the medical profession, always a self-protective guild; then to the military, where they adapted to the requirements of command; and finally to camps such as Auschwitz, where adaptation included assuming leadership roles in the existing death factory. The great majority of these doctors were ordinary people who had killed no one before joining murderous Nazi institutions. They were corruptible and certainly responsible for what they did, but they became murderers mainly in atrocity-producing settings.

When I presented my work on Nazi doctors to U.S. medical groups, I received many thoughtful responses, including expressions of concern about much less extreme situations in which American doctors might be exposed to institutional pressures to violate their medical conscience. Frequently mentioned examples were prison doctors who administered or guided others in giving lethal injections to carry out the death penalty and military doctors in Vietnam who helped soldiers to become strong enough to resume their assignments in atrocity-producing situations.

Physicians are no more or less moral than other people. But as heirs to shamans and witch doctors, we may be seen by others—and sometimes by ourselves—as possessing special magic in connection with life and death. Various regimes have sought to harness that magic to their own despotic ends. Physicians have served as actual torturers in Chile and elsewhere; have surgically removed ears as punishment for desertion in Saddam Hussein’s Iraq; have incarcerated political dissenters in mental hospitals, notably in the Soviet Union; have, as whites in South Africa, falsified medical reports on blacks who were tortured or killed; and have, as Americans associated with the Central Intelligence Agency, conducted harmful, sometimes fatal, experiments involving drugs and mind control.

With the possible exception of the www.sfms.org

altering of death certificates, the recent transgressions of U.S. military doctors have apparently not been of this order. But these examples help us to recognize what doctors are capable of when placed in atrocityproducing situations. A recent statement by the Physicians for Human Rights addresses this vulnerability in declaring that “torture can also compromise the integrity of health professionals” (Rubenstein 2004).

To understand the full scope of American torture and abuse at Abu Ghraib and other prisons, we need to look more closely at the behavior of doctors and other medical personnel, as well as at the pressures created by the war in Iraq that produced this behavior. It is possible that some doctors, nurses, or medics took steps, of which we are not yet aware, to oppose the torture. It is certain that many more did not. But all those involved could nonetheless reveal, in valuable medical detail, much of what actually took place. By speaking out, they would take an important step toward reclaiming their role as healers.

Reprinted with permission from the New England Journal of Medicine. Copyright © 2005 Massachusetts Medical Society. All rights reserved.

Please visit www.sfms.org/archives for a full list of references.

Humanitarian Consequences of War Continued from Page 10... those American soldiers—the real heroes—who uphold their oath to “defend the Constitution of the United States against all enemies, foreign and domestic,” including those in the legislative, executive, and judicial branches of our government.

In 1967 at Riverside Church in New York, Martin Luther King, Jr., said, “Silence is betrayal.” Today, remaining silent about our responsibility to the world and its future is an ultimate betrayal of the basic ethics of the medical profession.

Dr. Dahlia Wasfi is a graduate of Swarthmore College and the University of Pennsylvania School of Medicine. Born in the U.S. to an American Jewish mother and an Iraqi Muslim

father, she lived in Iraq as a child, returning to the United States at age five. Dr. Wasfi has made two trips to Iraq since the 2003 invasion to visit her extended family. Based on her experiences, she speaks out in support of immediate, unconditional withdrawal of American forces from Iraq and the need to end the occupation from“the Nile to the Euphrates.” Her website is www.liberatethis.com.

Please visit www.sfms.org/archives for a full list of references.

Iraq Action Group Continued from Page 17... financial costs of the war is probably around $1.2 trillion, in conflict with the current administration’s declaration of $600 billion.

Factoring in combatants injured, the cost of their physical and psychological care, and the costs of funneling funds for domestic needs to the war, Bilmes said that the price may be closer to $2 trillion.

“The expenses of the war go much deeper than combat wounds,” said student Jed Wolpaw. “There are so many things affected by this war, from trauma to the loss of money for medical research programs.”

The UCSF Action Group holds a biweekly meeting on campus and is already working on plans for future events and projects. Under current discussion are ideas ranging from bringing in more speakers and art exhibits to the campus to projects that would enable the group to help health care professionals and colleagues in Iraq directly.

“I think that all of us here are here because, in one way or another, we are dedicated to a life of service in which we try to advance the health of our society,” Lowenstein said of those in the medical profession.

“I think UCSF takes pride in our wanting to contribute not just to the Bay Area, not just to the nation, but to the world.”

For more information on the UCSF Iraq Action Group, visit the organization’s website at www.iraqactiongroup.org, where the text of the entire teach-in is available for order.

September 2007 San Francisco Medicine

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Medicine in the time of war

A Physician Holds Doctors Accountable Book Review: An Oath Betrayed Steve Heilig, MPH Oath Betrayed: Torture, Medical Complicity, and the War on Terror (Random House 2006), by Steven H. Miles, MD

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t the end of World War I, California Senator Hiram Johnson noted that “the first casualty when war comes is truth.” Given that one fundamental truth is that torture—the willful infliction of harm upon people, for whatever reason—is unethical and illegal, it seems that truth has again been tossed aside in our nation’s “war on terror.”

So argues Steven Miles convincingly in this most disturbing book, Oath Betrayed. He is no armchair ideologue. A distinguished physician and bioethicist, Miles is well qualified to present his independent “expert witness” review of 35,000 pages of documents from governments and the military, human rights groups and the press. It’s also worth adding that Miles states, “I am not a pacifist, a fact that may disappoint critics who would pigeonhole and dismiss me, and friends who would recruit this book to that cause.”

Miles was moved to undertake the extensive research needed for his book when, after first seeing the notorious photos of prisoners being abused at Abu Ghraib, his first thought was, “Where were the doctors, nurses, and medics while these abuses were happening?” As it turns out, Miles discovers those photos were just the tip of a very ominous iceberg. He states that there have been at least nineteen confirmed prisoner deaths due to abuse in Afghanistan and Iraq, and possibly many more.

Consider one of many such stories: “Dilawar was a twenty-two-year-old farmer and taxi driver, whom American soldiers 20

tortured to death over five days at Bagram Collection Point in Afghanistan in December 2002. He was shackled and suspended from his arms for hours, denied water, and beaten so severely that his legs would have been amputated had he survived…. During his final interrogation, soldiers told the delirious, injured prisoner that he would get medical attention after the session. Instead, he was returned to a cell and chained to the ceiling. Several hours later, a physician found him dead.”

But, as if that summary were not bad enough, there’s more: “By then, the interrogators had concluded that Dilawar was innocent and had simply been picked up after driving his new taxi by the wrong place at the wrong time.” Dilawar was far from alone: Miles notes that army experts “estimated that 80 percent to 90 percent of arriving Abu Ghraib prisoners either had no intelligence value or were outright innocent.”

Miles provides detailed charts of the types of abuse documented: beatings, starving, asphyxiation, burning, stretching (as in the medieval “rack”), rapes and other sexual degradations, all manner of psychological manipulation, mutilation via dog bites, and even “forcing a victim to watch abuse or torture of a loved one.”

As for the perpetrators, one soldier noted (albeit only after being accused), “I did not think that anyone cared what happened to the detainees as long as they did not die.” But what of the medical and psychological professionals, sworn by widely accepted codes not only to refrain from ever doing harm, but also to stop it and expose it where witnessed? The record Miles exposes and is clear and detailed: “Senior and frontline medical personnel” violated

San Francisco Medicine September 2007

codes of medical ethics in at least three ways by allowing and assisting in harsh and coercive interrogations, by failing to document and report such abuses, and by failing to advocate for better treatment. There are many long-standing medical policies against torture, but as Miles demonstrates, “the U.S. armed forces have ignored these standards.”

Beyond the pain and suffering, the ethical breaches, and the “embarrassment” lies the ironic fact that torture hardly ever achieves any useful end. As a Defense Department report admits, coercion “yields information of questionable quality,” is “a significant departure from traditional U.S. military norms,” and can endanger American POWs. On that count, Miles notes that Islamic extremists began beheadings of Westerners just after the Abu Ghraib photographs were made public.

In other words, all these abuses have been for naught or worse. Miles warns that “the vast majority of clinicians in military medicine are competent and caring professionals. They have been unjustly tarred by this scandal.” And to date, it seems that most of the perpetrators have escaped scrutiny and justice.

Miles has some recommendations in his book, and he concludes that, “Like the terrorism it would deter, torture undermines civil societies. The rejection of either must include the foreswearing of both.” Miles likens our nation’s use of torture to a scourge that has infected us; he’s now diagnosed it.

Will denial continue, or will treatment and prevention follow?

This review originally appeared in different form in the San Francisco Chronicle.

www.sfms.org

Medicine in the time of war

Angels, Devils, and Heroes Book Review: The Lucifer Effect Mike Denney, MD, PhD The Lucifer Effect: Understanding How Good People Turn Evil (Random House, 2007), by Philip Zimbardo, PhD

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hilip Zimbardo, professor emeritis of psychology, past president of the American Psychological Association, and chief investigator in the groundbreaking Stanford Prison Experiment’s research on the relationships of “guards” to “prisoners,” is arguably the most qualified person in the contemporary world to objectively evaluate torture in a time of war, such as occurred in 2003 and 2004 at the Abu Ghraib U.S. military prison in Iraq.

Yet, as he notes in his recently published book The Lucifer Effect, his testimony on behalf of one of the accused American soldiers—that situational forces influence individual behavior—was largely ignored by the American military tribunal.

Of course, the mandate of the military court was to determine guilt or innocence strictly according to military law, not to seek psychological understanding of the human behavior of normal young men and women who, while serving their country in a foreign war, were able to abuse and torture other human beings, prisoners whom the American soldiers were supposed to be guarding.

In this book, Zimbardo offers invaluable insights into this phenomenon. He starts by reviewing earlier work in conformance and obedience to authority, including that done in 1961 to 1962 by psychologist Stanley Milgrim at Yale, in which 65 percent of ordinary people recruited for research through advertisements in newspapers were willing, upon firm directions by scientists in white uniforms, to deliver 450 volts of electricity to pitifully protesting victims. For this research, Milgrim became known as “the www.sfms.org

man who shocked the world.”

Zimbardo then thoroughly reviews his own prison experiments done at Stanford in 1971, in which normal college students, divided into “guards” and “prisoners,” engaged in make-believe daily activities strictly defined and enforced by the rules of the researchers. Soon, the “guards” were transformed into devils who were willing to inflict verbal and physical abuse upon the “prisoners.” Early in the experiment, the weary “prisoners,” deprived of sleep by “loud, shrilling whistles and billy clubs rattling the bars on their stinking, barren cells, are lined up against the wall” and verbally abused. By the sixth day, “naked, shackled prisoners with bags over their heads” were paraded in a “toilet drill,” and, suffering from extreme distress, were sexually humiliated by supposed simulations of camels mating, and were physically abused with guards stepping on their backs as they did push-ups.

When Zimbardo saw the pictures of the American guards at Abu Ghraib humiliating and torturing Iraqi prisoners, he immediately recalled his own earlier experiments at Stanford. As in this book he details these unsettling comparisons, he can only conclude, once again, that the system is partly responsible for the behavior of individuals.

Perhaps the most chilling dynamic in this compelling narrative is Zimbardo’s own confession of how he finally terminated the Stanford experiment. A psychologist named Christina Maslach, with whom Zimbardo shared a close personal relationship (and later married), visited the research project on its sixth day. She was shocked when she talked with one of the “guards” and briefly witnessed one of the “toilet drills.” She was moved to tears and ran out of the building.

When Zimbardo caught up with her, she was furious, and he then starkly realized that he was personally responsible for the abusive behavior. In a self-referential paradox, the researcher had himself become part of the “system” that could influence the behavior of the participants. He immediately aborted the experiment.

Comparing his experiments with Abu Ghraib, Zimbardo likens his friend Christina with Joe Darby, the young Army Reservist who “blew the whistle” at Abu Ghraib and forced the military to acknowledge the existence of abusive practices. Both of them, he says, represent the “hero,” a role toward which we should all strive and about which Zimbaro offers detailed advice.

Now that we are aware that some of the doctors on duty at Abu Ghraib falsified records and otherwise aided the abuse, this book, The Lucifer Effect, is a must-read for physicians who might serve in the military, and for any of us who might judge doctors who practice medicine in a time of war.

For news, local events, CME opportunities, and to view San Francisco Medicine Magazine online, please visit our website:

www.sfms.org

September 2007 San Francisco Medicine

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Corpsmen in a Time of War Continued from Page 16... pitals. It was here that I was asked to serve as case volunteer for the Injured Marine Semper Fi Fund. The Fund’s founder, Karen Guenther, and a group of Marine Corps wives established this fund in May 2004 for the purpose of providing financial grants to our injured marines, sailors, and their family members, thus allowing the family to remain at the bedside of their loved one during the rehabilitation. This is where I met Shawn Nirdlinger. His story follows: It was an early morning in January that I found myself on the Camp Horno (52 area) parade deck waiting for the buses that would bring us to March Air Force Base, where a plane was waiting to fly us to Kuwait. After a two-day stay in the desert called Kuwait, we flew two hours in a C-130 to a military airfield in Al-Taqudum (TQ), Iraq. I was a Line Corpsman with First Battalion, First Marines Bravo Company. I provided the first line of treatment to any marine

who was injured in combat.

On May 23, 2006, my vehicle was struck by an IED outside of Al-Karma, Iraq. I suffered a degloving injury to my scalp and a fractured skull and jaw. A piece of shrapnel severed my radial artery, which had to be tied off and the severed part removed; the same piece of shrapnel shattered the radial bone in my right arm.

I am a patient at the V.A. in Palo Alto in the Brain Injury unit and attend therapies five days a week. I am still struggling with my recovery more than a year later. I have a Traumatic Brain Injury (TBI), mostly to my frontal lobe, and have lost most of the use of my right hand. I am still an active-duty sailor but will be medically retired soon. My hope is to one day attend Stanford University to finish a psychiatry degree.

To continue the story it should be noted that Shawn was awarded the Navy Commendation Medal with Combat V for his actions in rendering aid to his injured Marines several weeks prior to being injured himself.

The Injured Marine Semper Fi Fund has been there with financial assistance for the Nirdlingers during this long and arduous rehabilitation and will continue to support them as needs arise.

Shawn Nirdlinger is a native of Manhattan. He has been a United States Navy Hospital Corpsman since 2003 and is currently attached to the Naval Hospital Camp Pendleton and First Marine Division for deployment to Iraq.

Donald Barker, MD, is a native of Sidney, Nebraska, and a retired doctor of Podiatric Medicine currently residing in Atherton, California. He served as a United States Navy Hospital Corpsman from 1950 to 1954, attached to the First Marine Division in Korea and the Third Marine Division in Japan. He attended the California College of Podiatric Medicine, San Francisco, California.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members:

Steve Chang, MD (referred by Ella Faktorovich, MD) Nitin Chitale, MD (referred by George Susens, MD) Sung Choi, MD (referred by James Mailhot, MD) Jeff Critchfield, MD (referred by Stephen Follansbee, MD) Lisa Dana, MD Shelley Erford, MD Fiona Dulbecco, MD (referred by James Mailhot, MD) Susan Fernyak, MD (referred by Mitchell Katz, MD)

interested in sponsoring a new member?

SFMS has embarked on a New-Member Sponsorship program. Upon approval by the Board or Executive Committee, each new member is assigned a sponsor, an established SFMS member whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (such as the Annual Dinner, Legislative Day, Candidate’s Night, or a Mixer) during the course of their first year of membership. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information or to volunteer.

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www.sfms.org

Walking Wounded

By Nathan Rapheld

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he past never really remains the past—history follows us through life like a scar, reborn in our countries, in our homes, tossed before us like an old photograph. In Cambodia, a country where land mines are burrowed within the earth like a secret, a war that ended a decade ago has a way of revisiting at a mere footfall.

Kout Eoun, a twenty-six-year-old living in rural northwestern Cambodia with his wife and polio-stricken son of five, had been walking to a nearby pond for water, when a step changed his and his family’s lives forever. Like many of Cambodia’s rural poor, Eoun and his family have few economic opportunities available to them outside of subsistence farming and bamboo foraging. After nearly thirty years of military struggle against the Khmer Rouge, which ended in the late 1990s, the country’s economy and infrastructure has been decimated. Much of the most fertile agricultural land has been left pocketed with deadly land mines and unexploded ordinance, but as the population grows and resources are depleted, economic pressures push people deeper and deeper into these death zones.

The country’s economic and political turmoil is reflected in its suffering health care system, which is both overfilled and understaffed. Many of Cambodia’s most educated were put to death during the reign of the Khmer Rouge in the 1970s, including many in the medical profession. Public hospitals struggle with inadequate facilities and funding, and medical staffs are paid poverty-level wages, forcing them to find other means of income—often through private

practice, which is financially out of reach for the country’s poor.

In order to relieve some of the burdens on the healthcare system, International NGOs such as Emergency, Health Net International, and Save the Children Australia have opened clinics or are working with the Cambodian government to run existing public clinics more efficiently. In 1998, Emergency established the Surgical Center for War Victims in Battambang, Cambodia’s second largest city, offering free surgical and rehabilitation services to patients. However, these contributions notwithstanding, more than 60,000 Cambodians have been injured or killed by explosive remnants since 1979, and many have been unable to gain access to proper medical care. In 2006 alone, an average of nine people were killed or injured each week solely as a result of the mines.

Like so many before him, Eoun was walking to retrieve water for his family when the quiet of the afternoon was shattered in an explosion of land and metal. At the detonation, Eoun suffered irreparable damage to his lower left leg, soft-tissue wounds to his right leg and left hand, and corneal abrasions. Witnesses transported Eoun to a private clinic, where his left leg was amputated below the knee. After three weeks, he was released from the clinic with a US$2,500 medical bill, which, in a country where the annual per capita income is US$500, was and will continue to be an incredible economic hardship for Eoun and his family. Four days after his release, Eoun was forced to seek further medical attention at Emergency’s Surgical Center, where he could receive health care

While working in a rice field, Kout Eoun, 26, stepped on a land mine in Cambodia’s Bonteay Meanchey province near the border of Thailand. He lost his left leg from below the knee, suffered lesions on his left arm, and injured his left eye. After three weeks in a private clinic, Eoun was released with a medical bill that will take him years to pay off. Four days later, an infection forced him to seek further medical attention, this time at the Surgical Center for War Victims in Battambang, a hospital run by the Italian NGO Emergency, where reliable medical care is free. Eoun now has a stump where only four weeks prior he had a foot. As a poor rural farmer, physical labor is his only means to earn a living, and he must now find a new way to generate income for himself and his family.

The bandages on Eoun’s stump, arm, and hand are changed daily by hospital staff.

Eoun says the wounds feel better with the fresh dressings.

Kout Eoun’s wife, Bon So Chet, 24, is allowed to stay at the hospital to help him get around, as his vision is impaired. She is always with her husband, helping him in and out of his wheelchair, bringing him meals, supporting him during physical therapy, and keeping him company.

for free, to tend to a postsurgical infection.

In the early 1990s, intense campaigning by the International Campaign to Ban Land Mines, along with a coalition of NGOs and other organizations, directed political attention to the issue of land mines. This led to the creation of the United Nations Mine Ban Treaty in 1997, written to prohibit the use, stockpiling, and production of mines and their destruction. Today the treaty bears the signatures of 153 nations, though forty states have not yet signed, most notably China, India, Russia, and the United States.

Although nearly ten years have passed since the signing of the Mine Ban Treaty, Eoun and thousands like him continue to suffer the catastrophic consequences of war. If demining tactics continue at their current pace, Cambodia will, at best, see an additional 12,000 deaths and injuries.

Eoun does not show interest in interacting with others at the hosHowever, history has shown this does not need to be the case. After pital. According to one doctor, he is showing signs of depression.

World War II, millions of mines were cleared in France and other developed nations in five years, while it has taken more than twice that to clear far fewer mines in such postconflict countries as Croatia, Bosnia, Angola, Mozambique, Cambodia, and Vietnam.

Chet believes she can work When Eoun is finally released from the hospital, he will be hard enough to support the family faced with the enormous challenge of rebuilding his life, both on her own, even faced with no economically and personally. He will have to go through months permanent job, a sizable medical of physical therapy to learn to adapt to his new handicap. He bill to pay, her recently incapaciwill need to find a way to be a productive member of his family tated husband, and a five-year-old while learning to struggle with the reactions of others and with son suffering from polio. his own feelings of loss. For Eoun, a war supposedly long since finished will follow each of the steps of the rest of his life.

To find out how you can get involved, read the “Call to Action” on the following page. This article was co-edited by Ashley Skabar.

“If demining tactics continue at their current pace, Cambodia will, at best, see an additional 12,000 deaths and injuries.”

Cham Chorwan is a deminer with Team 138 of the Cambodian Mine Action Center (CMAC). He works to clear fields of mines and Unexploded Ordinance (UXO) in Battambang province.

Call to Action The following is a list of some NGOs that are involved with improving Cambodia’s land mine situation. Information about donating and volunteering can be found on the following websites.

Medical Cambodian Red Cross: www.redcross.org.kh Emergency: www.emergencyusa.org Handicap International: www.handicap-international.org.uk Health Net International: www.healthnetinternational.org International Committee of the Red Cross: www.icrc.org Save the Children Australia: www.savethechildren.org.au

Mine Action/Demining CMAC (Cambodian Mine Action Center): www.cmac.org.kh HALO Trust: www.halotrust.org MAG (Mine Action Group): mag.org.uk

Development Cambodian Volunteers for Community Development: www.cvcd.org.kh UNICEF: www.unicef.org

Medicine in the time of war

Caring for Our Soldiers Barriers to Care in Newly Returning Veterans Shira Maguen, PhD

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ilitary personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, including PTSD, depression, and generalized anxiety disorders. An initial report by Hoge and colleagues indicated that 15.6 to 17.1 percent of returning Operation Iraqi Freedom (OIF) combat veterans and 11.2 percent of returning Operation Enduring Freedom (OEF) combat veterans met screening criteria for at least one of these disorders (Hoge et al. 2004). In a more recent study, Hoge and colleagues found that the prevalence of screening positive for a mental health problem was 19.1 percent among service members returning from Iraq and 11.3 percent after returning from Afghanistan (Hoge 2006). Among OIF/OEF veterans seen at V.A. health care facilities, 25 percent received mental health diagnoses, with 56 percent of these meeting criteria for two or more mental health diagnoses (Seal et al. 2007).

Returning veterans are also at risk of alcohol abuse. In a smaller study of OIF/OEF veterans enrolled in V.A. healthcare, 12 percent screened positive for PTSD and 33 percent screened positive for problematic alcohol use. Despite these rates of mental health problems, few sought help. Even among those who were already enrolled in the V.A. system, of veterans who had screened positive for PTSD, just over half (56 percent) reported using mental health services; among those who screened positive for problem drinking, only 18 percent had sought mental health services (Erbes et al. 2007).

One of the biggest challenges that mental health care professionals face in providing services to military personnel returning from deployments to the Middle www.sfms.org

East are obstacles related to stigma and barriers to care. In one study, among those who screened positive for a mental health disorder, only 23 to 40 percent received

“One of the biggest challenges that mental health care professionals face in providing services to military personnel returning from deployments to the Middle East are obstacles related to stigma and barriers to care.” professional mental heath care in the last year, and only 38 to 45 percent were interested in receiving help. Furthermore, those who screened positive for a mental health disorder were twice as likely as those who did not meet screening criteria to report stigma and barriers to care for seeking mental health care.

Although there are many reasons that returning veterans do not seek mental health care, including common fears of being seen as weak (65 percent) and fears of different treatment from unit leadership (63 percent), both of which are related to stigma and military structure, there are several barriers to care that can be addressed within the context of the V.A. Healthcare System that serves these veterans upon their return home. More specifically, among veterans who screen positive for a mental health diagnosis, the majority reported that getting time off of work for treatment is a barrier to

care (55 percent); nearly half reported that it would be difficult to schedule an appointment (45 percent), and one quarter reported that treatment would cost too much money (25 percent) (Hoge et al. 2004).

In order to accommodate some of these concerns and reduce stigma associated with mental health treatment, our multidisciplinary treatment team at the San Francisco V.A. Medical Center has established several programs to reduce some of the aforementioned barriers to care. First, the returning veteran’s first point of contact is often our combat case manager, who orients the veteran to the hospital and clarifies systemic issues that may be causing confusion. For example, many veterans are not aware that they can receive two years of free mental health care following their return from their deployments in the Middle East. This is true even if they are still active in the National Guard or Reserves.

The combat case manager will next facilitate an appointment with primary care (PC). The veteran will be scheduled for a PC appointment in our Integrated Care Clinic (ICC). Our ICC exemplifies a “one-stop shop” model, meaning that when the veteran comes in for a PC appointment, he/she will be seen consecutively by a number of providers as a matter of course.

Following orientation to primary care and administration of several brief screening instruments (traumatic brain injury, mental health symptoms, alcohol use, etc.), the veteran will engage in a thorough primary care visit.

Next, every veteran who is seen through the ICC will meet with a mental health professional who will briefly speak to the veteran about any mental health areas

Continued on Page 28...

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Caring for our Soldiers Continued... of concern and assess for mental health symptoms, including PTSD symptoms, functional impairment (relationship problems, employment difficulties), drinking behaviors, drug use, and safety (firearms in home, suicidal/homicidal behavior, domestic violence, etc.). The veteran is also oriented to mental health services that are available for returning veterans, including a comprehensive mental health evaluation, skill-based groups focused on stabilization and readjustment (stress management, anger management, etc.), individual therapy (empirically validated therapies such as cognitive processing therapy, a cognitive, behaviorally based, trauma-focused therapy), family therapy (couples therapy, family therapy), medication management, and a process group for maintenance of gains.

The goal of this meeting with a mental health professional is to be able to facilitate transition to mental health services and to normalize many of the adjustment concerns that the veteran is experiencing. For example, while some veterans ultimately will receive diagnoses of PTSD and other mental health disorders, many veterans will experience subthreshold mental health symptoms upon returning home from service but will not go on to develop chronic problems if given appropriate assistance with reintegration.

As a result, we encourage veterans to enroll in skill-based adjustment groups that are appropriate for any veteran returning home after a deployment abroad. In addition to being taught specific skills, this also provides an arena for other veterans to share their adjustment struggles in order to nor-

malize these and reduce isolation and social withdrawal. Within these groups, veterans are able to share strategies for adjusting and offer one another support.

In this initial ICC appointment, veterans are informed of all of these choices and have the opportunity to ask any question about mental health services that may arise.

Following the ICC mental health appointment, the veteran has the option of meeting with a social worker if additional assistance is needed in areas such as employment or housing; this meeting is crucial for veterans who are struggling in these areas, in order to facilitate readjustment to civilian life and prevent chronic functional impairment in these areas.

The ICC care clinic at the SFVAMC was implemented within the last year, and we are currently in the process of evaluating whether this model facilitates better follow-up in mental health following the ICC appointment. Anecdotally, veterans report that they appreciate this “one-stop shop” model and that it reduces some of the barriers to care (by reducing the time they need to take off from work, and even the time spent having to worry about setting up a mental health appointment). Feedback has also been strong for our skill-based groups that emphasize adjustment rather than mental health diagnoses, which seems to further reduce stigma associated with mental health care.

The family therapy program is also a crucial component of our program. Veterans can meet with their partner or spouse or meet with other family members, since many of our veterans live with parents for various periods after returning home or have children of their own who must

also make sense of the veteran’s adjustment following homecoming. Although many veterans have mixed feelings about psychotropic medications and/or traumafocused therapies, those who have engaged in these treatment modalities have derived great benefits.

By providing treatment education and collaboration throughout the treatment process, we ensure that no matter which combination of treatments the veteran receives, he/she feels comfortable and well cared for in the process of readjustment.

As treatment providers, it is important for us to be aware of the stigma and the wide range of barriers to care that exist for these veterans, and, consequently, to continue to think creatively about the provision of services that may best assist veterans in achieving a strong quality of life upon their transition home.

Shira Maguen, PhD, is an Assistant Professor at the UCSF School of Medicine, Department of Psychiatry, and a Staff Psychologist with the Posttraumatic Stress Disorder Clinical Team at the San Francisco V.A. Medical Center. Dr. Maguen is involved with both the clinical and research components of the PTSD program.

Clinically, she is involved in the provision of services for the returning Afghanistan and Iraq War veterans and specializes in evidence-based cognitive behavioral therapies. Her research interests fall under the umbrella of PTSD and include risk and resilience factors in veterans, complicated grief, and coping with the ongoing threat of terrorism in countries such as Israel.

See our website, www.sfms.org, for a full list of references.

SFMS Symphony Night Returns This Fall!

Mark your calendars for Thursday, October 18! Enjoy a preconcert reception featuring hors d’oeuvres and beverages in the Davies Symphony Hall Green Room, followed by a dynamic and varied program of Liszt, Beethoven, and Prokofiev.

We have secured a block of tickets in the premier first tier, and tickets are $67 each, inclusive of the reception. Tickets are limited, so we must have your RSVP and payment no later than Tuesday, September 25.

To order tickets, or for more information, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

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www.sfms.org

Medicine in the time of war

Posttraumatic Stress Disorder Symptoms, Adjustments, and Diagnostic Issues Shira Maguen, PhD

P

osttraumatic Stress Disorder (PTSD) is the most commonly reported mental health diagnosis following deployment to the Middle East, with 12 to 13 percent of marines and soldiers screening positive (Hoge et al. 2004).

In addition to military personnel that meet full criteria for a PTSD diagnosis, many will evidence some combination of PTSD symptoms as they begin to adjust to civilian life.

It is not uncommon for returning soldiers to experience some PTSD symptoms such as hypervigilance, insomnia, reexperiencing events, and nightmares. Over time, most will recover, while others will develop chronic PTSD.

A PTSD diagnosis requires symptoms in four Criteria: Criterion A—a traumatic event that is a threat to life, serious injury, and/or a threat to physical integrity of self or other and that is experienced by intense fear, helplessness, or horror is linked to subsequent symptomatology.

Criterion B—nightmares, intrusive thoughts, flashbacks, psychological distress, and physical reactivity. A distinction should be made between intrusive thoughts (literally “intrusions” that are unsolicited) and flashbacks, during which the individual feels as though the traumatic event is happening again and they are “back in the war zone.”

Flashbacks can range from brief daydreams to more extreme dissociation, lasting for much longer periods. Flashbacks can be triggered by sensory stimuli (e.g., sounds, smells, images) or occur out of the blue.

Criterion C—avoidance and emotional numbing symptoms. Avoidance symptoms include efforts to avoid trauma-related thoughts, feelings, and/or conversations, as www.sfms.org

well as trauma-associated activities, places, or people. Emotional numbing symptoms include detachment or estrangement from others, being less interested in previously enjoyed activities, a restricted range of affect, inability to recall important aspects of the trauma, and a sense of a foreshortened future.

Criterion D—arousal symptoms such as increased anger and irritability, insomnia, difficulty with concentration, hypervigilence, and exaggerated startle response.

In order to meet diagnosis for PTSD, a veteran requires at least one Criterion A event, one Criterion B symptom, three Criterion C symptoms, two Criterion D symptoms, duration of these symptoms for at least one month, and an indication of clinically significant distress and/or impairment in social, occupational, or other areas of functioning.

One way to conceptualize many of these PTSD symptoms is by envisioning people who experience them at a specific point along a stress-response continuum. At one end are individuals who are returning home, burdened by stressors there and by reminders of traumatic events that happened in the war zone; yet they are coping well, with few mental health symptoms and little functional impairment In the middle of the spectrum are those people who have a variety of PTSD symptoms yet do not evidence clinically significant impairment in functioning. At the other extreme are veterans who are plagued with a host of PTSD symptoms and evidence severe difficulties in functioning. Veterans at each point along this continuum can benefit from treatment, whether it is assistance with adjustment to civilian life or more intensive evidence-based trauma process therapies.

Compounding the diagnosis of PTSD in newly returning veterans, Mild Traumatic Brain Injury (MTBI) due to exposure to explosions and blasts has been identified as a “signature injury” of war. While the diagnosis of Traumatic Brain Injury (TBI) is well defined, identifying Mild Traumatic Brain Injury (MTBI) is more challenging, given that it is not easily detected using traditional neuroimaging techniques—43 percent to 68 percent of MTBI patients exhibit normal structural scans on MRIs (Hofman et al. 2001) (Hughes et al. 2004).

Diagnosis is further complicated because many of the symptoms associated with MTBI, such as memory difficulties, poor concentration, irritability, and insomnia, are also hallmark symptoms of PTSD. In addition, rates of comorbid depression and comorbid substance abuse in those who are diagnosed with PTSD are important and may place veterans at higher risk of suicide as compared to those with PTSD without depression and/or substanceabuse disorders. Veterans with PTSD who return from modern deployments may also present with psychosomatic symptoms, panic symptoms, paranoia, and/or auditory hallucinations that can be confused with other disorders but are secondary to PTSD. In one recent study of newly returning veterans, those with PTSD also manifested more physical symptoms, greater somatic symptom severity, lower ratings of general health, more sick call visits, and more missed workdays (Hoge et al. 2007).

See our website, www.sfms.org, for a full list of references.

September 2007 San Francisco Medicine

29

Medicine in the time of war

Group Therapy at the V.A. World War II and Korean War Veterans Find Solace in One Another Chad S. Peterson, MD, PhD

T

he diagnosis of Posttraumatic Stress Disorder (PTSD) was introduced into the DSM-III in 1980. Given the date of development of the PTSD diagnosis, a veteran from the Korean conflict would, in the best-case scenario, have been struggling with an undefined mental illness for twenty-seven years (from 1953, the end of hostilities in Korea, to 1980, the official acceptance of PTSD into the psychiatric diagnostic pantheon). In practice, this “lag time” is significantly longer, more on the order of forty-five to forty-eight years for the Korean War veterans in the support group I lead. For World War II veterans, the average time between combat experience and learning about PTSD falls in the range of fifty-five to sixty years.

I currently treat a number of World War II and Korean War veterans at the San Francisco V.A. Medical Center in a therapy group. My experience with this group has led me to two broad conclusions: one, that PTSD can most certainly persist in some individuals for more than sixty years; and two, that symptoms of PTSD can be successfully addressed even in veterans who have been struggling with them for several decades.

During the long period of time that many veterans of these conflicts were symptomatic but undiagnosed, many developed alcohol dependence, and most experienced multiple failed romantic and other interpersonal relationships as well as failed jobs, which only in retrospect can be understood through the lens of PTSD. It is often a deeply emotional experience for these older veterans to learn that some of their “bad behaviors,” of which they have been ashamed for decades, might be due in part to emotional wounds that had gone unnoticed and untreated since they ended 30

their military service.

One group member, a Korean war veteran and a prisoner of war (POW) at the hands of the Chinese, described the devel-

“Given the date of development of the PTSD diagnosis, a veteran from the Korean conflict would, in the best-case scenario, have been struggling with an undefined mental illness for twenty-seven years.” opment of his understanding over time: “When I first got back, it seemed like the whole world had changed, because I couldn’t fit back in. I just figured there was something wrong with everyone else, but I was too drunk most of the time to care much about it. Then, maybe twenty years after, I started thinking it was something wrong with me, ’cause I just couldn’t keep anything together: three divorces, a couple dozen jobs, some jail time. When I came to the V.A. in 1999 and learned that I probably had PTSD before I even got back from Korea, the whole mess made a lot more sense, and I was able to focus on getting better instead of fighting one thing or another all the time.”

For other veterans, the changes they experienced during their time in combat were not only painful and isolating, but also puzzling, leading many to assume that they just weren’t “tough enough” for combat. As one World War II veteran put it: “When we got back, there were all

San Francisco Medicine September 2007

these parties and parades; we were these big heroes. But I felt like they must be talking about someone else, because I didn’t feel like a hero at all. I didn’t want anything to do with anyone. I just wanted to sit alone somewhere and forget all about the war. For the first year I was back, I didn’t hardly leave my room: I didn’t work, I didn’t talk to my family, I didn’t do anything. Eventually I figured I had to do something, so I went into business for myself so I wouldn’t have to deal with people as much.”

This veteran developed alcohol dependence after his return from combat, and he experienced several failed marriages before “just giving up on that particular custom altogether.” He initially believed himself to be somehow defective, a “weak soldier,” because he was so haunted by intrusive, disturbing memories of combat; this went against the military ideal of the strong, emotionally tough soldier who could “handle anything,” causing further stigmatization and isolation. Through his participation in the group he has been able to remove some of that stigma and begin to heal from these old wounds.

While the relatively late advent of a formal diagnosis contributed to a significant delay in treatment of many veterans from pre-1980 combat eras, other factors, specifically related to combat experience, were also at work. One of the most prominent among these is shame. While guilt and shame in combat veterans have been little studied, there are some data to suggest that shame is a major factor in development of avoidant symptoms.

The powerful impact of shame on veterans in my group is illustrated by two vignettes. The first example is provided by a former marine who served in the Pacific www.sfms.org

theater in World War II. He reluctantly joined the group and was relatively quiet and reserved for the first year or so of his time there. He eventually developed enough trust in the group members (and leaders) that he was able to discuss some of the horrific acts he saw and in which he was a participant, including torturing and then killing enemy soldiers captured during battle. While it was considered a “military expediency” to kill captured, defenseless, and even wounded enemy soldiers rather than expend the valuable resources it required to keep them as prisoners, many soldiers could never fully embrace this inhumane practice, and this former marine was no exception: he described more than sixty years of guilt and shame about his participation in these acts. One can only imagine the isolation, conscious self-loathing, and unconscious self-sabotage such a level of guilt could produce in a sensitive human being.

Another group member who served on the front lines in Korea and was awarded a medal for bravery in combat described his long and lonely struggle with his guilt over killing: “When I first got over there, sure, I was gung-ho, I wanted to serve my country, be a good soldier, all that stuff. But once I saw what it was really like, what was really going on, my attitude totally changed, and all I thought about was getting out of there alive. I wasn’t going to let nobody stop me from coming home, and all the guys I was with were exactly the same way. If we didn’t know you, you were the enemy, and you were dead. Yeah, we killed everyone we saw, because you just couldn’t take the chance that maybe they were there to kill you.”

After this initial, somewhat defensive, admission of perpetration of atrocities, the veteran was able to use the group to address the deep anguish he still feels about killing people who “may have been innocent.”

The gradual dehumanization this veteran experienced throughout his time in combat, driven primarily by intense fear of death experienced in a multitude of ambiguous situations, is extremely common among soldiers in every armed conflict. The poignant description provided by this Korean War veteran demonstrates that one can carry the resultant pain and confusion of acts performed in the terrifying heat of battle for decades.

Small wonder that caring medical professionals struggle to accurately diagnose, treat, and support patients diagnosed with PTSD. Given the relatively short length of its “official” existence and all that is still being learned about, it presents a number of clinical concerns for all health care professionals. To name one, there is its connection with various medical comorbidities, some of which have only recently come to light. Researchers examining archival data from Civil War veterans have found statistically significant correlations between greater exposure to combat trauma and subsequent physician-diagnosed cardiac and gastrointestinal ailments. These data are consistent with those presented by researchers who recently published the first prospective study to demonstrate a connection between PTSD and coronary heart disease. Theories about the impact of chronic stress on physiological functioning, especially as it relates to the HPA axis, are actively being researched.

To make matters more difficult, the actual diagnosis of PTSD itself is often overlooked, even by mental health clinicians; it is a great imitator. For the clinician who does not specialize in mental health, it can be the last, clarifying piece of the puzzle in the picture of an older patient whose anxiety seems a bit disproportionate to his condition; whose difficulties with sleep seem just a bit beyond that which one might consider “normal” at his age; or for the patient who presents with depression or an alcohol problem.

Exacerbations of PTSD can occur any time during its course, but they are especially likely when patients are confronted with more existential concerns brought on by aging. It is always worth asking whether a patient is a veteran and, if so, whether (s)he was in combat; there may be a connection between those distant events and the current presentation.

And it never hurts to remember that where there is life, there is hope. Currently, the therapy group I work with is looking forward to welcoming three new members.

Chad S. Peterson, MD, PhD, received his PhD from U.C. Berkeley, his MD from Vanderbilt University, and his psychiatric training at UCSF. Until recently he was the Medical Director of the PTSD Clinical Team, the Director of the Telepsychiatry program, and the primary outreach clinician for returning Iraq and Afghanistan veterans at the San Francisco VAMC. He is currently an Attending Physician in the psychiatric emergency department at SFGH and is in private practice in Berkeley.

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September 2007 San Francisco Medicine

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Medicine in the time of war

Couples Therapy for Veterans Healing Families at the San Francisco V.A. Keith Armstrong, LCSW

“M

y dad never talked about the war.

Once we brought out his medals and he started to cry. We never did that again.”—Quote from a daughter of a World War II veteran “I can’t believe I am in here talking with you and my wife about this stuff. My dad, who served in World War II, never would have done this.”—Quote from an OIF veteran in a recent therapy session The emotional cost of war is staggering.

Both soldier and civilian war survivors are directly impacted by their horrific experiences. Talk with anyone who has had a father or brother in a war (and now a mother or sister), and they will tell you how it has affected them and how it has impacted many of their family relationships.

Although our culture is now recognizing the impact war has on its veterans, we have only recently acknowledged that family members who did not directly experience combat are also victims of war, and we are now including them in therapy. At the San Francisco Department of Veterans Affairs Medical Center’s program for couples and families, we regularly treat Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans and their partners.

While there are many psychiatric problems that can occur after war (e.g., depression, substance abuse, general anxiety), Posttraumatic Stress Disorder (PTSD) is one of the more common problems that impacts couples.

Couples counseling initially began in the 1920s as a way to help couples deal with their anxieties about marriage. These counseling sessions were conducted by a variety of professionals including OB/GYNs, social workers, and clergy. In time, as the influence of psychoanalysis took hold over

32

the field of psychiatry, the individual became the sole focus of intervention, rather than the couple. By the early 1960s, however, many therapists again began experimenting with seeing couples rather than just the

“Although our culture is now recognizing the impact war has on its veterans, we have only recently acknowledged that family members who did not directly experience combat are also victims of war, and we are now including them in therapy.” individual.

Meanwhile mental health clinicians, influenced by the work of Bertanfly, began to view families as part of a system with each individual’s behavior impacting the entire system. Although there were some earlier articles written about treating war veterans with their families, therapy for military families began to increase in the late 1970s, due primarily to the work of Charles Figley, PhD, an early pioneer in the field of both PTSD and family therapy. The Department of Veterans Affairs was notoriously slow in meeting the needs of Vietnam veterans.

Consequently, in 1979 Congress funded a parallel system of care called Veteran Readjustment Counseling Centers (known as Vet Centers) as a way to provide individual, group, couples, and family therapy to war veterans and their families without having

San Francisco Medicine September 2007

to go through the bureaucracy of the V.A. Vet Centers continue to conduct couples and family therapy, while some V.A. centers have also developed couples and family programs.

While the family therapy program at the San Francisco V.A. began in the 1970s, it was not until 1989 that treating war veterans and their partners became a major part of the program’s mission. In 1989, the majority of our war veteran patients were males, ages forty to sixty-five, who had served in Vietnam, Korea, or World War II. Vietnam veterans usually sought treatment because of distress in their current relationships, which for many of them was their second or third marriage. Korean and World War II veterans typically came in after the veteran’s recent retirement or because of a medical illness within the family.

In our work with our most recent war veterans, the demographics are a bit different: The OEF/OIF war veterans and their partners in our program range in age from their early twenties to almost sixty. We are treating many couples in the early stages of their relationships—some have recently started living together, some are newly married, and some have recently returned from combat and want help sustaining their relationships. In addition, approximately five percent of war veterans in our couples program have been female.

Why Couples Therapy?

Intrusive, avoidant, and hyperarousal symptoms, which in combination produce a PTSD diagnosis, can wreak tremendous havoc on a couple’s relationship. When the veteran displays aspects of these symptoms, his or her partner may respond in a way that reinforces the distance between the partwww.sfms.org

ners. For example, intrusive symptoms can be experienced by a partner as the veteran not being attuned to the partner’s needs and only focusing on himself or herself. Likewise, avoidant symptoms in a veteran can communicate a lack of caring about the partner’s emotional world. The partner may respond by becoming less invested in the relationship and consequently not sharing his or her emotional life with the veteran. The veteran, in turn, may see this response as a confirmation of his fear that he is not able to connect with another, or is not worthy of such a connection. A veteran’s arousal or irritability toward the partner can also lead the partner to avoid discussing important, emotionally laden topics, because they do not want to upset the veteran or they are fearful of how the veteran may respond.

These patterns of interaction may become entrenched in the lives of the couple.

Since war zone exposure causes distress between the couple and changes the fundamental structure of the couple system, it stands to reason that repairing the ability to connect with the partner will improve the health and well-being of the veteran.

Furthermore, while individual and group psychotherapies can help the veteran reconnect, relationships with partners and with other significant family members will be the most important relationships to address. While other therapies address the concept of improving relationships through the reduction of psychiatric symptoms, or improving the ability to have relationships with therapists or other veterans, couples therapy for veterans diagnosed with PTSD can directly address the damaged attachment in the relationship. Helping members of the couple express their deep need for connection with each other, talk about how the war has impacted their lives, and plan for ways in which they can cope together—rather than suffer alone or in silence—is the predominant work of the couples therapist.

Book review

Components of Working with Couples or Families after War Trauma Exposure While there are no empirically validated approaches for treating war veterans and their families, there are components to www.sfms.org

couples and family therapy that we, after years of treating veterans and their families, believe are of significance:

ring them to well-researched websites or self-help books can be an additional resource for these couples.

1. Define the goal(s) for treatment.

Veterans of war and their partners may come in with anxiety and suspicion about the process of therapy. Clearly defining the couple’s understanding of the problems and their treatment goals will help keep the therapy sessions focused and may decrease any anxiety. Since each member of the couple may have different or even contradictory goals, the therapist must be adept at determining how to combine what each person wants in order to achieve successful results.

Individual sessions are also used in the evaluation phase of the therapy. These sessions allow time to develop a therapeutic alliance with each member of the couple.

In addition, through the use of individual sessions and standardized questionnaires, we asses each member of the couple for any history of trauma exposure, any active substance abuse problems, or any involvement in domestic violence.

3. Pay attention to the patterns or processes of interactions between members of the couple.

As members of a system, family members engage in enduring patterns of interaction that can help decrease war-related symptoms or can make those symptoms worse. Observing the couple’s interactions around both positive and problematic events can provide valuable information to the therapist. We find that observing these interactions can help the therapist identify the “stuck points” in the relationship and therefore plan for more useful interventions.

2. Provide psychoeducation about symptoms of PTSD. Veterans and their partners need to have a frame of reference to understand what someone with PTSD is going through. This understanding can help family members and veterans avoid taking personally much of what is happening in the relationship.

If, for example, a veteran displays avoidance or arousal symptoms by withdrawing or becoming enraged about an issue, the veteran and the partner have a framework for understanding that response. This framework may help the veteran “catch himself” or herself early on, and help him or her let the partner know how the current situation is reminiscent of the war experience.

In addition, psychoeducation can increase the likelihood of the partner responding in helpful ways to the veteran and to their relationship. Understanding PTSD or other common problems from war trauma, such as depression, anxiety, and substance abuse, can provide relief to the family. Providing information directly to the veteran and family as well as refer-

4. Deepen the connection between the couple by better understanding each member’s distress.

By taking an emotionally laden event and carefully understanding the meaning it has for each member of the couple, the therapy session can allow for a deeper understanding of each member’s distress. Helping the veteran see his wife as longing for connection rather than nagging, or aiding a partner in seeing her veteran’s withdrawal as a way of protecting the family rather than not caring, helps the couple feel better understood and more deeply connected. In providing a safe place to achieve this, the couples therapist creates an opportunity to deepen the attachment the individuals have for each other, allowing the relationship to help heal the wounds of war. Within this process, couples can learn to communicate and problem-solve more effectively about other issues, not just the issues with which they are currently having difficulty.

5. Talk about the trauma or the effect of the trauma on the veteran and the partner.

Discussing the trauma or the effects of the trauma can be an important topic for the couple to explore. Determining in what detail the couple should talk about war trauma will depend on the kind of exposure the veteran experienced (e.g., perpetrator

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Medicine in the time of war

A Soldier’s Heart and Mind The Strong Linkage of War, PTSD, and Addiction John A. Straznikas, MD

E

ver since Odysseus wandered the Aegean, blocked from home by the grudge of the angry sea god Poseidon, while Penelope wove and then unwove her tapestry every day and night in order to delay her suitors until Odysseus could return, the classical and medical literature has consistently reported on the negative impact of war on veterans and their families.

During the Civil war, “soldier’s heart” was a term coined by the medical profession to convey the physical and mental illnesses that plagued soldiers who survived combat.

Since then, terms have included “shell shock,” “combat fatigue,” “battle neurosis,” and, most recently from the study of Vietnam veterans, posttraumatic stress disorder or PTSD. Clinicians working with battlefield soldiers from Iraq, Afghanistan, Vietnam, and Korea need to keep a high index of suspicion not only for mental health problems but also for substance abuse and addiction.

From careful study of Vietnam veterans, we know that co-occuring disorder rates of PTSD and addiction are high in the veteran population. For those in Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan, 16 to 17 percent of returning soldiers met criteria for major depression, generalized anxiety disorder, or PTSD. The V.A., in April 2007, reported that one-third of veterans of the two wars have sought V.A. health care since fiscal 2002, and that mental disorders comprised 37 percent of possible diagnoses among recent battlefield veterans. The 1990 National Vietnam Veteran Readjustment Study showed that 73 percent of male veterans who met diagnostic criteria for PTSD also qualified for a lifetime diagnosis of alcohol abuse or dependence.

Among male veterans seeking treatment for 34

combat-related PTSD, high rates of lifetime alcohol disorders (ranging from 40 percent to 85 percent) and lifetime drug abuse and dependence (25 percent to 56 percent) have been consistently documented.

“From careful study of Vietnam veterans, we know that co-occuring disorder rates of PTSD and addiction are high in the veteran population.”

The risk of addiction is the end result of an interaction of three variables: the amount and route of administration of the drug, the genetics of the individual, and the environment of use of the drug. High-risk soldiers have family histories of addiction.

Environments with intermittent and unexpected doses of stress are associated with an increased risk of addiction. A useful clinical rule of thumb maps a dose-response curve with more combat tours and stressful war-related situations increasing the risk of addiction.

Protective cultural environmental factors that reduce the risk of addition are strong family connections, reintegration of the battlefield soldier back into family and community, and cultural or religious prohibitions against alcohol and drug use.

The bottom line of this complex calculus of risk factors and protective factors is that the combat environment casts a very long and dark shadow of potential addiction for the returning soldier. And sometimes the addiction doesn’t develop until years or decades after the war.

Combat veterans who served in Iraq

San Francisco Medicine September 2007

or Afghanistan require ongoing evaluation for the presence of concerning drug or alcohol use and/or addiction. Soldiers whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. So the general practitioner and internist have a very important screening role in this high-risk population of returning soldiers. First and foremost, a nonjudgmental clinical stance is essential when inquiring into the soldier’s past and current use of drugs and alcohol.

Asking about positive and negative impacts of drugs and laboratory testing for alcohol and drug abuse are essential.

For alcohol use disorders, CAGE remains a quick, easy, and useful screening tool. CAGE is an acronym for four questions: have you made any attempts to Cut down alcohol use; have people Annoyed you when criticizing your drinking; have you ever felt Guilty about your drinking; have you ever had an Eye-opener in the morning to steady your nerves or get over a hangover? The CAGE questionnaire has up to 75 percent sensitivity.

Loss of control and the negative consequences of drugs and alcohol are critical to the diagnosis of addiction. This is referred to as the C’s of addiction: loss of Control, negative Consequences, and (sometimes) Cravings. In diagnosing addiction, loss of control and negative consequence are even more important than the amount of alcohol or drugs used, the presence of physical tolerance, or the presence of withdrawal symptoms.

Medical practitioners who treat combat veterans at risk for addiction would do

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Medicine in the time of war

At Home without a Home Homelessness and Veterans Roberta Rosenthal, LCSW

V

eterans make up nearly one-third of the nation’s homeless population.

The recent San Francisco 2007 Homeless Count, conducted in January, reports there are 6,377 homeless in our city. Approximately 2,100 of those are veterans.

Who are our homeless veterans?

Carol D. is a forty-one-year-old Caucasian female veteran from the Bay Area who joined the Navy when she was eighteen, after dropping out of high school. Her military career was short-lived; she reports that she suffered a major sexual trauma and was discharged after only six months of service.

After discharge, she returned to her family and for several years worked in various restaurants and delivery jobs.

Carol moved to San Francisco in 1985 and began to use street drugs in an attempt to cope with the feelings, namely anxiety and depression, resulting from the sexual trauma she had experienced in the Navy.

She became homeless when she was in her late twenties and was on and off the streets until just recently. During the late 1990s she received inpatient psychiatric treatment several times for suicidal ideation but relapsed repeatedly. She developed a daily crack cocaine addiction, which she often supported through prostitution. She was in and out of jail for drug-related offenses. In 1998 she gave birth to a baby girl but was unable to care for her consistently. Her daughter was removed from her custody at the age of five and now lives with relatives in the Bay Area.

By the time Carol first came to the San Francisco V.A. Medical Center’s Downtown Clinic in March 2007, her life www.sfms.org

was unbearable. At her intake, she stated, “I can’t keep living like this.” She was living on the streets, which she said she preferred to shelters because they made her

“The recent San Francisco 2007 Homeless Count, conducted in January, reports there are 6,377 homeless in our city.

Approximately 2,100 of those are veterans.” claustrophobic.

The staff at the Downtown Clinic’s Healthcare for Homeless Veterans program (known as HCHV) connected Carol with a shelter bed and a substance-abuse day treatment program. After she became clean and sober, she began to see a V.A. Medical Center psychiatrist, who prescribed medications for depression. HCHV staff assisted her in applying for possible V.A. benefits for PTSD caused by military sexual trauma.

She applied for a residential substance abuse treatment program, and after several months she was able to move in. As of August 2007, she had achieved four months of continuous sobriety. She has begun to have regular phone contact with her daughter, and after six months of sobriety she will be able to see her in person for the first time in more than three years.

Terry R. is a fifty-nine-year-old African-American male combat Vietnam veteran, who came to the Downtown Clinic in May 2007. He had been living on the streets for the past twenty-six years and was “not

doing much of anything except using” his drugs of choice, alcohol and heroin. He panhandled for money and had a string of arrests for stealing from local warehouses. Terry had grown up in South Carolina and had experienced severe physical abuse as a child at the hands of his stepfather. When he was eleven years old, Terry had moved with his family to California, where he attended school through the seventh grade. He began drinking alcohol and using drugs in his teenage years and joined the army at age seventeen to escape his family situation. He served in the military for two years. After his discharge he returned to California and began to use drugs and alcohol more heavily.

He met a woman, was married for two years, and had three children, but he now has no contact with any of them. After his divorce, he moved to San Francisco for a fresh start, but due to heavy drug use he was unable to keep a home or a job. He has been homeless in San Francisco since 1980.

Terry was recently awarded disability income of almost $900 a month and is now renting a room in a single-room occupancy hotel. He comes to the Downtown Clinic regularly to check his mail and do his laundry. While the Downtown Clinic HCHV staff has been working intensively with him on becoming clean and sober, applying for a substance-abuse treatment program, accepting psychiatric medications for PTSD and depression, and exploring eligibility for service-connected compensation, Terry has continued to miss scheduled appointments.

He changes his mind about his plans from day to day and continues to use drugs and alcohol, despite his intentions to quit. While he has been assigned a primary care medical provider at the Downtown Clinic, Terry’s

Continued on Page 39...

September 2007 San Francisco Medicine

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A Soldier’s Heart and Mind Continued from Page 34... well to make urine toxicology a routine laboratory screen in their offices. Newer saliva-based technology will further remove the inconvience of urine drug testing, and it much more precisely identifies what drugs are present (including a discrimination between opiates of use and abuse). Saliva testing is as sensitive as and more specific than urine toxicology for most drugs of abuse.

Often there is resistance to being referred to AA or an addiction specialist.

Commonly, there is an “all or none,” “black or white,” and “zoned-out” cognitive style in combat soldiers, which results in overvaluation of functioning and denial of drug or health problems. Getting collateral history from family members about the social functioning and drug use of a soldier with concerning symptoms is often well worth the extra time and effort. Utmost care should be taken not to push the patient into treatment. Instead, a slow and steady approach that reduces barriers to seeking help is recommended.

For soldiers who have both PTSD and addiction, there is value in treating both disorders concurrently. This helps avoid two primary pitfalls of focusing on just one disorder. The first is that arousing memories as part of PTSD clinical work can trigger increased substance abuse or reinforce rationalizations that their addictive behaviors are “just” self-medication of their PTSD. Secondly, restrictive substance abuse treatments can inadvertently dismiss the current negative impact of the war experience and leave the soldier feeling even more alone and isolated.

Recent neurobiological models for both

PTSD and addiction have some interesting areas of overlap that may help explain this strong link. According to these models, addiction and PTSD both alter the soldier’s limbic circuitry, which severely reduces his or her ability to function and enjoy life to the fullest. The limbic structures, prefrontal cortex, and their interconnected circuitry are thought to increase the survivability of an organism. The limbic system functions as a MapQuest of sorts that enables an organism to navigate and remember the environments where it received maximal rewards (e.g., food, water, sex) and minimal risks (e.g., predators).

As addiction develops, the limbic neurons are rewired through an increased dopaminergic neurotransmission from the high doses and rapid onset of drugs or alcohol in the brain. The sufferer’s hijacked MapQuest begins to remember only the locations and rewards received from drugs and alcohol and fails to store the risks addiction causes (e.g., increased family, work, and legal problems). The limbic system loses the ability to maximize other rewards, such as fulfilling relationship and parenting duties, job performance, church and community activities, and hobbies; and it minimizes risks such as work deficiencies, debt, homelessness, and legal problems.

In PTSD, neural alterations in the limbic structures of the amygdala and hippocampus result in some of the significant clinical symptoms of this disorder. In the war environment, the severe risks of bodily injury and death to the soldier and his or her comrades results in a strongly wired limbic system that vividly remembers the environments and the associated experiences related to this increased risk. The soldier’s MapQuest is exquisitely sensitive to

anything that reminds him or her of the war environment and sends out a fight-or-flight signal. This hyperaroused emotional and bodily response results in withdrawal from or aggression toward family, work, and social contexts. Without effective psychological and pharmacologic treatment, this hyperarousal and social withdrawal can progress to debilitating levels of functioning. Addiction and PTSD are similar brain disorders that have a final, common limbic neurocircuitry pathway in false overappraisals of environmental drug rewards (in addiction) or false overappraisals of environmental risks (in PTSD): two diseased aspects of the same limbic-driven survival mechanism.

Our index of suspicion should remain high for both disorders in combat soldiers when either PTSD or addiction are present.

The neurobiologic changes of both disorders suggest longer term and often chronic treatment before the damaging reemergence of symptoms abates. With a nonjudgmental and attentive stance to the diagnosis and treatment of both addiction and PTSD in at-risk soldiers, physicians can assist these warriors in getting the kind of specialized treatment that will help them return home with their hearts, minds, and bodies more intact.

John A. Straznickas, MD, is an Associate Clinical Professor of Psychiatry at the University of California, San Francisco (UCSF). Dr. Straznickas works as the Team Leader for the Substance Use/Posttraumatic Stress Disorder Service at the San Francisco V.A. Medical Center. He leads the multidisciplinary team, supervises the clinical work of trainees, and provides pharmacologic, group-therapy, and individual treatment to combat veterans who suffer from PTSD and addiction.

The 2007/2008 SFMS Membership Directory has Arrived!

Members should receive their copies in the mail shortly! To order extra copies of this useful desk reference please contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@sfms.org.

Extra copies of the directory are $75 for nonmembers and $35 for members.

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San Francisco Medicine September 2007

www.sfms.org

At Home without a Home Continued from Page 35...

Book review

health has been deteriorating due to the effects of drug and alcohol use and years on the streets. He has cirrhosis of the liver, chronic pancreatitis, kidney failure, and hepatitis B and C. The Downtown Clinic staff use a harm-reduction approach and encourage his following through on plans for sobriety. They continue to hope that Terry will decide to change his lifestyle before it is too late.

These are two fairly typical examples of members of San Francisco’s homeless veteran population who have sought and found some of the available resources.

Outreach by those offering services to veterans and a willingness on the part of the homeless vet to participate in treatment programs or to accept services seem to be the necessary ingredients for any measure of success. Sometimes once is not enough, and repeated efforts on the part of both parties may be simply one regular component of the rehabilitation course. This is true, of course, not only for veterans but for the majority of the homeless population who suffer from substance abuse and/or mental illness.

According to the most recent reports from the U.S. Department of Veterans Affairs Northeast Program Evaluation Center (NEPEC), about one-third of the adult homeless population nationwide has served our country in the armed services. On any given day, as many as 200,000 veterans are living on the streets or in shelters, and perhaps twice as many experience homelessness at some point during the course of a year.

Many other veterans are considered near homeless, or at risk, because of poverty, lack of support from family and friends, and dismal living conditions in cheap hotels or in overcrowded or substandard housing.

Right now, the number of homeless male and female Vietnam Era veterans is greater than the number of service persons who died during that war; and a small number of Desert Storm veterans are also appearing in the homeless population.

The characteristics of the homeless veterans who have sought services in San Francisco (both at the V.A. and in community programs) are very similar to those www.sfms.org

seen in other large cities: • Ninety-five percent are male.

• The average age is fifty-one (about 4 percent are sixty-five or older).

• Fifty percent are Caucasian, 37 percent African American, 8 percent Hispanic, and 5 percent Other [like other California sites, San Francisco has a slightly higher percentage of Hispanics and Other (mostly Asian)].

• Fifty-five percent are divorced or separated, 35 percent never married, and 10 percent are married or did not report their marital status.

• Almost 70 percent are literally homeless at the time of program entry (i.e., staying in a shelter or having no residence).

• About 40 percent have been homeless for one year or longer.

• Over 80 percent have either psychiatric or substance abuse problems, and about 40 percent have both.

• About 25 percent of outreach clients go on to some form of residential treatment.

Since the V.A. started collecting data on participation in Operation Enduring Freedom (OEF, Afghanistan) and Operation Iraqi Freedom (OIF) in August 2004, the San Francisco HCHV program has seen ten clients who report service in the OEF/ OIF theater of operations. This is about 1 percent of the total number of clients seen during that time. Nationally, about 1.5 percent of HCHV clients report service in the OEF/OIF theater of operations (data from Healthcare for Homeless Veterans Program Evaluation, NEPEC/182, 2007).

What services and resources are available to homeless veterans in San Francisco?

The San Francisco V.A. Downtown Clinic has been designated as one of eight national Comprehensive Homeless Centers, due to its inclusive services and community partnerships. The Department of Veterans Affairs, Swords to Plowshares, and other community agencies in San Francisco offer an array of special programs and initiatives specifically designed to help homeless veterans live as self-sufficiently and independently as possible. These treatment programs and services include: • Aggressive outreach to veterans

living on the streets and in shelters who otherwise would not seek assistance; • Clinical assessment and referral to needed medical treatment for physical and psychiatric disorders, including substance abuse; • Long-term sheltered transitional assistance, case management, and rehabilitation; • Drop-in centers; • Legal services; • Employment assistance and linkage with available income supports; and • Supported permanent housing.

There are currently ninety-four transitional housing beds and 100 units of permanent supported housing designated specifically for homeless veterans. Veterans are eligible for other homeless housing or shelters as well.

Why does San Francisco appeal to homeless persons? The city is known for its liberal attitude toward everyone, including the homeless, and it offers a year-round temperate climate, easy public transportation, and—compared to other cities—a multitude of services that care for the homeless.

Perhaps more important, San Francisco is a relatively small and compact city: a homeless person can apply for general assistance, receive health care, and find a shelter bed and food within a two-mile radius.

All this being said, there is still an ongoing need for more housing and services to care for our homeless veterans and their families in the city of San Francisco. If the ratio of homeless Vietnam veterans to those who died in Vietnam is repeated, we will be seeing many more homeless vets in the aftermath of the current war.

Roberta (Bobbie) Rosenthal has been in the field of Social Work for the past thirty years.

She has worked in the V.A. system for the past eighteen years and has worked with homeless veterans since 1991. Bobbie served as the SFVAMC Chief of Social Work Services and as Director of the San Francisco Comprehensive Homeless Center program from 2000 until July 2007. She is currently the VISN 21 Network Homeless Coordinator, covering Northern California; Fresno; Reno, Nevada; and Hawaii. Bobbie was named the national V.A. Social Worker of the Year in 2005.

September 2007 San Francisco Medicine

39

hospital news Chinese

Joseph Woo, MD

The atmosphere at Chinese Hospital remains that of a small rural hospital in an urban setting. We have many events and gatherings that bind us almost like an extended family. For example, at our annual holiday party last December, the medical staff faced off in a bowling tournament against the hospital employees. Alas, despite stellar performances by Drs. Edmund “The Big Uneasy” Tsoi, James “Boom-Boom” Yan, and newcomer Irwin Chow, the hospital employees defeated us. However the spirit of competition persists and the need for redemption is great. On September 9, the medical staff will try to even the score in a biathlon of softball and basketball. Shu-Wing Chan will captain the basketball squad and we will surely be victorious.

The softball team will be led by James Yan, who promises a win. We expect to complete our medical staff trifecta, as this year’s holiday party theme is an amateur dancing competition. MaiSie Chan and Raymond Fay will show us their moves and bring us the trophy. Look for us to be tough at the Dragon Boat competition again this year, too!

We can all be proud of our small facility for another reason: the School of Public Health at U.C. Berkeley honored the Chinese Hospital as its Organizational Health Hero during its eleventh annual ceremony held earlier this year. We were recognized for providing culturally competent health care services to our community. UCB alumnus Dr. Rolland Lowe presented the award to our CEO Brenda Yee and Board President Joe Chan. The other awardees were Dr. Dean Ornish and the WHO’s Dr. D.A. Anderson, who directed the eradication of small pox. While these accolades are nice, we need to remember and thank the doctors, nurses, and staff who provide quality care day to day.

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Saint Francis

Wade Aubry, MD

Under the direction of infectious disease specialist Gifford Leoung, MD, Saint Francis has been operating its “CareConnect” EMR system over the last year. Due to its successful implementation at Saint Francis and other CHW hospitals, CHW received the 2007 team award from the Association of Medical Directors of Information Systems. This award commends the hospital and Dr. Leoung for the successful use of information technology to improve patient care and increase the effectiveness and flow of medical practice.

Orthopedic surgeon Susan Lewis, MD, has been honored with the Doctor Glick Award from the Sony Ericsson Women’s Tennis Association (WTA). For the past eight years, she has been the event physician for the Bank of the West Classic at Stanford. Dr. Lewis is also a role model for women athletes, showing that it is possible to combine a highly successful professional career with family life as a wife and mother. WTA “Physicians of the Year” have made outstanding contributions to sports medicine excellence.

A long-standing tradition, Saint Francis Day, will be revived this October with a full day of sports, including golf, tennis, running/walking, and biking, followed by an awards dinner and dance. During the dinner, doctors will be acknowledged for twenty-plus years of service.

Saint Francis Day is a day of relaxation, sports, and camaraderie and serves as the perfect opportunity to welcome new doctors into the Saint Francis community.

Lastly, we are sorry to announce the retirement of our award-winning librarian, Maryann Zaremska. Maryann has served the medical staff of Saint Francis in an exemplary manner for almost twenty-six years and, although we will miss working with her in the medical library, we wish her well in this new phase of her life.

San Francisco Medicine September 2007

St. Mary’s

Richard Podolin, MD

The experience of practicing medicine in a war zone is so profound that those of us who have been spared that experience haven’t the comprehension to discuss it meaningfully. Yet, despite our inability to imagine practicing in a war zone, we are certainly practicing medicine in a time of war. Setting aside questions about the justification for this or any war, how do we reconcile the values of our profession with our values as members of a society whose nation is at war?

The guiding principle of our profession is that every human life has intrinsic value, and it is our aspiration to value every life equally. Our values as citizens of a nation at war are very different. A nation at war has decided that certain values have greater intrinsic worth than life itself. Freedom, justice, equality, security, even territorial expansion or economic advantage have been considered of such importance that they have justified the sacrifice of lives. I believe that we can best reconcile these disparate values if we, practicing medicine in a time of war but distant from the battlefield, struggle to make our society worthy of this sacrifice.

At St. Mary’s Medical Center, we are committed to delivering compassionate, high-quality health services to all members of our community, including the poor and disenfranchised. The hospital operates one of the largest free medical clinics and HIV programs in San Francisco, second only to the county public health department. Last year alone, it provided nearly $18 million in charity care.

This year, St. Mary’s celebrates the 150th anniversary of its founding by the Sisters of Mercy, who came to this City on a mission to care for the poor and underserved—a mission that continues as our foundation despite epidemics, earthquakes, economic uncertainty, and war.

www.sfms.org

hospital news UCSF

Ronald Miller, MD

For the seventh consecutive year, UCSF Medical Center has been ranked among the nation’s top ten hospitals by U.S. News and World Report. The new 2007 survey ranked the Medical Center as number seven. The magazine evaluated sixteen specialties in this year’s report, and UCSF placed within the top ten in seven of those specialties: endocrinology, gynecology, neurology and neurosurgery, ophthalmology, respiratory disorders, rheumatology, and urology.

UCSF and ValleyCare Health System have signed a letter of intent to enhance health care services for women and children in the Tri-Valley region of the East Bay. The goal of the collaboration is to expand regional access to high-quality perinatal and pediatric care and to broaden the availability of specialty services. The two organizations began working together on July 1 on a long-term “shared vision” that centers on a three-phase plan. The collaboration marks the first time that UCSF is bringing together such a comprehensive aggregate of health care services at a facility outside UCSF. The agreement includes inpatient pediatric hospitalist and neonatology services, as well as outpatient subspecialties such as pulmonary medicine and gastroenterology. Services will be phased in during the next six months.

The UCSF Palliative Care Program has been named by the American Hospital Association as one of the top three programs nationwide for its innovative efforts to provide end-of-life care. The program received the AHA annual Circle of Life Award and was the only program in the West to receive the honor. Established in 1999, the UCSF program focuses on bringing physical, emotional, and spiritual solace to patients facing life-threatening illness. Its services include a consultation program for these patients, their families, and physicians, as well as special patient rooms that feature music, views, and space for family and friends to gather. www.sfms.org

Veterans

Couples Therapy for Veterans Continued from Page 33...

Diana Nicoll, MD, PhD, MPA

The San Francisco V.A. Medical Center provides state-of-the-art health care in areas specifically related to combat experience.

Our Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Integrated Clinic is designed to meet both the physical and psychological needs of returning veterans. This clinic collocates primary care, mental health, and social work services. During the first visit, the patient meets with a primary care provider for a comprehensive health exam, with a mental health professional to discuss readjustment, and with an OEF/OIF Case Manager to address other postdeployment issues.

“This clinic is unique because it provides three essential health care services in one setting, so the veteran can access them all on his or her first visit,” says Rina Shah, MD, Medical Practice Director. “With the busy schedules of our returning veterans, it is important for us to change our practices in order to accommodate their needs and expectations.”

We are adding new psychiatrists and psychologists to our mental health services and are increasing our hours into the evening, and a mental health professional is available twenty-four hours a day, seven days a week for urgent needs.

Our community-based outpatient clinics participate in an extensive telemedicine program that allows veterans to receive expert care in remote areas without having to travel to the Medical Center. This program will continue to grow in the future, especially in the area of mental health.

The San Francisco V.A. Medical Center is committed to providing medical care and counseling services that are second-to-none for returning service members. For more information on services available to OEF/OIF veterans, contact Polly Rose, LCSW, OEF/OIF Program Coordinator, at (415) 221-4810 ext. 4405.

trauma), the stability of the relationship, and the ability of the partner to listen to the veteran’s stories.

Through our work as couples therapists, we have developed great respect for veterans of war and their families. It takes tremendous work to develop and maintain a successful relationship, and couples who are struggling with the impact of war on their relationships have an even tougher time. In situations where the veteran needs more than couples therapy alone, the SFVA typically provides medication, individual, and/or group therapy for the veteran. The partner can obtain individual therapy from pro bono groups such as the Bay Area’s Coming Home Project (www. cominghomeproject.net).

External stressors can also negatively impact the quality of the relationship.

Aside from therapy resources, we need to provide support in employment and education, and we must help develop natural community supports (other couples coping with the same issues) in order to increase the likelihood of a successful relationship.

The responsibility for helping our men and women make a successful transition home depends on all of us.

Keith Armstrong, LCSW, is Clinical Professor of Psychiatry at the University of California, San Francisco; Director of Couples and Family Therapy at the San Francisco Department of Veterans Affairs Medical Center; and coauthor of the self-help book Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families.

September 2007 San Francisco Medicine

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Share your voice.

When we speak as one, physicians and patients win.

As a member of the American Medical Association (AMA), you play a vital role in shaping the future of medicine. Your voice will help reform America’s health care system and improve the health of the public and your patients. Become a member of the AMA today and lend your voice to the call for change. To renew or join the American Medical Association, call the San Francisco Medical Society at (415) 561-0850.

Helping doctors help patients.

For Hiroshima, the Healing Continues

T

his year marks nizations proclaimed their the thirtieth anstatus as sister medical niversary of biensocieties in 1981 at a cernial visits by a Japanese emony held at the Mayor medical team specializing of San Francisco’s office. in radiation effects. DurThis important relationing the summer the San ship was undertaken by Francisco Medical Society the two medical societies From left to right: SFMS Administrative Director Posi Lyon; Chair of the Friends of Hibakusha Medical (SFMS) was pleased to as a commitment to closer welcome the Sixteenth Committee Geri Handa; HPMA Board Member Yoshiteru Takada, MD; SFMS President-Elect Steve cooperation between U.S. Biennial Medical Mission Fugaro, MD; HPMA Board Member and Team Leader Kenichi Arita, MD, PhD; Radiation Effects and Japanese physicians to San Francisco.

Research Foundation Assistant Tadaaki Watanabe; HPMA Director of Secretariat Eiji Soramoto; SFMS with a particular concern Since 1977, the Japa- Immediate Past-President Gordon Fung, MD; and SFMS Board Member John Umekubo, MD. for the illnesses of atomic nese government has fibomb survivors. The renanced and sponsored these medical missions for the benefit of lationship is also a reminder that cooperation and friendship can bombing survivors living in the United States who, due to their survive and sometimes even grow from tragedies such as the Hiroexposure to radiation in the 1945 bombings, suffer from and are shima and Nagasaki atomic bombings. threatened by ongoing medical problems. The missions have also This important work will give the medical community a greater been sponsored by the Hiroshima Medical Prefectural Association, understanding of the longas well as many other organizations both in Japan and in the U.S. term effects of nuclear war The Japanese medical mission receives volunteer support and conand, more importantly, tributions from dedicated groups and individuals across the world. may serve as a deterrent to It is this spirit of cooperation and the humanitarian effort expressed such events in the future. by all involved that help make each biennial visit a truly worthy and meaningful endeavor.

(Pictured left) Kenichi Arita preSFMS is proud of its long-standing relationship with the Hisenting Steve Fugaro with a gift roshima Prefectural Medical Association (HPMA). The two orgafor SFMS on behalf of HPMA.

Physician Career Fair Sutter Health with facilities in Northern California, from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, provides boundless practice opportunities, and lifestyles.

Join us to meet Sutter Health physicians and administrators, and to learn about unique practice opportunities Sutter Health has to offer. ●Continental breakfast will be served ●Parking vouchers provided if hotel valet parking is used ●RSVP preferred (docjobs@sutterhealth.org) ●walk-ins welcome ●Free CV critique service available

September 29, 2007 San Francisco, CA 9:30 a.m. - 11:30 a.m.

Grand Hyatt San Francisco 345 Stockton St. San Francisco, CA 94108 For more information 866-448-7070

If unable to attend CVs may be faxed to 916-643-6677 or email to docjobs@sutterhealth.org. www.sfms.org

September 2007 San Francisco Medicine

43

Northern California Physician Opportunities Sutter Health offers a wide variety of practice styles, geographies, and life styles.

With facilities in Northern California from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, you have boundless career opportunities to fit your goals.

We have open opportunities in a variety of specialties. Contact us for more information.

Sutter Health Physician Recruitment 866-448-7070 916-454-6645 fax docjobs@sutterhealth.org www.sutterhealth.org

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